[Show abstract][Hide abstract] ABSTRACT: In order to establish a consensus recommendation for performing photopatch testing, a photopatch test taskforce group was established under the joint umbrella of the European Society for Contact Dermatitis and the European Society for Photodermatology in 2000. After proposing the most adequate methodology in 2004 and completing a European multicentre photopatch test study in 2011, this taskforce is recommending a list of photoallergens that should form part of a baseline series for photopatch testing in Europe. It contains mainly ultraviolet filters and drugs, mostly non-steroidal anti-inflammatory drugs. The choice of chemicals was based on the results of a recent multicentre study, previous published cases of photoallergy, and use of the substances in the European market. It is suggested that an extended list of photoallergens should be photopatch tested in selected cases, along with patients' own products. Two contact allergens, cinnamyl alcohol and decyl glucoside, should be simultaneously patch tested in order to clarify photopatch and patch test reactions, respectively, to ketoprofen and methylene bis-benzotriazolyl tetramethylbutylphenol (Tinosorb M™).
[Show abstract][Hide abstract] ABSTRACT: Background. Cosmetic products contribute considerably to the incidence of contact dermatitis. In response to a resolution of the Council of Europe, the National Institute for Public Health and the Environment (RIVM) in The Netherlands set up a pilot project to report undesirable effects attributed to cosmetic products. Objectives. To provide an overview of undesirable effects attributed to cosmetic products and to identify the ingredients involved. The information could contribute to the assessment of whether current EU legislation on cosmetics provides adequate protection. Patients/methods. General practitioners, dermatologists and consumers in The Netherlands completed questionnaires on reported undesirable effects of cosmetics. Dermatologists also carried out patch tests and, where necessary, tests with specific batch ingredients of the associated cosmetic product. A website and a public awareness campaign were launched to encourage consumers to report undesirable effects. Results. Between July 2009 and May 2011, the RIVM received more than 1600 reports. Severe undesirable effects were claimed in 1-4% of the cases. The most frequently reported cosmetic products were make-up and moisturisers, and the most frequently identified allergens were isothiazolinones and fragrance ingredients. Three patients tested positive for co-polymers/cross-polymers. Conclusions. Further investigations are recommended on the prevalence of isothiazolinone-induced allergic contact dermatitis and the allergenic potential of co-polymers/cross-polymers.
[Show abstract][Hide abstract] ABSTRACT: According to EU legislation, 26 fragrance substance allergens must be labelled on cosmetic products. For 12 of them, the optimal patch test concentration/dose has not been evaluated.
To establish the optimal patch test doses in mg/cm2 for the 12 fragrance substances that are not included in fragrance mix I or II in the European baseline patch test series.
Patch testing with the 12 fragrance substances was performed in a stepwise manner encompassing up to five rounds in at least 100 dermatitis patients for each round. Before patch testing, an individual maximum concentration/dose was determined for each fragrance substance.
The predetermined maximum patch test concentrations/doses could be tested for all 12 fragrance substances, with no observable adverse reactions being noted.
For each fragrance substance investigated, it is recommended that half of the maximum patch test dose (mg/cm2) be used for aimed and screening patch testing.
[Show abstract][Hide abstract] ABSTRACT: Background: The two most common agent groups currently responsible for photoallergic contact dermatitis (PACD) are organic ultraviolet (UV) absorbers in sunscreens and topical nonsteroidal anti-inflammatory drugs (NSAIDs). However, availability of information on the photoallergenic potential of these agents is scarce. Objectives: To obtain current information on the frequency of PACD to 19 organic UV absorbers and 5 topical NSAIDs, including newer agents, in common usage in Europe. Methods: A prospective, multi-centre photopatch test study of 1,031 patients attending for investigation of suspected PACD in 30 centres across 12 European countries. Results: A total of 346 PACD reactions in 200 (19.4%) subjects occurred. PACD was most commonly caused by the topical NSAIDs ketoprofen (128 subjects) and etofenamate (59 subjects). Of the organic UV absorbers, octocrylene, benzophenone-3 and butyl methoxydibenzoylmethane most frequently elicited PACD. The "newer" organic sunscreen absorbers rarely led to PACD. There appeared to be an association between the agents ketoprofen, octocrylene and benzophenone-3, with several subjects developing PACD to two or all three agents concomitantly. Allergic contact dermatitis (ACD) was less commonly observed than PACD, comprising 55 reactions in 47 (4.6%) subjects. Irritant reactions and photoaugmentation and photoinhibition of ACD occurred infrequently. Conclusions: The EMCPPTS has provided current information on the relative frequency of PACD to common photoallergens. Such data will be of value when deciding on which agents to include in future European "baseline" photopatch test series.
