Occupational dermatitis in Danish gardeners and greenhouse workers

The aim of the study was to assess the distribution of different types of occupational eczema among employees in floristry and detect the allergens most commonly involved. Based on a postal questionnaire, 253 gardeners and greenhouse workers with occupational skin symptoms and 52 randomly-selected without symptoms were examined and patch tested. Routine tests comprised the standard series, the Compositae mix, feverfew and 3 fungicides, with additional testing based on case records. 184 persons from the symptom group and 1 from the random group had occupational eczema. Irritant occupational contact eczema was suspected in 150 persons (59%). Nevertheless, 48% of the 250 persons patch tested had at least 1 positive reaction, most frequently to nickel, followed by Compositae which were positive in 25 cases (10%), of whom 24 were possibly occupationally sensitized. 13 persons from symptom group had positive reactions to fungicides. Occupational allergic eczema was suspected in 43 persons (17%), most often caused by plants belonging to the Compositae, Geraniaceae and Liliaceae families. New plant sensitizers were Exacum affine and Begonia lorraine. Exposure to specific plant species seemed to be the most important eliciting factors in both allergic and irritant occupational dermatitis in floristry, and preventive measures should include reduction of contact with plants.     

Patch test sensitization to Compositae mix, sesquiterpene-lactone mix, Compositae extracts, laurel leaf, Chlorophorin, Mansonone A, and dimethoxydalbergione.

BACKGROUND: Compositae mix and sesquiterpene-lactone (SL) mix are important patch test substances to show allergic contact dermatitis from various Compositae plants. OBJECTIVES: The aims of this study are to calculate the sensitization rates to Compositae mix and SL mix in an occupational dermatology clinic and to describe cases of active sensitization caused by patch testing with Compositae mix and SL mix. METHODS: Conventional patch testing was performed. SL mix (0.1%) and Compositae mix (6% in petrolatum) were tested in a modified European standard series and a plant allergen series. Testing with other appropriate patch test series was also performed. RESULTS: SL mix provoked 8 allergic patch test reactions (0.7%) in 1,076 patients, whereas Compositae mix was positive in 15 of 346 patients (4.2%). Three patients were actively sensitized to Compositae mix and 1 patient to SL mix. One patient was also sensitized to other plant allergens in a series of allergenic plant chemicals, namely to Mansonone A, an ortho-quinone; (R)-3,4-dimethoxydalbergione, a quinone; and Chlorophorin, a hydroxy stilbene. Allergic patch test reactions to laurel leaf were caused by cross-sensitization to SLs. CONCLUSION: Compositae mix seems to be a more important patch test substance than SL mix to detect allergic contact dermatitis to Compositae plants, but patch testing may sensitize. The concentration of the individual components of the Compositae mix should be adjusted so that the mix detects allergic patients but does not sensitize.     

Compositae dermatitis in a Danish dermatology department in 1 year

During our first year of routine testing with Compositae allergens and extracts, contact allergy to Compositae was frequently found in eczema patients (4.5%), especially in middle-aged or elderly persons. Based on clinical patterns, patch test reactions and the long-term course of the disease, 4 groups of patients were recognized: (a) a small group with localized eczema: (b) another with classic Compositae dermatitis of exposed skin; (c) a 3rd group, the largest, with localized eczema that suddenly one summer turned into a widespread dermatitis: (d) a 4th group with a vesicular hand eczema and more-or-less widespread dermatitis with seasonal variation from the beginning, 65% of the patients had vesicular hand eczema at some time, partly reflecting the frequency of atopy (25%) and metal allergy (44%). 75% of the patients had contact allergy to 5 ≥1 compounds besides Compositae Thus, Compositae allergy may be primary, e.g., in young patients with occupational plant contact, or secondary to other contact allergies, perhaps as a result of increased individual susceptibility. The clinical patterns in the latter patients were most often a widespread dermatitis with summer exacerbation. The variability in the clinical picture makes routine patch testing with Compositae allergens recommendable.     

