Indian Journal of Paediatric Dermatology

REVIEW ARTICLE
Year
: 2019  |  Volume : 20  |  Issue : 3  |  Page : 205--211

Contact dermatitis in pediatric age group: Indian scenario


Yasmeen Jabeen Bhat, Saniya Akhtar, Iffat Hassan 
 Department of Dermatology, Government Medical College, Srinagar, Jammu and Kashmir, India

Correspondence Address:
Dr. Yasmeen Jabeen Bhat
Department of Dermatology, Government Medical College, Karan Nagar, Srinagar - 190 010, Jammu and Kashmir
India

Abstract

Contact dermatitis was previously considered to be rare in children except some forms of irritant contact dermatitis which were seen commonly in children. However, nowadays, there are an increasing number of cases of allergic contact dermatitis (ACD) being reported in children due to increased exposure to a variety of allergens at an earlier age. Various predisposing factors which influence the occurrence of contact dermatitis include age, sex, atopy, and presence of any concomitant skin disease. Nickel has been identified as leading cause of ACD in children. Other common allergens reported are cobalt, fragrance mix, rubber, lanolin, thiomersal, neomycin, gold, mercapto mix, balsam of Peru, and colophony. Clinical presentation in children is similar to that in adults with eczema of the hands, feet, wrists, face, forehead, scalp, eyelids, earlobes, neck, axilla, trunk, thighs, and anogenital area being seen. Disseminated lesions can as well be seen. When ACD is suspected, patch testing is the gold standard diagnostic procedure. However, patch testing in children differs from adults as some technical difficulties are encountered in children due to their smaller test area and frequent movements. However, the general opinion stands that children can be patch tested with the same methods and patch test concentrations as adults. For the prevention of recurrence, allergen elimination should be the aim of treatment; however, in many cases, it is not possible to completely eliminate the allergen from the patients environment. Topical steroids and calcineurin inhibitors form the mainstay of treatment in most cases.



How to cite this article:
Bhat YJ, Akhtar S, Hassan I. Contact dermatitis in pediatric age group: Indian scenario.Indian J Paediatr Dermatol 2019;20:205-211


How to cite this URL:
Bhat YJ, Akhtar S, Hassan I. Contact dermatitis in pediatric age group: Indian scenario. Indian J Paediatr Dermatol [serial online] 2019 [cited 2019 Jul 16 ];20:205-211
Available from: http://www.ijpd.in/text.asp?2019/20/3/205/261875


Full Text



 Introduction



Contact dermatitis was previously considered to be rare in children[1],[2] except the irritant contact dermatitis (ICD) of the diaper area which was seen commonly in children. It was believed that due to the lower susceptibility of the immune system to develop contact allergy, children rarely present with this complaint. The other reason being - immaturity of the cell-mediated immune system during the first two years of life. Furthermore, the pediatric age group was less exposed to allergens which further supported this belief.[3],[4] However, nowadays, there are an increasing number of cases of allergic contact dermatitis (ACD) being reported in children.[5] This change in the trend of ACD in children can be attributed to the increased use of cosmetics and topical medicaments in children. Furthermore, vaccinations and body piercing in younger patients are potential causes of exposure to various allergens.[1] In addition, the increased recognition of this entity in children and more number of patch tests being conducted in the pediatric age group has led to increased incidence of ACD in children.[6] In developing countries like India, lifestyle has considerably been influenced by the west which has resulted in an increased use of cosmetics, dyes, and packed foods. Furthermore, rapid urbanization has resulted in a noticeable increase in the incidence of air-borne contact dermatitis.[7] There is an overall increase in the presence of allergens in the environment, which has resulted in children getting exposed to a variety of allergens early in life. ACD can lead to significant morbidity in children. They can experience chronic and recurrent episodes of dermatitis if the contact with the offending allergen is not avoided.[8] There can be loss of sleep, loss of school work, and low self-esteem due to chronic dermatitis in children which is associated with a lot of itching.[9]

 Epidemiology



The exact prevalence of both irritant and ACD in children is not known. ACD affects approximately 7% of the general population.[10] The prevalence of ACD in asymptomatic children is only rarely described. Most studies provide the prevalence of ACD in selected population groups referred for patch testing which differs from the prevalence of positive patch tests in population-based studies.[11] Mortz and Anderson found a prevalence rate of 13.3%–23.3% of positive patch test reactions in unselected groups of children while in selected population groups, positive patch test reactions were noted in 14.5%–70% and 56.4%–93.3% of the positive patch test reactions were determined to be clinically relevant.[12] In another study conducted on 1146 Danish unselected adolescents from the general population, 15.2% had one or more positive patch test reactions with present or past relevance seen in 47.7% cases only, giving the prevalence of 7.2% ACD in them.[13]

