Boards Fodder Contact Dermatitis Allergens by Alina Goldenberg, MD, MAS; Elise M

boards fodder Contact Dermatitis Allergens by Alina Goldenberg, MD, MAS; Elise M. Herro, MD; and Sharon E. Jacob, MD

Allergen (Standardized NACDG Allergen Category concentrations) AOY Ranka Common Sources TRUE Test Clinical Pearls

#1 allergen in tested populations. Jewelry, alloys, dentures, orthopedic Reactions can be local, ID, systemic. High point devices, scissors, razors, eating dietary nickel: legumes, chocolate, oat, dark green Nickel 2.5% pet. 2008 1 utensils, electronics (phone, tablets, Y leafy vegetables. Dimethylglyoxime [DMG] test-pink computers), metal buttons, belts, indicator. Clear-coating option may help but prone to metals finishes chipping.

Co-sensitizer with nickel and gold due to frequency of Metals/finishes; vitamin B12; jewelry, use together; blue tattoos. Cobalt 1.0% pet. 14 Y cosmetics, cement Cobalt spot test: disodium-1-nitroso-2-naphthol-3,6- Metals disulfonate

Potassium dichromate Used in leather tanning, green felt, green textiles, 40 Metals/finishes Y 0.25% pet. green tattoos, cement

Direct sensitivity to gold containing items is rare, more common is concomitant contact between gold and Gold sodium thiosulfate Jewelry, electronics, glass frames, titanium dioxide and zinc oxide (such as eyeglasses 2001 - Y Alina 0.5% pet. dental crowns frames or jewelry with sunscreen)-- these harder metals abrade the gold and release sensitizing gold Goldenberg particles.

MD, MAS, is Personal hygiene products (PHP) 8 fragrances: Geraniol, Hydroxycitronellal, perfumes, cinnamon, flavoring a preliminary a-Amylcinnamaldehyde, Eugenol (cloves), Fragrance Mix I 8.0% pet. 2007 2 agents, soaps, detergents, paper Y Cinnamaldehyde, Cinnamyl alcohol, Isoeugenol and internal medicine/ products,, metal working fluids, Evernia prunastri (Oak moss). dermatology resident incense, tobaccos at University of Tree sap from El Salvador; cross reacts with tomatoes Balsam of Peru 25% pet. because of cinnamic alcohol commonality; significant 3 PHP; diaper balm; wound salves Y California, San (Myroxylon.pereirae resin) sources: chocolate, soda, artificial flavors and Diego. benzoates. Fragrance (Citronellol, Hexyl cinnamal, Citral, Fragrance Mix II 14% pet. 8 PHP - Coumarin, Farnesol, Hydroxyisohexyl 3-cyclohexene carboxaldehyde (Lyral) 2.5%)

Fragrances Cinnamic aldehyde 1% pet. - 13 Oral hygiene products/PHP Y^ Component of Fragrance Mix 1 and balsam of Peru

Paper products, magazine gloss, toilet Abeitic acid – allergenic component in glues; pine Colophonium (rosin) seats, make up, adhesives, paints, - 29 Y (conifer) derivative; may cross react with BOP and 20% pet. varnishes; chewing gum, violin bows, propolis, contains coniferyl alcohol. epilation wax

Majantol 5% pet. 39 PHP - Fragrance

Ylang-ylang oil 2% pet. - 52 PHP - Fragrance

Limonene 2% pet. - 70 PHP; cleaning supplies - Fragrance Elise M. Herro, Eugenol 1% pet. - - PHP; dental products; cloves Y^ Balsam of Peru derivative, Fragrance Mix 1 component MD, is health Baby wipes, moist toilet tissue, sciences clinical MCI/MI 0.01% aq = 100 leather couch wipes, shampoo, lotion, 40% of MI allergy missed when only test with MCI/ ppm aq (aka Kathon CG) 2013 4 Y cosmetics, airborne associated with MI mix instructor, clinician- h aq. educator track, latex paint Iodopropyl butyl carbamate in the division - 12 Baby wipes, cosmetic products, PHP - Under regulation in cosmetic products in New Zealand of dermatology, 0.1% pet.

