airborne allergic contact dermatitis- isothiazolinones is not rare

2017 Apr 27. doi: 10.1111/cod.12795. [Epub ahead of print]

Airborne allergic contact dermatitis caused by isothiazolinones in water-based paints: a retrospective study of 44 cases.



Airborne allergic contact dermatitis caused by paints containing isothiazolinones has been recognized as a health hazard.


To collect epidemiological, clinical and patch test data on airborne allergic contact dermatitis caused by isothiazolinone-containing paints in France and Belgium.


A descriptive, retrospective study was initiated by the Dermatology and Allergy Group of the French Society of Dermatology, including methylchloroisothiazolinone (MCI)/methylisothiazolinone (MI)- and/or MI-sensitized patients who developed airborne allergic contact dermatitis following exposure to isothiazolinone-containing paint.


Forty-four cases were identified, with mostly non-occupational exposure (79.5%). Of the patients, 22.5% of also had mucosal symptoms. In several cases, the dermatitis required systemic corticosteroids (27.3%), hospitalization (9.1%), and/or sick leave (20.5%). A median delay of 5.5 weeks was necessary to enable patients to enter a freshly painted room without a flare-up of their dermatitis. Approximately one-fifth of the patients knew that they were allergic to MI and/or MCI/MI before the exposure to paints occurred.


Our series confirms that airborne allergic contact dermatitis caused by paints containing isothiazolinones is not rare, and may be severe and long-lasting. Better regulation of isothiazolinone concentrations in paints, and their adequate labelling, is urgently needed.

Patch Testing in Hand Eczema – Free Article!

REVIEW of: The Ecacy of the Patch Test in Diagnosing Hand Eczema

Original article: Vigneshkarthik, N, Ganguly, S, and Kuruvila, S. Patch Test as a Diagnostic Tool in Hand Eczema. Journal of Clinical Diagnostic and Research, 2016; 10(11): WC04–WC07. India

Reviewed by Jacqueline Chen, BA. MSI and Brittanya Limone, MA. MSIII, Loma Linda University.

  • Hand eczema is a frequently encountered dermatologic problem that may be secondary to an allergic contact dermatitis (ACD). Patch testing is a diagnostic tool that can confirm an ACD etiology and determine the necessary allergens to avoid to prevent future exacerbations.
  • Vigneshkarthik, Ganguly, and Krurvila’s cross-sectional study analyzed patch test results to determine common allergens associated with ACD in patients with hand eczema. The study included 54 individuals, 27 men and women. The authors discovered that:
    • Of the patients with hand eczema 37% had positive patch test results to 25 different allergens, confirming that ACD is a common cause of hand eczema
    • Specific occupations were more susceptible including housewives, agriculturists, students and masons
  • Nickel was the most common allergen associated with hand eczema, particularly amongst patients with a vesicular hand eczema, or pompholyx, morphology.
    • In patients with nickel allergy, high levels of nickel in the diet have been associated with this more severe form of hand eczema.
  • Risk factors thought to be associated with the development of nickel hand eczema:
    • Ear piercings and adornment with nickel jewelry.
    • Chores in wet environments
    • Use of nickel-containing utensils
  • Detergents were another important association with nickel allergy
    • Over one-third of patients with regular detergent exposure had a positive patch test result.
      • 54% of these positive patch test results were due to nickel, either alone or in combination with cobalt sensitivity.
      • The association of nickel and cobalt allergies was determined to be due to co-exposure to the metals from a common source.

PubMed Link:   Adobe PDF Icon

Free Article on Topical Steroid addiction – withdrawal

Free article on topical steroid addiction – “Cortisol production by keratinocytes [skin cells] might work to regulate or moderate the friction between the outer environment and inner immune system by suppressing excessive inflammation or immune reaction. However, prolonged or excessive use of TCS induces skin atrophy which can make barrier function weak. Moreover, the decreased self-production of cortisol by the keratinocytes can cause hypersensitivity. The author considers it is one of the mechanisms of TSA or rebound phenomenon after TSW.”

