Systemic contact dermatitis in children: how an avoidance diet can make a difference

Biopolymers Used for Receptor Immobilization for Nickel-Detection Biosensors in Food

Food is humans' main source of nickel intake, which is responsible for the prevalence of allergic contact dermatitis and other pathological afflictions. While robust, the classical methods for nickel detection-atomic absorption spectrometry and inductively coupled plasma mass spectrometry-are expensive and laborious; in contrast, modern methods that utilize sensors-of which most are electrochemical-have rapid run times, are cost-effective, and are easily assembled. Here, we describe the use of four biopolymers (alginate, agar, chitosan, and carrageenan) for receptor immobilization on biosensors to detect nickel ions and use an optimization approach with three biopolymer concentrations to assay analytical performance profiles. We measured the total performance of screen-printed carbon electrodes immobilized with the biopolymer-sensor combinations using cyclic voltammetry (CV). Voltammetric behavior favored the carrageenan biosensor, based on performance characteristics measured using CV, with sensitivities of 2.68 (for 1% biopolymer concentration) and 2.08 (for 0.5% biopolymer concentration). Our results indicated that among the four biopolymer combinations, carrageenan with urease affixed to screen-printed electrodes was effective at coupling for nickel detection.

Acute Adverse Effects Related to Consumption of Nonnutritive and Low-Calorie Sweeteners

Nonnutritive sweeteners (NNSs) and low-calorie sweeteners (LCSs) are commonly used as sugar substitutes. Many popular media Web sites caution against the use of these sweeteners because of their potential adverse effects such as inflammation; however, there are limited supporting data. A Medline search of articles published between 2010 and 2020 was conducted, resulting in 833 articles, of which 12 relevant studies were included in this review. Acute adverse effects associated with the consumption of NNSs and LCSs are rare. A few studies cite reports of acute adverse effects, including mild gastrointestinal disturbance, headaches, lightheadedness, hypersensitivity reactions, impaired spatial orientation, depression, and pain. Little scientific evidence has been reported in the literature since 2010 to support these warning statements to consumers about acute adverse effects to NNSs and LCSs.

Additives in Children's Nutrition-A Review of Current Events

Additives are defined as substances added to food with the aim of preserving and improving safety, freshness, taste, texture, or appearance. While indirect additives can be found in traces in food and come from materials used for packaging, storage, and technological processing of food, direct additives are added to food with a special purpose (canning). The use of additives is justified if it is in accordance with legal regulations and does not pose a health or danger to consumers in the prescribed concentration. However, due to the specificity of the child's metabolic system, there is a greater risk that the negative effects of the additive will manifest. Considering the importance of the potential negative impact of additives on children's health and the increased interest in the control and monitoring of additives in food for children, we have reviewed the latest available literature available through PubMed, Scopus, and Google Scholar. Expert data were taken from publicly available documents published from January 2010 to April 2022 by internationally recognized professional organizations. It was found that the most frequently present additives in the food consumed by children are bisphenols, phthalates, perfluoroalkyl chemicals, perchlorates, pesticides, nitrates and nitrites, artificial food colors, monosodium glutamate, and aspartame. Increasing literacy about the presence and potential risk through continuous education of parents and young people as well as active monitoring of newly registered additives and harmonization of existing legal regulations by competent authorities can significantly prevent the unwanted effects of additives on children's health.

Systemic Contact Dermatitis: The Routes of Allergen Entry

Systemic contact dermatitis (SCD) is a generalized reactivation of type IV hypersensitivity skin diseases in individuals with previous sensitization after a contact allergen is administered systemically. Patients with SCD may consider their dermatitis unpredictable and recalcitrant since the causative allergens are difficult to find. If a patient has a pattern of dermatitis suggestive of SCD but fails to improve with conventional treatment, SCD should be taken into consideration. If doctors are not familiar with the presentations of SCD and the possible routes of allergen sensitization and exposure, the diagnosis of SCD may be delayed. In this work, we summarized all of the routes through which allergens can enter the body and cause SCD, including oral intake, local contact (through skin, inhalation, nasal spray and anal application), implants, and other iatrogenic or invasive routes (intravenous, intramuscular, intraarticular, and intravesicular). This will provide a comprehensive reference for the clinicians to identify the culprit of SCD.

Patch Test Clinic Start-up: From Basics to Pearls

Allergic contact dermatitis is a prevalent burdensome condition affecting millions of Americans. Patch testing, the criterion-standard allergic contact dermatitis diagnostic tool, is underused by US dermatologists. Incorporating patch testing into modern dermatology practices is achievable with utilization of accurate resources and sustainable support. This review focuses on the basics of patch testing and provides practical pearls to assist novice providers in establishing a contact dermatitis specialty practice.

