LITHUANIAN troubles in the translation of the

LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
Contact sensitization profile in patients of Kaunas clinical hospital with suspected contact dermatitis; the results of patch testing
by
Rezwan Hussain
A thesis submitted in part fulfillment for the
degree of Master of Medicine
in the
Faculty of Medicine
Department of internal medicine
Kaunas
Supervisor: Palmira Leišyte
TABLE OF CONTENTS
TITLE PAGE1
TABLE OF CONTENTS2
SUMMARY3
ACKNOWLEDGEMENTS4
CONFLICT OF INTEREST5
ETHICS COMMITTEE CLEARANCE6
ABBREVIATIONS LIST7
INTRODUCTION8
AIM AND OBJECTIVES OF THE THESIS10
LITERATURE REVIEW 11
RESEARCH METHODOLOGY AND METHODS 25
RESULTS 26
DISCUSSION OF THE RESULTS 33
CONCLUSION 36
PRACTICAL RECOMMENDATIONS
LITERATURE LIST
SUMMARY
Author name: Rezwan Hussain
Title: Contact sensitization profile in patients of Kaunas clinical hospital with suspected contact dermatitis; the results of patch testing
Aim: The aim of the study was to determine Contact sensitization profile in patients with suspected contact dermatitis in the outpatient clinic of skin diseases of Kaunas clinical hospital using the standard European baseline patch testing technique.
Objectives:
To evaluate the most prevalent contact allergens in the outpatient clinic of skin diseases of Kaunas clinical hospital: in women, men and overall for both.
To evaluate the frequency of the hypersensitivity to one or more contact allergens
To evaluate the effects of age and gender and the correlation between age and gender in relation to ACD.

To determine the efficacy and efficiency of positive patch testing.

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Methods: 272 patients were selected from Kauno 2-oji klinikine ligonine, where they were patch tested and treated for allergic contact dermatitis. All subjects were patch-tested using Finn chambers and 24 standard chemical allergens from the European standard series. Patch tests ought to be connected to the upper back, as a result of the broad territory, encouraging the arrangement of different substances. Hairy zones ought to be maintained a strategic distance from because of low adhesion. Nonetheless, if fundamental, hair might be expelled utilizing extremely sharp edges toward hair development. This mediation can prompt troubles in the translation of the outcomes, as folliculitis may happen nearby. If there should be an occurrence of oily skin, mild cleansing with ethanol or solvents, just to expel abundance oil, might be finished.
After utilization of the chambers, sticky tape can be utilized to counteract separation and loss of bond of the tests, which encourage false negative outcomes. This progression is imperative in tropical and subtropical regions because of expanded sweating. The withdrawal of the tests is completed 48 hours after application, in a sufficiently bright place and utilizing particular plaques for the sort of chamber utilized, with openings relating to the area of allergens. The back ought to be set apart with a permanent pen, permitting future readings. The patient should return for reading 72-96 hours after use of the tests. This reading is central in light of the fact that a refinement response may happen over 72 hours after contact. (15)
Acknowledgements
Conflict of interest
Ethics committee clearance
Abbreviation list
ACD: Allergic contact dermatitis?
AD: Atopic dermatitis?
APT: Atopy patch test
?LTT: Lymphocyte transformation test?
MCI: Methylchloroisothiazolinone?
MI: Methylisothiazolinone?
ICD: Irritant contact dermatitis
IL: Interleukin
Tumor necrosis factor: TNF
OxS: Oxadative pressure
Ros: Reactive oxygen species
SCD: Systemic contact dermatitis
Introduction
Allergic contact dermatitis (ACD) is an induced hypersensitivity to a specific allergen/allergens, which occurs when a persons skin surface comes in contact with antigen, resulting in an allergic reaction. The inflammatory reaction takes place in the skin after percutaneous absorption of antigen resulting in recruitment of previously sensitized, antigen-specific T lymphocytes into the skin (1). It starts as normal cell-mediated response to intracellular pathogen such as bacteria, fungi and virus however the persistence of allergen sensitizes TDTH cells, causing secretion of inflammatory cytokines. The cytokines then activate the phagocytic cells resulting in non-specific tissue destruction and induce inflammation where symptoms usually take 24 – 72 hours to develop (13). The site of the inflammatory reaction, which came in contact with an allergen in a sensitized individual results in redness, papules and vesicles, followed by scaling and dry skin, these symptoms is Lithuania are most commonly caused by Nickel, cobalt chloride, Potassium dichromate, Formaldehyde and MCI/MI (2,11).
There are 2 types of Contact dermatitis, Allergic contact dermatitis and Irritant contact dermatitis (ICD), easily distinguishable based on the characteristics of symptoms and mechanism of response. ICD is a non-immune related physical and chemical modification of the skin due to pro-inflammatory and lethal effects of organic solvents, soaps, environmental factors and acids. ACD corresponds to type IV immune response, with an induction phase (afferent pathway) and an elicitation phase (efferent pathway), involving a complex series of events (12). The induction phase involves the Langerhans cells to uptake, processing, and presentation of the antigen by local antigen-presenting cells, and migrate to the limb node where they activate the T cells and activate production of memory T cells and in the elicitation phase, TH1 cells that have been primed by the previous exposure to the antigen which migrate and become activated because these cells are rare so there is little inflammation to attract the specific memory T cells to the site of dermis (14). ACD is very common in communities however, hard to determine the actual rate of incidence as patients often self-diagnose and self treat and are bought to a medical practitioners attention at various points, such as the emergency room, general practice, and urgent care clinics (10).
Patch testing is a gold standard technique discovered by Jozef Jadassohn in 1985 that revolutionised the way of identifying the explicit allergens triggering ACD.

