Allergic contact dermatitis as a complication of lid loading with gold implants

Paralysis of the orbicularis oculi muscle in patients with a facial nerve injury causes functional and cosmetic disabilities including inability to close the eyelid. This complication is often treated by implanting a gold weight in the upper eyelid, which, however, is not without side effects. Four patients are described who, after lid loading with a gold implant, acquired an inflammatory reaction due to contact allergy to the metal inserted. The allergy was demonstrated by patch testing with gold sodium thiosulfate. The implant was removed and the dermatitis resolved. Contact allergy to gold occurs frequently and may explain many cases of complications to lid loading with the metal.

Percutaneous absorption of gold sodium thiosulfate used for patch testing

Contact allergy to gold has been shown to be correlated to wearing of golden jewellery as well as to the presence of dental gold. The prerequisite for sensitization and elicitation of an allergic contact dermatitis to gold is ionization and percutaneous absorption of the allergen. The present study was undertaken with the aim to demonstrate gold in blood after an occlusive patch testing with gold sodium thiosulfate (GSTS). Patients were patch tested with GSTS 0.5, 2.0 and 5.0% in petrolatum. Venous blood was sampled before testing as well as on day 3 (D3) or day 7 (D7). Blood gold levels were analysed by inductively coupled plasma mass spectrometry. In all 66 patients, the blood level of gold was significantly higher in the 2nd blood sample than in the 1st (median 0.34 versus 0.03 micro g/l). The increase was similar in patients allergic and not allergic to gold. There was no difference between gold levels on D3 and on D7 after epicutaneous application. Presumably, other allergens may also be taken up in blood during patch testing.

Allergic contact dermatitis from dicyclohexylmethane-4,4′-diisocyanate

From August 1999 to April 2001, there was an outbreak of severe eczema at a factory manufacturing medical equipment. A glue, mainly based on the isocyanate dicyclohexylmethane-4,4'-diisocyanate (DMDI), was suspected as being the cause of the problem. 16 workers with recent episodes of eczema were patch tested with a standard series, an isocyanate series and work material. The latter consisted of, among other things, the glue, DMDI, and an amine, dicyclohexylmethane-4,4'-diamine (DMDA), which is formed when DMDI reacts with water. 13 patients reacted to DMDI, 9 to 1,6-hexamethylenediisocyanate (HDI) and 4 to isophoronediisocyanate (IPDI), all of which are aliphatic isocyanates. None reacted to the aromatic isocyanates, diphenylmethane-4,4'-diisocyanate (MDI) or toluenediisocyanate (TDI). One explanation for this pattern could be that aromatic diisocyanates are more reactive than the aliphatic ones and that, therefore, they are inactivated before penetrating the skin. 5 patients reacted to DMDA and 5 to 4,4'-diaminodiphenylmethane (MDA). Concurrent reactions to DMDA and or MDA with DMDI could be due to cross-reactivity. The positive reactions to MDA could also be a marker of MDI exposure. Yet another patient, investigated in 1997 with suspected work-related contact dermatitis from the glue, is described. She, however, showed no positive reactions to any isocyanates.

Occupational allergic contact dermatitis in a company manufacturing boards coated with isocyanate lacquer

Over a short period of time, there was an outbreak of work-related skin lesions among workers at a company producing flooring laminate boards, after the introduction of a water-repellent lacquer based on diphenylmethane-4,4'-diisocyanate (MDI). In 5 workers, patch testing was performed with a standard series, an isocyanate series and work-environmental products when indicated. 3 of the workers were tested with the lacquer, and contact allergy was found with concurrent reactions to 4,4'-diaminodiphenylmethane (MDA). 1 of the 3 workers also showed a simultaneous reaction to MDI, whereas 1 showed a positive reaction to dicyclohexylmethane-4,4'-diisocyanate (HMDI). Of the 2 individuals not tested with the lacquer, 1 reacted to both MDI and MDA, whereas the other reacted to a soap used at work. In 3 of 4 cases, the isocyanate reactions appeared after D3. Occupational contact with isocyanates should not exclusively be focused upon respiratory hazards, as this report shows that skin contamination probably increases the risk of developing contact allergy to isocyanates and isocyanate-related substances. When aiming at diagnosing contact allergy to isocyanates, it is desirable to perform a late reading, as positive reactions appear late. MDA appears to be a good marker for isocyanate hypersensitivity.

Contact allergy to gold is correlated to dental gold

Questionnaire studies have indicated that patients with dental gold will more frequently have contact allergy to gold. This study aimed at investigating the relationship between contact allergy to gold and the presence and amount of dental gold alloys. A total of 102 patients were referred for patch testing because of suspicion of contact allergy. Patch tests were performed with gold sodium thiosulphate 2% and 5%. The patients underwent an oral clinical and radiological examination. Contact allergy to gold was recorded in 30.4% of the patients, and of these 74.2% had dental gold (p=0.009). A significant correlation was found between the amount of gold surfaces and contact allergy to gold (p=0.008), but there was no statistical relationship to oral lesions. It is concluded that there is a positive relationship between contact allergy to gold and presence and amount of dental gold alloys.

