American Contact Dermatitis Group Screening Research Articles

Hand and foot dermatitis in patients referred for patch testing: Analysis of North American Contact Dermatitis Group Data, 2001-2018

Dermatitis localized to hands (HD), feet (FD), or both hands and feet (HFD) has multiple etiologies, including atopic dermatitis, irritant contact dermatitis, and allergic contact dermatitis. Unfortunately, little is known about clinical differences between patients with HD, FD, and HFD. To characterize differences in demographics, etiology, and patch testing results among patients presenting with HD, FD, or HFD referred for patch testing. A retrospective analysis of patients patch tested by the North American Contact Dermatitis Group between 2001 and 2018. Of 43,677 patients who were patch tested, 22.8% had HD, 2.9% had FD, and 3.7% had HFD. Allergic and currently relevant patch test reactions to ≥1 North American Contact Dermatitis Group screening allergen occurred in similar proportions in all 3 study groups. However, HD (18.0%) had higher proportions of occupationally relevant reactions than HFD (8.9%) or FD (4.0%). Nickel and fragrance mix I were in the top 5 currently relevant allergens for HD, FD, and HFD. Other top allergens, as well as allergen sources, differed between HD, FD, and HFD. No data on HD or FD morphology or distribution. HD, FD, and HFD have several differences with respect to patient characteristics, etiologies, and clinically relevant allergens.

Shoe Allergens: A Retrospective Analysis of Cross-sectional Data From the North American Contact Dermatitis Group, 2005-2018.

Shoe contact allergy can be difficult to diagnose and manage. The aim of the study was to characterize demographics, clinical characteristics, patch test results, and occupational data for the North American Contact Dermatitis Group patients with shoe contact allergy. This is a retrospective study of 33,661 patients, patch tested from 2005 to 2018, with a shoe source, foot as 1 of 3 sites of dermatitis, and final primary diagnosis of allergic contact dermatitis. Three hundred fifty-two patients met the inclusion criteria. They were more likely to be male (odds ratio = 3.36, confidence interval = 2.71-4.17) and less likely to be older than 40 years (odds ratio = 0.49, confidence interval = 0.40-0.61) compared with others with positive patch test reactions. The most common relevant North American Contact Dermatitis Group screening allergens were potassium dichromate (29.8%), p-tert-butylphenol formaldehyde resin (20.1%), thiuram mix (13.3%), mixed dialkyl thioureas (12.6%), and carba mix (12%). A total of 29.8% (105/352) had positive patch test reactions to supplemental allergens, and 12.2% (43/352) only had reactions to supplemental allergens. Shoe contact allergy was more common in younger and male patients. Potassium dichromate and p-tert-butylphenol formaldehyde resin were the top shoe allergens. Testing supplemental allergens, personal care products, and shoe components should be part of a comprehensive evaluation of suspected shoe contact allergy.

Medical adhesive allergens: Retrospective analysis of cross-sectional data from the North American Contact Dermatitis Group, 2001-2018

Identification of allergens causing medical adhesive contact allergy is difficult. To characterize the demographics, clinical characteristics, patch test results, and occupational data for North American Contact Dermatitis Group patients with medical adhesive contact allergy. A retrospective study of 43,722 North American Contact Dermatitis Group patients patch tested from 2001 to 2018 with medical adhesive (tapes/bandaids/adhesive aids/suture glue) sources, positive patch test results, and final primary diagnoses of allergic contact dermatitis. In total, 313 (0.7%) patients met the inclusion criteria. Compared with other patients with final primary diagnoses of allergic contact dermatitis, patients with a medical adhesive allergy were less likely to be male (odds ratio, 0.58; 95% CI, 0.45-0.77) and/or aged >40years (odds ratio, 0.76; 95% CI, 0.60-0.96). The most common North American Contact Dermatitis Group screening series allergens were colophony (80.7%), balsam of Peru (3.9%), 2-hydroxyethyl methacrylate (2.7%), and carba mix (2.7%). One-fourth of the patients (79/313, 25.2%) had positive patch test reactions to supplemental allergens/materials, and 54 (17.3%) of the 313 patients only had reactions to supplemental allergens/materials. Results of comprehensive patch testing may be prone to referral population selection bias and may not be representative of the general dermatology population. Colophony was the most common allergen. Supplemental allergens and materials should be tested in the evaluation of a suspected medical adhesive contact allergy.

