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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.

Tuesday, June 2, 2015

Systemic Contact Dermatitis and Nickel – How would AF handle this?

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!


"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."


“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.