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Arora P, Brumley C, Hylwa S. Clinical relevance of doubtful reactions in patch testing: A single-centre retrospective study. Contact Dermatitis 2024; 90:607-612. [PMID: 38382066 DOI: 10.1111/cod.14526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 01/29/2024] [Accepted: 02/08/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Doubtful reactions in patch testing are infrequently reported in the literature; however, recent reports have suggested they be assessed with the same scrutiny as stronger reactions. OBJECTIVE Assess the clinical relevance of doubtful reactions in patch testing. METHODS Retrospective study of 1514 patients comprehensively patch tested via the NACDG standard series and additional allergens based on history. The clinical relevance of each reaction was graded based on the NACDG scale: definite, probable, possible, past, unknown and irritant. Reactions were considered 'unique' if an additional mild-to-strong reaction to the same chemical at a different concentration was not observed. RESULTS 68.9% (1043) of patients demonstrated at least 1 doubtful reaction. Of 4453 total doubtful reactions, 92.2% (4106) were unique. Only 3.3% (137) and 12.2% (500) of these were determined to be of definite or probable clinical relevance respectively. 'Fragrance' was the most common allergen family present among the unique definite doubtful reactions (37). However, 24 (64.9%) of these also had a stronger reaction to another fragrance. Cocamidopropyl betaine was the second most frequent allergen demonstrating definite doubtful reactions (27) and unique in 85.2% (23) of cases. Methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) was most prevalent (36) but less frequently unique (58.3%, 21). CONCLUSIONS Doubtful reactions may not be as impactful to clinical decision making as theorised in the literature. Few demonstrate definite clinical significance, and many have related stronger reactions that capture them for clinical purposes. Identification of doubtful reactions to cocamidopropyl betaine and MCI/MI may be of greatest significance as they most frequently were not supported by stronger reactions.
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Affiliation(s)
- Puneet Arora
- Department of Dermatology, Park Nicollet Health Services, Minneapolis, Minnesota, USA
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Caroline Brumley
- Department of Dermatology, Park Nicollet Health Services, Minneapolis, Minnesota, USA
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Sara Hylwa
- Department of Dermatology, Park Nicollet Health Services, Minneapolis, Minnesota, USA
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Yang YW, Yiannias JA, Voss MM, Hall MR, Youssef MJ, Davis MDP, Voelker DH, Klanderman MC, Mangold AR. Systematic Identification of Copositivity Groups in Standard Series Patch Testing Through Hierarchical Clustering. JAMA Dermatol 2023; 159:945-952. [PMID: 37531132 PMCID: PMC10398544 DOI: 10.1001/jamadermatol.2023.2352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/27/2023] [Indexed: 08/03/2023]
Abstract
Importance Patients are frequently copositive for multiple allergens simultaneously, either due to chemical similarity or simultaneous sensitization. A better understanding of copositivity groups would help guide contact avoidance. Objective To use patient data to systematically determine copositivity groups in the Mayo Clinic Standard Series. Design, Setting, and Participants In this retrospective cross-sectional analysis, the Mayo Clinic patch test database was queried for pairwise copositivity rates in the 80 allergen Mayo Clinic Standard Series between 2012 and 2021. Data were collected from 3 tertiary care sites of the Mayo Clinic Contact Dermatitis Group and a total of 5943 patients were included, comprising all patients undergoing patch testing to the Mayo Clinic Standard Series allergens. Main Outcomes and Measures Copositivity rates between every 2 allergens in the 80-allergen Mayo Clinic Standard Series were estimated. After background correction, copositivity rates were analyzed using unsupervised hierarchical clustering to systematically identify copositivity groups in an unbiased manner. Results Overall, 394 921 total patches were applied to 5943 patients (4164 [70.1%] women, 1776 [29.9%] men, with a mean [SD] age of 52.3 [18.8] years ), comprising 9545 positive reactions. After background correction based on overall positivity rates, hierarchical clustering revealed distinct copositivity groups. Many were supported by prior literature, including formaldehyde releasers, cobalt-nickel-potassium dichromate, acrylates, 3-dimethylaminopropylamine-amidoamine-oleamidopropyl dimethylamine, alkyl glucosides, budesonide-hydrocortisone-17-butyrate, certain fragrances, compositae-sesquiterpene lactone mix, mercapto mix-mercaptobenzothiazole, carba mix-thiuram mix, and disperse orange-p-phenylenediamine. However, novel associations were also found, including glutaraldehyde-sorbitan sesquioleate, benzalkonium chloride-neomycin-bacitracin, bronopol-methylchloroisothiazolinone-methylisothiazolinone, and benzoic acid-iodopropynyl butylcarbamate. Conclusions and Relevance This retrospective cross-sectional analysis found that copositivity rates varied between allergens; allergens with extremely high positivity rates demonstrated nonspecific copositivity to multiple other allergens. Background correction based on positivity rates followed by hierarchical clustering confirmed prior known copositivity groups, contaminants and/or excipients leading to copositivity, and novel associations to guide contact avoidance.
