10 1111@ddg 12143 PDF

CME Article
Submitted: 18.3.2013
Accepted: 29.4.2013
Conflicts of interest
None.
DOI: 10.1111/ddg.12143
Allergic contact dermatitis
Detlef Becker
Summary
Department of Dermatology, University

Medicine Mainz, Germany
Allergic contact dermatitis is a frequent inflammatory skin disease. The suspected

diagnosis is based on clinical symptoms, a plausible contact to allergens and a suitable
history of dermatitis. Differential diagnoses should be considered only after careful
exclusion of any causal contact sensitization. Hence, careful diagnosis by patch testing
is of great importance. Modifications of the standardized test procedure are the strip
patch test and the repeated open application test. The interpretation of the SLS
(sodium lauryl sulfate) patch test as well as testing with the patients own products
and working materials are potential sources of error. Accurate patch test reading is
affected in particular by the experience and individual factors of the examiner. Therefore, a high degree of standardization and continuous quality control is necessary
and may be supported by use of an online patch test reading course made available by the German Contact Dermatitis Research Group. A critical relevance assessment of allergic patch test reactions helps to avoid relapses and the consideration of
differential diagnoses. Any allergic test reaction should be documented in an allergy
ID card including the INCI name, if appropriate. The diagnostics of allergic contact
dermatitis is endangered by a seriously reduced financing of patch testing by the
German statutory health insurances. Restrictive regulations by the German Drug
Law block the approval of new contact allergens for routine patch testing. Beside
the consistent avoidance of allergen contact, temporary use of systemic and topical
corticosteroids is the therapy of first choice.
Section Editor
Prof. Dr. Jan C. Simon, Leipzig
Introduction
The inflammatory reaction of the skin based on a contact sensitization is a typical
cause of dermatitis in clinical dermatology. Due to the long tradition and deep embedding of this disease in our specialty, extensive basic knowledge exists that can be
gained from textbooks [1, 2] as well as from guidelines on contact dermatitis [3], hand
dermatitis [4] and patch testing [5]. Even though the fundamentals appear so clear,
test substances for patch testing are easily available and the performance is technically
uncomplicated, there are numerous sources of error in daily practice. In recent years
interventions by lawmakers and shifts of emphasis in reimbursement have affected and
even endangered the diagnostics of allergic contact dermatitis. This directly impacts
current and future practical care of patients with contact allergies. This article cannot and does not intend to replace a textbook or guideline recommendations. Rather
it is designed to help clinically active dermatologists to follow current developments
in clinical aspects, diagnostics and therapy and to show ways to deepen this special
knowledge. A further purpose of this article is to transmit experience on frequent interrelations and to illustrate typical shortcomings in quality in the daily practice that
can only be eliminated by critically questioning of your own approach and routines.
The Author | Journal compilation Blackwell Verlag GmbH, Berlin | JDDG | 1610-0379/2013/1107
607
CME Article Allergic contact dermatitis
Pathophysiology
Allergic contact dermatitis belongs to the best-researched forms of allergy, as it is
employed in many experimental systems as a model of a typical immune reaction
of the delayed type. In recent times especially knowledge on the genetic fundamentals of the early processes in the sensitization phase, particularly the activation of
the innate immune system, and the regulation of both sensitization as well as initiation have been gained. It has been reviewed in detail [6], but the extensive scientific
background is not yet well-reflected in clinical practice.
Epidemiological and clinical significance

Epidemiological studies currently provide no evidence for a significant change
in prevalence and incidence of allergic
contact dermatitis.
Regressions in the diagnostic depth of
contact allergy favor recurrences of the
disease.
Contact sensitizations towards not
sufficiently avoidable occupational
substances are next to variants of atopic
dermatitis the most frequent causes of
occupational disability.
Contact sensitizations represent a common, even if not the most frequent, cause
of eczema in all age groups and social strata. Epidemiological studies currently
provide no evidence for a significant change in prevalence and incidence of allergic
contact dermatitis. Regulations of lawmakers and even more of the EU as well as
trends in the use of certain substances actually do lead to shifts in the significance
of individual allergens, but not to a perceptible in- or decrease of the disease itself.
Other factors have a much greater effect on the frequency of the disease in daily
practice. As will be shown later in detail, the basic conditions for diagnostics have
in part worsened dramatically. As only identification of the causal allergen and its
avoidance can prevent recurrences, it must be feared that the frequency in duration
of eczema episodes will increase. Contact sensitizations towards not sufficiently
avoidable occupational substances are next to variants of atopic dermatitis the
most frequent causes of occupational disability with the corresponding personal
consequences for those affected and high economic follow-up costs.
Clinical findings and differential diagnoses

