European Baseline Series Research Articles

A seven-year retrospective analysis of patch test data in a cohort of patients with contact dermatitis in Sri Lanka

BackgroundPatch testing with a baseline series is a common tool employed when the sensitizing agent in contact dermatitis is unclear. However, for Asian countries, there are no locally validated baseline series to utilize in screening.MethodsWe completed a retrospective analysis of all patients that had undergone patch testing with the European Baseline series, Shoe Series or Comprehensive International Baseline series, over 7 years from 2012 to 2018 in a tertiary care reference dermatology clinic in Sri Lanka to evaluate the suitability of these investigations to identify causes for contact dermatitis in the local study population.ResultsOut of 438 patients tested, 239 (54.8%) reacted to at least one substance in the series. The Shoe Series was significantly more likely to yield a positive result than the European Baseline Series (70.2% vs 46.9%, p < 0.05). The top three sensitizers identified by all series were nickel sulfate (16%, 70/438), p-phenylenediamine (12.3%, 54/438) and 2-mercaptobenzothiazole or mercapto mix (10.5%, 46/438).ConclusionShoe series has a comparatively high yield in the local population compared to European Baseline series. Since little less than half of the study population did not have any reactivity to any of the allergens tested it is important to develop or modify and validate a locally relevant, more suitable baseline series which is based on the Shoe Series in Sri Lanka. This is further evidence for the continuously changing nature of allergens in the environment and the need to modify existing patch testing standards accordingly.

Adding sorbitan sesquioleate to the European baseline series: Necessary, reasonable, or unavoidable?

Positive reactions to fragrance mix I (FM I) are frequent in consecutively patch tested patients suspected of having allergic contact dermatitis. However, the FM I test preparations contain 5% of the emulsifier sorbitan sesquioleate (SSO), and it is well known that SSO can cause contact allergic reactions in its own right. Indeed, the available data show that some patients with contact allergy to SSO react to FM I but are not allergic to fragrances. When SSO is not tested, this situation may go unnoticed, a wrong diagnosis of fragrance allergy may be given to the patient, and unjustified advice to avoid fragrances and fragranced products will be given in such cases. To avoid such suboptimal patient care, we postulate that testing with SSO in all patch tested individuals is mandatory. As it is well known that only a minority of FM I-reactive patients will undergo a breakdown test with the ingredients and SSO, testing with SSO in all patients can only be achieved by adding it to the European baseline series. Not testing with SSO may also result in misinterpretation of patch test reactions to Myroxylon pereirae resin and 2-hydroxyethyl methacrylate in the baseline series, as both (may) contain SSO, and, for the same reason, of reactions to several other hapten test materials.

New positive patch test reactions on day 7-The additional value of the day 7 patch test reading.

BackgroundNot performing a day (D) 7 patch test reading might result in positive patch test reactions being missed.ObjectivesTo investigate the added value of the D7 patch test reading for individual allergens, and to identify patient characteristics and allergen groups associated with new positive D7 reactions.MethodsData from patients patch tested between 2008 and 2018 with the extended European baseline series were analysed. Patch test readings were performed on D3 and D7. Positive reactions were categorized into positive on D3 or new positive on D7.ResultsA total of 3292 patients were consecutively patch tested with at least 43 allergens of the TRUE Test panels 1 and 2 supplemented with investigator‐loaded allergens. In total, 447 (13.6%) patients showed new positive D7 reactions. In univariable regression analysis, age between 18 and 30 years showed a negative association with new positive D7 reactions. Significantly more D7 positive reactions were seen for topicals (odds ratio [OR] 2.60, 95% confidence interval [CI]: 1.92‐3.51) and corticosteroids (OR 1.87, 95%CI: 1.09‐3.21). No associations were found between sex, atopic dermatitis and occupational dermatitis and a new positive D7 reaction.ConclusionA D7 reading to identify new positive patch test reactions is of added value, especially for topicals and corticosteroids.

