Nickel allergy in the United States: A public health issue in need of a “nickel directive”

Abstract

To the Editor: Once thought to be rare in the pediatric population, allergic contact dermatitis is now recognized as a significant problem,1Seidenari S. Giusti F. Pepe P. Mantovani L. Contact sensitization in 1094 children undergoing patch testing over a 7-year period.Pediatr Dermatol. 2005; 22: 1-5Crossref PubMed Scopus (101) Google Scholar, 2Lewis V.J. Statham B.N. Chowdhury M.M. Allergic contact dermatitis in 191 consecutively patch tested children.Contact Dermatitis. 2004; 51: 155-156Crossref PubMed Scopus (38) Google Scholar, 3Fernandez Vozmediano J.M. Armario Hita J.C. Allergic contact dermatitis in children.J Eur Acad Dermatol Venereol. 2005; 19: 42-46Crossref PubMed Scopus (56) Google Scholar and nickel has received much attention for being the most commonly sensitizing agent. Nickel sensitization among pediatric patients is well known, but recently it has become apparent that the prevalence is on the rise.4Beattie P.E. Green C. Lowe G. Lewis-Jones M.S. Which children should we patch test?.Clin Exp Dermatol. 2007; 32: 6-11PubMed Google Scholar, 5Wöhrl S. Hemmer W. Focke M. Götz M. Jarisch R. Patch testing in children, adults, and the elderly: influence of age and sex on sensitization patterns.Pediatr Dermatol. 2003; 20: 119-123Crossref PubMed Scopus (133) Google Scholar, 6Roul S. Ducombs G. Taieb A. Usefulness of the European standard series for patch testing in children. A 3-year single-centre study of 337 patients.Contact Dermatitis. 1999; 40: 232-235Crossref PubMed Scopus (115) Google Scholar, 7Duarte I. Lazzarini R. Kobata C.M. Contact dermatitis in adolescents.Am J Contact Dermat. 2003; 14: 200-202PubMed Google Scholar, 8Clayton T.H. Wilkinson S.M. Rawcliffe C. Pollock B. Clark S.M. Allergic contact dermatitis in children: should pattern of dermatitis determine referral? A retrospective study of 500 children tested between 1995 and 2004 in one U.K. centre.Br J Dermatol. 2006; 154: 114-117Crossref PubMed Scopus (91) Google Scholar, 9Hogeling M. Pratt M. Allergic contact dermatitis in children: the Ottawa hospital patch-testing clinic experience, 1996 to 2006.Dermatitis. 2008; 19: 86-89PubMed Google Scholar, 10Jacob S.E. Brod B. Crawford G.H. Clinically relevant patch test reactions in children—a United States based study.Pediatr Dermatol. 2008; 25: 520-527Crossref PubMed Scopus (81) Google Scholar, 11Rietschel R.L. Fowler J.F. Warshaw E.M. Belsito D. DeLeo V.A. Maibach H.I. et al.Detection of nickel sensitivity has increased in North American patch-test patients.Dermatitis. 2008; 19: 16-19PubMed Google Scholar The alarming frequency of sensitization to nickel—especially in women and children—led to nickel being named the 2008 “Allergen of the Year” by the American Contact Dermatitis Society.Galvanization eczema (nickel contact allergy) historically referred to the presentation of severe hand dermatitis in miners and electroplating manufacturers.12Blaschko A. Die Berufsdermatotosen der Arbeiterer: ein Beitrag zur Gewerbehygiene, I: das Galvaniseur-Ekzem.Dtsch Med Wochenschr. 1889; 15: 925-927Crossref Scopus (37) Google Scholar Today, however, patients with nickel contact allergy present with a range of reactions, from localized dermatitis, classically located in the periumbilical area or on the earlobes (relating to repeated contact with clothing snaps and jewelry, respectively), to a severe and debilitating systemic dermatitis.13Militello G. Jacob S.E. Crawford G.H. Allergic contact dermatitis in children.Curr Opin Pediatr. 2006; 18: 385-390Crossref PubMed Scopus (103) Google Scholar Studies demonstrating that females are more frequently affected14Rietschel R.L. Fowler J.F. Warshaw E.M. Belsito D. DeLeo V.A. Maibach H.I. et al.Detection of nickel sensitivity has increased in North American patch-test patients.Dermatitis. 2008; 19: 16-19PubMed Google Scholar, 15Meding B. Epidemiology of nickel allergy.J Environ Monit. 2003; 5: 188-189Crossref PubMed Scopus (21) Google Scholar suggests a likely relationship with early age exposure to nickel during ear piercing practices.16Dotterud L.K. Falk E.S. Metal allergy in north Norwegian schoolchildren and its relationship with ear piercing and atopy.Contact Dermatitis. 