Contact dermatitis from frullania, compositae and other plants

28 patients with dermatitis from plants were seen over the last 10 years. This was 1.45% of all patients with contact dermatitis. 7 reacted to Frullania , 4 to Compositae. and 1 to helenin. Patch tests with Frullanaceae, Lauraceae, Magnoliaceae, Compositae and helenin, showed no dominant allergen in the plant families with sesquiterpene lactone sensitivity. The positive reactions with feverfew ( Chrysanthemum parthenium ) in nearly all patients is probably due to the high content of the sesqueterpene lactone parthenolide; it is a better screening allergen for Compositae sensitivity than alantolactone (helenin).     

Airborne contact dermatitis from Compositae plants in northern India

60 patients (45 male and 15 female) with suspected airborne contact dermatitis from Compositae (Asteraceae) plants and 20 age-matched controls (15 male and 5 female) were investigated. Patch tests were performed with ethanolic plant extracts of 4 Compositae plants, Parthenium hysterophorus, Chrysanthemum morifolium, Dahlia pinnata and Tagetes indica, all prevalent in northern India. 55 (92%) patients showed positive patch tests, with 35 (64%) demonstrating positive tests to extracts of only 1 of the 4 plants tested. No positive patch tests were seen in the controls. Parthenium hysterophorus (78%) was the most frequent plant reacting, followed by Chrysanthemum morifolium (42%), Dahlia pinnata (18%) and Tagetes indica (7%).     

Compositae dermatitis

Compositae dermatitis is an allergic contact dermatitis. The most important allergens in the Compositae family are sesquiterpene lactones (SL), which are present in the oleoresin fraction of leaf, stem, flower and possibly pollen. Compositae dermatitis is most frequently seen in middle-aged and elderly people in patterns reflecting airborne or direct contact with the allergens. The pattern typically starts in summer and disappears in the autumn or winter. Repeated exposure over many years may lead to a chronic and, at times, a disseminated pattern. Seasonal variation does not occur in occupational Compositae dermatitis. In addition to the classically described airborne pattern of face, 'V' of neck, hands and forearms, hand dermatitis is now recognized to be an equally common presentation. This variability of clinical features, and the frequent occurrence of atopic dermatitis and contact allergy to one or more compounds, highlights the need for routine patch testing with sesquiterpene lactone mix 0.1% (Thermal, Hamburg, Germany), combined with aimed patch testing with Compositae plants and extracts. Avoidance of the plants and plant extracts of this large family can be difficult due to its widespread occurrence in flower, herb and vegetable gardens, urban and rural weed population and native vegetation. Importantly, Compositae plant extracts are present in many cosmetics, shampoos, herbal creams and ingested herbal remedies and tonics.     

The seamy side of natural medicines: contact sensitization to arnica (Arnica montana L.) and marigold (Calendula officinalis L.)

Medical remedies of plant origin have gained increasing popularity in recent years. Both anaphylactic and eczematous allergic reactions are on the rise, accordingly. Arnica and marigold, both of the Compositae family, are in widespread use, but only limited data are available on their allergenic potential. We tested 443 consecutive patients, in addition to the European standard and other series, with Compositae mix, sesquiterpene lactone mix, arnica, marigold, and propolis. 5 subjects ( approximately 1.13%) reacted to arnica, 9 ( approximately 2.03%) to marigold. The Compositae mix was positive in 18 cases ( approximately 4.06%). Among them were 3 out of 5 individuals with a sensitization to arnica, and 4 out of 9 who reacted to marigold. Sensitization to arnica and marigold was often accompanied by reactions to nickel, Myroxylon Pereirae resin, fragrance mix, propolis, and colophonium. We conclude that Compositae allergy contributes significantly to the epidemiology of contact dermatitis and that sensitization to arnica and marigold cannot be assessed by testing with the Compositae or sesquiterpene mix alone. As extracts of these plants are frequently used in occupational and cosmetic products, patch testing with additional plant extracts or adjustment of the commercial Compositae mix to regional conditions is recommended.     

