Article Type
Article
Changed
Thu, 12/12/2019 - 10:56
Author(s)
Jennifer M. Tran, BA
Amber Reck Atwater, MD
Margo Reeder, MD

The pediatric population has a unique product exposure profile due to the many care products specifically marketed for use in children. In fact, the prevalence of allergic contact dermatitis (ACD) in children may be as high as 24.5% in the United States.1 In patch tested children, relevant positive reaction rates of 56.7% and 48% have been reported by the North American Contact Dermatitis Group and the Pediatric Contact Dermatitis Registry, respectively.2,3 In this article, we provide an overview of current trends in pediatric patch testing as well as specific considerations in this patient population.

 

Patch Test Reactions in Children

Several publications have documented pediatric patch test reactions. The North American Contact Dermatitis Group reported patch test results in 883 children from the United States and Canada (2005-2012).2 The most common reactions were nickel (28.1%), cobalt (12.3%), neomycin (7.1%), balsam of Peru (5.7%), lanolin (5.5%), and fragrance mix I (5.2%). When compared to adults, children were more likely to have relevant positive patch tests to nickel, cobalt, and compositae mix.2 In comparison, data from the Pediatric Contact Dermatitis Registry showed that the most common reactions in 1142 children in the United States (2015-2016) were nickel (22%), fragrance mix I (11%), cobalt (9.1%), balsam of Peru (8.4%), neomycin (7.2%), and propylene glycol (6.8%).3

Allergen sensitivities may vary based on geographic region. In Spain, children showed the highest sensitivities to thiomersal (10.2%), cobalt (9.1%), colophony (9.1%), paraphenylenediamine (8.3%), mercury (7.9%), potassium dichromate (7.9%), and nickel (6.4%).4

Pediatric Patch Testing Pearls

History of Product Use
From diapers to drama club, pediatric exposures and sources of ACD are not the same as those seen in adults. Because obtaining a medical history from a toddler can be exasperating, the patient’s caregivers should be asked about potential exposures, ranging from personal care products and diapers to school activities, hobbies, and sports.5,6 It is important to keep in mind that the patient’s primary caregiver may not be the only individual who applies products to the child.7

Application of Allergens
Children are not merely small adults, but they usually do have smaller backs than adult patients. This reduced surface area means that the patch tester must carefully select the allergens to be patch tested. For reference, the back of a typical 6-year-old child can fit 40 to 60 allergens during patch testing.8

Patch Test Chambers
In children, the use of plastic patch test chambers may be preferred over aluminum chambers. Children with persistent pruritic subcutaneous nodules induced by aluminum-based vaccines also may have delayed-type sensitivity reactions to aluminum.9 These patients could react to the aluminum present in some patch test chambers, making interpretation of the results difficult. The authors (A.R.A. and M.R.) typically use plastic chambers in the pediatric population.

Managing Expectations
As with other procedures in the pediatric population, patch testing can elicit emotions of fear, anxiety, and distrust. Video distraction and/or role-playing games may help capture the attention of children and can be particularly helpful during patch application. Children may be apprehensive about the term allergy testing if they are familiar with the term needle testing from previous allergies.5

Securing Patches
Young children can be quite active, posing another challenge for keeping patches in place. We recommend using extra tape to secure the patches in place on a child’s back. In addition, a large transparent film dressing (ie, 12×8 in) can be used if quick application is needed. For extra precaution, the use of a tight T-shirt or favorite onesie during the patch test process may be helpful, making it more difficult for little fingers to remove tape edges.



Duration of Patch Testing
Some authors have proposed application of patch tests for 24 hours in pediatric patients, as compared to 48 hours in adults.10 This recommendation is based on a theory that the reduced application period will decrease the risk for irritant reactions in pediatric patients.

 

 

Pediatric Patch Test Screening Series

A summary of the published screening series for patch testing in the pediatric population is provided (Table).

The T.R.U.E. Test (SmartPractice) is approved by the US Food and Drug Administration for use in patients 6 years and older11; however, it may not adequately represent allergen exposures in the pediatric population. Brankov and Jacob14 found that 10 (40%) of their proposed top 25 pediatric allergens were not detected using the T.R.U.E. Test.



