The effect of race and ethnicity on patch test results

Diagnosis of Allergic Dermatoses in Skin of Color

PURPOSE OF REVIEW

This review aims to deliver a comprehensive report of the most recent knowledge on diagnosing allergic dermatoses in skin of color (SOC) patients.

RECENT FINDINGS

Allergic dermatoses can affect populations of all backgrounds. However, racial/ethnic variations in epidemiology, clinical features, and associated allergens have been reported. Nuances in the approach to diagnosis, including the assessment of erythema and interpretation of patch tests, are important considerations when treating patients with SOC. In this review, we outline various manifestations of allergic dermatoses in SOC with a focus on important clinical presentations and diagnostic tools, aiming to support clinicians in accurate recognition of diseases, thereby opening avenues to improve outcomes across diverse skin types.

Allergic Contact Dermatitis and Patch Testing in Skin of Color Patients

Objective: Skin of color patients face important health issues relevant to dermatologists, such as allergic contact dermatitis; however, there is a lack of information surrounding common allergens causing contact dermatitis that disproportionately affect skin of color patients, as well as interpreting patch testing in this population. Methods: Covidence, Embase, MEDLINE, PubMed, Web of Science, and Google Scholar were searched to identify relevant articles studying allergic and irritant contact dermatitis in skin of color patients. Results: The most common positive reactions in African American patients included PPD, balsam of Peru, bacitracin, fragrance mix, and nickel. The most common positive reactions in Hispanic patients included Carba mix, nickel sulfate, and thiuram mix. The most common positive reactions in Asian patients included nickel sulfate, fragrance mix, and potassium dichromate. When interpreting patch test results in patients with higher Fitzpatrick skin types, positive patch tests presented with lichenification and hyperpigmentation, rather than erythema and vesicles. Furthermore, characteristic bright red or pink hues for positive results may appear violaceous or faint pink. Conclusions: Awareness of the common allergens associated with allergic contact dermatitis in patients of skin of color can help guide patch testing as an important diagnostic tool. Further research must be conducted regarding contact dermatitis in this patient population, especially given the relative lack of data surrounding Hispanic, Asian and Pacific Islander, and Native American patients.

Lanolin

Lanolin is a complex mixture of high molecular weight esters, aliphatic alcohols, sterols, fatty acids, and hydrocarbons that has been widely used for centuries for its emollient properties. The purification of crude lanolin into lanolin wax and the processing of this wax into various derivatives began in 1882 and continue to this day with newer highly purified anhydrous lanolins. Controversy as to lanolin's allergenicity began in the 1920s and remains an issue. The most appropriate patch test preparation(s) for detecting allergy remain disputed. Detection of lanolin-induced contact dermatitis in diseased skin by patch testing on normal skin may lead to false negative results. Patients with a positive patch test to lanolin may tolerate use of lanolin on normal skin. Although lanolin is a weak sensitizer and the frequency of contact allergy to it in the European population reportedly is 0.4%, there are high-risk concomitant conditions: stasis dermatitis, leg ulcers, perianal/genital dermatitis, and atopic dermatitis (AD). Children and the elderly are also at greater risk of developing contact allergy to lanolin, partly because of comorbidities (AD and stasis dermatitis/leg ulcers, respectively). Finally, in the United States, non-Hispanic white patients are more likely than their non-Hispanic black counterparts to be lanolin allergic.

Standard patch test results and clinical relevance: A cross-sectional study of 10-year retrospective experience

Background:

Allergic contact dermatitis (ACD) is a type IV hypersensitivity reaction, and The European Standard Series (ESS) Patch Test (PT) is widely used in determining the possible responsible allergens causing ACD. The dynamic nature of the industrial products, socioeconomic and environmental factors cause the frequency of common allergens to change over the years and among different regions.

Aims and Objectives:

This study aimed to retrospectively evaluate the results of ESS PT of our centre in the last decade, and determine the current spectrum of allergens and their clinical relevance.

