Contact Dermatitis

NEW ORLEANS – Dimethyl fumarate – a volatile substance included in shipments of furniture, clothing, and shoes to inhibit growth of mold – earned the distinction as the American Contact Dermatitis Society's 2011 Allergen of the Year.

"We had a difficult decision," Dr. Donald V. Belsito said. "But we decided to go with dimethyl fumarate. It caused an epidemic in Europe starting in 2007."

The substance is now being regulated in Europe, "although apparently some stuff is still sneaking through," Dr. Belsito said. "To date, I know of no cases in the U.S., although Dr. Melanie Pratt has had a few cases in Ontario."

Dimethyl fumarate "produces an extremely severe dermatitis," said Dr. Belsito, a dermatologist in private practice in Shawnee, Kan.

The unlikely story behind identification of this preservative and fungicide demonstrates the benefits of international collaboration, he noted.

First noted by dermatologists in Finland, cases of the severe dermatitis began to appear in Sweden and the U.K. The severe rash, seen predominantly on the backs of the legs, buttocks, and back, was an etiologic mystery. Through extensive sleuth work, Finnish dermatologists determined a common link – each person recently purchased furniture from a particular Chinese manufacturer.

It then became commonly called "sofa dermatitis." A contact allergy to the upholstery fabric was initially suspected. However, no common chemical or fabric was identified among the different pieces of furniture purchased by affected patients.

Dr. Magnus Bruze, an occupational and environmental dermatologist at Malmo University in Sweden, and other investigators took apart the furniture, patch tested 40 affected patients to various components, and eventually identified the culprit: dimethyl fumarate. The allergen was enclosed in packets similar in appearance to silicone packets often labeled "Warning: Do Not Eat."

Dimethyl fumarate is so volatile it can vaporize within 6 weeks. The vapors cause the dermatitis – sometimes spread out and sometimes patchy – after permeating the sofas, clothing, and shoe products during shipment.

Particularly concerning is very low exposure levels to dimethyl fumarate can trigger a reaction, concentrations well below those of common contact dermatitis allergens.

In an unprecedented move, Dr. Belsito revealed the leading contender, at least for now, for the 2012 Allergen of the Year: acrylates and methacrylates. Acrylates and methacrylates are polymers and adhesives. Methacrylate, for example, is used as bone cement for prosthetic devices placed during orthopedic surgery. The ACDS is soliciting feedback from members about naming this class of compounds at their next Allergen of the Year.

Neomcyin was the 2010 Allergen of the Year. Dr. Belsito described neomycin reactions as "common, not readily recognized, and problematic." Neomycin was chosen because of its widespread use as an over-the-counter antibiotic product; its high propensity for cross-reaction with other agents in the aminoglycoside class, including gentamicin, kanamycin, and tobramycin; and because neomycin is included as a preservative in some vaccines. Because a neomycin allergy is not a type 1 IgE-mediated, a reaction results in eczema, not anaphylaxis and death.

Gold was the 2001 Allergen of the Year, and reactions to gold are common and clinically problematic. Bacitracin (2003) and glucocorticosteroids (2005) are other allergens that are both common and clinically relevant. In contrast, thimerosal (2002) is a common but nonrelevant allergen because it has been removed from most products in the United States. A reaction to mixed dialkyl thioureas (2009), used in production of rubber products, is relatively uncommon but important when it occurs.

Dr. Belsito said that he had no relevant disclosures.

NEW ORLEANS – Dimethyl fumarate – a volatile substance included in shipments of furniture, clothing, and shoes to inhibit growth of mold – earned the distinction as the American Contact Dermatitis Society's 2011 Allergen of the Year.

"We had a difficult decision," Dr. Donald V. Belsito said. "But we decided to go with dimethyl fumarate. It caused an epidemic in Europe starting in 2007."

The substance is now being regulated in Europe, "although apparently some stuff is still sneaking through," Dr. Belsito said. "To date, I know of no cases in the U.S., although Dr. Melanie Pratt has had a few cases in Ontario."

Dimethyl fumarate "produces an extremely severe dermatitis," said Dr. Belsito, a dermatologist in private practice in Shawnee, Kan.

The unlikely story behind identification of this preservative and fungicide demonstrates the benefits of international collaboration, he noted.

