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Background: Contact dermatoses are common in mechanic and repair occupations., Objectives: This study aimed to (1) estimate the prevalence of occupationally related contact dermatitis among mechanics/repairers patch tested from 1998 to 2014 by the North American Contact Dermatitis Group, (2) characterize responsible allergens and irritants, and their sources, and (3) compare results among 3 occupational subgroups (mechanics, electrical/electronic, and other)., Methods: A cross-sectional analysis of patients patch tested by the North American Contact Dermatitis Group between 1998 and 2014., Results: Of 38,784 patients patch tested, 691 (1.8%) were mechanics/repairers. Male sex (93.5%) and hand involvement (59.5%) were common overall. Occupationally related skin disease was more prevalent among vehicle and mobile equipment mechanics/repairers (52.7%) and other mechanics/repairers (41.4%) than electrical/electronic equipment mechanics/repairers (21.3%). Overall, carba mix, thiuram mix, and methylchloroisothiazolone/methylisothiazolone were the most common occupation-related clinically relevant allergens. Gloves, automotive vehicles, solvents, oils, lubricants, and fuels were the most common sources of responsible allergens., Conclusions: Common occupationally related allergens included rubber accelerators and the preservative methylchloroisothiazolone/methylisothiazolone.

Introduction: Corticosteroids may cause delayed hypersensitivity. On the basis of structure, the following 4 groups of corticosteroids are recognized: A, B, C, and D (subdivided into D1 and D2). More recently, a newer classification system subdivides corticosteroids into groups 1, 2, and 3. Cross-reactions are unpredictable. The objective of this study was to describe positive patch test and co-reaction patterns to corticosteroids., Methods and Results: A retrospective analysis of 17,978 patients patch tested by the North American Contact Dermatitis Group between 2007 and 2014 was performed. Corticosteroids tested during this period included the following: tixocortol-21-pivalate 1.0% petroleum (pet), budesonide 0.1% pet, triamcinolone acetonide 1.0% pet, desoximetasone 1.0% pet, clobetasol-17-propionate 1.0% pet, and hydrocortisone-17-butyrate (HC-17-B) 1.0% (pet and alcohol). Overall, 4.12% (n = 741) of patients had 1 or more positive reactions to corticosteroids. Tixocortol-21-pivalate positivity was the most common (2.26%), followed by budesonide (0.87%), HC-17-B (0.43%), clobetasol-17-proprionate (0.32%), and desoximetasone (0.16%). Reaction strength was strong (++ or +++) in almost twice as many tixocortol and budesonide reactions (>64%) as compared with the other 3 corticosteroids (<34.5%). Of the patients with positive corticosteroid reactions (n = 741), most (70.7%) had sensitivity to only 1 corticosteroid. Co-reactivity was highest between desoximetasone and budesonide., Conclusions: Sensitivity to corticosteroids is important. Consistent with other studies, the highest frequency of corticosteroid positivity was seen in group A (tixocortol-21-pivalate), followed by group B (budesonide) and D2 (HC-17-B). Co-reactivity varied; more studies are needed to fully understand structural cross-reactivity.

Background: The North American Contact Dermatitis Group patch tests patients with suspected allergic contact dermatitis (ACD) to a broad series of screening allergens and publishes periodic reports. We have previously reported on the association of race and ethnicity with the rates of positive responses to standard patch test allergens. This report extends those observations., Objective: The aim of the study was to report the North American Contact Dermatitis Group patch testing results from January 1, 1998, to December 31, 2006, comparing the frequency of positive reactions between white and black subjects., Methods and Materials: Standardized patch testing with 45 allergens was used at 13 centers in North America. χ analysis of results in black subjects as compared with whites was examined., Results: A total of 19,457 patients were tested; 92.9% (17,803) were white and 7.1% (1,360) were black. The final diagnoses of ACD (whites, 45.9%; blacks, 43.6%) and irritant contact dermatitis (13.0%/13.3%) were similar in the 2 groups. The diagnosis of atopic dermatitis was less common in the white patients (8.9%) as compared with the black patients (13.3%). Positive patch test reactions rates were similar for most allergens. However, statistically, blacks reacted more frequently to p-phenylenediamine (7.0% vs 4.4%, P < 0.001), bacitracin (11.6% vs 8.3%, P = 0.0004), as well as specific rubber accelerators mercaptobenzothiazole (2.7% vs 1.8%), thiuram (6.2% vs 4.3%), and mercapto mix (1.9% vs 0.8%, P < 0.001). Whites had an increase in positive reactions to fragrances (12.12% vs 6.77%, P < 0.0001), formaldehyde (9.25% vs 5.45%, P < 0.0001), and some formaldehyde releaser preservatives used in personal care products and textile resins (9.80% vs 6.18%, P < 0.0001)., Conclusions: There were statistically different rates of positive patch test reactions to specific allergens between black and white patients suspected of having ACD. The etiology of these differences is unclear but probably relates to culturally determined exposure patterns rather than genetic differences.

Background: Dust mites (DMs) play a role in type I respiratory allergy. Studies relating to DM irritant versus immune reactions are somewhat conflicting in atopic dermatitis (AD)., Objective: The aim of this study was to assess the diagnostic use of patch testing to DM in patients with AD and other dermatitides., Methods: We performed a prospective study of 323 adults recruited in a patch testing clinic. Patch testing antigens were DM extract (0.01%, 0.1%, 1%, 10%, and 20% in petrolatum; Chemotechnique) and/or 200 index of reactivity in petrolatum (Stallergenes). Patches were placed and read at 48 hours with delayed readings after 72 to 168 hours., Results: There was no association of DM positivity with AD, asthma, hay fever, or demographic factors. There was no association of DM positivity with the clinical diagnosis or phenotype. The number of positive (+, ++, and +++) and doubtful reactions to Chemotechnique DM extract increased with higher concentrations. Positive reactions to DM had a morphological appearance characterized by numerous discrete erythematous papules and, rarely, papulovesicles. Positive reactions to Stallergenes DM 200 IR were infrequent and all weak reactions, similar to DM 0.01%., Conclusions: Patch testing to DM does not seem to have clinical use for determining the etiology of dermatitis.

