IRISH DERM TUTOR

Introduction

Irritant contact dermatitis

Allergic contact dermatitis

Patch Testing

History - general questions to ask

British Standard Series

Allergens to know:

• Cosmetics

  • Hair dye allergy

  • Acrylates

  • Colophony

• Preservatives

  • Formaldehyde

  • Quaternium-15

  • Isothiazolinones - MI/MCI, Octy, Benzo

  • Sodium metabisulfite

• Fragrances

  • Myroxolon of Pereirae (balsam of peru)

  • Fragrance mix 1, Fragrance mix 2

  • Propolis

  • Limonene, linalool

• Metals

  • Nickel

  • Potassium dichromate

  • Cobalt

• Epoxys

• Rubbers and rubber accelerators

• Medicaments

  • Caine mix

  • Steroids

  • Emollients - lanolin, cetearyl alcohol

Plant Dermatitis:

• Allergic contact plant dermatitis

• Phytophotodermatitis

• Toxin mediated contact, Mechanical irritant, Chemical irritant

Occupational contact dermatitis

Dermatitis means inflammation in the skin

Contact dermatitis refers to a group of skin disorders in which the inflammation is due to direct contact with something in the environment

Contact dermatitis can be an irritant dermatitis, an allergic dermatitis or both.

Patients with a history of atopic dermatitis are at increased risk of developing both an irritant and allergic contact dermatitis.

Much more common than allergic dermatitis:

Causes a direct cytotoxic effect due to single or repeated application of a chemical substance or physical insult to a cutaneous site

Irritants are often substances like detergents and solvents that strip the skin of its natural oils and cause dermatitis to develop if contacted frequently

For instance if anyone is exposed to an irritant (such as repeatedly washing hands with a hand wash) for long enough and repeatedly enough they will develop an irritant reaction from overuse

Unlike allergic contact dermatitis there is no involvement of immunologic memory

Seen regularly in people involved in industries with lots of wet work exposure (eg nurses/chef), and people who work in industries exposed to irritants (eg machine tool operators, mechanics, labourer in building industry)

Irritant dermatitis characteristically leads to diffuse redness with dry, cracked, fissured skin.

Risk factors:

Intrinsic:

Atopic diathesis

Age: babies/young children and elderly (relatively compromised epidermal barrier)

Body site: face, dorsal hands, finger webs

Extrinsic:

Nature of irritants

Exposure volume and concentration

Repetition

Clinical types of ICD:

Cumulative:

This is the most common

Hands most commonly affected

Get specific pattern involvement of interdigital spaces and dorsal fingers

(think of the interdigital spaces as the ‘gutter’ of the hands where things collect)

Often related to wet work and exposure to detergents

Due to multiple exposures from weak irritants

Get erythema, scaling, dryness and fissuring

Hyperkeratosis and lichenification can occur

Examples of cumulative irritant contact dermatitis:

• Diaper dermatitis (urine, faeces and cleansing agents mix under occlusion)

• Lip smacking dermatitis (saliva vey irritating, drooling and food particles in young babies can also contribute to irritant dermatitis)

Acute ICD:

After exposure to a potent contact irritant which can cause acute vesiculation, erythema, oedema, oozing +/- necrosis

Peak usually in minutes to hours followed by healing

If leave on wash-off products for too long can cause an acute reaction if very potent

Examples:

• Acute plant dermatitis

• Bleach

• Industrial solvents
  

Delayed acute ICD:

Acute signs but delayed development from contact

Lag period can be > 8 hours

Examples:

• Wet cemet

• Acrylates

Moisturisers containing anti-microbial agents such as benzalkoinum chloride (BZKC) can cause irritant reactions especially in flexures

Dermol-500 and oilatum plus contain this - they should not be left on skin and should be washed off for this reason

In ACD the person develops an allergy to a specific allergen in the environment

He/she can then develop a rash whenever comes in contact with the allergen, even with small doses of exposure

Patient may have been in contact with this allergen for years with no issues previously prior to sensitisation

The allergen is usually harmless to people not allergic to it

It is a type 4 allergic reaction (aka delayed hypersensitivity reaction) - so this is modulated by CD4+ T cells with the reaction occurring about 48-72 hours after exposure to the antigen

Allergic contact dermatitis will characteristically give weeping, oozing very itchy skin

Can sometimes be very acute and severe with associated blistering, for example in plant contact dermatitis or hair dye (PPD) allergy

Patient’s with impaired barrier function of skin are more prone to developing allergic contact dermatitis, for example:

• Chronic irritant dermatitis

• Atopic dermatitis

• Chronic leg ulcers

Type 4 allergic reactions are in contrast to type 1 histamine mediated IgE reactions

To test for IgE mediated reactions you can do skin prick testing and RAST testing

To test for Type 4 allergic reactions as seen in ACD you can do patch testing

Allergens are introduced in a fixed concentration (often in petrolatum)

• Allergens are applied to small areas of the back under aluminium wells (non irritant and non allergic and serves as a from of occlusion to allow penetration of the allergen)

• Leave wells on for 48 hours and take them off (takes this time to develop a reaction) and mark the level of reaction seen.

