Contact Urticaria Syndrome: a Comprehensive Review

Purpose of Review

Contact urticaria syndrome includes contact urticaria and protein contact dermatitis. Underreport, underdiagnosis, or misdiagnosis of entities within the contact urticaria syndrome is believed to be common, especially in the occupational setting. This review provides a structured overview of the entities comprised in this syndrome as well as the diagnostic work-up and management strategies.

Recent Findings

Contact urticaria syndrome has been increasingly described due to personal protective equipment and hand sanitizers in the context of the COVID-19 pandemic. The use of legal cannabis products has led to a rise in occupational cases of contact urticaria to cannabis. A declining trend in the evolution of contact urticaria has been described for natural rubber latex allergy due to the use of synthetic gloves. Prick test has been proposed as a screening method, particularly if multiple products are to be tested, instead of the classical sequential scheme.

Summary

Physicians should be aware of the growing number of culprit agents leading to contact urticaria syndrome. Clinical presentation may be challenging since it includes immediate urticaria and/or eczema and even more generalized reactions. Diagnosis requires a high degree of suspicion, detailed occupational history, and complementary tests, including skin testing. The best treatment is to avoid contact with the culprit agent and to implement preventive measures.

Proteolytic activity accelerates the TH17/TH22 recall response to an epicutaneous protein allergen-induced TH2 response

Epicutaneous exposure to protein allergens, such as papain, house dust mite (HDM), and ovalbumin (OVA), represents an important mode of sensitization for skin diseases including protein contact dermatitis, immunologic contact urticaria, and atopic dermatitis. These diseases are inducible by re-exposure to an allergen at both original skin sensitization and distant skin sites. In this study, we examined the serum IgE/IgG₁ response, differentiation of T-helper (T_H) cells, and epicutaneous T_H recall response in mice pre-sensitized with protein allergens through the back skin and subsequently challenged on the ear skin. Repeated epicutaneous sensitization with allergenic proteins including papain, HDM, OVA, and protease inhibitor-treated papain, but not bovine serum albumin, induced serum allergen-specific antibody production, passive cutaneous anaphylaxis responses, and T_H2 differentiation in the skin draining lymph node (DLN) cells. Sensitization with papain or HDM, which have protease activity, resulted in the differentiation of T_H17 as well as T_H2. In papain- or HDM-sensitized mice, a subsequent single challenge on the ear skin induced the expression of T_H2 and T_H17/T_H22 cytokines. These results suggest that allergenic proteins induce the differentiation of T_H2 in skin DLN cells and an antibody response. These findings may be useful for identifying proteins of high and low allergenic potential. Moreover, allergenic proteins containing protease activity may also differentiate T_H17 and induce T_H2 and T_H17/T_H22 recall responses at epicutaneous challenge sites. This suggests that allergen protease activity accelerates the onset of skin diseases caused by protein allergens.

Contact Dermatitis: Classifications and Management

Contact dermatitis (CD) is a common inflammatory skin disease caused by exposure to contact allergens and irritants. It is also the most common reason of occupational dermatitis and contributes greatly to hand dermatitis and facial dermatitis. Besides the two major forms of contact dermatitis: allergic contact dermatitis and irritant contact dermatitis, other subtypes of CD have been recognized including immediate skin reactions, photoinduced contact dermatitis, systemic contact dermatitis, and non-eczematous contact dermatitis. CD is a great imitator which can mimic many kinds of skin diseases, such as atopic dermatitis, lichen planus, and angioedema. For the diagnosis of CD, a complete medical history, including occupational history, is very important. It can give a clue of CD and provide a list of suspected substances. Besides the well-known diagnostic test, patch testing, there are many other diagnostic tests can be used to help diagnosis of CD and identify the causative allergens, including photopatch test, skin tests for detecting of immediate contact reactions, serum allergen-specific IgE test, and qualitative and quantitative testing of allergen in the suspected materials patients exposed to and challenge test. Before the treatment, the suspected irritants or allergens should be avoided completely. This includes both the removal of the patient from the environment that contains those substances and the promotion of the metabolism and expulsion of the allergens that have been absorbed by the body. In addition, it is also important to restore the skin barrier and reduce skin inflammation through multiple treatments, such as emollients, topical corticosteroids, and antihistamines, as well as systemic corticosteroids and immunosuppressants. Early and appropriate treatments are important to prevent further deterioration and persistence of the skin condition.