Background: Patch testing is an important diagnostic tool for assessment of allergic contact dermatitis (ACD)., Objective: This study documents the North American Contact Dermatitis Group (NACDG) patch-testing results from January 1, 2011, to December 31, 2012., Methods: At 12 centers in North America, patients were tested in a standardized manner with a series of 70 allergens. Data were manually verified and entered into a central database. Descriptive frequencies were calculated, and trends analyzed using χ statistics., Results: Four thousand two hundred thirty-eight patients were tested; of these, 2705 patients (63.8%) had at least 1 positive reaction, and 2029 (48.0%) were ultimately determined to have a primary diagnosis of ACD. Four hundred eight patients (9.6%) had occupationally related skin disease. There were 7532 positive allergic reactions. As compared with previous reporting periods (2009-2010 and 2000-2010), positive reaction rates statistically increased for 6 allergens: methylchloroisothiazolinone/methylisothiazolinone (5.0%; risk ratios [RRs]: 2.01 [1.60-2.52], 1.87 [1.61-2.18]), lanolin alcohol (4.6%; RRs 1.83 [1.45-2.30], 2.10 [1.79-2.47]), cinnamic aldehyde (3.9%; 1.69 [1.32-2.15], 1.53 [1.28-1.82]), glutaral (1.5%; 1.67 [1.13-2.48], 1.31 [1.00-1.71]), paraben mix (1.4%; 1.77 [1.16-2.69], 1.44 [1.09-1.92]), and fragrance mix I (12.1%; RRs 1.42 [1.25-1.61], 1.24 [1.14-1.36]). Compared with the previous decade, positivity rates for all formaldehyde-releasing preservatives significantly decreased (formaldehyde 6.6%; RR, 0.82 [0.73, 0.93]; quaternium-15 6.4% RR 0.75 [0.66, 0.85]; diazolidinyl urea 2.1%; RR, 0.67 [0.54, 0.84]; imidazolidinyl urea 1.6%, 0.60 [0.47, 0.77]; bronopol 1.6%; RR, 0.60 [0.46, 0.77]; DMDM hydantoin 1.6%; RR, 0.59 [0.54, 0.84]). Approximately a quarter of patients had at least 1 relevant allergic reaction to a non-NACDG allergen. In addition, approximately one-fourth to one-third of reactions detected by NACDG allergens would have been hypothetically missed by T.R.U.E. TEST (SmartPractice Denmark, Hillerød, Denmark)., Conclusions: These data document the beginning of the epidemic of sensitivity to methylisothiazolinones in North America, which has been well documented in Europe. Patch testing with allergens beyond a standard screening tray is necessary for complete evaluation of occupational and nonoccupational ACD.

Background: Allergic contact dermatitis is common in children. Epicutaneous patch testing is an important tool for identifying responsible allergens., Objective: The objective of this study was to provide the patch test results from children (aged ≤18 years) examined by the North American Contact Dermatitis Group from 2005 to 2012., Methods: This is a retrospective analysis of children patch-tested with the North American Contact Dermatitis Group 65- or 70-allergen series. Frequencies and counts were compared with previously published data (2001-2004) using χ statistics., Conclusions: A total of 883 children were tested during the study period. A percentage of 62.3% had ≥1 positive patch test and 56.7% had ≥1 relevant positive patch test. Frequencies of positive patch test and relevant positive patch test reaction were highest with nickel sulfate (28.1/25.6), cobalt chloride (12.3/9.1), neomycin sulfate (7.1/6.6), balsam of Peru (5.7/5.5), and lanolin alcohol 50% petrolatum vehicle (5.5/5.1). The ≥1 positive patch test and ≥1 relevant positive patch test in the children did not differ significantly from adults (≥19 years) or from previously tested children (2001-2004). The percentage of clinically relevant positive patch tests for 27 allergens differed significantly between the children and adults. A total of 23.6% of children had a relevant positive reaction to at least 1 supplemental allergen. Differences in positive patch test and relevant positive patch test frequencies between children and adults as well as test periods confirm the importance of reporting periodic updates of patch testing in children to enhance clinicians' vigilance to clinically important allergens.

Background: Mercaptobenzothiazole (MBT) and mercapto compounds are primarily used in rubber products., Objective: This study aimed to examine concomitant-positive rates of MBT (1% pet) and the 4-part mercapto mix (MM) (1% pet)., Design: This is a retrospective cross-sectional data from the North American Contact Dermatitis Group., Results: A total of 30,880 patients were patch tested to MM and MBT. There were 333 positive reactions to MM and 427 positive reactions to MBT. Ninety-eight patients were positive to MM alone, 192 to MBT alone, and 235 reacted to both. Forty-five percent (192/427) of MBT reactions would have been missed by only testing to MM, and 29% (98/333) of MM reactions would have been missed by testing to MBT alone. Most of these "missed" reactions, however, were doubtful (+/-) or mild (+) (MBT, 65%; MM, 78%), whereas most reactions in patients who reacted to both were moderate (++) and/or strong (+++) (52.3%). Gloves were the most common source., Conclusions: Mercaptobenzothiazole is the preferential screening allergen for mercapto compounds because of the following: (1) greater proportion of missed reactions with MM; (2) greater proportion of doubtful/mild reactions in the missed group for MM; and (3) in the group positive to both, the low rate (2%) of moderate/strong reactions to MM and doubtful/mild reactions to MBT as compared with the converse (21%). Mercapto mix may be useful in an auxiliary rubber series.

Topically applied cosmetics and medicaments containing botanical extracts are commonly used. Despite popular beliefs of their benignancy, some botanicals have been implicated in causing allergic contact dermatitis in susceptible patients. The offending allergen may be the botanical extract itself or another ingredient such as a fragrance, preservative, dye, or sunscreen found in the product. Specific botanicals implicated in causing cosmetic contact dermatitis include Compositae family plants, tea tree oil, peppermint, lavender, lichens, henna, and others.

Background: Carba mix (CM) contains 3 chemicals used as accelerators in manufacturing of rubber products and agricultural chemicals. Iodopropynyl butylcarbamate (IPBC) is a preservative used in industrial and personal care products. Potential cross-reactivity between these allergens is unclear., Objective: This study aimed to determine concomitant reaction rates between CM (3% petrolatum [pet]) and IPBC (0.1% pet and/or 0.5% pet)., Design: A retrospective cross-sectional analysis of data from the North American Contact Dermatitis Group from 1998 to 2008 was conducted. Frequencies of positive reactions, strength of reactions, and concomitant reaction rates were calculated., Results: A total of 25,435 patients were tested. There were 1131 allergic reactions to CM and 346 positive reactions to IPBC (either 0.1% pet and/or 0.5% pet). Fifty-two patients reacted to both allergens. Most reactions (>69%) were doubtful/weakly positive, and of those who reacted to both, most (58%) had doubtful and/or weakly positive reactions. There was a statistically significant association of concomitant reactions between CM and IPBC; formaldehyde positivity was used as control and showed statistically significant concomitant reactions., Conclusions: Overall, concomitant reactions to CM and IPBC were low, and rates varied by strength of reaction. True cross-reactivity is unlikely; statistical association is likely due to frequent low-grade reactions to irritant patch test preparations.

Background: Both active and inactive ingredients in sunscreen may cause contact dermatitis., Objectives: This study aimed to describe allergens associated with a sunscreen source., Methods: A cross-sectional analysis of patients patch tested by the North American Contact Dermatitis Group between 2001 and 2010 was performed., Results: Of 23,908 patients patch tested, 219 (0.9%) had sunscreen coded as an allergen source. Patients who were male, with occupational dermatitis, or older (older than 40 years) had significantly lower rates of allergic reactions to sunscreens; the most commonly affected areas were the face and exposed sites (P < 0.0001). The top 3 most frequent allergens in sunscreens were benzophenone-3 (70.2% for 10% concentration, 64.4% for 3% concentration), DL-alpha-tocopherol (4.8%), and fragrance mix I (4.0%). Less than 40% of positive patch test reactions were detected by the North American Contact Dermatitis Group screening series of 65 to 70 allergens., Conclusions: A supplemental antigen series is important in detecting allergy to sunscreens.

