Allergic contact dermatitis caused by sodium metabisulfite: a challenging allergen. A case series and literature review

Contact allergy to topical ophthalmic medications: A retrospective single-centre study of three decades

BACKGROUND

The prevalence of contact allergy to various ophthalmic medications appears to be rare; however, data on culprits, clinical relevance of sensitizations, and changes in frequency within recent decades are limited.

OBJECTIVE

This study aimed to investigate the clinical relevance, risk factors, and prevalence of contact allergy to topical ophthalmic medications in patients suspected of allergic contact dermatitis to ophthalmic medication.

METHODS

We retrospectively analysed patch test results and clinical data for 754 patients patch-tested with an ophthalmic medication series at our tertiary referral centre between January 1992 and December 2022.

RESULTS

In total, 37.5% (283/754) of patch-tested patients had a contact allergy to at least one ophthalmic allergen, with 87.3% (247) being clinically relevant sensitization. Phenylephrine (31.8%, 192/604), povidone-iodine (29%, 27/93), and tobramycin (23%, 46/200) were the most important sensitizers. The incidence of contact allergies increased significantly in a linear manner (p = 0.008) from 20% to 44.1% within the study period. Male sex and age above 40 were risk factors for contact allergy to ophthalmic medication.

CONCLUSIONS

One third of patch tested patients had allergic contact dermatitis to ophthalmic medication, particularly phenylephrine. Male sex and age above 40 years were independent risk factors and drove the linear increase in contact allergy to ophthalmic medications within the past 31 years.

Trends in contact sensitization, results, and implications from a contact dermatitis clinic in Israel

BACKGROUND

The baseline series includes common allergens, evolves over time, and differs by location. Our study aims to characterize allergen sensitization trends among the Israeli population during the last two decades, compare our results to American and European registries, as well as to highlight significant allergens in additional series outside the European baseline series (OEBS).

METHODS

We analysed patch test results of 2086 patients from a designated contact dermatitis clinic in Tel Aviv between 2019 and 2022, compared them to European and North American registries and to 2156 patch test results conducted in Israel two decades ago.

RESULTS

38.6% of patients had at least one positive reaction to an allergen in the European baseline series (EBS), nickel sulphate (14.6%), fragrance mix I (4.6%), and Methylchloroisothiazolinone methylisothiazolinone (MCI/MI; 3.7%) were the most common among them. N-Isopropyl N-Phenyl-4-Phenylenediamine (NIPPD; 0%), Propolis (0.1%), Sesquiterpene lactone mix (0.1%), and Budesonide (0.1%) elicited a sensitization frequency significantly lower than the proposed threshold for baseline inclusion. Chi-square test revealed a statistically significant decrease (p < 0.05) in the sensitization frequency of fragrance mix I, Formaldehyde, Potassium dichromate, Neomycin sulphate, Myroxylon pereirae, Sesquiterpene lactone, and NIPPD during the last two decades. The overall sensitization frequency to the majority of allergens was lower in our cohort in comparison to the North American and European registries.

CONCLUSIONS

MCI/MI and 2-hydroxyethyl methacrylate-2 (HEMA) are common, relevant allergens, with high SPIN (significance and prevalence index number) and should be better regulated by the authorities. While among the EBS, NIPPD, Propolis, Sesquiterpene lactone, and Budesonide usually do not elicit a positive reaction and therefore should be reconsidered in baseline series, among the OEBS, Chloramphenicol, Quaternium 15, Propyl gallate, and Amerchol L101 have elicited high SPIN values and should be vigilantly examined in the suitable clinical scenario. Significantly lower sensitization frequency to propolis raises the possibility of a protective effect due to early oral exposure among the Israeli population.