According to Weston et al.[3] ACD accounts for 20% of all dermatitis in children. In a Spanish study, 1023 chidren up to the age of 14 years were patch tested, and positive reactions were found in 31% cases.[14] In another study from Singapore, 2340 children and adolescents were patch tested with 45.4% giving positive reaction to one or more allergens.[15] In a retrospective study conducted in a UK center on 500 children, patch test positivity was found in 27%, with 61% reactions being of current clinical relevance.[16]

In 2010, Jacob et al.[17] reported the highest rate of sensitization of 95.6% among 45 children of 0–16 years of age. In a study from India, 70 children in the age group of 1–15 years were studied. Eight percent showed positive allergic reactions with relevant allergy noted in 48.6% of the patients with potassium dichromate, paraben, and fragrance being the most relevant allergens.[7] The high susceptibility of indian children to ACD has been attributed by the authors to rapid urbaniisation, westernisation and the extremely relaxed vigilance on adherence to “product safety guidelines.

To assess the real prevalence of ACD in children, the positive patch test reactions which have a clinical correlation with dermatitis in symptomatic individuals are important as the prevalence seems to be low in unselected population groups when patch tested. Thus, the prevalence of ACD ranges from 14% to 77% among children referred for patch testing due to clinical suspicion of contact dermatitis.[18],[19],[20],[21]

As far ICD is concerned, the exact prevalence of ICD in children is not known. Perianal dermatitis has been reported to have an overall incidence of 5%–20%.[22] Primary irritant napkin dermatitis has been reported to affect 50% of infants to some degree at some stage.[23] In a survey conducted in the UK, 20% of all skin consultations in children aged under 5 years were for napkin dermatitis.[24] No racial or sexual predilection is seen.

 Predisposing Factors



Age

It was believed that ACD in children should increase with age as there is more exposure to environmental allergens with each passing day. However, Roul et al.[25] and Seidenari et al.[18] found highest sensitization in 0–3 years age group. Wöhrl et al.[26] in a study done on Austrian patients found the highest incidence of patch test reactivity in children up to 10 years of age. However, many other studies[1],[6],[11],[27] have no difference in sensitization rates when comparing different age groups. In an Indian study,[7] the authors found highest sensitivity of 83% in the 11–15 years age group. Furthermore, in another study from North India,[28] the authors found the highest percentage of positive patch test reaction in 13–18 years age group. There is no consensus among various studies regarding the influence of age on the occurrence of ACD in children.

Gender

In a study by Seidenari et al.,[18] the authors did not show significant variations in sensitization according to the gender. However, females are more patch tested and have more sensitivity than men.[29] Furthermore, in some Indian studies,[7],[28] girls have outnumbered boys in presentation as well as positive patch test reactions, but statistical analysis has not shown any significant role of sex on the prevalence of contact dermatitis.

Atopy

Atopic eczema is believed to be an important risk factor for the development of ACD in children as there are more chances of contact allergy due to impaired epidermal barrier in atopics. There is also more exposure of sensitizers in patients of atopic eczema due to use of various topical medications.[12],[16] In an Indian study by Sarma and Ghosh,[7] atopy was present in 25.7% children and another study by Bhat et al.[28] found no significant statistical association between atopic status and the occurrence of positive patch test reactions. Atopic eczema may be an important risk factor for the development of ACD in children rather than in adults.

Allergic contact dermatitis and filaggrin

The role of the protein filaggrin (FLG) in maintaining an effective skin barrier is well known. The role of FLG mutation carriage in ACD etiology appears to be less important than in atopic dermatitis. It is postulated that the lack of FLG expression may predispose an individual to ACD by allowing easier contact of haptens with epidermal antigen-presenting cells. However, other genetic factors are also postulated to play a role in the development of ACD.[30]

Associated skin disorder

The presence of any associated skin condition as hand eczema or ICD can increase the chances of sensitization as inflammatory changes in dermis can increase absorption of allergens as well as topical medications.[21]

 Common Allergens Seen in Children



Common irritants and allergens that can cause contact dermatitis in younger children include saliva, urine in a diaper, and various baby products such as soaps, detergents, lotions, and perfumes. Metals such as nickel, chrome, mercury, and various cosmetic products and topical medications are other causative agents. Plants such as poison ivy and oak can also cause contact dermatitis. Latex, found in products such as rubber toys, balloons, balls, rubber gloves, pacifiers, and nipples, is another potential source of allergen in the pediatric age group.

