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Baskar Murthy A, Palaniappan V, Karthikeyan K. Aluminium in dermatology - Inside story of an innocuous metal. Indian J Dermatol Venereol Leprol 2024; 0:1-9. [PMID: 38595024 DOI: 10.25259/ijdvl_188_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 07/23/2023] [Indexed: 04/11/2024]
Abstract
Aluminium, the third most abundant element in the earth's crust, was long considered virtually innocuous to humans but has gained importance in the recent past. Aluminium is ubiquitous in the environment, with various sources of exposure like cosmetics, the food industry, occupational industries, the medical field, transport and electronics. Aluminium finds its utility in various aspects of dermatology as an effective haemostatic agent, anti-perspirant and astringent. Aluminium has a pivotal role to play in wound healing, calciphylaxis, photodynamic therapy and vaccine immunotherapy with diagnostic importance in Finn chamber patch testing and confocal microscopy. The metal also finds significance in cosmetic procedures like microdermabrasion and as an Nd:YAG laser component. It is important to explore the allergic properties of aluminium, as in contact dermatitis and vaccine granulomas. The controversial role of aluminium in breast cancer and breast cysts also needs to be evaluated by further studies.
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Affiliation(s)
- Aravind Baskar Murthy
- Department of Dermatology, Venereology and Leprosy, Sri Manakula Vinayagar Medical College and Hospital, Madagadipet, Puducherry, India
| | - Vijayasankar Palaniappan
- Department of Dermatology, Venereology and Leprosy, Sri Manakula Vinayagar Medical College and Hospital, Madagadipet, Puducherry, India
| | - Kaliaperumal Karthikeyan
- Department of Dermatology, Venereology and Leprosy, Sri Manakula Vinayagar Medical College and Hospital, Madagadipet, Puducherry, India
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Badaoui A. Allergic contact dermatitis to aluminium in a sunscreen. Contact Dermatitis 2023; 89:305-307. [PMID: 37493188 DOI: 10.1111/cod.14387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/08/2023] [Accepted: 07/14/2023] [Indexed: 07/27/2023]
Affiliation(s)
- Antoine Badaoui
- Dermatology Department, Military Teaching Hospital, Paris, France
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Palmeiro AG, Silva L, Pimentel B, Amaro C. Pruritic subcutaneous nodules of the upper arm in a 2-year-old child. Pediatr Dermatol 2023; 40:952-954. [PMID: 37767646 DOI: 10.1111/pde.15311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/21/2023] [Indexed: 09/29/2023]
Affiliation(s)
- Ana Gusmão Palmeiro
- Department of Dermatology and Venereology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Leandro Silva
- Department of Dermatology and Venereology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Bernardo Pimentel
- Department of Dermatology and Venereology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Cristina Amaro
- Department of Dermatology and Venereology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
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Laera D, HogenEsch H, O'Hagan DT. Aluminum Adjuvants-'Back to the Future'. Pharmaceutics 2023; 15:1884. [PMID: 37514070 PMCID: PMC10383759 DOI: 10.3390/pharmaceutics15071884] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/24/2023] [Accepted: 06/26/2023] [Indexed: 07/30/2023] Open
Abstract
Aluminum-based adjuvants will continue to be a key component of currently approved and next generation vaccines, including important combination vaccines. The widespread use of aluminum adjuvants is due to their excellent safety profile, which has been established through the use of hundreds of millions of doses in humans over many years. In addition, they are inexpensive, readily available, and are well known and generally accepted by regulatory agencies. Moreover, they offer a very flexible platform, to which many vaccine components can be adsorbed, enabling the preparation of liquid formulations, which typically have a long shelf life under refrigerated conditions. Nevertheless, despite their extensive use, they are perceived as relatively 'weak' vaccine adjuvants. Hence, there have been many attempts to improve their performance, which typically involves co-delivery of immune potentiators, including Toll-like receptor (TLR) agonists. This approach has allowed for the development of improved aluminum adjuvants for inclusion in licensed vaccines against HPV, HBV, and COVID-19, with others likely to follow. This review summarizes the various aluminum salts that are used in vaccines and highlights how they are prepared. We focus on the analytical challenges that remain to allowing the creation of well-characterized formulations, particularly those involving multiple antigens. In addition, we highlight how aluminum is being used to create the next generation of improved adjuvants through the adsorption and delivery of various TLR agonists.
