The mainstay of Ni-ACD treatment is allergen avoidance. It is imperative to understand the types of products that may contain nickel and to find nickel-free alternatives. Many products, including belts, cell phones, and hair accessories, can be spot tested. Furthermore, consumers should aim to find products created with alloys (ie, brass), pewter, stainless steel, platinum, yellow gold, sterling silver, or pure copper.24 Although nickel-sensitive individuals usually tolerate contact to stainless steel, conditions such as high heat (ie, nickel leaching into food when cooking with stainless steel pots), prolonged contact, and sweat may allow increased nickel release.22,25 In addition, individuals should beware of inexpensive metal posts on earrings. With regard to nickel release from watches, avoidance strategies such as moleskin, cotton, or duct tape application on the watch backing can prevent nickel diffusion into the skin. Lastly, nickel-releasing watch buckles can be replaced (with brass) or coated (with rhodium) to prevent contact and potential nickel release. Nickel-free products including safe jewelry alternatives are listed in Table 4. Other alternatives and avoidance strategies include plastic eyeglass frames or plastic clothing buttons. However, even items labeled as “nickel-free” should be spot tested to prevent unnecessary exposure. Other nickel-releasing items, such as keys, are also potential sources of nickel exposure. Brass keys are an acceptable alternative, and electroplated keys also work as long as contact with the cut “teeth” of the key is avoided, because the exposed teeth may not have the electroplated coating.
In addition to products that release high rates of nickel, there are foods with notoriously high levels of nickel (Table 5) that may contribute to the development and elicitation of systemic Ni-ACD. Jensen et al26 reported that of patients sensitized to nickel up to 10% demonstrate cutaneous reactions secondary to oral ingestion of nickel, and there are many reports of improved dermatitis after low-nickel diets.26 The level of nickel required to elicit dermatitis is unknown and likely varies from patient to patient. Lastly, patients should be informed that stainless pots/pans and tap water may contribute to increased dietary nickel.27
Cobalt is a common metal that is found in a wide range of sources. Products that commonly contain cobalt include leather, jewelry, children's toys, and orthopedic and implanted devices. In addition, foods with high levels of cyanocobalamin (vitamin B12) may trigger flares in exquisitely sensitized persons (ie, meat, dairy, apricots, beans, beer, and chocolate). Objects plated with nickel are noted to be the most common source of cobalt. “Antiqued” costume jewelry is often made of a zinc and cobalt alloy. Rarely, topical cosmetics and medications may contain cobalt. Specific “spot tests” have been developed to identify sources of cobalt metal ion release. Coating objects that contain cobalt with a clear acrylic spray may possibly provide a barrier against exposure.
Potassium dichromate is an indicator for allergy to hexavalent chromium. Exposure to chromates used when tanning leather (see following section on leather) and in Portland cement is a common source of exposure. Occupationally, metallurgical use accounts for more than 90% of chromate usage. Sensitized individuals should avoid direct skin contact with tanned leather and should not do cement work.
The relevance of positive patch test reactions to gold is often uncertain. Gold exposure may occur from direct exposure to jewelry or gold dental fillings. In addition, reactions to gold often occur at sites where jewelry is not worn because of passive transfer of gold from the hands. Individuals allergic to gold can have a jeweler plate their jewelry with platinum or rhodium. Gold dental fillings causing mucosal contact allergy can be removed and replaced with other dental filling materials.
METALS IN TOPICAL PRODUCTS
Green color cosmetics can contain chromates. Nickel, cobalt, gold, and chromium are also found in a few other types of topical and household products. Instructions on the use of CAMP can be found in the cosmetic section of this article.
METAL DENTAL ALLERGENS
Metals are frequently used in dentistry. For patients with metal allergy, a number of appropriate replacements may be found. Table 6 provides more information.
There are a number of potential allergens found in shoes, which will be discussed individually in the following textile dye, leather, shoe adhesive, and rubber sections. Shoes free of various allergens are listed in Table 7. In general, patients with shoe allergy should wear only safe shoes until their feet have fully improved. They can then add their other shoes back into their wardrobe, 1 pair weekly. Any shoes that cause a flare-up should be avoided permanently. For rash limited to the soles, it is often possible to simply replace shoe insoles with a safe material or line the inside of the shoe with felt. Alternatives for rubber shoe insoles include ones made of polyurethane, plastic, leather, or cork. If the insole has been attached with glue, the old adhesive should be scraped out and the new insole installed with Elmer's Glue-All. Additional measures that can be implemented are consistent use of socks, avoiding sweating and prolonged exposures, and/or application of antiperspirants to the feet to limit sweat and resulting allergen diffusion potential. For leather allergy, any of the previously mentioned insole types (aside from leather) will be safe alternatives.
