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Mowitz M, Hosseini S, Siemund I, Ulriksdotter J, Svedman C. New device, 'old' allergens. Allergic contact dermatitis caused by the Dexcom G7 glucose sensor. Contact Dermatitis 2024; 90:495-500. [PMID: 38316128 DOI: 10.1111/cod.14514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/12/2024] [Accepted: 01/22/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Allergic contact dermatitis (ACD) has been reported as an adverse effect from the use of several glucose sensors and insulin pumps from different manufacturers. Isobornyl acrylate (IBOA) has been identified as a major culprit sensitizer, but also other acrylates and (modified) colophonium have been reported as causes of ACD. OBJECTIVES To report the two first cases diagnosed with ACD caused by the Dexcom G7 (DG7) glucose sensor. PATIENTS AND METHODS Two children with suspected ACD from DG7 were patch tested with our medical device series with an addition of selected test preparations including two variants of modified colophonium - methyl hydrogenated rosinate (MHR) and glyceryl hydrogenated rosinate (GHR). Both patients were also tested with acetone extracts made from different parts of the DG7 sensor. The extracts were analysed by gas chromatography-mass spectrometry (GC-MS). RESULTS Both patients tested positive to IBOA, hydroabietyl alcohol and GHR. In addition, patient 1 had a positive reaction to MHR and patient 2 had a positive reaction to colophonium. The GC-MS analyses showed the presence of IBOA and colophonium-related substances in the DG7 extracts. CONCLUSIONS Both patients were diagnosed with contact allergy to well-known medical device-related sensitizers. The presence of IBOA and (modified) colophonium in a newly introduced (on the Swedish market in 2023) glucose sensor is remarkable and indicates an inadequate toxicological assessment of the materials used in the sensor.
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Affiliation(s)
- Martin Mowitz
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Sarah Hosseini
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
- Department of Dermatology and Venereology, Ryhov County Hospital, Jönköping, Sweden
| | - Ingrid Siemund
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Josefin Ulriksdotter
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Cecilia Svedman
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
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2
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Hamnerius N, Dahlin J, Bruze M, Nilsson K, Sukakul T, Svedman C. Colophonium-related Allergic Contact Dermatitis Caused by Medical Adhesive Tape Used to Prevent Skin Lesions in Soldiers. Acta Derm Venereol 2023; 103:adv18428. [PMID: 38059803 PMCID: PMC10719863 DOI: 10.2340/actadv.v103.18428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/25/2023] [Indexed: 12/08/2023] Open
Abstract
Medical adhesive tapes are commonly recommended for the prevention of friction blisters during hiking and military marches. The aim of this paper is to report on the results of investigations into an outbreak of tape-related foot dermatitis in 26 military conscripts following continuous use of medical adhesive tapes for several days during a field exercise. Patch tests were performed using baseline series and aimed testing was performed with colophonium-related substances and different medical adhesive tapes. Contact allergy to the adhesive tapes used was found in 20 (77%) subjects, and contact allergy to colophonium in 16 (61%). Chemical analysis detected colophonium-related substances in the culprit tapes. Compared with consecutive dermatitis patients investigated at our Department of Occupational and Environmental Dermatology in the previous 10 years, conscripts with colophonium allergy had increased odds ratios for concomitant contact allergy to phenol formaldehyde resins and fragrance substances including hydroperoxides of limonene and linalool. The results show that prolonged use of medical adhesive tapes on intact skin carries a high risk for allergic contact dermatitis. Prior to their introduction on the market, medical devices should be assessed for possible side-effects.
