The Dermatologist – Features Regional Atlas on Contact Dermatitis

The Dermatologist is a print and digital brand that circulates to more than 14,798 dermatologists, dermatology residents, dermatology nurse practitioners, physician assistants and nurses, as well as other healthcare professionals. The Dermatologist is collaborating with numerous associations, including the National Psoriasis Foundation, the world’s leading patient advocacy organization dedicated to the 7.5 million Americans with psoriasis and psoriatic arthritis, to educate dermatologists on the latest research related to psoriasis through The Dermatologist print and digital brand. Others include The National Eczema Association, The National Rosacea Society, and The Skin Cancer Foundation.

The editorial mission of The Dermatologist  focuses on providing practical and clinical insight, industry news and peer perspectives into today’s general dermatology issues. This award-winning publication offers dermatologists reader-friendly, timely and informative articles that highlight clinical advances for treatment of cutaneous pathologies such as skin cancer, acne and psoriasis, as well as information on how to incorporate cosmetic procedures, such as Botox and laser skin resurfacing, into a dermatology practice. Practice management topics, such as managed care, Medicare regulations and marketing techniques that can easily be translated into current practice settings, are also featured.”

Check out the Regional Atlas of Contact Dermatitis!

The Dermatologist (formerly Skin and Aging) has had a column dedicated to allergic contact dermatitis (allergen focus) since January 2005!

Experimental T cell regulation in ACD – novel potential interventions

Original Article: Balmert SC, Donahue C, Vu JR, Erdos G, Falo LD Jr, Little SR. In vivo induction of regulatory T cells promotes allergen tolerance and suppresses allergic contact dermatitis. J Control Release. 2017 Sep 10; 261:223-233.

Reviewer: Calvin T Sung, BS. MSIII, University of California Riverside School of Medicine

  • Allergic contact dermatitis (ACD) is a T-cell mediated inflammatory skin condition commonly treated with topical corticosteroids through nonspecific immunosuppression.
  • The underlying immune hypersensitivity dysfunction can be addressed through identification and avoidance of the causative agent.
  • Essentially, ACD results from an inbalance between immune suppressing T regulatory cells (Tregs) and the pro-inflammatory cells that are inappropriately responding to specific allergens.
  • Immunologial chemical messengers, aka cytokines, (IL-2 and TGF-b1) and the antibiotic rapamycin can promote the expansion of Tregs to suppress the over active immune function underlying ACD.
  • Microparticle polymers are notable large molecules that can carry and release IL-2, TGF-b1, and rapamycin.
    • Balmert et al demonstarted that a Poly(ethylene glycol)-poly(lactic-co-glycolic acid) microparticle (PEG-PLGA) had a faster release rate of IL-2, TGF-b1, and rapamycin compared to the original PLGA microparticle formulation previously described by Jhunjhunwala et al.1
    • The cytokine and antibiotic releasing microparticle treatment was formulated as a subcutaneous injection and delivered experimentally to mice two days prior to topical and microneedle delivered allergen exposure (to induce sensitization).
    • Microparticle treatment injections at the ear (where allergens were introduced) revealed the potential for increasing the number of local Tregs to dampen unwanted immune responses upon subsequent allergen exposure.
  • Experiments demonstrated that microparticle treatment injections must be delivered locally near the site of allergen exposure (ear), whereas distal treatment (abdomen) failed to proliferate Tregs at the ear.
  • Interestingly, abdominal microparticle treatments followed by allergen exposure is capable of eliciting a systemic hyporesponsiveness that significantly reduces ear swelling when exposed to subsequent allergen challenges without any local prophylaxis.
  • This experimental data in mice suggests that prophylactic treatment during exposure and sensitization to a particular allergen could significantly suppresses immune dysfunction upon subsequent exposures anywhere on the body.
  • Considering that PEG-PLGA microparticle treatments can induce specific Tregs to suppress specific allergen mediated response, this modality offers a promising translatable novel treatment concept that could be used to decrease immune reactivity to known allergens inducing dermatitis.


For original article please visit: or

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If you’ve ever looked up “how to treat eczema” on the internet, no doubt you’ve seen every type of diet, herb or ointment under the sun. Dr. Peter Lio is here to clear up the confusion by presenting those complementary and alternative eczema treatments that are shown to be effective through rigorous, scientific research. Register for free today.