1994; 31: 308-313Crossref PubMed Scopus (112) Google ScholarNickel is ubiquitous in our environment, and exposure is difficult to prevent. Because it is durable and alloys easily with other metals, it is widely used, being present in many commonly encountered objects from zippers, paper clips, and belt buckles to jewelry, keys, and cell phones.17Savin J. The rise and fall of nickel allergy.J Cosmet Dermatol. 2003; 2: 57Crossref PubMed Google Scholar, 18Chayavichitsilp P. Jacob S.E. Avoiding nickel sensitization and allergic reactions in children.Pediatr Ann. 2008; (in press)Google Scholar In addition, higher plants extract nickel from the soil and use it as a cofactor in growth and metabolism.19Salisbury F.B. Ross C.W. Plant physiology. 4th ed. Wadsworth Publishing, Belmont, CA1994Google Scholar Food, therefore, is a source of environmental nickel exposure and can be of importance in the management of nickel allergic contact dermatitis. Some complementary and alternative remedies also contain high levels of nickel.20deMedeiros L.M. Fransway A.F. Taylor J.S. Wyman M. Janes J. Fowler Jr., J.F. et al.Complementary and alternative remedies: an additional source of potential systemic nickel exposure.Contact Dermatitis. 2008; 58: 97-100Crossref PubMed Scopus (22) Google Scholar Nickel can also be found in several multivitamins, including Centrum and One-a-Day Maximum, as well as in various generics such Rite Aid Whole Source Multivitamin and Kirkland Signature Daily Multivitamin. In addition, nickel and metal allergy may play a role in hypersensitivity reactions associated with endovascular, orthopedic, and dental devices, and dermatologists and allergists are increasingly being consulted about the risk of allergic reactions from inserting these devices.21Honari G. Ellis S.G. Wilkoff B.L. Aronica M.A. Svensson L.G. Taylor J.S. Hypersensitivity reactions associated with endovascular devices.Contact Dermatitis. 2008; 59: 1-16Crossref PubMed Scopus (103) Google Scholar, 22Bruze M. Thoughts on implants and contact allergy.Arch Dermatol. 2008; 144: 1042-1044Crossref PubMed Scopus (20) Google Scholar The ubiquitous presence of nickel and nickel-containing alloys in our environment makes frequent contact with the metal practically unavoidable. This, in addition to the rise in body piercing in both males and females where allergenic materials may be used has resulted in increasing rates of sensitization.In 1992, the Danish Ministry of Environment enacted legislation dictating that nickel release from products in prolonged contact with the skin, such as earrings, buttons, and spectacle frames, should be less than 0.5 μg/cm2 per week.23Danish Ministry of the Environment Statutory Order of the Danish Ministry of the Environment regarding prohibition of sale and labeling of certain nickel containing products. Statutory Order No. 854. Danish Ministry of the Environment, Copenhagen, Denmark1991Google Scholar Following implementation of this legislation, rates of nickel sensitization in the Danish population dropped; among Danish children 0 to 18 years of age, the prevalence of nickel allergy decreased from 24.8% to 9.2% between 1985 and 1998.24Johansen J. Menne T. Christophersen J. Kaaber K. Veien N. Changes in the pattern of sensitization to common contact allergens in Denmark between 1985-86 and 1997-98, with a special view to the effect of preventive strategies.Br J Dermatol. 2000; 142: 490-495Crossref PubMed Scopus (196) Google Scholar The European Union (EU) passed similar legislation in 1994, issuing “The Nickel Directive,” which mandated that the allowable release limit be less than 0.5 mg/cm2 per week in objects that come into direct and prolonged contact with the skin. The directive was amended in 2004 to reduce the permitted release of nickel from posts placed in wounds after piercing to 0.02 mg/cm2 per week.25Commission Directive 2004/96/EC of September 2004 amending Council Directive 76/769/EEC as regards restriction on the marketing and use of nickel for piercing post assemblies for the purpose of adapting its Annex I to technical progress.Google Scholar Observed rates of sensitization have been decreasing since then. For example, sensitization in German women under age 30 decreased from 36.7% to 25.8% over an 8-year period.26Schnuch A. Uter W. Decrease in nickel allergy in Germany and regulatory interventions.Contact Dermatitis. 