update on contact dermatitis - aaifncaaifnc.org/documents/symposium_2013/dr. jenny murase.pdfpool...
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Update on
Contact Dermatitis
Jenny Murase, MD
Palo Alto Foundation Medical Group
University of California, San Francisco
Department of Dermatology
Disclosures for:
Jenny Murase, MD
For the 12 months preceding this CME activity, I disclose
the following types of financial relationships:
Honoraria received from: None
Consulted for: None
Held Common Stock in: None
Research, clinical trial, or drug study funds received from:
None
I will not be discussing products that are investigational or
not labeled for use under discussion.
What kind of patient benefits from patch
testing?
Hand Dermatitis
Patient #4 (palms)
Patient #5 (dorsum)
What kind of patient benefits from patch
testing?
Patient #6 Fixed location
Patient #7 Lichenoid
morphology
What kind of patient benefits from patch
testing?
Patient #8 Nummular eczema
Patient #9 Chronic atopic
dermatitis
Outline
Comparison of TRUE test, NACDS,
Pediatric Series, and Surgical Series
Update on Patch Testing in Orthopedic
Surgery Patients
Update on Pediatric Patch Testing
Utility of Patch Test in Clinical Practice
Available Patch Test Trays
North American Contact Dermatitis Group
Standard 65 Allergens Dermatitis Vol 19 (3): 137-41, 2008. Use of North American Contact
Dermatitis Group Standard 65-Allergen Series Alone in the Evaluation of Allergic Contact Dermatitis: A Series of 794 Patients.
TRUE [35]: Thin-Layer Rapid Use Epicutaneous
Pediatric series [40] Pediatric Dermatology Vol 25 (1): 81-87, 2008. Patch Testing:
Another Steroid-Sparing Agent to Consider in Children. 38 from NACDS and 2 from Textile.
Pre-operative Surgery series [34] Archives of Dermatology Vol 148 (6): 687-94, 2012. The Effect of
Patch Testing on Surgical Practices and Outcomes in Orthopedic Patients with Metal Implants.
Specialty Patch Test Trays
Corticosteroid [13]
Fragrance [41]
Shoe [23]
Dental [30]
Hair Dresser [27]
Bakers [19]
Rubber [25]
Oil and Fluid Cooling [35]
Metal [42]
Emulsifiers [27]
Photopatch [20]
Sunscreen [20]
Textile [33]
NACDS vs. True Test
NACDS detects all of the allergens
in 65% of patients and at least
one allergen in 90% of patients
Additional supplemental increases
diagnostic accuracy 34%
TRUE test: 25% (vs. 65% NACDS)
JAAD Vol 49: 65-9, 2003. The detection of clinically relevant contact allergens using a standard screening tray of twenty-three allergens
Dermatitis Vol 19 (3): 137-41, 2008. Use of North American Contact Dermatitis Group Standard 65-Allergen Series Alone in the Evaluation of Allergic Contact Dermatitis: A Series of 794 Patients
Medicaments: Anesthetics
Allergen Description N T P S
Benzocaine Anesthetic X X
Lidocaine Anesthetic X
Dibucaine Anesthetic X
Prilocaine Anesthetic X
Caine mix Anesthetic X
Tetracaine Anesthetic X
Medicaments: Antibiotics
Allergen Description N T P S
Neomycin Antibiotic X X X X
Bacitracin Antibiotic X X X X
Quinoline mix
(Clioquinol/Chlorquinaldol) Antibiotic X
Chlorhexidine digluconate Antibiotic X
Benzoyl peroxide Antibiotic X
Gentamicin sulfate Antibiotic X
Corticosteroid Allergy
Class A: Hydrocortisone (7)/tixocortol
Class B: Triamcinolone (4) Fluocinonide (2), Fluocinolone (5), Desonide
(6)
Class C: Betamethasone Desoximetasone (2), Clocortolone (4)
Class D: Hydrocortisone-17-butyrate (5) Clobetasol (1), Betamethasone valerate (3),
Betamethasone dipropionate (3), Alclometasone (5)
Medicaments: Corticosteroids
Allergen Description N T P S
Desoximetasone Corticosteroids O