• You then review again at 72 hours and again mark the level of reaction seen

  • +/- doubtful reaction: faint erythema

  • + weak positive: infiltration, possible plaque

  • ++ strong positive: erythema, infiltration, papules, discrete vesicles

  • +++ very strong positive: intense erythema, infiltration, coaslescinge vesicles, bullae

Some allergens can also be irritant and can cause irritant rather than allergic reactions

If irritant: redness often has improved at 72 hours compared to 48 hours

If allergic: redness remains or is even worse at 72 hours

Sometimes at 48 hours if not sure if irritant or allergic can add the allergen elsewhere on the skin and a reaction should occur within 48 hours as you have already excited the immune system to this allergen elsewhere

Who to patch test?

Need in back of mind for awful lot of dermatology presentions

Basically anyone with eczema with particular patterns or not responding to treatment (resource dependent)

• Hand dermatitis

• Foot dermatitis

• Facial dermatitis

• Peri-ocular/eyelid dermatitis

• Patterned/regional dermatitis

• Worse/not improving with topicals

• Cheilitis

• Fingertip dermatitis

• High risk occupations: beauticians, hairdressers, factory workers

Onset of dermatitis and where did it begin?

Persistent or recurrent?

Triggers?

Prior history of rashes/reactions to other substances?

Occupation:

• Can ask them to take you through a standard day at work

• Material handled

• Wet work

• Gloves/barrier equipment

• Improvement while on holiday (may or may not see)

Hobbies:

• Gardening: Plants, flowers

• Musical instruments

• Exercises - type of exercise, grip work

• DIY, glues handled

Housework: cleaning agents

Cosmetics + Personal care products

Personal or family history of atopy

Medications

Can ask specific exposure history:

• Hair dye

• Nail varnish, gel, acryllics

• Dental/orthopaedic history

• Nickel - ask about cheap or costume jewelery (ask them do they get swelling, crusting, redness)

• Any known reactions to fragrance

• Rash to adhesive dressings or plasters

Different series of patch tests exist that cover many of the common allergens seen in contact dermatitis

I have included the British standard series (50 allergens) but other series exist like the European Standard Series (29 allergens) or the TRUE test (29 allergens)

In St. John’s for instance they also add a fragrance series (30 allergens) to their own Extended European Series (40 allergens) and the combination of these series can pick up about 80-90% of allergic contact dermatitis cases

What type of allergens are tested for in standard series:

• Fragrances

• Preservatives

• Emulsifiers

• Rubber accelerators (are chemicals used to speed up manufacturing process of rubber)

• Medicaments (antimicrobials + steroids)

• Plants

• Hair dye

• Formaldehyde and formaldehyde releasers (chemical that slowly releases formaldehyde)

Aswell as the British standard series you may add on extra types of series depending on the presentation, examples of specialised series are as follows:

• Face

• Cosmetics

• Medicaments

• Steroid

• Hairdressing

• Dental

• Nurses (contains chemicals in disinfectants_

• Caines

• Epoxies (if have strong suspicion to epoxy)

• Plasticisers and glues

• Plants

• Textiles (azo dyes)

• Acrylates

• Rubbers

• Extended fragrances

• Cutaneous adverse drug reactions

• Oils and cutting fluids

Any substance used on external part of the body, teeth or mucus membranes with a view to clean them, perfume them, change their appearance or correct body odours

Main cosmetic allergens:

• Fragrances

• Preservatives

• Bases (eg lanolin)

• Hair dyes

• Nail varnish resins

• Acrylates

• UV filters

Cosmetic allergy 2:1 Females: males

Women use an avearage of 12 personal care products per day (up to 168 ingredients)

Men use 6 (up to 85 ingredients)

EU Legislation:

Labelling of cosmetic ingredients mandatory in EU since 1997

Labelling of 26 individual fragrances mandatory in EU since 2004

If there are other fragrances not above it has to state: ‘aroma/fragrance/parfum’

Clinical presentation cosmetic allergy:

• Facial dermatitis (contact/airborne)

• Hand dermaitits, fingrtip dermatitis (used to apply cosmetic)

• Eyelid dermatitis (direct contact, airborne)

• Scalp and ears (hair dyes, conditioner, shampoo

• Peri-ungual (acrylates)

If suspect cosmetic allergy to personal care products can add on ‘facial’ and ‘cosmetic’ series

Can ask patient to bring in their own products: particularly leave on products

• Need to dilute wash off products and there is increased risk of irritation with these

• Ask them to bring in everything they use but be selective about what product they use

Commonest allergen in hair dye is paraphenylenediamine (PPD)

Well known allergy in consumers using permanent hair dye or in hairdressers with occupational exposure hand dermatitis