2003; 49: 107-108Crossref PubMed Scopus (96) Google ScholarDespite the success reported in Denmark and Europe, the United States has yet to enact similar legislation or regulations. In fact, infants as young as 6 months old have been reported to be sensitized to nickel.27Bruckner A.L. Weston W.L. Morelli J.G. Does sensitization to contact allergens begin in infancy?.Pediatrics. 2000; 105: e3Crossref PubMed Scopus (94) Google Scholar Furthermore, it has become apparent that rates of nickel allergy are increasing dramatically. The North American Contact Dermatitis Group (NACDG) reported an increase in positive patch tests to nickel from 10.5% between 1985 and 199028Marks Jr., J.G. Belsito D.V. DeLeo V.A. Fowler Jr., J.F. Fransway A.F. Maibach H.I. et al.North American Contact Dermatitis Group patch-test results, 1996-1998.Arch Dermatol. 2000; 136: 272-273Crossref PubMed Scopus (174) Google Scholar to 18.8% between 2003 and 2004.11Rietschel R.L. Fowler J.F. Warshaw E.M. Belsito D. DeLeo V.A. Maibach H.I. et al.Detection of nickel sensitivity has increased in North American patch-test patients.Dermatitis. 2008; 19: 16-19PubMed Google Scholar In the pediatric population, multiple studies have shown that nickel is the number one cause of positive patch tests, with 20% to 33% of the children evaluated in these studies experiencing positive reactions.4Beattie P.E. Green C. Lowe G. Lewis-Jones M.S. Which children should we patch test?.Clin Exp Dermatol. 2007; 32: 6-11PubMed Google Scholar, 5Wöhrl S. Hemmer W. Focke M. Götz M. Jarisch R. Patch testing in children, adults, and the elderly: influence of age and sex on sensitization patterns.Pediatr Dermatol. 2003; 20: 119-123Crossref PubMed Scopus (133) Google Scholar, 6Roul S. Ducombs G. Taieb A. Usefulness of the European standard series for patch testing in children. A 3-year single-centre study of 337 patients.Contact Dermatitis. 1999; 40: 232-235Crossref PubMed Scopus (115) Google Scholar, 7Duarte I. Lazzarini R. Kobata C.M. Contact dermatitis in adolescents.Am J Contact Dermat. 2003; 14: 200-202PubMed Google Scholar, 8Clayton T.H. Wilkinson S.M. Rawcliffe C. Pollock B. Clark S.M. Allergic contact dermatitis in children: should pattern of dermatitis determine referral? A retrospective study of 500 children tested between 1995 and 2004 in one U.K. centre.Br J Dermatol. 2006; 154: 114-117Crossref PubMed Scopus (91) Google Scholar, 9Hogeling M. Pratt M. Allergic contact dermatitis in children: the Ottawa hospital patch-testing clinic experience, 1996 to 2006.Dermatitis. 2008; 19: 86-89PubMed Google Scholar, 10Jacob S.E. Brod B. Crawford G.H. Clinically relevant patch test reactions in children—a United States based study.Pediatr Dermatol. 2008; 25: 520-527Crossref PubMed Scopus (81) Google Scholar, 11Rietschel R.L. Fowler J.F. Warshaw E.M. Belsito D. DeLeo V.A. Maibach H.I. et al.Detection of nickel sensitivity has increased in North American patch-test patients.Dermatitis. 2008; 19: 16-19PubMed Google Scholar It is important to note, however, that it is problematic to draw conclusions from these statistics. Earlier studies may have underestimated rates of nickel sensitization because fewer children were patch tested in the past, and more recent studies may similarly underestimate current rates of sensitization because today, most children with clinically obvious nickel allergy are not referred for patch testing.9Hogeling M. Pratt M. Allergic contact dermatitis in children: the Ottawa hospital patch-testing clinic experience, 1996 to 2006.Dermatitis. 2008; 19: 86-89PubMed Google ScholarBecause it is recognized that early exposure to nickel is a risk factor for developing allergy,29Czarnobilska E. Obtułowicz K. Wsołek K. Pietowska J. Spiewak R. Mechanisms of nickel allergy (in Polish).Przegl Lek. 2007; 64: 502-505PubMed Google Scholar regulation and/or legislation set forth to prevent or limit nickel contact at a young age would decrease rates of sensitization. We propose that a directive which limits the maximum allowable release of nickel from products with prolonged skin contact, consistent with the concentrations mandated in Europe, be adopted in the United States. Approximately 15.6% of males and 35.8% of females under the age of 18 are affected with nickel contact allergy in the United States,11Rietschel R.L. Fowler J.F. Warshaw E.M. Belsito D. DeLeo V.A. Maibach H.I. et al.Detection of nickel sensitivity has increased in North American patch-test patients.Dermatitis. 