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Affiliation(s)
- Donatello Laera
- Technical Research & Development, Drug Product, GSK, 53100 Siena, Italy
- Global Manufacturing Division, Corporate Industrial Analytics, Chiesi Pharmaceuticals, 43122 Parma, Italy
| | - Harm HogenEsch
- Department of Comparative Pathobiology, College of Veterinary Medicine, Purdue University, West Lafayette, IN 47906, USA
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Hoffmann SS, Elberling J, Skamstrup Hansen K, Thyssen JP, Mortz CG, Overgaard Bach R, Johansen JD. Adverse reactions after oral provocation with aluminium in children with vaccination granulomas and aluminium contact allergy. J Eur Acad Dermatol Venereol 2022; 37:1028-1035. [PMID: 36478462 DOI: 10.1111/jdv.18811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND According to their parents, some children with aluminium contact allergy and vaccination granulomas may react to aluminium-containing foods by developing dermatitis, granuloma itch and subjective symptoms. OBJECTIVES The objective of this study is to determine whether oral intake of aluminium-containing pancakes can cause adverse events and/or systemic contact dermatitis (SCD) in children with vaccination granulomas and aluminium contact allergy. PATIENTS/METHODS A total of 15 children aged 3-9 years (mean age, 5 years) with vaccination granulomas and positive patch-test results to aluminium chloride hexahydrate 2%/10% pet. completed a 3-week blinded randomized controlled crossover oral aluminium/placebo provocation study with pancakes. Granuloma itch and other subjective symptoms were evaluated daily on a visual analogue scale (VAS). Dermatitis was evaluated by the primary investigator, and sleep patterns were tracked with an electronic device. Aluminium bioavailability was assessed by measuring aluminium excretion in the urine. The children served as their own controls with the placebo provocations. RESULTS All 15 children completed the study. The mean VAS scores were slightly higher during aluminium provocations compared with placebo for granuloma itch (mean VAS, 1.5 vs. 1.4, p = 0.6) but identical for other subjective symptoms (0.6 vs. 0.6, p = 1). There were no differences in sleep patterns and no significant correlation between urinary aluminium excretion and symptom severity. Three children developed a symmetrical rash on the face or buttocks on day 4 of the aluminium provocations, but not during placebo provocations. CONCLUSIONS No difference was found between oral aluminium intake and the occurrence of subjective symptoms and granuloma itch, but on a case-basis oral aluminium may be associated with the development of systemic contact dermatitis.
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Affiliation(s)
- Stine Skovbo Hoffmann
- National Allergy Research Centre, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Jesper Elberling
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Kirsten Skamstrup Hansen
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.,Department of Pediatric and Adolescent Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Jacob P Thyssen
- National Allergy Research Centre, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Charlotte G Mortz
- Department of Dermatology and Allergy Centre, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Rasmus Overgaard Bach
- Department of Dermatology and Allergy Centre, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Jeanne Duus Johansen
- National Allergy Research Centre, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
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Skovbo Hoffmann S, Thiesson EM, Johansen JD, Hviid A. Risk factors for granulomas in children following immunisation with aluminium adsorbed vaccines: A Danish population-based cohort study. Contact Dermatitis 2022; 87:430-438. [PMID: 35778959 DOI: 10.1111/cod.14180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Aluminium adsorbed vaccines may in some children cause severely itching nodules at the injection site, known as vaccination granulomas. OBJECTIVE To investigate vaccine-, child- and maternal level risk factors for the development of vaccination granulomas following immunisation with aluminium adsorbed vaccines. METHODS A Danish population-based cohort study with 553 932 children born in Denmark from 1 January 2009 to 31 December 2018, vaccinated with an aluminium adsorbed vaccine during the first year of life, followed until 31 December 2020. Poisson regression was used to estimate granuloma rate ratios according to type of adjuvant, accumulated dose of aluminium, timing of vaccination appointments, sex, gestational age, having siblings with granulomas, maternal age, and maternal ethnicity. RESULTS We identified 1 901 vaccination granuloma cases (absolute risk, 0.34%). Among vaccine level factors, revaccination (third vs first vaccination appointment, adjusted rate ratio [RR] 1.26, 95% confidence interval [CI] 1.03-1.55), the specific adjuvant used (aluminium phosphate vs hydroxide, RR 0.58, 95% CI 0.48-0.70) and dosage (≥1.0 mg vs <1.0 mg, RR 1.34, 95% CI 1.19-1.52) were associated with risk of granulomas; the timing of vaccination appointments was not. Among child level factors, female sex (vs males, RR 1.12, 95% CI, 1.02-1.22), prematurity (vs term birth, RR 0.71, 95% CI, 0.54-0.93) and having sibling(s) with granulomas (vs no siblings with granulomas, RR 46.15, 95% CI, 33.67-63.26) were associated with risk of granulomas. Among maternal level factors, non-Danish ethnicity (vs. Danish, RR 0.51, 95% CI, 0.42-0.63) and young maternal age (<20 yrs. vs 20-39 yrs., RR 0.46, 95% CI 0.25-0.83) were associated with risk of granulomas. CONCLUSIONS Several risk factors for vaccination granulomas at both the vaccine, child, and maternal level, was identified. Reducing the dose of aluminium or replacing aluminium hydroxide with aluminium phosphate could reduce the risk of granulomas. However, this must be balanced against the potential for reduced immunogenicity.
