Allergic contact dermatitis mimicking angioedema due to paraphenylendiamine hypersensitivity: a case report

A clinical study and laboratory evaluation of the cardiac and hepatic toxic effects of paraphenylenediamine

INTRODUCTION

Paraphenylenediamine is the main component in many commercial hair dyes, and can produce severe local and systemic toxicity reactions after acute ingestion or dermal absorption. The aim of this study was to assess the factors contributing to morbidity and mortality in cases of acute paraphenylenediamine poisoning, with a focus on evaluating the resultant hepatic and cardiac toxicity.

METHODS

This observational study was conducted on patients with acute paraphenylenediamine poisoning presenting to Sohag University Hospitals, and included a retrospective part from February 2021 to January 2022 and a prospective part from February 2022 to July 2022. Clinical data were extracted and receiver operating characteristic curves created to identify prognostic markers.

RESULTS

Among 50 eligible patients 39 (78 percent) recovered, and 11 (22 percent) died or had permanent complications. Angioedema and anuria were the most frequent features in complicated cases. By receiver operating characteristic analysis, either an increase in aspartate aminotransferase activity greater than 644 IU/L or alanine aminotransferase activity greater than 798 IU/L, a time delay to presentation of greater than 4.5 hours, and a pH of less than 7.32 were associated with a significant increase in morbidity and mortality. While cardiac enzyme activities, and concentrations of blood urea nitrogen and creatinine increased in most cases, they were not associated with mortality.

DISCUSSION

Management of patients with paraphenylenediamine poisoning is mainly supportive, as there is no specific antidote. Respiratory failure and kidney failure are the most life threatening complications. Hepatoxicity and cardiotoxicity also occur. The ability to predict the events can help guide patient disposition and care.

CONCLUSION

Elevated liver enzyme activities, increased time delay to admission, decreased pH, and the presence of angioedema and anuria can be used as predictors of morbidity and mortality in patients with acute paraphenylenediamine poisoning.

Differential diagnosis of contact dermatitis: A practical-approach review by the EADV Task Force on contact dermatitis

The diagnosis of eczema ('dermatitis') is mostly clinical and depends on the clinical history and exploratory objective findings (primary lesions, patterns). Contact dermatitis remains as an important condition in the group of eczematous disorders, with important socioeconomic and occupational relevance. Although irritant and allergic contact dermatitis have a different pathogenesis, both are characterized by a rather typical morphology, are triggered by external factors and tend to occur primarily in the area of contact with the exogenous agent. In addition, allergic and irritant dermatitis may also co-exist. The importance of diagnosing contact dermatitis, especially when allergic in nature, is both due to the possibility of avoiding the trigger, and due to its role in aggravating other skin conditions. Nevertheless, the heterogeneity of clinical presentations in daily practice may pose an important challenge for the suspicion and correct diagnosis of contact dermatitis. Furthermore, other conditions, with different pathogenesis and treatment, may clinically simulate contact dermatitis. The Task Force aims to conduct a review of the unifying clinical features of contact dermatitis and characterize its main clinical phenotypes, and its simulators, in order to contribute to an early suspicion or recognition of contact dermatitis and enable a correct differential diagnosis.

Wenn es kein Angioödem ist, was dann? Diagnostisches Vorgehen bei Gesichtsödemen

Gesichtsödeme sind ein relativ häufiges Symptom bei Patienten allergologischer und dermatologischer Kliniken. Die Differentialdiagnose ist breit gefächert und die endgültige Diagnose kann manchmal eine Herausforderung für den Kliniker sein. Das faziale Angioödem selbst umfasst verschiedene Ätiopathologien (histaminerg, bradykinininduziert und weitere), die von anderen Ursachen des Gesichtsödems differenziert werden sollten, etwa allergischer Kontaktdermatitis, granulomatösen Erkrankungen, inflammatorischen Ursachen, Infektionen, Neoplasmen oder paraneoplastischen Syndromen, Autoimmunerkrankungen und anderen Entitäten, die hier als „Sonstige“ bezeichnet werden. Um die richtigen Untersuchungen anzuordnen und eine gezielte Therapie zu verordnen, ist ein angemessener diagnostischer Ansatz ausschlaggebend. Diese Übersicht konzentriert sich auf Entitäten, die mit Gesichtsödem einhergehen, und fasst ihre klinischen Charakteristika zusammen.

