Differential diagnosis of contact dermatitis: A practical-approach review by the EADV Task Force on contact dermatitis.

The diagnosis of eczema ('dermatitis') is mostly clinical and depends on the clinical history and exploratory objective findings (primary lesions, patterns). Contact dermatitis remains as an important condition in the group of eczematous disorders, with important socioeconomic and occupational relevance. Although irritant and allergic contact dermatitis have a different pathogenesis, both are characterized by a rather typical morphology, are triggered by external factors and tend to occur primarily in the area of contact with the exogenous agent. In addition, allergic and irritant dermatitis may also co-exist. The importance of diagnosing contact dermatitis, especially when allergic in nature, is both due to the possibility of avoiding the trigger, and due to its role in aggravating other skin conditions. Nevertheless, the heterogeneity of clinical presentations in daily practice may pose an important challenge for the suspicion and correct diagnosis of contact dermatitis. Furthermore, other conditions, with different pathogenesis and treatment, may clinically simulate contact dermatitis. The Task Force aims to conduct a review of the unifying clinical features of contact dermatitis and characterize its main clinical phenotypes, and its simulators, in order to contribute to an early suspicion or recognition of contact dermatitis and enable a correct differential diagnosis

European patch test results with audit allergens as candidates for inclusion in the European Baseline Series, 2019/20:Joint results of the ESSCA(A) and the EBSB working groups of the ESCD, and the GEIDAC(C)

Background In 2019, a number of allergens (haptens), henceforth, "the audit allergens," were considered as potential additions to the European Baseline Series (EBS), namely, sodium metabisulfite, 2-bromo-2-nitropropane-1,3-diol, diazolidinyl urea, imidazolidinyl urea, Compositae mix II (2.5% or 5% pet), linalool hydroperoxides (lin-OOH), limonene hydroperoxides (lim-OOH), benzisothiazolinone (BIT), octylisothiazolinone (OIT), decyl glucoside, and lauryl glucoside; Evernia furfuracea (tree moss), was additionally tested by some departments as well. Objectives To collect further data on patch test reactivity and clinical relevance of the audit allergens in consecutive patients across Europe. Methods Patch test data covering the audit allergens in 2019 and 2020 were collected by those departments of the European Surveillance System on Contact Allergies testing these, as well as further collaborators from the EBS working group of the European Society of Contact Dermatitis (ESCD), and the Spanish Grupo Espanol de Investigacion en Dermatitis de Contacto y Alergia Cutanea. As patch test outcome, reactions between day (D) 3 and D5 were considered. Results Altogether n = 12 403 patients were tested with any of the audit allergen. Positive reactions were most common to lin-OOH 1% pet. (8.74% [95%CI: 8.14-9.37%]), followed by lin-OOH 0.5% pet., and lim-OOH 0.3% pet (5.41% [95% CI: 4.95-5.89%]). Beyond these terpene hydroperoxides, BIT 0.1% pet. was the second most common allergen with 4.72% (95% CI: 4.2-5.28%), followed by sodium metabisulfite 1% pet. (3.75% [95%CI: 3.32-4.23%]) and Compositae mix 5% pet. (2.31% [95% CI: 1.84-2.87%]). For some allergens, clinical relevance was frequently difficult to ascertain. Conclusions Despite many positive patch test reactions, it remains controversial whether lin- and lim-OOH should be tested routinely, while at least the two preservatives BIT and sodium metabisulfite appear suitable. The present results are a basis for further discussion and ultimately decision on their implementation into routine testing among the ESCD members

WHO/ILO work-related burden of disease and injury: Protocol for systematic reviews of occupational exposure to solar ultraviolet radiation and of the effect of occupational exposure to solar ultraviolet radiation on melanoma and non-melanoma skin cancer

Background: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing a joint methodology for estimating the national and global work-related burden of disease and injury (WHO/ILO joint methodology), with contributions from a large network of experts. In this paper, we present the protocol for two systematic reviews of parameters for estimating the number of deaths and disability-adjusted life years from melanoma and non-melanoma skin cancer (or keratinocyte carcinoma) from occupational exposure to solar ultraviolet radiation, to inform the development of the WHO/ILO joint methodology. Objectives: We aim to systematically review studies on occupational exposure to solar ultraviolet radiation (Systematic Review 1) and systematically review and meta-analyse estimates of the effect of occupational exposure to solar ultraviolet radiation on melanoma and non-melanoma skin cancer (Systematic Review 2), applying the Navigation Guide systematic review methodology as an organizing framework and conducting both systematic reviews in tandem and in a harmonized way. Data sources: Separately for Systematic Reviews 1 and 2, we will search electronic academic databases for potentially relevant records from published and unpublished studies, including Ovid Medline, PubMed, EMBASE, and Web of Science. We will also search electronic grey literature databases, Internet search engines and organizational websites; hand-search reference list of previous systematic reviews and included study records and consult additional experts. Study eligibility and criteria: We will include working-age ( 6515 years) workers in the formal and informal economy in any WHO and/or ILO Member State, but exclude children (<15 years) and unpaid domestic workers. For Systematic Review 1, we will include quantitative studies on the prevalence of relevant levels of occupational exposure to solar ultraviolet radiation (i.e. <0.33 SED/d and 650.33 SED/d) and of the total working time spent outdoors, stratified by country, sex, age and industrial sector or occupation, in the years 1960 to 2018. For Systematic Review 2, we will include randomized controlled trials, cohort studies, case-control studies and other non-randomized intervention studies with an estimate of the effect of any occupational exposure to solar ultraviolet radiation (i.e., 650.33 SED/d) on the prevalence of, incidence of or mortality due to melanoma and non-melanoma skin cancer, compared with the theoretical minimum risk exposure level (i.e. <0.33 SED/d). Study appraisal and synthesis methods: At least two review authors will independently screen titles and abstracts against the eligibility criteria at a first stage and full texts of potentially eligible records at a second stage, followed by extraction of data from qualifying studies. At least two review authors will assess the risk of bias and the quality of evidence, using the most suited tools currently available. For Systematic Review 2, if feasible, we will combine relative risks using meta-analysis. We will report results using the guidelines for accurate and transparent health estimates reporting (GATHER) for Systematic Review 1 and the preferred reporting items for systematic reviews and meta-analyses guidelines (PRISMA) for Systematic Review 2. PROSPERO registration number: CRD42018094817