department of Methyldibromoglutaro Preservative in paper products (paper Industrial exposures include: cutting oils, coolants nitrile + Phenoxyethanol - 16 Y# medicine, UCLA. towels), ultrasound gels, PHP and adhesives (Euxyl K400) 1% pet. NON-FRP (Formaldehyde Preservative in creams, lotions, and “paraben paradox” – aka only reactive on involved skin Paraben mix 12% pet. - 22 Y Releasing foods - patch test on normal skin (-) Preservative) Antifungals, antibacterials, topical Quinoline mix 190 mcg/ - - antibiotic and antifungal creams, Y Clioquinol and Chlorquinaldol cm2 lotions, ointments, paste bandages

Mercurcial preservatives, until recently was found Cosmetic preservative, vaccines, Thimerosal 7mg/cm2 or in a number of vaccines. Significant # of irrelevant 2002 - mercurial contact lens solution, Y 0.1% pet. reactions (aka “non-allergen” of the year award). tuberculin skin test Cross-reacts with piroxicam.

Propyl Gallate 0.5% pet. - - PHP, lubricants, foods -

Contact urticarial and DTH reported; CO-reacts (NOT Sharon E. Bacitracin 20% pet. 2003 10 Component of triple antibiotic Y Jacob, MD, is cross-react) with neomycin.

associate professor Component of triple antibiotic; Cross reacts with gentamycin, tobramycin. Neomycin 20% pet. 2010 17 Y aminoglycoside CO-reacts with bacitracin. of dermatology, Antibiotics Loma Linda Carbolated Vaseline, Cooling fluids, University. Chloroxylenol (4-chloro- - 56 PHP, Disinfectants, EKG paste, - 3.5-xylenol) 1% pet. Surgical Scrubs

p. 1 • Summer 2017 www.aad.org/DIR boards fodder Contact Dermatitis Allergens by Alina Goldenberg, MD, MAS; Elise M. Herro, MD; and Sharon E. Jacob, MD

Allergen Allergen (Standardized NACDG TRUE Category concentrations) AOY Ranka Common Sources Test Clinical Pearls

#1 cause hand dermatitis FRP Quaternium-15 2% pet. - 5 Y Not allergic patients have a cross-reactivity with latex paints, topics meds, adhesives formaldehyde

Embalming/preserving fluid, aspartame, pressed wood, industrial metal working fluids and coolants, glues, inks, toners, paints, cleaning agents, waxes and polishes, Reactions can be local, ID, systemic. Aspartame may Formaldehyde 1% aq. 2015 7 Y cosmetics, PHP, durable press trigger systemic response (wrinkle-resistant) fabrics, cleaning products, tobacco and cigarette smoke, smoke from wood, coal, kerosene, or charcoal fires.

Formaldehyde and FRPs Diazolidinyl urea 1% pet. - 20 FRP Y Cosmetics; lotions

DMDM hydantoin 1% pet. - 23 FRP Y Hand soaps; lotions

Bronopol (2-Bromo- 2nitropropane-1,3-diol) - 26 FRP Y Baby wipes 0.5% pet.

Cleansers,PHP, cosmetics, burn Imidazolidinyl urea 2% pet. - 28 Y #1 FRP in medicaments; used in cosmetics remedies

PABA-back bone, may cross react with disperse Antioxidant – used as hair dye Paraphenylenediamine dyes, hydrochlorothiazide, ester anesthetics, 2006 6 -inks, photodeveloping solutions, Y (PPD) 1% pet. sulfonamides, azo and aniline dyes, sulfonamides, textile dyes, henna tattoos para-aminosalicylic acid

Glyceryl thioglycolate (GTG) - - Permanent wave solutions - “Acid” permanent waves solution 1% pet.

Hair Care

Ammonium persulfate - - Hair bleach, western blot - Oxidizing agent 2.5% pet.

Ammonium thioglycolate ‘Allergy often assumed, but rarely if ever, proven’. - - Perm salt used in perm-ing hair - 1% aq. Cross- reaction with GTG rare. May cause ICD.