Patch testing with ammonium persulfate: The North American Contact Dermatitis Group Experience, 2015-2018

Ammonium persulfate (APS), an oxidizing agent used in hair products, manufacturing, and pool/spa water, can cause skin reactions, including allergic contact dermatitis. To characterize positive patch test reactions to APS (2.5% petrolatum). Retrospective analysis of patients tested to the North American Contact Dermatitis Group screening series from 2015 to 2018. Of 10,526 patients, 193 (1.8%) had positive patch test reactions to APS. Compared with APS-negative patients, APS-positive patients were significantly more likely to be male (43.2% vs 28.0%; P<.0001); have primary hand dermatitis (30.2% vs 22.0%; P=.0064), scattered generalized dermatitis (25.5% vs 17.9%; P=.0064), or trunk dermatitis (8.9% vs 4.9%; P=.0123); and have dermatitis that is occupationally related (22.2% vs 10.9%; P<.0001). More than half of the APS-positive reactions were currently relevant (57.0%); 19 (9.8%) were related to occupation, especially hairdressers (68.4%). Swimming pools/spas (23.3%) and hair care products (19.2%) were the most common sources of APS. Immediate reactions and follow-up testing were not captured. The proportion of patients positive to APS was 1.8%. APS positivity was significantly associated with male sex and hand dermatitis. Swimming pool/spa chemicals were important sources of APS exposure.

Prevalence and Trend of Allergen Sensitization in Adults and Children with Atopic Dermatitis Referred for Patch Testing, North American Contact Dermatitis Group Data, 2001-2016

The association between atopic dermatitis (AD) and allergic contact dermatitis (ACD) is controversial. To analyze the prevalence, reaction strength, and trends of the most commonly positive and relevant allergens in patients with AD referred for patch testing. This was a retrospective analysis of 38,482 patients from the North American Contact Dermatitis Group, 2001 to2016. Most adults (56.0%) and children (52.8%) with a history of AD had a final diagnosis of ACD. Adults (66.5% vs 65.6%; χ2, P= .1459) and children (61.4% vs 62.3%, P= .7074) with or without a history of AD had similar proportions of one or more allergic patch test reactions. Adults with a history of AD had a greater number of allergic patch test positive reactions than those without it (2.0 ± 2.4 vs 1.9 ± 2.3; t test, P < .0001), whereas children did not (1.5 ± 1.8 vs 1.4 ± 1.6; P= .3839). Nickel sulfate, methylisothiazolinone, formaldehyde, fragrance mix I, sodium gold thiosulfate, and thimerosal were the most common allergens in adults and children with a history of AD. In multivariable logistic regression models, adults with versus without a history of AD had increased odds of reacting to 10 of the top 25 North American Contact Dermatitis Group screening allergens. Most allergens had similar strengths of reaction in adults or children with and without a history of AD or a current AD diagnosis; cobalt, fragrance mix I, and propylene glycol had weaker reactions. In multivariable logistic regression, adults with versus without an AD history had increased odds of relevance for 10 of the 25 most currently relevant allergens, whereas children with an AD history did not have increased relevance for any specific allergens. Most patients referred for patch testing with AD history had a final diagnosis of ACD. Patients with AD history had a similar likelihood of having a positive patch test reaction as those without an AD history. Adults with an AD history had a higher number of positive patch test reactions.

Patch Testing of Mercaptobenzothiazole and Mercapto Mix: The North American Contact Dermatitis Group Experience, 1994-2016.

