Prevalence of contact allergy to metals in the European general population with a focus on nickel and piercings: The EDEN Fragrance Study

Trends in occupational and work-related contact dermatitis attributed to nickel, chromium and cobalt in the UK: findings from The Health and Occupation Research network 1996-2019

BACKGROUND

Occupational exposure to metals such as nickel, chromium and cobalt can be associated with contact dermatitis, which can adversely affect an individual's health, finances and employment. Despite this, little is known about the incidence of metal-related occupational contact dermatitis over prolonged periods of time.

OBJECTIVES

To investigate the medically reported trends in the incidence of work-related contact dermatitis attributed to nickel, chromium and cobalt in the UK.

METHODS

Incidence and trends in cases of occupational contact dermatitis caused by nickel, chromium or cobalt between 1996 and 2019 (inclusive), reported to the EPIDERM surveillance scheme, were investigated and compared with trends in the incidence of occupational contact dermatitis attributed to agents other than the aforementioned metals. A sensitivity analysis restricting the study cohort to cases attributed to only one type of metal was also conducted.

RESULTS

Of all cases reported to EPIDERM during the study period, 2374 (12%) were attributed to nickel, chromium or cobalt. Cases predominantly comprised females (59%), with a mean (SD) age (males and females) of 38 (13) years. Cases were most frequently reported in manufacturing, construction, and human health and social activity industries. The most frequently reported occupations were hairdressing, and sales and retail (assistants, cashiers and checkout operators). The highest annual incidence rate of contact dermatitis was observed in females (2.60 per 100 000 persons employed per year), with the first and second peak seen in those aged 16-24 and ≥ 65 years, respectively. A statistically significant decrease in the incidence of occupational contact dermatitis attributed to metals over the study period was observed for all occupations (annual average change -6.9%, 95% confidence interval -7.8 to -5.9), with much of the decrease occurring between 1996 and 2007. Similar findings were obtained in the sensitivity analyses.

CONCLUSIONS

Over a period of 24 years, there has been a statistically significant decline in the incidence of metal-related occupational contact dermatitis in the UK. This could be attributed not only to improvements in working conditions, which have reduced metal exposure, but could also be due to the closure of industries in the UK that might have generated cases of contact dermatitis owing to metal exposure.

The new Italian SIDAPA Baseline Series for patch testing (2023): an update according to the new regulatory pathway for contact allergens

Allergic contact dermatitis (ACD) is a common inflammatory skin disease caused by delayed hypersensitivity to chemical and biotic contact allergens. ACD significantly affects the patients' quality of life negatively impacting both occupational and non-occupational settings. Patch testing is the gold standard diagnostic in vivo test to precise the ACD etiology and to correctly perform prevention. According to the Italian Medicines Agency (AIFA) legislative decree no. 178 of 29th May 1991, allergens are defined as medicines and therefore they are subject to strict regulation. In 2017, AIFA (decree no. 2130/2017) started a procedure to regulate contact allergens on the Italian market and actually the contact allergens temporarily authorized are reported in AIFA decree no. 98/2022, valid until November 2023. The availability on the market of contact allergens to diagnose ACD and continuous updating on the basis of new epidemiological trends are mandatory, jointly with the continuous update of the baseline and integrative series for patch testing. For this reason, the scientific community represented in Italy by the Skin Allergies Study Group of SIDeMaST (Italian Society of Dermatology and Venereology) and SIDAPA (Italian Society of Allergological, Occupational and Environmental Dermatology) are constantly working, in close relationship with the European scientific communities with large expertise in this important sector of the modern Dermatology. Herein, we report the setting up of regulatory legislation by AIFA and the new Italian Adult Baseline Series for patch testing.

Contact allergens in African countries: A review of published patch test studies

Only few studies on contact allergy in African countries have been published. The aim of the present study was to provide an overview of the most common contact allergens identified by the use of patch tests in African countries based on a review of the existing literature. A total of twenty-four publications from eight African countries were initially identified by search in PubMed. The abstracts and method sections were screened, and 15 studies in which patch tests were actually used to identify the allergen causing the allergic contact dermatitis (ACD) were finally selected. Nickel, cobalt, chromium, fragrance mix and p-tert-butylphenol-formaldehyde resin were the dominating contact allergens responsible for 40%-90% of the positive patch test reactions. This study indicates that a targeted effort directed towards prevention, avoidance and regulation of reliably identified contact allergens could reduce the disease burden of ACD considerable in some African countries.

Associations of exposure to metals with total and allergen-specific IgE: An NHANES analysis (2005-2006)

BACKGROUND

Immunoglobulin E (IgE) is a diagnostic biomarker for allergic diseases. While some metal exposure has been found to be associated with allergic diseases, there are still a lot of knowledge gaps regarding the relationship between metal exposure and allergen-specific IgE antibodies, particularly in adults.

METHODS

We included a total of 1433 adult participants from the 2005-2006 National Health and Nutrition Examination Survey (NHANES), all of whom had concentrations of 10 metals (including Barium (Ba), Cadmium (Cd), Cobalt (Co), Cesium (Cs), Molybdenum (Mo), Lead (Pb), Antimony (Sb), Thallium (Tl), Tungsten (Tu), and Uranium (Ur)) in urine, as well as measurements of 19 allergen-specific IgE and total IgE antibodies. Linear regression, logistic regression, weighted quantile sum (WQS) regression, and Bayesian kernel machine regression (BKMR) were used to estimate associations between metals and total and allergen-specific IgE.

RESULTS

Linear regression models revealed a positive correlation between Pb and Cd levels and the total IgE levels. Furthermore, the WQS and BKMR models suggested a positive association between mixed metals and total IgE levels, with the WQS model highlighting Pb and Cd as the major contributors. Logistic regression models showed positive correlations between Pb and food sensitization, Ur and plant sensitization, negative correlations between Cs and plant sensitization, Co and dust mite and pet sensitization, Mo and dust mite and cockroach sensitization, and Tl and mold sensitization. Moreover, the BKMR results indicated a statistically significant negative correlation between mixed metals and mold sensitization.

