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New Horizons Session on Skin Diseases Contact Dermatitis

Long Island, New York. World Allergy Organization December, 2011 Cancun, Mesxico. New Horizons Session on Skin Diseases Contact Dermatitis. Luz Fonacier MD, FACAAI, FAAAAI Section Head of Allergy Program Director, Allergy and Immunology Winthrop University Hospital

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New Horizons Session on Skin Diseases Contact Dermatitis

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  1. Long Island, New York World Allergy Organization December, 2011 Cancun, Mesxico New Horizons Session on Skin DiseasesContact Dermatitis Luz Fonacier MD, FACAAI, FAAAAI Section Head of Allergy Program Director, Allergy and Immunology Winthrop University Hospital Professor of Clinical Medicine SUNY at Stony Brook

  2. Long Island, New York Disclosure • Research and Educational Grants: • AAAAI ART Grant • Genentech • Dyax • Lev • Speaker’s Bureau • Baxter

  3. Long Island, New York Objectives WAO Upon completion of this workshop, participants should be able to: • Recognize important contact allergens • Be familiar with the clinical correlation of the results of the patch test

  4. Long Island, New York Dermatitis Contact Allergens of the Year 2011: Dimethyl Fumarate Bruze M, Zimerson E. Dermatitis 2011,Vol 22,No 1 2010: Neomycin Sasseville D. Dermatitis 2010, Vol. 21, No 1 2009: Mixed Dialkyl Thioureas Anderson B, Dermatitis 2009, Vol. 20, No. 1 2008: Nickel 2008 Komik R. Zug K Dermatitis 2008 Vol. 19, No. 1 2007: Fragrance Storrs F. Dermatitis 2007 Vol.28, No. 1 2006: P-Phenylenediamine DeLeo V. Dermatitis 2006 Vol. 17, No. 2 2005: Corticosteroids Isaksson BM. Dermatitis 2005 Vo. 16, No. 1 2004: Cocoamidopropyl Betaine Fowler J. Dermatitis 2004 Vol 15, No.1 2003: Bacitracin Sood A, Taylor J. Dermatitis 2003 Vol 14, No. 1 2002: Thimerosal Belsito D. Dermatitis 2002 Vol.13, No.1 2001: Gold Fowler J Dermatitis 2001 Vol.12, No.1 2000: Disperse Blue Dyes Storrs F Dermatitis 2000 Vol. 11, No. 1

  5. Long Island, New York Dimethyl Fumarate Contact Allergen of 2011 • Furniture-Related Dermatitis • Common sites were trunk, limbs, buttocks, face • Blistering, lichenoid, contact urticaria • Shoe Related Dermatitis • Textile Related Dermatitis Photo from: Bruze M, Zimerson E. Dermatitis 2011,Vol 22,No 1

  6. Long Island, New York Neomycin Contact Allergen of 2010 • Fifth most common allergen in NA (ACDS database) • Higher rate of sensitization due to availability of antibiotic in OTC: ‘‘triple antibiotic’’ • High risk groups: stasis dermatitis, leg ulcers, anogenital dermatitis & otitis externa

  7. Long Island, New York Patch Test with Neomycin • In T.R.U.E. Test: 20% in petrolatum • False (-) may occur in 10% of cases * • If strongly suspected, ROAT with commercial preparation or PT with 20% aqueous solution • Intradermal tests: 1% solution of neomycin • Patch-test slow to appear, peaking at day 4 or even at day 7** • Similar to gold, (+) reactions may persist for days to weeks *Epstein E. Contact dermatitis to neomycin with false negative patch tests: allergy established by intradermal and usage tests. Contact Dermatitis 1980;6:236–7 **Bjarnason B, Flosado´ ttir E. Patch testing with neomycin sulfate. Contact Dermatitis 2000;43:295–302

  8. Long Island, New York Neomycin Cross Reactivity • 90% for paromomycin & butirosin • 70% for framycetin • 60% for tobramycin & kanamycin • 50% for gentamicin • 4% for streptomycin • Concomitant sensitizations: neomycin and bacitracin

