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The association between hand eczema and nickel allergy has weakened among young women in the general population following the Danish nickel regulation: results from two cross‐sectional studies
Abstract
An association between nickel contact allergy and hand eczema has previously been demonstrated. In 1990, Denmark regulated the extent of nickel release in the ear-piercing process as well as nickel release from consumer products.
This study aimed to evaluate the effect of the Danish nickel regulation by comparing the prevalence of concomitant nickel allergy and hand eczema observed in two repeated cross-sectional studies performed in the same general population in Copenhagen.
In 1990 and 2006, 3881 18-69 year olds completed a postal questionnaire and were patch tested with nickel. Data were analysed by logistic regression analyses and associations were expressed as odds ratios (ORs) with 95% confidence intervals (CIs).
The prevalence of concomitant nickel contact allergy and a history of hand eczema decreased among 18-35-year-old women from 9.0% in 1990 to 2.1% in 2006 (P < 0.01). The association between nickel contact allergy and a history of hand eczema decreased in this age group between 1990 (OR = 3.63; CI = 1.33-9.96) and 2006 (OR = 0.65; CI = 0.29-1.46). Among older women, no significant changes were observed in the association between nickel contact allergy and hand eczema. Conclusions: Regulatory control of nickel exposure may have reduced the effect of nickel on hand eczema in the young female population.
... A significantly lower prevalence of nickel allergy was found in younger girls than in older girls (3.9% versus 17.1%) (p = 0.004), indicating an effect of the Danish Nickel Regulation, and possibly differences in nickel exposure. The same pattern was reflected in a study that compared the prevalence in a Danish population at two time points (274 women in 1990-1991, and 1843 women in 2006-2008) (12). A significantly lower prevalence of nickel allergy was seen among the youngest women (18-35 years) in 2006 than in 1990 (11.4% versus 19.8%) (p = 0.02). ...
... A lower prevalence was also found among Danish women ear-pierced after than those ear-pierced before implementation of the Danish Nickel Regulation (e.g. 6.9% for those ear-pierced between 1990-2006, and 15.6% for those ear-pierced before 1990) (p = 0.004) (10,12,14,20). After implementation of the EU Nickel Directive, a considerable decrease in the prevalence of nickel allergy among dermatitis patients aged 1-16 years was seen in several EU countries (28). ...
Nickel contact allergy remains a problem in EU countries, despite the EU Nickel Directive. To study the prevalence of nickel allergy in EU countries following the implementation of the EU Nickel Directive, we performed a systematic search in PubMed for studies that examined the prevalence of nickel allergy in EU countries published during 2005–2016. We identified 46 studies: 10 in the general population and 36 in patch tested dermatitis patients. A significantly lower prevalence of nickel allergy after than before the implementation of the EU Nickel Directive was found in women aged 18–35 years (11.4% versus 19.8%) (p = 0.02), in female dermatitis patients aged ≤17 years (14.3% versus 29.2%) (p < 0.0001), and in dermatitis patients aged 18–30 years (women: 20.2% versus 36.6%) (p < 0.0001) (men: 4.9% versus 6.6%) (p < 0.0001). Overall, the prevalence was higher in southern than in northern EU countries, and generally remained high, affecting 8–18% of the general population. A consistent pattern of decreasing prevalence of nickel allergy in some EU countries was observed, although the prevalence among young women remains high. Steps should be taken for better prevention of nickel allergy in EU countries.
... These publications have mainly focused on hand eczema, contact allergy, atopic dermatitis, rhinitis, airway symptoms, lung function and chemical intolerance. 5,6,[25][26][27][28] Exposure to environmental tobacco smoke has been associated with decreased lung function, respiratory symptoms and rhinitis symptoms whereas no associations were found between other sources of indoor air pollution and lung function, allergic or respiratory symptoms. 5,6 Data from the Health2006 cohort have also demonstrated a decreased prevalence of nickel allergy 26,27 after the Danish nickel regulation initiative and a modest decrease in contact allergy to a wide panel of allergens. ...
... 5,6,[25][26][27][28] Exposure to environmental tobacco smoke has been associated with decreased lung function, respiratory symptoms and rhinitis symptoms whereas no associations were found between other sources of indoor air pollution and lung function, allergic or respiratory symptoms. 5,6 Data from the Health2006 cohort have also demonstrated a decreased prevalence of nickel allergy 26,27 after the Danish nickel regulation initiative and a modest decrease in contact allergy to a wide panel of allergens. 28 Mutations in the filaggrin gene are also the topic of a number of publications. ...
... Kivétel Olaszország, ahol növekedést tapasztaltak [42]. Dániában szintén a fiatalabb generáció, a 18-35 éves nőbetegek nikkelpozitivitása csökkent [43,44]. A pozitivitások gyakorisága a felsőbb korosztályokban regisztrálható, aminek elsősorban terápiás következményeivel kell számolnunk, mint például protézisek, sztentek stb. ...
Összefoglaló. Bevezetés: A nikkel széleskörűen elterjedt fém és kontaktallergén. Megtalálható mindennapi használati tárgyainkban, feldolgozza az ipari termelés, és az egészségügyben is rendre bővül alkalmazási köre. Egyidejűleg a társadalom növekvő hányadánál fordul elő nikkel-kontaktszenzibilizáció. Célkitűzés: Az epicutan tesztelt betegcsoport adatainak feldolgozása, kiemelve a nikkelpozitív betegek megoszlását nem, életkor, diagnózis, a klinikai tünetek lokalizációja és a társult fémérzékenység szerint, továbbá a 2004 óta érvényes európai uniós Nikkel Direktívák hatásainak tanulmányozása. Módszer: A közlemény a Semmelweis Egyetem Bőr-, Nemikórtani és Bőronkológiai Klinikájának Allergológia Laboratórium és Szakambulanciáján 1994-től 2014-ig 13 693 fő (10-87 év közötti) standard környezeti epicutan sorral tesztelt beteg adatait vizsgálja retrospektív módon. Eredmények: Az összes vizsgált bőrbeteg nikkelszenzibilizációs aránya 1994-ben 13,1%, 2004-ben 11,5%, 2014-ben 19,1% volt. A nikkel-kontaktdermatitis főként nőbetegeknél (93,0%) fordul elő. A klinikai tünetek elsősorban a karokra és az arcra lokalizálódnak. Nikkelérzékenyeknél az allergiás kontaktdermatitis diagnózisa 65,8%, atopiás dermatitis 9,7%-nál fordul elő. A nikkelérzékenységhez leggyakrabban társult fémallergének a kobalt és a króm. Az 1994-2004-es periódushoz képest az európai uniós Nikkel Direktívákat követő 10 évben a szenzibilizáció százalékos emelkedése szignifikáns volt, ugyanakkor a nikkelpozitívak évenkénti száma csökkent. 1994-ben a betegek legnagyobb hányada (26,5%) a 20-24 éves korcsoportba tartozott, 2004-ben szintén (20,8%), 2014-ben azonban a 35-39 éves korosztályhoz (15,1%). Következtetések: A nikkelszenzibilizáció korban eltolódást mutat az idősebb korosztály felé, a 35 évesnél fiatalabb betegek száma mérséklődött. A Nikkel Direktívák révén a fiatalabbak későbbi életkorban és kisebb mértékű nikkelexpozíciónak vannak kitéve. A vizsgált betegek nikkelérzékenységének százalékos emelkedése miatt azonban újabb szabályozások bevezetése és a hatályban lévők módosítása szükségszerű. Orv Hetil. 2021; 162(16): 629-637.
Summary:
Introduction:
Nickel is a widely used metal and contact allergen. It can be found in our everyday objects and it is becoming more prevalent in healthcare. Simultaneously, nickel contact sensitization occurs more frequently.
Objective:
Analysis of data of patch tested patients by gender, age, diagnosis, localization of skin lesions, and associated metal sensitivity. Furthermore, to study the effects of the European Nickel Directives in force since 2004.
Method:
Retrospective analysis of data of 13 693 patients (aged 10-87) tested with a standard series of contact allergens at the Allergy Outpatient Unit and Laboratory of the Department, Venereology and Dermatooncology, Semmelweis University.
Result:
Nickel sensitization of all examined patients was 13.1% in 1994, 11.5% in 2004, and 19.1% in 2014. Contact dermatitis occurred mainly in females (93.0%). Skin lesions are primarily localized to the arms and face. Diagnosis of allergic contact dermatitis occurred in 65.8%, and atopic dermatitis in 9.7% of tested patients. Commonly associated metal sensitivities were cobalt and chromium. In the 10 years following the Nickel Directives, the increase of the ratio of sensitized patients was significant while the number of nickel-positives per year decreased. Both in 1994 and 2004, the largest proportion of patients belonged to the 20-24 age group (26.5% and 20.8%, respectively), but in 2014, to the 35-39 age group (15.1%).
Conclusion:
Nickel sensitization shifts towards the older age group, with a decrease in young patients. Because of the Nickel Directives, people are exposed to nickel at a later age and to a lesser extent. Due to the increase of the ratio of nickel-sensitive patients, it is necessary to introduce new regulations and amend the existing ones. Orv Hetil. 2021; 162(16): 629-637.
... 208 The association between nickel allergy and hand eczema declined in young Danish women of the general population following implementation of the EU Nickel Directive, indicating a better prognosis due to reduced nickel exposure. 209 ...
Nickel is the most frequent cause of contact allergy worldwide and has been studied extensively. This clinical review provides an updated overview of the epidemiology, exposure sources, methods for exposure quantification, skin deposition and penetration, immunology, diagnosis, thresholds for sensitization and elicitation, clinical expression, prevention and treatment. The implementation of a nickel regulation in Europe led to a decrease in the prevalence of nickel allergy, as well as a change in the clinical expression and disease severity. Still, the prevalence of nickel allergy in the European general population is approximately 8‐19% in adults and 8‐10% in children and adolescents, with a strong female predominance. Well‐known consumer items such as jewellery and metal in clothing are still the main causes of nickel allergy and dermatitis, although a wide range of items for both private and occupational use may cause dermatitis. Allergic nickel dermatitis may be localized to the nickel exposure site, be more widespread or present as hand eczema. Today, efficient methods for exposure quantification exist, and new insights regarding the associated risk factors and the immunological mechanisms underlying the disease have been accomplished. Nevertheless, questions remain in relation to the pathogenesis, the persistent high prevalence and treatment of severe cases.
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... Increased exposure to Ni has attracted attention in human health not only for industrial workers but also for the general population (Thyssen et al. 2009;Jensen et al. 2011). Of particular interest is potential adverse health effect associated with prenatal exposure to Ni (Forgacs et al. 2012). ...
There is a proposed link between prenatal nickel (Ni) exposure and preterm low birth weight (PLBW); however, this association remains unclear. Selenium (Se) may modify this relationship by protecting against Ni toxicity. Concentrations of Ni and Se were measured in urine samples collected from 408 pregnant women (102 PLBW cases and 306 matched controls) in China. Conditional logistic regression was utilized to explore the association between Ni levels and PLBW, as well as the effect modification by Se on this association. A significant association was observed between higher maternal urinary Ni levels and risk of PLBW [adjusted odds ratio (OR) = 2.80 (95% confidence interval (CI): 1.44, 5.44) for the highest tertile], and this association was more apparent among female infants than that among male infants. Further analyses showed that mothers with high urinary Ni and low urinary Se levels had a significantly increased risk for PLBW [adjusted OR = 2.87 (95% CI: 1.09, 7.56)] compared with the mothers with low urinary Ni and high urinary Se levels. Our study indicates that prenatal exposure to Ni was a risk factor for PLBW. Se might provide protection against the toxicity of Ni.
