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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Isothiazolinones are preservatives found in cosmetic&#44; industrial&#44; and home cleaning products&#46; The isothiazolinone mix Kathon&#8212;methylchloroisothiazolinone &#40;MCI&#41; and methylisothiazolinone &#40;MI&#41;&#8212;was approved in 1980&#46; Since then&#44; several cases of allergic contact dermatitis to these preservatives have been detected&#44; with sensitization rates &#62;<span class="elsevierStyleHsp" style=""></span>5&#37;&#46; Despite regulation of the maximum concentration in cosmetics&#44; sensitization rates remain high&#44; especially in recent years after the approval of MI alone at high concentrations&#46; These rates have now reached epidemic proportions &#40;8&#37;-11&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Allergic contact dermatitis to isothiazolinones mainly affects middle-aged women and is associated with the use of cosmetics&#46; It manifests as dermatitis affecting the face and dorsum of the hands&#59; therefore&#44; many patients are initially considered to have photodermatosis and are referred for a photobiologic study &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The objective of the present study was to identify cases of allergic sensitization to MCI&#47;MI in patients sent for a photobiologic study&#46; The secondary objective was to investigate clinical-epidemiological variables&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We performed a retrospective descriptive study of all patients assessed at the Photobiology Unit of the Dermatology Department of Hospital General de Valencia&#44; Valencia&#44; Spain between January 2013 and December 2015 for eczematous dermatitis affecting areas exposed to sunlight&#46; The clinical histories were reviewed&#44; and all cases of sensitization to isothiazolinones were recorded&#46; We also collected demographic variables &#40;eg&#44; sex and age&#41;&#44; source of sensitization&#44; and personal or family history of atopy&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">All patients were assessed using photopatches according to the recommendations of the European Society of Contact Dermatitis&#46; The patches were applied in duplicate&#44; and one of the series was irradiated at 48<span class="elsevierStyleHsp" style=""></span>hours using UV-A lamps &#40;5<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span>&#41;&#46; We also applied the standard series of the Spanish Contact Dermatitis and Skin Allergy Research Group &#40;MartiTor&#41; in use at the time&#44; as well as an MI patch at 500<span class="elsevierStyleHsp" style=""></span>ppm&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Depending on the clinical history&#44; complementary patch tests were performed with specific allergen series or with the patient&#39;s own products&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Of the 142 patients referred to the Photobiology Unit during the study period&#44; 18 were sensitized to isothiazolinones &#40;12&#46;7&#37;&#41;&#46; Most were sensitized both to MCI&#47;MI and to MI alone &#40;72&#46;2&#37;&#41;&#44; 16&#46;7&#37; were sensitized to MCI&#47;MI alone&#44; and 11&#46;1&#37; to MI alone&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">More cases were identified in women &#40;77&#46;8 vs 22&#46;2&#37;&#41; with a mean age of 62 years &#40;median&#44; 59 years&#41;&#46; Atopy was reported by 16&#46;7&#37; of patients&#44; and 16&#46;7&#37; had a positive phototest result&#46; The source of sensitization in all cases was cosmetics&#44; mainly moisturizing cream&#46; Of note&#44; the source of sensitization was sunscreen in 3 cases &#40;<a class="elsevierStyleCrossRef" href="#sec0010">Supplementary Material</a>&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Of the patients initially considered to have photodermatosis and therefore sent for the photobiologic study&#44; 12&#46;7&#37; actually had allergic contact dermatitis to isothiazolinones&#46; Consequently&#44; skin allergy to isothiazolinones must always be taken into consideration in the differential diagnosis of photodistributed skin lesions&#46; In fact&#44; this percentage is probably underestimated&#58; our experience led us to progressively reclassify many of these patients with apparently photodistributed eczema as contact dermatitis and refer them directly to the skin allergy unit&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Moreover&#44; with the application of the new standard series of the Spanish Contact Dermatitis and Skin Allergy Research Group&#44; which has double the concentration of MCI&#47;MI and includes MI at 2000<span class="elsevierStyleHsp" style=""></span>ppm&#44; the number of cases detected is expected to decrease&#59; therefore&#44; we must familiarize ourselves with the habitual clinical presentation of these allergens&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In 2015&#44; Pirmez et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> found that up to 70&#37; of patients sensitized to isothiazolinones presented photodistributed lesions&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">A possible explanation for the distribution of the skin lesions is that the exposed areas &#40;face&#44; intermammary area&#44; forearms&#44; dorsum of the hands&#41; are where cosmetics&#44; and sunscreens in particular&#44; are most commonly applied&#44; as we observed in 16&#46;7&#37; of the cases in the present study&#46; However&#44; other theories can be proposed&#46; In 2014&#44; Aerts et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> reported a case of potentially photoaggravated sensitization to isothiazolinones&#46; A subsequent photopatch-based study published in the <span class="elsevierStyleItalic">British Journal of Dermatology</span> demonstrated the role of isothiazolinones in photoaggravation&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Therefore&#44; we conclude that not only should ACD to isothiazolinones be taken into consideration in the differential diagnosis of patients with photodermatosis&#44; but that studies are also necessary to identify the pathogenic mechanism&#46;</p></span>"
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Letter to the Editor
Allergic Sensitization to Isothiazolinones in Patients Referred for Photobiologic Study
Sensibilización alérgica a isotiazolinonas en pacientes remitidos a estudio fotobiológico
M. Giácaman-von der Weth
Autor para correspondencia
mmgiacaman@gmail.com

Corresponding author.
