Contact allergy in atopic dermatitis: A prospective study on prevalence, incriminated allergens and clinical insights

BACKGROUND

The relationship between atopic dermatitis (AD) and allergic contact dermatitis (ACD) is a matter of debate.

OBJECTIVES

The purpose of our study is to assess the frequency of ACD in patients with AD, the incriminated allergens and the potential risk factors.

METHODS

This is a prospective study, including cases of AD diagnosed based on Hanifin and Rajka's criteria. All patients were patch tested to the European baseline series and corticosteroid series.

RESULTS

Ninety-three patients were included. Fifty-six patients (60.2%) had positive patch test results of which 71.4% were relevant. The most frequent allergens were: textile dye mix (24.7%), nickel (20.4%), cobalt (12.9%), isothiazolinone (8.6%), quanterium 15 (4.3%) and balsam of Peru (4.3%). Chromium, fragrance mix I, fragrance mix II and PTBP were positive in three cases (3.2%). Two cases of allergy to corticoids were identified. Facial involvement and duration of AD were significantly associated with contact sensitization (p = 0.04 and p = 0.005, respectively). Avoidance of relevant allergens resulted in a statistically significant decrease in SCORAD (p < 0.001).

CONCLUSIONS

ACD remains an important co-morbidity of AD. We observed a high frequency of ACD to textile dyes, isothiazolinones and fragrances. Avoidance of relevant allergens has resulted in an improvement of patients' skin symptoms.

Cheilitis: A Diagnostic Algorithm and Review of Underlying Etiologies

Cheilitis, or inflammation of the lips, is a common reason for dermatologic consultation. The inflammation can include the vermillion lip, vermillion border, and surrounding skin, and can present with an acute or chronic course. There are many etiologies, including irritant and allergic contact dermatitis, atopic cheilitis, actinic cheilitis, infectious etiologies, nutritional deficiencies, drug-induced cheilitis, and rare etiologies, including granulomatous cheilitis, cheilitis glandularis, plasma cell cheilitis, lupus cheilitis, and exfoliative cheilitis. Distinguishing among the various etiologies of cheilitis is clinically difficult, as many causes may produce similar erythema and superficial desquamation of mucosal skin. In addition, patients report dryness, redness, irritation, burning, fissuring, and itch in many of the underlying causes. Thus, the specific etiology of cheilitis is often difficult to diagnose, requiring extensive testing and treatment trials. In this review, we summarize the various types of cheilitis, synthesizing novel cases, clinical presentations, histopathology, epidemiology, and advancements in diagnostic methods and therapeutics. We provide a diagnostic algorithm aimed to assist clinicians in the management of cheilitis.

Prevalence and causative allergens of contact cheilitis in Thailand

BACKGROUND

Cheilitis is an inflammatory condition of the lips. Its causes can be exogenous (irritants, allergens), endogenous (atopic dermatitis, systemic disorders) or unknown.

OBJECTIVES

To determine the prevalence of allergic contact cheilitis (ACC), its risk factors, and common allergens in patients with cheilitis at a Thai university-based tertiary care hospital.

METHODS

A retrospective chart review was conducted on patients with cheilitis referred for patch testing between January 2007 and December 2021.

RESULTS

Among 5366 patients referred for patch testing, 410 (7.6%) had cheilitis. ACC was diagnosed in 32% of the cheilitis patients. Compared to non-ACC cases, the patients with ACC were more likely to be young and female and have a disease duration of <3 months, no underlying disease and a white-collar job (p-value <0.05). The most common contact allergens were patient's products (73.3%), nickel sulfate (29.8%), potassium dichromate (14.5%), castor oil (14.3%) and benzalkonium chloride (13.0%). Lip cosmetics and toothpastes were major ACC sources.

CONCLUSIONS

ACC should be considered in cheilitis patients, especially in patients with specific risk factors. Castor oil is an emerging allergen. Patch testing using commercial allergen series and patients' own products is crucial for identifying causative agents. The development of a specific cheilitis series is warranted.

Prevalence and trend of allergen sensitization in patients with cheilitis referred for patch testing, North American Contact Dermatitis Group data, 2001-2018

BACKGROUND

An updated understanding of allergic contact cheilitis is needed.

OBJECTIVES

To characterize clinical characteristics and allergen relevance in patients with cheilitis referred for patch testing.

METHODS

Retrospective analysis of 43 772 patients patch tested with the North American Contact Dermatitis Group (NACDG) screening series from 2001 to 2018.