Materials and Methods:

The data of patients who underwent ESS PT in our clinic between January 2010 and March 2020 were included in the study. The patient files were examined retrospectively. The clinical relevance was evaluated according to the COADEX system. Statistical analysis used: SPSS for Windows version 23.0 software program.

Results:

The data of 1037 patients [623 (60.1%) female, 414 (39.9%) male] were analysed. The mean age was 38.34 ± 14.55 years. The five most common allergens were nickel sulphate (23.1%), cobalt chloride (12%), potassium dichromate (9.5%), Fragrance mix II (7.3%) and balsam of Peru (5.7%). According to the COADEX coding system, current relevance was detected in 319 (49.3%) of 646 patients who had a positive reaction to any substance in the patch test.

Conclusion:

Our study showed that with increasing awareness in society, the tendency to avoid some well-known allergenic substances and consumer products causes changes in common allergens. These results prove the value of long-term surveillance of contact allergy.

Pediatric Contact Dermatitis Registry Data on Contact Allergy in Children With Atopic Dermatitis

Importance

Atopic dermatitis (AD) and allergic contact dermatitis (ACD) have a dynamic relationship not yet fully understood. Investigation has been limited thus far by a paucity of data on the overlap of these disorders in pediatric patients.

Objective

To use data from the Pediatric Contact Dermatitis Registry to elucidate the associations and sensitizations among patients with concomitant AD and ACD.

Design, Setting, and Participants

This retrospective case review examined 1142 patch test cases of children younger than 18 years, who were registered between January 1, 2015, and December 31, 2015, by 84 health care providers (physicians, nurse practitioners, physician assistants) from across the United States. Data were gathered electronically from multidisciplinary providers within outpatient clinics throughout the United States on pediatric patients (ages 0-18 years).

Exposures

All participants were patch-tested to assess sensitizations to various allergens; history of AD was noted by the patch-testing providers.

Main Outcomes and Measures

Primary outcomes were sensitization rates to various patch-tested allergens.

Results

A total of 1142 patients were evaluated: 189 boys (34.2%) and 363 girls (65.8%) in the AD group and 198 boys (36.1%) and 350 girls (63.9%) in the non-AD group (data on gender identification were missing for 17 patients). Compared with those without AD, patch-tested patients with AD were 1.3 years younger (10.5 vs 11.8 years; P < .001) and had longer history of dermatitis (3.5 vs 1.8 years; P < .001). Patch-tested patients designated as Asian or African American were more likely to have concurrent AD (odds ratio [OR], 1.92; 95% CI, 1.20-3.10; P = .008; and OR, 4.09; 95% CI, 2.70-6.20; P <.001, respectively). Patients with AD with generalized distribution were the most likely to be patch tested (OR, 4.68; 95% CI, 3.50-6.30; P < .001). Patients with AD had different reaction profiles than those without AD, with increased frequency of reactions to cocamidopropyl betaine, wool alcohol, lanolin, tixocortol pivalate, and parthenolide. Patients with AD were also noted to have lower frequency of reaction to methylisothiazolinone, cobalt, and potassium dichromate.

Conclusions and Relevance

Children with AD showed significant reaction patterns to allergens notable for their use in skin care preparations. This study adds to the current understanding of AD in ACD, and the continued need to investigate the interplay between these disease processes to optimize care for pediatric patients with these conditions.

Patch testing in Iranian children with allergic contact dermatitis

Background

Allergic contact dermatitis is a common disorder in adults and children alike and appears to be on the increase. The purpose of this study was to determine the sensitization trends in Iranian children with contact dermatitis.

Methods

The result of 109 patch tests performed using the 24 allergens of the European Standard Series in patients below 18 years old from September 2007 to March 2009 were recorded and analyzed. The tests were evaluated at 48 and 72 h after performing.

