Atopic Dermatitis

The Food and Drug Administration has announced recalls of three types of over-the-counter medications by McNeil Consumer Healthcare.

Consumers may continue to take previously purchased products, and no action is required by health care providers.

Three Tylenol Cold Multi-Symptom liquid products sold in the United States (Daytime 8-ounce Citrus Burst liquid, Severe 8-ounce Cool Burst Liquid, and Nighttime 8-ounce Cool Burst Liquid) were recalled Nov. 24. No adverse events were reported, but the product labeling needs to be updated to more prominently note the small (less than 1%) presence of alcohol from flavoring agents as an inactive ingredient. This ingredient had been listed on the package but not on the front of the medicine bottle. Tylenol’s maker, McNeil Consumer Healthcare, began the recall after an internal company review identified this issue. The FDA says that health care providers do not need to take any action as a result of the recall, and consumers may continue to use the medicine.

McNeil also issued a voluntary recall of all product lots of Children’s Benadryl Allergy Fastmelt Tablet in cherry and grape flavors that were sold in the United States, Belize, Barbados, Canada, Puerto Rico, St. Martin and St. Thomas, as well as all Junior Strength Motrin Caplets 24 count that were sold in the United States. These recalls, issued Nov. 15, are the result of a review that found insufficiencies in the development of the manufacturing process. Consumers may continue to use these products, and no action is required for health care providers, according to the FDA. There is no reason to believe that the products are unsafe, and no adverse events have been reported.

Questions about the recalls should be directed to the company’s Consumer Care Center at 1-888-222-6036.

The Food and Drug Administration has announced recalls of three types of over-the-counter medications by McNeil Consumer Healthcare.

Consumers may continue to take previously purchased products, and no action is required by health care providers.

Three Tylenol Cold Multi-Symptom liquid products sold in the United States (Daytime 8-ounce Citrus Burst liquid, Severe 8-ounce Cool Burst Liquid, and Nighttime 8-ounce Cool Burst Liquid) were recalled Nov. 24. No adverse events were reported, but the product labeling needs to be updated to more prominently note the small (less than 1%) presence of alcohol from flavoring agents as an inactive ingredient. This ingredient had been listed on the package but not on the front of the medicine bottle. Tylenol’s maker, McNeil Consumer Healthcare, began the recall after an internal company review identified this issue. The FDA says that health care providers do not need to take any action as a result of the recall, and consumers may continue to use the medicine.

McNeil also issued a voluntary recall of all product lots of Children’s Benadryl Allergy Fastmelt Tablet in cherry and grape flavors that were sold in the United States, Belize, Barbados, Canada, Puerto Rico, St. Martin and St. Thomas, as well as all Junior Strength Motrin Caplets 24 count that were sold in the United States. These recalls, issued Nov. 15, are the result of a review that found insufficiencies in the development of the manufacturing process. Consumers may continue to use these products, and no action is required for health care providers, according to the FDA. There is no reason to believe that the products are unsafe, and no adverse events have been reported.

Questions about the recalls should be directed to the company’s Consumer Care Center at 1-888-222-6036.

The Food and Drug Administration has announced recalls of three types of over-the-counter medications by McNeil Consumer Healthcare.

Consumers may continue to take previously purchased products, and no action is required by health care providers.

Three Tylenol Cold Multi-Symptom liquid products sold in the United States (Daytime 8-ounce Citrus Burst liquid, Severe 8-ounce Cool Burst Liquid, and Nighttime 8-ounce Cool Burst Liquid) were recalled Nov. 24. No adverse events were reported, but the product labeling needs to be updated to more prominently note the small (less than 1%) presence of alcohol from flavoring agents as an inactive ingredient. This ingredient had been listed on the package but not on the front of the medicine bottle. Tylenol’s maker, McNeil Consumer Healthcare, began the recall after an internal company review identified this issue. The FDA says that health care providers do not need to take any action as a result of the recall, and consumers may continue to use the medicine.

McNeil also issued a voluntary recall of all product lots of Children’s Benadryl Allergy Fastmelt Tablet in cherry and grape flavors that were sold in the United States, Belize, Barbados, Canada, Puerto Rico, St. Martin and St. Thomas, as well as all Junior Strength Motrin Caplets 24 count that were sold in the United States. These recalls, issued Nov. 15, are the result of a review that found insufficiencies in the development of the manufacturing process. Consumers may continue to use these products, and no action is required for health care providers, according to the FDA. There is no reason to believe that the products are unsafe, and no adverse events have been reported.

Questions about the recalls should be directed to the company’s Consumer Care Center at 1-888-222-6036.

SAN FRANCISCO - Exposure to one or more irritant allergens can incite atopic dermatitis in pediatric patients, Dr. Sharon E. Jacob said.

Start by educating patients to avoid these common irritants: fragrance, formaldehyde, and cocamidopropyl betaine. "These are frequently used together and end up on the top list of allergens for children," she said.

Skin barrier repair is another essential component of a supersensitive skin regimen she recommends for these patients. Provide atopic patients with recommendations for cleansing, aseptic baths, and use of emollients and ceramides, she said.

The top 10 allergens (irritant and allergic) in pediatric patients, in order, are:

1. Nickel sulfate

2. Cobalt chloride

3. Thimerosal

4. Gold

5. Fragrance mix

6. Neomycin

7. Balsam of Peru

8. Colophony

9. Formaldehyde

10. Lanolin

Cocamidopropyl betaine, a common ingredient in shampoo, soaps, and toothpastes, comes in at number 16 on the list. Dr. Jacob compiled the list from the literature and presented it at a seminar on women’s and pediatric dermatology sponsored by Skin Disease Education Foundation (SDEF).

"The allergens causing big problems in atopic pediatric patients are the same [most common] allergens in our general population," Dr. Jacob said.

In addition, urine that causes diaper dermatitis and soap that leads to hand dermatitis are common irritant exposures. "Any substance that acts as mild toxic substance can give you an irritant dermatitis, said Dr. Jacob, an assistant clinical professor of medicine (dermatology) and pediatrics at the University of California, San Diego, and at Rady Children’s Hospital.

A meeting attendee asked about the safest diapers to recommend to parents. "Cloth is the best, but may not be practical," Dr. Jacob replied. Safer options include fragrance-free, dye-free diapers available at Whole Foods Market and the Huggies brand organic cotton diaper, she said.

In terms of differential diagnosis, keep in mind that irritant contact dermatitis is a nonimmunologic reaction – unlike agents that cause allergic contact dermatitis, Dr. Jacob said.

Fragrances are a challenge to avoid – they are in virtually every product with a scent, Dr. Jacob said. "It is very hard to find fragrance products these patients can use. Many have multiple ingredients."

One pearl is to recommend "fragrance-free" but not "unscented" products, Dr. Jacob said. Unscented items might contain a masking fragrance, she said. For example, she compared two "sensitive skin" deodorants with the same brand name and very similar packaging. One was labeled fragrance free and one unscented. However, the ingredient list on the unscented deodorant included parfum. "You cannot just go by the way it looks."

You can identify about 80% of fragrance allergies by patch testing with Balsam of Peru and Fragrance Mix 1, Dr. Jacob said. "When you add jasmine, ylang ylang, sandalwood, and narcissus, you get to 95%."

Also consider allergy to Lyral, "one of the new reported fragrance allergens," Dr. Jacob said. This potential allergen is included in the Fragrance Mix 2 series. Lyral, also known as hydroxyisohexyl 3-cyclohexene carboxaldehyde, is found in fine fragrances, many aerosol deodorants, and other personal care items.

Formaldehyde is a colorless, readily-soluble gas that is used extensively as a preservative. It has been a top allergen for 70 years, Dr. Jacob said, and has a potential role in systemic contact allergies. The artificial sweetener aspartame can metabolize to formaldehyde and some chewable "gummy" vitamins contain this ingredient, she said.

Another meeting attendee asked about tear-free shampoos and soaps for children that do not contain cocamidopropyl betaine. Dr. Jacob suggested the California Baby product line, but again cautioned that parents should read labels carefully and purchase the 'fragrance-free' items, versus products that contain 'essential oils.'

SDEF and this news organization are owned by Elsevier.

Dr. Jacob is a speaker for Coria Laboratories, Astellas Pharma Inc., and Shire. She is also an independent investigator for Allerderm, maker of the T.R.U.E. test.

SAN FRANCISCO - Exposure to one or more irritant allergens can incite atopic dermatitis in pediatric patients, Dr. Sharon E. Jacob said.

Start by educating patients to avoid these common irritants: fragrance, formaldehyde, and cocamidopropyl betaine. "These are frequently used together and end up on the top list of allergens for children," she said.

Skin barrier repair is another essential component of a supersensitive skin regimen she recommends for these patients. Provide atopic patients with recommendations for cleansing, aseptic baths, and use of emollients and ceramides, she said.

