Influence of detergent washing powders on minimal eliciting patch test concentrations of nickel and chromium

Nickel Allergy of the Skin and Beyond

BACKGROUND

Hypersensitization to nickel is one of the most common contact allergies in the modern world and it is considered to be a major cause of contact dermatitis, especially for hand eczema.

OBJECTIVE

The aim of this paper is to describe many faces of the nickel allergy and to find out different diagnostic, potential strategies for treatment and prevention in hypersensitized patients. A personal clinical experience with practical clinical cases of contact dermatitis to nickel has also been presented.

METHODS

Electronic databases on this topic was carried out using PubMed-Medline.

RESULTS

The literature review identified many articles reporting for nickel contact allergy and pointing the metal as number one allergen in the frequency of positive skin patch test reactions in a large population worldwide. Herein, a summary of the current understanding and evidence on nickel allergy with practical approach and proposed recommendations to the dermatologist, general practitioner, and the allergist were prepared.

CONCLUSION

The prevalence of nickel allergy represents an important socio-economical and health issue. Metal is one of the most common sensitizing agents worldwide. The morbidity due to this metal represents the allergic contact dermatitis and it is constantly growing in many countries. There are also cases of systemic allergic contact dermatitis, where they could be easily misdiagnosed as adverse drug reactions, which lead to delay of the correct diagnosis and inappropriate treatment.

Chromium and leather: a review on the chemistry of relevance for allergic contact dermatitis to chromium

Abstract

As other causes decline in importance, chromium-tanned leather has become a more important source for chromium allergy, which affects around 1% of the general population. The aim of this review is to give suggestions on how to minimize the risk of leather-related allergic contact dermatitis, which can be elicited in chromium-allergic persons by hexavalent and trivalent chromium released from leather. Hexavalent chromium is the more potent chromium form and requires a lower skin dose to elicit allergic reactions. It is formed on the surface of some, antioxidant-free, leathers at dry conditions (< 35% relative humidity) and is influenced by the tanning process and other conditions, such as UV irradiation, contact with alkaline solutions, and leather age. Trivalent chromium is the dominant form released from chromium-tanned leather and its released amount is sufficient to elicit allergic reactions in some chromium-allergic individuals when they are exposed repetitively and over longer time (days – months). A low initial test result (< 3 mg/kg) for hexavalent chromium with the current standard test (ISO 17075) does not guarantee a low release of chromium from the leather or a low release of hexavalent chromium under typical exposure conditions during the service life of the leather. Information, labels, and certificates regarding leather products are often insufficient to protect chromium-allergic individuals. Correct labelling and information on the possible content of different allergens, as well as different tanning alternatives for certain leather products, are crucial.

Graphical abstract

Risks of Allergic Contact Dermatitis Elicited by Nickel, Chromium, and Organic Sensitizers: Quantitative Models Based on Clinical Patch Test Data

Risks of allergic contact dermatitis (ACD) from consumer products intended for extended (nonpiercing) dermal contact are regulated by E.U. Directive EN 1811 that limits released Ni to a weekly equivalent dermal load of ≤0.5 μg/cm² . Similar approaches for thousands of known organic sensitizers are hampered by inability to quantify respective ACD-elicitation risk levels. To help address this gap, normalized values of cumulative risk for eliciting a positive ("≥+") clinical patch test response reported in 12 studies for a total of n = 625 Ni-sensitized patients were modeled in relation to observed ACD-eliciting Ni loads, yielding an approximate lognormal (LN) distribution with a geometric mean and standard deviation of GM_Ni = 15 μg/cm² and GSD_Ni = 8.0, respectively. Such data for five sensitizers (including formaldehyde and 2-hydroxyethyl methacrylate) were also ∼LN distributed, but with a common GSD value equal to GSD_Ni and with heterogeneous sensitizer-specific GM values each defining a respective ACD-eliciting potency GM_Ni /GM relative to Ni. Such potencies were also estimated for nine (meth)acrylates by applying this general LN ACD-elicitation risk model to respective sets of fewer data. ACD-elicitation risk patterns observed for Cr(VI) (n = 417) and Cr(III) (n = 78) were fit to mixed-LN models in which ∼30% and ∼40% of the most sensitive responders, respectively, were estimated to exhibit a LN response also governed by GSD_Ni . The observed common LN-response shape parameter GSD_Ni may reflect a common underlying ACD mechanism and suggests a common interim approach to quantitative ACD-elicitation risk assessment based on available clinical data.

Chromium(III) release from chromium-tanned leather elicits allergic contact dermatitis: a use test study

Background

Chromium (Cr) is a common skin sensitizer. The use of Cr(VI) in leather is restricted in the EU, but that of Cr(III) is not.

Objectives

To assess whether prolonged exposure to Cr‐tanned leather with mainly Cr(III) release may elicit allergic contact dermatitis in Cr‐allergic individuals.

Method

Ten Cr‐allergic subjects and 22 controls were patch tested with serial dilutions of Cr(III) and Cr(VI), and with leather samples. They then conducted a use test with a Cr‐tanned and a Cr‐free leather bracelet over a period of 3 weeks, for 12 h per day. Cr deposited on the skin from the bracelets was measured in the controls, and the diphenylcarbazide test for Cr(VI) and extraction tests for Cr(III) and Cr(VI) were conducted for the different leathers.

Results

Four of 10 Cr‐allergic subjects developed positive reactions to the Cr‐tanned bracelet within 7–21 days, whereas only 1 of 10 had a positive patch test reaction to this leather. Cr released from the Cr‐tanned leather was most probably entirely Cr(III), with a quantifiable amount being deposited on the skin.

Conclusions

This study strongly suggests that prolonged and repeated exposure to Cr‐tanned leather with mainly Cr(III) release is capable of eliciting allergic contact dermatitis in Cr‐allergic individuals.