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Affiliation(s)
- Stine Skovbo Hoffmann
- National Allergy Research Centre, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, Hellerup, Denmark
| | | | - Jeanne Duus Johansen
- National Allergy Research Centre, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, Hellerup, Denmark
| | - Anders Hviid
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark.,Pharmacovigilance Research Centre, Department of Drug Design and Pharmacology, University of Copenhagen, Denmark
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Abstract
ABSTRACT Exposure to elemental aluminum and its salts is unavoidable. Aluminum as a metal is present in transport, construction, packaging, and electronic equipment. Aluminum salts are present in consumer products, food items and drinking water, vaccines, drugs, and antiperspirants. Aluminum in vaccines and preparations for allergen-specific immunotherapy are the major sensitization sources. The predominent clinical manifestations of aluminum allergy are pruritic subcutaneous nodules and eczematous dermatitis. Patch testing shall be performed with aluminum chloride hexahydrate (ACH) in petrolatum. The preparation with ACH 10% detects substantially more aluminum allergy than ACH 2%. A patch test with elemental aluminum, for example, an empty Finn Chamber, is only positive when there is a strong aluminum allergy. A patch test reading should be performed 1 week after the application so as not to miss 15% to 20% of aluminum allergy. Aluminum should be included in any baseline patch test series for children and investigated for a possible inclusion in baseline series for adults. Aluminum test chambers can interfere with the testing resulting in both false-negative and false-positive patch test reactions to nonaluminum contact sensitizers.
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Hoffmann SS, Elberling J, Thyssen JP, Hansen KS, Johansen JD. Does aluminium in sunscreens cause dermatitis in children with aluminium contact allergy: A repeated open application test study. Contact Dermatitis 2021; 86:9-14. [PMID: 34536036 DOI: 10.1111/cod.13973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/12/2021] [Accepted: 09/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Parents report that children with aluminium contact allergy and vaccination granulomas may react to aluminium-containing sunscreen following application. OBJECTIVES To evaluate whether contact dermatitis develops following repeated application of aluminium-containing sunscreens in children with aluminium sensitization and vaccination granulomas. METHODS Sixteen children aged 2-9 years (mean age 5 years) with vaccination granulomas and a positive patch test reaction to aluminium chloride hexahydrate 2%/10% petrolatum completed a blinded repeated open application test (ROAT) with two daily applications of two sunscreens for 14 days. One cream contained aluminium and the other did not. The children served as their own controls. RESULTS Sixteen children completed the study. Only one child (6%) had a positive skin reaction during ROAT on day 2 to the sunscreen with aluminium. None reacted to the sunscreen without aluminium. CONCLUSIONS Use of aluminium-containing sunscreens may on a case basis lead to allergic contact dermatitis in aluminium allergic children.