Gold concentration in blood in relation to the number of gold restorations and contact allergy to gold

Previous studies have demonstrated an association between gold allergy and the presence of dental gold restorations. The aim of the present study was to investigate the relationship between the concentration of gold in blood (B-Au) and the number of tooth surfaces with gold alloys in subjects with and without contact allergy to gold. In 80 patients referred for patch testing because of eczematous disease, blood samples were taken and analyzed for B-Au using inductively coupled plasma mass spectrometry. The detection limit for the Au determination was 0.04 microg/L. In addition, a dentist made a clinical and radiological examination of the patients and registered the number of dental gold surfaces. Patients with dental gold restorations had a statistically significantly higher B-Au in Mann-Whitney U test (P = 0.025), (range < 0.04-1.07 microg/L) than patients without (range < 0.04-0.15 microg/L). Furthermore, a positive correlation was found between B-Au and the number of dental gold surfaces (P < 0.01). There was no statistically significant difference in B-Au between persons with and without contact allergy to gold. The study thus indicates that gold is released from dental restorations and taken tip into the circulation.

Copper allergy from dental copper amalgam?

A 65-year-old female was investigated due to a gradually increasing greenish colour change of her plastic dental splint, which she used to prevent teeth grinding when sleeping. Furthermore, she had noted a greenish/bluish colour change on the back of her black gloves, which she used to wipe her tears away while walking outdoors. The investigation revealed that the patient had a contact allergy to copper, which is very rare. She had, however, had no occupational exposure to copper. The contact allergy may be caused by long-term exposure of the oral mucosa to copper from copper-rich amalgam fillings, which were frequently used in childhood dentistry up to the 1960s in Sweden. The deposition of a copper-containing coating on the dental splint may be caused by a raised copper intake from drinking water, increasing the copper excretion in saliva, in combination with release of copper due to electrochemical corrosion of dental amalgam. The greenish colour change of the surface of the splint is probably caused by deposition of a mixture of copper compounds, e.g. copper carbonates. Analysis by the X-ray diffraction technique indicates that the dominant component is copper oxide (Cu2O and CuO). The corresponding greenish/bluish discoloration observed on the back of the patient's gloves may be caused by increased copper excretion in tears.

Rheumatoid arthritis, gold therapy, contact allergy and blood cytokines

OBJECTIVE

To study the clinical and biochemical effects of a low starting dose for gold therapy in rheumatoid arthritis patients with a contact allergy to gold.

METHODS

Serum cytokines were assayed before and 24 h after the first injection of gold sodium thiomalate (GSTM).

RESULTS

Contact allergy to gold was found in 4 of 19 patients. Compared to gold-negative patients (starting dose: 10 mg GSTM), there was a larger increase in serum TNFalpha (p < 0.05), sTNF-R1 (NS), and IL-1 ra (p < 0.05) in gold-allergic patients.

CONCLUSIONS

Cytokines are released in blood by GSTM in RA patients with gold allergy. To minimize the risk of acute adverse reactions the starting dose of GSTM should be lowered to 5 mg. Alternatively, patients should be patch-tested before gold therapy; in test-positive cases, 5 mg is recommended as the first dose.

Standardization of the TRUE Test imidazolidinyl urea and diazolidinyl urea patches

The preservatives imidazolidinyl urea (IMID, Germall 115) and diazolidinyl urea (DU, Germall II) are commonly used in cosmetic products and are well-known sensitizers. The aim of the present study was to establish the optimal patch test concentration in hydrophilic dried-in vehicle (TRUE Test) for IMID and DU. 181 patients were included in the study. Of these, 150 were patients referred for patch testing, 12 were patients with known allergy to IMID and 19 were patients with known allergy to DU. 76 consecutive patients and the 12 IMID-allergic patients were patch tested with a dilution series IMID (0 to 600 microg/cm(2)), formaldehyde (180 microg/cm(2)) and DU (200 microg/cm(2)). 74 consecutive patients and the 19 DU-allergic patients were patch tested with a dilution series of DU (0 to 600 microg/cm(2)), formaldehyde (180 microg/cm) and IMID (200 microg/cm(2)). A positive dose-response relationship was found. The number of doubtful reactions decreased with increasing test concentrations. No late reactions were observed. A patch test concentration in hydrophilic dried-in vehicle (TRUE Test) of 600 microg/cm(2) was found to be adequate and safe for both IMID and DU.

Protective gloves in Swedish dentistry: use and side-effects

BACKGROUND

During the 1980s routine wearing of gloves in dentistry was recommended by health authorities in several countries. However, prolonged glove use is associated with side-effects of irritant and allergic origin.

OBJECTIVES

To investigate the extent of glove use and self-reported glove intolerance reactions among Swedish dentists, and to examine how far IgE-mediated allergy to natural rubber latex (NRL) occurs in subjects who report rapid itching when in contact with protective gloves.

SUBJECTS/METHODS

A postal questionnaire was answered by 3083 of 3500 licensed dentists, a response rate of 88%. Of the dentists who reported rapidly occurring itching of the hands from gloves, 131 of 170 attended a clinical examination including a skin prick test (SPT) and a serological examination (RAST) for IgE-mediated allergy.