, A. Pérez-Ferriols, C. Sierra-Talamantes, V. Zaragoza-Ninet
Servicio de Dermatología, Hospital General, Valencia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Isothiazolinones are preservatives found in cosmetic&#44; industrial&#44; and home cleaning products&#46; The isothiazolinone mix Kathon&#8212;methylchloroisothiazolinone &#40;MCI&#41; and methylisothiazolinone &#40;MI&#41;&#8212;was approved in 1980&#46; Since then&#44; several cases of allergic contact dermatitis to these preservatives have been detected&#44; with sensitization rates &#62;<span class="elsevierStyleHsp" style=""></span>5&#37;&#46; Despite regulation of the maximum concentration in cosmetics&#44; sensitization rates remain high&#44; especially in recent years after the approval of MI alone at high concentrations&#46; These rates have now reached epidemic proportions &#40;8&#37;-11&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Allergic contact dermatitis to isothiazolinones mainly affects middle-aged women and is associated with the use of cosmetics&#46; It manifests as dermatitis affecting the face and dorsum of the hands&#59; therefore&#44; many patients are initially considered to have photodermatosis and are referred for a photobiologic study &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The objective of the present study was to identify cases of allergic sensitization to MCI&#47;MI in patients sent for a photobiologic study&#46; The secondary objective was to investigate clinical-epidemiological variables&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We performed a retrospective descriptive study of all patients assessed at the Photobiology Unit of the Dermatology Department of Hospital General de Valencia&#44; Valencia&#44; Spain between January 2013 and December 2015 for eczematous dermatitis affecting areas exposed to sunlight&#46; The clinical histories were reviewed&#44; and all cases of sensitization to isothiazolinones were recorded&#46; We also collected demographic variables &#40;eg&#44; sex and age&#41;&#44; source of sensitization&#44; and personal or family history of atopy&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">All patients were assessed using photopatches according to the recommendations of the European Society of Contact Dermatitis&#46; The patches were applied in duplicate&#44; and one of the series was irradiated at 48<span class="elsevierStyleHsp" style=""></span>hours using UV-A lamps &#40;5<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span>&#41;&#46; We also applied the standard series of the Spanish Contact Dermatitis and Skin Allergy Research Group &#40;MartiTor&#41; in use at the time&#44; as well as an MI patch at 500<span class="elsevierStyleHsp" style=""></span>ppm&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Depending on the clinical history&#44; complementary patch tests were performed with specific allergen series or with the patient&#39;s own products&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Of the 142 patients referred to the Photobiology Unit during the study period&#44; 18 were sensitized to isothiazolinones &#40;12&#46;7&#37;&#41;&#46; Most were sensitized both to MCI&#47;MI and to MI alone &#40;72&#46;2&#37;&#41;&#44; 16&#46;7&#37; were sensitized to MCI&#47;MI alone&#44; and 11&#46;1&#37; to MI alone&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">More cases were identified in women &#40;77&#46;8 vs 22&#46;2&#37;&#41; with a mean age of 62 years &#40;median&#44; 59 years&#41;&#46; Atopy was reported by 16&#46;7&#37; of patients&#44; and 16&#46;7&#37; had a positive phototest result&#46; The source of sensitization in all cases was cosmetics&#44; mainly moisturizing cream&#46; Of note&#44; the source of sensitization was sunscreen in 3 cases &#40;<a class="elsevierStyleCrossRef" href="#sec0010">Supplementary Material</a>&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Of the patients initially considered to have photodermatosis and therefore sent for the photobiologic study&#44; 12&#46;7&#37; actually had allergic contact dermatitis to isothiazolinones&#46; Consequently&#44; skin allergy to isothiazolinones must always be taken into consideration in the differential diagnosis of photodistributed skin lesions&#46; In fact&#44; this percentage is probably underestimated&#58; our experience led us to progressively reclassify many of these patients with apparently photodistributed eczema as contact dermatitis and refer them directly to the skin allergy unit&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Moreover&#44; with the application of the new standard series of the Spanish Contact Dermatitis and Skin Allergy Research Group&#44; which has double the concentration of MCI&#47;MI and includes MI at 2000<span class="elsevierStyleHsp" style=""></span>ppm&#44; the number of cases detected is expected to decrease&#59; therefore&#44; we must familiarize ourselves with the habitual clinical presentation of these allergens&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In 2015&#44; Pirmez et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> found that up to 70&#37; of patients sensitized to isothiazolinones presented photodistributed lesions&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">A possible explanation for the distribution of the skin lesions is that the exposed areas &#40;face&#44; intermammary area&#44; forearms&#44; dorsum of the hands&#41; are where cosmetics&#44; and sunscreens in particular&#44; are most commonly applied&#44; as we observed in 16&#46;7&#37; of the cases in the present study&#46; However&#44; other theories can be proposed&#46; In 2014&#44; Aerts et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> reported a case of potentially photoaggravated sensitization to isothiazolinones&#46; A subsequent photopatch-based study published in the <span class="elsevierStyleItalic">British Journal of Dermatology</span> demonstrated the role of isothiazolinones in photoaggravation&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Therefore&#44; we conclude that not only should ACD to isothiazolinones be taken into consideration in the differential diagnosis of patients with photodermatosis&#44; but that studies are also necessary to identify the pathogenic mechanism&#46;</p></span>"
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