When performing patch testing it must be recalled that the patch test is a biological incitement test and in that capacity the result is subject to different variables including the test framework and test material, the organic/functional status of the tested individual, and the dependable dermatologist. To get desired bioavailability of a hapten, one can impact the accompanying five factors. (15)
Intrinsic penetration capacity?
Concentration, dose?
Vehicle?
Occlusivity of patch test system and tape
Exposure time
Patch testing is a complex but very effective mean to establish contact allergy although the diagnosis of allergic contact dermatitis comes from the combination of patch-test results and clinical data. However, different countries and centers usually have their own patch test traditions despite the efforts to standardize the procedure by international societies. This makes it difficult to compare results obtained in different countries (2). 2
The the European standard series is commonly used across Lithuania, which is the baseline series of most frequently appearing allergens and the choice of test concentration is based on reading and interpretation of complex test results that requires training and experience with clinical history of contact dermatitis (8, 16).
The diagnosis of ACD is based on clinical history and patch testing. The patch test determines whether a specific substance causes allergic inflammation of a patient’s skin. The positive patch test indicates contact sensitization of present or past relevance. However, sometimes the test gives false-positive and false-negative results, which can be correctly interpreted only by experienced allergists (3).
AIM AND OBJECTIVES OF THESIS
The aim of the study was to determine Contact sensitization profile in patients with suspected contact dermatitis in the outpatient clinic of skin diseases of Kaunas clinical hospital using the standard European baseline patch testing technique.
Objectives
To evaluate the most prevalent contact allergens in the outpatient clinic of skin diseases of Kaunas clinical hospital: in women, men and overall for both.
To evaluate the frequency of the hypersensitivity to one or more contact allergens
To evaluate the effects of age and gender and the correlation between age and gender in relation to ACD.

To determine the efficacy and efficiency of positive patch testing.