The top 10 allergens (irritant and allergic) in pediatric patients, in order, are:

1. Nickel sulfate

2. Cobalt chloride

3. Thimerosal

4. Gold

5. Fragrance mix

6. Neomycin

7. Balsam of Peru

8. Colophony

9. Formaldehyde

10. Lanolin

Cocamidopropyl betaine, a common ingredient in shampoo, soaps, and toothpastes, comes in at number 16 on the list. Dr. Jacob compiled the list from the literature and presented it at a seminar on women’s and pediatric dermatology sponsored by Skin Disease Education Foundation (SDEF).

"The allergens causing big problems in atopic pediatric patients are the same [most common] allergens in our general population," Dr. Jacob said.

In addition, urine that causes diaper dermatitis and soap that leads to hand dermatitis are common irritant exposures. "Any substance that acts as mild toxic substance can give you an irritant dermatitis, said Dr. Jacob, an assistant clinical professor of medicine (dermatology) and pediatrics at the University of California, San Diego, and at Rady Children’s Hospital.

A meeting attendee asked about the safest diapers to recommend to parents. "Cloth is the best, but may not be practical," Dr. Jacob replied. Safer options include fragrance-free, dye-free diapers available at Whole Foods Market and the Huggies brand organic cotton diaper, she said.

In terms of differential diagnosis, keep in mind that irritant contact dermatitis is a nonimmunologic reaction – unlike agents that cause allergic contact dermatitis, Dr. Jacob said.

Fragrances are a challenge to avoid – they are in virtually every product with a scent, Dr. Jacob said. "It is very hard to find fragrance products these patients can use. Many have multiple ingredients."

One pearl is to recommend "fragrance-free" but not "unscented" products, Dr. Jacob said. Unscented items might contain a masking fragrance, she said. For example, she compared two "sensitive skin" deodorants with the same brand name and very similar packaging. One was labeled fragrance free and one unscented. However, the ingredient list on the unscented deodorant included parfum. "You cannot just go by the way it looks."

You can identify about 80% of fragrance allergies by patch testing with Balsam of Peru and Fragrance Mix 1, Dr. Jacob said. "When you add jasmine, ylang ylang, sandalwood, and narcissus, you get to 95%."

Also consider allergy to Lyral, "one of the new reported fragrance allergens," Dr. Jacob said. This potential allergen is included in the Fragrance Mix 2 series. Lyral, also known as hydroxyisohexyl 3-cyclohexene carboxaldehyde, is found in fine fragrances, many aerosol deodorants, and other personal care items.

Formaldehyde is a colorless, readily-soluble gas that is used extensively as a preservative. It has been a top allergen for 70 years, Dr. Jacob said, and has a potential role in systemic contact allergies. The artificial sweetener aspartame can metabolize to formaldehyde and some chewable "gummy" vitamins contain this ingredient, she said.

Another meeting attendee asked about tear-free shampoos and soaps for children that do not contain cocamidopropyl betaine. Dr. Jacob suggested the California Baby product line, but again cautioned that parents should read labels carefully and purchase the 'fragrance-free' items, versus products that contain 'essential oils.'

SDEF and this news organization are owned by Elsevier.

Dr. Jacob is a speaker for Coria Laboratories, Astellas Pharma Inc., and Shire. She is also an independent investigator for Allerderm, maker of the T.R.U.E. test.

SAN FRANCISCO - Exposure to one or more irritant allergens can incite atopic dermatitis in pediatric patients, Dr. Sharon E. Jacob said.

Start by educating patients to avoid these common irritants: fragrance, formaldehyde, and cocamidopropyl betaine. "These are frequently used together and end up on the top list of allergens for children," she said.

Skin barrier repair is another essential component of a supersensitive skin regimen she recommends for these patients. Provide atopic patients with recommendations for cleansing, aseptic baths, and use of emollients and ceramides, she said.

The top 10 allergens (irritant and allergic) in pediatric patients, in order, are:

1. Nickel sulfate

2. Cobalt chloride

3. Thimerosal

4. Gold

5. Fragrance mix

6. Neomycin

7. Balsam of Peru

8. Colophony

9. Formaldehyde

10. Lanolin

Cocamidopropyl betaine, a common ingredient in shampoo, soaps, and toothpastes, comes in at number 16 on the list. Dr. Jacob compiled the list from the literature and presented it at a seminar on women’s and pediatric dermatology sponsored by Skin Disease Education Foundation (SDEF).

"The allergens causing big problems in atopic pediatric patients are the same [most common] allergens in our general population," Dr. Jacob said.

In addition, urine that causes diaper dermatitis and soap that leads to hand dermatitis are common irritant exposures. "Any substance that acts as mild toxic substance can give you an irritant dermatitis, said Dr. Jacob, an assistant clinical professor of medicine (dermatology) and pediatrics at the University of California, San Diego, and at Rady Children’s Hospital.

A meeting attendee asked about the safest diapers to recommend to parents. "Cloth is the best, but may not be practical," Dr. Jacob replied. Safer options include fragrance-free, dye-free diapers available at Whole Foods Market and the Huggies brand organic cotton diaper, she said.

In terms of differential diagnosis, keep in mind that irritant contact dermatitis is a nonimmunologic reaction – unlike agents that cause allergic contact dermatitis, Dr. Jacob said.

Fragrances are a challenge to avoid – they are in virtually every product with a scent, Dr. Jacob said. "It is very hard to find fragrance products these patients can use. Many have multiple ingredients."

One pearl is to recommend "fragrance-free" but not "unscented" products, Dr. Jacob said. Unscented items might contain a masking fragrance, she said. For example, she compared two "sensitive skin" deodorants with the same brand name and very similar packaging. One was labeled fragrance free and one unscented. However, the ingredient list on the unscented deodorant included parfum. "You cannot just go by the way it looks."

You can identify about 80% of fragrance allergies by patch testing with Balsam of Peru and Fragrance Mix 1, Dr. Jacob said. "When you add jasmine, ylang ylang, sandalwood, and narcissus, you get to 95%."

Also consider allergy to Lyral, "one of the new reported fragrance allergens," Dr. Jacob said. This potential allergen is included in the Fragrance Mix 2 series. Lyral, also known as hydroxyisohexyl 3-cyclohexene carboxaldehyde, is found in fine fragrances, many aerosol deodorants, and other personal care items.

Formaldehyde is a colorless, readily-soluble gas that is used extensively as a preservative. It has been a top allergen for 70 years, Dr. Jacob said, and has a potential role in systemic contact allergies. The artificial sweetener aspartame can metabolize to formaldehyde and some chewable "gummy" vitamins contain this ingredient, she said.

Another meeting attendee asked about tear-free shampoos and soaps for children that do not contain cocamidopropyl betaine. Dr. Jacob suggested the California Baby product line, but again cautioned that parents should read labels carefully and purchase the 'fragrance-free' items, versus products that contain 'essential oils.'

SDEF and this news organization are owned by Elsevier.

Dr. Jacob is a speaker for Coria Laboratories, Astellas Pharma Inc., and Shire. She is also an independent investigator for Allerderm, maker of the T.R.U.E. test.

SAN FRANCISCO – What do you consider when one of your atopic pediatric patients has recalcitrant dermatitis? Or a new-onset dermatitis that lasts longer than 2 months? It might be time to expand your differential diagnosis to consider contact dermatitis, Dr. Sharon Jacob said.

There is a high prevalence of allergic contact dermatitis in moderate to severe atopic patients. Also, think systemic allergic contact dermatitis in highly sensitized children. Although more commonly reported in adults, systemic allergies can affect pediatric patients, Dr. Jacob said at a meeting sponsored by Skin Disease Education Foundation (SDEF).

Exposure to nickel, cobalt, fragrances, formaldehyde and balsam of Peru – including from dietary sources – can trigger a systemic reaction. System allergy "should be considered in children with a positive patch test who fail to improve with skin contact avoidance," she said.

A diet devoid of the suspected trigger(s) for 6 weeks or more can make a difference for some recalcitrant children, said Dr. Jacob, an assistant clinical professor of medicine (dermatology) and pediatrics at the University of California, San Diego, and at Rady Children’s Hospital. Such an avoidance diet improved the outcome for eight pediatric patients with systemic allergies, according to a recent report from Dr. Jacob and Dr. C. Matiz (Pediatr. Dermatol. 2010 Aug 27 [doi: 10.1111/j.1525-1470.2010.01130.x]).

An avoidance diet is particularly challenging for children with allergy to balsam of Peru. This allergen is found in many foods, including tomatoes, citrus, and certain spices, according to a study in adults (J. Am. Acad. Dermatol. 2001;45:377-81).

"The food we have the most problem with is ketchup. Ketchup and pizza are the bane of my existence," Dr. Jacob said. Keep the diet simple if possible and encourage adherence with incentives for the child, such as a points and rewards system, she added.

Be careful how you counsel these children, Dr. Jacob said. "Start off with the fact they cannot have asparagus – 'Yes!' – or spinach 'Yay!' Then mention ketchup, chocolate, and soda, and you become the evil contact derm pediatrician."

