FO64:ControversiesandChallengesinContactDerma88s:SystemicAllergensandAvoidanceDiets

BrianC.Machler,M.D.CenterforDermatology,FlorhamPark,NJ

NYUSchoolofMedicine,RonaldPerelmanDepartmentofDermatologyUniversityofMiami,DepartmentofDermatology&CutaneousSurgery

SystemicContactDerma88s(SCD)

•  Acutaneous,mucosal,orvisceralimmunereac8onuponsystemicre-exposuretoaknownTypeIV,lymphocyte-mediatedallergeninasensi8zedindividual

RoutesofExposureforSCD

•  Transepidermal•  Transmucosal•  Oral•  Intravenous•  Subcutaneous•  Intramuscular•  Inhala8on

SCD

•  Shouldbeconsideredinpa8entswithaposi8vepatchtesttoanallergen(knowntocauseSCD)whohavenotclearedaVeravoidanceofcutaneousexposure.

Presenta8onsofSCD•  Flare-upofexis8ng,previousACDorpatchtestreac8ons

•  Pompholyx/Dyshidrosis/VesicularDerma88s•  Maculopapularerup8on•  ChronicPruritus•  Exfolia8veErythroderma/Toxiderma•  ChronicUr8caria•  Erythemamul8formeandvasculi8s•  SDRIFE(SymmetricDrug-RelatedIntertriginousandFlexuralErythema)/“BaboonSyndrome”

•  AGEP•  Hyperkerato8cpapulesoftheelbows•  Pruritusani•  EyelidDerma88s

SCDExtracutaneousManifesta8ons

•  Headache•  Fa8gue,Fibromyalgia,Jointpain,ChronicFa8gue

•  Gastrointes8nalSx•  RespiratorySx•  Fever•  Vasculi8cdisturbances

CommonCausesofSCD•  Metals:Nickel,Cobalt,Gold,Chromium

•  Medica8ons:Aminoglycosides,Cor8costeroids,Ethylenediamine

•  PlantsandHerbs:Compositae,Anacardiaceae,BalsamofPeru,Propolis

•  Other:Formaldehyde,PropyleneGlycol, Methylisothiazolinone

SpecificAllergenswithDietaryExposure

•  Urushiol•  Nickel•  BalsamofPeru•  CompositaeandSesquiterpeneLactone•  Formaldehyde•  PropyleneGlycol•  Carmine

NickelDietHeavyHi_ers

•  Soy•  PeanutsandotherNuts•  Legumes•  Chocolateandcocoa•  Oats•  WholeWheatFlours

BOPFreeDiet•  NoCitrus

•  Nodanish,bakerygoods,candy,gum•  Nospicessuchascinnamon,cloves,vanilla,curry,allspice,anise,andginger

•  Nospicycondimentssuchasketchup,chilisauce,barbecuesauce

•  Nopickles•  Nowine,beer,ginorvermouth•  Noperfumedorflavoredteaortobacco•  Nochocolateoricecream•  NoColaorotherspicedsoVdrinks•  NoChili,Pizza,ItalianorMexicanfoodswithredsauces•  NoTomatoes

BOPCrossReactors•  BalsamofTolu•  Beeswax•  Colophony•  EugenolandIsoeugenol•  FragranceMix•  Propolis•  Styrax•  Turpen8ne•  WoodTar

PropolisandSCD

•  Propolisor“beeglue”isamixtureoftreeandflowerresinscollectedbyworkerbeestorepairandbuildnests

•  Commonlyusedinmedicines,cosme8cs,lozengesandsyrups

•  Cancausereac8onsinBOPallergicpa8ents

PropyleneGlycol

•  Anexcipientusedincosme8cs,medicaments,andfoods

•  Infoodsitisusedasahumectant,preserva8ve,andsoVeningagentaswellasasolventforflavoringsandcolors

Formaldehyde

•  AspartameisbrokendownbythelivertoMethanolwhichleadstotheforma8onof

•  MostreportedcasesofformaldehyderelatedSCDfromaspartamehaveEYELIDinvolvement

“Inac8veIngredients”inMedica8ons

•  AspartameinMotelukastchewabletabs•  PropyleneGlycol,BenzoicAcid,Azodyes,Sorbitan,andParabensinoralan8histamines

•  PropolisinGummyVitamins

Compositae/Asteraceae

•  Aplantfamilywhosemainallergenissesquiterpenelactoneandparthenolide

•  Includeschrysanthemums,daisy,ragweed,feverfew,sunflower,chamomile,endive,arugula,ar8choke,echinacea,chicoryle_ucesandroot,andelecampane.

Carmine

•  Anaturaldye(NaturalRed4)fromthedriedfemalecochinealinsectDactylopiuscoccus

•  Ancienttex8leandornamentaldyeusedinfoods,drinks,drugsandcosme8cs

•  Immediatehypersensi8vityreac8onstoproteinshavebeenreportedmorecommonlythanACD

Carmine

•  Salami,sausages•  OldversionsofCampari•  Popsicles,fruitjuices,candy•  Yogurt•  Ar8ficialcrabandfishpaste•  Genericazithromycin

HowtoHandletheDiet

•  Elimina8ondietforatleast3-4weeks•  Reintroduc8onofsuspectedtriggerfoodsoneaweek

•  EncourageuseofFoodDiary/App•  ConsiderreferraltoAllergistforAllergenChallengeandDesensi8za8onTherapy

•  Givepa8entscopiesofprimaryar8cles

ReferencesofAr8clesandSitestogivetopa8entswithSCD

Mislankar,M,ZirwasMJ.Lownickel-dietscoringsystemforsystemicnickelallergy.Derma88s.2013Jul-Aug;24(4):190-5.FabbroSK,ZirwasMJ.Systemiccontactderma88stofood:nickel,BOP,andmore.CurrAllergyAsthmaRep.2014Oct;14(10):463.SchemanA,RakowskiEM,ChouV,ChhatriwalaA,RossJ,JacobSE.BalsamofPeru,PastandFuture.Derma88s.2013Jul-Aug;24(4):153-60.SalamTN,FowlerJFJr.JBalsam-relatedsystemiccontactderma88s.AmerAcadDermatol.2001Sep;45(3):377-81.SchemanA,ChaC,JacobSE,NedorostS,FoodAvoidanceDietsforSystemic,Lip,andOralContactAllergy:AnAmericanContactAlterna8vesGroupAr8cleDerma88sAcademy(www.derma88sacademy.com)