Nickel and Cobalt Release From Children’s Toys Purchased in Denmark and the United States

Patch Testing With Nickel, Cobalt, and Chromium in Patients With Suspected Allergic Contact Dermatitis

Background: Allergic contact dermatitis is frequently caused by metals, including multiple metals simultaneously. Objectives: To assess characteristics and associations of positive and clinically relevant patch test (PT) reactions with solitary and concurrent metal sensitization. Methods: A retrospective analysis of PT results for nickel, cobalt, and/or chromium from the North American Contact Dermatitis Group between 2001 and 2018 (n = 43,522). Results: 18.0% had a positive/allergic reaction to nickel sulfate hexahydrate, 7.3% to cobalt chloride hexahydrate, and 3.0% to potassium dichromate. 87.9% patients had a currently relevant reaction to 0, 9.4% to 1, and 2.7% to multiple metals tested. Patients with 1 versus no currently relevant reactions to metal were more likely to have a primary dermatitis site of trunk, feet, and ears; patients with currently relevant reactions to multiple metals had more dermatitis affecting the trunk and ears. Metal sources varied by co-reacting metal, especially for patients with cobalt and chromium allergy. Jewelry was the most commonly identified source of nickel and cobalt for both solitary and concurrent metal allergy. Conclusions: Sensitization to multiple metals occurred in 6% of patients. Allergen sources varied between patients with sensitivity to 1 metal versus those who had concurrent sensitivity to cobalt and/or chromium.

Adverse Food Reactions in Inflammatory Bowel Disease: State of the Art and Future Perspectives

Limited knowledge is available about the relationship between food allergies or intolerances and inflammatory bowel disease (IBD). Clinicians frequently encounter patients who report food allergies or intolerances, and gastroenterologists struggle distinguishing between patients with organic disorders and those with functional disorders, which the patients themselves may associate with specific dietary components. This task becomes even more arduous when managing patients with significant underlying organic conditions, like IBD. The aim of this review is to summarize and emphasize any actual associations between food allergies and intolerances and inflammatory diseases, such as ulcerative colitis and Crohn's disease. Through a narrative disceptation of the current literature, we highlight the increased prevalence of various food intolerances, including lactose, fructose, histamine, nickel, and non-celiac gluten sensitivity, in individuals with IBD. Additionally, we explore the association between increased epithelial barrier permeability in IBD and the development of food sensitization. By doing so, we aim to enhance clinicians' awareness of the nutritional management of patients with IBD when facing complaints or evidence of food allergies or intolerances.

An investigation into the present levels of contamination in children's toys and jewelry in different countries: a systematic review

Contamination by heavy metals and toxic elements in children's toys and jewelry is an ongoing challenge in different countries. These contaminants can enter the children's body via oral, dermal, and respiratory routes, leading to adverse health effects. This study aimed to investigate the present levels of contamination in children's toys and jewelry in 15 countries, including UK, Saudi Arabia, Cambodia, China, Kosovo, Nigeria, North American, Kazakhstan, UAE, Pakistan, Iraq, Israel, West Bank/Palestine, Czech Republic, and Turkey. In this review, the legislation and recommendation of the United States (U.S.), the Bureau of Indian Standards (BIS), Turkish Standards Institute (TSE), Canada, and the European Union (E.U.) on toxic elements in toys and jewelry are introduced. Plastic or metallic toys and children's jewelry still have the most severe toxic elements pollution and the existence of lead (Pb), nickel (Ni), cadmium (Cd), arsenic (As), mercury (Hg), chromium (Cr), copper (Cu), selenium (Se), barium (Ba), Zinc (Zn), cobalt (Co), manganese (Mn), bisphenol A, phthalates, parabens, azo dyes, and flame retardants has been regarded as an ongoing challenge in these articles. Finally, this review offers benchmarking of the concentrations of toxic elements in all types of children's toys and jewelry in different nations.

Nickel release from hairdressing tools in the United States

BACKGROUND

Hairdressers have a high prevalence of contact dermatitis, especially to nickel. The presence of nickel in hairdressing tools has been evaluated in the European Union, where the government limits nickel release levels from objects.

OBJECTIVES

The aim of this study is to qualitatively investigate nickel release in hairdresser tools in both rural and urban United States, a country without nickel release legislation.

METHODS

Hairdressers and individuals with hairdressing tools were invited to participate. Metallic parts of each tool were tested with dimethylglyoxime (DMG), which detects nickel release. Data on tool cost were recorded.