Literature review
In Lithuania as in the most Eastern European countries atopic dermatitis is considered to be mainly an allergic disease (both by patients and clinicians). Thus, almost all patients diagnosed with atopic dermatitis are referred firstly to allergologists and later to dermatologists. In Scandinavia and most Western European countries atopic dermatitis is diagnosed and treated mostly by dermatologists (2).
The frequencies of sensitization to allergens of the European baseline series, often supplemented by region-specific contact allergens, are continuously analyzed in most European countries. On the basis of resulting findings, the composition of the European baseline series is constantly revised (last modified in 2008) and the relevance to allergen exposure is maintained (4). Monitoring time trends of contact allergy allows evaluation of the need for, and effectiveness of, preventive measures (5).
Pathophysiology of ACD
ACD is a type IV, delayed-type reaction that is caused by skin contact with allergens that activate antigen-specific T cells in a sensitized individual. The sensitized T cells are primarily T-helper 1 (TH1) type. In the sensitization phase, innate immunity is activated through keratinocyte release of interleukin (IL)-1a, IL-1b, tumor necrosis factor alpha, granulocyte-macrophage colony-stimulating factor, and ILs-8 and -18. Langerhans and dermal dendritic cells uptake the allergen and migrate to the regional lymph nodes to activate antigen- specific T cells. These T cells then proliferate and enter the circulation and site of exposure. When exposed to the allergen again, antigen-specific T cells are activated through the release of cytokines and induce an inflammatory process. We now also recognize that patients with atopic dermatitis (AD) have barrier dysfunction that contributes to ACD in that population. Dermal dendritic cells, as opposed to epidermal Langerhans cells, play an important role in educating naive T cells in the lymph node to become antigen-specific effector cells during cutaneous sensitization. The recognition of skin resident T cells has enlightened our understanding of the role of Langerhans cells. Langerhans cells have now been shown to interact with skin resident T cells and generally promote tolerance when encountering antigens by stimulating Treg cells (9).
Top 5 most frequent allergens in Lithuania
Consecutive patients with suspected ACD were tested in Lithuania in the years 2010–2012. A ?Positive patch test reaction to at least one allergen was observed. The top 5 most frequent allergens in Lithuania were as follows: nickel sulphate, methylchloroisothiazolinone/methylisothiazolinone (MCI/MI), cobalt chloride, potassium dichromate, formaldehyde (2). Nickel is the leading allergen in Lithuania, with the sex and age factors strongly influencing the prevalence of nickel sensitization. Refer to sex-related and age-related patterns of nickel exposure, early ear piercing, and contact with nickel-releasing jewelry (5). Women under 40 years are more sensitive to nickel than older ones (7).
Factors with correlation to delayed hypersensitivity
Influence of age
Allergic contact dermatitis (ACD) in children appears to be on the increase, and contact sensitization may already begin in infancy (6). It has been reported children with atopic dermatitis have tested positive to more than one allergen and statistically more girls than boys (1). Younger patients were patch test-positive to nickel sulfate almost two times more often than older ones (5). Allergic contact dermatitis (ACD) in children appears to be on the increase (9).

