Pediatric allergic contact dermatitis. Part I: Clinical features and common contact allergens in children
2020; Elsevier BV; Volume: 84; Issue: 2 Linguagem: Inglês
10.1016/j.jaad.2020.11.002
ISSN1097-6787
AutoresHolly Neale, Anna Cristina Garza‐Mayers, Idy Tam, JiaDe Yu,
Tópico(s)Dermatology and Skin Diseases
ResumoAllergic contact dermatitis (ACD), a delayed hypersensitivity skin reaction to environmental allergens, has a prevalence that is similar in children and adults. However, diagnostic testing for ACD in pediatric populations accounts for less than one tenth of all patch tests. The relative infrequency of pediatric patch testing may be attributed to the difficulty in testing in this population, which includes a smaller surface area for patch test placement and maintaining cooperation during patch testing, especially in younger children. Diagnosis can be difficult in children because the appearance of ACD can mimic other common pediatric skin conditions, particularly atopic dermatitis and irritant contact dermatitis. Comprehensive history taking, guided by patient presentation, age group, and location of dermatitis, helps build clinical suspicion. Such clinical suspicion is one of the major reasons behind patch testing, with additional indications being recalcitrant dermatitis and dermatitis with atypical distribution. US pediatric data have shown the top allergens to be metals, fragrances, topical antibiotics, preservatives, and emollients. These trends are important to recognize to guide management and accurate diagnosis, because ACD tends to persist if the allergen is not identified and can affect patients' quality of life. Allergic contact dermatitis (ACD), a delayed hypersensitivity skin reaction to environmental allergens, has a prevalence that is similar in children and adults. However, diagnostic testing for ACD in pediatric populations accounts for less than one tenth of all patch tests. The relative infrequency of pediatric patch testing may be attributed to the difficulty in testing in this population, which includes a smaller surface area for patch test placement and maintaining cooperation during patch testing, especially in younger children. Diagnosis can be difficult in children because the appearance of ACD can mimic other common pediatric skin conditions, particularly atopic dermatitis and irritant contact dermatitis. Comprehensive history taking, guided by patient presentation, age group, and location of dermatitis, helps build clinical suspicion. Such clinical suspicion is one of the major reasons behind patch testing, with additional indications being recalcitrant dermatitis and dermatitis with atypical distribution. US pediatric data have shown the top allergens to be metals, fragrances, topical antibiotics, preservatives, and emollients. These trends are important to recognize to guide management and accurate diagnosis, because ACD tends to persist if the allergen is not identified and can affect patients' quality of life. Learning objectivesAfter completing this learning activity, participants should be able to describe the most common clinical presentation of allergic contact dermatitis in children; identify pediatric patients who are appropriate for patch testing; discuss current trends in allergic contact dermatitis in children; recognize the significant negative impact on the quality of life allergic contact dermatitis has on children; and name and discuss the most common allergens causing allergic contact dermatitis in children.DisclosuresEditorsThe editors involved with this CME activity and all content validation/peer reviewers of the journal-based CME activity have reported no relevant financial relationships with commercial interest(s).AuthorsThe authors involved with the journal-based CME activity have reported no relevant financial relationships with commercial interest(s).PlannersThe planners involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). The editorial and education staff involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). Learning objectives After completing this learning activity, participants should be able to describe the most common clinical presentation of allergic contact dermatitis in children; identify pediatric patients who are appropriate for patch testing; discuss current trends in allergic contact dermatitis in children; recognize the significant negative impact on the quality of life allergic contact dermatitis has on children; and name and discuss the most common allergens causing allergic contact dermatitis in children. Disclosures Editors The editors involved with this CME activity and all content validation/peer reviewers of the journal-based CME activity have reported no relevant financial relationships with commercial interest(s). Authors The authors involved with the journal-based CME activity have reported no relevant financial relationships with commercial interest(s). Planners The planners involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). The editorial and education staff involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). •Allergic contact dermatitis affects children at similar rates to adults, but childhood cases are likely underdiagnosed•Children of all ages may develop allergic contact dermatitis, with increased prevalence with age Allergic contact dermatitis (ACD) is a biphasic, type IV hypersensitivity reaction of the skin. In the first phase (sensitization phase), initial exposure to 1 of many environmental haptens (allergens) results in allergen processing in regional lymph nodes and subsequent formation of antigen-specific T cells.1Nassau S. Fonacier L. Allergic contact dermatitis.Med Clin North Am. 2020; 104: 61-76Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar In the second phase (elicitation phase), re-exposure to the allergen results in sensitized T cells migrating to the epidermis and triggering an inflammatory response seen in acute ACD including erythema, vesiculation, pruritus, and edema.2Carder K.R. Hypersensitivity reactions in neonates and infants.Dermatol Ther. 2005; 18: 160-175Crossref PubMed Scopus (51) Google Scholar Although it was once believed to be rare for young children to develop ACD because of immature immune systems and lack of allergen exposures, data over the past several decades have shown a prevalence comparable to that in adults.3Zug K.A. Pham A.K. Belsito D.V. et al.Patch testing in children from 2005 to 2012: results from the North American contact dermatitis group.Dermatitis. 2014; 25: 345-355Crossref PubMed Scopus (64) Google Scholar Infants as young as 1 week have been reported to develop ACD,4Fisher A.A. Allergic contact dermatitis in early infancy.Cutis. 1994; 54: 315-316PubMed Google Scholar and more than 20% of asymptomatic healthy children are sensitized to common allergens such as nickel.5Weston W.L. Weston J.A. Kinoshita J. et al.Prevalence of positive epicutaneous tests among infants, children, and adolescents.Pediatrics. 1986; 78: 1070-1074PubMed Google Scholar,6Bruckner A.L. Weston W.L. Morelli J.G. Does sensitization to contact allergens begin in infancy?.Pediatrics. 2000; 105: e3Crossref PubMed Google Scholar Despite increased awareness of pediatric ACD, less than 10% of patch tests (the current diagnostic standard) are performed on children,3Zug K.A. Pham A.K. Belsito D.V. et al.Patch testing in children from 2005 to 2012: results from the North American contact dermatitis group.Dermatitis. 2014; 25: 345-355Crossref PubMed Scopus (64) Google Scholar,7Tam I. Schalock P.C. González E. Yu J. Patch testing results from the Massachusetts General Hospital Contact Dermatitis Clinic, 2007-2016.Dermatitis. 