Nickel sensitization: impact of the European Union Nickel Directives

Összefoglaló. Bevezetés: A nikkel széleskörűen elterjedt fém és kontaktallergén. Megtalálható mindennapi használati tárgyainkban, feldolgozza az ipari termelés, és az egészségügyben is rendre bővül alkalmazási köre. Egyidejűleg a társadalom növekvő hányadánál fordul elő nikkel-kontaktszenzibilizáció. Célkitűzés: Az epicutan tesztelt betegcsoport adatainak feldolgozása, kiemelve a nikkelpozitív betegek megoszlását nem, életkor, diagnózis, a klinikai tünetek lokalizációja és a társult fémérzékenység szerint, továbbá a 2004 óta érvényes európai uniós Nikkel Direktívák hatásainak tanulmányozása. Módszer: A közlemény a Semmelweis Egyetem Bőr-, Nemikórtani és Bőronkológiai Klinikájának Allergológia Laboratórium és Szakambulanciáján 1994-től 2014-ig 13 693 fő (10-87 év közötti) standard környezeti epicutan sorral tesztelt beteg adatait vizsgálja retrospektív módon. Eredmények: Az összes vizsgált bőrbeteg nikkelszenzibilizációs aránya 1994-ben 13,1%, 2004-ben 11,5%, 2014-ben 19,1% volt. A nikkel-kontaktdermatitis főként nőbetegeknél (93,0%) fordul elő. A klinikai tünetek elsősorban a karokra és az arcra lokalizálódnak. Nikkelérzékenyeknél az allergiás kontaktdermatitis diagnózisa 65,8%, atopiás dermatitis 9,7%-nál fordul elő. A nikkelérzékenységhez leggyakrabban társult fémallergének a kobalt és a króm. Az 1994-2004-es periódushoz képest az európai uniós Nikkel Direktívákat követő 10 évben a szenzibilizáció százalékos emelkedése szignifikáns volt, ugyanakkor a nikkelpozitívak évenkénti száma csökkent. 1994-ben a betegek legnagyobb hányada (26,5%) a 20-24 éves korcsoportba tartozott, 2004-ben szintén (20,8%), 2014-ben azonban a 35-39 éves korosztályhoz (15,1%). Következtetések: A nikkelszenzibilizáció korban eltolódást mutat az idősebb korosztály felé, a 35 évesnél fiatalabb betegek száma mérséklődött. A Nikkel Direktívák révén a fiatalabbak későbbi életkorban és kisebb mértékű nikkelexpozíciónak vannak kitéve. A vizsgált betegek nikkelérzékenységének százalékos emelkedése miatt azonban újabb szabályozások bevezetése és a hatályban lévők módosítása szükségszerű. Orv Hetil. 2021; 162(16): 629-637.

SUMMARY

INTRODUCTION

Nickel is a widely used metal and contact allergen. It can be found in our everyday objects and it is becoming more prevalent in healthcare. Simultaneously, nickel contact sensitization occurs more frequently.

OBJECTIVE

Analysis of data of patch tested patients by gender, age, diagnosis, localization of skin lesions, and associated metal sensitivity. Furthermore, to study the effects of the European Nickel Directives in force since 2004.

METHOD

Retrospective analysis of data of 13 693 patients (aged 10-87) tested with a standard series of contact allergens at the Allergy Outpatient Unit and Laboratory of the Department, Venereology and Dermatooncology, Semmelweis University.

RESULT

Nickel sensitization of all examined patients was 13.1% in 1994, 11.5% in 2004, and 19.1% in 2014. Contact dermatitis occurred mainly in females (93.0%). Skin lesions are primarily localized to the arms and face. Diagnosis of allergic contact dermatitis occurred in 65.8%, and atopic dermatitis in 9.7% of tested patients. Commonly associated metal sensitivities were cobalt and chromium. In the 10 years following the Nickel Directives, the increase of the ratio of sensitized patients was significant while the number of nickel-positives per year decreased. Both in 1994 and 2004, the largest proportion of patients belonged to the 20-24 age group (26.5% and 20.8%, respectively), but in 2014, to the 35-39 age group (15.1%).

CONCLUSION

Nickel sensitization shifts towards the older age group, with a decrease in young patients. Because of the Nickel Directives, people are exposed to nickel at a later age and to a lesser extent. Due to the increase of the ratio of nickel-sensitive patients, it is necessary to introduce new regulations and amend the existing ones. Orv Hetil. 2021; 162(16): 629-637.

