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Reactions

We named the blog “Reactions” as a double entendre to remind the participants that this is an opportunity to weigh in on topics of importance to our field. Our goal is for the blog to stimulate thought provoking, collaborative conversations in the field of clinical and experimental dermatitis. The blog will include hot topics, controversial topics, and in depth, less formalized discussions from articles in Dermatitis.

Sunday, May 28, 2017

 

 

When the evidence is lacking we often rely on the consensus of experts when it comes to patient care. Such is the case in the realm of metal hypersensitivity resulting in orthopedic implant complications. This month a letter was published in Current Orthopaedic Practice that highlights a recent consensus paper published in the journal, Dermatitis.

ACDS guidelines for implant-associated metal hypersensitivity reactions Vassantachart, Janna M. MD; Brod, Bruce A. MD; Schalock, Peter C. MD; Crawford, Glen H. MD; Jacob, Sharon E. MD Current Orthopaedic Practice: May/June 2017 - Volume 28 - Issue 3 - p 334–335

The paper outlines the key points of the consensus article published In Dermatitis.

Patch Testing for Evaluation of Hypersensitivity to Implanted Metal Devices: A Perspective From the American Contact Dermatitis Society Schalock, Peter C. MD; Crawford, Glen MD; Nedorost, Susan MD; Scheinman, Pamela L. MD; Atwater, Amber Reck MD; Mowad, Christen MD; Brod, Bruce MD; Ehrlich, Alison MD; Watsky, Kalman L. MD; Sasseville, Denis MD; Silvestri, Dianne MD; Worobec, Sophie M. MD; Elliott, John F. MD; Honari, Golara MD; Powell, Douglas L. MD; Taylor, James MD; DeKoven, Joel M De Koven. Dermatitis . 27(5):241-247, September/October 2016.

 

Key take home points from the consensus paper are listed below.

 

Preimplantation

* We do not recommend routine preoperative patch testing in individuals who deny a history of adverse cutaneous reactions to metals and who deny a history of previous implant-related adverse events.

* Patients with a clear self-reported history of metal reactions should be evaluated by patch testing before device implant.

* Testing with manufacturer-provided metal discs has limited utility. We recommend use of standardized, commercially available test materials when possible.

* Positive patch test or LTT does not consistently predict in vivo metal-induced complications from metallic device implantation.

* Negative testing is only indicative of the current state of allergy.

* If preoperative patch testing is not performed in a patient with self-reported metal sensitivity, use of titanium or oxidized zirconium containing devices may be preferable.

* Documented informed consent is essential in situations when an allergen cannot be avoided.

* If testing before implant is not possible or refused, titanium- or oxinium-containing devices are preferable.

Postimplantation

* Patients who are symptom free after implantation do not require patch testing.

* Patch testing is only 1 element in the assessment of causation. The decision as to whether or not to remove an implanted device must include an assessment of all clinical factors and a thorough risk-benefit analysis by the treating physician(s) and patient.

* Metal exposure from the implanted device can cause sensitization, but a positive metal test does not prove causality of symptoms. The prevalence of nickel sensitization in the population without implant is high (15%–20%). Other causes of implant failure treatable without device removal, such as infection, should be carefully considered.

* Fixed devices with poor healing or eruptions above or adjacent to the incision site are more indicative of potential MHR likely caused by allergy.

* Dynamic joint systems are complex. Replacement of hardware with a nonallergenic alternative may be helpful, but each case must be individually considered. There is not enough evidence at this time to make overreaching recommendation.

* Mucosal and cardiovascular devices present further challenges. The local environment may produce reactions locally, regionally, or systemically.

* Patch testing does not definitively predict reactions to the metal-containing device. Caution and careful assessment of risks of placement and potential hypersensitivity reaction should be weighed with the potential benefits of placement.

At the end of the day we want to make the best decision for our patients based on our clinical acumen and our findings on physical exam and laboratory testing including patch testing. It is important not to try to fit a square peg into a round hole when it comes to the management of positive patch test reactions to nickel. On the other hand, relevant reactions can make a real impact on patient care. Not long ago I saw a patient who reacted to Vanadium screws and manifested with a severe local reaction and a systemic reaction. After years of suffering the patient improved based on her positive patch test triggering a removal of the device and Vanadium screws.  This was published along with another case in Dermatitis.