Mercapto compounds are a category of rubber accelerators that may cause allergic contact dermatitis. This study characterizes patch test reactions to mercaptobenzothiazole (MBT) and mercapto mix (MM) in a large North American population. The 1994-2016 North American Contact Dermatitis Group screening series data were analyzed. Patients with allergic reactions to either MBT or MM (mercapto+) were included. The following characteristics were analyzed: strength of reaction, clinical and occupational relevance, coreactivity with other rubber accelerators, and sources of exposure. A total of 49,795 patients were tested to mercapto compounds from 1994 to 2016; 633 (1.3%) had positive reactions to MBT and/or MM. The frequency to both MBT and MM significantly decreased over time (P < 0.0001). Mercapto+ patients were significantly more likely to be male, have occupationally related skin disease, and report involvement of the hands and/or feet (P < 0.0001). They were significantly less likely to have face, scalp/ears/neck, or trunk involvement (P ≤ 0.0001). There was significant coreactivity with carba mix (23.4%) and thiuram mix (32.5%). Mercaptobenzothiazole and MM reactions were frequently clinically (81.7% and 83.5%, respectively) and occupationally relevant (29.8% and 33.4%, respectively). Gloves were the most common source (31.3% and 30.9%, respectively). Patch test positivity to mercapto compounds significantly decreased from 1994 to 2016 but remains clinically and occupationally relevant.

Men's Facial Moisturizers in the Metrosexual Era.

Manufacturers are increasingly branding personal care products (PCPs) specifically for men. The aim of the study was to characterize ingredients and claims of facial moisturizers marketed to men. Men's facial moisturizers from 7 different online retailers were identified in June-September 2018. Ingredients were grouped and identified per the Ingredient Database of the Personal Care Products Council. Potential allergens were identified using the 2017 American Contact Dermatitis Society (ACDS) Core Allergen Series and 2017-2018 North American Contact Dermatitis Group Screening Series. Sixty-five men's facial moisturizers were identified with a total of 1930 ingredients. On average, there were 12 ACDS Core and 9 North American Contact Dermatitis Group Screening allergens per product. A total of 70.8% of products contained between 6 and 15 ACDS Core allergens. The most notable allergens were fragrances (present in 98.5% of products), propylene glycol/derivatives (32.3%), parabens (29.2%), and alkyl glucosides (26.2%). Interestingly, less than 10% of products contained the most common allergenic preservatives in PCPs: formaldehyde releasers and methylisothiazolinone. Men's facial moisturizers commonly contain fragrances, emulsifiers, and glucosides but relatively few allergenic preservatives. This may reflect changes in modern PCP preservation. These findings are important for modern dermatologists to be aware, especially in a new era of male skincare.

Patients with negative patch tests: Retrospective analysis of North American Contact Dermatitis Group (NACDG) data 2001-2016

Little is known regarding the characteristics of patients with negative patch test (NPT) results. To characterize patients with NPT results. Retrospective cross-sectional analysis of 34,822 patch tested patients. NPT results were defined as negative or irritant final interpretations of all North American Contact Dermatitis Group screening allergens and no relevant allergens on supplemental series. Almost one-third of patients (n=10,888 [31.3%]) had NPT results. Patients with NPT results were significantly more likely to be male (P<.0001), be age 40years or younger (P=.0054), be nonwhite (P=.0005), and have dermatitis primarily having a scattered generalized distribution (P=.0007) or primarily located on the lips (P=.0214) or eyelids (P=.0364). However, the absolute differences in age, race, and site were small and may not be clinically meaningful. Patients with NPT results were significantly less likely to have occupationally related skin disease (P<.0001). Overall, 8.3% of patients with NPT results had occupationally related skin disease, with precision production worker/machine operator (28.5%), health care worker (17.0%), and mechanic/repairer (7.5%) being the most commonly related occupations. In all, 22.9% of patients with NPT results had relevant irritants and 41.6% of irritants were occupationally related; cosmetics/health care products and soaps were common sources for both occupationally related and non-occupationally related irritants. Retrospective cross-sectional study of tertiary referral population. Patients with NPT results have distinct characteristics.