Hairdresser patch testing may detect a problem although it is not reliable

Also used in:

• Eyelash tinting and eyebrow tinting

• Light colour dyes such as those used for highlights (found in higher concentrations in darker dyes)

• Wigs

• Fur, leather and clothing dyes

• Rubber and plastic manufacturing, epoxy resin hardeners

• Photographic developing fluids

• Photocopying dyes and printing inks

PPD when fully oxidized has low sensitization

PPD when partially oxidized it is most allergenic

Very wide spectrum of severity (some reported cases of death)

Not uncommon for patients to present to A&E

Can spread to chest, neck and upper arms

As skin on scalp is thicker the reaction with PPD is usually be worse in areas surrounding the scalp such as the forehead, neck, ears and temples

The peri-orbital area can also be affected

PPD allergy can be a great mimicker and look like EM-like, lichenoid, pigmented, hypopigmented, urticarial and other types of reactions

Black henna tattoo can sometimes lead to sensitisation to PPD

Pure henna shouldn’t contain PPD but it sometimes does to make it appear darker (up to 30% PPD can be found in very black henna tattoos)

So sometimes people getting dark henna tattoos on beach holidays can get sensitised

How you do patch testing to PPD may change depending on history from patient:

Children and young adults under the age of 16 do not get tested to PPD as this may sensitise them

May also put PPD on arm if suspect hair dye allergy so patient can remove it easily if it appears they are having a severe reaction

British standard series: 1% PPD

0.1% PPD: may do if have history of black henna tattoo due to risk of severe reaction on patch testing

0.01% PPD: if have history of any hair reaction

• If negative at day 2 try 0.1%, at day 4 go to 1%, then bring patient back for day 7 testing if can offer this service

• You might not put hair dressing series at start of testing if suspect hair dye allergy as there is a 50% chance of an allergen cross reacting with PPD and risk of severe reaction on back

Need to warn patients that if have PPD allergy that they can react with multiple other compouds

If patient has a reaction to PPD you have to advise patients that they will often also have allergies to other chemicals in other hair dyes and even in semi-permanent hair dyes and eyebrow/eyelash tints and should advise other types of hair dyes

You could perhaps do a hairdressing series to further investigate but warn them they could get a severe reaction

Hairdressing series:

1. P-Toluenediamine: 50% cross reaction with PPD

2. Glyceryl monothioglycolate (perming)

3. Ammonium persulphate (highlights - bleaching agent)

4. Hydroquinone (highlights - bleaching agent)

5. Resorcinol

6. Ammonium thiglycolate (perming)

7. 2-nitro-4-phenyldiamine:

8. Hydrogen peroxide (highlights - bleaching agent)

If have PPD allergy could consider brand called Renaissance

Advice for hairdressers:

• You can protect your hands by using nitrile or plastic gloves. Avoid latex rubber gloves as dye can penetrate through

• Change gloves often

• Avoid cutting newly dyed hair without gloves. Previously dyed hair not so much an issue

Of note, permanent tattoos use pigment and not PPD
So in tattoos you are more likely to get foreign body type of reaction (eg granulomatous) rather than an acute allergic dermatitis

They are most irritant allergenic and sensitising as monomers (liquid/powder/paste)

They can be combined and made into polymers to make a pliable mixture which can be made into any shape and hardned

The polymerised states are relatively non-irritant and non-allergenic

Acrylates found in multiple substances including:

• Artifical finger nail adhesives (gels or shellac)

  • Shellac is semi-permanent nail varnish that usually should be removed by a nail technician

  • Is becoming very popular

  • Can get perinungual dermatitis and nail dystrophy

  • But consider in anyone with eyelid, face or neck dermatitis that has used these nails

• Healthcare equipment:

  • Dental materials: crowns, veneers, fillings

  • Bone cement, joint prosthesis

  • Hearing aids, ECG electrodes

• Adhesives for false eyelashes/eyebrows

• Automative coatings and sealants

• Printing

• Plastics

  
  

2-HEMA (2-hydroxyethylmethacrylate:

Is the commonest acrylate and is used in the standard series

Ca be found in many of the situations mentioned above

Other acrylates:

Ethyl acryalte:

• Artificial nails

Cyanoacrylate:

• Fast acting sticky, adhesive

• In some dressings

• Quick acting glues (Superglue, Wound glue, Eyelid extension glue)

Isobornyl acrylate:

• Used to be in glucose sensors

Occupation and acrylates:

Thinks about in dentists as often exposed to acrylates (they mix acrylates in composite fillings, seals, veneers etc)

May get rash in non-dominant hand as often do alot of the mixing and wiping with this hand while doing dental work with dominant hand

Nitrile gloves offer the best protection for dentists but they are still advised to change them every 15 minutes as acrylates can penetrate through

(aka rosin)

Abitol and abietic acid are 2 sub-fractions of colophonium

Abitol is the most commonly used sub-fraction in cosmetic products

From the sap of pine trees

Is found in the base of many glues and resins:

• Gum

• Wood

• Tall oil resin

Can be found in:

• Cosmetics:

  • Lipsticks, mascara, eyeshadow, concealer, nail varnish

• Toiletries:

  • Hair removing waxes, sanitary towels, dental floss

• Different types of dressings

  • Duoderm

• ECG electrodes

• Shoe adhesives (ballet dancers)

• Woodwork (pine wood dust)

• Dental products:

  • Dental cement, dental dressings, fluoride pastes

• Wax used on musical instruments

• Used on baseball bats, gymnastic groups, violin bows to increase friction

Other adhesive material to be aware of:

Epoxy resin chemicals which are often used to makes plastics, adhesives and glues.

• Often seen as an occupational allergy in electrical, building and manufacturing industries

• Will be discussed in more detail later

P-tert-butylphenol formaldehyde resin which is a leather/rubber adhesive

Chemicals that prevent colonisations of compounds with microbes

Most cosmetics and industrial products contain preservatives

Formaldehyde is a strong smelling, colourless glass

Found in many products:

• Cosmetics

• Medications

• Nail hardners

• Textiles

• Paints

• Cigarette smoke

• Paper

• Formalehyde resins (eg plastic bottles)

Formaldehyde/formaldehyde releasers can cause:

• Irritant contact dermaitis

• Allergic contact dermatitis

• Contact urticaria

• Mucus membrane irritation

Contact allergy is often seen in association with formaldhyde releasers found in many personal care products/:

• Liquid soaps, shampoo, rinse off products

• Can be associated with textile dermatitis where it is used in ‘wrinkle resistant’ and ‘wash and wear’ clothes/sheets

A formaldehyde releaser

Used to be common cause of allergic contact dermatitis from personal care products and cosmetics

It is now banned

80% of patients were positive to formaldehyde also

It is often relevant tot the patient’s presentation when positive on patch testing

The general advice is to avoid all formaldehyde releasers if positive to one formaldehyde releasers due to concomitant reactions

Other types of formaldehyde releaseres:

Quaternium (was most common comsetic preservative)

Bronopol (PCPs and industrial applications)

Imidazolindyl urea (Cosmetics)

Diazolindinyl urea (bubble baths, baby wipes, household detergents)

DMDM hydantoin (shampoo, hair conditioners)

Tosylamide: Substance formed by the combination of formaldehyde and toluene sulfonamide and is found in most nail laqeurs, polishes and hardeners so keep in mind in any contact dermatitis related to nails (not on standard series)

Water based preservatives

MI is typically used in conjunction with MCI

Combination orginally sold under trademark of Kathon CG

Were used in a huge range of personal care products

Also used in industry and paints (found in high concentrations in house paints)

Banned from use in leave on cosmetic in 2013 as there was a ‘MI epidemic’

Still allowed in ‘wash off products’ and still allowed in higher concentrations in cleaning products/paints

Can be linked to airborne symptoms

For example, if are painting at home can get severe symptoms of contact allergy even with systemic symptoms such as shortness of breath and wheeze

Exposure to MI:

• Wash off products (eg shampoos, bubble baths)

• Used to be in make up

  • Eye shadows, mascaras, make up removers, moisturisers, foundation, concealers, bronzers, self tanners

• Hair products

• Wet wipes, baby wipes, moist toilet paper

• Reports with ‘home made slime’

• Household products

  • Detergents and washing up liquid

  • Fabric softener

  • Polishes

• Sunscreens

• Mouthwashes

• Wet wall paints

  • Occupational and airborne ACD

• Industrial

  • Car polish, windscreen products

  • Cutting oils and coolants

• Printing inks

• Adhesive/glues

• Fabric softeners/washing detergents

How to avoid?

Use products without this preservative

Always check the label

Products can sometimes have ingredients added or changed and ingredients can even vary in products between shops so need to keep checking labels

Other isothiazinlones:

• Octylisothiazolinone/benzoisothiazolinone

  • Also banned in cosmetic agents but can be seen in dosmetic/industrial products

  • Octy - can cross react with MI. Can be a preservative in leather. Can cause a sofa dermatitis.

  • Benzo - in lots of cleaning agents. Has replaced MI in fairy liquid.