RESULTS

A total of 89 tools from 9 salons and 2 over-the-counter sets were tested. Twenty-four (27%) tested positive: trimmers (100%), curling irons (100%), clippers (50%), hair clips (36%), texturizing shears (26%), and trimming shears (4%). Nickel was detected in both salon and over-the-counter tools, and rural and urban salons. Nickel-releasing tools were cheaper than DMG-negative tools of the same type.

CONCLUSIONS

Our findings help explain the high prevalence of contact dermatitis among hairdressers, alert clinicians to consider occult occupational nickel when assessing patients with allergic contact dermatitis, reinforces the importance of using barrier protection including gloves when handling hairdressing tools including at home, and augments impetus for more legislation regulating common allergens.

Patch testing with Cobalt in Children and Adolescents: North American Contact Dermatitis Group experience, 2001 to 2018

BACKGROUND

Allergic contact dermatitis (ACD) to cobalt is more common in children and adolescents than adults. However, detailed information on sites and sources of cobalt ACD are limited.

OBJECTIVES

To assess trends in positive and clinically relevant patch test reactions to cobalt in children and associated patient characteristics, common sources, and body sites affected.

METHODS

A retrospective analysis of children (<18 years) patch tested to cobalt by the North American Contact Dermatitis Group between 2001-2018.

RESULTS

Of 1,919 children patch tested, 228 (11.9%) and 127 (6.6%) had a positive/allergic or currently relevant patch test reaction to cobalt, respectively. The most common primary body sites affected were scattered generalized (30.0%), face, not otherwise specified (NOS, 10.6%), and trunk (10.1%). Patients with allergic and currently relevant allergic patch test reactions were more likely to have a primary site of trunk (P=.0160 and P=.0008) ears (P=.0005 and P<.0001). Affected body site(s) varied by cobalt source among patients with currently relevant reactions, especially for less common sources. The most commonly identified sources of cobalt included jewelry, belts, and clothing.

CONCLUSIONS

Positive patch test reactions to cobalt were common in children. Most common body site was scattered generalized and the sources of cobalt varied by body site. This article is protected by copyright. All rights reserved.

Contact allergens for the allergist

OBJECTIVE

The objective of this article is to provide an overview and describe typically encountered skin contact allergens implicated in allergic contact dermatitis (ACD).

DATA SOURCES

Published literature obtained through textbooks, online PubMed, and Google Scholar database searches, author photography, and adapted figures were used.

STUDY SELECTIONS

Studies on the evaluation of ACD and specific skin contact allergens were selected, with a focus on original research articles and clinical reviews.

RESULTS

Major classifications of common contact allergens include the following: (1) fragrances, (2) preservatives, (3) excipients, (4) rubber chemicals, (5) textile dyes, (6) topical medications, and (6) metals and other biomedical device components. The dermatitis distribution can aid in identifying the suspected contact allergen culprit. Certain contact allergens have features that are important to consider in the patch testing (PT) interpretation; these include possible irritant reactions, false-negative reactions or missed detection, and delayed reactions. Fragrances, preservatives, and excipients are culprits in personal products and facial or neck dermatitis. Patch testing with fragrances, preservatives, and patient-supplied products requires careful interpretation. Hand or foot dermatitis may be attributed to rubber chemicals or textile dyes. The management of topical corticosteroid contact allergy is guided on the basis of structural group classifications. Metal sensitization has been associated with dermatitis or biomedical device complications.

CONCLUSION

Each skin contact allergen has unique characteristics with regard to the dermatitis clinical presentation and potential PT nuances. These features are critical to recognize in the evaluation of ACD and PT interpretation and clinical relevance, leading to an accurate diagnosis.

Nickel release from metal items in contact with skin: a comparison of methods and practical implications for regulation in Europe

Contact allergy to Nickel is the most prevalent contact allergy in western societies. This has led to regulation for metallic items that come into prolonged and direct contact with the skin, such as buttons on clothing, belt buckles, jewelry and watches. In Europe, the legal provision is based on a test in which there is a limit to the amount of nickel that may be released from the item to an artificial sweat solution (EN 1811). This test is costly and has reproducibility issues. The resulting undertesting of items placed on the market, leads to many nickel releasing non-compliant articles being available in spite of the regulations that are in place. In this study, the performance of the standard release test is compared to the performance of a rapid nickel spot test based on dimethylglyoxime (DMG-test). The data suggest that using the rapid DMG-test for compliance testing is sufficiently equivalent to the current gold standard of EN 1811. Previously published comparisons between the DMG-test and EN 1811 did not consider the effect of accelerated wear and corrosion testing according to EN 12472. This study shows that by applying EN 12472, the number of deviating results between the DMG-test and EN 1811 decreases significantly. Regarding consumer protection, it is necessary for wear and corrosion resistance to be considered.