Sodium Metabisulfite Inhibits Acanthamoeba Trophozoite Growth through Thiamine Depletion

Acanthamoeba keratitis (AK) is a severe infection of the cornea. Prevention and treatment are difficult due to the inefficacy of currently available compounds. The impact of many commonly used compounds for routine examinations of Acanthamoeba is unexplored but might offer insight useful in combatting AK. In this study, we demonstrate that sodium metabisulfite, a common preservation constituent of eye care solutions, was found to be active against Acanthamoeba trophozoites at concentrations lower than that commonly found in eye drops (IC50 0.03 mg/mL). We demonstrate that sodium metabisulfite depletes thiamine from growth medium and that Acanthamoeba is a thiamine auxotroph, requiring thiamine salvage for growth. The inhibitory effects of sodium metabisulfite can be overcome by thiamine supplementation. These results are consistent with the lack of key enzymes for thiamine biosynthesis in the genome of Acanthamoeba, an area which might prove exploitable using new or existing compounds. Indeed, this study highlights sodium metabisulfite as a useful inhibitor of Acanthamoeba castellanii trophozoites in vitro and that it acts, at least in part, by limiting available thiamine.

The new Italian SIDAPA Baseline Series for patch testing (2023): an update according to the new regulatory pathway for contact allergens

Allergic contact dermatitis (ACD) is a common inflammatory skin disease caused by delayed hypersensitivity to chemical and biotic contact allergens. ACD significantly affects the patients' quality of life negatively impacting both occupational and non-occupational settings. Patch testing is the gold standard diagnostic in vivo test to precise the ACD etiology and to correctly perform prevention. According to the Italian Medicines Agency (AIFA) legislative decree no. 178 of 29th May 1991, allergens are defined as medicines and therefore they are subject to strict regulation. In 2017, AIFA (decree no. 2130/2017) started a procedure to regulate contact allergens on the Italian market and actually the contact allergens temporarily authorized are reported in AIFA decree no. 98/2022, valid until November 2023. The availability on the market of contact allergens to diagnose ACD and continuous updating on the basis of new epidemiological trends are mandatory, jointly with the continuous update of the baseline and integrative series for patch testing. For this reason, the scientific community represented in Italy by the Skin Allergies Study Group of SIDeMaST (Italian Society of Dermatology and Venereology) and SIDAPA (Italian Society of Allergological, Occupational and Environmental Dermatology) are constantly working, in close relationship with the European scientific communities with large expertise in this important sector of the modern Dermatology. Herein, we report the setting up of regulatory legislation by AIFA and the new Italian Adult Baseline Series for patch testing.

Potential Anaphylaxis to Systemic Phenylephrine: A Case Report

This case summarizes a 66 year old woman with a past medical history of asthma, breast cancer, anxiety, and chronic back pain with prior surgical insertion of spinal hardware, presenting for removal of spinal hardware at L5-S1 and spinal laminectomy and fusion at L4-L5. Her course was complicated by acute blood loss anemia and post-operative hypotension managed with a phenylephrine infusion, for which she experienced a possible anaphylactic reaction requiring upgrade to the intensive care unit. She was managed using intramuscular epinephrine, diphenhydramine, methylprednisolone, albuterol, famotidine, and oxygen. As phenylephrine is structurally similar to the endogenous catecholamines epinephrine and norepinephrine, diagnosis of her reaction was difficult. However, phenylephrine contains sodium metabisulfite, a preservative sulfite that may cause allergic-type reactions, particularly in patients with asthma in their medical history. Her hypersensitivity reaction was likely secondary to her use of phenylephrine, and she was discharged with a plan for outpatient follow up with the allergy team. As this case exemplifies, patients with a predisposition to allergic reactions should be closely monitored for possible hypersensitivity to preservatives and excipients in medications.

Sulfites: Allergen of the Year 2024

Sodium disulfite, also known as sodium metabisulfite or sodium pyrosulfite, is an inorganic compound, which may cause allergic contact dermatitis. Sulfites act as antioxidants and preservatives; common sources include food/beverages, pharmaceuticals, and personal care products. Importantly, sulfites are not included in most screening patch test series and thus may be missed as a relevant contact allergen. The American Contact Dermatitis Society chose sulfites as the Allergen of the Year for 2024 to raise awareness about this significant allergen.

