Allergic contact dermatitis in children

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.

Abating Mercury Exposure in Young Children Should Include Thimerosal-Free Vaccines

Pediatric immunization is essential to prevent, control and eradicate children`s infectious diseases. Newborns and infants in less developed countries have a concentrated schedule of Thimerosal-containing vaccines (TCVs); pregnant mothers are also immunized with TCVs. Metabolic changes during early development are demonstrably an important risk factor for ethylmercury (EtHg) effects on neurodevelopment, while exposure to Thimerosal sensitizes susceptible individuals to life-long contact dermatitis. Concerns regarding toxicity of Hg have moved rich nations to withdraw it from medicines and, in particular, Thimerosal from pediatric vaccines; it has been more than 20 years since rich countries started using Thimerosal-free vaccines. TCVs and Thimerosal-free vaccines show dissimilar profiles of adverse effects. Thimerosal-free vaccines have shown a decrease in contact dermatitis, while TCVs showed a significant association with increased risk of tic disorders; in some circumstances, EtHg in combination with other neurotoxic substances negatively impacted neurobehavioral tests. In studies that explored vaccines and risk of tics, Thimerosal was a necessary factor. However, when the binary exposure to organic Hg forms (TCV-EtHg and fish-MeHg) was considered, effects on neurobehavioral tests were inconsistent.

CONCLUSIONS

(a) The indiscriminate use of pediatric-TCVs in less developed countries carries an unjustifiable and excessive EtHg exposure with an unnecessary risk of neurotoxicity to the developing brain; (b) measurable benefits (of Thimerosal-free) and measurable risks of tic disorders have been associated with the (Thimerosal-containing) type of vaccine;

Patch-test results in children and adolescents: systematic review of a 15-year period

The number of studies on patch-test results in children and adolescents has gradually increased in recent years, thus stimulating reviews. This paper is a systematic review of a 15-year period devoted to studying the issue. Variations pertaining to the number and age groups of tested children and/or adolescents, the number of subjects with atopy/atopic dermatitis history, the quantity, type and concentrations of the tested substances, the test technique and type of data regarding clinical relevance, must all be considered in evaluating these studies, as they make it harder to formulate conclusions. The most common allergens in children were nickel, thimerosal, cobalt, fragrance, lanolin and neomycin. In adolescents, they were nickel, thimerosal, cobalt, fragrance, potassium dichromate, and Myroxylon pereirae. Knowledge of this matter aids health professionals in planning preventive programs aimed at improving children's quality of life and ensuring that their future prospects are not undermined.

Patch test results in children and adolescents. Study from the Santa Casa de Belo Horizonte Dermatology Clinic, Brazil, from 2003 to 2010

BACKGROUND

Patch testing is an efficient method to identify the allergen responsible for allergic contact dermatitis.

OBJECTIVE

To evaluate the results of patch tests in children and adolescents comparing these two age groups' results.

METHODS

Cross-sectional study to assess patch test results of 125 children and adolescents aged 1-19 years, with suspected allergic contact dermatitis, in a dermatology clinic in Brazil. Two Brazilian standardized series were used.

RESULTS

Seventy four (59.2%) patients had "at least one positive reaction" to the patch test. Among these positive tests, 77.0% were deemed relevant. The most frequent allergens were nickel (36.8%), thimerosal (18.4%), tosylamide formaldehyde resin (6.8%), neomycin (6.4%), cobalt (4.0%) and fragrance mix I (4.0%). The most frequent positive tests came from adolescents (p=0.0014) and females (p=0.0002). There was no relevant statistical difference concerning contact sensitizations among patients with or without atopic history. However, there were significant differences regarding sensitization to nickel (p=0.029) and thimerosal (p=0.042) between the two age groups under study, while adolescents were the most affected.

CONCLUSION

Nickel and fragrances were the only positive (and relevant) allergens in children. Nickel and tosylamide formaldehyde resin were the most frequent and relevant allergens among adolescents.

