Contact Dermatitis

NAPA, CALIF. – There is little risk that patients with orthopedic metal implants will have a skin reaction or joint pain from the device, said Dr. Joseph F. Fowler.

"I do patch test patients ... who have concerns about a metal allergy or are going to have an implant. I tell them if they have a positive patch test, they may have a skin reaction," said Dr. Fowler. However, there is a small chance they will have a cutaneous reaction, and a smaller chance they will have problems with the joint.

Metals used in orthopedic implants include stainless steel, which is composed of an iron-chromium alloy plus nickel and molybdenum, and sometimes a little chromium and titanium; nitinol (55% nickel and 45% titanium); vitallium (iron cobalt plus chromium 30% and molybdenum 5%); and titanium. Two of the four metals contain nickel, a common contact allergen, noted Dr. Fowler, a dermatologist at the University of Louisville (Ky.).

When it comes to joint pain from implants, findings from a small German study of 15 patients showed that levels of the inflammatory marker interleukin-17 (IL-17) were increased in only those patients with nickel containing replacement joints who both had a positive patch test to nickel and complaints of joint pain. IL-17 levels were not increased in patients with a positive patch test to nickel who did not complain of joint pain (Contact Dermatitis 2010;63:15-22).

In an unpublished study, Dr. James Taylor of the Cleveland Clinic found that 60% of a small group of patients (10) with a metal implant who had a positive patch to metal experienced resolution of joint pain after the metal was replaced. "There is getting to be more and more of a suggestion that metal allergies and joint problems do go hand in hand," said Dr. Fowler.

If you just had to guess what would be the best material to put in a patient who with a chance of a metal allergy, titanium is the best bet, he said. "It comes down to a medical legal question. Will doctors and patients accept a small amount of risk if there is an implant that is better than titanium?"

He said that he will patch test patients if requested by the physician who will be performing the implant surgery, but it is not normally done because there is less than a 1% chance that even if they do have a positive patch test to metal, dermatitis will occur. There have been reports, although rare, that a metal allergy may cause joint failure, but prospective studies are needed, he said.

Dr. Fowler reported financial conflicts of interest with multiple pharmaceutical companies.

NAPA, CALIF. – There is little risk that patients with orthopedic metal implants will have a skin reaction or joint pain from the device, said Dr. Joseph F. Fowler.

"I do patch test patients ... who have concerns about a metal allergy or are going to have an implant. I tell them if they have a positive patch test, they may have a skin reaction," said Dr. Fowler. However, there is a small chance they will have a cutaneous reaction, and a smaller chance they will have problems with the joint.

Metals used in orthopedic implants include stainless steel, which is composed of an iron-chromium alloy plus nickel and molybdenum, and sometimes a little chromium and titanium; nitinol (55% nickel and 45% titanium); vitallium (iron cobalt plus chromium 30% and molybdenum 5%); and titanium. Two of the four metals contain nickel, a common contact allergen, noted Dr. Fowler, a dermatologist at the University of Louisville (Ky.).

When it comes to joint pain from implants, findings from a small German study of 15 patients showed that levels of the inflammatory marker interleukin-17 (IL-17) were increased in only those patients with nickel containing replacement joints who both had a positive patch test to nickel and complaints of joint pain. IL-17 levels were not increased in patients with a positive patch test to nickel who did not complain of joint pain (Contact Dermatitis 2010;63:15-22).

In an unpublished study, Dr. James Taylor of the Cleveland Clinic found that 60% of a small group of patients (10) with a metal implant who had a positive patch to metal experienced resolution of joint pain after the metal was replaced. "There is getting to be more and more of a suggestion that metal allergies and joint problems do go hand in hand," said Dr. Fowler.

If you just had to guess what would be the best material to put in a patient who with a chance of a metal allergy, titanium is the best bet, he said. "It comes down to a medical legal question. Will doctors and patients accept a small amount of risk if there is an implant that is better than titanium?"