RESULTS

Seventy-three per cent of the dentists reported daily glove use of more than 2 h, 48% more than 6 h a day, and 6% reported no use. NRL gloves were used most frequently (P < 0.001) and were the main material that elicited symptoms (P < 0.001). Female dentists reported more frequent glove use than males, as did young dentists (P < 0.001) compared with older ones. Females also preferred vinyl gloves. Glove intolerance reactions were reported by 723 (23%) dentists, [females 28%, males 21% (P < 0.001)] and were more common in younger dentists. Of the 417 dentists with reported hand eczema during the previous year, 54% reported glove intolerance, compared with 20% of the dentists without hand eczema (P < 0.001). A logistic regression analysis including hand eczema, age, sex and atopy showed that all these factors contributed significantly to the risk of glove intolerance, and that hand eczema was a stronger factor than atopy. In 15 of 131 (11%) dentists examined for reported glove-related itch, latex allergy was verified by SPT and/or RAST. Glove-related conjunctivitis, rhinitis and asthma, in contrast to skin symptoms, showed a significant association with IgE-mediated allergy to NRL.

CONCLUSIONS

Swedish dentists show good compliance with the recommendations for routine glove use. Intolerance reactions are frequently reported, especially by dentists with hand eczema, which emphasizes the need for preventive skin care programmes. Glove-related symptoms from mucous membranes showed a higher association with IgE-mediated allergy to NRL than reported itching of the skin, a fact that should be considered when composing screening questionnaires for NRL sensitization

Exposure to metallic gold in patients with contact allergy to gold sodium thiosulfate

Gold allergy is common, with approximately 10% of patients patch tested because of eczematous disease being positive to gold sodium thiosulfate (GSTS). However, clinical relevance seems to be rare. The aim of this prospective double-blind study was to demonstrate the effects of exposure to metallic gold, in this case earrings, in gold-positive patients. 60 female patients with pierced earlobes test-positive to GSTS were included in the study. The patients were randomized into 2 groups, 30 patients receiving earrings with a surface layer consisting of 24-carat gold and 30 patients earrings with a surface layer of titanium nitride, virtually indistinguishable from gold. The patients wore the earrings for 8 weeks. During the study, any dermatitis on the earlobes, as well as on other body sites, was registered. The skin reactions observed were weak but, in total, 17 of the 60 patients had a skin reaction (local or remote) during the study, 12 of whom had received gold earrings and 5 titanium (p<0.05). 11 patients had a reaction on the earlobes, 7 of whom had received gold earrings and 4 titanium (NS). With these facts it is hard to exclude that exposure to gold jewelry can be clinically relevant in persons hypersensitive to gold.

In vivo testing of the protection provided by non-latex gloves against a 2-hydroxyethyl methacrylate-containing acetone-based dentin-bonding product

In dentistry, allergic contact dermatitis to acrylates and allergic contact urticaria to latex are important occupational hazards. There is a need to identify non-latex gloves which are suitable for dental work but at the same time provide adequate protection against acrylate monomers. In a previous study, a new open-chamber system was used for testing the in vivo protection of 6 different gloves against an acrylate-containing ethanol-based dental adhesive. A nitrile glove gave the best protection among the gloves suitable for dental work. In the present study, the test model was used to investigate the in vivo protection of 7 non-latex gloves against a dental bonding product containing 2-hydroxyethyl methacrylate (2-HEMA) in an acetone/water vehicle. Eight 2-HEMA-allergic patients participated. Two neoprene gloves gave the best protection. The protection of the poorest glove was comparable to that of the positive control (no glove). The study produced in vivo data useful in the implementation of individual preventative measures against contact allergy to acrylates.

Contact allergy and hand eczema in Swedish dentists

Hand eczema and contact allergy in Swedish dentists were studied in a multidisciplinary project. The aims of the study were to establish diagnoses, to investigate the occurrence of contact allergy, in particular to (meth)acrylates, and to evaluate certain consequences of hand eczema. A postal questionnaire on skin symptoms, atopy and occupational experience was mailed to 3,500 dentists aged <65 years, and licensed 1965-1995. The response rate was 88%. Among dentists living in 3 major cities, 14.9% (n= 191) reported hand eczema during the previous year. They were invited to a clinical examination, including patch testing with a standard and a dental series. 158/191 (83%) dentists attended, and hand eczema diagnosis was confirmed in 149/158 (94%). Irritant contact dermatitis was diagnosed in 67% and allergic contact dermatitis in 28%. On patch testing, 50% presented at least 1 positive reaction. The most frequent allergens were nickel sulfate, fragrance mix, gold sodium thiosulfate and thiuram mix. 7 (5%) had positive reactions to (meth)acrylates, all to 2-hydroxyethyl methacrylate and 6 also to ethyleneglycol dimethacrylate. 38% had consulted a physician, 4% had been on sick-leave and 1% had changed occupational tasks due to hand eczema. No dentist with allergy to acrylates had been on sick-leave or changed occupation. It is concluded that dentistry is a high-risk occupation for hand eczema, and that irritant contact dermatitis is most common. The prevalence of contact allergy to acrylates was below 1% in the population of responding dentists, and in most cases did not have serious medical, social or occupational consequences.

In vivo testing of the protection of gloves against acrylates in dentin-bonding systems on patients with known contact allergy to acrylates

Occupational contact allergies to dental acrylates are increasing. Commonly used gloves protect poorly against acrylates. The protective efficacy in vivo of other, newer glove materials is not fully known. In this study, an open chamber system was used for testing the protection in vivo of 6 different gloves (1 vinyl glove, 2 latex gloves, 2 nitrile gloves and the 4H glove) against a commonly used dental adhesive, Scotchbond 1, containing 2-hydroxyethyl methacrylate (2-HEMA) and triethylene glycol dimethacrylate (TREGDMA). 8 patients with known contact allergy to 2-HEMA participated. Provocation with 50 microl of the adhesive for 7.5, 15 and 30 min was performed for each glove. The test demonstrated clear differences in the protective efficacy between the gloves. The 4H glove gave by far the best protection, followed by one of the nitrile gloves. One of the latex gloves and the vinyl glove gave a very poor protection against the adhesive. A dose-response relationship was observed between different application times of the acrylate product. The test model promises to be a useful clinical complement to in vitro methods in individual preventive measures against contact sensitization to acrylates.