Irritant dermatitis and the various forms
of atopic dermatitis are the most important differential diagnoses of allergic
contact dermatitis.
The possible causes of allergic contact

dermatitis are as diverse as the exposures, but can be usually be identified
by utilizing the available test allergens
selected on the basis of history.
608
Irritant dermatitis and the various forms of atopic dermatitis are the most important differential diagnoses of allergic contact dermatitis. Even if contact dermatitis is frequently more inflammatory in comparison to the differential diagnoses
(Figure 1), this in an insecure parameter. Only the total picture of clinical findings,
comprehensible allergen exposure of the affected region and the clinical course
in the history raise suspicion that can be confirmed or excluded by patch testing
(Figure 2).
Hardly any region is that frequently affected by dermatitis as the hands. The
possible causes of allergic contact dermatitis are as diverse as the exposures, but
can be usually be identified by utilizing the available test allergens selected on the
basis of history.
It is helpful to establish that in reality only the hands are affected. Thus,
many substances can be excluded that contact the hands during personal hygiene
(e.g. perfume, deodorant, shampoo, hair colors, decorative cosmetics, moist toilet
paper, skin care creams, topical medications) but are also applied elsewhere. The
clear dependence on occupational activities also provides important indications.
Only by careful exclusion of possible sensitizations or lack of control of the dermatitis despite avoidance of possible allergens reactive in the patch test can the initial
suspected diagnosis be excluded (Figure 2).
Patients with chronic stasis dermatitis display an increased risk of sensitization to ointment bases and active ingredients repeatedly applied within the context
Figure 1 Severe allergic contact dermatitis of the scalp following hair coloring
with a customary hair dye due to contact hypersensitivity to p-phenylenediamine.
Figure 2 Flow chart for the diagnosis and therapy of allergic contact dermatitis.
Several critical decisions have to be made and should lead to a successful and
lasting cure of the disease or a differential diagnosis. The complete diagnostic
procedure makes sense only if there is sufficient evidence for this suspected
d iagnosis.
609
Due to the special environmental factors of stasis dermatitis, sensitizations

can develop towards weak allergens
that are otherwise only rarely observed.
True allergic reactions of the oral mucosa

towards dental materials are very rare.
of therapy of the dermatitis and chronic ulcers. Due to the special environmental factors of stasis dermatitis, sensitizations can develop towards weak allergens
that are otherwise only rarely observed. For rapid orientation, if an acute contact
reaction is present, the employed therapeutic agents can be tested on the back
under the conditions of the patch test as own substances. In the event of positive
reactions, comprehensive diagnostics are needed to manage further therapy of the
basic disease.
Further typical locations are foot dermatitis, whose cause by leather allergens
is more often suspected than is finally confirmed. Atopic dermatitis of the dorsa
of the feet and vesicular plantar dermatitis are the most important differential
diagnoses. Also in the face and particularly on the eyelids atopic dermatitis tops
the charts. In dermatitis of the anogenital region environmental factors such as
microbial colonization, irritant contacts to excrements and particularly occlusion and mechanical friction under tight clothing as well as maceration through
sweating in the face of high temperatures must be considered. Similar conditions
are found in the axillary vaults and body folds in morbid obesity. In contrast, the
numbers of potential contact allergens in these special locations are limited and
easily diagnosed.
Besides clinically manifest or a history of eczema reactions, many patients in
the office situation complain of in part diffuse symptoms in the mouth that they
attribute to suspected allergy towards dentures or other dental materials. Only a
very small share actually do have allergic contact stomatitis, due to incompletely
hardened dentures in sensitizations towards methacrylate or chronic lichenoid
reactions at the sites of contact to dental metals.
Patch testing
Performance
The sensitivity and specificity of the

patch test are in part critically impacted
by comorbidities and medications, the
skin status in the test area and deviations from the defined test conditions.
As the gold standard the patch test has a prominent place in the clinical management of allergic contact dermatitis. In contrast to in vitro diagnostics of
immediate-type sensitizations, where only the existence of specific IgE independent of the functional status of the immune system is detected, the patch test is
an in vivo test. Its sensitivity and specificity are in part critically impacted by
comorbidities and medications, the skin status in the test area and deviations
from the defined test conditions. Recommendations of the medical societies
on details of performance exist [5], that are currently being expanded to an
S3-guideline.
Important contact allergens

The allergens of the standard series
are of particular importance and are
supplemented by special test series on
the basis of history.
610
Due to the frequency of reactions in the patch test, the allergens of the standard
series (Table 1) are of particular importance. In addition, there are special test
series, whose selection is oriented to a certain, usually occupational exposure
(hairdressing, construction industry, dental technicians, etc.) or an exposure to
certain products (rubber, fragrances, topical medications, etc.). Due to the high
number of available allergens and their possible combinations in different situations, even an overview on this subject will remain incomplete within the context
of this article. Various sources of information give advice on setting up a diagnostic spectrum sensibly. The test allergens in their entirety and their arrangement
in series are found at the manufacturers of the substances (www.hautstadt.de)
(www.hal-allergie.de). The respective recommendations of the German Contact
Table 1 Standard patch test series recommended by the German Contact

Dermatitis Research Group (DKG).
Name of substance
Vehicle
Concentration
Potassium dichromate
PET
0.5 %
Thiuram mix
PET
1%
Cobalt (II) chloride, 6*H2O
PET
1%
Balsam of Peru
PET
25 %
Colophony
PET
20 %
N-isopropyl-N-phenyl paraphenylenediamine
PET
0.1 %
Wool alcohols
PET
30 %
Mercapto mix without MBT (only CBS,