The European Baseline Series in Romania: Results of Patch Testing in Contact Dermatitis and Determination of the Most Frequently Awareness in Adult Patients

In Romania, data on patch testing are lacking and the significance and applicability of the European baseline series (EBS) needs to be evaluated. The aim of the study was to examine the prevalence of contact allergy to the EBS and to determine the most common post-test sensitization occurred in the population of patients with suspected allergic contact dermatitis in Romania. Demographic data were collected from 252 patients with suspected allergic contact dermatitis. Pacients were patch tested with 28-allergen EBS.The positive patch test was observed in 80.16% patients. The most prevalent contact allergens were nickel sulphate (15.08%), fragrance mix I &amp; II (13.10%) and potassium dichromate (9.52%). Differences in sensitization prevalences to some allergens of the EBS compared with other European countries were recognized. The current EBS is a suitable diagnostic tool for contact allergy in Romania.

Patch test results obtained with the European baseline series at a diagnostics centre in Abuja, Nigeria.

Patch test results obtained with the European baseline series at a diagnostics centre in Abuja, Nigeria.

Allergic contact dermatitis caused by synthetic rubber gloves in healthcare workers: Sensitization to 1,3-diphenylguanidine is common.

The frequency of allergic contact dermatitis has significantly increased in healthcare workers since the transition from latex to synthetic rubber gloves, with 1,3-diphenylguanidine being identified as the most frequently implicated allergen. To highlight the role of 1,3-diphenylguanidine as the culprit allergen in contact allergies to synthetic rubber gloves, to propose recommendations for patch testing, and to discuss alternatives for sensitized subjects. Patch test data from healthcare workers who developed hand dermatitis after wearing rubber gloves and who reacted positively to glove samples and rubber additives were collected from September 2010 to December 2017 in a Belgian hospital. A total of 44 caregivers were included in this study. Patch tests showed that: (a) 84% of the study population reacted positively to carba mix; (b) 86% reacted positively to 1,3-diphenylguanidine; and (c) 13 (30%) reacted positively to thiuram mix. Half of the subjects reacted positively to gloves containing 1,3-diphenylguanidine, whereas none reacted to accelerator-free gloves. The most commonly identified allergen was 1,3-diphenylguanidine, far ahead of thiurams, which were previously described as the most sensitizing accelerators. The use of 1,3-diphenylguanidine-free gloves is recommended. No subject reacted to gloves without accelerators, thus confirming their efficiency among accelerator-sensitized patients. We recommend that 1,3-diphenylguanidine be added to the European baseline series.

An Update on Fragrance Contact Dermatitis

Fragrances are a group of substances present in many cosmetic products, which are one of the most common sources of allergic contact dermatitis (ACD) in Europe. Their widespread distribution, the presence of these substances as combinations, their ability to transform into more reactive substances, and the relatively recent regulations regarding these products are the main reasons for this high prevalence. In the last few years, advances on knowledge about haptens in fragrances have made possible to discover new allergens, to state that current fragrance markers are not enough to detect most of fragrance ACD cases and to know the products that should be patched and their concentrations. In this review, we revise the mechanisms of sensitization to allergens that are not represented in baseline series and the concentrations at which they should be used, which should be included in specific series and the usefulness of baseline and fragrance specific series. To revise the most recent advances in knowledge about fragrance contact dermatitis, especially about sensitization mechanisms and effectivity of fragrance markers in baseline series and fragrances in essential oils. Fragrance allergic contact dermatitis (ACD) is one of the most common sources of ACD only preceded by nickel sulfate. Many studies have shown that fragrance mix (FM)I, FMII, and colophonium, fragrance markers in baseline series, are not enough to screen for cases of ACD to fragrances. Some fragrances use limonene and linalool hydroperoxides, which have shown a high prevalence of sensitization and have been proposed as new allergens to include in the European Baseline Series, while other fragrances like Evernia furfuracea, which have also shown a high prevalence of sensitization, will not be included. Essential oils are obtained by distillation process and are widely used. In some cases, their allergenic components are not known. Co-sensitization to other fragrance components is frequent and they should be patch tested if allergic contact dermatitis to fragrances or cosmetics is suspected. A more extensive group of fragrance markers should be included in the European Baseline Series, with at least limonene and linalool hydroperoxides and Evernia furfuracea. The use of products containing fragrances is very common and people sensitized to one of these substances should be suspected of multiple co-sensitizations.

