To view the tables for this article, please download the pdf version.
Allergic contact dermatitis (ACD) affects over 14.5 million Americans each year, notably defining itself as an important widespread disease.1 Due to overwhelming patient morbidity, loss of school and work time and significant expenditures for healthcare visits and medicaments ACD presents with a high economic burden. Fortunately, through keen patient interviewing and patch testing, an avoidable culprit may be identified. Remission can occur with implementation of an allergen avoidance regimen. Education becomes the critical bridging intervention to ensure treatment adherence and symptom resolution. Patients who are unable to comply with avoidance regimens are at risk for sustained, recurrent, progressive or even systemic dermatitis.2,3 To ensure patients have an appropriate understanding of all the potential outcomes and their central role in disease pathology and treatment, education of the patient may occur even before the diagnostic patch test is performed.
Important aspects of patient counseling include explaining the nature of their disease, for example, the delayed presentation of ACD [aka the importance of a delayed read at 96 hours]; the relationship with the immune system (sensitization to a chemical followed by elicitation of dermatitis with re-exposure) and the indifference to time (a substance the patient has been using regularly, briefly or intermittently can sensitize at any point). Notably, irritant contact dermatitis (ICD), the most prevalent form of contact dermatitis, can at times precede or be a concomitant diagnosis with ACD.4,5 Unlike ACD, ICD may occur on the first exposure to an irritating or abrasive substance. The innate immune system is activated and inflammation ensues. Contact urticaria (wheal and flare reaction), on the other hand, represents one of the least prevalent forms of ACD. It is an immune-mediated phenomenon governed by a hallmark IgE and mast cell-mediated immediate-type hypersensitivity reaction. We acknowledge this form of hypersensitivity due to its potentially deadly anaphylactic reactions and direct the reader to key sources.6-8
Although ACD is not “curable,” many individuals will achieve complete remission with assiduous avoidance. In this article, we focus on ACD allergen avoidance education. We also explore top relevant allergens, regional- and topic-based dermatitis presentations and clinical tips and pearls for diagnosis and treatment.
Allergen Avoidance Education: The Bane of Providers’ and Patients’ Existence
Contact dermatitis is an immune-mediated process where the skin develops itching, erythema and scaling. Often topical steroids are applied as a first-line treatment and an effort is made to simplify the patient’s skincare regimen. If this fails to result in clinical improvement of the dermatitis, patch tests are often performed. It is important to note that this disorder may be associated with a range of environmental sources, from plants and fragrances to preservatives or other additives found in skincare products. Once a patch test is performed and an is allergen detected, the patient and/or the care provider carefully review current topicals the patient is using to investigate for potential sources of the patient’s allergen(s), eg, soaps, shampoos, lubricants, make-up and even prescription topical preparations.
The traditional approach is to give the name of the allergen to the patient with information sheets stating the common and uncommon sources of this allergen to promote awareness in the patient of his/her environment. The patient is then asked to take on the cumbersome task of reviewing package labeling to identify allergen-free products, in an attempt to find safe products. Because typical allergen names are long, difficult to spell, commonly have numerous complex synonyms and are often intimidating for patients, compliance with allergen avoidance is frequently difficult. Patients are challenged when they encounter chemical names such as the preservative dimethyl dimethyl-hydantoin, and a formaldehyde allergic patient may not remember that this is a chemical that releases formaldehyde.
In 1998, Mayo Clinic transformed the management of skincare product allergen avoidance with the launch of the Contact Allergen Replacement Database (CARD).9 At the end of patch testing, patients were given an extensive list of products they can safely use, free of their patch-test proven allergens. CARD became available to American Contact Dermatitis Society (ACDS) members in 2001 and the American Academy of Dermatology Awarded CARD the Gold Triangle Award for excellence in public education in dermatology. Dermatologists, allergists and patients who used CARD found it to be tremendously helpful in assisting patients with avoidance of allergens and improved compliance.10-14 Specifically, CARD was found to increase patient satisfaction and allowed for high impact counseling and a decrease in physician or physician extender time required for patient education. In 2011, CARD was licensed to Preventice (Rochester, MN) and expanded to include a mobile app. A similar database, the Contact Allergen Management Program (CAMP) became available for ACDS members in 2011.
Modern Allergen Avoidance Tools
Features contrasting CARD and CAMP are outlined in the Table (below). In the overview, both CARD and CAMP include a large number of skincare products that are divided into skincare product categories (Figure). Both databases include over-the-counter and prescription products.