Compositae dermatitis from airborne parthenolide

BACKGROUND: Compositae dermatitis confined to exposed skin has often been considered on clinical grounds to be airborne. Although anecdotal clinical and plant chemical reports suggest true airborne allergy, no proof has been procured. Feverfew (Tanacetum parthenium) is a European Compositae plant suspected of causing airborne contact allergy, and its most important allergen is the sesquiterpene lactone (SQL) parthenolide (PHL). OBJECTIVES: The aims of this study were to (i) assess the allergenicity of feverfew-derived monoterpenes and sesquiterpenes and their oxidized products in feverfew-allergic patients and (ii) re-assess the role of PHL and other SQLs in airborne contact allergy. PATIENTS AND METHODS: Feverfew-allergic patients were patch tested with extracts and fractions containing volatile monoterpenes and sesquiterpenes as well as extracts of airborne particles from flowering feverfew plants, obtained by fractionation of ether extracts, dynamic headspace and high-volume air sampler (HIVAS) technique, respectively. RESULTS: Among 12 feverfew-allergic patients, eight had positive patch-test reactions to a HIVAS filter extract, while two tested positive to a headspace extract. Subsequent analysis of the HIVAS extract by gas chromatography and mass spectrometry detected PHL in a concentration of 510 ng mL(-1) in the HIVAS extract. Testing with a dilution series of PHL showed positive reactions down to 8.1 ng in selected patients. None of the 12 patients tested positive to monoterpenes or sesquiterpenes, whether they were oxidized or not. CONCLUSIONS: The clinical results have proved that some feverfew-allergic patients are sensitive to airborne particles released from the plant, and isolation of PHL from the particle-containing HIVAS extract in allergenic amounts is strong evidence of PHL as the responsible allergen.     

Clinical evaluation of patients patch tested with plant series: a prospective study

Background:

Plants are ubiquitous in nature and are essential for human life, though some do have detrimental effects. In India, there are various indigenous and foreign plants that are well known to cause dermatitis, Parthenium hysterophorus being the foremost.

Aims of the Study:

To study the clinical features of patients presenting with plant dermatitis and evaluate plant allergen series patch test results.

Materials and Methods:

50 patients with suspected plant dermatitis were evaluated regarding evolution of dermatitis, precipitating factors and contact with various plants. 31 patients (62%) complained of photo sensitivity and 24 (48%) had involvement of sun-exposed areas. Our provisional diagnoses included allergic contact dermatitis in 16, air borne contact dermatitis in 9, phytophotodermatitis in 7, photodermatitis in 6, airborne contact dermatitis to other causes in 4, phytodermatitis in 3. Patients were patch tested with Indian standard series of allergens as well as plant allergen series consisting of common allergenic plants of local flora in and around Manipal and also with plants strongly suspected by the patient. 35 tested positive with maximum positives (26 patients, i.e., 52%) to Parthenium hysterophorus (Compositae).

Results:

The result of patch testing was correlated with the history and clinical examination and relevance established.

Conclusions:

Majority of the patients with clinically suspected plant dermatitis belonged to 3^rd or 4^th decade and Parthenium was the leading plant allergen Sensitization to Leguminosae plants and Hopea ponga, seen in 9 cases, have not been reported earlier in literature.     

Lower incidence of sesquiterpene lactone sensitivity in a population in Asia versus a population in Europe: an effect of chrysanthemum tea?

Sesquiterpene lactones (SLs) (Fig. 1) are an important cause of allergic plant contact dermatitis but are uncommon in the Far East. They belong to the Compositae family of plants. Sensitivity to SL may be airborne or via the topical route [topical herbal remedies, cosmetic products, and in many occupations such as gardeners and florists].     

