A synthetic detergent as a provocative agent in patch tests

Health impact assessment of a skin sensitizer: Analysis of potential policy measures aimed at reducing geraniol concentrations in personal care products and household cleaning products

A methodology to assess the health impact of skin sensitizers is introduced, which consists of the comparison of the probabilistic aggregated exposure with a probabilistic (individual) human sensitization or elicitation induction dose. The health impact of potential policy measures aimed at reducing the concentration of a fragrance allergen, geraniol, in consumer products is analysed in a simulated population derived from multiple product use surveys. Our analysis shows that current dermal exposure to geraniol from personal care and household cleaning products lead to new cases of contact allergy and induce clinical symptoms for those already sensitized. We estimate that this exposure results yearly in 34 new cases of geraniol contact allergy per million consumers in Western and Northern Europe, mainly due to exposure to household cleaning products. About twice as many consumers (60 per million) are projected to suffer from clinical symptoms due to re-exposure to geraniol. Policy measures restricting geraniol concentrations to <0.01% will noticeably reduce new cases of sensitization and decrease the number of people with clinical symptoms as well as the frequency of occurrence of these clinical symptoms. The estimated numbers should be interpreted with caution and provide only a rough indication of the health impact.

"New" techniques for more sensitive patch testing?

The patch test is the mainstay of diagnosis in allergic contact dermatitis. In its nearly 120-year-long history, numerous efforts to standardize several methodical aspects proved successful. The aim was always to enhance the validity and reliability of patch testing. This article reviews modifications of the basic patch test technique for enhancing test sensitivity. We expand on the recently validated strip patch test, which is a modification that involves affixing tape strips to the skin and removing them prior to patch testing. Although it was first described in 1953, we proposed the first protocol for standardized performance of the "strip patch test." The protocol was then tested in studies. As a result, test sensitivity of standardized strip patch test versus patch test was increased. The protocol produced a uniform reduction in the thickness of the stratum corneum and a good inter-rater agreement. Additionally, there was evidence of a non-specific stimulation of the inflammatory epidermal system. With regard to patient history, the standardized strip patch test showed a vastly better sensitivity than the patch test with only marginally lower specificity. As a complementary measure to patch testing diagnostic accuracy could be improved significantly by performing the standardized strip patch test. Further studies are needed on the reproducibility of the standardized strip patch test.

Augmentation of skin response by exposure to a combination of allergens and irritants - a review

Clinical experimental studies on contact dermatitis (CD) often evaluate the effect of one allergen or one irritant at a time. In real life, the skin is often exposed to more allergens, more irritants or allergens and irritants in combination. This combined exposure may potentially influence irritant effects as well as allergenicity of the substances. Mechanisms for a changed response can be immunological effects or enhanced penetration. Knowledge about the influence on skin reaction of combined exposures may influence skin reactivity and is important for prevention of CD. For allergens, threshold values may be influenced by the presence of other allergens or irritants, and prevention of CD by regulation of threshold values may not be sufficient if this is not taken into account.

Combined effects of irritants and allergens. Synergistic effects of nickel and sodium lauryl sulfate in nickel- sensitized individuals

Knowledge of the combined effects of irritants and allergens is of interest with respect to accurate risk assessment. The threshold for elicitation of allergic contact dermatitis in previously sensitized individuals may theoretically be markedly influenced by the simultaneous presence of irritants and allergens. Combined exposures have, however, only been studied infrequently. In the present study, the combined effect of an irritant and an allergen was evaluated in a dose-response designed experimental study. 20 nickel-sensitized subjects were exposed to patch testing with varying concentrations of NiCl2 (nickel chloride) and sodium lauryl sulfate (SLS) alone and in combination. Evaluation of skin reactions was performed by colorimetry, measurement of transepidermal water loss and clinical evaluation, and the data were analyzed by logistic dose-response models. A synergistic effect was found of combined exposure to NiCl2 and SLS, as compared to each of the substances applied separately, as evaluated by colorimetry and clinical scoring. This means that the effect produced by the combined exposure was substantially greater than the effect produced by either of the substances alone. A synergistic effect of combined exposure on skin barrier impairment was not found, since the barrier function is significantly influenced by SLS-exposure only and not by NiCl2. Concentration limits are used by industry and government agencies to protect consumers. The present results clearly illustrate that elicitation thresholds and concentration limits may be influenced considerably by combined exposure to allergens and irritants.