Concentrations and exposure risks of some metals in facial cosmetics in Nigeria

The concentrations of nine metals (Cd, Pb, Ni, Cr, Co, Cu, Fe, Mn and Zn) were determined in lip sticks, lip glosses, lip balms, eye pencils, eyeliners, eye shadows, blushes, mascaras and face powders. The study was aimed at providing information on the risk associated with human exposure to metals in these facial cosmetic products. The concentrations of metals in the samples were measured by atomic absorption spectrometry after digestion with a mixture of nitric acid, hydrochloric acid and hydrogen peroxide. The mean concentrations of metals in these facial cosmetics ranged from 3.1 to 8.4 μg g^-1 Cd, 12-240 μg g^-1 Pb, 9.1-44 μg g^-1 Cr, 18-288 μg g^-1 Ni, 1.6-80 μg g^-1 Cu, 7.9-17 μg g^-1 Co, 2.3-28 mg g^-1 Fe, 12-230 μg g^-1 Mn, and from 18 to 320 μg g^-1 Zn. The concentrations of Ni, Cr and Co were above the suggested safe limit of 1 μg g^-1 for skin protection, while Cd and Pb were above the Canadian specified limits. The systemic exposure dosage (SED) values for these metals obtained from the use of these facial cosmetic products were below their respective provisional tolerable daily intake (PTDI)/or recommended daily intake (RDI) values. The margin of safety values obtained were greater than 100 which indicated that the concentrations of the metals investigated in these facial cosmetics do not present considerable risk to the users except in the case of face powders.

Hexavalent and trivalent chromium in leather: What should be done?

Trivalent chromium compounds are used for leather tanning, and chromium may be released during use of leather goods. In certain instances, small amounts of hexavalent chromium can be formed and released. Both trivalent and hexavalent chromium can elicit allergic skin reaction in chromium sensitised subjects, the latter being significantly more potent. Induction of sensitisation only occurs after exposure to hexavalent chromium. A minority of subjects are sensitised to chromium, and in a fraction of these subjects allergic skin reaction have been described after wearing leather shoes or, less frequently, other leather goods. The evidence that in all these cases the reaction is related to hexavalent chromium is not always strong. The content of hexavalent chromium in leather is regulated in European Union, but rate of release rather than content is relevant for allergic skin reaction. The role of trivalent chromium appear much less relevant if at all. Modern tanning procedure do not pose significant risk due to either hexavalent or trivalent chromium. Dismissing bad quality and worn-off leather goods is relevant in reducing or eliminating the skin reaction. It should also be pointed out that shoe components or substances other than chromium in leather may cause allergic/irritative skin reactions.

Chromium released from leather - I: exposure conditions that govern the release of chromium(III) and chromium(VI)

Background

Approximately 1–3% of the adult population in Europe is allergic to chromium (Cr). A new restriction in REACH (Registration, Evaluation, Authorization and Restriction of Chemicals) based on the ISO 17075 standard has recently been adopted in the EU to limit Cr(VI) in consumer and occupational leather products.

Objectives

The aim of this study was to critically assess key experimental parameters in this standard on the release of Cr(III) and Cr(VI) and their relevance for skin exposure.

Material and methods

Four differently tanned, unfinished, leather samples were systematically investigated for their release of Cr(III) and Cr(VI) in relation to surface area, key exposure parameters, temperature, ultraviolet irradiation, and time.

Results

Although the total release of Cr was largely unaffected by all investigated parameters, except exposure duration and temperature, the Cr oxidation state was highly dynamic, with reduced amounts of released Cr(VI) with time, owing to the simultaneous release of reducing agents from the leather. Significantly more Cr(III) than Cr(VI) was released from the Cr-tanned leather for all conditions tested, and it continued to be released in artificial sweat up to at least 1 week of exposure.

Conclusions

Several parameters were identified that influenced the outcome of the ISO 17075 test.

Consideration of criteria required for assignment of a (skin) sensitiser a substance of very high concern (SVHC) under the REACH regulation

The identification, characterisation, risk assessment and risk management of materials that cause allergic sensitisation is an important requirement for human health protection. It has been proposed that for some chemical and protein allergens, and in particular for those that cause sensitisation of the respiratory tract (associated with occupational asthma), it may be appropriate to regard them as Substances of Very High Concern (SVHC) under the provisions of REACH (Registration, Evaluation, Authorisation and restriction of CHemicals). We have argued previously that categorisation of sensitising agents as SVHC should be used only in exceptional circumstances. In the present article, the subject of SVHC is addressed from another perspective. Here the information that would be required to provide a compelling case for categorisation of a skin sensitising substance as a SVHC is considered. Three skin sensitising chemicals have been identified to serve as working examples. These are chromate, a potent contact allergen, and the skin sensitisers formaldehyde and isoeugenol. The key criterion influencing the decision regarding a skin sensitiser being categorised as SVHC is the extent to which impacts on the quality of life are reversible. Consequently, SVHC categorisation for skin sensitising chemicals should be used only in exceptional circumstances.

Evaluation of electric arc furnace-processed steel slag for dermal corrosion, irritation, and sensitization from dermal contact

Electric arc furnace (EAF) steel slag is alkaline (pH of ~11-12) and contains metals, most notably chromium and nickel, and thus has potential to cause dermal irritation and sensitization at sufficient dose. Dermal contact with EAF slag occurs in many occupational and environmental settings because it is used widely in construction and other industrial sectors for various applications including asphaltic paving, road bases, construction fill, and as feed for cement kilns construction. However, no published study has characterized the potential for dermal effects associated with EAF slag. To assess dermal irritation, corrosion and sensitizing potential of EAF slag, in vitro and in vivo dermal toxicity assays were conducted based on the Organisation for Economic Co-operation and Development (OECD) guidelines. In vitro dermal corrosion and irritation testing (OECD 431 and 439) of EAF slag was conducted using the reconstructed human epidermal (RHE) tissue model. In vivo dermal toxicity and delayed contact sensitization testing (OECD 404 and 406) were conducted in rabbits and guinea pigs, respectively. EAF slag was not corrosive and not irritating in any tests. The results of the delayed contact dermal sensitization test indicate that EAF slag is not a dermal sensitizer. These findings are supported by the observation that metals in EAF slag occur as oxides of low solubility with leachates that are well below toxicity characteristic leaching procedure (TCLP) limits. Based on these results and in accordance to the OECD guidelines, EAF slag is not considered a dermal sensitizer, corrosive or irritant.