Sulfites

The Expert Panel for Cosmetic Ingredient Safety reviewed newly available studies since their original assessment in 1998, along with updated information regarding product types and concentrations of use, and confirmed that Sodium Sulfite, Potassium Sulfite, Ammonium Sulfite, Sodium Bisulfite, Ammonium Bisulfite, Sodium Metabisulfite, and Potassium Metabisulfite are safe as cosmetic ingredients in the practices of use and concentration as described in this report.

Effects of sodium metabisulfite on pyroptosis, mitophagy and degranulation in mast cells

Sodium metabisulphite (SMB) is the most used foods and drugs antioxidant among sulfites. So far, there were few studies about its harm, especially in mast cells. Our study was to investigate the effects of SMB on mitophagy and pyroptosis in mast cells. The results revealed that SMB dose-dependently promoted the expressions of NLRP3, GSDMD-N and other marker proteins of pyroptosis. Knockdown of GSDMD, NLRP3 inhibitor, mitophagy activator and mtROS inhibitor all reversed the changes in pyroptosis indicators caused by SMB. Considering the degranulation characteristics of mast cells and the sensitization of sulfite, we examined the effects of the above inhibitors on the degranulation of mast cells caused by SMB. The results showed that SMB-mediated mast cell degranulation was significantly inhibited by the above inhibitors. Meanwhile, we used immunofluorescence co-localization experiments and found that GSDMD pore-forming protein and histamine co-localized near the cell membrane. Overall, evidence suggested that SMB caused pyroptosis by inhibiting mitophagy, leading to mast cell degranulation. These findings are of great significance to the sensitization mechanism of SMB and provide a new insight into SMB toxicology and mast cell degranulation.

Trends in preservative allergy: Benzisothiazolinone emerges from the pack

BACKGROUND

Preservatives are used widely in cosmetic, household, and industrial products to prevent microbial growth and spoiling of the products. There has been a recent epidemic of contact allergy to methylisothiazolinone (MI).

OBJECTIVES

To establish emerging trends in preservative contact allergy as MI is replaced.

METHODS

We performed a retrospective study on consecutively patch-tested patients at our center from January 2011 to December 2019.

RESULTS

A total of 7846 consecutively patch-tested patients were included who were patch tested between January 2011 and December 2019. The prevalence of allergy to MI fell from a peak of 9.39% in 2013 to 1.98% in 2019. MI/methylchloroisothiazolinone (MCI) followed a similar trend, with a peak prevalence of 7.85% in 2014 and falling to 1.39% in 2018. The prevalence of contact allergy to benzisothiazolinone (BIT) has increased steadily increased in 2014 from 0.26% (confidence interval [CI] 0.03-0.93) to 3.42% (CI 2.43-4.66) in 2019.

CONCLUSIONS

Our data show a significant increase in the prevalence of contact allergy to BIT over the last 6 years, probably as a consequence of increased use in household products. It is essential to continue to look for emerging trends in contact allergy to enable prompt preventative measures to be taken.

Contact Allergens in Prescription Topical Ophthalmic Medications

BACKGROUND/OBJECTIVE

Both active and inactive ingredients in topical ophthalmic agents may cause allergic contact dermatitis. Here, we examined ingredients in prescription topical ophthalmic medications available in the United States.

METHODS

A comprehensive list of topical ophthalmic medications was generated using AccessPharmacy. Categories included antiglaucoma, antibiotic, antibiotic/corticosteroid, corticosteroid, antiviral, antifungal, mydriatic, and miotic agents. For each formulation, ingredients were investigated using the National Institutes of Health US National Library of Medicine database and/or manufacturer websites. Counts and proportions were calculated for inactive ingredients, including those in the American Contact Dermatitis Society (ACDS) Core 90 Allergen Series.