Sodium sulfite, sodium bisulfite, sodium metabisulfite

Occur naturally in some foods and can be a food preservative in foods such as jam, crisps, baked products, fruit juices and pickles

Also in cosmetic products: shampoos, hair dyes, hair sprays, tanning lotions

Topical medicaments: nizoral cream

Rubber gloves (latex and non-latex)

If positive for sulfite tend to be positive for metabisulfite so general advice is to avoid all

Any basic ingredient used in the manufacture of fragrance materials for its odorous, odour enhancing or blending properties

2500 fragrance ingredients are in current use for compounding perfumes

A typical perfume can contain anywhere from 5 to 200 fragrance ingredients

Fragrance allergy affects around 1% of adults (second only to nickel as a cause of ACD)

Around 10% of those undegoing patch testing have a fragrance allergy

Baseline series will contain myroxylon pereirae (balsam of peru), fragrance mix 1 (8 ingredients) and fragrance mix 2 (6 ingredients)

Balsam of Peru patch testing picks up approx 50% of fragrance allergies

When combine it with FM1 can identify 75% of those with fragrance allergy

To diagnose fragrance allergy:

Standard series will do Myroxolon of pereirae, FM1, FM2 and colophony (due to possible cross reactions it can be marker for fragrance allergy)

Can ask patient to bring in their own products

Can do a fragrance series and even extended fragrance series

European legislation in 2005 - 26 selected fragrance chemicals that are known to cause allergic reactions in humans are mandated on the label if present above a certain concentration

(USA more difficult as all it has to say is ‘contains fragrance or perfume’)

Clinical presentation of fragrance allergy can vary widely:

• Direct exposure - for instance something applied on neck

• Can get it by proxy (eg partner using a fragrance which is coming in contact with patient)

• Airborne (fragrances are volatile chemicals) - see rash in exposed areas of face (including wilkinson’s triangle behind ear, nasolabial fold and under chin unlike photodermatosis), V of neck, arms

• It can exacerbate endogenous eczema

• Systemic contact dermatitis (get flexural, intertriginous, symmetric contact dermatitis)

• Granulomatous cheilitis (benzoates, cinnamates)

• Contact urticaria

• Oral contact dermatitis

Balsam of peru is an aromatic liquid

It comes from cutting the bark of the tree myroxylon balsamum

Sensitisation seen in 4-8% of patient’s in patch clinics

Contains many ingredients including:

• Eugenol

• Cinnamates

• Benzoates

• Vanillin

• Limonene

Can be found in:

• Flavourings in food and drink

  • Artificially baked goods, aperitifs, soft drinks, perfumed tea/coffee/tobacco

• Fragrance

  • Perfumes/aftershave, deodorants, sunscreens, shampoo, conditioner, baby powders, cosmetics

• Medicineal products

  • Toothpaste, mouthwash, ointments, wound sprays, lozenges, surgical dressings

Can be found as a fragrance or in antibacterial ingredients

Can think of it as a naturally occuring frrgrance mix and it picks up 50% of fragrance allergies on patch testing

A wax-like substance produced by the honeybee for bee’s nests (aka Bee’s glue)

Contains many indgredients - waxes, balsams, oil, cinnamic alcohol, flavanoids etc

Shares multiple sensitisers with balsam of peru

Not in standard fragrance series

Is becoming popular especially in products saying they are ‘natural’

Therefore often labelled as fragrance free

Thought to have anti-microbial, anti-inflammatory and anti-oxidant effect

Seen in lip balms, lotions, toothpastes, cosmetics, shampoos

Also in cough syrup, lozenges, bees wax

Occupational allergy to propolis in bee keepers, musicians (varnish)

Both are ubiqituous in personal care and household agents (can be difficult to avoid)

More allergenic in oxidised form so the longer you leave the product on the greater chance of getting sensitised to them

Limonene:

• In citrus oils and lavender geraniums

• Lemony smell

• Seen in perfumes, toothpastes, mouthwash, handwash, deodarants, detergents…

• In tea tree oil, aloe vera

• Seen in 75% of household products and 98% fine fragrances

Linalool:

Synthetic and natrually occuring

Particularly associated with lavender

Seen in perfumes, deodorants, household products

In 95% of fine fragrances



Most common allergen

10% of women and at least 1% of men affected by nickel allergy

Jewellery, coins, keys, zips, buckles, scissors, glasses, instruments, clothing

Released from metals such as alloys or electroplated items

Found in pacemakers and batteries

Can do dimethylglyoxime nickel spot test which the patient can buy (‘eg nickel alert’) - apply a swab of it on the object and the swab comes up pink it has nickel in it

EU nickel directive: when a substance is in direct or prolonged contact with the skin it is only allowed a certain amount of nickel to be released from it

But when do the dimethylglyoxime nickel spot test on items that shouldn’t be releasing a ceratain level of nickel it can often be positive

Occupational risk for builders and people working in leather industry

Nowadays iron is added to cement as a chelating agent which decreases risk

Chromium found in:

• Tanned leather - shoes, gloves, jackets, belts, watch straps, leather steering wheel covers, furniture

  • Approx 90% of leathers are chromate-tanned

  • Leathers that are vegetable tanned are fine to wear

  • Other allergen that used to be in leather was dimethyl fumarate but has been removed

• Cement

  • European legislation has limited the amount of chromate in cement but it can still cause a problem

• Cosmetics:

  • Some eyeshadows and mascaras (unlikely to be labelled as containing chromium)

• Chromium plated metals (may be called chrome)