In 2014, the North American Pediatric Patch Test Series was proposed as a basic screening panel for children aged 6 to 12 years.12 This series of 20 allergens was developed based on a literature review of pediatric patch test results and case reports as well as a database review. The authors proposed additional allergens to be considered based on patient history.12

More recently, a 2017 American Contact Dermatitis Society physician work group proposed the Pediatric Baseline Patch Test Series. This series of 38 allergens for children aged 6 to 18 years was developed based on expert consensus.8 Studies to determine the efficacy of this series have yet to be conducted, but it may have high sensitivity in detecting relevant allergens in children as demonstrated by a theoretical detection rate of 84%.14

There are 2 recommended patch test series for allergic diaper dermatitis.15 The first series focuses on 23 potential allergens found in wet wipes and topical diaper preparations. The second series contains 10 potential allergens found in diapers. These series contain common topical medications for children including corticosteroids, antimicrobials, and sensitizers specific to diapers such as rubbers and adhesives.15

Similar to adults, it may be difficult to designate one screening panel that can identify all relevant allergens in children; thus, it is always important to obtain a thorough exposure history and customize testing to suspected allergens and/or patient products based on history and clinical relevance.

Unique Pediatric Allergens

Hobbies
Sports gear such as shin guards and splints often contain allergens such as formaldehyde resin, thiuram mix, and dialkyl thioureas.16 Perioral dermatitis may be caused by musical instrument mouthpieces containing nickel.6

Preservatives
Commonly reported causes of ACD in children include methylisothiazolinone (MI) and methylchloroisothiazolinone (MCI) found in wet wipes. A 2016 analysis of diaper wipes showed a low prevalence of MI (6.3%) and MCI (1.6%) in these products, which may reflect the industry’s awareness of these potential allergens and a subsequent change in the preservatives they utilize.17 However, the prevalence of MCI/MI contact allergy may be on the rise due to the popularity of homemade slime, which is made from common household products such as laundry detergent, dishwashing soap, and liquid glue. The Pediatric Baseline Patch Test Series captures most of the potential allergens in these homemade slime recipes and is recommended for use in pediatric patients suspected of having dermatitis secondary to playing with slime.8,18

Toilet Seat Dermatitis
Toilet seat dermatitis presents as a pruritic dermatitis on the posterior upper thighs and buttocks. Although most cases of toilet seat dermatitis are irritant rather than allergic, potential allergens include plastics, fragrances, and components of cleaning products. Thus, physicians should maintain a high index of suspicion for ACD to toilet seats.19

Fragrance and Natural Ingredients
A 2018 study evaluating personal care products marketed specifically for infants and children found that 55% of products (294/533) contained at least 1 common allergen, with fragrance being the most common (48% [255/533]). Other common allergens include betaines (18%), propylene glycol (9%), lanolin (6%), and MCI/MI (3%).20 Caregivers should be advised against the myth that natural products are safer and less allergenic and should be provided with resources such as the Contact Allergen Management Program (CAMP) database (https://www.contactderm.org/resources/acds-camp) for safe alternative personal care products.



Metal Allergens
Nickel, the American Contact Dermatitis Society 2008 Allergen of the Year, is another common allergen that affects children. Nickel allergy, commonly thought to affect the ears due to jewelry and ear piercing, may actually be found in a wide range of daily items such as braces, eyeglasses, keys, zippers, school chairs, electronics, toys, and even food.3,6,21,22 With increased use of electronics in children of all ages, nickel found in mobile phones and other devices may be of particular concern. Caregivers can use a case or cover for metallic-appearing electronics.

Final Interpretation

Pediatric ACD is common. With limited surface area for patch testing in children, we recommend customized panels based on patient history and exposure. It is important for clinicians to recognize the unique causes of ACD in children and develop age-appropriate management plans.