Tixocortol-21-pivalate Corticosteroids X X X
Budesonide Corticosteroids X X X
Hydrocortisone-17-butyrate Corticosteroids X X
Clobetasol-17-propionate Corticosteroids O
Preservatives
(formaldehyde-releasing)
Allergen Description N T P S
Formaldehyde Preservative X X X X
Quaternium 15 Preservative X X X
Diazolidinyl urea (1% pet/1% aq) Preservative XX X X
Imidazolidinyl urea (2% pet/20% aq) Preservative XX X X
DMDM hydantoin (1%pet/1%aq) Preservative XX X
2-bromo-2-nitropropane -1,3-diol Preservative X X X
Preservatives
Allergen Description N T P S
Methylchloroisothiazolinone Preservative X X X
Benzalkonium chloride Preservative X
Paraben mix Preservative X X X
Iodopropynyl butyl carbamate Preservative X
Methyldibromo glutaronitrile/
Phenoxyethanol (1% pet/2%pet/1%pet)
Preservative XX
X X X
Glutaraldehyde Preservative X
Chloroxylenol (PCMX) Preservative X
Other toiletry related allergens
Allergen Description N T P S
Propylene glycol Preservative, humectant,
emolliant X X
2-hydroxy-4-methoxy-
benzophenone
Synthetic perfumes;
starting material
dyes/drugs/pesticide
X X
Lanolin alcohol
(Amerchol L 101--
products with lanolin)
Wool fat (skin care
products) X X X
Propolis Bee glue (lipsticks) O X
Other toiletry related allergens
Allergen Description N T P S
Cocamidopropyl betaine Foaming agent X X
Amidoamine (stearamido
propyl dimethylamine) Foaming agents
(intermediates in
production of above)
X
Dimethylaminoproplyamine
(DMAPA) X
Coconut diethanolamide
(cocamide DEA)
Foaming agent, creates
"creamy texture" X
Oleamidopropyl
dimethylamine Emulsifier O
Decyl glucoside Surfactant ("sensitive
skin" products) O
Hair Dressing and Nail Polish
Allergen Description N T P S
Para-phenylenediamine
(also NACDS has IPPD = N-
isopropyl-N'-phenyl-4-
phenylenediamine)
Permanent hair dye XX X X
Glyceryl thioglycolate Perm solutions X
Tosylamide formaldehyde Nail varnish X X
Consider Ammonium persulfate
Used in hair bleaching, flour, dentures
-Journal of Clinical Aesthetic Dermatology Vol 3(2): 2010. Allergy to a Hot Tub Water Treatment Chemical.
-Potassium peroxymonosulfate is potassium triple salt used as an oxidizing compound in pool and hot tub shock treatments
-#1 Sanitation: microorganisms killed (chlorine or bromine)
-#2 Oxidation: organic contaminants
(body oils, cosmetics) removed
Hot tub dermatitis
-Consider asking
about hot tub use in
men with generalized
dermatitis
-Alternative:
Hyperchlorination- or
hydrogen-peroxide-
based shock tx.
Fragrance Related
Allergen Description N T P S
Fragrance mix I (Geraniol, Oak moss,
Hydroxycitronellal, a-Amylcinnamaldehyde,
Eugenol, Cinnamaldehyde, Cinnamyl alcohol,
Isoeugenol)
8 fragrances X X X
Fragrance mix 2 (Lyral, Citral,
Farnesol, Citronellol, Hexyl cinnamic aldehyde,
Coumarin)
6 fragrances O X
Cinnamic aldehyde Flavor/odor of
cinnamon X
Balsam of Peru In trees from
Central America X X X
Fragrance Related
Allergen Description N T P S
D-limonene Oil of citrus rind O
Benzyl alcohol Produced by plants,
preservative O X
Majantole Fragrance O
Carvone Essential oil O
Cananga odorata oil
(ylang ylang)
Oil from canaga tree
flower X
Fragrance Related
Allergen Description N T P S
Sesquiterpene lactone
(Parthenolide-T)
Compositae
(Asteracea) family X X
Compositae mix 5 plant extracts X X
Jasminum officinate oil Jasmine flower oil X
Mentha piperita oil Peppermint oil O
Tea tree oil, oxidized Leaves of
Melaleuca plant O
Lavandula angustifolia oil Lavendar O
Glue related
Allergen Description N T P S
Rosin (colophony) Sap of coniferous
trees (pines) X X X X
Bisphenol A (epoxy resin) Paints, glues,
adhesives X X X
4-tert-butylphenol