If not angioedema, what is it? Diagnostic approach to facial edema

Facial edema is a relatively frequent clinical presentation encountered in patients seen in allergology and dermatology clinics. The differential diagnosis is broad, and sometimes the definitive diagnosis can be a challenge for the clinician. Facial angioedema itself encompasses different etiopathologies (histaminergic, bradykinergic, etc.) that must be distinguished from other causes of facial edema, such as allergic contact dermatitis, granulomatous conditions, inflammatory causes, infections, neoplasms or paraneoplastic syndromes, autoimmune diseases, among other entities hereby referred as miscellanea. A proper diagnostic approach is essential to order the appropriate tests, as well as to prescribe a targeted treatment. This review focuses on entities that present with facial edema and summarize their characteristic clinical features.

Hair Product Allergy: A Review of Epidemiology and Management

Allergy to hair products is an increasingly common issue among people given the exposure to these products on a daily basis. Allergic reactions could be in the form of delayed-type contact dermatitis or the form of immediate-type hypersensitivity reactions. Hair products contain many ingredients and chemicals that patients may have allergies to, but common allergens are hair dyes, fragrances, persulfate salts, ammonium thioglycolate, coconut fatty acid derivatives, and acrylates. Allergy to hair dye is the most common followed by other allergens such as fragrances and persulfate salts. We discussed testing for hair dye allergy along with suggestions for alternative hair dyes that patients may use. Allergy to topical scalp medications is also seen in patients using those products. Allergy to topical minoxidil is seen more often due to the increased use of minoxidil sprays and foams among patients to increase hair growth. We will discuss in this review the diagnosis and alternatives for patients with minoxidil allergy. Hairdressers are at higher risk of allergy to hair products compared to the general population due to prolonged exposure to allergens and specific measures should be implemented to minimize the hazards of exposure.

Chronic Urticaria and Angioedema: Masqueraders and Misdiagnoses

Chronic urticaria is a common condition presenting with intensely pruritic wheals. Although individual lesions resolve within 24 hours, by definition, chronic urticaria lasts for a duration of at least 6 weeks. Both spontaneous and inducible forms exist. In the spontaneous variant, chronic urticaria occurs in the absence of clearly identifiable triggers. In chronic inducible urticaria, specific triggers may include dermatographism, cholinergic (heat), cold, exercise, delayed pressure, and solar. Extensive laboratory evaluation for chronic spontaneous urticaria is not required unless indicated by clinical history or physical examination. Angioedema describes sudden onset of localized edema involving the deep layers of the skin and submucosal tissues. It can be seen in isolation or in conjunction with chronic urticaria. Angioedema typically resolves slower than wheals, taking up to 72 hours or longer. Histamine- and bradykinin-mediated forms exist. Both chronic urticaria and angioedema have many mimics, and a broad range of differential diagnoses should be considered. Importantly, an incorrect diagnosis may have significant implications for the additional investigation, treatment, and prognosis of the affected patient. The aim of this article is to discuss the characteristics of chronic urticaria and angioedema, and an approach to the investigation and diagnosis of their mimics.

Recent Advancements in Natural Plant Colorants Used for Hair Dye Applications: A Review

There is an on-going demand in recent years for safer and "greener" hair coloring agents with the global consumer awareness of the adverse effects of synthetic hair dyes. The belief in sustainability and health benefits has focused the attention of the scientific community towards natural colorants that serve to replace their synthetic toxic counterparts. This review article encompasses the historical applications of a vast array of natural plant hair dyes and summarizes the possible coloration mechanisms (direct dyeing and mordant dyeing). Current information on phytochemicals (quinones, tannins, flavonoids, indigo, curcuminoids and carotenoids) used for hair dyeing are summarized, including their botanical sources, color chemistry and biological/toxicological activities. A particular focus is given on research into new natural hair dye sources along with eco-friendly, robust and cost-effective technologies for their processing and applications, such as the synthetic biology approach for colorant production, encapsulation techniques for stabilization and the development of inorganic nanocarriers. In addition, innovative in vitro approaches for the toxicological assessments of natural hair dye cosmetics are highlighted.

Allergic Contact Dermatitis and Concomitant Dermatologic Diseases: A Retrospective Study

BACKGROUND

Allergic contact dermatitis (ACD) can exist in the setting of other dermatologic conditions. It is known that the treatment of these conditions can cause ACD, increasing both diagnostic and treatment difficulty.

OBJECTIVE

The aim of this study was to determine the frequency of common dermatologic conditions in the setting of ACD and in specific patient populations.

METHODS

A retrospective database study was completed using Truven Health to collect information on patch-tested ACD patients. Demographics and diagnostic information were retrieved. Of those with ACD, the presence of 15 dermatologic diagnoses was investigated. Subanalyses were conducted for each condition, including International Classification of Diseases, 10th Revision code specificity, demographics, and diagnostic information.