2020; 31: 202-208Crossref PubMed Scopus (0) Google Scholar although children comprise more than 22% of the US population.8American Community Survey. ACS demographic and housing estimates: 2019: ACS 1-year estimates data profiles. US Census Bureau. Accessed October 18, 2020. https://data.census.gov/cedsci/tableq=Age%20and%20Sex&tid=ACSST1Y2019.S0101&hidePreview=falseGoogle Scholar,9American Community Survey. ACS demographic and housing estimates: 2014: ACS 1-year estimates data profiles. US Census Bureau. Accessed October 18, 2020. https://data.census.gov/cedsci/tableq=Age%20and%20Sex&tid=ACSST1Y2019.S0101&hidePreview=falseGoogle Scholar In the hopes of eliminating this diagnostic discrepancy, the goal of part 1 of this continuing medical education series is to describe current epidemiologic and clinical characteristics of childhood ACD, pediatric-relevant allergens, and indications for patch testing. Part 2 discusses childhood patch-testing approaches, providing both diagnostic and management strategies. The estimated prevalence of pediatric ACD is 16.5%,10Alinaghi F. Bennike N.H. Egeberg A. Thyssen J.P. Johansen J.D. Prevalence of contact allergy in the general population: a systematic review and meta-analysis.Contact Dermatitis. 2019; 80: 77-85Crossref PubMed Scopus (45) Google Scholar currently affecting 4.4 million children in the United States.11Borok J. Matiz C. Goldenberg A. Jacob S.E. Contact dermatitis in atopic dermatitis children—past, present, and future.Clin Rev Allergy Immunol. 2019; 56: 86-98Crossref PubMed Scopus (7) Google Scholar Although the prevalence of pediatric ACD is increasing,12Lembo S. Lembo C. Patruno C. et al.Contact sensitization of children: a two-decade years history in Naples.G Ital Dermatol Venereol. 2018; 153: 483-490PubMed Google Scholar cases remain underreported. Only 1% to 10% of patch tests are performed on children,3Zug K.A. Pham A.K. Belsito D.V. et al.Patch testing in children from 2005 to 2012: results from the North American contact dermatitis group.Dermatitis. 2014; 25: 345-355Crossref PubMed Scopus (64) Google Scholar,7Tam I. Schalock P.C. González E. Yu J. Patch testing results from the Massachusetts General Hospital Contact Dermatitis Clinic, 2007-2016.Dermatitis. 2020; 31: 202-208Crossref PubMed Scopus (0) Google Scholar,13Francuzik W. Geier J. Schubert S. Worm M. A case-control analysis of skin contact allergy in children and adolescents.Pediatr Allergy Immunol. 2019; 30: 632-637PubMed Google Scholar,14Ortiz Salvador J.M. Esteve Martínez A. Subiabre Ferrer D. Victoria Martínez A.M. de la Cuadra Oyanguren J. Zaragoza Ninet V. Pediatric Allergic Contact Dermatitis: clinical and Epidemiological Study in a Tertiary Hospital.Actas Dermosifiliogr. 2017; 108: 571-578Crossref PubMed Scopus (6) Google Scholar even though the frequency of positive patch test reactions does not differ significantly from that of adults.10Alinaghi F. Bennike N.H. Egeberg A. Thyssen J.P. Johansen J.D. Prevalence of contact allergy in the general population: a systematic review and meta-analysis.Contact Dermatitis. 2019; 80: 77-85Crossref PubMed Scopus (45) Google Scholar,15Zug K.A. McGinley-Smith D. Warshaw E.M. et al.Contact allergy in children referred for patch testing: North American contact dermatitis group data, 2001-2004.Arch Dermatol. 2008; 144: 1329-1336Crossref PubMed Scopus (121) Google Scholar Although ACD can occur in infancy,4Fisher A.A. Allergic contact dermatitis in early infancy.Cutis. 1994; 54: 315-316PubMed Google Scholar,6Bruckner A.L. Weston W.L. Morelli J.G. Does sensitization to contact allergens begin in infancy?.Pediatrics. 2000; 105: e3Crossref PubMed Google Scholar the majority of pediatric cases are diagnosed in older children. Reports suggest more than 75% of diagnosed children are older than 10 years,16Hammonds L.M. Hall V.C. Yiannias J.A. Allergic contact dermatitis in 136 children patch tested between 2000 and 2006.Int J Dermatol. 