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Nickel allergy and hand eczema: epidemiological aspects
Örebro University, School of Health and Medical Sciences.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Nickel allergy is the most prevalent contact allergy and has been discussed as a possible riskfactor for hand eczema. However, hand eczema is one of the most frequently occurring skindiseases and has multifactorial origin. The aim of this thesis was to study the association between nickel allergy and hand eczema in the general population. There are only a fewpopulation-based studies previously published, that include patch testing. In addition, this thesis aimed to evaluate methods to follow the prevalence of nickel allergy.The study cohort consisted of 908 women who had been patch tested for the occurrence of nickel allergy as schoolgirls. Twenty years later, they were invited to participate in a follow-up questionnaire study. The response rate was 81%. In total, 17.6% of respondents reported handeczema after the age of 15 years and there was no statistically significant difference in the occurrence of hand eczema between those who were nickel-positive and those who were nickel negativeas schoolgirls. To further investigate possible links, another study was performed,which included a second questionnaire, a clinical investigation and patch testing. All schoolgirls from the baseline study who were still living in the area as adults were invited to participate and the participation rate was 77%. Patch test showed 30.1% nickel-positive individuals.When all participants were included in the analysis, there was no statistically significant difference between nickel-positive and nickel-negative women regarding occurrence of hand eczema. The most important risk factor for hand eczema was childhood eczema. Adjusted prevalence proportion ratio (PPR) for hand eczema after age 15 in relation to nickel patch testresults was 1.03 (95% CI 0.71--1.50) and in relation to childhood eczema 3.68 (95% CI 2.45--5.54). When women with and without history of childhood eczema were analyzed separately, the hand eczema risk was doubled in nickel-positive women without history of childhood eczema. In conclusion, the risk of hand eczema in nickel-positive women may previously havebeen overestimated. Next, the validity of self-reported nickel allergy was investigated. In the established cohort; two questions regarding nickel allergy were compared with patch test results. The validity of self-reported nickel allergy was low, and the questions regarding nickel allergy overestimated the true prevalence of nickel allergy. The positive predictive values were 59% and 60%. Another method for estimating the prevalence of nickel allergy, namely self-patch testing, was validated in the last study. In total, 191 patients from three different dermatology departments participated. The validity of self-testing for nickel allergy was adequate, with sensitivity 72%and proportion of agreement 86%.

Abstract [sv]

Nickelallergi är vanligt förekommande. Prevalensen i Skandinavien är 15--25% hos kvinnor och cirka 3% hos män. Sambandet mellan nickelallergi och uppkomst av handeksem har tidigare diskuterats och i vissa studier anges att 30--45% av alla individer med nickelallergi får handeksem. Det finns dock endast ett fåtal publicerade studier där personer ur normalbefolkningen har lapptestats för nickel. Handeksem ärvanligt och har ofta flera olika kombinerade orsaker. Det övergripande syftet med avhandlingen var att studera nickelallergins betydelse för uppkomst av handeksem. Detfinns ett intresse av att följa förekomsten av nickelallergi över tid, speciellt sedan det i början av 2000-talet infördes ett EU-direktiv som begränsar nickelinnehåll i klockor,smycken, metallknappar etc. Ytterligare ett syfte med avhandlingen var att utvärderaepidemiologiska metoder för att följa förekomsten av nickelallergi.Den första studien var en uppföljningsstudie av 908 flickor ur normalbefolkningen,vilka i skolåldern lapptestats med nickel. Tjugo år senare skickades en enkät till dessa kvinnor, svarsfrekvensen var hög (81%). Förekomsten av självrapporterat handeksemefter 15 års ålder var 17.6%. Det förelåg ingen signifikant skillnad i förekomst avhandeksem mellan de kvinnor som var nickelallergiska som barn jämfört med dem som inte var nickelallergiska. År 2006 utfördes ytterligare en studie, som inkluderade de kvinnor som fortfarande bodde i Örebro län. Studien omfattade en klinisk undersökning av händerna samt ett lapptest. 30% av kvinnorna var positiva för nickel.Det förelåg ingen signifikant skillnad i förekomst av handeksem mellan de som var positiva för nickel och de som var negativa. Vid separat analys av de kvinnor som angav tidigare barneksem jämfört med dem som aldrig hade haft barneksem visade det sig att risken för handeksem var dubbelt så stor hos nickelallergiker i den gruppen som aldrig hade haft barneksem. Båda studierna visade att barneksem var den största riskfaktorn för att få handeksem som vuxen, med en 3-4 gånger ökad risk. Den tredje studien var en validering av självrapporterad nickelallergi. Överensstämmelsen var låg mellan enkätfrågor gällande nickelallergi och lapptestverifierad nickelallergi. Av dem som själva bedömde sig vara nickelallergiska var endast 59% positiva enligt lapptest. För att följa förekomsten av nickelallergi i befolkningen behövs därför andra metoder. I den fjärde studien utvärderades ett självtest för nickelallergi. 191 patienter från tre olika hudkliniker i Sverige deltog i studien. Validiteten för metoden självtest var tillfredsställande, sensitiviteten var 72%och graden av överensstämmelse var 86%.