  9. Long Island, New York Neomycin in vaccines • Vaccines contain 25 mg of neomycin • Reactions are minimal, local or transient • The Committee on Infectious Diseases of the American Academy of Pediatrics no longer considers contact hypersensitivity to neomycin a contraindication to vaccination Kwittken PL, Rosen S, Sweinberg SK. MMR vaccine and neomycin allergy. Am J Dis Child 1993;147:128–9

  10. Long Island, New York Mixed Dialkyl ThioureasContact Allergen of 2009 • Mixture of diethylthiourea (DETU) & dibutylthiourea (DBTU) • Applications and Uses • Adhesive manufacturing • Anticorrosive agents • Paint & glue removers • Pesticides & fungicides • Photocopy paper (diazo copy paper) • Photography, as an antioxidant • Rubber accelerator (especially neoprene) • Synthetic resins • Textile and dye industry 1.1% + PT reaction rate and of highest relevance rate in NACD Anderson B. Mixed Dialkyl Thioureas. Dermatitis 20:1 pp 3-5. 2009

  11. Long Island, New York Nickel: Contact Allergen of 2008 • 10% of population are nickel allergic • Increasing incidence of allergic sensitization to nickel in North America • New sources of nickel ACD: cell phones • New insight was offered into the possible genetics of nickel contact allergy

  12. Long Island, New York Dietary Nickel • Evidence support the contribution of dietary nickel to dermatitis such as vesicular hand eczema • Meta-analysis of systemic contact dermatitis following oral exposure to nickel estimated that: • 1% of nickel allergic patients would have systemic reaction to nickel content of a normal diet • 10% would react to 0.55 - 0.89 mg of nickel * Kornik R & Zug K. Dermatitis2008;19(1):3-8 * Jensen CS, Menné T, Johansen JD. Systemic contact dermatitis after oral exposure to nickel: a review with a modified meta-analysis Contact Dermatitis 2006;54:79–86

  13. Nickel Pyramid Soybean, Boiled ~ 1 cup: 895mcg Figs ~5: 85 mcg Cocoa, 1 tbsp: 147 mcg Lentils ½ cup cooked: 61 mcg Cashew, ~ 18 nuts:143 mcg Raspberry: 56 mcg >50 mcg Vegetables, canned½ cup: 40 mcg Asparagus, 6 spears: 25 mcg Lobster 3 oz: 30 mcg Oat Flakes 2/3 cup: 25 mcg Peas Frozen, ½ cup: 27 mcg Pistaccios, 47 nuts: 23 mcg 20-50 mcg Strawberries, 7 med: 9 mcg Cheese 1.5 oz:3 mcg Bread wheat, 1 slice: 5 mcg Yogurt, 1 cup:3 mcg Poultry, 3.5 oz: 5 mcg Mineral water, 8 fl oz: 3 mcg Carrots, 8 sticks: 5 mcg Mushroom raw, ½ cup: 2 mcg Apple, 1 med: 5 mcg Corn Flakes, 1 cup: 2mcg <20mcg

  14. Long Island, New York Nickel in Biomedical Devices Reports of dermatitis to biomedical devices lead to: • Consultation requests from orthopedic surgeons & orthodontists regarding safety of permanent or semipermanent metal medical devices in suspected nickel-sensitized patients • High variability of care in terms of testing & recommendations • Increased health care costs • Medicolegal concerns contribute to testing consultations • In some instances of joint replacement, selection of a more expensive & less durable option As nickel allergy incidence increases, this problem also presumably will increase Kornik R and Zug K. Dermatitis2008;19(1):3-8

  15. Long Island, New York METAL IMPLANT “ALLERGY”Often suspected but rarely documented • Nickel: 10% of population are nickel allergic • 25% of nickel sensitive patients are also cobalt sensitive • 5% of orthopedic implant patients & up to 21% of patients with preoperative metal sensitivity may develop cutaneous allergic reactions upon reexposure to the same metal* • Clinical manifestations • Cutaneous • localized • generalized: mostly eczematous (urticaria & vasculitis reported) • Implant Failure Basko-Plluska JL, Thyssen, JP & Schalock PC. Cutaneous &Systemic Hypersensitivity Reactions to Metallic Implants. Dermatitis, 2011. 22;2: 65–79 *Niki Y, Matsumoto H, Otani T, et al. Screening for symptomatic metal sensitivity: a prospective study of 92 patients undergoing total knee arthroplasty. Biomaterials 2006;26:1019–26.