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Affiliation(s)
- Yul W. Yang
- Department of Dermatology, Mayo Clinic, Scottsdale, Arizona
| | | | - Molly M. Voss
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Arizona
| | - Matthew R. Hall
- Department of Dermatology, Mayo Clinic, Jacksonville, Florida
| | | | | | - Dayne H. Voelker
- Department of Allergy, Mayo Clinic Health System, Austin, Minnesota
| | - Molly C. Klanderman
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Arizona
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Warshaw EM, Xiong M, Belsito DV, Adler BL, Atwater AR, DeKoven JG, Taylor JS, Reeder MJ, Houle MC, Silverberg JI, Pratt MD, Dunnick CA, Botto N, DeLeo VA, Mowad CM, Maibach HI, Yu J, Fowler JF. Patch Testing With Benzophenone-3 and -4: The North American Contact Dermatitis Group Experience, 2013-2020. Dermatitis 2023; 34:105-112. [PMID: 36917534 DOI: 10.1089/derm.2022.29013.ewa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background: Benzophenone (BZP)-3 and BZP-4 are ultraviolet (UV) absorbers used in sunscreens and personal care products (PCPs) and may cause allergic contact dermatitis. Objective: To characterize positive patch test reactions to BZP-3 (10% in petrolatum [pet]) and BZP-4 (2% pet) in a screening allergen series. Methods: Retrospective analysis of patients tested to BZP-3 and BZP-4 was conducted by the North American Contact Dermatitis Group from 2013 to 2020. Results: Of 19,618 patients patch tested to BZP-3 and BZP-4, 103 (0.5%) and 323 (1.6%) had positive reactions, respectively: 413 (2.1%) reacted to at least 1 BZP (BZP-positive patient). As compared with BZP-negative patients, BZP-positive patients were significantly more likely to have a history of hay fever (39.3% vs 33.4%, P = 0.0134), history of atopic dermatitis (39.8% vs 30.7%, P = 0.0001), and facial involvement (37.4% vs 32.2%, P = 0.0272). Most reactions were currently clinically relevant (BZP-3: 90.4%; BZP-4: 65.8%). Common identified sources included PCPs and sunscreens. Coreactivity between BZP-3 and BZP-4 was low: 13.5% (14/104) of BZP-3-positive patients were allergic to BZP-4 and 4.3% (14/322) of BZP-4-positive patients were allergic to BZP-3. Conclusions: Eight-year prevalence of BZP positivity was 2.1%. Reactions were frequently clinically relevant and linked to PCPs and sunscreens.