The Medical Necessity of Comprehensive Patch Testing.

Allergic contact dermatitis is associated with significant disease and economic burden in the United States. To properly manage allergic contact dermatitis, it is important to accurately identify the substance(s) implicated in the dermatitis to prevent disease recurrence. The commercially available T.R.U.E Test (36 allergens) screening panel has been reported to have a conservative hypothetical allergen detection rate of 66.0%, at most. Importantly, these calculations are based on the 78% of patients who had clinically relevant reactions to allergens present on the North American Contact Dermatitis Group screening series (70 allergens), without the use of supplemental allergens. Testing with supplemental allergens beyond a screening series can more fully evaluate an individual's environmental and occupational exposure, which may significantly increase diagnostic accuracy. Comprehensive patch testing with additional allergens in sunscreens, cosmetics, and fragrances, for example, may increase the diagnostic yield as well as the likelihood of achieving a cure if the dermatitis is chronic and recalcitrant.

Wet Wipe Allergens: Retrospective Analysis From the North American Contact Dermatitis Group 2011-2014.

Although there are several case reports of wet wipe-associated contact dermatitis, the prevalence of wipes as a source of allergic contact dermatitis in larger populations and the responsible allergens are largely unknown. The aim of the study was to determine the prevalence of wet wipes as a source of contact allergy and the most commonly associated allergens in a North American tertiary referral patch test population. Data collected from 2011 to 2014 by the North American Contact Dermatitis Group was used to conduct a retrospective cross-sectional analysis of patient demographics and patch test results associated with the triple-digit source code for "wet wipe." Of the 9037 patients patch tested during the study period, 79 (0.9%) had a positive patch test reaction to an allergen identified with a wet wipe source. The most commonly associated allergens were preservatives, including the following: methylisothiazolinone (MI) (59.0%), methylchloroisothiazolinone (MCI)/MI (35.6%), bronopol (2-bromo-2-nitropropane-1,3-diol) (27.4%), and iodopropynyl butylcarbamate (12.3%). Fragrance (combined) represented 12.3%. Anal/genital dermatitis was 15 times more likely (P < 0.0001) in those with wet wipe allergy. More than 92% of patients with wipe-associated contact allergy had their contact allergens detected by the North American Contact Dermatitis Group screening series. Wet wipes are an important source of contact allergy. Preservatives are the main allergens, especially isothiazolinones.

Cutaneous Delayed-Type Hypersensitivity to Surfactants

Repeated and prolonged use of surfactants can cause irritant as well as allergic contact dermatitis. This study reports the frequency of positive patch test results to surfactants tested on the North American Contact Dermatitis Group screening series including cocamidopropyl betaine (CAPB), amidoamine (AA), dimethylaminopropylamine (DMAPA), oleamidopropyl dimethylamine (OPD), and cocamide diethanolamide (CDEA), and correlations of positive reactions between CAPB and the other surfactants. This was a retrospective analysis of 10 877 patients patch tested between 2009 and 2014 to the surfactants CAPB, AA, DMAPA, OPD, and CDEA. Frequencies of positive reactions to these surfactants were calculated, and trends of reactivity between the surfactants analyzed. The OPD had the highest rate of positive patch reactions (2.3%) followed by DMAPA (1.7%), and CAPB (1.4%). The AA and CDEA had the lowest rate of positive reactions (0.8%). There was a high degree of overlap in positive patch tests between the surfactants. The CDEA was the least likely to coreact with another surfactant.