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Affiliation(s)
- Nils Hamnerius
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden.
| | - Jakob Dahlin
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Magnus Bruze
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Kristina Nilsson
- Department of Current Operations, Army Command, Swedish Armed Forces, Sweden
| | - Thanisorn Sukakul
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Cecilia Svedman
- Department of Occupational and Environmental Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden
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Dendooven E, Kerre S, Goossens A, Aerts O. Allergic contact dermatitis from a medical device containing Picea abies (Norway spruce) resin: Skin sensitizers other than resin acids might be of importance. Contact Dermatitis 2023; 88:60-62. [PMID: 36068985 DOI: 10.1111/cod.14215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/25/2022] [Accepted: 09/04/2022] [Indexed: 01/06/2023]
Affiliation(s)
- Ella Dendooven
- Department of Dermatology, University Hospital Antwerp (UZA) and Research Group Immunology, University of Antwerp, Antwerp, Belgium
| | - Stefan Kerre
- Department of Dermatology, Imelda Hospital, Bonheiden, Belgium
| | - An Goossens
- Department of Dermatology, University Hospitals KU Leuven, Leuven, Belgium
| | - Olivier Aerts
- Department of Dermatology, University Hospital Antwerp (UZA) and Research Group Immunology, University of Antwerp, Antwerp, Belgium
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Aerts O, Dendooven E, Raison-Peyron N. Sensitization to modified colophonium in glucose sensors: another problem for diabetes patients. Contact Dermatitis 2022; 87:553-555. [PMID: 36068926 DOI: 10.1111/cod.14213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/18/2022] [Accepted: 09/04/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Olivier Aerts
- Department of Dermatology, University Hospital Antwerp (UZA) and Research group Immunology, Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium
| | - Ella Dendooven
- Department of Dermatology, University Hospital Antwerp (UZA) and Research group Immunology, Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium
| | - Nadia Raison-Peyron
- Department of Dermatology, Saint Eloi Hospital, Montpellier University, 80 avenue Augustin Fliche, Montpellier, France
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Dendooven E, Foubert K, Naessens T, Pieters L, Lambert J, Goossens A, Aerts O. Allergic contact dermatitis from ("hypoallergenic") adhesives containing D-limonene. Contact Dermatitis 2021; 86:113-119. [PMID: 34786729 DOI: 10.1111/cod.14008] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/11/2021] [Accepted: 11/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Besides being a potential component of (some species of) colophonium, D-limonene is also used as a tackifier in the production of adhesives. Hydroperoxides of limonene are well-known skin sensitizers. OBJECTIVES To show that D-limonene may be present in colophonium-containing but also colophonium-free ("hypoallergenic") adhesives, and that patients suffering from allergic contact dermatitis (ACD) from both types of adhesives might display positive patch test reactions to limonene hydroperoxides in this regard. METHODS Five patients with suspected ACD from adhesives were patch tested to the baseline series (containing limonene hydroperoxides 0.3 and 0.2% pet.), additional series and, if available, to the culprit adhesives. The adhesives labelled as containing colophonium (n = 3) or free from it (n = 2) were analysed with gas chromatography - mass spectrometry (GC-MS) for the presence of D-limonene. RESULTS All five patients sensitised to adhesives had (strong) positive patch test reactions to limonene hydroperoxides. The presence of D-limonene, and/or related components, could be demonstrated in all three colophonium-containing and, surprisingly, also in two colophonium-free ("hypoallergenic") tapes. CONCLUSIONS D-limonene may be present in both regular and "hypoallergenic" adhesives, with limonene hydroperoxides potentially contributing to ACD from such medical devices. The use of fragrance chemicals in adhesives deserves further research.