RESULTS

A total of 6380 patients (76.83% female) were given a diagnosis of ACD via patch testing. Of those with concomitant disease, those most common include atopic dermatitis (23.98%), urticaria (16.69%), and acne (11.51%). Eight of the concomitant conditions were found to have statistical significance in comparing the average age of ACD diagnosis with the selected diagnoses (α = 0.05).

CONCLUSIONS

Common dermatologic diseases can exist concomitantly with ACD, many of which can be treated by compounds that precipitate or worsen preexisting ACD. The average age of the diagnosis varies from concomitant diagnoses, which can contribute to difficulty in ACD diagnosis and treatment.

Proposed ICDRG Classification of the Clinical Presentation of Contact Allergy

The International Contact Dermatitis Research Group proposes a classification for the clinical presentation of contact allergy. The classification is based primarily on the mode of clinical presentation. The categories are direct exposure/contact dermatitis, mimicking or exacerbation of preexisting eczema, multifactorial dermatitis including allergic contact dermatitis, by proxy, mimicking angioedema, airborne contact dermatitis, photo-induced contact dermatitis, systemic contact dermatitis, noneczematous contact dermatitis, contact urticaria, protein contact dermatitis, respiratory/mucosal symptoms, oral contact dermatitis, erythroderma/exfoliative dermatitis, minor forms of presentation, and extracutaneous manifestations.

Severe Neck and Face Edema in an Adolescent-Delayed Hypersensitivity Reaction to Hair Dye

Allergic contact reactions to hair dyes arise mostly due to sensitization to para-phenylenediamine (PPD). Para-phenylenediamine, a derivative of p-nitroanaline, is widely used as an oxydizable hair dye and is also found in black henna tattoo. Subsequent exposure to PPD may lead to delayed type IV hypersensitivity reaction manifesting as acute contact dermatitis. Here, a 15-year-old girl is presented, who developed a hypersensitivity reaction after first exposure to hair dye. She was found to have been sensitized to PPD before, through application of black henna tatto.

Hypersensitivity reactions due to black henna tattoos and their components: are the clinical pictures related to the immune pathomechanism?

Hypersensitivity to para-phenylenediamine (PPD) and related compounds induced by temporary black henna tattoos has become a serious health problem worldwide. Different patterns of sensitization with various clinical aspects are described in literature due to PPD associated to henna tattoo and these manifestations are likely correlated with the immunological and dermatological pathomechanisms involved. Henna is the Persian name of the plant Lawsonia inermis, Fam. Lythraceae. It is a woody shrub that grow in regions of North Africa, South Asia, India and Sri Lanka. Nowadays it is rather frequent to see temporary "tattoos" performed with henna. To make tattoos darker and long-lasting PPD has been associated to henna in tattoo drawings mixtures, so obtaining "black henna". In these years there has been a rise of contact sensitization to PPD and in medical literature an increased number of cases have been reported on temporary henna tattoo application. Here we review the various clinical patterns related to PPD and henna tattoo, to investigate the possible link between clinic-morphological pictures and the immunological response to PPD and henna. The literature underlines that different clinical manifestations are related to black henna containing PPD, and its derivative products may cause delayed-type as well as immediate-type reactions. Further studies are needed to investigate the relationship between clinical and morphological aspects of PPD contact dermatitis and the T cell subsets predominance.

Angioedema After Squaric Acid Treatment in a 6-Year-Old Girl

Alopecia areata (AA) involves the immune-related destruction of hair follicles, resulting in patches of complete hair loss, most often on the scalp. The topical sensitizer squaric acid dibutylester (SADBE) is a popular treatment option given its low side-effect profile, hair regrowth potential, and lack of cross-reactivity with other chemicals. We describe a unique case of a 6-year-old girl who developed angioedema after SADBE treatment for AA.

Implication of microRNA regulation in para-phenylenediamine-induced cell death and senescence in normal human hair dermal papilla cells

Para-phenylenediamine (PPD) is a major component of hair coloring and black henna products. Although it has been largely demonstrated that PPD induces allergic reactions and increases the risk of tumors in the kidney, liver, thyroid gland and urinary bladder, the effect on dermal papilla cells remains to be elucidated. Therefore, the current study evaluated the effects of PPD on growth, cell death and senescence using cell-based assays and microRNA (miRNA) microarray in normal human hair dermal papilla cells (nHHDPCs). Cell viability and cell cycle analyses demonstrated that PPD exhibited a significant cytotoxic effect on nHHDPCs through inducing cell death and G₂ phase cell cycle arrest in a dose-dependent manner. It was additionally observed that treatment of nHHDPCs with PPD induced cellular senescence by promoting cellular oxidative stress. In addition, the results of the current study indicated that these PPD-mediated effects were involved in the alteration of miRNA expression profiles. Treatment of nHHDPCs with PPD altered the expression levels of 74 miRNAs by ≥2-fold (16 upregulated and 58 downregulated miRNAs). Further bioinformatics analysis determined that these identified miRNA target genes were likely to be involved in cell growth, cell cycle arrest, cell death, senescence and the induction of oxidative stress. In conclusion, the observations of the current study suggested that PPD was able to induce several cytotoxic effects through alteration of miRNA expression levels in nHHDPCs.

