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BACKGROUND: Recently, aluminum chloride hexahydrate (ACH) 10.0% petrolatum (pet) was recommended for patch testing to detect aluminum contact allergy. Aluminum lactate (AL) may be as reliable a test substance as ACH. OBJECTIVE: We aimed to investigate the frequencies of aluminum allergy when ACH and AL were used in patch testing consecutive patients. METHODS: Petrolatum preparations of ACH 10.0% and AL 12.0% were added to the baseline series in 2010-2017. Aluminum chloride hexahydrate 10.0% pet was added to the children baseline series from July 1, 2012, to December 31, 2017. RESULTS: A total of 5448 patients were patch tested with the extended baseline series and 196 children with the extended children baseline series. Forty-eight of the 5448 adults (0.9%) and 10 of the 196 children (5.1%) were diagnosed with aluminum contact allergy. A significant difference was found between the aluminum allergy frequencies in children and adults patch tested with ACH in 2013-2017 (P < 0.001). The difference between the frequencies of contact allergies for the 2 aluminum salts is not statistically significant. CONCLUSIONS: Patch testing with ACH and AL demonstrated similar contact allergy frequencies. To detect aluminum allergy, patch testing with ACH 10.0% pet is recommended. Aluminum chloride hexahydrate 10.0% pet should be considered for inclusion in baseline series for patch testing adults and children.

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BACKGROUND: Contact allergy to fragrance mix I (FM I) is over-represented in patients photoallergic to ketoprofen. The prevalence of contact allergy to two components of FM I, cinnamal and cinnamyl alcohol, in ketoprofen-photoallergic patients is higher than in dermatitis patients. OBJECTIVE: To explore the prevalence of contact allergy to FM I and its individual components in patients with photocontact allergy to ketoprofen, and to compare with a dermatitis and the general population. METHODS: Data on patch and photopatch tests performed between 2009-2018 were collected. Ketoprofen-photoallergic patients were compared with dermatitis patients and published data on the general population regarding the prevalence and the distribution of contact allergy to FM I and its components. RESULTS: A higher prevalence of contact allergy to cinnamyl alcohol compared with cinnamal (23.3% vs 10.0%), and eugenol compared with isoeugenol (23.3% vs 6.7%), was observed in ketoprofen-photoallergic patients, while the relationship was the opposite in the dermatitis group (0.7% vs 1.05%; 0.4% vs 0.9%). The overall prevalence of contact allergy to several components of FM I was significantly higher in ketoprofen-photoallergic patients. CONCLUSIONS: Contact allergy to FM I and many of its components is over-represented in patients photoallergic to ketoprofen compared with dermatitis patients and the general population.

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BACKGROUND: Most patients with contact allergy to Asteraceae plants are patch test positive to sesquiterpene lactone mix (SLM). There are several reports among these patients of a flare-up of hand eczema after ingestion of food and beverages originating from Asteraceae plants. AIM: To investigate whether German chamomile tea can elicit systemic allergic dermatitis. PATIENTS AND METHODS: Individuals with or without contact allergy to SLM were patch tested with an extract of German chamomile tea. Six weeks later, they were provoked with capsules containing either freeze-dried German chamomile tea or placebo capsules containing lactose, in a double-blind, randomized study. A numerical rating scale (NRS) was used to ascertain the volunteers' opinion of their hand eczema status. The study individuals were examined to detect a possible flare-up of healed patch test reactions to chamomile. RESULTS: None of the subjects had a flare-up of healed patch test reactions. According to the NRS, SLM-positive individuals experienced a significant worsening of hand eczema, independently of whether they received chamomile or lactose capsules. CONCLUSION: No evidence suggestive of systemic allergic dermatitis was found.

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BACKGROUND: In 2001, the EU nickel directive was introduced to prevent contact allergy to nickel. Contact allergy to palladium and/or cobalt is often seen together with contact allergy to nickel. OBJECTIVES: To compare the contact allergy prevalence of nickel, palladium, and cobalt allergy before and after the introduction of the EU nickel directive in consecutive patients with dermatitis. METHODS: A retrospective analysis of patch test results from 1995-2016 was performed (n = 18 264). Chi-square tests were used to examine trends for nickel, palladium, and cobalt across test years. Logistic regression was used for associations. RESULTS: The prevalence of nickel allergy decreased significantly in the youngest age group (6-30 years) for both female and male patients from 1995-1999 to 2012-2016: females: 33.4% to 19.1% (P < .001); males: 5.9% to 2.1% (P < .05). The concomitant reactions between nickel and palladium and nickel and cobalt among young females, respectively, also decreased significantly. Isolated palladium and cobalt allergy remained stable (1.4% and 2.3%, respectively) during the same time period for both men and women. CONCLUSIONS: The prevalence of nickel has decreased among young females and males suspected of contact allergy in Southern Sweden after the introduction of the EU nickel directive. There has been no change in isolated palladium or cobalt allergy.