A high rate of cross-sensitivity between Parthenium hysterophorus and Xanthium strumarium in Indian patients with contact dermatitis

Parthenium hysterophorus is well known to produce contact dermatitis in India. Xanthium strumarium is another weed also belonging to the Compositae family present in India since much earlier times, but not recognised among the plants causing contact dermatitis. We have found a very high rate of cross-sensitivity between the two plants in patients presenting air-borne contact dermatitis. Of the 28 patients with air-borne contact dermatitis. 22 revealed positive patch tests with aqueous extracts of both plants, one patient showed a negative patch test with Parthenium hysterophorus and a positive test with Xanthium strumarium , while five patients were negative with both plants. In a control group of 15 patients with contact dermatitis due to other agents, only one patient showed a positive patch test with Xanthium strumarium , while the patch test with Parthenium hysterophorus was negative. Patch tests performed with serial 10-fold dilutions of standard extracts of both plants to determine the degree (titre) of contact hypersensitivity (TCH) revealed variable litres in different patients. Some patients had a much higher titre with Parthenium hysterophorus while others had a higher titre with Xanthium strumarium. The antigen in Xanthium strumarium , like that of Parthenium hysterophorus , could be extracted with water, acetone, ethanol, chloroform, benzene, ether and carbon tetrachloride. Infra-red spectrophotometry of extracts in ether revealed similar spectra in the two plants. The antigens in the two plants seem lo be very similar.     

Contact dermatitis from chrysanthemums in India

32 patients (24 male, 8 female) with contact dermatitis from Chrysanthemum morifolium are reported. 24 (75%) patients gave a history of seasonal variation and 16 (50%) of photoaggravation and/or photosensitivity. Exposure to chrysanthemums was occupational in 18 and recreational in 12. The common clinical presentations were hand and face dermatitis in 13 (41%) and airborne contact dermatitis in 10 (31%) patients. All 32 patients demonstrated positive patch tests to ethanolic extracts of the flowers, 30 to the leaves, 28 to the whole plant, and only 6 to the stems, in that order of intensity.     

The current status of the weed Parthenium hysterophorus L. as a cause of allergic contact dermatitis

The dissemination of allergenic plants as horticultural introductions, or in the case of the weed Parthenium hysterophorus L. apparently by chance, can have undesirable results. This species of the Compositae family, native to the Caribbean region, has spread widely in India, causing allergic contact dermatitis from its content of sesquiterpene lactones, and has recently appeared in Australia.
The clinical features consist of dermatitis of the exposed skin surfaces from direct contact with the weed, but resembling photo dermatitis. In fact, contact dermatitis from the plant can coexist with light sensitivity. The plant does not show phototoxic activity but may contain an unidentified photo allergen. Since plant hairs and the pollen contain sesquiterpene lactones, they can probably cause air bone contact dermatitis. Attempts to control spread of the plant have so far not been successful.     

P57Allergic contact dermatitis to compositae mix in children

Background and aim:  Recent studies have demonstrated that contact sensitization to Compositae is not uncommon in adults. However, to our knowledge, no data are available in children. Our purpose was to investigate the prevalence of contact sensitization to Compositae in a pediatric population.
Methods:  434 consecutive pediatric patients (205 M; 229 F; mean age 6,7„,,b3,4 years) with suspected allergic contact dermatitis were patch tested with 30 haptens comprising Composite mix 5%(Tenacetum volgare, Arnica montana, Partenolide, Chamomilla recutitia, Achillea millefolium) at the Dermatology Unit of the Department of Pediatrics in Padua.
Results:  11 patients (7 M; 4 F; mean age 5,6„,,b2,8 years) had a positive patch test reaction to Compositae mix. In all these patients dermatitis was localized on the face and/or on the hands. Most of them had more than one positive reaction. 6 were affected by atopic dermatitis, 2 had a personal history of mucosal atopy and one had both. In 8 patients (5 with atopic dermatitis, 2 with mucosal atopy) the reaction was considered clinically relevant.
Conclusion: It might be useful to add Compositae mix to the pediatric screening series, when investigating dermatitis of air‐exposed areas in children with atopic diseases.     