RESULTS

Two hundred sixty-four unique prescription ophthalmic medications met the inclusion criteria. The most common ACDS Core 90 allergen/cross-reactor inactive ingredient was benzalkonium chloride (68.1%, 180/264), followed by sorbates (11.7%, 31/264), parabens (6.8%, 18/264), sodium metabisulfite (3.8%, 10/264), propylene glycol (3.0%, 8/264), and lanolin (3.0%, 8/264). Approximately 21% (20.8%, 55/264) of products had no ACDS Core 90 allergens/cross-reactor inactive ingredients. The most common ACDS Core 90 allergen/cross-reactor active ingredients were aminoglycoside antibiotics, bacitracin/polymyxin B, and corticosteroids. Important non-ACDS Core 90 allergens included inactive ingredients, such as EDTA 28.0% and thimerosal 2.7%, as well as active ingredients, especially β-blockers.

CONCLUSIONS

Benzalkonium chloride, sodium metabisulfite, propylene glycol, and lanolin were common inactive ingredient allergens. Most ophthalmic categories had low allergen formulations available for patients with contact allergy.

Candidate Allergens for Inclusion in the Spanish Standard Series Based on Data from the Spanish Contact Dermatitis Registry

BACKGROUND

Standard patch test series must be updated using objective data on allergen sensitization. The Spanish standard series was last updated in 2016 and the European series in 2019, and the inclusion of several emerging allergens needs to be evaluated.

MATERIAL AND METHODS

We conducted a prospective, observational, multicenter study of consecutive patients from the registry of the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC) who were patch tested in 2019 and 2020 with linalool hydroperoxide, limonene hydroperoxide, 2-hydroxyethyl-methacrylate, benzisothiazolinone, octylisothiazolinone, textile dye mix (TDM), sodium metabisulfite, propolis, bronopol, Compositae mix II, diazolidinyl urea, imidazolidinyl urea, decyl glucoside, and lauryl glucoside.

RESULTS

We analyzed data for 4654 patients tested with diazolidinyl urea, imidazolidinyl urea, and bronopol, and 1890 tested with the other allergens. The values for the MOAHLFA index components were 30% for male, 18% for occupational dermatitis, 15% for atopic dermatitis, 29% for hand, 6.5% for leg, 23% for face, and 68% for age > 40 years. Sensitization rates above 1% were observed for 7 allergens: linalool hydroperoxide, 2-hydroxyethyl-methacrylate, benzisothiazolinone, limonene hydroperoxide, TDM, sodium metabisulfite, and propolis. Three allergens had a current relevance rate of over 1%: linalool hydroperoxide, 2-hydroxyethyl-methacrylat, and limonene hydroperoxide. Benzisothiazolinone and TDM had a relevance rate of between 0.9% and 1%.

CONCLUSIONS

Our results indicate that 7 new allergens should be considered when extending the Spanish standard patch test series. The data from our series could be helpful for guiding the next extension of the European baseline series.

Patch testing with sodium disulfite: North American Contact Dermatitis Group experience, 2017 to 2018

BACKGROUND

Sodium disulfite (SD), also known as sodium metabisulfite, is an increasingly recognized cause of allergic contact dermatitis.

OBJECTIVES

The objective of this work was to characterize individuals with positive patch test reactions to SD as well as analyse reaction strength, clinical relevance, and sources.

METHODS

This is a retrospective analysis of patients patch tested with SD (1% petrolatum) by the North American Contact Dermatitis Group (NACDG), 2017 to 2018.

RESULTS

Of 4885 patients patch tested with SD, 132 (2.7%) had a positive reaction. Common primary anatomic sites of dermatitis were face (28.8%), hands (20.5%), and a scattered/generalized distribution (13.6%). Compared with SD-negative patients, SD-positive patients were more likely male (odds ratio 2.81, 95% confidence interval 1.98-4.00) and/or over 40 years (odds ratio 1.95, 95% confidence interval 1.30-2.94). Reactions were most commonly + (50.4%) or ++ (34.1%); 65.2% were considered currently relevant. About 15.2% were definitively confirmed in sources, commonly personal care products (18.9%, especially hair dye), and drugs/medications/alcoholic beverages (9.1%). Only 2.3% of positive reactions were linked to occupation.

CONCLUSIONS

Positive reactions to SD occurred in 2.7% of tested patients. Reactions were often clinically relevant and linked to personal care products and drugs/medications/alcoholic beverages.