Results

The study population consisted of 72 (66.1 %) females and 37 (33.9 %) males. Hands were the most commonly affected anatomic site. In the final evaluation of the tests on day three, 51 (46.8 %) individuals showed a positive reaction to at least one allergen. Females were significantly more likely to show a positive response to at least one allergen (p-value = 0.031, odds ratio: 2.46). The most common allergens were nickel sulfate, cobalt, methylisothiazolinone, and colophony with 21 (19.3 %), 11 (10.1 %), 7 (6.4 %), and 6 (5.5 %) positive reactions, respectively. Contact allergy to nickel sulfate was more common in females than males (23.6 % vs. 10.8 %). There was no statistically significant relationship between personal or family history of atopy and a positive reaction to patch testing. The clinical and practical relevance were assessed for nickel and cobalt with a clinical current relevance in 11 (52.3 %) and 4 (36.4 %), respectively.

Conclusions

Nickel sulfate, cobalt, methylisothiazolinone, and colophony are the most common allergens responsible for induction of allergic contact dermatitis in Iranian children and adolescents. Females tended to show more positive reactions to allergens.

Electronic supplementary material

The online version of this article (doi:10.1186/s12895-016-0047-0) contains supplementary material, which is available to authorized users.

Decreasing Rates of Neomycin Sensitization in Western Canada

Background:

Neomycin contact sensitization rates in North America range from 7% to 13%, whereas in Europe they average approximately 1.9%.

Objectives:

Given that topical neomycin products are no longer readily available in Canada, the aim of this study was to examine what influence this may have had on neomycin sensitization rates in the 3 western provinces.

Methods:

On the basis of an observation originally communicated by L. M. Parsons and C. Zhang of the University of Calgary, which suggested significantly reduced rates of neomycin sensitization in Calgary, Alberta, Canada, a multicenter study of patch test results from 5690 patient charts was undertaken. Data from 3 other western Canadian Universities (the University of Saskatchewan, the University of Alberta, and the University of British Colombia) were analyzed. Data were available from 2001 to 2013 for the University of Saskatchewan (except 2006), whereas the University of Alberta and the University of British Columbia had data from 2009 to 2013. Descriptive statistics, trend analysis, and risk estimates were determined using SPSS version 20.

Results:

Sensitization rates for neomycin have decreased in western Canada and are now similar to those of Europe.

Conclusions:

This trend is likely influenced by the reduced availability of over-the-counter and prescription neomycin products in Canada.

Skin differences, needs, and disorders across global populations

Accurately determining the incidence and prevalence of dermatologic disease in most large populations has been challenging for reasons ranging from the lack of easily quantifiable tests and measures to imprecision around definitions of race, ethnicity, photo skin type, pigmentation, and population groups. Compounding the problems with these categorizations is the fact that skin disease and skin health are affected not just by inherent risk factors but also by habits and environment. Thus, a fundamental question remains as we evaluate the effects of cultural and environmental factors: do genetic factors account for most of the difference that we see in skin types? Is the primary influence the way the skin mediates the environmental insult of UV radiation or how inflammation is handled? Is melanization the primary characteristic that we should measure and consider? This article will provide an introduction to current knowledge and future directions researchers are taking in differentiating both the biological differences of skin and the clinical manifestations of skin disease among the groups described above. This discussion will be followed by a brief overview of cultural practices and environmental factors that are known to have significant impact on skin disease and a summary of the most common conditions that are encountered worldwide.

Dermatologia na pele negra

Este estudo aborda a dermatologia na pele negra. Inicialmente, discute os conceitos de raça e etnia, assim como os critérios de classificação da população brasileira, indicando as regiões em que a população negra se concentra. A seguir, faz breve explanação sobre os sistemas de classificação da cor da pele e descreve particularidades estruturais, biológicas e funcionais da epiderme, derme e anexos cutâneos que diferenciam as peles clara e escura. Posteriormente, mostra algumas alterações fisiológicas comumente observadas na pele, nas unhas e nas mucosas dos indivíduos negros. Aponta, também, alguns padrões de reações e modificações da cor das lesões, decorrentes da hiperpigmentação cutânea, que determinam aspectos inusitados às dermatoses, dificultando seu reconhecimento. Finalmente, destaca algumas doenças em especial, enfatizando particularidades inerentes ao padrão das lesões e à freqüência de algumas dermatoses na pele negra. Nesse contexto, a intenção foi fornecer dados para auxiliar o dermatologista a se familiarizar com as diferentes nuanças que as doenças podem adquirir na pele mais pigmentada.