... Based on experience, limitations in exposure based on elicitation thresholds will, apart from helping the sensitised consumer, also significantly reduce the risk of induction. This is the case for nickel allergy, where the restrictions in the EU nickel directive are based on elicitation threshold, leading to a significant reduction in new cases of sensitisation in young women (273) and in a reduction in morbidity, i.e. elicitation (274). Another example is restriction of chromium VI in cement (275). ...
... Regulations in Europe reducing the permissible amount of nickel release from jewelry and other items have significantly reduced the prevalence of nickel allergy and nickel dermatitis [17,42,43]. Similar measures have been advocated in regards to nickel containing coins. ...
Introduction
Contact with nickel-releasing coins as a cause of hand dermatitis has been debated.
Aim
Studying a hand dermatitis risk from handling Kuwaiti cupronickel coins among nickel-allergic and nickel non-allergic subjects.
Material and methods
One hundred hand dermatitis patients (group I: nickel-allergic) and 100 matched patients (group II: nickel non-allergic) were selected from over 500 hand dermatitis cases seen between September 2014 and September 2015. Nickel released from Kuwaiti cupronickel coins immersed in a standardized artificial sweat solution was measured at 1, 24, 48, 144 and 168 h at room temperature. Subjects in both groups were exposed to nickel releasing coins. The process was repeated after 3 months using nickel coated coins as controls.
Results
Nickel released from 20, 50 and 100 fils Kuwaiti cupronickel coins at 1 week was 28.64, 32.76, 35.76 μg/cm²/week, respectively. Ninety-one patients (29 males, 62 females) in group I and 87 patients (38 males, 49 females) in group II completed the study. 47.3% in group I vs. 13.8% in group II developed dermatitis on exposure to nickel releasing coins. Nickel coated coins resulted in dermatitis in 8.8% of group I vs. 5.7% in group II.
Conclusions
Nickel is released significantly from cupronickel Kuwaiti coins. Handling of coins caused dermatitis more often in patients with nickel-allergy compared to nickel non-allergic patients.
... with dermatitis (4,14,15). However, a significant proportion of young individuals still become sensitized to nickel and report dermatitis (16,17), and a high prevalence of allergy, exceeding 10%, is seen both among young women in the general population and among young female patients with dermatitis in Europe (1)(2)(3). There may be several explanations for the persistence of nickel allergy, in particular related to the nickel regulation and its enforcement (4). ...
Background:
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.
Objectives:
To identify current self-reported metallic exposures leading to dermatitis in nickel-allergic patients, and the minimum contact time needed for dermatitis to occur.
Methods:
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.
Results:
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.
Conclusions:
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.
... 15,[21][22][23] No entanto, a aplicação destas medidas preventivas tem exercido efeitos positivos na sensibilização, reduzindo significativamente a percentagem da população sensibilizada ao Ni, sobretudo nos países nórdicos, pioneiros nesta iniciativa. 14,15,24 Comprovando o interesse destas medidas verifica-se que a sensibilização ao Ni na Dinamarca é significativamente inferior nas mulheres jovens cujas orelhas foram furadas depois da implementação destas medidas que regulamentam a quantidade de níquel libertada pelos adornos metálicos (odds ratio 1,20 vs 3,34). 25 Pela análise dos dados do presente estudo infere-se que, para já, a Directiva do Níquel que foi transcrita para a legislação nacional apenas em 2005 poderá começar a ter algum efeito nas mulheres jovens. ...
strong>Introduction: Metals are a common cause of allergic contact dermatitis. After the introduction of the EU Nickel Directive (1994/27/CE; 2004/96/EC) and, more recently, the Cement Directive (2003/53/EC) there has been a significant decrease in sensitization to metals mainly in the Nordic countries. The applicability of these directives and their impact in the Portuguese population is unknown.
Material and Methods: A retrospective study (1992-2011) was carried out in our patch test clinic to assess the temporal trend of metal sensitization (nickel [Ni], cobalt [Co] and chromium [Cr]) along the last 20 years, particularly considering age, sex and its relation with occupational activity.
Results: Out of 5 250 consecutively patch-tested patients, 1 626 (31%) were reactive to at least one metal (26.5% to Ni; 10.0% to Co and 7.9% to Cr). Women had a higher prevalence of sensitization to Ni (34.4% vs 8.9%) whereas men were more reactive to Cr (11.5% vs 5.0%). Nickel sensitization did not decrease significantly over the years, although in recent years among women sensitized to nickel the percentage of younger patients (16-30 years-old) is significantly lower (p < 0.001). Chromium sensitization significantly decreased, particularly in men (r = -0.535), and mainly in the construction workers (r = -0.639). Chromium reactivity associated with the shoe dermatitis has remained stable.
Discussion: We emphasize the higher and stable percentage of nickel sensitized individuals suggesting, so far, a low impact from the EU Ni directive, although a decreasing percentage in the the younger group among Ni sensitized women may suggest a beneficial effect is becoming evident is this age group. On the contrary, the impact of the directive regarding the modification of Cr in cement seems to be effective. There is now a need to regulate chromium content in leather products, namely in shoes.
Conclusions: The regulation of interventional measures related either to the manufacture and trade of adornments or professional use will better protect the population of allergy to metals.
Keywords: Dermatitis, Allergic Contact; Chromium; Cobalt; European Union; Metals; Nickel; Patch Tests; Portugal.
... Thyssen i wsp. [8]. Badacze wykazali, że częstość uczulenia na nikiel wśród kobiet w wieku 18-35 lat spadła z 9,0% w 1990 roku do 2,1% w roku 2006. ...
Introduction. Eczema is a syndrome of polimorphous dermal eruptions in response to inflammation. Contact eczema is an eczema caused by contact with environmental agents, usually irritating chemicals or contact allergens. Aim of the study. The aim of the study was the analysis of epidermal patch tests in contact eczema patients. Material and methods. The study participants included 70 patients with contact eczema, 41 women and 29 men, aged 18-70. The patients underwent physical examination and epidermal patch tests with European Standard Series of allergens using IQ Ultra (Chemotechnique Diagnostics) chamber application system. The patches were applied onto patients' back, in the interscapular region, for 48 hours. After that time, the patches were removed and first readout was made. The second readout was after 72 hours from the moment of patch application. The results were interpreted according to the international patch test results recording system. Results. Positive results of patch tests were obtained from 22 (31.4%) patients. Nickel sulphate was the most frequent sensitizer, with 14 (63.6%) patients showing positive patch tests to that metal. It was followed, in the descending order, by potassium dichromide - 8 patients (36.3%), cobalt chloride - 5 (22.7%), PPD - 3 (13.6%), balsam of Peru - 2 (9.0%), and fragrance mix I - 2 patients (9.0%). Single patients (4.5%) were allergic to benzocaine, budesonide, colophony, thiuram mix and cathon CG. Ten patients (45.4%) were positive to more than 1 hapten. Hands were the site most often affected by contact eczema, and this was the case in 22 patients (31.4%). Conclusions. Hands are the sites which are most frequently affected by contact eczema. Metals, in particular nickel, are the most frequent sensitizers in patients with contact eczema.
... BHave your ears been pierced?^, and BHave you ever experienced dermatitis following skin exposure to jewelry, buttons, and watches?^, and information on post-operative changes or progression in hypersensitivity symptoms such as urticaria, dermatitis, erythema, and itching around the hip was assessed by the following questions BHave you experienced a postoperative, subsequent redness around the operated hip?^, and BHave you experienced postoperative progress in hypersensitivity?^ [28,29]. A history of atopic dermatitis was assessed by an affirmative response to the following question BHave you ever experienced dermatitis in the creases of the knees and elbows?Ŝ ...
Objective:
The relationship between metal wear debris, pseudotumor formation and metal hypersensitivity is complex and not completely understood. The purpose of this study was to assess the prevalence of pseudotumor formation in a consecutive series of metal-on-metal (MoM) total hip arthroplasty (THA) and to investigate its relationship to serum metal-ion levels and hypersensitivity to metal.
Methods:
Forty-one patients (31 males), mean age 52 (28-68) years, with a total of 49 large-head MoM THA participated in a 5-7-year follow-up study. Patients underwent ultrasonography, serum metal-ion concentrations were measured, metal allergy and atopic dermatitis were evaluated, and the questionnaires of the Oxford Hip Score (OHS), Harris Hip Score (HHS) and the Short-Form Health Survey (SF-36) were completed.
Results:
Pseudotumors were found in eight patients, but they were asymptomatic and their serum metal-ion levels were similar to those observed in patients with no pseudotumors (p > 0.36). The capsule-stem distance of mean 8.6 mm (SD 3.82, 95 % CI: 5.40-11.79) was wider (p = 0.02) in patients with pseudotumours than in patients without pseudotumors of mean 5.6 mm (SD 2.89, 95 % CI: 4.68-6.58). Positive patch test reactions were seen in three patients. Higher serum metal-ion levels of chromium and cobalt were significantly correlated with steeper cup inclination and smaller femoral head sizes, and were associated with female gender (p < 0.04).
Conclusion:
We found no association between pseudotumor formation, serum metal-ion levels, metal patch test reactivity, and atopic dermatitis. However, clinicians should be aware of asymptomatic pseudotumors, and we advise further exploration into the mechanisms involved in the pathogenesis of pseudotumors.
... In 2001, the EU, to reduce prevalence of nickel contact dermatitis, according to Menne et al. imposed limits on the amount of nickel up to 0.5 μg/cm 2 per week from items intended for prolonged skin contact [20]. Northen European governments introduced this restriction 10 years before the EU nickel directive, and a decrease in nickel allergy has been just observed in young Danish women from the general population [21]. Despite the new legislation, the prevalence of nickel allergy has remained high in Europe and Italy, in particular, is a leading country in Europe for the prevalence of individuals suffering from nickel allergy (32.1%) [22]. ...
... Atopic dermatitis is one of the most important risk factors for hand eczema, [8][9][10][11] whereas a possible association between hand eczema and nickel allergy has been debated. [12][13][14][15] Furthermore, occupational exposure to water and detergents is associated with hand eczema. However, although wet work has been associated with hand eczema, 7,16 some studies have also rejected an association. ...
Background:
Several studies have evaluated the incidence and prevalence of hand eczema in unselected adults. However, no studies have followed unselected adolescents from primary school into adult life to evaluate the course and risk factors for hand eczema.
Objectives:
To estimate the incidence of hand eczema from adolescence to adulthood and the prevalence of hand eczema in young adults, together with risk factors for hand eczema.
Methods:
A cohort of 1501 unselected eighth-grade schoolchildren (mean age 14 years) was established in 1995. In 2010, 1206 young adults from the cohort were asked to complete a questionnaire and participate in a clinical examination, including patch testing.
Results:
The incidence of hand eczema was 8·8 per 1000 person-years. The 1-year-period prevalence of hand eczema in the young adults was 14·3% (127 of 891) and the point prevalence 7·1% (63 of 891), with significantly higher prevalence in females. At the clinical examination 6·4% (30 of 469) had hand eczema. Factors in childhood of importance for adult hand eczema were atopic dermatitis and hand eczema. Wet work in adulthood was a risk factor, as was taking care of small children at home. Interestingly, hand eczema among unselected young adults was associated with sick leave/pension/rehabilitation, indicating possible severe social consequences. Only 39·0% of patients participated in the clinical examination, while 75·0% answered the questionnaire.