First noted by dermatologists in Finland, cases of the severe dermatitis began to appear in Sweden and the U.K. The severe rash, seen predominantly on the backs of the legs, buttocks, and back, was an etiologic mystery. Through extensive sleuth work, Finnish dermatologists determined a common link – each person recently purchased furniture from a particular Chinese manufacturer.

It then became commonly called "sofa dermatitis." A contact allergy to the upholstery fabric was initially suspected. However, no common chemical or fabric was identified among the different pieces of furniture purchased by affected patients.

Dr. Magnus Bruze, an occupational and environmental dermatologist at Malmo University in Sweden, and other investigators took apart the furniture, patch tested 40 affected patients to various components, and eventually identified the culprit: dimethyl fumarate. The allergen was enclosed in packets similar in appearance to silicone packets often labeled "Warning: Do Not Eat."

Dimethyl fumarate is so volatile it can vaporize within 6 weeks. The vapors cause the dermatitis – sometimes spread out and sometimes patchy – after permeating the sofas, clothing, and shoe products during shipment.

Particularly concerning is very low exposure levels to dimethyl fumarate can trigger a reaction, concentrations well below those of common contact dermatitis allergens.

In an unprecedented move, Dr. Belsito revealed the leading contender, at least for now, for the 2012 Allergen of the Year: acrylates and methacrylates. Acrylates and methacrylates are polymers and adhesives. Methacrylate, for example, is used as bone cement for prosthetic devices placed during orthopedic surgery. The ACDS is soliciting feedback from members about naming this class of compounds at their next Allergen of the Year.

Neomcyin was the 2010 Allergen of the Year. Dr. Belsito described neomycin reactions as "common, not readily recognized, and problematic." Neomycin was chosen because of its widespread use as an over-the-counter antibiotic product; its high propensity for cross-reaction with other agents in the aminoglycoside class, including gentamicin, kanamycin, and tobramycin; and because neomycin is included as a preservative in some vaccines. Because a neomycin allergy is not a type 1 IgE-mediated, a reaction results in eczema, not anaphylaxis and death.

Gold was the 2001 Allergen of the Year, and reactions to gold are common and clinically problematic. Bacitracin (2003) and glucocorticosteroids (2005) are other allergens that are both common and clinically relevant. In contrast, thimerosal (2002) is a common but nonrelevant allergen because it has been removed from most products in the United States. A reaction to mixed dialkyl thioureas (2009), used in production of rubber products, is relatively uncommon but important when it occurs.

Dr. Belsito said that he had no relevant disclosures.

NEW ORLEANS – Dimethyl fumarate – a volatile substance included in shipments of furniture, clothing, and shoes to inhibit growth of mold – earned the distinction as the American Contact Dermatitis Society's 2011 Allergen of the Year.

"We had a difficult decision," Dr. Donald V. Belsito said. "But we decided to go with dimethyl fumarate. It caused an epidemic in Europe starting in 2007."

The substance is now being regulated in Europe, "although apparently some stuff is still sneaking through," Dr. Belsito said. "To date, I know of no cases in the U.S., although Dr. Melanie Pratt has had a few cases in Ontario."

Dimethyl fumarate "produces an extremely severe dermatitis," said Dr. Belsito, a dermatologist in private practice in Shawnee, Kan.

The unlikely story behind identification of this preservative and fungicide demonstrates the benefits of international collaboration, he noted.

First noted by dermatologists in Finland, cases of the severe dermatitis began to appear in Sweden and the U.K. The severe rash, seen predominantly on the backs of the legs, buttocks, and back, was an etiologic mystery. Through extensive sleuth work, Finnish dermatologists determined a common link – each person recently purchased furniture from a particular Chinese manufacturer.

It then became commonly called "sofa dermatitis." A contact allergy to the upholstery fabric was initially suspected. However, no common chemical or fabric was identified among the different pieces of furniture purchased by affected patients.

Dr. Magnus Bruze, an occupational and environmental dermatologist at Malmo University in Sweden, and other investigators took apart the furniture, patch tested 40 affected patients to various components, and eventually identified the culprit: dimethyl fumarate. The allergen was enclosed in packets similar in appearance to silicone packets often labeled "Warning: Do Not Eat."

Dimethyl fumarate is so volatile it can vaporize within 6 weeks. The vapors cause the dermatitis – sometimes spread out and sometimes patchy – after permeating the sofas, clothing, and shoe products during shipment.