References
  1. Bruckner AL, Weston WL, Morelli JG. Does sensitization to contact allergens begin in infancy? Pediatrics. 2000;105:e3.
  2. Zug KA, Pham AK, Belsito DV, et al. Patch testing in children from 2005 to 2012: results from the North American contact dermatitis group. Dermatitis. 2014;25:345-355.
  3. Goldenberg A, Mousdicas N, Silverberg N, et al. Pediatric Contact Dermatitis Registry inaugural case data. Dermatitis. 2016;27:293-302.
  4. Ortiz Salvador JM, Esteve Martinez A, Subiabre Ferrer D, et al. Pediatric allergic contact dermatitis: clinical and epidemiological study in a tertiary hospital. Actas Dermosifiliogr. 2017;108:571-578.
  5. Jacob SE, Steele T, Brod B, et al. Dispelling the myths behind pediatric patch testing—experience from our tertiary care patch testing centers. Pediatr Dermatol. 2008;25:296-300.
  6. Brod BA, Treat JR, Rothe MJ, et al. Allergic contact dermatitis: kids are not just little people. Clin Dermatol. 2015;33:605-612.
  7. Elliott JF, Ramzy A, Nilsson U, et al. Severe intractable eyelid dermatitis probably caused by exposure to hydroperoxides of linalool in a heavily fragranced shampoo. Contact Dermatitis. 2017;76:114-115.
  8. Yu J, Atwater AR, Brod B, et al. Pediatric Baseline Patch Test Series: Pediatric Contact Dermatitis Workgroup. Dermatitis. 2018;29:206-212.
  9. Bergfors E, Inerot A, Falk L, et al. Patch testing children with aluminium chloride hexahydrate in petrolatum: a review and a recommendation. Contact Dermatitis. 2019;81:81-88.
  10. 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;5:107-109.
  11. T.R.U.E. Test (Thin-Layer Rapid Use Epicutaneous Patch Test) [package insert]. Hillerød, Denmark: SmartPractice Denmark ApS; 2017.
  12. Jacob SE, Admani S, Herro EM. Invited commentary: recommendation for a North American pediatric patch test series. Curr Allergy Asthma Rep. 2014;14:444.
  13. Castanedo-Tardana MP, Zug KA. Methylisothiazolinone. Dermatitis. 2013;24:2-6.
  14. Brankov N, Jacob SE. Pre-emptive avoidance strategy 2016: update on pediatric contact dermatitis allergens. Expert Rev Clin Immunol. 2017;13:93-95.
  15. Yu J, Treat J, Brod B. Patch test series for allergic perineal dermatitis in the diapered infant. Dermatitis. 2017;28:70-75.
  16. Sung CT, McGowan MA, Jacob SE. Allergic contact dermatitis evaluation: strategies for the preschooler. Curr Allergy Asthma Rep. 2018;18:49.
  17. Yu J, Treat J, Chaney K, et al. Potential allergens in disposable diaper wipes, topical diaper preparations, and disposable diapers: under-recognized etiology of pediatric perineal dermatitis. Dermatitis. 2016;27:110-118.
  18. Anderson LE, Treat JR, Brod BA, et al. “Slime” contact dermatitis: case report and review of relevant allergens. Pediatr Dermatol. 2019;36:335-337.
  19. Dorfman CO, Barros MA, Zaenglein AL. Contact dermatitis to training toilet seat (potty seat dermatitis). Pediatr Dermatol. 2018;35:e251-e252.
  20. Bonchak JG, Prouty ME, de la Feld SF. Prevalence of contact allergens in personal care products for babies and children. Dermatitis. 2018;29:81-84.
  21. Chen JK, Jacob SE, Nedorost ST, et al. A pragmatic approach to patch testing atopic dermatitis patients: clinical recommendations based on expert consensus opinion. Dermatitis. 2016;27:186-192.
  22. Goldenberg A, Silverberg N, Silverberg JI, et al. Pediatric allergic contact dermatitis: lessons for better care. J Allergy Clin Immunol Pract. 2015;3:661-667; quiz 668.
Article PDF
Atwater November 2019 CT10400528.PDF
Author and Disclosure Information

Ms. Tran and Dr. Reeder are from the Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison. Dr. Atwater is from the Department of Dermatology, Duke University School of Medicine, Durham, North Carolina.

The authors report no conflict of interest.

Correspondence: Margo Reeder, MD, One S Park St, 7th Floor, Madison, WI 53715 (mreeder@dermatology.wisc.edu).

Issue
Cutis - 104(5)
Publications
MDedge Dermatology
Cutis
Topics
Contact Dermatitis
Pediatrics
Page Number
288-290
Sections
Contact Dermatitis
Author(s)
Jennifer M. Tran, BA
Amber Reck Atwater, MD
Margo Reeder, MD
Author(s)
Jennifer M. Tran, BA
Amber Reck Atwater, MD
Margo Reeder, MD
Author and Disclosure Information

Ms. Tran and Dr. Reeder are from the Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison. Dr. Atwater is from the Department of Dermatology, Duke University School of Medicine, Durham, North Carolina.

The authors report no conflict of interest.

Correspondence: Margo Reeder, MD, One S Park St, 7th Floor, Madison, WI 53715 (mreeder@dermatology.wisc.edu).

Author and Disclosure Information

Ms. Tran and Dr. Reeder are from the Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison. Dr. Atwater is from the Department of Dermatology, Duke University School of Medicine, Durham, North Carolina.

The authors report no conflict of interest.

Correspondence: Margo Reeder, MD, One S Park St, 7th Floor, Madison, WI 53715 (mreeder@dermatology.wisc.edu).

Article PDF
Atwater November 2019 CT10400528.PDF
Article PDF
Atwater November 2019 CT10400528.PDF

The pediatric population has a unique product exposure profile due to the many care products specifically marketed for use in children. In fact, the prevalence of allergic contact dermatitis (ACD) in children may be as high as 24.5% in the United States.1 In patch tested children, relevant positive reaction rates of 56.7% and 48% have been reported by the North American Contact Dermatitis Group and the Pediatric Contact Dermatitis Registry, respectively.2,3 In this article, we provide an overview of current trends in pediatric patch testing as well as specific considerations in this patient population.