Young individuals with atopic disease and asthma or rhinoconjunctivitis may have clinically relevant contact allergies

BACKGROUND

Children and adolescents with atopic disease who have allergic asthma and/or rhinitis with and without atopic dermatitis may have hidden, clinically relevant contact allergies.

OBJECTIVE

The objective of this study was to survey contact allergies in children and adolescents who had been offered allergen-specific immunotherapy and accepted (exposed)/not accepted (unexposed) such treatment.

METHODS

Thirty-seven exposed and 24 unexposed individuals with atopic disease were patch tested with a standard series supplemented with aluminum chloride hexahydrate, an empty Finn Chamber, and 8 antigen preparations.

RESULTS

In the exposed group, 18 allergies were detected in 13 individuals with atopic disease when excluding reactions to aluminum and antigen preparations, whereas the corresponding figures for the unexposed group were 9 and 6, respectively (non-significant difference). Independent of the allergen-specific immunotherapy, significantly more (P = 0.013) individuals with atopic dermatitis had at least 1 contact allergy. Clinically relevant allergies were represented by sesquiterpene lactone mix, para-tertiary butylphenol-formaldehyde resin, tixocortol pivalate, and colophony.

CONCLUSIONS

Clinically relevant contact allergies are not uncommon in children and adolescents with atopic disease, which is why patch testing always should be considered in the management of dermatitis in individuals with atopic disease.

Current strategies in treating severe contact dermatitis in pediatric patients

Allergic contact dermatitis in children is underdiagnosed and undertreated, and its incidence is increasing. Appropriate history taking and the suspicion for allergic contact dermatitis is essential, and patch testing remains the gold standard in diagnosis. Avoidance of the offending allergen, once identified, is the first goal of treatment. Medical therapies include topical corticosteroid and topical immunomodulators. In severe cases, oral corticosteroids or immunomodulators are utilized, although prospective randomized trials for the treatment of this disease in children are lacking. A PubMed literature search was performed to identify publications on allergic contact dermatitis in the pediatric population with the keywords: dermatitis, children, allergic contact dermatitis, pediatrics, contact hypersensitivity, contact allergy, treatment, and management. This review will address the major principles behind the diagnosis and management of this disease in the pediatric population, and highlight useful strategies that may result in improved treatment of this condition.

Contact sensitivity to metals (chromium, cobalt and nickel) in childhood

Metals, especially nickel, are the most common contact allergens in children. Recent data has shown increased incidence of allergy in industrialized countries. Sensitization can occur at any age, even in neonates. Costume jewelry, particularly earrings, is linked to increased sensitization to nickel. Sensitization to cobalt often occurs by the use of costume jewelry. The most common source of sensitization to chromium is leather. Due to the absence of a specific therapy, the main treatment is to identify and avoid the responsible allergens. This article presents an updated view on the epidemiological and clinical aspects of contact allergy to metals, focusing on prevention strategies and risk factors, and warns about possible and new sources of contact.

[Contact dermatitis in children - a review of current opinions]

In the not so distant past, in the United States contact dermatitis was considered to be a condition that affected mainly adults. The diagnosis was certainly less often rendered in pediatrics, mainly because it was believed that a child's immune system was immature and that children were generally exposed to fewer allergens. With this in mind, we can attribute the low prevalence formerly reported for this disease partly to the fact that most affected children were not (and are still not) evaluated using appropriate skin tests. Patch testing in children requires certain modifications, but the international literature of the last decade and US data published in the past year indicate that contact dermatitis is a common condition in the pediatric population and that the prevalence is similar in children and adults.

Contact sensitization in very young children

BACKGROUND

Allergic contact dermatitis is an increasingly recognized clinical problem in children.

OBJECTIVE

The aim of our study was to evaluate contact sensitization in patients younger than 3 years of age with suspected contact dermatitis.

METHODS

During a 6-year period (2002-2008), 321 children underwent routine patch testing with a screening pediatric standard series of 30 allergens.