Particularly concerning is very low exposure levels to dimethyl fumarate can trigger a reaction, concentrations well below those of common contact dermatitis allergens.

In an unprecedented move, Dr. Belsito revealed the leading contender, at least for now, for the 2012 Allergen of the Year: acrylates and methacrylates. Acrylates and methacrylates are polymers and adhesives. Methacrylate, for example, is used as bone cement for prosthetic devices placed during orthopedic surgery. The ACDS is soliciting feedback from members about naming this class of compounds at their next Allergen of the Year.

Neomcyin was the 2010 Allergen of the Year. Dr. Belsito described neomycin reactions as "common, not readily recognized, and problematic." Neomycin was chosen because of its widespread use as an over-the-counter antibiotic product; its high propensity for cross-reaction with other agents in the aminoglycoside class, including gentamicin, kanamycin, and tobramycin; and because neomycin is included as a preservative in some vaccines. Because a neomycin allergy is not a type 1 IgE-mediated, a reaction results in eczema, not anaphylaxis and death.

Gold was the 2001 Allergen of the Year, and reactions to gold are common and clinically problematic. Bacitracin (2003) and glucocorticosteroids (2005) are other allergens that are both common and clinically relevant. In contrast, thimerosal (2002) is a common but nonrelevant allergen because it has been removed from most products in the United States. A reaction to mixed dialkyl thioureas (2009), used in production of rubber products, is relatively uncommon but important when it occurs.

Dr. Belsito said that he had no relevant disclosures.

LAS VEGAS – Immunosuppressive drug therapy is not an absolute contraindication for allergy patch testing, according to Dr. Joseph F. Fowler Jr.

A recent report on 11 patients who underwent patch testing while on a variety of systemic immunosuppressive drugs suggested patch testing may be more successful than many clinicians think, Dr. Fowler said. Speaking at the seminar sponsored by Skin Disease Education Foundation (SDEF), he fleshed out the findings with advice from his own experience in patch testing patients on immunosuppressives.

The retrospective chart review included patients on prednisone, cyclosporine, mycophenolate mofetil, or infliximab (Dermatitis 2009;20:265-70).

All but one of the patients who were taking 10 mg/day of prednisone had positive patch test reactions, said Dr. Fowler of the University of Louisville (Ky.) and president of the North American Contact Dermatitis Group.

"In the past, we had thought that about 10 mg/day was the maximum" prednisone dose that could still allow successful patch testing, but this belief was based on extrapolations of animal studies and case reports, with no hard data, he said. "I have personally seen patients who are on higher doses of prednisone produce good positive reactions."

Ideally, though, it’s best to patch test when patients are off prednisone, or on doses of 10 mg/day or less, he added. "If you could get them on every-other-day prednisone dosing, that would be even better."

For an untreated patient with fairly bad dermatitis, especially on the back, Dr. Fowler may treat for 5-7 days with a corticosteroid, perhaps prednisone 40-60 mg/day with no taper, and then stop the corticosteroid for 2-3 days before patch testing. "That’s one way you can get a person clear enough to patch test them if they’re already broken out," he said.

If the patient already is on chronic corticosteroid therapy, he tries to reduce the dose to 10 mg/day or less for several weeks before patch testing.

Dr. Fowler was surprised patients in the report who were being treated with cyclosporine 200 or 300 mg/day all had positive reactions to patch testing. "Generally, we expect cyclosporine to reduce the likelihood of positive reactions because of its broad immunosuppressant effect," he said. "These folks were on relatively low doses, so maybe that was a factor." In his own experience, Dr. Fowler said he has rarely seen positive reactions to patch testing in patients on cyclosporine, "so I think that’s problematic," he added.

One patient on mycophenolate (CellCept) 2 g/day had a negative result when patch tested but then stopped the drug and had a positive reaction on repeat patch testing. "That would suggest that the CellCept suppressed reactions," Dr. Fowler said. He advised not patch testing patients who are on CellCept, cyclosporine, tacrolimus, or azathioprine if at all possible.

One patient on infliximab (Remicade) whose last infusion occurred 3 weeks before patch testing developed multiple positive reactions. "That mirrors what I’ve been perceiving in clinical practice," he said.

Use of methotrexate or tumor necrosis factor–alpha inhibitors such as Remicade or etanercept (Enbrel) should not prevent patch testing. "I’ve had no problem patch testing people on methotrexate," Dr. Fowler said.