Hypersensitivity Reactions to Metallic Implants Containing Vanadium Asemota, Eseosa MD, MPH; Scheman, Andrew J. MD; Brod, Bruce A. MD Dermatitis:  November/December 2016 - Volume 27 - Issue 6 - p 387–388

I welcome your thoughts and look forward to the start of a robust discussion on this topic.​


Saturday, July 25, 2015

​ Wood allergens may cause contact dermatitis, but patch testing with patient-provided samples often presents technical challenges in the clinical setting. Discussion: Patients commonly present with various items from home or work for patch testing. While guidelines exist for industrial chemicals,1 other products may be challenging. The following case illustrates a common scenario and solution. A middle-aged male was referred to our patch testing clinic with a widespread dermatitis of several months duration; the most severely affected body areas were his hands and face. The patient was a custom cabinet maker who worked daily with a variety of wood species. Allergic contact dermatitis to woods has been well described and wood allergens may cause contact dermatitis, often in an airborne pattern.2, 3 Because of concern for occupational contact dermatitis, the patient was asked to provide samples of the different types of wood from his workplace. The patient brought in over 20 small samples of different types of wood. The solid wood samples were not practical for skin application as sawdust is typically required for patch testing.4 Without sandpaper available in the clinic, we sought other methods to produce sawdust. Surgical blades were unwieldy. However, using disposable dermatology curettes to apply friction across the end grain of the solid wood samples, we were able to create fine sawdust suitable for dilution (Figures 1-3). Using a separate curette for each type of wood also ensured a purified sample of sawdust, reducing the risk for cross-contamination between samples. Pearl: Disposable dermatology curettes are an effective, inexpensive, and readily available tool that can be used to create purified wood sawdust suitable for patch testing. References: 1. De Groot AC. Patch Testing. Test Concentrations and Vehicles for 4350 Chemicals, 3rd edition. Wapserveen, the Netherlands: acdegroot publishing, 2008. 2. Hausen BM. Contact allergy to woods. Clin Dermatol 1986;4:65-76. 3. Swinnen I, Goossens A. An update on airborne contact dermatitis: 2007-2011. Contact Dermatitis. 2013 Apr;68(4):232-8. 4. Podjasek JO, Cook-Norris RH, Richardson DM, et al. Allergic contact dermatitis from exotic woods: importance of patch-testing with patient-provided samples. Dermatitis. 2011 Mar-Apr;22(2):E1-6. Authors: Jamie Hanson, MD, Erin Warshaw, MD

Tuesday, June 2, 2015

Welcome to the first posting to the official blog of the American Contact Dermatitis Society (ACDS). We named the blog “Reactions” as a double entendre to remind the participants that this is an opportunity to weigh in on topics of importance to our field. Our goal is for the blog to stimulate thought provoking, collaborative conversations in the field of clinical and experimental dermatitis. The blog will include hot topics, controversial topics, and in depth, less formalized discussions from articles in Dermatitis.

 

For this first blog we started the dialogue ahead of time, so it is posted en bloc. This format was chosen to pay tribute to Alex Fisher, M.D., one of the great American leaders in contact dermatitis. The topic focuses on systemic contact dermatitis to nickel. Nickel is the most common allergen seen on patch testing and highly relevant. It was the ACDS 2008 allergen of the year. Nickel is also the most common allergen in the pediatric age group. While cutaneous exposure is well understood, there are many questions about the relevance of oral intake of nickel in patients with dermatitis. This preamble frames this conversation in its context and extends an invitation to the readers to engage in further discourse.

 

I hope you enjoy the blog and look forward to your comments.
- Bruce A. Brod, MD, President ACDS

 

Systemic Contact Dermatitis and Nickel – How would AF advise on this?


In 1990, the ‘Ask Alex’ column debuted in the American Contact Dermatitis Journal.  For over three decades this landmark column provided sound, evidence-based advice that was presented in a straightforward good friend style, much like Dear Abby.  What resulted was a bank of key advices and an opportunity to stimulate active discussion.  In 2015, the American Contact Dermatitis Society launched “Reactions”, an interactive web log of highlighted topics from this interactive discussion forum.  And in the words of Alex Fisher, don't forget to …“Keep in contact!”  Alex Fisher, 1990
- Sharon E. Jacob, MD

 

Doctissimi Queries!

 

Question:
"We were wondering if you could provide an estimate (a range is fine) of the prevalence of nickel sensitive individuals that have systemic nickel allergic contact dermatitis.  I realize this is likely to only be an estimate given the lack of data on this issue but would appreciate any help you can provide."