Protein Causes of Urticaria and Dermatitis

Protein contact dermatitis is a cutaneous hypersensitivity reaction after chronic, recurrent exposure or chronic irritation to animal or plant protein. Although the pathophysiological mechanisms underlying protein contact dermatitis are not well characterized, protein contact dermatitis is thought to be caused by combined type I/IV-mediated, type-1 mediated, or a Langerhans cell immunoglobulin E-mediated delayed hypersensitivity reaction. This chapter reviews the epidemiology, pathogenesis, clinical features, common protein allergens, diagnostic process, treatment options, and prognosis of protein contact dermatitis.

Contact Urticaria

This article discusses contact urticaria syndrome definition, history, epidemiology, occupational relevance, mechanisms, clinical manifestations, diagnostic tools, agents responsible, and how to prevent and treat the patients affected. Contact urticaria syndrome is often misdiagnosed because it is not well known or recognized by physicians. Commonly the patient recognizes the cause of the clinical symptom, but the cause can be exceptional or new. Triggers include proteins, chemical compounds, agricultural chemicals, metals, plants, foods, and other substances. The objective of this article is to help dermatologists, toxicologists, and immunologists by providing diagnostic tools to avoid the culprit agent and treat the patients.

Contact dermatitis

Contact dermatitis (CD) is among the most common inflammatory dermatological conditions and includes allergic CD, photoallergic CD, irritant CD, photoirritant CD (also called phototoxic CD) and protein CD. Occupational CD can be of any type and is the most prevalent occupational skin disease. Each CD type is characterized by different immunological mechanisms and/or requisite exposures. Clinical manifestations of CD vary widely and multiple subtypes may occur simultaneously. The diagnosis relies on clinical presentation, thorough exposure assessment and evaluation with techniques such as patch testing and skin-prick testing. Management is based on patient education, avoidance strategies of specific substances, and topical treatments; in severe or recalcitrant cases, which can negatively affect the quality of life of patients, systemic medications may be needed.

In Vitro and Clinical Safety Assessment of the Multiple W/O/W Emulsion Based on the Active Ingredients from Rosmarinus officinalis L., Avena sativa L. and Linum usitatissimum L

The multiple W/O/W emulsion supplemented with the extracts of Rosmarinus officinalis L., Avena sativa L. and Linum usitatissimum L. was prepared in the study, its active compounds were determined by HPLC and its safety was evaluated in vitro by the means of reconstituted human skin model EpiDerm™ for the assessment of its irritation, phototoxicity and early skin inflammation effects and by the 48 h human skin patch test for its skin irritation and allergenic potential. The microbiological challenge test of W/O/W emulsion was performed to ensure its preservation efficiency. The results showed that the W/O/W emulsion loaded with self-preserving plant-based bio-actives had no irritant potential, was not phototoxic and did not provoke skin inflammation or sensitization and thus could be used as a safe base for cosmetic products. Furthermore, our results demonstrate that the safety evaluation of cosmetic ingredients of natural or organic origin could be easily performed using reconstructed human skin model EpiDerm™ similar to the well-defined chemicals used in the cosmetics industry.

Total dose defines the incidence of percutaneous IgE/IgG1 mediated immediate-type hypersensitivity caused by papain

Assessment of human health risk requires an understanding of antigen dose metrics associated with toxicity. Whereas assessment of the human health risk for delayed-type hypersensitivity is understood, the metrics remain unclear for percutaneous immediate-type hypersensitivity (ITH) mediated by IgE/IgG1. In this work, we aimed to investigate the dose metric for percutaneous ITH mediated by IgE/IgG1 responses. Papain, which causes ITH via percutaneous sensitization in humans, was used to sensitize guinea pigs and mice. The total dose per animal or dose per unit area was adjusted to understand the drivers of sensitization. Passive cutaneous anaphylaxis (PCA) and enzyme-linked immunosorbent assay (ELISA) for papain-specific IgG1 enabled quantification of the response in guinea pigs. In mice, the number of antigen-bearing B cells in the draining lymph nodes (DLN) was calculated using flow cytometry papain-specific IgG1 and IgE levels were quantified by ELISA. PCA positive test rates and the amounts of antigen-specific antibody corresponded with total dose per animal, not dose per unit area. Furthermore, the number of B cells taking up antigen within DLN also correlated with total dose. These findings indicate that the total antigen dose is the important metric for percutaneous IgE/IgG1-mediated ITH.

