Publications by authors named "Erin M Warshaw"

252 Publications

Occupational Contact Dermatitis in Dental Personnel: A Retrospective Analysis of the North American Contact Dermatitis Group Data, 2001 to 2018.

Dermatitis 2022 Jan-Feb 01;33(1):80-90

Associates in Dermatology, Fort Myers, FL.

Background: Dental personnel are at risk of developing occupational contact dermatitis.

Objectives: The aims of the study were to determine prevalence of occupational contact dermatitis in dental personnel referred for patch testing and to characterize relevant allergens and sources.

Methods: The study used a retrospective, cross-sectional analysis of the North American Contact Dermatitis Group (NACDG) data, 2001-2018.

Results: Of 41,109 patients, 585 (1.4%) were dental personnel. Dental personnel were significantly more likely than nondental personnel to be female (75.7% vs 67.4%, P < 0.0001), have occupationally related dermatitis (35.7% vs 11.5%, P < 0.0001), and/or have primary hand involvement (48.6% vs 22.5%, P < 0.0001). More than one quarter of dental personnel (62/585, 27.7%) had 1 or more occupationally related allergic patch test reaction(s). There were 249 occupationally related reactions to NACDG screening allergens, most commonly glutaraldehyde (18.1%), thiuram mix (16.1%), and carba mix (14.1%). The most common sources of NACDG screening allergens were gloves (30.7%), dental materials (26.6%), and sterilizing solutions (13.1%). Seventy-three dental personnel (12.5%) had 1 or more positive patch test reactions to occupationally related allergen(s)/substances not on the screening series. Occupationally related irritant contact dermatitis was identified in 22.2% (n = 130) of dental personnel, most commonly to nonskin soaps/detergents/disinfectants (32.0%).

Conclusions: Occupational contact dermatitis is common in dental personnel referred for patch testing. Comprehensive testing beyond screening series is important in these patients.
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http://dx.doi.org/10.1097/DER.0000000000000847DOI Listing
January 2022

Shoe Allergens: A Retrospective Analysis of Cross-sectional Data From the North American Contact Dermatitis Group, 2005-2018.

Dermatitis 2022 Jan-Feb 01;33(1):62-69

Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles.

Background: Shoe contact allergy can be difficult to diagnose and manage.

Objective: The aim of the study was to characterize demographics, clinical characteristics, patch test results, and occupational data for the North American Contact Dermatitis Group patients with shoe contact allergy.

Methods: This is a retrospective study of 33,661 patients, patch tested from 2005 to 2018, with a shoe source, foot as 1 of 3 sites of dermatitis, and final primary diagnosis of allergic contact dermatitis.

Results: Three hundred fifty-two patients met the inclusion criteria. They were more likely to be male (odds ratio = 3.36, confidence interval = 2.71-4.17) and less likely to be older than 40 years (odds ratio = 0.49, confidence interval = 0.40-0.61) compared with others with positive patch test reactions. The most common relevant North American Contact Dermatitis Group screening allergens were potassium dichromate (29.8%), p-tert-butylphenol formaldehyde resin (20.1%), thiuram mix (13.3%), mixed dialkyl thioureas (12.6%), and carba mix (12%). A total of 29.8% (105/352) had positive patch test reactions to supplemental allergens, and 12.2% (43/352) only had reactions to supplemental allergens.

Conclusions: Shoe contact allergy was more common in younger and male patients. Potassium dichromate and p-tert-butylphenol formaldehyde resin were the top shoe allergens. Testing supplemental allergens, personal care products, and shoe components should be part of a comprehensive evaluation of suspected shoe contact allergy.
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http://dx.doi.org/10.1097/DER.0000000000000750DOI Listing
January 2022

Contact Allergens in Over-the-Counter Topical Vasoconstricting Ophthalmic Agents.

Dermatitis 2021 Dec 21. Epub 2021 Dec 21.

University of Minnesota Medical School, Minneapolis, MN Park Nicollet Contact Dermatitis Clinic, HealthPartners Institute, Minneapolis, MN Park Nicollet Contact Dermatitis Clinic, HealthPartners Institute, Minneapolis, MN. Department of Dermatology, University of Minnesota, Minneapolis, MN.

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http://dx.doi.org/10.1097/DER.0000000000000818DOI Listing
December 2021

Medical adhesive allergens: Retrospective analysis of cross-sectional data from the North American Contact Dermatitis Group, 2001-2018.

J Am Acad Dermatol 2021 Dec 5. Epub 2021 Dec 5.

Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, California.

Background: Identification of allergens causing medical adhesive contact allergy is difficult.

Objective: To characterize the demographics, clinical characteristics, patch test results, and occupational data for North American Contact Dermatitis Group patients with medical adhesive contact allergy.

Methods: A retrospective study of 43,722 North American Contact Dermatitis Group patients patch tested from 2001 to 2018 with medical adhesive (tapes/bandaids/adhesive aids/suture glue) sources, positive patch test results, and final primary diagnoses of allergic contact dermatitis.