MBTS, MOR)
PET
1%
Epoxy resin
PET
1%
Nickel (II) sulfate, 6*H2O
PET
5%
Paratertiarybutyl phenol formaldehyde resin
PET
1%
Formaldehyde
AQU
1%
Fragrance mix
PET
8%
Turpentine
PET
10 %
(Chloro)-methylisothiazolinone (MCI/MI)
AQU
100 ppm
Paraben mix
PET
16 %
Cetyl stearyl alcohol
PET
20 %
Zinc bis(diethyldithiocarbamate)
PET
1%
Dibromodicyanobutane (methyldibromo
glutaronitrile)
PET
0.2 %
Propolis
PET
10 %
Bufexamac
PET
5%
Compositae mix II
PET
5%
Mercaptobenzothiazole
PET
2%
Hydroxymethylpentylcyclohexenecarboxaldehyde (Lyral)
PET
5%
Bronopol (2-bromo-2-nitropropane-1,3-diol)
PET
0.5 %
Fragrance mix II
14 %
Sodium lauryl sulfate
AQU
0.25 %
Ylang-ylang (I + II) oil
PET
10 %
Sandlewood oil
PET
10 %
Jasmine absolute
PET
5%
Dermatitis Research Group (DKG) can be found on the website (http://dkg.ivdk.

org/). Monographs have been developed with test recommendations and further
valuable information on allergen occurrence for various occupational fields. These
are available for the test practice in summarized form free of charge in the internet
611
Table 2 Reading criteria for patch test reactions used by the DKG.
Symbol
Morphology
Evaluation
No reaction
Negative
Only erythema, no infiltrate
Questionable
Few follicular papules
Questionable
Erythema, infiltrate, discrete papules
Single positive reaction
++
Erythema, infiltrate, papules, vesicles
Double positive reaction
+++
Erythema, infiltrate, confluent vesicles
Triple positive reaction
Ir
Soap effect, blister, necrosis
Irritant
(www.hautstadt.de/hs/pages/intern/infozentrum/berufstestreihen/berufstestreihen.
php). A recommendation of the DKG has been published on the special aspects of
testing children from the age of 6 years [7].
Reading the test

The reading of a reaction ideally is done
only according to morphological criteria and at first disregards the question
of the clinical relevance. Unfortunately,
when at least a +-reaction is
observed, it is often automatically assumed that a contact sensitization exists
and sometimes it is concluded without
further critical evaluation that this is
also relevant for the disease process.
From large data bases by means of

calculations problem allergens can be
identified, whose relevance must be
evaluated particularly critically.
612
Reading criteria for patch test reactions have been defined (Table 2) and are valid
unchanged. The reading of a reaction ideally is done only according to morphological criteria and at first disregards the question of the clinical relevance. Unfortunately, when at least a +-reaction is observed, it is often automatically assumed
that a contact sensitization exists and sometimes it is concluded without further
critical evaluation that this is also relevant for the disease process. It should,
however, not be forgotten that an extensive, more or less infiltrated erythema
(Figure 3a) can actually correspond to a weak allergic reaction, that can just as
well represent a dermatitis triggered by irritation. The decrescendo course postulated for irritant reactions is in fact a frequent occurrence, by which many irritant
reactions at the first reading fade again until the reading at 72 hours. If the reaction
remains unchanged, however, this is still no proof of a contact allergic reaction,
but is still compatible with a false-positive, irritant reaction. Here the limits of a
method based on purely morphologic criteria are reached. With increasing reaction
intensity (Figure 3b) the probability of a plausible allergic genesis of the reaction
rises exponentially. When a large number of test data are registered in data banks
and analyzed, as is done in the Information Network of Departments of Dermatology (IVDK), evaluation parameters from the relationship between irritant,
doubtful and weak test reactions as well as probable allergic reactions, such as the
reaction index and the positivity ratio can be calculated [8], that express in which
frequency the test substance elicits irritant or doubtful reactions. It is thus possible
to describe problem allergens [8] that are characterized in the clinical routine by
unclear, u
sually only doubtful or +-reactions. Frequent problem allergens are
listed in Table 3; they demand particular care in the evaluation of the relevance.
Reading of a patch test is learned under supervision during allergologic
t raining. After this, however, the possibilities to compare ones own reading
practice with a standard are lacking. Besides the classical reaction patterns of
allergic or irritant reactions we must always again and again categorize and evaluate morphological peculiarities (Figure 3c, d). To promote continuing education and quality assurance in the reading of the patch test, the German Contact
Dermatitis Research Group (DKG) offers on its website (http://dkg.ivdk.org/)
Figure 3: Examples of irritant, doubtful and positive patch test reactions. Weak
positive reaction with erythema and palpable infiltrate to fragrance mix (a). Strong
positive reaction to colophony (b). Follicular and hemorrhagic erythema without
palpable infiltrate rated as irritant to cobalt chloride (c). Doubtful reaction with follicular papules to MCI/MI (d).
Table 3 Problem allergens frequently eliciting doubtful, weak and false positive
test reactions [8].
Substance
Typical use
Benzalkonium chloride
Disinfectant and preservative
Benzylhemiformal
Technical preservative
Methylene-bis(methyloxazolidine) Technical preservative