The report did not include antihistamines, which also are not a barrier to patch testing. "Other docs, allergists especially, tell patients they can’t take antihistamines when they’re being patch tested," he explained. "They may not be able to take antihistamines and get a good scratch test result, but remember in patch testing you’re looking at a T cell–mediated process. Antihistamines have essentially no effect on that."

Dr. Fowler has been a consultant, speaker, or researcher for Coria, Galderma, Graceway, Hyland, Johnson & Johnson, Quinnova, Ranbaxy, Shire, Stiefel, Triax, UCB, Medicis, Novartis, Abbott, Taro, Allerderm, Allergan, Amgen, Astellas, Centocor, Dermik, Dow, Genentech, Taisho, and 3M.

SDEF and this news organization are owned by Elsevier.

LAS VEGAS – Immunosuppressive drug therapy is not an absolute contraindication for allergy patch testing, according to Dr. Joseph F. Fowler Jr.

A recent report on 11 patients who underwent patch testing while on a variety of systemic immunosuppressive drugs suggested patch testing may be more successful than many clinicians think, Dr. Fowler said. Speaking at the seminar sponsored by Skin Disease Education Foundation (SDEF), he fleshed out the findings with advice from his own experience in patch testing patients on immunosuppressives.

The retrospective chart review included patients on prednisone, cyclosporine, mycophenolate mofetil, or infliximab (Dermatitis 2009;20:265-70).

All but one of the patients who were taking 10 mg/day of prednisone had positive patch test reactions, said Dr. Fowler of the University of Louisville (Ky.) and president of the North American Contact Dermatitis Group.

"In the past, we had thought that about 10 mg/day was the maximum" prednisone dose that could still allow successful patch testing, but this belief was based on extrapolations of animal studies and case reports, with no hard data, he said. "I have personally seen patients who are on higher doses of prednisone produce good positive reactions."

Ideally, though, it’s best to patch test when patients are off prednisone, or on doses of 10 mg/day or less, he added. "If you could get them on every-other-day prednisone dosing, that would be even better."

For an untreated patient with fairly bad dermatitis, especially on the back, Dr. Fowler may treat for 5-7 days with a corticosteroid, perhaps prednisone 40-60 mg/day with no taper, and then stop the corticosteroid for 2-3 days before patch testing. "That’s one way you can get a person clear enough to patch test them if they’re already broken out," he said.

If the patient already is on chronic corticosteroid therapy, he tries to reduce the dose to 10 mg/day or less for several weeks before patch testing.

Dr. Fowler was surprised patients in the report who were being treated with cyclosporine 200 or 300 mg/day all had positive reactions to patch testing. "Generally, we expect cyclosporine to reduce the likelihood of positive reactions because of its broad immunosuppressant effect," he said. "These folks were on relatively low doses, so maybe that was a factor." In his own experience, Dr. Fowler said he has rarely seen positive reactions to patch testing in patients on cyclosporine, "so I think that’s problematic," he added.

One patient on mycophenolate (CellCept) 2 g/day had a negative result when patch tested but then stopped the drug and had a positive reaction on repeat patch testing. "That would suggest that the CellCept suppressed reactions," Dr. Fowler said. He advised not patch testing patients who are on CellCept, cyclosporine, tacrolimus, or azathioprine if at all possible.

One patient on infliximab (Remicade) whose last infusion occurred 3 weeks before patch testing developed multiple positive reactions. "That mirrors what I’ve been perceiving in clinical practice," he said.

Use of methotrexate or tumor necrosis factor–alpha inhibitors such as Remicade or etanercept (Enbrel) should not prevent patch testing. "I’ve had no problem patch testing people on methotrexate," Dr. Fowler said.

The report did not include antihistamines, which also are not a barrier to patch testing. "Other docs, allergists especially, tell patients they can’t take antihistamines when they’re being patch tested," he explained. "They may not be able to take antihistamines and get a good scratch test result, but remember in patch testing you’re looking at a T cell–mediated process. Antihistamines have essentially no effect on that."

Dr. Fowler has been a consultant, speaker, or researcher for Coria, Galderma, Graceway, Hyland, Johnson & Johnson, Quinnova, Ranbaxy, Shire, Stiefel, Triax, UCB, Medicis, Novartis, Abbott, Taro, Allerderm, Allergan, Amgen, Astellas, Centocor, Dermik, Dow, Genentech, Taisho, and 3M.