  • Mobile phones, screws, fittings, construction materials, sheet metal, musical instrument strings

• Joint replacment prosthesis

  • eg for hip and knee (patient needs to inform surgeon)

80% will also have positive patch testing to nickel/chromate

So they don’t actually cross react but they co-sensitise, ie:

• When there are more dangerous signals created nearby it makes you more likely to be sensitised to a weaker allergen

• Patients end up being sensitised to cobalt at same time, as are often in same jewellery as other allergens

• They often co-sensitise with nickel because nickel is a more potent allergen and is more irritant

Cobalt found in:

• Jewellery

  • Usually cheap or costume jewellery - necklaces, earrings, wristwatches, bracelets, piercings, hair clips

  • 22-carat gold and platinum unlikely to cause problems

• Metal parts in clothing

  • Jean studs, zips, belt buckles, handbag clasps, metal toe clasps

• Cosmetics

  • Eye shadows

• Hair dyes

• Orthopaedic and dental implants

• Pottery glazes (blue colours)

• Ceramics

• Enamel

• Cement

• Paints

• Resins

• +/- B12 injections (don’t recommend avoidance unless get timely generalised dermatitis around injections)

Note colours of colourings in products to be aware of:

Nickel - green

Cobalt - blue

Chromium - metal green

(can be used in eyelash curlers, tints, other things)

Epoxy resin chemicals are used to make plastics, adhesives and glues

Is often used in electrical, building and manufacturing industries

Seen in surface coatings, electrical insulations, paints/inks, PVC

So is often an occupational allergy - can be irritant or allergic

Think in industries like aircraft fitters, pipe fitters, carpenters

Can be relevant to certain types of DIY

When cured, fully set or hardened they are non-irritating or sensitizing

ACD can also be due to the hardeners or additives to the epoxides

Presents on hands/face most frequently

Airborne occupational allergy can occur which may be facial or periorbital

Can be severe and can become chronic

In patients with epoxy allergy they need to wear right type of gloves (eg heavy duty vinyl/neoprene/nitrile/butyl rubber over thin cotton inner gloves) as epoxy resins can penetrate certain gloves (eg latex)

Can still occur despite using good PPE

Rubber accelerators are added to rubber during processing

Used in the production of rubber from latex and can also be found in synthetic rubber products such as nitrile and neoprene gloves

Labelling is poor or non-existent so it is rarely possible to know whether a particular rubber product contains the chemical to which you are allergic

If possibly work related could ask occupational health to contact manufacturers about chemicals in the gloves

Types of rubber acclerators:

Mercaptobenzothiazole (MBT)

Mercapto mix

Thiuram mix

IPPD (black rubber)

Carbamates

Thioureas

Rubber allergy can present in many ways with many different patterns, eg:

• Hosiery/compression bandaging

Rubber accelerators may be found in:

• Gloves

  • Including those used in medical and dental examinations

  • Household

  • Gardening

  • Protective heavy duty gloves

• Footwear

  • Shoes (soles and insoles)

  • Rubber boots

  • Flip-flops

• Rubber products - balloons, condoms

• Other rubber procuts to wear - goggles, ear plugs/pieces

• Sports equipment grips, rubber mats

• Compressionn hosiery

• Fungicides

• Cutting oils, paints etc

• Electrical cords

• Rubber tubing like hoses

Glove allergy:

Many reactions to gloves are irritant and not allergic

Need to consider immediate allergy as well as delayed

Immediate allergy is caused by latex allergy

Latex allergy less common as many hospitals banned latex

Latex allergy can be tested by allergen-specific IgE or skin prick test (always do in any case of glove reaction)

If have allergy to rubber accelerator in gloves:

• Advise accelerator free gloves (eg gammex have a range)

• Vinyl gloves

• Leather gloves

If rubber acceleator allergy is affecting footwear:

• Use leather shoes

• Make sure there is rubber soles, insoles or linings

• Discard old socks as sweat can cause allergens to leach in to the socks where they may remain

Specific allergens for rubber accelerator allergy:

Mercaptobenzothiazole -

• Most common cause of allergic shoe dermatitis (runners, tennis shoes)

• Can be found in other rubber products listed above

• Also think about:

  • Cutting fluids, cooling water/oils/greases

  • Antifreeze, anticorrosive agents

Thiuram mix:

Chemicals in thiuram mix are Tetramehtylthiuram disulfide (TMTD) and Tetramethylthiuram monosulfide (TMTM)

Used as additives in manufacturing rubber products:

Found in other rubber products listed above:

Also think about:

• Agriculartural products (fungicides)

• Animal repellant

• Disinfectants, medical devices,

Thiruam cross reacts with disulfiram (for alcohol abstinence)

May cross react with carba mix

Carba mix and mercapto mix:

Found in usual rubber products listed above

IPPD (black rubber):

Used in heavy-use rubber products (tires, hoses, cables, belts)