 

Patch Test Reactions in Children

Several publications have documented pediatric patch test reactions. The North American Contact Dermatitis Group reported patch test results in 883 children from the United States and Canada (2005-2012).2 The most common reactions were nickel (28.1%), cobalt (12.3%), neomycin (7.1%), balsam of Peru (5.7%), lanolin (5.5%), and fragrance mix I (5.2%). When compared to adults, children were more likely to have relevant positive patch tests to nickel, cobalt, and compositae mix.2 In comparison, data from the Pediatric Contact Dermatitis Registry showed that the most common reactions in 1142 children in the United States (2015-2016) were nickel (22%), fragrance mix I (11%), cobalt (9.1%), balsam of Peru (8.4%), neomycin (7.2%), and propylene glycol (6.8%).3

Allergen sensitivities may vary based on geographic region. In Spain, children showed the highest sensitivities to thiomersal (10.2%), cobalt (9.1%), colophony (9.1%), paraphenylenediamine (8.3%), mercury (7.9%), potassium dichromate (7.9%), and nickel (6.4%).4

Pediatric Patch Testing Pearls

History of Product Use
From diapers to drama club, pediatric exposures and sources of ACD are not the same as those seen in adults. Because obtaining a medical history from a toddler can be exasperating, the patient’s caregivers should be asked about potential exposures, ranging from personal care products and diapers to school activities, hobbies, and sports.5,6 It is important to keep in mind that the patient’s primary caregiver may not be the only individual who applies products to the child.7

Application of Allergens
Children are not merely small adults, but they usually do have smaller backs than adult patients. This reduced surface area means that the patch tester must carefully select the allergens to be patch tested. For reference, the back of a typical 6-year-old child can fit 40 to 60 allergens during patch testing.8

Patch Test Chambers
In children, the use of plastic patch test chambers may be preferred over aluminum chambers. Children with persistent pruritic subcutaneous nodules induced by aluminum-based vaccines also may have delayed-type sensitivity reactions to aluminum.9 These patients could react to the aluminum present in some patch test chambers, making interpretation of the results difficult. The authors (A.R.A. and M.R.) typically use plastic chambers in the pediatric population.

Managing Expectations
As with other procedures in the pediatric population, patch testing can elicit emotions of fear, anxiety, and distrust. Video distraction and/or role-playing games may help capture the attention of children and can be particularly helpful during patch application. Children may be apprehensive about the term allergy testing if they are familiar with the term needle testing from previous allergies.5

Securing Patches
Young children can be quite active, posing another challenge for keeping patches in place. We recommend using extra tape to secure the patches in place on a child’s back. In addition, a large transparent film dressing (ie, 12×8 in) can be used if quick application is needed. For extra precaution, the use of a tight T-shirt or favorite onesie during the patch test process may be helpful, making it more difficult for little fingers to remove tape edges.



Duration of Patch Testing
Some authors have proposed application of patch tests for 24 hours in pediatric patients, as compared to 48 hours in adults.10 This recommendation is based on a theory that the reduced application period will decrease the risk for irritant reactions in pediatric patients.

 

 

Pediatric Patch Test Screening Series

A summary of the published screening series for patch testing in the pediatric population is provided (Table).

The T.R.U.E. Test (SmartPractice) is approved by the US Food and Drug Administration for use in patients 6 years and older11; however, it may not adequately represent allergen exposures in the pediatric population. Brankov and Jacob14 found that 10 (40%) of their proposed top 25 pediatric allergens were not detected using the T.R.U.E. Test.



In 2014, the North American Pediatric Patch Test Series was proposed as a basic screening panel for children aged 6 to 12 years.12 This series of 20 allergens was developed based on a literature review of pediatric patch test results and case reports as well as a database review. The authors proposed additional allergens to be considered based on patient history.12

More recently, a 2017 American Contact Dermatitis Society physician work group proposed the Pediatric Baseline Patch Test Series. This series of 38 allergens for children aged 6 to 18 years was developed based on expert consensus.8 Studies to determine the efficacy of this series have yet to be conducted, but it may have high sensitivity in detecting relevant allergens in children as demonstrated by a theoretical detection rate of 84%.14

There are 2 recommended patch test series for allergic diaper dermatitis.15 The first series focuses on 23 potential allergens found in wet wipes and topical diaper preparations. The second series contains 10 potential allergens found in diapers. These series contain common topical medications for children including corticosteroids, antimicrobials, and sensitizers specific to diapers such as rubbers and adhesives.15

Similar to adults, it may be difficult to designate one screening panel that can identify all relevant allergens in children; thus, it is always important to obtain a thorough exposure history and customize testing to suspected allergens and/or patient products based on history and clinical relevance.