Contact allergy and human biomonitoring--an overview with a focus on metals

Humans are widely exposed to chemicals. Today, there is an increased acknowledgement of the importance of measuring human and environmental exposures to man-made or refined chemicals. Different approaches have been applied over time, but during the past 25 years, there has been a general trend towards the use of human biomonitoring. A few studies have used human biomonitoring methodology to track contact allergens together with information on patch test reactivity. Hypothetically, the internal load of reactive chemicals might modify the immune response to haptens and the propensity to sensitize and elicit allergic contact dermatitis or develop tolerance. This review offers a general overview of human biomonitoring, including information about its typical application and methodology. Furthermore, studies that have attempted to perform simultaneous biomonitoring and patch testing are reviewed. It is concluded that all studies conducted until the present have focused on one or two routes of exposure (typically skin and oral exposure, but also skin and airway exposure), whereas no studies have investigated all routes at the same time. Also, there is a need for prospective studies, as all epidemiological studies so far have been cross-sectional.

Metal allergy--a review on exposures, penetration, genetics, prevalence, and clinical implications

The prevalence of metal allergy is high in the general population, and it is estimated that up to 17% of women and 3% of men are allergic to nickel and that 1-3% are allergic to cobalt and chromium. Among dermatitis patients, the prevalence of metal allergy is even higher. Metal allergy is mainly an environmental disorder although null mutations in the filaggrin gene complex were recently found to be associated with nickel allergy and dermatitis. Environmental metal exposures include jewelry, buttons, clothing fasteners, dental restorations, mobile phones, and leather. Although consumer exposure is responsible for most cases of metal allergy, the importance of occupational metal exposure remains present and should always be taken into consideration when one interprets allergic patch test reactions to metals. Traditionally, nickel, cobalt, and chromium have been the most important contact allergens. However, recently, gold and palladium have drawn much attention as the prevalence of contact allergy to these metals is high. Palladium allergy is mainly a result of cross-sensitization to nickel, whereas gold allergy is rarely clinically relevant when one takes its high prevalence into account. The epidemiology of metal allergy has recently changed in Europe as nickel allergy among ear-pierced Danish women has decreased following regulatory intervention on nickel release from consumer products. In the United States, the prevalence of nickel allergy is still increasing, which may be explained by the absence of regulation. The prevalence of chromium allergy is increasing in the United States, Singapore, and Denmark among dermatitis patients. This increase is significantly associated with leather exposure in Denmark. Metal allergy may result in allergic contact dermatitis and systemic allergic (contact) dermatitis. Furthermore, metal allergy has been associated with device failure following insertion of intracoronary stents, hip and knee prostheses, as well as other implants. This area is in need of more research.

Dose-Response Relationships and Threshold Levels in Skin and Respiratory Allergy

A literature study was performed to evaluate dose-response relationships and no-effect levels for sensitization and elicitation in skin- and respiratory allergy. With respect to the skin, dose-response relationships and no-effect levels were found for both intradermal and topical induction, as well as for intradermal and topical elicitation of allergenic responses in epidemiological, clinical, and animal studies. Skin damage or irritation may result in a significant reduction of the no-effect level for a specific compound. With respect to the respiratory tract, dose-response relationships and no-effect levels for induction were found in several human as well as animal studies. Although dose-response relationships for elicitation were found in some epidemiological studies, concentration-response relationships were present only in a limited number of animal studies. Reported results suggest that especially relatively high peak concentrations can induce sensitization, and that prevention of such concentrations will prevent workers from developing respiratory allergy. Moreover, induction of skin sensitization may result in subsequent heightened respiratory responsiveness following inhalation exposure. The threshold concentration for the elicitation of allergic airway reactions in sensitized subjects is generally lower than the threshold to induce sensitization. Therefore, it is important to consider the low threshold levels for elicitation for recommendation of health-based occupational exposure limits, and to avoid high peak concentrations. Notwithstanding the observation of dose-response relationships and no-effect levels, due to a number of uncertainties, no definite conclusions can be drawn about absolute threshold values for allergens with respect to sensitization of and elicitation reactions in the skin and respiratory tract. Most predictive tests are generally meant to detect the potential of a chemical to induce skin and/or respiratory allergy at relatively high doses. Consequently, these tests do not provide information of dose-response relationships at lower doses such as found in, for example, occupational situations. In addition, the observed dose-response relationships and threshold values have been obtained by a wide variety of test methods using different techniques, such as intradermal exposure versus topical or inhalation exposure at the workplace, or using different endpoints, which all appear important for the outcome of the test. Therefore, especially with regard to respiratory allergy, standardized and validated dose-response test methods are urgently required in order to be able to recommend safe exposure levels for allergens at the workplace.

Evaluating the nickel content in metal alloys and the threshold for nickel-induced allergic contact dermatitis

Many patients are currently suffering from nickel (Ni)-induced allergic contact dermatitis (ACD). There have been few Korean studies dealing with the threshold of Ni-induced ACD and quantifying the total amount of Ni in the metal alloys. The aim of this study is to evaluate the amount of Ni leached from metal alloys and Ni contents in metal alloys, and to estimate the threshold of Ni-induced ACD. All the earrings we examined leached below 0.5 microg/cm(2)/week, the upper limit of European Union (EU) regulation, but the other metal alloys leached a much higher amount of Ni than the limit. Likewise, all the earrings we examined contained less than 0.05% Ni (500 microg/g), the upper limit of EU regulation, but the other metal alloys exceeded this limit. Twenty Ni-sensitive subjects, who were patch-tested with various concentrations of Ni sulphate, showed positive reactions to 5% and 1% Ni sulphate, 10 subjects showed positive reactions to 0.01%, and the most sensitive subject showed reaction even to 0.0001%. The subjects in this study were more sensitive to Ni than those in the previous studies done in Europe. Taken together, strictly regulating the Ni-containing alloys that are made in Korea is needed to lower the occurrence of Ni-induced ACD.