p-Phenylenediamine and other allergens in hair dye products in the United States: a consumer exposure study

BACKGROUND

Hair dye products constitute an important source of allergen exposure, and contribute importantly to allergic contact dermatitis in consumers and hairdressers.

OBJECTIVES

To evaluate the presence of potent contact sensitizers in oxidative hair dye products intended for home use on the US market.

METHODS

Ingredient labels of 107 hair dyes from 10 major brands were examined and used to assess the prevalence of hair dye substances known to be potent contact sensitizers.

RESULTS

One hundred and six of 107 (99%) products contained at least one potent sensitizer, and the average product contained six (range 0-11). p-Phenylenediamine (PPD) was found in 83 products (78%), but resorcinol (89%), m-aminophenol (75%), p-aminophenol (60%) and toluene-2,5-diamine (21%) were also frequently identified.

CONCLUSIONS

Potent contact sensitizers were almost universally included in the hair dyes investigated in the United States. Although PPD is a common allergen, resorcinol and m-aminophenol were found more frequently. In total, 30 potent sensitizers were found. Clinicians should consider other allergens in addition to PPD when evaluating patients with suspected hair dye allergy.

Positive relationship-intensity of response to p-phenylenediamine on patch testing and cross-reactions with related allergens

BACKGROUND

Hair dye exposure is the most common cause of sensitization to p-phenylenediamine (PPD). Cross-reactions with structurally related allergens occur.

OBJECTIVES

It is suggested that a stronger patch test reaction (3+ rather than 1+) to PPD (usually tested as 1% petrolatum) is associated with an increased propensity for cross-reactions. In this article we will demonstrate this association.

METHODS

Of 230 patients with allergic reactions to PPD on patch testing identified during 2007-2012 from clinical records, notes for 221 were available for review. Data were collected regarding age, sex, and grade of reaction [International Contact Dermatitis Research Group (ICDRG) criteria] to PPD. Cross-reactions with the following allergens, found in our baseline series, were recorded: Disperse Yellow 3, N-isopropyl-N'-phenyl-p-phenylenediamine (IPPD), and caine mix. Having excluded 23 doubtful reactions, the reactions from 198 patients were further considered.

RESULTS

Of the patients, 75.3% (n = 149) were female, and the mean age was 48.6 years (12-82 years). Of the patients allergic to PPD, 16.6% (n = 33) showed cross-reactions with one or more related allergens. Cross-reactions were seen in 16% with a grade of 1+, 14.5% with a grade of 2+, 28.6% with a grade of 3+ when PPD was tested 1% pet., and 50.0% when PPD was tested at 0.1-0.001%, arbitrarily considered to be 4+ (p = 0.02; Cramér's V = 0.23).

CONCLUSION

An increasing likelihood of reactions to Disperse Yellow 3, IPPD or caine mix was seen with increasing strength of patch test reaction to PPD. The clinical relevance of these cross-reactions is unclear.

Side-effects of henna and semi-permanent 'black henna' tattoos: a full review

Henna, the dried and powdered leaf of Lawsonia inermis, is widely used as a dye for the skin, hair, and nails, and as an expression of body art, especially in Islamic and Hindu cultures. As it stains the skin reddish-brown, it is also called red henna. Black henna is the combination of red henna with p-phenylenediamine (PPD), and is used for temporary 'black henna tattoos'. This article provides a full review of the side-effects of topical application of red and black henna, both cutaneous (allergic and non-allergic) and systemic. Red henna appears to be generally safe, with rare instances of contact allergy and type I hypersensitivity reactions. In children with glucose-6-phosphate dehydrogenase deficiency, topical application of henna may cause life-threatening haemolysis. Black henna tattoos will induce contact allergy to its ingredient PPD at an estimated frequency of 2.5%. Once sensitized, the patients may experience allergic contact dermatitis from the use of hair dyes containing PPD. There are often cross-reactions to other hair dyes, dyes used in textiles, local anaesthetics, and rubber chemicals. The sensitization of children to PPD may have important consequences for health and later career prospects. Systemic toxicity of black henna has been reported in certain African countries.