Evaluation of Antioxidant and Anti-Inflammatory Activity of Anthocyanin-Rich Water-Soluble Aronia Dry Extracts

Aronia fruits contain many valuable components that are beneficial to human health. However, fruits are characterized by significant variations in chemical composition dependent on the growing conditions and harvesting period. Therefore, there is a need to formulate the extracts with a precisely defined content of health-promoting substances. Aronia dry extracts (ADE) were prepared from frozen pomace applying water extraction, followed by purification and spray-drying. Subsequently, the content of anthocyanins, phenolic acids, and polyphenols was determined. The high-quality chokeberry pomace enabled obtaining extracts with anthocyanin content much higher than the typical market standards. Moreover, it was found that the antioxidant capacity of aronia extracts exceeded those found in other fruit preparations. Antioxidant and free-radical scavenging properties were evaluated using a 2,2'-diphenyl-1-picrylhydrazyl using Electron Paramagnetic Resonance (EPR) spectroscopy (DPPH-EPR) test and Oxygen Radical Absorbance Capacity (ORAC) assay. The inhibition of lipid peroxidation and the level of inflammatory markers have been also investigated using lipopolysaccharide (LPS)-stimulated RAW 264 cells. It was revealed that ADE standardized to 25% of anthocyanins depresses the level of markers of inflammation and lipid peroxidation (Interleukin 1 beta (IL-1β), tumor necrosis factor alpha (TNF-α), and malondialdehyde (MDA)) in in vitro conditions. Additionally, it was confirmed that ADE at all analyzed concentrations did not show any cytotoxic effect as demonstrated by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay.

An evaluation of subcutaneous apomorphine for the treatment of Parkinson's disease

INTRODUCTION

Heterogeneity of symptoms and individual variability of progression characterizes Parkinson's disease. Unmet therapeutic needs include a cure, disease modification, and improvement of available marketed dopamine-substituting compounds. Personalized treatment, tailored to the patients' needs and symptoms, aims to ameliorate impaired motor behavior and non-motor features. Injection or infusion of apomorphine is a therapeutic option for more advanced patients with severe levodopa associated motor complications.

AREAS COVERED

This narrative review summarizes the subcutaneous administration, efficacy, and side effects of the non-ergot derivative dopamine agonist apomorphine following a non-systematic literature research.

EXPERT OPINION

Subcutaneous apomorphine hydrochloride application rapidly terminates intervals with severe motor impairment with bolus injections. Oscillation of motor behavior well responds to continuous apomorphine infusions. Long-term application of the commercially available apomorphine hydrochloride solution sooner or later affects skin and oral mucosa. Onset of skin nodules associated with subcutaneous tissue inflammation probably results from the antioxidant preservative sodium metabisulfite in the apomorphine solution. Addition of another better tolerated and safer antioxidant instead of sodium metabisulphite or use of an already available concentrated apomorphine-free base formulation will enhance its future use, its tolerability, safety, and acceptance of subcutaneous and sublingual application.

Understanding the role of cutaneous allergy testing in anogenital dermatoses: a retrospective evaluation of contact sensitization in anogenital dermatoses

BACKGROUND

Patients with anogenital symptoms may delay before seeking medical attention. Attempted self-treatment with multiple topical preparations and excessive hygiene measures offer ideal conditions for sensitization. The aim of this study was to identify the common allergens detected on cutaneous allergy testing in patients presenting with anogenital symptoms.

METHODS

A retrospective chart review of patients who underwent cutaneous allergy testing for perianal and/or genital symptoms over a 3-year period, January 2013 to December 2015, n = 99. Information was gathered from medical records, pretesting questionnaires, and cutaneous allergy testing records.

RESULTS

At least one relevant allergen(s) was identified in 44/99 (45%) in our cohort, with allergic reactions to fragrances, Myroxylon pereirae, caine mix, sodium metabisulfite, and methylisothiazolinone most frequently observed.