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Affiliation(s)
- Ella Dendooven
- Department of Dermatology, University Hospital Antwerp (UZA) and Research group Immunology, INFLA-MED Centre of Excellence, University of Antwerp, Antwerp, Belgium.,Research Group Natural Products & Food - Research and Analysis (NatuRA), Department of Pharmaceutical Sciences, University of Antwerp, Antwerp, Belgium
| | - Kenn Foubert
- Research Group Natural Products & Food - Research and Analysis (NatuRA), Department of Pharmaceutical Sciences, University of Antwerp, Antwerp, Belgium
| | - Tania Naessens
- Research Group Natural Products & Food - Research and Analysis (NatuRA), Department of Pharmaceutical Sciences, University of Antwerp, Antwerp, Belgium
| | - Luc Pieters
- Research Group Natural Products & Food - Research and Analysis (NatuRA), Department of Pharmaceutical Sciences, University of Antwerp, Antwerp, Belgium
| | - Julien Lambert
- Department of Dermatology, University Hospital Antwerp (UZA) and Research group Immunology, INFLA-MED Centre of Excellence, University of Antwerp, Antwerp, Belgium
| | - An Goossens
- Department of Dermatology, University Hospitals K.U.Leuven, Leuven, Belgium
| | - Olivier Aerts
- Department of Dermatology, University Hospital Antwerp (UZA) and Research group Immunology, INFLA-MED Centre of Excellence, University of Antwerp, Antwerp, Belgium
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Karlberg AT, Albadr MH, Nilsson U. Tracing colophonium in consumer products. Contact Dermatitis 2021; 85:671-678. [PMID: 34291483 DOI: 10.1111/cod.13944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/29/2021] [Accepted: 07/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Colophonium (rosin) can cause allergic contact dermatitis, mainly due to autoxidation of abietic acid (AbA). Products containing ≥0.1% colophonium should be labeled with EUH208 - "Contains rosin; colophony. May produce an allergic reaction." How should this be measured? OBJECTIVE To compare the results from different strategies for estimating colophonium levels in consumer products: (a) from AbA, and (b) the sum of all major resin acids. To investigate the ratio of 7-oxodehydroabietic acid (7-O-DeA)/AbA as indication of autoxidation. METHODS Resin acids were extracted from consumer products, derivatized, and then separated by gas chromatography/mass spectrometry (GC/MS). RESULTS Resin acids were detected in 9 of 15 products. No product contained colophonium ≥0.1%. Estimation based on AbA resulted in underestimation of the colophonium levels in four of nine products. For three products, the obtained levels from this strategy were only one of two compared to when estimating from the sum of all resin acids. The ratio 7-O-DeA/AbA varied from 74% to 1.4%. CONCLUSIONS We propose to measure colophonium based on the sum of all detectable major resin acids, including 7-O-DeA. The ratio of 7-O-DeA/AbA should be used as a marker of autoxidation, indicating an increased risk of sensitization. The presented analytical method is simple to use and suitable for further screening studies.
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Affiliation(s)
- Ann-Therese Karlberg
- Department of Chemistry and Molecular Biology, University of Gothenburg, Gothenburg, Sweden
| | - Mhd-Hussam Albadr
- Department of Materials and Environmental Chemistry, Stockholm University, Stockholm, Sweden
| | - Ulrika Nilsson
- Department of Materials and Environmental Chemistry, Stockholm University, Stockholm, Sweden
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Suzuki K, Futamura K, Kawakami T, Numata M, Sasaki K, Matsunaga K, Yagami A. Contact dermatitis caused by a disposable paper napkin containing colophonium. Contact Dermatitis 2021; 85:377-379. [PMID: 33861875 DOI: 10.1111/cod.13864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Kayoko Suzuki
- Department of Allergology, Fujita Health University School of Medicine, Nagoya, Japan.,General Allergy Center, Fujita Health University, Nagoya, Japan
| | - Kyoko Futamura
- Department of Allergology, Fujita Health University School of Medicine, Nagoya, Japan.,General Allergy Center, Fujita Health University, Nagoya, Japan
