Allergic contact dermatitis in children is on the rise and closely associated
with lifestyle changes. With increasing exposure to common allergens
due to the popularity of jewelry, body paints, cosmetics etc., children
are developing contact sensitivity very early on.
That children rarely contract a contact allergy is now a myth. In the
last 10-20 years, contact allergy has become a challenge for pediatricians
worldwide. Positive patch test results have registered a variant rate
of 14.5% to 70% of cases, with clinical relevance in 20% to 92% of cases.
This variance in the rates reported by different studies has made the
prevalence of contact allergy in kids difficult to define. However, most
studies have commonly concluded that allergic contact dermatitis occurs
more in older children than younger ones and rate of incidence increases
with age, as contact with allergens increases. Generally, by the age of
10, it is as frequent as in adults.
The spread of eczematous lesions is a key indicator rather than the manifestation
of specific lesions. A skin eruption that has an uncommon appearance or
is confined to a particular skin location (face, feet etc.) should be
screened for allergic contact.
The clinical appearances also have a major role to play in proper prognosis
of the disease in kids. They typical forms are:
- Earlobe, neck, or sub-umbilical (below the belly button) skin eczema
with nickel allergy (ear rings, jewellery, metal snaps on pants).
eruption including shoe dermatitis.
- Now-a-days a new kind of diaper
dermatitis occurs due to rubber, chemicals or glues in disposable
- The ‘baboon syndrome’ (the term is derived as
an association with the red gluteal region of the baboon), which is
a systemic allergy
in the flexural regions of the extremities, the buttocks, and
the anogenital areas. Though rare, it occurs in children after systemic
exposure to mercury,
ampicillin, amoxycillin, nickel, erythromycin, heparin and food
- Medication related aggravation of atopic dermatitis, during
therapy of the same, might occur as a result of allergy to
of the preparation.
Patch tests in children
Patch testing is mainstay in the accurate diagnosis of contact allergy.
Before a patch test, a medical history and screening could give an indication
of allergens the child may be reactive to. However, one must patch test
not only with probable allergens but also unknown ones as well. For instance,
in one patient with eruptions on the areas of the soles that undergo maximum
pressure, was initially diagnosed with allergic contact dermatitis from
shoe linings or adhesives. But on testing, medication to contact allergy
was found to be the real trigger.
There is considerable debate about the concentration of allergens to
be used for patch testing in children. Initially, it was suggested that
children be tested with a lower intensity of allergens than adults to
avoid risk of too much skin irritability.
However, that might result in false-negative test outcomes. While some
recommended that the concentration be half for nickel, rubber chemicals
and formaldehyde, others suggested that it be suited to the age of the
child and all positive patch reactions be repeated using the half intensity
formula. However, nowadays the accepted practice is to test children
with the same strength as used in adults.
A key disadvantage of patch testing in children is inadequate space on
their small backs. This can be addressed by testing with a lesser number
of series of allergens at a time.
The first step for a proper management of this disease among children
is to understand its earlier neglected childhood occurrence. Once that
is clear here are a few points to remember:
- The patient’s medical history is a must.
- Details about the
patient’s fashion, personal care and lifestyle
preferences is vital.
- The recreational activities are also required.
For instance, the source of dermatitis in a student was actually
traced to her cellist
finger dermatitis and residue on the instrument strings that in
turn was due to a chemical p-phenylendiamine.
This apart, one must be aware of the main triggers. They are:
- Jewellery that includes procedures like body piercing, ear piercing.
tattoos that includes use of black henna mixtures, containing indigo,
henna and chemical coloring agents such as p-phenylendiamine
(PPD) and/or diaminotoluens.
- Natural remedies that includes herbal
preparations and aromatic therapies.
- Vaccination that includes
the mercury-based vaccine preservative thiomersal.
cosmetics that includes fragrances.
Prevention and therapy
Since there is no standard therapeutic practice, avoiding the triggers
is the standard means of prevention. There have been a number of legislations
from time to time, which has reinforced the prevention process. They are:
- The Cosmetics Directive 76/768/EEC and its amendments: This deals
with the safe use of cosmetics. A section of it concentrates on the
of contact dermatitis, with a chart of preservative ingredients of
cosmetics, with their maximum permissible concentrations. However, it
does not provide
any data about the restrictions for children other than toxicological
- The EU Nickel Directive: It restricts the nickel component
in some products.
- In 1992, the Danish Ministry of the Environment
came up with a directive on how to avoid nickel contamination of the
Moreover, since children come in contact with allergens at a very early
age ways to avoid them should start off early and must involve the parents.
Hence, parents should be extensively educated about common allergens.
Here are some tips:
- Paediatric detergents should be very gentle to avoid irritant dermatitis
and chemically simple to avoid allergic dermatitis.
- Topical preparations
for children should be not contain fragrances and preservatives.
dose of topical antibiotics should be limited during childhood in
order to prevent the possibility of sensitization to some antibiotics
and to prevent bacteria in children from becoming resilient to
- Ear piercing should not be allowed in kids under
ten years of age.
- Parents should be educated about skin care during
childhood. They must be made aware that ‘herbal’ does not
mean preparations are absolutely safe.