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Concomitant reactions to palladium chloride (PdCl2), sodium tetrachloropalladate (Na2PdCl4), and nickel hexahydrate sulphate (NiSO4·6H2O) are very common during patch testing and have mainly been explained by cross-sensitisation. Whether there is variation in reactivity to palladium or covariation to nickel and palladium is not known. The aim of this study was to investigate the variation in patch test reactivity to PdCl2 and Na2PdCl4 over time and compare this to variation in patch test reactivity to NiSO4·6H2O. Fifteen females known to be sensitised to nickel and palladium were patch tested four times with 12-week intervals using a dilution series of NiSO4·6H2O, PdCl2 or Na2PdCl4. Patch test reactivity to Na2PdCl4 was less variable compared to that for NiSO4·6H2O or PdCl2. All test salts showed higher patch test reactivity during wintertime. No significant correlation was observed between the variation in patch test reactivity to Na2PdCl4 and PdCl2 and the variation in patch test reactivity to NiSO4·6H2O during the entire test period. Patch test reactivity to Na2PdCl4 is less variable over time compared to that for PdCl2 or NiSO4·6H2O. No clear covariation was identified between tests for palladium salts and NiSO4·6H2O. The variation in patch test reactivity found in this study could be due to seasonal changes.

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BACKGROUND: Sometimes, patients with a history of metal intolerance react negatively or doubtfully to nickel at patch testing. OBJECTIVE: The aim of the study was to investigate whether aqueous nickel sulfate hexahydrate at 15% and 30% traces more contact allergy than the nickel preparation in the baseline series at 5%. METHODS: In the period 1995-2015, more than 800 of 16,059 patients with a negative or doubtful patch test reaction to the petrolatum preparation of nickel at 5% on the day 3 reading were additionally tested with aqueous nickel at 15% and/or 30%. CONCLUSIONS: In this retrospective study with aimed patch testing with aqueous nickel solutions, significantly more (P < 0.001) contact allergy was obtained as compared with the 5% preparation in petrolatum. The 30% solution was significantly better (P < 0.001) than the 15% solution. To demonstrate that patch testing with nickel at 15% or 30% is better than the present testing with 5% requires simultaneous testing with the 3 nickel preparations.

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BACKGROUND: Contact allergy to aluminium has been reported more frequently in recent years. It has been pointed out that positive patch test reactions to aluminium may not be reproducible on retesting. OBJECTIVES: To investigate possible variations in patch test reactivity to aluminium over time. METHODS: Twenty-one adults, who had previously reacted positively to aluminium, were patch tested with equimolar dilution series in pet. of aluminium chloride hexahydrate and aluminium lactate, four times over a period of 8 months. RESULTS: Thirty-six of 84 (43%) serial dilution tests with aluminium chloride hexahydrate and 49 of 84 (58%) serial dilution tests with aluminium lactate gave negative results. The range of reactivity varied between a negative reaction to aluminium chloride hexahydrate at 10% and/or to aluminium lactate at 12%, and a positive reaction to aluminium chloride hexahydrate at 0.1% and/or to aluminium lactate at 0.12%. The highest individual difference in test reactivity noticed was 320-fold when the two most divergent minimal eliciting concentrations were compared. CONCLUSIONS: The patch test reactivity to aluminium varies over time. Aluminium-allergic individuals may have false-negative reactions. Therefore, retesting with aluminium should be considered when there is a strong suspicion of aluminium contact allergy.

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Type I sensitizations and atopic dermatitis (AD) often appear in the same patient. Beneficial effects of allergen-specific immunotherapy (ASIT) in patients with both AD and type I allergies have been reported. The predisposing role of AD to the development of type IV sensitization is discussed. Whether ASIT for type I allergy also influences type IV allergies is unknown. To compare the number of contact allergies between patients with and without AD, before and after one year's treatment with ASIT. A controlled, single-blind multicentre study of children/adults with allergic asthma and/or rhinoconjunctivitis, treated or untreated with ASIT, was performed. The history of AD was collected using questionnaires. The number of contact allergies was assessed by patch testing with a baseline series. 205 individuals completed the study; 133 treated with ASIT (exposed) and 72 before starting ASIT (unexposed). For participants with AD, significantly more contact allergies were found in the groups of all children (p = 0.002), all exposed children (p<0.001), and all exposed study persons (p = 0.013). Independent of AD, significantly more contact allergies were noted in the groups of all unexposed adults (p = 0.004) and all unexposed study persons (p = 0.004). The higher number of contact allergies in patients with AD indicates that AD may be a risk factor for type IV sensitization in those with allergic asthma and/or rhinoconjunctivitis. The lower number of contact allergies in patients exposed to ASIT suggests an immunomodulatory effect on type IV sensitization.