Background: Persistent photosensitivity after allergic contact dermatitis (ACD) to epoxy resin has rarely been described., Objective: The aim of this study was to create awareness that ACD to epoxy may be a trigger for persistent photosensitivity., Methods: We present a series of 5 patients who developed ACD to epoxy resin and later a photodistributed eczematous eruption when exposed to sunlight, with a documented decrease in minimal erythema dose to UVA and UVB., Results: The age of patients ranged from 34 to 71 years, and there were 3 men and 2 women. Each patient had occupational exposure to epoxy. Symptoms of epoxy ACD preceded photosensitivity by 5 months to 12 years in 3 cases and occurred simultaneously in 2 cases. Patch testing to epoxy resin was positive in all patients. Phototesting revealed a decreased minimal erythema dose to UVA and UVB in each of the 3 patients who were phototested. Photopatch testing was positive for epoxy resin in 1 of the 2 patients tested. All patients remained photosensitive for at least 2 years after diagnosis, with only 1 case of photosensitivity resolving with extended avoidance of epoxy., Conclusions: There is an association between ACD to epoxy resin and development of persistent photosensitivity. Possible mechanisms to explain the relationship between the 2 phenomena are discussed.

Background: The American Contact Dermatitis Society (ACDS) is the principal organization representing the subspecialty of contact dermatitis in the United States., Objective: The aim of this study was to characterize ACDS members with respect to demographic characteristics, patch-test practices, and sentiments regarding the Society and its journal Dermatitis., Methods: We conducted cross-sectional postal and online surveys of ACDS members., Results: More than a third of ACDS members responded to the survey, 92% of whom practice dermatology, and most of whom are community practitioners. Responders manage patients with allergic and irritant dermatitis at a similar frequency. On average, they patch test 4 patients per week using 66 allergens per patient, which often include customized trays. Almost half of these practitioners learned patch testing from their residency programs. Most of the responders read and value the Society journal, value the Contact Allergen Management Program database, and attend society meetings., Conclusions: The ACDS is comprised overwhelmingly of dermatologists who are primarily community-based, young relative to the start of their practices, and use the Society's resources for continuing education.

Background: Patch testing is an important diagnostic tool for determination of substances responsible for allergic contact dermatitis., Objective: This study reports the North American Contact Dermatitis Group (NACDG) patch testing results from January 1, 2009, to December 31, 2010., Methods: At 12 centers in North America, patients were tested in a standardized manner with a screening series of 70 allergens. Data were manually verified and entered into a central database. Descriptive frequencies were calculated, and trends were analyzed using χ2 statistics., Results: A total of 4308 patients were tested. Of these, 2614 (60.7%) had at least 1 positive reaction, and 2284 (46.3%) were ultimately determined to have a primary diagnosis of allergic contact dermatitis. Four hundred twenty-seven (9.9%) patients had occupationally related skin disease. There were 6855 positive allergic reactions. As compared with the previous reporting period (2007-2008), the positive reaction rates statistically decreased for 20 allergens (nickel, neomycin, Myroxylon pereirae, cobalt, formaldehyde, quaternium 15, methydibromoglutaronitrile/phenoxyethanol, methylchlorisothiazolinone/methylisothiazolinone, potassium dichromate, diazolidinyl urea, propolis, dimethylol dimethylhydantoin, 2-bromo-2-nitro-1,3-propanediol, methyl methacrylate, ethyl acrylate, glyceryl thioglycolate, dibucaine, amidoamine, clobetasol, and dimethyloldihydroxyethyleneurea; P < 0.05) and statistically increased for 4 allergens (fragrance mix II, iodopropynyl butylcarbamate, propylene glycol, and benzocaine; P < 0.05). Approximately one quarter of tested patients had at least 1 relevant allergic reaction to a non-NACDG allergen. Hypothetically, approximately one quarter of reactions detected by NACDG allergens would have been missed by TRUE TEST (SmartPractice Denmark, Hillerød, Denmark)., Conclusions: These results affirm the value of patch testing with many allergens.

Background: The North American Contact Dermatitis Group (NACDG) tests patients with suspected allergic contact dermatitis to a broad series of screening allergens and publishes periodic reports., Objective: The aims of this study were to report the NACDG patch-testing results from January 1, 2007, to December 31, 2008, and to compare results to pooled test data from the previous 2 and 10 years to analyze trends in allergen sensitivity., Methods and Materials: Standardized patch testing with 65 allergens was used at 13 centers in North America. χ analysis was used for comparisons., Results: A total of 5085 patients were tested; 11.8% (598) had an occupationally related skin condition, and 65.3% (3319) had at least 1 allergic patch test reaction, which is identical to the NACDG data from 2005 to 2006. The top 15 most frequently positive allergens were nickel sulfate (19.5%), Myroxylon pereirae (11.0%), neomycin (10.1%), fragrance mix I (9.4%), quaternium-15 (8.6%), cobalt chloride (8.4%), bacitracin (7.9%), formaldehyde (7.7%), methyldibromoglutaronitrile/phenoxyethanol (5.5%), p-phenylenediamine (5.3%), propolis (4.9%), carba mix (4.5%), potassium dichromate (4.1%), fragrance mix II (3.6%), and methylchloroisothiazolinone/methylisothiazolinone (3.6%). There were significant increases in positivity rates to nickel, methylchloroisothiazolinone/methylisothiazolinone, and benzophenone-3. During the same period of study, there were significant decreases in positivity rates to neomycin, fragrance mix I, formaldehyde, thiuram mix, cinnamic aldehyde, propylene glycol, epoxy resin, diazolidinyl urea, amidoamine, ethylenediamine, benzocaine, p-tert-butylphenol formaldehyde resin, dimethylol dimethyl hydantoin, cocamidopropyl betaine, glutaraldehyde, mercaptobenzothiazole, tosylamide formaldehyde resin, budesonide, disperse blue 106, mercapto mix, and chloroxylenol. Twenty-four percent (1221) had a relevant positive reaction to a non-NACDG supplementary allergen; and 180 of these reactions were occupationally relevant., Conclusions: Periodic analysis, surveillance, and publication of multicenter study data sets document trends in allergen reactivity incidence assessed in the patch test clinic setting and provide information on new allergens of relevance.

Background: Contact dermatoses are common in food service workers (FSWs)., Objectives: This study aims to (1) determine the prevalence of occupationally related contact dermatitis among FSWs patch tested by the North American Contact Dermatitis Group (NACDG) and (2) characterize responsible allergens and irritants as well as sources., Methods: Cross-sectional analysis of patients patch tested by the NACDG, 1994 to 2010, was conducted., Results: Of 35,872 patients patch tested, 1237 (3.4%) were FSWs. Occupationally related skin disease was significantly more common in FSWs when compared with employed non-FSWs. Food service workers were significantly more likely to have hand (P < 0.0001) and arm (P < 0.0006) involvement. The rates for irritant and allergic contact dermatitis in FSWs were 30.6% and 54.7%, respectively. Although the final diagnosis of irritant contact dermatitis was statistically higher in FSWs as compared with non-FSWs, allergic contact dermatitis was lower in FSWs as compared with non-FSWs. The most frequent currently relevant and occupationally related allergens were thiuram mix (32.5%) and carba mix (28.9%). Gloves were the most common source of responsible allergens. The NACDG standard tray missed at least 1 occupationally related allergen in 38 patients (4.3%)., Conclusions: Among FSWs patch tested by the NACDG between 1994 and 2010, the most common allergens were thiuram mix and carba mix. Gloves were the most common source of responsible allergens.