Nickel release from metallic earrings: A survey of the Danish market and validation of the nickel spot test

BACKGROUND

Exposure to nickel-releasing ear-piercing jewellery may explain the persistently high prevalence of nickel allergy in Europe. While nickel release from earrings is regulated, field studies show that the regulation is not always respected. More knowledge is needed regarding the risk of piercing exposure including suitable screening methods.

OBJECTIVE

To examine the proportion of earrings on the Danish market that release more nickel than allowed, and to validate the use of the dimethylglyoxime (DMG) test as a screening tool.

METHODS

A total of 304 earrings were purchased and tested with the DMG test and X-ray fluorescence spectrometry. The level of nickel release was quantified in a selected subsample of 100 earrings by the European reference test EN 1811. The DMG spot test was validated against EN 1811 at different thresholds.

RESULTS

Excessive nickel release according to the European regulation was found in 45 (14.8%) tested earrings. The sensitivity of the DMG test decreased with reduced levels of nickel release (sensitivity of 45.2% at ≥0.2 μg/cm2 /week vs 61.1% at >0.5 μg/cm2 /week).

CONCLUSION

Excessive nickel release is common in earrings on the Danish market. Because of low sensitivity, the DMG test has limited use in screening of earrings for research but may still be used clinically.

Pediatric allergic contact dermatitis. Part I: Clinical features and common contact allergens in children

Allergic contact dermatitis (ACD), a delayed hypersensitivity skin reaction to environmental allergens, has a prevalence that is similar in children and adults. However, diagnostic testing for ACD in pediatric populations accounts for less than one tenth of all patch tests. The relative infrequency of pediatric patch testing may be attributed to the difficulty in testing in this population, which includes a smaller surface area for patch test placement and maintaining cooperation during patch testing, especially in younger children. Diagnosis can be difficult in children because the appearance of ACD can mimic other common pediatric skin conditions, particularly atopic dermatitis and irritant contact dermatitis. Comprehensive history taking, guided by patient presentation, age group, and location of dermatitis, helps build clinical suspicion. Such clinical suspicion is one of the major reasons behind patch testing, with additional indications being recalcitrant dermatitis and dermatitis with atypical distribution. US pediatric data have shown the top allergens to be metals, fragrances, topical antibiotics, preservatives, and emollients. These trends are important to recognize to guide management and accurate diagnosis, because ACD tends to persist if the allergen is not identified and can affect patients' quality of life.

Pediatric contact allergens in the neonatal intensive care unit

OBJECTIVE

The degree of neonatal exposure to potentially sensitizing agents on neonatal intensive care units (NICUs) and the process by which personal care products are selected for use in the NICU are poorly documented.

STUDY DESIGN

We evaluated personal care products used in three NICUs for potentially sensitizing agents. We interviewed NICU staff to analyze how products are selected and approved for use.

RESULTS

Twenty-four personal care products were evaluated. 75% contained one or more potential contact allergen, with fragrances being most common. Staff preference, brand loyalty, cost, and small product size were often considered when approving NICU products.

CONCLUSIONS

The prevalence of potentially sensitizing agents in the products indicates a need for improvement in the evaluation and acquisition process of over-the-counter products used for neonatal skin care. The involvement of dermatology in this process may be beneficial.

Pediatric contact dermatitis: what's new

PURPOSE OF REVIEW

Allergic contact dermatitis (ACD) was once thought to be rare in children but recent studies have demonstrated that the prevalence of ACD is common and appears to be increasing in children. Current trends including toys, hobbies, and personal care products may play a role in potentially new allergen exposure or resurgence of certain allergens, making ACD a moving target in children.

RECENT FINDINGS

ACD and atopic dermatitis can coexist and certain clinical features can help differentiate ACD from endogenous atopic dermatitis in children. It is important to consider ACD in children with recalcitrant atopic dermatitis or dermatitis with atypical distribution. Patch testing has become a more common practice in children. In 2018, the first expert consensus-derived pediatric baseline series consisting of 38 allergens was proposed to aid in the diagnosis of ACD in children. Comparing recent patch testing data in the pediatric population, the top allergens ubiquitously identified were nickel, cobalt, neomycin, Myroxylon pereirae (balsam of Peru), fragrance mix I, fragrance mix II, methylisothiazolinone, methylchloroisothiazolinone/ methylisothiazolinone, formaldehyde, and lanolin.

SUMMARY

ACD is a common problem in children. Detection through patch testing, avoidance of offending allergens, and prevention of common allergens are the main focus of management of ACD in children.