Sometimes an affected anatomic site is an important clinical clue. For example, Dr. Jacob described a 10-month-old child with generalized dermatitis who also presented with specific perioral dermatitis. "When we see this we think balsam of Peru." Involvement of the eyelids is another clinical clue.

Another interesting case Dr. Jacob presented was a toddler with a fragrance contact allergy that triggered a systemic reaction. Initially, however, she had to figure out how a toddler could have an allergy to fragrance. She discovered that the toddler became sensitized from "connubial contact" – or a physical transfer – of fragrance from the mother’s neck. Following this discovery, the child was doing well until a flare associated with vanilla teething wafers. "It’s amazing how much vanilla is everywhere."

When an allergen or chemical is transferred by the patient to another site on their body, it is called "ectopic dermatitis." Dr. Jacob cited the case of a 3-year-old whose older sister lacquered her fingernails, for example. The younger child scratched other areas and reacted to the tosylamide formaldehyde resin on her nails.

If you have a child whose controlled condition suddenly worsens in their atopic areas, consider these potential culprits: lanolin, neomycin, and bacitracin, Dr. Jacob said.

Lanolin is derived from the sebaceous gland in sheep. Although removed from most wool clothing during processing, it remains in cashmere clothing to keep it soft. "Lanolin is a top offender in children – because it is used in emollients," Dr. Jacob said.

Also assess these patients for exposure to plants in the Compositae family – including feverfew and chamomile. Keep in mind some components may be found in preparations you prescribe for their atopic dermatitis, such as bisabolol, an alcohol compound derived from chamomile and found in Aquaphor ointment (Beiersdorf Inc.) and sometimes prescribed for atopic dermatitis in children (Pediatr. Dermatol. 2010;27:103-4)

Also watch out for emulsifiers used in diaper creams and topical steroids, including sorbitan sesquioleate. Reports of contact dermatitis to this sorbitan are increasing (Dermatitis. 2008:19:339-41).

Dr. Jacob noted that patch testing of children for contact allergies is "off-label" – not approved by the Food and Drug Administration.

A meeting attendee asked Dr. Jacob about the youngest age patient that she will patch test. "I have patch tested a patient as young as 10 months old. But I generally do not patch test children under 5 years old unless absolutely indicated," she replied. She first tries "preemptive avoidance" of suspected allergens in these young children before patch testing.

SDEF and this news organization are owned by Elsevier. Dr. Jacob is a speaker for Coria Laboratories, Astellas Pharma Inc., and Shire. She is also an independent investigator for Allerderm, maker of the T.R.U.E. test.

SAN FRANCISCO – What do you consider when one of your atopic pediatric patients has recalcitrant dermatitis? Or a new-onset dermatitis that lasts longer than 2 months? It might be time to expand your differential diagnosis to consider contact dermatitis, Dr. Sharon Jacob said.

There is a high prevalence of allergic contact dermatitis in moderate to severe atopic patients. Also, think systemic allergic contact dermatitis in highly sensitized children. Although more commonly reported in adults, systemic allergies can affect pediatric patients, Dr. Jacob said at a meeting sponsored by Skin Disease Education Foundation (SDEF).

Exposure to nickel, cobalt, fragrances, formaldehyde and balsam of Peru – including from dietary sources – can trigger a systemic reaction. System allergy "should be considered in children with a positive patch test who fail to improve with skin contact avoidance," she said.

A diet devoid of the suspected trigger(s) for 6 weeks or more can make a difference for some recalcitrant children, said Dr. Jacob, an assistant clinical professor of medicine (dermatology) and pediatrics at the University of California, San Diego, and at Rady Children’s Hospital. Such an avoidance diet improved the outcome for eight pediatric patients with systemic allergies, according to a recent report from Dr. Jacob and Dr. C. Matiz (Pediatr. Dermatol. 2010 Aug 27 [doi: 10.1111/j.1525-1470.2010.01130.x]).

An avoidance diet is particularly challenging for children with allergy to balsam of Peru. This allergen is found in many foods, including tomatoes, citrus, and certain spices, according to a study in adults (J. Am. Acad. Dermatol. 2001;45:377-81).

"The food we have the most problem with is ketchup. Ketchup and pizza are the bane of my existence," Dr. Jacob said. Keep the diet simple if possible and encourage adherence with incentives for the child, such as a points and rewards system, she added.

Be careful how you counsel these children, Dr. Jacob said. "Start off with the fact they cannot have asparagus – 'Yes!' – or spinach 'Yay!' Then mention ketchup, chocolate, and soda, and you become the evil contact derm pediatrician."

Sometimes an affected anatomic site is an important clinical clue. For example, Dr. Jacob described a 10-month-old child with generalized dermatitis who also presented with specific perioral dermatitis. "When we see this we think balsam of Peru." Involvement of the eyelids is another clinical clue.

Another interesting case Dr. Jacob presented was a toddler with a fragrance contact allergy that triggered a systemic reaction. Initially, however, she had to figure out how a toddler could have an allergy to fragrance. She discovered that the toddler became sensitized from "connubial contact" – or a physical transfer – of fragrance from the mother’s neck. Following this discovery, the child was doing well until a flare associated with vanilla teething wafers. "It’s amazing how much vanilla is everywhere."

When an allergen or chemical is transferred by the patient to another site on their body, it is called "ectopic dermatitis." Dr. Jacob cited the case of a 3-year-old whose older sister lacquered her fingernails, for example. The younger child scratched other areas and reacted to the tosylamide formaldehyde resin on her nails.

If you have a child whose controlled condition suddenly worsens in their atopic areas, consider these potential culprits: lanolin, neomycin, and bacitracin, Dr. Jacob said.

Lanolin is derived from the sebaceous gland in sheep. Although removed from most wool clothing during processing, it remains in cashmere clothing to keep it soft. "Lanolin is a top offender in children – because it is used in emollients," Dr. Jacob said.

Also assess these patients for exposure to plants in the Compositae family – including feverfew and chamomile. Keep in mind some components may be found in preparations you prescribe for their atopic dermatitis, such as bisabolol, an alcohol compound derived from chamomile and found in Aquaphor ointment (Beiersdorf Inc.) and sometimes prescribed for atopic dermatitis in children (Pediatr. Dermatol. 2010;27:103-4)

Also watch out for emulsifiers used in diaper creams and topical steroids, including sorbitan sesquioleate. Reports of contact dermatitis to this sorbitan are increasing (Dermatitis. 2008:19:339-41).

Dr. Jacob noted that patch testing of children for contact allergies is "off-label" – not approved by the Food and Drug Administration.

A meeting attendee asked Dr. Jacob about the youngest age patient that she will patch test. "I have patch tested a patient as young as 10 months old. But I generally do not patch test children under 5 years old unless absolutely indicated," she replied. She first tries "preemptive avoidance" of suspected allergens in these young children before patch testing.

SDEF and this news organization are owned by Elsevier. Dr. Jacob is a speaker for Coria Laboratories, Astellas Pharma Inc., and Shire. She is also an independent investigator for Allerderm, maker of the T.R.U.E. test.

SAN FRANCISCO – What do you consider when one of your atopic pediatric patients has recalcitrant dermatitis? Or a new-onset dermatitis that lasts longer than 2 months? It might be time to expand your differential diagnosis to consider contact dermatitis, Dr. Sharon Jacob said.

There is a high prevalence of allergic contact dermatitis in moderate to severe atopic patients. Also, think systemic allergic contact dermatitis in highly sensitized children. Although more commonly reported in adults, systemic allergies can affect pediatric patients, Dr. Jacob said at a meeting sponsored by Skin Disease Education Foundation (SDEF).

Exposure to nickel, cobalt, fragrances, formaldehyde and balsam of Peru – including from dietary sources – can trigger a systemic reaction. System allergy "should be considered in children with a positive patch test who fail to improve with skin contact avoidance," she said.

A diet devoid of the suspected trigger(s) for 6 weeks or more can make a difference for some recalcitrant children, said Dr. Jacob, an assistant clinical professor of medicine (dermatology) and pediatrics at the University of California, San Diego, and at Rady Children’s Hospital. Such an avoidance diet improved the outcome for eight pediatric patients with systemic allergies, according to a recent report from Dr. Jacob and Dr. C. Matiz (Pediatr. Dermatol. 2010 Aug 27 [doi: 10.1111/j.1525-1470.2010.01130.x]).

An avoidance diet is particularly challenging for children with allergy to balsam of Peru. This allergen is found in many foods, including tomatoes, citrus, and certain spices, according to a study in adults (J. Am. Acad. Dermatol. 2001;45:377-81).

"The food we have the most problem with is ketchup. Ketchup and pizza are the bane of my existence," Dr. Jacob said. Keep the diet simple if possible and encourage adherence with incentives for the child, such as a points and rewards system, she added.

Be careful how you counsel these children, Dr. Jacob said. "Start off with the fact they cannot have asparagus – 'Yes!' – or spinach 'Yay!' Then mention ketchup, chocolate, and soda, and you become the evil contact derm pediatrician."