Background: European studies document that occupational contact dermatitis (CD) is common in hairdressers, but studies from North America are lacking., Objectives: The objectives of this study were to estimate the prevalence of occupational CD among North American hairdressers/cosmetologists (HD/CS) and to characterize responsible allergens and irritants as well as their sources., Methods: A cross-sectional analysis of patients patch tested by the North American Contact Dermatitis Group between 1994 and 2010 was conducted., Results: Of 35,842 patients, 432 (1.2%) were HD/CS. Significantly, most of the HD/CS were female (89.8%) and younger than 40 years (55.6%) as compared with non-hairdressers (P < 0.0001). The rates for allergic and irritant CD in HD/CS were 72.7% and 37.0%, respectively. The most common body site of involvement was the hand, and this was significantly more common than in non-HD/CS (P < 0.0001). The most frequent currently relevant and occupationally related allergens were glyceryl thioglycolate, p-phenylenediamine, nickel sulfate, 2-hydroxyethyl methacrylate, and quaternium-15. Hair dyes, permanent wave solutions, and other hair products were common sources of allergens. The North American Contact Dermatitis Group allergen series missed at least 1 occupationally-related allergen in 26.2% of patients., Conclusions: Contact dermatitis in North American HD/CS is common, and occupationally related allergens are those found in HD/CS products. Supplemental hairdressing/cosmetology antigen series are important in detecting all occupationally related allergens in this population.

Background: iodopropynyl butylcarbamate (IPBC), a commonly used preservative, is found in industrial and personal care products., Objective: to evaluate prevalence, clinical relevance, occupational relationship, and sources of positive reactions to IPBC in patients in North America., Methods: the North American Contact Dermatitis Group (NACDG) tested IPBC 0.1% and/or 0.5% in petrolatum (pet) between 1998 and 2008. Two patient groups of interest were defined, based on patch-test reactions to IPBC: weak (+) reactors and strong (++ or +++) reactors. Patient characteristics, site(s) of dermatitis, sources of positive reactions, clinical relevance, and occupational relevance to IPBC were tabulated., Results: of the 25,321 patients tested, there were 226 (0.9%) weak reactors and 67 (0.3%) strong reactors. For IPBC-positive patients, the most frequent sites of dermatitis were scattered generalized distribution, hands, and arms. The majority (> 50%) of currently relevant reactions were to personal care products, and most reactions (> 90%) were not related to occupation. Only four of the strong reactors had definite clinical relevance (positive use-test reaction or positive patch-test reaction to a product containing IPBC). The frequency of positive reactions increased (0.2% vs 1.5%) when the higher concentration of IPBC was utilized, but most (> 64%) were weak reactions, of which some were likely irritant., Conclusions: allergy to IPBC is relatively uncommon. When clinically relevant, personal care products were the most likely allergen source. Because IPBC is a marginal irritant, caution should be utilized when testing with higher concentrations of IPBC (≥ 0.5% pet) and when interpreting weak (+) reactions. Verification of clinical relevance by use test or repeat patch testing or both is also important.

Allergic contact dermatitis due to citrus fruits is rare, but has been reported in cooks and bartenders. We report an interesting case of a bartender with hand dermatitis who had an allergic contact sensitivity to lime peel, fragrance mix I, and fragrance mix II. Most reported cases of citrus peel allergy are due to d-limonene, which makes up the majority of the peel oil. However, our patient had an allergic reaction to geraniol, which is a minor component of the peel oil and is present in fragrance mix I. It is important to consider a contact sensitivity to citrus in patients who have positive reactions to fragrance mix I and II and who are occupationally exposed to citrus fruits. An initial positive reaction to fragrance mixes should prompt further testing to citrus in these individuals.

Background: The positivity ratio (PR) and reaction index (RI) characterize the ability of patch-test preparations to produce strong (++ or +++) reactions as opposed to weak (+), questionable, or irritant reactions., Objective: This study evaluates these measures for North American Contact Dermatitis Group (NACDG) patch-test preparations., Methods: The PR and RI were calculated for 79 NACDG standard allergens tested from 1994 to 2006 (n = 26,479 patients). The median values were used as cutoff values for "acceptable" versus "problematic" preparations., Results: The top 10 "acceptable" patch-test preparations (PR < or = 55 and RI > 0.46) were mixed dialkyl thioureas 1% in petrolatum (pet), tixocortol-21-pivalate 1% pet, ethylenediamine dihydrochloride 1% pet, sesquiterpene lactone mix 0.1% pet, nickel sulfate 2.5% pet, bacitracin 20% pet, thimerosal 0.1% pet, epoxy resin 1% pet, colophony 20% pet, and mercaptobenzothiazole 1% pet. The most "problematic" patch-test preparations (PR > 55 and RI < or = 0.46) were cocamidopropyl betaine 1% aqueous (aq), benzalkonium chloride 0.1% aq, jasmine absolute 2% pet, iodopropynyl butyl carbamate 0.1% pet, 2-bromo-2-nitropropane-1,3-diol 0.5% pet, methyldibromoglutaronitrile 0.4% pet, methyldibromoglutaronitrile/phenoxyethanol 2% pet and 2.5% pet, dimethylol dihydroxyethyleneurea 4.5% aq, and clobetasol-17-propionate 1% pet., Conclusion: Caution should be used when interpreting reactions to "problematic" patch-test preparations with a high proportion of weak, irritant, and questionable reactions.

Background: Identification of putative contact allergen and source material is often done by a combination of patch testing and manufacturer-supplied product information. The accuracy of the identification of allergen-source material and level of allergen in that allergen-source material is not known., Objective: The objectives of the study were to survey the chemical allergen content of glove allergic contact dermatitis (ACD) patient-identified problem and nonproblem gloves and to evaluate the ability of the patient to discriminate between problem and nonproblem gloves., Methods: Gloves from patch-tested rubber allergen-positive ACD patients were analyzed for species and amount of rubber allergen., Results: Approximately half the subjects were able to correctly identify their problem and nonproblem gloves. Correct association of a glove with ACD was directly related to patch-test reaction severity and inversely related to the number of glove brands being used by the patient. Of note, thiurams were not detected in any of the gloves examined., Conclusions: Although patch testing is invaluable in identifying individual allergen sensitivities, the identification of the ACD-causative specific chemical allergen and source material remains problematic. All glove brands used within days prior to and during an ACD episode should be considered potential sources of the contact allergen.

Background: The North American Contact Dermatitis Group (NACDG) tests patients who have suspected allergic contact dermatitis with a broad series of screening allergens, and publishes periodic reports of its data., Objective: To report the NACDG patch-test results from January 1, 2005, to December 31, 2006, and to compare results to pooled test data from the previous 10 years., Methods: Standardized patch testing with 65 allergens was used at 13 centers in North America. Chi-square statistics were utilized for comparisons with previous NACDG data., Results: NACDG patch-tested 4,454 patients; 12.3% (557) had an occupation-related skin condition, and 65.3% (2,907) had at least one allergic patch-test reaction. The 15 most frequently positive allergens were nickel sulfate (19.0%), Myroxilon pereirae (balsam of Peru, 11.9%), fragrance mix I (11.5%), quaternium-15 (10.3%), neomycin (10.0%), bacitracin (9.2%), formaldehyde (9.0%), cobalt chloride (8.4%), methyldibromoglutaronitrile/phenoxyethanol (5.8%), p-phenylenediamine (5.0%), potassium dichromate (4.8%), carba mix (3.9%), thiuram mix (3.9%), diazolidinylurea (3.7%), and 2-bromo-2-nitropropane-1,3-diol (3.4%). As compared to the 1994-2004 data, there were significant increases in rates of positivity to nickel, quaternium-15, potassium dichromate, lidocaine, and tea tree oil. Of patch-tested patients, 22.9% (1,019) had a relevant positive reaction to a supplementary allergen; 4.9% (219) had an occupationally relevant positive reaction to a supplementary allergen., Conclusion: Nickel has been the most frequently positive allergen detected by the NACDG; rates significantly increased in the current study period and most reactions were clinically relevant. Other common allergens were topical antibiotics, preservatives, fragrance mix I and paraphenylenediamine. Testing with an expanded allergen series and supplementary allergens enhances detection of relevant positive allergens.