2008; 19: 16-19PubMed Google Scholar and we believe that a similar nickel directive would lead to dramatic reductions in these rates because of the combined effect of regulation and heightened public awareness. The American Contact Dermatitis Society has recommended such action and the American Academy of Dermatology is actively considering similar proposals. The importance of implementing an EU-like “Nickel Directive” in the United States is paramount; only then will there be recognition of this public health problem.Another highly effective strategy to combat the rising rates of nickel sensitization is to encourage manufacturers to use products that adhere to the EU's guidelines for acceptable nickel release. Heim and McKean30Heim KE, McKean BA. Children's clothing fasteners as a potential source of exposure to releasable nickel. Contact Dermatitis. In press.Google Scholar recently demonstrated that children's clothing fasteners, including zippers and snaps, constitute a significant source of nickel exposure in this age group, with approximately 6% of fasteners on the market in the United States releasing an unacceptable amount of nickel. Levi Strauss recently added nickel to their restricted substances list and required that all metal parts used in their products abide by the EU guidelines.31Levi Strauss & Co Web site. Restricted substances list “RSL.” Available at: http://www.levistrauss.com/Downloads/RSL2008.pdf. Accessed December 12, 2008.Google Scholar Other manufacturers and retailers should be educated about this growing health issue and urged to play their part in protecting the health of their customers.Currently, many parents are not conscious of the dangers of nickel exposure and therefore cannot be held accountable for the growing frequency of nickel allergy. Increased awareness of the rising rates of sensitization through the implementation of nickel limiting legislation will be a major step in reducing the number of children affected. Through awareness and legislation, we together can potentially prevent this public health problem. To the Editor: Once thought to be rare in the pediatric population, allergic contact dermatitis is now recognized as a significant problem,1Seidenari S. Giusti F. Pepe P. Mantovani L. Contact sensitization in 1094 children undergoing patch testing over a 7-year period.Pediatr Dermatol. 2005; 22: 1-5Crossref PubMed Scopus (101) Google Scholar, 2Lewis V.J. Statham B.N. Chowdhury M.M. Allergic contact dermatitis in 191 consecutively patch tested children.Contact Dermatitis. 2004; 51: 155-156Crossref PubMed Scopus (38) Google Scholar, 3Fernandez Vozmediano J.M. Armario Hita J.C. Allergic contact dermatitis in children.J Eur Acad Dermatol Venereol. 2005; 19: 42-46Crossref PubMed Scopus (56) Google Scholar and nickel has received much attention for being the most commonly sensitizing agent. Nickel sensitization among pediatric patients is well known, but recently it has become apparent that the prevalence is on the rise.4Beattie P.E. Green C. Lowe G. Lewis-Jones M.S. Which children should we patch test?.Clin Exp Dermatol. 2007; 32: 6-11PubMed Google Scholar, 5Wöhrl S. Hemmer W. Focke M. Götz M. Jarisch R. Patch testing in children, adults, and the elderly: influence of age and sex on sensitization patterns.Pediatr Dermatol. 2003; 20: 119-123Crossref PubMed Scopus (133) Google Scholar, 6Roul S. Ducombs G. Taieb A. Usefulness of the European standard series for patch testing in children. A 3-year single-centre study of 337 patients.Contact Dermatitis. 1999; 40: 232-235Crossref PubMed Scopus (115) Google Scholar, 7Duarte I. Lazzarini R. Kobata C.M. Contact dermatitis in adolescents.Am J Contact Dermat. 2003; 14: 200-202PubMed Google Scholar, 8Clayton T.H. Wilkinson S.M. Rawcliffe C. Pollock B. Clark S.M. Allergic contact dermatitis in children: should pattern of dermatitis determine referral? A retrospective study of 500 children tested between 1995 and 2004 in one U.K. centre.Br J Dermatol. 2006; 154: 114-117Crossref PubMed Scopus (91) Google Scholar, 9Hogeling M. Pratt M. Allergic contact dermatitis in children: the Ottawa hospital patch-testing clinic experience, 1996 to 2006.Dermatitis. 