Conclusions:
A high incidence and prevalence of hand eczema were found in 28-30-year-old adults, and were highly associated with childhood hand eczema and atopic dermatitis, along with wet work and taking care of small children in adulthood. There was no association with smoking, education level or nickel allergy in childhood.
... Patients answered an allergy-specific questionnaire for assessment of allergies, information on previous exposure to metals, and information on postoperative changes or progression in hypersensitivity symptoms such as hives, eczema, redness, and itching around the hip (Hallab et al. 2001, Thyssen et al. 2009c. ...
Background
Metal-on-metal (MOM) total hip arthroplasties were reintroduced because of the problems with osteolysis and aseptic loosening related to polyethylene wear of early metal-on-polyethylene (MOP) arthroplasties. The volumetric wear rate has been greatly reduced with MOM arthroplasties; however, because of nano-size wear particles, the absolute number has been greatly increased. Thus, a source of metal ion exposure with the potential to sensitize patients is present. We hypothesized that higher amounts of wear particles result in increased release of metal ions and ultimately lead to an increased incidence of metal allergy.
Methods
52 hips in 52 patients (median age 60 (51–64) years, 30 women) were randomized to either a MOM hip resurfacing system (ReCap) or a standard MOP total hip arthoplasty (Mallory Head/Exeter). Spot urine samples were collected preoperatively, postoperatively, after 3 months, and after 1, 2, and 5 years and tested with inductively coupled plasma-sector field mass spectrometry. After 5 years, hypersensitivity to metals was evaluated by patch testing and lymphocyte transformation assay. In addition, the patients answered a questionnaire about hypersensitivity.
Results
A statistically significant 10- to 20-fold increase in urinary levels of cobalt and chromium was observed throughout the entire follow-up in the MOM group. The prevalence of metal allergy was similar between groups.
Interpretation
While we observed significantly increased levels of metal ions in the urine during the entire follow-up period, no difference in prevalence of metal allergy was observed in the MOM group. However, the effect of long-term metal exposure remains uncertain.
... Despite the fact that the prevalence of nickel allergy decreased in European countries after the introduction of regulations on nickel, nickel allergy remains prevalent, and the proportion of positive nickel patch test reactions has remained stable at 10-20% in Europe (34)(35)(36). Nickel regulations can be regarded as an approach to reduce nickel allergy problems, but not as an attempt to abolish nickel allergy. ...
In Korea, the prevalence of nickel allergy has shown a sharply increasing trend. Cobalt contact allergy is often associated with concomitant reactions to nickel, and is more common in Korea than in western countries.
The aim of the present study was to investigate the prevalence of items that release nickel and cobalt on the Korean market.
A total of 471 items that included 193 branded jewellery, 202 non-branded jewellery and 76 metal clothing items were sampled and studied with a dimethylglyoxime (DMG) test and a cobalt spot test to detect nickel and cobalt release, respectively.
Nickel release was detected in 47.8% of the tested items. The positive rates in the DMG test were 12.4% for the branded jewellery, 70.8% for the non-branded jewellery, and 76.3% for the metal clothing items. Cobalt release was found in 6.2% of items. Among the types of jewellery, belts and hair pins showed higher positive rates in both the DMG test and the cobalt spot test.
Our study shows that the prevalence of items that release nickel or cobalt among jewellery and metal clothing items is high in Korea.
Background
The impact of hand eczema (HE) on Health‐Related Quality of Life (HRQoL) has only been sparsely studied in a general population setting, and never by use of the disease specific Quality Of Life in Hand eczema Questionnaire (QOLHEQ).
Objectives
To examine the HRQoL of unselected individuals with HE using the QOLHEQ. Further, to provide prevalence estimates of severe and chronic HE (CHE), and to contrast overall health related outcomes between individuals with and without HE.
Methods
In this nationwide, cross‐sectional study a questionnaire covering questions on HE related outcomes, and overall health was sent to a random sample of 100 000 Danish adults via a secure digital mailbox, linked to their unique civil registration numbers. Data on demographic characteristics were retrieved from the civil registration system. Individuals reporting HE, further answered the QOLHEQ and other disease specific questions.
Results
The response rate was 42.7% ( n = 42 691). Total estimates of lifetime, 1‐year and point prevalences of HE were 24.4%, 13.3% and 5.8%. Of individuals reporting a 1‐year prevalence, 35.1% reported moderate–severe disease and 82.6% CHE. Individuals with HE were more likely to report less good or poor overall health, and sick leave (any reason), compared to those without. In the 2176 (92.5%) with current HE who completed the QOLHEQ, median QOLHEQ scores corresponded to a moderate impairment of the symptoms and treatment and prevention domains and a slight impairment overall and for the emotions and functioning domains. Factors that were strongly associated with moderate to severe HRQoL impairment included severe, chronic and occupational HE as well as female sex.
Conclusions
HE is highly prevalent, bears a considerable burden on society and significantly affects the lives of impacted individuals. Our findings indicate a necessity for targeted prevention aimed at high‐risk groups, and support and treatment for those most affected.
Background
An updated understanding of allergic contact dermatitis (ACD) is needed, particularly in children.
Objectives
To compare positive and clinically-relevant reactions in children vs. adults referred for patch testing.
Methods
Retrospective analysis of 1,871 children and 41,699 adults from the North American Contact Dermatitis Group from 2001-2018.
Results
Both final diagnosis of ACD (55.2% vs. 57.3%; Chi-square, P-value: 0.0716) and prevalence of ≥1 currently relevant reaction to a NACDG screening allergen (49.2% vs. 52.2%; P-value: 0.1178) were similar between children and adults. In children, the most commonly currently-relevant allergens were nickel sulfate (17.3%), hydroperoxides of linalool (7.8%), methylisothiazolinone (7.7%), cobalt chloride (7.0%), and fragrance mix I (4.9%). Approximately, one-fifth of children were positive to a non-NACDG allergen.
Conclusion
Over half of children referred for patch testing were diagnosed with ACD. The most common relevant allergens in children were nickel sulfate, cobalt chloride, and hydroperoxides of linalool. Twenty percent of children had at least one positive reaction to allergens/substances not on the NACDG screening series, underscoring the need for comprehensive testing.
Contact dermatitis (CD) is among the most common inflammatory dermatological conditions and includes allergic CD, photoallergic CD, irritant CD, photoirritant CD (also called phototoxic CD) and protein CD. Occupational CD can be of any type and is the most prevalent occupational skin disease. Each CD type is characterized by different immunological mechanisms and/or requisite exposures. Clinical manifestations of CD vary widely and multiple subtypes may occur simultaneously. The diagnosis relies on clinical presentation, thorough exposure assessment and evaluation with techniques such as patch testing and skin-prick testing. Management is based on patient education, avoidance strategies of specific substances, and topical treatments; in severe or recalcitrant cases, which can negatively affect the quality of life of patients, systemic medications may be needed. Contact dermatitis results from the exposure to exogenous allergens or irritants that stimulate immune responses leading to inflammation of the skin.
Background
The association between atopic dermatitis (AD) and allergic contact dermatitis (ACD) is controversial.
Objectives
To analyze the prevalence, reaction strength, and trends of the most commonly positive and relevant allergens in patients with AD referred for patch testing.
Methods
Retrospective analysis of 36,834 patients from the North American Contact Dermatitis Group 2001-2016.
Results
Most adults (56.0%) and children (52.8%) with a history of AD had a final diagnosis of ACD. Adults (66.5% vs. 65.6%; Chi-square, P=0.1459) and children (61.4% vs. 62.3%, P=0.7074) with or without a history of AD had similar proportions of ≥1 allergic patch test reaction. Adults with a history of AD had a greater number of allergic patch test positive reactions than without (2.0±2.4 vs. 1.9±2.3; t-test, P<0.0001), while children did not (1.5±1.8 vs 1.4±1.6, P=0.3839). Nickel sulfate, methylisothiazolinone, formaldehyde, fragrance mix I, sodium gold thiosulfate, and thimerosal were the most common allergens in adults and children with a history of AD. In multivariable logistic regression models, adults with vs. without a history of AD had increased odds of reacting to 10 of the top 25 NACDG screening allergens. Most allergens had similar strengths of reaction in adults or children with and without a history or current AD diagnosis, with cobalt, fragrance mix I, and propylene glycol having weaker reactions. In multivariable logistic regression, adults with vs. without AD history had increased odds of relevance for 10 of the 25 most currently relevant allergens, whereas children with AD history did not have increased relevance for any specific allergens.
Conclusion
Most patients referred for patch testing with AD history had a final diagnosis of ACD. Patients with AD history had similar likelihood of having a positive patch test reaction as those without AD history. Adults with AD history had a higher number of positive patch test reactions.
Background
Accurate assessments of the burden of hand eczema (HE) in the general population are important for public awareness and intervention.
Objectives
To provide updated estimates of prevalence and incidence, alongside additional epidemiological endpoints on HE in the general population.
Methods
PubMed, Embase and Web of Science were searched for studies reporting the prevalence and/or incidence of HE in the general population. Proportion meta‐analyses were performed to calculate pooled estimates of prevalence, incidence, severity, and proportion of individuals with HE and a history of atopic dermatitis.
Results
Sixty‐six studies were included in the quantitative analysis encompassing 568100 individuals. The pooled estimates for lifetime‐, 1‐year‐ and point prevalence were 14.5% (95% confidence interval (CI): 12.6‐16.5), 9.1 % (95% CI: 8.4‐9.8) and 4.0% (95% CI: 2.6‐5.7). The pooled incidence rate of HE was 7.3 cases/1000 person years (95% CI: 5.4‐9.5). The occurrence of HE was 1.5‐2 times higher in females than males. More than one third suffered from moderate/severe disease and around one third had a history of atopic dermatitis. HE was a recurrent, long‐lasting disease with an average age at onset in the early‐mid‐twenties.
Conclusion
HE is a highly prevalent disease in the general population and carries a significant risk of long‐term or chronic disease.
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Contact dermatitis and contact allergy are common medical conditions. But how common are they? Are certain populations, e.g., certain occupations, more affected than others? Are reactions to specific contact allergens more prevalent than to other allergens or more common in a particular subgroup? This chapter presents some basic epidemiologic principles which are important in population-based or clinic-based studies on contact dermatitis. The chapter deals with methodological issues in the analysis of clinical epidemiological studies, i.e., among patients undergoing patch testing. Common pitfalls are addressed, and factors important for the occurrence of contact dermatitis and/or contact allergy are discussed. Examples of studies on contact allergy as well as contact dermatitis in general are presented.
Nickel, chromium, and cobalt remain the most frequent causes of contact allergy in the general population, certain occupational groups, and dermatitis patients. Consumer products and occupational exposure are the main sources of sensitization and elicitation, whereas the role of medical and surgical implant is unclear. Pure metals, alloys, platings, and compounds have different ability to cause sensitization and dermatitis. Nickel release from certain items in contact with the skin and hexavalent chromium in cement and leather are limited by EU regulation for allergy prevention. Strong indications concerning reduced exposure and health benefits have been noted following the implementation of the regulations; however, the problems are still very large. The presence of cobalt in leather and the association with dermatitis among cobalt allergic patients is a new understanding. Several other metals are less frequent sensitizers, and some cause cross-reactivity. New data on cocktail effects and reactivity to nickel following short-term exposure have been published. Spot tests remain useful in the assessment of metal exposure and exposure reduction, but clearly better techniques are needed for most metals.
Background
Nickel (Ni) dermatitis remains a highly prevalent allergic condition in Italy. There is a continuous need for clinical and epidemiological surveillance to evaluate whether or not European Ni Directive has been effective in contact allergy prevention.