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

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

Nickel Allergic Contact Dermatitis: Identification, Treatment, and Prevention

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

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.

Hypersensitivity reactions to food and drug additives: problem or myth?

BACKGROUND AND AIM OF THE WORK

The possibility of an allergic reaction or an intolerance to additives is frequently suspected by parents, especially for chronic illness with frequent exacerbations such as atopic dermatitis or chronic urticaria. For more than 50 years, potential adverse reactions to additives have been suggested, but to date data are conflicting. The purpose of this article is to provide the clinicians with general information about additives and adverse reactions to them and to suggest a practical approach to children suspected to have reactions to food additives.

METHODS

We performed an extensive research on all English-language Medline articles, case reports and reviews published online until December 2018. Used search terms were: food additives, food dye, adverse reactions, food allergy, food hypersensitivity, intolerance, drugs, children.

RESULTS

There are only few case reports of adverse reactions in childhood with a clear involvement of additives. In this review article we reported the associations between additives and adverse reactions described in literature, in order to inform the pediatrician about the potential clinical manifestations.

CONCLUSIONS

Prior to suspect an adverse reaction to additives, it is important to rule out other possible causes: the diagnostic process is complicated and rarely conclusive. The gold standard is the double-blind placebo controlled oral challenge after an exclusion diet.

Food Avoidance Diets for Dermatitis

Food allergy is relatively common in both children and adults, and its prevalence is increasing. Early exposure of food allergens onto skin with an impaired epidermal barrier predisposes to sensitization and prevents the development of oral tolerance. While immediate-type food allergies are well described, less is known about delayed-type food allergies manifesting as dermatitis. This is due, in part, to limitations with current diagnostic testing for delayed-type food allergy, including atopy patch testing. We conducted a systematic review of food avoidance diets in delayed-type food allergies manifesting as dermatitis. While beneficial in some clinical circumstances, avoidance diets should be used with caution in infants and children, as growth impairment and developmental delay may result. Ultimately, dermatitis is highly multifactorial and avoidance diets may not improve symptoms of delayed-type food allergy until combined with other targeted therapies, including restoring balance in the skin microbiome and re-establishing proper skin barrier function.

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

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

Easter egg hunt dermatitis: systemic allergic contact dermatitis associated with chocolate ingestion

Pediatric systemic allergic contact dermatitis to nickel has previously been reported in association with cocoa. We present four clinical cases of hypersensitivity temporally associated with chocolate consumption at Easter. Clinicians should be aware of the potential for foods high in nickel to provoke patients with known nickel sensitivity and systemic dermatitis.

Systemic contact dermatitis to foods: nickel, BOP, and more

Systemic contact dermatitis (SCD), a cutaneous reaction that is a direct manifestation of systemic exposure to a known allergen in a sensitized individual, has been increasingly recognized as a cause of persistent cutaneous contact dermatitis that is refractory to conventional therapies. While SCD in response to drugs has been described well in the literature, SCD to allergens in common foodstuffs is a less well-articulated phenomenon. Several foods that are universally consumed throughout the world contain potent allergens including nickel, balsam of Peru, trace metals, urushiol, and sesquiterpene lactones as well as a host of others that may cause a distinctive clinical picture. In this review article, the authors review the typical presentation and prevalence of SCD to foods, pathophysiology, the most common offensive ingestible food allergens, several appropriate diets, and effectiveness of dietary avoidance for situations in which SCD is suspected.

Propolis: a review of properties, applications, chemical composition, contact allergy, and other adverse effects

Propolis (bee glue) is the resinous substance that bees collect from living plants for the construction and adaptation of their nests. It has antibacterial, antifungal, and antiviral properties and may have a wide range of other beneficial biological activities. Propolis is available as a dietary supplement, in products for the protection of health and prevention of diseases, in biopharmaceuticals, and as a constituent of (bio)cosmetics. In this article, the following aspects of propolis are reviewed: the nature and chemical composition, its biological properties and applications, contact allergy and allergic contact dermatitis (sensitizing potential, products causing contact allergy, clinical picture, frequency of sensitization, coreactivity and cross-reactivity, the allergens in propolis), and other adverse effects.