Statistical data on occupational contact urticaria

Data on occupational contact urticaria (protein contact dermatitis included) in Finland during 1990–1994 were analyzed. Altogether 815 cases were reported to the Finnish Register Occupational Diseases during this period, compared with l944 cases of occupational allergic contact dermatitis. Accordingly, the total number Of Occupational allergic contact derma loses was 2759. 29.5% being contact urticaria and 70.5% being allergic contact dermatitis. Occupational contact urticaria was much more common in women 70%) than in men (30%). The 6 most common causes of contact urticaria were (1) cow dander (362 cases=44.4%) (2) natural rubber latex (193 cases -23.7%), (3) Hour, grains and Iced (92 cases=113%), (4) handling of foodstuffs (25 cases=3.1 %), (5) industrial enzymes 14 cases = 1.7%) and (b) decorative plants l3 cases=1.6%), The occupations with the highest numbers occupational contact urticaria were farmers (341 cases), domestic animal attendants (61). bakers (140.5). nurses (42) chefs (40) and denial assistants (28) The ranking list of the most common occupations with occupational contact urticaria per 100,000 employed workers was as follows: (I) bakers (140.5 cases per 10(1,000 employed persons), (2) prepares of processed food. (3) dental assistants. (4) veterinary surgeons. (5) domestic animal attendants. (i) fanners and silviculturalists (7) chefs, cooks and cold buffet managers. (S) dairy workers. (9) horticultural supervisors. (10) laboratory technicians and radiographers, (II) physicians. (12) butchers and sausage makers. (1.1) laboratory assistants, (14) dentists and (15) nurses(121.2 cases per 100.000 employed person). Low-molecular-weight chemicals caused very few cases of occupational contact urticaria, the most common being 2-ethyhexyl very late (5 cases)- To Summarize occupational contact urticaria forms a large group of occupational contact dermatoses. and dermatologists need to he able to diagnose IgE-mediated immediate skin allergic diseases.     

Contact allergy to thiuram in a musician

Objectives: Persistent post‐occupational dermatitis (PPOD) was mentioned by Wall and Gebauer in 1991 to describe ongoing skin disease precipitated by occupational contact dermatitis (OCD). There has been little formal recognition or clarification of this condition.
Methods: Approximately 1600 records from our Occupational Dermatology Clinic were searched to identify likely cases. PPOD was difficult to diagnose as relatively few patients had been reviewed after initial assessment.
Results: A number of patients with reasonably clear histories of persistent occupational contact dermatitis were identified, which followed either irritant or allergic occupational contact dermatitis. These included a 57 yr old male who worked with photographic chemicals, a 51 yr old female food handler and a 25 yr old female food handler who were all diagnosed with irritant contact dermatitis and yet experienced persistent dermatitis even after avoiding the irritants that were associated with causing their dermatitis. A 51 yr old process worker allergic to acrylates, a 28 yr old laboratory worker allergic to rubber accelerators and coconut diethanolamide in her hand wash and a 48 yr old epoxy applicator allergic to epoxy resins experienced recurrent dermatitis for years after avoiding their causative allergens, although with gradual decrease in the frequency of outbreaks of dermatitis. Unfortunately, many patients experienced difficulties with workers' compensation because the persistence of their dermatitis was thought by some medical examiners negate its work‐relatedness.
Conclusion: There needs to be greater recognition and understanding of PPOD. We are planning to follow‐up patients from our clinic to better study and define this condition.     

Do monoterpenes released from feverfew (Tanacetum parthenium) plants cause airborne Compositae dermatitis?