  16. Long Island, New York Metals and Alloys Used in Implants Basko-Plluska JL, Thyssen, JP & Schalock PC. Cutaneous &Systemic Hypersensitivity Reactions to Metallic Implants. Dermatitis, 2011. 22;2: 65–79

  17. Long Island, New York Knee replacements • Incidence of sensitivity for all types of orthopedic implants is probably < 0.1% • includes static orthopedic implants (higher probability of sensitization than dynamic prostheses) • Rare partly because modern knee prostheses are metal-on-plastic, as opposed to metal-on-metal • Other components that very rarely cause sensitization • bone cement (methyl methacrylate) • polyethylene (plastic spacer) Merritt K, Rodrigo JJ. Immune response to synthetic materials. Clin Orthop Relat Res 1996;(326):71–9

  18. Long Island, New York Prospective Longitudinal Studies and Reviews Carlsson A, Mo¨ller H. Implantation of orthopaedic devices in patients with metal allergy. Acta Derm Venereol 1989;69:62–6 Merritt K, Rodrigo JJ. Immune response to synthetic materials.Sensitization of patients receiving orthopaedic implants. Clin Orthop 1996;326:71–9.. Niki Y, Matsumoto H, Otani T, et al. Screening for symptomatic metal sensitivity: a prospective study of 92 patients undergoing total knee arthroplasty. Biomaterials 2006;26:1019–26. Thyssen JP, Jakobsen SS, Engkilde K, et al. The association between metal allergy, total hip arthroplasty, and revision. Acta Orthop 2009;80:646–52. Eben R, Dietrich KA, Nerz C, et al. Contact allergy to metals and bone cement components in patients with intolerance of arthroplasty. Dtsch Med Wochenschr 2010;135:1418–22.

  19. Long Island, New York Allergic contact dermatitis from bone cement components • Reported in 24.8% of patients (n = 239)* • Orthopedic bone cements composition: • methyl methacrylate (MMA) • N,N-dimethylp- toluidine (DPT) • may be a significant cause of aseptic loosening • **7 /15 patients with aseptic loosening of a total hip replacement were DPT allergic • benzoyl peroxide*** • antibiotics (gentamicin, tobramycin, clindamycin, erythromycin)*** *Thomas P, Schuh A, Eben R, et al. Allergy to bone cement components. Orthopa¨de 2008;37:117–20. **Haddad FS, Cobb AG, Bentley G, et al. Hypersensitivity in aseptic loosening of total hip replacements. The role of constituents of bone cement. J Bone Joint Surg Br 1996;78:546–9. *** Kuehn KD, Ege W, Gopp U. Acrylic bone cements: composition and properties. Orthop Clin North Am 2005;36:17–28.

  20. Long Island, New York Implant Failure • 16 patients with failed metal-on-metal arthroplastic implants; 81% had metal sensitivity (PT &/or lymphocyte transformation test)* • Accumulated reports in total hip arthroplasty : • prevalence of metal allergy • ~ 25% in patients with a well-functioning hip arthroplastic implant • ~ 60% among patients with a failed or poorly functioning implant** * Thomas P, Braathen LR, Dorig M, et al. Increased metal allergy in patients with failed metal-on-metal hip arthroplasty and periimplant T-lymphocytic inflammation. Allergy 2009;64:1157–65. ** Hallab N, Merritt K, Jacobs JJ. Metal sensitivity in patients with orthopaedic implants. J Bone Joint Surg Am 2001;83:428–36. Basko-Plluska JL, Thyssen, JP & Schalock PC. Cutaneous &Systemic Hypersensitivity Reactions to Metallic Implants. Dermatitis, 2011. 22;2: 65–79