Dermatological toxicity of hexavalent chromium

Hexavalent chromium causes two types of dermatological toxicities: allergic contact dermatitis (ACD) and skin ulcers. This report reviews the etiology, prevalence, pathology, dose-response, and prognosis of both of these reactions. Reports in the literature indicate that repeated exposure to hexavalent chromium in concentrations of 4-25 ppm can both induce sensitization and elicit chromium ACD. Exposure to 20 ppm hexavalent chromium can cause skin ulcers in nonsensitized people. The prevalence of chromium sensitivity in cement workers, exposed to 10-20 ppm hexavalent chromium for years, is approximately 4-5%. Chromium ACD can be a chronic debilitating disease, perhaps because chromium is ubiquitous in foods and in the environment and is difficult to avoid. Due to the high rates of sensitization in populations chronically exposed to chromium and the chronic nature of chromium ACD, some investigators recommend reducing the hexavalent chromiumconcentrations in consumer products, such as detergents, to less than 5 ppm.

Sensitization to nickel: etiology, epidemiology, immune reactions, prevention, and therapy

Nickel is a contact allergen causing Type I and Type IV hypersensitivity, mediated by reagins and allergen-specific T lymphocytes, expressing in a wide range of cutaneous eruptions following dermal or systemic exposure. As such, nickel is the most frequent cause of hypersensitivity, occupational as well as among the general population. In synoptic form, the many effects that nickel has on the organism are presented to provide a comprehensive picture of the aspects of that metal with many biologically noxious, but metallurgically indispensable characteristics. This paper reviews the epidemiology, the prognosis for occupational and non-occupational nickel allergic hypersensitivity, the types of exposure and resulting immune responses, the rate of diffusion through the skin, and immunotoxicity. Alternatives toward prevention and remediation, topical and systemic, for this pervasive and increasing form of morbidity are discussed. The merits and limitations of preventive measures in industry and private life are considered, as well as the effectiveness of topical and systemic therapy in treating nickel allergic hypersensitivity.

Determination of hexavalent chromium in cosmetic products by ion chromatography and postcolumn derivatization

Chromium hydroxide green [Cr(2)O(OH)(4)] and chromium oxide green (Cr(2)O(3)) are colouring agents for use in cosmetic products. These colourants may contain chromium (VI), which cause skin allergies through percutaneous adsorption on the skin. Eye shadow is a representative cosmetic product in which significant colourants are used. We analysed the chromium (VI) in the eye shadows by ion chromatography and post column derivatization. We optimize conditions of chromium (VI) analysis in eye shadows. During the pretreatment procedure, there are no exchange of chromium (III) to chromium (VI). This method has a limit of quantification for chromium (VI) of 1.0 microg l(-1), recovery rate of 100 +/- 3% and analysis time less than 10 min. This result is 300 times more sensitive than the high-performance liquid chromatography method. We applied the optimized method to analyse 22 eye shadows and 6 colouring agents. 2 out of 22 of the products contained more than 5 mg l(-1). In our previous work, 5 mg l(-1) of Cr represented a threshold level. There was much more Cr(VI) in the colouring agents. The Cr(VI) in one of the colouring agents was 97.6 mg l(-1).

Cr(III) and Cr(VI) in leather and elicitation of eczema

The aim of the present study was to investigate the relation between the content of Cr(VI) and soluble Cr(III) in leather and the ability of the leather to elicit eczema in chromium allergic patients. An array of chromium-tanned leather samples was analysed for the content of total Cr(VI) and soluble Cr(III) using the DIN 53314 and the DS/EN 420 methods. Subsequently, a group of 15 patients with a history of foot eczema and leather exposure was exposed to a selection of 14 chromium- and 1 vegetable-tanned leather sample on the upper back for 48 hr. In addition, one leather sample was used for a prolonged 14-day exposure study. In total, 4 of the 15 patients reacted to at least one leather sample, and 5 of the 14 leather samples elicited a reaction in at least 1 patient. The prolonged exposure study demonstrated that an extended exposure period may reveal allergenic potential of a leather sample not otherwise identified using an ordinary 48-hr exposure period. No relation was observed between the measured content of Cr(VI) and soluble Cr(III) in the leather and the elicitation of eczema. Thus, in order to evaluate the quality of chromium-tanned leather in relation to preventing allergic skin reactions, other more clinical relevant methods reflecting the actual bioavailable Cr(III) and Cr(VI) fractions should be developed.

Capillary electrophoresis hyphenated to inductively coupled plasma-sector field-mass spectrometry for the detection of chromium species after incubation of chromium in simulated sweat

The presence of chromium in chromium-tanned leather represents a considerable health problem since it can lead to chronic allergic contact dermatitis. Apart from trivalent chromium (Cr(III)), which is used for tanning, leather often contains hexavalent chromium (Cr(VI)), resulting from the oxidation of Cr(III) during the tanning process. This study deals with the chromium compounds in simulated sweat when brought into contact with Cr(III) or Cr(VI) and with chromium-tanned leathers. A capillary electrophoresis (CE) method was developed, with inductively coupled plasma-sector field-mass spectrometry (ICP-SF-MS) for element-specific detection. Two different electrophoretic runs, applying once the positive and once the negative polarity mode, were necessary for the detection of positively and negatively charged chromium species. Although sometimes described in the literature, a pre-run derivatization of the chromium-species was not performed here to prevent species transformation. 50 mmol.L(-1) sodium phosphate at a pH of 2.5 was used as CE separation buffer and as make-up liquid for the CE-ICP-SF-MS interface. When applied to simulated sweat samples incubated with Cr(VI), this method showed that methionine is responsible for the reduction of Cr(VI) into Cr(III), which, at its turn, forms a complex with lactic acid. In the case of sweat plus Cr(III), the latter step was also seen. Applied to simulated sweat in contact with leather samples, the method developed showed the presence of the former species among a much more complex pattern.

