Contact Dermatitis Flashcards by Molly Moye

Patients with paraphenylenediamine allergy may cross-react with what?

PABA, sulfa drugs, benzocaine and procaine (esters), azo dyes

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What are the formaldehyde-releasing preservative?

- Which is the most common to cause ACD
- Where are these found?

Quaterniun-15 - most common preservative to cause ACD (in personal care items)

Bronopol (2-bromo-2-nitropane-1,3-diol - in personal care products and industrial things

Germall II (Diazolidinyl urea) - in bubble baths, baby wipes, detergents

Germall 115 (Imidazolidinyl urea) - cosmetics

DMDM hydantoin - shampoo/conditioner, skin care products

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Anacardiaceae.

Name the plants, allergen and cross reactants

Poison ivy, poison sumac, poison oak
Allergen: urushiol
Cross Reacts: cashew, mango peel, gingko, Japanese lacquer tree, indian marking nut

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Asteraceae (Compositae)

Name the plants, allergen and cross reactants

chrysanthemum, ragweed, sunflower, artichoke, daisy, marigold (does not actually contain SQL)
Allergen: sesquiterpene lactone
Cross Reacts: permethrin

*Can cause airborne dermatitis (think “Aster”kids are airborne)

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Alstroemeriaceae

Name the plants, allergen and cross reactants

Peruvian Lily, tulip, hyacinth
Allergen: tuliposide A
Cross Reacts: N/A

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Alliaceae

Name the plants, allergen and cross reactants

onions, garlic, chives
Allergen: diallyl disulfide, allicin, allylpropyl disulfide
Cross Reacts: N/A

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Myrtaceae

Name the plant and allergen

tea tree oil (Melaleuca alternifolia)

Allergen: contains 16 different sensitizers (terpinolene, ascaridol, alpha-terpinene and 1,2,4-trihydroxy menthane)

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What two families are implicated in phytophotodermatitis?

Inciting agent?

Wavelength of light?

Apiaceae (celery, fennel, parsnip, parsley)
Rutaceae (lime, sweet orange, bitter orange, lemon, grapefruit)

Furocoumarin. They induce psoralens!

UVA

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Most common cause of toxin mediated (non-immunologic) contact urticaria?

The plants contain what irritants within their hairs?

Stinging nettles! (Urticaceae species)

Histamine, serotonin and acetylcholine

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Euphorbiaceae

Name the plants and the irritant
Cross reacts with what?

Poinsettia, spurges, crotons

Phorbol esters

Cross reacts with latex!

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Ranunculaceae

Name the plant and the irritants

Buttercups

protoanemonin

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Solanaceae

Name the plant and the irritant

Chili peppers

capsaicin

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Brassicaceae

Name the plant and the irritant

black mustard, radish

thiocyanates

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Bromeliaceae

Name the plant and the irritants

Pineapple

bromelain (stem), calcium oxalate (all parts)

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Which allergens have delayed contact reactions (4)?

Gold
Dispersed blue dye (textiles)
Neomycin
Tixocortol pivalate

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Bezophenone

- What is it?
- Where is it found?
- Derivatives?

Aromatic ketones that absorb UVA and UVB

Found in: sunscreens, perfumes, soap, nail polish, hair spray, hair dye, body wash, moisturizers, shampoos, paint, pesticides, textiles, inks, adhesives, plastic lens filters,

Benzophenone derivatives:

-Oxybenzone (#1 photoallergen in sunscreens; in TONS of products)
-Sulisobenzone
-Diozybenzone
- Mexenone

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Methylisothiazolinone

- What is it?
- Where is it found?

Biocidal preservative added to bubble solutions, bubble baths, soaps, other cosmetics.

Found in: soaps, cleaning products, cosmetics, new leather sofas (report in 2014), WET WIPES!!!

Allergy is easy to miss on patch testing – if methylchloroisothiazolinone (MCI) is used to do test, 40% of allergies will be missed

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Acrylates

- Where is it found?
- How should people protect themselves from it?

Initially developed as Plexiglass; entered world of consume goods in dental fillers and nail enhancing substances, superglue (Dermabond), liquid bandages

Nitrile gloves provide better protection than latex/vinyl in individuals with allergy

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Dimethyl Fumarate

- What is it?
- Where is it found?

Historically used to treat psoriasis (fumaric acid), as preservative and in dessicant sachets in transport of furniture and shoes. Inhibits growth of bread mold and E.coli, so used in items transported by sea to prevent mold development.

In 2008, dramatic increase in ACD due to dimethyl fumarate in shoes. Other reports of back dermatitis due to exposure in leather sofas and armchairs imported from China.