Patients allergic to textile dyes and resins often present with dermatitis accentuated in areas of tight clothing and perspiration (eg, anterior/posterior axillary folds with sparing of the vault), waist, antecubital and popliteal fossae, and groin/medial thighs. However, these areas are also common sites for atopic dermatitis. Therefore, both textile allergy and atopic eczema (with reaction to commensal organisms) should be considered in patients with dermatitis in these areas.28,29
Textile resins provide wrinkle resistance to fabrics such as cotton, linen, wool, and rayon. Dimethylol dihydroxyethyleneurea (Fixapret CPN) releases less free formaldehyde than older resins and screens for allergy to textile resins on the ACDS Core Allergen Series. Ethylene urea melamine formaldehyde is used for screening on some other standard testing series.
Formaldehyde-sensitized patients may react to fabrics containing free formaldehyde as a result of being treated with formaldehyde-containing resins. Older textile resins that release high amounts of free formaldehyde are rarely used for apparel fabrics today. However, they may still be present in very stiff fabrics such as upholstery and draperies. Patients reacting to upholstery finish will have dermatitis in exposed areas such as the extensor forearm and posterior legs, rather than the classic textile clothing pattern. For automobile upholstery, some protection can be achieved by providing a barrier, such as a folding seat cushion covered with synthetic materials and/or wearing long sleeves and pants when driving.
Older textile resins may also be found in other settings; melamine formaldehyde resin is used in composite dental molds, and urea formaldehyde resin is used in fiberboard. These types of exposure could be relevant to occasional patients who react to this antigen but have hand dermatitis rather than a typical textile allergy pattern.30
Urea and melamine formaldehyde may also be used to bind pigments to fibers on 1 side of fabrics such as polypropylene (Olefin).31 Patients can be advised to avoid sheets with pattern on only 1 side. In addition, urea formaldehyde and melamine formaldehyde may be used to bind fibers together in nonwoven textiles such as surgical masks.32
Textile resin dermatitis from apparel is rarely reported now, because contemporary garments are no longer commonly finished with resins that release sensitizing levels of formaldehyde resin. However, patients allergic to these resins should avoid vintage clothing containing cotton and rayon. Patients allergic to textile finishes are best advised to use fabrics that are not finished (eg, 100% polyester, silk, acrylic, or nylon). Denim jeans are also not finished. Products that may be unfinished include 100% wool and linen that wrinkles easily. On the other hand, rayon is a modified cotton and is often highly finished, as are permanent press garments made of cotton/polyester blends. Uniforms made of shrink proof wool or twill may be heavily finished as well.
Textile dyes are the most common source of ACD to apparel. Disperse dyes are used to color polyester and other synthetic fabrics and blends; reactive dyes are used to color cotton or cotton blend fabrics.33
Disperse dyes are the most common allergenic textile dyes. Disperse orange 3 and a mixture of disperse blues 106 and 124 are on the ACDS core allergen series. Patients with disperse dye allergy may also react to p-aminoazobenzene or PPD. These compounds and samples of dampened fabric from suspect garments should be included when testing with a disperse dye series.34 One patient sensitized to PPD in a temporary black henna tattoo later reacted to cross-reacting clothing dyes.35
Disperse dyes are released from synthetic fabrics such as polyester, acrylic, acetate, and nylon. Disperse blue dyes are commonly found in black or navy blue acetate liners of dress clothing or in dark-colored polyester velour. Compared with acetate, acrylic, and polyester, disperse dyes are more color-fast on nylon, but nylon stockings can occasionally be the culprit in dermatitis of the posteromedial thighs in women sensitized to disperse dyes. Disperse dyes sensitivity can sometimes present as pigmented purpura.36–38
As with textile resin allergy, there is no product labeling of the dyes used in the United States. There is poor correlation between positive patch tests to disperse dyes and presence of those dyes in the garments that patients suspect as the cause of their symptoms.39 Patients allergic to disperse dyes should avoid colored polyester, nylon, acrylic, and acetate fabrics, including blends of fabrics with these fibers with cotton. For synthetic fabrics, white is the safest choice for these patients. Dark synthetic liners can be removed from dress clothing and replaced with white liners. One hundred percent cotton, rayon, Tencel (Lyocell), silk, linen, denim, or wool of any color is also an alternative choice. Dyes are water soluble, and washing clothing before use may be of some benefit in removing dye.40 Reactive dyes are more color-fast than disperse dyes and therefore rarely cause contact allergy.33
In Europe, fabrics certified by Oeko-Tex are not dyed with disperse blues 1, 3, 7, 26, 35, 102, 106, and/or 124; disperse brown 1; disperse yellows 1, 3, 9, 39, and 49; disperse orange 1, 3, 37, 59, and 76; and disperse reds 1, 11, and 17.41
This labeling also signifies minimal formaldehyde release.41 Fabrics certified by Oeko-Tex should be safe for patients with textile dye or finish allergies. In the United States, 1 way to locate bedding and clothing with this certification is by searching Amazon for “Oeko-Tex.”