SDEF and this news organization are owned by Elsevier.

LAS VEGAS – Immunosuppressive drug therapy is not an absolute contraindication for allergy patch testing, according to Dr. Joseph F. Fowler Jr.

A recent report on 11 patients who underwent patch testing while on a variety of systemic immunosuppressive drugs suggested patch testing may be more successful than many clinicians think, Dr. Fowler said. Speaking at the seminar sponsored by Skin Disease Education Foundation (SDEF), he fleshed out the findings with advice from his own experience in patch testing patients on immunosuppressives.

The retrospective chart review included patients on prednisone, cyclosporine, mycophenolate mofetil, or infliximab (Dermatitis 2009;20:265-70).

All but one of the patients who were taking 10 mg/day of prednisone had positive patch test reactions, said Dr. Fowler of the University of Louisville (Ky.) and president of the North American Contact Dermatitis Group.

"In the past, we had thought that about 10 mg/day was the maximum" prednisone dose that could still allow successful patch testing, but this belief was based on extrapolations of animal studies and case reports, with no hard data, he said. "I have personally seen patients who are on higher doses of prednisone produce good positive reactions."

Ideally, though, it’s best to patch test when patients are off prednisone, or on doses of 10 mg/day or less, he added. "If you could get them on every-other-day prednisone dosing, that would be even better."

For an untreated patient with fairly bad dermatitis, especially on the back, Dr. Fowler may treat for 5-7 days with a corticosteroid, perhaps prednisone 40-60 mg/day with no taper, and then stop the corticosteroid for 2-3 days before patch testing. "That’s one way you can get a person clear enough to patch test them if they’re already broken out," he said.

If the patient already is on chronic corticosteroid therapy, he tries to reduce the dose to 10 mg/day or less for several weeks before patch testing.

Dr. Fowler was surprised patients in the report who were being treated with cyclosporine 200 or 300 mg/day all had positive reactions to patch testing. "Generally, we expect cyclosporine to reduce the likelihood of positive reactions because of its broad immunosuppressant effect," he said. "These folks were on relatively low doses, so maybe that was a factor." In his own experience, Dr. Fowler said he has rarely seen positive reactions to patch testing in patients on cyclosporine, "so I think that’s problematic," he added.

One patient on mycophenolate (CellCept) 2 g/day had a negative result when patch tested but then stopped the drug and had a positive reaction on repeat patch testing. "That would suggest that the CellCept suppressed reactions," Dr. Fowler said. He advised not patch testing patients who are on CellCept, cyclosporine, tacrolimus, or azathioprine if at all possible.

One patient on infliximab (Remicade) whose last infusion occurred 3 weeks before patch testing developed multiple positive reactions. "That mirrors what I’ve been perceiving in clinical practice," he said.

Use of methotrexate or tumor necrosis factor–alpha inhibitors such as Remicade or etanercept (Enbrel) should not prevent patch testing. "I’ve had no problem patch testing people on methotrexate," Dr. Fowler said.

The report did not include antihistamines, which also are not a barrier to patch testing. "Other docs, allergists especially, tell patients they can’t take antihistamines when they’re being patch tested," he explained. "They may not be able to take antihistamines and get a good scratch test result, but remember in patch testing you’re looking at a T cell–mediated process. Antihistamines have essentially no effect on that."

Dr. Fowler has been a consultant, speaker, or researcher for Coria, Galderma, Graceway, Hyland, Johnson & Johnson, Quinnova, Ranbaxy, Shire, Stiefel, Triax, UCB, Medicis, Novartis, Abbott, Taro, Allerderm, Allergan, Amgen, Astellas, Centocor, Dermik, Dow, Genentech, Taisho, and 3M.

SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO – What do you consider when one of your atopic pediatric patients has recalcitrant dermatitis? Or a new-onset dermatitis that lasts longer than 2 months? It might be time to expand your differential diagnosis to consider contact dermatitis, Dr. Sharon Jacob said.

There is a high prevalence of allergic contact dermatitis in moderate to severe atopic patients. Also, think systemic allergic contact dermatitis in highly sensitized children. Although more commonly reported in adults, systemic allergies can affect pediatric patients, Dr. Jacob said at a meeting sponsored by Skin Disease Education Foundation (SDEF).