The Compositae plant feverfew (Tanacetum parthenium) is an important sensitizer in Europe and has been suspected of causing airborne Compositae dermatitis. A previous investigation of substances emitted from feverfew plants detected no sesquiterpene lactones, however, but mainly monoterpenes. The aims of this study were to test whether feverfew-allergic patients were also sensitive to some of the above-mentioned monoterpenes and, if so, to study associations between sensitization patterns, relevance of feverfew allergy and clinical features. 17 patients with + +/+ + + reactions to feverfew and parthenolide were tested with 15 selected monoterpenes and 2 sesquiterpenes. Of the 17 persons, 13 had positive and/or doubtful positive reactions to 1 or more monoterpenes. Only 1 person was allergic to several monoterpenes. Her history of gradually worsening Compositae dermatitis culminating in a probable airborne dermatitis, mimicking photosensitivity, and the disappearance of symptoms upon removal of feverfew plants suggest monoterpenes as a possible contributing factor. Similar associations between doubtful positive monoterpene reactions and clinical patterns, fragrance/colophonium allergy and relevance of feverfew allergy were not established with certainty. In conclusion, sensitization to the sesquiterpene lactones of feverfew is not invariably accompanied by sensitization to its volatile monoterpenes. The presence of monoterpene allergy, however, may contribute to airborne Compositae dermatitis.     

The validity of the Mathias criteria for establishing occupational causation and aggravation of contact dermatitis

Mathias proposed 7 criteria for establishing occupational causation and aggravation of contact dermatitis (Mathias, J Am Acad Dermatol 1989, 20, 842-848). 4 of the 7 criteria must be positive to conclude occupational dermatitis. In order to evaluate the validity of these criteria, we re-examined 19 patients (17 male and 2 female) with contact dermatitis, who had given a positive answer to at least 4 of the criteria and had either exchanged their workplace or stopped working. We re-evaluated them, 2-5 years later, for the presence of contact dermatitis. 14 of 19 patients (74%) reported that their dermatitis had cleared after they had left their previous workplace. Only 5 patients still suffered from dermatitis, 2-5 years later. 3 of these 5 patients could have been exposed to the causative allergens in their new workplace. We conclude that the Mathias criteria are useful to assess occupational contact dermatitis.     

Compositae dermatitis in childhood

Compositae dermatitis occurred in a 9-year-old boy with a strong personal and family history of atopy. Positive patch test reactions were 2+ for dandelion (Taraxacum officinale), false ragweed (Ambrosia acanthicarpa), giant ragweed (Ambrosia trifida), short ragweed (Ambrosia artemisifolia), sagebrush (Artemisia tridentata), wild feverfew (Parthenium hysterophorus), yarrow (Achillea millifolium), and tansy (Tanacetum vulgare) and 1+ for Dahlia species and English ivy (Hedera helix). Patch tests were negative for another 30 plants, including cocklebur (Xanthium strumarium), dog fennel (Anthemis cotula, fleabane (Erigeron strigosus), sneezeweed (Helenium autumnale), and feverfew (Tanacetum parthenium). The eruption resembled atopic dermatitis morphologically but was prominent on the palms and face and dramatically spared the area of the boy's feet covered by his shoes. The condition has always been seasonal, worsening in summer, especially July, and it clears on avoidance of contact. This case is believed to represent a contact dermatitis to oleoresins of Compositae plants; inhalants as a cause of systemic aggravation are not likely to be important in this patient.     

Reactions to Aquaphor®: Is Bisabolol the Culprit?

Abstract:  Bisabolol is a sesquiterpene alcohol compound derived from the German chamomile plant, a member of the Compositae family. Only two case reports of adults with allergic contact dermatitis to this chemical exist in the literature, and we describe three more cases of children with recalcitrant atopic dermatitis found to have potential allergic contact dermatitis to bisabolol- a component of the Aquaphor^® emollient they were using to treat their atopic dermatitis. Of note, Compositae dermatitis has been shown to have a higher prevalence in children with atopic dermatitis, so it is important for physicians to be aware of the potential allergens (like bisabolol) in products they are recommending as first line treatments.