2009; 48: 271-274Crossref PubMed Scopus (41) Google Scholar but this may reflect age referral bias because other studies report no difference in prevalence of ACD and age.15Zug K.A. McGinley-Smith D. Warshaw E.M. et al.Contact allergy in children referred for patch testing: North American contact dermatitis group data, 2001-2004.Arch Dermatol. 2008; 144: 1329-1336Crossref PubMed Scopus (121) Google Scholar Girls are at higher risk for ACD16Hammonds L.M. Hall V.C. Yiannias J.A. Allergic contact dermatitis in 136 children patch tested between 2000 and 2006.Int J Dermatol. 2009; 48: 271-274Crossref PubMed Scopus (41) Google Scholar, 17Clayton T.H. Wilkinson S.M. Rawcliffe C. Pollock B. Clark S.M. Allergic contact dermatitis in children: should pattern of dermatitis determine referral? A retrospective study of 500 children tested between 1995 and 2004 in one U.K. centre.Br J Dermatol. 2006; 154: 114-117Crossref PubMed Scopus (83) Google Scholar, 18Duarte I. Lazzarini R. Kobata C.M. Contact dermatitis in adolescents.Am J Contact Dermat. 2003; 14 (Accessed June 7, 2020. Available at:): 200-202http://www.ncbi.nlm.nih.gov/pubmed/14738721Crossref PubMed Scopus (45) Google Scholar, 19Zafrir Y. Trattner A. Hodak E. Eldar O. Lapidoth M. Ben Amitai D. Patch testing in Israeli children with suspected allergic contact dermatitis: a retrospective study and literature review.Pediatr Dermatol. 2018; 35: 76-86Crossref PubMed Scopus (10) Google Scholar because of behavioral and exposure differences between the sexes. It has been found that female patients are more likely to react to nickel,20Warshaw E.M. Zhang A.J. DeKoven J.G. et al.Epidemiology of nickel sensitivity: retrospective cross-sectional analysis of North American Contact Dermatitis Group data 1994-2014.J Am Acad Dermatol. 2019; 80: 701-713Abstract Full Text Full Text PDF PubMed Google Scholar which may be explained by an increased tendency for ear piercings.21Jacob S.E. Goldenberg A. Pelletier J.L. Fonacier L.S. Usatine R. Silverberg N. Nickel allergy and our children's health: a review of indexed cases and a view of future prevention.Pediatr Dermatol. 2015; 32: 779-785Crossref PubMed Scopus (25) Google Scholar This trend may also reflect testing patterns, because up to 91% of adolescents patch tested are female.18Duarte I. Lazzarini R. Kobata C.M. Contact dermatitis in adolescents.Am J Contact Dermat. 2003; 14 (Accessed June 7, 2020. Available at:): 200-202http://www.ncbi.nlm.nih.gov/pubmed/14738721Crossref PubMed Scopus (45) Google Scholar Notably, some research suggests that in younger children (<10 years), boys are more likely to have relevant positive patch tests (RPPTs),16Hammonds L.M. Hall V.C. Yiannias J.A. Allergic contact dermatitis in 136 children patch tested between 2000 and 2006.Int J Dermatol. 2009; 48: 271-274Crossref PubMed Scopus (41) Google Scholar whereas other studies have found no difference in sensitization between boys and girls.22Belloni Fortina A. Cooper S.M. Spiewak R. Fontana E. Schnuch A. Uter W. Patch test results in children and adolescents across Europe. Analysis of the ESSCA Network 2002-2010.Pediatr Allergy Immunol. 2015; 26: 446-455Crossref PubMed Scopus (50) Google Scholar Current pediatric patch testing data show that White children are more likely to be diagnosed with ACD compared to children of other races.7Tam I. Schalock P.C. González E. Yu J. Patch testing results from the Massachusetts General Hospital Contact Dermatitis Clinic, 2007-2016.Dermatitis. 2020; 31: 202-208Crossref PubMed Scopus (0) Google Scholar,18Duarte I. Lazzarini R. Kobata C.M. Contact dermatitis in adolescents.Am J Contact Dermat. 2003; 14 (Accessed June 7, 2020. Available at:): 200-202http://www.ncbi.nlm.nih.gov/pubmed/14738721Crossref PubMed Scopus (45) Google Scholar There are no known geographic prevalence differences among North America, Europe, and Asia.10Alinaghi F. Bennike N.H. Egeberg A. Thyssen J.P. Johansen J.D. Prevalence of contact allergy in the general population: a systematic review and meta-analysis.Contact Dermatitis. 