Objectives
To assess the prevalence of Ni dermatitis among patch‐tested patients and self‐interviewed school students, and to analyze Ni release from earlobe jewelry.
Methods
Results of patch‐tests performed in 2006‐2007, 2015‐2016, and 2017‐2018 were retrieved. A questionnaire was compiled by 315 secondary school students. Ni release from earring parts was analyzed with the EN1811:2015 method.
Results
A significant time trend of decreasing Ni‐positivity from 2006‐2007 to 2017‐2018 was observed both in the overall population (44.1% in 2006‐2007, 33.0% in 2015‐2016, 31.6% in 2017‐2018, p<0.0001) and in female patients (p<0.0001). Conversely, change was not significant in males (p=0.16). Decrease was significant for all age groups, except for those aged >60 years (p=0.51). Among 242 students who reported earring use, 130 (54%) reported symptoms at earlobes, mostly associated with jewelry of materials other than gold and silver (59% of those with earlobe symptoms). Ni release exceeded the migration limit in 4/21 (20%) earring parts.
Conclusions
A high prevalence of Ni dermatitis and earlobe symptoms were found in Rome. A decreasing time trend was noted, with a significant decline in Ni sensitivity compared to the situation observed right after Ni Directive implementation. This most likely represents the consequence of reduced Ni content in earring parts, although a major care in the use of Ni‐containing objects could contribute to explain these findings.
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Background
Contact allergy and allergic contact dermatitis are frequent conditions in the general population.
Objectives
To provide an updated estimate of the prevalence of contact allergy in the general population based on data from our previous review combined with new data from an updated search for relevant studies published between 2007 and 2017.
Methods
Two authors independently searched PubMed for studies reporting on the prevalence of contact allergy in samples of the general population. Proportion meta‐analyses were performed to calculate the pooled prevalence estimates of contact allergy.
Results
A total of 28 studies were included in the analysis, covering 20 107 patch tested individuals from the general population. Overall, the pooled prevalence of contact allergy was 20.1% (95% confidence interval [CI]: 16.8%‐23.7%). In children and adolescents (<18 years), the prevalence was 16.5% (95%CI: 13.6%‐19.7%). The prevalence was significantly higher in women (27.9% [95%CI: 21.7%‐34.5%]) than in men (13.2% [95%CI: 9.3%‐17.6%]). The most common allergen was nickel (11.4% [95%CI: 9.4%‐13.5%]), followed by fragrance mix I (3.5% [95%CI: 2.1%‐5.4%]), cobalt (2.7% [95%CI: 2.1%‐3.4%]), Myroxylon pereirae (1.8% [95%CI: 1.0%‐2.7%]), chromium (1.8% [95%CI: 1.3%‐2.6%]), p‐phenylenediamine (1.5% [95%CI: 1.0%‐2.1%]), methylchloroisothiazolinone/methylisothiazolinone (1.5% [95%CI: 0.8%‐2.5%]), and colophonium (1.3% [95%CI: 1.0%‐1.6%]).
Conclusions
This meta‐analysis confirmed that at least 20% of the general population are contact‐allergic to common environmental allergens. It highlights the need for more effective preventive strategies for common allergens in consumer goods, cosmetics, and the workplace.
Background
Hand eczema (HE) in healthcare workers (HCWs) is common. Besides wet work, healthcare work also implies exposure to contact allergens.
Objectives
To assess HE and contact allergy related to occupational exposures in HCWs.
Methods
In a cross‐sectional study, 311 HCWs with HE within the preceding 12 months and a control group of 114 HCWs without HE were investigated with the baseline series and a special patch test series based on substances found in the gloves, soaps, alcoholic hand disinfectants and hand creams provided at the hospitals.
Results
Contact allergy to rubber additives was significantly more common in HCWs with HE (6%) than in HCWs without HE (1%, P = .02). The corresponding percentages for fragrances were 11% and 3%, respectively (P = .004). Occupational HE was found in 193 of 311 (62%) HCWs. Of these, 22 of 193 (11%) had occupational allergic contact dermatitis, including 17 with glove‐related rubber contact allergy. Contact allergy to diphenylguanidine was as common as contact allergy to thiurams. Occupational contact allergy to rubber additives was significantly associated with sick‐leave related to HE.
Conclusion
Contact allergy to rubber additives in medical gloves is the most common cause of occupational allergic contact dermatitis in HCWs. Aimed patch testing with relevant rubber additives is mandatory when HE in HCWs is investigated.
Nickel is the most common skin sensitizer, affecting large proportions of the population. Nickel allergy is more prevalent among girls and women than boys and men, owing to differences in exposure patterns. There are large differences in prevalence between age groups, countries and occupations, over time. Skin exposure to nickel in various consumer articles results in nickel allergy and dermatitis on exposed body parts, including the hands. Occupational exposure to nickel is an important cause of occupational skin disease, particularly hand eczema. Nickel allergy has started to decline in some countries owing to the EU restriction of nickel.
Background:
Knowledge about the relations between skin exposures, skin symptoms and contact allergy in adolescents is limited.
Objectives:
To explore self-reported skin exposures and skin symptoms in girls and boys, and to assess the associations between exposures, symptoms and contact allergy at age 16 years.
Participants and methods:
In all, 3115 adolescents from the population-based BAMSE birth cohort answered a questionnaire at age 16 concerning various skin exposures and related skin symptoms. Of these, 2285 were patch tested.
Results:
The prevalences of self-reported piercing (55.4%), hair dyeing (50.1%) and related skin symptoms were high, particularly in girls. Piercing and itchy rash after contact with metal items were associated with increased risks of nickel allergy [respectively: odds ratio (OR) 1.77, 95%CI: 1.04-3.03, and OR 2.25, 95%CI: 1.57-3.23]. An itchy rash resulting from the use of personal hygiene products or makeup was associated with a positive patch test reaction to fragrance mix I (OR 2.11, 95%CI: 1.02-4.35).
Conclusions:
Adolescents are exposed to skin-sensitizing substances, for example because of piercing, hair dyeing, and tattooing. Such early-life skin exposure may lead to lifelong contact allergy and future allergic contact dermatitis and hand eczema.
Background
Cobalt is a strong skin sensitizer and a prevalent contact allergen. Recent studies have recognized exposure to leather articles as a potential cause of cobalt allergy.Objectives
To examine the association between contact allergy to cobalt and a history of dermatitis resulting from exposure to leather.MethodsA questionnaire case–control study was performed: the case group consisted of 183 dermatitis patients with a positive patch test reaction to cobalt chloride and a negative patch test reaction to potassium dichromate; the control group consisted of 621 dermatitis patients who did not react to either cobalt or chromium in patch testing. Comparisons were made by use of a χ2-test, Fisher's exact, and the Mann–Whitney test. Logistic regression analyses were used to test for associations while taking confounding factors into consideration.ResultsLeather was observed as the most frequent exposure source causing dermatitis in the case group. Although the case group significantly more often reported non-occupational dermatitis caused by leather exposure (p < 0.001), no association was found between cobalt allergy and dermatitis caused by work-related exposure to leather.Conclusions
Our study suggests a positive association between cobalt allergy and a history of dermatitis caused by non-occupational exposure to leather articles.
Introduction: Metals are a common cause of allergic contact dermatitis. After the introduction of the EU Nickel Directive (1994/27/CE; 2004/96/EC) and, more recently, the Cement Directive (2003/53/EC) there has been a significant decrease in sensitization to metals mainly in the Nordic countries. The applicability of these directives and their impact in the Portuguese population is unknown. Material and Methods: A retrospective study (1992-2011) was carried out in our patch test clinic to assess the temporal trend of metal sensitization (nickel [Ni], cobalt [Co] and chromium [Cr]) along the last 20 years, particularly considering age, sex and its relation with occupational activity. Results: Out of 5 250 consecutively patch-tested patients, 1 626 (31%) were reactive to at least one metal (26.5% to Ni; 10.0% to Co and 7.9% to Cr). Women had a higher prevalence of sensitization to Ni (34.4% vs 8.9%) whereas men were more reactive to Cr (11.5% vs 5.0%). Nickel sensitization did not decrease significantly over the years, although in recent years among women sensitized to nickel the percentage of younger patients (16-30 years-old) is significantly lower (p < 0.001). Chromium sensitization significantly decreased, particularly in men (r = -0.535), and mainly in the construction workers (r = -0.639). Chromium reactivity associated with the shoe dermatitis has remained stable. Discussion: We emphasize the higher and stable percentage of nickel sensitized individuals suggesting, so far, a low impact from the EU Ni directive, although a decreasing percentage in the the younger group among Ni sensitized women may suggest a beneficial effect is becoming evident is this age group. On the contrary, the impact of the directive regarding the modification of Cr in cement seems to be effective. There is now a need to regulate chromium content in leather products, namely in shoes. Conclusions: The regulation of interventional measures related either to the manufacture and trade of adornments or professional use will better protect the population of allergy to metals.
Chronic hand dermatitis is often multifactorial but allergic causes are frequent and can complicate atopic dermatitis or irritant dermatitis. The management of patients affected by hand dermatitis includes detailed interrogation and a complete examination of the skin. Allergologic tests must be systematically realized if examination is suggestive of contact dermatitis or protein contact dermatitis, if an occupational origin is suspected but also in all patients in which treatment is ineffective. Skin tests include patch tests with the European standard series, specialized or additional series if necessary. Skin tests may also include personal items used by patients on a daily basis. If protein contact dermatitis is suspected skin tests include prick tests. Only complete and definitive eviction of allergens can allow a complete and definitive cure of chronic hand dermatitis.
Copyright © 2014 Elsevier Masson SAS. All rights reserved.
Nickel is used in coins because the metal has beneficial properties, including price, colour, weight, and corrosion resistance, and also because it is easy to stamp. It has often been claimed that the duration of skin contact with coins is too short to cause nickel release and dermatitis. However, it is well known by dermatologists specialized in occupational skin diseases, and by their nickel-allergic patients, that hand eczema in cashiers and other professionals who handle coins may be caused or aggravated by nickel release from coins. In this review, we present evidence from past studies showing that nickel-containing coins can indeed pose a risk for those who handle them. For protection of the health of consumers, cashiers, and other workers who handle coins, it is suggested that coins without nickel release should be used as a substitute for the high nickel-releasing coins currently in widespread use. The key risk factor in this situation is the ability of metal alloys in coins to release nickel and contaminate the skin after repeated contact from coin handling.
Background. Sensitization to nickel, cobalt and chromium is frequent in patch test populations. The prevalence is affected by geographical and socio-cultural factors.
Objectives. To investigate the temporal trend of nickel, cobalt and chromium contact sensitization between 1996 and 2010 in north-eastern Italy.
Patients/methods. Nineteen thousand and eighty-eight patients (67.2% women and 32.8% men) with suspected allergic dermatitis underwent patch testing with the European baseline series. The associations between nickel, cobalt and chromium sensitization and patient age (in quintiles) and year of patch testing were investigated by means of multivariate logistic regression analysis.
Results. The prevalence of nickel sensitization decreased significantly among younger women (≤26 years), from 38.3% (1996–1998) to 31.9% (2002–2004), 28.3% (2005–2007) and 29.0% (2008–2010), whereas an increase was observed in the 36–45-year and 46–58-year age groups. The overall prevalence of chromium sensitization dropped from 10.2% (1996–1998) to 4.6% (2008–2010) among women, and from 11.3% (1996–1998) to 5.9% (2008–2010) among men. The prevalence of cobalt sensitization increased among younger men (≤26 years), from 2.7% (1996–1998) to 7.3% (1999–2001), 9.6% (2002–2004), and 6.6% (2005–2007).