RESULTS

Overall, 2094 patients (4.8%) had lips as one of three sites of dermatitis, 1583 (3.6%) had lips as the primary site and 1167 (2.7%) had lips as the sole site of dermatitis. Prevalences of cheilitis at any, primary, and sole sites significantly increased throughout the study cycle from 2001-2002 (2.7%, 2.2% and 1.7%) to 2017-2018 (7.8%, 5.2% and 3.7%). Approximately 60% of patients with any, a primary, or a sole site of cheilitis had one or more positive allergic patch-test reactions compared to 65% of those without cheilitis.

CONCLUSION

Patients with cheilitis who were referred for patch testing had high rates of positive and relevant allergens. More than one in four patients with any, primary, or sole cheilitis had a positive reaction to non-NACDG screening allergens (28.0%, 26.8%, 31.1% vs. 21.6%) compared to patients without cheilitis, emphasizing the need for expanded patch test series in cheilitis.

Environmental Causes of Dermatitis

Environmental, or exogenous, dermatitis is comprised of irritant and allergic contact dermatitis, which account for 80% and 20% of cases of contact dermatitis, respectively. Contact dermatitis is extremely common, and failure to diagnose this entity may result in overlooking a potentially curable driver of disease. In this review, we describe how clinical features, such as morphology or history, can assist in distinguishing exogenous from endogenous causes of dermatitis, and allergic from irritant contact dermatitis. Additionally, we provide an overview of common contact allergens and how dermatitis distribution can suggest possible culprit allergens. Patch testing is needed to confirm contact allergy.

Facial Dermatitis in Male Patients Referred for Patch Testing: Retrospective Analysis of North American Contact Dermatitis Group Data, 1994 to 2016

Importance

Facial dermatitis in women is well characterized. However, recent shifts in the men's grooming industry may have important implications for male facial dermatitis.

Objective

To characterize male patients with facial dermatitis.

Design, Setting, and Participants

A 22-year retrospective cross-sectional analysis (1994-2016) of North American Contact Dermatitis Group (NACDG) data, including 50 507 patients who underwent patch testing by a group of dermatology board-certified patch test experts at multiple centers was carried out. Facial dermatitis was defined as involvement of the eyes, eyelids, lips, nose, or face (not otherwise specified).

Main Outcomes and Measures

The main outcome was to compare characteristics (including demographics and allergens) between male patients with facial dermatitis (MFD) and those without facial dermatitis (MNoFD) using statistical analysis (relative risk, CIs). Secondary outcomes included sources of allergic and irritant contact dermatitis and, for occupationally related cases, specific occupations and industries in MFD.

Results

Overall, 1332 male patients (8.0%) were included in the MFD group and 13 732 male patients (82.0%) were included in MNoFD. The mean (SD) age of participants was 47 (17.2) years in the MFD group and 50 (17.6) years in the MNoFD group. The most common facial sites were face (not otherwise specified, 817 [48.9%]), eyelids (392 [23.5%]), and lips (210 [12.6%]). Participants in the MFD group were significantly younger than MNoFD (mean age, 47 vs 50 years; P < .001). Those in the MFD group were less likely to be white (relative risk [RR], 0.92; 95% CI, -0.90 to 0.95) or have occupationally related skin disease (RR, 0.49; 95% CI, -0.42 to 0.58; P < .001) than MNoFD. The most common allergens that were associated with clinically relevant reactions among MFD included methylisothiazolinone (n = 113; 9.9%), fragrance mix I (n = 27; 8.5%), and balsam of Peru (n = 90; 6.8%). Compared with MNoFD, MFD were more likely to react to use of dimethylaminopropylamine (RR, 2.49; 95% CI, -1.42 to 4.37]) and paraphenylenediamine (RR, 1.43; 95% CI, -1.00 to 2.04; P < .001). Overall, 60.5% of NACDG allergen sources were personal care products.

Conclusions and Relevance

Although many allergens were similar in both groups, MFD were more likely to react to use of dimethylaminopropylamine and paraphenylenediamine, presumably owing to their higher prevalence in hair products. Most sources of allergic and irritant contact dermatitis in MFD were personal care products. This study provides insight into the risks and exposures of the increasing number of grooming products used by male dermatology patients. This will enable clinicians to better identify male patients who would benefit from patch testing and treat those with facial dermatitis.

Contact allergy to beeswax and propolis among patients with cheilitis or facial dermatitis

BACKGROUND

Beeswax, both white and yellow, has many uses, such as in lip balm. This material can cause contact allergy, although not many cases have been described.

METHODS

Ninety-five patients with contact cheilitis, facial eczema or a suspicion of contact allergy to beeswax were patch tested with yellow and white beeswax and with propolis, in addition to the Swedish baseline series. Patients who reacted positively to beeswax were additionally tested with caffeic acid, and two derivatives thereof that are believed to be important haptens in propolis.