2019; 80: 77-85Crossref PubMed Scopus (45) Google Scholar •The clinical presentation, along with exposure history, can help guide need for patch testing in children•Understanding the indications for pediatric patch testing (suggestive clinical history, dermatitis with atypical distribution, recalcitrant dermatitis) may help overcome undertesting•Atopic dermatitis can co-occur and complicate the diagnosis of allergic contact dermatitis ACD is difficult to diagnose in children because it may present with similar signs and symptoms as atopic dermatitis (AD). Recognizing the distinguishing features of ACD, such as the distribution of dermatitis and the clinical course, can prompt evaluation. Acute ACD presents as pruritic, eczematous papules and plaques with erythema, edema, vesicles or bullae, and serous crust.23Belloni Fortina A. Caroppo F. Tadiotto Cicogna G. Allergic contact dermatitis in children.Expert Rev Clin Immunol. 2020; 16: 579-589Crossref PubMed Scopus (0) Google Scholar Chronic ACD presents with lichenification, fissuring, and hyperpigmentation (Fig 1). The body area where allergen contact occurs usually coincides with dermatitis distribution. Distributions that should raise clinical suspicion of ACD in children include the head and neck,12Lembo S. Lembo C. Patruno C. et al.Contact sensitization of children: a two-decade years history in Naples.G Ital Dermatol Venereol. 2018; 153: 483-490PubMed Google Scholar,17Clayton T.H. Wilkinson S.M. Rawcliffe C. Pollock B. Clark S.M. Allergic contact dermatitis in children: should pattern of dermatitis determine referral? A retrospective study of 500 children tested between 1995 and 2004 in one U.K. centre.Br J Dermatol. 2006; 154: 114-117Crossref PubMed Scopus (83) Google Scholar,23Belloni Fortina A. Caroppo F. Tadiotto Cicogna G. Allergic contact dermatitis in children.Expert Rev Clin Immunol. 2020; 16: 579-589Crossref PubMed Scopus (0) Google Scholar hands,13Francuzik W. Geier J. Schubert S. Worm M. A case-control analysis of skin contact allergy in children and adolescents.Pediatr Allergy Immunol. 2019; 30: 632-637PubMed Google Scholar,17Clayton T.H. Wilkinson S.M. Rawcliffe C. Pollock B. Clark S.M. Allergic contact dermatitis in children: should pattern of dermatitis determine referral? A retrospective study of 500 children tested between 1995 and 2004 in one U.K. centre.Br J Dermatol. 2006; 154: 114-117Crossref PubMed Scopus (83) Google Scholar and legs.17Clayton T.H. Wilkinson S.M. Rawcliffe C. Pollock B. Clark S.M. Allergic contact dermatitis in children: should pattern of dermatitis determine referral? A retrospective study of 500 children tested between 1995 and 2004 in one U.K. centre.Br J Dermatol. 2006; 154: 114-117Crossref PubMed Scopus (83) Google Scholar,23Belloni Fortina A. Caroppo F. Tadiotto Cicogna G. Allergic contact dermatitis in children.Expert Rev Clin Immunol. 2020; 16: 579-589Crossref PubMed Scopus (0) Google Scholar The feet and lips are more commonly affected in children compared to adults.13Francuzik W. Geier J. Schubert S. Worm M. A case-control analysis of skin contact allergy in children and adolescents.Pediatr Allergy Immunol. 2019; 30: 632-637PubMed Google Scholar Special attention should be paid to diapered areas in young children, because ACD affects this area more often than AD.24De Yu J. Treat J. Chaney K. Brod B. Potential allergens in disposable diaper wipes, topical diaper preparations, and disposable diapers: under-recognized etiology of pediatric perineal dermatitis.Dermatitis. 2016; 27: 110-118Crossref PubMed Scopus (26) Google Scholar It is important to note that ACD can affect any area of the body, and atypical morphologies such as purpuric and pustular reactions have been reported.25Goldenberg A. Silverberg N. Silverberg J.I. Treat J. Jacob S.E. Pediatric allergic contact dermatitis: lessons for better care.J Allergy Clin Immunol Pract. 