Place, publisher, year, edition, pages
Örebro: Örebro university , 2010. , 73 p.
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 47
Keyword [en]
childhood eczema, contact allergy, patch test, population-based, predictive value, questionnaire, self-test, sensitivity, specificity, validity, wet work
National Category
Medical and Health Sciences Dermatology and Venereal Diseases
Research subject
Dermatology and Venerology
Identifiers
URN: urn:nbn:se:oru:diva-11855ISBN: 978-91-7668-765-9 (print)OAI: oai:DiVA.org:oru-11855DiVA: diva2:352075
Public defence
2010-12-17, Wilandersalen USÖ, Örebro, 13:00
Opponent
Supervisors
Available from: 2010-09-17 Created: 2010-09-17 Last updated: 2011-04-21Bibliographically approved
List of papers
1. Nickel allergy and hand eczema: a 20-year follow up
Open this publication in new window or tab >>Nickel allergy and hand eczema: a 20-year follow up
2006 (English)In: Contact Dermatitis, ISSN 0105-1873, E-ISSN 1600-0536, Vol. 55, no 5, 286-290 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to investigate the occurrence of hand eczema after 20 years in women patch tested to nickel during childhood. In 1982-1983, 960 schoolgirls were patch tested for nickel allergy; its prevalence was found to be 9%. 20 years later, the same individuals received a questionnaire regarding hand eczema and factors of importance for the development of hand eczema. 735 of 908 women (80.9%) answered the questionnaire. In total, 17.6% of respondents reported hand eczema after the age of 15 years, and the 1-year prevalence was 12.8%. There was no statistically significant difference in the occurrence of hand eczema between the groups who had previously tested positive and negative for nickel allergy. 38.3% of the respondents considered themselves to be nickel sensitive at the time they answered the questionnaire; in this group, the reported prevalence of hand eczema after age 15 was 22.5%. 31.4% of those with a history of atopic dermatitis reported hand eczema after age 15, compared with 10.6% of those without (P < 0.001). In conclusion, contact allergy to nickel in childhood did not seem to increase the prevalence of hand eczema later in life.

Place, publisher, year, edition, pages
Oxford: Wiley, 2006
Keyword
nickel allergy, hand eczema, childhood eczema, population-based, childhood eczema, epidemiology, interaction, missing value analysis, patch test, wet work
National Category
Medical and Health Sciences Dermatology and Venereal Diseases
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-12500 (URN)10.1111/j.1600-0536.2006.00958.x (DOI)
Available from: 2010-11-19 Created: 2010-11-18 Last updated: 2010-11-22Bibliographically approved
2. Nickel allergy as risk factor for hand eczema: a population-based study
Open this publication in new window or tab >>Nickel allergy as risk factor for hand eczema: a population-based study
2009 (English)In: British Journal of Dermatology, ISSN 0007-0963, E-ISSN 1365-2133, Vol. 160, no 4, 828-834 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: In population-based studies using self-reported nickel allergy, a hand eczema prevalence of 30-43% has been reported in individuals with nickel allergy. In a previous Swedish study, 958 schoolgirls were patch tested for nickel. In a questionnaire follow up 20 years later no association was found between nickel allergy and hand eczema. OBJECTIVES: To investigate further the relation between nickel allergy and hand eczema. METHODS: Three hundred and sixty-nine women, still living in the same geographical area, now aged 30-40 years, were patch tested and clinically investigated regarding hand eczema. RESULTS: Patch testing showed 30.1% nickel-positive individuals. The adjusted prevalence proportion ratio (PPR) for hand eczema after age 15 years in relation to nickel patch test results was 1.03 (95% confidence interval, CI 0.71-1.50). A history of childhood eczema was reported by 35.9%, and the PPR for hand eczema in relation to childhood eczema was 3.68 (95% CI 2.45-5.54). When analysing the relation separately in women with and without a history of childhood eczema a statistical interaction was found. The hand eczema risk was doubled in nickel-positive women without a history of childhood eczema, with a PPR of 2.23 (95% CI 1.10-4.49) for hand eczema after age 15 years. CONCLUSIONS: A doubled risk for hand eczema was found in nickel-positive women without a history of childhood eczema. When analysing all participants, there was no statistically significant difference between nickel-positive and nickel-negative women regarding occurrence of hand eczema. The most important risk factor for hand eczema was childhood eczema. The risk for hand eczema in nickel-positive women may previously have been overestimated.