Exposure to nickel, cobalt, fragrances, formaldehyde and balsam of Peru – including from dietary sources – can trigger a systemic reaction. System allergy "should be considered in children with a positive patch test who fail to improve with skin contact avoidance," she said.

A diet devoid of the suspected trigger(s) for 6 weeks or more can make a difference for some recalcitrant children, said Dr. Jacob, an assistant clinical professor of medicine (dermatology) and pediatrics at the University of California, San Diego, and at Rady Children’s Hospital. Such an avoidance diet improved the outcome for eight pediatric patients with systemic allergies, according to a recent report from Dr. Jacob and Dr. C. Matiz (Pediatr. Dermatol. 2010 Aug 27 [doi: 10.1111/j.1525-1470.2010.01130.x]).

An avoidance diet is particularly challenging for children with allergy to balsam of Peru. This allergen is found in many foods, including tomatoes, citrus, and certain spices, according to a study in adults (J. Am. Acad. Dermatol. 2001;45:377-81).

"The food we have the most problem with is ketchup. Ketchup and pizza are the bane of my existence," Dr. Jacob said. Keep the diet simple if possible and encourage adherence with incentives for the child, such as a points and rewards system, she added.

Be careful how you counsel these children, Dr. Jacob said. "Start off with the fact they cannot have asparagus – 'Yes!' – or spinach 'Yay!' Then mention ketchup, chocolate, and soda, and you become the evil contact derm pediatrician."

Sometimes an affected anatomic site is an important clinical clue. For example, Dr. Jacob described a 10-month-old child with generalized dermatitis who also presented with specific perioral dermatitis. "When we see this we think balsam of Peru." Involvement of the eyelids is another clinical clue.

Another interesting case Dr. Jacob presented was a toddler with a fragrance contact allergy that triggered a systemic reaction. Initially, however, she had to figure out how a toddler could have an allergy to fragrance. She discovered that the toddler became sensitized from "connubial contact" – or a physical transfer – of fragrance from the mother’s neck. Following this discovery, the child was doing well until a flare associated with vanilla teething wafers. "It’s amazing how much vanilla is everywhere."

When an allergen or chemical is transferred by the patient to another site on their body, it is called "ectopic dermatitis." Dr. Jacob cited the case of a 3-year-old whose older sister lacquered her fingernails, for example. The younger child scratched other areas and reacted to the tosylamide formaldehyde resin on her nails.

If you have a child whose controlled condition suddenly worsens in their atopic areas, consider these potential culprits: lanolin, neomycin, and bacitracin, Dr. Jacob said.

Lanolin is derived from the sebaceous gland in sheep. Although removed from most wool clothing during processing, it remains in cashmere clothing to keep it soft. "Lanolin is a top offender in children – because it is used in emollients," Dr. Jacob said.

Also assess these patients for exposure to plants in the Compositae family – including feverfew and chamomile. Keep in mind some components may be found in preparations you prescribe for their atopic dermatitis, such as bisabolol, an alcohol compound derived from chamomile and found in Aquaphor ointment (Beiersdorf Inc.) and sometimes prescribed for atopic dermatitis in children (Pediatr. Dermatol. 2010;27:103-4)

Also watch out for emulsifiers used in diaper creams and topical steroids, including sorbitan sesquioleate. Reports of contact dermatitis to this sorbitan are increasing (Dermatitis. 2008:19:339-41).

Dr. Jacob noted that patch testing of children for contact allergies is "off-label" – not approved by the Food and Drug Administration.

A meeting attendee asked Dr. Jacob about the youngest age patient that she will patch test. "I have patch tested a patient as young as 10 months old. But I generally do not patch test children under 5 years old unless absolutely indicated," she replied. She first tries "preemptive avoidance" of suspected allergens in these young children before patch testing.

SDEF and this news organization are owned by Elsevier. Dr. Jacob is a speaker for Coria Laboratories, Astellas Pharma Inc., and Shire. She is also an independent investigator for Allerderm, maker of the T.R.U.E. test.

SAN FRANCISCO – What do you consider when one of your atopic pediatric patients has recalcitrant dermatitis? Or a new-onset dermatitis that lasts longer than 2 months? It might be time to expand your differential diagnosis to consider contact dermatitis, Dr. Sharon Jacob said.

There is a high prevalence of allergic contact dermatitis in moderate to severe atopic patients. Also, think systemic allergic contact dermatitis in highly sensitized children. Although more commonly reported in adults, systemic allergies can affect pediatric patients, Dr. Jacob said at a meeting sponsored by Skin Disease Education Foundation (SDEF).