2008; 19: 86-89PubMed Google Scholar, 10Jacob S.E. Brod B. Crawford G.H. Clinically relevant patch test reactions in children—a United States based study.Pediatr Dermatol. 2008; 25: 520-527Crossref PubMed Scopus (81) Google Scholar, 11Rietschel R.L. Fowler J.F. Warshaw E.M. Belsito D. DeLeo V.A. Maibach H.I. et al.Detection of nickel sensitivity has increased in North American patch-test patients.Dermatitis. 2008; 19: 16-19PubMed Google Scholar The alarming frequency of sensitization to nickel—especially in women and children—led to nickel being named the 2008 “Allergen of the Year” by the American Contact Dermatitis Society. Galvanization eczema (nickel contact allergy) historically referred to the presentation of severe hand dermatitis in miners and electroplating manufacturers.12Blaschko A. Die Berufsdermatotosen der Arbeiterer: ein Beitrag zur Gewerbehygiene, I: das Galvaniseur-Ekzem.Dtsch Med Wochenschr. 1889; 15: 925-927Crossref Scopus (37) Google Scholar Today, however, patients with nickel contact allergy present with a range of reactions, from localized dermatitis, classically located in the periumbilical area or on the earlobes (relating to repeated contact with clothing snaps and jewelry, respectively), to a severe and debilitating systemic dermatitis.13Militello G. Jacob S.E. Crawford G.H. Allergic contact dermatitis in children.Curr Opin Pediatr. 2006; 18: 385-390Crossref PubMed Scopus (103) Google Scholar Studies demonstrating that females are more frequently affected14Rietschel R.L. Fowler J.F. Warshaw E.M. Belsito D. DeLeo V.A. Maibach H.I. et al.Detection of nickel sensitivity has increased in North American patch-test patients.Dermatitis. 2008; 19: 16-19PubMed Google Scholar, 15Meding B. Epidemiology of nickel allergy.J Environ Monit. 2003; 5: 188-189Crossref PubMed Scopus (21) Google Scholar suggests a likely relationship with early age exposure to nickel during ear piercing practices.16Dotterud L.K. Falk E.S. Metal allergy in north Norwegian schoolchildren and its relationship with ear piercing and atopy.Contact Dermatitis. 1994; 31: 308-313Crossref PubMed Scopus (112) Google Scholar Nickel is ubiquitous in our environment, and exposure is difficult to prevent. Because it is durable and alloys easily with other metals, it is widely used, being present in many commonly encountered objects from zippers, paper clips, and belt buckles to jewelry, keys, and cell phones.17Savin J. The rise and fall of nickel allergy.J Cosmet Dermatol. 2003; 2: 57Crossref PubMed Google Scholar, 18Chayavichitsilp P. Jacob S.E. Avoiding nickel sensitization and allergic reactions in children.Pediatr Ann. 2008; (in press)Google Scholar In addition, higher plants extract nickel from the soil and use it as a cofactor in growth and metabolism.19Salisbury F.B. Ross C.W. Plant physiology. 4th ed. Wadsworth Publishing, Belmont, CA1994Google Scholar Food, therefore, is a source of environmental nickel exposure and can be of importance in the management of nickel allergic contact dermatitis. Some complementary and alternative remedies also contain high levels of nickel.20deMedeiros L.M. Fransway A.F. Taylor J.S. Wyman M. Janes J. Fowler Jr., J.F. et al.Complementary and alternative remedies: an additional source of potential systemic nickel exposure.Contact Dermatitis. 2008; 58: 97-100Crossref PubMed Scopus (22) Google Scholar Nickel can also be found in several multivitamins, including Centrum and One-a-Day Maximum, as well as in various generics such Rite Aid Whole Source Multivitamin and Kirkland Signature Daily Multivitamin. In addition, nickel and metal allergy may play a role in hypersensitivity reactions associated with endovascular, orthopedic, and dental devices, and dermatologists and allergists are increasingly being consulted about the risk of allergic reactions from inserting these devices.21Honari G. Ellis S.G. Wilkoff B.L. Aronica M.A. Svensson L.G. Taylor J.S. Hypersensitivity reactions associated with endovascular devices.Contact Dermatitis. 2008; 59: 1-16Crossref PubMed Scopus (103) Google Scholar, 22Bruze M. Thoughts on implants and contact allergy.Arch Dermatol. 