Conclusions. Our study showed a decreasing trend of nickel sensitization (only among younger women) and of chromium sensitization in both sexes.
Hypersensitivity reactions to nickel are one of the most common in the modern world. Nickel allergy prevalence is constantly growing in many countries and represents a major health and socioeconomic issue. Herein the current understanding on nickel allergy is summarized with a practical approach to the dermatologist, allergist, and general practitioner. The personal experience with some practical clinical cases of nickel dermatitis is shared. A special emphasis is put on the possible strategies for treatment and prevention of the disease.
For those chemicals identified in point 2 above, to collect and critically analyse clinical and statistical evidence on the incidence and morbidity (clinical picture) of skin contact allergy (contact dermatitis) cases in the EU before (at least 3 years) and after the limits were set, so as to allow an assessment of the possible effect of the limits in the reduction/prevention of the incidence and morbidity of contact dermatitis.
Nickel is a frequent allergen throughout the world. However, the extent to which nickel is relevant as an occupational contact allergen as opposed to being simply a reflection of jewellery exposure has been unclear. Some thresholds for cutaneous nickel exposure to induce a dermatitis reaction in nickel-allergic individuals have been defined. Over recent years it has become possible to measure accurately the quantity of nickel on the skin of individuals in a number of occupations.
To measure the quantities of nickel on the skin of the fingers in workers employed in occupations for which nickel has been suspected as a contact allergen. To define the threshold for a dermatitis reaction after the single application of a quantity of nickel to the skin of nickel-allergic individuals when read at 2days.
We employed the 'finger immersion' technique for sample collection and induction coupled plasma mass spectrometry for the nickel measurement. Nickel platers, cashiers, sales assistants, caterers, healthcare assistants, office workers, dental nurses and hairdressers were studied (five in each group except for seven cashiers). A correction was made for the fact that the finger immersion method underestimates the amount of nickel on the fingertip. The threshold for reactivity to a single application of nickel was studied by the application of various concentrations of nickel (μgcm(-2) ) [0·05 (two subjects), 0·5 (two subjects), 2·5 (three subjects), 5·0 (21 subjects), 15 (19 subjects), 30 (19 subjects) and 45 (18 subjects)] in 21 subjects overall using Finn chambers on forearm skin. The reading was made at 2days and reactions were graded using the International Contact Dermatitis Research Group classification.
Nickel levels on the fingers of platers, cashiers, sales assistants, caterers, and even office staff, were at or above the 0·035μgcm(-2) level at which 22% of nickel-allergic subjects will react (after applying a correction). The single open application of nickel study demonstrated a dose-response relationship, with no subjects reacting to ≤ 2·5μgcm(-2) , but increasing numbers reacting at the higher concentrations as follows: six of 21 (28%) at 5·0μgcm(-2) , six of 19 (31%) at 15μgcm(-2) , seven of 19 (37%) at 30μgcm(-2) and 11 of 18 (61%) at 45μgcm(-2) .
This study confirms that nickel levels on the skin in coin handling occupations and some others are sufficient to induce an allergic contact dermatitis in some nickel-allergic subjects. A single application of 5μgcm(-2) when read at 2days induced a dermatitis reaction in six of 21 nickel-allergic subjects.
Occupational contact allergy is a common problem in the cleaning industry.
To identify the most frequent occupation-associated allergens and time trends in contact allergy in female cleaners.
We analysed the patch test data concerning 803 female cleaners, who were evaluated for occupational contact dermatitis in 45 dermatological departments contributing to the Information Network of Departments of Dermatology (IVDK) from 1996 to 2009. Female patients, except cleaners, with occupational dermatitis (n = 14494) and female controls without occupational dermatitis (n = 64736) patch tested during this time period formed the control groups.
One hundred and fifty-six (19.4%) cleaners had past or present atopic dermatitis. Six hundred and fifty-five (81.6%) cleaners suffered from occupational hand dermatitis. Allergic contact dermatitis was diagnosed in 249 (31%) of the cleaners. As compared with the control group without occupational dermatitis, female cleaners were significantly more often sensitized to occupationally relevant allergens such as rubber additives, especially thiurams [11.6%, 95% confidence interval (CI) 9.1-14.1 vs. 1.5%, 95% CI 1.4-1.6], zinc diethyldithiocarbamate (3.4%, 95% CI 2.1-4.7 vs. 0.4, 95% CI 0.3-0.4), and mercaptobenzothiazole (1.8, 95% CI 0.7-2.9 vs. 0.5, 95% CI 0.4-0.6), as well as formaldehyde (3.4, 95% CI 2.0-4.7 vs. 1.4%, 95% CI 1.3-1.5). No differences were seen in patterns of sensitization to occupational allergens in younger (≤40 years of age) and older (>40 years of age) female cleaners.
Formaldehyde and rubber additives such as thiurams, zinc diethyldithiocarbamate and mercaptobenzothiazole are occupationally relevant allergens in female cleaners. Prevention strategies are needed to address the problem.
Nickel is the most common cause of contact allergy and an important risk factor for hand eczema. Visualization techniques may be powerful in showing exposures. The dimethylglyoxime (DMG) test might be used to establish skin exposure to nickel.
To develop and evaluate methods for visualization of nickel on the skin by the DMG test and hand imprints.
Nickel solutions at different concentrations were applied in duplicate on the hands in healthy subjects (n = 5). The DMG test and acid wipe sampling for quantification were then performed. Hand imprints were taken after manipulation of nickel-releasing tools (n = 1), and in workers performing their normal tasks (n = 7). The imprints were developed by the DMG test.
The DMG test on hands gave positive results in all subjects. The lowest concentration giving rise to a colour change was set to 0.13 µg/cm(2) for DMG testing on skin. DMG test-developed imprints worked well except when hands were heavily contaminated by other particles/dust.
The DMG test may be used as a simple and powerful tool for visualization of nickel on skin. DMG test-developed hand imprints may, in the future, be used for semi-quantitative or quantitative exposure assessment.
The prevalence of nickel allergy (sensitization) and the associations with ear piercing, use of dental braces and hand eczema were assessed in a cohort of 1, 501 8th grade schoolchildren (aged 12-16 years) in Odense, Denmark. Nickel allergy was found in 8.6% and was clinically relevant in 69% of cases. Nickel allergy was found most frequently in girls and the association with ear piercing was confirmed. Application of dental braces (oral nickel exposure) prior to ear piercing (cutaneous nickel exposure) was associated with a significantly reduced prevalence of nickel allergy. In adolescents a significant association was found between hand eczema and nickel allergy. A follow-up study of this population is planned in order to assess the course and development of contact dermatitis, hand eczema and atopic diseases in adulthood and after choice of occupation.
The prevalence of nickel allergy (sensitization) and the associations with ear piercing, use of dental braces and hand eczema were assessed in a cohort of 1,501 8th grade schoolchildren (aged 12-16 years) in Odense, Denmark. Nickel allergy was found in 8.6% and was clinically relevant in 69% of cases. Nickel allergy was found most frequently in girls and the association with ear piercing was confirmed. Application of dental braces (oral nickel exposure) prior to ear piercing (cutaneous nickel exposure) was associated with a significantly reduced prevalence of nickel allergy. In adolescents a significant association was found between hand eczema and nickel allergy. A follow-up study of this population is planned in order to assess the course and development of contact dermatitis, hand eczema and atopic diseases in adulthood and after choice of occupation.
Systemic contact dermatitis is usually seen as flare-up of previous dermatitis or de novo dermatitis similar to allergic contact dermatitis. Although systemic contact dermatitis from medicaments is a well-established entity, the existence of clinically relevant systemic reactions to oral nickel exposure, in particular systemic reactions to nickel in the daily diet, remains controversial. Several studies have shown that oral exposure to nickel can induce systemic contact dermatitis in nickel-sensitive individuals. In most of these studies, however, the exposure dose of nickel used has been considerably higher than the nickel content in the normal daily diet. The aim of the current investigation was to study dose-response dependency of oral exposure to nickel. In a double-blind, placebo-controlled oral exposure trial, 40 nickel-sensitive persons and 20 healthy (non-nickel-sensitive) controls were given nickel sulfate hexahydrate in doses similar to and greater than the amount of nickel ingested in the normal Danish daily diet. The nickel content in urine and serum before and after oral exposure was measured to determine nickel uptake and excretion. The influence of the amount of nickel ingested on the clinical reactions to oral exposure and on nickel concentrations in serum and urine was evaluated. Among nickel-sensitive individuals, a definite dose-response dependency was seen, following oral exposure to nickel. 7 of 10 nickel-sensitive individuals had cutaneous reactions to oral exposure to 4.0 mg nickel, an amount approximately 10 times greater than the estimated normal daily dietary intake of nickel. 4 of 10 nickel-sensitive individuals had cutaneous reactions to 1.0 mg nickel, a dose which is close to the estimated maximum amount of nickel contained in the daily diet. 4 of 10 nickel-sensitive individuals reacted to 0.3 mg nickel or to the amount equivalent to that contained in a normal daily diet, and 1 of 10 reacted to a placebo. None of the 20 healthy controls had cutaneous reactions to 4.0 mg nickel or to a placebo. Prior to oral exposure, there was no measurable difference in the amount of nickel in the urine or serum of nickel-sensitive persons and healthy controls. Following the oral challenge, the nickel content in the urine and serum of both nickel-sensitive and healthy control individuals was directly related to the dose of nickel ingested.
Hand eczema is a chronic disease with negative impact on quality of life (QoL). In this study, QoL in hand eczema patients is assessed and related to age, sex, severity, and diagnostic subgroups.
A total of 416 patients with hand eczema from 10 European patch test clinics participated in the study. Data on QoL were obtained from a self-administered questionnaire using the Dermatology Life Quality Index (DLQI). Severity was assessed by a scoring system (Hand Eczema Severity Index, HECSI) as well as frequency of eruptions and sick leave due to hand eczema.
No significant difference was found between males and females with respect to QoL [DLQI median values and 25/75 percentiles for males and females being 7.0 (3-14) and 8.0 (3-13), respectively], although males were more severely affected than females (P < 0.025). A significant positive correlation was found for hand eczema severity and age (P < 0.001), while no significant correlation was found for QoL and age. QoL was found increasingly reduced when sick leave was getting higher (P < 0.001). A statistically significant correlation between QoL (as measured by DLQI) and hand eczema severity as measured by HECSI was found (P < 0.001). No significant difference in QoL was found between diagnostic subgroups.
QoL was found markedly negatively affected in hand eczema patients and was significantly correlated to disease severity. No significant difference in QoL was found between males and females, in spite of significantly more severe eczema in males, indicating that QoL in female patients is more easily affected.
Background: Cutaneous nickel allergy in the very young is not well documented or characterized. A significant number of individuals are nickel sensitized by their mid-teenage years. Recent studies suggest that children may become sensitized to nickel at an early age.
Objectives: The purpose of this study was to investigate nickel release from children’s clothing fasteners as one potential route of exposure of pre-school age children to nickel ions.
Patients/Methods: Fasteners from new and used children’s clothing purchased in the USA were tested using the dimethylglyoxime (DMG) and EN1811 tests for nickel ion release.