Each database is developed and maintained by a high-quality team of experts in contact dermatitis. CARD is programmed by default to err on the side of caution, assertively eliminating potential cross-reactors from a patient’s shopping list. CARD also offers customization of cross-reactors, so that the provider can determine the allergens they feel their patients should avoid. CAMP predefines allergen cross-reactions resulting in a straightforward user interface. Furthermore, CAMP can generate an alphanumeric allergen code that identifies a specific combination of allergens, for example, fragrance mix 1, neomycin and quaternium-15. This list can be printed or e-mailed to the patient. CARD generates allergen codes that are specific to a given patient, which allows them to retrieve updated shopping lists online.
Fee Structure
CARD is available to healthcare providers and patients via a subscription fee, while CAMP is available to all members of the ACDS and their patients at no additional cost outside of the Society’s membership dues (See Table). CAMP is available for members of the ACDS at www.contact-derm.org, while patients can access updated shopping lists at www.acdscamp.org. CARD is available to physician and patient subscribers at www.AllergyFreeSkin.com, while patients may also access their customized shopping lists via the CARD app.
Inclusion in the Database
The Table outlines the details of the electronic programs. It is important to note that CARD and CAMP each contain more than 4,000 products. Furthermore, the information for CAMP is obtained from package labels, while the product names and ingredients are obtained directly from the manufacturer or their websites for CARD. Products for both databases are generally chosen for inclusion based on their widespread availability, while trying to focus on products that are free of common allergens. Both programs have a strict quality assurance process.
Virtual Patch Testing
Researchers at the Mayo Clinic reviewed 8,348 standard series patch tests that were performed in the last decade, which included 1,927 patients tested only with their standard series. They identified the 12 most common allergens and noted that 55% reacted to 1 of these chemicals. Furthermore, 35% of these patients tested positive to only 1 of these 12 allergens. As a result, the group suggests pre-emptive avoidance of these highly prevalent and relevant allergens in situations where patch testing is not available, referred to as virtual patch testing.15 CARD offers patients the opportunity to empirically avoid both the Mayo Clinic and North American Contact Dermatitis Groups’ most common skincare product allergens. By providing a shopping list free of these common allergens, “virtual patch testing” (pre-emptive avoidance) can be performed. This population health management tool is available to patients at no charge via the CARD app, available from the Apple iTunes. Virtual patch testing holds particular appeal to healthcare providers who do not perform patch testing or only have a modest number of patients with eczema by providing a listing of skincare products free of common allergens. Notably, CAMP can also generate a list of products free of common allergens, which would be guided by an ACDS provider.
Implementing Electronic Solutions
Traditional allergen avoidance handouts continue to be an important part of allergen avoidance education, especially for allergens that can be found outside of skincare products. Both electronic programs are offering information on a majority of allergens that are tested in North America via allergens vended by Chemotechnique (Chemotechnique Diagnostics, Sweden), AllergEAZE (SmartPractice Dermatology, Calgary, Alberta) and the commercially available FDA approved thin-layer rapid use epicutaneous test (TrueTest, SmartPractice Dermatology, Phoenix, AZ).16 Along with the ACDS, these companies provide avoidance handouts and some web-based video informatics (mypatchlink.com).
Practicals of Patch Testing
Patch testing is often necessary to confirm the diagnosis of ACD and to identify the relevant allergen(s) responsible. Screening patch test trays are available, which isolate the most common chemicals and offer the provider clues for potential sources. The ACDS Standard Series includes 80 allergens from several different categories.16 Supplemental trays are also available.17 Avoidance information on these 80 allergens is widely available. As contact dermatitis becomes diagnosed with more frequency, particularly with increased utilization of the commercially available patch testing, improved avenues for patient education and avoidance compliance need to explored; the electronic database tools to create “shopping lists” represent an essential and effective clinical implementation tool.
Pearls of Treatment: Every Dose Counts
A person might be exposed to and subsequently sensitized to a contact allergen for days to years before demonstrating the clinical picture of ACD. With each exposure, there is an increasing risk of reaching a point at which the immune system meets its metaphorical “threshold” and subsequent exposures at this point can lead to elicitation of a cutaneous response.18 Just as repeated contact over time led to an immune response, repeated avoidance over time will induce remission. These electronic tools help to ensure an improved clinical outcome by enabling patients to easily find alternative products devoid of their allergens.
Dr. Yiannias is an associate professor of dermatology, associate medical director for the Center for Innovation, and medical director for the Center for Connected Care at the Mayo Clinic in Arizona. He is a general dermatologist with a special interest in contact dermatitis. Dr. Yiannias invented the Contact Allergen Replacement Database.
Ms. Johnson has 45 years of dermatology experience at Mayo Clinic in outpatient and inpatient settings. She was a patch test coordinator for 12 years and is presently the Contact Allergen Replacement Database Coordinator.