Of note, Repeated washing of elastic fibres (undergarments) with bleach can cause elastic to become more allergenic (due to increased carbamates) which can lead to elastic dermtitis but patch test will be negative to rubber acclerators

Caine mix is used to assess frequency of contact allergy to local anaesthetics

Caine mix is a known cross-sensitiser to PPD so often have positive Caine mix on patch testing if PPD positive

Local anaesthetics are divided into esters and amides

Caine mix tests for:

Esters - benzocaine, tetracaine (aka amethocaine)

Amide - dibucaine (aka cinchocaine)

Positive patch test to caine mix is a good test to indicate contact allergy to ester anaesthetic as they are more likely to cross react with each other

If get a positive test to caine mix you might bring the patient back for patch testing at a later date to look further into the 3 ingredients within it

Lignocaine which is used in dental extractions, is an amide anaesthetic and true allergy is extremely rare

Allergy to lignocaine usually manifests itself as a type 1 hypersensitivity reaction and is not diagnosed by patch testing

As mentioned previously ester anaesthetics can cross react with PPD and other similar compounds

Another presentation where people may have positivity to caine mix is perinal dermatitis secondary to scheriproct (cinchocaine in it)

Clinical signs of steroid allergy may be subtle and minor and show atypical chronology

Suspect if:

1. Unexpected poor or no response to CS treatment

2. Worse with withdrawal

3. Reoccur rapidly with withdrawal

4. Chronic eczema with ‘edge effect’: eczema appears worse at edge: as in centre immunosuppressive effect working where it is concentrated but the allergic dermatitis is more apparent at edge

5. Use of ocular/nasal/inhaled steroids with lack of reponse/exacerbation and/or localized eczemaous reaction surrounding skin

Tixocortol pivalate a marker for Group A allergy (eg hydrocorisone, prednisolone)

Budesonide is a marker for Group B allergy (eg triamcinolone, fluocinolone)

Clobetasol proprionate and betamethasone-17-valerate is a marker for Group D1 allergy

Hydrocortisone-17-butyrate (locoid) is a marker for Group D2 allergy

Group A can cross react with Group D2

Budesonide can also cross react with Group D2

(so can consider budesonide a marker for allergy to Group B and Group D2)

If have allergy to a steroid cream this can very rarely translate to an allergy to systemic steroids given orally or by injection

If allergic to tixocortol pivolate dexamethasone is a good option if a systemic steroid is required


Management advice with steroid allergy:

Switch topical steroid to a different class

Switch to a a non-fluorinated steroid such as elocon (sensitisation uncommon)

Unfortunately despite all the classification systems including new systems they are still imperfect and can get unpredictable cross reactions (eg with fluorinated and non-fluoreinated)

Can do repeat open application test (ROAT) of all topical steroid products intended for use

ROAT: use the topical agent under antecubital fossa two to three times per day for one to weeks

(With topical steroid might just ask twice a day for 1 week)

Comes from sheep’s sebum where it is used to condition the wool

Has excellent emolliating and sealing properties

Found in wide range of emollients and medicaments

More common in patients with atopic dermatitis who would be using these topical agents

Weak sensitiser but more likely to lead to allergic dermatitis with repeated, prolonged exposure, particularly in inflammed skin with an impaired barrier

Also think of it in patients with chronic leg ulcers

Found in:

• Steroid ointments + emollients:

  • Fucidin, synalar, lyclear, eucerin, E45, oilatum, zerocream, sudocream

• Face creams, lipsticks, self-tanners, sunscreens, foundations, make-up removers

• Shoe and furniture polishes

• Printing inks

• Cutting oils

It can cross react with other fatty alchols such as cetearyl and stearyl alcohols

Cetylstearal alcohol:
Is an emollient and lubricant found in multiple topical agents

Tends to be in many topical steroids and emollients used in practice

Topical emollients without it: 50:50, doublebase, diprobase

GSK range of topical eumovate, betnovate (other brands may include it)

Can get many different types of reactions to plants

• Allergic contact dermatitis

• Phytophotodermatitis

• Toxin mediated contact urticaria

• Mechanical irritant dermatitis

• Chemical irritant deramtitis
  

Can get many different types of reactions to plants

A true contact plant allergy often due to two families of plants:

Anacardiaceae family:

• Poison ivy (toxicodendron radicans)

• Poison oak

• Part of mango tree

• Cashew

• Japanese Lacquer tree

• Indian marking tree

• Brazilian pepper tree

• Gingko

  • Urushiol is the allergenic substance found in this family of plants which is clear liquid made of sap (to add to the names urushiol contains pentadecacatechol)

Poison Ivy (Toxicodendron radicans) can cause a severe, pruritic, papulovesicular eruption.

Also known as ‘black spot dermatitis’ which derives its name from oxidised resin on the skin.

Onset usually within 2 days of exposure and typically peaks at 14 days.

This is a poisonous North American flowering plant and does not grow in the UK.