2008; 144: 1042-1044Crossref PubMed Scopus (20) Google Scholar The ubiquitous presence of nickel and nickel-containing alloys in our environment makes frequent contact with the metal practically unavoidable. This, in addition to the rise in body piercing in both males and females where allergenic materials may be used has resulted in increasing rates of sensitization. In 1992, the Danish Ministry of Environment enacted legislation dictating that nickel release from products in prolonged contact with the skin, such as earrings, buttons, and spectacle frames, should be less than 0.5 μg/cm2 per week.23Danish Ministry of the Environment Statutory Order of the Danish Ministry of the Environment regarding prohibition of sale and labeling of certain nickel containing products. Statutory Order No. 854. Danish Ministry of the Environment, Copenhagen, Denmark1991Google Scholar Following implementation of this legislation, rates of nickel sensitization in the Danish population dropped; among Danish children 0 to 18 years of age, the prevalence of nickel allergy decreased from 24.8% to 9.2% between 1985 and 1998.24Johansen J. Menne T. Christophersen J. Kaaber K. Veien N. Changes in the pattern of sensitization to common contact allergens in Denmark between 1985-86 and 1997-98, with a special view to the effect of preventive strategies.Br J Dermatol. 2000; 142: 490-495Crossref PubMed Scopus (196) Google Scholar The European Union (EU) passed similar legislation in 1994, issuing “The Nickel Directive,” which mandated that the allowable release limit be less than 0.5 mg/cm2 per week in objects that come into direct and prolonged contact with the skin. The directive was amended in 2004 to reduce the permitted release of nickel from posts placed in wounds after piercing to 0.02 mg/cm2 per week.25Commission Directive 2004/96/EC of September 2004 amending Council Directive 76/769/EEC as regards restriction on the marketing and use of nickel for piercing post assemblies for the purpose of adapting its Annex I to technical progress.Google Scholar Observed rates of sensitization have been decreasing since then. For example, sensitization in German women under age 30 decreased from 36.7% to 25.8% over an 8-year period.26Schnuch A. Uter W. Decrease in nickel allergy in Germany and regulatory interventions.Contact Dermatitis. 2003; 49: 107-108Crossref PubMed Scopus (96) Google Scholar Despite the success reported in Denmark and Europe, the United States has yet to enact similar legislation or regulations. In fact, infants as young as 6 months old have been reported to be sensitized to nickel.27Bruckner A.L. Weston W.L. Morelli J.G. Does sensitization to contact allergens begin in infancy?.Pediatrics. 2000; 105: e3Crossref PubMed Scopus (94) Google Scholar Furthermore, it has become apparent that rates of nickel allergy are increasing dramatically. The North American Contact Dermatitis Group (NACDG) reported an increase in positive patch tests to nickel from 10.5% between 1985 and 199028Marks Jr., J.G. Belsito D.V. DeLeo V.A. Fowler Jr., J.F. Fransway A.F. Maibach H.I. et al.North American Contact Dermatitis Group patch-test results, 1996-1998.Arch Dermatol. 2000; 136: 272-273Crossref PubMed Scopus (174) Google Scholar to 18.8% between 2003 and 2004.11Rietschel R.L. Fowler J.F. Warshaw E.M. Belsito D. DeLeo V.A. Maibach H.I. et al.Detection of nickel sensitivity has increased in North American patch-test patients.Dermatitis. 2008; 19: 16-19PubMed Google Scholar In the pediatric population, multiple studies have shown that nickel is the number one cause of positive patch tests, with 20% to 33% of the children evaluated in these studies experiencing positive reactions.4Beattie P.E. Green C. Lowe G. Lewis-Jones M.S. Which children should we patch test?.Clin Exp Dermatol. 2007; 32: 6-11PubMed Google Scholar, 5Wöhrl S. Hemmer W. Focke M. Götz M. Jarisch R. Patch testing in children, adults, and the elderly: influence of age and sex on sensitization patterns.Pediatr Dermatol. 2003; 20: 119-123Crossref PubMed Scopus (133) Google Scholar, 6Roul S. Ducombs G. Taieb A. Usefulness of the European standard series for patch testing in children. A 3-year single-centre study of 337 patients.Contact Dermatitis. 1999; 40: 232-235Crossref PubMed Scopus (115) Google Scholar, 7Duarte I. Lazzarini R. Kobata C.M. Contact dermatitis in adolescents.Am J Contact Dermat. 2003; 14: 200-202PubMed Google Scholar, 8Clayton T.H. Wilkinson S.M. Rawcliffe C. Pollock B. Clark S.M. Allergic contact dermatitis in children: should pattern of dermatitis determine referral? A retrospective study of 500 children tested between 1995 and 2004 in one U.K. centre.Br J Dermatol. 