Patch test results with serial dilutions of nickel sulfate (with and without detergent), palladium chloride, and nickel and palladium metal plates

Clinical experience suggests the existence of different degrees of sensitivity in nickel-allergic patients. For quantification of this phenomenon, 462 consecutive patients with previously diagnosed or strongly suspected nickel allergy were tested with serial dilution patch tests with 5 ppm to 5% nickel sulfate in pet. (Ni), and 5 ppm to 1% nickel sulfate in pet. with 1% detergent (Ni/D). Additionally, nickel and palladium metal plates were tested in 103, and cobalt salts, dichromate and palladium chloride (PdCl2) in most patients. 332 patients reacted positively to Ni or Ni/D. The influence of a concomitantly administered detergent was not significant. A significant correlation was found between positive reactions to low concentrations of Ni (or Ni/D), i.e., 0.1% or less (N = 166), and concomitant reactions to nickel metal plates, cobalt salts and PdCl2 and a history of ear piercing with metal intolerance. The clinical relevance of reactions to PdCl2 is at present not clear. A subgroup of nickel-allergic patients with "high sensitivity" can be defined. In future studies further addressing the clinical relevance of high versus low sensitivity, patch testing with 0.01, 0.1, 1.0 and 5% nickel sulfate in pet. is recommended instead of routine tests with 5% only.

Influence of detergent washing powders on minimal eliciting patch test concentrations of nickel and chromium

Minimum eliciting levels of nickel have been estimated in 25 nickel-sensitive subjects, and of chromium in 14 chromium-sensitive subjects by patch tests with aqueous solutions of the respective metals. The minimum level of each metal required to provoke a patch test reaction was considerably greater than that found in fabric washing powder solutions and was in the majority of patients tested of the order of 112 ppm nickel (0.05% nickel sulphate) or 885 ppm hexavalent chromium (0.25% potassium dichromate). One nickel-sensitive subject and one chromium-sensitive subject reacted to 1 ppm of the respective metal. Fabric washing powder did not significantly alter the patch test reaction to nickel sulphate or provoke reactions in nickel- or chromium-sensitive subjects. EDTA significantly reduced the number and severity of patch test reactions to nickel sulphate but not those to potassium dichromate or trivalent chromium.

Occupational dermatoses in hospital cleaning women

In an investigation of 541 members of a hospital cleaning department, a prevalence rate of occupational skin diseases of 15.3% was found. During their hospital employment, 39.1% had a skin disease. Higher prevalence in the younger age groups can be explained by the selection of those with skin diseases for work away from the cleaning department. A large number developed their disease shortly after employment began. This was an indication that the observed prevalent conditions were irritant diseases. The distribution by diagnosis confirms this conclusion in as much as 75% of the occupational skin diseases were irritant dermatitis, 21% allergic contact dermatitis, and 4% monilia of the finger webs. The causes of allergic contact dermatitis were found to be formaldehyde, glutaraldehyde and chloramine in addition to nickel and rubber. Among the causes of irritant dermatitis were detergents, alkaline substances, acids and sodium perborate as well as hypochlorite and hypobromite combinations. In order to reduce occupational skin diseases among cleaning personnel, it is necessary to extend both local and more general prophylactic measures.

Exposure of nickel and the relevance of nickel sensitivity among hospital cleaners

The nickel content of water specimens from consecutive stages during the cleaning process in a Danish hospital was analyzed. Statistically significant increases of the nickel concentrations were found from step to step of the cleaning, eventually exceeding the theoretical sensitizing safety limit. The relevance of the findings in relation to hand eczema is discussed.