Wednesday, September 13, 2017
5:00 p.m. PDT/7:00 p.m. CDT/8 p.m. EDT

Peter A. Lio, M.D.
Clinical Assistant of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine

Karey Gauthier, M.S.
Associate Director of Communications, National Eczema Association

T.R.U.E. Test (patch test) receives pediatric indication

T.R.U.E Pediatric indication: T.R.U.E. Test (patch test) receives approval letter from Food and Drug Administration (FDA) for children 6 and older. After 12 years of investigations, evidence and data indicating that the patch testing is safe and efficacious in children suffering from recalcitrant dermatitis – the FDA has approved T.R.U.E Pediatric indication – the use of TRUE test to aid in the diagnosis of ACD in children.

This is the first commercially available patch test to receive approval for use in children 6 and older.  The T.R.U.E. test has 36 components, one is a negative control.

To read more about patch testing in children:

Article on Pediatric Allergic Contact Dermatitis.

“August 25, 2017

Dear Ms. Sullivan:
August 25, 2017
We have approved your request dated October 26, 2016, to supplement your Biologics License Application submitted under section 351(a) of the Public Health Service Act (42 U.S.C. 262) for Thin-layer Rapid Use Epicutaneous Patch Test (T.R.U.E. TEST), to use as an aid in the diagnosis of allergic contact dermatitis in persons 6 years of age and older whose history suggests sensitivity to one or more of the 35 substances included on the T.R.U.E. TEST panels.”

FDA indication
Approval letter

MI contact allergy up!

31689 patients evaluated —  the prevalence of contact allergy to methylisothiazolinone went up to around 20% in several departments!
2017 Jun 19. doi: 10.1111/jdv.14423. [Epub ahead of print]

“European Surveillance System on Contact Allergies (ESSCA): results with the European baseline series, 2013/14.



Contact allergy is a common condition and can severely interfere with daily life or professional activities. Due to changes in exposures, a consequence of introduction of new substances, new products or formulations, and regulatory intervention, the spectrum of contact sensitisation changes.


To evaluate the current spectrum of contact allergy to allergens present in the European baseline series (EBS) across Europe.


Retrospective analysis of data collected by the European Surveillance System on Contact Allergies (ESSCA, in consecutively patch tested patients, 2013/14, in 46 departments in 12 European countries.


Altogether, 31689 patients were included in the analysis. Compared to a similar analysis in 2004, the prevalence of contact allergy to methylisothiazolinone went up to around 20% in several departments. In comparison, contact allergy to the metals nickel, cobalt and chromium remained largely stable, at 18.1, 5.9 and 3.2%, respectively, similar to mostly unchanged prevalences with fragrance mix I, II and Myroxylon pereirae (Balsam of Peru) at 7.3, 3.8 and 5.3%, respectively. In the subgroup of departments diagnosing (mainly) patients with occupational contact dermatitis, the prevalence of work-related contact allergies such as to epoxy resin or rubber additives was increased, compared to general dermatology departments.


Continuous surveillance of contact allergy based on network data offers the identification of time trends or persisting problems, and thus enables focussing in-depth research (subgroup analyses, exposure analysis) on areas where it is needed.”

This article is protected by copyright. All rights reserved.

New Nickel Quiz

Take this new Nickel Quiz and test your savvy.  A study of 125,478 people with a nickel sensitivity, showed that developing allergic dermatitis, increases the risk of multiple sensitizations.

The quizzes are an educational endeavor created by the DA scholars to help promote awareness of contact dermatitis.

Nickel Quiz Here

Loma Linda University researchers are investigating the impact of nickel allergy – please share the nickel allergy survey and increase the knowledge…

Nickel Allergy Survey


Thank you!


It’s True – Metals in a Tattoo – Systemic Contact Dermatitis

Yes, indeed metals can be implanted in a tattoo… and systemically activated reactions can occur in those tattoos related to those metals…

“We recommend assessment of permanent tattoos for inflammation in all patients undergoing patch testing, for additional diagnostic correlation.”  [ 2008 Sep-Oct;19(5):E33-4]


Article 1 (came out yesterday) :de Cuyper C1Lodewick E2Schreiver I3Hesse B4Seim C5,6Castillo-Michel H4Laux P3Luch A3.   2017 Aug 9. doi: 10.1111/cod.12862. [Epub ahead of print]  Are metals involved in tattoo-related hypersensitivity reactions? A case report.

“BACKGROUND:  Allergic reactions to tattoos are not uncommon. However, identification of the culprit allergen(s) remains challenging.

OBJECTIVES: We present a patient with papulo-nodular infiltration of 20-year-old tattoos associated with systemic symptoms that disappeared within a week after surgical removal of metal osteosynthesis implants from his spine. We aimed to explore the causal relationship between the metal implants and the patient’s clinical presentation.

METHODS: Metal implants and a skin biopsy of a reactive tattoo were analysed for elemental contents by inductively coupled plasma mass spectrometry and synchrotron-based X-ray fluorescence (XRF) spectroscopy.