Chromate, cobalt, and formaldehyde are allergens in leather that may cause dermatitis from contact with leather furniture,42 clothes, belts, purses, and briefcases. These allergens in leather are discussed in the previous section on metals, and avoidance of contact with leather is recommended for allergic patients. Leather shoe and boot alternatives are listed in Table 7.
For patients with suspected ACD to adhesives, a number of allergens must be considered. The North American Contact Dermatitis Group standard tray contains several screening allergens for adhesive allergy, including colophony, epoxy resin, ethyl acrylate, methyl methacrylate, multiple rubber allergens, and para-tertiary-butylphenol formaldehyde resin. Other allergens to consider include cyanoacrylates and other acrylates and methacrylates. In addition, mass spectrometry analysis of 38 consumer adhesives showed that 44.7% contained MI and 31.6% contained MCI.43 Methylisothiazolinone is an emerging problem in glues used by school children, including those used in “slime making.”
Unfortunately, a number of challenges exist when recommending alternate adhesives. For household adhesives, many of the products on store shelves do not list ingredients. This information may be found on manufacturers' websites or from the household product database, available online at the US National Library of Medicine (https://householdproducts.nlm.nih.gov/). Patients must always be cautioned that some product ingredient lists will only include information from material safety data sheets (MSDSs). These may be of limited utility for contact allergy, because most allergens are not listed as hazardous ingredients.
Table 8 provides an overview of household adhesives, categorized by function. Likely safe alternatives can be selected for various purposes using this table.
In the category of medical products, adhesives may be used in bandages, in adhesive tapes, and in wound dressings. These may use allergens such as colophony or rubber additives. Unfortunately, the ingredient composition of medical adhesives is not required on labels and can be difficult to determine.
Table 9 lists medical bandage and tape alternatives for allergic patients. Potential alternatives for rubber allergy include bandages or adhesive tapes that contain acrylate copolymers. Although these don’t often cross-react with acrylate and methacrylate monomers and are unlikely to trigger contact allergy, newer bandages with silicone-based adhesives are probably a safer choice. For routine wound care, to use medical tape to bandage a wound, a nonstick dressing (such as Telfa) can be cut to the desired size, placed over the wound, and taped over.
Nail Product Adhesives
To achieve longer nails or longer-lasting polishes, various types of nail products have been developed. Almost all of these products use acrylates and methacrylates and should be avoided by patients allergic to these compounds.
Acrylic nails use liquid mixed with acrylic powder that is applied to the nail plate, sculpted to the desired shape, and allowed to dry.
UV-gel nails also use acrylates/methacrylates. They are usually done in the salon (there are now a few home gel units), and a UV light is used for activation of the polish.
Dip powder requires a base coat (bond) to be applied; then, each nail is dipped into an acrylic powder. An activating liquid is then applied to dry and harden the powder.
No-light gels are gel (“no-chip”) nail polishes that can be done at home. Most of these products contain 2-hydroxyethyl methacrylate and other acrylates/methacrylates. These products do not require activation by light.
Because acrylates and methacrylates commonly cross-react, patients allergic to either should avoid all of the above types of nail products and instead use standard nail polishes listed on their CAMP safe list.
Preformed nails are pieces of preformed plastic that are applied to the nail using an adhesive glue. Tips are shorter pieces of plastic that can be glued to the end of the nails, to achieve longer length. Wraps are pieces of silk, linen, or fiberglass that are cut to a desired shape and glued to the nail plate. Various types of plastics are used in these types of products. There are also dip nail products using cyanoacrylate as a base coat. If patients are patch test negative to ethyl cyanoacrylate, they can use preformed nails attached with cyanoacrylate adhesive, as long as they are free of acrylates and methacrylates.