Glutardialdehyde
Surface and device disinfectant
Iodopropynyl butylcarbamate
Preservative
Amerchol L-101
Emulsifier in topical products
Cocamidopropyl betaine
Detergent
Octyl gallate
Antioxidant
Sorbitan sesquioleate
Emulsifier in topical products and fragrance mix
Triethanolamine (TEA)
Emulsifier and technical use
Benzoyl peroxide
Acne medication, polymerization of synthetics
Chlorhexidine digluconate
Skin disinfectant, preservative
Phenylmercuric acetate
Preservative in topical ophthalmological

products (only isolated)
Povidone iodine
Skin disinfectant
1,3-diphenylguanidine
Rubber chemical
613
An online reading training of the

German Contact Dermatitis Research
Group (DKG) is available for quality
assurance and further education.
r eading training with which any physician working in the field of allergology can
test her/his own reading habits online for correspondence to and deviations from
the standard. This reading tool is also suitable for didactic purposes within the
context of training.
Irritant control
An abnormal irritant control

nderscores the need for careful
u
interpretation of other weak positive
erythema reactions, that can hide
false-positive reactions.
Contact sensitizations towards sodium
lauryl sulfate do not occur; the
substance is a pure irritant.
Since inclusion of an irritant control with 0.25 % sodium lauryl sulfate in the standard series, such reactions are also interpreted as an indicator for increased skin sensitivity in general. This statement, however, is not supported by the underlying study
data [9] that in the event of a reaction to this concentration of sodium lauryl sulfate
only prove an increased irritability at the time point of the test. This fact underscores
the need for careful interpretation of other weak erythema reactions that can hide
false-positive reactions. Totally wrong is the conclusion that a contact sensitization
towards sodium lauryl sulfate is present. The attempt of avoidance presents great
problems due to the wide distribution in detergents of all kinds and is not sensible, as
the substance is a pure irritant and contact sensitizations do not occur. Documentation of the reaction in an allergy ID card must be avoided, as this can be misunderstood by patients and be misinterpreted as a recommendation to avoid the substance.
Modifications of the patch test and further diagnostics

In the strip patch test a disturbance
of the barrier function is simulated
in order to test allergens with poor
penetration capabilities.
A ROAT can be very helpful to evaluate

mixtures, such as cosmetics and contact
substances at the workplace, for
e xisting sensitizations towards one of
the ingredients.
In vitro diagnostics with the lymphocyte transformation test (LTT) hardly has a
place in the clinical management.
Histologically, the various causes of

an eczema cannot be differentiated
sufficiently.
For the differentiation from a fungal

infection and an atopic dermatitis appropriate diagnostics may be necessary.
614
The intact stratum corneum represents a distinct barrier for some contact allergens,
so that the elicitation of a positive test reaction is made more difficult despite an
existing sensitization. On previously damaged skin, in contrast, allergen contact
leads to a reaction. This problem is addressed by the strip patch test that has
recently been standardized and evaluated [10] and is of value in targeted use.
When the relevance of a test reaction for the use of an end-product is unclear,
a repeated open application test (ROAT) can be performed [11]. For this purpose
there is controlled twice daily open use on a defined area of the forearm for up to
two weeks. A ROAT can also be very helpful to evaluate mixtures such as cosmetics and contact substances at the workplace, for existing sensitization towards one
of the ingredients, when this question cannot be clarified due to lack of suitable
test allergens or information. This method demands skin tolerability of the product
and can only be justified when concentration and application time in the ROAT
correspond to the real exposure to the diseased skin.
In vitro diagnostics with the lymphocyte transformation test (LTT) hardly has a
place in the clinical management. Performance is costly and time-consuming and usually can be offered only by the larger allergological centers. Finally, the LTT can only
confirm the result of the patch test and in only very special cases, such as the contraindication for patch testing or as a building block in the diagnostics of endoprosthesis intolerance, independently deliver additional information. This method often located on
the border to complementary medicine is not validated for the study of sensitizations
in denture problems and is disapproved by evidence-based medicine in this context.
When doubts about the diagnosis of eczema exist, a biopsy may be requested.
This makes no sense for the differentiation between the various causes of eczema,
as still even with the most modern molecular methods, no secure differentiation
can be made between an allergic and non-allergic reaction.
To exclude a fungal infection as a differential diagnosis or secondary problem,
the appropriate diagnostics may be needed. Due to the increasing significance of
atopy as a cause or at least partial cause of dermatitis, basic diagnostics to uncover an atopic diathesis is recommended. Even in face of obvious elicitation of the
dermatitis by a contact allergen, an atopic skin diathesis can exist in combination.

This can lead to unjustified doubts on the cause of the contact allergic disease share
or allergen avoidance, respectively, when an in parallel provoked atopic dermatitis
process is superimposed on the course of healing.
Sensible extent of patch testing

