The Empty Truths Behind “Hypoallergenic” Labeling

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Zirwas MJ. Attempting to Define “Hypoallergenic”. JAMA Dermatol. 2017;153(11):1093‐1094. doi:10.1001/jamadermatol.2017.3045

Liem O, Kessen K, de Groot H. Hypoallergene dieren behoren tot het rijk der fabeldieren [Hypoallergenic animals, fact or myth?]. Ned Tijdschr Geneeskd. 2019;164:D4298. Published 2019 Dec 31.

Reviewed by Jalal Maghfour and Dr. Alina Goldenberg

Hypoallergenic is a term that has been traditionally associated with “allergens/fragrance free”.  Often time, products labeled as hypoallergenic are expensive and are advertised as a safe alternative for individuals who are sensitized to certain allergens.  Additionally, the term has gradually gained popularity in describing certain domestic animals, such as cats and dogs, that in theory, will not cause an allergic reaction. In reality, the term “hypoallergenic” is a dynamic word; its definition continues to evolve and change. 

In this synopsis, we focused on articles that discuss what the new criteria of hypoallergenic term is  and we hope, through this synopsis, to dismantle common misconceptions about hypoallergenic products as well as domesticated animals with the goal to aid clinicians in counseling patients suffering from allergic conditions.

The most important question to ask is: Are there any products that are truly hypoallergenic? The simple answer is “No”.  There are no such products that are “non-allergenic”. Instead, certain allergenic compounds can still be used if they induce a skin reaction at a low frequency in the general population.

Recently, the North American Contact Dermatitis Group (NACDG) has decided that for a product to be considered hypoallergenic it should not contain any allergenic ingredients that have a frequency of positive patch test results of 1 % or greater. This data was derived from a comprehensive patch test database containing at least 1,000 patients. While this frequency was set arbitrarily, it has been partially followed in practice—allergens yielding a positive patch test at a frequency greater than 1% are often added to screening trays used in patch testing.

In parallel, there is an increasing belief that some breeds/types of cats and dogs are hypoallergenic. This is a common misconception, as these types of animals do not exist. Instead, sensitized individuals may experience a reduction in skin reaction episodes in the presence of animals that shed less fur. This is because the offending allergen— dander (dead flaky skin), is often adherent to the fur which is shed at a different frequency based on the type of animal.

Hence, when counseling patients, it is important to emphasize that there are no such things as hypoallergenic products and/or animals. If manufacturers adhere to the 2017 NACDG definition of “hypoallergenic” for their product labeling, these products will truly be less likely to cause a skin reaction and will promote patients’ safety.

Unmask the facts- the truth behind “fragrance free”

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Original Article:

Scheinman PL. Exposing covert fragrance chemicals. Am J Contact Dermat. 2001;12(4):225‐228. doi:10.1053/ajcd.2001.28697

Reviewed by Jalal Maghfour and Dr. Alina Goldenberg

Fragrances are widely used in personal care products, cosmetics, medicaments, and foods within the US. Fragrances are responsible for many cases of allergic contact dermatitis, leading it to be perceived as a significant public health problem. 

We aim to provide an overview of fragrance chemicals and how knowledge of fragrance elements can shape patient outcomes.

Patch testing continues to be the gold standard for the diagnosis of fragrance sensitization. Patch test commonly include fragrance mix (FM) and balsam of Peru. FM, which includes cinnamic aldehyde, cinnamic alcohol, eugenol, isoeugenol, hydroxycitronellal geraniol, oak moss absolute, and alpha-amyl cinnamic aldehyde,  is highly ubiquitous worldwide with an estimated sensitization prevalence of 11%.  

While patch testing can detect 70 to 80% of fragrance elements, false negative reactions to FM may occur. Hence, it is important to conduct an expanded series of fragrance chemicals if the suspicion for an allergy is high. This is of clinical importance since identification of the exact etiology may guide disease management and empowers patients to take control over their own health.

Although being aware of fragrance allergy is important, many products that are labeled as “fragrance-free” are not truly free of chemical fragrance. For instance, benzyl alcohol is often used as a preservative but it is also considered a fragrance agent. However, because benzyl alcohol has a dual function, companies can legally label a product as “fragrance-free”. This makes it challenging for sensitized patients to avoid certain “fragrance-free” products.  Hence, knowledge of various products by clinicians can be vital for patient care. Historically, plant and animal ingredients were the main extracts used in making fragrance. It is therefore important to note that a patient who is allergic to a fragrance agent in a product may also react to the same ingredient found in plants and flowers.  