Patch Test Reactions Associated With Sunscreen Products and the Importance of Testing to an Expanded Series

Both active and inactive ingredients in sunscreen may cause contact dermatitis. This study aimed to describe allergens associated with a sunscreen source. A cross-sectional analysis of patients patch tested by the North American Contact Dermatitis Group between 2001 and 2010 was performed. Of 23,908 patients patch tested, 219 (0.9%) had sunscreen coded as an allergen source. Patients who were male, with occupational dermatitis, or older (older than 40 years) had significantly lower rates of allergic reactions to sunscreens; the most commonly affected areas were the face and exposed sites (P < 0.0001). The top 3 most frequent allergens in sunscreens were benzophenone-3 (70.2% for 10% concentration, 64.4% for 3% concentration), DL-alpha-tocopherol (4.8%), and fragrance mix I (4.0%). Less than 40% of positive patch test reactions were detected by the North American Contact Dermatitis Group screening series of 65 to 70 allergens. A supplemental antigen series is important in detecting allergy to sunscreens.

Tea Tree Oil

Tea tree oil is an increasingly popular ingredient in a variety of household and cosmetic products, including shampoos, massage oils, skin and nail creams, and laundry detergents. Known for its potential antiseptic properties, it has been shown to be active against a variety of bacteria, fungi, viruses, and mites. The oil is extracted from the leaves of the tea tree via steam distillation. This essential oil possesses a sharp camphoraceous odor followed by a menthol-like cooling sensation. Most commonly an ingredient in topical products, it is used at a concentration of 5% to 10%. Even at this concentration, it has been reported to induce contact sensitization and allergic contact dermatitis reactions. In 1999, tea tree oil was added to the North American Contact Dermatitis Group screening panel. The latest prevalence rates suggest that 1.4% of patients referred for patch testing had a positive reaction to tea tree oil.

Patch test results in 66 hairdressers 1973--81.

Over a period of 8 years, 66 hairdresser patients were patch tested to the North American Contact Dermatitis Group screening trays, to a hairdressers' screening tray or to both trays. Paraphenylenediamine (PPD) produced positive reactions in 45% and nickel sulphate in 27% of the patients tested. Apart from the PPD substances and glyceryl monothioglycollate, other chemicals tested produced allergic reactions in no more than 4/66 (6%) patients.

Propylidene phthalide

The association between atopic dermatitis (AD) and allergic contact dermatitis (ACD) is controversial.To analyze the prevalence, reaction strength, and trends of the most commonly positive and relevant allergens in patients with AD referred for patch testing.This was a retrospective analysis of 38,482 patients from the North American Contact Dermatitis Group, 2001 to 2016.Most adults (56.0%) and children (52.8%) with a history of AD had a final diagnosis of ACD. Adults (66.5% vs 65.6%; χ2, P = .1459) and children (61.4% vs 62.3%, P = .7074) with or without a history of AD had similar proportions of one or more allergic patch test reactions. Adults with a history of AD had a greater number of allergic patch test positive reactions than those without it (2.0 ± 2.4 vs 1.9 ± 2.3; t test, P < .0001), whereas children did not (1.5 ± 1.8 vs 1.4 ± 1.6; P = .3839). Nickel sulfate, methylisothiazolinone, formaldehyde, fragrance mix I, sodium gold thiosulfate, and thimerosal were the most common allergens in adults and children with a history of AD. In multivariable logistic regression models, adults with versus without a history of AD had increased odds of reacting to 10 of the top 25 North American Contact Dermatitis Group screening allergens. Most allergens had similar strengths of reaction in adults or children with and without a history of AD or a current AD diagnosis; cobalt, fragrance mix I, and propylene glycol had weaker reactions. In multivariable logistic regression, adults with versus without an AD history had increased odds of relevance for 10 of the 25 most currently relevant allergens, whereas children with an AD history did not have increased relevance for any specific allergens.Most patients referred for patch testing with AD history had a final diagnosis of ACD. Patients with AD history had a similar likelihood of having a positive patch test reaction as those without an AD history. Adults with an AD history had a higher number of positive patch test reactions.