| | - Tsuyoshi Kawakami
- Division of Environmental Chemistry, National Institute of Health Sciences, Kawasaki, Japan
| | - Mitsuru Numata
- Administrative Affairs Division, Biological Resource Center, National Institute of Technology and Evaluation, Tokyo, Japan
| | - Kazumi Sasaki
- Administrative Affairs Division, Biological Resource Center, National Institute of Technology and Evaluation, Tokyo, Japan
| | - Kayoko Matsunaga
- Department of Allergology, Fujita Health University School of Medicine, Nagoya, Japan.,Department of Integrative Medical Science for Allergic Disease, Fujita Health University School of Medicine, Nagoya, Japan
| | - Akiko Yagami
- Department of Allergology, Fujita Health University School of Medicine, Nagoya, Japan.,General Allergy Center, Fujita Health University, Nagoya, Japan
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Lahouel I, Thabouti M, Belhadjali H, Fadhel NB, Soua Y, Youssef M, Zili J. Pustular allergic contact dermatitis caused by colophonium in depilatory wax. Contact Dermatitis 2020; 84:130-132. [PMID: 32876340 DOI: 10.1111/cod.13695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Ines Lahouel
- Dermatology Department, Fattouma Bourguiba Hospital, University of Medicine, Monastir, Tunisia
| | - Marwa Thabouti
- Dermatology Department, Fattouma Bourguiba Hospital, University of Medicine, Monastir, Tunisia
| | - Hichem Belhadjali
- Dermatology Department, Fattouma Bourguiba Hospital, University of Medicine, Monastir, Tunisia
| | - Najeh B Fadhel
- Pharmacology Department, Fattouma Bourguiba Hospital, University of Medicine, Monastir, Tunisia
| | - Yosra Soua
- Dermatology Department, Fattouma Bourguiba Hospital, University of Medicine, Monastir, Tunisia
| | - Monia Youssef
- Dermatology Department, Fattouma Bourguiba Hospital, University of Medicine, Monastir, Tunisia
| | - Jameleddine Zili
- Dermatology Department, Fattouma Bourguiba Hospital, University of Medicine, Monastir, Tunisia
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9
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Oiso N, Kawada A. A safety illustration printed on an intermittent pneumatic compression device caused allergic contact dermatitis. Contact Dermatitis 2020; 82:244-245. [PMID: 31794055 DOI: 10.1111/cod.13447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 12/02/2019] [Indexed: 11/28/2022]
Affiliation(s)
| | - Akira Kawada
- Department of Dermatology, Kindai University Faculty of Medicine, Osaka, Japan
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10
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Paulsen E, Andersen F. Fragrant and sticky allergens from the pinewood: Cohabiting and coreacting. Contact Dermatitis 2019; 81:374-377. [PMID: 31281968 DOI: 10.1111/cod.13348] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/03/2019] [Accepted: 07/05/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tree moss (Pseudevernia furfuracea [L.] Zopf.), a lichen growing on conifers, is a frequent fragrance sensitizer. Previous studies have shown two subgroups of tree moss-allergic patients: a group sensitized to common allergens of tree and oak moss (Evernia prunastri), and another group sensitized to colophonium-derived allergens, which may contaminate tree moss extract. OBJECTIVES To report the results of including tree moss extract in the baseline series and discuss the clinical implications. METHODS Tree moss extract was included in the baseline series and sensitized patients were assessed for concomitant allergy to colophonium and oak moss, and the relevance of these reactions was analyzed. RESULTS Altogether, 22 of 632 patients (3.5%) had positive reactions to tree moss. Eight patients were sensitized to tree moss only (among fragrance allergens) and 75% had relevant reactions to colophonium. Fourteen patients were sensitized to other fragrance allergens as well and 28.5% had relevant colophonium reactions. CONCLUSIONS The prevalence of positive tree moss reactions is high enough to justify its inclusion in the baseline series. If tree moss is not included, patients with positive colophonium reactions should be informed of possible (false) cross-reactivity to tree moss to avoid this labeled fragrance allergen.