Laser Doppler perfusion imaging for the documentation of flare-up in contact allergy to gold

A healed or healing allergic contact dermatitis is easily reactivated to a flare-up if the patient is provoked systemically with his particular allergen. 5 patients with contact allergy to gold were patch tested with a serial dilution of gold sodium thiosulfate. 1 to 2 months later, when positive test reactions were healed, the patients were given 1 intramuscular injection of gold sodium thiomalate. This resulted in a flare-up of patch tests as well as a transient fever and toxicoderma-like reactions. The flaring tests were registered by digital photographs and laser Doppler imaging (LDI). An increased cutaneous blood flow in the formerly positive patch tests was discernible within 1 h after provocation, increased to a vigorous maximum after 4-6 h, and subsided during the following few days. The earliest increase and the highest peak of blood flow were observed in the test areas of the strongest original test concentration. LDI provides a most suitable technique for studying the dynamics of this rapidly developing inflammation of a mainly dermal character.

The flare-up reactions after systemic provocation in contact allergy to nickel and gold

In a controlled double-blind experimental study, patients with contact allergy to nickel or gold were exposed systemically to their contact allergen. Nickel sulfate was given orally, gold sodium thiomalate intramuscularly, and placebo by both routes. Clinical reactions including body temperature were followed and 7 plasma cytokines and acute phase reactants were assayed before and 24 h after provocation. Clinical flare-up, with reactivation of healing patch tests and/or toxicoderma-like reactions, was observed in patients receiving their specific allergen. A transient fever was noted in patients allergic to gold when exposed to gold, not in others. There was a significant increase in plasma tumour necrosis factor-alpha, soluble tumour necrosis factor receptor 1, interleukin-1 receptor antagonist, and neutrophil gelatinase associated lipocalin in patients allergic to gold when exposed to gold allergen. Furthermore, in patients allergic to nickel exposed to nickel allergen there was a highly significant increase in plasma soluble tumour necrosis factor receptor 1. Interferon-gamma, interleukin-4, and C-reactive protein did not increase in any of the patient groups. Clinical reactions during flare-up in contact allergy are accompanied by release in the blood of several cytokines. This release is not a consequence of a toxic effect or bound to a particular allergen. Instead, the cytokine release should be considered a general phenomenon characteristic of the flare-up in contact allergy.

The benefit of patch testing with a corticosteroid at a low concentration

BACKGROUND

Patch testing with corticosteroid marker molecules is advocated because testing with all available corticosteroids is impossible in clinical practice. Most commonly used are budesonide, tixocortol pivalate, and hydrocortisone-17-butyrate. We have been patch testing not only with the three markers, but also with two corticosteroid mixes, each consisting of different concentrations of the three markers.

OBJECTIVE

We describe a patient allergic to tixocortol pivalate, who was diagnosed by using a lower patch test concentration that recommended, 0.1% in petrolatum, as well as a weak corticosteroid mix, 0.202%.

METHODS

The patient was patch tested to a standard series, including the two corticosteroid mixes and its three constituents.

RESULTS

None of the corticosteroid preparations were positive on the first ordinary reading day, day 3, whereas both tixocortol pivalate at 0.1% and the corticosteriod mix at 0.202% were positive on the second ordinary reading day, day 7, whereas all tested corticosteroids in the standard series gave positive reactions on d10.

CONCLUSION

The possible benefit of patch testing with a corticosteroid at a low concentration is supported, as is the significance of late readings beyond D4.

[New dental materials a health risk for dental staff. Acrylates can cause contact allergy and other problems]

The acrylic content of modern dental materials poses a risk of adverse reactions. Although the quantities of the substances released are normally too small to cause systemic reactions, local reactions may occur resulting in damage to the skin. A study, in which 81 dental workers referred to dermatologists for a variety of adverse reactions were patch tested, showed work-related dermatoses to represent a serious problem for dental staff, sometimes entailing occupational disability and re-schooling. Much of this could be avoided by observing special precautions to prevent direct contact with the sensitising substances in composite materials used in dental surgery. Since the use of dental amalgam has been reduced to about 10 per cent of all fillings in Sweden, the prevalence of adverse local reactions to the acrylic composite materials which are used instead may be expected to increase.

Cytokines and acute phase reactants during flare-up of contact allergy to gold

BACKGROUND AND OBJECTIVE

Patients with contact allergy experience cutaneous, as well as general reactions, when exposed systemically to their contact allergen. This study focused on the release in blood of pertinent cytokines and acute phase reactants as a consequence of parenteral allergen exposure.

DESIGN

Ten patients with contact allergy to gold were given one intramuscular injection of gold sodium thiomalate; plasma levels of some cytokines and acute phase reactants were followed for 24 hours.