Experimental nickel elicitation thresholds - a review focusing on occluded nickel exposure

Nickel (Ni) is the most frequent cause of contact allergy among the female population. This makes it interesting to examine thresholds for elicitation under different conditions. Even though Ni exposure may be open, occluded, penetrating or oral, most dose-response studies in the literature concern single occluded application. The aims of this study were to assess thresholds of response by making a statistical analysis of available dose-response studies with single occluded exposure and comparing the results to thresholds from other modes of exposure. 8 occluded Ni dose-response studies were selected based on statistical considerations. The statistical analysis showed that 5% of a sensitized population react to 0.44 microg Ni/cm2 and 10% react to 1.04 microg Ni/cm2. In another study with a single open application, 7.8% of sensitized persons responded to a dose x6 higher than the dose to which 10% reacted in occluded exposure. When combining the exposure to Ni with an irritant, divagating results were found, although the literature shows evidence of an augmented response when combining exposure to an allergen and an irritant. The thresholds of penetrating exposure were found to be lower than the thresholds of single occluded exposure. Comparisons of different kind of exposures across studies are difficult, because of differences in the studies, although a comparison could be made by a study that compares the different exposures within the same individuals at the same time.

Chromium allergy: significance of both Cr(III) and Cr(VI)

Most studies investigating chromium allergy have been performed with Cr(VI). However, real exposure to chromium from leather products includes both Cr(III) and Cr(VI). We have determined and compared the minimum elicitation threshold (MET) concentration for Cr(III) and Cr(VI) in Cr(VI)-sensitive patients. In addition, reactions to combinations of Cr(III) and Cr(VI) were compared to reactions elicited by Cr(III) and Cr(VI) alone. Dilution series of Cr(III) and Cr(VI) were applied in Finn Chambers on the back of 18 patients. The patches were left for 2 days and readings were done on days 2, 3 and 7. The MET10% for Cr(III) and Cr(VI) was calculated from the dose-response curves to be 0.18 microg/cm2/48 h (6 p.p.m.) and 0.03 microg/cm2/48 h (1 p.p.m.), respectively. No significant differences in the response to combined Cr(III) and Cr(VI) solutions versus single solutions were found. Cr(III) was concluded to play an important role in chromium allergy, because Cr(III) and Cr(VI) were both capable of eliciting eczema at low concentrations. Rather than regarding chromium dermatitis as a result of Cr(VI) allergy alone, it may be more correct to consider it as a result of a combined Cr(III) and Cr(VI) allergy.

Factors determining percutaneous metal absorption

Metals play a vital role in human, animal and plant physiology, and important research, past and ongoing, is directed towards exploring the interrelated mechanisms that govern their penetration through skin. Much insight has been gained through these efforts, but our understanding of the process is still incomplete, mainly due to the failure to allow for the effects of chemical speciation of metallic elements, especially the transition metals. Also, the skin as target organ presents imponderable and wide margins of variability. In vivo permeability is subject to homeostasis regulating the overall organism; in vitro, the sections of skin used for diffusion experiments are likely to present artifacts. Endeavors to define rules governing skin penetration to give predictive quantitative structure-diffusion relationships for metallic elements for risk assessment purposes have been unsuccessful, and penetration of the skin still needs to be determined separately for each metal species, either by in vitro or in vivo assays. Phenomena observed by us and other investigators, which appear to determine the process of skin permeation for a number of metals, are reviewed, separating the exogenous factors from the characteristics of the skin or other endogenous factors.

Fragrance contact allergy: a clinical review

Most people in modern society are exposed daily to fragrance ingredients from one or more sources. Fragrance ingredients are also one of the most frequent causes of contact allergic reactions. The diagnosis is made by patch testing with a mixture of fragrance ingredients, the fragrance mix. This gives a positive patch-test reaction in about 10% of tested patients with eczema, and the most recent estimates show that 1.7-4.1% of the general population are sensitized to ingredients of the fragrance mix. Fragrance allergy occurs predominantly in women with facial or hand eczema. These women typically have a history of rash to a fine fragrance or scented deodorants. Chemical analysis has revealed that well known allergens from the fragrance mix are present in 15-100% of cosmetic products, including deodorants and fine fragrances, and most often in combinations of three to four allergens in the same products. This means that it is difficult to avoid exposure, as products labelled as 'fragrance free' have also been shown to contain fragrance ingredients, either because of the use of fragrance ingredients as preservatives or masking perfumes, or the use of botanicals. About 2500 different fragrance ingredients are currently used in the composition of perfumes and at least 100 of these are known contact allergens. Therefore, it is advisable to supplement standard patch testing with the patient's own stay-on cosmetic products, as well as the fragrance chemical hydroxyisohexyl-3-cyclohexane carboxaldehyde, which on its own gives responses in 1-3% of tested patients. The focus in recent years on the ingredients of the fragrance mix will probably result in the fragrance industry changing the composition of perfumes, and thus make the current diagnostic test less useful. New diagnostic tests are under development to identify contact allergy to new allergens, reflecting the continuous developments and trends in exposure.

Quantitative aspects of contact allergy to chromium and exposure to chrome-tanned leather

The potential of trivalent and hexavalent chromium to induce and elicit allergic contact dermatitis and the degree of chromium exposure from leather products are reviewed. Chromium dermatitis is often due to exposure in the occupational environment, with cement being one of the most common chromium sources. However, consumer products such as chromium(III)-tanned leather products are also an important source of chromium exposure. Apart from Cr(III), which is used for tanning, leather often also contains trace amounts of Cr(VI), which is formed by oxidation of Cr(III) during the tanning process. In a recent study of the Cr(VI) content of leather products bought on the Danish market, 35% of such articles had a Cr(VI) content above the detection limit of 3 p.p.m., ranging from 3.6 p.p.m. to 14.7 p.p.m. Leachable Cr(III) was detected at levels of 430-980 p.p.m. An examination of available dose-response studies showed that exposure to occluded patch test concentrations of 7-45 p.p.m. Cr(VI) elicits a reaction in 10% of the chromium-sensitive patients. When reviewing repeated open exposure studies, it is seen that either exposure to 5 p.p.m. Cr(VI) in the presence of 1% sodium lauryl sulfate (SLS) or exposure to 10 p.p.m. Cr(VI) alone both elicit eczema in chromium-sensitive patients. The eliciting capacity of Cr(III) has not been systematically investigated but, compared to Cr(VI), much higher concentrations are needed to elicit eczema.