Unique Pediatric Allergens

Hobbies
Sports gear such as shin guards and splints often contain allergens such as formaldehyde resin, thiuram mix, and dialkyl thioureas.16 Perioral dermatitis may be caused by musical instrument mouthpieces containing nickel.6

Preservatives
Commonly reported causes of ACD in children include methylisothiazolinone (MI) and methylchloroisothiazolinone (MCI) found in wet wipes. A 2016 analysis of diaper wipes showed a low prevalence of MI (6.3%) and MCI (1.6%) in these products, which may reflect the industry’s awareness of these potential allergens and a subsequent change in the preservatives they utilize.17 However, the prevalence of MCI/MI contact allergy may be on the rise due to the popularity of homemade slime, which is made from common household products such as laundry detergent, dishwashing soap, and liquid glue. The Pediatric Baseline Patch Test Series captures most of the potential allergens in these homemade slime recipes and is recommended for use in pediatric patients suspected of having dermatitis secondary to playing with slime.8,18

Toilet Seat Dermatitis
Toilet seat dermatitis presents as a pruritic dermatitis on the posterior upper thighs and buttocks. Although most cases of toilet seat dermatitis are irritant rather than allergic, potential allergens include plastics, fragrances, and components of cleaning products. Thus, physicians should maintain a high index of suspicion for ACD to toilet seats.19

Fragrance and Natural Ingredients
A 2018 study evaluating personal care products marketed specifically for infants and children found that 55% of products (294/533) contained at least 1 common allergen, with fragrance being the most common (48% [255/533]). Other common allergens include betaines (18%), propylene glycol (9%), lanolin (6%), and MCI/MI (3%).20 Caregivers should be advised against the myth that natural products are safer and less allergenic and should be provided with resources such as the Contact Allergen Management Program (CAMP) database (https://www.contactderm.org/resources/acds-camp) for safe alternative personal care products.



Metal Allergens
Nickel, the American Contact Dermatitis Society 2008 Allergen of the Year, is another common allergen that affects children. Nickel allergy, commonly thought to affect the ears due to jewelry and ear piercing, may actually be found in a wide range of daily items such as braces, eyeglasses, keys, zippers, school chairs, electronics, toys, and even food.3,6,21,22 With increased use of electronics in children of all ages, nickel found in mobile phones and other devices may be of particular concern. Caregivers can use a case or cover for metallic-appearing electronics.

Final Interpretation

Pediatric ACD is common. With limited surface area for patch testing in children, we recommend customized panels based on patient history and exposure. It is important for clinicians to recognize the unique causes of ACD in children and develop age-appropriate management plans.

The pediatric population has a unique product exposure profile due to the many care products specifically marketed for use in children. In fact, the prevalence of allergic contact dermatitis (ACD) in children may be as high as 24.5% in the United States.1 In patch tested children, relevant positive reaction rates of 56.7% and 48% have been reported by the North American Contact Dermatitis Group and the Pediatric Contact Dermatitis Registry, respectively.2,3 In this article, we provide an overview of current trends in pediatric patch testing as well as specific considerations in this patient population.

 

Patch Test Reactions in Children

Several publications have documented pediatric patch test reactions. The North American Contact Dermatitis Group reported patch test results in 883 children from the United States and Canada (2005-2012).2 The most common reactions were nickel (28.1%), cobalt (12.3%), neomycin (7.1%), balsam of Peru (5.7%), lanolin (5.5%), and fragrance mix I (5.2%). When compared to adults, children were more likely to have relevant positive patch tests to nickel, cobalt, and compositae mix.2 In comparison, data from the Pediatric Contact Dermatitis Registry showed that the most common reactions in 1142 children in the United States (2015-2016) were nickel (22%), fragrance mix I (11%), cobalt (9.1%), balsam of Peru (8.4%), neomycin (7.2%), and propylene glycol (6.8%).3

Allergen sensitivities may vary based on geographic region. In Spain, children showed the highest sensitivities to thiomersal (10.2%), cobalt (9.1%), colophony (9.1%), paraphenylenediamine (8.3%), mercury (7.9%), potassium dichromate (7.9%), and nickel (6.4%).4

Pediatric Patch Testing Pearls

History of Product Use
From diapers to drama club, pediatric exposures and sources of ACD are not the same as those seen in adults. Because obtaining a medical history from a toddler can be exasperating, the patient’s caregivers should be asked about potential exposures, ranging from personal care products and diapers to school activities, hobbies, and sports.5,6 It is important to keep in mind that the patient’s primary caregiver may not be the only individual who applies products to the child.7

Application of Allergens
Children are not merely small adults, but they usually do have smaller backs than adult patients. This reduced surface area means that the patch tester must carefully select the allergens to be patch tested. For reference, the back of a typical 6-year-old child can fit 40 to 60 allergens during patch testing.8

Patch Test Chambers
In children, the use of plastic patch test chambers may be preferred over aluminum chambers. Children with persistent pruritic subcutaneous nodules induced by aluminum-based vaccines also may have delayed-type sensitivity reactions to aluminum.9 These patients could react to the aluminum present in some patch test chambers, making interpretation of the results difficult. The authors (A.R.A. and M.R.) typically use plastic chambers in the pediatric population.