Carba mix 3% ( includes: zinc Rubber accelerator (eg: vulcanizes “Thio” in name indicates the sulfa bonds to vulcanize. diethyldithiocarbamate, - 11 liquid latex to solid rubbery product, Y Used in underpants – “do not bleach” due to bleached zinc through sulfide bonds) rubber syndrome. dibutyldithiocarbamate, Diphenylguanidine) pet.

Rubber accelerator -prevents degradation in rubber Thiuram mix 1% pet. - 18 products, latex, adhesives, pesticides, Y Significant glove-hand dermatitis association medications -condoms, diaphragms, repellents

BRM (includes: N-phenyl-N’ isopropyl p-phenylenediamine, PABA-back bone, may cross react with disperse dyes, N-phenyl-N’ cyclohexyl- Aka black rubber mix, antioxidant - 45 Y hydrochlorothiazide, ester anesthetics, sulfonamides; phenylenediamine, used in rubber materials hair dressers at risk and N,N’ diphenyl- Rubber Additives phenylenediamine) 0.6% pet.

Mixed dialkyl thioureas Rubber accelerator, one of the 2009 48 - Neoprene is Thiourea + PTBFR 1% pet. neoprene cement allergens

2-Mercaptobenzothiazole - 58 Rubber accelerator Y Significant cause of shoe-foot dermatitis 1% pet.

Mercapto mix 1% (4-morpholinyl-2- benzothiazyl disulfide, Rubber accelerator Surgeons, nurses, dentists, hairdressers at risk for N-cyclohexyl-2- - 61 Y occupational exposure benzothiazolesulfenamide, 2,2-benzothiazyl disulfide) pet.

p. 2 • Summer 2017 www.aad.org/DIR boards fodder Contact Dermatitis Allergens by Alina Goldenberg, MD, MAS; Elise M. Herro, MD; and Sharon E. Jacob, MD

Allergen Allergen (Standardized NACDG TRUE Category concentrations) AOY Ranka Common Sources Test Clinical Pearls

Emollients, cosmetics, adhesives, From sheep sebum; allergenic component amerchol; Lanolin alcohol 50% topical medications, polishes, soaps, biologic variability may get “lanolin paradox” – aka only - 9 Y (wool wax alcohols) pet. printing inks, and textiles. reactive on involved skin - patch test on normal skin (-) --common allergen in leg ulcers

Solvent, emulsifier, preservative, May also be an irritant; systemic reaction due to oral Propylene glycol 30% aq. - 15 vehicle, humectant and/or penetration medication or food ingestion reported enhancer, medicaments, foods

Oleamidopropyl betaine - 21 PHP - 1% pet.

Cocamidopropyle betaine Surfactant chemical – used in no more Amido amine, 3-(dimethylamino) propylamine (DMAPA) 2004 24 - (CAPB) 1% aq. tear ingredient may be the true allergens

Dimethylaminopropylamine Manufacturing component for CAPB – may be a - 27 CAPB-component - (DMAPA) 1% pet. contaminant allergen post production

Cosmetics, polishes, coating for From secretions of Laccifer lacca (formerly Coccus Shellac 20% pet. - 31 medications, fruit, candies and dental - lacca), which feeds on varnish certain trees in southern Asia.

CAPB component found in: body Vehicle and Amidoamine washes; conditioners; cosmetics; hair Manufacturing component for CAPB – may be a PHP/cosmetic (stearamidopropyl - 33 - detanglers; hair dyes; shampoos; contaminant allergen post production ingredients dimethylamine) 0.01%h aq. soaps

Dl alpha tocopherol 100% - 36 Vitamin E - #2 allergen in sunscreen; used in PHP

Cocamide DEA (coconut PHP, especially shampoos, hand- - 37 - diethanolamide) 0.5% pet washing liquids and body washes.

