Contact dermatitis in the elderly

Comorbid Scenarios in Contact Dermatitis: Atopic Dermatitis, Irritant Dermatitis, and Extremes of Age

Contact dermatitis (allergic and irritant) occurs when the skin encounters haptens that elicit a T cell-mediated hypersensitivity reaction (allergic) or a nonimmunologic, toxic reaction (irritant). Patch testing is the reference standard for diagnosing allergic contact dermatitis (ACD), although positive results are not always relevant. Therefore, the definitive diagnosis of ACD requires an astute clinician able to connect the results of patch testing appropriately with the clinical history and the cutaneous examination findings. Comorbid conditions such as atopic dermatitis can confound the accurate diagnosis of ACD because of the similarities in clinical presentation. Furthermore, both extremes of age can further challenge the diagnostic specificity of ACD owing to the maturing immune system and the space limitations present when the very young are patch tested. The goal of this Continuing Medical Education article is to discuss the challenges of diagnosing ACD in patients with unique comorbidities such as atopic dermatitis, given the morphologic similarities, and when to patch test these patients. Diagnosis of ACD will also be discussed in very young patients with a focus on patch test allergen selection despite the limited geographic space. The most common allergens reported in very young and old patients will also be discussed.

Contact Allergy in the Elderly: A Study of 600 Patients

The proportion of elderly in the general population is increasing. Ageing of the skin and immune system can modify the features of contact hypersensitivity (CH). The number of epidemiological studies according to the age-related features of CH is very limited. We aimed to analyse the clinical characteristics of CH in an elderly patient population. A total of 600 patients (patient age > 60 years old) were patch tested with the European Environmental Baseline Series (EEBS) and 440 of them with the Complementary Fragrance Series (CFS) at the same time according to the actual international methodological standards in the Allergy Outpatient Unit of Department of Dermatology, Venereology and Dermato-Oncology of Semmelweis University between 2015−2019. Out of 600 tested patients, 54.8% had at least one allergen positivity. Female predominance was observed (78.7%). The most common diagnosis was contact dermatitis (63.7%), followed by psoriasis (6.2%). Most of the cases (58.0%) were found in the age group of 60−69. The five most common contact allergens were benzoic acid, methylisothiazolinone (MI), wood tar, nickel, and balsam of Peru. Allergic skin symptoms are present in all ages and also in the elderly. According to our data, the most common contact allergens are preservatives, followed by balsam of Peru among men and nickel among women. In case of contact dermatitis, stasis dermatitis, rosacea, and atopic dermatitis are worth patch testing to verify CH even in those above 60 years old.

Update on Contact Sensitization in the Older Adult Population

BACKGROUND

Little is known about the epidemiology of allergic contact dermatitis in the aging US population.

OBJECTIVE

The aim of this study was to describe patch test results in a cohort of older adult patients evaluated in a patch testing clinic in a tertiary medical center.

METHODS

This study was a retrospective analysis of patch test results of adults 65 years and older from February 2013 to December 2019.

RESULTS

Data from a total of 169 patients 65 years and older were analyzed. Of these patients, 84.6% (143/169) had 1 or more positive reactions on patch testing, 84.6% (121/143) of which were felt to be clinically relevant and received a final diagnosis of allergic contact dermatitis. The most common allergen categories were fragrances (30.1%), preservatives (20.8%), metals (11.0%), medicaments (8.3%), and textile dyes (6.5%). The most common individual allergens were Myroxylon pereirae resin (balsam of Peru), hydroperoxide of linalool, methylisothiazolinone, nickel sulfate, and fragrance mix I. Personal products were by far the most common presumed source of allergen exposure.

CONCLUSIONS

Allergic contact dermatitis is a common diagnosis in the older adult population, and patch testing with allergen avoidance counseling can be an important diagnostic step and potential cure for this allergic condition.

Allergic diseases in the elderly

Demographic distribution of the population is progressively changing with the proportion of elderly persons increasing in most societies. This entails that there is a need to evaluate the impact of common diseases, such as asthma and other allergic conditions, in this age segment. Frailty, comorbidities and polymedication are some of the factors that condition management in geriatric patients. The objective of this review is to highlight the characteristics of allergic diseases in older age groups, from the influence of immunosenescence, to particular clinical implications and management issues, such as drug interactions or age-related side effects.