Background: The prevalence of lanolin sensitivity in referred patients is less than 4%., Objectives: To (1) describe patients with positive patch-test reactions to lanolin, (2) determine clinical and occupational relevance associated with reactions to lanolin and common sources, and (3) examine the frequency of co-reacting allergens., Methods: A retrospective analysis of 26,479 patients patch-tested by the North American Contact Dermatitis Group (NACDG), 1994 to 2006., Results: Overall, 2.5% of patients (643 of 25,811) tested to lanolin alcohol 30% in petrolatum had positive reactions. Prevalence decreased from 3.7% in 1996 to 1998 to 1.8% in 2005 to 2006 (p <.0001); 83.4% of all positive reactions were currently relevant, but only 2.5% were occupationally relevant. Lanolin-positive patients were 1.2 times more likely to be male and 1.4 times more likely to have a history of atopic dermatitis when compared to allergic, but lanolin-negative, patients (p < .0002 and p < .0001, respectively). Cosmetics were the most common source. Lanolin-positive patients were significantly more likely to be co-sensitized to another NACDG standard screening allergen (p <.0001)., Conclusions: The prevalence of allergic patch-test reactions to lanolin in North America patch-test populations is decreasing. Current relevance of reactions was high, but occupational relevance was low. Concomitant reactions were more common in lanolin-positive patients.

Background: Allergy to cosmetics is common., Objectives: We sought to characterize patients with positive patch test reactions associated with a cosmetic source, to identify common allergens; and to explore gender and occupational associations., Methods: We performed a retrospective, cross-sectional analysis., Results: Of 6621 female and 3440 male patients, 1582 female (23.8%) and 611 of male (17.8%) patients had at least one allergic patch test reaction associated with a cosmetic source. Of "allergic" patients (>1 allergic reaction, n = 6815), females were 1.21 times more likely to have an allergic reaction associated with a cosmetic source than were male patients (p < .0001, 95% confidence interval [CI] 1.12-1.31). Within the "cosmetic allergic" group (n = 2243), head and neck involvement was significantly higher in female than in male patients (49.3% vs 23.7%, p < .0001). One hundred twenty-five patients had occupationally related allergic reactions associated with a cosmetic., Limitations: This study is limited by its cross-sectional, retrospective design., Conclusion: Of all patients studied, 21.8% had an allergic reaction associated with a cosmetic. Site of dermatitis, cosmetic categories, and specific allergens differed somewhat by gender.

Background: Propylene glycol (PG) may cause allergic or irritant contact dermatitis. It primarily functions as a vehicle, solvent, or emulsifier in cosmetics and topical medications., Objectives: To characterize the prevalence of positive patch-test reactions to PG and the epidemiology of affected patients., Methods: Retrospective analysis of cross-sectional data compiled by the North American Contact Dermatitis Group (NACDG) from 1996 to 2006., Results: Of 23,359 patients, 810 (3.5%) had allergic patch-test reactions to 30% PG; 12.8% of the reactions were of definite clinical relevance (positive reaction to a personal product containing PG), 88.3% were considered to be currently relevant (definite, probable, or possible relevance), and 4.2% of reactions were occupation related, most commonly to mechanical and motor vehicle occupations. Common sources of PG were personal care products (creams, lotions, and cosmetics, 53.8%), topical corticosteroids (18.3%), and other topical medicaments (10.1%). In patients positive only to PG (n = 135), the face was most commonly affected (25.9%), followed by a scattered or generalized pattern (23.7%). The most common concomitant reactions included reactions to Myroxilon pereirae, fragrance mix, formaldehyde, bacitracin, methyldibromoglutaronitrile/phenoxyethanol, carba mix, and tixocortol pivalate., Conclusions: In this select population of patients referred for patch testing, allergic reactions to PG were often currently clinically relevant but were rarely related to occupation. The most common sources were personal care products and topical corticosteroids.

Objectives: To determine the frequency of positive and relevant patch tests in children referred for patch testing in North America; to compare results of patch testing children and adults; and to compare our results with international data on contact allergy in children., Design: Retrospective cross-sectional analyses of North American Contact Dermatitis Group (NACDG) data from January 1, 2001, through December 31, 2004. Patch test reactions for allergens that were positive and considered of clinical importance to the patient's eczematous problem were defined as being of current or past relevance., Setting: Clinical patch test data from 13 NACDG members, primarily a referral population., Patients: The pediatric population (hereafter referred to as "children") was defined as patients aged 0 to 18 years (n = 391). Patients 19 years and older constituted the comparison adult group (n = 9670)., Main Outcome Measures: The frequency of positive patch test reactions and number of relevant ones. Secondary measures included the association of atopic markers, frequency of irritant reactions, and sources of relevant supplementary allergens., Results: No significant difference in the overall frequency of at least 1 relevant positive patch test reaction was noted in children (51.2%) compared with adults (54.1%). The most frequent positive reactions in children were to nickel (28.3%), cobalt chloride (17.9%), thimerosal (15.3%), neomycin sulfate (8.0%), gold sodium thiosulfate (7.7%), and fragrance mix (5.1%). For children aged 0 to 18 the most frequent relevant positive reactions were to nickel sulfate (26.0%), cobalt (12.4%), neomycin (4.4%), fragrance mix (4.1%), gold (3.6%), and quaternium 15 (3.6%). The frequency of irritant reactions in adults and children was similar. Of the children with a relevant positive reaction, 34.0% had atopic dermatitis included as one of their final diagnoses, compared with 11.2% of adults (P < .001). Fifteen percent and 39% of children had relevant allergens not included in the NACDG series and a commercially available skin patch test (T.R.U.E. TEST [thin-layer rapid use epicutaneous test], panel 1.1 and 2.1; Allerderm, Phoenix, Arizona), respectively., Conclusions: Adults and children in this group are equally likely to have allergic contact dermatitis; frequency of relevant allergen reactions differs.

Background: Allergic and irritant contact dermatitis to food is likely underreported., Objectives: To characterize relevant allergens and irritants associated with food in patients referred to the North American Contact Dermatitis Group (NACDG) for patch testing., Methods: Retrospective analysis of cross-sectional data from the NACDG from 2001 to 2004., Results: Of 10,061 patch-tested patients, 109 (1.1%) had a total of 122 reactions associated with food. Approximately two-thirds of patients (66%) were female, and one-third (36%) were atopic. The hands were the most common sites of dermatitis (36.7%). There were 78 currently relevant (definite, probable, or possible) allergic reactions to NACDG standard series allergens with a food source; the most common allergen was nickel (48.7%), followed by Myroxilon pereirae (balsam of Peru) (20.6%) and propylene glycol (6.4%). Twenty allergic reactions to non-NACDG standard allergens and 24 relevant food irritants were also identified. Overall, 21% (25 of 122) of all reactions (irritant and allergic) were occupation related; the majority of these (17 of 25) were relevant irritant reactions. Cooks were the most commonly affected occupational group (40%)., Conclusions: In this limited data set, nickel, Myroxilon pereirae, and propylene glycol were the most common allergens identified with a food source. Of food-related occupational disease, irritation was more common than allergy.