Decyl glucoside 5% pet. - 44 PHP - Surfactant

Spearmint oil: toothpaste, chewing Carvone 5% pet. - 50 - gum; mandarin orange peels

Preservative used in PHP and Balsam of Peru-derivative – used in fragrance Benzyl alcohol 10% pet. - 57 - medicaments free products as a preservative; cross reacts with

Ethylenediamine Stabilizer, emulsifier and preservative, X-reacts with piperazine antihistamines aminophylline - 59 Y dihydrochloride 1% pet. used in some mycology formulations & hydroxyzine

Benzalkonium chloride Preservative, used in hand wipes, hand - - - In toilettes (wipes) 0,1% pet. sanitizers, Spermicidal creams

Tixocortol-21-pivalate Screening agent for hydrocortisone type (OTC) steroids; 19 Group A Y 1% pet. prednisone group

Triamcinolone and Budesonide often used for screening Budesonide 0.1% pet. 42 Group B Y of group B, because budesonide specifically can cross react with D2 steroids

Corticosteroids Clobetasol-17-propionate 2005 65 Group D1 - 1% pet.

Hydrocortisone-17- Cross-reacts with Group A 68 Group D2 Y butyrate 1% pet.

Do not cross-react with each other, thus considered Desoximetasone 1% pet. 69 Group C - more “hypoallergenic”

2-Hydroxyethyl methacrylate 2012 30 Artificial nails, dental work - (HEMA) 2% pet.

Bisphenol A epoxy resin Glues, coating for steel, cars, electrical - 35 Y 1% pet. insulation, some plastics, vinyl

Exterior latex house paint, dental Methyl methacrylate - 46 restorations, adhesive cements and - Dental technicians, artificial nails 2% pet. surgical bone implants.

Plastics and Glues Resins, plastics, rubber, and denture Ethyl acrylate 0.1% pet. - 51 - material

p-tertbutyl formaldehyde Adhesive in leather/rubber products Neoprene cement chemical; cross-reacts with - 62 Y resin (PTBFR) 1% pet. and neoprene formaldehyde; may cause depigmentation

Ethyl-2-cyanoacrylate Liquid bandages & for suture-less - 66 - 10% pet. surgery

Tosylamide/formaldehyde Tosylamide (toluene sulfonamide is the main allergen - 47 Nail polish - resin 10% pet. over the formaldehyde resin)

p. 3 • Summer 2017 www.aad.org/DIR boards fodder Contact Dermatitis Allergens by Alina Goldenberg, MD, MAS; Elise M. Herro, MD; and Sharon E. Jacob, MD

Allergen Allergen NACDG Category (Standardized AOY Common Sources TRUE Clinical Pearls Ranka concentrations) Test

Pro-before, Polis- the city. Lines the channels into the Propolis 10% pet. - 32 ‘Organic’ cosmetics; gummy vitamins - beehive (combination of beeswax, plant extracts and bee saliva).

The Compositae family refers to plants in which the flower heads are a composite of individual flowers. PHP, Teas, Group of plants; leaf/stem/ (Asteraceae: flowerheads are star-shaped (aster is flower (Tanacetum vulgare, Arnica Greek for star)--20,000 species of flowers, herbs, Compositae mix 6% pet. - 34 montana, Parthenolide, Chamomilla - Compositae weeds and vegetables (including asters, daisies and romana, and Achillea millefolium). sunflowers) account for 10% of all flowering plants. (Chrysanthemum, daisy, echineacea, thistle, feverfew, ragweed, artichoke, tansy, endive).

PHP Alantolactone, dehydroxosus lactone, costunolide Sesquiterpene lactone mix - 55 Compositae plants: oleoresin fraction - (SQL) 0.1% pet. Florists and gardeners; cross-reactors: parthenolide, of leaf, stem, flower and possibly in compositae mix, propolis. the pollen

Used on the commercially available patch test device in lieu of SQL. Natural remedies and supplements Parthenolide 3 mcg/cm2 - - Y Naturally found in the flowers and fruit of the plant, feverfew (Tanacetum parthenium); relief of migraines and blood clots; anti-inflammatory for the relief of arthritis and as a digestive aid.