CONCLUSION

According to the research findings, exposure to metals is associated with total and allergen-specific IgE in American adults. Further assessment of these relationships is necessary in representative populations of other countries.

Analysis of patch testing results in patients with contact dermatitis in Istanbul, Turkey, from 2012 to 2022

BACKGROUND

Allergens responsible for allergic contact dermatitis (ACD) differ between populations. They can even change over the years with the effect of environmental factors.

AIMS

To evaluate the results of patch testing performed in our center.

METHODS

In this study, the thin-layer rapid-use epicutaneous (T.R.U.E.) test results of patients with a diagnosis of ACD between 2012 and 2022 were retrospectively evaluated.

RESULTS

In 431 (42.5%) of the total 1012 patients, a positive reaction to at least one allergen was detected in the patch test. Allergen positivity was most detected for nickel sulphate (16.8%), gold sodium thiosulfate (GST) (6.9%), thimerosal (4.2%), fragrance mix (3.4%), carba mix (3.2%), and cobalt dichloride (2.9%). Nickel sulfate and GST sensitivity was found to be significantly higher in women, fragrance mix sensitivity in men, thimerosal sensitivity in individuals aged under 40 years, colophony and balsam of Peru sensitivity in head and neck dermatitis, and carba mix and thiuram mix sensitivity in atopic individuals.

CONCLUSIONS

This study presents comprehensive data from Turkey concerning the sensitivity frequencies for allergens included in the T.R.U.E. test.

Heavy metals in contact dermatitis: A review

Contact dermatitis is an inflammatory skin reaction caused by direct contact with chemical substances in the environment and can either be irritant or allergic in nature. The clinical symptoms of contact dermatitis, include local skin rash, itching, redness, swelling, and lesions. Nowadays, 15-20% of people have some degree of contact dermatitis, which can be more or less severe. Immune responses in allergic contact dermatitis (ACD) are due to the effects of cytokines and allergen-specific CD4⁺ and CD8⁺ T cells on the skin. Acids and alkalis such as drain cleaners, plants such as poinsettias, hair colors, and nail polish remover, are all prominent causes of irritant contact dermatitis (ICDs). Heavy metals are metallic elements with a high atomic weight that are hazardous in low quantities and are known to cause dermatitis after systemic or local exposure. Nickel (Ni), chromium (Cr), lead (Pb), and copper (Cu) are among the most common heavy metals used in various industries. Metal allergies may cause ACD and also systemic contact dermatitis (SCD). Contact dermatitis is detected by laboratory tests such as patch testing, lymphocyte stimulation test (LST), and evaluation of cytokine production by primary cultures of peripheral blood mononuclear cells. This article presents an update on the epidemiological and clinical characteristics of ACD and SCD caused by three heavy metals (Cr, Cu, and Pb). Ni is not discussed due to recent coverage. Furthermore, the effects of contact sensitivity to some other heavy metals, such as gold (Au), cobalt (Co), palladium (Pd), and mercury (Hg) are discussed.

Levels and determinants of urinary and blood metals in the geothermal area of Mt. Amiata in Tuscany (Italy)

Natural sources and anthropogenic activities are responsible for the widespread presence of heavy metals in the environment in the volcanic and geothermal area of Mt. Amiata (Tuscany, Italy). This study evaluates the extent of the population exposure to metals and describes the major individual and environmental determinants. A human biomonitoring survey was carried out to determine the concentrations of arsenic (As), mercury (Hg), thallium (Tl), antimony (Sb), cadmium (Cd), nickel (Ni), chromium (Cr), cobalt (Co), vanadium (V), and manganese (Mn). The associations between socio-demographics, lifestyle, diet, environmental exposure, and metal concentrations were evaluated using multiple log-linear regression models, adjusted for urinary creatinine. A total of 2034 urine and blood samples were collected. Adjusted geometric averages were higher in women (except for blood Hg) and younger subjects (except for Tl and Cd). Smoking was associated with Cd, As, and V. Some dietary habits (rice, fish, and wine consumption) were associated with As, Hg, Co, and Ni. Amalgam dental fillings and contact lenses were associated with Hg levels, piercing with As, Co, and Ni. Among environmental determinants, urinary As levels were higher in subjects using the aqueduct water for drinking/cooking. The consumption of locally grown fruits and vegetables was associated with Hg, Tl, and Co. Exposure to geothermal plant emissions was associated only with Tl.

Team Approach: Metal Hypersensitivity in Total Joint Arthroplasty

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As total joint arthroplasty volume continues to grow nationwide, more uncommon complications such as metal implant hypersensitivity are reported with greater frequency in the literature.

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Metal hypersensitivity is a challenging diagnosis given the potentially vague symptomology. It should be considered a diagnosis of exclusion, necessitating careful consideration of other potential etiologies of a failing implant before arriving at the final diagnosis of metal hypersensitivity.

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Patients can experience substantial morbidity from implant rejection and in severe, refractory cases may even require revision arthroplasty and conversion to a hypoallergenic implant.

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Given the complex nature of the condition, successful treatment of metal hypersensitivity to orthopaedic implants is best achieved through the use of a multidisciplinary, team-based approach. Immunologists, radiologists, and infectious disease physicians as well as orthopaedic surgeons and mechanical engineers are all vital in appropriate diagnosis and treatment of the condition.