Results: Of 173 fasteners tested, 10 (6%) tested positive using the DMG test for nickel release. EN 1811 standardized nickel release testing of these 10 items demonstrated that 70% (4% of all fasteners tested) released nickel in excess of the European Nickel Directive release limit (0.5 μg/cm2/week). Ten randomly selected DMG-negative fasteners were also EN 1811 tested, of which 30% of fasteners exceeded the European Nickel Directive release limit. Therefore, not less than 6% of the fasteners tested released excessive nickel.
Conclusion: This study concluded that clothing fasteners purchased in the USA could be a source of early childhood exposure to releasable nickel.
The incidence of nickel sensitivity in a population above the age of 10 was examined through epicutaneous tests with 5 % nickel sulphate performed on certain school and occupational test subjects and on subjects at a home for elderly people. Nickel sensitivity was observed in 4.5 % (in 44 cases of 980 tested subjects), in 8 % of the females and in 0.8 % of the males. In 42 of the 44 nickel-sensitive subjects there was a history of dermatitis from metal contact.
At the time of testing, 16 (34 %) of the nickel-sensitive subjects revealed eczema. A manifest nickel sensitivity was thus found in 1.6 % of all tested subjects, in 2.8 % of females and in 0.4 % of males. Nickel sensitivity and a simultaneous hand eczema was noted in 0.9 % of the tested population, in 1.6 % of females and in 0.2 % of males.
Hand eczemas were rarer (20.5 %) in the nickel-sensitive subjects in the population study than in the nickel-sensitive patients tested at the same time in the clinic (56.6 %). No case of nickel sensitivity was occupationally related.
Factors related to hand eczema were studied. Their relative importance as predictors was ranked by multiple logistic regression analysis. Questionnaires were sent to 20,000 individuals aged 20–65 years, randomly selected from the population register. Those subjects (1385) considering themselves to have had hand eczema within the previous 12 months were invited to a dermatological examination. It was found that it history of childhood eczema was the most important predictive factor for hand eczema. Second was female sex, followed by occupational exposure, a history or asthma and or hay fever, and service occupation. A small decrease in risk with advancing age was also found. The difference in the probability of having hand eczema In a l-year period, between individuals having the most important risk factors studied and those having none of them proved to be for females 48% compared to 8%, and for males 34% compared to 4%. A history of childhood eczema was found to be more common among voting persons, indicating an increase in the prevalence of atopic dermatitis. Of those individuals who reported childhood eczema, 27% reported hand eczema on some occasion during the last 12 months.
The occurrence of nickel allergy and hand eczema has been investigated in a stratified sample (2 500) of the Danish female population by an interview technique. The incidence density (allergy intensity) has been estimated by standard maximum likelihood methods. The age-specific prevalence rates have been calculated by life table techniques. The incidence density has doubled in all age groups from 1948 to 1973. The highest prevalence rate of nickel allergy was found in the 45-year-olds (0.189 +/- 0.023). The possible interaction between nickel allergy and hand eczema was analysed by a Markov chain model. Compared with non-nickel-sensitive women, a woman who has become nickel sensitized ran an increased risk of developing hand eczema. And those who had first developed hand eczema ran an increased risk of subsequently developing nickel allergy. In future efforts to reduce direct skin contact with nickel, the close relation between nickel allergy and hand eczema should be the main argument. Statistical methods based on the incidence density will be useful in the evaluation of these efforts.
Wolfgang Uter, Werner Aberer, José Carlos Armario-Hita, José M. Fernandez-Vozmediano, Fabio Ayala, Anna Balato, Andrea Bauer, Barbara Ballmer-Weber, Aiste Beliauskiene, Anna Belloni Fortina, Andreas Bircher, Jochen Brasch, Mahbub M. U. Chowdhury, Pieter-Jan Coenraads, Marie-Louise Schuttelaar, Sue Cooper, Magda Czarnecka-Operacz, Maria Zmudzinska, Peter Elsner, John S. C. English, Peter J. Frosch, Thomas Fuchs, Juan García-Gavín, Virginia Fernández-Redondo, David J. Gawkrodger, Ana Giménez-Arnau, Cathy M. Green, Helen L. Horne, Jeanne Duus Johansen, Riitta Jolanki, Maria Pesonen, Clodagh M. King, Beata Krêcisz, Dorota Chomiczewska, Marta Kiec-Swierczynska, Francesca Larese, Vera Mahler, Anthony D. Ormerod, Andrea Peserico, Tapio Rantanen, Thomas Rustemeyer, Javier Sánchez-Pérez, Jane E. Sansom, Juan Fco. Silvestre, Dagmar Simon, Radoslaw Spiewak, Barry N. Statham, Natalie Stone, Mark Wilkinson, Axel Schnuch. (2012) Current patch test results with the European baseline series and extensions to it from the ‘European Surveillance System on Contact Allergy’ network, 2007-2008. Contact Dermatitis 67:10.1111/cod.2012.67.issue-1, 9-19
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The prevalence of sensitization to fragrance mix (FM) I and Myroxylon pereirae (MP, balsam of Peru) has decreased in recent years among Danish women with dermatitis.
This study investigated whether the decrease could be confirmed among women in the general population. Furthermore, it addressed the morbidity of FM I sensitization.
In 1990, 1998 and 2006, 4299 individuals aged 18-69 years (18-41 years only in 1998) completed a premailed questionnaire and were patch tested to FM I and MP. Data were analysed by logistic regression analyses and associations were expressed as odds ratios (ORs) with 95% confidence intervals (CIs).
The prevalence of FM I and MP sensitization followed an inverted V-pattern among women aged 18-41 years (i.e. an increase from 1990 to 1998, followed by a decrease from 1998 to 2006). Logistic regression analyses showed that 'medical consultation due to cosmetic dermatitis' (OR 3.37, 95% CI 1.83-6.20) and 'cosmetic dermatitis within the past 12 months' (OR 3.53, CI 2.02-6.17) were significantly associated with sensitization to FM I.
In line with trends observed in Danish patients with dermatitis, our results supported a recent decrease in the prevalence of FM I and MP sensitization in Denmark. The study also showed that fragrance sensitization was associated with self-reported cosmetic dermatitis and use of health care related to cosmetic dermatitis.
In population-based studies using self-reported nickel allergy, a hand eczema prevalence of 30-43% has been reported in individuals with nickel allergy. In a previous Swedish study, 958 schoolgirls were patch tested for nickel. In a questionnaire follow up 20 years later no association was found between nickel allergy and hand eczema.
To investigate further the relation between nickel allergy and hand eczema.
Three hundred and sixty-nine women, still living in the same geographical area, now aged 30-40 years, were patch tested and clinically investigated regarding hand eczema.
Patch testing showed 30.1% nickel-positive individuals. The adjusted prevalence proportion ratio (PPR) for hand eczema after age 15 years in relation to nickel patch test results was 1.03 (95% confidence interval, CI 0.71-1.50). A history of childhood eczema was reported by 35.9%, and the PPR for hand eczema in relation to childhood eczema was 3.68 (95% CI 2.45-5.54). When analysing the relation separately in women with and without a history of childhood eczema a statistical interaction was found. The hand eczema risk was doubled in nickel-positive women without a history of childhood eczema, with a PPR of 2.23 (95% CI 1.10-4.49) for hand eczema after age 15 years.
A doubled risk for hand eczema was found in nickel-positive women without a history of childhood eczema. When analysing all participants, there was no statistically significant difference between nickel-positive and nickel-negative women regarding occurrence of hand eczema. The most important risk factor for hand eczema was childhood eczema. The risk for hand eczema in nickel-positive women may previously have been overestimated.
The purpose of the study was to evaluate a self-administered questionnaire on hand dermatitis that was developed to identify persons with hand dermatitis in epidemiological studies. A total of 109 nurses were subject to dermatological examination of the hands within 1 month of returning the questionnaire. 2 types of questionnaire diagnoses were made: a 'symptom-based' diagnosis and a 'self-reported diagnosis'. These were compared to the medical diagnosis of hand dermatitis. The prevalence of hand dermatitis in the 12 months before the study, based on the medical diagnosis, was 18.3%. The prevalence according to the symptom-based diagnosis and the self-reported diagnosis was 47.7% and 17.4%, respectively. The sensitivity and specificity of the symptom-based diagnosis were 100% and 64%, respectively. It is concluded that the symptom-based diagnosis can be used as screening instrument for the detection of cases in large study populations, if followed by dermatological examination of persons with a positive diagnosis. The sensitivity and specificity of the self-reported diagnosis were 65% and 93%, respectively. It is concluded that the self-reported diagnosis can be used to obtain a rough estimate of the prevalence, although comparison of prevalence figures between study populations may be distorted due to a difference in reporting of hand dermatitis. The results of the study illustrate the size of the differences in prevalence estimates that may arise as a result of differences in the definition and method of diagnosing hand dermatitis.
An outbreak of occupational dermatitis in an electroforming plant where there was heavy exposure to nickel is described. Patch test investigations confirmed nickel allergy in 13 of 27 exposed individuals Nickel chloride was found to be a more reliable patch test allergen than nickel sulphate.
Improvements in industrial hygiene led to an immediate decrease in the incidence of dermatitis. Persistent patch test sensitivity to nickel was found in three individuals who had been removed from the process chemicals for some years.
Piercing the earlobes has increased in popularity among males in recent years. This habit would be expected to increase the incidence of nickel and cobalt sensitization. Patch testing with nickel sulfate and cobalt chloride was performed in 520 young Swedish men doing compulsory military service. The overall frequency of nickel/cobalt positive tests was 4.2%. The prevalence of nickel/cobalt positive tests was significantly higher (p < 0.05) in 152 men with pierced earlobes (7.9%) than in those 368 with unpierced earlobes (2.7%). A history of hand eczema (7/152 = 4.6%) or other types of eczema (22/152 = 14.5%) in individuals with pierced earlobes was no more common than in those with unpierced earlobes: 24/368 = 6.5% and 51/386 = 13.9%, respectively (n.s.). Hand eczema was no more common in sensitized (1/22 = 4.5%) than in nonsensitized individuals (32/498 = 6.4%) (n.s.).
In order to qualify as a case of atopic dermatitis, we propose that an individual must have an itchy skin condition plus three or more of the following: history of flexural involvement, a history of asthma/hay fever, a history of a generalized dry skin, onset of rash under the age of 2 years, or visible flexural dermatitis. When tested in an independent sample of 200 consecutive dermatology outpatients of all ages, this arrangement of the diagnostic criteria achieved 69% sensitivity and 96% specificity when validated against physician's diagnosis. Based on the findings of this first exercise, minor modifications in the wording of the criteria were undertaken, and these were tested on a sample of 114 consecutive children attending out-patient paediatric dermatology clinics. Overall discrimination improved, with a sensitivity of 85% and specificity of 96%. The simplified criteria are easy to use, take under 2 min per patient to ascertain, and do not require subjects to undress. These two independent validation studies suggest that the newly proposed criteria for atopic dermatitis perform reasonably well in hospital out-patient patients. Further validation in community settings and in developing countries is needed.
A questionnaire was sent to 143 patients who had shown a positive patch test reaction to nickel sulfate more than 10 years earlier. 91 patients returned the questionnaire, revealing that after the testing, 73 had suffered from dermatitis, 61 especially from hand dermatitis. 37 of these patients were clinically examined and patch tested with standard series and in addition, 12 patients were tested with nickel sulfate and nickel chloride with different occlusion times. At the clinic visit, 23 patients had dermatitis, 16 hand dermatitis, and 11 were symptom-free. 26 of the patients had metal items close to their skin and 21 of them had current dermatitis, 14 hand dermatitis. Of the 11 patients who had no metal exposure, 9 were symptom-free. The association of dermatitis with exposure to metal objects was statistically significant (p < 0.001). Those patients who had current dermatitis had also developed multiple allergies and reacted to nickel with shorter application times in patch tests, as compared to those who were symptom-free. It seemed possible that the prognosis for nickel dermatitis could be improved if nickel-allergic patients would strictly avoid metal contact, especially in clothing and jewelry.