Disclosure: The authors report no relavent financial relationships.
Dr. Jacob, the Section Editor of Allergen Focus, is associate professor, dermatology; director of the Contact Dermatitis Clinic, Loma Linda University.
Disclosure: Dr. Jacob is an investigator for Smartchoice USA PREA-2 trial.
References
1. Bickers DR, Lim HW, Margolis D, et al. The burden of skin diseases: 2004 a joint project of the American Academy of Dermatology and the Society for Investigative Dermatology. J Am Acad of Dermatol. 2006;55(3):490-500.
2. Hsu JW, Matiz C, Jacob SE. Nickel allergy: localized, id, and systemic manifestations in children. Pediatr Dermatol. 2011;28(3):276-280.
3. Salam TN, Fowler JF Jr. Balsam-related systemic contact dermatitis. J Am Acad Dermatol. 2001;45(3):377-381.
4. Nijhawen RI, Matiz C, Jacob SE. Contact dermatitis: from basics to allergodromes. Pediatric Annals. 2009;38(2):99-108.
5. Militello G, Jacob SE, Crawford GH. Allergic contact dermatitis in children. Curr Opin Pediatr. 2006;18(4):385-390.
6. Valks R, Conde-Salazar L, Cuevas M. Allergic contact urticaria from natural rubber latex in healthcare and non-healthcare workers. Contact Dermatitis. 2004;50(4):222-224.
7. Walsh ML, Smith VH, King CM. Type 1 and type IV hypersensitivity to nickel. Australas J Dermatol. 2010;51(4):285-286.
8. Gimenez-Arnau A, Maurer M, De La Cuadra J, Maibach H. Immediate contact skin reactions, an update of Contact Urticaria, Contact Urticaria Syndrome and Protein Contact Dermatitis -- “A Never Ending Story.” Eur J Dermatol. 2010;20(5):552-562.
9. Yiannias JA, Miller R, Kist JM. Creation, history, and future of the Contact Allergen Replacement Database (CARD). Dermatitis. 2009;20(6):322-326.
10. Kist J, Yiannias J, el-Azhary RA. Efficacy of contact allergen replacement database in the treatment of allergic contact dermatitis. Am J Contact Derm. 2001;12(2):124.
11. Yiannias JA. Facilitation of the management of allergic contact dermatitis via on-line tools. Presented at: 15th Annual Meeting of the American Contact Dermatitis Society; February 5, 2004; Washington, DC.
12. El-Azhary RA, Yiannias JA. A new patient education approach in contact allergic dermatitis: the Contact Allergen Replacement Database (CARD). Int J Dermatol. 2004;43(4):278-280.
13. Kist JM, el-Azhary RA, Hentz JG, Yiannias JA. The contact allergen replacement database and treatment of allergic contact dermatitis. Arch Dermatol. 2004;140(12):1448-1450.
14. Nelson SA, Yiannias JA. Relevance and avoidance of skin-care product allergens: pearls and pitfalls. Dermatol Clin. 2009;27(3):329-336.
15. Yiannias JA. Virtual patch testing: data driven empiric contact allergen avoidance. Presented at: Annual Meeting of the American College of Allergy, Asthma, & Immunology; November 7-11, 2013; Baltimore, MD.
16. allergEAZE Allergens website. https://www.allergeaze.com/allergens.aspx?ID=Series. Accessed July 30, 2014.
17. Patch Test Products 2011. Chemotechnique Diagnostics website. https://www.chemotechnique.se/Catalogue.htm. Accessed July 30, 2014.
18. Jacob SE, Herro EM, Taylor J. Contact dermatitis: diagnosis and therapy. In: Elzouki AV, Harfi HA, Nazer H, Oh W, Stapleton FB, Whitley RJ, eds. Textbook of Clinical Pediatrics. 2nd ed. New York, NY: Springer; 2011.
Dr. Jacob, the Section Editor of Allergen Focus, is associate professor, dermatology; director of the Contact Dermatitis Clinic, Loma Linda University.
Disclosure: Dr. Jacob is an investigator for Smartchoice USA PREA-2 trial.
To view the tables for this article, please download the pdf version.
Allergic contact dermatitis (ACD) affects over 14.5 million Americans each year, notably defining itself as an important widespread disease.1 Due to overwhelming patient morbidity, loss of school and work time and significant expenditures for healthcare visits and medicaments ACD presents with a high economic burden. Fortunately, through keen patient interviewing and patch testing, an avoidable culprit may be identified. Remission can occur with implementation of an allergen avoidance regimen. Education becomes the critical bridging intervention to ensure treatment adherence and symptom resolution. Patients who are unable to comply with avoidance regimens are at risk for sustained, recurrent, progressive or even systemic dermatitis.2,3 To ensure patients have an appropriate understanding of all the potential outcomes and their central role in disease pathology and treatment, education of the patient may occur even before the diagnostic patch test is performed.