Allergic Contact Dermatitis in Children: Recommendations for Patch Testing

PURPOSE OF REVIEW

Allergic contact dermatitis (ACD) affects 20% of children. However, diagnosis of ACD may be underreported in children due to lack of recognition. Patch testing is the gold standard for evaluation of ACD in children but poses unique challenges in this population.

RECENT FINDINGS

Recent studies highlight the significance of ACD and the utility of patch testing in children. Evaluation of ACD in children is difficult and requires knowledge of a child's exposure history, careful selection of allergens, and knowledge of specialized patch testing considerations to minimize irritation and maximize cooperation. Until recently, there were no agreed upon patch test series for children. In 2018, a comprehensive pediatric baseline series was published enabling thorough evaluation of ACD in children (Yu J, Atwater AR, Brod B, Chen JK, Chisolm SS, Cohen DE, et al. Dermatitis. 2018;29(4):206-12). This review provides an overview of the current literature, an update on pediatric ACD, and patch testing methods in children to effectively evaluate and manage ACD.

Nickel Allergic Contact Dermatitis: Identification, Treatment, and Prevention

Nickel is a ubiquitous metal added to jewelry and metallic substances for its hardening properties and because it is inexpensive. Estimates suggest that at least 1.1 million children in the United States are sensitized to nickel. Nickel allergic contact dermatitis (Ni-ACD) is the most common cutaneous delayed-type hypersensitivity reaction worldwide. The incidence among children tested has almost quadrupled over the past 3 decades. The associated morbidities include itch, discomfort, school absence, and reduced quality of life. In adulthood, individuals with Ni-ACD may have severe disabling hand eczema. The increasing rate of Ni-ACD in children has been postulated to result from early and frequent exposure to metals with high amounts of nickel release (eg, as occurs with ear piercing or with products used daily in childhood such as toys, belt buckles, and electronics).To reduce exposure to metal sources with high nickel release by prolonged and direct contact with human skin, Denmark and the European Union legislated a directive several decades ago with the goal of reducing high nickel release and the incidence of Ni-ACD. Since then, there has been a global reduction in incidence of Ni-ACD in population-based studies of adults and studies of children and young adults being tested for allergic contact dermatitis. These data point to nickel exposure as a trigger for elicitation of Ni-ACD and, further, provide evidence that legislation can have a favorable effect on the economic and medical health of a population.This policy statement reviews the epidemiology, history, and appearances of Ni-ACD. Examples of sources of high nickel release are discussed to highlight how difficult it is to avoid this metal in modern daily lives. Treatments are outlined, and avoidance strategies are presented. Long-term epidemiological interventions are addressed. Advocacy for smarter nickel use is reviewed. The American Academy of Pediatrics supports US legislation that advances safety standards (as modeled by the European Union) that protect children from early and prolonged skin exposure to high-nickel-releasing items. Our final aim for this article is to aid the pediatric community in developing nickel-avoidance strategies on both individual and global levels.

Contamination of skin and surfaces by cobalt in the hard metal industry

BACKGROUND

It is well known that hard metal workers have historically been affected by contact allergy to cobalt. Knowledge is sparse about occupational skin exposure to cobalt, in terms of skin doses and sources of exposure, which could be used to improve protection of workers.

OBJECTIVES

To improve knowledge about skin doses and sources of skin exposure to cobalt within hard metal production, thereby facilitating better protection of workers.

METHODS

Forty workers were sampled on the index finger by acid wipe sampling after 2 hours of work. The samples were analysed with inductively coupled plasma mass spectrometry. Cobalt spot testing was performed in the work environment.

RESULTS

The highest skin doses were found among raw material workers. Skin doses among other production workers were also significant. Most office workers had low, but measurable, levels of cobalt on the skin. Glove use varied between workers. Cobalt was found on production equipment, on items in the canteen area, and on handles and buttons throughout the company.

CONCLUSIONS

Cobalt skin doses were prominent, and originated from contact with raw materials, sintered materials, and contaminated surfaces. Cobalt was present on surfaces outside production areas. Companies need to identify and reduce skin exposure for protection of workers.

Patch testing in Israeli children with suspected allergic contact dermatitis: A retrospective study and literature review

BACKGROUND/OBJECTIVES

Childhood allergic contact dermatitis is recognized as a significant clinical problem. The objective was to evaluate the rate of positive patch tests in Israeli children with clinically suspected allergic contact dermatitis, identify possible sex and age differences, compare results with those in Israeli adults, and review pediatric studies in the literature.

