CURRENT ALLERGY & CLINICAL IMMUNOLOGY JOURNAL OF THE ALLERGY SOCIETY OF SOUTH AFRICA
Vol 36, No 2 June 2023
- CONTACT DERMATITIS – BEYOND PATCH TESTING
- Irritant dermatitis
- Patch testing patients’ own products
- New contact allergens and exposures in the home and environment
- Occupational allergic contact dermatitis: are there emerging haptens?
- Patch tests in children with active atopic dermatitis
- House dust mites: Challenges establishing causal associations in occupational health for ubiquitous agents
- Curbside consultation
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GUEST EDITORIAL
Author: Gail Todd
Abstract: When I was asked to guest edit this issue of Current Allergy and Clinical Immunology, it seemed appropriate to dedicate it to contact dermatitis (CD). Five articles on this common, important, yet poorly understood and taught subject cover practical aspects of contact dermatitis beyond commercial patch testing.
REVIEW ARTICLE
IRRITANT DERMATITIS
Authors: Kajal Patel, Rosemary Nixon
Abstract: Irritant contact dermatitis is the most common form of both contact dermatitis and occupational skin disease. The diagnosis of irritant dermatitis is often difficult, given the lack of confirmatory testing, and it is usually diagnosed confidently only after allergic contact dermatitis has been excluded with patch-testing. Early recognition, prevention and treatment are the mainstays of management, particularly when it is work-related. This article provides a comprehensive summary of the disease, clinical presentations and management.
Keywords: irritant contact dermatitis, patch-testing, allergic contact dermatitis, hands, occupational skin disease
REVIEW ARTICLE
PATCH-TESTING PATIENTS’ OWN PRODUCTS: A PRACTICAL OVERVIEW FOR CLINICIANS
Authors: Ella Dendooven, An Goossens, Olivier Aerts
Abstract: Patch tests are the gold standard in the work-up of allergic contact dermatitis. Apart from commercial products, it is also of utmost importance to include the patients’ own products. Products with unknown content or containing strong irritant, corrosive, toxic or poisonous chemicals should never be patch-tested, though. Recommendations on how to patch-test finished products can easily be retrieved in the literature and in specialised reference books; practical advice on test modalities (test methods, concentrations, vehicles) have been outlined for leave-on and rinse-off cosmetics, household detergents, chemical products (glues, paints), solid materials (gloves, shoes, textiles, leather goods, metal, plastic and rubber items), occupational products, plants, woods and food items. Separate guidelines exist on how to patch-test drugs. Whenever a positive or negative reaction to a product is obtained, practitioners should always question the possibility of a false-positive or a false-negative reaction, respectively. In these cases, additional test procedures may be required (eg testing of separate ingredients, repeated open-application tests, serial dilutions of a chemical or product, glove-repeated application tests). In this article we provide a practical overview for clinicians on how to test patients’ own products.
Keywords: Repeated open-application test (ROAT), semi-open, patch test, prick test, cosmetics, occupational products, allergic contact dermatitis
REVIEW ARTICLE
NEW CONTACT ALLERGENS AND EXPOSURES IN THE HOME AND ENVIRONMENT: AN UPDATE
Authors: Olivier Aerts, Ella Dendooven, An Goossens
Abstract: New chemicals are continually being introduced in consumer products such as cosmetics, pharmaceuticals, medical devices, textiles, tattoo inks, rubber materials and footwear. Allergic contact dermatitis (ACD) arising from new sensitisers in such items is a frequent problem in daily practice, and a correct diagnosis is often difficult. In this overview we provide a practical update illustrated by clinical examples of new and sometimes unexpected sensitisers and some old ones in new applications. Notable examples include the emergence of amino acid alkyl amides (AAAs), vitamin C compounds, resorcinol derivatives, glycols, metals (eg tin) and lipid/carbohydrate allergens in cosmetics; benzophenone residues in octocrylene-containing sunscreens, plastics and inks; the replacement of tosylamide/formaldehyde resin in nail varnishes by sensitising copolymers based on phthalic anhydride/adipic acid and (meth)acrylates; epoxy resin as a non-occupational contact allergen in domestically used glues; fragrances (including terpenes) in, for example, (medical) adhesives; persulfates in hot-tub detergents; isothiazolinones in leather wear and rubber gloves; chemicals such as chlorophenols in textiles and acetophenone azine in foot and sportswear; biguanides and quaternary ammonium salts used as antimicrobial agents in cosmetic and non-cosmetic products (eg wound-care products); acrylates and silicone components in medical devices.