RESULTS

There was a flare-up of 1-week-old patch tests in all 10 patients; a maculopapular rash in 5 of 10; and a transient fever in 4 of 10. Biochemical analyses showed some increase of plasma levels of several cytokines in most patients, interleukin 1 receptor antagonist (IL-ra) and tumor necrosis factor (TNF) in particular, and of C-reactive protein (CRP) and leukocyte proteins. A marked increase of IL-1ra, TNF-alpha, soluble tumor necrosis factor receptor 1 (sTNF RI), neutrophil gelatinase associated lipocalin (NGAL), human (leukocyte) elastase antitrypsin (HEAT), and CRP was observed mainly in the four patients with fever and general skin reactions.

CONCLUSION

Systemic exposure to the allergen in contact allergy elicits cutaneous and general reactions; at least in the case of gold allergy, it is accompanied by an emergence of cytokines and acute phase reactants.

Morphology of endogenous flare-up reactions in contact allergy to gold

In a double-blind study, 20 patients with contact allergy to gold were given an intramuscular injection of gold sodium thiomalate or placebo, inducing a clinical and histological flare-up of healed patch test sites in the gold-injected but not in the placebo group. The test area of the placebo group showed some perivascular lymphocytic foci (UCHL-1+) and vascular endothelial ELAM-1 staining. The gold group, with flare-up, showed larger and more extensive lymphocytic foci with ELAM-1+ endothelium as well as lymphocytic epidermotropism. CD1a+ LC cells were downgraded, tryptase+ mast cells accumulated and CD68+ monocytes/macrophages markedly increased. Probably, a significant part of the tissue priming as a result of patch testing comprises memory T-cells and endothelial ELAM-1 upgrading, but blood-borne CD68+ monocytes may also be instrumental in the flare-up.

Contact allergy to gold and gold therapy in patients with rheumatoid arthritis

Patients with rheumatoid arthritis were investigated for contact allergy to gold in connection with treatment with gold preparations. There were 57 patients with rheumatoid arthritis previously treated with gold, with or without cutaneous side-effects, as well as 20 patients intended for such treatment; all were exposed to patch and intradermal tests with gold sodium thiosulfate, gold sodium thiomalate and auranofin. Contact allergy to gold was demonstrated in 8 out of 77 patients (10.4%). In the retrospective material, gold allergy was found in 1.8%, in the prospective material in 35.0%. Contact allergy to gold is very frequent among patients with rheumatoid arthritis before gold therapy. In order to avoid early hypersensitivity reactions skin tests should be carried out before gold therapy is instituted.

Contact allergy to the UV absorber Tinuvin P in a dental restorative material

A case of contact allergy to the UV absorber Tinuvin P is described in a patient with gingivitis who was previously treated with a dental restorative material. With high-performance liquid chromatography analysis, the presence of Tinuvin P could be shown in the restorative material.

Clinical reactions to systemic provocation with gold sodium thiomalate in patients with contact allergy to gold

In a double blind experimental study, 20 patients with a contact allergy to gold sodium thiosulphate were challenged intramuscularly with the chemically similar gold sodium thiomalate and with placebo. The most spectacular clinical reaction in the 10 patients given the active agent, was an epidermal and dermal flare up of healed patch-test reactions to the gold salts, as well as a high, but transient, rise in body temperature. Previous intradermal tests were similarly reactivated. In addition, toxicoderma-like rashes were observed in several cases, but a flare up of a previous contact dermatitis site was seen in one patient only. The specificity of the positive provocations was demonstrated.

Occupational dermatoses in nursery workers

BACKGROUND

Several workers at a nursery complained of skin problems. An occupational allergic contact dermatitis from tulip was diagnosed in 2 of the workers.

OBJECTIVE

The aim of this study was to survey the frequency of occupational dermatoses among nursery workers and to investigate whether the tulip sensitizer alpha-methylene-chi-butyrolactone traces all contact allergy to tulip.

METHODS

A questionnaire was delivered to 41 employees, and everyone with a present or previous skin disease was offered a consultation including patch testing with the known tulip sensitizer as well as two types of tulip extracts and parts of the plant.

RESULTS

Occupational dermatoses were diagnosed in 11 workers, allergic contact dermatitis in 9 workers (tulip and/or daffodil), and irritant contact dermatitis in 2 workers.

CONCLUSION

Occupational dermatoses are common among nursery workers. All workers with contact allergy to tulip was traced by alpha-methylene-chi-butyrolactone.

Flare-up at contact allergy sites in a gold-treated rheumatic patient

Contact allergy to gold sodium thiosulfate and gold sodium thiomalate was established by skin testing in a rheumatic patient intended for gold therapy. An intramuscular test dose of gold sodium thiomalate (Myocrisin) induced a flare-up of previously positive epicutaneous and intradermal test reactions, with a histological and immunohistochemical picture compatible with an allergic contact dermatitis. Since gold allergy is frequent, the cutaneous side-effects of gold therapy ("gold dermatitis") may be explained by such an immunopathological reaction.