The exclusive testing of the standard
series is not sufficient in many cases.
Occupationally-related diagnostics,
when an occupational contact dermatitis is suspected, as well as the testing
of occupational contact substances is
reimbursed much more favorably within
the context of the medical fee schedule
of the statutory occupational accident
insurance (UV-GO) since 2010.
The present downward trend in the

extent and availability of patch testing
delays the diagnosis and prolongs the
treatment-requiring duration of an
allergic contact dermatitis.
In increasing degree in some dermatology offices only the standard series or even
only a fragment of it is routinely tested. With the exception of some frequent
sensitizations, such as towards nickel, fragrances and colophony, this is not sufficient for well-founded diagnostics. Particularly occupational contact sensitizations
thus remain undetected or are referred to dermatologic centers. This often results
in a distinct delay in the diagnosis and in rural regions long distances. The cause
is the reform of the reimbursement of the patch test in the currently valid Uniform
Value Scale (EBM). The patch test is no longer reimbursed according to its extent,
but only represents a share of the standard service volume. The increased effort of
diagnostics with special test series is no longer reflected leading a not inconsiderable
number of offices to limit themselves to the standard series.
Occupationally-related diagnostics, when an occupational contact dermatitis
is suspected, as well as the testing of occupational contact substances is reimbursed
much more favorably within the context of the medical fee schedule of the statutory occupational accident insurance (UV-GO) since 2010. This was done with the
intent to make the supply of occupational test series independent of the statutory
health insurance care. The aim is preservation of the up to now natural extensive diagnostics within the context of the dermatologists procedure. All relevant
innovations can be found in the brochure Honorare in der Berufsdermatologie
(Reimbursement in Occupational Dermatology) as a download on the website
of the German Social Accident Insurance Institution for the Health and Welfare
Services (BGW) (www.bgw-online.de).
The present downward trend in the extent and availability of patch testing
delays the diagnosis and prolongs the treatment-requiring duration of an allergic
contact dermatitis. In addition, the danger exists, that special allergens, that can
be of great significance in the individual case, but are hardly tested on a large scale,
will be removed from the market by the manufacturers of the test allergens on
economic grounds. They will then also not be available in specialized centers with
a direct impact on the quality of medical care.
Impediments to the further development of patch testing

Allergologic test substances are drugs
and therefore are regulated with respect
to manufacturing and licensing by the
German Drug Law (AMG).
Due to the stipulations of the AMG,

since 2008 no new contact allergens
have been licensed for testing.
Allergologic test substances are drugs and therefore are regulated with respect to
manufacturing and licensing by the German Drug Law (AMG). This demands also
for new contact allergens a costly and time-consuming licensing process with the
corresponding studies. It is well-known that the associated costs are enormous and
one of the grounds for the high prices of newly licensed medication. This type of
financing is, however, not realistic for test substances, so that the manufacturers
neither actively perform nor sufficiently promote such licensing studies [12]. Since
the expiration of interim arrangements in the fall of 2008, it has therefore come
to a complete stop in the licensing of new test allergens. As technological further
developments also produce new contact allergens, the discrepancy between exposure
and the available allergens for diagnostics is continually increasing. Therefore, particularly for occupationally induced diseases, the possibility must be considered,
that the decisive cause for a contact dermatitis is not detected with the available
615
commercial test allergens. Therefore, testing with the patients own substances is
of increasing significance.
Testing of patients own substances

The testing of patients own substances
will become more important in order to
close gaps in the diagnostic spectrum.
Diagnostics with patients own

substances requires consideration of
additional quality criteria.
Since the 15th reform of the AMG

t esting of patients own substances
requires reporting to the responsible
state authority.
Due to the blockade of the further development and actualization of commercially

available test substances, situations are on the rise, where the suspicion for contact
sensitization can only be clarified by the testing of patients own substances from the
private and occupational surroundings. As far as it is possible to avoid false-positive
reactions to the often complicated substance mixtures or at least to recognize them, the
question then still remains, which individual allergen is responsible for the reaction, so
that targeted avoidance is possible. Surely, the detection of an allergic reaction to a suspected agent is better than no diagnostics at all. The testing of patients own substances
cannot, however, replace well-founded diagnostics with defined individual substances.
Diagnostics with patients own substances requires consideration of additional
quality criteria. Practical advice on the proper selection of suitable substance samples and their dilution including the selection of the dilution medium are found on
the website of a large test allergen manufacturer (www.hautstadt.de) in the login
area for physicians. The recommendations were drawn up with the cooperation
of the experts of the DKG and IVDK. Textbooks provide detailed information on
testing of special substances and substance mixtures [13].
The Working Group on Occupational and Environmental Dermatology (ABD)
and the DKG have developed a checklist for the process of testing workplace substances (Table 4).
Since the 15th reform of the AMG testing of patients own substances requires
reporting to the responsible state authority, in which it must be stated that test preparations and thus drugs in the sense of the AMG for testing on individual patients
are being manufactured. Further important details on reporting are available on
the website of the DKG (http://dkg.ivdk.org/).
Through a substantial increase in the fee for patch testing of workplace substances within the context of the UV-GO since 2010 the increased efforts are
reimbursed. Thus, quality loss due to stagnation of the further development of the
test spectrum will be prevented at least in the occupational dermatology sector.
Prerequisite for this is the responsible utilization of this option through serious
diagnostics oriented on the literature and following a concrete suspicion.
Evaluation of relevance of positive test reactions

As the test result presents the sum of all
sensitizations acquired in the past, even
strong reactions must always be critically analyzed for their actual relevance
for the current disease.
Even reactions whose developments are

puzzling should be brought to the attention of the patient. This succeeds by
handing out an allergy ID card in which
the listing of the allergens with the INCI
terminology mandated for the declaration of ingredients is documented.
616
As the test result presents the sum of all sensitizations acquired in the past, even
strong reactions must always be critically analyzed for their actual relevance for
the current disease. Premature conclusions delay the management of the disease,
because when another allergen is the cause, targeted avoidance fails. Should no
contact allergic disease be present, but a dermatitis provoked by irritation or constitutional factors, important steps in secondary prevention are not taken. Every
reaction clearly identified as allergic is ideally discussed with the patient in order
to determine past relevance and thus avoid future dermatitis. Even reactions whose
developments are puzzling should be brought to the attention of the patient. This
succeeds by handing out an allergy ID card in which the listing of the allergens
with the INCI terminology mandated for the declaration of ingredients is documented. The common substance names sometimes deviate considerably from this
terminology (Table 5) and thus do not allow for consistent allergen avoidance.
Manufacturers of the test allergens provide information on the occurrence of each
Table 4 Checklist for patch testing of workplace materials.