Important aspects of patient counseling include explaining the nature of their disease, for example, the delayed presentation of ACD [aka the importance of a delayed read at 96 hours]; the relationship with the immune system (sensitization to a chemical followed by elicitation of dermatitis with re-exposure) and the indifference to time (a substance the patient has been using regularly, briefly or intermittently can sensitize at any point). Notably, irritant contact dermatitis (ICD), the most prevalent form of contact dermatitis, can at times precede or be a concomitant diagnosis with ACD.4,5 Unlike ACD, ICD may occur on the first exposure to an irritating or abrasive substance. The innate immune system is activated and inflammation ensues. Contact urticaria (wheal and flare reaction), on the other hand, represents one of the least prevalent forms of ACD. It is an immune-mediated phenomenon governed by a hallmark IgE and mast cell-mediated immediate-type hypersensitivity reaction. We acknowledge this form of hypersensitivity due to its potentially deadly anaphylactic reactions and direct the reader to key sources.6-8
Although ACD is not “curable,” many individuals will achieve complete remission with assiduous avoidance. In this article, we focus on ACD allergen avoidance education. We also explore top relevant allergens, regional- and topic-based dermatitis presentations and clinical tips and pearls for diagnosis and treatment.
Allergen Avoidance Education: The Bane of Providers’ and Patients’ Existence
Contact dermatitis is an immune-mediated process where the skin develops itching, erythema and scaling. Often topical steroids are applied as a first-line treatment and an effort is made to simplify the patient’s skincare regimen. If this fails to result in clinical improvement of the dermatitis, patch tests are often performed. It is important to note that this disorder may be associated with a range of environmental sources, from plants and fragrances to preservatives or other additives found in skincare products. Once a patch test is performed and an is allergen detected, the patient and/or the care provider carefully review current topicals the patient is using to investigate for potential sources of the patient’s allergen(s), eg, soaps, shampoos, lubricants, make-up and even prescription topical preparations.
The traditional approach is to give the name of the allergen to the patient with information sheets stating the common and uncommon sources of this allergen to promote awareness in the patient of his/her environment. The patient is then asked to take on the cumbersome task of reviewing package labeling to identify allergen-free products, in an attempt to find safe products. Because typical allergen names are long, difficult to spell, commonly have numerous complex synonyms and are often intimidating for patients, compliance with allergen avoidance is frequently difficult. Patients are challenged when they encounter chemical names such as the preservative dimethyl dimethyl-hydantoin, and a formaldehyde allergic patient may not remember that this is a chemical that releases formaldehyde.
In 1998, Mayo Clinic transformed the management of skincare product allergen avoidance with the launch of the Contact Allergen Replacement Database (CARD).9 At the end of patch testing, patients were given an extensive list of products they can safely use, free of their patch-test proven allergens. CARD became available to American Contact Dermatitis Society (ACDS) members in 2001 and the American Academy of Dermatology Awarded CARD the Gold Triangle Award for excellence in public education in dermatology. Dermatologists, allergists and patients who used CARD found it to be tremendously helpful in assisting patients with avoidance of allergens and improved compliance.10-14 Specifically, CARD was found to increase patient satisfaction and allowed for high impact counseling and a decrease in physician or physician extender time required for patient education. In 2011, CARD was licensed to Preventice (Rochester, MN) and expanded to include a mobile app. A similar database, the Contact Allergen Management Program (CAMP) became available for ACDS members in 2011.
Modern Allergen Avoidance Tools
Features contrasting CARD and CAMP are outlined in the Table (below). In the overview, both CARD and CAMP include a large number of skincare products that are divided into skincare product categories (Figure). Both databases include over-the-counter and prescription products.
Each database is developed and maintained by a high-quality team of experts in contact dermatitis. CARD is programmed by default to err on the side of caution, assertively eliminating potential cross-reactors from a patient’s shopping list. CARD also offers customization of cross-reactors, so that the provider can determine the allergens they feel their patients should avoid. CAMP predefines allergen cross-reactions resulting in a straightforward user interface. Furthermore, CAMP can generate an alphanumeric allergen code that identifies a specific combination of allergens, for example, fragrance mix 1, neomycin and quaternium-15. This list can be printed or e-mailed to the patient. CARD generates allergen codes that are specific to a given patient, which allows them to retrieve updated shopping lists online.