Background: A scattered generalized distribution (SGD) of dermatitis is a challenging problem; patch testing is a strategy for evaluating allergic contact dermatitis as a relevant factor., Objective: We sought to analyze patient characteristics and most frequently relevant positive allergens in patients presenting for patch testing with SGD., Methods: We conducted retrospective cross-sectional analysis of North American Contact Dermatitis Group 2001 to 2004 data. Patients with SGD were compared with patients without SGD., Results: Of 10,061 patients, 14.9% (n = 1497) had only a SGD. Men and patients with a history of atopic eczema were more likely to have dermatitis in a SGD (P < .001). Preservatives, fragrances, propylene glycol, cocamidopropyl betaine, ethyleneurea melamine formaldehyde, tixocortol pivalate, and budesonide were among the more frequently relevant positive allergens. Top allergen sources included cosmetics/beauty preparations/skin and health care products, clothing, and topical corticoids., Limitations: This was a retrospective analysis of patch-tested patients with SGD suspected to have allergy., Conclusions: A total of 49% of patients with SGD had at least one relevant positive allergen, thus demonstrating the benefit of patch testing these patients.

Background: Contact dermatoses are common in health care workers (HCWs)., Objectives: To (1) estimate the prevalence of occupation-relevant allergic contact dermatitis (ACD) among health care workers patch-tested from 1998 to 2004 by the North American Contact Dermatitis Group (NACDG), (2) characterize responsible allergens among health care workers overall as well as in specific health care occupational subgroups, and (3) compare these results to those of nonhealth care workers., Methods: Between 1998 and 2004, 15,896 patients were patch-tested by the NACDG. Occupation-related allergic patch-test results were analyzed among HCWs, subgroups of HCWs, and non-HCWs., Results: 1,255 patients (7.9%) were HCWs. Female gender (HCWs, 86.2%; non-HCWs, 63.6%) and hand involvement (HCWs, 54.7%; non-HCWs, 27.8%) were more common in HCWs (p < .05); 18.2% of HCWs and 6.6% of non-HCWs had occupation-related allergens of current clinical relevance. Thiuram mix (HCWs, 8.87% non-HCWs, 0.90%) and carba mix (HCWs, 5.43%; non-HCWs, 0.87%) were the most common occupation-related currently relevant antigens in HCWs and were more common in HCWs than in non-HCWs (p < .05)., Conclusions: Among HCWs patch-tested by the NACDG between 1998 and 2004, the most common allergens were thiuram mix and carba mix, followed by glutaraldehyde, cocamide diethanolamine, and chloroxylenol. Gloves, sterilizing solutions, and soaps were common sources of responsible allergens.

Background: The most common differential diagnoses for patients presenting with lip dermatitis or inflammation include atopic, allergic, and irritant contact dermatitis. Patch testing can be performed to identify the allergic contact conditions., Objective: To report North American Contact Dermatitis Group (NACDG) patch-test results of patients who presented for patch testing with only lip involvement from 2001 to 2004. Patient characteristics, allergen frequencies, relevance, final diagnoses, and relevant allergic sources not in the NACDG screening series were evaluated., Methods: The NACDG 2001-2004 database was used to select patients presenting with only lip involvement., Results: Of 10,061 patients tested, 2% (n = 196) had lips as the sole involved site. Most (84.2%) were women. After patch testing, 38.3% (n = 75) were diagnosed with allergic contact cheilitis. Fragrance mix, Myroxilon pereirae, and nickel were the most common relevant allergens. Of 75 patients, 27 (36%) had relevant positive patch-test reactions to items not on the NACDG series; lipstick and cosmetics were the predominant sources., Conclusions: Patch testing is valuable in the evaluation and identification of contact allergy in patients referred for lip dermatitis. The use of supplementary allergens based on history and exposure is important in the identification of additional relevant allergens. Over a third of patients with contact allergy had other factors, such as irritant dermatitis, considered relevant to their condition.

Background: Allergic contact dermatitis from thioureas is uncommon but may result from exposure to rubber, especially neoprene., Objectives: To (1) describe the population with positive patch-test reactions to mixed dialkyl thioureas (MDTU) (ie, diethylthiourea and dibutylthiourea); (2) determine clinical and occupational relevance associated with reactions to MDTU and identify the most commonly related sources and occupations; and (3) examine the frequency of co-reacting allergens in MDTU-positive patients., Methods: A retrospective analysis of cross-sectional data of 22,025 patients patch-tested by the North American Contact Dermatitis Group between 1994 and 2004., Results: Of 21,898 patients tested with MDTU, 225 (1.0%) had positive reactions; of these, 173 (76.9%) were currently relevant and 29 (17.1%) were occupationally relevant. Patients positive to MDTU were 2.6 times more likely to have foot involvement than patients with positive reactions to other allergens (p < .0001). Footwear was the most commonly identified source overall (20.0%) whereas gloves were the most common occupational source. Of the 173 patients with currently relevant MDTU reactions, 24.9% also reacted to another rubber allergen., Conclusions: Current clinical relevance of reactions to MDTU was high; occupational relevance was less frequent. Patch tests with common rubber allergens (carbamates, thiurams, and mercaptobenzothiazole) may fail to detect many cases of thiourea-induced rubber allergic contact dermatitis.

Objectives: To characterize patients with anogenital dermatitis referred for patch testing by the North American Contact Dermatitis Group, to identify common allergens, and to explore sex associations., Design: Retrospective, cross-sectional analysis of the North American Contact Dermatitis Group database, 1994-2004., Patients: Five hundred seventy-five patients with anogenital signs or symptoms were referred for patch testing; 347 had anogenital disease only., Main Outcome Measure: Currently relevant allergic patch test reaction in patients with anogenital signs or symptoms., Results: Sex percentages and mean age were not significantly different in patients with anogenital involvement only compared with those without anogenital involvement. In patients with anogenital involvement only, a final diagnosis of "other dermatoses" was statistically significantly more common in female patients compared with male patients (n = 347; relative risk, 1.99; 95% confidence interval, 1.37-2.91), but the diagnosis of allergic contact dermatitis was not associated with sex. Specific allergens that were statistically significantly more common in patients with anogenital involvement included cinnamal (or cinnamic aldehyde), dibucaine, benzocaine, hydrocortisone-17-butyrate, and budesonide (all P < .005). Those that were statistically significantly less frequent included quaternium-15, cobalt chloride, formaldehyde, p-phenylenediamine, and thiuram mix (all P < .04). Seventy-three patients had anogenital allergic contact dermatitis, defined as anogenital involvement only, allergic contact dermatitis as the only diagnosis, and at least 1 positive reaction of current clinical relevance. In that subgroup, the most common allergen sources were cosmetics, medications, and corticosteroids., Conclusion: In patients in the North American Contact Dermatitis Group with anogenital involvement only, male and female patients were equally likely to have allergic contact dermatitis but female patients were more likely to have other dermatoses. Common allergens and sources consisted of those likely to have contact with the anogenital area.

