**7.4.2 Preservatives**

Conti et al. (Conti et al., 1997) reviewed contact sensitization to 8 preservatives (imiadazolidinyl urea, diazolidinyl urea, parabens, formaldehyde, quaternium-15, Katon CG, Euxyl K400 and butylated hydroxyanizole) in the child population and found 7.3% of the children reacted positively. Almost 50% of preservative-sensitive children had AD. Baby toilet tissues have been occasionally reported to cause CA in babies and those who take care of them. The allergens considered most often are fragrances and preservatives. Methylchloroisothiazolinone and methylisothiazolinone (MCI/MI) is widely used as a preservative in many products (De Groot & Herxheimer, 1989). Tosti et al. (Tosti et al., 2003) found MCI/MI to be a frequent cause of ACD, i.e. in 7 of 95 children between 3 and 11 years old were positive to MCI/MI. The use of moist toilet papers (baby wipes) can be responsible for ACD, especially of perianal area (De Groot et al., 1991). MCI/MI was replaced from them by other preservatives, particularly with Euxyl K400 (methydibromoglutaronitrile and phenoxyethanol) (Senff et al., 1989) and 1,2-dibromo-2,4-dicyanobutane (Van Ginkel & Rutdervoort, 1995).

#### **7.4.3 Sorbitan sesquioleate**

De Waard-van der Spek and Oranje (De Waard-van der Spek & Oranje, 2009) found 3 children patch tested positive to sorbitan sesquioleate (SSO), all clinically relevant. Two children used emollient contained SSO as emulsifier. They also reported a child positive patch tested to Adaptic non-adhering dressing containing SSO. Castanedo-Tardan and Jacob (Castanedo-Tardan & Jacob, 2008) reported the case series of 6 pediatric patients with clinically relevant contact allergy to SSO. 5 children were atopics and suffered with recalcitrant dermatitis.

#### **7.5** *Para***-Phenylenediamine and tattoos**

An increased prevalence of *para*-Phenylenediamine (PPD) allergy has been noted in the pediatric population. Eczematous reactions are mostly seen at the site of the tattoo and they may be long-lasting (Lewis et al., 2004). Henna dye is a dark green powder, used for hair dyeing and body tattooing. Henna itself is relatively safe. However, PPD is added on an illegal basis in semi-permanent tattoos (black henna tattoos), in order to obtain a darker colour and a faster drying time than natural henna can provide. Although many parents and consumers believe these black henna tattoos to be temporary, adverse events to them

(Balsam of Peru) is used as a screen for fragrance allergy, due to its wide usage and natural cross-reactivity with other frequently encountered fragrances (Tomar et al., 2005; Garg et al., 2009; Lee et al., 2009). These allergens (or chemically similar ones) are also used in soft drinks and flavouring such as cinnamon, cloves, curry and vanilla. Although dietary intervention remains controversial, there is evidence that it may help those with significant disease that is not resolving with more typical fragrance avoidance (Magnusson & Wilkinson, 1975; Salam & Fowler Jr., 2001; Tomar et al., 2005). Although guidelines for the maximum concentration of preservatives and fragrances in cosmetics have been provided (Goossens et al., 2004), it has been demonstrated that toys may contain much higher concentrations of fragrance (Rastogi et al., 1999). No extra safety requirements for toys

Conti et al. (Conti et al., 1997) reviewed contact sensitization to 8 preservatives (imiadazolidinyl urea, diazolidinyl urea, parabens, formaldehyde, quaternium-15, Katon CG, Euxyl K400 and butylated hydroxyanizole) in the child population and found 7.3% of the children reacted positively. Almost 50% of preservative-sensitive children had AD. Baby toilet tissues have been occasionally reported to cause CA in babies and those who take care of them. The allergens considered most often are fragrances and preservatives. Methylchloroisothiazolinone and methylisothiazolinone (MCI/MI) is widely used as a preservative in many products (De Groot & Herxheimer, 1989). Tosti et al. (Tosti et al., 2003) found MCI/MI to be a frequent cause of ACD, i.e. in 7 of 95 children between 3 and 11 years old were positive to MCI/MI. The use of moist toilet papers (baby wipes) can be responsible for ACD, especially of perianal area (De Groot et al., 1991). MCI/MI was replaced from them by other preservatives, particularly with Euxyl K400 (methydibromoglutaronitrile and phenoxyethanol) (Senff et al., 1989) and 1,2-dibromo-2,4-dicyanobutane (Van Ginkel &