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Neomycin (#2 contact allergen)

- What is it?
- Where is it found?
- Concern for cross-reactivity?

Aminoglycoside antibiotic (block ribosomal 30S subunit, disrupting protein synthesis) often in triple antibiotic creams (effective against gram-negative but only partially against gram-positives)

Found in: medicated ophthalmic and antibiotic drops, deodorants, soaps, root canal fillings

Can have cross-reaction with other aminoglycoside antibiotics, like gentamicin, tobramycin, kanamycin and streptomycin

Mixed Dialkylthiourea

- What is it?
- Where is it found?
- Common name for products people wear with this allergen?

Thioureas are compounds used in synthetic rubber synthesis to speed up cross-linking of chloroprene to neoprene. Neoprene is one of the most common synthetic rubbers used in car parts, diving gear, sports gear, orthopedic medical devices, shoe insoles, elastic, pain remover.

Also found in: fixative agents used in photography and photocopying, keyboard wrist supports

Nickel (#1 contact allergen)

- What is it?
- Where is it found?

Used in metal alloys and found in zippers, safety pins, doorknobs, keys, scissors, eyelash curlers, belt buckles, metal glasses, razors, thimbles, coins, construction tools, appliances, alkaline batteries, paper clips, multivitamins, jewelry, mobile phones, etc.

Nickel-steel alloys = stainless steel; but nickel is bound so firmly in stainless steel that it rarely causes a contact dermatitis

Organic acids at cooking temps can release nickel from stainless steel cookware

Reports in 2014 of iPads releasing a significant amount of nickel

Fragrances (Fragrance Mix 1 is #3 contact allergen)

- What is it?
- Where is it found?
- What are the Fragrance Mixes made of?

Fragrances are responsible for 30-45% of ACD to cosmetics; fragrance allergy more common in women than men

o Fragrance Mix I contains isoeugenol, eugenol, cinnamic aldehyde, cinnamic alcohol, hydroxycitronellal, geraniol, a-amyl cinnamic aldehyde and oak moss absolute
o Fragrancs Mix II contains citronellol, hydroxyisohexyl 3-cyclo-hexene carboxaldehyde, hexyl cinnamal, citral, coumarin and farnesol

Para-Phenylenediamine

- What is it?
- Where is it found?

Paraphenylenediamine is an easily oxidized substance used in permanent hair dyes. PPD hair dyes are packaged in two containers – the PPD dye and the developer (also called oxidizer). PPD is colorless and requires oxidation to color. It becomes the allergenic hapten when partially oxidized in an intermediate state in the epidermis and dermis.

Can be found in black henna tattoo to enhance drying and lasting color but FDA regulates that PPD cannot be used in personal care items except for hair dye

Causes ACD in haidressers, cosmetologists, printers, textile dyers, photograph developers and people who dye their hair

Skin reaction can cause typical dermatitis, bullous dermatitis, anaphylaxis; ingestion is associated with angioedema, rhabdo, renal tubular damage, right bundle branch block

Corticosteroids - - What are the groups when considering contact allergens? - - What is the tested allergen for each group? - - Most common corticosteroid to be allergic to?

Corticosteroid Groups – people typically react to one group; the groups differ in whether they are methylated or halogenated o Group A: hydrocortisone, prednisone, triamcinolone (tested = tixocortol-21-pivalate) o Group B: desonide, fluocinonide, triamcinolone (tested = budesonide) o Group D: betamethasone, clobetasol propionate, mometasone furoate, hydrocortisone valerate (tested = hydrocortisone-17-butyrate / budesonide) Tixocortol accounts for 50% of corticosteroid allergies

Cocamidopropyl Betaine - - What is it? - - Where is it found?

Cocamidopropyl Betaine is a zwitterion used as a surfactant in shampoos, cleansers and cosmetics Found in: shampoos, soaps, body wash gels, toothpastes, contact lens solutions, makeup removers, gynecologic hygiene products

Bacitracin (#4 contact allergen) - - What is it? - - Where is it found?

Antibiotic effective against gram-positives; interferes with dephosphorylation of C55-isoprenyl pyrophosphate, inhibiting peptidoglycan cell wall synthesis Systemic use limited by nephrotoxicity, so it is limited to topical and ophthalmic use now Nurses have the highest rates of positivity to bacitracin, likely due to wound care

Thimerosal - - What is it? - - Where is it found? - - Is it in patch test kits?