British Journal of Dermatology 01/2012; · 3.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hand dermatitis is a prevalent disease with an episodic, chronic character. The use of medical resources is high and is often related to reduced (work) functioning. The burden is therefore high for patients and society. Management of hand dermatitis is often unsatisfactory, and for this reason prevention is important. The effectiveness of prevention programmes is, however, unknown. This study evaluates if comprehensive prevention programmes for hand dermatitis, that include worker education as an element, are effective on occurrence, adherence to preventive measures, clinical outcomes and costs compared to usual care or no intervention. The literature was systematically searched using PubMed and Embase, from the earliest to January 2010 for relevant citations. The methodological quality was assessed by two reviewers using the Cochrane criteria. The GRADE approach was used to determine the level of evidence. After reading the full text articles, 7 publications met our inclusion criteria. We found that there is moderate evidence for the effect of prevention programmes on lowering occurrence and improving adherence to preventive measures, and low evidence for the effect on improving clinical outcomes and self-reported outcomes. No studies reporting on costs were found. It can be concluded that there is moderate evidence for the effectiveness of prevention programmes of hand dermatitis versus usual care or no intervention. However, more high quality studies including cost-effectiveness are needed.
[Show abstract][Hide abstract] ABSTRACT: Cutaneous adverse drug reactions (CADRs), defined as skin eruptions induced by drugs used in adequate doses and in the correct
indications, present under different clinical patterns, and the pathogenic mechanisms underlying the reaction are very different.
Some are due to immune reactions, particularly dependent on T cells, namely, maculopapular exanthema, drug hypersensitivity
syndrome/DRESS, acute generalized exanthematous pustulosis, Stevens–Johnson syndrome, toxic epidermal necrolysis, and fixed
drug eruption. These, which bear some similarities with allergic contact dermatitis, can be studied by patch testing performed
according to the guidelines presented. Positive results depend mainly on the drug involved and on the type of reaction. They
can be of help in confirming a clinically plausible history of a drug eruption and in studying cross-reactions. On the other
hand, a negative test does not exclude the involvement of a drug in a cutaneous reaction.
[Show abstract][Hide abstract] ABSTRACT: The individual and societal burden of hand eczema is high. Literature indicates that moderate to severe hand eczema is a disease with a poor prognosis. Many patients are hampered in their daily activities, including work. High costs are related to high medical consumption, productivity loss and sick leave. Usual care is suboptimal, due to a lack of optimal instruction and coordination of care, and communication with the general practitioner/occupational physician and people involved at the workplace. Therefore, an integrated, multidisciplinary intervention involving a dermatologist, a care manager, a specialized nurse and a clinical occupational physician was developed. This paper describes the design of a study to investigate the effectiveness and cost-effectiveness of integrated care for hand eczema by a multidisciplinary team, coordinated by a care manager, consisting of instruction on avoiding relevant contact factors, both in the occupational and in the private environment, optimal skin care and treatment, compared to usual, dermatologist-led care.
The study is a multicentre, randomized, controlled trial with an economic evaluation alongside. The study population consists of patients with chronic, moderate to severe hand eczema, who visit an outpatient clinic of one of the participating 5 (three university and two general) hospitals. Integrated, multidisciplinary care, coordinated by a care manager, including allergo-dermatological evaluation by a dermatologist, occupational intervention by a clinical occupational physician, and counselling by a specialized nurse on optimizing topical treatment and skin care will be compared with usual care by a dermatologist. The primary outcome measure is the cumulative difference in reduction of the clinical severity score HECSI between the groups. Secondary outcome measures are the patient's global assessment, specific quality of life with regard to the hands, generic quality of life, sick leave and patient satisfaction. An economic evaluation will be conducted alongside the RCT. Direct and indirect costs will be measured. Outcome measures will be assessed at baseline and after 4, 12, 26 and 52 weeks. All statistical analyses will be performed on the intention-to-treat principle. In addition, per protocol analyses will be carried out.
To improve societal participation of patients with moderate to severe hand eczema, an integrated care intervention was developed involving both person-related and environmental factors. Such integrated care is expected to improve the patients' clinical signs, quality of life and to reduce sick leave and medical costs. Results will become available in 2011.