W
hat does the occupational product consist
of?
[Security data sheet does

not content all information;
inquiry to manufacturer]
C
an the occupational product be patch tested
at all?
[Specialist literature]
Which test concentration is appropriate?
Which test vehicle is appropriate?
Was the pH value of the product controlled?

W
hich individual components of the product
come into question as allergens?
H
ow do I obtain the individual components of
the product?
[Inquiry to manufacturer]
Which test concentrations are appropriate?
Which test vehicle is appropriate?
D
ocumentation of test results (including
vehicle, test concentration, etc.) and feedback
of results to manufacturer
Table 5 Relevant differences in the designation of contact allergens from the

standard series in German versus the mandatory declaration by INCI.
German term
INCI name
Perubalsam
Myroxylon pereirae
Wollwachsalkohole
Lanolin alcohol
Terpentin
Turpentine
Cetylstearyalkohol
Cetearyl alcohol
Dibromodicyanobutan
Methyldibromo glutaronitrile
Lyral
Hydroxyisohexyl 3-cyclohexene carboxaldehyde
Bronopol
2-bromo-2-nitropropane-1.3-diol
Ylang-ylang (I + II) l
Cananga odorata
Sandelholzl
Santalum album
allergen. These are available for patients via open internet websites. As this information also lists rare occurrences or are even outdated, at least an informative
discussion of the realistic contact possibilities is highly recommendable. Anxious
characters otherwise tend to a severe and only sometimes sensible avoidance behavior that can result in drastic effects on the quality of life.
In sensitizations with occupational relevance, expanded knowledge on the occurrence and the legal evaluation is offered by monographs with open access in
the internet (http://abd.dermis.net/content/e03abd/e1046/e1047/index_ger.html).
617
Therapy
Topical corticosteroids are still the
mainstay in the therapy of allergic
contact dermatitis.
An important prerequisite for therapy
success is allergen avoidance.
Short-term pulse therapy with systemic

corticosteroids helps to bring extensive
contact dermatitis rapidly under control.
Alitretinoin cannot be recommended

for the therapy of allergic contact
dermatitis.
An effective protocol for hyposensitization of allergic contact dermatitis is still

not available.
Topical corticosteroids are still the mainstay in the therapy of allergic contact
dermatitis. A broad spectrum of active ingredients of varying potency in diverse
galvanic bases allows in the end for an adaptation to the severity and the location of
the dermatitis. An important prerequisite for therapy success is, however, allergen
avoidance. This demands in the beginning often an unselective avoidance of potential causes and ideally after successful diagnostics the consistent elimination of the
contact substance from the private or occupational surroundings or at least effective
protection measures. If it is not possible to avoid the causative allergen, a satisfactory
and particularly long-lasting treatment success will fail. For this reason the indispensable corticosteroid-free treatment paths for chronic eczema with topical immunomodulators (tacrolimus, pimecrolimus), UV therapies and tar preparations can hardly be employed sensibly. Either it succeeds to eliminate the causes and thus achieve
rapid healing with corticosteroids or a chronic course develops that can hardly be
managed with therapy methods that are weaker in comparison to corticosteroids.
A systemic immunosuppressive therapy is surely rarely indicated. Nonetheless,
there are situations conceivable in which allergen avoidance is impossible or would
lead to a dramatic loss in quality of life. Therapeutic benefits and side effects must
be balanced in such individual cases. Uncomplicated and commonly recommended
is, in contrast, the short-term pulse therapy with systemic corticosteroids. It helps
to bring extensive and especially spreading contact dermatitis under rapid control
and in consistent allergen avoidance will be required for only a short period of time.
Alitretinoin has opened new possibilities in the past years for the therapy of severe,
chronic hand dermatitis. The active agent has, however, not been explicitly tested
for contact allergic dermatitis. Comprehensible experience on efficacy is lacking,
even the impact of alitretinoin on the course of patch testing is open. Alitretinoin
can therefore not be recommended for the therapy of allergic contact dermatitis.
Despite the long tradition of clinical and basic scientific research in the field
of contact allergy, the desire for an effective protocol for hyposensitization, as is
available for some immediate-type sensitizations, has remained unfulfilled. With
the exception of individual experimental approaches to date no validated and
clinically utilizable procedure has been established.
References
1
2
3
4
Correspondence to
Priv.-Doz. Dr. Detlef Becker
Department of Dermatology
University Medicine Mainz
Langenbeckstrae 1
55131 Mainz, Germany
E-mail: detlef.becker@
unimedizin-mainz.de
618
5
6
7
Johansen JD, Frosch PJ, Lepoittevin JP (eds). Contact Dermatitis, 5th edn., Berlin,
Springer, 2011.
Saloga J, Klimek L, Buhl R et al. (eds), Allergologie-Handbuch, 2nd edn., Schattauer,
Stuttgart, 2011.
Brasch J, Becker D, Aberer W et al. Kontaktekzem. Leitlinie der Deutschen
Dermatologischen Gesellschaft. Allergo Journal 2007; 16: 17685.
Diepgen TL, Elsner P, Schliemann S et al. Guideline on the management of hand
eczema ICD-10 Code: L20. L23. L24. L25. L30. J Dtsch Dermatol Ges 2009; 7(Suppl 3):
S116.
Schnuch A, Aberer W, Agathos M et al. Durchfhrung des Epikutantests mit
Kontaktallergenen. J Dtsch Dermatol Ges 2008; 9: 7705.
Martin SF. Allergic contact dermatitis: xenoinflammation of the skin. Curr Opin
Immunol 2012; 24: 110.
Worm M, Aberer W, Agathos M et al. Patch testing in children recommendations of
the German Contact Dermatitis Research Group (DKG). J Dtsch Dermatol Ges 2007; 5:
1079.
Geier J, Weisshaar E, Lessmann H et al. Bewertung von Epikutantestreaktionen auf
Problemallergene mit vermehrt fraglichen oder schwach positiven Reaktionen.
Dermatol Beruf Umwelt 2010; 58: 348.
Lffler H, Becker D, Brasch J et al. Simultaneous sodium lauryl sulphate testing improves the diagnostic validity of allergic patch tests. Results from a prospective multicentre study of the German Contact Dermatitis Research Group (Deutsche Kontaktallergie-Gruppe, DKG). Br J Dermatol 2005; 152: 70919.
10 Dickel H, Altmeyer P, Brasch J. New techniques for more sensitive patch testing? J
Dtsch Dermatol Ges 2011; 9: 88996.
11 Hannuksela M, Salo H. The repeated open application test (ROAT). Contact Dermatitis
1986; 14: 2217.
12 Becker D. Neue Kontaktallergene fr die Epikutantestung: ein Auslaufmodell?
Hautarzt 2009; 60: 225.
13 de Groot AC. Patch testing, acdegroot publishing, Wapserveen, 2008: 1455.
619
Fragen zur Zertifizierung durch die DDA