Mercury-containing compound used as an antiseptic and preservative in vaccines, cosmetic products, tattoo inks and ophthalmic solutions Historically mercury was in bleaching creams because mercury inhibits melanin synthesis by competing with copper necessary for tyrosine kinase activity Found in cosmetics, mascaras, makeup removers, ear and eye drops, antifungals, tattoo inks, antiseptic sprays, hormone injections, antimicrobial cleaners, etc. Not currently tested by NACDG panels

Gold - - Where is it found? - - Other skin findings associated with gold?

Skins reactions found on areas of skin where eye makeup, foundation or sunscreens are applied that contain harder metals (e.g. titanium, zinc) Black dermographism = phenomemon when cosmetics contain hard metals abrade softer jewelry metals and leave black deposits on skin Pseudolymphoma reaction reported to gold in 2014

Disperse Blue Dye - - What is it? - - Where is it found?

Disperse Blue 106 is a disperse dye and an azo dye (dyes are categorized by use and by chemical structure) Disperse Blue 124 and 106 are the most frequent dye sensitizers Disperse dyes are partially water soluble and tend to leach out of fabrics and rub on skin, which is why they are especially allergic. Found on areas with increased friction and sweating

List potential causes of shoe allergies (5)

All rubber accelerators: - - Thiuram (also in condoms, gloves, elastics) - - Mercaptobenzothiazole (MBT) (most common cause of shoe ACD; found in cutting oils, tires, antifreeze, etc) - - Carba Mix (leather shoes, tires, condoms; cross-reacts with thiuram derivatives) - - Mercapto mix (tires, gloves, cords, rubber shoe soles) - - Mixed dialkyl thiourea (neoprene, shoe insoles, ortho devices, etc) Black rubber mix (another rubber accelerator, used in heavy-use rubbers like tires)

Repeated bleaching of clothing can cause ACD to which allergen?

Carba mix Hypochlorite (bleach) causes elastic to become more allergenic due to increased availability of carbamites). Patch testing is often negative though.

A violin player develops a rash where her instrument touches her body...what is going on here?

Colophony (Rosin, Abietic Acid) allergy. Found in paper, cosmetics, paint, adhesives, wax, chewing gum, baseballs/ballet/musical instruments...causes rash where there is increased friction

PABA (Padimate O) - - Found where? - - Blocks UVA or UVB? - - Cross-reacts with...

Found in sunscreen - UVB blocker. Cross-reacts with sulfonamides, azo dyes, benzocaine, para-phenelynediamine (PPD)

Oxybenzone - - Found where? - - Blocks UVA or UVB?

Sunscreen Blocks UVA Oxybenzone = #1 sunscreen agent to cause photo allergic contact dermatitis

Allergens in hair care products (3)

Para-phenylenediamine Monothioglycolate - permanent waves Ammonium persulfate - hair bleach (also bleaches flour)

Balsam of Peru -- Found in what surgical prep?

Tincture of Benzoin

Test to determine whether nickel is in something...

Dimethylglyoxime test (positive if turns pink)

Potassium Dichromate -- Found where?

``` Cement Leather footwear Plaster Wood finishes Green felt on pool tables ```

Lotion that can be used to prevent poison ivy?

Quaternium-18 Bentonite

Latex allergy cross-reacts with what?

Avocado, Banana, Chestnut, Pineapple, Kiwi, Mango, Passionfruit, Strawberry, Soy (ABC + others)

Chromates | -- Found in which products?

metals leather cemment

Cobalt - -purpose? - -found in?

- -hardens metals | - -cosmetics, enamels, hair dyes, ceramics, artificial joints

Bacitracin might hide where?

in a lot of OTC products, including some labeled as "unscented"

Product labeled "permanent press" may contain this contactant:

formaldehyde (in cosmetics, textiles, medications, paint)

Some weirdo decided to eat a cashew wrapped in a mango peel - he then broke out in a diffuse eruption c/w systemic contact derm; you now know he should also avoid which cutaneous contactant?

Poison Ivy

Bacitracin - Neomycin - Polymyxin B These topical antibiotics often cross-react as contacts. Which of the two are structurally related?

Bacitracin & Polymyxin B (Bacillus spp. derived) are structurally related and co-reactors Bacitracin & Neomycin are NOT structurally related, but do often x-react (Per Warshaw lecture, a board-relevant fact)

Pt presented with rash around stoma after colostomy - what contactant is at play?

Colophony (resin, in adhesives) | Warshaw - "Colophony = Colostomy"

Three commonly missed contactants when Patch testing read at 48 hours (i.e. they are delayed reactions)?

Gold, Neomycin, Steroids | Warshaw board pearl