RESULTS

Seventeen patients had positive reactions to beeswax. Fourteen of these patients had been tested with both yellow and white beeswax. Among those 14, eight had positive reactions to both types of wax, five only to yellow wax, and one only to white wax. Of the 10 wax-positive patients tested with caffeic acid derivatives, three reacted positively. Fourteen beeswax-positive patients also had positive reactions to propolis.

CONCLUSION

Patch testing cheilitis patients is important, as contact allergy is common. Our suggestion is to patch test, apart from the baseline series and the patient's own products, also with beeswax and propolis. Many beeswax-allergic cheilitis patients would not have been diagnosed with a relevant contact allergy if only the Swedish baseline series had been used.

European Surveillance System on Contact Allergies (ESSCA): Contact allergies in relation to body sites in patients with allergic contact dermatitis

Background

Analyses of the European Surveillance System on Contact Allergies (ESSCA) database have focused primarily on the prevalence of contact allergies to the European baseline series, both overall and in subgroups of patients. However, affected body sites have hitherto not been addressed.

Objective

To determine the prevalence of contact allergies for distinct body sites in patients with allergic contact dermatitis (ACD).

Methods

Analysis of data collected by the ESSCA (www.essca‐dc.org) in consecutively patch tested patients, from 2009 to 2014, in eight European countries was performed. Cases were selected on the basis of the presence of minimally one positive patch test reaction to the baseline series, and a final diagnosis of ACD attributed to only one body site.

Results

Six thousand two hundred and fifty‐five cases were analysed. The head and hand were the most common single sites that ACD was attributed to. Differences between countries were seen for several body sites. Nickel, fragrance mix I, cobalt and methylchloroisothiazolinone/methylisothiazolinone were the most frequent allergens reported for various body sites.

Conclusions

Distinct allergen patterns per body site were observed. However, contact allergies were probably not always relevant for the dermatitis that patients presented with. The possibility of linking positive patch test reactions to relevance, along with affected body sites, should be a useful addition to patch test documentation systems.

Contact Dermatitis for the Practicing Allergist

This article provides an overview of important practice recommendations from the recently updated Contact Dermatitis Practice Parameter. This updated parameter provides essential recommendations pertaining to clinical history, physical examination, and patch testing evaluation of patients suspected of allergic contact dermatitis. In addition to providing guidance for performing and interpreting closed patch testing, the updated parameter provides concrete recommendations for assessing metal hypersensitivity in patients receiving prosthetic devices, for evaluating workers with occupational contact dermatitis, and also for addressing allergic contact dermatitis in children. Finally, the document provides practical recommendations useful for educating patients regarding avoidance of exposure to known contact sensitizers in the home and at work. The Contact Dermatitis Parameter is designed as a practical, evidence-based clinical tool to be used by allergists and dermatologists who routinely are called upon to evaluate patients with skin disorders.

Contact dermatitis: a practice parameter-update 2015

This parameter was developed by the Joint Task Force on Practice Parameters, which represents the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma & Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "Contact Dermatitis: A Practice Parameter-Update 2015." This is a complete and comprehensive document at the current time. The medical environment is changing and not all recommendations will be appropriate or applicable to all patients. Because this document incorporated the efforts of many participants, no single individual, including members serving on the Joint Task Force, are authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information or interpretation of this practice parameter by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology. These parameters are not designed for use by the pharmaceutical industry in drug development or promotion. Previously published practice parameters of the Joint Task Force on Practice Parameters for Allergy & Immunology are available at http://www.JCAAI.org or http://www.allergyparameters.org.

Fragrance allergic contact dermatitis

Fragrances are a common cause of allergic contact dermatitis in Europe and in North America. They can affect individuals at any age and elicit a spectrum of reactions from contact urticaria to systemic contact dermatitis. Growing recognition of the widespread use of fragrances in modern society has fueled attempts to prevent sensitization through improved allergen identification, labeling, and consumer education. This review provides an overview and update on fragrance allergy. Part 1 discusses the epidemiology and evaluation of suspected fragrance allergy. Part 2 reviews screening methods, emerging fragrance allergens, and management of patients with fragrance contact allergy. This review concludes by examining recent legislation on fragrances and suggesting potential additions to screening series to help prevent and detect fragrance allergy.

Perioral lesions and dermatoses

The purpose of this article is to review the common neoplasms, infections, and inflammatory dermatoses that may present around or near the mouth. Dental professionals are well positioned to evaluate perioral skin conditions, further contributing to patients' general health. This article includes a review of seborrheic keratosis, warts, actinic keratoses, actinic cheilitis, and squamous cell carcinoma, among several other perioral cutaneous lesions.