formaldehyde resin
Glues/adhesives in
shoes/leather X X X
Glue related
Allergen Description N T P S
Ethyl acrylate
Acrylates: used as
glue, molded into
shapes that will
harden
X
Ethyl-2-cyanoacrylate O
N,N-Dimethyl-4-toluidine X
4,4-Diaminodiphenylmethane X
Methyl methacrylate X X
2-hydroxyethyl methacrylate O
Rubber related
Allergen Description N T P S
2-mercaptobenzothiazole Rubber accelerator X X X
Carba mix (3) Chemicals used to
manufacture rubber
products
X X X
Thiuram mix (4) X X X
Mercapto mix (3) X X X
Black rubber mix (3) O X
Hydroquinone Antioxidants used to
make rubber
X
Mixed dialkyl thioureas X
Metals
Allergen Description N T P S
Nickel sulfate (2.5% pet/5% pet) Jewelry, zippers/
snaps, tools, etc. X X X XX
Cobalt Jewelry, dental
impants, tools, etc. X X X X
Potassium dichromate Tanner leather, green
felt, cement X X X X
Sodium gold thiosulfate Gold X X X
Thimerosal Mercury, vaccines X X X
Additional Metals for Surgery
Ammonium
heptamolybdate
Palladium chloride
Copper sulfate
Ammonium
tetrachloroplatinate
Indium (III) chloride
Manganese chloride
Tin (II) Chloride
Zirconium (IV) oxide
Ferrous chloride
Ferrous sulfate
Tantal
Titanium
Titanium (IV) oxide
Titanium dioxide
Vanadium
Iridium
Iridium (III) chloride
Textile and Dyes
Allergen Description N T P S
Disperse blue mix
(124/106, T-106 only) Textile dye X X X
Carmine Red dye (paints,
cosmetics, flowers) O
Disperse Yellow 3/9 mix Textile dye X
Dimethylol dihydroxy
ethylene urea Textile resins in
permanent press
fabric
X
Ethyleneurea/melamine
formaldehyde X
Others
Allergen Description N T P S
Ethylenediamine
dihydrochloride
Manufacturing drugs
and industrial
compounds
X X X
Shellac Resin secreted by
insects O
Tocopherol Vitamin E X
Surgical Patch Testing
Impact of Orthopedic Surgery
Archives of Dermatology Vol 148 (6): 687-94,
2012. The Effect of Patch Testing on
Surgical Practices and Outcomes in
Orthopedic Patients with Metal Implants.
Pre-Implant testing: If patch test
negative, free of complications (n=21)
Post-implant testing: Removal improved
symptoms (6/10 pts)
Orthopedic Surgery Algorithm
Additional resource
-Contact Dermatitis Vol 66: 4-19, 2011.
Hypersensitivity reactions to metallic
implants—diagnostic algorithm and
suggested patch test series for clinical use.
-Up to 5% of implanted metals will result in
cutaneous complications post-implant
-Figure 1 provides algorithm for pre- and
post-implant patch testing
Pre-Implant Algorithm
No history of
dermatitis History of
dermatitis
-Extended Series
-Metals
-Implant test disc
No concern for
hypersensitivity
reaction
Possible
hypersensitivity
reaction
No testing
indicated
-Baseline Series
-Metals
Post-Implant Algorithm
Symptoms
-Extended Series
-Metals
-Bone cements
-Implant test discs
-Lymphocyte
transformation test
No symptoms
No testing indicated
Pediatric Patch Testing
Utility of patch testing in pediatric
patients (43% of atopics positive rxn)
-Pediatric Dermatology Vol 25 (1): 81-87,
2008. Patch Testing: Another Steroid-
Sparing Agent to Consider in Children. 38
from NACDS and 2 from Textile.
-43% of atopic children had positive reaction
Pediatric Patch Testing
Criteria for patch testing in children
1. Uncontrollable/worsening chronic
dermatitis > 2 months
2. Failure to improve w/ avoidance
Dilute to half concentration to avoid
irritant reaction false-positives (nickel,
formaldehyde, accelerators, anti-
oxidants)
Topic: Pediatric Patch Testing
Mercaptobenzothiazole/mercapto mix: found in vulcanized rubber, hard rubber, rubber gloves, elastic straps. 3-8% of children have hypersensitivity.