  21. Long Island, New York Endovascular stenting procedures & in-stent restenosis * Retrospective study of coronary in-stent restenosis 6 mos post stainless steel stent placement & PT 2 months after angioplasty • 11 (+) PT in 10/ 131 (8%) • 7 to nickel & 4 to molybdenum • Clinical history not predictive of a (+) or (-) patch-test result • All 10 with (+) PT to metal had in-stent restenosis (higher frequency of restenosis than in patients with no metal allergy) Conclusion: …suggest that allergy to metals, nickel in particular, plays a relevant role in inflammatory fibroproliferatory restenosis **Prospective study of 174 stented patients • 109 for initial placement & 65 for in-stent restenosis) • Patients with recurrence of in-stent restenosis had significantly higher (+) PT to metals (nickel & manganese) • No correlation with restenosis after initial stent placement *Köster R, Vieluf D, Kiehn M, et al. Nickel and molybdenum contact allergies in patients with coronary in-stent restenosis Lancet 2000;356:1895–7 **Iijima R, Ikari Y, Amiya E, et al. The impact of metallic allergy on stent implantation: metal allergy & recurrence of in-stent restenosis Int J Cardiol 2005;104:319–25

  22. Long Island, New York Diagnostic Criteria for Metal-Induced Cutaneous Allergic Reactions 1. Chronic eczema beginning weeks or months after the implant 2. Eczema most severe around the implant site 3. Absence of other contact allergens or systemic cause 4. Patch tests positive or strongly positive for one of the metals in the alloy 5. Complete & rapid recovery after total removal of foreign metal implant Merle C, Vigan M, Devred D, et al. Generalized eczema from Vitalliumosteosynthesis material. Contact Dermatitis 1992;27:257–8.

  23. Long Island, New York METAL IMPLANT “ALLERGY”Conclusions • Most reactions to endovascular, cardiovascular, orthopedic, dental metal implants are based on anecdotal case reports or on data from relatively small cohorts • The temporal & physical evidence before and after removal of implants leaves little doubt that a considerable number of patients develop metal sensitivity & cutaneous allergic dermatitis in association with metallic orthopedic implants • Conflicting Data: Prospective longitudinal studies are strongly needed • Recent case study showed that ~ 5% developed eczematous reactions directly associated with metallic implants* • Preexisting metal sensitivity with implant containing the offending metal had a higher rate of cutaneous dermatitis • proven cases incriminate nickel, cobalt, chromium, copper Basko-Plluska JL, Thyssen, JP & Schalock PC. Cutaneous &Systemic Hypersensitivity Reactions to Metallic Implants. Dermatitis, 2011. 22;2: 65–79 *Niki Y, Matsumoto H, Otani T, et al. Screening for symptomatic metal sensitivity: a prospective study of 92 patients undergoing total knee arthroplasty. Biomaterials 2006;26:1019–26. **Merritt K, Rodrigo JJ. Immune response to synthetic materials. Sensitization of patients receiving orthopaedic implants. Clin Orthop 1996;326:71–9.

  24. Long Island, New York METAL IMPLANT “ALLERGY”Conclusion • Need for patch testing is controversial, poorly reliable in predicting or confirming implant reaction • Preimplantation PT: may be considered if suspected of having a strong metal allergy • Post cutaneous eruption (months to years after implant): PT can be done with an appropriate series of metals • A negative PT is reassuring for absence of delayed hypersensitivity reaction • A positive PT does not prove relevance • If relevant allergens are identified and corticosteroid therapy is insufficient to clear the eruption, removal of the implant may be considered Basko-Plluska JL, Thyssen, JP & Schalock PC. Cutaneous &Systemic Hypersensitivity Reactions to Metallic Implants. Dermatitis, 2011. 22;2: 65–79