Allergic contact dermatitis to topical antibiotics: Epidemiology, responsible allergens, and management

Topical antibiotics are widely used to treat cutaneous, ocular, and otic infections. Allergic contact dermatitis to topical antibiotics is a rare but well-documented side effect, especially in at-risk populations. The purpose of this article is to review the epidemiology, responsible allergens, and management of allergic contact dermatitis to topical antibiotics.

LEARNING OBJECTIVE

After completing this learning activity, participants should be able to describe the epidemiology of allergic contact dermatitis related to topical antibiotics; show knowledge of the most common allergenic topical antibiotics; and understand the allergenic cross-reactivity pattern amongst topical antibiotics.

Health effects of recreational exposure to Moreton Bay, Australia waters during a Lyngbya majuscula bloom

A survey of residents in an area subject to annual toxic cyanobacterial blooms was undertaken to examine potential health effects of cyanobacteria toxins. The survey assessed the health of marine recreational water users in Deception Bay/Bribie Island area in northern Moreton Bay, Queensland, which is exposed to blooms of the nuisance and potentially harmful cyanobacterium Lyngbya majuscula. A postal survey was mailed to 5000 residents with a response rate of 27%. High numbers of people (78%) responding to the survey reported recreational water activity in Moreton Bay. Of those having marine recreational water activity, 34% reported at least one symptom after exposure to marine waters, with skin itching the most reported (23%). Younger participants had greater water exposure and symptoms than older participants. Participants with greater exposures were more likely to have skin and eye symptoms than less exposed groups, suggesting agents in the marine environment may have contributed to these symptoms. Of those entering Moreton Bay waters 29 (2.7%) reported severe skin symptoms, 12 of whom attended a health professional. Six (0.6%) reported the classic symptoms of recreational water exposure to L. majuscula, severe skin symptoms in the inguinal region. Participants with knowledge of L. majuscula were less likely to report less skin, gastrointestinal and fever and headache symptoms. In conclusion, high numbers of participants reported symptoms after exposure to waters subject to L. majuscula blooms but only a small number appeared to be serious in nature suggesting limited exposure to toxins.

The impact of various patient factors on contact allergy to nickel, cobalt, and chromate

BACKGROUND

Positive patch-test results to nickel, cobalt, and chromate alone and in combinations with one another are well known to occur. Patient factors that may play a role in isolated and concurrent sensitization to these allergens have not been studied in the US population.

OBJECTIVE

We sought to determine the prevalence of isolated and concurrent nickel, cobalt, and chromate sensitizations and to investigate the impact of various patient factors on their development.

METHODS

A retrospective analysis was carried out on patch-test data of 1187 patients evaluated at one US center from January 1, 1995, to December 31, 2004, 208 of whom had a positive reaction to at least one metal. Statistical analyses to evaluate associations of metal contact allergy with patient factors were performed using the chi(2) test and conditional odds ratio.

RESULTS

All patients who reacted to metal had increased odds of cosensitization to another metal. Patients who reacted to nickel were more likely to be female. Those who reacted to chromate were more likely to be male and to have an occupational cause for their dermatitis. There was a strong trend for patients who reacted to cobalt to be non-Caucasian. All those who reacted to metal had increased odds of a history of atopic eczema. Chromate reactions and isolated cobalt reactions were less likely to have known relevance than other (nonmetal) allergens. Several metal allergy combinations showed a predilection toward specific dermatitis sites, especially the scalp, eyelids, ears, and lips.

LIMITATIONS

The study was a retrospective analysis, exploratory in nature, and had relatively small numbers of patients with particular multiple metal allergy combinations.

CONCLUSION

This research confirms the sex predilections toward nickel and chromate allergy and suggests enhanced sensitivity to metals among those with atopic eczema. The results also serve to raise questions regarding occupationally related chromate allergy in men, the relevance of cobalt allergy, exposure patterns resulting in enhanced sensitivity to cobalt in non-Caucasians, and associations between metal allergens and dermatitis site. The answers to these questions require more detailed studies.