Results: In total, 313 (0.7%) patients met the inclusion criteria. Compared with other patients with final primary diagnoses of allergic contact dermatitis, patients with a medical adhesive allergy were less likely to be male (odds ratio, 0.58; 95% CI, 0.45-0.77) and/or aged >40 years (odds ratio, 0.76; 95% CI, 0.60-0.96). The most common North American Contact Dermatitis Group screening series allergens were colophony (80.7%), balsam of Peru (3.9%), 2-hydroxyethyl methacrylate (2.7%), and carba mix (2.7%). One-fourth of the patients (79/313, 25.2%) had positive patch test reactions to supplemental allergens/materials, and 54 (17.3%) of the 313 patients only had reactions to supplemental allergens/materials.

Limitations: Results of comprehensive patch testing may be prone to referral population selection bias and may not be representative of the general dermatology population.

Conclusion: Colophony was the most common allergen. Supplemental allergens and materials should be tested in the evaluation of a suspected medical adhesive contact allergy.
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http://dx.doi.org/10.1016/j.jaad.2021.11.055DOI Listing
December 2021

Prevalence and trend of allergen sensitization in patients with a diagnosis of stasis dermatitis referred for patch testing, North American contact dermatitis group data, 2001-2016.

Arch Dermatol Res 2021 Nov 8. Epub 2021 Nov 8.

Department of Dermatology, Pennsylvania State University, State College, USA.

Background: Few studies explored the relationship between stasis dermatitis (SD) and allergic contact dermatitis (ACD).

Objective: To examine trends, associations, and clinical relevance of ACD in patients referred for patch testing who had a final SD diagnosis.

Methods: Retrospective analysis from 2001 to 2016 of 38,723 patients from the North American Contact Dermatitis Group.

Results: After patch testing, 303 (0.7%) patients were diagnosed with SD; 46.7% had a concomitant diagnosis of ACD. Patients with vs. without a final SD diagnosis had similar proportions of ≥ 1 positive allergic reaction (59.7% vs. 64.7%; Chi-square, P = 0.0724) but higher odds of allergic reactions to fragrance mix I, bacitracin, quaternium-15, Myroxylon pereirae, benzalkonium chloride, ethyleneurea melamine formaldehyde, diazolidinyl urea, and propylene glycol. The most commonly relevant allergens in patients with final SD diagnosis were fragrance mix I, Myroxylon pereirae, bacitracin, quaternium-15, and formaldehyde. The most common allergen sources were personal care products, topical medications and other health aid products.

Conclusion: Nearly half of patients with a final SD diagnosis were also diagnosed with ACD, supporting the role of patch testing in select SD patients.
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http://dx.doi.org/10.1007/s00403-021-02295-yDOI Listing
November 2021

Importance of Supplemental Patch Testing Beyond a Screening Series for Patients With Dermatitis: The North American Contact Dermatitis Group Experience.

JAMA Dermatol 2021 Dec;157(12):1456-1465

Department of Dermatology, University of Colorado, Boulder.

Importance: Patch test screening series for patients with dermatitis are limited and may miss clinically relevant contact allergens.

Objective: To characterize individuals with dermatitis who showed clinically relevant patch test findings to supplemental (nonscreening) allergens or substances.

Design, Setting, And Participants: A 17-year, retrospective cross-sectional analysis (January 1, 2001, to December 31, 2018) of North American Contact Dermatitis Group (NACDG) data from multiple centers in North America was conducted. A total of 43 417 patients with dermatitis underwent patch testing to the NACDG screening series in a standardized manner with 65 to 70 allergens and supplemental allergens as clinically indicated. Patients with 1 or more clinically relevant reactions to a supplemental (nonscreening) allergen/substance were analyzed between November 18, 2020, and March 12, 2021.

Main Outcomes And Measures: The main outcomes were to assess the number of patients with clinically relevant reactions to supplemental (nonscreening) allergens and compare characteristics (including demographic characteristics and occupations) between patients with a clinically relevant patch test reaction to 1 or more supplemental allergens or substances (supplement-positive) and those without a reaction (supplement-negative) using odds ratios (ORs) and 95% CIs. Secondary outcomes included sources of allergic contact dermatitis and, for occupationally related cases, specific occupations and industries.

Results: Of 43 417 patients included in the study who underwent patch testing to the NACDG screening series (65-70 allergens), 9507 individuals (21.9%) had currently relevant reactions to 1 or more supplemental allergens or substances. Of these, 6608 were women (69.5%) and the mean (SD) age was 47.2 (0.54) years. Compared with patients who had supplement-negative results, patients with supplement-positive findings were significantly less likely to be male (OR, 0.90; 95% CI, 0.85-0.94; P < .001) and/or have atopic dermatitis (OR, 0.89; 95% CI, 0.84-0.93; P < .001). Common primary sites of dermatitis in 9499 patients with supplement-positive findings included the face (2856 [30.1%]), hands (2029 [21.4%]), and scattered/generalized distribution (1645 [17.3%]). Frequent sources of supplemental allergens in 9235 patients included personal care products (4746 [51.4%]) and clothing/wearing apparel (1674 [18.1%]). Of 9362 patients with available data, supplemental allergens/substances were occupationally related in 1580 (16.9%); of those with identified occupations, 25.1% (384 of 1529) were precision production, craft, or repair workers. Of 9507 patients with supplement-positive findings, 2447 (25.7%) had no currently relevant reactions to NACDG screening allergens.