2015; 3: 661-667Abstract Full Text Full Text PDF PubMed Google Scholar Patients may not be able to recall an inciting exposure during the visit because there are thousands of potential exposures in daily life. Understanding environmental allergen sources helps guide thorough and targeted interview questions (Table I).Table ITargeted history by age groupAge groupHigh-yield history questionsInfants and toddlersWhat type of diapers, wipes, and powders are used?Has the child recently begun toilet training?Who else cares for the child (eg, day care, grandparents, babysitters)?Does the child, parent, or caregiver wear jewelry or perfume?School-aged childrenWhat toys or crafts does the child play with?What sports does the child play at home and at school?Does the child play with slime or other putty?What after-school activities does the child participate in?Is the rash better during the school year or while on vacation?Does he or she play an instrument?AdolescentsAre any other cosmetic products (hair dye, nail polish, makeup) used?What sporting and recreational activities are performed?Does her or she have any after school jobs?Does he or she do any chores requiring cleaning or household products? Open table in a new tab Children can develop ACD at any age. Specific predisposing factors, other than exposure, are not yet known. Therefore, all children should be asked about the use of personal care products such as shampoos, soaps, lotions, detergents, and topical medications. Clothing, shoes, sports, hobbies, after-school activities, and jewelry are similarly pertinent. Additionally, systemic contact dermatitis can occur through oral ingestion of contact allergens in food, such as carmine in red velvet cupcakes,26Machler B.C. Jacob S.E. Carmine red: a potentially overlooked allergen in children.Dermatitis. 2018; 29: 92-93Crossref PubMed Scopus (4) Google Scholar nickel in oatmeal and cocoa,27Tuchman M. Silverberg J.I. Jacob S.E. Silverberg N. Nickel contact dermatitis in children.Clin Dermatol. 2015; 33: 320-326Abstract Full Text Full Text PDF PubMed Google Scholar, 28Krecisz B. Chomiczewska D. Kiec-Swierczynska M. Kaszuba A. Systemic contact dermatitis to nickel present in cocoa in 14-year-old boy.Pediatr Dermatol. 2011; 28: 335-336Crossref PubMed Scopus (19) Google Scholar, 29Jacob S.E. Hamann D. Goldenberg A. Connelly E.A. Easter egg hunt dermatitis: systemic allergic contact dermatitis associated with chocolate ingestion.Pediatr Dermatol. 2015; 32: 231-233Crossref PubMed Scopus (4) Google Scholar and balsam of Peru (BoP) in ketchup.30Matiz C. Jacob S.E. Systemic contact dermatitis in children: how an avoidance diet can make a difference.Pediatr Dermatol. 2011; 28: 368-374Crossref PubMed Scopus (32) Google Scholar,31Herro E.M. Jacob S.E. Systemic contact dermatitis—kids and ketchup.Pediatr Dermatol. 2013; 30Crossref PubMed Scopus (11) Google Scholar Targeted history can also be guided by affected body area, age group, and lifestyle. Questions about diapers, baby powder, creams, and toilet training are applicable for infants and toddlers.24De Yu J. Treat J. Chaney K. Brod B. Potential allergens in disposable diaper wipes, topical diaper preparations, and disposable diapers: under-recognized etiology of pediatric perineal dermatitis.Dermatitis. 2016; 27: 110-118Crossref PubMed Scopus (26) Google Scholar,25Goldenberg A. Silverberg N. Silverberg J.I. Treat J. Jacob S.E. Pediatric allergic contact dermatitis: lessons for better care.J Allergy Clin Immunol Pract. 2015; 3: 661-667Abstract Full Text Full Text PDF PubMed Google Scholar,32Chang M.W. Nakrani R. Six children with allergic contact dermatitis to methylisothiazolinone in wet wipes (baby wipes).Pediatrics. 2014; 133Crossref Scopus (49) Google Scholar,33Litvinov I.V. Sugathan P. Cohen B.A. Recognizing and treating toilet-seat contact dermatitis in children.Pediatrics. 