Sensitization to an allergen is necessary for elicitation to occur in which the rash of ACD is present. Initial sensitization usually requires a higher dose of the chemical allergen. However, if a fragrance is applied to skin areas with high absorption capacity such as face, genitals, and traumatized areas (shaving, post-surgical sites, excoriated lesions of atopic dermatitis/eczema), a lower dose is may be necessary to sensitize an individual. It is noteworthy that for sensitized individuals subsequent exposure of a lower dose of the allergen may be enough to elicit a cutaneous eruption. Hence, in addition to removing fragrances from commonly used products, public policy should also focus on reducing the levels of fragrance use to prevent reactions in sensitized individuals.

Nickel Allergic Contact Dermatitis: Identification, Treatment, and Prevention

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Review and Synopsis by Jalal Maghfour, MD and Alina Goldenberg, MD of Original Peer-Reviewed Article:

Silverberg NB, Pelletier JL, Jacob SE, Schneider LC; SECTION ON DERMATOLOGY, SECTION ON ALLERGY AND IMMUNOLOGY. Nickel Allergic Contact Dermatitis: Identification, Treatment, and Prevention. Pediatrics. 2020;145(5):e20200628. doi:10.1542/peds.2020-0628

Nickel (Ni) remains one of the most common causes of allergic contact dermatitis (ACD), a type IV hypersensitivity reaction, since the publication of its first case in 1888 by Dr. George Henry Fox. This metal continues to be highly prevalent in every day goods within the US. Ni ACD is considered a public health issue and has been gaining international attention.

The impact of nickel on both adults and children has been increasingly reported in the literature. However, Ni ACD is primarily a disease of the young as it rarely affects elderly (> 60 years). In this synopsis, we provide a brief overview on an article written by Silverberg et al. in which the authors discussed epidemiology, clinical presentation, pathogenesis and management of Ni ACD among pediatric population.

With the discovery of Ni in the 18th century and advancement in the steel industry in early 19th century, Ni has become commonly utilized among manufacturers and is now considered the 5th most common metal in the world. Ni ACD may manifest as mild pruritus with ill-defined erythema to diffuse and pronounced redness with oozing and bullae. Classically, Ni ACD presents as an erythematous lichenified papule/plaque and matches the object touching the specific skin area. Any parts of the body can be affected by nickel.

Ni ACD has a multifactorial etiology with a combination of genetic and environmental factors. Contact with nickel is simply not enough for a reaction to occur. The following conditions must be met for both induction and elicitation phase to occur: 1) Contact with a metal containing corroded Ni, 2) degree of solubility of Ni (higher the solubility the higher ion leakage); 3) Ni ions being absorbed by the skin.

In case of a Ni ACD, the majority of diagnoses are clinical. However, when the cutaneous patterns are atypical, the diagnosis may be difficult in which cases patch testing can be performed. Patch testing is the criterion standard method to diagnose Ni ACD. While it is usually a localized reaction, the appearance of 3 large papules following Ni patch testing strongly suggests a systemic nickel hypersensitization.  

Ni ACD can be a diagnostic challenge in AD patients as the morphologic eruption may not match the triggering object. In addition, patients may also experience an exacerbation of their AD. In parallel, adults with psoriasis often experience flare of their disease during a Ni ACD episode. Although Ni ACD is primarily a type IV reaction, immediate hypersensitivity through IgE has been reported as a cause of Ni ACD.

For Ni ACD treatment, this review recommends the avoidance of the offending agent as the next best step in management, followed by the treatment of inflammation with the use of glucocorticoids (potency is based on the affected area). Finally, restoration of the skin barrier is essential. This can be performed with a generous application of emollients. 

As exemplified by Denmark and Finland, enacting a national policy to regulate the amount of Ni that a population is exposed to was proven efficacious in reducing the rate of Ni ACD and has increased awareness on the topic among adolescents. There is no such regulation within the US. Because Ni is primarily found in jewelry and ear piercings, it may be beneficial to regulate Ni found in other forms of jewelry, as well as children’s toys, metal protectors for phone which are now increasingly recognized to as a cause of Ni ACD.

Increased production and manufacturing regulations, specific diagnoses and focused avoidance strategies can make Ni ACD a preventable pediatric health issue.  As it was shown with European countries, the United States can benefit from limiting Ni exposure to its population.  Until then, individual awareness and knowledge of daily objects containing nickel should be encouraged as part of avoidance.