Conclusions And Relevance: This cross-sectional study found that 21.9% of patients who underwent patch testing to an allergen screening series of 65 to 70 allergens had at least 1 relevant reaction to supplemental allergens/substances. Of these, one-quarter reacted only to a supplemental allergen/substance. Screening series include common, important allergens, but these findings suggest that the addition of specialty allergens and personal or work products is critical for the successful diagnosis and management of allergic contact dermatitis.
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http://dx.doi.org/10.1001/jamadermatol.2021.4314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8567181PMC
December 2021

Photopatch test results of the North American contact dermatitis group, 1999-2009.

Photodermatol Photoimmunol Photomed 2021 Oct 15. Epub 2021 Oct 15.

Division of Dermatology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1111/phpp.12742DOI Listing
October 2021

Patch Testing to Ethylhexylglycerin: The North American Contact Dermatitis Group Experience, 2013-2018.

Dermatitis 2022 Jan-Feb 01;33(1):36-41

Department of Dermatology, Keck School of Medicine, Los Angeles, CA.

Background: Ethylhexylglycerin (EHG) is a recently recognized contact allergen.

Objective: The aims of the study were to characterize individuals with positive patch test reactions to EHG and to analyze reaction strength, clinical relevance, and allergen sources.

Methods: This study was a retrospective analysis of the patients patch tested to EHG (5% petrolatum) by the North American Contact Dermatitis Group (2013-2018).

Results: Of 15,560 patients tested to EHG, 39 (0.25%) had positive (final interpretation of "allergic") reactions. Most were female (71.8%) and/or older than 40 years (76.9%). There were no statistically significant differences between age, sex, or atopic history when compared with EHG-negative patients. The most common anatomic sites of dermatitis were the face (28.2%) and scattered generalized distribution (25.6%). Most EHG-positive reactions were + (35.9%) or ++ (33.3%). Current clinical relevance was high (79.5%); none, however, were related to occupation. Personal care products were the most common source of exposure to EHG (59.0%).

Conclusions: Ethylhexylglycerin is a rare contact allergen; the positive frequency of 0.25% is similar to other low allergenic preservatives including parabens, benzyl alcohol, and phenoxyethanol. The patch test concentration of 5.0% seems to be nonirritating. Although relatively uncommon, EHG reactions were usually clinically relevant (79.5%), often because of moisturizers/lotions/creams.
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http://dx.doi.org/10.1097/DER.0000000000000709DOI Listing
September 2021

Characterization of Tattoo Aftercare Products: Allergenic Ingredients and Marketing Claims.

Dermatitis 2021 Sep-Oct 01;32(5):301-307

University of Minnesota Medical School.

Background: Common recommendations for tattoo aftercare to ensure proper healing include application of topical products. Little is known about tattoo aftercare products.

Methods: Tattoo aftercare products were identified from a previous study and a search on Amazon.com using the phrase "tattoo aftercare." Duplicates and products without complete ingredient lists were excluded. Marketing claims were tabulated. All ingredients were entered in Excel and grouped according to Contact Allergen Management Program categories. Comparison of ingredients to North American Contact Dermatitis Group (NACDG) screening and American Contact Dermatitis Society (ACDS) Core allergens was conducted.

Results: A total of 84 tattoo aftercare products from 52 distinct brands were found. Forty-eight distinctive market claims were identified; the use of "natural ingredient(s)" (42.9%) was most common. There were 4 to 28 ingredients per product (mean = 11.8 ± 5.5) with a total of 369 distinct ingredients listed. Products contained an average of 7.9 ± 3.9 ACDS Core allergens per product and 7.0 ± 3.7 NACDG allergens per product. Most common allergens included fragrance/botanicals (n = 529), vitamin E derivatives (n = 43), and vitamin B5 derivatives (n = 11).

Conclusions: This review of 84 products found that tattoo aftercare products contain an average of 8 ACDS Core and 7 NACDG allergens. Clinicians should be aware of potential allergens in tattoo aftercare products.
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http://dx.doi.org/10.1097/DER.0000000000000635DOI Listing
January 2022

Patch Test Reactions Associated With Topical Medications: A Retrospective Analysis of the North American Contact Dermatitis Group Data (2001-2018).

Dermatitis 2021 Sep 1. Epub 2021 Sep 1.

From the Department of Dermatology, Park Nicollet Health Services Department of Dermatology, University of Minnesota Department of Dermatology, Minneapolis Veterans Affairs Medical Center University of Minnesota Medical School, Minneapolis Division of Dermatology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada Department of Dermatology, Cleveland Clinic, OH Department of Dermatology, Duke University Medical Center, Durham, NC Associates in Dermatology, Fort Myers, FL Department of Dermatology, University of California San Francisco Department of Dermatology, Columbia University Irving Medical School, New York, NY Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, DC Division of Dermatology, CHU de Québec, Laval University, Canada Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison Department of Dermatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH Division of Dermatology, University of Louisville, KY Division of Dermatology, Montreal General Hospital, McGill University, Quebec, Canada Division of Dermatology, University of Ottawa, Ontario, Canada Department of Dermatology, University of Colorado, Boulder Department of Dermatology, Keck School of Medicine, Los Angeles, CA.

