ARTICLE
Auteur(s) : Birgitta KÜTTING*+, Randolf
BREHLER*, Heiko TRAUPE*
* Department of Dermatology and Venerology University of Mnster,
Von-Esmarchstr. 58, 48149 Mnster, Germany
+ Institute and outpatient clinic for occupational, social
and environmental medicine,
University of Erlangen- Nrnberg, Schillerstr. 25 + 29,
D- 91054 Erlangen, Germany
Article accepted on 12/01/2004
Until recently, allergic contact dermatitis was considered
uncommon in children. This opinion was based on beliefs rather than
on facts. It was suggested that children are less exposed to
contact allergens or that the immune system in children may be less
susceptible to contact allergens [1]. However, during the last
10-20 years, several reports have shown that allergic contact
dermatitis is a significant clinical problem in childhood.
Published series have reported positive patch test results varying
from 14.5% to 70%, clinically relevant results in 20% to 92% of
cases [2]. Different studies have found various percentages of
reactivity in children depending on selection criteria such as age
limits, sex, and type of population tested (normal children,
children with a history of contact allergy or atopic children) [3].
Most studies consider only the prevalence of positive patch test
reactions without evaluating the clinical relevance, e.g. the
prevalence of allergic contact dermatitis [1]. Therefore, the exact
incidence and prevalence of allergic contact dermatitis in children
is still largely unknown. Hitherto, the general impression is that
allergic contact dermatitis is rare in young children compared to
older children, and that allergic contact dermatitis becomes more
frequent with increasing age, especially after the 1st
decade, as exposure to environmental allergens increases.
Distribution of eczematous lesions as a diagnostic clue
Diagnosis is based upon the distribution of eczematous lesions
rather than the appearance of individual lesions. Any dermatitis
with an unusual shape, such as linear, or that is localized to a
skin area, such as the face or the dorsum of the feet, should alert
the physician to the possibility of allergic contact
dermatitis.
The distribution of the reaction may also provide clues to the
source or identity of the allergen.
Classic examples include involvement of the earlobes, neck, or
subumbilical skin with nickel allergy (ear rings, jewellery, metal
snaps on pants) [4] and in cases of foot eruption shoe dermatitis
must be considered [5, 6]. The most common allergens responsible
for footwear dermatitis are rubber chemicals, adhesives and leather
constituents. However, rashes affecting the weight bearing area of
the soles, which one might expect to indicate allergic contact
dermatitis to shoe insoles, shoe linings or glues (due to rubber
chemicals), occurred in contact allergy to medicaments, too. Dorsal
foot dermatitis is suggestive of contact allergy to potassium
dichromate, but only one out of 8 children reacted to this
allergen [5].
Recently, a particular type of diaper dermatitis due to rubber
chemicals [7] (mercaptobenzothiazole) or glues
(p-tertiarybutylphenol-formaldehyde resin) [8] was reported.
Distribution of eczema, predominantly located on the outer buttocks
and hips in toddlers, is quite characteristic of this particular
type of diaper dermatitis. Skin lesions recalling a cowboy’s
gunbelt holster led to the term “Lucky Luke” contact dermatitis,
used in the literature. This dermatitis is caused by the use of
diapers with a new anti-leaking system. This system maintains
elastic bands tight on the thighs. Recently, the same clinical
pattern was related to a third allergen, namely cyclohexyl
thiophathalimide, used as a vulcanization retarder in rubber
[9].
Another diagnosis at first glance, is the so-called
baboon-syndrome [10]. Here, an acute light-red symmetrical eruption
involving the major flexural areas of the extremities, the buttocks
and the anogenital region develops within hours or days after
systemic exposure to an allergen. Andersen et al. [11]
introduced the term “baboon syndrome” (the term “baboon” refers to
the red gluteal region of the baboon) to illustrate the
characteristic distribution of this particular type of systemic
contact dermatitis. Even though the baboon syndrome is supposed to
be uncommon among children, nevertheless, it has been observed in
children, mainly after exposure to mercury. Goosens et al.
[12] reported a typical pattern of baboon-syndrome in an
18-month-old child after oral treatment with erythromycin syrup for
a sore throat, Audicana et al. [13] observed the same
clinical pattern in a five-year-old girl 24 h after ingestion
of a homeopathic tablet containing mercury. Alegre [14] published
the case of a seven-year-old boy suffering from baboon syndrome
after exposure to mercury, Bartolome [15] a similar case in a
15-year-old boy. Mercury, ampicillin, amoxycillin, nickel,
erythromycin, heparin and food additives are the most frequently
incriminated allergens [10-12, 16].