False eyelashes may be purchased individually, in clusters, or as full strips that may be applied to the base of the eyelid (where the roots of the eyelashes are) with a temporary adhesive. Eyelash extensions require professional application of false lashes onto natural lashes individually, with semipermanent adhesive. Eyelash adhesives may contain latex rubber, cyanoacrylate, or other acrylates (Table 10). Alternatives include topical growth products, such as bimatoprost, which can be applied to the lash-line daily until a desired length is accomplished.
Electrocardiogram Electrode Adhesives
Patients may also react to adhesives used to tape on the electrodes during an electrocardiogram (ECG). Table 11 shows alternative ECG electrodes for allergic patients.
For patients allergic to acrylates, epoxies, and metals, finding safe dental products may be challenging. It is important that patients discuss these allergies with their dentist. Acrylate and methacrylate allergy in particular must be reviewed, because modern dentistry makes frequent use of these materials. Although some materials may be considered appropriate from an allergy standpoint, multiple other issues, including function and durability, must be considered. In some cases, patients may need to consult a prosthodontist. These dental specialists are trained in formulating replacements for structures of the oral cavity.
For patients with acrylate allergies, a number of factors must be taken into account when planning dental procedures. Acrylates are chemical monomers that can cross-link to form “plastic” substances. The monomers may be in the form of a powder, liquid, or gel that is easily manipulated. For example, monomers can be poured into a cavity, such as a dental filling, or applied between objects, as in dental cements. The mixture can then be hardened in a process known as curing. During this process, the monomers undergo polymerization. Some acrylates are “self-curing” and polymerization will occur after the addition of a catalyst. In other cases, curing is initiated by a UV light, heat, or the absence of oxygen. The lower-molecular-weight monomers serve as allergens; once full polymerization occurs, the object is no longer allergenic. Unfortunately, studies have indicated that residual monomers may persist after curing, with the highest levels noted after self-cured acrylates. Self-cured acrylates are often used in temporary crowns and denture repair.
For patients allergic to acrylates and epoxies, the main concerns are with materials used in dental cements or in dental restorations. Dental restorations are used to replace missing or damaged tooth structures. This includes fillings, as well as permanent restorations such as crowns and bridges. Removable restorations, such as dentures, may also be an issue.
Temporary restorations are of particular concern. Temporary crowns, which are often left in place for weeks before the permanent crown is available, are a concerning source of allergenic unpolymerized acrylate monomers. The use of temporary crowns in allergic patients has resulted in severe symptoms.44
Because acrylate monomers may cross-react, switching from 1 monomer to another may not be sufficient. In addition, information in the MSDS may not be reliable. One study evaluated acrylates in commercial dental restoration materials using gas chromatography. Results indicated that the MSDS provided accurate information on the methacrylates present in these commercial materials for approximately only half of the products.45
Table 12 provides information on dental alternatives for acrylate allergy, including for fillings, crowns, veneers, and dentures. Acrylates are frequently used in “white” or “plastic” fillings. These are made of composite resins. Composites consist of hard filler particles, which are surrounded by a matrix that acts to bind the filler particles together. Dental composite fillings contain an inorganic “filler” such as quartz or silica to provide strength, surrounded by a resin material that acts as a “binder.” The first dental composites consisted of silica powder with a methacrylate monomer system and many commercial dental composites today still make use of methacrylate monomer derivatives. Although residual monomers have been demonstrated in composite resin fillings,46,47 newer formulations may result in fewer residual monomers.48 For patients allergic to acrylates or epoxies, amalgam fillings are a potential alternative. Dental amalgams include mercury and an alloy powder, usually composed of silver, zinc, tin, copper, or palladium. Other possible alternative metal fillings include nickel, cobalt chrome alloy, and gold. Porcelain fillings may also be used in some settings, but because they are hard and brittle, they are not recommended for certain teeth.
For crowns, which are permanent dental restorations, alternate materials include porcelain or metals, cemented in place with an appropriate material. In the case of veneers, which are shells affixed to the tooth to improve appearance, porcelain may be used instead of composite resins. Because these need to be bonded in place, appropriate bonding materials should be used.