European Surveillance System on Contact Allergies (ESSCA): Characteristics of patients patch tested and diagnosed with irritant contact dermatitis

Background Irritant contact dermatitis (ICD) is caused by the acute locally toxic effect of a strong irritant, or the cumulative exposure to various weaker physical and/or chemical irritants. Objectives To describe the characteristics of patients with ICD in the population patch tested in the European Surveillance System on Contact Allergies (ESSCA; ) database. Methods Data collected by the ESSCA in consecutively patch-tested patients from January 2009 to December 2018 were analyzed. Results Of the 68 072 patients, 8702 were diagnosed with ICD (without concomitant allergic contact dermatitis [ACD]). Hand and face were the most reported anatomical sites, and 45.7% of the ICD was occupational ICD (OICD). The highest proportions of OICD were found in metal turners, bakers, pastry cooks, and confectionery makers. Among patients diagnosed with ICD, 45% were found sensitized with no relevance for the current disease. Conclusions The hands were mainly involved in OICD also in the subgroup of patients with contact dermatitis, in whom relevant contact sensitization had been ruled out, emphasizing the need for limiting irritant exposures. However, in difficult-to-treat contact dermatitis, unrecognized contact allergy, or unrecognized clinical relevance of identified allergies owing to incomplete or wrong product ingredient information must always be considered

Impact of tumour necrosis factor-a polymorphisms on irritant contact dermatitis

Background. Genetic variations in genes coding for cytokines involved in skin inflammation may alter their expression, thus changing the susceptibility to irritant contact dermatitis (ICD). Objectives. To determine the prevalence of polymorphisms in the cytokine genes TNFA-238 and TNFA-308 in patients with occupational ICD, and to compare it with that in controls. Methods. In a case-control study, 478 patients with occupational ICD of the hands were genotyped for TNFA-238 and TNFA-308 polymorphisms. The results were compared with those for 393 apprentices from the same high-risk occupations (controls). Results. For a carrier of a variant TNFA-238A allele, the odds ratio (OR) of acquiring ICD was 0.57 [95% confidence interval (CI) 0.34-0.97], suggesting a protective effect of the A allele. The genotype distributions were 94.4% wild type (G/G), 5.6% heterozygous (G/A) and 0% homozygous for variant allele (A/A) in patients, and 90.9%, 8.5%, and 0.6%, respectively in controls. In contrast, carriers of the variant TNFA-308A allele had an increased risk of ICD [OR 1.33; 95% CI 1.05-1.74; G/G 66.4%, G/A 31.2%, and A/A 2.4% (patients) versus 73.5%, 24.6%, 1.9% in controls]. Conclusions. Individuals with a TNFA-238 polymorphism are less prone and those with a TNFA-308 polymorphism are more prone to develop ICD of the hands, suggesting a protective versus a detrimental effect of the A allele respectivel

Genotype-phenotype associations in filaggrin loss-of-function mutation carriers

Loss-of-function mutations in the filaggrin gene (FLG) have been reported to be associated with specific phenotypic characteristics such as hyperlinearity and keratosis pilaris. To study phenotypic features in patients with occupational irritant contact eczema of the hands in relation to FLG loss-of-function mutations. In a prospective cohort study, genotype was determined for 459 study subjects for four FLG null alleles, and investigated for selected history, clinical and laboratory features. Overall, 68 patients showed a mutation in the FLG alleles R501X, R2447X, S3247X, and/or 2282del4. Flexural eczema, xerosis cutis, pityriasis alba, dirty neck, pulpitis sicca, hyperlinear palms, keratosis pilaris and family history of eczema were positively associated with FLG mutations (p < 0.05). Although we observed a statistically significant correlation with higher serum IgE in FLG mutation carriers, allergic rhinoconjunctivitis and allergic asthma were not over-represented in this group. This study shows further genotype-phenotype correlations in patients with occupational irritant contact eczema and FLG mutation carrier status. These features may help to identify those with FLG mutations on a specific phenotype basi