Keywords: allergic contact dermatitis, cosmetics, medical devices, diagnosis, patch test
REVIEW ARTICLE
OCCUPATIONAL ALLERGIC CONTACT DERMATITIS: ARE THERE EMERGING ALLERGENS?
Authors: Amreeta Kaur, Rosemary Nixon, Amanda Palmer
Background: Most occupational skin disease (OSD) is caused by contact dermatitis which affects workplace productivity, quality of life (QoL) and is associated with a substantial economic burden. We report on whether there have been any emerging workplace allergens identified over the past six years.
Methods: A retrospective study was performed using de-identified data obtained from patients assessed at our Occupational Dermatology Clinic in Melbourne, Victoria, Australia from 2017 to 2022. Patch-testing was performed to identify allergens causing allergic contact dermatitis (ACD).
Results: Of a total of 657 patch-tested patients, ACD (151/298, 50.3%) was the most common diagnosis in those with significant work-related skin conditions,. The top occupational groups affected were healthcare workers (HCW) (29%; 45/151), trade workers (25.2%; 38/151) and health-and-beauty workers (13.2%; 20/151). The most common allergens were rubber chemicals, particularly thiurams. The next most common were the preservatives such as methylchloroisothiazolinone (MCI) and methylisothiazolinone (MI).
Conclusion: Rubber chemicals remain the most common occupational allergens followed by MCI and MI. HCW were the largest affected occupational group. Despite occasional case reports of new allergens, no major change in the causes of OCD was detected. Where possible, workplaces should provide allergen-free products to reduce the risk of developing ACD.
Keywords: contact dermatitis, occupational, allergic contact dermatitis, allergen, patch testing, irritant contact dermatitis, thiurams, methylisothiazolinone, hand dermatitis
Research article
PATCH TESTS IN CHILDREN WITH ACTIVE ATOPIC DERMATITIS: A PROSPECTIVE STUDY AND REVIEW OF THE SIGNIFICANCE OF EUROPEAN BASELINE SERIES TO THE AFRICAN REGION
Authors: Perpetua U Ibekwe, Eno Ekop, Theresa Out, Peter Bassi, Bob A Ukonu
Background: Atopic dermatitis (AD) is associated with impaired epidermal barrier and therefore it is prone to contact sensitisations. The results of patch-testing vary based on allergens tested, selection criteria for patch-testing, referral patterns and regional or social variations in allergen exposure. The aim of this study was to patch-test children with AD and compare the results with those of children with other forms of dermatitis. Our results were compared with those reported in the literature, especially those from the African region.
Methods: This was a prospective cross-sectional study of children younger than 18 years who were recently diagnosed with AD or with suspected contact dermatitis (CD). Patch tests were performed using a modified European baseline series of 28 allergens. The variables examined were age, sex, location of the eczema, personal or familial atopy and AD severity.
Results: Seventy-two children were patch-tested and had a mean age (±SD) of 8.1±5.1years. The sensitisation rate for AD was 54.9% (28/51) and for other forms of dermatitis was 47.6% (10/21). There was no statistically significant difference between sensitisation and sex, age group, AD severity, location of the eczema or personal and family history of atopy. Among the AD patients, paraben mix, methyldibromoglutaronitrile, fragrance mix I and cobalt chloride were the commonest sensitising allergens, whereas propolis, nickel sulphate and the methylchloroisothiazolinone or methylisothiazolinone combination were commonest in non-AD patients.
Conclusions: Our AD patients showed high sensitisation rates to low-allergenic substances commonly used as preservatives in body-care products when compared to non-AD patients. A search of the literature for patterns and frequency of contact sensitisations in children with AD across African countries showed a dearth of publications on this topic.
Keywords: patch test, atopic dermatitis, European baseline series, contact sensitisation, African preservatives
Allergies in the workplace
HOUSE-DUST MITES: CHALLENGES WITH ESTABLISHING CAUSAL ASSOCIATIONS IN OCCUPATIONAL HEALTH FOR UBIQUITOUS AGENTS – A RETROSPECTIVE STUDY
Authors: Dikeledi O Matuka, Edith Ratshikhopha, Tanusha Singh
Abstract: In this retrospective study, the sensitisation profiles of 846 workers (≥18 years old) were tested with house-dust mite (HDM) allergens and other common aeroallergens for the ten-year period 2002–2022. This study aimed to determine the proportion of HDM sensitisation among workers from various industries and to highlight the role of HDM exposure and current developments in occupational settings. Exposure to HDM allergen can occur in both households and work environments. Dermatophagoides farinae and Dermatophagoides pteronyssinus are the most commonly distributed dust mites worldwide. Inhaling allergens produced from these mites can result in respiratory symptoms, rhinitis and asthma in sensitised individuals. Exposure to these allergens in the workplace may result in occupationally acquired or workaggravated allergic reactions, leading to poor quality of life, an increase in absenteeism arising from sickness and, consequently, reduced productivity. The percentage sensitisation among workers referred to the NIOH Occupational Allergy clinic was 41.67% for D farinae and 33.81% for D pteronyssinus. Nineteen per cent of the patients who reported work-related symptoms tested positive for HDM; therefore, work-related sensitisation is plausible. While Blomia tropicalis was not tested in the current study, it may be beneficial in tropical areas.