 

Answer(s):
“The prevalence in nickel sensitive patients is on the order of 10-15%, but consistently under-recognized (esp. in the pediatric population).”  [SEJ, CA]
""There's no lack of data - just a lack of awareness of data!   There was a meta-analysis published in 2006 (can't have a meta-analysis without data, right?).  Dose response curve shows that with normal American diet, 1 - 10% of nickel allergic individuals will have symptoms as a result of dietary nickel intake, with current dietary trends favoring the 10% figure.  End of discussion."  [MZ, OH]
"I’m in the <1% camp." [KW, CT] 
"I have told my patients around 10%."  [DP, UT]
"I agree on the 10%." [AT, FL & BB, PA]
"I typically tell patient 5%... I suspect the 20% positive rate of SPT includes some false positive given that so many of these patients are also dermatographic, but it is certainly very intriguing. I have a number of patients with cheilitis and perioral lesions with immediate symptoms that appear to be improving with nickel avoidance diet." [JS, IL]
"Veien estimates that 10% of patients with dyshidrotic eczema are triggered by systemic nickel. So prevalence of dyshidrotic eczema X 0.10 should be close.  That will be much smaller than even 1% of the general population.
     Systemic contact dermatitis is allergic contact dermatitis with Th2 skew and generation of antigen specific IgE. We know that Th2 skewing occurs in "atopic dermatitis" which presents early in life, so it makes sense that the prevalence in Sharon Jacob’s pediatric population is much higher.
     What we don't know is how many people have Th2/type 1 (immediate type) allergy to nickel and also retain Th1 response to nickel, the likely recipe for systemic contact dermatitis.  Doug Powell has some data on positive prick tests to nickel.
This is why we need allergists and dermatologists to work together.
I suspect that the number of people with positive prick tests is higher than the number who have systemic contact dermatitis to nickel, analogous to oat or wheat which we have studied. In other words, extrinsic atopic dermatitis or systemic contact dermatitis, whichever term you prefer! It occurs when there is percutaneous sensitization with both Th1 and Th2 response. Newell et al showed that most people with a Th2 response lose the Th1 response after 3 months, but a substantial minority retain it.  These can be identified with a combination of an atopy patch test (a nickel patch test in this case read at 48 hours and expecting a multi papular response) and any test for antigen specific IgE. In conjunction with Dan Kaplan at the Univ. of Minnesota, I speculate that follicular nickel patch test morphology is predictive of Th2 skewing. T follicular helper cells, recently discovered, skew to Th 2. This would also explain why atopy patch tests in general have multi papular morphology."  [STN, OH]

“I have some cases who are prick test positive and patch test negative (contact urticaria) to nickel in some patients whose clinical history was consistent with a very rapid reaction to nickel.  There are also some scattered cases in the literature.  I have not checked IgE in these patients but from what I remember from the cases in the literature—they didn’t necessarily have positive IgE to nickel either.  These cases that I had seem to be much higher risk to systemic nickel reactions.  I agree with SN, we ought to combine with allergists on some of these (this) issues.”  [DP, UT]

“Alina Goldenberg and I checked the LLU Pediatric Contact Dermatitis Registry Case log today. There are 64 Nickel-ACD Pediatric cases logged for 2014 in database, so far (unpublished data, March 11, 2015) and 20 have generalized clinically relevant reactions. (~31%!)  I think this may be a skewed #, because of referral bias.”  [SEJ, CA]

“I documented papular reaction to nickel in kids in 2002 in a cohort of kids with id reactions-”   [NS, NY]

“This is Awesome!! …that the papular morphology (seen in all atopy patch tests) had been documented to relate to a systemic reaction for nickel. Nickel patch tests, like compositae patch tests, are functioning as atopy patch tests. Also, helps to support the notion that all dermatitis should be managed with a combination of looking for allergic triggers with patch tests, attending to barrier, and attending to the microbiome/biofilm. Splitting atopic derm from contact derm is not helpful to patients.”  [STN,  OH]

The ongoing blog for this conversation can be found at [CITE] .

Participants in this discussion: Brod BA, Jacob SE, Zirwas M, Watsky K, Powell D, Tosti A, Silverberg J, Nedorost ST, and Silverberg N.


i. Antico A, Soana R.  Nickel sensitization and dietary nickel are a substantial cause of symptoms provocation in patients with chronic allergic-like dermatitis syndromes.  Allergy Rhinol (Providence). 2015 Mar 5. [Epub ahead of print]

 

ii. Newell L1, Polak ME, Perera J, Owen C, Boyd P, Pickard C, Howarth PH, Healy E, Holloway JW, Friedmann PS, Ardern-Jones MR.  Sensitization via healthy skin programs Th2 responses in individuals with atopic dermatitis.  J Invest Dermatol. 2013 Oct;133(10):2372-80. doi: 10.1038/jid.2013.148. Epub 2013 Mar 25.

 

iii. Silverberg NB, Licht J, Friedler S, Sethi S, Laude TA.  Nickel contact hypersensitivity in children.   Pediatr Dermatol. 2002 Mar-Apr;19(2):110-3.