Contact urticaria and protein contact dermatitis in the Finnish Register of Occupational Diseases in a period of 12 years

BACKGROUND

Although occupational contact urticaria (CU) and protein contact dermatitis (PCD) are considered frequent among workers with exposure to proteinaceous materials, data on occupations at risk and the main causes of these occupational skin diseases are relatively limited.

OBJECTIVES

To report the causative agents and risk occupations for CU and PCD in the Finnish Register of Occupational Diseases (FROD).

METHODS

We retrieved from the FROD all recognized cases of CU/PCD in the years 2005-2016.

RESULTS

With 570 cases, CU and PCD constituted 11% of all recognized cases of occupational skin diseases in the study period. Occupations with the highest incidence of CU/PCD included bakers, chefs and cooks, farmers and farm workers, veterinarians, gardeners, and hairdressers. The most common causative agents were cow dander and flour and grain, followed by natural rubber latex (NRL) and other food. In food-related occupations, wheat and other flours were by far the most common cause of CU/PCD, with 76 cases, whereas fish and other animal-derived food caused 33 and other plant-derived food caused 23 cases.

CONCLUSIONS

Apart from the Finnish peculiarity of cow dander allergy, a striking finding was a large share of CU/PCD caused by flours in food handlers as compared to other food.

Contact urticaria: Frequency, elicitors and cofactors in three cohorts (Information Network of Departments of Dermatology; Network of Anaphylaxis; and Department of Dermatology, University Hospital Erlangen, Germany)

BACKGROUND

Contact urticaria (CU) is an infrequent, mostly occupational disease that may be life-threatening (CU syndrome stage 4).

OBJECTIVES

To identify the current frequency, elicitors and cofactors of CU.

PATIENTS

Three cohorts were retrospectively analysed for CU: (a) patients from the Information Network of Departments of Dermatology (IVDK) database (2000-2014; n = 159 947); (b) patients from an allergy unit (Department of Dermatology, University Hospital Erlangen, 2000-2015; n = 4741); and (c) patients from the Anaphylaxis Registry (2007-2015: 6365 reported cases, including 2473 patients with Ring and Messmer grade III-IV reactions) for severe cases with skin/mucosal manifestations occurring at the workplace vs cases not occurring at the workplace (n = 68 vs n = 1821).

RESULTS

Four hundred and forty-eight CU patients (0.28%) were diagnosed in the IVDK cohort, and 16 (0.34%) (10 of immunological aetiology, and 6 of non-immunological aetiology) in the Erlangen cohort. The most frequent elicitors in the IVDK cohort were cosmetics, creams, sun protection agents (although these were less frequent in CU patients than in controls without CU; 26.8% vs 35.6%, P < .0001), and gloves (significantly more frequent in CU patients than in controls; 18.1% vs 6.5%, P < .0001). The most frequent elicitors in the Erlangen cohort were natural rubber latex and sorbic acid. Among the MOAHLFA index characteristics, in both cohorts occupational disease was more common in CU patients than in patients without CU. CU was significantly associated with allergic rhinitis and allergic asthma. Wet work was a relevant cofactor. In the Anaphylaxis Registry, 19 cases (0.3%) were identified with severe reactions including skin symptoms at the workplace linked to common occupational elicitors.

CONCLUSIONS

CU is a rare occupational skin manifestation with a frequency of <0.4% in the examined patients; it may, however, progress to anaphylaxis. Preventive measures are important, and should take into account the identified elicitors and cofactors.