RESULTS: Nickel (Ni) and chromium (Cr) as well as high levels of titanium (Ti) and aluminium were detected in both the skin biopsy and the implants. XRF analyses identified Cr(III), with Cr(VI) being absent. Patch testing gave negative results for Ni and Cr. However, patch tests with an extract of the implants and metallic Ti on the tattooed skin evoked flare-up of the symptoms.

CONCLUSION: The patient’s hypersensitivity reaction and its spontaneous remission after removal of the implants indicate that Ti, possibly along with some of the other metals detected, could have played a major role in this particular case of tattoo-related allergy.”


Article 2: Cobalt tattoo reaction:

2017 Jun 1;15(3):221-222. eCollection 2017.  Chemical Tattoo Treatment Leading to Systemic Cobalt Hypersensitivity.  Zajdel NJ1, Smith WA2, Taintor AR3, Jacob SE4, Olasz EB5.

“An otherwise healthy 36-year-old Caucasian woman, without prior history of atopic dermatitis or eczema, presented to an outside dermatologist with a generalized, severely pruritic eruption involving the entire body except the face. One month previously, she had used a 50% trichloroacetic acid tattoo removal solution on a blue-colored tattoo on the medial aspect of the left ankle. The patient’s eruption persisted for 7 months, and after several attempts to slowly taper her prednisone dose, she presented to our institution. On physical examination, there was a 3-cm erythematous, lichenified plaque surrounding the tattoo (Figure). On the trunk and upper regions of the arms, there were scattered, 1- to 2-cm, nummular patches and plaques. Biopsy of a truncal lesion revealed spongiotic pustules with a mixed dermal infiltrate and scattered eosinophils, consistent with subacute spongiotic dermatitis.”


Article 3:  Systemic Dermatitis following surgery — presenting as tattoo reaction

2017 Jul 19;3(4):348-350. doi: 10.1016/j.jdcr.2017.05.003. eCollection 2017 Jul.  Systemic contact dermatitis to a surgical implant presenting as red decorative tattoo reaction.
“The patient reported that within 2 weeks of surgery, the red-containing areas of her tattoos, which were previously flat and uninflamed, became raised and pruritic.”…
Read this article
Article 4: SCD to chromate in a tattoo triggered by patch testing
2008 Sep-Oct;19(5):E33-4.Inflammation in green (chromium) tattoos during patch testing.  Jacob SE1, Castanedo-Tardan MP, Blyumin ML.

“We report three patients with permanent tattoos and chronic dermatitis. During patch testing, the patients’ dermatitis worsened, and the previously quiescent green-colored portions of the tattoos became inflamed. All three patients were patch-tested and had positive reactions to potassium dichromate 0.25% in petrolatum. Avoidance led to the resolution of both the dermatitis and the tattooinflammation. We recommend assessment of permanent tattoos for inflammation in all patients undergoing patch testing, for additional diagnostic correlation.”

Article 5: 1962
1962 Aug-Sep;74:288-94.Green tattoo reactions associated with cement dermatitis.
And … one of those reads that just makes you think… Article 6:
2004 Aug 21-27;364(9435):730.  A red tattoo and a swordfish supper.
Read more here
“Tsuruta et al. report- ed a case of a 40-year-old Japanese man with a red tattoo who developed a whole-body rash after eating 250 g of raw swordfish and alfonsino.”
Researchers are investigating metal allergic dermatitis and the role of piercing in nickel allergy.  Please pass along this survey.

Fiddler’s Neck and Nickel

Review of: Fiddler’s neck: Chin rest-associated irritant contact dermatitis and allergic contact dermatitis in a violin player

Original Article: Caero, Jennifer E & Cohen, Philip R. (2012). Fiddler’s neck: Chin rest-associated irritant contact dermatitis and allergic contact dermatitis in a violin player. Dermatology Online Journal, 18(9).