Allergic skin reactions in the tropics

Cutaneous allergic reactions are relatively common in tropical countries, with some caused by the tropical environment and others by changes in the traditional living conditions combined with poverty. HIV infection is a major contributory factor. A large number of reactions are eczematous. Atopic dermatitis is on the increase together with contact allergic reactions. Available products are often of inferior quality and contain irritants and allergens that may be forbidden elsewhere in the world. The extensive and uncontrolled use of drugs and indigenous medications together with an increase in HIV prevalence leads to drug eruptions such as the Stevens-Johnson syndrome and toxic epidermal necrolysis. Poverty plays an important role in the prevalence of insect bites and resulting papular urticaria and possibly in acropustulosis infantum. Many unexplained environmentally induced blistering diseases occur, ranging from phytophotodermatitis to fogo selvagem and from pemphigus foliaceus to chronic bullous dermatosis of childhood. This article describes the allergic conditions that occur in the tropics. Special attention is given to those cases of eczema and eruptions that are specific to tropical countries. Available treatments are also discussed.

Assessing the role of race in quantitative measures of skin pigmentation and clinical assessments of photosensitivity

BACKGROUND

Given the increasing demographic diversity in the United States, clarifying relationships between race, color, ethnicity, and disease processes is critical.

OBJECTIVES

We sought to examine the correlation between objective measures of skin pigmentation, racial identification, and physician-diagnosed and self-reported skin phototypes.

METHODS

A total of 558 participants (76 nonwhite) were evaluated. A subset underwent spectrometric readings and digital photography of the upper aspect of the inner arm. Self-identified race was compared with 7 measures of pigmentation.

RESULTS

Race correlates best with physician-diagnosed skin phototype (r = 0.55, P < .01), whereas self-reported skin phototype, spectrometry, and colorimetry correlate poorly with race (r = 0.28, < 0.40, and r > -0.31, respectively, P < .01). Associations between race and subjective measures strengthen among patients with darker skin.

CONCLUSION

Objective measures of pigmentation fail to correlate well with race, whereas race correlates moderately with physician-diagnosed skin phototype. Including objective methods of analyzing skin color may reduce subjective influences of race in assessing photosensitivity and potential risk for skin cancer.

Cutaneous diseases in the black races

Laser therapy is routinely used today to treat a myriad of general and cosmetic dermatologic conditions. Most laser procedures are performed on lighter skin types with an abundance of published literature. There is a dearth of information about lasers on darker ethnic skin types. The demand for laser procedures on ethnic skin is growing dramatically. The dermatologic surgeon needs a conservative approach combined with ingenuity, sound judgment, and a clear understanding of laser optics in treating ethnic skin.

Patch testing for allergic contact dermatitis in the allergist office

The identification of allergens responsible for allergic contact dermatitis (ACD) is key to the management of this disease. The patch test (PT) is the only safe, objective, scientific, and practical method for the diagnosis of ACD. There is no single PT panel that will screen all the relevant allergens in a patient's environment. It is generally thought that 20 to 30 allergens in routine screening tests can identify 50% to 70% of clinically relevant ACD. However, the usefulness of patch testing is enhanced with the number of allergens tested. Although the PT might be simple to apply, it might be difficult to read, interpret, and correlate to the patient's symptoms. A familiarity with the patient's environment, the process of the industry in that environment, and the uses of various chemicals in the industry is needed in most cases.

Ethnic skin: overview of structure and function

Racial variability in skin function is an area in which data often conflict. Understanding and quantifying racial differences in skin function are important for skin care and the prevention and treatment of skin diseases. A key feature that characterizes race is skin color: Is deeply pigmented skin different from fair skin in terms of responses to chemical and environmental insults? Is skin care the same? Are there different risks among racial groups of developing a skin disease after exposure to the same insults? The interpretation of pathophysiologic phenomena should consider not only anatomic and functional characteristics of ethnic groups but also socioeconomic, hygienic, and nutritional factors. This article reviews and discusses recent findings.