Innovative Natural Ingredients-Based Multiple Emulsions: The Effect on Human Skin Moisture, Sebum Content, Pore Size and Pigmentation

The increased interest in natural cosmetics has resulted in a higher market demand for preservative-free products based on herbal ingredients. An innovative W/O/W type emulsions containing herbal extracts were prepared directly; its cation form was induced by an ethanolic rosemary extract and stabilized using weak herbal gels. Due to the wide phytochemical composition of herbal extracts and the presence of alcohol in the emulsion system, which can cause skin irritation, sensitization or dryness when applied topically, the safety of the investigated drug delivery system is necessary. The aim of our study was to estimate the potential of W/O/W emulsions based on natural ingredients for skin irritation and phototoxicity using reconstructed 3D epidermis models in vitro and to evaluate in vivo its effect on human skin moisture, sebum content and pigmentation by biomedical examination using a dermatoscopic camera and corneometer. According to the results obtained after in vitro cell viability test the investigated emulsion was neither irritant nor phototoxic to human skin keratinocytes. W/O/W emulsion did not cause skin dryness in vivo, despite the fact that it contained ethanol. We can conclude that the emulsion is safe for use as a leave-on product due to the positive effect on human skin characteristics or as a semisolid pharmaceutical base where active compounds could be encapsulated.

Gluten-related disorders: certainties, questions and doubts

In the last decade, the ingestion of gluten, a heterogeneous complex of proteins present in wheat, rice, barley and probably in oats, has been associated with clinical disorders, such as celiac disease, wheat allergy and recently to non-celiac gluten sensitivity or wheat intolerance syndrome. Gluten-related disorders, which are becoming epidemiologically relevant with an estimated global prevalence of about 5%, require the exclusion of gluten from the diet. For the past 5 years, an important shift in the availability of gluten-free products, together with increased consumption in the general population, has been recorded and is estimated to be about 12-25%. Many people follow a self-prescribed gluten-free diet, despite the fact that the majority have not first been previously excluded, or confirmed, as having gluten disorders. They rely on claims that a gluten-free diet improves general health. In this review, we provide an overview of the clinical disorders related to gluten or wheat ingestion, pointing out the current certainties, open questions, possible answers and several doubts in the management of these conditions. KEY MESSAGE Incidence of gluten-related disorders is increased in the last decade and self-diagnosis is frequent with inappropriate starting of a gluten-free diet. Gluten and wheat are considered as the most important triggers to coeliac disease, wheat allergy and non-celiac gluten sensitivity. Pediatricians, allergologist and gastroenterologist are involved in the management of these conditions and appropriate diagnostic protocols are required.

Occupational contact dermatitis from protein in sea products: who is the most affected, the fisherman or the chef?

BACKGROUND

Protein contact dermatitis has frequently been reported in case studies (usually in cases involving contact with seafood products), but there are very few descriptive series. The objectives of this present study were firstly to determine the incidence of protein contact dermatitis among fishermen in France and compare it with data from onshore work involving seafood exposure. Second, to discover what factors could explain any differences. In order to answer these questions we analysed data from the French national occupational disease surveillance and prevention network (RNV3P) and occupational diseases declared to the French National Network for Monitoring and Prevention of Occupational Disease. This retrospective study was done for a 13 year period.

CASE PRESENTATION

Between 2000 and 2012, we only found eight cases of protein contact dermatitis in the French network. There were no cases of protein contact dermatitis in the seafaring population. The eight cases from the French network are essentially allergies to different fish and chefs are the professionals most affected. Atopy is present in half of these cases. In the seafaring population we found several cases of allergic delayed-time contact dermatitis due to bryozoans and to gloves but no protein contact dermatitis.

CONCLUSIONS

Chefs who have to cook seafood are more at risk of occupational protein contact dermatitis than fishermen. We think that skin protection (that is to say glove wearing) is better implemented in the fishing sector than in the catering profession on shore in France.

Pattern of Skin Diseases and Occupational Dermatoses in Veterinarians and Veterinary Workers of Kashmir

Background:

Across the globe, skin disorders represent a frequent occupational concern for many health professionals including veterinarians and there is a serious impact of skin diseases on their lives and careers. But little is known about the prevalence and distribution of skin diseases (especially occupational) within this important professional group across Asia, especially India.

Materials and Methods:

The study was a cross-sectional study carried out over a period of one year in which veterinarians and veterinary workers of Kashmir valley were screened for various skin diseases and occupational dermatoses.