Patch test results of the European baseline series among 1309 patients in Turkey between 2013 and 2019

BACKGROUND

Prevalences of sensitivity to contact allergens change over time as a result of variations in allergen exposure.

OBJECTIVES

The aim of the study was to describe trends in sensitisation to allergens of the European baseline series in Turkey between 2013 and 2019.

METHODS

The patch test results of 1309 patients with suspected allergic contact dermatitis (ACD) were analysed retrospectively, and the prevalence of contact allergies to European baseline series allergens was compared with previous data (for 1998-2005).

RESULTS

A total of 534 (40.8%) patients exhibited one or more positive patch test reaction. The five most frequent allergens were nickel sulfate (19.6%), potassium dichromate (6.5%), cobalt chloride (6%), Myroxylon pereirae resin (5%), and p-phenylenediamine (PPD; 3.7%). Statistically significant increases in the prevalence of sensitisation to methylchloroisothiazolinone/methylisothiazolinone (MCI/MI; P < .001), Myroxylon pereirae resin (P < .001), PPD (P = .008), and fragrance mix I (P = .036) were observed in the 2013 to 2019 period compared with the 1998 to 2005 period. Conversely, positive reactions to neomycin sulfate (P = .029), clioquinol (P = .031), and primin (P = .001) decreased significantly.

CONCLUSION

This study provides a comprehensive profile of ACD in Turkey. The remarkable increase in the MI and MCI/MI contact allergy observed underlines the urgent need for regulatory measures to reduce exposure to MI and MCI/MI in Turkey.

Regulation of contact sensitivity in non-obese diabetic (NOD) mice by innate immunity

BACKGROUND

Genetic background influences allergic immune responses to environmental stimuli. Non-obese diabetic (NOD) mice are highly susceptible to environmental stimuli. Little is known about the interaction of autoimmune genetic factors with innate immunity in allergies, especially skin hypersensitivity.

OBJECTIVES

To study the interplay of innate immunity and autoimmune genetic factors in contact hypersensitivity (CHS) by using various innate immunity-deficient NOD mice.

METHODS

Toll-like receptor (TLR) 2-deficient, TLR9-deficient and MyD88-deficient NOD mice were used to investigate CHS. The cellular mechanism was determined by flow cytometry in vitro and adoptive cell transfer in vivo. To investigate the role of MyD88 in dendritic cells (DCs) in CHS, we also used CD11c^MyD88+  MyD88^-/- NOD mice, in which MyD88 is expressed only in CD11c⁺ cells.

RESULTS

We found that innate immunity negatively regulates CHS, as innate immunity-deficient NOD mice developed exacerbated CHS accompanied by increased numbers of skin-migrating CD11c⁺ DCs expressing higher levels of major histocompatibility complex II and CD80. Moreover, MyD88^-/- NOD mice had increased numbers of CD11c⁺  CD207^-  CD103⁺ DCs and activated T effector cells in the skin-draining lymph nodes. Strikingly, re-expression of MyD88 in CD11c⁺ DCs (CD11c^MyD88+  MyD88^-/- NOD mice) restored hyper-CHS to a normal level in MyD88^-/- NOD mice.

CONCLUSION

Our results suggest that the autoimmune-prone NOD genetic background aggravates CHS regulated by innate immunity, through DCs and T effector cells.

A subset of AID-dependent B-1a cells initiates hypersensitivity and pneumococcal pneumonia resistance

We propose that there is a special B-1a B cell subset ("sB-1a" cells) that mediates linked processes very early after immunization to initiate cutaneous contact sensitivity (CS), delayed-type hypersensitivity (DTH), and immune resistance to pneumococcal pneumonia. Our published data indicate that in CS and DTH, these initiating processes are required for elicitation of the delayed onset and late-occurring classical T cell-mediated responses. sB-1a cells resemble memory B2 cells, as they are stimulated within 1 h of immunization and depend on T helper cytokines-uniquely IL-4 from hepatic iNKT cells--for activation and rapid migration from the peritoneal cavity to the spleen to secrete IgM antibody (Ab) and Ab-derived free light chains (FLCs) by only 1 day after immunization. Unlike conventional B-1a (cB-1a) cell-produced IgM natural Ab, IgM Ab produced by sB-1a cells has high Ag affinity owing to immunoglobulin V-region mutations induced by activation-induced cytidine deaminase (AID). The dominant cB-1a cells are increased in immunized AID-deficient mice but do not mediate initiation, CS, or pneumonia resistance because natural Ab has relatively low Ag affinity because of unmutated germ-line V regions. In CS and DTH, sB-1a IgM Ag affinity is sufficiently high to mediate complement activation for generation of C5a that, together with vasoactive mediators such as TNF-α released by FLC-sensitized mast cells, activate local endothelium for extravascular recruitment of effector T cells. We conclude by discussing the possibility of functional sB-1 cells in humans.