European Surveillance System on Contact Allergies (ESSCA): Contact allergies in relation to body sites in patients with allergic contact dermatitis.

BackgroundAnalyses of the European Surveillance System on Contact Allergies (ESSCA) database have focused primarily on the prevalence of contact allergies to the European baseline series, both overall and in subgroups of patients. However, affected body sites have hitherto not been addressed.ObjectiveTo determine the prevalence of contact allergies for distinct body sites in patients with allergic contact dermatitis (ACD).MethodsAnalysis of data collected by the ESSCA (www.essca‐dc.org) in consecutively patch tested patients, from 2009 to 2014, in eight European countries was performed. Cases were selected on the basis of the presence of minimally one positive patch test reaction to the baseline series, and a final diagnosis of ACD attributed to only one body site.ResultsSix thousand two hundred and fifty‐five cases were analysed. The head and hand were the most common single sites that ACD was attributed to. Differences between countries were seen for several body sites. Nickel, fragrance mix I, cobalt and methylchloroisothiazolinone/methylisothiazolinone were the most frequent allergens reported for various body sites.ConclusionsDistinct allergen patterns per body site were observed. However, contact allergies were probably not always relevant for the dermatitis that patients presented with. The possibility of linking positive patch test reactions to relevance, along with affected body sites, should be a useful addition to patch test documentation systems.

The European baseline series and recommended additions: 2019.

The European baseline series and recommended additions: 2019.

Contact sensitization to hydroperoxides of limonene and linalool: Results of consecutive patch testing and clinical relevance.

BackgroundHydroperoxides of limonene and linalool are potent sensitizers.ObjectivesTo investigate the prevalence of contact allergy to both hydroperoxides of limonene and hydroperoxides of linalool, to report clinical relevance, and to investigate patient demographics.MethodsA total of 821 patients (35.6% male, mean age 42.4 years ± 17.8 years) were consecutively patch tested with our departmental baseline series and our fragrance series, including hydroperoxides of limonene 0.3% pet. and hydroperoxides of linalool 1.0% pet. The clinical relevance was assessed for all positive reactions.ResultsPositive patch test reactions to hydroperoxides of limonene and to hydroperoxides of linalool were observed in 77 patients (9.4%, 95% confidence interval [CI]: 7.4%‐11.4%) and in 96 patients (11.7%, 95%CI: 9.5%‐13.9%), respectively; 38 of these patients (4.6%, 95%CI: 3.2%‐6.0%) reacted to both. Most reactions were considered to be possibly or probably clinically relevant (66.3% and 68.8%, respectively), and a small proportion were deemed to be of certain clinical relevance (18.2% and 19.8%, respectively).ConclusionAs compared with previous studies, high numbers of positive reactions to both hydroperoxides of limonene and hydroperoxides of linalool were observed, the majority of which were clinically relevant, supporting their inclusion in the European baseline series.

Eczéma de contact allergique d’origine professionnelle

ObjectiveTo assess the clinical, aetiological and allergological characteristics of occupational eczema, to assess the effect of this dermatitis on ability to work, and to evaluate the relevance of European baseline series. MethodsThis is a retrospective study of occupational eczema cases collected from the Occupational Medicine department at the University Hospital of La Rabta between 2000 and 2015. ResultsThe study involved 215 working people who were predominantly male (71.2%). The mean age was 41.75 years. The sectors with the highest proportion of eczema were the construction sector (32.6%), followed by the health sector (13.5%) and the textile sector (8.8%). The main cause for consultation was itchy squamous red patches (63.8%), chiefly on the hands (61.3%). The most common offending allergens were metals and rubber additives. Patch tests were deemed relevant in 66.5% of cases. Modification of the workplace was warranted for half of the study population, and transfer to another workplace was proposed to 43.3% of the affected subjects. ConclusionOccupational eczema poses a number of problems in terms of therapeutic skills and management. The adoption of appropriate preventive measures together with concomitant medical care is the only means of ensuring that employees remain in their workplace.