Fee Structure
CARD is available to healthcare providers and patients via a subscription fee, while CAMP is available to all members of the ACDS and their patients at no additional cost outside of the Society’s membership dues (See Table). CAMP is available for members of the ACDS at www.contact-derm.org, while patients can access updated shopping lists at www.acdscamp.org. CARD is available to physician and patient subscribers at www.AllergyFreeSkin.com, while patients may also access their customized shopping lists via the CARD app.
Inclusion in the Database
The Table outlines the details of the electronic programs. It is important to note that CARD and CAMP each contain more than 4,000 products. Furthermore, the information for CAMP is obtained from package labels, while the product names and ingredients are obtained directly from the manufacturer or their websites for CARD. Products for both databases are generally chosen for inclusion based on their widespread availability, while trying to focus on products that are free of common allergens. Both programs have a strict quality assurance process.
Virtual Patch Testing
Researchers at the Mayo Clinic reviewed 8,348 standard series patch tests that were performed in the last decade, which included 1,927 patients tested only with their standard series. They identified the 12 most common allergens and noted that 55% reacted to 1 of these chemicals. Furthermore, 35% of these patients tested positive to only 1 of these 12 allergens. As a result, the group suggests pre-emptive avoidance of these highly prevalent and relevant allergens in situations where patch testing is not available, referred to as virtual patch testing.15 CARD offers patients the opportunity to empirically avoid both the Mayo Clinic and North American Contact Dermatitis Groups’ most common skincare product allergens. By providing a shopping list free of these common allergens, “virtual patch testing” (pre-emptive avoidance) can be performed. This population health management tool is available to patients at no charge via the CARD app, available from the Apple iTunes. Virtual patch testing holds particular appeal to healthcare providers who do not perform patch testing or only have a modest number of patients with eczema by providing a listing of skincare products free of common allergens. Notably, CAMP can also generate a list of products free of common allergens, which would be guided by an ACDS provider.
Implementing Electronic Solutions
Traditional allergen avoidance handouts continue to be an important part of allergen avoidance education, especially for allergens that can be found outside of skincare products. Both electronic programs are offering information on a majority of allergens that are tested in North America via allergens vended by Chemotechnique (Chemotechnique Diagnostics, Sweden), AllergEAZE (SmartPractice Dermatology, Calgary, Alberta) and the commercially available FDA approved thin-layer rapid use epicutaneous test (TrueTest, SmartPractice Dermatology, Phoenix, AZ).16 Along with the ACDS, these companies provide avoidance handouts and some web-based video informatics (mypatchlink.com).
Practicals of Patch Testing
Patch testing is often necessary to confirm the diagnosis of ACD and to identify the relevant allergen(s) responsible. Screening patch test trays are available, which isolate the most common chemicals and offer the provider clues for potential sources. The ACDS Standard Series includes 80 allergens from several different categories.16 Supplemental trays are also available.17 Avoidance information on these 80 allergens is widely available. As contact dermatitis becomes diagnosed with more frequency, particularly with increased utilization of the commercially available patch testing, improved avenues for patient education and avoidance compliance need to explored; the electronic database tools to create “shopping lists” represent an essential and effective clinical implementation tool.
Pearls of Treatment: Every Dose Counts
A person might be exposed to and subsequently sensitized to a contact allergen for days to years before demonstrating the clinical picture of ACD. With each exposure, there is an increasing risk of reaching a point at which the immune system meets its metaphorical “threshold” and subsequent exposures at this point can lead to elicitation of a cutaneous response.18 Just as repeated contact over time led to an immune response, repeated avoidance over time will induce remission. These electronic tools help to ensure an improved clinical outcome by enabling patients to easily find alternative products devoid of their allergens.
Dr. Yiannias is an associate professor of dermatology, associate medical director for the Center for Innovation, and medical director for the Center for Connected Care at the Mayo Clinic in Arizona. He is a general dermatologist with a special interest in contact dermatitis. Dr. Yiannias invented the Contact Allergen Replacement Database.
Ms. Johnson has 45 years of dermatology experience at Mayo Clinic in outpatient and inpatient settings. She was a patch test coordinator for 12 years and is presently the Contact Allergen Replacement Database Coordinator.
Disclosure: The authors report no relavent financial relationships.
Dr. Jacob, the Section Editor of Allergen Focus, is associate professor, dermatology; director of the Contact Dermatitis Clinic, Loma Linda University.
Disclosure: Dr. Jacob is an investigator for Smartchoice USA PREA-2 trial.
References
1. Bickers DR, Lim HW, Margolis D, et al. The burden of skin diseases: 2004 a joint project of the American Academy of Dermatology and the Society for Investigative Dermatology. J Am Acad of Dermatol. 2006;55(3):490-500.