A comprehensive summary of disease variants implicated in metal allergy

Allergic disease represents one of the most prominent global public health crises of the 21^st century. Although many different substances are known to produce hypersensitivity responses, metals constitute one of the major classes of allergens responsible for a disproportionately large segment of the total burden of disease associated with allergy. Some of the most prevalent forms of metal allergy - including allergic contact dermatitis - are well-recognized; however, to our knowledge, a comprehensive review of the many unique disease variants implicated in human cases of metal allergy is not available within the current scientific literature. Consequently, the main goal in composing this review was to (1) generate an up-to-date reference document containing this information to assist in the efforts of lab researchers, clinicians, regulatory toxicologists, industrial hygienists, and other scientists concerned with metal allergy and (2) identify knowledge gaps related to disease. Accordingly, an extensive review of the scientific literature was performed - from which, hundreds of publications describing cases of metal-specific allergic responses in human patients were identified, collected, and analyzed. The information obtained from these articles was then used to compile an exhaustive list of distinctive dermal/ocular, respiratory, gastrointestinal, and systemic hypersensitivity responses associated with metal allergy. Each of these disease variants is discussed briefly within this review, wherein specific metals implicated in each response type are identified, underlying immunological mechanisms are summarized, and major clinical presentations of each reaction are described.Abbreviations: ACD: allergic contact dermatitis, AHR: airway hyperreactivity, ASIA: autoimmune/ autoinflammatory syndrome induced by adjuvants, BAL: bronchoalveolar lavage, CBD: chronic beryllium disease, CTCL: cutaneous T-cell lymphoma, CTL: cytotoxic T-Lymphocyte, DRESS: drug reaction with eosinophilia and systemic symptoms, GERD: gastro-esophageal reflux disease, GI: gastrointestinal, GIP: giant cell interstitial pneumonia, GM-CSF: granulocyte macrophage-colony stimulating factor, HMLD: hard metal lung disease, HMW: high molecular weight, IBS: irritable bowel syndrome, Ig: immunoglobulin, IL: interleukin, LMW: low molecular weight, PAP: pulmonary alveolar proteinosis, PPE: personal protective equipment, PRR: pathogen recognition receptor, SLE: systemic lupus erythematosus, SNAS: systemic nickel allergy syndrome, Th: helper T-cell, UC: ulcerative colitis, UV: ultraviolet.

Impurities in commercial titanium dental implants - A mass and optical emission spectrometry elemental analysis

OBJECTIVE

Titanium (Ti) is considered bioinert and is still regarded as the "gold standard" material for dental implants. However, even 'commercial pure' Ti will contain minor fractions of elemental impurities. Evidence demonstrating the release of Ti ions and particles from 'passive' implant surfaces is increasing and has been attributed to biocorrosion processes which may provoke immunological reactions. However, Ti observed in peri-implant tissues has been shown to be co-located with elements considered impurities in biomedical alloys. Accordingly, this study aimed to quantify the composition of impurities in commercial Ti dental implants.

METHODS

Fifteen commercial titanium dental implant systems were analyzed using inductively coupled plasma-mass spectrometry (ICP-MS) and optical emission spectrometry (ICP-OES).

RESULTS

The elemental composition of implants manufactured from commercially pure grades of Ti, Ti-6Al-4V, and the TiZr alloy (Roxolid) conformed to the respective ISO/ASTM standards or manufacturers´ data (TiZr/Roxolid). However, all implants investigated included exogenous metal contaminants including Ni, Cr, Sb, and Nb to a variable extent. Other contaminants detected in a fraction of implants included As and the radionuclides U-238 and Th-232.

SIGNIFICANCE

Although all Ti implant studies conformed with their standard compositions, potentially allergenic, noxious metals and even radionuclides were detected. Since there are differences in the degree of contamination between the implant systems, a certain impurity fraction seems technically avoidable. The clinical relevance of these findings must be further investigated, and an adaptation of industry standards should be discussed.

Health risks for body pierced community: a systematic review

OBJECTIVE

Body piercing is defined as the penetration of jewellery into openings made in different body areas. In the last decades, it has become increasingly common in the general population. The aim is to analyse the available literature about complications from body piercing for contributing to raise the awareness towards this issue and to plan and perform appropriate prevention interventions.

STUDY DESIGN

This is a systematic review.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to perform this systematic review; the protocol was registered with PROSPERO [CRD42020177972]. PubMed, Scopus and Web of Science were searched from database inception to April 2020, and articles in English language reporting a proven association between piercings and health risks were included, and their quality were assessed by adequate quality assessment tools.

RESULTS

A total of 4748 studies were found, and after duplicates removal and screening, 84 articles were included. Studies dealing with microbiological effects reported these complications both locally and at distant sites as a result of the spreading of the primary site infection: mastitis, endocarditis, glomerulonephritis, cephalic tetanus, viral hepatitis, HIV, cerebellar brain abscess and toxic shock syndrome. In addition, bleeding, gingival recession, dental injuries, contact dermatitis, granulomatous dermatitis, keloid, fibroma and basal cell carcinoma were reported.

CONCLUSIONS

Health authorities should promote educational campaigns to spread the knowledge on health risks related to piercings. Besides, piercers are often not adequately aware of all the possible adverse effects due to piercings because their professional training differs among countries. It is therefore advisable to provide periodical upgrade of their education in this field.

Contact allergy to haptens in the Swedish baseline series: Results from the Swedish Patch Test Register (2010 to 2017)

BACKGROUND

Allergic contact dermatitis has considerable public health impact and causative haptens vary over time.

OBJECTIVES

To report the prevalence of contact allergy to allergens in the Swedish baseline series 2010 to 2017, as registered in the Swedish Patch Test Register.

METHODS

Results and demographic information for patients tested with the Swedish baseline series in 2010 to 2017 were analysed.