Sometimes an affected anatomic site is an important clinical clue. For example, Dr. Jacob described a 10-month-old child with generalized dermatitis who also presented with specific perioral dermatitis. "When we see this we think balsam of Peru." Involvement of the eyelids is another clinical clue.

Another interesting case Dr. Jacob presented was a toddler with a fragrance contact allergy that triggered a systemic reaction. Initially, however, she had to figure out how a toddler could have an allergy to fragrance. She discovered that the toddler became sensitized from "connubial contact" – or a physical transfer – of fragrance from the mother’s neck. Following this discovery, the child was doing well until a flare associated with vanilla teething wafers. "It’s amazing how much vanilla is everywhere."

When an allergen or chemical is transferred by the patient to another site on their body, it is called "ectopic dermatitis." Dr. Jacob cited the case of a 3-year-old whose older sister lacquered her fingernails, for example. The younger child scratched other areas and reacted to the tosylamide formaldehyde resin on her nails.

If you have a child whose controlled condition suddenly worsens in their atopic areas, consider these potential culprits: lanolin, neomycin, and bacitracin, Dr. Jacob said.

Lanolin is derived from the sebaceous gland in sheep. Although removed from most wool clothing during processing, it remains in cashmere clothing to keep it soft. "Lanolin is a top offender in children – because it is used in emollients," Dr. Jacob said.

Also assess these patients for exposure to plants in the Compositae family – including feverfew and chamomile. Keep in mind some components may be found in preparations you prescribe for their atopic dermatitis, such as bisabolol, an alcohol compound derived from chamomile and found in Aquaphor ointment (Beiersdorf Inc.) and sometimes prescribed for atopic dermatitis in children (Pediatr. Dermatol. 2010;27:103-4)

Also watch out for emulsifiers used in diaper creams and topical steroids, including sorbitan sesquioleate. Reports of contact dermatitis to this sorbitan are increasing (Dermatitis. 2008:19:339-41).

Dr. Jacob noted that patch testing of children for contact allergies is "off-label" – not approved by the Food and Drug Administration.

A meeting attendee asked Dr. Jacob about the youngest age patient that she will patch test. "I have patch tested a patient as young as 10 months old. But I generally do not patch test children under 5 years old unless absolutely indicated," she replied. She first tries "preemptive avoidance" of suspected allergens in these young children before patch testing.

SDEF and this news organization are owned by Elsevier. Dr. Jacob is a speaker for Coria Laboratories, Astellas Pharma Inc., and Shire. She is also an independent investigator for Allerderm, maker of the T.R.U.E. test.

GOTHENBURG, SWEDEN – Patients with longstanding chronic pruritus refractory to the full array of conventional therapies had a high response rate to a neurokinin-1 receptor antagonist in a proof-of-concept study.

"To the best of our knowledge, this is the first clinical report demonstrating that targeting the neuropeptide substance P via applying the NK-1 receptor antagonist aprepitant is an effective approach for the treatment of chronic pruritus," Dr. Sonja Ständer said at the annual congress of the European Academy of Dermatology and Venereology.

She reported on 20 patients, mean age 67 years, with an average 61-month duration of pruritus refractory to antihistamines, topical and systemic steroids, cyclosporine, and/or UV phototherapy.

Participants were placed on oral aprepitant at 80 mg once daily for 1 week, with no other anti-pruritic therapy allowed. Sixteen of the 20 patients responded with a significant reduction in itching. Mean values on a daily self-rated pruritus visual analog scale improved from 8.4 points on the 0-10 scale at baseline to 4.9 points after a week on aprepitant (Emend).

Four patients reported complete or nearly complete relief, eight others had a 40%-60% reduction in pruritus, and four patients had a modest 10%-30% improvement. Four others were nonresponders, according to Dr. Ständer of the University Hospital, Münster, Germany.

Responses varied considerably depending upon the presumed pathophysiology of a patient’s pruritus. The best results were seen in the 10 patients with an atopic predisposition and in the 13 with prurigo nodularis and scratch lesions. The seven patients whose pruritus was thought to be caused by underlying systemic disease, such as diabetes or chronic kidney disease, had a far more modest mean 24% reduction in pruritus. However, those who had uremic pruritus, caused by chronic kidney disease as well as an atopic predisposition, fared much better on aprepitant, with a mean 50% reduction in pruritus.

Side effects were limited to mild nausea, drowsiness, and vertigo in three patients.

Aprepitant is approved for the prevention of chemotherapy-induced nausea and vomiting, as well as postoperative nausea and vomiting. The rationale for studying this antiemetic as a potential therapy for chronic pruritus lies in the fact that as an NK-1 receptor antagonist, aprepitant inhibits substance P. And studies in both animals and humans indicate substance P is an important mediator of itch.

Substance P binds to the NK-1 receptor, which is expressed in the skin and the central nervous system. When substance P binds to NK-1 receptors on mast cells, it triggers mast cell degranulation, with release of pruritus-inducing tumor necrosis factor–alpha, histamine, leukotriene B4, and prostaglandin D2. And when substance P binds to NK-1 receptors on keratinocytes, it stimulates production of interleukin-1–alpha and –beta, interleukin-8, and other proinflammatory cytokines, Dr. Ständer explained.

Previous studies indicate chronic pruritus patients with prurigo nodularis or an atopic predisposition are characterized by particularly high levels of substance P in the skin – and these were just the patients with the greatest response to aprepitant in this initial study, she added. Based upon the encouraging results of this pilot study, a randomized, controlled study is planned.

Dr. Ständer declared having no relevant financial interests.

GOTHENBURG, SWEDEN – Patients with longstanding chronic pruritus refractory to the full array of conventional therapies had a high response rate to a neurokinin-1 receptor antagonist in a proof-of-concept study.

"To the best of our knowledge, this is the first clinical report demonstrating that targeting the neuropeptide substance P via applying the NK-1 receptor antagonist aprepitant is an effective approach for the treatment of chronic pruritus," Dr. Sonja Ständer said at the annual congress of the European Academy of Dermatology and Venereology.

She reported on 20 patients, mean age 67 years, with an average 61-month duration of pruritus refractory to antihistamines, topical and systemic steroids, cyclosporine, and/or UV phototherapy.

Participants were placed on oral aprepitant at 80 mg once daily for 1 week, with no other anti-pruritic therapy allowed. Sixteen of the 20 patients responded with a significant reduction in itching. Mean values on a daily self-rated pruritus visual analog scale improved from 8.4 points on the 0-10 scale at baseline to 4.9 points after a week on aprepitant (Emend).

Four patients reported complete or nearly complete relief, eight others had a 40%-60% reduction in pruritus, and four patients had a modest 10%-30% improvement. Four others were nonresponders, according to Dr. Ständer of the University Hospital, Münster, Germany.

Responses varied considerably depending upon the presumed pathophysiology of a patient’s pruritus. The best results were seen in the 10 patients with an atopic predisposition and in the 13 with prurigo nodularis and scratch lesions. The seven patients whose pruritus was thought to be caused by underlying systemic disease, such as diabetes or chronic kidney disease, had a far more modest mean 24% reduction in pruritus. However, those who had uremic pruritus, caused by chronic kidney disease as well as an atopic predisposition, fared much better on aprepitant, with a mean 50% reduction in pruritus.

Side effects were limited to mild nausea, drowsiness, and vertigo in three patients.

Aprepitant is approved for the prevention of chemotherapy-induced nausea and vomiting, as well as postoperative nausea and vomiting. The rationale for studying this antiemetic as a potential therapy for chronic pruritus lies in the fact that as an NK-1 receptor antagonist, aprepitant inhibits substance P. And studies in both animals and humans indicate substance P is an important mediator of itch.

Substance P binds to the NK-1 receptor, which is expressed in the skin and the central nervous system. When substance P binds to NK-1 receptors on mast cells, it triggers mast cell degranulation, with release of pruritus-inducing tumor necrosis factor–alpha, histamine, leukotriene B4, and prostaglandin D2. And when substance P binds to NK-1 receptors on keratinocytes, it stimulates production of interleukin-1–alpha and –beta, interleukin-8, and other proinflammatory cytokines, Dr. Ständer explained.

Previous studies indicate chronic pruritus patients with prurigo nodularis or an atopic predisposition are characterized by particularly high levels of substance P in the skin – and these were just the patients with the greatest response to aprepitant in this initial study, she added. Based upon the encouraging results of this pilot study, a randomized, controlled study is planned.

Dr. Ständer declared having no relevant financial interests.

GOTHENBURG, SWEDEN – Patients with longstanding chronic pruritus refractory to the full array of conventional therapies had a high response rate to a neurokinin-1 receptor antagonist in a proof-of-concept study.

"To the best of our knowledge, this is the first clinical report demonstrating that targeting the neuropeptide substance P via applying the NK-1 receptor antagonist aprepitant is an effective approach for the treatment of chronic pruritus," Dr. Sonja Ständer said at the annual congress of the European Academy of Dermatology and Venereology.