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The preservative methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) is a well-known sensitiser and present in most baseline series since at least 20 years. The proportions of MCI/MI are 3:1. MI alone has been used as a preservative in occupational and household products, and cosmetics since less than 10 years. MCI/MI tested at 100 ppm fails to detect a significant percentage of contact-allergic reactions to MI. Our aim was to investigate whether a separate test preparation with MI picks up additional cases of contact allergy to MI not detected with MCI/MI 200 ppm. MI was inserted into the baseline series of the Malmö clinic in 2003 starting at 475 ppm, then 900 ppm, then 1,000 ppm, 1,500 ppm and finally 2,000 ppm. In 5,881 consecutively tested dermatitis patients the contact allergy rate for MI varied between 0.5 and 6.5%, with a marked increase in recent years. The contact allergy rate to MI 2,000 ppm alone, not traced by MCI/MI 200 ppm, varied between 0 and 1.9 %. In conclusion, due to the increase of contact allergy to MI not traced by MCI/MI 200 ppm, MI in water at 2,000 ppm should be tested in a baseline series. Independent of patch test technique a dose of 60 µg/cm should not be exceeded to avoid adverse reactions and particularly patch test sensitisation.

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BACKGROUND: Rubber accelerators are common contact allergens in healthcare personnel, owing to exposures from medical gloves. OBJECTIVES: To analyse glove extracts used for patch testing for the presence of guanidine-type accelerators, and to describe the results of patch testing with triphenylguanidine (TPG) in 2 cases of contact allergy and with TPG added to the rubber series. MATERIALS AND METHODS: Gas chromatography-mass spectrometry and liquid chromatography with ultraviolet detection were used for analysis of glove extracts. Patch tests were performed with guanidine accelerators detected in the extracts. RESULTS: TPG, an accelerator not previously reported as being present in rubber gloves, was found in the glove extracts. Patch testing with TPG showed relevant contact allergic reactions in patients with hand dermatitis caused by rubber gloves. CONCLUSIONS: Chemical analysis of extracts for patch testing is important in the identification of new possible allergens. In this case, a rubber accelerator previously not reported as a possible contact allergen was found in extracts of surgical gloves.

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BACKGROUND: Children and adolescents with atopic disease who have allergic asthma and/or rhinitis with and without atopic dermatitis may have hidden, clinically relevant contact allergies. OBJECTIVE: The objective of this study was to survey contact allergies in children and adolescents who had been offered allergen-specific immunotherapy and accepted (exposed)/not accepted (unexposed) such treatment. METHODS: Thirty-seven exposed and 24 unexposed individuals with atopic disease were patch tested with a standard series supplemented with aluminum chloride hexahydrate, an empty Finn Chamber, and 8 antigen preparations. RESULTS: In the exposed group, 18 allergies were detected in 13 individuals with atopic disease when excluding reactions to aluminum and antigen preparations, whereas the corresponding figures for the unexposed group were 9 and 6, respectively (non-significant difference). Independent of the allergen-specific immunotherapy, significantly more (P = 0.013) individuals with atopic dermatitis had at least 1 contact allergy. Clinically relevant allergies were represented by sesquiterpene lactone mix, para-tertiary butylphenol-formaldehyde resin, tixocortol pivalate, and colophony. CONCLUSIONS: Clinically relevant contact allergies are not uncommon in children and adolescents with atopic disease, which is why patch testing always should be considered in the management of dermatitis in individuals with atopic disease.

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BACKGROUND: Since the EU Nickel Directive came into force, concern has been raised that palladium may increasingly replace nickel in alloys used in jewellery and dentistry, and that it may cause as many allergy problems as nickel. OBJECTIVES: (i) To investigate the clinical relevance of contact allergy to palladium resulting from the wearing of palladium-coated earrings, and (ii) to evaluate the concordance in test results between palladium chloride (PdCl2 ), sodium tetrachloropalladate (Na2 PdCl4 ), and nickel(II) sulfate hexahydrate (NiSO4 .6H2 O), as well as variability in patch test reactivity. MATERIALS/METHODS: Forty female patients with pierced earlobes and previously known contact allergy to palladium and nickel were patch tested with dilution series of nickel and palladium salts. They wore earrings covered with palladium and titanium for 9 weeks to monitor the appearance of any clinical manifestations. RESULT/CONCLUSION: There is a low risk of eczema in palladium-allergic and nickel-allergic individuals when they wear jewellery coated with pure palladium, but further studies are needed to determine whether palladium, when present in alloys, could cause allergic reactions. PdCl2 , like NiSO4 .6H2 O, shows variability in patch test reactivity over time. Furthermore, Na2 PdCl4 seems to be a more sensitive test substance than PdCl2 for the detection of palladium allergy.