RESULTS

Data for 21 663 individuals (females 69%) were included. Females had significantly more positive patch tests (54% vs 40%). The reaction prevalence rates were highest for nickel sulfate (20.7%), fragrance mix I (7.1%), Myroxylon pereirae (6.9%), potassium dichromate (6.9%), cobalt chloride (6.8%), methylchloroisothiazolinone/methylisothiazolinone (MCI/MI; 6.4%), MI (3.7%), colophonium (3.5%), fragrance mix II (3.2%), and formaldehyde (3.2%). Myroxylon pereirae reaction prevalence increased from 5% in 2010 to 9% in 2017 and that for methyldibromo glutaronitrile from 3.1% to 4.6%. MCI/MI and MI reactions decreased in prevalence after 2014. Nickel reaction prevalence decreased among females aged 10 to 19 years.

CONCLUSIONS

Nickel remains the most common sensitizing agent, with reaction prevalence decreasing among females younger than 20 years. The changes in MCI/MI and MI reaction prevalence mirrored those in Europe. The register can reveal changes in contact allergy prevalence over time among patients patch tested in Sweden.

Immunological Mechanisms of Metal Allergies and the Nickel-Specific TCR-pMHC Interface

Besides having physiological functions and general toxic effects, many metal ions can cause allergic reactions in humans. We here review the immune events involved in the mediation of metal allergies. We focus on nickel (Ni), cobalt (Co) and palladium (Pd), because these allergens are among the most prevalent sensitizers (Ni, Co) and immediate neighbors in the periodic table of the chemical elements. Co-sensitization between Ni and the other two metals is frequent while the knowledge on a possible immunological cross-reactivity using in vivo and in vitro approaches remains limited. At the center of an allergic reaction lies the capability of a metal allergen to form T cell epitopes that are recognized by specific T cell receptors (TCR). Technological advances such as activation-induced marker assays and TCR high-throughput sequencing recently provided new insights into the interaction of Ni2+ with the αβ TCR-peptide-major histocompatibility complex (pMHC) interface. Ni2+ functionally binds to the TCR gene segment TRAV9-2 or a histidine in the complementarity determining region 3 (CDR3), the main antigen binding region. Thus, we overview known, newly identified and hypothesized mechanisms of metal-specific T cell activation and discuss current knowledge on cross-reactivity.

Epidemics of Dermatitis

Allergic contact dermatitis (ACD) remains a globally prevalent disease for both children and adults. The silent ACD epidemic continues to be fueled by the introduction of novel allergens in industrial and household products and the continued presence of known allergens. In 1997, Allan Dillarstone noted a sinusoidal pattern to epidemics when allergenic preservatives were replaced by alternative chemicals within the market, which then similarly increased in allergenicity. A call for public health vigilance and prevention initiatives is needed to intervene in the ACD epidemic.

Validation of questionnaire algorithm based on repeated open application testing with the constituents of fragrance mix II: the EDEN Fragrance Study

BACKGROUND

In a European study on contact allergy in the general population, it has been hypothesized that the combination of contact allergy to a fragrance together with a history indicating dermatitis at exposure and thereafter subsequent avoidance of scented products implied a diagnosis of allergic contact dermatitis.

OBJECTIVES

The primary aim of this study was to validate this hypothesis/algorithm. The secondary aim was to investigate whether there was any association between the outcome of the recent repeated open application test (ROAT) and the patch test reactivity.

METHODS

One hundred nine subjects with and without contact allergy to fragrance mix II (FM II) were recruited. Volunteers from six European dermatology clinics participated in the study including a patch test and a ROAT.

RESULTS

Twenty-four positive ROAT reactions were noted in total including 20 of those 32 with contact allergy to FM II. None of the volunteers reacted to the vehicle (P < 0.001). More individuals with a positive algorithm had positive ROATs when compared with those with a negative algorithm. However, the difference was not statistically significant (P = 0.12). The lower the patch test concentration eliciting a positive test reaction, the more likely was a positive ROAT and the more likely that the positive ROAT appeared early during the investigative period.

CONCLUSIONS

The algorithm used in this study was not validated but it was indicated in this ROAT setup. The stronger the patch test reactivity the more likely was a positive ROAT and the more likely it was that the positive ROAT appeared early during the application period.

Patch Test Results to European Baseline Series in Turkey: A Prospective and Multicenter Study

BACKGROUND

Patch testing with the European Baseline Series (EBS) is an essential diagnostic tool for the assessment of allergic contact dermatitis.

OBJECTIVE

The aims of the study were to describe the most common contact allergens identified with patch testing in Turkey and to establish the distribution of contact allergens among different regions in Turkey.

PATIENTS AND METHODS

Twelve centers consisting of tertiary health care institutions were included in the study. A total of 1169 patients were patch tested with the EBS from 2015 to 2017.

RESULTS

A total of 596 patients (51.0%) had 1 or more positive patch test reactions to the EBS. A total of 30.2% (n = 353) of those tested had clinical relevance. Contact sensitivity was more common in young patients. The most common 10 allergens were nickel sulfate (20.4%), followed by textile dye mix (8.6%), cobalt chloride (8.3%), potassium dichromate (8.0%), p-phenylenediamine base (4.5%), balsam of Peru (4.3%), methylchloroisothiazolinone/methylisothiazolinone (3.8%), thiuram mix (3.6%), fragrance mix I (3.0%), and methylisothiazolinone (2.9%).

CONCLUSIONS

This study provides a comprehensive profile of patch test results with the EBS in Turkey. An ongoing decrease in contact allergy to methylchloroisothiazolinone/methylisothiazolinone and methylisothiazolinone was observed. Textile dye mix and p-phenylenediamine are beginning to pose a new risk in Turkey.

Skin exposure to scented products used in daily life and fragrance contact allergy in the European general population - The EDEN Fragrance Study

BACKGROUND

Fragrances are widely used in scented products used in daily life with the potential to induce skin sensitization.

OBJECTIVE

To evaluate exposure to scented products and to explore associations between exposure and fragrance contact allergy.

METHODS

A cross-sectional study on individuals from 18 to 74 years of age, who were randomly selected from the general population in five European countries. A random sample (N = 3119) was patch tested and interviewed on exposure to scented products.