Colophony derivatives may be found in shoe adhesives. One common use is a tackifier in the rubber cements that are used for attaching the sole or for attaching layers below the insole. para-Tertiary-butylphenol formaldehyde resin is often used to adhere leather parts in shoes. Rubber-based adhesives are also common in shoes. Shoe alternatives are shown in Table 7.
Rubber Allergy and Accelerators
Rubber products are commonplace, both in personal lives and in the workplace. Rubber (polyisoprene) can be naturally derived in the form of latex from the rubber tree, Hevea brasiliensis, or it can be made synthetically. Whereas H. brasiliensis is the main source of rubber latex, other potential natural sources include the Parthenium argentatum shrub (known as guayule rubber) and the Russian dandelion (Taraxacum koksaghyz).49 Both natural and synthetic polyisoprenes are resistant to damage and tearing, have good elasticity and flexibility, and are waterproof. Synthetic polyisoprenes have better weather resistance and relatively less odor compared with natural latex; however, natural rubber has slightly better strength and resiliency.50 Common sources of latex include gloves, balloons, condoms, diaphragms, bandages, carpeting, resistance bands, pacifiers, baby bottles, tourniquets, erasers, and rubber bands.
Other synthetic rubbers include nitrile (acrylonitrile-butadiene) and neoprene (polychloroprene). Nitrile is favored at times because it overall performs comparably to natural rubber latex but is more chemically resistant and highly puncture resistant (3–5 times more than latex).51 Common sources of nitrile include footwear, adhesives, sealants, hoses, belts, gloves, floor mats, and synthetic leather. Neoprene is a synthetic rubber, which is favored because of its soft texture, cushioning properties, and resistance to degradation and burning. It can also be made into a foam, which is waterproof and insulating. Thus, it is commonly used for wetsuits and diving gloves. Other common sources of neoprene include laptop sleeves and tablet holders, mouse pads, foam weather strips, make-up applicators, car seats and covers, shoe insoles, adhesives, orthopedic braces, wrist supports, gloves, swimming goggles, and Continuous Positive Airway Pressure masks.52
Allergy to natural rubber can be either a type I (immediate) or type IV (delayed hypersensitivity) reaction. Approximately 1% of the general population has a type I sensitivity to latex, which are due to allergenic proteins (Hev b 1–15) in the natural latex itself.53 Because of increasing rates of type I latex allergy among the general population, synthetic rubbers became increasingly used. This, however, resulted in an increase in type IV delayed hypersensitivity reactions.54 These reactions are in large part due to rubber accelerators (thiurams, dithiocarbamates, mercaptobenzothiazoles, and diphenylguanidine). These accelerators become impregnated in the final rubber product but are not bound by chemical bonds and have limited compatibility with rubber itself, and thus these become free on the surface of rubber materials leading to sensitization.55
Rubber production includes the creation of chemical cross-links through the formation of covalent bonds with sulfur between the rubber chains to produce ideal mechanical and physical properties; this process is known as vulcanization. Rubber accelerators are used to speed up this vulcanization process, and typically, more than 1 accelerator is used in production to optimize vulcanization.55 There are several families of accelerators represented on the ACDS core series, which are classified according to the speed at which they facilitate vulcanization. Fast accelerators include thiurams (thiuram mix) and dithiocarbamates (carba mix). Moderately fast accelerators include 1,3-diphenylguanidine (which is not a carbamate but is part of carba mix) and benzothiazoles (mercaptobenzothiazole and mercapto mix). Slow accelerators include thioureas (mixed dialkyl thioureas).52,55
In gloves, thiurams were traditionally the primary accelerant used and also a major source of sensitization. Given this, there has been a shift away from using this accelerator, and instead, use of dithiocarbamates and diphenylguanidine. In neoprene, it is the thioureas that are the most frequent sensitizer.52 Other potential type IV sensitizers in rubber include rubber antioxidants, which are added to inhibit rubber degeneration by ozone (black rubber PPD mix).
Table 13 lists medical examination, surgical, household, and industrial gloves that are latex-free and free of all of the rubber accelerators and black rubber mix antioxidants found on the ACDS core series. Table 14 lists other consumer items, which are also free of these substances. Table 7 lists shoes and other footwear free of specific rubber-related substances.