Nickel has been identified as the leading cause of ACD in children.[31] Other common allergens reported are cobalt, fragrance mix, rubber, lanolin, thiomersal, neomycin, gold, mercapto mix, balsam of Peru, and colophony.[10],[11],[16],[32],[33],[34],[35],[36] Ear piercing, jewellery, eyeglass frames, belt buckles, jean snaps, zippers, coins, keys, and cell phones are considered to be the main sources of nickel.[21] Systemic contact dermatitis with nickel has also been reported.[37] In a study from India by Sarma and Ghosh,[7] 70 children were studied and most common allergens identified were paraben (43%), potassium dichromate (27%), fragrance mix (26%), and cobalt chloride (23%). The most relevant allergens were potassium dichromate and paraben. In another Indian by Bhat et al.,[28] nickel sulfate was the most common allergen identified causing 25% positive reactions with a positive relevance in 63.6% of the patients. Other allergens identified were cobalt chloride, neomycin sulfate, fragrance mix, potassium dichromate, paraphenylenediamine, balsam of Peru, parthenium, and black rubber mix. When considering the western scenario, a review of data by Simonsen et al.[5] published in 2011 found nickel, cobalt, thimerosal, and fragrance to be the most common allergens. In another review by Spek et al.,[30] the most frequent contact allergens identified in children were metals, fragrances, preservatives, neomycin, rubber chemicals, and colorings.

In the Indian scenario, it is pertinent to mention about the availability and use of many topical medications by the patients without any prescription for the same. Due to the relaxed guidelines in India, patients use many combination topical treatments available in the market on their own, which increases the chances of contact dermatitis. Neomycin is the most sensitizing of all topical antimicrobials, and its patch test positivity in children has been reported to be 8%.[38] Use of henna tattoos is also very common among teenage girls in India and acts as another source of allergen responsible for contact dermatitis. [Table 1] summarizes the common allergens and their sources.{Table 1}

 Clinical Presentation



The skin of a newborn child is particularly sensitive to irritants, and various factors contribute to the high incidence of primary irritant reactions in this age group. The widespread use of antiseptics and wet tissues, prolonged contact of skin with urine and feces, and the frequent presence of occlusive conditions lead to primary irritant perianal and napkin dermatitis. In perianal dermatitis, the erythema is confined to a zone around the anus with the affected skin being edematous and superficially eroded. Primary irritant napkin dermatitis presents as confluent erythema of the convex surfaces of the buttocks, genitalia, lower abdomen, pubic area, and upper thighs which are in close contact with the diaper. The deeper parts of the groin flexures generally tend to be spared.[39] Lip lickers dermatitis is another form of irritant dermatitis of the lips seen in children, especially young girls who keep on biting, sucking, and licking the lips. It starts in the middle of the lower lip and spreads to involve the whole of the lower or both lips. Patients present with scaling and crusting of the lips, more or less confined to the vermilion border.

ACD in children presents in the same way as in adults.[40] Classically, ACD presents as pruritic eczematous dermatitis mostly restricted to the contact site but disseminated lesions can as well be seen. Eczema of the hands and feet, wrists, face, forehead, scalp, eyelids, earlobes, neck, axilla, trunk, thighs, and anogenital area can be seen. Contact irritants as well as allergens are responsible for hand eczema in children. All patterns of hand eczema are possible in contact allergy including apron eczema, fingertip eczema, discoid eczema, and ring eczema [Figure 1]. Furthermore, children with hobbies such as gardening are more prone to develop hand eczemas.{Figure 1}

The clinical presentation and sites of frequent involvement in childhood contact dermatitis is more or less similar to adults. In a study by Toledo et al.,[41] ACD was the most common cause of hand eczema in children followed by atopic dermatitis and dyshidrotic hand eczema. The arms can be involved later on by the same allergens affecting hands. Dermatitis around the wrist can be due to allergy to nickel, chromate, and p-tertiary butylphenol formaldehyde resin from sensitivity to the metal, leather, and glue in watches and watch straps. Feet can be involved due to contact allergy to shoe materials including leather, rubber, glues, nickel, stockings, topical medicaments, antiseptics, and antiperspirants.[42] Shoe dermatitis presents as pruritic papular oozy dermatitis on the dorsum of toes, extending onto the feet and sparing the toe webs and needs to be differentiated from juvenile plantar dermatosis[43] [Figure 2].{Figure 2}