2. Hsu JW, Matiz C, Jacob SE. Nickel allergy: localized, id, and systemic manifestations in children. Pediatr Dermatol. 2011;28(3):276-280.
3. Salam TN, Fowler JF Jr. Balsam-related systemic contact dermatitis. J Am Acad Dermatol. 2001;45(3):377-381.
4. Nijhawen RI, Matiz C, Jacob SE. Contact dermatitis: from basics to allergodromes. Pediatric Annals. 2009;38(2):99-108.
5. Militello G, Jacob SE, Crawford GH. Allergic contact dermatitis in children. Curr Opin Pediatr. 2006;18(4):385-390.
6. Valks R, Conde-Salazar L, Cuevas M. Allergic contact urticaria from natural rubber latex in healthcare and non-healthcare workers. Contact Dermatitis. 2004;50(4):222-224.
7. Walsh ML, Smith VH, King CM. Type 1 and type IV hypersensitivity to nickel. Australas J Dermatol. 2010;51(4):285-286.
8. Gimenez-Arnau A, Maurer M, De La Cuadra J, Maibach H. Immediate contact skin reactions, an update of Contact Urticaria, Contact Urticaria Syndrome and Protein Contact Dermatitis -- “A Never Ending Story.” Eur J Dermatol. 2010;20(5):552-562.
9. Yiannias JA, Miller R, Kist JM. Creation, history, and future of the Contact Allergen Replacement Database (CARD). Dermatitis. 2009;20(6):322-326.
10. Kist J, Yiannias J, el-Azhary RA. Efficacy of contact allergen replacement database in the treatment of allergic contact dermatitis. Am J Contact Derm. 2001;12(2):124.
11. Yiannias JA. Facilitation of the management of allergic contact dermatitis via on-line tools. Presented at: 15th Annual Meeting of the American Contact Dermatitis Society; February 5, 2004; Washington, DC.
12. El-Azhary RA, Yiannias JA. A new patient education approach in contact allergic dermatitis: the Contact Allergen Replacement Database (CARD). Int J Dermatol. 2004;43(4):278-280.
13. Kist JM, el-Azhary RA, Hentz JG, Yiannias JA. The contact allergen replacement database and treatment of allergic contact dermatitis. Arch Dermatol. 2004;140(12):1448-1450.
14. Nelson SA, Yiannias JA. Relevance and avoidance of skin-care product allergens: pearls and pitfalls. Dermatol Clin. 2009;27(3):329-336.
15. Yiannias JA. Virtual patch testing: data driven empiric contact allergen avoidance. Presented at: Annual Meeting of the American College of Allergy, Asthma, & Immunology; November 7-11, 2013; Baltimore, MD.
16. allergEAZE Allergens website. https://www.allergeaze.com/allergens.aspx?ID=Series. Accessed July 30, 2014.
17. Patch Test Products 2011. Chemotechnique Diagnostics website. https://www.chemotechnique.se/Catalogue.htm. Accessed July 30, 2014.
18. Jacob SE, Herro EM, Taylor J. Contact dermatitis: diagnosis and therapy. In: Elzouki AV, Harfi HA, Nazer H, Oh W, Stapleton FB, Whitley RJ, eds. Textbook of Clinical Pediatrics. 2nd ed. New York, NY: Springer; 2011.
Dr. Jacob, the Section Editor of Allergen Focus, is associate professor, dermatology; director of the Contact Dermatitis Clinic, Loma Linda University.
Disclosure: Dr. Jacob is an investigator for Smartchoice USA PREA-2 trial.
To view the tables for this article, please download the pdf version.
Allergic contact dermatitis (ACD) affects over 14.5 million Americans each year, notably defining itself as an important widespread disease.1 Due to overwhelming patient morbidity, loss of school and work time and significant expenditures for healthcare visits and medicaments ACD presents with a high economic burden. Fortunately, through keen patient interviewing and patch testing, an avoidable culprit may be identified. Remission can occur with implementation of an allergen avoidance regimen. Education becomes the critical bridging intervention to ensure treatment adherence and symptom resolution. Patients who are unable to comply with avoidance regimens are at risk for sustained, recurrent, progressive or even systemic dermatitis.2,3 To ensure patients have an appropriate understanding of all the potential outcomes and their central role in disease pathology and treatment, education of the patient may occur even before the diagnostic patch test is performed.