  25. Long Island, New York Regulating Nickel • 1992: Danish Ministry of Environment regulated nickel exposure to products in prolonged contact with the skin • Danish schoolgirls with ears pierced after 1992 regulations had significantly less nickel sensitization compared to those pierced prior to the regulations (5.7% vs 19%) • 1994: European Union • limited nickel release threshold from objects in prolonged contact with skin to 0.05 mg/cm2/ week • nickel content of post assemblies (material inserted into pierced parts of the body) to a migration limit of 0.2 mg/cm2/week Laws regulating nickel products, appears to be decreasing sensitization in the younger population Kornik R and Zug K. Dermatitis2008;19(1):3-8 Jensen CS, Lisby S, Baadsgaard O, et al. Decrease in nickel sensitization in a Danish schoolgirl population with ears pierced after implementation of a nickel-exposure regulation Br J Dermatol 2002;146:636–42

  26. Cosmetics • Facial cosmetic dermatitis • Bilateral • Patchy • Eyelid • Neck • “run-off” pattern • Cosmtics applied to face, scalp or hair often initially affect the neck • Most afftected site of ACVD from nail varnish is the neck • LipsConsort/Connubial Dermatitis: primarily fragrance

  27. Long Island, New York FragranceContact Allergen of 2007 • > 2800 fragrance ingredients in database of Research Institute for Fragrance Materials, Inc • ~100 are known allergens • Complex substances containing hundreds of different chemicals • Most common cause of ACD from cosmetic • Patch test 4th in frequency (10.4%) • 1.7-4.1% of general population have + PT to fragrance mix Johansen JD. Fragrance contact allergy: a clinical review. Am J Clin Dermatol 2003;4:789-98 Pratt MD et a;. North American Contact Dermatitis Group Patch-test Results 2001-2002 study period. Dermatitis 2004;15:176-83 *Buckley DA et al. The frequency of fragrance allergy in a patch-test polulation over a 17 year period. Br J Dermatol 2000;142:203-4

  28. Fragrance Mix Patch test

  29. Long Island, New York Tricky Aspects of Fragrance Allergy • New fragrance chemicals are constantly introduced • Regulation of fragrance ingredients in cosmetics exempts fragrance formulas as “trade secrets” • Some manufacturers do not consider essential oils to be fragrance • Tree tea oil (Melaleuca alternifolia) • Ylang-ylang oil (Cananga odorata) • Jasmine flower oil (Jasminum officinale) • Peppermint oil (Mentha piperita) • Lavander oil (Lavandula angustifolia) • Citrus oil (limonene) • “Covert fragrances”- used for purposes other that for aroma (ie preservatives) can be added to “fragrance free” products • Bensaldehyde • Benzyl alcohol • Bisabolol • Citrus oil • Unspecified essential oils Castanedo-Tardan M & Zug K. Patterns of Cosmetic Contact Allergy. Dermatol Clin 2009 27: 265-280

  30. Long Island, New York Balsam of PeruMyroxylon pereirae • One of 5 most prevalent allergens in TT • Found in toothpaste, mouthwash scents, flavors of food & drinks • Cross react with colophony, wood and coal tar, turpentine, resorcinol monobenzoate • Systemic CD to certain fruits in patients sensitive to fragrance

  31. Fragrance • Leave on fragrances: induce dermatitis at normally utilized concentrations • Wash on/wash off products: ? Relevance of brief exposure • Concentration of fragrance left on fabric by laundering was very low & threshold were below induction levels -Contact Dermatitis. 2003 Jun;48(6):310-6. -Contact Dermatitis. 2003 Jun;48(6):324-30. -Contact Dermatitis 2002 Dec;47(6):345-52 -Am J Contact Dermat 1996 Jun;7(2):77-83

  32. Long Island, New York Fragrance Systemic Contact Dermatitis Foods to Avoid in Balsam-Restricted Diet • Citrus fruits: oranges, lemons, grapefruit, tangerines, marmalade, juices • Flavoring agents: pastries, bakery goods, candy, chewing gum • Spices: cinnamon, cloves, vanilla, curry, allspice, anise, ginger • Spicy condiments: ketchup, chili sauce, barbecue sauce, chutney, pickles, pizza • Perfumed or flavored tea & tobacco • Chocolate • Certain cough medicines & lozenges • Ice cream • Cola, spiced soft drinks such as Dr Pepper • Tomatoes & tomato-containing products  ~ half of patients with positive PT to MP who followed BOP reduction diet had significant improvement of their dermatitis Salam TN, Fowler JF Jr. Balsam-related systemic contact dermatitis J Am Acad Dermatol. 2001 Sep;45(3):377-81

