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and in 1 case&#44; the reaction was accompanied by eczema and hypertrichosis&#44; which had first appeared more than 1 year previously &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; The vaccinations had been administered according to the corresponding schedule&#44; and the clinical picture was associated with the vaccines included in the schedule&#46; Given that the clinical suspicion included other conditions in 2 cases&#44; diagnosis was based on skin biopsy&#44; which revealed findings typical of this type of reaction &#40;histiocytes with granular cytoplasm&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; All 3 patients underwent patch testing with aluminum chloride 2&#37; in petrolatum &#40;Chemotechnique&#41;&#44; which yielded positive readings at 72 and 168 hours &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Aluminum compounds have been used as adjuvants in vaccines for more than 80 years to boost the immune response to the antigen&#46; Administration of vaccines can lead to cutaneous lesions&#44; mostly in the form of pruritus or subcutaneous nodules&#59; areas of hypertrichosis or eczema are less common&#46; The reactions persist in 0&#46;5&#37;&#8211;6&#37; of cases&#44; mainly because of a type IV hypersensitivity reaction to aluminum hydroxide&#46; Patch testing with aluminium hydroxide 2&#37; is positive in 77&#37;&#8211;95&#37; of children with persistent reactions&#44; thus demonstrating the presence of contact allergy to the metal<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Various histologic patterns have been described &#40;panniculitis&#44; pseudolymphomatous&#44; granuloma annulare&#8211;like&#41;&#44; although the characteristic finding is histiocytes with a granular cytoplasm&#46; Nevertheless&#44; given the high sensitivity of patch testing&#44; skin biopsy is not considered essential for diagnosis<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The lesions generally appear at 12&#8211;18 months of life&#44; mostly after several vaccinations &#40;usually after the third&#41; and with subcutaneous vaccines&#46; It is thought that&#44; at the subcutaneous level&#44; aluminum comes into contact with dendritic cells&#44; thus triggering a hypersensitivity reaction&#46; The reactions usually occur 2&#46;5 months after the vaccination&#44; although reports indicate that this interval can vary from 2 weeks to 13 months&#46; The duration of symptoms also varies widely&#44; from months to up to 10 years<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Children who are sensitized to aluminum can experience contact dermatitis when exposed to objects that contain it &#40;e&#46;g&#46;&#44; deodorants&#44; toothpaste&#44; pigments used in tattoos&#41;&#46; However&#44; some studies show that contact allergy to aluminum can diminish or disappear over time&#44; with negative results in up to 77&#37; of cases 7 years after the initial positive patch test reading<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Aluminum-containing vaccines should be replaced by aluminum-free vaccines in patients with contact dermatitis to aluminum&#46; However&#44; since not all vaccines have an aluminum-free version&#44; the patient should receive a deep intramuscular injection to reduce the risk of new lesions in cases where no substitute is available&#46; In general terms&#44; the benefits of vaccines outweigh potential complications&#59; therefore&#44; the appearance of the lesions does not justify nonadherence to the vaccination schedule&#46; Similarly&#44; given that aluminum is also a standard adjuvant in subcutaneous allergen-specific immunotherapy&#44; 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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">PCV13&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Nodules&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">DTP&#44; Hib&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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Case and Research Letters
Contact allergy to aluminum following vaccination: A report of 3 cases
Alergia de contacto a aluminio tras vacunación: presentación de tres casos
F. Tous Romeroa,
Autor para correspondencia
Fatimatousro@gmail.com

Corresponding author.