Keywords: house-dust mite allergy, asthma, occupational exposure, occupational risk
Ethics Article
CURBSIDE CONSULTATION
Author: Sharon Kling
Abstract: A curbside consultation is an informal consultation obtained from a health professional by either a layperson or a fellow healthcare professional. The consultations are usually solicited in person or telephonically, but with the advent of social media such as WhatsApp, this has become a common way to obtain opinions from other doctors. Curbside consultations from laypersons should preferably be avoided, but inter-professional informal consultations hold advantages for both the doctors and the patient, and should be encouraged, provided they are simple and straightforward questions.
Keywords: curbside consultation, informal consultation, laypersons
Research Article
ASSESSING THE IMPACT PAEDIATRIC ATOPIC DERMATITIS HAS ON THE MENTAL HEALTH AND QUALITY OF LIFE OF CAREGIVERS ATTENDING A TERTIARY HOSPITAL IN CAPE TOWN, SOUTH AFRICA
Authors: Shwetha Suresh, Susanna Kannenberg, Anusha Lachman
Background: Atopic dermatitis (AD) is a chronic and often debilitating illness in children but it also has a significant effect on the quality of life (QoL) and mental health of caregivers. The aim of this study was to explore the relationship between AD in children and the QoL and mental health of their caregivers.
Methods: We conducted a cross-sectional study of patients and their caregivers who attended the Dermatology Clinic at Tygerberg Hospital in Cape Town, South Africa. The participants were recruited between February and August 2021.
Results: Most of the children in this study experienced mild AD symptoms. Almost 90% of the children had an identifiable trigger, the most common triggers being an environmental temperature change (66.7%) and stress (57.4%). We noted a weak but significant correlation between QoL and AD severity (rs = 0.395, p = 0.003) and a strong positive correlation between the caregivers’ QoL and their mental health (rs = 0.650, p < 0.001).
Conclusion: Uncomplicated and rapid screening tools for caregiver mental health and QoL should be used when treating patients with AD. Understanding the burden and allowing room for these modifiable factors to be mitigated will play a large role in ensuring a better therapeutic outcome for children with a chronic illness such as AD.
Keywords: atopic dermatitis, eczema, quality of life, mental health, attachment, caregiver, South Africa
ABC OF ALLERGY
Describing skin findings
Authors: Shaunagh Emanuel, Di Hawarden
Abstract: Allergy symptoms often manifest in the skin. From eczema to urticaria to the plethora of manifestations of drug hypersensitivity reactions, allergy can result in a vast variety of skin changes. This is what makes it important to be able to describe dermatological findings accurately. For instance, what is the difference between a papule and a nodule? If the skin appears red, should we use scarlet, hyperaemia or erythema to describe it? Is that purple patch purpura, petechiae, ecchymosis or a haematoma?
DR SPUR’S MYSTERY CASE
PRIMARY IMMUNODEFICIENCY DISORDERS
Authors: Sylvia van den Berg, Petri Swanepoel, Lizelle Nagel1, André van Niekerk
Abstract: Primary immunodeficiencies (PID) are now being referred to as ‘Inborn Errors of Immunity’ (IEI). Patients may present with five clinical phenotypes, including infections, autoimmunity, autoinflammation, allergy and malignancy. Some of these manifestations may be present simultaneously or follow in no specific order. In my next five letters to you, I will focus on the five clinical phenotypes of IEI, starting with infections.
ON FAILURE, TRUST AND OUR COMMON HUMANITY
Author: Elmi Muller
Abstract: A few weeks ago, a patient came to see me. He had received a transplant from his sister in 2017 and the kidney failed in 2022. I had done the transplant. He told me that his graft never really functioned properly. According to him, this was most likely the result of how I did his surgery in 2017. Now he was coming for a second transplant – a kidney donated by his wife. He was meeting me to tell me that he didn’t want me to be involved in his transplant, although he was worked up for this procedure by people in my practice and in my team.