Recently Sharma et al. [17] reported a case series of
38 children with suspected allergic contact dermatitis to
nickel who presented with prominent subumbilical and periumbilical
papules and a generalized, lichenoid papular dermatitis resembling
an id reaction. Patch tests were performed in 9 patients and
all 9 patients had positive patch test results for nickel.
An important aspect not to be overlooked is that general worsening
of atopic dermatitis while treating the skin with ointments might
be caused by sensitization to ingredients of the products used as
well (as described in case 3).
Risk factors and hidden risk factors
Jewellery
Body piercing, and particularly ear piercing is becoming
increasingly common in young children. The potential for serious
infection such as Hepatitis B, C and HIV or the risk of inducing
nickel allergy is not appreciated by the parents of these children
[18]. Jewellery, especially ear-piercing is known to be the most
important predisposing factor for nickel allergy. The prevalence of
nickel allergy among those children with pierced ears was 13%
compared to 1% among those without pierced ears [19]. The risk of
incurring nickel allergy is higher when earlobes are pierced before
the age of 20 (p < 0.05) [20] and is increased with
the number of piercings [21].
Temporary tattoos
Recently, a worldwide vogue of decorative skin painting started.
Transient artists have begun to use black henna mixtures,
containing indigo, henna and chemical colouring agents such as
p-phenylendiamine (PPD) and/or diaminotoluens to temporarily paint
the skin. Henna normally gives a temporary auburn to red colour;
addition of p-phenylendiamine gives henna a darker shade of a brown
to black colour. Lesions confined strictly to the painted area
indicate the presence of a skin sensitizer in such preparations.
Patch testing revealed severe hypersensitivity to PPD [22-26]. The
use of p-phenylendiamine and other diaminobenzenes is only allowed
for hair dyes in the European Union, the same directive forbids the
use of p-phenylendiamine and its derivatives for dying lashes,
eyebrows or skin [27]. However, these regulations are often not
followed by studios or transient artists performing tattoos.
Natural remedies
The use of herbal preparations is increasing dramatically. Many
of these herbal therapies have been used for centuries and show
good anecdotal results, whereas randomized trials are mostly
missing [28]. In response to this strong demand for natural
remedies and aromatic substances the commercial production of tea
tree oil, extracted from Melaleuca alternifolia Cheel, has
considerably increased over the past 15 years. The number of
case reports that describe allergic contact dermatitis to this
essential oil is also on the rise [29-34]. Even cases of erythema
multiforme-like reactions secondary to allergic contact dermatitis
from tea tree oil have been reported [35, 36]. Tea tree oil is
currently enjoying popularity as a “cure-all” for a variety of skin
conditions, from infections (viral, bacterial and fungal) to
dermatological disorders such as acne and psoriasis [28, 37-41].
Tea tree oil has about 100 components, predominating are
monoterpene as terpinen-4-ol (28-58%), α- and γ-terpinene (5-28%),
1,8-Cineol (= Eukalyptol, 11-18%), terpinolen (2-6%), p-Cymene
(0.5-13%) and d-Limonene (0.5-3%) (28). The allergic potential of
low concentrations of tea tree oil is presumed to be low on healthy
skin. But photoaged tea tree oil must be considered to be a strong
sensitizer [29]. The degradation products of monoterpenes in the
tea tree oil actually appear to be the sensitizing agents [42].
Children and their parents are usually not aware that tea tree oil
has to be kept in the dark and that “older“ tea tree oil becomes a
strong sensitizer due to oxidation.
Calendula officionalis, more commonly known as marigold, has been
used topically since ancient times and is currently approved by the
German Commission E as an antiseptic and to heal wounds [43]. It is
widely accepted as a topical treatment for diaper dermatitis [44],
but in spite of widespread use only limited data are available on
its allergenic potential. In Austria 443 consecutive patients
were tested with compositae mix, sesquiterpene lactone mix, arnica,
marigold and propolis. 9 patients (approximately 2.03%)
reacted to marigold. The Compositae mix was positive in
18 cases. Among them there were 4 out of 9 who
reacted to marigold. Therefore, sensitization to marigold cannot be
assessed by testing with the compositae or sesquiterpene mix alone
[45]. Apart from specific hypersensitivity, Marigold belonging to
the compositae family, is also known to cause irritant as well as
phototoxic reactions [46].
With the growing interest in alternative and complementary
therapies, practitioners need more information on
phytotherapeutics. Because patients or their parents often neglect
to mention that they have used natural remedies, it is important
that physicians are aware of the potential adverse effects of these
products.
