Update on Contact Dermatitis - AAIFNCaaifnc.org/Documents/symposium_2013/Dr. Jenny Murase.pdfpool and hot tub shock treatments -#1 Sanitation: microorganisms killed (chlorine or bromine)

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?

Facial rash

Patient #1

Patient #2


testing?

Patient #3 Airborne Contact


testing?

Hand Dermatitis

Patient #4 (palms)

Patient #5 (dorsum)


testing?

Patient #6 Fixed location

Patient #7 Lichenoid

morphology


testing?

Patient #8 Nummular eczema

Patient #9 Chronic atopic

dermatitis


testing?

Patient #10

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


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


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)


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


testing?

Facial rash

Patient #1

Patient #2


testing?

Patient #3 Airborne Contact

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,

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=uHLjuHU6a21EnM:&imgrefurl=http://pu

bs.rsc.org/en/content/articlehtml/2013/pp/c2pp25186h&docid=x52ETDfOVy4iMM&imgurl=http://www.rsc.org/ej/PP/2013/c2pp25186h/c2pp25186h-

f3.gif&w=392&h=521&ei=3-

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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

Patch test to sunscreen as well

(photoallergic or allergic contact possible)


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?)

Often solution is multifactorial


testing?

Patient #6 Fixed location

Patient #7 Lichenoid

morphology


testing?

Patient #8 Nummular eczema

Patient #9 Chronic atopic

dermatitis

Patch Testing Nummular Eczema

Irritant vs. Allergen

Atopic Patients flares: Infection (Staph),

Allergens (Family/Self), Sunlight

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


testing?

Patient #10

Final Pearl

Positives are helpful. But you need to

help the patient look for clinical

relevance.

Negatives are not necessarily

reassuring.

Questions? Comments?

Happy

Birthday,

Mommy!

http://itstrivial.blogspot.com/2007_03_01_archive.html