Welche Aussage ist falsch?
Kontaktallergien sind hufige
Ursachen einer Berufsunfhigkeit.
b) Die Inzidenz des allergischen
Kontaktekzems ist relativ konstant.
c) Eine unzureichende Diagnostik
erschwert die Krankheitskontrolle.
d) Das allergische Kontaktekzem ist
die mit Abstand hufigste
Ekzemerkrankung.
e) Allergische Kontaktekzeme kommen
in allen Altersgruppen vor.
1.
a)
2. Welche Aussage ist falsch?

a) Auf intertriginse Bereiche wirkt
eine groe Zahl potenzieller
Kontaktallergene ein.
b) Allergische Kontaktekzeme sind oft
stark entzndliche Hautreaktionen.
c) Die Lokalisation gibt wichtige
Hinweise auf die mglichen Ursachen.
d) Kontaktsensibilisierungen sind
hufige Komplikationen einer
Stauungsdermatitis.
e) Allergische Reaktionen der
Mundschleimhaut gegen dentale
Werkstoffe sind selten.
3. Welche Aussage ist richtig?

a) Der Epikutantest ist ein berholtes
Verfahren und wird zunehmend
durch In-vitro-Methoden ersetzt.
b) Die Testung weiterer Allergene
auerhalb der Standardreihe ist nur

in begrndeten Ausnahmefllen
ntig.
c) Testempfehlungen fr spezielle
Berufe sind wegen der Heterogenitt der Arbeitspltze nicht sinnvoll.
d) Die Verwendung von Testblcken
ist zugunsten einer individuellen
Zusammenstellung von
Testallergenen abzulehnen.
e) Fr die Epikutantestung von Kindern
gelten gesonderte Testempfehlungen.
4. Welche Aussage ist falsch

a) Die Ablesung der Epikutantest-
Reaktionen erfolgt nach rein
morphologischen Kriterien.
620
b) Eine wenigstens einfach positive

Reaktion gilt als Beweis fr eine
Kontaktsensibilisierung.
c) Ein konstanter Reaktionsverlauf ist
mit einer irritativen, falsch positiven
Testreaktion vereinbar.
d) Aus den Verhltnisse zwischen
irritativen, schwach positiven und
fraglichen Testreaktionen lassen
sich Bewertungsgren fr die
diagnostische Zuverlssigkeit eines
Allergens berechnen.
e) Ein fortlaufendes Training in der Bewertung von Epikutantestreaktionen
verbessert die Qualitt der Diagnostik.
5. Was verstehen Sie unter einem