Facial involvement is seen in cases of ACD resulting from use of various cosmetics, hair dyes, fragrances, and preservatives or active ingredients in skincare products [Figure 3] and [Figure 4]. Eyelid dermatitis can sometimes be due to use of cosmetics, fragrances, eye drops, eye makeup, and mascara. Nail varnish on hands can also lead to eyelid dermatitis[44] and sometimes has been referred to as ectopic dermatitis [Figure 5]. Involvement of forehead can be due to use of hair dyes and gels and also due to chromate in leather hatbands. Dermatitis around the eyes involving cheeks, nose, eyelids, and ears can be due to nickel or plastics in spectacle frames. Lips and perioral area may be involved due to use of cosmetics, lip balms, lipsticks, flavoring agents, and toothpastes.[42] Furthermore, small children experimenting with toys and putting them in mouth can lead to perioral dermatitis. There is growing trend of earlobe dermatitis seen in children as ear piercing is done in young girls even infants.{Figure 3}{Figure 4}{Figure 5}

Necklaces or zip fasteners produce a small area of dermatitis on the nape of the neck due to the presence of nickel. Furthermore, textiles may cause a collar-like dermatitis or eruptions on the sides of the neck and around axillae. In adolescent patients, axillary exanthem may be caused by fragrance allergy due to the use of deodorants.[21] Nickel buttons and zip fasteners can cause dermatitis around the area where they are worn. Anogenital region is a common site for medicament sensitization. Furthermore, use of moist toilet tissues and wipes in small children and infants is a growing trend leading to more of contact dermatitis seen in this area.[45] Textile dermatitis may involve the thighs and be more pronounced in the popliteal spaces or gluteal folds.[42]

 Patch Testing in Children



When ACD is suspected, patch testing is the gold standard diagnostic procedure.[46] However, patch testing in children differs from adults in many ways. Several authors believed that children should be tested with lower concentrations of allergens, to avoid the risk of irritant reactions and false-positive results.[47],[48] Other technical difficulties encountered in children include smaller test area[25],[49] for patch testing and increased risk of losing patch test material due to the frequent movement in children.[50] Some authors have raised questions about the reliability of the adult patch test methodology being used in the pediatric population.[51],[52] However, Storrs[53] concluded that standard methods used in adults are safe as well as reliable in children. Similarly, other authors[12],[38] have confirmed the general opinion that children can be patch tested with the same methods and patch test concentrations as adults, and this is the current opinion on patch testing children. For small backs, sequential patch test applications to test all potentially important allergens may be tried. In order to secure the patch test on back in small children, stretch gauze bandage can be applied around the trunk of children as shown in [Figure 6].{Figure 6}

Patch test technique in children is the same as in adults.

Looking for relevance is equally important in positive patch test reactions. A positive reaction does not always mean that the cause of presenting dermatitis has been found. Likewise, a negative patch test result does not fully exclude ACD.

 Treatment



For the treatment of ACD, adequate knowledge as to the offending allergen is very important for the patient and caretaker. Patch testing helps to identify the offending allergens. Allergen elimination should be the aim in treatment; however, in many cases, it is not possible to completely eliminate the allergen from the patients' environment. Patients should be advised to avoid the responsible allergens as much as possible. A detailed list of the allergens and its sources should be provided to the patients/caretaker. Cross-reacting substances should also be listed.

In mild-to-moderate cases, topical steroids are used in the acute stage. Topical calcineurin inhibitors such as tacrolimus and pimecrolimus are another therapeutic options and should be considered when steroid-sparing agents are required, especially for certain areas, such as the face, axilla, and groin, which are more susceptible to steroid-induced atrophy. Since the condition is associated with a lot of itching, oral H1-antihistamines are widely used as an adjuvant treatment for pruritus in infants and children.[8] In case of severe and widespread disease, short course of systemic corticosteroids may be indicated.[54]

 Conclusion



Contact dermatitis is an ever-increasing problem in our country at present. A large number of products are available in the market in the form of cosmetics, medications, skin care products, dyes, soaps, detergents, temporary tattoos, and packed foods which have the potential of inducing both irritant as well as ACD, especially in children. The product safety guidelines are only poorly being adhered to in our country. In addition, the rapid urbanization and change in lifestyle have contributed to the overall problem. However, simultaneously, the diagnosis and recognition of this condition, especially in pediatric population has increased. ACD is now easily diagnosed due to the routine performance of patch testing in many centers across india. In conclusion, a better coordination is required between the health and government sectors so that the quality of products available in the market is improved and periodically checked. Furthermore, the availability of over-the-counter topical medications need to be regulated as many patients, especially children get sensitized to various allergens at an early stage of life before they are ever seen by any health professional.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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