Contact sensitivity in patients with recalcitrant atopic dermatitis

Patients with atopic dermatitis are usually responsive to conventional treatment such as topical steroids; however, they are sometimes refractory to the treatment. The influence of contact sensitivities on the course of patients with recalcitrant atopic dermatitis is not known. The aim of this study was to investigate whether contact sensitivities affect the course of patients with recalcitrant atopic dermatitis. We evaluated 45 patients with atopic dermatitis who had failed conventional therapy. Patch testing was performed with the Japanese standard series, metal series and/or suspected items. A total of 15 patients had a positive patch test reaction to at least one allergen. The most common allergens were nickel, topical drugs and rubber accelerators. Avoidance of products or food containing allergic substances greatly or partially improved skin symptoms in nine patients. These results suggest that contact allergens and metals may be critical factors causing eczematous lesions in patients with recalcitrant atopic dermatitis.

Natural killer cell-mediated contact sensitivity develops rapidly and depends on interferon-α, interferon-γ and interleukin-12

Natural killer (NK) cell-mediated contact sensitivity was recently described in mice. Here, we confirm NK cell-mediated contact sensitivity (CS) in SCID and RAG1(-/-) mice but not in SCIDbeige mice, which have non-functional NK cells that lack NK cell granules. NK cell-mediated CS was transferred by liver mononuclear cells and the DX5(+) fraction of liver cells, confirming that NK cells mediate CS in the absence of T and B cells. Participation of NKT cells and B-1 cells was ruled out using Jα18(-/-) and JH(-/-) mice, respectively. Remarkably, NK cell-mediated CS was observed just 1 hr after immunization and was detectable as early as 30 min after challenge. Further, we examined cytokine requirements for NK cell-mediated CS, and found that liver mononuclear cells from interleukin-12(-/-) , interferon-γ(-/-) and interferon-α receptor(-/-) donors fail to transfer NK cell-mediated CS to naive hosts. Our studies clearly show that dinitrofluorobenzene sensitized NK cells mediate very rapid, antigen-specific cell-mediated immunity, with features of both innate and acquired immune responses.

Impaired CD40-signalling in Langerhans' cells from murine neonatal draining lymph nodes: implications for neonatally induced cutaneous tolerance

Cutaneous tolerance to antigens may be induced in mice through application of antigen during the first few days following birth. The mechanism governing this neonatally induced tolerance remains uncertain. We employed a contact hypersensitivity model to analyse dendritic cell (DC) function and the expression of classical and non-classical lymphocyte populations within the neonate. Examination of draining lymph node DC after antigenic challenge of the skin revealed these DC to be significantly deficient in their ability to stimulate antigen-specific T cell proliferation. Co-stimulatory molecule (CD40, CD80 and CD86) expression of these cells was deficient in comparison to adult DC, and functional tests revealed these cells to possess a critical absence of CD40 signalling. A numerical analysis of classical and non-classical lymphocyte expression demonstrated that while the neonatal spleen is devoid of T cells, the lymph nodes have a normal repertoire of T, B, gammadelta and CD4+CD25+ lymphocytes but an increased expression of natural killer (NK) cells. This study indicates that functionally deficient DC are likely contributors to neonatally induced cutaneous tolerance.

Pathogenic roles of eosinophils in guinea-pig contact sensitivity: regulation of dermal eosinophilia with remotely administered IL-5