Fukaya M1. .Histological and Immunohistological Findings Using Anti-Cortisol Antibody in Atopic Dermatitis with Topical Steroid Addiction.   2016 Mar;6(1):39-46. doi: 10.1007/s13555-016-0096-7. Epub 2016 Feb 2.  Dermatol Ther (Heidelb)



Though topical steroid addiction (TSA) in patients with atopic dermatitis (AD) has been recently discussed as a clinical problem, there are very few studies about its mechanism. The purpose of this study was to elucidate histological and immunohistological characteristics of TSA using anti-cortisol antibody.


Skin biopsy specimen from eight patients with AD was stained by anti-cortisol antibody (Biorbyt, orb79379). Subjects consisted of a child patient with a short history of topical corticosteroids (TCS) application, an adult patient with a long history of TCS application, and six adult patients who have experienced topical steroid withdrawal (TSW) and the rebound phenomenon.


The staining in the epidermis by anti-cortisol antibody presented patchy defects in the child patient, the patient with a long history of TCS application, and two patients at the rebound period. Parakeratosis with poor formation of corneal layer was obvious in the child patient, the patient with a long history of TCS application, two patients recovered from TSA, and two patients at the rebound period.


Prolonged application of TCS might suppress the cortisol production of keratinocytes which is poorly developed at the early ages before childhood and completed naturally as to growth. Rebound phenomenon after TSW can occur due to the relative insufficiency of cortisol in the epidermis and the immature corneal layer formation.”

Not all nickel allergy reactions are delayed

Nickel allergy early reactions reported within 30 min of contact!

 Nickel allergy in a Danish population 25 years after the first nickel regulation.

Author information

 Contact Dermatitis. 2017 Apr 7. doi: 10.1111/cod.12782. [Epub ahead of print]



Nickel in metallic items has been regulated in Denmark since 1990; however, 10% of young Danish women are still sensitized to nickel. There is a need for continuous surveillance of the effect of regulation.


To identify current self-reported metallic exposures leading to dermatitis in nickel-allergic patients, and the minimum contact time needed for dermatitis to occur.


A questionnaire was sent to all patients who reacted positively to nickel sulfate 5% pet. within the last 5 years at the Department of Dermatology and Allergy, Gentofte Hospital.


The response rate was 63.2%. Earrings were the foremost cause of dermatitis after the EU Nickel Directive had been implemented, followed by other jewellery, buttons on clothing, belt buckles, and wrist watches. Dermatitis reactions within 10 min of contact were reported by 21.4% of patients, and dermatitis reactions within 30 min of contact were reported by 30.7% of patients. [Noting nickel allergy early reactions]


Nickel exposures that led to implementation of a nickel regulation seem to persist. The durations of contact with metallic items to fall under the current REACH regulation of nickel correspond well with the results of this study.


EU directive; allergic nickel dermatitis; metallic items; nickel; prolonged direct contact


Facing topical steroid withdrawal TSW – health matters

TSW – topical withdrawal syndrome

Facing up to withdrawal from topical steroids 

By Mary C. Smith, RN, MSN; Susan Nedorost, MD; and Brandie Tackett, MD

“Topical corticosteroids applied to the face to treat these symptoms can cause steroid rosacea and steroid addiction syndrome, resulting in new symptoms that perpetuate the topical steroid usage.”  “withdrawal … which is called steroid addiction syndrome.”

” The best time to prevent … is when topical corticosteroids are first prescribed.”

” Getting the red out

” Uncovering steroid rosacea

” Stopping the cycle

” Patient teaching

Call to Action: “Learn to recognize this condition”

Get article here


Nickel in Cocoa – speciation

Food Chem. 2017 Sep 1;230:327-335. doi: 10.1016/j.foodchem.2017.03.050. Epub 2017 Mar 10.

Nickel speciation in cocoa infusions using monolithic chromatography – Post-column ID-ICP-MS and Q-TOF-MS.


Nickel (Ni) is considered to be a potentially harmful element for humans. Its levels in foodstuffs are normally low (below 0.2mgkg-1), but sensitive individuals may develop allergy to Ni as a result of dietary consumption. Cocoa contains relatively high Ni concentrations (around 3mgkg-1). Ni bioavailability, its role in the flavour of food and its potential impact on human health depends primarily on its chemical species. However, there is a lack of information about Ni speciation in cocoa. In this work Ni species were separated on a weak convective interaction media diethylamine (CIM DEAE) monolithic chromatographic column and quantified by the post-column isotope dilution inductively coupled plasma mass spectrometry (ID-ICP-MS). The Ni binding ligands in the separated fractions were identified “off line” by quadrupole time-of-flight mass spectrometry (Q-TOF MS). Ni was found to be present in the cocoa infusions as Ni2+ and Ni-gluconate and Ni-citrate complexes.