Avifauna of the Southeastern Himalayan Mountains and neighboring Myanmar hill country

The northern Myanmar hill jungle and neighboring highlands found along the southeastern slopes of the Himalayas (Hkakabo Razi region, northern Kachin State, northernmost Myanmar) is almost untouched by humans, and can be considered as primary forest in the literal sense. Until the efforts reported on in this monograph, no ornithologist had the opportunity to visit this remote area since the late 1940s. Beginning in 1997, we made several visits to this extraordinary, species-rich area, and compiled an inventory of the regional avifauna while also studying the ecology, behavior, systematics, taxonomy, biogeography, and origin of the region’s birds. We report on these aspects for the 441 species found in the area and add data on species new to the area and those for which there are only a few representatives in the world’s specimen collections. In addition, we provide information on taxa that are likely endemic (Jabouilleia naungmungensis), suggest splits or revisions of subspecies and species, and describe two new subspecies from the area, Alcippe cinereiceps hkakaboraziensis ssp. nov. and Malacocincla abbotti kachinensis ssp. nov., based on plumage and morphometric differentiation. Last but not least, we analyze the species affinities (i.e. the biogeographic origin of the species occurring in Hkakabo Razi and surrounding areas). We found a lack of data in general for bird species in Southeast Asia, India and Tibet/China, but especially in the northern hill mountains of Kachin State around Hkakabo Razi National Park. Efforts by conservation organizations and ourselves has improved the situation, but much more work, particularly on ecology and global change effects, is warranted. We have added considerable information on the distribution, systematics, ecology, and biogeography of a number of species. Although much work remains to be done, our research provides significant new insights into the biology and biogeography of the region’s birds, and in particular, on delineation of major zoogeographic regions. We conclude that Ernst Mayr was correct in essence when he stated that the eastern border between the Oriental and Southeast Asian regions is roughly equivalent to the political boundary between Myanmar (Burma) and China. However, our work provides new understanding of the reasons, and challenges some of the fundamental assumptions on which the ‘zoogeographic region’ concept is based. In particular, such delineations often fail to take into account the geological and ecological history of a region. By evaluating in detail the subspecific relationships of the Hkakabo Razi rainforest avifauna, we were able to determine that the avifauna most similar is found in the temperate rainforests of northeastern India. We conclude that the likely reason for this similarity is that these two avifaunas shared the same refugium during the maximum of the last glacial period (18,000 years ago), and that other south and southeast Asian rainforest species shared different refugia during this time period, and probably during previous glacial events as well.Other parts of this work have been funded through six SYNTEHSYS grants (visits to BMNH, NMN, NMW, ZMUC, NRM, and Museo de la Historia Natural de Madrid: ES-TAF-2501; AT-TAF-2481; GB-TAF-108, SE-TAF-1312; NL-TAF-4369, AT-TAF-7), under the European Community’s 7th Framework Program (www.synthesys.info).Peer reviewe

Skin picking: A problem among healthcare workers?

Skin picking (SP) with manipulation of the skin using nails or other tools leads to various degrees of skin damage. Clinical signs of SP on the hands include erythema, erosions and bleeding wounds, crusts, hyperkeratosis, and often loss of the cuticles. The manipulation ranges from relatively normal behavior to self-injurious pathological SP related to compulsive-impulsive behavior or other psychiatric comorbidities causing functional interferences or distress

Stratum corneum levels of inflammatory mediators and natural moisturizing factor in patch test reactions to thiurams and fragrances and their possible role in discrimination between irritant and allergic reactions to hapten mixtures

Background: Patch test (PT) reactions to thiuram mix (TM) and fragrance mix (FM) I or II without concomitant reactions to their single constituents are potentially caused by the irritant properties of the mixes. Objective: Comparing inflammatory profiles of PT reactions to TM, FM I, FM II, and their constituents and assessing their potential in discrimination of irritant and allergic reactions. Patients and Methods: Levels of 14 cytokines and natural moisturizing factor (NMF) were determined in stratum corneum samples collected from PT reactions to TM, FM I or II, their constituents, and petrolatum (pet.) control sites in 36 individuals. Results: Levels of interleukin (IL)-16, chemokine (CXC motif) ligand (CXCL) 8, CXCL10, chemokine (CC motif) ligand (CCL) 17, and CCL22 were significantly increased in reactions (+, ++) to thiurams and fragrances compared to their pet. controls, except for PT reactions to FM I/II with negative breakdown testing in which, however, decreased levels of NMF were observed. In doubtful reactions to FM I/II with negative breakdown testing, NMF was significantly lower than in petrolatum controls. Conclusions: PT reactions to thiurams and fragrances indicate a Th2-skewed inflammation. The inflammatory profiles suggest that weak or doubtful FM I/II reactions without accompanying reaction to a constituent were irritant. IL-16 might be suitable to distinguish irritant from allergic reaction