Exposure to nickel, cobalt, fragrances, formaldehyde and balsam of Peru – including from dietary sources – can trigger a systemic reaction. System allergy "should be considered in children with a positive patch test who fail to improve with skin contact avoidance," she said.

A diet devoid of the suspected trigger(s) for 6 weeks or more can make a difference for some recalcitrant children, said Dr. Jacob, an assistant clinical professor of medicine (dermatology) and pediatrics at the University of California, San Diego, and at Rady Children’s Hospital. Such an avoidance diet improved the outcome for eight pediatric patients with systemic allergies, according to a recent report from Dr. Jacob and Dr. C. Matiz (Pediatr. Dermatol. 2010 Aug 27 [doi: 10.1111/j.1525-1470.2010.01130.x]).

An avoidance diet is particularly challenging for children with allergy to balsam of Peru. This allergen is found in many foods, including tomatoes, citrus, and certain spices, according to a study in adults (J. Am. Acad. Dermatol. 2001;45:377-81).

"The food we have the most problem with is ketchup. Ketchup and pizza are the bane of my existence," Dr. Jacob said. Keep the diet simple if possible and encourage adherence with incentives for the child, such as a points and rewards system, she added.

Be careful how you counsel these children, Dr. Jacob said. "Start off with the fact they cannot have asparagus – 'Yes!' – or spinach 'Yay!' Then mention ketchup, chocolate, and soda, and you become the evil contact derm pediatrician."

Sometimes an affected anatomic site is an important clinical clue. For example, Dr. Jacob described a 10-month-old child with generalized dermatitis who also presented with specific perioral dermatitis. "When we see this we think balsam of Peru." Involvement of the eyelids is another clinical clue.

Another interesting case Dr. Jacob presented was a toddler with a fragrance contact allergy that triggered a systemic reaction. Initially, however, she had to figure out how a toddler could have an allergy to fragrance. She discovered that the toddler became sensitized from "connubial contact" – or a physical transfer – of fragrance from the mother’s neck. Following this discovery, the child was doing well until a flare associated with vanilla teething wafers. "It’s amazing how much vanilla is everywhere."

When an allergen or chemical is transferred by the patient to another site on their body, it is called "ectopic dermatitis." Dr. Jacob cited the case of a 3-year-old whose older sister lacquered her fingernails, for example. The younger child scratched other areas and reacted to the tosylamide formaldehyde resin on her nails.

If you have a child whose controlled condition suddenly worsens in their atopic areas, consider these potential culprits: lanolin, neomycin, and bacitracin, Dr. Jacob said.

Lanolin is derived from the sebaceous gland in sheep. Although removed from most wool clothing during processing, it remains in cashmere clothing to keep it soft. "Lanolin is a top offender in children – because it is used in emollients," Dr. Jacob said.

Also assess these patients for exposure to plants in the Compositae family – including feverfew and chamomile. Keep in mind some components may be found in preparations you prescribe for their atopic dermatitis, such as bisabolol, an alcohol compound derived from chamomile and found in Aquaphor ointment (Beiersdorf Inc.) and sometimes prescribed for atopic dermatitis in children (Pediatr. Dermatol. 2010;27:103-4)

Also watch out for emulsifiers used in diaper creams and topical steroids, including sorbitan sesquioleate. Reports of contact dermatitis to this sorbitan are increasing (Dermatitis. 2008:19:339-41).

Dr. Jacob noted that patch testing of children for contact allergies is "off-label" – not approved by the Food and Drug Administration.

A meeting attendee asked Dr. Jacob about the youngest age patient that she will patch test. "I have patch tested a patient as young as 10 months old. But I generally do not patch test children under 5 years old unless absolutely indicated," she replied. She first tries "preemptive avoidance" of suspected allergens in these young children before patch testing.

SDEF and this news organization are owned by Elsevier. Dr. Jacob is a speaker for Coria Laboratories, Astellas Pharma Inc., and Shire. She is also an independent investigator for Allerderm, maker of the T.R.U.E. test.

SAN FRANCISCO – What do you consider when one of your atopic pediatric patients has recalcitrant dermatitis? Or a new-onset dermatitis that lasts longer than 2 months? It might be time to expand your differential diagnosis to consider contact dermatitis, Dr. Sharon Jacob said.