CONCLUSIONS

Cutaneous allergy testing is a useful investigation in patients presenting with anogenital symptoms, but advice regarding general skin care measures should not be omitted. The most commonly identified relevant allergens in our study were those present in over-the-counter cleansing and hemorrhoid preparations.

Differential diagnosis of late-type reactions to injected local anaesthetics: Inflammation at the injection site is the only indicator of allergic hypersensitivity

BACKGROUND

Anaphylaxis-like reactions developing within a few minutes are the most frequent complications of subcutaneous or submucosal injections of local anaesthetics (LAs), and topically applied LAs are potential contact allergens. In addition, injected LAs have been reported to induce delayed reactions, including local inflammation at the injection site, and various general symptoms.

OBJECTIVES

To assess the frequency and symptoms of late-type hypersensitivity occurring several hours after LA injections.

METHODS

We retrospectively evaluated clinical data and test results from all patients referred to our allergy clinic in a period of 20 years for diagnostic work-up of LA-associated late-type reactions.

RESULTS

Of 202 patients reporting symptoms with onset at least 1 hour after LA injection, 40 had cutaneous inflammation confined to the injection site, and 162 reported various systemic symptoms. LA hypersensitivity could be excluded in all patients with systemic complaints by means of skin testing and subsequent subcutaneous provocation. In 8 of the 40 patients (20%) with local inflammatory reactions, late-type allergic LA hypersensitivity was confirmed.

CONCLUSIONS

Late-type LA allergy commonly causes inflammatory skin reactions confined to the injection site. Conversely, LAs are highly unlikely to trigger delayed systemic symptoms such as urticarial or exanthematous skin eruptions.

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.

Systematic Review of Hypersensitivity to Parenteral Nutrition

Hypersensitivity to the components of parenteral nutrition (PN) is a rare but important complication of PN. We performed a systematic review of hypersensitivity to PN to enable us to build an approach to the individual patient who presents with PN hypersensitivity. A systematic literature search was performed in Ovid Medline, CINAHL, Scopus, and Web of Science using terms for "hypersensitivity" AND "parenteral nutrition" and relevant synonyms. A total of 28 articles were analyzed, and 33 hypersensitivities to PN or components of PN were reported in these 28 articles. Reports of hypersensitivity and subsequent conclusions were based on the clinical observations made by each reporting author. These reactions were evenly split between pediatric and adult patients. Hypersensitivity to PN occurred on day of starting PN in 60.6% patients and after that time in 36.3% patients (range: 1-21 days). Of the hypersensitivities that occurred on day 1 of PN, 70% occurred in the first 30 minutes of initiation of PN. Cutaneous manifestations were the most common, followed by anaphylaxis, respiratory symptoms, and hemodynamic instability. The components most frequently identified as allergens were intravenous fat emulsion (48.4%), multivitamin solution (33.3%), and amino acid solution (9%). Based on this review, an algorithm was created to guide the practitioner on management of PN after the occurrence of such a reaction.

A proposal to create an extension to the European baseline series

BACKGROUND

The current European baseline series consists of 30 allergens, and was last updated in 2015.

OBJECTIVES

To use data from the European Surveillance System on Contact Allergies (ESSCA) to propose an extension to the European baseline series in response to changes in environmental exposures.

METHODS

Data from departmental and national extensions to the baseline series, together with some temporary additions from departments contributing to the ESSCA, were collated during 2013-2014.

RESULTS

In total, 31689 patients were patch tested in 46 European departments. Many departments and national groups already consider the current European baseline series to be a suboptimal screen, and use their own extensions to it. The haptens tested are heterogeneous, although there are some consistent themes. Potential haptens to include in an extension to the European baseline series comprise sodium metabisulfite, formaldehyde-releasing preservatives, additional markers of fragrance allergy, propolis, Compositae mix, and 2-hydroxyethyl methacrylate.

CONCLUSION

In combination with other published work from the ESSCA, changes to the current European baseline series are proposed for discussion. As well as addition of the allergens listed above, it is suggested that primin and clioquinol should be deleted from the series, owing to reduced environmental exposure.