Background/objectives: Topical medications may lead to allergic contact dermatitis. This study characterized positive patch test reactions associated with medications in patients evaluated by the North American Contact Dermatitis Group (NACDG).

Methods: This study is a retrospective analysis of the NACDG data (2001-2018). Patients with at least 1 positive patch test reaction associated with a medication source were included. Allergens, reaction characteristics, clinical relevance, and source details were tabulated.

Results: Of 43,722 patients, 6374 (14.6%) had positive allergic patch test reactions associated with 1 or more topical medication sources. Patients with versus without allergic reactions to medications were more likely to be older than 40 years (P < 0.0001) and/or have primary sites of dermatitis on the legs, anal/genital region, or trunk (P < 0.0001). There were 8787 reactions to NACDG allergens; the most common were neomycin (29.4%), bacitracin (29.1%), propylene glycol 100% (10.6%), tixocortol-17-pivalate (10.0%), lidocaine (7.9%), budesonide (4.9%), and dibucaine (4.4%). Propylene glycol 100% was the most common inactive ingredient (10.6%). Current relevance was present in 61.0%. A total of 6.5% of the individuals with medication allergy would have had 1 or more positive patch test reactions missed if only tested to the NACDG screening series.

Conclusions: Positive patch test reactions associated with topical medications were common (14.6%), and most were clinically relevant. Patients with topical medication allergy were twice as likely to have anal/genital involvement. Active ingredients, especially neomycin, bacitracin, and tixocortol-17-pivalate, were frequent culprits.
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http://dx.doi.org/10.1097/DER.0000000000000777DOI Listing
September 2021

Patch testing with ammonium persulfate: The North American Contact Dermatitis Group Experience, 2015-2018.

J Am Acad Dermatol 2021 Aug 11. Epub 2021 Aug 11.

Department of Dermatology, University of Colorado, Boulder, Colorado.

Background: Ammonium persulfate (APS), an oxidizing agent used in hair products, manufacturing, and pool/spa water, can cause skin reactions, including allergic contact dermatitis.

Objective: To characterize positive patch test reactions to APS (2.5% petrolatum).

Methods: Retrospective analysis of patients tested to the North American Contact Dermatitis Group screening series from 2015 to 2018.

Results: Of 10,526 patients, 193 (1.8%) had positive patch test reactions to APS. Compared with APS-negative patients, APS-positive patients were significantly more likely to be male (43.2% vs 28.0%; P < .0001); have primary hand dermatitis (30.2% vs 22.0%; P = .0064), scattered generalized dermatitis (25.5% vs 17.9%; P = .0064), or trunk dermatitis (8.9% vs 4.9%; P = .0123); and have dermatitis that is occupationally related (22.2% vs 10.9%; P < .0001). More than half of the APS-positive reactions were currently relevant (57.0%); 19 (9.8%) were related to occupation, especially hairdressers (68.4%). Swimming pools/spas (23.3%) and hair care products (19.2%) were the most common sources of APS.

Limitations: Immediate reactions and follow-up testing were not captured.

Conclusion: The proportion of patients positive to APS was 1.8%. APS positivity was significantly associated with male sex and hand dermatitis. Swimming pool/spa chemicals were important sources of APS exposure.
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http://dx.doi.org/10.1016/j.jaad.2021.08.005DOI Listing
August 2021

Age-related differences in patch testing results among children: Analysis of North American Contact Dermatitis Group Data, 2001-2018.

J Am Acad Dermatol 2021 Jul 24. Epub 2021 Jul 24.

Department of Dermatology, Pennsylvania State University, State College, Hershey, Pennsylvania.

Background: An updated understanding of allergic contact dermatitis is needed, particularly in children.

Objectives: To compare positive and clinically relevant reactions in children versus adults referred for patch testing.

Methods: Retrospective analysis of 1871 children and 41,699 adults from the North American Contact Dermatitis Group (NACDG) from 2001-2018.

Results: Both final diagnosis of allergic contact dermatitis (55.2% versus 57.3%; chi square, P = .0716) and prevalence of ≥ 1 currently relevant reaction to a NACDG screening allergen (49.2% vs 52.2%; P = .1178) were similar between children and adults. Currently in children, the most common relevant allergens were nickel sulfate (17.3%), hydroperoxides of linalool (7.8%), methylisothiazolinone (7.7%), cobalt chloride (7.0%), and fragrance mix I (4.9%). Approximately a fifth of children had a positive reaction to a non-NACDG allergen.

Conclusion: Over half of children referred for patch testing were diagnosed with allergic contact dermatitis. The most common relevant allergens in children were nickel sulfate, cobalt chloride, and hydroperoxides of linalool. Twenty percent of children had at least 1 positive reaction to allergens/substances not on the NACDG screening series, underscoring the need for comprehensive testing.
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http://dx.doi.org/10.1016/j.jaad.2021.07.030DOI Listing
July 2021

Contact Allergy in Canada Versus United States: Analysis of the North American Contact Dermatitis Group Data 2005-2016.