An epidemiological study of allergic contact dermatitis in Greece: prevalence of sensitization to an adapted European baseline series’ allergens

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Contact dermatitis is a common skin disorder related to environmental exposures affecting, all age groups, and both genders. The pattern of contact sensitization to a series of allergens included in the European baseline series has already been studied for a number of EU countries by the ESSCA Network. The current study aims to explore the patterns of contact dermatitis in Greece through a patch test against a large number of allergens provoking contact dermatitis.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Retrospective analyses of routine data of 668 patients were collected during 2014 in the Laboratory of Patch Testing, National Referral Centre of Occupational Dermatoses. Sensitization in all cases was tested with a battery of 28 allergens of the European baseline series and additional ones aiming to identify new sensitizations to inform the National baseline of allergens; information for an extended MOAHLFA index was also collected.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; One at least positive result was found in 61.5% of the patients while 19.1% of those found to be sensitized in two or more allergens. Nickel sulphate, fragrance mix and balsam of Peru were the most prevalent allergens in the total population, as well as with respect to gender. Nickel is the most frequent allergen of baseline series, a result which is in agreement with other reports.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Allergic contact dermatitis surveillance is of great importance towards the clinical and systematic understanding of the disease. Further studies should be directed towards that end, in order to facilitate more effective health policies.&lt;/p&gt;

European photopatch test baseline series: A 3-year experience.

In 2012, a consensus was reached regarding a baseline photopatch test series on the basis of the results of a European multicentre study. To describe experience with the European photopatch test series. A retrospective analysis of 116 patients tested with the European photopatch test series between 2014 and 2016 was performed. Fifty-five positive photopatch test reactions in 25 subjects were recorded, most commonly caused by the topical non-steroidal anti-inflammatory drugs ketoprofen, dexketoprofen, and etofenomate. Organic ultraviolet (UV) absorbers constituted the second main category of agents eliciting positive photopatch test reactions. Among UV absorbers, benozophenone-3 and octocrylene were the most frequent photoallergens. UV absorbers that have been introduced more recently rarely elicited positive photopatch test reactions. Positive patch test reactions were less commonly observed than positive photopatch test reactions, namely, 21 reactions in 14 patients. We present the largest clinical experience with the European photopatch test baseline series hitherto reported. The results are similar to those underlying the above consensus process, reaffirming the usefulness of this series.

Allergic contact reaction to antiseptics in very young children.

Contact dermatitis from topical antiseptic use has been reported mostly in adults, but rare cases of chlorhexidine contact dermatitis have also been described in young children. To evaluate contact allergic dermatitis to antiseptics in young children. The children mostly referred for a misdiagnose (cellulitis) were patch tested with a selection of the European baseline series, an antiseptics series and the personal topical products used. Fourteen children (8 boys, 6 girls) received a diagnosis of contact dermatitis to antiseptics between May 2010 and December 2017. The mean age at diagnosis was 38 months (8 months to 8 years); three children only had a personal history of atopy. Chlorhexidine gluconate was positive in seven cases, and benzalkonium chloride in eight cases, and in four cases, both allergens were positive. These small case series confirm that both chlorhexidine and benzalkonium chloride are implicated in contact dermatitis from antiseptic use in the paediatric population. We emphasize the initial misdiagnose of these patients, the very young age of the children and the allergenic potential of common antiseptics in non-atopic children. We hypothesize that the systematic use of antiseptics for umbilical cord care could be responsible for the sensitization in newborns.

Is a specific eyelid patch test series useful? Results of a French prospective study.