Eosinophils have a variety of functions. Although increasing evidence links the presence of eosinophils to airway damage, studies have not examined in detail if, and how, eosinophils affect skin inflammation. The purpose of this study was to determine whether eosinophil infiltration augments the contact sensitivity reaction in vivo. Guinea-pigs were sensitized with 2, 4-dinitrochlorobenzene and challenged on the dorsal skin or on the right ear lobe. The number of eosinophils and macroscopic changes of the skin lesion in the presence or absence of human recombinant IL-5 (rIL-5) administered at the remote site was assessed. The reaction on the dorsal skin was acutely eczematous with considerable basophil infiltration. In contrast, eosinophils had extensively infiltrated the right ear lobe and major basic protein was deposited in the dermis. A subcutaneous injection of rIL-5 (10 pmol/kg) at the remote site (left ear lobe) 12 h after challenge induced transient blood eosinophilia and enhanced eosinophil accumulation in the challenged ear lobe. These changes were accompanied by increased ear swelling and severe erythema. In contrast, eosinophil infiltration was significantly inhibited by rIL-5 administered at the time of challenge. Ear thickness, as well as the erythema and oedema, were also reduced. These data suggest that marked eosinophil infiltration enhances skin inflammation in allergic contact dermatitis. Moreover, locally administered IL-5 functions remotely by controlling eosinophil recruitment into the skin. The guinea-pig model of contact sensitivity may be useful for evaluating therapies and pharmaceuticals targeted at eosinophil infiltration.

The murine buccal mucosa is an inductive site for priming class I-restricted CD8+ effector T cells in vivo

The present study shows that Langerhans cells of the buccal mucosa and the skin share a similar phenotype, including in situ expression of MHC class II, the mannose receptor DEC-205 and CD11c, and absence of the costimulatory molecules B7.1, B7.2 and CD40 as well as Fas. Application of 2,4-dinitrofluorobenzene (DNFB) onto the buccal mucosa is associated with a rapid migration of dendritic cells (DC) to the epithelium and induction of B7.2 expression on some DC. Buccal sensitization with DNFB elicited a specific contact sensitivity (CS) in response to skin challenge, mediated by class I-restricted CD8+ effector T cells and down-regulated by class II-restricted CD4+ T cells, demonstrated by the lack of priming of class I-deficient mice and the enhanced response of class II-deficient mice, respectively. CS induced by buccal immunization is associated with priming of class I-restricted CD8+ effector T cells endowed with hapten-specific cytotoxic activity. Thus, the buccal epithelium is an inductive site, equivalent to the epidermis, for the generation of CS independent of CD4 help, and of cytotoxic T lymphocyte (CTL) responses mediated by class I-restricted CD8+ T cells. We propose that immunization through the buccal mucosa, which allows antigen presentation by epithelial DC efficient for priming systemic class I-restricted CD8+ CTL, may be a valuable approach for single-dose mucosal vaccination with subunit vaccines.

The effect of cyclosporin A, FK506 and rapamycin on the murine contact sensitivity reaction

We have evaluated the effects of three potent immunosuppressive agents, cyclosporin A (CsA), FK506 and rapamycin, on the murine contact sensitivity (CS) reaction to the hapten trinitrochlorobenzene. Development of CS reaction requires participation of three distinct T cell subsets: alphabeta+, CD4+ T lymphocytes, which are the classical effector cell of the CS reaction, gammadelta+ T lymphocytes, and alphabeta+, double-negative (CD4- CD8-) T lymphocytes that express the B220 molecule and produce IL-4. We found that all three drugs inhibit the development of the CS reaction, but they affect different target cells. In fact, rapamycin and FK-506 block both alphabeta+, CD4+ and gammadelta+ T lymphocytes, while CsA inhibits only the alphabeta+, CD4+ T lymphocyte. None of the three drugs exerted any inhibitory activity on the alphabeta+, double-negative (CD4- CD8-) T lymphocytes. Hapten-immune lymph node cells from mice treated in vivo with CsA or FK506 failed to proliferate and to produce IL-2 when re-exposed to the specific antigen in vitro. In contrast, immune lymph node cells from mice that had been treated in vivo with rapamycin gave optimal antigen-specific proliferation and IL-2 production in vitro. The implications of these observations are discussed in relation to the use of these immunosuppressive agents for prevention of allograft rejection.

Role of IL-4 in delayed type hypersensitivity

IL-4 plays a key role in the contact sensitivity skin reaction. This has several implications. First, the view that contact sensitivity (CS) is only mediated by cells with a Th1 profile of cytokine secretion needs modification, in the light of the essential role of IL-4 at the effector stage. Second, the concept of a single cell involved in the systemic transfer of CS is no longer tenable, as it is known that both alpha beta and gamma delta cells are required. Studies with the cell lines (which contain both alpha beta and a few gamma delta cells) suggest that this double requirement may involve the action of IL-4 on gamma delta cells, which bear receptors for IL-4. Finally, the view that T cell lines only transfer CS when injected locally, but not when injected intravenously (systemic transfer), is correct but incomplete, as T cell lines actually give systemic transfer of CS, providing the cell line or the recipient is treated with IL-4.