De Waard-van der Spek and Oranje (De Waard-van der Spek & Oranje, 2009) found 3 children patch tested positive to sorbitan sesquioleate (SSO), all clinically relevant. Two children used emollient contained SSO as emulsifier. They also reported a child positive patch tested to Adaptic non-adhering dressing containing SSO. Castanedo-Tardan and Jacob (Castanedo-Tardan & Jacob, 2008) reported the case series of 6 pediatric patients with clinically relevant contact allergy to SSO. 5 children were atopics and suffered with

An increased prevalence of *para*-Phenylenediamine (PPD) allergy has been noted in the pediatric population. Eczematous reactions are mostly seen at the site of the tattoo and they may be long-lasting (Lewis et al., 2004). Henna dye is a dark green powder, used for hair dyeing and body tattooing. Henna itself is relatively safe. However, PPD is added on an illegal basis in semi-permanent tattoos (black henna tattoos), in order to obtain a darker colour and a faster drying time than natural henna can provide. Although many parents and consumers believe these black henna tattoos to be temporary, adverse events to them

intended for children are required (White, 2000).

**7.4.2 Preservatives** 

Rutdervoort, 1995).

recalcitrant dermatitis.

**7.5** *Para***-Phenylenediamine and tattoos** 

**7.4.3 Sorbitan sesquioleate** 

(scaring and sensitization) can be permanent. PPD is a very potent contact sensitizer included in the European baseline series for patch testing. PPD is also contained in permanent hair dyes and related compounds (Lee et al., 2009). The content of PPD in semipermanent tattoo ink has been reported to vary between 0.4 and 15.7%, far exceeding the limit permissible for hair dyes (<6%) (Brancaccio et al., 2002; Avnstorp et al., 2002; Sosted et al., 2006; Lee et al., 2009). The long duration of skin contact, the high concentrations of sensitizing materials (diaminobenzenes or diaminotoluenes) and the lack of a neutralizing agent increase the risk of skin sensitization. Because of the worldwide vogue for skin painting, a greater number of patients sensitized to PPD and diaminobenzenes or diaminotoluenes can be expected (Le Coz et al., 2000; Onder et al., 2001; Neri et al., 2002; Jovanovic & Slavkovic-Jovanovic, 2009). The unusually severe reactions to PPD in young 12 to 15 year old adolescents have occurred after dyeing their hair having been previously sensitized to PPD in black henna tattoo at a younger age. In some cases, the children developed severe angioedema-like reactions necessitating admission to hospital and intensive care treatment (Sosted et al., 2006). Severe allergic reactions were reported in 1.4% of women and 1.3% of men after dying their hair (Sosted et al., 2005). Sensitization to PPD is potential for lifelong sensitization and systemic contact dermatitis can be evoked with exposure to cross-reactors such as benzocaine, diuretics (hydrochlorothiazide) and sulfonamide medications (Sosted et al., 2006; Lee et al., 2009). Notably, 25% of those allergic to PPD can also be reactive to semi-permanent dyes found in synthetic clothing. PPD base, being a part of the European baseline series, is regarded as a screening agent for contact allergy to *para* and azo compounds in hair dyes, but not for textile and leather dye allergy (Koopmans & Bruynzeel, 2003).

#### **7.6 Rubber compounds**

Rubber additives are typically present in many rubber products (e.g. elastic waistbands, socks, swimwear, shoes, toys, cosmetic applicators and adhesives) and could be main allergens from them. Thiurams, mercapto chemicals and less commonly carbamates are the responsible allergens in rubber allergy in children; thiourea derivates in neoprene may also be the cause of dermatitis (Goossens & Morren, 2006; Lee et al., 2009). Roul et al. (Roul et al., 1998) reported a particular type of diaper dermatitis called ʻLucky Luke' dermatitis. The rubber parts used for a new anti-leaking system in these diapers provoked the reaction. Mercaptobenzothiazole and thiuram derivates are also present in certain types of glues (Roul et al., 1996; Cockayne et al., 1998). Type I allergic reactions may also occur (contact urticaria syndrome), sometimes associated with a type IV reaction. It is typical for children who had undergone multiple surgical operations (for example children suffering from spina bifida). Moreover, these children are particularly susceptible to natural rubber latex proteins in this regard (Goossens & Morren, 2006).