Important aspects of patient counseling include explaining the nature of their disease, for example, the delayed presentation of ACD [aka the importance of a delayed read at 96 hours]; the relationship with the immune system (sensitization to a chemical followed by elicitation of dermatitis with re-exposure) and the indifference to time (a substance the patient has been using regularly, briefly or intermittently can sensitize at any point). Notably, irritant contact dermatitis (ICD), the most prevalent form of contact dermatitis, can at times precede or be a concomitant diagnosis with ACD.4,5 Unlike ACD, ICD may occur on the first exposure to an irritating or abrasive substance. The innate immune system is activated and inflammation ensues. Contact urticaria (wheal and flare reaction), on the other hand, represents one of the least prevalent forms of ACD. It is an immune-mediated phenomenon governed by a hallmark IgE and mast cell-mediated immediate-type hypersensitivity reaction. We acknowledge this form of hypersensitivity due to its potentially deadly anaphylactic reactions and direct the reader to key sources.6-8
Although ACD is not “curable,” many individuals will achieve complete remission with assiduous avoidance. In this article, we focus on ACD allergen avoidance education. We also explore top relevant allergens, regional- and topic-based dermatitis presentations and clinical tips and pearls for diagnosis and treatment.
Allergen Avoidance Education: The Bane of Providers’ and Patients’ Existence
Contact dermatitis is an immune-mediated process where the skin develops itching, erythema and scaling. Often topical steroids are applied as a first-line treatment and an effort is made to simplify the patient’s skincare regimen. If this fails to result in clinical improvement of the dermatitis, patch tests are often performed. It is important to note that this disorder may be associated with a range of environmental sources, from plants and fragrances to preservatives or other additives found in skincare products. Once a patch test is performed and an is allergen detected, the patient and/or the care provider carefully review current topicals the patient is using to investigate for potential sources of the patient’s allergen(s), eg, soaps, shampoos, lubricants, make-up and even prescription topical preparations.
The traditional approach is to give the name of the allergen to the patient with information sheets stating the common and uncommon sources of this allergen to promote awareness in the patient of his/her environment. The patient is then asked to take on the cumbersome task of reviewing package labeling to identify allergen-free products, in an attempt to find safe products. Because typical allergen names are long, difficult to spell, commonly have numerous complex synonyms and are often intimidating for patients, compliance with allergen avoidance is frequently difficult. Patients are challenged when they encounter chemical names such as the preservative dimethyl dimethyl-hydantoin, and a formaldehyde allergic patient may not remember that this is a chemical that releases formaldehyde.
In 1998, Mayo Clinic transformed the management of skincare product allergen avoidance with the launch of the Contact Allergen Replacement Database (CARD).9 At the end of patch testing, patients were given an extensive list of products they can safely use, free of their patch-test proven allergens. CARD became available to American Contact Dermatitis Society (ACDS) members in 2001 and the American Academy of Dermatology Awarded CARD the Gold Triangle Award for excellence in public education in dermatology. Dermatologists, allergists and patients who used CARD found it to be tremendously helpful in assisting patients with avoidance of allergens and improved compliance.10-14 Specifically, CARD was found to increase patient satisfaction and allowed for high impact counseling and a decrease in physician or physician extender time required for patient education. In 2011, CARD was licensed to Preventice (Rochester, MN) and expanded to include a mobile app. A similar database, the Contact Allergen Management Program (CAMP) became available for ACDS members in 2011.
Modern Allergen Avoidance Tools
Features contrasting CARD and CAMP are outlined in the Table (below). In the overview, both CARD and CAMP include a large number of skincare products that are divided into skincare product categories (Figure). Both databases include over-the-counter and prescription products.
Each database is developed and maintained by a high-quality team of experts in contact dermatitis. CARD is programmed by default to err on the side of caution, assertively eliminating potential cross-reactors from a patient’s shopping list. CARD also offers customization of cross-reactors, so that the provider can determine the allergens they feel their patients should avoid. CAMP predefines allergen cross-reactions resulting in a straightforward user interface. Furthermore, CAMP can generate an alphanumeric allergen code that identifies a specific combination of allergens, for example, fragrance mix 1, neomycin and quaternium-15. This list can be printed or e-mailed to the patient. CARD generates allergen codes that are specific to a given patient, which allows them to retrieve updated shopping lists online.
Fee Structure
CARD is available to healthcare providers and patients via a subscription fee, while CAMP is available to all members of the ACDS and their patients at no additional cost outside of the Society’s membership dues (See Table). CAMP is available for members of the ACDS at www.contact-derm.org, while patients can access updated shopping lists at www.acdscamp.org. CARD is available to physician and patient subscribers at www.AllergyFreeSkin.com, while patients may also access their customized shopping lists via the CARD app.