She reported on 20 patients, mean age 67 years, with an average 61-month duration of pruritus refractory to antihistamines, topical and systemic steroids, cyclosporine, and/or UV phototherapy.

Participants were placed on oral aprepitant at 80 mg once daily for 1 week, with no other anti-pruritic therapy allowed. Sixteen of the 20 patients responded with a significant reduction in itching. Mean values on a daily self-rated pruritus visual analog scale improved from 8.4 points on the 0-10 scale at baseline to 4.9 points after a week on aprepitant (Emend).

Four patients reported complete or nearly complete relief, eight others had a 40%-60% reduction in pruritus, and four patients had a modest 10%-30% improvement. Four others were nonresponders, according to Dr. Ständer of the University Hospital, Münster, Germany.

Responses varied considerably depending upon the presumed pathophysiology of a patient’s pruritus. The best results were seen in the 10 patients with an atopic predisposition and in the 13 with prurigo nodularis and scratch lesions. The seven patients whose pruritus was thought to be caused by underlying systemic disease, such as diabetes or chronic kidney disease, had a far more modest mean 24% reduction in pruritus. However, those who had uremic pruritus, caused by chronic kidney disease as well as an atopic predisposition, fared much better on aprepitant, with a mean 50% reduction in pruritus.

Side effects were limited to mild nausea, drowsiness, and vertigo in three patients.

Aprepitant is approved for the prevention of chemotherapy-induced nausea and vomiting, as well as postoperative nausea and vomiting. The rationale for studying this antiemetic as a potential therapy for chronic pruritus lies in the fact that as an NK-1 receptor antagonist, aprepitant inhibits substance P. And studies in both animals and humans indicate substance P is an important mediator of itch.

Substance P binds to the NK-1 receptor, which is expressed in the skin and the central nervous system. When substance P binds to NK-1 receptors on mast cells, it triggers mast cell degranulation, with release of pruritus-inducing tumor necrosis factor–alpha, histamine, leukotriene B4, and prostaglandin D2. And when substance P binds to NK-1 receptors on keratinocytes, it stimulates production of interleukin-1–alpha and –beta, interleukin-8, and other proinflammatory cytokines, Dr. Ständer explained.

Previous studies indicate chronic pruritus patients with prurigo nodularis or an atopic predisposition are characterized by particularly high levels of substance P in the skin – and these were just the patients with the greatest response to aprepitant in this initial study, she added. Based upon the encouraging results of this pilot study, a randomized, controlled study is planned.

Dr. Ständer declared having no relevant financial interests.

Sunscreens are an important part of a dermatologist's tool kit, but they're not a panacea for UV-induced damage, according to Dr. Timothy Berger.

Although sunscreens work well in laboratory testing, almost no one applies them in a way that will provide the advertised UV protection, Dr. Berger noted at the Las Vegas Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF). And for some patients, sunscreens can exacerbate their UV-induced problems.

Sunscreens themselves, not the vehicular preservatives, are usually the culprit when a patient presents with a complaint of being allergic to sunscreens, said Dr. Berger, a professor of dermatology at the University of California, San Francisco.

"You will usually find that the dermatitis only occurs in areas touched by the sun," he said in an interview. "The problem is often an allergy to the PABA or PABA-related substances in the sunscreen they are using."

Photo courtesy Dr. Timothy Berger

For patients like this, the best alternative is a PABA-free sunscreen that contains zinc and titanium oxide – inert compounds that are physical barriers against UV light, rather than chemical barriers.

And although SPF ratings might look great in advertisements, it is almost a sure bet that sun-seeking patients are not getting nearly the protection promised, Dr. Berger noted. "Some interesting recent studies have looked at what SPF you actually get what you put on sunscreen. The amount used in testing is actually about four times more than what people really use."

One study found that most people apply about 0.5 mg/cm2, while the lab tests use a volume of 2 mg/cm2 to achieve the advertised SPF (J. Am. Acad. Dermatol. 2010;62:218-22). "The problem is, efficacy falls off in a very sharp way," Dr. Berger said. "If you apply SPF 30 sun block [at one-quarter the recommended amount], you only end up with an actual SPF of about 3."

"We need to make sure our patients understand this. And while most people are still not going to use the necessary amount, we can stress the importance of reapplying frequently, which can help keep the protective value up somewhat," he said.

Light Therapy for Atopy

UV light therapy is a frequent treatment for eczema and other atopic dermatoses, but for about 3% of patients, it the wrong thing to offer, Dr. Berger said. "For this small population, sun exposure actually makes the condition worse. Put them in the light box and the eczema will flare."

More than a cursory skin exam should be performed on patients with atopic dermatitis, he recommended. "Have them remove their clothing at least from the waist up. Look for eczema that has a photo distribution: It might be worse on the face and side of the neck, but beneath the chin the skin could be spared. If it looks like a photo-distributed rash, and they report a history of flare with sun exposure, then prescribing aggressive sun protection might make a big difference."

A frequently missed diagnosis in young children – particularly infants – is erythropoietic protoporphyria (EPP). "The first time these infants go out into the sun, they will start screaming, because their skin is burning," Dr. Berger said. As quickly as 1 hour after sun exposure, they may develop erythema, edema, urticarial lesions, or purpura on exposed skin.

Europeans are somewhat ahead in drug research for treating EPP, Dr. Berger noted, but the United States is catching up. The University of California is one of six U.S. study sites participating in a phase II placebo-controlled trial of afamelanotide, a synthetically produced analog of human alpha-melanocytic–stimulating hormone (alpha-MSH).

"The hope is that the drug will stimulate the production of melanin, which actually has two benefits," Dr. Berger said. "First, it's a photo protectant, but it's also an antioxidant."

When porphyrins absorb UV rays, they release free radicals that lead to the acute and chronic damage that occurs on EPP patient skin. The porphyrins can accumulate and damage other tissues – including the liver, which causes problems for about 20% of EPP patients. The extra melanin can help neutralize these highly reactive oxygen species and provide protection from the acute symptoms patients suffer when skin is exposed.

While afamelanotide can never cure EPP, Dr. Berger said, it might afford patients the opportunity to live a more normal life. "While they will never be going out looking for a tan, at least they may be able to enjoy being outdoors without having to be completely encased in clothing."

Dr. Berger disclosed serving as a consultant for Prescription Solutions. SDEF and this news organization are owned by Elsevier.

Sunscreens are an important part of a dermatologist's tool kit, but they're not a panacea for UV-induced damage, according to Dr. Timothy Berger.

Although sunscreens work well in laboratory testing, almost no one applies them in a way that will provide the advertised UV protection, Dr. Berger noted at the Las Vegas Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF). And for some patients, sunscreens can exacerbate their UV-induced problems.

Sunscreens themselves, not the vehicular preservatives, are usually the culprit when a patient presents with a complaint of being allergic to sunscreens, said Dr. Berger, a professor of dermatology at the University of California, San Francisco.

"You will usually find that the dermatitis only occurs in areas touched by the sun," he said in an interview. "The problem is often an allergy to the PABA or PABA-related substances in the sunscreen they are using."

Photo courtesy Dr. Timothy Berger

For patients like this, the best alternative is a PABA-free sunscreen that contains zinc and titanium oxide – inert compounds that are physical barriers against UV light, rather than chemical barriers.

And although SPF ratings might look great in advertisements, it is almost a sure bet that sun-seeking patients are not getting nearly the protection promised, Dr. Berger noted. "Some interesting recent studies have looked at what SPF you actually get what you put on sunscreen. The amount used in testing is actually about four times more than what people really use."

One study found that most people apply about 0.5 mg/cm2, while the lab tests use a volume of 2 mg/cm2 to achieve the advertised SPF (J. Am. Acad. Dermatol. 2010;62:218-22). "The problem is, efficacy falls off in a very sharp way," Dr. Berger said. "If you apply SPF 30 sun block [at one-quarter the recommended amount], you only end up with an actual SPF of about 3."

"We need to make sure our patients understand this. And while most people are still not going to use the necessary amount, we can stress the importance of reapplying frequently, which can help keep the protective value up somewhat," he said.

Light Therapy for Atopy

UV light therapy is a frequent treatment for eczema and other atopic dermatoses, but for about 3% of patients, it the wrong thing to offer, Dr. Berger said. "For this small population, sun exposure actually makes the condition worse. Put them in the light box and the eczema will flare."

More than a cursory skin exam should be performed on patients with atopic dermatitis, he recommended. "Have them remove their clothing at least from the waist up. Look for eczema that has a photo distribution: It might be worse on the face and side of the neck, but beneath the chin the skin could be spared. If it looks like a photo-distributed rash, and they report a history of flare with sun exposure, then prescribing aggressive sun protection might make a big difference."

A frequently missed diagnosis in young children – particularly infants – is erythropoietic protoporphyria (EPP). "The first time these infants go out into the sun, they will start screaming, because their skin is burning," Dr. Berger said. As quickly as 1 hour after sun exposure, they may develop erythema, edema, urticarial lesions, or purpura on exposed skin.