The development and course of test reactions to gold sodium thiosulfate

In our department, gold sodium thiosulfate has become the 2nd most common allergen in routinely patch tested dermatitis patients, with a rate around 10%. Test reactions to this compound often appear late, sometimes so late that active sensitization may be suspected. This study was performed to study the time course of the allergic reaction to gold sodium thiosulfate and to elucidate whether late test reactions mean active sensitization. 10 patients with contact allergy to gold sodium thiosulfate (0.5% pet.) were retested epicutaneously (e.c.) and intracutaneously (i.c.) with dilution series. The clinical course was followed for 2 months with initially short intervals, later more extended. During the entire study, 26 positive e.c. reactions were diagnosed. Within the 1st week, 17 (65%) were recorded. 12 reactions (46% of 26) were noted at the ordinary reading, 3 days after test application. After 10 days, another 9 reactions (35%) appeared. The patients with the latter reactions also had positive test reactions within the 1st week. After 2 months, 9 reactions remained. Out of 30 i.c. tests applied, 25 became positive within 1 week. 19 (76%) of these reactions changed in morphology from thin infiltrates to deep nodules. Another 4 nodules appeared in patients with previous negative i.c. tests. All 23 nodules remained after 2 months. E.c. and i.c. test reactions to gold sodium thiosulfate are long-lasting. Positive patch test reactions emerging after 10 days do not automatically imply active sensitization. To diagnose contact allergy to gold sodium thiosulfate, the ordinary reading at day 3 is insufficient; even reading at 1 week is insufficient and must be supplemented by a reading at 3 weeks. All the i.c. test reactions, however, appeared within 1 week and, in several, a dermal nodule was formed.

A study on expert reading of patch test reactions: inter-individual accordance

To diagnose allergic or irritant contact dermatitis, a clinically relevant contact allergy has to be demonstrated or ruled out, respectively. Although patch testing has been used for 100 years, it remains the method of choice for diagnosing contact allergy. A disadvantage of patch testing is that reading is subjective, based on inspection and palpation of the test area, implying that the assessment is subject to the reader's knowledge and experience. This study was carried out to investigate the accordance in reading patch test reactions between 5 dermatologists. 4 groups, each with 10 patients, participated. Within each group, all 10 were allergic to one and the same sensitizer; nickel, epoxy resin, ethylenediamine, or Kathon CG. The sensitizers were tested in serial dilutions and applied randomly to the back. The tests were read independently by the dermatologists in a blinded fashion. A protocol was used where the dermatologists had to note the presence of the morphological features erythema, infiltration, papules, vesicles, and bullae. In this way, it was possible to allocate the various readings into 4 classification systems, 3 European and one American, although the definition of the various classifications might differ slightly. Based on the readings and classifications, it was possible to calculate the degree of accordance within the 4 systems used. It was also possible to analyze the degree of accordance for the various morphological features. Total accordance for the 5 reading dermatologists for positive and negative test reactions was noted in 36% and 46%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Occupational allergic contact dermatitis from ethyl cyanoacrylate

Glues based on cyanoacrylates are widely used as contact adhesives for metal, glass, rubber, plastics and textiles, as well for biological materials, including binding tissues and sealing wounds in surgery. In this paper, an apprentice cobbler with an occupational allergic contact dermatitis from an ethyl cyanoacrylate glue, in which the major monomer was shown to be the sensitizer, is reported. Initial patch testing with the cyanoacrylate glue dissolved in acetone with the Finn Chamber (aluminium) technique yielded false-negative reactions. Positive test reactions were obtained with the same preparations using Van der Bend chambers. With petrolatum as vehicle for the glue, there was no difference between Finn Chamber technique and Van der Bend chamber technique. The role of aluminium in the false-negative reactions is discussed.

Skin testing with gold sodium thiomalate and gold sodium thiosulfate

Recently gold sodium thiosulfate was found to be the most common sensitizer after nickel sulfate in our routinely patch tested dermatitis patients. When patients hypertensive to gold sodium thiosulfate were tested with another monovalent gold salt, gold sodium thiomalate, at equimolar concentrations, in principle, no positive reactions were obtained. Gold sodium thiomalate is used for treatment of rheumatoid arthritis, a treatment with a high frequency of adverse skin reactions. To investigate whether the reactivity difference between the 2 gold salts was due to differences in bioavailability, some experiments were carried out. Intracutaneous tests with the 2 gold salts at equimolar concentrations yielded equivalent reactions. When the concentration of gold sodium thiomalate for epicutaneous testing was increased, all 12 gold-allergic patients reacted positively. Therefore, in our department, contact allergy to gold sodium thiomalate is probably as common as contact allergy to gold sodium thiosulfate.

The histological and immunohistochemical pattern of positive patch test reactions to gold sodium thiosulfate

Gold sodium thiosulfate, inserted in the patch test standard series, gives a surprisingly high yield of positive reactions, about 10% of tested eczema patients, but with a low degree of clinical relevance. A histopathological study on patch test reactions was carried out in patients selected because of a combined contact allergy to gold sodium thiosulfate and nickel. Biopsies were taken from macroscopically similar reactions in dilution series of each allergen. The histological picture was clearly eczematous, without irritative features. In a blind comparison, test reactions induced by the two allergens could not be differentiated from each other. Long-lasting patch test reactions to gold sodium thiosulfate were characterized by an intense lymphocytic dermal infiltrate without epidermal involvement. Immunohistochemically, CD4+ and CD8+ T lymphocytes could be detected already 4-8 h post-challenge, and "naive" as well as "memory"-type T cells were demonstrated. Apparently, our findings reflect a true contact allergy to gold sodium thiosulfate.

Clinical relevance of contact allergy to gold sodium thiosulfate

BACKGROUND

In our routinely patch tested patients with dermatitis gold was shown to be the second most common sensitizer. In most patients it was difficult to explain the source of sensitization to gold and to see any clinical relevance.

OBJECTIVE

Our purpose was to elucidate the clinical relevance of contact allergy to gold sodium thiosulfate.