Combined effects of irritants and allergens. Synergistic effects of nickel and sodium lauryl sulfate in nickel- sensitized individuals

Knowledge of the combined effects of irritants and allergens is of interest with respect to accurate risk assessment. The threshold for elicitation of allergic contact dermatitis in previously sensitized individuals may theoretically be markedly influenced by the simultaneous presence of irritants and allergens. Combined exposures have, however, only been studied infrequently. In the present study, the combined effect of an irritant and an allergen was evaluated in a dose-response designed experimental study. 20 nickel-sensitized subjects were exposed to patch testing with varying concentrations of NiCl2 (nickel chloride) and sodium lauryl sulfate (SLS) alone and in combination. Evaluation of skin reactions was performed by colorimetry, measurement of transepidermal water loss and clinical evaluation, and the data were analyzed by logistic dose-response models. A synergistic effect was found of combined exposure to NiCl2 and SLS, as compared to each of the substances applied separately, as evaluated by colorimetry and clinical scoring. This means that the effect produced by the combined exposure was substantially greater than the effect produced by either of the substances alone. A synergistic effect of combined exposure on skin barrier impairment was not found, since the barrier function is significantly influenced by SLS-exposure only and not by NiCl2. Concentration limits are used by industry and government agencies to protect consumers. The present results clearly illustrate that elicitation thresholds and concentration limits may be influenced considerably by combined exposure to allergens and irritants.

Labelling of skin sensitizers: the new European Dangerous Preparations Directive

The new Dangerous Preparations Directive (DPD, 1999/45/EC) introduces a special labelling requirement for skin sensitizers in products that are regulated under this Directive. The packaging of products containing 0.1% of a sensitizer must bear the inscription "Contains 'name of sensitizer'. May produce an allergic reaction." The aim is to protect individuals already sensitized by providing information which enables them to avoid products containing ingredients which may elicit their allergy. However, this is only of benefit where such sensitized individuals do exist in the population. Moreover, this labelling requirement does not take into account the potency of the skin sensitizer. For each sensitizer and type of skin exposure, there will be levels below which it will not elicit allergic contact dermatitis reactions in individuals who are sensitized to that chemical. We therefore propose that within the new DPD, it should be possible to override this labelling requirement with well-documented data, to ensure that information provided to the consumer on the product label is not misleading. The current implementation in the DPD of what is in principle a good idea means that further action (legislative changes; scope for derogation) is needed if the potential benefits are not to be lost.

Investigation of the threshold for allergic reactivity to chromium

Allergy to chromium is relatively common, often in association with exposure to cement or in leather manufacture. However, in certain locations, there appears to be a relatively large cohort of chromium-sensitive individuals whose allergy cannot be explained by these common sources. In particular, this group include Israeli housewives with persistent hand eczema and concomitant patch test positivity to chromium. The causation of their allergy has been linked with relatively high levels of chromium contamination in household products. To provide further information in respect of the definition of safe levels for such products, we examined 17 chromium-allergic individuals to determine their threshold for reaction under closed patch test and repeated open application test (ROAT) conditions. The data derived indicated that, on normal skin, the patch test threshold was 10 ppm chromium; in the presence of an irritant (sodium lauryl sulfate) the threshold was closer to 1 ppm, 2/17 subjects giving 1+ reactions at this concentration. In the more realistic exposure conditions of the ROAT, 8/14 individuals failed to react to 50 ppm, whilst 3/15 reacted to 5 ppm. Interestingly, there was very poor correlation between patch test sensitivity and ROAT sensitivity. To ensure the large majority of chromium-allergic individuals do not suffer elicitation of their allergy, as well as to limit the development of new chromium-sensitive subjects, it is recommended that household products adhere to a previously published standard of a maximum limit of 5 ppm, with an ultimate target of 1 ppm contamination by chromium.

Thresholds in contact sensitization: theoretical and practical considerations

The existence of thresholds for both the induction and the elicitation of contact sensitization is an important issue for hazard assessment in this area of toxicology. In this paper, the evidence for such thresholds has been reviewed from both theoretical and practical perspectives. When the mechanisms of skin sensitization are considered, the existence of thresholds can be shown to occur at several stages. They are both quantitative, for example in terms of the degree of protein haptenation and in the sufficiency of the signals for Langerhans cell migration and maturation, as well as qualitative, in terms of the type of immune response that is engaged. Such considerations are evidenced by a substantial body of practical observation. In humans and in animal models of skin sensitization there is abundant evidence for the existence of thresholds for both the induction and the elicitation of reactions. In addition to, and in distinction from, the experimental situation, in the general human population there is extensive evidence for threshold effects. This evidence arises directly from the observation that only a proportion of those who are exposed become sensitized (i.e. are patch test positive), and of that latter group only a proportion develop allergic contact dermatitis.

Cutaneous reactivity of the hands in nickel-sensitive patients with hand eczema

This study compares the cutaneous reactivity between the hand and the back for 7 female patients with active hand eczema, who were found to be nickel-sensitive on routine patch testing with the European standard series. Patients were patch tested to a dilution series of nickel sulfate on the back in order to determine the threshold concentration for elicitation of allergic contact dermatitis, and based upon this result a lower concentration of nickel was then used for patch tests on the hand. We found that in the majority of patients (6/7) the cutaneous responsiveness of the hand was not increased compared with that of the back. However, the hand of 1 patient was more sensitive to nickel and patch testing was accompanied with a flare of her eczema, which suggests that cutaneous hyperreactivity may be important in individual patients with hand eczema.