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BACKGROUND: Trifluoroacetic acid is a very strong carboxylic acid. The acid has been suspected to have similar toxic effects as hydrofluoric acid on skin contact. Hydrofluoric acid is highly toxic, owing to skin penetration by fluoride ions. A spill of hydrofluoric acid on the skin may be fatal. As trifluoroacetic acid contains fluorine, patients with chemical burns caused by trifluoroacetic acid have been given particular attention when treated in the hospital. OBJECTIVES: To gather the known cases of trifluoroacetic acid burns from our department to give an overview of how they were exposed, the clinical presentation, and treatment. METHODS: Five patients with chemical skin burns caused by trifluoroacetic acid were reviewed with regard to the extent of the burn, treatment, blood samples taken, and systemic effects. RESULTS: The chemical burns reported were limited (<1% of the total body surface). The burns healed as expected for chemical burns caused by acids. None of the patients showed any symptoms or signs that are typical for hydrofluoric acid burns. CONCLUSION: Localized chemical burns caused by trifluoroacetic acid should be regarded as being similar to burns from other acids, with the exception of hydrofluoric acid. To our knowledge, there are no indications that trifluoroacetic acid causes the same toxic effects as hydrofluoric acid.

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BACKGROUND: Cushion bush [Leucophyta brownii Cass. = Calocephalus brownii (Cass.) F. Muell.] is an Australian Compositae shrub that has been introduced into Scandinavia as a pot plant. The first case of sensitization occurred in a gardener, and the main allergen was identified as the guaianolide calocephalin. OBJECTIVE: To present the identification of the main allergen, and to assess the prevalence of sensitization to calocephalin in Compositae-allergic patients. MATERIALS AND METHODS: Calocephalin was isolated from a dichloromethane extract of aerial parts of cushion bush. Calocephalin 0.1% ethanol was included in the plant series in Malmö, Sweden, and Odense, Denmark. RESULTS: Nuclear magnetic resonance (NMR) analysis of calocephalin resulted in a revision of its chemical structure to 4α-acetoxy-1α,2α-epoxy-5α,10αH-guai-11(13)-en-12,8ß-olide. The prevalence of patch test positivity was up to 28% in aimed patch testing. Despite strongly positive patch test reactions, the relevance was unknown in the majority of cases, and only 1 person was occupationally sensitized. CONCLUSION: Calocephalin is a potent contact allergen, but, as cushion bush is a low-maintenance pot plant, primary sensitization is most likely to occur through occupational exposure. Positive reactions in Compositae-sensitive persons probably occur because of cross-reactivity, and patients should be warned about contact with cushion bush plants.

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Persistent, itching nodules have been reported to appear at the injection site after allergen-specific immuno-therapy with aluminium-precipitated antigen extract, occasionally in conjunction with contact allergy to aluminium. This study aimed to quantify the development of contact allergy to aluminium during allergen-specific immunotherapy. A randomized, controlled, single-blind multicentre study of children and adults entering allergen-specific immunotherapy was performed using questionnaires and patch-testing. A total of 205 individuals completed the study. In the 3 study groups all subjects tested negative to aluminium before allergen-specific immunotherapy and 4 tested positive after therapy. In the control group 4 participants tested positive to aluminium. Six out of 8 who tested positive also had atopic dermatitis. Positive test results were found in 5/78 children and 3/127 adults. Allergen-specific immunotherapy was not shown to be a risk factor for contact allergy to aluminium. Among those who did develop aluminium allergy, children and those with atopic dermatitis were more highly represented.

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BACKGROUND: Traditionally, contact allergy to aluminium has been established by patch testing with aluminium chloride hexahydrate in petrolatum at 2.0% and an empty Finn Chamber®. OBJECTIVES: The aim of this study was to investigate different aluminium test preparations regarding an optimal compound and an optimal test concentration. METHODS: Six different aluminium compounds and an empty Finn Chamber® were used to patch test 21 patients with aluminium contact allergy. Aluminium chloride hexahydrate in saline was used for intracutaneous injection of 19 patients. RESULTS: One test preparation, aluminium lactate 2.4%, was found to show significantly more positive patch test reactions than aluminium chloride hexahydrate 2.0% (p = 0.03). Aluminium chloride hexahydrate at 10.0% pet. gave the highest number of positive reactions to aluminium [14/21 (67%)]. No positive reactions were noted to an empty Finn Chamber®, and 3 of 19 (16%) patients reacted positively to the intradermal test. CONCLUSIONS: The results of this study indicate that patch testing with aluminium chloride hexahydrate 2.0%, with an empty Finn Chamber® and the intradermal test with the salt and doses used are insufficient methods to detect contact allergy to aluminium. Aluminium chloride hexahydrate at 10.0% gave the highest number of positive reactions to aluminium.

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