Eyelids are frequent sites of contact dermatitis. No prospective study focused on eyelid allergic contact dermatitis (EACD) has yet been published, and this topic has never been studied in French patients. To prospectively evaluate the usefulness of an eyelid series in French patients patch tested because of EACD, and to describe these patients. We prospectively analysed standardized data for all patients referred to our departments between September 2014 and August 2016 for patch testing for suspected EACD as the main reason. All patients were patch tested with an eyelid series, the European baseline series (EBS), the French additional series, and their personal products. Patch testing with additional series and repeated open application tests (ROATs) or open tests were performed if necessary. A standardized assessment of the relevance was used, and the analysis of the results was focused on patients having positive test results with a current certain relevance. Two-hundred and sixty-four patients (238 women and 26 men) were included. Three-hundred and twenty-two tests gave positive results in 167 patients, 84 of whom had currently relevant reactions: 56 had currently relevant positive test reactions to the EBS, 16 had currently relevant positive test reactions to their personal products, 8 had currently relevant positive test reactions to the French additional series, and 4 had currently relevant positive test reactions to the eyelid series. Sixty-seven per cent of all relevant cases were related to cosmetic products. The most frequent allergens with current relevance were methylisothiazolinone (10.2%), fragrance mix I (3%), nickel (2.7%), hydroxyperoxides of linalool (2.7%) and limonene (2.3%), and Myroxylon pereirae (2.3%). Current atopic dermatitis was found in 9.5% of patients. The duration of dermatitis was shorter (23.2 vs 34.2 months; P = .035) in patients with currently relevant test reactions. The percentage of currently relevant tests remained the same when atopic patients or dermatitis localized only on the eyelids were taken into account. In French patients, testing for EACD with the extended baseline series and personal products, also including ROATs and use tests, appears to be adequate, considering the currently relevant positive test reactions. The regular addition of an eyelid series does not seem to be necessary.

Patch testing with the European baseline series fragrance markers: a 2016 update

Fragrance contact allergy is a common cause of allergic skin reactions that can cause eczema. Contact allergy can develop by repeated skin exposure to allergens over time. Fragrance contact allergy is diagnosed by patch testing (applying known allergens to the skin to assess for reactions). In the EU, cosmetic products are regulated to limit the exposure to known allergens. Furthermore, there is a requirement to label cosmetic products that contain any of 26 known individual fragrance allergens to help consumers avoid those allergens to which they are allergic. In most dermatology departments in the UK, instead of patch testing to all 26 individual fragrance allergens, fragrance contact allergy is diagnosed by patch testing to 4 screening markers: Fragrance Mix I, Fragrance Mix II, Myroxylon pereirae and hydroxyisohexyl 3‐cyclohexane carboxaldehyde. In this study, the authors reviewed 2084 records of patients with eczema who underwent patch testing to all the individual fragrance allergens, as well as the screening markers of fragrance allergy, to find out the proportion of actual fragrance contact allergy detected by testing only to the screening markers. They found that patch testing only to the screening markers detected 40.8% of patients with actual fragrance contact allergy (patients who were diagnosed with fragrance allergy when additionally tested with individual fragrance allergens). They also found that the majority of patients with fragrance contact allergy were not aware that they developed skin reactions upon exposure to fragrances. The authors concluded that the current screening markers used are not sufficient for the diagnosis of fragrance contact allergy.

European Surveillance System on Contact Allergies (ESSCA): polysensitization, 2009-2014.

Polysensitization, defined as being allergic to three or more haptens from the European baseline series, is considered to reflect increased susceptibility to developing a contact allergy, and is likely to be associated with an impaired quality of life. To evaluate the prevalences of polysensitization across Europe and to analyse factors associated with polysensitization. Patch test data collected by the European Surveillance System on Contact Allergies (ESSCA; www.essca-dc.org) in consecutively patch tested patients from January 2009 to December 2014, comprising 11 countries and 57 departments, were retrospectively analysed. A total of 86 416 patients were available for analysis, showing a standardized prevalence of polysensitization of 7.02%, ranging from 12.7% (Austria) to 4.6% (Italy). Allergen pairs with the strongest association are reported for the total population, for South Europe, and for North/Central Europe. Overall, polysensitized patients showed a higher percentage of extreme (+++) positive patch test reactions than oligosensitized patients. Female sex, occupational dermatitis and age > 40 years were risk factors for polysensitization. The varying prevalences of polysensitization across Europe most likely reflect differences in patient characteristics and referral patterns between departments. Known risk factors for polysensitization are confirmed in a European dermatitis population.