BMC Public Health 12/2009; 9:438. · 2.32 Impact Factor
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[Show abstract][Hide abstract] ABSTRACT: Contact sensitisation has been identified as a factor associated with poor prognosis for patients with hand eczema.
To study implications of contact sensitisation with respect to severity, quality of life (QoL) and subdiagnosis of hand eczema.
The study was performed as a multi-centre, cross-sectional study from 10 European clinics. All patients were patch tested, and severity of hand eczema assessed by Hand Eczema Severity Index. A multi-variate analysis was performed to explore which factors influenced severity, QoL and sick leave.
A total 416 patients were included, and 63% had contact sensitisation to one or more of the tested allergens. More women (66%) than men (51%) were sensitized. No significant association was found between sensitisation to specific allergens, disease severity, QoL or diagnostic subgroups. High age, male sex, atopic eczema and presence of contact sensitisation were independent risk factors for increased severity as measured by Hand Eczema Severity Index. Furthermore, the severity of hand eczema increased by the number of contact sensitisations detected (P = 0.023). High age and personal history of atopic eczema were independent risk factors for low QoL, as measured by Dermatology Life Quality Index, and atopic eczema as well as allergic contact dermatitis as subdiagnosis was associated with increased sick leave.
Diagnostic subgroups were not found to be related to specific allergens. Contact sensitisation was found to be a risk factor for increased severity of hand eczema, as did high age, male sex and atopic eczema.
[Show abstract][Hide abstract] ABSTRACT: Use of sunscreens has increased dramatically worldwide, and some sunscreen chemicals may be allergens. Ultraviolet (UV) filters are added to various cosmetic products. Cinnamate UV filters are structurally related to cinnamon-related fragrances.
The purpose of this study was to determine if 'cinnamon-sensitive' patients show positive photopatch tests to cinnamate UV filters and, therefore, should avoid these UV filters.
We photopatch tested cinnamon-sensitive patients (n = 18) with cinnamon, cinnamon-related fragrances, Myroxylon pereirae, and two cinnamate UV filters.
No positive photopatch test to cinnamate UV filters was found (95% confidence interval 0-13%).
The risk of developing unwanted allergic contact dermatitis because of cinnamate UV filters in cinnamon-sensitive patients seems to be low, but our study population was small. Therefore, we recommend cinnamon-sensitive patients to perform a use test, for example the repeated open application test, before using cosmetic products containing cinnamate UV filters. In addition, physicians and patients should be aware that many sunscreens contain (cinnamon-related) fragrances and could, therefore, elicit allergic contact dermatitis in cinnamon-sensitive patients, independently from other potential sensitizing components of the sunscreen.
[Show abstract][Hide abstract] ABSTRACT: Allergic contact dermatitis results from a T-cell-mediated, delayed-type hypersensitivity immune response induced by allergens. Skin dendritic cells (DCs) play a central role in the initiation of allergic skin responses. Following encounter with an allergen, DCs become activated and undergo maturation and differentiate into immunostimulatory DCs and are able to present antigens effectively to T cells. The frequency of allergic skin disorders has increased in the past decades. Therefore, the identification of potential sensitizing chemicals is important for skin safety. Traditionally, predictive testing for allergenicity has been conducted in animal models. For regulatory reasons, animal use for sensitization testing of compounds for cosmetic purposes is shortly to be prohibited in Europe. Therefore, new non-animal-based test methods need to be developed. Several DC-based assays have been described to discriminate allergens from irritants. Unfortunately, current in vitro methods are not sufficiently resilient to identify allergens and therefore need refinement. Here, we review the immunobiology of skin DCs (Langerhans' cells and dermal dendritic cells) and their role in allergic and irritant contact dermatitis and then explore the possible use of DC-based models for discriminating between allergens and irritants.
[Show abstract][Hide abstract] ABSTRACT: A voluntary surveillance scheme of occupational skin diseases (OSDs) in The Netherlands starting in 2001 aimed to improve insight in the incidence of OSD especially occupational contact dermatitis (OCD), risk professions and causal agents. This paper presents the results of this scheme during 2001-05.
Reports of new cases of OSD received from the participating dermatologists on a monthly basis were analysed. Data evaluated included information on diagnosis, sex, age, sickness, absenteeism, profession and causal agents. Relative differences in incidence rates between industries or branches were estimated by calculating incidence rate ratios.