Peripheral blood lymphocyte typing as a useful tool to objectify the oral mucosa patch test in the diagnosis of allergic contact mucositis to nickel

Nickel (Ni) exposure through the intestinal mucosa may cause a hypersensitivity reaction recently defined as allergic contact mucositis (ACM). This condition is identifiable by the oral mucosa patch test (omPT), a qualitative and subjective examination that requires clinical expertise. Our aim was to evaluate if a peripheral blood lymphocyte typing performed before and after the omPT for Ni may be able to objectify this examination for diagnostic purposes. Thirty patients with symptoms referable to the ingestion of Ni-rich foods were subjected to omPT for Ni. Before and after the omPT, each patient underwent blood sampling for the typing of total lymphocytes and their subsets (T, T helper or Th, T cytotoxic or Tc, B, natural killer or NK). Statistical analysis was performed by Student t test and receiver operating characteristic (ROC) curve analysis. According to the omPT outcomes, 18 patients were defined as Ni-sensitive and the remaining 12 as controls. In Ni-sensitive patients, the number of total, T, Th, Tc, and B lymphocytes/μL whole blood increased after the omPT (p<0.0001 for the first three, p=0.0004 and p=0.0001 for the last two lymphocyte types). No omPT-dependent lymphocyte increase was observed in controls. The post/pre omPT cell ratio, especially if calculated for Th lymphocytes, appears to be an effective index for diagnostic purposes (sensitivity=100%, specificity=83.3%, Youden index=0.833, area under curve (AUC)=0.926, p<0.0001). In conclusion, the peripheral blood lymphocyte typing with calculation of post/pre omPT cell ratio has the potential to support the omPT in diagnosing ACM, with the advantage of providing quantitative and objective data.

Invited commentary: recommendation for a north american pediatric patch test series

Given the increased recognition of pediatric allergic contact dermatitis and lack of patch testing consensus in children, we present a minimum basic 20-allergen North American pediatric series, for screening children ages 6-12 with suspected contact allergy.

Immunological characterization of the allergic contact mucositis related to the ingestion of nickel-rich foods

BACKGROUND

The ingestion of nickel (Ni)-rich foods may result in allergic contact mucositis (ACM), a not yet well defined condition identifiable by oral mucosa patch test (omPT). Our aim was to characterize immunologically the ACM taking advantage from the allergen exposure that occurs during the omPT for Ni.

METHODS

Thirty-seven symptomatic patients underwent to omPT for Ni. Before and after omPT, serum and urine Ni concentrations were determined by mass spectrometry, the white blood cells were counted by hemochromocytometric assay, the peripheral lymphocyte typing was carried out by flow cytometry, total IgE and cytokine serum concentrations were measured by immunoenzymatic assays. The local lymphocyte typing was performed by immunohistochemistry only after omPT.

RESULTS

According to the omPT outcomes, 25 patients were defined as Ni-sensitive and the remaining 12 as controls. After omPT, serum and urine Ni concentrations increased significantly in all patients, while a significant increment of circulating lymphocytes and neutrophils was highlighted, respectively, in Ni-sensitive and control patients. Consistently, the Th and Tc circulating lymphocytes, as well as the Th/Tc ratio increased significantly in Ni-sensitive patients after omPT. No noteworthy increment in serum concentrations of total IgE and selected cytokines was observed in any patient after omPT. The presence of CD3+, CD4+, and CD8+ cells was highlighted on the oral mucosa biopsy samples taken from Ni-sensitive patients after omPT.

CONCLUSIONS

In patients with ACM, a local adaptive response with increased lymphocyte trafficking appears to be the most likely mechanism of reaction to Ni administered with the omPT.

Contact alternatives to nickel

Allergic contact dermatitis to nickel is a continued health concern internationally. Nickel has been found to be the most prevalent and relevant allergen in tested populations for the last 3 decades. Furthermore, recent data from the North American Contact Dermatitis Group demonstrate positive patch-test reactions to nickel at approximately 19.5% of their tested population and a significant increase in the positivity rates for the last decade (Dermatitis. 2013;24:10-21. J Am Acad Dermatol. 1998;38:911-918). Because of the rise in allergic contact dermatitis rates to nickel, the American Contact Dermatitis Society recognized nickel to be the 2008 Allergen of the Year (J Am Acad Dermatol. 2009;60:1067-1069; Dermatitis. 2008;19:3-8). This article recognizes the importance of nickel avoidance and highlights potential alternatives.

Systemic contact dermatitis--kids and ketchup

Systemic manifestations of allergic contact dermatitis due to consumption of foods containing balsam of Peru (Myroxylon pereirae)-associated chemicals have recently been reported in children. We present seven children with widespread, recalcitrant dermatitis who experienced 60-80% clearance after initiating a diet low in balsam of Peru, specifically the tomato product ketchup. Furthermore, because we have observed a high prevalence of ketchup in our pediatric patients' diets, we recommend consideration of moderate consumption of this product in patients with recalcitrant widespread dermatitis.

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.