  33. Long Island, New York Summary on Fragrance Allergy • Fragrance mix I allergens found in 15- 100% of cosmetic products (especially deodorants) • 2nd - 5th most common (+) PT in series around the world • Testing FM I–allergic patients with ingredients of the mix is successful only about 50% of the time • Testing to FM I and BOP picks up 60-70% of fragrance allergic individuals* • Many persons have (+) PT to fragrance, but few have clinical allergies to fragrances (allergic contact dermatitis) Storrs F J. Fragrance. Dermatitis Volume 18, Issue 01, March  2007, Pages 3-7 *Larsen W et al. Fragrance contact dermatiis: a worldwide multicenter investigation (part III)> Contact Dermatitis 2002;46:141-4

  34. P-phenylenediamine (PPD)Contact Allergen of 2006 Permanent Hair Dye • Theoretically, does not cause reaction if fully oxidized • In reality, it is likely that PPD is never completely oxidized • Other reactions: IgE mediated anaphylaxis & lymphomatoid reactions

  35. Long Island, New York Risk Factors & Ethnic Differences • Aging Population • 40% of women in America & Europe color their hair (70% are over 35 y.o.) • Black men have higher incidence –use darker shades of dye with higher concentration of PPD • Occupational: Currently the most common cause of contact dermatitis in hairdressers Hesse et al. Contact Dermatitis to hair dyes in a Danish Adult population: an interview based study. Br J of Dermatol 2005; 153:132-5 Dickel H et al. Comparison of patch test with standard series among white and black racial groups. Am J Contact Dermat 2001;12:77-82

  36. Long Island, New York New Route of Exposure • Body tattooing has increased among the youth of many cultures • Use of black henna tattoo (higher PPD than in hair color) • Sensitization to PPD from tattoos is likely lifelong • likely see individuals who react to their attempts at hair coloring as they age (reported in 5.3% who never used hair dye) Hesse et al. Contact Dermatitis to hair dyes in a Danish Adult population: an interview based study. Br J of Dermatol 2005; 153:132-5 Dickel H et al. Comparison of patch test with standard series among white and black racial groups. Am J Contact Dermat 2001;12:77-82 De Leo V. p-PhenylenediamineDermatitis Volume 17, Issue 02, June  2006, Pages 53-55

  37. Chemicals that may cross react with PPD Product ClassChemicals • Sunscreens PABA & padimate O • Antiinfectives Sulfonamides & p-aminosalicylic acid • Diuretics Thiazides • Anesthetics Benzocaine and related “caines” • Textile dyes Azo dyes • Antidiabetic Sulfonylureas • COX-2 inhibitors Celecoxib • Rubber Accelerators N-isopropyl-N’-phenyl-p-phenylenediamine • Black Rubber mix De Leo V. p-Phephenylenediamine. Dermatitis 2006. 17;2: 53-55

  38. CorticosteroidsContact Allergen of 2005 • Increase detection probably due to • Greater awareness • Expanding market for CS • Improved testing procedure • Suspect • In stasis ulcers & chronic eczema • When dermatitis fails to respond to CS • When dermatitis worsens with treatment

  39. Long Island, New York SKIN TESTING TO TOPICAL CORTICOSTEROID * Tixocortol Pivalate (1%) - Class A * Budesonide (0.1%) - Class B&D Hydrocortisone (1%) Hydrocortisone-17-butyrate (0.1%) Betamethasone-17-valerate (0.12%) Clobetasol-17-propionate (0.25%) Prednisolone (1%) *Triamcinolone (0.1%) Patient’s commercial steroid Repeat open application test * Found in current TRUE Test Identifies > 91% of CS allergy Bjarnason et al. Assessment of budesonide patch tests. Contact Dermatitis 1999, 41:211-217 Bofa et al. Screening for corticosteroid contact hypersensitivity. Contact Dermatitis 1995,33: 149-151