METHODS

A questionnaire on gold exposure and gold sensitivity was answered by 156 consecutive patients with dermatitis. In another group of 1056 routinely tested patients data were collected and analyzed regarding factors such as profession, atopy, localization of the dermatitis, and presence of contact allergies.

RESULTS

Gold allergy was overrepresented in those having dental gold. In persons with contact allergy to gold a dermatitis on the ears, fingers, or eye area was most frequent.

CONCLUSION

Exposure to gold jewelry and to dental gold may be important in the sensitization and elicitation of dermatitis.

High frequency of contact allergy to gold sodium thiosulfate. An indication of gold allergy?

When gold sodium thiosulfate was added to the patch test standard series, positive reactions were obtained in 8.6% of 823 consecutive patients with suspect contact allergy. The test reactions were clinically of an allergic type and, in several cases, long-lasting. There was no correlation with other allergens in the standard series. In a special study on 38 patients with contact allergy to gold sodium thiosulfate, the following principal findings were obtained: positive patch tests to the compound itself in dilute concentration; positive patch tests to potassium dicyanoaurate; negative patch tests to gold sodium thiomalate, sodium thiosulfate, and metallic gold; positive intradermal tests to gold sodium thiosulfate. Our findings make gold sodium thiosulfate the 2nd most common contact allergen after nickel sulfate. It is suggested that a positive skin test to gold sodium thiosulfate represents gold allergy.

Contact allergy to a fatty acid ester component of cutting fluids

6 patients employed in the metalworking industry developed a hand dermatitis after exposure to a vegetable-oil-based cutting fluid. After thorough investigation, including patch testing with components in the cutting fluid as well as an oil and cutting fluid series, contact allergy was demonstrated to a fatty acid ester EM-550 in the cutting fluid.

Contact allergy to Duraphat

Skin-sensitizing rosin is present in Duraphat, a fluoride varnish used all over the world. Two cases of hypersensitivity to Duraphat are presented: a dental nurse with dermatitis of the hand and a patient with allergic contact stomatitis.

Contact sensitization to 5-chloro-2-methyl-4-isothiazolin-3-one and 2-methyl-4-isothiazolin-3-one (MCI/MI). A European multicentre study

The frequency of positive reactions to 5-chloro-2-methyl-4-isothiazolin-3-one and 2-methyl-4-isothiazolin-3-one (MCI/MI) were studied at 22 European contact dermatitis clinics over a period of 1 year. A total of 4713 patients participated. All the patients were patch tested with nickel sulphate, formaldehyde, paraben-mix, and MCI/MI. 19.4% of the patients had positive patch tests to nickel, making this the most common allergen. 3% of the patients reacted to 100 ppm MCI/MI, while 2.6% reacted to formaldehyde and 1.1% to parabens. There was great variation in the frequency of MCI/MI sensitivity among the 22 centres. MCI/MI contact allergy was most common among women and in patients with facial dermatitis, while it was rarely seen in patients with dermatitis on the lower legs. There were no fluctuations in the number of positive patch tests to MCI/MI on a monthly basis when the results from all centres were combined. 117 of the 141 MCI/MI sensitized patients included in the study were retested. 88% had positive patch tests when retested. 101 of the MCI/MI-sensitive patients participated in a double-blind, placebo-controlled product use test. This test showed that 31% of the MCI/MI-sensitive patients had a positive reaction to a MCI/MI-preserved product. Only a few patients reacted to a control product. It is concluded that the preservative MCI/MI is an important new contact allergen.

Contact allergy to the UV-absorber Tinuvin P in plastics

Contact allergy to the UV-absorber 2-(2-hydroxy-5-methylphenyl)benzotriazole (Tinuvin P) was revealed in a patient with wrist dermatitis caused by a plastic watch strap. A high-performance liquid chromatography method was developed and subsequent chemical analysis showed the presence of Tinuvin P in the watch strap. The possibility of cross-reactions between Tinuvin P and various substituted benzotriazole compounds was investigated. No cross-reactions were found.

Contact allergy to a cyclohexanone resin in humans and guinea pigs

5 patients with allergic contact dermatitis caused by various paints were demonstrated to be sensitive to a cyclohexanone resin (C-R) present in the paints. Sensitization studies in guinea pigs with C-R and cyclohexanone showed one batch of C-R to be a sensitizer.

Demonstration of Kathon CG in some commercial products

The preservative Kathon CG has become one of the most common sensitizers. It has, however, been difficult to explain the sensitization and to assess the clinical relevance of the contact allergy, partly due to lack of specification of the preservative in products. A high-performance liquid chromatography method was used to demonstrate Kathon CG in 123 commercial products of both "leave on" and "rinse off" types. 38 of these contained Kathon CG in the range of 1-15 ppm of active ingredients. There were no differences between "leave on" and "rinse off" products concerning the relative number of products containing Kathon CG and the concentrations of the preservative.