Dermatitis 2021 Nov-Dec 01;32(6):421-429

Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles.

Objective: The aim of the study was to describe the differences in contact allergy between the United States (US) and Canada.

Methods: This is a retrospective cross-sectional analysis of the North American Contact Dermatitis Group data from 2005 to 2016. Frequencies of demographics, clinical characteristics, positive reactions, trends, and occupations were calculated.

Results: A total of 28,640 patients underwent patch testing. At least 1 positive patch test was observed in 18,599 patients (US, 11,641 [66.5%]; Canada, 6958 [62.5%]). When comparing the 2 groups, US positive reactions were more likely to occur in male patients (odds ratio [OR] = 1.40, 95% confidence interval [CI] = 1.31-1.49), older than 40 years (OR = 1.30, 95% CI = 1.22-1.38), Black (OR = 2.67, 95% CI = 2.24-3.19) or Hispanic race (OR = 3.53, 95% CI = 2.61-4.78), and/or patients with scattered generalized dermatitis (OR = 1.96, 95% CI = 1.80-2.13). They were less likely to occur in patients with eczema (OR = 0.61, 95% CI = 0.57-0.65) and Asian race (OR = 0.50, 95% CI = 0.44-0.56). Nickel (US, 16.0%; Canada, 22.4%) and methylisothiazolinone (US, 13.4%; Canada, 11.0%) were the top allergens. The third most frequent was neomycin (US, 11.7%) and fragrance mix I (Canada, 10.2%).

Conclusions: National differences in allergen prevalence and trends exist in North America.
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http://dx.doi.org/10.1097/DER.0000000000000701DOI Listing
July 2021

Patch Testing With Tocopherol and Tocopherol Acetate: The North American Contact Dermatitis Group Experience, 2001 to 2016.

Dermatitis 2021 Sep-Oct 01;32(5):308-318

Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison.

Background: Vitamin E (tocopherol) a naturally occurring mixture of antioxidants commonly used in topical skin care products, may cause allergic contact dermatitis.

Objective: The aim of this study was to characterize positive patch test reactions to tocopherol and tocopherol acetate.

Methods: This is a retrospective analysis of North American Contact Dermatitis Group patch test data to tocopherols (dl-α-tocopherol 100% and/or dl-α-tocopherol acetate 100%) from 2001 to 2016.

Results: Of the 38,699 patients patch tested to tocopherol and/or tocopherol acetate, 349 (0.9%) had positive reactions; of these, 87.6% were currently relevant. Most (51.4%) were weak (+) and/or not related to occupation (99.1%). Compared with tocopherol-negative patients, tocopherol-positive individuals were more likely to be female (72.5% vs 67.2%, P = 0.0355), have a final primary diagnosis of allergic contact dermatitis (74.2% vs 52.6%, P < 0.0001), and have dermatitis in a scattered generalized distribution (23.8% vs 18.2%, P = 0.0072); they were also less likely to have hand involvement (16.6% vs 22.3%, P = 0.0064). The most common source of tocopherol was personal care products, especially moisturizers.

Conclusions: Positive patch test reactions to tocopherols were relatively rare given their widespread use. When positive, current clinical relevance was high. Tocopherol-positive patients were more likely to be female and presented with dermatitis on the face or in a scattered generalized pattern.
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http://dx.doi.org/10.1097/DER.0000000000000706DOI Listing
January 2022

Contact Dermatitis Associated With Hair Care Products: A Retrospective Analysis of the North American Contact Dermatitis Group Data, 2001-2016.

Dermatitis 2022 Jan-Feb 01;33(1):91-102

Department of Dermatology, Keck School of Medicine, Los Angeles, CA.

Background: Hair care products (HCPs) may cause both allergic contact dermatitis (ACD) and irritant contact dermatitis (ICD).

Objectives: The aims of the study were to determine the prevalence of HCP-associated ICD/ACD and to characterize relevant allergens.

Methods: This study is a retrospective analysis of North American Contact Dermatitis Group (NACDG) patch test data, 2001-2016.

Results: Of 38,775 patients tested, 3481 (9.0%) had positive patch test reactions associated with HCPs. The HCP-positive patients were significantly more likely to be female (79.9% vs 66.0%) and/or have primary sites of dermatitis on the face (32.0% vs 27.8%) or scalp (15.4% vs 2.2%) compared with the HCP-negative patients (P < 0.0001). Of 4908 HCP-associated positive patch test reactions, 86.9% (n = 4263) were due to allergens on the NACDG screening series; p-phenylenediamine (35.8%), methylisothiazolinone (9.7%), methylchloroisothiazolinone/methylisothiazolinone (8.7%), and cocamidopropyl betaine (5.9%) were the most frequent. Most reactions (87.7%, 3736/4263) were currently clinically relevant. The most common job associated with 366 occupationally related NACDG HCP-associated allergens was hairdresser/cosmetologist (71.9%). Two hundred eighty-two patients (0.7%) had ICD associated with HCPs. Shampoo/conditioners were the most frequent source of NACDG HCP-associated reactions (47.3%) and HCP-associated ICD (45.0%).