  40. Long Island, New York STRUCTURAL GROUPS OF CORTICOSTEROIDSCross reactivity based on 2 immune recognition sites- C 6/9 & C16/17 substitutions Class A (Hydrocortisone & Tixocortol pivalate: has C17 or C21 short chain ester) Hydrocortisone, -acetate, Tixocortol, Prednisone, Prednisolone, -acetate, Cloprednol, Cortisone, -acetate, Fludrocortisone, Methylprednisolone-acetate Class B (Acetonides: has C16 C17 cis-ketal or –diol additions) Triamcinolone acetonide, -alcohol, Budesonide, Desonide, Fluocinonide, Fluocinolone acetonide, Amcinonide, Halcinonide Class C (non-esterified Betamethasone; C16 methyl group) Betamethasone sodium phosphate, Dexamethasone, Dexamethasone sodium phosphate, Fluocortolone Class D1 (C16 methyl group & halogenated B ring) Clobetasone 17-butyrate, -17-propionate Betamethasone-valerate, - dipropionate, Aclometasone dipropionate, Fluocortone caproate, -pivalate, mometasone furoate Class D2 (labile esters w/o C16 methyl nor B ring halogen substitution) Hydrocortisone 17-butyrate ,-17-valerate,-17-aceponate,-17-buteprate, methylprednisolone aceponate • Wilkinson SM Corticosteroid cross reactions: an alternative view. Contact dermatitis 2000;42:59-63

  41. Cocoamidopropyl betaineContract Allergen of 2004 • Second most common allergen in shampoo • Amphoteric surfactant often found in shampoos, bath products, eye & facial cleaners • Less irritating than are older polar surfactants such as sodium lauryl sulfate but more capable of allergic sensitization. • Positive reactions to this allergen are often clinically relevant

  42. Long Island, New York ShampoosTypically composed of 10-30 ingredients • eyelid dermatitis, facial dermatitis, neck dermatitis, scalp • dermatitis, dermatitis of the upper back, or dermatitis in • more than one of these areas, often leading to difficulty in • clinical diagnosis. Of 9 products with no fragrance, 4 had fragrance related potential allergens; 3 of these 4 had botanical ingredients, & 1 had benzyl alcohol Thus, only 5 products in database were truly fragrance free & definitely safe for patients with fragrance allergy. Matthew Zirwas and Jessica Moe Shampoos. Dermatitis, Vol 20, No 2 (March/April), 2009: pp 106–110

  43. Cocoamidopropyl betaine • Typically presents as eyelid, facial, scalp, and/or neck dermatitis • frequent exposure to personal cleansing products • enhanced ability of “sensitive skin” in these areas to develop ACD • 3.3% of 975 patients had a + reaction to CAPB (NACDG 2001) • Found in >600 personal care products (FDA data voluntarily reported by industry) • Commercial bulk production of CAPB may result in contamination of the final product with two chemicals used in the synthesis of CAPB, namely, amidoamine (AA) and dimethylaminopropylamine (DMAPA) Fowler JF. Cocamidopropyl Betaine. Dermatitis 2004;15:3-4

  44. Formaldehyde Formaldehyde* (8.4) Quarternium 15* (9.3) Diazolidinyl urea*(3.2) (Germall II) Imidazolidinyl urea* (3.0) (Germall) Bromonitropropane (3.3) (Bronopol) DMDM Hydantoin (2.6) (Glydant) Non Formaldehyde Methyldibromoglutaronitrile (5.8) (Euxyl K400) MCI/MI (2.3) Parabens* (0.5) Chloroxylenol (0.8) Iodopropynylbutylcarbamate (0.4) Long Island, New York Cosmetic Preservatives Paraben, quarternium-15 & formaldehyde preservatives are frequently combined & cosensitize *** (% Prevalence PT reaction based on NACDG or TT) *Antigen present in the T.R.U.E. Test ***Albert MR et al. Concomitant positive reactions to allergens in the patch testing standard from 1988-1997. Am J Contact Dermat 1999. 10:219-223