Background: Allergic contact dermatitis is a significant cause of both occupational and non-occupational skin disease. Patch testing is an important diagnostic tool for the determination of responsible allergens., Objective: This study reports the results of patch testing by the North American Contact Dermatitis Group from January 1, 2003, to December 31, 2004., Methods: At 13 centers in North America, patients were tested with the same screening series of 65 allergens, with a standardized patch-testing technique. Data were recorded on standardized forms and manually verified and entered. Descriptive frequencies were calculated, and trends were analyzed with chi-square statistics., Results: A total of 5,148 patients were tested. Of these, 3,432 (66.7%) had at least one positive reaction, 2,284 (44.4%) were ultimately determined to have primary allergic contact dermatitis, and 676 (13.1%) had occupation-related skin disease. There were 9,762 positive allergic reactions. Compared to the previous reporting period (2001-2002), allergies to nickel, budesonide, mercaptobenzothiazole, and paraben mix were at least 1.12 times more common (all p values < .03). Compared with the previous 8 years (1994-2002), only the prevalence rates of allergies to nickel and budesonide were statistically significantly higher (p values < .003)., Conclusion: Allergic contact dermatitis from nickel and budesonide may be increasing in North America. These results again underscore the value of patch-testing with many allergens.

Background: Allergy to topical anesthetics is not uncommon. The cross-reactivity among topical anesthetics and the screening value of benzocaine alone are not well understood., Objectives: The goals for this study were: (1) to evaluate the frequency and pattern of allergic patch-test reactions to topical anesthetics, using North American Contact Dermatitis Group (NACDG) data, and (2) to compare these results to allergen frequencies from other published studies., Methods: The NACDG patch-tested 10,061 patients between 2001 and 2004. In this analysis patients were included who had positive patch-test reactions to one or more of the following: benzocaine, lidocaine, dibucaine, tetracaine, and prilocaine., Results: Of patch-tested patients, 344 (3.4%) had an allergic reaction to at least one anesthetic. Of those, 320 (93.0%) had an allergic reaction to only one topical anesthetic. Overall, reactions to benzocaine (50.0%, 172 of 344) were most prevalent, followed by reactions to dibucaine (27.9%, 96 of 344); however, reactions to dibucaine were significantly more frequent in Canada than in the United States (relative risk [RR], 2.31; 95% confidence interval [CI], 1.67-3.20; p < .0001). Of patients reacting to more than one anesthetic, most (79%, 19 of 24) reacted to both an amide and an ester., Conclusions: Of the topical anesthetics tested, benzocaine was the most frequent allergen overall. Over 50% of allergic reactions to topical anesthetics in this study would have been missed had benzocaine been used as a single screening agent. Cross-reactivity patterns were not consistent with structural groups.

Frictional hyperkeratotic hand dermatitis (FHHD) is an unusual form of chronic eczema relating to repeated frictional trauma. This form of hand eczema is often occupationally related and recalcitrant to therapy. We describe the case of FHHD in a 48-year-old dermatologic surgeon. The eruption was resistant to all topical and protective modalities, but responded completely to 6 sessions of Grenz ray treatment. No recurrence has been noted for over 4 years since completion of therapy. We suggest that Grenz ray treatment is a safe and effective option in treating this form of chronic hand dermatitis.

Background: Nickel allergy has been studied by contact dermatitis groups around the world, and the frequency of nickel sensitivity has been reported to be decreasing in some populations., Objective: To review the prevalence of nickel allergy as observed by the North American Contact Dermatitis Group from 1992 to 2004., Methods: The computer database of the North American Contact Dermatitis Group was used to examine the prevalence of nickel allergy over the study period and to analyze it by time, sex, and age., Results: From 1992 to 2004, 25,626 patients were patch-tested. The percentage of women tested was fairly constant (61.4-66.3%). A steady increase in nickel sensitivity was seen from 1992 to 2004. Subgroup analysis did not identify a population with declining nickel allergy., Conclusions: Nickel allergy continues to increase in younger and older men and women patch-tested in North America.

Background: Medical adhesive bandages are extensively used in both inpatient and outpatient medicine. However, few reports describing proven allergic contact dermatitis (ACD) from medical adhesive bandages exist in the literature. These reports do not adequately correspond to the frequency that patients report having an "allergy" to medical adhesive bandages., Objective: To determine if there is a chemical present in medical adhesive bandages that causes ACD in people who identify themselves as having an "allergy" to medical adhesive bandages., Methods: Twenty-six patients were enrolled and underwent patch testing with our standard trays (104 chemicals) and a customized adhesive tray (54 chemicals and 10 tapes and bandages in their whole form)., Results: We were able to identify an allergen in four patients that was related to their presumed adhesive allergy (Mastisol, neomycin/bacitracin [two different patients], and cortisone-10 cream, respectively). However, there were no positive allergic reactions to the tapes or bandages or any relevant allergic reactions to our customized adhesive tray. Eight (73%) of the 11 patients who had the bandage or tape left on for 7 days had an irritant reaction., Conclusion: We feel that the perceived reactions are not secondary to ACD but instead are due to an irritant contact dermatitis.

Background: Chemicals used in leather tanning, rubber processing, and/or adhesives are the most often-cited culprits in footwear dermatitis. Patch testing patients with suspected shoe dermatitis is essential for diagnosis and management., Objectives: The four goals for this study were to (1) determine the frequency of allergens associated with a shoe source in North American Contact Dermatitis Group (NACDG) patients with footwear allergic contact dermatitis; (2) compare these results to allergen frequencies from other published studies; (3) quantify the number of shoe-related reactions that were not identified with the NACDG standard series; and (4) identify relevant allergens not included on the NACDG standard series, based on data from other published studies., Methods: The NACDG patch-tested 10,061 patients between 2001 and 2004. Data were retrospectively analyzed by (1) allergen source coded as "shoe," (2) site of dermatitis as "feet," and (3) diagnosis of "allergic contact dermatitis.", Results: Among the 109 NACDG patients with allergic contact dermatitis (ACD) of the foot and a shoe source of allergens, p-tertiary butylphenol formaldehyde resin, an adhesive, was the most common allergen, accounting for 24.7% of positive patch-test results, followed by potassium dichromate (17.5%) and carba mix (11.7%). When the data were examined according to groups of allergens, rubber chemicals (40.4%) were the most frequent allergens, followed by adhesives (32.5%), and leather components (20.1%). When data from published studies were pooled, potassium dichromate (31.5%) was the most frequent allergen, followed by p-tertiary butylphenol formaldehyde resin (17.1%) and cobalt chloride (12.9%). NACDG patients were statistically more likely to have positive patch-test reactions to p-tertiary butylphenol formaldehyde resin and statistically less likely to have a positive patch-test reaction to potassium dichromate than patients represented in pooled data from past studies. Nineteen (17.4%) of the 109 NACDG patients with ACD of the foot and a shoe source of allergens were identified as having a shoe source of a relevant allergen not included in the NACDG standard series., Conclusions: In NACDG patients, the most common individual shoe allergen was p-tertiary butylphenol formaldehyde resin. As a group, rubber chemicals were most common, a finding consistent with those of other studies.

Objective: To determine whether petrolatum or aqueous vehicles are more sensitive for detecting allergy to imidazolidinylurea (IU), diazolidinylurea (DU), and dimethylol dimethyl hydantoin (DM). The relationship of these allergens to formaldehyde sensitivity was also explored., Methods: Retrospective analysis of patients patch-tested by the North American Contact Dermatitis Group. All patients were simultaneously tested to seven allergens (formaldehyde, IU in petrolatum [pet], IU aqueous [aq], DU pet, DU aq, DM pet, and DM aq). Data were analyzed in pairs with various "gold standard" definitions of "true allergy" and adjusting for correlated data., Results: Reaction to at least one of the seven allergens occurred in 2,398 patients. In all cases except one (which just approached statistical significance), the petrolatum-based allergen was statistically significantly more sensitive than the same allergen in an aqueous base. Most of the patients allergic to the three preservatives were also allergic to formaldehyde, but most formaldehyde-allergic patients were not allergic to the IU, DU, or DM., Conclusion: Of these two vehicles, petrolatum is significantly more sensitive than an aqueous vehicle is for detecting allergy to IU, DU, and DM.