Vaccination
Recently the mercury-based vaccine preservative thiomersal has
come under scrutiny because of its presence in certain vaccines
that provide the foundation of childhood immunisation schedules.
The potential toxicity in children seems to be of much more concern
than the hidden sensitizing properties. Therefore, as a
precautionary measure efforts are under way to remove and replace
thiomersal from vaccines. Over the past decade new vaccines have
been added to the recommended childhood schedule, and the relation
of bodyweight and surface of infants had led to concern that the
cumulative exposure of mercury from infant vaccines may exceed
certain guidelines for the human consumption of mercury [47].
The renewed attention to a reduction of children’s exposure to
mercury from all sources will decrease the clinical relevance of
hypersensitivity to thiomersal. In the near future hypertensitivity
to thiomersal will hopefully be a problem of the past. At present
all relevant vaccines are already available without thiomersal.
Based on the potential toxicity of thiomersal, in The Netherlands,
unlike many other countries, the pharmaceutical exposure to
thiomersal has already been reduced. In the USA and other European
countries replacement of thiomersal is still being debated [48,
49].
Data available on the overall frequency of sensitization to
thiomersal in children vary; differences depend on the population
selected and considerably diverging exposures between countries. In
some countries (e.g. Portugal, Spain, Japan) thiomersal is also
used in higher concentrations as a topical antiseptic [48, 50,
51].
Bruckner et al. [52] recruited 95 asymptomatic
children between the age of six months and 5 years for patch
testing. In their study population, thiomersal was the second most
prevalent allergen, and 9.5% of their subjects were sensitized.
Others reported a frequency varying from 2-4% of positive skin test
reactions to thiomersal without related symptoms of the skin or
mucous membranes in children [53-55]. Investigation of age and sex
distribution of positive patch test results in 234 children
with suspected contact dermatitis identified thiomersal as the most
frequent contact allergen in girls from 0-7 years (37.5%),
whereas in boys at the same age thiomersal was only the second most
prevalent allergen (25%) [56]. Despite the high percentage of
thiomersal positive patch test reactions, only a few of these were
found to be clinically relevant [57, 58]. However, in children with
atopic dermatitis exacerbation of skin lesions was reported
2-10 days after mandatory vaccinations with vaccines
containing thiomersal. Patrizi [59] observed cutaneous lesions of
nummular eczema on the trunk, limbs and face in five children, aged
7 to 28 months. A positive patch test reaction to
thiomersal 0.1% pet. was observed in all five children.
These diverging data indicate that the prevalence and incidence of
thiomersal hypersensitivity largely depend on selection criteria
for the study population. Precautionary measurements such as
replacement or reduction of thiomersal in medical and non-medical
applications will decrease the clinical relevance of contact
allergy to thiomersal.
In summary, hypersensitivity reactions to vaccines fall into six
categories, depending on the causative agent: reactions due to some
component of the infectious agent or one of its products, reactions
due to adjuvants (e.g. aluminium hydroxide), reactions due to
stabilizers (e.g. gelatin), reactions due to preservatives,
reactions due to antibiotics (e. g. neomycin) and finally reactions
due to the biological culture medium. The different causes can be
detected by patch testing.
Children’s cosmetics
Fragrances are one of the major causes of allergic contact
dermatitis from the use of cosmetics. In a previous study, a
vapo-spray for babies was found to contain 14 of
21 selected fragrance substances. Among these, 4 were
contact allergens present in fragrance mix: geraniol,
hydroxycitronella, cinamic alcohol and α-amyl cinnamic aldehyde
[60]. Recently, a series of 25 cosmetic products specially
marketed for infants and young children was analysed to evaluate
the exposure of this group to fragrance allergens. It was found
that the allergens of the fragrance mix were either not used or
they were present fairly low concentrations in shampoo/shower gels
and creams/lotions. Hydroalcoholic products (eau de toilette and
perfume) and a roll on, however were found to contain the
ingredients of the fragrance mix more frequently [61]. In the
study, one cosmetic toy perfume was found to contain 3.68% of
cinnamic alcohol, while the IFRA guidline states that a maximum of
0.8% is allowed (International Fragrance Association, [62]).
Characteristic clinical examples of allergic contact dermatitis
in children
Case 1
A nine-year-old girl presented with a 6-year history of
recurrent eczema. Skin lesions usually occurred one day after
wearing a bathing suit and were strictly symmetrical. Wetness and
transpiration turned out to be factors of aggravation. The lesions
persisted at least for one week up to several weeks. Her mother had
observed itching and reddening of the skin with the use of several
diapers, when she was a toddler. By the age of three, she was
playing with gloves in her father’s dental office; thereafter she
suffered from skin lesions on the back of her hands for several
weeks. Balloons could be blown up without problems (no angioedema).