Asteraceae family (aka compositae family):

• Sunflower

• Chrysantheum

• Arnica

• Ragweed

• Dandelion

• Daisies

• Marygold

  • Typically these cause a contact allergic dermatitis resembling airborne contact dermatitis in middle-aged gardeners in the summer months

  • Compositae allergy diagnosed by patch testing to sesquiterpene lactone mix

  • Compositae allergy may cross react with permethrin

[Sesqy Aster Completely SCARDD Mary]

Others:

Alliaceae/Diallyly disuflide

(Ally would die for garlic, onion ad chives)

• Garlic

• Onion

• Chives

  • Classically causes an eczematous rash on fingertips

  • Think in cooks, greengrocers
    
    

This is a clinical diagnosis and does not require patch testing as the phototoxic reaction is independent of the immune system

It is a phototoxic inflammatory reaction caused by contact with certain plants and subsequent sun exposure ( eg UVA)

The chemicals responsible for the phototoxic reaction in the plants are called furocoumarins

Erythema starts within 24 hours after exposure to UV light and is subsequently followed by bullae over 24-72 hours

Classically is a painful, non-pruritic rash in sun-exposed sites

Lesions heal with hyperpigmentation occurring a week to two weeks later

Common family causes:

Umbelliferae (aka apiaceae)

• Cow parsley

• Celery

• Common hogweed

• Parsnip

• Fennel

• Angelica

• Wild rubarb/chervil

Rutaceae:

• Lime

• Lemon

• Grapefruit

• Oranges-citrus fruits

• Rue

• Burning brush

Moraceae;

• Fig tree

• Seen in St. John’s wort

Mechanical irritant dermatitis:

• Spines and thorns cause a penetrating injury (prickly pear, thistle, cacti)

Chemical irritant dermatitis (irritants from plants)

• Calcium oxalate:

  • Daffodil bulbs (narcissus sp)

  • Dumb cane (araceae)

  • Pineapple

  • Hyacinth (liliaceae)

• Capsaicin found in hot peppers

Toxin mediated contact dermatitis

• Plants with sharp hairs that implant chemicals such as histamine and serotonin causing an urticarial response - eg with a nettle sting
  
  

Irritant contact dermatitis is more common occupationally than allergic contact dermatitis

Irritation can facilitate the induction of contact allergy

So many cases of occupational contact dermatitis can be a mix of ICD and ACD

Irritatnts:

• Water

• Soap/Detergents

• Alkalies

• Acids

• Metal working fluids

• Organic solvents

• Other petroleum products

• Oxidizing agents

• Reducing agents

• Animal products

• Physical factors

Allergens:

Biocides (including isothizolinones)

Chromate

Dyes

Epoxy resin systems

Essences and fragrances

Formaldehyde

(Meth)acrylates

Nickel

Plants and wood

Rubber processing chemicals

Where can workers be:

Agricultural: cleansers, tractor/machinery fuels, chemical fertilizer, animal feed, preservatives, pesticides

Automotive/aerospace assemby and maintenance: Chromate (anti-coorrosive), epoxy resins, methacrylate

Baking and patisserie: Cinnamon, cardamom, flour

Catering and food production: Garlic, onion, hardwood knife handles

Chemical and pharmaceutical production

Cleaning: Rubber gloves, fragrances, d-limonene

Dentistry: latex, metals, acrylates, balsam of peru/fragrances, thiuram, colophony

Electrics and electronics

Floristry and horticulture: Compositae (sequisterpene lactone mix)

Hairdressing and beautry: PPD, formaldehyde, MCI/MI, fragrances

Healthcare: type 1 allergy to natural rubber latex, type 4 fragrances, preservatives

Additional notes to put in somewhere:

Systemic contact dermatitis:

To Balsam of peru possible (in large amounts), to B12 injections, to Gentamicin

Drugs (iv/im) or more likely to cause a systemic ocntact allergy in comparison to foods as allergens get digested

Amalgam:

Dental fillings that can give a lichnoid reaction in the gum

Persisting lichenoid reaction leads to risk of malignancy

Orthopaedic contact allergy:

Cement joints - acrylate, nickel, gentamicin, chrome-cobalt alloy

Alternatives that are good to use - ceramic, titanium

Suncreen allergys:

UVA blockers:

Avobenzone

Benzophenone (oxybenzone)

Others: Ecamsule (mexoryl SX), meradimate

UVB:

PABA

Octocrylene

Padimate O

Salicylates (salate or salicylate in name)

Others: Ensulizole, Mexoryl XL

Blocks UVA and UVB:

Oxybenzone

Titanium and zinc oxide

Mexoryl

Benzophenone-3: sunscreens, rubber products, cosmetics

PABA: Sunscreen to UVB (PABA can crosss react with PPD, benzocaine, azo dye, sulfonamide)

Oxybenzone: Sunscreen to UVA (oxybenzone is the most common sunscreen agetn to cause photoallergic contact dermatitis)