#### **7.7 Toxicodendron dermatitis (Poison Ivy, Poison Oak, Poison Sumac)**

*Toxicodendron* (Poison Ivy) dermatitis can occur at any age, although infants are apparently not as easily sensitized as adults. After the age of 3, children become highly susceptible and by 12 years of age nearly all have become sensitized to poison ivy (Kligman 1974). Plants belonging to the Rhus family are the ones most often involved in ACD among children living in the United States (Goossens & Morren, 2006). The oleoresin (urushiol) of the sap of the *Toxicodendron* plants contains catechols, which are very strong sensitizing chemicals. The

Allergic Contact Dermatitis in Children 121

principal factor associated with ACD is the pattern of exposure to the various allergens (Vozmediano & Hita, 2005). In the unselected population, the prevalence of CA is about 20% (Mortz & Andersen, 1999; Weston & Weston, 1984; Barros et al., 1991), while in the selected population, the prevalence of ACD is found to be variable, with a mean of 40% (Mortz & Andersen, 1999; Wöhrl et al., 2003; Heine et al., 2004; Lewis et al., 2004; Seidenari et al., 2005; Vozmediano & Hita, 2005; Militello et al., 2006; Goossens & Morren, 2006; Jacob et al., 2008). The susceptibility to contact sensitization increases with the age. The most important allergens observed in this population are metals, mercury, pharmaceutical products and cosmetics (Vozmediano & Hita, 2005; Militello et al., 2006; Goossens & Morren, 2006; Jacob et al., 2008). ACD in childhood may also affect decisions regarding future occupations in adulthood. Therefore, it is very important that any CA in a child is recognized and dealt with in time. The impact of CA must not be underestimated, both on a complex individual scale of quality of life and socio-economically, for example, due to job options (Uter et al., 2004). Patch testing is both well tolerated and diagnostically essential in the evaluation of pediatric patients with potential ACD. Once allergen is documented, treatment relies on symptomatic use of topical or oral corticosteroids and meticulous allergen avoidance (Militello et al., 2006). Good information on preventing the development of ACD in children

Many thanks to Mrs. Susan Harley and Mr. Christopher J. Garlick for their linguistic

Akhavan, A. & Cohen, SR. (2003). The relationship between atopic dermatitis and contact

Avnstorp, C., Rastogi, SC. & Menné, T. (2002). Acute fingertip dermatitis from temporary

Barros, MA., Baptista, A., Correia, TM. & Azevedo, F. (1991). Patch testing in children: a

Beattie, PE., Green, C., Lowe, G. & Lewis-Jones, MS. (2007). Which children should we patch

Brancaccio, RR., Brown, LH., Chang, YT., Fogelman, JP., Mafong, EA. & Cohen, DE. (2002).

Brasch, J. & Geier, J. (1997). Patch test results in schoolchildren. *Contact Dermatitis* 37: 286-

Bruckner, AL., Weston, WL. & Morelli, JG. (2000). Does sensitization to contact allergens

Buckley, DA., Rycroft, RJG., White, IR. & McFadden, JP. (2003). The frequency of fragrance allergy in patch-tested patients increases with age. *Br J Dermatol* 149: 986-989.

study of 562 schoolchildren. *Contact Dermatitis* 25: 156–159.

tattoo and quantitative chemical analysis of the product. *Contact Dermatitis* 47: 119-

Identification and quantification of para-phenylenediamine in a temporary black

is useful for the caregivers.

**10. Acknowledgment** 

*The project was supported by grants MZOFNM 2005/6904* 

dermatitis. *Clin Dermatol* 21(2): 158-162.

henna tattoo. *Am J Contact Dermat* 13: 15-18.

Brasch J. (2009). Contact Allergy in children. *Hautarzt* 60: 194-196.

test? *Clin Exp Dermatol* 32: 6-11.

begin in infancy? *Pediatrics* 105: 3-9.

assistance.

**11. References** 

120.

293.

eruption produced by poison ivy is characterized by redness, papules, vesicles and bullae plus linear streaking. Occasionally, urticaria and eruptions, resembling erythema multiforme, measles or scarlatina, occur from systemic absorption of the poison ivy antigen (Rietschel & Fowler Jr., 2008b). Exposure can be direct or indirect, such as transfers of the allergen via animals, tools, clothing, golf clubs, etc. (Goossens & Morren, 2006; Rietschel & Fowler Jr., 2008b), which is more difficult to diagnose (Epstein 1971). A few cases of phytophotodermatitis from *Toxicodendron* in children were also reported (Goossens & Morren, 2006).