2006; 154: 114-117Crossref PubMed Scopus (91) Google Scholar, 9Hogeling M. Pratt M. Allergic contact dermatitis in children: the Ottawa hospital patch-testing clinic experience, 1996 to 2006.Dermatitis. 2008; 19: 86-89PubMed Google Scholar, 10Jacob S.E. Brod B. Crawford G.H. Clinically relevant patch test reactions in children—a United States based study.Pediatr Dermatol. 2008; 25: 520-527Crossref PubMed Scopus (81) Google Scholar, 11Rietschel R.L. Fowler J.F. Warshaw E.M. Belsito D. DeLeo V.A. Maibach H.I. et al.Detection of nickel sensitivity has increased in North American patch-test patients.Dermatitis. 2008; 19: 16-19PubMed Google Scholar It is important to note, however, that it is problematic to draw conclusions from these statistics. Earlier studies may have underestimated rates of nickel sensitization because fewer children were patch tested in the past, and more recent studies may similarly underestimate current rates of sensitization because today, most children with clinically obvious nickel allergy are not referred for patch testing.9Hogeling M. Pratt M. Allergic contact dermatitis in children: the Ottawa hospital patch-testing clinic experience, 1996 to 2006.Dermatitis. 2008; 19: 86-89PubMed Google Scholar Because it is recognized that early exposure to nickel is a risk factor for developing allergy,29Czarnobilska E. Obtułowicz K. Wsołek K. Pietowska J. Spiewak R. Mechanisms of nickel allergy (in Polish).Przegl Lek. 2007; 64: 502-505PubMed Google Scholar regulation and/or legislation set forth to prevent or limit nickel contact at a young age would decrease rates of sensitization. We propose that a directive which limits the maximum allowable release of nickel from products with prolonged skin contact, consistent with the concentrations mandated in Europe, be adopted in the United States. Approximately 15.6% of males and 35.8% of females under the age of 18 are affected with nickel contact allergy in the United States,11Rietschel R.L. Fowler J.F. Warshaw E.M. Belsito D. DeLeo V.A. Maibach H.I. et al.Detection of nickel sensitivity has increased in North American patch-test patients.Dermatitis. 2008; 19: 16-19PubMed Google Scholar and we believe that a similar nickel directive would lead to dramatic reductions in these rates because of the combined effect of regulation and heightened public awareness. The American Contact Dermatitis Society has recommended such action and the American Academy of Dermatology is actively considering similar proposals. The importance of implementing an EU-like “Nickel Directive” in the United States is paramount; only then will there be recognition of this public health problem. Another highly effective strategy to combat the rising rates of nickel sensitization is to encourage manufacturers to use products that adhere to the EU's guidelines for acceptable nickel release. Heim and McKean30Heim KE, McKean BA. Children's clothing fasteners as a potential source of exposure to releasable nickel. Contact Dermatitis. In press.Google Scholar recently demonstrated that children's clothing fasteners, including zippers and snaps, constitute a significant source of nickel exposure in this age group, with approximately 6% of fasteners on the market in the United States releasing an unacceptable amount of nickel. Levi Strauss recently added nickel to their restricted substances list and required that all metal parts used in their products abide by the EU guidelines.31Levi Strauss & Co Web site. Restricted substances list “RSL.” Available at: http://www.levistrauss.com/Downloads/RSL2008.pdf. Accessed December 12, 2008.Google Scholar Other manufacturers and retailers should be educated about this growing health issue and urged to play their part in protecting the health of their customers. Currently, many parents are not conscious of the dangers of nickel exposure and therefore cannot be held accountable for the growing frequency of nickel allergy. Increased awareness of the rising rates of sensitization through the implementation of nickel limiting legislation will be a major step in reducing the number of children affected. Through awareness and legislation, we together can potentially prevent this public health problem.