RESULTS

Female participants were strongly associated with exposure to scented products relative to male participants. Participants age 40 years and older showed an inverse association with exposure to scented products. Compared to Sweden, The Netherlands followed by Germany showed the highest overall exposure to scented products. Sensitive skin was associated with exposure to scented products and with fragrance allergy. In univariable regression analysis, exposure to leave-on products and to specific scented product subgroups was significantly associated with fragrance allergy.

CONCLUSION

Exposure to scented products depends primarily on sex and age. Female sex and sensitive skin are relevant indicators for developing fragrance allergy. Because aggregate exposure, especially to scented leave-on products, may enhance the prevalence of contact allergy to fragrances, further investigations into exposure amounts and frequencies is warranted.

Ceramic Coating in Cemented Primary Total Knee Arthroplasty is Not Associated With Decreased Risk of Revision due to Early Prosthetic Joint Infection

BACKGROUND

Prosthetic joint infection (PJI) is one of the most frequent and devastating causes of short-term revision total knee arthroplasty (TKA). In vitro evidence suggests ceramic surfaces demonstrate resistance to biofilm, but the clinical effect of bearing surface modifications on the risk of PJI remains unclear. This premier registry-based study examines the influence of ceramic bearing surface coatings on the outcome in cemented primary TKA.

METHODS

In total, 117,660 cemented primary TKAs in patients with primary osteoarthritis recorded in the German arthroplasty registry since 2012 were followed up for a maximum of 3 years. The primary endpoint was risk of revision for PJI on ceramic coated and uncoated cobalt-chromium-molybdenum femoral components. Propensity score matching for age, gender, obesity, diabetes mellitus, depression and Elixhauser comorbidity index, and substratification on common design twins with and without coating was performed.

RESULTS

In total, 4637 TKAs (85.1% female) with a ceramic-coated femoral component were identified, 42 had been revised for PJI and 122 for other reasons at 3 years. No survival advantage due to the risk of revision for PJI could be determined for ceramic-coated components. Revision for all other reasons demonstrated a significant higher rate for TKAs with ceramic-coated components. However, the results of this were confounded by a strong prevalence (20.7% vs 0.3%) of metal sensitivity in the ceramic-coated group.

CONCLUSION

No evidence of reduced risk for PJI due to ceramic-coated implants in cemented primary TKA was found. Further analysis for revision reasons other than PJI is required.

Nickel: Intrinsic Skin Sensitization Potency and Relation to Prevalence of Contact Allergy

Nickel remains the most commonly identified contact allergen. However, it has proven difficult to demonstrate significant skin-sensitizing activity for nickel in toxicology tests, which typically have indicated a weak skin sensitization potential. Information indicates that in vivo assays are not predictive of dermal sensitization hazard or potency for nickel due to a human-specific mechanistic route for nickel sensitization that animals lack. A similar rationale will apply to in vitro alternatives-although these currently have limited ability to determine intrinsic potency. Generally, in silico methods are not designed for metal allergens and cannot contribute to the analysis. For ethical reasons, human experimental work has been limited, with a single study suggesting moderate potency. Accordingly, it seems reasonable to conclude that the high frequency of contact allergy to nickel in humans is a function of both its intermediate potency coupled with a high level of dermal exposure, particularly to damaged/inflamed skin.

Contact allergen sensitivity in children with contact dermatitis

Objective

Irritant contact dermatitis and Allergic contact dermatitis are two distinct forms of contact dermatitis. Allergic contact dermatitis is a Type 4 (delayed-type) hypersensitivity reaction that occurs during subsequent contact with an allergen to a previously sensitized person. The number of allergens that cause allergic contact dermatitis is increasing day by day. Although it is not the gold standard for the detection of these allergens, skin patch testing is a very helpful method. This study aimed to determine the most common contact allergens in the pediatric age group.

Material and Methods

All patients with the diagnosis of contact dermatitis who underwent a skin patch test (TRUE TEST) in the department of Pediatric Allergy and Immunology between March 2017-February 2018 were enrolled in this study. The patch test was evaluated 72 hours later by the same physician and interpreted as recommended by the American Academy of Dermatology. In addition to the patient files, demographic and clinical characteristics, localization of lesions, and itch score according to visual analog scale were recorded.

Results

A total of 80 children enrolled in the study; 45 (56.3%) were girls and 35 (43.7%) were boys. The mean age of the children was 7.37±3.84 years and 57.5% of the patients who underwent skin patch testing had a positive response to at least one or more allergens. The most common allergens were Nickel sulfate, CI + Me-Isothiazolinone, Thiuram Mix, Formaldehyde, and P-tert-butylphenol formaldehyde resin (14.8%, 10%, 6.3%). There was no difference in terms of age, sex, duration of complaints, and pruritus score according to nickel sensitization.

Conclusion

In the presence of chronic dermatitis in children, allergic contact dermatitis should be considered in the differential diagnosis. The culprit allergen should be determined. Also, the most common contact allergen is Nickel Sulphate in the world and the increased sensitization to other allergens is due to the increased contact of children with cosmetics and different contact allergens.

Self-reported metal hypersensitivity in patients undergoing unicondylar knee arthroplasty

OBJECTIVES

There is ongoing discussion about arthroplasty surgery of patients with metal hypersensitivity. The aim of this study was to compare the functional outcomes and eosinophil counts of unicondylar knee arthroplasty (UKA) patients with and without a history of metal hypersensitivity.

METHODS

A retrospective review was made of the medical records of 148 extremities of 140 consecutive patients who underwent primary UKA between January 2016 and December 2017. The patients who met the inclusion criteria were screened for history of metal hypersensitivity using a questionnaire. The functional outcomes of patients and eosinophil levels were evaluated immediately before and at 6 weeks after surgery.