He said that he will patch test patients if requested by the physician who will be performing the implant surgery, but it is not normally done because there is less than a 1% chance that even if they do have a positive patch test to metal, dermatitis will occur. There have been reports, although rare, that a metal allergy may cause joint failure, but prospective studies are needed, he said.

Dr. Fowler reported financial conflicts of interest with multiple pharmaceutical companies.

NAPA, CALIF. – There is little risk that patients with orthopedic metal implants will have a skin reaction or joint pain from the device, said Dr. Joseph F. Fowler.

"I do patch test patients ... who have concerns about a metal allergy or are going to have an implant. I tell them if they have a positive patch test, they may have a skin reaction," said Dr. Fowler. However, there is a small chance they will have a cutaneous reaction, and a smaller chance they will have problems with the joint.

Metals used in orthopedic implants include stainless steel, which is composed of an iron-chromium alloy plus nickel and molybdenum, and sometimes a little chromium and titanium; nitinol (55% nickel and 45% titanium); vitallium (iron cobalt plus chromium 30% and molybdenum 5%); and titanium. Two of the four metals contain nickel, a common contact allergen, noted Dr. Fowler, a dermatologist at the University of Louisville (Ky.).

When it comes to joint pain from implants, findings from a small German study of 15 patients showed that levels of the inflammatory marker interleukin-17 (IL-17) were increased in only those patients with nickel containing replacement joints who both had a positive patch test to nickel and complaints of joint pain. IL-17 levels were not increased in patients with a positive patch test to nickel who did not complain of joint pain (Contact Dermatitis 2010;63:15-22).

In an unpublished study, Dr. James Taylor of the Cleveland Clinic found that 60% of a small group of patients (10) with a metal implant who had a positive patch to metal experienced resolution of joint pain after the metal was replaced. "There is getting to be more and more of a suggestion that metal allergies and joint problems do go hand in hand," said Dr. Fowler.

If you just had to guess what would be the best material to put in a patient who with a chance of a metal allergy, titanium is the best bet, he said. "It comes down to a medical legal question. Will doctors and patients accept a small amount of risk if there is an implant that is better than titanium?"

He said that he will patch test patients if requested by the physician who will be performing the implant surgery, but it is not normally done because there is less than a 1% chance that even if they do have a positive patch test to metal, dermatitis will occur. There have been reports, although rare, that a metal allergy may cause joint failure, but prospective studies are needed, he said.

Dr. Fowler reported financial conflicts of interest with multiple pharmaceutical companies.

Patients with a history of contact allergies may be less likely to develop nonmelanoma skin cancer, brain cancer, and breast cancer, a study has shown.

In research published online July 11 in BMJ Open (doi:10.1136/bmjopen-2011-000084), investigators conversely found diagnoses of bladder cancer more likely in people with a history of contact allergies.

Any protective effects could possibly be explained by the stimulation of natural killer T (NKT) cells through contact allergic reactions, the observational study’s lead author, Kaare Engkilde, Ph.D., of the national allergy research center at Copenhagen University Hospital, said in an interview. "You would probably think that [contact allergy] could lead to skin cancer, but that is not what we found," Dr. Engkilde said.

Contact allergic reactions are delayed reactions caused by chemicals small enough to penetrate the skin – triggers can include perfumes, hair dyes, cobalt, nickel, and formaldehyde. Animal studies have shown that contact allergens have the ability to increase the number of NKT cells, at least temporarily, Dr. Engkilde said.

For their research, Dr. Engkilde and his colleagues used a database of 16,922 Danish patients patch tested for type IV allergies between 1984 and 2008. Of these, 6,065 (35.8%) had at least one positive reaction (26.1% of men, 41.4% of women). Linkage with the Danish Cancer Registry showed 3,200, or 18.9%, of dermatitis patients had a benign tumor, a malignant cancer diagnosis, or both, and 1,207 (37.7%) of these patients had had a positive patch test reaction.