Background: Hand dermatitis, including irritant and allergic contact dermatitis (ACD), is common., Objective: To evaluate allergens, relevant irritants, sources and occupations associated with hand contact dermatitis using North American Contact Dermatitis Group (NACDG) data., Methods: A cross-sectional analysis of 22,025 patients patch tested between 1994 and 2004., Results: Hand involvement was found in 6953 patients; 959 had ACD as the only diagnosis. In these 959 patients, the 12 most frequent relevant allergens were quaternium-15 (16.5%), formaldehyde (13.0%), nickel sulfate (12.2%), fragrance mix (11.3%), thiuram mix (10.2%), balsam of Peru (9.6%), carba mix (7.8%), neomycin sulfate (7.7%), bacitracin (7.4%), methyldibromoglutaronitrile/phenoxyethanol 2.0% (7.4%), cobalt chloride (6.5%), and methyldibromoglutaronitrile/phenoxyethanol 2.5% (6.3%). Rubber allergens were most commonly associated with occupation. One third of patients with hand ACD had identifiable relevant irritants., Limitations: Cross-sectional analyses prevent evaluation of causal associations., Conclusion: In NACDG patients with hand ACD, the most common allergens included preservatives, metals, fragrances, topical antibiotics, and rubber additives.

Background: Allergic contact dermatitis can be manifest as an eruption confined to the eyelids. In regard to this specific presentation, only limited information on which to base the selection of patch tests for proper evaluation is available., Objective: To identify the contact allergens most frequently found to be both patch test positive and relevant when only the eyelids are involved., Methods: Data collected from 2003 to 2004 by the North American Contact Dermatitis Group (NACDG) were analyzed for relevant allergens in the setting of dermatitis on the eyelids only. Data on eyelid dermatitis patients whose relevant allergens were not among the 65 allergens used for screening during this study period were also tabulated., Results: Data showed that 268 patients had only eyelid dermatitis and a final diagnosis of allergic contact dermatitis. In 193 (72%) of these, reactions were of current relevance and were identified from a screening series of 65 allergens. The top 26 allergens identified 65% of cases (175 cases). Gold was the most frequently encountered allergen (22 of 175 cases [12.5%]). Of the 268 cases, 33 showed relevant reactions to an allergen that was not among the 65 NACDG standard screening allergens. No specific allergen was identified in the remaining 42 cases., Conclusion: The top 26 allergens identified in this study represent a potential eyelid dermatitis screening series.

Background: Botanical ingredients used in personal care products are a significant and underreported cause of allergic contact dermatitis., Objective: To evaluate allergic contact dermatitis from a widely-used botanical deodorant., Methods: We conducted patch testing in four patients who were using the botanical deodorant and were referred to the contact dermatitis clinic; three patients had axillary dermatitis and one had dermatitis of the external ear., Results: All four patients had positive patch test reactions to lichen acid mix and D-usnic acid. Of the three patients who were patch tested to the botanical deodorant, all had positive reactions., Limitations: We did not test to the specific lichen used in the natural deodorant but rather used our own lichen acid mix and d-usnic acid in addition to testing to the actual product. One of the patients declined to be tested with the natural deodorant, but did test positive to the lichen acid mix and d-usnic acid., Conclusion: Personal care products such as deodorants may represent a new route of exposure to lichen extract, a known allergen.

Background: In published reports from Europe, 3- and 4-(4-hydroxy-4-methylpentyl)cyclohexene-1-carboxaldehyde (HMPCC) (Lyral) has been described as a common cause of allergic contact dermatitis (ACD). In Europe, the rates of reaction to HMPCC among patients undergoing patch testing for suspected ACD have varied from 1.2 to 17.0%, depending on the country. Data on the incidence of sensitivity to HMPCC among North Americans with suspected ACD have not been reported., Objectives: The goals of this study were (1) to assess the incidence of delayed-type hypersensitivity reactions to HMPCC among patients undergoing patch testing for evaluation of eczematous dermatitis at six centers throughout North America; (2) to determine the most appropriate concentration of HMPCC to use in performing patch tests; and (3) to compare and contrast the incidence rates for HMPCC hypersensitivity to those for other fragrance materials screened with the North American Contact Dermatitis Group (NACDG) screening tray, which includes fragrance mix, Myroxilon pereirae (balsam of Peru), cinnamic aldehyde, ylang ylang oil, jasmine absolute, and tea tree oil., Methods: This report represents the prospective multicenter data on patients tested with the fragrance-related allergens on the NACDG standard screening tray and with HMPCC at 5%, 1.5%, and 0.5% concentrations in petrolatum. Statistical analyses were performed with Student's t-test (two tailed) and the chi-square test., Results: Data from 1,603 patients evaluated at five US sites and one Canadian site were analyzed. Most patients (87.8%) were Caucasian. The majority (67%) were women, and 26.2% had a history consistent with atopic dermatitis. The patients ranged in age from 1 to 88 years, and the mean +/- standard deviation was 46.3 +/- 16.5 years. Myroxilon pereirae (balsam of Peru) and fragrance mix were the most frequent patch-test-positive fragrance allergens (6.6% and 5.9%, respectively). Cinnamic aldehyde (1.7%), ylang ylang oil (0.6%), jasmine absolute (0.4%), HMPCC (0.4% for 5% HMPCC, 0.3% for 1.5% HMPCC, and 0.2% for 0.5% HMPCC), and tea tree oil (0.3%) less frequently yielded positive reactions. Men were more likely than women to be allergic to cinnamic aldehyde. Women were more likely than men to be allergic to jasmine absolute. Atopic patients were no more likely to react to fragrance materials than were nonatopic patients. Patients who reacted to jasmine absolute tended to be older than the general population whereas those who reacted to tea tree oil tended to be younger than the general population. There were no other demographic differences between patients who reacted to a given fragrance material and the entire population studied. Testing with fragrance mix and balsam of Peru failed to identify the majority of patients in this study who were found to be sensitized to jasmine absolute, HMPCC, or tea tree oil., Conclusion: HMPCC is an uncommon allergen in the North American population. We recommend testing with 5% HMPCC in petrolatum for those patients suspected of having a fragrance allergy.

Sarcoidosis encompasses a heterogeneous spectrum of clinical presentations, including sarcoidosis in association with tattoos. We report the development of cutaneous and pulmonary sarcoidosis in a patient with long-standing eyebrow tattoos whose cutaneous sarcoidosis almost completely resolved when treated with tacrolimus 0.1% ointment. A 70-year-old woman with a 3-year history of an erythematous eruption circumscribing her eyebrow tattoos presented with a chronic, nonproductive cough of 8 months' duration. Skin biopsy results demonstrated naked tubercles consistent with sarcoidosis. Results of radiographs and a computed tomography scan of the chest revealed multiple pulmonary nodules with mediastinal and hilar adenopathy. The results of transbronchial biopsy were consistent with the diagnosis of pulmonary sarcoidosis. Initial treatment with oral prednisone only improved the pulmonary sarcoidosis. The cutaneous sarcoidosis almost completely resolved after the addition of tacrolimus 0.1% ointment.