RESULTS

The mean follow-up period was 37 months (range, 18-48 months). Of the total 128 patients, 13 (10.2%) reported a history of metal hypersensitivity before the operation. There was no statistically significant difference between patients with or without a history of metal hypersensitivity in respect of the functional outcomes or eosinophil counts (p > 0.05).

CONCLUSIONS

The results of this study showed that the functional outcomes of patients who underwent UKA using a standard alloy did not change between the groups who reported having or not having a history of metal hypersensitivity. Although the study also showed that the eosinophil counts decreased after surgery compared to the preoperative counts, there was no statistical relationship between the eosinophil count and functional outcomes or metal hypersensitivity history.

TCRs with segment TRAV9-2 or a CDR3 histidine are overrepresented among nickel-specific CD4+ T cells

BACKGROUND

Nickel is the most frequent cause of T cell-mediated allergic contact dermatitis worldwide. In vitro, CD4+ T cells from all donors respond to nickel but the involved αβ T cell receptor (TCR) repertoire has not been comprehensively analyzed.

METHODS

We introduce CD154 (CD40L) upregulation as a fast, unbiased, and quantitative method to detect nickel-specific CD4+ T cells ex vivo in blood of clinically characterized allergic and non allergic donors. Naïve (CCR7+ CD45RA+) and memory (not naïve) CD154+ CD4+ T cells were analyzed by flow cytometry after 5 hours of stimulation with 200 µmol/L NiSO₄ ., TCR α- and β-chains of sorted nickel-specific and control cells were studied by high-throughput sequencing.

RESULTS

Stimulation of PBMCs with NiSO₄ induced CD154 expression on ~0.1% (mean) of naïve and memory CD4+ T cells. In allergic donors with recent positive patch test, memory frequencies further increased ~13-fold and were associated with markers of in vivo activation. CD154 expression was TCR-mediated since single clones could be specifically restimulated. Among nickel-specific CD4+ T cells of allergic and non allergic donors, TCRs expressing the α-chain segment TRAV9-2 or a histidine in their α- or β-chain complementarity determining region 3 (CDR3) were highly overrepresented.

CONCLUSIONS

Induced CD154 expression represents a reliable method to study nickel-specific CD4+ T cells. TCRs with particular features respond in all donors, while strongly increased blood frequencies indicate nickel allergy for some donors. Our approach may be extended to other contact allergens for the further development of diagnostic and predictive in vitro tests.

Heavy metals and the skin: Sensitization patterns in Lithuanian metalworkers

BACKGROUND

Metalworkers are exposed to many sensitizing and irritant substances. There are no published data on contact allergy in this population in the Baltic countries.

OBJECTIVES

To detect skin symptoms related to occupational exposure and to describe the reactivity pattern to the European baseline series in workers from two metal plants in Lithuania.

METHODS

In this cross-sectional study 185 metalworkers (154 production workers and 31 office staff) filled an interviewer-administered questionnaire. Patch testing was performed in 135 metalworkers and office staff, as a control group.

RESULTS

Metalworkers younger than 40 years complained statistically significantly more often of skin symptoms, especially on the hands and face, than older workers. Physician-diagnosed skin diseases were reported in 1.7% of cases. Metalworkers, working <20 years in the factory, more often had skin symptoms. Contact with chemicals at the workplace was suspected as the main factor provoking skin symptoms. Metalworkers were sensitized mainly to cobalt, and nickel was the most prevalent allergen among office staff.

CONCLUSION

Younger metalworkers more often had skin symptoms suspected of being work-related compared to older ones. Sensitization to cobalt was more prevalent in the metalworkers than in the control group.

European Standard Series Patch Test Results in Contact Dermatitis Patients in a Tertiary Care Hospital

Objectives:

Sensitization of allergens varies among societies and also it is influenced by various factors, such as age and gender. It may even change over the years. In this study, we aimed to evaluate the patch test results in patients with contact dermatitis (CD) in our center.

Methods:

European standard series patch test results of patients with CD between 2017 and 2018 were evaluated retrospectively.

Results:

Of the 135 patients, 65 (48.1%) were males, 70 (51.9%) were females. The mean age of patients was 41.43±14.26 (11-78) years. In 78 (57.8%) patients, a positive reaction against at least one allergen was detected. The most common allergens were nickel sulfate (27.4%), potassium dichromate (14.8%), cobalt chloride (11.9%), textile dye mix (8.1%), fragrance mix i, ii (6.7%) and balsam of Peru (4.4%). The sensitization of nickel sulfate was higher in females and sensitization of cobalt chloride and potassium dichromate in males (p=0.03, 0.05, 0.03, respectively). In the multivariate logistic regression analysis, age was independently related to a positive reaction against at least one allergen.

Conclusion:

Nickel sulfate, potassium dichromate, cobalt chloride and textile dye mix were the most common allergens. Legal regulations should be made to decrease exposure to allergens.

Peptide bond cleavage in the presence of Ni-containing particles

NiO nanoparticles and non-stoichiometric black NiO were shown to be effective sources of Ni2+ ions causing sequence-selective peptide bond hydrolysis. NiO nanoparticles were as effective in this reaction as their molar equivalent of soluble Ni(ii) salt. These findings highlight the efficacy of delivery of toxic Ni2+ by these environmentally available particles.

A comprehensive study of nickel levels in everyday items in Brazil

BACKGROUND

Nickel is a ubiquitous element used in many everyday items. In recent decades nickel has become a leading allergen, which has become a public health problem.

OBJECTIVE

To evaluate frequently used nickel products in Brazil. We investigated if these objects release nickel that is capable of inducing sensitization or cause clinical manifestations in terms of allergic contact dermatitis (ACD).

METHODS

Dimethylglyoxime (DMG) spot tests assessed nickel release from several common utensils used in everyday life in São Paulo and Rio de Janeiro, Brazil.