, S.I. Palencia Péreza, J.L. Rodríguez Peraltob, F.J. Ortiz de Frutosa
a Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, Spain
b Servicio de Anatomía Patológica, Hospital Universitario 12 de Octubre, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Vaccination is an essential measure in preventive medicine&#46; However&#44; it is not free from complications&#44; since it can lead to adverse reactions&#44; although these are mainly mild&#44; transient&#44; and self-limiting<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; The reactions are rarely persistent&#44; with most cases involving a hypersensitivity reaction to aluminum<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the cases of 2 girls &#40;age&#44; 2 and 3 years&#41; and a boy &#40;8 years&#41; who experienced persistent cutaneous reactions after vaccination &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; All 3 patients developed nodules at the injection site&#44; and in 1 case&#44; the reaction was accompanied by eczema and hypertrichosis&#44; which had first appeared more than 1 year previously &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; The vaccinations had been administered according to the corresponding schedule&#44; and the clinical picture was associated with the vaccines included in the schedule&#46; Given that the clinical suspicion included other conditions in 2 cases&#44; diagnosis was based on skin biopsy&#44; which revealed findings typical of this type of reaction &#40;histiocytes with granular cytoplasm&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; All 3 patients underwent patch testing with aluminum chloride 2&#37; in petrolatum &#40;Chemotechnique&#41;&#44; which yielded positive readings at 72 and 168 hours &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Aluminum compounds have been used as adjuvants in vaccines for more than 80 years to boost the immune response to the antigen&#46; Administration of vaccines can lead to cutaneous lesions&#44; mostly in the form of pruritus or subcutaneous nodules&#59; areas of hypertrichosis or eczema are less common&#46; The reactions persist in 0&#46;5&#37;&#8211;6&#37; of cases&#44; mainly because of a type IV hypersensitivity reaction to aluminum hydroxide&#46; Patch testing with aluminium hydroxide 2&#37; is positive in 77&#37;&#8211;95&#37; of children with persistent reactions&#44; thus demonstrating the presence of contact allergy to the metal<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Various histologic patterns have been described &#40;panniculitis&#44; pseudolymphomatous&#44; granuloma annulare&#8211;like&#41;&#44; although the characteristic finding is histiocytes with a granular cytoplasm&#46; Nevertheless&#44; given the high sensitivity of patch testing&#44; skin biopsy is not considered essential for diagnosis<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The lesions generally appear at 12&#8211;18 months of life&#44; mostly after several vaccinations &#40;usually after the third&#41; and with subcutaneous vaccines&#46; It is thought that&#44; at the subcutaneous level&#44; aluminum comes into contact with dendritic cells&#44; thus triggering a hypersensitivity reaction&#46; The reactions usually occur 2&#46;5 months after the vaccination&#44; although reports indicate that this interval can vary from 2 weeks to 13 months&#46; The duration of symptoms also varies widely&#44; from months to up to 10 years<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Children who are sensitized to aluminum can experience contact dermatitis when exposed to objects that contain it &#40;e&#46;g&#46;&#44; deodorants&#44; toothpaste&#44; pigments used in tattoos&#41;&#46; However&#44; some studies show that contact allergy to aluminum can diminish or disappear over time&#44; with negative results in up to 77&#37; of cases 7 years after the initial positive patch test reading<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Aluminum-containing vaccines should be replaced by aluminum-free vaccines in patients with contact dermatitis to aluminum&#46; However&#44; since not all vaccines have an aluminum-free version&#44; the patient should receive a deep intramuscular injection to reduce the risk of new lesions in cases where no substitute is available&#46; In general terms&#44; the benefits of vaccines outweigh potential complications&#59; therefore&#44; the appearance of the lesions does not justify nonadherence to the vaccination schedule&#46; Similarly&#44; given that aluminum is also a standard adjuvant in subcutaneous allergen-specific immunotherapy&#44; contact allergy to aluminum is a relative contraindication&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">It is essential to be aware of the cutaneous complications associated with administration of vaccines&#46; Consequently&#44; in the case of a persistent reaction after administration&#44; we should consider the presence of contact allergy to aluminum&#46; A suggestive clinical history&#44; together with positive patch tests results&#44; should be sufficient to confirm the diagnosis&#46; Early diagnosis will prevent parental anxiety and other&#44; unnecessary and invasive procedures&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Tous Romero F&#44; Palencia P&#233;rez SI&#44; Rodr&#237;guez Peralto JL&#44; Ortiz de Frutos FJ&#46; Alergia de contacto a aluminio tras vacunaci&#243;n&#58; presentaci&#243;n de tres casos&#46; Actas Dermosifiliogr&#46; 2021&#59;112&#58;930&#8211;932&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lesions on the right thigh in the form of excoriated erythematous macules clustered over a nodular lesion with hypertrichosis on the surface&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Skin biopsy from one of the case reports&#46; A&#44; Normal epidermis&#44; with lesions mainly in the dermis and subcutaneous cellular tissue &#40;hematoxylin-eosin&#44; &#215;4&#41;&#46; B&#44; Areas of sclerosis&#44; together with follicular lymphoid hyperplasia and histiocytic infiltrate &#40;hematoxylin-eosin&#44; &#215;4&#41;&#46; C&#44; Histiocytes with granular cytoplasm &#40;hematoxylin-eosin&#44; &#215;20&#41;&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patch test readings at 168&#8239;h in one of the cases&#46; Note the positive result to aluminum hydroxide 2&#37; &#40;&#43;&#43;&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; DPT&#44; diphtheria&#44; pertussis&#44; tetanus&#59; Hib&#58; <span class="elsevierStyleItalic">Haemophilus influenzae</span> b&#59; PCV&#44; pneumococcal conjugate vaccine&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Duration of Symptoms at the First Evaluation&#44; mo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Female&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Nodules&#44; eczema&#44; and hypertrichosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">PCV13&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Nodules&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">DTP&#44; Hib&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                          "etal" => false
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                            1 => "E&#46; Bergfors"
                            2 => "A&#46; Inerot"
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Información del artículo
ISSN: 15782190
Idioma original: Inglés
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