Dr. Engkilde and his colleagues looked specifically at 15 types of cancers, all of which affected at least 40 people in the study population.

The investigators found an inverse association between diagnosed contact allergy and nonmelanoma skin cancer (OR, 0.82) along with breast cancer (OR, 0.80) among both men and women. Dr. Engkilde and his colleagues also noted an inverse trend for brain cancer among women with contact allergies, though the P value was above.05 (OR, 0.36).

The findings related to nonmelanoma skin cancers were on some level expected, Dr. Engkilde said; however, the researchers said they were surprised not to see any protective effect against melanomas.

Dr. Engkilde said his group had no hypothesis for the inverse breast cancer finding, but noted that an earlier study had found that self-reported perfume allergy, a type IV allergy, was related inversely to brain cancer incidence (Am. J. Epidemiol. 2007;166:941-50).

The positive association between contact allergy and bladder cancer (OR, 1.44) was more likely related to accumulations of chemical metabolites of type IV allergens in the bladder than to an effect on NKT cells or another immune response, the investigators said.

They cautioned that the relationships between type IV reactions and cancers were "uncertain and not necessarily the result of causality," and that future analyses would have to adjust for social class and smoking, as the latter can increase the risk of developing nickel contact allergies and several types of cancer.

Also, they wrote, "studies focusing on specific chemical exposures are required to further our understanding of the role of contact allergies in the development of cancer." However, if the relationships are in fact etiologic, the findings have "implications for understanding how contact allergy can affect cancer development and vice versa," they said.

Dr. Engkilde and his coauthors received research support from Aage Bang’s Foundation and the Capital Region’s Research Foundation, and disclosed no competing interests.

Patients with a history of contact allergies may be less likely to develop nonmelanoma skin cancer, brain cancer, and breast cancer, a study has shown.

In research published online July 11 in BMJ Open (doi:10.1136/bmjopen-2011-000084), investigators conversely found diagnoses of bladder cancer more likely in people with a history of contact allergies.

Any protective effects could possibly be explained by the stimulation of natural killer T (NKT) cells through contact allergic reactions, the observational study’s lead author, Kaare Engkilde, Ph.D., of the national allergy research center at Copenhagen University Hospital, said in an interview. "You would probably think that [contact allergy] could lead to skin cancer, but that is not what we found," Dr. Engkilde said.

Contact allergic reactions are delayed reactions caused by chemicals small enough to penetrate the skin – triggers can include perfumes, hair dyes, cobalt, nickel, and formaldehyde. Animal studies have shown that contact allergens have the ability to increase the number of NKT cells, at least temporarily, Dr. Engkilde said.

For their research, Dr. Engkilde and his colleagues used a database of 16,922 Danish patients patch tested for type IV allergies between 1984 and 2008. Of these, 6,065 (35.8%) had at least one positive reaction (26.1% of men, 41.4% of women). Linkage with the Danish Cancer Registry showed 3,200, or 18.9%, of dermatitis patients had a benign tumor, a malignant cancer diagnosis, or both, and 1,207 (37.7%) of these patients had had a positive patch test reaction.

Dr. Engkilde and his colleagues looked specifically at 15 types of cancers, all of which affected at least 40 people in the study population.

The investigators found an inverse association between diagnosed contact allergy and nonmelanoma skin cancer (OR, 0.82) along with breast cancer (OR, 0.80) among both men and women. Dr. Engkilde and his colleagues also noted an inverse trend for brain cancer among women with contact allergies, though the P value was above.05 (OR, 0.36).

The findings related to nonmelanoma skin cancers were on some level expected, Dr. Engkilde said; however, the researchers said they were surprised not to see any protective effect against melanomas.

Dr. Engkilde said his group had no hypothesis for the inverse breast cancer finding, but noted that an earlier study had found that self-reported perfume allergy, a type IV allergy, was related inversely to brain cancer incidence (Am. J. Epidemiol. 2007;166:941-50).