National Category
Medical and Health Sciences Dermatology and Venereal Diseases
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-11994 (URN)10.1111/j.1365-2133.2008.09006.x (DOI)19183170 (PubMedID)
Available from: 2010-10-04 Created: 2010-10-04 Last updated: 2010-11-22Bibliographically approved
3. Validity of self-reported nickel allergy
Open this publication in new window or tab >>Validity of self-reported nickel allergy
2010 (English)In: Contact Dermatitis, ISSN 0105-1873, E-ISSN 1600-0536, Vol. 62, no 5, 289-293 p.Article in journal (Refereed) Published
Abstract [en]

Background: To estimate the prevalence of nickel allergy, self-reports are sometimes used in epidemiological studies. Self-reports are practical and may facilitate estimation of prevalence provided that the questions are validated.Objectives: To investigate the validity of self-reported nickel allergy.Methods: Three hundred and sixty-nine women, aged 30–40 years, from the general population participated in the study. The participants answered a questionnaire before a clinical examination and patch testing. The two questions being validated were ‘Are you sensitive/hypersensitive/allergic to nickel?’ and ‘Do you get a rash from metal buttons, jewellery or other metal items that come in direct contact with your skin?’Results: Patch test showed nickel-positive reaction in 30% of the subjects. Self-reported prevalence of nickel allergy as indicated by the two respective questions was 40% and 35%. Positive predictive values for the two questions were 59% (95% CI 50–67) and 60% (95% CI 51–69). History of childhood eczema was over-represented among women with ‘false-positive’ self-reported nickel allergy (P = 0.008). Self-reported hand eczema or ‘high wet exposure’ did not influence the validity.Conclusions: The validity of self-reported nickel allergy is low. The questions regarding nickel allergy overestimate the true prevalence of nickel allergy.

Place, publisher, year, edition, pages
Oxford: Wiley, 2010
Keyword
epidemiology, patch test, predictive value, questionnaire, sensitivity, specificity
National Category
Medical and Health Sciences Dermatology and Venereal Diseases
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-12502 (URN)10.1111/j.1600-0536.2010.01702.x (DOI)
Available from: 2010-11-19 Created: 2010-11-18 Last updated: 2010-11-22Bibliographically approved
4. Validation of self-testing as a method to estimate the prevalence of nickel allergy
Open this publication in new window or tab >>Validation of self-testing as a method to estimate the prevalence of nickel allergy
Show others...
2011 (English)In: Acta Dermato-Venereologica, ISSN 0001-5555, E-ISSN 1651-2057, Vol. 91, no 5, 526-530 p.Article in journal (Refereed) Published
Abstract [en]

Background: Valid epidemiological tools are required for surveillance of the prevalence of contact allergy. Population based studies including patch testing is the most reliable method, but implies heavy expenses and logistical problems. Clinical data are not representative for the general population and questionnaires concerning contact allergy have a low validity. Self-testing might be a useful method but it has to be validated and evaluated.

Objectives: To investigate the validity of self-patch testing for nickel allergy. Methods: Patients from three dermatology clinics were included consecutively when referred to patch testing. In total, 191 patients participated and they were provided with a self-test package including written instructions. The self-test was applied on the arm by the patient, on the same day as the patch test was applied on the back, in the clinic. The patient evaluated the self-test before the patch test reading at the clinic.

Results: Patch test at dermatology clinic (‘gold standard’) gave 46/191 (24%) nickel-positive individuals. The sensitivity of the self-test was 72% (95% CI 57–84), the specificity was 91% (95% CI 85–95) and the proportion of agreement was 86% (95% CI 81–91).Conclusions: The validity of self-testing for nickel allergy was adequate in the studied population. To determine whether self-testing is a useful tool for measuring the prevalence of nickel allergy in the general population further studies will be needed.

Place, publisher, year, edition, pages
Society for Publication of Acta Dermato-Venereologica, 2011
Keyword
contact allergy, epidemiology, patch test, self-test, sensitivity, specificity
National Category
Medical and Health Sciences Dermatology and Venereal Diseases
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-12503 (URN)10.2340/00015555-1120 (DOI)000294887800006 ()21874219 (PubMedID)2-s2.0-80051991751 (Scopus ID)
Available from: 2010-11-19 Created: 2010-11-18 Last updated: 2017-02-15Bibliographically approved

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