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Affiliation(s)
- Erin M Warshaw
- From the Department of Dermatology, Park Nicollet/Health Partners Health Services, Minneapolis, Minnesota, USA
- Department of Dermatology, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Dermatology, Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota, USA
| | - Michelle Xiong
- From the Department of Dermatology, Park Nicollet/Health Partners Health Services, Minneapolis, Minnesota, USA
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Donald V Belsito
- Department of Dermatology, Columbia University Irving Medical School, New York, New York, USA
| | - Brandon L Adler
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Amber R Atwater
- Department of Dermatology, Duke University Medical Center, Durham, North Carolina, USA
| | - Joel G DeKoven
- Division of Dermatology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - James S Taylor
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Margo J Reeder
- Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Marie-Claude Houle
- Division of Dermatology, Centre Hospitalier Universitaire de Québec, Laval University, Québec, Canada
| | - Jonathan I Silverberg
- Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Melanie D Pratt
- Division of Dermatology, University of Ottawa, Ontario, Canada
| | - Cory A Dunnick
- Department of Dermatology, University of Colorado, Aurora, Colorado, USA
| | - Nina Botto
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - Vincent A DeLeo
- From the Department of Dermatology, Park Nicollet/Health Partners Health Services, Minneapolis, Minnesota, USA
| | - Christen M Mowad
- Division of Dermatology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Howard I Maibach
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - JiaDe Yu
- Department of Dermatology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph F Fowler
- Division of Dermatology, University of Louisville, Louisville, Kentucky, USA
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Chen JY, Yiannias JA, Hall MR, Youssef MJ, Drage LA, Davis MDP, Yang YW. Reevaluating Corticosteroid Classification Models in Patient Patch Testing. JAMA Dermatol 2022; 158:1279-1286. [PMID: 36169950 PMCID: PMC9520446 DOI: 10.1001/jamadermatol.2022.3774] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/02/2022] [Indexed: 11/14/2022]
Abstract
Importance Individuals with allergic contact dermatitis to one topical corticosteroid may also react to other corticosteroids. Corticosteroid classification models have been proposed to predict such copositivity, recommend representative screening corticosteroids, and guide allergen avoidance. Objective To use patient data to determine copositivity patterns between corticosteroids and evaluate against previous corticosteroid classification models. Design, Setting, and Participants This qualitative study included a retrospective analysis of the Mayo Clinic Contact Dermatitis Group corticosteroid patch test data from 2010 to 2019. Among patients undergoing patch testing with the Mayo Clinic's standard or steroid series who consented to research participation, 5637 patients were included in the analysis. Copositivity rates were determined between corticosteroids and analyzed by hierarchical clustering for comparison to previous classification models. Main Outcomes and Measures The frequency of patch test positivity to each of the analyzed corticosteroids was noted and compared with previously published patch test positivity rates. Copositivity rates between each pair of corticosteroids were determined, and overall copositivity patterns were analyzed and evaluated against known steroid classes. Results A total of 49 472 individual patches were applied to 5637 patients, testing 18 corticosteroids. Patch test positivity rates ranged between 0.3% and 4.7%. The fluocinonide positivity rate corresponded to the highest copositivity rate with other corticosteroids (mean [SD], 50.7% [26.1%]). Tixocortol-21-pivalate, 0.1%, and tixocortol-21-pivalate, 1%, positivity rates corresponded to the lowest copositivity rates (mean [SD], 4.1% [1.7%] and 3.6% [1.4%], respectively). Hierarchical clustering elucidated patterns that did not support previous corticosteroid classification models. Conclusions and Relevance In this qualitative study, copositivity rates were variable between corticosteroids, and overall patch test positivity for allergy to topical corticosteroids was rare. Previously published corticosteroid classifications are not supported by real patient-derived data and may not be accurate in predicting corticosteroid copositivity.
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Affiliation(s)
- Joyce Y. Chen
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona
| | | | - Matthew R. Hall
- Department of Dermatology, Mayo Clinic, Jacksonville, Florida
| | | | - Lisa A. Drage
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | | | - Yul W. Yang
- Department of Dermatology, Mayo Clinic, Scottsdale, Arizona
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