  45. Long Island, New York Formaldehyde Most common potential source of exposure • Cosmetics • rarely listed on ingredient label, direct use forbidden in some countries • Contain formaldehyde releasers • Permanent press textiles • Increase strength, prevent shrinking, resist wrinkling (permanent press) of cellulose and rayon fibers *Agner et al.Formaldehyde allergy: a follow up study. Am J Contact Dermatitis 1999;10:12-17

  46. Formaldehyde & Formaldehyde Releasing Preservatives • Difficult to avoid because formaldehyde is present in cleaning products, biocides • Cross reactivity varies • A high cross-reactivity rate between formaldehyde, Bioban (mixture of 4-(2-nitrobutyl)-morpholine and 4,49-(2-ethyl-2-nitrotrimethylene) Dimorpholine), and other formaldehyde-releasing agents • Only half of patients with formaldehyde/ FRP allergies reacted to 1-2 allergens and only 1% reacted to all 6** *Anderson B et al Patch-Test Reactions to Formaldehydes, Bioban, and Other Formaldehyde ReleasersDermatitis, Vol 18, No 2 (June), 2007: pp 92–95. **Herbert C, Reitschel RL. Formaldehyde and formaldehyde releasers: how much avoidance of cross reacting agents is required? Contact Dermatiits 2004;50:371-3

  47. Long Island, New York Formaldehyde in Textile Resin • Reactions: irritant & ACD, exacerbation of AD, urticaria, phototoxic eruptions* • more subacute and chronic dermatitis • Testing with formaldehyde alone identifies only ~70% of patients who are allergic to the formaldehyde resins • PT with resins as well • Slow resolution of dermatitis even with careful avoidance • As much as 50% still had constant dermatitis * *Hatch KL, Maibach HI. Textile chemical finish dermatitis. Contact Dermatitis 1986;14:1–13. Allergic Contact Dermatitis from Formaldehyde Textile Resins Fowler JF Jr, Skinner SM, Belsito DV. Allergic contact dermatitisfrom formaldehyde resins in permanent press clothing: an underdiagnosed cause of generalized dermatitis. J Am Acad Dermatol .1992;27:962–8. Hilary C. Reich and Erin M. Warshaw Allergic Contact Dermatitis from Formaldehyde Textile Resins . Dermatitis, Vol 21, No 2 (March/April), 2010: pp 65–76

  48. Long Island, New York Key Diagnostic Criteria for Allergic Contact Dermatitisfrom Formaldehyde Textile Resins 1. Characteristic location of eruption corresponding with contact with clothing 2. Positive PT to formaldehyde 3. Positive PT to suspected fabric 4. Demonstration of free formaldehyde in the suspected fabric 5. Negative reaction to other potential clothing allergens (eg, rubber, nickel, dyes) Reich H & Warshaw E. Allergic Contact Dermatitis from Formaldehyde Textile Resins . Dermatitis. 2010. 21;2:65–76

  49. Long Island, New York Treatment for Textile Finish/Formaldehyde Resin Allergic Contact Dermatitis • Use 100% silk, polyester, acrylic, nylon • Linen & denim are acceptable if soft & wrinkle easily • Avoid ‘‘easy care,’’ ‘‘permanent press,’’ or ‘‘wrinkle free’’ • Some experts also recommend avoidance of formaldehyde-releasing preservatives in personal products* • AVOID FORMALDEHYDE RESINS AT ALL TIMES. Even exposure once a month (‘‘Dress clothes’’ only worn on weekends) is enough to maintain your dermatitis Reich H & Warshaw E. Allergic Contact Dermatitis from Formaldehyde Textile Resins . Dermatitis. 2010. 21;2:65–76 *Scheman A, Jacob S, Zirwas M, et al. Contact allergy: alternatives for the 2007 North American Contact Dermatitis Group (NACDG) standard screening tray. Dis Mon 2008;54:7–156.

  50. Long Island, New York Quarternium 15 • Most common cosmetic preservative allergen • Most sensitization is caused by formaldehye releaser • Most Quarternium allergic patients are also allergic to formaldehyde Castanedo-Tardan M & Zug K. Patterns of Cosmetic Contact Allergy. Dermatol Clin 2009 27: 265-280

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