Results:

The study group comprised 910 veterinarians and associated workers working across the valley with the majority being males; 846 workers (93%). The mean age of the group was 38.53 years. Out of these, 267 veterinarians and associated workers (29.3%) were found to have skin lesions. Of the 267 cases, 165 (61.80%) had non-infectious lesions, while the rest had 102 (38.20%) had infectious skin diseases. The main non-infectious lesions included friction-related disorders, eczemas, pigmentary disorders, papulosquamous disorders, and many others; while the infectious lesions were of fungal, bacterial, viral, and parasitic etiology. Fungal infections, eczemas, and melasma were more common in them, indicating an occupational etiology.

Conclusion:

A huge group of skin diseases was seen in veterinarians and veterinary workers, with some diseases showing an occupational nature. To reduce the burden of skin diseases in this particular group, proper prevention measures need to be instituted at work places by veterinary governing bodies of the state.

Occupational contact urticaria: lessons from the French National Network for Occupational Disease Vigilance and Prevention (RNV3P)

BACKGROUND

Occupational contact urticaria (OCU) is an occupational contact dermatitis that can cause serious health consequences and disability at work.

OBJECTIVES

To describe OCU and its temporal trends by the main causal agents and activity sectors in a nationwide scheme in France.

METHODS

Using data from the French National Network for Occupational Disease Vigilance and Prevention (RNV3P), we described OCU reported during the period 2001-10 and analysed the temporal trends of OCU and OCU attributed to the most frequent agents over the study period. Trends analyses were supported by reporting odds ratios using a logistic regression model with reference to 2001, or with time as a continuous variable.

RESULTS

During the study period, 251 cases of OCU were reported in RNV3P, half of which were due to natural rubber latex, in particular in the health and social work activity sector (HSW). The number of these cases declined significantly over the study period (19% per year), and particularly after 2006. Conversely, the other causes of OCU did not decrease.

CONCLUSIONS

Using surveillance data from a French national network, this study has found that there was a significant decline in OCU due to natural rubber latex, particularly in the HSW, when powdered latex gloves were banned from French hospitals. Our results show the effectiveness of this preventive measure, and suggest that this practice should be extended to other sectors.

Guidelines for diagnosis, prevention and treatment of hand eczema

The guidelines aim to provide advice on the management of hand eczema (HE), using an evidence- and consensus-based approach. The guidelines consider a systematic Cochrane review on interventions for HE, which is based on a systematic search of the published literature (including hand-searching). In addition to the evidence- and consensus-based recommendation on the treatment of HE, the guidelines cover mainly consensus-based diagnostic aspects and preventive measures (primary and secondary prevention). Treatment recommendations include non-pharmacological interventions, topical, physical and systemic treatments. Topical corticosteroids are recommended as first line treatment in the management of HE, however continuous long-term treatment beyond six weeks only when necessary and under careful me-dical supervision. Alitretinoin is recommended as a second line treatment (relative to topical corticosteroids) for patients with severe chronic HE. Randomized control trials (RCT) are missing for other used systemic treatments and comparison of systemic drugs in “head-to-head” RCTs are needed.The guidelines development group is a working group of the European Society of Contact Dermatitis (ESCD) and has carefully tried to reconcile opposite views, define current optimal practice and provide specific recommendations, and meetings have been chaired by a professional moderator of the AWMF (Arbeitsgemeinschaft der Wis-senschaftlichen Medizinischen Fachgesellschaften; Association of the Scientific Medi-cal Societies in Germany).No financial support was given by any medical company. The guidelines are expected to be valid until December 2017 at the latest.

[Protein contact dermatitis in a butcher]

Protein contact dermatitis is a disease primarily seen in food handlers. The usual presenting finding is hand dermatitis. It is triggered by an IgE-mediated food sensitization, so that after local exposure T cells are recruited and cause the dermatitis. The diagnosis is based on history, clinical features and demonstration of IgE-dependent sensitization, which can also cause contact urticaria and even contact anaphylaxis. We report a case of PCD in a butcher, who could continue his work due to adequate diagnosis and management.

Clinical profile and quality of life of patients with occupational contact dermatitis from New Delhi, India

BACKGROUND

Data regarding occupational contact dermatitis (OCD) and its effect on quality of life (QOL) in India are limited.