Triggers of ACD – allergens and the jewelry addict

Discussion of Triggers of Allergic Contact Dermatitis in Accessories – the Jewelry addict

Original article: Nanette B. Silverberg. (2016). The “Jewelry Addict”: Allergic contact dermatitis from repetitive multiple children’s jewelry exposures. Pediatric Dermatology 33: e103-e105

Reviewed by Lauren A. Ivey, MS. MSI & Brittanya A. Limone, MA, BS. MSIII Loma Linda University

  • Nickel Allergic Contact Dermatitis (Ni-ACD) can be a distressing problem, especially for young girls with pierced ears and a love for costume jewelry.
  • Nickel is the most commonly confirmed contact allergen in both children and adults.
  • Confirmed Ni-ACD has increased 3 to 4-fold since 1986.
    • Common sources of nickel exposure in children include jewelry and adornments, electronics, and school chairs.
    • Girls are especially at risk to early nickel exposure through earrings and daily us of costume jewelry (aka “jewelry addict”)
    • Electronics, eg cell phones, laptops, and tablets have increased the frequency of nickel exposure.
  • Silverberg presents a case study of a 9-year-old girl “addicted to costume jewelry” who developed ACD after exposure to different metal- and rubber-containing accessories.
    • Confirmed sources of the allergen exposure included rubber bracelets, cheaper metal jewelry, lip balm case and belt buckles.
    • Physical examination: classic involvement of the antecubital fossa (crease of arms) consistent with a diagnosis of atopic dermatitis, and lichenified plaques on the fingertips and dorsal hands.
    • Notable plaques were seen on the lips and perioral region associated with application of lip balm kept in the metal case.
    • Patch testing revealed a 3+ reaction to nickel (papular variant), 2+ to gold thiosulfate, and 3+ to thiuram, all of which were deemed clinically relevant considering the child’s history with jewelry containing these allergens and her  presentation.
  • Parents and caregivers must remain cognizant of important allergens in jewelry.
  • Because virtually any type of jewelry can be a source of allergy, children who exhibit persistent dermatitis should be tested for suspected allergens based on history and exposure.

Contact Dermatitis Awareness Ribbon

Announcing the Contact Dermatitis Awareness Ribbon:

On March 19, 2016 a Montessori Teacher and a Customer Service Representative, two mothers with children suffering with allergic contact dermatitis, joined together to start a patient-centered outreach group on Facebook called “Eczema, Contact Dermatitis and Patch Testing Alliance”. Currently, this 1,925 member focus group is providing educational resources to sufferers of allergic contact dermatitis worldwide.

As the eve of the anniversary of the group approached the lead administrator (Misha Bertolino, MA) raised the question, Why is there not a contact dermatitis awareness ribbon?

**Contact dermatitis costs a reported $1,529 million/year in medical costs!

**Contact dermatitis is the 8th most costly skin disease!

**Contact dermatitis is preventable!


The Contact Dermatitis Awareness Ribbon is indeed very much needed!

In a collaborative effort, the Eczema, Contact Dermatitis and Patch Test alliance along with artist Janna Vassantachart, MD, logistician Chandler Rundle, BS, practicing contact dermatitis specialists, and global advocates – the orchid (eczema) and teal (allergy) contact dermatitis awareness ribbon has become a reality.

This symbol can be worn to show support and solidarity for the millions of people who suffer from this disease.  In alignment with these symbols, our mission at the Dermatitis Academy is to educate the public, the medical providers, the manufacturers and the legislators on ACD, while cultivating a community of support for those impacted by this disease.

With early diagnosis, education, and intervention, we HOPE for a future where allergic contact dermatitis can be controlled by remission or prevention.

Please visit the Dermatitis Academy to learn more about allergic contact dermatitis, allergens, and patch testing and to download the Contact Dermatitis Awareness Ribbon.