Inclusion in the Database
The Table outlines the details of the electronic programs. It is important to note that CARD and CAMP each contain more than 4,000 products. Furthermore, the information for CAMP is obtained from package labels, while the product names and ingredients are obtained directly from the manufacturer or their websites for CARD. Products for both databases are generally chosen for inclusion based on their widespread availability, while trying to focus on products that are free of common allergens. Both programs have a strict quality assurance process.
Virtual Patch Testing
Researchers at the Mayo Clinic reviewed 8,348 standard series patch tests that were performed in the last decade, which included 1,927 patients tested only with their standard series. They identified the 12 most common allergens and noted that 55% reacted to 1 of these chemicals. Furthermore, 35% of these patients tested positive to only 1 of these 12 allergens. As a result, the group suggests pre-emptive avoidance of these highly prevalent and relevant allergens in situations where patch testing is not available, referred to as virtual patch testing.15 CARD offers patients the opportunity to empirically avoid both the Mayo Clinic and North American Contact Dermatitis Groups’ most common skincare product allergens. By providing a shopping list free of these common allergens, “virtual patch testing” (pre-emptive avoidance) can be performed. This population health management tool is available to patients at no charge via the CARD app, available from the Apple iTunes. Virtual patch testing holds particular appeal to healthcare providers who do not perform patch testing or only have a modest number of patients with eczema by providing a listing of skincare products free of common allergens. Notably, CAMP can also generate a list of products free of common allergens, which would be guided by an ACDS provider.
Implementing Electronic Solutions
Traditional allergen avoidance handouts continue to be an important part of allergen avoidance education, especially for allergens that can be found outside of skincare products. Both electronic programs are offering information on a majority of allergens that are tested in North America via allergens vended by Chemotechnique (Chemotechnique Diagnostics, Sweden), AllergEAZE (SmartPractice Dermatology, Calgary, Alberta) and the commercially available FDA approved thin-layer rapid use epicutaneous test (TrueTest, SmartPractice Dermatology, Phoenix, AZ).16 Along with the ACDS, these companies provide avoidance handouts and some web-based video informatics (mypatchlink.com).
Practicals of Patch Testing
Patch testing is often necessary to confirm the diagnosis of ACD and to identify the relevant allergen(s) responsible. Screening patch test trays are available, which isolate the most common chemicals and offer the provider clues for potential sources. The ACDS Standard Series includes 80 allergens from several different categories.16 Supplemental trays are also available.17 Avoidance information on these 80 allergens is widely available. As contact dermatitis becomes diagnosed with more frequency, particularly with increased utilization of the commercially available patch testing, improved avenues for patient education and avoidance compliance need to explored; the electronic database tools to create “shopping lists” represent an essential and effective clinical implementation tool.
Pearls of Treatment: Every Dose Counts
A person might be exposed to and subsequently sensitized to a contact allergen for days to years before demonstrating the clinical picture of ACD. With each exposure, there is an increasing risk of reaching a point at which the immune system meets its metaphorical “threshold” and subsequent exposures at this point can lead to elicitation of a cutaneous response.18 Just as repeated contact over time led to an immune response, repeated avoidance over time will induce remission. These electronic tools help to ensure an improved clinical outcome by enabling patients to easily find alternative products devoid of their allergens.
Dr. Yiannias is an associate professor of dermatology, associate medical director for the Center for Innovation, and medical director for the Center for Connected Care at the Mayo Clinic in Arizona. He is a general dermatologist with a special interest in contact dermatitis. Dr. Yiannias invented the Contact Allergen Replacement Database.
Ms. Johnson has 45 years of dermatology experience at Mayo Clinic in outpatient and inpatient settings. She was a patch test coordinator for 12 years and is presently the Contact Allergen Replacement Database Coordinator.
Disclosure: The authors report no relavent financial relationships.
Dr. Jacob, the Section Editor of Allergen Focus, is associate professor, dermatology; director of the Contact Dermatitis Clinic, Loma Linda University.
Disclosure: Dr. Jacob is an investigator for Smartchoice USA PREA-2 trial.
References
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15. Yiannias JA. Virtual patch testing: data driven empiric contact allergen avoidance. Presented at: Annual Meeting of the American College of Allergy, Asthma, & Immunology; November 7-11, 2013; Baltimore, MD.
16. allergEAZE Allergens website. https://www.allergeaze.com/allergens.aspx?ID=Series. Accessed July 30, 2014.
17. Patch Test Products 2011. Chemotechnique Diagnostics website. https://www.chemotechnique.se/Catalogue.htm. Accessed July 30, 2014.
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Dr. Jacob, the Section Editor of Allergen Focus, is associate professor, dermatology; director of the Contact Dermatitis Clinic, Loma Linda University.
Disclosure: Dr. Jacob is an investigator for Smartchoice USA PREA-2 trial.