Pediatric Dermatology Vol 28 No. 6; 2011
Topic: Pediatric Patch Testing
Polyurethane Toilet
Seat Contact Dermatitis
-Chemicals produced by reaction of isocyanates (toluene 2,4-diisocyanate) and polyethers -Leather rubbed off exposing foam
Pediatric Dermatology Vol. 28 No. 6; 2011
Topic: Pediatric Patch Testing
Car Seat Dermatitis Possible Expanded Polystyrene vs. Flame Retardant (in nylon material)
Pediatric Dermatology Vol 28 No. 3; 2011
Utility of Patch Testing in
Clinical Practice
What resources do you have available to
provide information to your patients?
What types of patients could benefit
from patch testing?
Patient Counseling: Skin Care
Product Recommendations
Allergen information sheets (online)
Contact Allergen Management Program
[CAMP] through the American Contact
Dermatitis Society
- List of products that are safe for patients to
use that do not contain allergens they are
allergic to or their cross reactants
Patient Counseling: Non-Skin
care Product Related Allergens
Contact Allergy: Alternatives for the
2007 North American Contact Dermatitis Group (NACDG) Standard Screening Tray [DM (Disease-a-Month), Jan/Feb 2008, 54 (1-2): 7-156]
-Rubber (gloves, footwear, condoms, home medical equipment, sporting equipment)
-Clothing (dyes)
-Household adhesives
Parthenium Dermatitis
Patients of East Indian descent
http://www.google.com/imgres?um=1&hl=en&sa=N&tbo=d&qscrl=1&rlz=1T4GGHP_enUS468US468&biw=1150&bih=644&tbm=isch&tbnid=xo2afZ1IyR4JpM:&imgrefurl=http://ww
w.mmc.tn.gov.in/Department/OCD/services.html&docid=DplfOd8zOXW25M&imgurl=http://www.mmc.tn.gov.in/Department/OCD/images/8.jpg&w=461&h=346&ei=3-
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w=195&start=0&ndsp=21&ved=1t:429,r:11,s:0,i:120,
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9&start=0&ndsp=21&ved=1t:429,r:15,s:0,i:132
Photochemical & Photobiological Sciences Vol 12 No. 1; 2012
Chronic actinic dermatitis vs.
Airborne Contact
Compositae family contain Sesquiterpene lactones
Second largest family of flowering plants and most common plant dermatitis (1% of population affected)
Plant: Parthenium hysterophorus (weed, “feverfew”)
Others: dahlia, marigold, chrysanthemum, sunflowers, asters, artichokes,
lettuce, chicory, ragweed
What kind of patient benefits from patch
testing?
Hand Dermatitis
Patient #4 (palms)
Patient #5 (dorsum)
Palmar dermatitis
Irritant Contact vs. Allergic Contact
#1 PROTECTION
#2 MOISTURIZATION #3 MEDICATION
Habits washing hands (soap, frequency)
Solvents and weather
Citrus fruit, tomatos, potatoes, raw food
Vinyl gloves and white cotton
Dorsal hand dermatitis
Think psoriasis, lupus, dermatomyositis,
photo, AND allergic contact (biopsy?)
What kind of patient benefits from patch
testing?
Patient #6 Fixed location
Patient #7 Lichenoid
morphology
What kind of patient benefits from patch
testing?
Patient #8 Nummular eczema
Patient #9 Chronic atopic
dermatitis
Atopic Dermatitis vs. Psoriasis
http://www.femail.com.au/eczemafacts.htm http://www.steadyhealth.com/2996/Image/copy-of-psoriasis.jpg http://www.lib.uiowa.edu/hardin/md/pictures22/dermnet/psoriasis_03f.jpg
Papulosquamous
(psoriasis)
Eczematous
(eczema)
Location, location, location (and biopsy)
Nail photo: http://itstrivial.blogspot.com/2007_03_01_archive.html
Final Pearl
Positives are helpful. But you need to
help the patient look for clinical
relevance.
Negatives are not necessarily
reassuring.