RESULTS

Two hundred children (62.3%; 102 girls and 98 boys aged 3-36 months [mean age 27 + 5.6 months]) developed at least one positive reaction. The most frequent reactions were to nickel sulfate (26.8%), followed by potassium dichromate (9%), cocamidopropylbetaine (7.2%), cobalt chloride (6.2%), neomycin sulfate (5%), and methylchloroisothiazolinone/methylisothiazolinone (4.4%). The prevalence of contact sensitization was similar in children with (61.3%) and without (63%) atopic dermatitis.

LIMITATIONS

The prevalence of contact sensitization in children younger than 3 years of age was not compared with the prevalence in older children.

CONCLUSION

A high prevalence of contact sensitization was found in preschool children, even younger than 3 years of age. Patch testing should be considered in this age group when persistent dermatitis does not respond to conventional treatment.

Prevalence of nickel sensitization and urinary nickel content of children are increased by nickel in ambient air

In a cross-sectional study performed in 2000, an unexpected positive association between nickel (Ni) in ambient air, urinary Ni content and the prevalence of Ni sensitization in a subgroup of 6-yr-old children living near a steel mill was observed. Between 2005 and 2006, in a different and larger study population, we examined if Ni from ambient air or urinary Ni concentration was related to Ni sensitization in children living next to Ni-emitting steel mills. We studied 749 school beginners living in four Ni-polluted industrial areas of North Rhine-Westphalia, Germany. We assessed Ni in ambient air, Ni in urine from children and mothers, and Ni in tap water, conducted patch tests in children (including the NiSO(4)-dilution test) and collected questionnaire data. Statistics were done by linear and logistic regression analyses, adjusted for covariates. At increased Ni concentration in ambient air (unit of increase: 10 ng/m(3)), urinary Ni concentrations rose in both mothers (9.1%; 95% CI: 6.8-11.4%) and children (2.4%; 95% CI: 0.4-4.4%). The prevalence of Ni sensitization in children was associated with increased Ni from ambient air (unit of increase: 18 ng/m(3); odds ratio 1.28; 95% CI: 1.25-1.32) and urinary Ni concentration (unit of increase: 7.1 μg/L; odds ratio 2.4; 95% CI: 1.20-4.48). Ni in ambient air of areas with Ni-emitting factories contributes to internal Ni exposure in residents via inhalation and, furthermore, is a risk factor for the development of Ni sensitization in children.

Patch tests in children: a review of 13 years of experience in comparison with previous data

The true prevalence of allergic contact dermatitis (ACD) in children remains unknown. Our aim was to compare the results of patch tests in children with suspected ACD between two different periods of time and identify possible changes in emerging allergens. We compared contact allergens, gender, age distribution, and personal history of atopic dermatitis (AD), in correlation with the positivity of patch tests, between two equal periods of time (232 children tested during 1980-1993, period A, and 255 children during 1994-2007, period B) in the same region and in the same institution. Patch test positivity was 47.8% in period A, and 60% in period B (p = 0.083). The most common allergens in period A were: nickel sulfate (16.3%), cobalt chloride (8.6%), fragrance mix (7.3%), potassium dichromate (4.3%), and thimerosal only (1.7%). In period B, the allergen distribution was as follows: nickel sulfate (21.56%), thimerosal (18.03%), cobalt chloride (12.9%), potassium dichromate (9.4%), and fragrance mix (4.7%). Girls were more likely to have a positive patch test compared with boys, with reactions in 53% of girls and 39% of boys in period A (p = 0.003), and 61% of girls and 58% of boys in period B (p = 0.691). Twenty-nine per cent of patients with positive results had a personal history of AD in period A and 44% in period B (p = 0.015). Differences in the positivity of allergens between different time periods reflect changes in habits, of allergens exposure or preventive measures.

Allergic contact dermatitis in children: common allergens and treatment: a review

PURPOSE OF REVIEW

The following study reviews the recent literature pertaining to allergic contact dermatitis (ACD) in the pediatric population. This study also provides an overview of the most common allergens and discusses various therapeutic modalities.