Para-phenylenediamine and its multiple co-sensitisations – two case reports

Introduction. In contact allergology, the situations with simultaneous positive tests to multiple molecules are not rare; sometimes, in these cases, interpretation and clinical relevance of the tests are difficult. Case report I. A 73-year-old woman, with chronic blepharoconjunctivitis and chronic rhinitis (under observation), not responding to the treatment with tobramycin ophthalmic drops, olopatadine ophthalmic drops, dexamethasone phosphate injectable solution, mometazone furoate nasal spray and fluorometholone ophthalmic drops. Personal history: ten years ago - dermatitis on the face and scalp after using black dye hair. Epicutaneous tests: European Baseline Series + additional series, three components of cortico­steroid series. Results: +++ to para-phenylenediamine (PFD), ++ to neomycin, Peru balsam, budesonide, tixocortol-21-pivalate, benzalkonium chloride, textile dye mix, disperse orange. Case report II. A 50-year-old woman, without personal history of atopy, presented three months ago an acute eczema on the scalp and neck after using black dye hair. Under treatment with strong corticosteroids, the evolution was favorable, the eczema being at the time of testing in the chronic stage (lichenification). Epicutaneous tests: European Baseline Series + additional series. Results: ++ to PFD and nickel, + to colophane, Peru Balsam, Paladium, Orange Disperse 1, textile dye mix. Clinical relevance of the tests. In both cases primary sensitization was caused by hair dye, the responsible hapten being para-phenylenediamine; the positive results to textile dye mix and disperse orange 3 in the first case, respectively, to textile dye mix and disperse orange 1, in the second case, are justified by the cross-reactions they may have with PFD. The positivity of the tests to budesonide and tixocortol pivalate but also to benzalkonium chloride, in the first case, can be explained by sensitization via fluorometolone, respectively, by the presence of benzalkonium chloride as an excipient in dexamethasone phosphate injectable solution,tobramycin ophthalmic drops, olopatadine ophthalmic drops and fluorometholone ophthalmic drops. Conclusion. Our results are concordant with those recently published, which showed that PFD is one of the top-ranking allergens regarding the absolute number of significant associations with concomitantly patch tested allergens, suggesting the possibility to identify a subset of patients who are genetically prone to multiple sensitizations.

The Evaluation of Contact Sensitivity with Standard and Cosmetic Patch Test Series in Rosacea Patients.

BackgroundRosacea is a common dermatosis characterized by erythema, telangiectasia, papules and pustules.ObjectiveWe aimed to evaluate contact sensitivity in the rosacea patients.MethodsWe included 65 rosacea patients and 60 healthy volunteers in the study. The patient and control groups were patch tested with European baseline series and cosmetic series.ResultsA positive reaction to at least 1 allergen in the European standard series was found in 32.3% of rosacea patients and 20.0% of subjects in the control group while the relevant numbers were 30.8% of rosacea patients and 10% of controls with the cosmetic series (p=0.08). In total, we found a positive reaction to at least 1 allergen in 38.5% of patients and 25.0% of controls (p=0.15). We did not find a statistically significant relationship between a positive reaction to 1 allergen in total and the gender, skin type, rosacea type, ocular involvement, age and disease duration. There were more symptoms in patients with a positive reaction to allergens (p<0.001).ConclusionContact sensitivity was detected more common in rosacea patients. Patch testing may be useful in the treatment and follow up of rosacea patients especially if symptoms such as itching, burning and stinging are present.

Allergic contact dermatitis caused by topical herbal remedies: importance of patch testing with the patients' own products.

Natural ingredients have variable compositions, so their allergenic potencies may differ. To retrospectively analyse subjects reacting to herbal remedies over the past 27 years, with the aim of (i) evaluating demographic characteristics and lesion locations, (ii) describing the frequencies of positive patch test reactions, (iii) identifing sensitization sources, and (iv) studying concomitant sensitivity. In total, 15980 patients were patch tested between 1990 and 2016 with the European baseline series and/or other series, product(s) used, and, whenever possible, the respective ingredients. Altogether, 8942 (56%) of 15 980 patients presented with at least one positive reaction. Reactions to topical herbal medicines, most often applied to treat an eczematous condition, leg ulcers, or other wounds, were seen in 125 (0.8%), that is, 1.4% of the contact-allergic subjects. Hands, legs and feet were the most frequently affected body sites. Twenty-one botanical allergens were identified, the commonest being Myroxylon pereirae (balsam of Peru), Compositae plants, and tincture of benzoin. Many patients presented with multiple positive test reactions, and some did not react to the commercial allergens but only to the products used. Topical herbal remedies should not be applied on damaged skin, as multiple sensitization may develop. Moreover, patch testing with the culprit products is important for the diagnosis.