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What challenges and barriers exist when patch testing children?
Clinical Applications
Dr. Schwarzenberger is the former physician editor of DermWorld. She interviews the author of a recent study each month.
By Kathryn Schwarzenberger, MD, June 1, 2021
In this month’s Clinical Applications column, Physician Editor Kathryn Schwarzenberger, MD, talks with JiaDe (Jeff) Yu, MD, about his recent JAAD articles on pediatric allergic contact dermatitis, "Part I: Clinical features and common contact allergens in children" and "Part 2: Patch testing series, procedure, and unique scenarios."
DermWorld: You and your colleagues recently published two review articles in JAAD on pediatric allergic contact dermatitis. What got you interested in this topic and why did you feel it warranted continuing medical education?
Dr. Yu: Allergic contact dermatitis affects up to 20% of all children, although children are still infrequently evaluated for this condition. Among a consortium of patch testing experts — the North American Contact Dermatitis Society — on average, one child was patch tested for every 30 adults. Initially, it was falsely believed that children’s immune systems cannot develop allergic contact dermatitis either due to immaturity or lack of exposure. However, studies began to emerge that demonstrated even infants down to six months of age can develop allergic contact dermatitis. Even among pediatric dermatologists, allergic contact dermatitis is not routinely considered when evaluating a child with recalcitrant dermatitis. Therefore, this continuing medical education article hopefully provides a framework and guide for suspecting and evaluating allergic contact dermatitis in children.
DermWorld: How often do children develop allergic contact dermatitis and what features should make you suspect it?
Dr. Yu: The exact population-level prevalence is still unknown, but experts estimate that about 20% of all children have allergic contact dermatitis. This rate is higher in patients who are referred to specialty centers for patch testing. Among children with atopic dermatitis (the most common inflammatory skin disease in children), 42.2% of children in one study who were patch tested were found to have concomitant allergic contact dermatitis.
The most common time we suspect and/or evaluate for allergic contact dermatitis in children is when they have 1) unusual location of involvement of their dermatitis; 2) recalcitrant dermatitis that is not improving with appropriate treatment; 3) when the child or parent suspects a trigger; 4) prior to initiation of systemic therapies.
DermWorld: Are we patch testing enough children? If not, what do you see as barriers to testing and how can we overcome them?
Dr. Yu: We are not patch testing enough children because, likely, the level of suspicion is low and the barrier to patch testing is high. One way to overcome the barrier is by helping physicians who are seeing a lot of children in their practice and are interested in doing patch testing. Hopefully, the CME helps lay the groundwork for what is needed to do patch testing in children. The CME also recommends several patch testing series that can be used with high-yield allergens. One is the pediatric baseline series which was developed by members of the American Contact Dermatitis Society to test 38 allergens that are of highest value in children.
“We are not patch testing enough children because, likely, the level of suspicion is low and the barrier to patch testing is high. One way to overcome the barrier is by helping physicians who are seeing a lot of children in their practice and are interested in doing patch testing.”
─ JiaDe (Jeff) Yu, MD
DermWorld: Do children react to the same allergens as adults? Can you comment on emerging allergens? Is there anything we should not test children for when doing patch testing?
Dr. Yu: Children and adults largely react to the same allergens. Some common allergens in both populations include metals such as nickel and cobalt, topical antibiotics (neomycin and bacitracin), preservatives (formaldehyde and methylisothiazolinone), and fragrances.
Emerging allergens in children include isobornyl acrylate, which is a newly discovered adhesive seen in continuous glucose monitors and insulin devices, as well as acetophenone azine which is a newly identified byproduct of EVA foam used in sports equipment, padding, and shoes. I would recommend not always testing for paraphenylenediamine (PPD), which is a common allergen in hair dyes, due to lack of exposure and high sensitization risk with PPD.
DermWorld: Some of our colleagues have likely never done patch testing on children. Are there logistical issues to consider in children that might not be an issue in adults?
Dr. Yu: While teenagers and older adolescents can be patch tested similarly to adults, younger children can be sometimes challenging. Young children may have less real estate on the back to apply patches. Therefore, they may require a smaller or modified patch testing series. Young children may also be less compliant with patch testing, and therefore more time is required to reassure and distract the child. Finally, the skin of young children may be more
susceptible to irritation. In children younger than 6 years old, we will sometimes recommend removal of patches in 24 hours (instead of the standard 48).
DermWorld: How do we encourage more dermatologists to do patch testing on children?
Dr. Yu: The most important aspect is recognizing that the clinical presentation may be consistent with allergic contact dermatitis. Once that differential is considered, referring the child to a dermatologist who is also a member of the American Contact Dermatitis Society (ACDS) for patch testing is ideal. These providers are identified via the “Find a Provider” link on ACDS.
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