Europeans are somewhat ahead in drug research for treating EPP, Dr. Berger noted, but the United States is catching up. The University of California is one of six U.S. study sites participating in a phase II placebo-controlled trial of afamelanotide, a synthetically produced analog of human alpha-melanocytic–stimulating hormone (alpha-MSH).

"The hope is that the drug will stimulate the production of melanin, which actually has two benefits," Dr. Berger said. "First, it's a photo protectant, but it's also an antioxidant."

When porphyrins absorb UV rays, they release free radicals that lead to the acute and chronic damage that occurs on EPP patient skin. The porphyrins can accumulate and damage other tissues – including the liver, which causes problems for about 20% of EPP patients. The extra melanin can help neutralize these highly reactive oxygen species and provide protection from the acute symptoms patients suffer when skin is exposed.

While afamelanotide can never cure EPP, Dr. Berger said, it might afford patients the opportunity to live a more normal life. "While they will never be going out looking for a tan, at least they may be able to enjoy being outdoors without having to be completely encased in clothing."

Dr. Berger disclosed serving as a consultant for Prescription Solutions. SDEF and this news organization are owned by Elsevier.

Sunscreens are an important part of a dermatologist's tool kit, but they're not a panacea for UV-induced damage, according to Dr. Timothy Berger.

Although sunscreens work well in laboratory testing, almost no one applies them in a way that will provide the advertised UV protection, Dr. Berger noted at the Las Vegas Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF). And for some patients, sunscreens can exacerbate their UV-induced problems.

Sunscreens themselves, not the vehicular preservatives, are usually the culprit when a patient presents with a complaint of being allergic to sunscreens, said Dr. Berger, a professor of dermatology at the University of California, San Francisco.

"You will usually find that the dermatitis only occurs in areas touched by the sun," he said in an interview. "The problem is often an allergy to the PABA or PABA-related substances in the sunscreen they are using."

Photo courtesy Dr. Timothy Berger

For patients like this, the best alternative is a PABA-free sunscreen that contains zinc and titanium oxide – inert compounds that are physical barriers against UV light, rather than chemical barriers.

And although SPF ratings might look great in advertisements, it is almost a sure bet that sun-seeking patients are not getting nearly the protection promised, Dr. Berger noted. "Some interesting recent studies have looked at what SPF you actually get what you put on sunscreen. The amount used in testing is actually about four times more than what people really use."

One study found that most people apply about 0.5 mg/cm2, while the lab tests use a volume of 2 mg/cm2 to achieve the advertised SPF (J. Am. Acad. Dermatol. 2010;62:218-22). "The problem is, efficacy falls off in a very sharp way," Dr. Berger said. "If you apply SPF 30 sun block [at one-quarter the recommended amount], you only end up with an actual SPF of about 3."

"We need to make sure our patients understand this. And while most people are still not going to use the necessary amount, we can stress the importance of reapplying frequently, which can help keep the protective value up somewhat," he said.

Light Therapy for Atopy

UV light therapy is a frequent treatment for eczema and other atopic dermatoses, but for about 3% of patients, it the wrong thing to offer, Dr. Berger said. "For this small population, sun exposure actually makes the condition worse. Put them in the light box and the eczema will flare."

More than a cursory skin exam should be performed on patients with atopic dermatitis, he recommended. "Have them remove their clothing at least from the waist up. Look for eczema that has a photo distribution: It might be worse on the face and side of the neck, but beneath the chin the skin could be spared. If it looks like a photo-distributed rash, and they report a history of flare with sun exposure, then prescribing aggressive sun protection might make a big difference."

A frequently missed diagnosis in young children – particularly infants – is erythropoietic protoporphyria (EPP). "The first time these infants go out into the sun, they will start screaming, because their skin is burning," Dr. Berger said. As quickly as 1 hour after sun exposure, they may develop erythema, edema, urticarial lesions, or purpura on exposed skin.

Europeans are somewhat ahead in drug research for treating EPP, Dr. Berger noted, but the United States is catching up. The University of California is one of six U.S. study sites participating in a phase II placebo-controlled trial of afamelanotide, a synthetically produced analog of human alpha-melanocytic–stimulating hormone (alpha-MSH).

"The hope is that the drug will stimulate the production of melanin, which actually has two benefits," Dr. Berger said. "First, it's a photo protectant, but it's also an antioxidant."

When porphyrins absorb UV rays, they release free radicals that lead to the acute and chronic damage that occurs on EPP patient skin. The porphyrins can accumulate and damage other tissues – including the liver, which causes problems for about 20% of EPP patients. The extra melanin can help neutralize these highly reactive oxygen species and provide protection from the acute symptoms patients suffer when skin is exposed.

While afamelanotide can never cure EPP, Dr. Berger said, it might afford patients the opportunity to live a more normal life. "While they will never be going out looking for a tan, at least they may be able to enjoy being outdoors without having to be completely encased in clothing."

Dr. Berger disclosed serving as a consultant for Prescription Solutions. SDEF and this news organization are owned by Elsevier.

GOTHENBURG, Sweden – While the hygiene hypothesis is the most popular explanation offered for the increase in atopic disease in developed countries., it's not the only plausible explanation, according to Dr. John P. McFadden.

The hapten hypothesis holds that the 400% rise in atopic dermatitis, asthma, and hay fever during the past 50 years is caused at least in part by the revolutionary increase in exposure to chemical haptens in the personal environment during the same time frame, Dr. McFadden said at the annual congress of the European Academy of Dermatology and Venereology.

Haptens are low-molecular-weight organic chemicals that aren't allergenic on their own but can bind to a peptide or protein, thereby altering its configuration and rendering it foreign and allergenic. Examples of haptens include antibiotics and some other drugs, as well as chemicals present in toiletries, processed foods, powdered milk, preservatives used in vaccines, and metal jewelry, explained Dr. McFadden of St. John's Institute of Dermatology, St. Thomas' Hospital, London.

He noted that Scottish investigators have documented a relentless rise in cases of childhood asthma and eczema in that country from 1945 to 1997 occurring in parallel with an increasing prevalence of adult nickel allergy.

"Obviously, association doesn't prove causation. But there does seem to be a change, not just in nickel exposure, but in exposure to other haptens," he said.

Photo:© Monika Wisniewska/ fotolia.com

Exposure to haptens has exploded in modern life. For example, global sales of toiletries quadrupled during 1959-76. Today more than 80% of baby skin care products contain chemical fragrances. Various brands of powdered milk contain a mean of 12 haptens each. In 1992, just 6% of young women living in Tokyo dyed their hair; by 2001, this figure had jumped to 89% – and meanwhile the incidence of atopic disease in the Tokyo area doubled. Antibiotics weren't in general use until the second half of the 20th century. And that’s when pierced earrings took off in popularity as well, Dr. McFadden noted.

Also, epidemiologic studies show that certain maternal occupations predispose to the birth of atopic children. Among these occupations are hairdresser, beautician, cleaner, electroplater, bar staff, dental assistant, confectionary maker, and book binder. What these diverse occupations have in common is increased environmental exposure to haptens.

The cornerstone of the hygiene hypothesis is that major improvements in public health have led to a cleaner home environment, resulting in less microbial stimulation of immune function and a consequent predisposition to atopic disease. Under audience questioning, Dr. McFadden conceded the hygiene hypothesis "may have some validity," but he added he finds it troubling that many adherents of the hypothesis have "a tendency to be slightly in lazy in explaining away discrepancies.

"When you go back home," Dr. McFadden continued, "I want you to ask your allergist colleagues three questions: One, the biggest reduction in infections came at the end of the 19th century, with improvements in sanitation and nutrition – not in the second half of the 20th century, when the greatest increase in atopic disease occurred – so why was there no reported increase in allergy back then? Two, they say our immune systems haven’t met infections, but actually the vaccination programs mean our immune systems think we've met polio, tetanus, diphtheria, and measles, all by the age of 1 year – how does that fit with the hygiene hypothesis? And three, studies have repeatedly shown that respiratory infections are associated with the development of atopic disease, and we've all seen cases of eczema that are triggered by cutaneous infections – how does that fit in?"

The hapten hypothesis holds that persistent low-grade exposure to environmental haptens via the skin and oral routes at key times of Th2 cytokine immune dominance – namely, pregnancy and the first year of life – can lead to atopy. Dietary hapten intake may interfere with oral immune tolerance mechanisms, while repeated cutaneous exposure to haptens could skew the innate immune system into promoting Th2 responses.

"We're postulating that all of this hapten exposure probably doesn’t matter the rest of the time, but during these vulnerable periods it may be important," Dr. McFadden said.

Last year he and his coworkers laid out in detail the proposed immunologic mechanisms driving the hapten-atopy hypothesis (Trends Immunol. 2009;30:67-74). Consistent with their hypothesis, mouse studies have shown that repeated low-grade exposure to haptens can result in two types of nontolerogenic response: the classic one, namely, allergic contact dermatitis, but also atopic dermatitis. In humans, it’s well established that repeated exposure to haptens can cause allergic contact dermatitis, but it is as yet unknown if hapten exposure contributes in any way to atopic dermatitis. But it’s an issue well worth pursuing, noted Dr. McFadden.