RESULTS

We tested 46 coins (two denominations) and 90 common utensils. Approximately 91.1% produced nickel-positive results using the DMG spot test.

CONCLUSIONS

The DMG limit of detection was 1.67 ppm of nickel. We observed that many objects in our test series released nickel above the DMG test limit. This observation suggests that nickel-sensitive individuals may be exposed to nickel, representing a public health issue.

Contact Allergy-Emerging Allergens and Public Health Impact

Contact allergy (sensitisation) and allergic contact dermatitis (ACD) resulting from it have a considerable public health impact. For the present review, all pertinent articles were systematically searched via Medline and Web of Science™; additionally, all available issues of the journals "Contact Dermatitis" and "Dermatitis" were manually searched, covering the years 2018-2019, thereby extending and re-focusing a previous similar review. New allergens, or previously described allergens found in a new exposure context or of other current importance, are described in sections according to substance classes, e.g., metals, preservatives, fragrances. As a common finding in many investigations, a lack of information on product composition has been noted, for instance, regarding a newly described allergen in canvas shoes (dimethylthiocarbamylbenzothiazole sulfide) and, most notably, absence of co-operation from manufacturers of glucose-monitoring devices and insulin pumps, respectively. These latter devices have been shown to cause severe ACD in a considerable number of diabetic patients caused by the liberation of isobornyl acrylate and N,N'-dimethylacrylamide, respectively, as demonstrated by an international collaboration between dermatologists and chemists. Improved and complete ingredient labelling for all types of products, and not just cosmetics, must be put on the legislative agenda.

Red Grape Polyphenol Oral Administration Improves Immune Response in Women Affected by Nickel-Mediated Allergic Contact Dermatitis

BACKGROUND

Our previous findings demonstrated that in vitro supplementation of polyphenols, extracted from seeds of red grape (Nero di Troia cultivar), to peripheral lymphomonocytes from patients affected by allergic contact dermatitis (ACD) to nickel (Ni) could reduce the release of proinflammatory cytokines and nitric oxide (NO), while increasing the levels of interleukin (IL)-10, an anti-inflammatory cytokine.

OBJECTIVE

To assess whether an intervention with oral administration of polyphenols leads to a reduction of peripheral biomarkers in ACD patients.

METHODS

At T0, 25 patients affected by ACD to Ni were orally administered with 300 mg polyphenols prodie extracted from seeds of red grape (Nero di Troia cultivar) (NATUR-OX®) for 3 months (T1). The other 25 patients affected by ACD to Ni received placebo only for the same period of time. Serum biomarkers were analyzed at T0 and T1. In both groups, seven dropouts were recorded.

RESULTS

At T1 in comparison to T0, in treated patients, values of interferon-γ, IL-4, IL-17, pentraxin 3 and NO decreased, while IL-10 levels increased when compared with T0 values. Conversely, in placebo- treated patients, no modifications of biomarkers were evaluated at T1.

CONCLUSION

Present laboratory data rely on the anti-oxidant, anti-inflammatory and anti-allergic properties of polyphenols.

A Comprehensive Artificial Sweat Study for Quantitation of Nickel and Other Inorganic Elements Released from Imitation Earrings Purchased in Istanbul Market

Element sensitization is frequent cause of allergic contact dermatitis, and Ni is the main reason for this condition owing to daily use of different Ni-containing items. European Union established a limit of 0.2 μg/cm²/week Ni release for the items by the Ni Directive in 2004. The aim of this study was to determine the amount of element release of imitation earrings sold in different points of Istanbul with different prices and consider the element release levels including 29 trace and toxic elements. After calculation of released nickel amounts, 31.80% of earrings (71 of 223) were observed over the limit of European Commission Directive's migration limit. Minimum and maximum nickel release amounts were found as 0.21 and 30.11 μg/cm²/week, respectively, and mean level was found 3.24 μg/cm²/week among 71 positive earrings. Results showed that essential part of imitation earrings used especially by women release nickel particles over the European Commission Directive's migration limit. In addition, other elements such as Cu, Cr, and Co were found to be in the structure of the imitation earrings, as well as high amounts of toxic element Pb.

Impact of Heavy Metals on Host Cells: Special Focus on Nickel-Mediated Pathologies and Novel Interventional Approaches

BACKGROUND

Heavy metals [arsenic, aluminium, cadmium, chromium, cobalt, lead, nickel (Ni), palladium and titanium] are environmental contaminants able to impact with host human cells, thus, leading to severe damage.

OBJECTIVE

In this review, the detrimental effects of several heavy metals on human organs will be discussed and special emphasis will be placed on Ni. In particular, Ni is able to interact with Toll-like receptor-4 on immune and non-immune cells, thus, triggering the cascade of pro-inflammatory cytokines. Then, inflammatory and allergic reactions mediated by Ni will be illustrated within different organs, even including the central nervous system, airways and the gastrointestinal system.

DISCUSSION

Different therapeutic strategies have been adopted to mitigate Ni-induced inflammatoryallergic reactions. In this context, the ability of polyphenols to counteract the inflammatory pathway induced by Ni on peripheral blood leukocytes from Ni-sensitized patients will be outlined. In particular, polyphenols are able to decrease serum levels of interleukin (IL)-17, while increasing levels of IL- 10. These data suggest that the equilibrium between T regulatory cells and T helper 17 cells is recovered with IL-10 acting as an anti-inflammatory cytokine. In the same context, polyphenols reduced elevated serum levels of nitric oxide, thus, expressing their anti-oxidant potential. Finally, the carcinogenic potential of heavy metals, even including Ni, will be highlighted.

CONCLUSION

Heavy metals, particularly Ni, are spread in the environment. Nutritional approaches seem to represent a novel option in the treatment of Ni-induced damage and, among them, polyphenols should be taken into consideration for their anti-oxidant and anti-inflammatory activities.