RECENT FINDINGS

The pathophysiology of ACD is intricate and multifaceted, resulting in a characteristic, delayed inflammatory response. Although commonly recognized in adults, its existence in the pediatric population was questioned. Recent literature suggests that pediatric ACD exists and is more common than previously recognized. The diagnosis relies on the clinical presentation combined with appropriate use and interpretation of a patch test. Although many studies have investigated ACD in children, few have documented the relevance of positive patch test reactions until recently. The most current prevalence estimates of positive patch test reactions range from 14 to 70% of children patch tested. Although that range is broad, these studies have demonstrated the relevance of positive reactions and confirmed ACD as a disease entity in children.

SUMMARY

ACD is a previously underrecognized disease process in the pediatric population that can manifest as a serious dermatologic challenge for both patients and physicians. This review will address the prevalence, diagnostic methods, frequent allergens and treatment options in pediatric ACD.

Prevalence and risk factors for allergic contact dermatitis to topical treatment in atopic dermatitis: a study in 641 children

BACKGROUND

There is little information regarding the risk of sensitization associated with topical atopic dermatitis (AD) treatment.

OBJECTIVES

To assess the frequency of sensitization to topical treatment of AD in children and to determine risk factors associated with skin sensitization.

METHODS

Six hundred and forty-one children with AD were systematically patch tested with seven agents of common topical treatment: chlorhexidine, hexamidine, budesonide, tixocortol pivalate, bufexamac, sodium fusidate and with the current emollient used by the child. The following variables were recorded: age, sex, age at onset of AD, associated asthma, severity of AD, and history of previous exposure to topical agents used in the treatment of AD. Skin prick tests to inhalant and food allergens were used to explore the IgE-mediated sensitization.

RESULTS

Forty-one positive patch tests were found in 40 patients (6.2%). Allergens were emollients (47.5%), chlorhexidine (42.5%), hexamidine (7.5%), tixocortol pivalate and bufexamac (2.5% each). Risk factors associated with sensitization to AD treatment were AD severity [OR: 3.3; 95% confidence interval (CI):1.5-7.1 for moderate to severe AD], AD onset before the age of 6 months (OR: 2.7; 95% CI: 1.2-6.1), and IgE-mediated sensitization (OR: 2.5; 95% CI: 1.1-5.9).

CONCLUSIONS

Topical treatment of AD is associated with cutaneous sensitization. Antiseptics and emollients represent the most frequent sensitizers and may be included in the standard series in AD children when contact dermatitis is suspected. Risk factors associated with sensitization to AD topical treatments are AD severity, early AD onset and IgE-mediated sensitization.

Clinically relevant patch test reactions in children--a United States based study

Allergic contact dermatitis in the pediatric population is more common than previously recognized, with recent prevalence estimates of positive patch test reactions in the range of 14-70% of children patch tested. The aim of this study was to confirm the prevalence of clinically relevant allergic contact dermatitis in children at two referral centers and determine the most common contact allergens. We performed a retrospective case series analysis of 65 symptomatic children (35 girls and 30 boys) aged 1-18 years old who were patch tested over a 5-year period for recalcitrant dermatitis. Positive patch test reactions were noted in 54 of the 65 children (prevalence rate of 83%) to 80 different allergens. Fifty children (77%) had positive reactions which were determined to be of "definite" or "probable" current clinical relevance. We conclude that the diagnosis of allergic contact dermatitis to specific relevant allergens is common in children referred for patch testing and that contact allergy should be considered in all children with recalcitrant dermatitis. With this article, we review the literature and present a US based study regarding the clinical relevance of positive patch test reactions in children.