About 80% of the notifications concerned OCD. The highest number of notifications was recorded in the first year of the scheme. This was probably due to reporting of a mixture of incident and prevalent cases. During the following 5 years, the number of yearly notifications of OSD declined. Hairdressers, nurses, metalworkers, mechanics and cleaners were the most commonly affected professions. Wet work and irritating substances were the most frequently reported causal agents. Most patients with OCD were not absent from work.
A voluntary surveillance scheme with dermatologists provides valuable data about the distribution of OCD in risk professions and the causal agents. However, it has certain limitations in assessing trends in incidence. Active medical surveillance in populations at risk should be encouraged not only to improve secondary prevention but also to obtain more reliable information about the incidence of OCD.
Occupational Medicine 01/2009; 59(1):38-43. · 1.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Local anesthetics are widely used drugs. In contrast to the local anesthetics of the ester group, the ones of the amide group (for example prilocaine and lidocaine) are considered to be rare sensitizers. Positive patch test results to both prilocaine and lidocaine in EMLA cream might indicate potential cross-reactivity.
Journal der Deutschen Dermatologischen Gesellschaft 12/2008; 7(3):237-8. · 1.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In patients with vulval or anogenital dermatitis, irritant contact dermatitis is more common than allergic contact dermatitis. The reported frequency and relevance of contact sensitivity in anogenital dermatitis varies greatly.
To determine the frequency and relevance of contact sensitization in a Dutch group of female patients with chronic anogenital complaints.
We reviewed patch test results of 53 women with chronic anogenital complaints, with sole vulval symptoms in 29 women and sole perianal in 5, in whom inflammatory skin diseases like lichen sclerosus, lichen planus, psoriasis, as well as infectious diseases were unlikely or excluded as a cause of their symptoms. All women were tested with the European baseline series plus additional test series according to their personal history.
Thirty-five patients (66%) showed one or more positive test reactions. Seven of these patients (20%) had one or more clinically relevant positive reactions, most often to flavours and spices.
A considerable number of patients with anogenital dermatitis have a contact sensitization. Clinically relevant reactions were mainly found to spices and flavours. This is in contrast to the data reported in the literature that shows most contact allergies in vulval patients to ingredients of topical medication.
[Show abstract][Hide abstract] ABSTRACT: The initial step in Langerhans cell (LC) migration from the epidermis to the lymph node involves migration of maturing LC into the dermis. Here, we investigated the migration of LC out of the epidermis after exposure of the skin to contact allergens. Ex vivo intact human skin, epidermal sheets, and LC derived from the MUTZ-3 cell line (MUTZ-LC) were used to determine whether dermal fibroblasts play a role in mediating LC migration towards the dermis. Exposure of epidermal sheets or MUTZ-LC to allergens (nickel sulphate, 2,4-dinitrochlorobenzene, and cinnamaldehyde) or a cytokine maturation cocktail resulted in LC migration towards dermal fibroblasts. This was due to upregulation of CXCR4 on maturing LC and secretion of CXCL12/stromal derived factor-1 chemokine by fibroblasts. Neutralizing antibodies to either CXCL12 or CXCR4 completely blocked migration. Injection of CXCL12 neutralizing antibodies into intact human skin totally inhibited LC migration into the dermis. In contrast, neutralizing antibodies to CCL19/CCL21 did not inhibit migration into the dermis. We describe a novel and essential role of dermis-derived CXCL12 in initiating migration of maturing human LC to the dermis thus permitting their further journey to the draining lymph nodes.
European Journal of Immunology 11/2008; 38(11):3050-9. · 4.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hand eczema is a long-lasting disease with a high prevalence in the background population. The disease has severe, negative effects on quality of life and sometimes on social status. Epidemiological studies have identified risk factors for onset and prognosis, but treatment of the disease is rarely evidence based, and a classification system for different subdiagnoses of hand eczema is not agreed upon. Randomized controlled trials investigating the treatment of hand eczema are called for. For this, as well as for clinical purposes, a generally accepted classification system for hand eczema is needed.
The present study attempts to characterize subdiagnoses of hand eczema with respect to basic demographics, medical history and morphology.
Clinical data from 416 patients with hand eczema from 10 European patch test clinics were assessed.
A classification system for hand eczema is proposed.
It is suggested that this classification be used in clinical work and in clinical trials.
British Journal of Dermatology 11/2008; 160(2):353-8. · 3.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.