Contact allergy to the preservative Kathon CG

Of 976 patients routinely patch tested with Kathon CG (Rohm & Haas), 300 ppm, 43 (4.4%) gave a positive reaction. Of 170 patients routinely tested with Kathon CG 250 ppm, 10 (5.9%) gave a positive reaction. Out of 34 patients tested with serial dilutions of Kathon CG, 17 (50%) reacted to 100 ppm, 8 to 30 ppm and 2 to 10 ppm. The concentration of 1000 ppm of Kathon CG was irritant in some cases, but 300 ppm was not irritant. Of the 976 patients tested with Kathon CG 300 ppm, 8 (0.8%) showed a "flare-up" reaction, indicating patch test sensitization. Of the 170 tested with Kathon CG 250 ppm, 2 (1.2%) were sensitized. When the patch-test-sensitized patients were retested with serial dilutions, they showed the same pattern as the other patients. 13 sensitized patients were use tested and 7 (54%) gave responses. In the literature, Kathon CG 100 ppm is recommended as the routine patch test concentration. However, 50% of the sensitive persons may then be overlooked. In our clinics, Kathon CG has become the second most common contact sensitizer, but the sensitivity cannot be traced in all patients with clinically relevant allergy without an unacceptable risk of patch test sensitization.

Influence of the vehicle on elicitation of contact allergic reactions to acrylic compounds in the guinea pig

Many factors can influence the elicitation of hypersensitivity reactions in guinea pigs and humans. The effect which the vehicle might have on the test response in guinea pigs sensitized with various acrylic compounds, using the "guinea pig maximization test", has been investigated. A marked decrease in the number of positive animals was seen when acetone was used as test vehicle, compared to petrolatum. The same result was seen with alcohol as vehicle, when neopentyl glycol diacrylate (NPGDA) was used as an acrylic monomer model. The patch test locations on the guinea pig flank, also affected the test response. Half of the animals did not react when challenged near the abdomen, compared to a test site near the back. By means of HPLC-analysis, the possible adsorption of the acrylic monomer to the aluminium chamber or filter paper disc, was analysed. Our findings did not indicate that adsorption occurs. A decrease in the amount of acrylic monomer in the chamber with increasing time, was noted. There was a marked difference in the monomer residue between solutions with (darkness) and without (daylight) inhibitor. The monomer decrease was also more affected by an aluminium surface than a glass or filter paper surface. Aluminium oxide probably enhances the polymerization process. The discrepancy between the test results in this study, when petrolatum and acetone were used as test vehicles, is due to a polymerization process of the acrylic compounds. Thus, the petrolatum vehicle probably prevents polymerization of the acrylic monomer.

The sensitizing capacity of multifunctional acrylates in the guinea pig

The multifunctional acrylates used in ultraviolet (UV) curable resins act as cross-linkers and "diluents". They are usually based on di(meth)acrylate esters of dialcohols or tri- and tetra-acrylate esters of polyalcohols. In UV-curable coatings, the most commonly used are pentaerythritol triacrylate (PETA), trimethylolpropane triacrylate (TMPTA) and 1,6-hexanediol diacrylate (HDDA). In other uses, such as dental composite resin materials, the dimethacrylic monomers based on n-ethylene glycol are the most useful. The sensitizing capacity of various multifunctional acrylates and their cross-reactivity pattern have been investigated with the guinea pig maximization test. The tests show that BUDA (1,4-butanediol diacrylate) and HDDA are moderate to strong sensitizers and that they probably cross-react with each other. The n-ethylene glycol diacrylates and methacrylates tested are weak or non-sensitizers. Tripropylene glycol diacrylate (TPGDA) is a moderate and neopentyl glycol diacrylate (NPGDA) a strong sensitizer, whereas neopentyl glycol dimethacrylate is a non-sensitizer. The commercial PETA is a mixture of pentaerythritol tri- and tetra-acrylate (PETA-3 and PETA-4). PETA-3 is a much stronger sensitizer than PETA-4. Simultaneous reactions were seen between PETA-3, PETA-4 and TMPTA. The oligotriacrylate OTA 480 is a moderate sensitizer, but no concomitant reactions were seen with PETA-3, PETA-4 or TMPTA. Of the multifunctional acrylates tested, the di- and triacrylic compounds should be regarded as potent sensitizers. The methacrylated multifunctional acrylic compounds are weak or non-sensitizers.

Sensitizing potential of urethane (meth)acrylates in the guinea pig

Urethane (meth)acrylates are used as prepolymers in ultraviolet-curable inks, varnishes and coating formulations for industrial purposes as well as resins for dental applications. The sensitizing capacity of 3 commonly used urethane (meth)acrylates was investigated using the guinea pig maximization test. The study shows that an aliphatic urethane acrylate is not only a more potent sensitizer than an aromatic one, but also more sensitizing than a (meth)acrylated aliphatic urethane.

Contact allergic reaction to D & C Yellow No. 11 and Quinoline Yellow

D & C Yellow No. 11 and Quinoline Yellow belong to a group of quinophtalone dyes with a common basic structure. D & C Yellow No. 11 is used mostly in plastics, spirit lacquers, coloured smokes and cosmetics, but it is also increasingly used as a dye in soaps and shampoos. Quinoline Yellow is used for dyeing wool, silk and nylon in cases where good light fastness is not required, but is most commonly used as a drug and food colouring agent. A patient, extremely sensitive to D & C Yellow No. 11 with a positive patch test reaction down to 0.00001%, also reacted to Quinoline Yellow at a test concentration of 0.1%. To establish if any cross-reactivity occurs between the two compounds, a high pressure liquid chromatograph was used for analysis, purification and separation of the two colours. The patient was then patch tested with the two colours and the pure fraction of Quinoline Yellow. The test results confirm a true sensitivity to Quinoline Yellow and to D & C Yellow No. 11, and may indicate cross-reactivity between the colours.