OBJECTIVES/AIMS

To evaluate patients with OCD and record the outcome of treatment.

PATIENTS/MATERIALS/METHODS

All patients with OCD were evaluated for severity of disease (by the use of physician global assessment) and its effect on QOL (by use of the Dermatology Life Quality Index) questionnaire) at the first visit and after 3 months of treatment.

RESULTS

Among 117 patients with OCD, hand eczema was present in 81.2%. Positive patch test reactions were found in 76%. The most common allergens were Parthenium hysterophorus and potassium dichromate. The most frequent diagnosis was occupational allergic contact dermatitis (OACD) (57%), caused by farming and construction work, followed by occupational irritant contact dermatitis (OICD) (24%), caused by wet work. Severe psychosocial distress was recorded in 62.5% of patients. After 3 months of treatment, 83% improved significantly, and 54% had improvement in QOL.

CONCLUSIONS

Farmers were most frequently affected, followed by construction workers and housewives. OACD was found at a higher frequency than OICD. The most frequent allergens were Parthenium hysterophorus in farmers, potassium dichromate in construction workers, and vegetables in housewives. OCD has a significant impact on QOL. Patch testing, in addition to standard treatment, improves the outcome considerably.

Clinical characterization and IgE profiling of birch (Betula verrucosa)--allergic individuals suffering from allergic reactions to raw fruits and vegetables

BACKGROUND

Hypersensitivity to raw fruits and vegetables is often associated with respiratory allergy to birch (Betula verrucosa) pollen and is considered to be the most prevalent form of food allergy in adults sensitized to birch pollen.

OBJECTIVE

The aim of the study was to investigate the association of clinical allergy and IgE profiles in individuals with birch pollen allergy and hypersensitivity to raw fruits and vegetables.

METHODS

A total of 59 adults with clinical and skin prick test confirmed birch pollen allergy were included in the study. All the subjects were interviewed by using a structured questionnaire and were examined in vivo by the open test, with the appropriate fruits and vegetables. ImmunoCAP and ImmunoCAP ISAC were used as in vitro diagnostics to assess sensitization profiles for each individual, and principal components analysis was used to analyze the IgE data sets.

RESULTS

Of 59 individuals, 54 (92%) had positive prick-prick test with raw potato, carrot, apple, and/or hazelnut, and the skin prick test was always positive when the corresponding skin challenge was defined as positive. Specific IgE in the ImmunoCAP and inhibition assays with rMal d 1 and rBet v 1 demonstrated that Bet v 1 is driving the sensitization against pathogenesis related-10 proteins. However, positive IgE in vitro results could not be used to predict clinical reactivity to raw fruits and vegetables.

CONCLUSIONS

The present study showed that component-based IgE profiling does not enhance the diagnostic potential in case of pollen-food syndrome, which may be associated with other as yet unidentified components.

Occupational food-related hand dermatoses seen over a 10-year period

BACKGROUND. Protein contact dermatitis was originally defined in 1976 by Hjorth and Roed-Petersen as a distinct kind of dermatitis seen in patients with occupational food contact. Even though occupational skin diseases are frequent in Denmark, little attention has been paid to protein contact dermatitis, and the frequency is unknown.

OBJECTIVES

To evaluate the frequency of occupational food-related hand dermatoses and test results in patients occupationally exposed to foods.

MATERIALS AND METHODS

This was a retrospective study based on examinations, including skin prick testing and patch testing, performed at the Department of Dermato-Allergology, Gentofte University Hospital, Denmark between 2001 and 2010.

RESULTS

Of all patients (n = 372), 57.0% had irritant contact dermatitis, 22.0% had protein contact dermatitis, 2.4% had contact urticaria, and 1.8% had allergic contact dermatitis. A suggestion for diagnostic criteria is presented. Frequent risk occupations were cooking in restaurants, baking, and kitchen work. Substantially more patients reacted in skin prick testing with fresh foods than with food extracts. Conclusion. Protein contact dermatitis is a frequent disorder among patients who professionally handle foods, and should be considered to be a distinct clinical entity. When diagnosing protein contact dermatitis and in other food-related skin prick testing procedures, it is important to include fresh foods.