Problemallergen?
a) eine Substanz, die nach dem Arzneimittelgesetz nicht routinemig
getestet werden darf
b) eine toxikologisch bedenkliche
Testsubstanz
c) eine Testsubstanz, die viele
z weifelhafte, kritisch zu bewertende
Reaktionen auslst
d) ein Kontaktallergen, das sehr s chwere
und lang anhaltende Ekzeme auslst
e) eine Testsubstanz, die trotz b
ekannter
Sensibilisierung hufig falsch negativ
reagiert

a) Natriumlaurylsulfat ist ein seltenes
Kontaktallergen.
b) Bei einer Reaktion gegen 0,25 %
Natriumlaurylsulfat im Epikutantest profitieren Patienten von der
Meidung des Stoffs im Alltag.
c) Der Abrisstest simuliert das Einwirken von Testsubstanzen auf eine
Haut mit gestrter Barrierefunktion.
d) Beim repetitiven offenen Anwendungstest wird eine Testsubstanz
offen auf das vorerkrankte Hautareal
aufgetragen.
e) Der repetitive offene Anwendungstest ist nur fr definierte Einzelallergene geeignet.
7. Welche Aussage ist falsch?

a) Eine mykologische Untersuchung
kann zur Differenzierung der
Ursachen sinnvoll sein.
b) Der Lymphozyten-TransformationsTest ist fr die klinische Routinediagnostik nicht geeignet.
c) Bei Kontraindikationen fr den
Epikutantest kann der LymphozytenTransformations-Test eingesetzt
werden.
d) Mischbilder aus einem atopischen
Ekzem und einem allergischen
Kontaktekzem kommen vor.
e) In diagnostisch schwierigen Fllen
kann histologisch zwischen einer
kontaktallergischen und nicht-
allergischen Ursache des Ekzem
differenziert werden.

a) Die Testung berufsbezogener
Kontaktallergene im Hautarztverfahren wird seit 2010 besser
vergtet.
b) Der Umfang der Epikutantestung
hat in der kassenrztlichen Versorgung in den letzten Jahren erheblich
zugenommen.
c) Kontaktallergene stehen als
Testsubstanzen auerhalb des
Arzneimittelgesetzes.
d) Studien zur Zulassung neuer
Kontaktallergene fr die
Routinediagnostik werden von
Bundesbehrden mit Frdermitteln
untersttzt.
e) Die Testung komplexer Eigensubstanzen kann die Austestung
definierter Einzelsubstanzen
regelhaft ersetzen.
9. Welche Antwort ist falsch?

a) Die Testung von Eigensubstanzen und Arbeitsstoffen erfordert
besondere Sorgfalt und die
Beachtung von Empfehlungen zum
Vorgehen.
b) Die grundstzliche Durchfhrung
von Testungen mit Eigensubstanzen
muss der zustndigen Landesbehrde angezeigt werden.

c) Die Auslsung einer allergischen
Testreaktion durch ein
Testallergen beweist nicht
dessen Relevanz fr das aktuelle
Krankheitsgeschehen.
d) Nur Reaktionen gegen aktuell
relevante Allergene sollten
mit den Patienten errtert werden,
um Missverstndnisse zu
vermeiden.
e) Fr die im Allergiepass dokumentierten Allergene sollten immer auch die
Bezeichnungen nach INCI angegeben werden.
10. Welche Antwort ist falsch?

a) Topische und systemische Kortikoide
sind die Therapie der ersten Wahl
beim allergischen Kontaktekzem.
b) Alitretinoin hat sich als eine
wirksame Behandlungsalternative
fr therapieresistente allergische
Kontaktekzeme erwiesen.
c) Die Meidung urschlicher Allergenkontakte ist ein unverzichtbarer Teil
der Therapie.
d) Eine systemische immunsuppressive
Therapie kann in Ausnahmefllen
ntig sein.
e) Ein wirksames Protokoll zur Hyposensibilisierung einer Kontaktallergie
steht bisher nicht zur Verfgung.
Liebe Leserinnen und Leser,

der Einsendeschluss an die DDA fr diese
Ausgabe ist der 16. August 2013. Die richtige Lsung zum Thema Nagelpsoriasis
eine therapeutische Herausforderung
in Klinik und Praxis in Heft 3
(Mrz 2013) ist: 1c, 2b, 3a, 4c, 5d, 6b, 7d,
8d, 9e, 10d.
Bitte verwenden Sie fr Ihre Einsendung
das aktuelle Formblatt auf der folgenden
Seite oder aber geben Sie Ihre Lsung
online unter http://jddg.akademie-dda.
de ein.
621

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CME Article

Allergic contact dermatitis

Department of Dermatology, University

Allergic contact dermatitis is a frequent inflammatory skin disease. The suspected

CME Article Allergic contact dermatitis

Epidemiological and clinical significance

Clinical findings and differential diagnoses

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Cobalt (II) chloride, 6*H2O

Mercapto mix without MBT (only CBS,

Nickel (II) sulfate, 6*H2O

Paratertiarybutyl phenol formaldehyde resin

Cetyl stearyl alcohol

Sodium lauryl sulfate

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Only erythema, no infiltrate

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Erythema, infiltrate, discrete papules

Single positive reaction

Erythema, infiltrate, papules, vesicles

Double positive reaction

Erythema, infiltrate, confluent vesicles

Triple positive reaction

Soap effect, blister, necrosis

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Disinfectant and preservative

Methylene-bis(methyloxazolidine) Technical preservative

Surface and device disinfectant

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Emulsifier in topical products and fragrance mix

Emulsifier and technical use

Acne medication, polymerization of synthetics

Skin disinfectant, preservative

Preservative in topical ophthalmological

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An online reading training of the

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