Hexavalent chromium-contaminated soils: options for risk assessment and risk management

Risk assessment involves establishing scientifically defensible dose-response relationships for end points of concern. For Cr(VI)-contaminated soils, this includes conducting dose-response assessments for blood, liver, and kidney toxicity following oral exposure; lung cancer following inhalation exposure; and allergic contact dermatitis following dermal exposure. This dose-response information is then integrated with a site-specific exposure assessment (or default assumptions) in order to develop a site-specific (or generic) soil criterion within the framework of a comprehensive risk characterization. Risk managers develop cleanup standards designed to protect against all possible adverse effects, taking into account these site-specific (or generic) criteria and other factors such as technical feasibility, cost-benefit analyses, and socio-political concerns. Recently a push for cost-benefit analyses of environmental decisions has occurred, further supporting the need for risk assessors to prepare a comprehensive risk characterization, with its attendant uncertainties. These risk assessment and management issues are brought to the forefront by risk assessors and risk managers dealing with Cr(VI)-contaminated soils. This article offers a review and analysis of the risk characterization of Cr(VI)-contaminated soils, showing that the differing toxicities with route of exposures do not necessarily lead to different characterizations or risk. Soil concentrations in the range of 130 to 450 ppm appear to protect against noncancer toxicity from oral exposure, cancer toxicity from inhalation exposure, and allergic contact dermatitis from dermal exposure.

Nickel dermatitis: how much nickel is safe?

The Nickel Directive will become law in the countries of the European Union in 1996. This directive states that the concentration of nickel in post assemblies (used after ear piercing) may not exceed 0.05%, that products which come into direct and prolonged contact with the skin, e.g. earrings, watchstraps or zippers, may not release greater than 0.5 microgram/cm2/week, and that nickel release from coated products will not exceed this level after 2 years of normal use. The data relating to the threshold for reacting to nickel and the levels of nickel release from nickel-containing objects, are considered in this review. Although the level of 0.5 microgram/cm2/week is one below which a minority of nickel-allergic subjects will react, it is not safe in every nickel-sensitive individual. This level of nickel release is currently exceeded by many nickel-containing alloys and jewelery items that are made from high-sulfur stainless steel, and manufacturers are going to have to change the composition of jewelery to comply with the directive.

Pre-treatment of nickel test areas with sodium lauryl sulfate detects nickel sensitivity in subjects reacting negatively to routinely performed patch tests

A fair % of patients with a clinical history of nickel allergy show negative patch test results. To improve the response rate to NiSO4 5% pet. patch tests, a testing procedure utilizing pre-treatment of the test area by a 24-h application of sodium lauryl sulfate (SLS) was introduced. 46 women with a clinical history of nickel sensitivity, who exhibited negative reactions to nickel sulfate 5% pet. patch tests, were studied. Patients underwent 6 patch tests on adjacent sites on the volar surface of the forearms. 4 patch tests were performed with a 72-h application of 40 mg nickel sulfate 5% pet. While 1 of these patch tests served as control, 3 test areas underwent 24-h pre-treatment with 40 microliters SLS, 1 with 0.1% and 2 with 0.5% solution. To evaluate differences in the reactivity to SLS plus nickel sulfate related to the site on the forearm, 0.5% SLS pre-treatment was performed both on a proximal and on a distal test site. At the 72-h evaluation, 19 subjects out of 46 showed positive reactions to nickel sulfate 5% pet. at skin sites pre-treated with 0.1% SLS, whereas 23 patients reacted positively at 0.5% SLS pre-treated areas. Echographic values of skin thickness and of hypo-echogenic dermal areas at positive pre-treated nickel test areas were higher than at control test areas, confirming the clinical evidence of an increased response to NiSO4 after SLS pre-treatment. The inflammatory reaction, as evaluated clinically and echographically, was much higher at distal skin areas (0.1% SLS and distal 0.5% SLS) than at proximal 0.5% SLS ones.

Pretreatment of the test area with 1-day occlusion improves the response rate to NiSO4 5% pet. patch tests in subjects with a positive history of nickel allergy

A group of 58 women, aged 18 to 51 years, with a clinical history of nickel allergy, who exhibited equivocal or negative reactions to nickel sulfate 5% pet. patch tests performed on the skin of the back, were recruited consecutively from the patch test clinic from September 1993 to June 1994. In order to improve the response rate to NiSO4 5% pet. patch tests, a testing procedure utilizing pretreatment of the test area by 1-day (24-h) occlusion was introduced. Patients underwent 2 patch tests on adjacent sites of the volar surface of both forearms. 3 of the patch tests were performed with 40 mg nickel sulfate 5% pet., whereas a control test was carried out by occluding with an empty chamber. 2 of the nickel sulfate test sites were pretreated with 1-day occlusion performed with an empty chamber. A visual grading system and echographic measurement were used to quantify the responses 30-40 min after patch test removal. Echographic evaluations were carried out using a 20 MHz B-scanner. Measurement of skin thickness and determination of the hypoechogenic dermal area, both considered to be parameters of inflammation, were used to evaluate the intensity of the allergic reaction. At the 3-day (72-h) evaluation, 19 subjects out of 58 clearly showed positive reactions to nickel sulfate 5% pet. at pre-occluded skin sites. Moreover, values of skin thickness and of 0-30 areas at positive pre-occluded nickel test areas were higher in respect to control test areas, confirming clinical evidence of increased response to NiSO4 after occlusion.

The prevention of nickel contact dermatitis. A review of the use of binding agents and barrier creams

Chelating agents and other substances can be used to bind nickel or reduce its penetration through the skin, and hence to reduce the symptoms in subjects with nickel sensitivity. Topical usage is mostly described but, in some studies, chelating agents have been given systemically. The most effective ligand for nickel so far described is 5-chloro-7-iodoquinolin-8-ol. Although normally regarded as safe, its usage in some situations may be limited by concerns about its toxicity. Other ligands with demonstrable effect include ethylenediaminetetraacetic acid in various forms, diphenylglyoxime and dimethylglyoxime. Cation exchange resins can effectively bind nickel and work both in vitro and in vivo. Propylene glycol, petrolatum and lanolin reduce the absorption of nickel through the skin. Corticosteroids and cyclosporin work in nickel dermatitis by suppressing the immunological reaction rather than through an effect on nickel. Studies of the oral administration of ligands such as tetraethylthiuram disulphide have given conflicting results but the use of these agents is limited by hepatoxicity in any case. Some compounds offer potential for use in the prophylaxis of nickel dermatitis. Further work is required to develop the existing agents and to look at the use of novel combinations, such as that of a cation exchanger with a ligand.