New positive patch test reactions on day 7-The additional value of the day 7 patch test reading

BACKGROUND

Not performing a day (D) 7 patch test reading might result in positive patch test reactions being missed.

OBJECTIVES

To investigate the added value of the D7 patch test reading for individual allergens, and to identify patient characteristics and allergen groups associated with new positive D7 reactions.

METHODS

Data from patients patch tested between 2008 and 2018 with the extended European baseline series were analysed. Patch test readings were performed on D3 and D7. Positive reactions were categorized into positive on D3 or new positive on D7.

RESULTS

A total of 3292 patients were consecutively patch tested with at least 43 allergens of the TRUE Test panels 1 and 2 supplemented with investigator-loaded allergens. In total, 447 (13.6%) patients showed new positive D7 reactions. In univariable regression analysis, age between 18 and 30 years showed a negative association with new positive D7 reactions. Significantly more D7 positive reactions were seen for topicals (odds ratio [OR] 2.60, 95% confidence interval [CI]: 1.92-3.51) and corticosteroids (OR 1.87, 95%CI: 1.09-3.21). No associations were found between sex, atopic dermatitis and occupational dermatitis and a new positive D7 reaction.

CONCLUSION

A D7 reading to identify new positive patch test reactions is of added value, especially for topicals and corticosteroids.

Delayed hypersensitivity to palladium dichloride: 15-year retrospective study in a skin allergy unit

BACKGROUND

Metal allergies are the most frequent causes of allergic contact dermatitis. Although the use of palladium is increasing, it is not included in any baseline series.

OBJECTIVE

To assess the prevalence of hypersensitivity to palladium and to describe the clinical and demographic characteristics of patients who are sensitized to palladium dichloride (PdCl₂ ).

METHODS

A single-centre, retrospective study of 15 years of patch testing with the Spanish baseline series supplemented with PdCl₂ 2% pet. was performed. We collected clinical and demographic data and data on co-sensitization among the metals studied, and we compared patients who were sensitized to palladium, with or without co-sensitization to nickel, with the rest of the study population.

RESULTS

Among the 3678 included patients, 730 (19.9%) were sensitized to nickel sulfate. The prevalence of sensitization to PdCl₂ (n = 316, 8.6%) was higher than the prevalence of sensitization to potassium dichromate (n = 240, 6.5%) and similar to the prevalence of sensitization to cobalt chloride (n = 353, 9.6%). Only 26 (8.2%) of the patients sensitized to palladium were not co-sensitized to nickel. The percentage of men and patients aged ≥40 years was higher in this subgroup than in the patients with nickel co-sensitization.

CONCLUSIONS

Given the high prevalence of hypersensitivity to PdCl₂ , this metal salt should be included in the Spanish baseline series, notwithstanding the frequency of co-sensitization to nickel.

Experience in patch testing: A 6-year retrospective review from a single academic allergy practice

BACKGROUND

Patch testing is the "gold standard" to identify culprit allergen(s) causing allergic contact dermatitis (ACD), but there are limited studies of patch testing from allergy practice settings.

OBJECTIVE

We sought to explore patch test findings in a large academic allergy practice, including patch testing results, history of atopy, location of dermatitis, and referral source. We also wanted to determine whether patch testing using an extended panel, such as the North American screening series, compared with a limited series, such as the Thin-Layer Rapid-Use Epicutaneous (T.R.U.E.) Test, increased the sensitivity.

METHODS

A retrospective chart review was conducted of patients referred for patch testing over a 6-year period.

RESULTS

A total of 585 patients (mean age 48.7 years, 71.6 % female) underwent patch testing over the 6-year period, of which 369 (63%) had a positive test. Of those who tested positive, 202 (55%) reported a history of atopy. The extremities were the most commonly involved site, followed by the head/neck and trunk. The 5 most common positive allergens were nickel sulfate, gold sodium thiosulfate, methylchloroisothiazolinone, thimerosal, and bacitracin. Three hundred fourteen (53.6%) patients were positive to at least 1 allergen on TRUE testing. Extended screening series identified an additional 10.8% of patients with positive tests who were negative to T.R.U.E. test allergens.

CONCLUSION

Patch testing is a valuable diagnostic tool for the practicing allergist and provides early identification of culprit allergens in ACD. Performing an extended screening series such as the North American Contact Dermatitis Group (NACDG) or supplemental panel of allergens increased sensitivity when compared with a limited series.

Prevalence of contact allergy to metals in the European general population with a focus on nickel and piercings: The EDEN Fragrance Study

Background

Studies on sensitization to metals in the general population are scarce.

Objectives

To determine the prevalence of sensitization to metals in the general population, and factors associated with nickel sensitization.

Methods

In 5 European countries (The Netherlands, Germany, Italy, Portugal and Sweden), a random sample (N = 3119) from the general population (aged 18‐74 years) was patch tested and interviewed by use of a questionnaire on exposure to metals, piercing, and jewellery.

Results

Overall, the age‐standardized prevalences of sensitization to nickel, cobalt and chromium were, respectively, 14.5%, 2.1%, and 0.8%. The highest prevalence of nickel sensitization was seen in Portugal (18.5%) and the lowest (8.3%) in Sweden. The prevalence of cobalt sensitization varied between 3.8% (The Netherlands) and 0.9% (Italy), and the prevalence of chromium sensitization varied between 1.3% (Portugal) and 0.2% (Sweden). Significant associations were observed between nickel allergy and female sex (odds ratio [OR] 5.19; 95% confidence interval [95%CI]: 3.99‐6.74), past piercing use (OR 3.86; 95%CI: 2.85‐5.24), and currently having ≥3 piercings (OR 5.58; 95%CI: 4.02‐7.76).

Conclusions

The prevalence of sensitization to metals in the European general population was high, mostly because of nickel. The lowest prevalence of contact allergy to nickel and chromium observed in Sweden supports the effectiveness of long‐standing regulation.