METHODS

The study sample included 343 children and adolescents (197 female, 146 male; 1-18 years of age, mean age 11.8 years) with clinically suspected allergic contact dermatitis who underwent patch testing with a standard pediatric series of 23 allergens at a tertiary medical center from 1999 to 2012. Data on clinical characteristics and test results were collected retrospectively from the medical files.

RESULTS

Ninety-eight subjects (28.6%) (75 girls [38.1%], 23 boys [15.8%]) had at least one positive reaction. The most frequent reactions were to nickel sulfate, followed by potassium dichromate and cobalt chloride. Nickel sulfate sensitivity was more common in girls, especially those younger than 3 years and older than 12 years. The prevalence of contact sensitization was similar in subjects with and without atopic dermatitis (50% and 51%, respectively).

CONCLUSION

Nickel is the most common allergen in Israeli children, especially girls. Patch testing should be performed in children with clinically suspected allergic contact dermatitis regardless of atopic background.

Contact Sensitization in Children: A Retrospective Study of 2,614 Children from a Single Center

BACKGROUND

Contact sensitization in children is more common than previously thought, but few studies have been performed on a large population assessed by the same team. The objective was to evaluate contact sensitization in children with suspected contact dermatitis, the relationship with atopic dermatitis (AD), and the most common allergens.

METHODS

The same team patch tested 2,614 children younger than 11 years old with a standard series of 30 allergens.

RESULTS

A total of 1220 children (46.7%) developed at least one positive reaction, 606 of which were clinically relevant (49.7%). The most frequent reactions were to nickel sulfate (22.7%), cobalt chloride (11.1%), potassium dichromate (9.9%), neomycin sulfate (5.2%), thimerosal (4.2%), cocamidopropyl betaine (3.4%), and methylchloroisothiazolinone/methylisothiazolinone (3.2%). The prevalence of contact sensitization was similar in children with (47.3%) and without (46.1%) AD. Children with AD had a higher prevalence of positive reactions to potassium dichromate (p < 0.001), Compositae mix (p = 0.01), and disperse blue (p = 0.03).

CONCLUSIONS

Contact sensitization is quite common in young children. This study adds some information on the most common contact allergens. A similar prevalence of positive patch test reactions was found in children with and without AD, but children with AD had a greater prevalence of positive patch test reactions to potassium dichromate, Compositae mix, and disperse blue.

Nickel Allergy and Our Children's Health: A Review of Indexed Cases and a View of Future Prevention

Nickel is the leading cause of allergic contact dermatitis (ACD) from early childhood through adolescence. Studies have shown that skin piercings and other nickel-laden exposures can trigger the onset of nickel ACD in those who are susceptible. Nickel ACD causes a vast amount of cutaneous disease in children. Cases of nickel ACD in children have been reported in peer-reviewed literature from 28 states. Common items that contain inciting nickel include jewelry, coins, zippers, belts, tools, toys, chair studs, cases for cell phones and tablets, and dental appliances. The diagnosis of nickel ACD has been routinely confirmed by patch testing in children older than 6 months suspected of ACD from nickel. Unlike in Europe, there are no mandatory restrictions legislated for nickel exposure in the United States. Denmark has demonstrated that regulation of the nickel content in metals can lower the risk of ACD and the associated health care-related costs that arise from excess nickel exposure. To further awareness, this article reviews the prominent role of nickel in pediatric skin disease in the United States. It discusses the need for a campaign by caretakers to reduce nickel-related morbidity. Lastly, it promotes the model of European legislation as a successful intervention in the prevention of nickel ACD.

EAACI position paper for practical patch testing in allergic contact dermatitis in children

INTRODUCTION

Allergic contact dermatitis (ACD) in children appears to be on the increase, and contact sensitization may already begin in infancy. The diagnosis of contact dermatitis requires a careful evaluation of a patient's clinical history, physical examination, and skin testing. Patch testing is the gold standard diagnostic test.

METHODS

Based on consensus, the EAACI Task Force on Allergic Contact Dermatitis in Children produced this document to provide details on clinical aspects, the standardization of patch test methodology, and suggestions for future research in the field.

RESULTS

We provide a baseline list of test allergens to be tested in children with suspected ACD. Additional tests should be performed only on specific indications.

Belt Buckles-Increasing Awareness of Nickel Exposure in Children: A Case Report

Children, especially those with atopic dermatitis, are at risk for nickel sensitization and subsequent dermatitis from metal-containing objects, namely belt buckles. We describe allergic contact dermatitis in 12 children with peri-umbilical nickel dermatitis (with and without generalized involvement) caused by dimethylglyoxime-positive belt buckles. The patients' symptoms resolved with avoidance of the nickel-containing products.