Rubber in Sports Protective Equipment
Table 14 shows safe athletic equipment alternatives for those with rubber accelerator allergies. For some common sports, such as hockey and football, we were unable to confirm safe alternative equipment products. However, prosthetics and orthotics makers can apply a polyurethane foam to protective equipment that will establish a barrier between the allergen(s) and the skin. The application of a foam will require the use of an adhesive, so it is important to ensure that the orthotics provider does not use a rubber-based adhesive. Although insurance will likely not cover these services, 1 orthotic company estimated that applying polyurethane foam to a piece of protective equipment would likely cost less than US $100. Nonetheless, prices may fluctuate by region or by sport. Another possible approach is to have a tailor line equipment with Gore-Tex cloth. Gore-Tex has been established as an effective barrier against contact allergy to rubber medical gloves and may possibly be broadly protective for rubber-related allergens.56
Rubber in Bandages
Bandages for rubber allergic patients have been discussed in the adhesives section previously. Alternatives are listed in Table 9.
Compositae (Asteraceae) family of plants has long been reported to cause ACD from direct contact and airborne exposure. There are more than 32,000 known species of Compositae plants. The ACDS Core Allergen Series includes Compositae mix, which consists of German chamomile, arnica, feverfew, tansy, and yarrow. Other well-known plants in this family include sunflowers, dandelions, lettuce, ragweed, and Parthenium; the latter has been responsible for an epidemic of airborne ACD in India.57 The most important sensitizers in this group of plants are sesquiterpene lactones, which are oil constituents found in stems, leaves, and pollen. The ACDS Core Allergen Series also includes a sesquiterpene lactone mix of alantolactone, dehydrocostus lactone, and costunolide. Classic airborne allergy due to Compositae and/or sesquiterpene lactones appears in the typical airborne clinical distribution. Flares typically occur in the spring and summer, whereas remissions typically occur in winter, although chronic severe cases can persist year-round.58 Although most airborne ACD to Compositae results from outdoor plant exposure, some individuals may react to edible Compositae plants; facial airborne ACD has been reported from chamomile tea vapor.59
Allergen avoidance strategies are necessary to prevent flares of Compositae-related dermatitis. Avoidance of Compositae in topical products can be achieved using ACDS CAMP. Clicking the quick check box for either Compositae mix or sesquiterpene lactone mix will avoid all Compositae allergens in the database. Avoiding of direct contact with Compositae plants is also essential. Examples of common garden plants to avoid are aster, black-eyed susan, coreopsis, chrysanthemum, coneflower, cosmos, dahlia, daisy, marguerite, marigold, sunflower, yarrow (colored), and zinnia. Avoidance of Compositae weeds is more difficult. Some common Compositae weeds are burdock, chicory, cocklebur, dandelion, feverfew, fireweed, goldenrod, mayweed, ragweed, sagebrush, thistle, and yarrow (white). Protective gloves and long-sleeve shirts when gardening will be helpful; however, gardeners should avoid contact with used gardening clothes, which should be washed after each usage. Avoidance of airborne ACD is even more difficult. Two case reports describe adequate control of long-standing Compositae dermatitis after removing Compositae plants, which were in close proximity to their homes.60,61 An informal, verbal survey of attendees at the 29th Annual ACDS meeting (San Diego, February 15, 2018) revealed no success with barrier creams for airborne ACD (verbal communication, Erin Warshaw, MD).
The current mainstay of treatment of airborne ACD is immunosuppression. For mild disease, it may be possible to manage symptoms with topical steroids alone. For more severe disease, oral steroids may be used for short-term therapy. Systemic immunotherapy has been used successfully as steroid-sparing treatment in India to address Parthenium airborne ACD. Commonly, azathioprine (100 mg daily or 300 mg weekly) has been coupled with a short course of oral steroids during treatment initiation.62–68 More recent studies have shown that methotrexate may also be effective (15 mg/wk).69 A study of 30 patients with airborne ACD to Parthenium in India compared 100 mg daily azathioprine with 15 mg daily methotrexate and found that the safety and efficacy of both drugs were comparable, although methotrexate response was earlier than azathioprine (5.6 vs 9.5 weeks to 75% clearance).70 Finally, cyclosporine has been mentioned in 2 case reports to successfully control symptoms at a dose of 2.5 mg/kg per day.71 Narrowband (nb)-UVB has also been reported as an effective method to treat airborne ACD. In a 2004 case report, a man with severe Parthenium airborne contact allergy was successfully treated with nb-UVB 3 times weekly at an initiating dose of 280 mJ cm2, increasing by 20% each visit, and achieved almost complete remission after 6 to 8 weeks of therapy. After completion of therapy, he was successfully maintained with biweekly nb-UVB thereafter.72
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