She denied any history of asthma, allergic rhinitis or atopic
eczema. Clinical examination revealed slight linear eczematous
lesions on the buttocks in symmetric order. The extension of eczema
was strictly limited to the area where rubber bands of the swimming
suit had direct contact with the skin. Patch testing revealed a
specific hypersensitivity to Tetramethyl-thiurammonosulfid and
Benzothiazoles after 48, 72 and 96 h. Skin prick tests
with standard allergens (latex, house dust mite and seasonal
allergens) were negative.
Here, we recommended contacting producers of swimming suits to
find a suitable material (free of thiuram mix and benzothiazoles).
According to the patient’s history sensitization had already been
acquired in early childhood by use of diapers.
Case 2
A 12-year-old boy applied tea tree oil on his face to treat a
minimal skin affection. Four days later his face was extremely
reddened and swollen, but he continued to use the tea tree oil for
another three days before consulting our department. Previous use
of tea tree oil was negative. He presented with massive facial
oedema, erythema, vesiculation and yellow crusts. We recommended
stopping the use of tea tree oil and prescribed a steroid lotion
for three days. A new appointment was fixed and the patient was
instructed to bring the bottle of tea tree oil along. Skin lesions
cleared up within 2 weeks. Patch testing was performed when
skin lesions had completely resolved. The patient reacted to
diluted tea tree oil (2.5%), formaldehyde, turpentine and
quaternium.
The allergic potential of fresh tea tree oil is presumed to be low
in comparison to oxidized tea tree oil. Heat, light and oxygen
enhance the risk of skin sensitization to this product. Therefore,
photoaged tea tree oil must be considered to be a strong sensitizer
[63, 64].
Case 3
The 6-year-old girl recurrently used bufexamac-containing
ointments and creams for the treatment of atopic eczema since
babyhood. Due to the exacerbation of atopic dermatitis
bufexamac-containing ointments were applied, but this time instead
of resolving, eczema worsened on day six. The girl and her mother
presented in our clinic on day 14. Clinical investigation showed
extreme scaling and mild erythema on the face, chest and throat. We
recommended stopping treatment with bufexamac and the skin lesions
resolved within 2 weeks. Patch testing to prove the suspected
contact allergy to bufexamac was refused by the mother. The
clinical course and clinical picture were consistent with that of
allergic contact dermatitis. Almost 30 years ago the
arylacanoic acid derivative bufexamac was introduced to
dermatological therapy. Bufexamac – containing
preparations are widely used in the treatment of atopic or other
eczematous skin disorders as an alternative to topical
corticosteroids. First cases of contact allergy to a 5% bufexamac
cream had been reported as early as 1973, almost 20 years
later a 2nd type of adverse reaction after topical
application of bufexamac was observed, an erythema multiforme-like
eruption [65]. Contact allergy induced by bufexamac, which belongs
to the group of nonsteroidal anti-inflammatory drugs, is still rare
but increasing [65-67]. Kränke et al. [65] reported
clinically relevant patch test reactions to bufexamac in
20 out of 35 patients having applied (n = 30)
or having probably applied (n = 5) bufexamac ointment
(57%), whereas, in their unselected test population of
500 routinely patch tested patients, the overall frequency was
4%.
In all forms of eczematous skin disorders, especially in patients
suffering from chronic eczema or in patients with exacerbation of
long-standing eczemas, contact allergy to bufexamac should be
considered, even if bufexamac preparations were used for only a
short time [68]. The appropriate test concentration is 5%.
Further comments
As outlined in the introduction, allergic contact dermatitis is,
indeed, a significant clinical problem in childhood. We include in
our review examples of all other cases of allergic contact
dermatitis in childhood, three of our own cases to illustrate the
clinical characteristics. Pediatric dermatologists, in particular,
should be aware of this previously underestimated diagnosis in
childhood.
Taking the patient’s history, specific questions concerning
fashion trends and lifestyle such as piercing, decorative skin
paintings, the hype of natural remedies and cosmetics (e.g. tea
tree oil) or the use of cosmetical products with fragrances or
herbal ingredients should be asked.
Leisure activities should also be a point of interest. Recently a
cellist’s finger dermatitis due to PPD was reported in an
11 year-old schoolgirl. Bow hair is frequently dyed or
impregnated and this may lead to allergic contact dermatitis [69].
Azurdia and King [70] observed a 12-year-old girl with a 12-month
history of an itchy, red periorbital rash associated with the
wearing of her swimming goggles, which improved by their avoidance
for a 2-week period. Patch testing revealed positive reactions to
phenol-formaldehyde resin and benzol peroxide.