2010; 125: e419-e422Crossref PubMed Scopus (15) Google Scholar In school-aged children, toys and crafts are known exposure sources, such as slime, which has resulted in pediatric hand ACD.34Anderson L.E. Treat J.R. 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Allergic contact dermatitis to slime: the epidemic of isothiazolinone allergy encompasses school glue.Pediatr Dermatol. 2019; 36: e37-e38Crossref PubMed Scopus (14) Google Scholar In adolescents, hair dye,40Işik S. Caglayan-Sözmen S. Anal Ö. Karaman Ö. Uzuner N. severe neck and face edema in an adolescent-delayed hypersensitivity reaction to hair dye.Pediatr Emerg Care. 2017; 33: 422-423Crossref PubMed Scopus (4) Google Scholar,41Soffer G.K. Toh J. Clements S. Jariwala S. A case of chronic contact dermatitis resulting from the use of blue hair dye.Contact Dermatitis. 2016; 75: 258-259Crossref PubMed Scopus (0) Google Scholar perfume,42Vigan M. Castelain F. Fragrance and cosmetic contact allergy in children.Curr Treat Options Allergy. 2014; 1: 310-316Crossref Scopus (1) Google Scholar nail polish,43Romita P. Foti C. Barlusconi C. Hansel K. Tramontana M. Stingeni L. 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Because exposures could be from the home, school, work, pets, or homes of peers and caregivers, a complete understanding of the child's daily life is an important element of patient history.50Tam I. Yu J. Allergic contact dermatitis in children: recommendations for patch testing.Curr Allergy Asthma Rep. 2020; 20: 41Crossref PubMed Google Scholar Information gathered can aid management decisions, such as the choice to patch test, include patient products in a patch test, or empirically avoid suspected allergens (discussed in part 2). ACD is traditionally thought to be primarily mediated by T helper (Th) type 1 cells and cytotoxic T cells, whereas AD is mediated by Th2 cells.51Rustemeyer T. Van Hoogstraten I.M.W. Von Blomberg B.M.E. Gibbs S. Scheper R.J. Mechanisms of irritant and allergic contact dermatitis.in: Johansen J.D. Frosch P.J. Lepoittevin J.-P. Contact Dermatitis. 5th ed. Springer Berlin Heidelberg, 2011: 43-90Crossref Scopus (41) Google Scholar,52Owen J.L. Vakharia P.P. Silverberg J.I. The role and diagnosis of allergic contact dermatitis in patients with atopic dermatitis.Am J Clin Dermatol. 2018; 19: 293-302Crossref PubMed Scopus (27) Google Scholar Because of this polarization, it was initially thought that patients with AD are less likely to develop ACD because of Th2 skewing in AD. However, recent literature has indicated that both ACD and AD have shared immune pathways, including Th1, Th2, and/or Th17.53Dhingra N. Shemer A. Correa Da Rosa J. et al.Molecular profiling of contact dermatitis skin identifies allergen-dependent differences in immune response.J Allergy Clin Immunol. 2014; 134: 362-372Abstract Full Text Full Text PDF PubMed Google Scholar, 54Roesner L.M. Heratizadeh A. Begemann G. et al.Der p1 and der p2-specific T cells display a Th2, Th17, and Th2/Th17 phenotype in atopic dermatitis.J Invest Dermatol. 2015; 135: 2324-2327Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 55Oyoshi M.K. He R. Kumar L. Yoon J. Geha R.S. Chapter 3 cellular and molecular mechanisms in atopic dermatitis.Adv Immunol. 2009; 102: 135-226Crossref PubMed Scopus (0) Google Scholar In fact, more than one third of children diagnosed with ACD have concurrent AD.15Zug K.A. McGinley-Smith D. Warshaw E.M. et al.Contact allergy in children referred for patch testing: North American contact dermatitis group data, 2001-2004.Arch Dermatol. 2008; 144: 1329-1336Crossref PubMed Scopus (121) Google Scholar,56Schena D. Papagrigoraki A. Tessari G. Peroni A. Sabbadini C. Girolomoni G. Allergic contact dermatitis in children with and without atopic dermatitis.Dermatitis. 2012; 23: 275-280Crossref PubMed Scopus (34) Google Scholar, 57Jacob S.E. McGowan M. Silverberg N.B. et a
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