The positive association between contact allergy and bladder cancer (OR, 1.44) was more likely related to accumulations of chemical metabolites of type IV allergens in the bladder than to an effect on NKT cells or another immune response, the investigators said.

They cautioned that the relationships between type IV reactions and cancers were "uncertain and not necessarily the result of causality," and that future analyses would have to adjust for social class and smoking, as the latter can increase the risk of developing nickel contact allergies and several types of cancer.

Also, they wrote, "studies focusing on specific chemical exposures are required to further our understanding of the role of contact allergies in the development of cancer." However, if the relationships are in fact etiologic, the findings have "implications for understanding how contact allergy can affect cancer development and vice versa," they said.

Dr. Engkilde and his coauthors received research support from Aage Bang’s Foundation and the Capital Region’s Research Foundation, and disclosed no competing interests.

Patients with a history of contact allergies may be less likely to develop nonmelanoma skin cancer, brain cancer, and breast cancer, a study has shown.

In research published online July 11 in BMJ Open (doi:10.1136/bmjopen-2011-000084), investigators conversely found diagnoses of bladder cancer more likely in people with a history of contact allergies.

Any protective effects could possibly be explained by the stimulation of natural killer T (NKT) cells through contact allergic reactions, the observational study’s lead author, Kaare Engkilde, Ph.D., of the national allergy research center at Copenhagen University Hospital, said in an interview. "You would probably think that [contact allergy] could lead to skin cancer, but that is not what we found," Dr. Engkilde said.

Contact allergic reactions are delayed reactions caused by chemicals small enough to penetrate the skin – triggers can include perfumes, hair dyes, cobalt, nickel, and formaldehyde. Animal studies have shown that contact allergens have the ability to increase the number of NKT cells, at least temporarily, Dr. Engkilde said.

For their research, Dr. Engkilde and his colleagues used a database of 16,922 Danish patients patch tested for type IV allergies between 1984 and 2008. Of these, 6,065 (35.8%) had at least one positive reaction (26.1% of men, 41.4% of women). Linkage with the Danish Cancer Registry showed 3,200, or 18.9%, of dermatitis patients had a benign tumor, a malignant cancer diagnosis, or both, and 1,207 (37.7%) of these patients had had a positive patch test reaction.

Dr. Engkilde and his colleagues looked specifically at 15 types of cancers, all of which affected at least 40 people in the study population.

The investigators found an inverse association between diagnosed contact allergy and nonmelanoma skin cancer (OR, 0.82) along with breast cancer (OR, 0.80) among both men and women. Dr. Engkilde and his colleagues also noted an inverse trend for brain cancer among women with contact allergies, though the P value was above.05 (OR, 0.36).

The findings related to nonmelanoma skin cancers were on some level expected, Dr. Engkilde said; however, the researchers said they were surprised not to see any protective effect against melanomas.

Dr. Engkilde said his group had no hypothesis for the inverse breast cancer finding, but noted that an earlier study had found that self-reported perfume allergy, a type IV allergy, was related inversely to brain cancer incidence (Am. J. Epidemiol. 2007;166:941-50).

The positive association between contact allergy and bladder cancer (OR, 1.44) was more likely related to accumulations of chemical metabolites of type IV allergens in the bladder than to an effect on NKT cells or another immune response, the investigators said.

They cautioned that the relationships between type IV reactions and cancers were "uncertain and not necessarily the result of causality," and that future analyses would have to adjust for social class and smoking, as the latter can increase the risk of developing nickel contact allergies and several types of cancer.

Also, they wrote, "studies focusing on specific chemical exposures are required to further our understanding of the role of contact allergies in the development of cancer." However, if the relationships are in fact etiologic, the findings have "implications for understanding how contact allergy can affect cancer development and vice versa," they said.

Dr. Engkilde and his coauthors received research support from Aage Bang’s Foundation and the Capital Region’s Research Foundation, and disclosed no competing interests.