Lidocaine hydrochloride - 49 Amide anesthetic - Paraben preservative reported to cause allergy in 15% pet. association with this medication.

PABA-derivative, basis for ester anesthetics cross- Benzocaine 5% pet. - 54 Ester anesthetics Y^ reactions; caine mix includes: benzocaine, tetracaine, and dibucaine. Dibucaine is an amide. Anesthetics

Dibucaine (cinchocaine- - 63 Amide anesthetic Y^ Hcl) 2.5% pet.

Tetracaine 2% pet. or 630 - - Ester anesthetic Y^ mcg/cm2

Highly sensitizing resin oil/black dot dermatitis (black Poison ivy (toxicodendron - Leaves of 3+ let them be - lacquer-like substance forms on skin after exposure radican) - of resin to air).

Poison sumac - - “ (toxicodendron vernix) -

Poison oak (toxicodendron quercifolium and - - - “ toxicodendron diversilobum)

Leaves, bark, stems and skin of Mango (Mangifera indica) - - “ - mango contain uroshiol

Viscous bark sap used for varnishing Japanese Lacquer tree - furniture, floors, wooden toilets, - Varnish; stays allergenic for >100 years! (Toxicodendron verniciflua) - ornaments

Uroshiol Ginkgo biloba* Cross-reacts with poison ivy and poison oak. Oldest (Toxicodendron (Ginkgoaceae) - Pulp and seed kernel - - tree known (fossils date 200 million years old). genus (maidenhair tree) Anacardiaceae)

Indian Marking nut Black juice of the tree is mixed with Dhobie Mark dermatitis (Indian laundry workers are (Semecarpus anacardium) - - - alum to mark laundry in India dhobies). (bhilawa tree)

The oil is an occupational sensitizer mechanics; Cashew (Anacardium urushiol, containing cardol and ancardic acid, is found - Shell oil contains cardol - occidentale) - in cashew nut shell oil; resorcinol cardol is both an irritant and an allergen.

Florida Holly/Brazilian Pepper Tree (Schinus - - Tree bark and berries - Common cause of ACD in southern Florida terebinthifolius)

Pistachio - - Cross-reacts to cashew nut (Pistacia vera) -

Pepeo tree - - ACD and ICD (Mauria puberula) -

p. 4 • Summer 2017 www.aad.org/DIR boards fodder Contact Dermatitis Allergens by Alina Goldenberg, MD, MAS; Elise M. Herro, MD; and Sharon E. Jacob, MD

Allergen Allergen NACDG Category (Standardized AOY Common Sources TRUE Clinical Pearls Ranka concentrations) Test

Melaleuca alternifolia (tea Co-reactions/cross-reactions to d-limonene (a - 41 Used as an anti-inflammatory in PHP - tree leaf oil) oxidized fragrance) and turpentine have been reported.

Lavandula angustifolia oil - 60 Used as an anti-inflammatory in PHP - Massage therapists at risk (lavender oil) 2%

Jasiminum officinale oil (J. - 64 PHP, massage oils, aromatherapy - grandiflorum) 2% pet.

M. piperita oil (peppermint - 67 PHP, aromatherapy - oil) 2% pet.

Lichen (d-usnic acid , - - Cosmetics, PHP - evenic acid)

Celery, dill, fig, lime, bergamot orange Phytophotodermatitis (berloque dermatitis) parsley, parsnip, Furocoumarin - - - (Apiaceae, Rutaceae, Moraceae, Leguminosae; meadow grass, hogweed (strimmer psoralens) dermatitis)

St. John’s wort - - - Hypericaceae Family Other plants “daffodil itch” is an irritant contact dermatitis seen in Daffodil (Narcissus spp, - - Sap contains calcium oxalate crystals - flower pickers, packers, florists and gardeners; similar Amaryllidaceae) chemical found in “dumb cane”.