Contact sensitization in the elderly

Contact dermatitis from irritant and allergic sources is the reason for 6% to 10% of all dermatologic visits with considerable morbidity and economic impact. Allergic contact dermatitis is a T-cell-mediated inflammatory reaction and develops in predisposed individuals as a consequence of environmental exposure to allergens. Aging is correlated with the rate and type of contact sensitization because of "immunosenescence." The number of old people is growing around the world. This contribution reviews the main findings from published epidemiologic studies on contact allergy in elderly populations. In all examined studies, patch testing was performed in patients with cutaneous manifestations possibly related to contact dermatitis; the prevalence of contact dermatitis in the elderly was from 33% to 64%. Establishing the most frequent allergens responsible for allergic contact dermatitis in the elderly is a hard task. The commonest allergens reported were nickel sulfate, fragrance mix, diamino diphenylmethane, lanolin alcohols, paraben mix, Euxyl K400, quinoline mix, and balsam of Peru. We emphasize that allergens surveillance is needed to realize an "elderly series" for having a useful adjunct to contact allergy that may help the treatment of each patient.

Contact dermatitis in older adults: a review of the literature

Contact dermatitis is a significant health problem affecting the elderly. Impaired epidermal barrier function and delayed cutaneous recovery after insult enhances susceptibility to both irritants and allergens. Exposure to more numerous potential sensitizers and for greater durations influences the rate of allergic contact dermatitis in this population. Medical co-morbidities, including stasis dermatitis and venous ulcerations, further exacerbate this clinical picture. However, while these factors tend to increase the degree of sensitization in the elderly, waning immunity can actually decrease such a propensity. This interplay of both intrinsic and extrinsic factors makes a generalization on trends for contact dermatitis in older adults challenging. The literature has varying reports on the overall incidence of allergic contact dermatitis with advancing age. Nevertheless, it does clearly show that sensitivity to topical medicaments increases with age. Irritant contact dermatitis studies are more consistent, with less reactivity (to irritants) in older compared with younger skin. Diagnosis of both irritant and allergic contact dermatitis is based on a thorough history, complete skin examination, and comprehensive patch testing. The mainstay of therapy is avoidance of the offending chemical substances and the use of topical along with systemic therapies, depending on the severity of the condition.

Epidemiological data on consumer allergy to p-phenylenediamine

Many women and men now dye their hair. p-Phenylenediamine (PPD) is a frequent and important component of permanent hair dye products; exposure to it may cause allergic contact sensitization, acute dermatitis, and severe facial oedema. To increase our understanding of PPD allergy, we reviewed published literature containing PPD patch test data from dermatitis patients and individuals in the general population. This was performed to estimate the median prevalence and the weighted average of PPD sensitization and thereby assess the burden of PPD-containing hair care products on health. Literature was examined using PubMed-MEDLINE, Biosis, and Science Citation Index. The median prevalence among dermatitis patients was 4.3% in Asia, 4% in Europe, and 6.2% in North America. A widespread increase in the prevalence of PPD sensitization was observed among Asian dermatitis patients. In Europe, a decrease in the 1970s was replaced by a plateau with steady, high prevalences ranging between 2% and 6%. The prevalence remained high in North America, although a decreasing tendency was observed. Contact allergy to PPD is an important health issue for both women and men. More stringent regulation and enforcement are required as public health measures to reduce the burden of disease that exposure to PPD has brought to populations.

Unexpected sensitization routes and general frequency of contact allergies in an elderly stented Swedish population

Contact allergy to stent material has been proposed to be a risk factor for restenosis, after percutaneous transluminal coronary angioplasty (PTCA) and stenting. Information on the general frequency of contact allergy in the elderly population is scarce and knowledge of possible sensitization routes is important to investigate. The aim of this study was to investigate contact allergy to stent materials and other allergens. Here we report our findings on the frequency of contact allergies apart from those from stent material. In this retrospective study, we patch tested an elderly population, treated with PTCA and stented, with our standard series. A dermatitis population served as controls. We found a high frequency of contact allergy in both groups but a greater 'contact allergy burden', with generally higher frequencies for contact allergens, in the dermatitis patients as expected. Myroxylon pereirae and caine mix were apart from metals exceptions with statistically significant higher frequencies (P < 0.01) for the stented patients. Contact allergy to nonmetal sensitizers is common in an elderly Swedish stent population although, on the whole, substantially less than in an age and sex-matched dermatitis population. The findings indicate the importance of the oral mucosa for sensitization. In a general population that has been treated with a special medication/treatment procedure, contact allergies not suspected (such as to M. pereirae and to the metals) might suddenly peak. This underlines the importance of a careful evaluation of new products and routines with regard to contact allergies in the population.