Please share!

Free article on Suspender Nickel dermatitis – prevention is the key

Review of: ‘ Suspender ’ Dermatitis and Nickel Sensitivity

Original article:  D. Calnan and G. C. Wells. (1956). Suspender Dermatitis and Nickel Sensitivity. British Medical Journal, 1(4978), p. 1265-1268.

Reviewed by Brittanya Limone, BS, MA, MSIII, Loma Linda University.

  • Historically, nickel allergy contact dermatitis was primarily associated with women working in industrial processes.
    • Calnan and Wells use a case of suspender dermatitis, one of the most common causes of nickel allergic contact dermatitis c. 1956, to highlight the prevalence of this condition amongst women regardless of their employment.
  • A dermatitis reaction is thought to occur after friction and sweat wear on nickel-containing products. These mediums gradually remove the nickel coatings and allow for nickel ion absorption across one’s skin.
    • In addition to suspenders, other everyday nickel-containing products that may induce an allergic contact dermatitis include watches, bra clasps, and earrings.
  • Typically, the first reaction site occurs in direct contact with the metal, also known as the primary site. This region appears as excoriated, superficial papules or a confluent patch.
    • Of note, pierced earrings were noted to cause earlobe dermatitis with crusts and exudates that might be mistaken for impetigo (infection).
  • Eruptions at sites distant to the metal’s direct contact are secondary sites. These occur in a symmetric fashion on the eyelids, sides of the neck, inner thighs, and elbow flexures.
    • Secondary reactions develop as papules or vesicles overlying an erythematous, edematous background with or without crusts and exudates.
  • A secondary flare-up is a more important clinical feature for diagnosis and treatment.
    • In terms of diagnosis, patients might not typically seek medical care until a secondary eruption. Therefore, recognition of these lesions, more commonly, leads to the diagnosis of nickel sensitivity.
    • However, conditions with secondary flare-up reactions are more difficult to treat. Patients with a primary lesion respond quickly to therapy, but once a secondary eruption occurs, clearing the condition is difficult and recurrences are more common.
  • Patch testing is used to confirm the diagnosis of nickel allergic contact dermatitis. However, waiting for the alleviation of an acute exacerbation is important as false positives from local reactions to patch testing may occur.


  • Prevention is key to this condition’s treatment and reduces recurrences.
    • The first step is the removal of all jewelry, metal clips or fasteners.
    • If nickel-containing products must be worn, then they should be covered with a protective coating of fabric, plastic, or enamel.
    • Alternatively, replacement products may be used such as items made of 100% plastic or nylon.

Nickel sensitivity and atopy

Early insight into the contributory role genetic factors play in the development of contact dermatitis

Synopsis of Nickel Sensitivity and Atopy (1964)

Original article:

A. Caron. (1964). Nickel Sensitivity and Atopy. British Journal of Dermatology, vol. 76: p. 384 – 387.

Reviewed by Brittanya Limone, BS, MA. MSIII, Loma Linda University.

  • “Atopy” is a genetic predisposition toward developing one or more of the following conditions: asthma, hay fever, urticaria, infantile eczema, or atopic dermatitis.
  • Determining the incidence of atopy has proven difficult because of reliance on clinical judgment and variable utilization of set parameters in making the diagnosis. For instance, the presentation of nasal congestion and recurrent sneezing episodes may be diagnosed as either hay fever, allergic rhinitis, or vasomotor rhinitis.
    • Several authors c.1964 estimated the prevalence of atopy in the United States’ general population being between 10-20%.
  • In the Caron case series, 37 patients with an established diagnosis of nickel contact dermatitis underwent further evaluation regarding their personal and family history of atopy, the results included the following:
    • Twenty-one (54%) had no history of atopy
    • Seven (19%) only had a family history.
    • Four (11%) had both a personal and family history
    • Five (14%) only had a personal history
  • The results from Caron’s case series suggested that the incidence of atopy amongst patients with nickel allergic contact sensitivity was no greater than its occurrence in the general population.
    • The frequency of atopy in 19% of family members was noted to be higher than expected for the general population but was attributed to the contributory role genetic factors play in the development of contact dermatitis.
  • This study concluded that nickel sensitivity occurs independently of atopy.