The purpose of this study was to investigate the reliability and validity of a self-reported questionnaire for estimating the prevalence of hand eczema and other hand dermatoses. All pupils in grades 1 and 3 from the secondary schools in Växjö, in southern Sweden, were invited to participate in the study, which consisted of two parts, a questionnaire and a clinical examination. Of those invited, 2572 (98.6%) responded to the questionnaire. Of the respondents, 2535 pupils (98.5%) were clinically examined. The kappa value for the questionnaire findings, compared with the diagnosis from the clinical examination, was 0.79, indicating good agreement. The sensitivity of the questionnaire findings was 73% (95% confidence interval [CI]: 0.6425-0.7975), and the specificity was 99% (95% confidence interval [CI]: 0.9860-0.9940). The self-reported questionnaire was suitable for detecting hand dermatosis in a population of secondary school children and may be used as a cost-effective and reliable method of investigating the prevalence of hand dermatosis in epidemiological studies.
Nickel allergy in women has been thoroughly studied: its prevalence, the most important sources of sensitization, and risk factors for elicitation of dermatitis. Preventive measures have also been introduced. Nickel allergy in men has not, however, been equally focused on. Based on clinical experience, some publications indicating that tools may be a risk factor for nickel allergy and hand eczema in men, and the fact that large occupational groups regularly use tools, we decided to carry out a study, of the prevalence on the market of tools that release nickel. 27% of 565 hand-held tools with metal parts that come into contact with the skin were found to be dimethylglyoxime (DMG) test positive. Release of nickel and other metals into artificial sweat and composition of metals on the surface and in the base alloy were also studied. It is suggested that tool producers should consider nickel allergy and avoid nickel-releasing materials, and that analytical methods, relevant for nickel release from tools, should be further developed.
The main aim of this study was to measure the amount of nickel released from jewelry available in Israel. We also evaluated the relevance of the results and the relationship between nickel sensitivity, atopy and hand eczema.
We studied the effects of repeated daily exposure to low nickel concentrations on the hands of patients with hand eczema and nickel allergy. The concentrations used were chosen to represent the range of trace to moderate occupational nickel exposure. The study was double-blinded and placebo controlled. Patients immersed a finger for 10 min daily into a 10-p.p.m. nickel concentration in water for the first week, and during the second week into a 100-p.p.m. nickel concentration. This regimen significantly increased (P = 0.05) local vesicle formation and blood flow (P = 0.03) as compared with a group of patients who immersed a finger into water. The nickel concentrations used also provoked significant inflammatory skin changes on sodium lauryl sulphate (SLS)-treated forearm skin of the patients, whereas inflammatory skin changes were not observed in healthy volunteers without hand eczema and nickel allergy, either on normal or on SLS-treated forearm skin. The present study strongly suggests that the changes observed were specific to nickel exposure. Standardized methods to assess trace to moderate nickel exposure on the hands, and the associated effects in nickel-sensitized subjects, are needed.
The objective of the present study is to describe any changes in the prevalence of sensitization to common contact allergens in patch-tested patients over a 12-year period. Attention is given to possible effects of preventive strategies introduced in Denmark regarding nickel and chromate sensitization during that period, and particular areas of concern are identified. Members of the Danish Contact Dermatitis Group collected patch-test results from consecutive eczema patients as well as information about exposures and demographic variables over a 6-month period in 1985-86. The investigation was repeated in 1997-98 in the same clinics, at the same time of year, using identical methods and patch-test substances, including nickel sulphate 5%, potassium dichromate 0.5% and fragrance mix 8%. Nickel was the most common contact allergen in both study periods, followed by the fragrance mix. In children 0-18 years of age, the frequency of nickel allergy decreased from 24.8% in the first study period to 9.2% in the second study period (P < 0. 0008). Fragrance mix allergy doubled in frequency from 4.1% in 1985-86 to 9.9% in 1997-98, an increase that affected all age groups. Contact allergy to potassium dichromate decreased significantly from 3.0% in the first period to 1.2% in the second period (P = 0. 001). The decrease was seen in both sexes and was most pronounced among those of working age. No other significant changes were found in the frequency of sensitization to common allergens over the 12-year observation period.
Nickel allergy is by far the most frequent contact allergy, affecting 10-15% of women in the general population, and causing dermatitis and hand eczema. The EU Nickel Directive, aimed at the prevention of nickel allergy, comes fully into force by July 2001. The Directive covers piercing materials, items in contact with the skin, and requirements on resistance to wear. We carried out a study of the prevalence on the market, before the Nickel Directive, of items that release nickel and of nickel in piercing posts. Nickel release, as shown by a positive dimethylglyoxime (DMG) test, was detected in 25% of 725 items intended for direct and prolonged contact with the skin. Of 15 posts intended for use during epithelialization after piercing, 60% contained more than 0.05% nickel. These products do not comply with the requirements of the EU Nickel Directive. It is suggested that experts in contact dermatitis participate in the prevention of nickel allergy by explaining its effects: the r le of skin exposure and which parts of an item are in contact with the skin, and the crucial question of nickel release versus nickel content.
In most western countries, nickel is the most common contact allergen among young women. In 1991, Denmark implemented a statutory order calling for the reduction of exposure to nickel in nickel-plated items in close contact with the skin. In a retrospective analysis, a comparison is made of the number of positive patch tests to nickel seen in a private practice of dermatology before and after this statutory order was implemented. From 1 January 1986 to 31 December 1989, 35 of 1135 (3.1%) men patch tested and 628 of 3024 (20.8%) women patch tested had positive reactions to nickel. From 1 January 1996 to 31 December 1999, 48 of 1104 (4.3%) men and 424 of 2193 (19.3%) women had positive patch tests to nickel. During the 1st period, 155 of 702 women under the age of 20 (22.1%) had positive patch tests to nickel, compared to 54 of 324 (16.7%) during the second period (p<0.05). The most likely explanations of this decrease in nickel sensitivity are reduced exposure to nickel and increased public awareness of the risk of nickel sensitization.
The validity of questionnaire answers with respect to hand eczema was investigated. Car mechanics, dentists and office workers answered a questionnaire on the occurrence of hand eczema on any occasion during the past 12 months. "Yes"-responders and a random sample of "no"-responders were subsequently interviewed and examined by a dermatologist. 10.0% of the car mechanics, 12.0% of the dentists and 12.5% of the office workers were found to have hand eczema despite previous "no"-answers. In the same populations, 81%, 94% and 80% of the "yes"-answers were confirmed at the clinical examination. Considering false-negative and false-positive answers, the sensitivity was 53-59% and the specificity 96-99% in the 3 groups. The 1-year prevalence changed from self-reported 15% to estimated 21% in the car mechanics, from 15% to 24% in the dentists and from 15% to 23% in the office workers. It is concluded that self-reported 1-year prevalence of hand eczema considerably underestimates the true prevalence.
In 1990, a random sample of 567 persons of the 15-69-year-old population living in the Western part of Copenhagen County, Denmark, was patch tested in a cross-sectional study. In 1998, a follow-up study was performed. Out of 540 invited, 365 (68%) were re-patch tested. In the follow-up study, the persistence of allergic contact sensitivity, defined as 1 or more positive patch tests in both surveys, was 71% (37 out of 52 subjects). Nickel allergy persisted in 79% (19 out of 24 subjects), while 60% (21 out of 35 subjects) had a positive patch test reaction to 1 or more allergens, other than nickel, in both surveys. The lowest persistence was 50% (5 out of 10 subjects) and this was found for patch test reactivity to 1 or more of the cosmetic ingredients included in the patch test series. 8 years after the baseline study had demonstrated allergic contact sensitivity, 71% of the subjects still had at least 1 positive patch test. Nickel allergy persisted in 79%. Allergen avoidance should probably be lifelong to prevent elicitation of contact dermatitis.
Hand eczema is the most frequent occupational skin disease. Our aim was to study changes in its prevalence in Swedish adults. Cross-sectional studies were performed in 1983 and 1996. Random samples from the population of Gothenburg, Sweden, aged 20-65 y, were drawn from the population register. Data were collected with a postal questionnaire, which was identical in the two studies. The response rate was 83.5% (16,708 out of 20,000) in 1983 and 73.9% (2218 out of 3000) in 1996. The reported 1 y prevalence of hand eczema decreased from 11.8% in 1983 to 9.7% in 1996 (p < 0.01), a large difference being found in the youngest age group. Reported childhood eczema increased from 10.4% to 12.4%, however (p < 0.01). Of those with childhood eczema 27.9% and 25.2% reported hand eczema, compared to 10.0% and 7.5% among those without childhood eczema. In total 76.8% were gainfully employed in 1983 and 68.3% in 1996 (p < 0.001). In 1983 23.0% were employed in "high-risk" occupations for hand eczema compared to 19.4% in 1996 (p < 0.001). Even though the increase in childhood eczema was largest in the youngest group, there was a large decrease in the prevalence of hand eczema in that age group among both sexes. The study indicates that the prevalence of hand eczema in Swedish adults had decreased between 1983 and 1996 despite an increasing prevalence of childhood eczema. Secular changes in reporting hand eczema and childhood eczema may explain some of the changes, but a decreased occupational exposure to skin irritants is a probable cause, implying that occupational factors may be important predictors of hand eczema.
To reduce the skin nickel exposure of the population, the Danish Ministry of Environment issued a regulation that was implemented in 1992, and the European Union countries have recently adopted an expanded regulation.
The aim of our combined patch testing and questionnaire investigation of girls in public schools and high schools/production schools was to evaluate whether the regulation has had an impact on the prevalence of nickel sensitization.
To find a group of girls with ears pierced mainly after implementation of the nickel-exposure regulation in Denmark, girls were recruited from the fifth and sixth grade in 12 public schools (the public school group). After the public school level almost all girls from a public school population continue their education in high schools or other schools such as production schools or technical schools. Therefore, to find girls demographically similar to the public school girls but older, and with ears pierced before implementation of the regulation, girls from seven high schools and two production schools were recruited (the high school group). Four hundred and twenty-seven girls in the public school group (mean age 12.4 years, range 10-14) and 534 in the high school group (mean age 18.8 years, range 17-22) participated. All participants filled out a questionnaire concerning ear piercing, use of oral braces and former patch testing for nickel sensitivity. Three hundred and five girls (71.4%) in the public school group and 275 (51.5%) in the high school group were patch tested or had been tested previously and the results of these tests were included in the study. The relation between the frequency of nickel sensitization and the various factors that might influence the prevalence of nickel sensitization was evaluated by multivariate logistic regression analysis. The investigation was conducted from March 1999 to March 2000.
The study showed that both increasing age and having ears pierced before 1992 enhanced the prevalence of nickel sensitization. We found that 17.1% of the girls in the high school group demonstrated a positive patch test reaction to nickel. In contrast, the prevalence of nickel sensitization in the public school group was only 3.9%. Comparing girls with and without pierced ears, the prevalence of nickel sensitization was significantly higher in girls with ears pierced before, but not after, 1992 (odds ratio 3.34 and 1.20, respectively). Only in the high school group was there a tendency that wearing oral braces before ear piercing had a protective effect on nickel sensitization, but this did not reach statistical significance.