"The question as to whether increases in environmental hapten exposure are contributing to atopy is a legitimate one," he said.

Dr. McFadden disclosed that he has no relevant financial interests.

GOTHENBURG, Sweden – While the hygiene hypothesis is the most popular explanation offered for the increase in atopic disease in developed countries., it's not the only plausible explanation, according to Dr. John P. McFadden.

The hapten hypothesis holds that the 400% rise in atopic dermatitis, asthma, and hay fever during the past 50 years is caused at least in part by the revolutionary increase in exposure to chemical haptens in the personal environment during the same time frame, Dr. McFadden said at the annual congress of the European Academy of Dermatology and Venereology.

Haptens are low-molecular-weight organic chemicals that aren't allergenic on their own but can bind to a peptide or protein, thereby altering its configuration and rendering it foreign and allergenic. Examples of haptens include antibiotics and some other drugs, as well as chemicals present in toiletries, processed foods, powdered milk, preservatives used in vaccines, and metal jewelry, explained Dr. McFadden of St. John's Institute of Dermatology, St. Thomas' Hospital, London.

He noted that Scottish investigators have documented a relentless rise in cases of childhood asthma and eczema in that country from 1945 to 1997 occurring in parallel with an increasing prevalence of adult nickel allergy.

"Obviously, association doesn't prove causation. But there does seem to be a change, not just in nickel exposure, but in exposure to other haptens," he said.

Photo:© Monika Wisniewska/ fotolia.com

Exposure to haptens has exploded in modern life. For example, global sales of toiletries quadrupled during 1959-76. Today more than 80% of baby skin care products contain chemical fragrances. Various brands of powdered milk contain a mean of 12 haptens each. In 1992, just 6% of young women living in Tokyo dyed their hair; by 2001, this figure had jumped to 89% – and meanwhile the incidence of atopic disease in the Tokyo area doubled. Antibiotics weren't in general use until the second half of the 20th century. And that’s when pierced earrings took off in popularity as well, Dr. McFadden noted.

Also, epidemiologic studies show that certain maternal occupations predispose to the birth of atopic children. Among these occupations are hairdresser, beautician, cleaner, electroplater, bar staff, dental assistant, confectionary maker, and book binder. What these diverse occupations have in common is increased environmental exposure to haptens.

The cornerstone of the hygiene hypothesis is that major improvements in public health have led to a cleaner home environment, resulting in less microbial stimulation of immune function and a consequent predisposition to atopic disease. Under audience questioning, Dr. McFadden conceded the hygiene hypothesis "may have some validity," but he added he finds it troubling that many adherents of the hypothesis have "a tendency to be slightly in lazy in explaining away discrepancies.

"When you go back home," Dr. McFadden continued, "I want you to ask your allergist colleagues three questions: One, the biggest reduction in infections came at the end of the 19th century, with improvements in sanitation and nutrition – not in the second half of the 20th century, when the greatest increase in atopic disease occurred – so why was there no reported increase in allergy back then? Two, they say our immune systems haven’t met infections, but actually the vaccination programs mean our immune systems think we've met polio, tetanus, diphtheria, and measles, all by the age of 1 year – how does that fit with the hygiene hypothesis? And three, studies have repeatedly shown that respiratory infections are associated with the development of atopic disease, and we've all seen cases of eczema that are triggered by cutaneous infections – how does that fit in?"

The hapten hypothesis holds that persistent low-grade exposure to environmental haptens via the skin and oral routes at key times of Th2 cytokine immune dominance – namely, pregnancy and the first year of life – can lead to atopy. Dietary hapten intake may interfere with oral immune tolerance mechanisms, while repeated cutaneous exposure to haptens could skew the innate immune system into promoting Th2 responses.

"We're postulating that all of this hapten exposure probably doesn’t matter the rest of the time, but during these vulnerable periods it may be important," Dr. McFadden said.

Last year he and his coworkers laid out in detail the proposed immunologic mechanisms driving the hapten-atopy hypothesis (Trends Immunol. 2009;30:67-74). Consistent with their hypothesis, mouse studies have shown that repeated low-grade exposure to haptens can result in two types of nontolerogenic response: the classic one, namely, allergic contact dermatitis, but also atopic dermatitis. In humans, it’s well established that repeated exposure to haptens can cause allergic contact dermatitis, but it is as yet unknown if hapten exposure contributes in any way to atopic dermatitis. But it’s an issue well worth pursuing, noted Dr. McFadden.

"The question as to whether increases in environmental hapten exposure are contributing to atopy is a legitimate one," he said.

Dr. McFadden disclosed that he has no relevant financial interests.

GOTHENBURG, Sweden – While the hygiene hypothesis is the most popular explanation offered for the increase in atopic disease in developed countries., it's not the only plausible explanation, according to Dr. John P. McFadden.

The hapten hypothesis holds that the 400% rise in atopic dermatitis, asthma, and hay fever during the past 50 years is caused at least in part by the revolutionary increase in exposure to chemical haptens in the personal environment during the same time frame, Dr. McFadden said at the annual congress of the European Academy of Dermatology and Venereology.

Haptens are low-molecular-weight organic chemicals that aren't allergenic on their own but can bind to a peptide or protein, thereby altering its configuration and rendering it foreign and allergenic. Examples of haptens include antibiotics and some other drugs, as well as chemicals present in toiletries, processed foods, powdered milk, preservatives used in vaccines, and metal jewelry, explained Dr. McFadden of St. John's Institute of Dermatology, St. Thomas' Hospital, London.

He noted that Scottish investigators have documented a relentless rise in cases of childhood asthma and eczema in that country from 1945 to 1997 occurring in parallel with an increasing prevalence of adult nickel allergy.

"Obviously, association doesn't prove causation. But there does seem to be a change, not just in nickel exposure, but in exposure to other haptens," he said.

Photo:© Monika Wisniewska/ fotolia.com

Exposure to haptens has exploded in modern life. For example, global sales of toiletries quadrupled during 1959-76. Today more than 80% of baby skin care products contain chemical fragrances. Various brands of powdered milk contain a mean of 12 haptens each. In 1992, just 6% of young women living in Tokyo dyed their hair; by 2001, this figure had jumped to 89% – and meanwhile the incidence of atopic disease in the Tokyo area doubled. Antibiotics weren't in general use until the second half of the 20th century. And that’s when pierced earrings took off in popularity as well, Dr. McFadden noted.

Also, epidemiologic studies show that certain maternal occupations predispose to the birth of atopic children. Among these occupations are hairdresser, beautician, cleaner, electroplater, bar staff, dental assistant, confectionary maker, and book binder. What these diverse occupations have in common is increased environmental exposure to haptens.

The cornerstone of the hygiene hypothesis is that major improvements in public health have led to a cleaner home environment, resulting in less microbial stimulation of immune function and a consequent predisposition to atopic disease. Under audience questioning, Dr. McFadden conceded the hygiene hypothesis "may have some validity," but he added he finds it troubling that many adherents of the hypothesis have "a tendency to be slightly in lazy in explaining away discrepancies.

"When you go back home," Dr. McFadden continued, "I want you to ask your allergist colleagues three questions: One, the biggest reduction in infections came at the end of the 19th century, with improvements in sanitation and nutrition – not in the second half of the 20th century, when the greatest increase in atopic disease occurred – so why was there no reported increase in allergy back then? Two, they say our immune systems haven’t met infections, but actually the vaccination programs mean our immune systems think we've met polio, tetanus, diphtheria, and measles, all by the age of 1 year – how does that fit with the hygiene hypothesis? And three, studies have repeatedly shown that respiratory infections are associated with the development of atopic disease, and we've all seen cases of eczema that are triggered by cutaneous infections – how does that fit in?"

The hapten hypothesis holds that persistent low-grade exposure to environmental haptens via the skin and oral routes at key times of Th2 cytokine immune dominance – namely, pregnancy and the first year of life – can lead to atopy. Dietary hapten intake may interfere with oral immune tolerance mechanisms, while repeated cutaneous exposure to haptens could skew the innate immune system into promoting Th2 responses.

"We're postulating that all of this hapten exposure probably doesn’t matter the rest of the time, but during these vulnerable periods it may be important," Dr. McFadden said.

Last year he and his coworkers laid out in detail the proposed immunologic mechanisms driving the hapten-atopy hypothesis (Trends Immunol. 2009;30:67-74). Consistent with their hypothesis, mouse studies have shown that repeated low-grade exposure to haptens can result in two types of nontolerogenic response: the classic one, namely, allergic contact dermatitis, but also atopic dermatitis. In humans, it’s well established that repeated exposure to haptens can cause allergic contact dermatitis, but it is as yet unknown if hapten exposure contributes in any way to atopic dermatitis. But it’s an issue well worth pursuing, noted Dr. McFadden.