Patch test results with serial dilutions of nickel sulfate (with and without detergent), palladium chloride, and nickel and palladium metal plates

Clinical experience suggests the existence of different degrees of sensitivity in nickel-allergic patients. For quantification of this phenomenon, 462 consecutive patients with previously diagnosed or strongly suspected nickel allergy were tested with serial dilution patch tests with 5 ppm to 5% nickel sulfate in pet. (Ni), and 5 ppm to 1% nickel sulfate in pet. with 1% detergent (Ni/D). Additionally, nickel and palladium metal plates were tested in 103, and cobalt salts, dichromate and palladium chloride (PdCl2) in most patients. 332 patients reacted positively to Ni or Ni/D. The influence of a concomitantly administered detergent was not significant. A significant correlation was found between positive reactions to low concentrations of Ni (or Ni/D), i.e., 0.1% or less (N = 166), and concomitant reactions to nickel metal plates, cobalt salts and PdCl2 and a history of ear piercing with metal intolerance. The clinical relevance of reactions to PdCl2 is at present not clear. A subgroup of nickel-allergic patients with "high sensitivity" can be defined. In future studies further addressing the clinical relevance of high versus low sensitivity, patch testing with 0.01, 0.1, 1.0 and 5% nickel sulfate in pet. is recommended instead of routine tests with 5% only.

The inhibitory effects of topical chelating agents and antioxidants on nickel-induced hypersensitivity reactions

BACKGROUND

Nickel sensitivity is a common problem, often causing significant morbidity from chronic eczematous dermatitis. The main treatment, topical steroids, usually is unable to suppress the dermatitis completely.

OBJECTIVE

Our purpose was to study the effects of "barrier" ointments containing either chelating agents (clioquinol or ethylenediaminetetraacetic acid [EDTA]) or antioxidants (ascorbic acid or alpha-tocopherol) and 1% hydrocortisone on nickel-induced hypersensitivity reactions.

METHODS

Nickel-sensitive subjects were challenged with nickel-containing coins coated with the desired barrier ointment and their inhibitory effects observed. Patients with bilateral hand or earring dermatitis explored the efficacy of these agents in clinical use.

RESULTS

Clioquinol (3%) completely abolished the allergic reaction in all 29 subjects tested. EDTA (15%), ascorbic acid (20%), and alpha-tocopherol (10%) were less effective, and 1% hydrocortisone had no significant effect. In clinical use sites treated with a commercially available preparation containing 3% clioquinol and 1% hydrocortisone showed marked clinical improvement in all 10 subjects.

CONCLUSION

Clioquinol is a potent inhibitor of nickel-induced hypersensitivity reactions and is feasible to use as a barrier ointment to block the allergenic effects of nickel in sensitive patients.

The effect of repeated open exposure to low levels of nickel on compromised hand skin of nickel-allergic subjects

Nickel is a very common contact allergen, with some reports showing that more than 10% of women are affected. It is therefore important to be able to assess the risk of elicitation of nickel dermatitis in such individuals, particularly in relation to repeated exposure to low levels of this metal. It has been shown previously that under the conditions of a 48-h occluded patch test, some subjects will react to as little as 0.5 ppm nickel on compromised skin. In the present study, the effect of repeated open nickel application combined with repeated treatment with the anionic surfactant sodium dodecyl sulphate has been evaluated on the hand skin of 4 nickel-allergic subjects. Despite 2 of these being known to be particularly sensitive, there was no evidence of a nickel-allergic reaction following 2x daily immersion of hand skin sites in up to 1 ppm nickel over a period of 23 days.

Risk assessment of the allergic dermatitis potential of environmental exposure to hexavalent chromium

Although hexavalent chromium, Cr(VI), is a potent sensitizer and inducer of allergic contact dermatitis and is found in many common materials, no standard or guideline currently exists for protection against these effects in environmental exposure. There appears to be a generalized allergenic potential among the various compounds of Cr(VI). Estimates of the prevalence of Cr sensitivity in the population are uncertain, but range from about 2% of the total population in Finland to as high as 20% in U.S. populations with a dermatitis. Based on the thresholds reported for nine separate patch-test studies and statistical analysis of the aggregate dose-response relationship from 72 separate observations from these studies and on studies of allergic responses to bleaches and detergents, the effective threshold for elicitation of allergic contact dermatitis in sensitized populations is about 10 ppm (mg/L) Cr(VI) (as chromium) in solution. Based on evaluation of the literature on cement dermatitis, the threshold concentration of extractable Cr(VI) in solid material may be as low as 10 ppm (microgram/g). For ingestion of Cr(VI), the lowest observed effect level (LOEL) dose for elicitation is 0.26 microgram/kg. In calculating the threshold concentration of Cr(VI) in soil for elicitation of contact dermatitis, extractability must be taken into account.

Concentration threshold of non-occluded nickel exposure in nickel-sensitive individuals and controls with and without surfactant

Most cases of primary nickel sensitization are caused by occluded exposure to nickel released from earrings, buttons, etc. Nickel-sensitive females are both domestically and occupationally exposed to trace amounts of nickel. The present study was designed to define the minimum eliciting threshold concentration of nickel exposure in previously nickel-sensitized individuals, after open application on normal forearm skin with and without surfactant. A dilution series of NiCl2, ranging from 0.1 to 4000 ppm nickel with and without 4% sodium lauryl sulfate, was applied to healthy volar forearm skin. None reacted with definite allergic reactions to 100 ppm and below. Follicular reactions were seen in the concentration range from 0.1-100 ppm in a few patients and 1 healthy control. The results are discussed in relation to consumer products containing 1-10 ppm nickel.