The biocide polyhexamethylene biguanide remains an uncommon contact allergen

Polyhexamethylene biguanide (PHMB) is used as a preservative in cosmetics and personal care products. Previous studies had shown a frequency of sensitization to PHMB of 0.5% and 0.4% in unselected dermatitis patients. The objective of this study was to determine the current frequency of sensitization to PHMB. From July 2005 until December 2005, a total of 1975 consecutive patients were patch tested with PHMB. 10 patients (0.5%) had positive patch test reactions to PHMB 2.5% aq. (9+ and 1++) and 16 patients (0.8%) to PHMB 5.0% aq. (12 +, and 4 ++). The test reaction pattern (reaction index and positivity ratio) of both preparations and a limited concordance between results from both concentrations (Cohen's kappa = 0.35) are probably indicative of a substantial number of false positive reactions. Potential causal exposures were assessed by a case by case analysis and by referring to surrogate markers of exposure in terms of concomitant reactions. Occupational exposures were identified as a probable cause of sensitization. Further risk factors included leg dermatitis and old age. The frequency of sensitization remains low. It is very unlikely that exposure to cosmetics or personal care products may have played a role in the few cases sensitized.

Contact allergy to topical medicaments becomes more common with advancing age: an age-stratified study

Eczema is common in the elderly people who often use topical medicaments. Previous studies in the elderly people have noted allergic positive patch tests in between 43% and 64% of those tested. We set out to assess whether medicament contact allergies are more common in elderly patients. We undertook a retrospective age-stratified study of all patients patch tested at the Royal Hallamshire Hospital, Sheffield, between January 1994 and July 2005. We confirmed that contact allergy to topical medicaments is more common in those aged more than 70 years compared with the younger age groups. There was no sex difference. The commonest problematic allergen types found in medicaments were fragrances and preservatives. The most frequent individual allergens were fragrance mix, Myroxylon pereirae, lanolins, local anaesthetic agents, neomycin and gentamicin, and tixocortol pivolate. The pattern of medicament contact allergens was similar to that of the younger age groups except that multiple allergic positives were more frequent and sensitivities to local anaesthetics and Myroxylon pereirae were proportionally more common. Elderly patients were more likely to have multiple contact allergies than the younger ones. Care needs to be taken when prescribing topical medicaments to elderly patients with eczema, especially for preparations that contain perfumes, lanolins, and local anaesthetics.

Contact sensitivity to standard series allergens in 1038 patients with contact dermatitis in Turkey

We planned to determine the frequency of sensitivity to European standard patch test allergens in 1038 patients with contact dermatitis. From 1992 to 2004, 1038 patients with the diagnosis of contact dermatitis were patch tested with the European standard series. Seven hundred and five patients were female (67.9%) and 333 patients were male (32.1%). A total of 336 patients (32.3%) had one or more positive patch test reactions. The most common allergens were nickel (17.6%), cobalt chloride (5.3%), potassium dichromate (4.6%), neomycin (2.4%), fragrance mix (2.1%) and balsam of Peru (2.1%). Contact sensitivity to potassium dichromate and thiuram was significantly more frequent in male patients, whereas nickel and primin sensitivity was significantly more frequent in female patients. Higher sensitivity rates for potassium dichromate, neomycin, balsam of Peru, wool alcohol, fragrance mix and primin were noted in patients over 40 years of age. Sensitivity rates of the standard series allergens were all similar in atopic patients and in non-atopic patients. Metals, neomycin and fragrances are the leading allergens in Turkey. Although fragrances are among the most important sensitizers, sensitivity rates to fragrances and also to preservatives are much lower than the rates in Europe and the US.