Dispelling the myths behind pediatric patch testing-experience from our tertiary care patch testing centers

Allergic contact dermatitis is now known to be a common problem in pediatric populations, accounting for up to 20% of all dermatitis seen in children. Seminal studies conducted over the past decade have demonstrated a prevalence rate in the range of 25% to 60% of children referred for epicutaneous patch testing. This patch test procedure is generally accepted as the gold standardin vivo technique to diagnose allergic contact dermatitis. However, the overwhelming majority of research studies to date have been conducted on adult populations. Increasingly, pediatric patients are undergoing patch test procedures with techniques that have been standardized and optimized almost exclusively in adults. With this article, we hope to emphasize common misconceptions and pitfalls encountered with this approach. In addition, we hope to stimulate research interest in this field so as to determine the optimum patch test conditions and techniques for children.

Bullous dermatoses in childhood: part I

A classification of bullous dermatoses in childhood is presented, according to the histologic location of the bulla and the heritability of the disease, combined with the most recent laboratory examinations used in dermatologic practice. For a better understanding of the proposed classification, the authors also present a review of this group of diseases, which vary greatly within the group. In this first part of the classification and review, the group of bullous dermatoses with nonhereditary characteristics and intraepidermal cleavage is described.

Sensitizations to allergens of TRUE test�in 864 consecutive eczema patients in Israel

The TRUE test is a widespread diagnostic tool for initial patch testing of patients with contact dermatitis (CD). From 2002 to 2005, 864 patients with eczema were patch-tested using TRUE test in one Israeli allergology clinic. 547 (63.3%) patients were female and 317 (36.7%) were male. 346 (40%) patients had > or =1 positive patch test reactions. The most common allergens were nickel sulfate for 114 (13.2%) patients, potassium dichromate 111 (12.8%), fragrance mix 59 (6.8%), cobalt chloride 12 (1.4%), ethylenediamine dihydrochloride 11 (1.3%), epoxy resin 11 (1.3%), balsam of Peru 9 (1.0%), carba mix 7 (0.8%), thiomersal 6 (0.7%), wool alcohol 5 (0.6%), black rubber (PPD) mix 5 (0.6%), neomycin 4 (0.5%); Kathon CG, Colophony and Quaternium 15 - each 2 (0.2%), other allergens - each 1 (0.1%). In male patients, carba mix, black rubber (PPD) mix and epoxy resin sensitivity was more frequent, whereas nickel sulfate, fragrance mix, ethylenediamine dihydrochloride and cobalt chloride sensitivity was significantly more frequent in female patients. Our results are in general agreement with previously published reports, excluding the low sensitivity rates to cobalt, which maybe is missed by TRUE test.

Allergic contact dermatitis in children: should pattern of dermatitis determine referral? A retrospective study of 500 children tested between 1995 and 2004 in one U.K. centre

BACKGROUND

Allergic contact dermatitis (ACD) increases with age, and a prevalence of between 13.3% and 24.5% has been reported. Patch testing infants may be particularly difficult, and false-positive reactions may occur.

OBJECTIVES

The purpose of this retrospective study was to determine whether the site of primary dermatitis in children could predict a diagnosis of ACD. The current frequency of sensitization in children was also evaluated and the main sensitizing substances among children were verified.

METHODS

Between 1995 and 2004, 500 children were patch tested and entered on to the patch test database at Leeds General Infirmary. Analysis of the database included identifying the presenting patterns of eczema and reviewing the patch test results for each child.

RESULTS

Of the children, 133 (27%) had one or more positive patch test result. The effect of age on the likelihood of a positive patch test was highly significant (P < 0.001). Girls were significantly more likely to have a positive patch test compared with boys: odds ratio for a positive test 0.62 (95% confidence interval 0.41-0.95; P = 0.029). Type IV allergy to nickel (33%) was the most frequent finding. Reactions to fragrance mix (18%), cobalt (11%), mercapto chemicals, Myroxylon pereirae and p-phenylenediamine (each 8%) were the next most common. No statistical significance was found in the relationship between the site of primary dermatosis and a positive patch test result.

CONCLUSIONS

The pattern of presenting dermatitis in children should not determine referral for patch testing. Any child with persistent eczema should be referred for patch testing.