The diagnosis of allergic contact dermatitis is a 2-step process:
i) the establishing of delayed-type hypersensitivity and ii) the
subsequent demonstration that the patient is exposed to the
sensitizer and that the hypersensitivity and exposure explain the
dermatitis under investigation.
Although it is more than 100 years since Jadassohn introduced
the technique of epicutaneous testing, patch testing is still the
method of choice to establish the diagnosis of contact allergy. A
perfect patch test should give neither false-positive nor
false-negative reactions [71]. The history and examination of a
child with suspected allergic contact dermatitis will usually give
clues to possible sensitizers. Unfortunately, it is not sufficient
to patch test only with initially suspected sensitizers,
unsuspected sensitizers frequently turn out to be the real cause of
the dermatitis [72]. Rashes affecting the weight bearing area of
the soles, which one might expect to indicate allergic contact
dermatitis to shoe insoles, shoe linings or glues (due to rubber
chemicals), occurred in contact allergy to medicaments, too
[5].
Recommendations for patch testing in children has been
controversial. Previously, several authors have suggested that
children should be tested with lower concentrations of allergens
than adults due to the risk of irritant reactions leading to
false-positive test results. Fisher [73] proposes test
concentrations of half strength for nickel, rubber chemicals and
formaldehyde solution, Hjorth [74] suggested that patch test
concentrations should be adjusted according to the age of patients,
and that all positive patch test reactions should be repeated using
the half strength concentration. However, the general opinion today
is that children can be tested with the same concentration as
adults [1, 2, 55, 75-78].
The major problem of patch testing in children remains the lack of
space on small children’s backs, but with a reduced series of
allergens, this can be easily resolved.
Due to the lack of specific therapy, allergen avoidance is the
mainstay of prevention.
Legislation can be a useful tool in the prevention of contact
dermatitis. The Cosmetics Directive 76/768/EEC [79] and its
amendments aim to guarantee the safety of cosmetic products for
human use. Parts of the Directive focus on the prevention of
contact dermatitis. Annex VI gives a list of preservatives, which
cosmetic products may contain. This list provides data on
authorized maximum concentrations for each preservative, but
limitations and requirements for children are made only according
to toxicological side effects, and not in consideration of the
potential risk of sensitization. Annex III lists substances which
are restricted. A well-known example of a restriction due to the
risk of sensitization is
methylchlorisothiazolone/methylisothiazolone, which is not allowed
above 15 ppm [80].
Another effective tool for primary and secondary prevention of
nickel allergy is the EU Nickel Directive limiting the nickel
content in some types of product [81].
In 1992 the Danish Ministry of the Environment implemented a
regulation to reduce the skin nickel exposure of the population.
Recently Jensen et al. [82] found an effect of ear piercing,
before but not after 1992, in a study population of schoolgirls in
Denmark. This study strongly suggests that implementation of the
nickel-exposure regulation in 1992 in Denmark has had the intended
effect of protecting the female population from becoming allergic
to nickel.
Silverberg et al. [83] even suggest that the presence of a
positive family history may be a positive predictor of nickel
allergic contact dermatitis, requiring nickel avoidance, especially
in atopic children. Knowledge of reactivity to nickel in the family
would then allow parents and patients to initiate nickel avoidance
earlier in life.
Nowadays, we have to be aware that children are already exposed at
an early age to well-known allergens. Only precise knowledge of the
allergens responsible allows us to practice successful prevention
of allergic contact dermatitis in children from an early age
onward.
Consequently the risk of developing allergic contact dermatitis
can only be reduced by following several strategies of avoiding
possible risk factors as follows:
1. The ideal paediatric detergent should be very mild to avoid
irritant dermatitis, and very simple to avoid allergic dermatitis
[84].
2. Topically applied products for children should generally be
free of fragrances and preservatives.
3. The use of topical antibiotics in childhood should be
restricted for at least two reasons: i) the high potential of
sensitization of some antibiotics and ii) the development of
resistance.
4. Ear piercing cannot be recommended for children under the age
of ten years.
5. Parents should routinely be informed on the aspects of ideal
skin care in childhood. They have to be made aware of the
misconception that, because herbal supplements are “natural”, there
are no adverse effects.
Prevention of allergic contact dermatitis in children is a problem
of interdisciplinary concern not only for dermatologists and
paediatricians, but also for midwives. Frequently, children are
already exposed at an early age to well-known allergens, and
therefore, strategies of avoidance must gain or regain importance
and should start as early as possible. n
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