There is a high prevalence of allergic contact dermatitis in moderate to severe atopic patients. Also, think systemic allergic contact dermatitis in highly sensitized children. Although more commonly reported in adults, systemic allergies can affect pediatric patients, Dr. Jacob said at a meeting sponsored by Skin Disease Education Foundation (SDEF).

Exposure to nickel, cobalt, fragrances, formaldehyde and balsam of Peru – including from dietary sources – can trigger a systemic reaction. System allergy "should be considered in children with a positive patch test who fail to improve with skin contact avoidance," she said.

A diet devoid of the suspected trigger(s) for 6 weeks or more can make a difference for some recalcitrant children, said Dr. Jacob, an assistant clinical professor of medicine (dermatology) and pediatrics at the University of California, San Diego, and at Rady Children’s Hospital. Such an avoidance diet improved the outcome for eight pediatric patients with systemic allergies, according to a recent report from Dr. Jacob and Dr. C. Matiz (Pediatr. Dermatol. 2010 Aug 27 [doi: 10.1111/j.1525-1470.2010.01130.x]).

An avoidance diet is particularly challenging for children with allergy to balsam of Peru. This allergen is found in many foods, including tomatoes, citrus, and certain spices, according to a study in adults (J. Am. Acad. Dermatol. 2001;45:377-81).

"The food we have the most problem with is ketchup. Ketchup and pizza are the bane of my existence," Dr. Jacob said. Keep the diet simple if possible and encourage adherence with incentives for the child, such as a points and rewards system, she added.

Be careful how you counsel these children, Dr. Jacob said. "Start off with the fact they cannot have asparagus – 'Yes!' – or spinach 'Yay!' Then mention ketchup, chocolate, and soda, and you become the evil contact derm pediatrician."

Sometimes an affected anatomic site is an important clinical clue. For example, Dr. Jacob described a 10-month-old child with generalized dermatitis who also presented with specific perioral dermatitis. "When we see this we think balsam of Peru." Involvement of the eyelids is another clinical clue.

Another interesting case Dr. Jacob presented was a toddler with a fragrance contact allergy that triggered a systemic reaction. Initially, however, she had to figure out how a toddler could have an allergy to fragrance. She discovered that the toddler became sensitized from "connubial contact" – or a physical transfer – of fragrance from the mother’s neck. Following this discovery, the child was doing well until a flare associated with vanilla teething wafers. "It’s amazing how much vanilla is everywhere."

When an allergen or chemical is transferred by the patient to another site on their body, it is called "ectopic dermatitis." Dr. Jacob cited the case of a 3-year-old whose older sister lacquered her fingernails, for example. The younger child scratched other areas and reacted to the tosylamide formaldehyde resin on her nails.

If you have a child whose controlled condition suddenly worsens in their atopic areas, consider these potential culprits: lanolin, neomycin, and bacitracin, Dr. Jacob said.

Lanolin is derived from the sebaceous gland in sheep. Although removed from most wool clothing during processing, it remains in cashmere clothing to keep it soft. "Lanolin is a top offender in children – because it is used in emollients," Dr. Jacob said.

Also assess these patients for exposure to plants in the Compositae family – including feverfew and chamomile. Keep in mind some components may be found in preparations you prescribe for their atopic dermatitis, such as bisabolol, an alcohol compound derived from chamomile and found in Aquaphor ointment (Beiersdorf Inc.) and sometimes prescribed for atopic dermatitis in children (Pediatr. Dermatol. 2010;27:103-4)

Also watch out for emulsifiers used in diaper creams and topical steroids, including sorbitan sesquioleate. Reports of contact dermatitis to this sorbitan are increasing (Dermatitis. 2008:19:339-41).

Dr. Jacob noted that patch testing of children for contact allergies is "off-label" – not approved by the Food and Drug Administration.

A meeting attendee asked Dr. Jacob about the youngest age patient that she will patch test. "I have patch tested a patient as young as 10 months old. But I generally do not patch test children under 5 years old unless absolutely indicated," she replied. She first tries "preemptive avoidance" of suspected allergens in these young children before patch testing.

SDEF and this news organization are owned by Elsevier. Dr. Jacob is a speaker for Coria Laboratories, Astellas Pharma Inc., and Shire. She is also an independent investigator for Allerderm, maker of the T.R.U.E. test.