As we found an effect of ear piercing before but not after 1992, this study strongly suggests that implementation of the nickel-exposure regulation in 1992 in Denmark has had the intended effect of protecting the female population from becoming allergic to nickel.
Hand eczema is a recurrent chronic skin disease related to contact allergy and atopic dermatitis. When possible, efforts should be redoubled to eliminate provoking factors. Our objective was to assess changes in the prevalence of self-reported hand eczema and to evaluate the association between contact allergy and hand eczema among adult Danes before and after nickel exposure regulation in Denmark. In 1990 and 1998, random samples of 15-41-year-old persons were examined in 2 cross-sectional studies of the general population in Copenhagen, Denmark. The studies included questionnaires, patch and prick testing. From 1990 to 1998 the prevalence of a history of hand eczema increased significantly. This increase did not appear to be fully explained by changes in the prevalence of flexural eczema, prick test reactivity, patch test reactivity, and nickel allergy. In 1990, nickel allergy and allergic nickel contact dermatitis were significantly associated with a history of hand eczema among women. In 1998, these associations were not found. It can be concluded that, from 1990 to 1998, the prevalence of a history of hand eczema rose significantly. It was indicated that it might be possible to prevent the hand eczema related to nickel allergy by exposure regulation, public education or both.
A population-based twin study has recently shown that genetic factors are of significance for hand eczema.
To characterize further a sample of this twin material with regard to contact allergy, atopic dermatitis and wet work.
In total, 1076 individual twins were examined clinically and patch tested. The diagnosis of atopic dermatitis was based on the U.K. Working Party criteria. The decision concerning wet work was based on the individual job description, taking into account the later introduced definition of at least 2 h of water exposure daily. The data were analysed by a newly developed statistical method which makes it possible to analyse the individual risk factor and at the same time discriminate between genetic and environmental factors.
The statistical analysis confirmed atopic dermatitis as an important risk factor for hand eczema. Contact allergy was also confirmed as a significant risk factor for hand eczema, and the risk was related to strength (+ to + + +) of contact allergy. The results indicated that the high frequency of hand eczema in women in comparison with men was caused by environmental and not genetic factors. Aggregation of hand eczema within twin pairs was only to a minor degree explained by atopic dermatitis and nickel allergy (or other contact allergies).
We suggest that a hitherto unrecognized genetic risk factor for hand eczema independent of atopic dermatitis and contact allergy is probably of importance for the development of irritant contact dermatitis on the hands.
Nickel is the most ubiquitous contact allergen among children and adolescents. Metal blue jeans buttons and belts have been noted to cause nickel dermatitis around the umbilicus. For these children, traditional teaching is strict avoidance of all pants with metal snaps/buttons, particularly blue jeans. In this study we tested 90 pairs of blue jeans and 47 belts for nickel using the dimethylglyoxime spot test. Only 10% of blue jeans tested positive, while 53% of belts tested positive. Furthermore, 10 pairs of nickel-negative blue jeans remained negative after 10 washings. Overall we found no resistance to testing in clothing stores. From these results, we recommend that patients with allergic contact dermatitis secondary to nickel need not strictly avoid blue jeans and metal belt buckles. Rather, families should be encouraged to use the dimethylglyoxime spot test to test these items for nickel prior to purchase.
The Nickel Directive aims at the prevention of sensitization and elicitation of nickel dermatitis. It limits nickel release from, and nickel content in, certain items. The Directive came into full force by July 2001. The aim of this study was to investigate the frequency on the market of items that release nickel and of nickel content in piercing posts, 2 years after coming into force of the Directive. Of special interest was to study changes compared to the situation in 1999, when a baseline study had been carried out. Nickel release from 786 items covered by the Nickel Directive was tested with the dimethylglyoxime (DMG) test, and nickel content in 18 piercing posts was analysed. Nickel release was shown from 8% of items intended for direct and prolonged contact with the skin, and 17% of the piercing posts contained too much nickel, a decrease compared to 1999. There has been significant adaptation to the requirements of the Nickel Directive. The DMG test is useful for screening for nickel release and for monitoring the market. Provided there is further adaptation to the requirements, the risk of sensitization and elicitation of nickel dermatitis will be significantly reduced.
The aim of this study was to investigate the occurrence of hand eczema after 20 years in women patch tested to nickel during childhood. In 1982-1983, 960 schoolgirls were patch tested for nickel allergy; its prevalence was found to be 9%. 20 years later, the same individuals received a questionnaire regarding hand eczema and factors of importance for the development of hand eczema. 735 of 908 women (80.9%) answered the questionnaire. In total, 17.6% of respondents reported hand eczema after the age of 15 years, and the 1-year prevalence was 12.8%. There was no statistically significant difference in the occurrence of hand eczema between the groups who had previously tested positive and negative for nickel allergy. 38.3% of the respondents considered themselves to be nickel sensitive at the time they answered the questionnaire; in this group, the reported prevalence of hand eczema after age 15 was 22.5%. 31.4% of those with a history of atopic dermatitis reported hand eczema after age 15, compared with 10.6% of those without (P < 0.001). In conclusion, contact allergy to nickel in childhood did not seem to increase the prevalence of hand eczema later in life.
Little is known about time trends of allergic respiratory disease in adults, in particular in older adults. Furthermore, few trend studies have used objective measurements of IgE sensitization against inhalant allergens.
To investigate time trends of aeroallergen sensitization in adults over a 25-year period.
The study includes a total of 7820 persons, aged 30, 40, 50, and 60 years, who participated in three repeated cross-sectional studies of the general population of Copenhagen, Denmark, in 1976-1977, 1982-1984, and 1999-2001, respectively. Respiratory allergy was assessed by determination of specific IgE aeroallergen sensitization in stored serum samples.
Over this 25-year period, a marked and statistically significant increase in the prevalence of aeroallergen sensitization had occurred. This increase was seen in all age-groups challenging the notion that the allergy epidemic only affects generations born 1960 onwards. For example, in 40-year-olds the prevalence (with 95% confidence intervals) of aeroallergen sensitization was 14.9% (12.7-17.1), 19.7% (17.1-22.3), and 27.6% (25.1-30.1) in 1976-1977, 1982-1984, and 1999-2001, respectively.
Our results support that the allergy epidemic has spread to older adults resulting in a continuing increase in the overall prevalence of aeroallergen sensitization and an increase in the mean age of allergic patients.
A substantial number of studies have investigated the prevalence of contact allergy in the general population and in unselected subgroups of the general population. The aim of this review was to determine a median prevalence and summarize the main findings from studies on contact allergy in the general population. Published research mainly originates from North America and Western Europe. The median prevalence of contact allergy to at least 1 allergen was 21.2% (range 12.5-40.6%), and the weighted average prevalence was 19.5%, based on data collected on all age groups and all countries between 1966 and 2007. The most prevalent contact allergens were nickel, thimerosal, and fragrance mix. The median nickel allergy prevalence was 8.6% (range 0.7-27.8%) and demonstrates that nickel was an important cause of contact allergy in the general population and that it was widespread in both men and women. Numerous studies demonstrated that pierced ears were a significant risk factor for nickel allergy. Nickel was a risk factor for hand eczema in women. Finally, heavy smoking was associated with contact allergy, mostly in women. Population-based epidemiological studies are considered a prerequisite in the surveillance of national and international contact allergy epidemics.
Nickel sensitization is frequent among US patients with dermatitis and in the general population. In Europe, decreasing prevalences of nickel sensitization are observed as a result of the European Union Nickel Directive. However, no directive exists in the United States.
We sought to examine nickel release from inexpensive earrings and discuss possible methods of reducing nickel exposure among consumers.
A total of 34 different stores and artists were visited. A total of 277 earrings were purchased and examined with the dimethylglyoxime (DMG) test.
DMG-positive earrings were identified from local artists (69%) and tourist stores (42.9%) but also chain stores targeting young (24.1%) and mature (1.7%) women. No correlation between price and outcome of DMG testing was identified.
Our study does not reflect buying trends in the United States. Pretreatment of earrings with artificial sweat was not performed and the DMG may lead to both false-positive and false-negative results.
Nickel exposure from inexpensive earrings is frequent in the United States. A regulatory governmental intervention may be warranted.
Nickel dermatitis may be caused by frequent and prolonged use of cell phones. Because little is known about the frequency of nickel release from cell phones, it is difficult to estimate the risk of nickel sensitization and dermatitis among their users.
Inspired by a recent case of nickel dermatitis from prolonged cell phone use, the frequency of dimethylglyoxime (DMG)-positive cell phones on the Danish market was investigated.
Five major cell phone companies were contacted. Two were visited, and the DMG test was performed on a sample of their products.
5 of 15 (33.3%) phones from company A and 3 of 26 (11.5%) phones from company B showed at least 1 positive reaction. 3 phones had more than 1 positive DMG spots.
This study documents that excessive nickel release (i.e. a positive DMG test) is relatively frequent in a sample of cell phones from the Danish market. Prolonged use of cell phones may in some cases fulfil the criteria for items included in the European Union Nickel Directive. We believe that this new cause of nickel dermatitis should be carefully followed and that regulatory steps may be necessary.
Nickel exposure is the most common cause of contact allergy. The role of contact with nickel-containing coins has been controversial.
To compare the release of nickel from 1 and 2 EUR coins (both composed of two alloys: Cu 75%, Zn 20%, Ni 5% and Cu 75%, Ni 25%) and Swedish 1 SEK coin (alloy: Cu 75%, Ni 25%) and to assess the deposition of nickel onto skin by coin handling.
Nickel release was determined by immersion in artificial sweat (2 min, 1 hr, 24 hr, and 1 week). Deposition of nickel onto the skin was assessed in three subjects after 1-hr handling of 2 EUR and 1 SEK coins. Samples (n = 48) were taken from fingers and palms by acid wipe sampling and analysed by inductively coupled plasma mass spectrometry.
Amounts of nickel released by 1 week from 1 SEK, 1 EUR, and 2 EUR coins were 121, 86, and 99 microg/cm(2), respectively. Corresponding 2 min values were 0.11, 0.25, and 0.22 microg/cm(2). Nickel was deposited onto the skin by 1 hr coin handling (range 0.09-4.1 microg/cm(2)), the largest amounts were on fingers; similar amounts of nickel were deposited from 1 SEK and 2 EUR coins.
Nickel is released from 1 and 2 EUR and 1 SEK coins at similar amounts. Nickel is deposited onto skin at substantial and similar amounts by coin handling. Acid wipe sampling is suitable for studies of skin exposure to nickel and in risk assessment.
amending for the 12th time Dir. 76/769/EEC on the approximation of the laws, regulations and administrative provisions of the Member States relating to restrictions on the marketing and use of dangerous substances
- European Communities European
- Dir
European Communities. European Dir. 94/27/EC of 30 June 1994 amending for the 12th time Dir. 76/769/EEC on the approximation of the laws, regulations and administrative provisions of the Member States relating to restrictions on the marketing and use of dangerous substances. Official J Eur Commun 1994: 37: 1–2.
MD National Allergy Research Centre Department of Dermato-Allergology
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Address: Jacob Pontoppidan Thyssen, MD National Allergy Research Centre Department of Dermato-Allergology, Gentofte Hospital, University of Copenhagen Niels Andersens Vej 65, 2900 Hellerup Copenhagen, Denmark Tel: +45 3977 7307
European Dir. 94/27/EC of 30 June 1994 amending for the 12th time Dir. 76/769/EEC on the approximation of the laws, regulations and administrative provisions of the Member States relating to restrictions on the marketing and use of dangerous substances.
- European Communities