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Affiliation(s)
- Stine S Hoffmann
- National Allergy Research Centre, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Jesper Elberling
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Jacob P Thyssen
- National Allergy Research Centre, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Kirsten S Hansen
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.,The Pediatric Department, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Jeanne D Johansen
- National Allergy Research Centre, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
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Nikpour S, Hedberg YS. Using chemical speciation modelling to discuss variations in patch test reactions to different aluminium and chromium salts. Contact Dermatitis 2021; 85:415-420. [PMID: 34013976 DOI: 10.1111/cod.13904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/20/2021] [Accepted: 05/18/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Allergic contact dermatitis to metals is diagnosed by applying a metal salt in a patch test. The bioavailability of the metal salt might depend on the choice of metal salt, the concentration, sweat composition, and pH. OBJECTIVES The main purpose of this study was to apply chemical speciation modelling, which is based on experimentally derived input data and calculates the concentrations of chemical forms (species) in solutions, to reproduce and discuss clinical patch test results of aluminium and chromium. METHODS Joint Expert Speciation System (JESS), Hydra/Medusa, and Visual MINTEQ were employed to study the bioavailable fraction and chemical form of clinically applied aluminium and chromium salts as a function of salt type, applied concentration, sweat composition, and pH. RESULTS Investigated aluminium and chromium salts can have a very low bioavailability with a large dependency on sweat composition, pH, metal salt, and concentration. Both aluminium and chromium ions could shift the pH towards acidic or basic values based on their chemical form. CONCLUSIONS Reported seasonal and interpatient variability in positive reactions to aluminium is likely related to sweat pH and composition. Potassium dichromate increases the pH, whereas aluminium and trivalent chromium chloride strongly decrease the pH, possibly increasing skin diffusion.
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Affiliation(s)
- Saman Nikpour
- Department of Chemistry, The University of Western Ontario, London, Ontario, Canada
| | - Yolanda S Hedberg
- Department of Chemistry, The University of Western Ontario, London, Ontario, Canada.,Surface Science Western, The University of Western Ontario, London, Ontario, Canada.,Lawson Health Research Institute, The University of Western Ontario, London, Ontario, Canada
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Miyachi H, Matsue H. Post-vaccination subcutaneous aluminum granuloma. IDCases 2020; 22:e00951. [PMID: 32983893 PMCID: PMC7495116 DOI: 10.1016/j.idcr.2020.e00951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 10/29/2022] Open
Abstract
Vaccination is a successful and cost-effective public health intervention. Aluminum-containing adjuvants are used worldwide to improve the immune response of vaccines. Side effects of aluminum-containing adjuvants in skin and subcutis are usually accompanied by persistent itch, and it may be challenging to diagnose asymptomatic cases. Here we present a case of a 1-year-old girl with asymptomatic subcutaneous nodules. Magnetic resonance imaging (MRI) revealed subcutaneous lesions: 16 mm on the upper right and 4 mm on the upper left arms. Histological examination revealed a granulomatous reaction with lymphoid follicle-like structures in the subcutis, accompanied by a considerable number of macrophages with PAS-positive granular cytoplasm. Moreover, the granules stained positive with aluminon staining, which revealed the existence of aluminum. These findings indicate post-vaccination aluminum granuloma. Due to the benign nature of aluminum granuloma and the benefit of routine vaccination, we decided to recommend that the patient continue taking the routine vaccination.
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Affiliation(s)
- Hideaki Miyachi
- Department of Dermatology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Hiroyuki Matsue
- Department of Dermatology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
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Hedberg YS, Wei Z, Matura M. Quantification of aluminium release from Finn chambers under different in vitro test conditions of relevance for patch testing. Contact Dermatitis 2020; 83:380-386. [DOI: 10.1111/cod.13629] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 05/27/2020] [Accepted: 05/31/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Yolanda S. Hedberg
- Division of Surface and Corrosion Science, Department of Chemistry School of Engineering Sciences in Chemistry, Biotechnology, and Health, KTH Royal Institute of Technology Stockholm Sweden
| | - Zheng Wei
- Division of Surface and Corrosion Science, Department of Chemistry School of Engineering Sciences in Chemistry, Biotechnology, and Health, KTH Royal Institute of Technology Stockholm Sweden
| | - Mihály Matura
- Unit of Occupational and Environmental Dermatology Centre for Occupational and Environmental Medicine, Stockholm County Council Stockholm Sweden
- Unit of Dermatology Skaraborgs Hospital Skövde Skövde Sweden
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