"The question as to whether increases in environmental hapten exposure are contributing to atopy is a legitimate one," he said.

Dr. McFadden disclosed that he has no relevant financial interests.

Tackling the tough questions parents sometimes have about food allergies is not easy for pediatric dermatologists, in part because there is so little consensus in the literature. However, a large review of the literature may offer some guidance.

Tackling the tough questions parents sometimes have about food allergies is not easy for pediatric dermatologists, in part because there is so little consensus in the literature. However, a large review of the literature may offer some guidance.

Tackling the tough questions parents sometimes have about food allergies is not easy for pediatric dermatologists, in part because there is so little consensus in the literature. However, a large review of the literature may offer some guidance.

When a patient fails to respond to treatment for atopic dermatitis, it is important to consider whether nonadherence might be responsible, according to Dr. Lawrence F. Eichenfield.

Dr. Eichenfield, professor of pediatrics and dermatology at the University of California, San Diego, cited a study that found a low level of adherence in children whose use of twice daily triamcinolone ointment was monitored covertly for 8 weeks. Of 26 children who completed the study, the mean rate of adherence was only 32% (J. Am. Acad. Dermatol. 2007;56:211-6).

But the study offered at least one glimmer of hope on improving adherence. Among the children in the study, adherence was substantially higher on or near office-visit days, but rapidly dropped off. Given this finding, more frequent office visits appear to be indicated, Dr. Eichenfield reported at a seminar on women's and pediatric dermatology sponsored by Skin Disease Education Foundation.

Results of other studies suggest that physicians treating atopy should prescribe the simplest possible intervention. They should attend to the psychological and educational needs of patients and their parents. And they should keep therapies short, he said.

He put these lessons into practice when he established the Eczema Center at Rady Children's Hospital in San Diego. Among the most important features of the center is an intensive education component for patients and their families, which Dr. Eichenfield calls "atopic dermatitis school." It is led by a nurse with extensive training and experience in the disorder.

Dr. Eichenfield described the case of a 2-year-old child who had severe inflammatory eczema involving 60%-70% of body surface area with a secondary bacterial infection. The parents were using very small quantities of topical corticosteroids because of fear of possible side effects, and they could not recall the last time their child’s skin had been clear.

Dr. Eichenfield prescribed aggressive topical corticosteroid therapy with wet wraps and a standard course of antibiotics. In atopy school, the family learned not to fear using an appropriate quantity of mid-strength topical corticosteroid. In 2-3 weeks, the child was 90%-95% better and "was easily transitioned to a maintenance regimen of only intermittent prescriptive medicines with excellent disease control over the next 4 months," he said in an interview.

"The intervention wasn't different than what we did before the Eczema Center was established," Dr. Eichenfield added, "But having the dedicated nurse to explain how to do the wet wrap therapy, and providing the opportunity for the parents to explore their questions and concerns about safety with other families in the atopic dermatitis school, made them feel comfortable taking on a regimen that was very effective in treating the disease with a minimum of stronger medicine."

The Eczema Center's Web site includes printable handouts for families and a "Virtual Curriculum," which includes videos on the main topics covered in atopic dermatitis school

Disclosures: Dr. Eichenfield diisclosed serving as a clinical investigator and past consultant for Astellas, Galderma, Johnson & Johnson, Promius, and Stiefel/GSK. He said that neither he nor his family has any equity interest in these companies and no ongoing consultancy relationship, and that the companies had no influence on the content of any of his educational activities.

SDEF and this news organization are owned by Elsevier.

When a patient fails to respond to treatment for atopic dermatitis, it is important to consider whether nonadherence might be responsible, according to Dr. Lawrence F. Eichenfield.

Dr. Eichenfield, professor of pediatrics and dermatology at the University of California, San Diego, cited a study that found a low level of adherence in children whose use of twice daily triamcinolone ointment was monitored covertly for 8 weeks. Of 26 children who completed the study, the mean rate of adherence was only 32% (J. Am. Acad. Dermatol. 2007;56:211-6).

But the study offered at least one glimmer of hope on improving adherence. Among the children in the study, adherence was substantially higher on or near office-visit days, but rapidly dropped off. Given this finding, more frequent office visits appear to be indicated, Dr. Eichenfield reported at a seminar on women's and pediatric dermatology sponsored by Skin Disease Education Foundation.

Results of other studies suggest that physicians treating atopy should prescribe the simplest possible intervention. They should attend to the psychological and educational needs of patients and their parents. And they should keep therapies short, he said.

He put these lessons into practice when he established the Eczema Center at Rady Children's Hospital in San Diego. Among the most important features of the center is an intensive education component for patients and their families, which Dr. Eichenfield calls "atopic dermatitis school." It is led by a nurse with extensive training and experience in the disorder.

Dr. Eichenfield described the case of a 2-year-old child who had severe inflammatory eczema involving 60%-70% of body surface area with a secondary bacterial infection. The parents were using very small quantities of topical corticosteroids because of fear of possible side effects, and they could not recall the last time their child’s skin had been clear.

Dr. Eichenfield prescribed aggressive topical corticosteroid therapy with wet wraps and a standard course of antibiotics. In atopy school, the family learned not to fear using an appropriate quantity of mid-strength topical corticosteroid. In 2-3 weeks, the child was 90%-95% better and "was easily transitioned to a maintenance regimen of only intermittent prescriptive medicines with excellent disease control over the next 4 months," he said in an interview.

"The intervention wasn't different than what we did before the Eczema Center was established," Dr. Eichenfield added, "But having the dedicated nurse to explain how to do the wet wrap therapy, and providing the opportunity for the parents to explore their questions and concerns about safety with other families in the atopic dermatitis school, made them feel comfortable taking on a regimen that was very effective in treating the disease with a minimum of stronger medicine."

The Eczema Center's Web site includes printable handouts for families and a "Virtual Curriculum," which includes videos on the main topics covered in atopic dermatitis school

Disclosures: Dr. Eichenfield diisclosed serving as a clinical investigator and past consultant for Astellas, Galderma, Johnson & Johnson, Promius, and Stiefel/GSK. He said that neither he nor his family has any equity interest in these companies and no ongoing consultancy relationship, and that the companies had no influence on the content of any of his educational activities.

SDEF and this news organization are owned by Elsevier.

When a patient fails to respond to treatment for atopic dermatitis, it is important to consider whether nonadherence might be responsible, according to Dr. Lawrence F. Eichenfield.

Dr. Eichenfield, professor of pediatrics and dermatology at the University of California, San Diego, cited a study that found a low level of adherence in children whose use of twice daily triamcinolone ointment was monitored covertly for 8 weeks. Of 26 children who completed the study, the mean rate of adherence was only 32% (J. Am. Acad. Dermatol. 2007;56:211-6).

But the study offered at least one glimmer of hope on improving adherence. Among the children in the study, adherence was substantially higher on or near office-visit days, but rapidly dropped off. Given this finding, more frequent office visits appear to be indicated, Dr. Eichenfield reported at a seminar on women's and pediatric dermatology sponsored by Skin Disease Education Foundation.

Results of other studies suggest that physicians treating atopy should prescribe the simplest possible intervention. They should attend to the psychological and educational needs of patients and their parents. And they should keep therapies short, he said.

He put these lessons into practice when he established the Eczema Center at Rady Children's Hospital in San Diego. Among the most important features of the center is an intensive education component for patients and their families, which Dr. Eichenfield calls "atopic dermatitis school." It is led by a nurse with extensive training and experience in the disorder.

Dr. Eichenfield described the case of a 2-year-old child who had severe inflammatory eczema involving 60%-70% of body surface area with a secondary bacterial infection. The parents were using very small quantities of topical corticosteroids because of fear of possible side effects, and they could not recall the last time their child’s skin had been clear.

Dr. Eichenfield prescribed aggressive topical corticosteroid therapy with wet wraps and a standard course of antibiotics. In atopy school, the family learned not to fear using an appropriate quantity of mid-strength topical corticosteroid. In 2-3 weeks, the child was 90%-95% better and "was easily transitioned to a maintenance regimen of only intermittent prescriptive medicines with excellent disease control over the next 4 months," he said in an interview.

"The intervention wasn't different than what we did before the Eczema Center was established," Dr. Eichenfield added, "But having the dedicated nurse to explain how to do the wet wrap therapy, and providing the opportunity for the parents to explore their questions and concerns about safety with other families in the atopic dermatitis school, made them feel comfortable taking on a regimen that was very effective in treating the disease with a minimum of stronger medicine."

The Eczema Center's Web site includes printable handouts for families and a "Virtual Curriculum," which includes videos on the main topics covered in atopic dermatitis school

Disclosures: Dr. Eichenfield diisclosed serving as a clinical investigator and past consultant for Astellas, Galderma, Johnson & Johnson, Promius, and Stiefel/GSK. He said that neither he nor his family has any equity interest in these companies and no ongoing consultancy relationship, and that the companies had no influence on the content of any of his educational activities.

SDEF and this news organization are owned by Elsevier.