Conclusions: Of the HCP-positive patients, 18.5% had HCP reactions to allergens not on the NACDG screening series, underscoring the importance of patch testing to expanded series in patients suspected of HCP allergy.
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http://dx.doi.org/10.1097/DER.0000000000000760DOI Listing
June 2021

Trends in Patch Testing in the Medicare Part B Fee-for-Service Population.

Dermatitis 2021 Jun 9. Epub 2021 Jun 9.

From the University of Minnesota Medical School Biostatistical Design and Analysis Center, Clinical and Translational Science Institute Division of Healthy Policy and Management, School of Public Health, University of Minnesota Department of Dermatology, University of Minnesota, Minneapolis Veterans Affairs Health Care System Departments of Medicine Dermatology, University of Minnesota Departments of Medicine Dermatology, Minneapolis Veterans Affairs Health Care System, MN.

Background: Patch testing is a vital component of the workup for allergic contact dermatitis. There are limited data on changes of patch testing use among Medicare providers, as well as patch testing reimbursement rates.

Objective: The aim of the study was to evaluate trends in the use of patch testing among various Medicare providers and Medicare patch testing reimbursement.

Design: A longitudinal analysis of patch testing claims was performed with the Medicare Part B Physician/Supplier Procedure Summary files from 2010 to 2018. The primary outcomes were the total number and change in the number of submitted patch testing services from 2010 to 2018 by 3 provider groups: dermatology physicians, nondermatology physicians, and nonphysician providers. Secondary outcome measures included Medicare reimbursement amounts and changes in reimbursement amounts for patch test services (total and per 1000 enrollees) from 2010 to 2018 for the 3 provider groups, as well as per patch test service.

Results: From 2010 to 2018, submitted patch testing services per 1000 enrollees grew by 89.0%. The annual trend estimate for submitted services relative to 2010 was +10.1% (95% confidence interval [CI] = 8.1 to 12.0) for physicians and +34.1% (95% CI = 32.1 to 36.0) for nonphysician providers (physician assistants and nurse practitioners). Among physicians, the annual trend estimate for submitted services was +5.1% (95% CI = -11.3 to 21.5) for dermatologists and +31.40% (95% CI = 15.00 to 47.81) for allergists.

Conclusions: Patch testing increased in the US Medicare population from 2010 to 2018, and this increase was largely driven by nonphysician providers and allergists.
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http://dx.doi.org/10.1097/DER.0000000000000754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8655313PMC
June 2021

Contact Allergens in Prescription Topical Ophthalmic Medications.

Dermatitis 2021 Jun 9. Epub 2021 Jun 9.

From the Department of Dermatology, Park Nicollet Health Services University of Minnesota Medical School, Minneapolis.

Background/objective: Both active and inactive ingredients in topical ophthalmic agents may cause allergic contact dermatitis. Here, we examined ingredients in prescription topical ophthalmic medications available in the United States.

Methods: A comprehensive list of topical ophthalmic medications was generated using AccessPharmacy. Categories included antiglaucoma, antibiotic, antibiotic/corticosteroid, corticosteroid, antiviral, antifungal, mydriatic, and miotic agents. For each formulation, ingredients were investigated using the National Institutes of Health US National Library of Medicine database and/or manufacturer websites. Counts and proportions were calculated for inactive ingredients, including those in the American Contact Dermatitis Society (ACDS) Core 90 Allergen Series.

Results: Two hundred sixty-four unique prescription ophthalmic medications met the inclusion criteria. The most common ACDS Core 90 allergen/cross-reactor inactive ingredient was benzalkonium chloride (68.1%, 180/264), followed by sorbates (11.7%, 31/264), parabens (6.8%, 18/264), sodium metabisulfite (3.8%, 10/264), propylene glycol (3.0%, 8/264), and lanolin (3.0%, 8/264). Approximately 21% (20.8%, 55/264) of products had no ACDS Core 90 allergens/cross-reactor inactive ingredients. The most common ACDS Core 90 allergen/cross-reactor active ingredients were aminoglycoside antibiotics, bacitracin/polymyxin B, and corticosteroids. Important non-ACDS Core 90 allergens included inactive ingredients, such as EDTA 28.0% and thimerosal 2.7%, as well as active ingredients, especially β-blockers.

Conclusions: Benzalkonium chloride, sodium metabisulfite, propylene glycol, and lanolin were common inactive ingredient allergens. Most ophthalmic categories had low allergen formulations available for patients with contact allergy.
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June 2021

North American Contact Dermatitis Group Patch Test Results: 2017-2018.

Dermatitis 2021 Mar-Apr 01;32(2):111-123

Division of Dermatology, University of Louisville, KY.

Background: Patch testing is an important diagnostic tool for assessment of allergic contact dermatitis (ACD).

Objective: This study documented the North American Contact Dermatitis Group (NACDG) patch testing results from March 1, 2017, to December 31, 2018.

Methods: At 14 centers in North America, patients with dermatitis were tested in a standardized manner with a screening series of 70 allergens and supplemental allergens as clinically indicated. Data were manually verified and entered into a central database. Descriptive statistics were estimated, and trends were analyzed using χ2 test.