Managing Expectations
As with other procedures in the pediatric population, patch testing can elicit emotions of fear, anxiety, and distrust. Video distraction and/or role-playing games may help capture the attention of children and can be particularly helpful during patch application. Children may be apprehensive about the term allergy testing if they are familiar with the term needle testing from previous allergies.5

Securing Patches
Young children can be quite active, posing another challenge for keeping patches in place. We recommend using extra tape to secure the patches in place on a child’s back. In addition, a large transparent film dressing (ie, 12×8 in) can be used if quick application is needed. For extra precaution, the use of a tight T-shirt or favorite onesie during the patch test process may be helpful, making it more difficult for little fingers to remove tape edges.



Duration of Patch Testing
Some authors have proposed application of patch tests for 24 hours in pediatric patients, as compared to 48 hours in adults.10 This recommendation is based on a theory that the reduced application period will decrease the risk for irritant reactions in pediatric patients.

 

 

Pediatric Patch Test Screening Series

A summary of the published screening series for patch testing in the pediatric population is provided (Table).

The T.R.U.E. Test (SmartPractice) is approved by the US Food and Drug Administration for use in patients 6 years and older11; however, it may not adequately represent allergen exposures in the pediatric population. Brankov and Jacob14 found that 10 (40%) of their proposed top 25 pediatric allergens were not detected using the T.R.U.E. Test.



In 2014, the North American Pediatric Patch Test Series was proposed as a basic screening panel for children aged 6 to 12 years.12 This series of 20 allergens was developed based on a literature review of pediatric patch test results and case reports as well as a database review. The authors proposed additional allergens to be considered based on patient history.12

More recently, a 2017 American Contact Dermatitis Society physician work group proposed the Pediatric Baseline Patch Test Series. This series of 38 allergens for children aged 6 to 18 years was developed based on expert consensus.8 Studies to determine the efficacy of this series have yet to be conducted, but it may have high sensitivity in detecting relevant allergens in children as demonstrated by a theoretical detection rate of 84%.14

There are 2 recommended patch test series for allergic diaper dermatitis.15 The first series focuses on 23 potential allergens found in wet wipes and topical diaper preparations. The second series contains 10 potential allergens found in diapers. These series contain common topical medications for children including corticosteroids, antimicrobials, and sensitizers specific to diapers such as rubbers and adhesives.15

Similar to adults, it may be difficult to designate one screening panel that can identify all relevant allergens in children; thus, it is always important to obtain a thorough exposure history and customize testing to suspected allergens and/or patient products based on history and clinical relevance.

Unique Pediatric Allergens

Hobbies
Sports gear such as shin guards and splints often contain allergens such as formaldehyde resin, thiuram mix, and dialkyl thioureas.16 Perioral dermatitis may be caused by musical instrument mouthpieces containing nickel.6

Preservatives
Commonly reported causes of ACD in children include methylisothiazolinone (MI) and methylchloroisothiazolinone (MCI) found in wet wipes. A 2016 analysis of diaper wipes showed a low prevalence of MI (6.3%) and MCI (1.6%) in these products, which may reflect the industry’s awareness of these potential allergens and a subsequent change in the preservatives they utilize.17 However, the prevalence of MCI/MI contact allergy may be on the rise due to the popularity of homemade slime, which is made from common household products such as laundry detergent, dishwashing soap, and liquid glue. The Pediatric Baseline Patch Test Series captures most of the potential allergens in these homemade slime recipes and is recommended for use in pediatric patients suspected of having dermatitis secondary to playing with slime.8,18

Toilet Seat Dermatitis
Toilet seat dermatitis presents as a pruritic dermatitis on the posterior upper thighs and buttocks. Although most cases of toilet seat dermatitis are irritant rather than allergic, potential allergens include plastics, fragrances, and components of cleaning products. Thus, physicians should maintain a high index of suspicion for ACD to toilet seats.19

Fragrance and Natural Ingredients
A 2018 study evaluating personal care products marketed specifically for infants and children found that 55% of products (294/533) contained at least 1 common allergen, with fragrance being the most common (48% [255/533]). Other common allergens include betaines (18%), propylene glycol (9%), lanolin (6%), and MCI/MI (3%).20 Caregivers should be advised against the myth that natural products are safer and less allergenic and should be provided with resources such as the Contact Allergen Management Program (CAMP) database (https://www.contactderm.org/resources/acds-camp) for safe alternative personal care products.