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Affiliation(s)
- Evy Paulsen
- Department of Dermatology and Allergy Centre, Odense University Hospital, University of Southern Denmark, Odense, Denmark
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11
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Lyapina MG, Stoyanova Dencheva M. Contact sensitization to ingredients of dental materials and cosmetics in dental students: a pilot study. Cent Eur J Public Health 2019; 27:73-77. [PMID: 30927402 DOI: 10.21101/cejph.a4756] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the rate of contact sensitization to selected cosmetic allergens, i.e. ingredients of dental materials, in students of dental medicine and dental patients. METHODS A total of 50 participants were included in the study: 40 students of dental medicine exposed to the studied allergens during the course of practical education; and 10 randomly selected dental patients without occupational exposure to the investigated substances served as a control group. All of them were patch-tested with colophonium, myroxylon pereirae resin, paraben mix, fragrance mix I, isopropyl myristate, triclosan, polysorbate 80, compositae mix II, and hydroperoxides of limonene. RESULTS The sensitization rates for colophonium and polysorbate 80 were the highest. For the group of dental students, we established significantly higher sensitization rate for colophonium compared to the ones for myroxylon pereirae resin and hydroperoxides of limonene (χ2 = 4.93; p = 0.026), paraben mix (χ2 = 3.6; p = 0.05), isopropyl myristate (χ2 = 6.56; p = 0.01), and triclosan (χ2 = 8.5; p < 0.001); and to polysorbate 80 compared to the ones for myroxylon pereirae resin and hydroperoxides of limonene (χ2 = 3.97; p = 0.046), isopropyl myristate (χ2 = 5.47; p = 0.02) and triclosan (χ2 = 7.34; p = 0.007). Significantly increased concomitant sensitization rate to compositae mix and to hydroperoxides of limonene was established (χ2 = 12.55; p < 0.001). Generally, the incidence of concomitant sensitization to the studied allergens in the whole studied population was high. CONCLUSIONS Colophonium and polysorbate 80 could be outlined as sensitizers of paramount importance for both dental students and dental patients. We consider the major importance of exposure to colophonium during the course of practical education in dentistry for the onset of the sensitization. Sensitization to compositae mix was observed only among dental students. We consider the leading role of consumer exposure for the onset of the sensitization to triclosan and to hydroperoxides of limonene. Unexpected and unreported reactions of concomitant sensitization were observed.
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Affiliation(s)
| | - Maria Stoyanova Dencheva
- Department of Oral and Image Diagnostic, Faculty of Dental Medicine, Medical University, Sofia, Bulgaria
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Affiliation(s)
- Lise Gether
- Department of Dermatology and Allergy, Herlev-Gentofte Hospital, University of Copenhagen, 2900 Hellerup, Denmark
| | - Mette Gyldenløve
- Department of Dermatology and Allergy, Herlev-Gentofte Hospital, University of Copenhagen, 2900 Hellerup, Denmark
| | - Jacob P Thyssen
- Department of Dermatology and Allergy, Herlev-Gentofte Hospital, University of Copenhagen, 2900 Hellerup, Denmark
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13
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Corazza M, Musmeci D, Scuderi V, Bernardi T, Cristofaro D, Borghi A. Occupational systemic allergic dermatitis in a football player sensitized to colophonium. Contact Dermatitis 2018; 79:325-326. [PMID: 30019518 DOI: 10.1111/cod.13081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 06/19/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Monica Corazza
- Section of Dermatology, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Dario Musmeci
- Section of Dermatology, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Valeria Scuderi
- Section of Dermatology, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Tatiana Bernardi
- Section of Chemistry, Department of Chemical and Pharmaceutical Sciences, University of Ferrara, Ferrara, Italy
| | - Dario Cristofaro
- Section of Chemistry, Department of Chemical and Pharmaceutical Sciences, University of Ferrara, Ferrara, Italy
| | - Alessandro Borghi
- Section of Dermatology, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
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14
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Kaur S, Vasar M. Contact allergy to the ingredients of moisturizers in a boy with atopic dermatitis. Contact Dermatitis 2017; 76:180-181. [PMID: 28220565 DOI: 10.1111/cod.12660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 06/14/2016] [Accepted: 06/19/2016] [Indexed: 01/31/2023]
Affiliation(s)
- Sirje Kaur
- Clinic of Dermatology, Tartu University, 50417 Tartu, Estonia.,Clinic of Dermatology, Tartu University Hospital, Tartu, Estonia
| | - Maire Vasar
- Children's Clinic, Tartu University, Tartu, Estonia.,Children's Clinic, Tartu University Hospital, 51014 Tartu, Estonia
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