Results: Overall, 4947 patients were tested. There were 3235 patients (65.4%) who had at least 1 positive reaction and 2495 patients (50.4%) had a primary diagnosis of ACD. Five hundred eighty-one patients (11.7%) had occupationally related dermatitis. There were 10,122 positive patch test reactions. Nickel remained the most commonly detected allergen (16.2%), followed by methylisothiazolinone 0.2% aqueous (15.3%) and methylchloroisothiazolinone/methylisothiazolinone 0.02% aqueous (200 ppm, 11.0%). Compared with the previous reporting periods (2015-2016 and 2007-2016), the proportion of positive reactions for the top 20 screening allergens statistically increased for only 1 allergen, propolis (3.4%; risk ratios = 2.05 [confidence interval = 1.66-2.54] and 1.82 [confidence interval = 1.57-2.11]).Four newly added allergen preparations, hydroperoxides of linalool (8.9%), benzisothiazolinone (7.3%), sodium metabisulfite (2.7%), and hydroperoxides of limonene (2.6%), all had a prevalence of greater than 2%. Approximately 1 (19.7%) in 5 tested patients had 1 or more clinically relevant reactions to an allergen not on the NACDG screening series; 13.2% of these were occupationally related. T.R.U.E. TEST (SmartPractice Denmark, Hillerød, Denmark) would have hypothetically missed 30% to 40% of reactions detected by the NACDG screening series.

Conclusions: These results demonstrate the importance of a regularly updated screening allergen series. Methylisothiazolinone continues to be a significant allergen in North America. Patch testing with allergens beyond a screening tray is necessary for complete evaluation of occupational and non-occupational ACD.
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November 2021

Allergic contact dermatitis due to polyvinylpyrrolidone (PVP)/eicosene copolymer.

Contact Dermatitis 2021 Oct 11;85(4):458-460. Epub 2021 May 11.

Department of Dermatology, Park Nicollet Health Services, Minneapolis, Minnesota, USA.

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October 2021

Prevalence and trend of allergen sensitization in patients referred for patch testing with a final diagnosis of psoriasis: North American Contact Dermatitis Group data, 2001-2016.

Contact Dermatitis 2021 Oct 19;85(4):435-445. Epub 2021 May 19.

Division of Dermatology, CHU de Quebec, Laval University, Quebec, Quebec, Canada.

Background: Little is known about the relationship between psoriasis and allergic contact dermatitis (ACD).

Objective: To examine the associations with ACD, related clinical characteristics, and common positive and clinically relevant allergens of patients with a final diagnosis of psoriasis who were referred for patch testing.

Methods: Retrospective analysis of 38 723 patients from the North American Contact Dermatitis Group.

Results: Patients with a final diagnosis of psoriasis had lower proportions of ACD than those without psoriasis (32.7% vs 57.8%). In multivariable logistic regression models, psoriasis was inversely associated with female sex, Black or Asian race, and history of atopic dermatitis and hay fever. Patients with a final diagnosis of psoriasis were less likely to have one or more positive allergic patch-test reactions or to have a current clinically relevant patch-test reaction to the majority of the most commonly positive and/or relevant allergens. The most clinically relevant allergens included nickel sulfate, methylisothiazolinone, and fragrance mix I.

Conclusion: Approximately one-third of patients who were referred for patch testing with a final diagnosis of psoriasis were also diagnosed with ACD. In select patients with suspected psoriasis who also have a clinical presentation suggestive of ACD, patch testing may be helpful.
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October 2021

Patch Testing to Carvone: North American Contact Dermatitis Group Experience, 2009 to 2018.

Dermatitis 2022 Jan-Feb 01;33(1):42-50

Department of Dermatology, Keck School of Medicine, Los Angeles, CA.

Background/objectives: Carvone, a flavoring agent, may cause allergic contact dermatitis. This study summarizes patch test reactions to carvone in patients tested by the North American Contact Dermatitis Group, 2009 to 2018.

Methods: This was a retrospective analysis of patients positive to carvone (5% petrolatum). Demographics were compared with those of patients who were negative. Other analyses included reaction strength, clinical relevance, coreactivity with other fragrance/flavor allergens, and exposure sources.

Results: Of 24,124 patients tested to carvone, 188 (0.78%) were positive. As compared with carvone-negative patients, carvone-positive patients were significantly more likely older than 40 years (P = 0.0284). Women (76.1%) and/or facial involvement (33.0%) were common in the carvone-positive group but not statistically different from carvone-negative patients; 73.3% (n = 138) of the reactions were currently relevant. Relevant sources were personal care products (46.3%, n = 87) and food (14.3%, n = 27). Coreactivity with other fragrance/flavor markers was present in 60.6% of carvone-positive patients, most commonly fragrance mix I (34.6%), balsam of Peru (24.5%), and cinnamic aldehyde (15.4%).

Conclusions: Ten-year prevalence of carvone sensitivity was 0.78%. Most carvone-positive patients were female, were older than 40 years, and/or had facial dermatitis. Personal care products were the most common source. Two-fifths of carvone reactions would have been missed by relying on other fragrance/flavoring allergens.
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April 2021

Patch testing with sodium disulfite: North American Contact Dermatitis Group experience, 2017 to 2018.

Contact Dermatitis 2021 Sep 25;85(3):285-296. Epub 2021 Apr 25.

Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio, USA.

Background: Sodium disulfite (SD), also known as sodium metabisulfite, is an increasingly recognized cause of allergic contact dermatitis.

Objectives: The objective of this work was to characterize individuals with positive patch test reactions to SD as well as analyse reaction strength, clinical relevance, and sources.

Methods: This is a retrospective analysis of patients patch tested with SD (1% petrolatum) by the North American Contact Dermatitis Group (NACDG), 2017 to 2018.

Results: Of 4885 patients patch tested with SD, 132 (2.7%) had a positive reaction. Common primary anatomic sites of dermatitis were face (28.8%), hands (20.5%), and a scattered/generalized distribution (13.6%). Compared with SD-negative patients, SD-positive patients were more likely male (odds ratio 2.81, 95% confidence interval 1.98-4.00) and/or over 40 years (odds ratio 1.95, 95% confidence interval 1.30-2.94). Reactions were most commonly + (50.4%) or ++ (34.1%); 65.2% were considered currently relevant. About 15.2% were definitively confirmed in sources, commonly personal care products (18.9%, especially hair dye), and drugs/medications/alcoholic beverages (9.1%). Only 2.3% of positive reactions were linked to occupation.

Conclusions: Positive reactions to SD occurred in 2.7% of tested patients. Reactions were often clinically relevant and linked to personal care products and drugs/medications/alcoholic beverages.
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September 2021

Inter-rater variability in patch test readings and final interpretation using store-forward teledermatology.

Contact Dermatitis 2021 Sep 6;85(3):274-284. Epub 2021 May 6.

Department of Dermatology, Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota, USA.

Background: Data regarding teledermatology for patch testing are limited.

Objectives: Compare patch test readings and final interpretation by two in-person dermatologists (IPDs) with eight teledermatologists (TDs).

Methods: Patch tested patients had photographs taken of 70 screening series of allergens at 48 hours and second readings. Eight TDs reviewed photos and graded reactions (negative, irritant, doubtful, +, ++, +++) at 48 hours and second readings; in addition, they coded a final interpretation (allergic, indeterminant, irritant, negative) for each reaction. TDs rated overall image quality and confidence level for each patient and patch test reaction, respectively. Percentage of TD-IPD agreement based on clinical significance (success, indeterminate, and failure) was calculated. Primary outcome was agreement at the second reading.

Results: Data were available for 99, 101, and 66 participants at 48 hours, second reading, and final interpretation, respectively. Pooled failure (+/++/+++ vs negative) at second reading was 13.6% (range 7.9%-20.4%). Pooled failure at 48 hours and final interpretation was 5.4% (range 2.9%-6.8%) and 24.6% (range 10.2%-36.8%), respectively. Confidence in readings was statistically correlated with quality of images and disagreement.

Conclusion: For patch testing, teledermatology has significant limitations including clinically significant pooled failure percentages of 13.6% for second readings and 24.6% for final interpretation.
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September 2021

Prevalence and Trend of Allergen Sensitization in Adults and Children with Atopic Dermatitis Referred for Patch Testing, North American Contact Dermatitis Group Data, 2001-2016.

J Allergy Clin Immunol Pract 2021 07 27;9(7):2853-2866.e14. Epub 2021 Mar 27.

Department of Dermatology, Duke University Medical Center, Durham, NC.

Background: The association between atopic dermatitis (AD) and allergic contact dermatitis (ACD) is controversial.

Objective: To analyze the prevalence, reaction strength, and trends of the most commonly positive and relevant allergens in patients with AD referred for patch testing.

Methods: This was a retrospective analysis of 38,482 patients from the North American Contact Dermatitis Group, 2001 to 2016.

Results: Most adults (56.0%) and children (52.8%) with a history of AD had a final diagnosis of ACD. Adults (66.5% vs 65.6%; χ, P = .1459) and children (61.4% vs 62.3%, P = .7074) with or without a history of AD had similar proportions of one or more allergic patch test reactions. Adults with a history of AD had a greater number of allergic patch test positive reactions than those without it (2.0 ± 2.4 vs 1.9 ± 2.3; t test, P < .0001), whereas children did not (1.5 ± 1.8 vs 1.4 ± 1.6; P = .3839). Nickel sulfate, methylisothiazolinone, formaldehyde, fragrance mix I, sodium gold thiosulfate, and thimerosal were the most common allergens in adults and children with a history of AD. In multivariable logistic regression models, adults with versus without a history of AD had increased odds of reacting to 10 of the top 25 North American Contact Dermatitis Group screening allergens. Most allergens had similar strengths of reaction in adults or children with and without a history of AD or a current AD diagnosis; cobalt, fragrance mix I, and propylene glycol had weaker reactions. In multivariable logistic regression, adults with versus without an AD history had increased odds of relevance for 10 of the 25 most currently relevant allergens, whereas children with an AD history did not have increased relevance for any specific allergens.

Conclusions: Most patients referred for patch testing with AD history had a final diagnosis of ACD. Patients with AD history had a similar likelihood of having a positive patch test reaction as those without an AD history. Adults with an AD history had a higher number of positive patch test reactions.
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July 2021
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