Metal Allergens
Nickel, the American Contact Dermatitis Society 2008 Allergen of the Year, is another common allergen that affects children. Nickel allergy, commonly thought to affect the ears due to jewelry and ear piercing, may actually be found in a wide range of daily items such as braces, eyeglasses, keys, zippers, school chairs, electronics, toys, and even food.3,6,21,22 With increased use of electronics in children of all ages, nickel found in mobile phones and other devices may be of particular concern. Caregivers can use a case or cover for metallic-appearing electronics.

Final Interpretation

Pediatric ACD is common. With limited surface area for patch testing in children, we recommend customized panels based on patient history and exposure. It is important for clinicians to recognize the unique causes of ACD in children and develop age-appropriate management plans.

References
  1. Bruckner AL, Weston WL, Morelli JG. Does sensitization to contact allergens begin in infancy? Pediatrics. 2000;105:e3.
  2. Zug KA, Pham AK, Belsito DV, et al. Patch testing in children from 2005 to 2012: results from the North American contact dermatitis group. Dermatitis. 2014;25:345-355.
  3. Goldenberg A, Mousdicas N, Silverberg N, et al. Pediatric Contact Dermatitis Registry inaugural case data. Dermatitis. 2016;27:293-302.
  4. Ortiz Salvador JM, Esteve Martinez A, Subiabre Ferrer D, et al. Pediatric allergic contact dermatitis: clinical and epidemiological study in a tertiary hospital. Actas Dermosifiliogr. 2017;108:571-578.
  5. Jacob SE, Steele T, Brod B, et al. Dispelling the myths behind pediatric patch testing—experience from our tertiary care patch testing centers. Pediatr Dermatol. 2008;25:296-300.
  6. Brod BA, Treat JR, Rothe MJ, et al. Allergic contact dermatitis: kids are not just little people. Clin Dermatol. 2015;33:605-612.
  7. Elliott JF, Ramzy A, Nilsson U, et al. Severe intractable eyelid dermatitis probably caused by exposure to hydroperoxides of linalool in a heavily fragranced shampoo. Contact Dermatitis. 2017;76:114-115.
  8. Yu J, Atwater AR, Brod B, et al. Pediatric Baseline Patch Test Series: Pediatric Contact Dermatitis Workgroup. Dermatitis. 2018;29:206-212.
  9. Bergfors E, Inerot A, Falk L, et al. Patch testing children with aluminium chloride hexahydrate in petrolatum: a review and a recommendation. Contact Dermatitis. 2019;81:81-88.
  10. 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;5:107-109.
  11. T.R.U.E. Test (Thin-Layer Rapid Use Epicutaneous Patch Test) [package insert]. Hillerød, Denmark: SmartPractice Denmark ApS; 2017.
  12. Jacob SE, Admani S, Herro EM. Invited commentary: recommendation for a North American pediatric patch test series. Curr Allergy Asthma Rep. 2014;14:444.
  13. Castanedo-Tardana MP, Zug KA. Methylisothiazolinone. Dermatitis. 2013;24:2-6.
  14. Brankov N, Jacob SE. Pre-emptive avoidance strategy 2016: update on pediatric contact dermatitis allergens. Expert Rev Clin Immunol. 2017;13:93-95.
  15. Yu J, Treat J, Brod B. Patch test series for allergic perineal dermatitis in the diapered infant. Dermatitis. 2017;28:70-75.
  16. Sung CT, McGowan MA, Jacob SE. Allergic contact dermatitis evaluation: strategies for the preschooler. Curr Allergy Asthma Rep. 2018;18:49.
  17. Yu J, Treat J, Chaney K, et al. Potential allergens in disposable diaper wipes, topical diaper preparations, and disposable diapers: under-recognized etiology of pediatric perineal dermatitis. Dermatitis. 2016;27:110-118.
  18. Anderson LE, Treat JR, Brod BA, et al. “Slime” contact dermatitis: case report and review of relevant allergens. Pediatr Dermatol. 2019;36:335-337.
  19. Dorfman CO, Barros MA, Zaenglein AL. Contact dermatitis to training toilet seat (potty seat dermatitis). Pediatr Dermatol. 2018;35:e251-e252.
  20. Bonchak JG, Prouty ME, de la Feld SF. Prevalence of contact allergens in personal care products for babies and children. Dermatitis. 2018;29:81-84.
  21. Chen JK, Jacob SE, Nedorost ST, et al. A pragmatic approach to patch testing atopic dermatitis patients: clinical recommendations based on expert consensus opinion. Dermatitis. 2016;27:186-192.