Reviewed by: Jacqueline Chen, BA. MSII

  • String players such as violinists and violists can develop dermatitis (inflammatory skin disease), colloquially called ‘Fiddler’s Neck, which may occur on the submandibular region (just below the jaw) or the supraclavicular (on the neck) region.
    • Submandibular Fiddler’s neck, or Fiddler’s neck type 1, refers to the irritation caused by mechanical frictional that occurs following prolonged contact with the chinrest.
      • Submandibular Fiddler’s neck is often described as a lichenified (thickened) plaque that may be darker than the surrounding skin.
      • Four main factors contribute to Fiddler’s neck Type I: pressure of the fiddle, friction, hygiene, and the instrument position.
      • A barrier cushion and adjustment to more horizontal positioning of the instrument has been recommended between the chinrest and submandibular neck to avoid fiddler’s neck type 1
    • Supraclavicular Fiddler’s neck, or Fiddler’s neck Type II occurs from contact allergy to the materials in the chinrest apparatus on the instrument.
      • Supraclavicular dermatitis usually presents as a pruritic (itchy) and erythematous (red) eczematous plaques.
      • Allergic contact dermatitis (the allergic skin response) to the chinrest is most often caused by nickel sulfate in the bracket that holds the chinrest to the instrument, but can also be caused by allergens in the composite woods.
      • The diagnosis of Fiddler’s neck Type 2 is often made based on the patient history and through observing the musician playing his/her instrument to evaluate the contact point of the rash with the instrument.
      • A patch test is the diagnostic test to confirm allergic contact dermatitis
      • Notably, sweat can dissolve nickel, contributing to its corrosion and increasing nickel absorption by skin.
      • To confirm nickel release, the dimethylglyoxime (DMG) test can be used
      • Treatment of supraclavicular Fiddler’s neck should be focused on avoidance of the component in the chinrest containing the allergenic material.


To read the article by Caero and Cohen please click here.

If you suffer from an allergy to your musical instrument, and would like to participate in a nickel allergy awareness survey, please click here.

Nickel allergy – immunologic inflammatory pathways

Review of: Nickel sulfate promotes IL-17A producing CD4+ T-cells by an IL-23 dependent mechanism regulated by TLR4 and Jak-STAT pathways

Original article: Bechara, R, Antonios, D, Azouri, H, Pallardy, M, Nickel sulfate promotes IL-17A producing CD4+ T-cells by an IL-23 dependent mechanism regulated by TLR4 and Jak-STAT pathways. The Journal of Investigative Dermatology. 2017 Jun 17.

Reviewed by: Jacqueline Chen, BA. MSI & Brittanya A. Limone, MS, BS. MSIV

  • Allergic contact dermatitis (ACD) is classically described as a Type IV hypersensitivity reaction, however, the distinctive characteristics of a nickel-induced allergic contact dermatitis (Ni-ACD) lead to immunologic mechanisms that not only encompass a Th1 response but involve additional inflammatory cells, cytokines, and pathways.
  • In Ni-ACD, dendritic cells (antigen presenting [accessory] cells) play a critical role. Dendritic cells bind the antigenic nickel absorbed in the skin and then present it to T-cells at local lymph nodes, coordinating T-cell differentiation through cytokine messengers.
    • The two most crucial cytokine signals include:
      • IL-12p70 which promotes a T-helper Cell 1 type (Th1) response
      • IL-23 which stimulates the development of T-helper Cell 17 type (Th17) cells
    • Notably, the presence of IL-17A produced by Th17 cells correlates with the clinical reaction in nickel allergic patients. An injection of anti-IL-17 neutralizing antibodies may limit the severity of the contact hypersensitivity.
    • The IL-23/IL-12p70 balance determines the primary immunologic mechanism of the hypersensitivity reaction.
      • Increases in the IL-23/IL12p70 balance lead to a greater Th1 cell polarization
      • Decreases in the IL-23/IL-12p70 ratio produce a stronger Th17 cell response.
    • Brechara et al identified 5 specific modulators of T-cell differentiation that are important in the development of Ni-ACD through alterations in the IL-23/IL-12p70 balance.
      • IFN-γ
        • Produced by Th1 cells.
        • Greatly increases the IL-23 levels produced by nickel sulfate (NiSO4)-treated dendritic cells.
        • The increase in the IL-23/IL-12p70 ratio favors Th17 cell development.
      • Jak-STAT pathway
        • Inhibition of the Jak-STAT pathway increases IL-23.
        • Alternatively, activation of the pathway will increase IL-12p40 and IL-12p70 levels and decrease the IL-23/IL-12p70 balance.
        • This decrease in the IL-23/IL-12p70 balance favors a Th1 cell response.
      • TLR4, p38MAPK and NFkB pathways
        • Activation of these pathways is essential for nickel-induced production of IL-23, IL-12p40 and IL-12p70.
        • Since both IL-23 and IL-12 cytokines are produced, the IL-23/IL-12p70 balance remains high.
      • In summary, Ni-ACD is a complex immunologic disease involving not only a cell-mediated Th1 response but also Th17 cell development with alterations in IFN- γ levels and TLR4, Jak-STAT, p38MAPK, and NF-kβ immunologic pathways.

Article: link to publishers site

Researchers are investigating the role of piercings and the development of nickel allergy – please consider to take the Loma Linda University Nickel Allergy Survey:

Nickel allergy survey



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.