SAN FRANCISCO - Exposure to one or more irritant allergens can incite atopic dermatitis in pediatric patients, Dr. Sharon E. Jacob said.
Start by educating patients to avoid these common irritants: fragrance, formaldehyde, and cocamidopropyl betaine. "These are frequently used together and end up on the top list of allergens for children," she said.
Skin barrier repair is another essential component of a supersensitive skin regimen she recommends for these patients. Provide atopic patients with recommendations for cleansing, aseptic baths, and use of emollients and ceramides, she said.
The top 10 allergens (irritant and allergic) in pediatric patients, in order, are:
1. Nickel sulfate
2. Cobalt chloride
3. Thimerosal
4. Gold
5. Fragrance mix
6. Neomycin
7. Balsam of Peru
8. Colophony
9. Formaldehyde
10. Lanolin
Cocamidopropyl betaine, a common ingredient in shampoo, soaps, and toothpastes, comes in at number 16 on the list. Dr. Jacob compiled the list from the literature and presented it at a seminar on women’s and pediatric dermatology sponsored by Skin Disease Education Foundation (SDEF).
"The allergens causing big problems in atopic pediatric patients are the same [most common] allergens in our general population," Dr. Jacob said.
In addition, urine that causes diaper dermatitis and soap that leads to hand dermatitis are common irritant exposures. "Any substance that acts as mild toxic substance can give you an irritant dermatitis, said Dr. Jacob, an assistant clinical professor of medicine (dermatology) and pediatrics at the University of California, San Diego, and at Rady Children’s Hospital.
A meeting attendee asked about the safest diapers to recommend to parents. "Cloth is the best, but may not be practical," Dr. Jacob replied. Safer options include fragrance-free, dye-free diapers available at Whole Foods Market and the Huggies brand organic cotton diaper, she said.
In terms of differential diagnosis, keep in mind that irritant contact dermatitis is a nonimmunologic reaction – unlike agents that cause allergic contact dermatitis, Dr. Jacob said.
Fragrances are a challenge to avoid – they are in virtually every product with a scent, Dr. Jacob said. "It is very hard to find fragrance products these patients can use. Many have multiple ingredients."
One pearl is to recommend "fragrance-free" but not "unscented" products, Dr. Jacob said. Unscented items might contain a masking fragrance, she said. For example, she compared two "sensitive skin" deodorants with the same brand name and very similar packaging. One was labeled fragrance free and one unscented. However, the ingredient list on the unscented deodorant included parfum. "You cannot just go by the way it looks."
You can identify about 80% of fragrance allergies by patch testing with Balsam of Peru and Fragrance Mix 1, Dr. Jacob said. "When you add jasmine, ylang ylang, sandalwood, and narcissus, you get to 95%."
Also consider allergy to Lyral, "one of the new reported fragrance allergens," Dr. Jacob said. This potential allergen is included in the Fragrance Mix 2 series. Lyral, also known as hydroxyisohexyl 3-cyclohexene carboxaldehyde, is found in fine fragrances, many aerosol deodorants, and other personal care items.
Formaldehyde is a colorless, readily-soluble gas that is used extensively as a preservative. It has been a top allergen for 70 years, Dr. Jacob said, and has a potential role in systemic contact allergies. The artificial sweetener aspartame can metabolize to formaldehyde and some chewable "gummy" vitamins contain this ingredient, she said.
Another meeting attendee asked about tear-free shampoos and soaps for children that do not contain cocamidopropyl betaine. Dr. Jacob suggested the California Baby product line, but again cautioned that parents should read labels carefully and purchase the 'fragrance-free' items, versus products that contain 'essential oils.'
SDEF and this news organization are owned by Elsevier.
Dr. Jacob is a speaker for Coria Laboratories, Astellas Pharma Inc., and Shire. She is also an independent investigator for Allerderm, maker of the T.R.U.E. test.