  22. Goldenberg A, Silverberg N, Silverberg JI, et al. Pediatric allergic contact dermatitis: lessons for better care. J Allergy Clin Immunol Pract. 2015;3:661-667; quiz 668.
References
  1. Bruckner AL, Weston WL, Morelli JG. Does sensitization to contact allergens begin in infancy? Pediatrics. 2000;105:e3.
  2. Zug KA, Pham AK, Belsito DV, et al. Patch testing in children from 2005 to 2012: results from the North American contact dermatitis group. Dermatitis. 2014;25:345-355.
  3. Goldenberg A, Mousdicas N, Silverberg N, et al. Pediatric Contact Dermatitis Registry inaugural case data. Dermatitis. 2016;27:293-302.
  4. Ortiz Salvador JM, Esteve Martinez A, Subiabre Ferrer D, et al. Pediatric allergic contact dermatitis: clinical and epidemiological study in a tertiary hospital. Actas Dermosifiliogr. 2017;108:571-578.
  5. Jacob SE, Steele T, Brod B, et al. Dispelling the myths behind pediatric patch testing—experience from our tertiary care patch testing centers. Pediatr Dermatol. 2008;25:296-300.
  6. Brod BA, Treat JR, Rothe MJ, et al. Allergic contact dermatitis: kids are not just little people. Clin Dermatol. 2015;33:605-612.
  7. Elliott JF, Ramzy A, Nilsson U, et al. Severe intractable eyelid dermatitis probably caused by exposure to hydroperoxides of linalool in a heavily fragranced shampoo. Contact Dermatitis. 2017;76:114-115.
  8. Yu J, Atwater AR, Brod B, et al. Pediatric Baseline Patch Test Series: Pediatric Contact Dermatitis Workgroup. Dermatitis. 2018;29:206-212.
  9. Bergfors E, Inerot A, Falk L, et al. Patch testing children with aluminium chloride hexahydrate in petrolatum: a review and a recommendation. Contact Dermatitis. 2019;81:81-88.
  10. 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;5:107-109.
  11. T.R.U.E. Test (Thin-Layer Rapid Use Epicutaneous Patch Test) [package insert]. Hillerød, Denmark: SmartPractice Denmark ApS; 2017.
  12. Jacob SE, Admani S, Herro EM. Invited commentary: recommendation for a North American pediatric patch test series. Curr Allergy Asthma Rep. 2014;14:444.
  13. Castanedo-Tardana MP, Zug KA. Methylisothiazolinone. Dermatitis. 2013;24:2-6.
  14. Brankov N, Jacob SE. Pre-emptive avoidance strategy 2016: update on pediatric contact dermatitis allergens. Expert Rev Clin Immunol. 2017;13:93-95.
  15. Yu J, Treat J, Brod B. Patch test series for allergic perineal dermatitis in the diapered infant. Dermatitis. 2017;28:70-75.
  16. Sung CT, McGowan MA, Jacob SE. Allergic contact dermatitis evaluation: strategies for the preschooler. Curr Allergy Asthma Rep. 2018;18:49.
  17. Yu J, Treat J, Chaney K, et al. Potential allergens in disposable diaper wipes, topical diaper preparations, and disposable diapers: under-recognized etiology of pediatric perineal dermatitis. Dermatitis. 2016;27:110-118.
  18. Anderson LE, Treat JR, Brod BA, et al. “Slime” contact dermatitis: case report and review of relevant allergens. Pediatr Dermatol. 2019;36:335-337.
  19. Dorfman CO, Barros MA, Zaenglein AL. Contact dermatitis to training toilet seat (potty seat dermatitis). Pediatr Dermatol. 2018;35:e251-e252.
  20. Bonchak JG, Prouty ME, de la Feld SF. Prevalence of contact allergens in personal care products for babies and children. Dermatitis. 2018;29:81-84.
  21. Chen JK, Jacob SE, Nedorost ST, et al. A pragmatic approach to patch testing atopic dermatitis patients: clinical recommendations based on expert consensus opinion. Dermatitis. 2016;27:186-192.
  22. Goldenberg A, Silverberg N, Silverberg JI, et al. Pediatric allergic contact dermatitis: lessons for better care. J Allergy Clin Immunol Pract. 2015;3:661-667; quiz 668.
Issue
Cutis - 104(5)
Issue
Cutis - 104(5)
Page Number
288-290
Page Number
288-290
Publications
MDedge Dermatology
Cutis
Publications
MDedge Dermatology
Cutis
Topics
Contact Dermatitis
Pediatrics
Article Type
Article
Sections
Contact Dermatitis
Inside the Article

Practice Points

  • Pediatric allergic contact dermatitis (ACD) is common with children having unique product exposures.
  • Children suspected to have ACD should be patch tested with customized panels based on history and exposure.
  • Common pediatric allergens have been identified in personal care products, household products, and recreational gear and toys.
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