Allyl isothiocyanate - - Mustard, radish - Bakers with hand dermatitis; Thiocyanate is an irritant. Brassicaceae

Diallyl disulfide - - Onions, garlic, leeks, chives (bulbs) - Alliaceae Family

Peruvian Lily (Tulipalin A, tulliposide A) Liliaceae has tulipalin A/B (ACD) and calcium oxalate Peruvian lily stem and tulip bulb (Alstromeriaceae) and - - - (ICD) – leads to combined ACD and ICD called “tulip respectively Tulip (Tulipalin A/B) fingers”. (Liliaceae)

Primula obconica May be direct contact, indirect or airborne dermatitis. - - Primin on leaves, stems, flowers - (Primulaceae) Primin-free Primula obconica has been developed

Castor Oil Plant (Ricinus PHP - Castor oil is contact irritant communis) Seeds contain ricin (poisonoius)

Oxybenzone 10% pet. Photocontact dermatitis; low prevalent allergen; risk (benzophenone-3 of hormone disruption reported in animal studies; & 2-hydroxy-4- 2014 38 Sunscreen ingredient - most common sunscreen agent to cause photoallergic methoxybenzophenone) contact dermatitis; cross-reacts with other aminoglycosides often co-reacts with bacitracin. Sunscreens Cross reacts with paraphenylene diamine, ester Padimate O (PABA) 5% pet. - - Sunscreen - anesthetics, disperse dyes.

Sulisobenzone/ - - Sunscreen - benzophenone -4 10% pet.

Carmine 2.5% pet. - 25 Food dye -

Cross-reacts with PABA based chemicals Disperse blue mix 124/106 Clothing dyes used on synthetics 2000 43 Y# (paraphenylene diamine); only disperse blue 106 on 1% pet. (nylon, polyesters, blends) TRUE

Glutaraldehyde (Glutaral) - 53 Cold sterilizer - Cross-reacts with formaldehyde Other 1% pet.

Bleaching agent in flour, acne Benzoyl peroxide 1% pet. - - - medication

Anti-yeast/bacterial agent used in Dimethyl fumarate 0.001% 2011 - sachets to prevent molding of wares - Shoes, sofas, and garments pet. during shipping

ABBREVIATIONS: ACD: allergic contact dermatitis; aq: aqueous; AOY: “Allergen of the Year” is an ACDS “award” reviewed annually in Dermatitis; ICD: irritant contact dermatitis; FRP: formaldehyde releasing preservative; MCI/MI: Methylchloroisothiazolinon; PABA: para-aminobenzoic acid; pet: petrolatum; PHP: personal hygiene products; SQL: Sesquiterpene lactone. ANNOTATIONS: [a] Based on Table 8 Significance-Prevalence Index Number from Warshaw et al. Dermatitis, 2015; 26:56-57. Dermatitis, 2015; 26: 56-57; [h] also in category of “Hair Care”; [Y^] included in a mix; [Y#] MDBGN on TRUE, PE is not; Disperse blue 106 on TRUE, not 124. REFERENCE: 1. Jacob SE, Herro EM. Practical Patch Testing and Chemical Allergens in Contact Dermatitis. London, England: Springer-Verlag; 2013. 2. Warshaw EM1, Maibach HI, Taylor JS, Sasseville D, DeKoven JG, Zirwas MJ, Fransway AF, Mathias CG, Zug KA, DeLeo VA, Fowler JF Jr, Marks JG, Pratt MD, Storrs FJ, Belsito DV. North American contact dermatitis group patch test results: 2011-2012. Dermatitis. 2015 Jan-Feb;26(1):49-59. AFFILIATIONS: Alina Goldenberg MD, MAS is a Preliminary Internal Medicine/Dermatology resident at University of California, San Diego; Elise Herro, MD is the Health Sciences Clinical Instructor, Clinician-Educator track, in the Division of Dermatology, Department of Medicine, UCLA., and Sharon E. Jacob, MD, Associate Professor of Dermatology, Loma Linda University. DISCLOSURE: SEJ is a member of the ACDS Education Committee.This committee has developed a lecture series for the ACDS aimed at practical knowledge and boards review. Available at www.contactderm.org. EH and AG have nothing to declare. Table Reviewed by the Executive Committee of the American Contact Dermatitis Society June 5, 2015.

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