RESEARCH ALERT: Topical and Systemic Therapies for Nickel Allergy (2011)
Tammaro, A., Narcisi, A., Persechino, S., Caperchi, C., & Gaspari, A.
Every month I dissect a research article related to systemic nickel and cobalt allergies. This month's article discusses treatment options for people with a nickel allergy. Keep in mind this article was written in 2011, treatments options may have changed or evolved since then.
Allergic contact dermatitis (ACD) from nickel is defined as an inflammatory skin condition mediated by a type IV hypersensitivity that manifests after frequent contact with nickel. The prevalence is increasing worldwide because nickel is common in our environment. The risk factors for developing a nickel allergy include frequent exposures, prolonged time of contact and compromised skin barrier. Some genetic variations may be mutations in the filaggrin gene complex and an alteration of toll-like receptor 4 (TLF4). Nickel allergy prevalence varies from 4 – 13.1% in different countries throughout the world, the rates are still rising. Nickel allergy is more common in women than men. Some professions are more likely to develop a nickel allergy such as hairdressers, domestic cleaners, metal workers and caterers. Nickel is also present in a large number of foods (mainly vegetables) which is another source of exposure for people who are sensitized. Nickel allergy can result in skin and systemic symptoms, which can range from mild to severe. Systemic nickel allergy syndrome (SNAS) is a severe form of this disease. The researchers describe SNAS as cutaneous manifestations (contact dermatitis, pompholyx, dyshydrosis and urticaria) and systemic symptoms (headache, abnormal physical weakness, itching and GI disorders).
Topical Emollients, Corticosteroids, and Immunosuppressive Therapies
Topical treatments are the first-line therapy for contact dermatitis, the main purpose is to repair the skin barrier. The researchers state that “barrier damage is directly correlated to the severity of dermatitis.” The use of emollients and barrier creams can help reduce the need of topical corticosteroids and immunosuppressive agents (tacrolimus and pimecrolimus). There are varying strengths of topical steroids and they are often used during the acute phase of eczema. The use of topical steroids is not advised longer than 1-3 weeks because of possible side effects such as spider veins and thinning of the skin. Tacrolimus and pimecrolimus are anti-inflammatory medications that down-regulate the immune system, this class of drugs is known as topical calcineurin inhibitors (TCIs). They are indicated in chronic eczema sufferers. TCI’s help to limit the use of steroids and, in particular, pimecrolimus does not increase the occurrence of skin infections when compared to steroids.
Narrowband Ultraviolet B
Phototherapy is discussed as an effective treatment option for hand eczema, in addition, to psoriasis and atopic dermatitis. The researchers discuss, broadband and narrowband UVB and state it seems to be as effective as topical psoralen plus ultraviolet A (PUVA) therapy. However, there are risks with phototoxicity and dyspigmentation when using local PUVA therapy; therefore, UVB is the preferred treatment option.
Systemic Immunosuppressive Therapy
Systemic immunosuppressive therapy is considered for those patients who don’t respond to topical steroids or phototherapy. If ACD involves more than 20% of the skin, the researchers say that “systemic steroid therapy is required.” It is important to taper off oral prednisone over 2-3 weeks because stopping it abruptly can cause rebound dermatitis. Cyclosporine is discussed as a short-term treatment option but the studies on its effectiveness vary.
Oral zinc is discussed as a treatment option. Nickel may interact with essential divalent ions because of its similar chemical properties. The researchers state “some effects of nickel may be eliminated or reduced by supplementing with divalent essential metals.” They highlight a study that showed improvement in nickel dermatitis after the administration of oral zinc sulfate. Based on this study zinc therapy was shown to be effective and safe.
The low nickel diet is highlighted as a treatment option to help reduce symptoms. The say that nickel is frequently found in food which makes it hard to avoid. The researchers list nickel rich food as oatmeal, nuts, cocoa, chocolate and soybean. They state that nickel consumption can cause recurrence of contact dermatitis and also trigger symptoms mediated by IgE such as hives. They discuss how a nickel allergy can have a more involved immune response, “potentially causing both IgE antibody production (from type 1 helper T cells) and the development of ACD (from type 2 helper cells).” The researcher discuss how meta-analysis results have generally confirm a relationship between dietary nickel and dermatitis flares. Furthermore, ingesting a range of 0.6-5.6mg daily of nickel was found to elicit an eczema response.
Disulfiram is a nonconventional pharmacologic agent used as a chelating agent for metals such as nickel and cobalt. Its main use is for alcohol addiction. Studies have shown it is helpful to reduce frequency and intensity of flare-ups. Side effects of this treatment include fatigue, headache, and dizziness. They highlight studies that show it is a risky treatment that can cause liver toxicity.
Hyposensitization With Nickel
Oral nickel sulfate hyposensitization treatment is discussed as an effective treatment option to reduce symptoms. They state one study "clearly demonstrated that oral nickel administration in humans may importantly reduce the number of circulating T-cell lymphocytes activated against this antigen." The researchers note a few studies and mention that this is the only therapeutic option that treats both skin and GI manifestations related to a nickel allergy.
Below is a pdf version of this blog post and the original research article. Feel free to print and share with your doctor. For more information on research articles related to systemic contact dermatitis or systemic nickel allergy syndrome check out my resource page, or for help with managing this allergy you can check out the services I offer.