Gender related patterns
One of the main allergens in the group is nickel, age and sex strongly influencing the prevalence of sensitization. These results refer to sex-related and age-related patterns of nickel exposure, early ear piercing, and contact with nickel-releasing jewelry (5). While the proportion of positive patch tests is significantly lower among men than women (7). Women were significantly more often patch test-positive to nickel sulfate than men (5). The correlation between positive patch test in men being lower than women could be related to fashion related jewelry. The more than two-crease higher prevalence in women is because of various exposures, for example, nickel through piercing. Nonetheless, regardless of whether nickel isn’t considered, women still have a higher pervasiveness for ACD. This higher powerlessness is likely caused by hormonal impacts. (26)
Ladies have higher immunoglobulin levels (IgM and IgG) than men, and more grounded cell-intervened immune reactions. Both in animal studies and in people, there is a prevalence of immune system illness in ladies contrasted with men. The fundamental explanation behind female dominance in clinical patch test contemplates is the high number of nickel and cobalt-delicate ladies. This is undoubtedly an outcome of various introductions, with ear puncturing the primary hazard factor for nickel hypersensitivity in ladies. A current investigation of nickel hypersensitivity in men with pierced ears affirmed the part of ear puncturing as a hazard factor for nickel sharpening additionally in men, yet the recurrence of nickel sensitivity in men with pierced ears was lower than the recurrence announced in ladies. The impact of sex hormones on enlistment and elicitation of contact sensitivity is to a great extent obscure. In a pilot study, think about the reaction to DNCB was improved in ladies getting oral prophylactic hormones and a preparatory report shows that the cutaneous reactivity to fix testing varies inside the menstrual cycle. The restricted information in this field is uncertain, and merits encourage efficient assessment. (17)
Atopy
Atopics down regulate Th1 cells, which discloses their inclination to serious viral contaminations, especially with herpes simplex. In view of this Th1-cell down regulation, a diminished affinity to contact dermatitis is normal. Clinical investigations tending to this issue are conflicting, yet most locate a diminished propensity to contact sharpening. A few investigations propose that particularly patients with extreme atopic dermatitis have a diminished capacity to create contact sensitivities. In a population-based examination no relationship, either positive or negative, was found between the nearness of a positive patch test and IgE affectability. Respiratory side effects may likewise be of significance, and distinctive subgroups of atopic patients concerning contact sharpening may exist. Another conceivable inclination is the expanded number of aggravation patch test brings about atopic patients, particularly when testing metals, e.g., nickel, cobalt, and chromate. Late examinations do, in any case, demonstrate that atopics appear to have an expanded recurrence of nickel refinement. As a result of these vulnerabilities, patch test results ought to determine the quantity of patients included with atopy. (17)
Stress
There has been an investigation found to help aggravation and oxidative pressure, coming about because of overproduction of receptive oxygen and also responsive nitrogen species nearby with associative inadequacy of against oxidative resistances of an individual, is indivisibly identified with physiological and infection states. Introductory allergen refinement and in addition advancement of pathogenic insusceptible reaction has been identified with an ascent in foundational interleukin – IL-6, IL-1, and furthermore tumor corruption factor (TNF-irritation and oxidative pressure (OxS)), the last characterized as an overproduction of receptive oxygen and in addition nitrogen species (ROS and RSN, resp.) with corresponding inadequacy of antioxidative resistances of the body, have been observed to be inseparably associated in physiological and also ailment states. In hypersensitive contact dermatitis, hoisted fundamental levels of IL-6, IL-1, and tumor necrosis factor (TNF) and ROS are proposed to take an interest in the underlying allergen sharpening and in addition in the advancement of pathogenic unfavorably susceptible reactions.
Both, OxS and inflammatory mediators, for example, cytokines and CRP have an impact on the adipokine status. Adiponectin, a cytokine created exclusively by fat tissue, has antidiabetic, antiatherogenic, and powerful mitigating exercises. As per its mitigating character, adiponectin levels are expanded, instead of diminished, in various chronic inflammatory and autoimmune diseases. Opposite correlations of adiponectin with markers of OxS and aggravation have been already found. The second most vital adipokine leptin is known fundamentally by its capacity to direct sustenance admission and vitality use. Leptin has overwhelmingly pro-inflammatory capacities, advancing, for instance, the initiation and generation of oxidative burst of fiery cells. (18)
Dietary
While both ACD and systemic contact dermatitis (SCD) are interceded by White blood cells, the pathogenesis of SCD isn’t surely understood. A key inquiry is the reason just a subset of patients with ACD will respond to allergens upon dietary presentation. No research center test is accessible to decide whether a patient with ACD is likewise influenced by SCD. In this manner, if a patient with ACD to nickel or another all around perceived dietary allergen does not enhance shirking of cutaneous contact, dietary evasion would be prescribed for a time of 6 weeks to two months. It is additionally essential to take note of that SCD may happen in conjunction with Promotion. In these cases, dermatitis may enhance with allergen evasion, however not resolve, because of the underlying AD. (22)
Implants
Complex immune responses that occur around the implants may bring about torment, irritation, and relaxing of the implant. Nickel, cobalt, and chromium are considered as the most common metals inspiring both cutaneous and extracutaneous unfavorably susceptible responses from unending inner presentation. Sporadically, other metal particles and bone bond segments cause excessive touchiness responses. (27)
Concomitant diseases (atopic dermatitis)
In spite of the way that audits have shown conflicting results, the standard appreciation is that contact sharpening is less ceaseless in patients with atopic dermatitis, inferable from a prevented cell safe response of the skin provoking a lessened ability to fight skin defilements and raise Type IV sensitivities.
Latest studies, be that as it may, have demonstrated that contact sharpening may vary with the seriousness of atopic dermatitis, proposing an additionally confusing relationship. An exploratory examination found that solitary 33% of patients with outrageous atopic dermatitis could be honed with the intense sensitizer dinitrochlorobenzene, as differentiated and 95% and 100% of patients with direct and gentle atopic skin inflammation, separately. Similarly, an observational examination found a decreased transcendence of contact refinement in patients with outrageous atopic dermatitis, yet not in patients with gentle to direct disease. Conflicting results have in like manner been appropriated, uncovering a higher repeat of positive fix test response in patients with extraordinary atopic dermatitis than in those with direct infection and mellow ailment. (23)
Quality of life
Skin conditions can diminish personal satisfaction, characterized by the World Wellbeing Association as a condition of finish physical, mental, and social prosperity. This can regularly be ascribed to feeling constrained to look ordinary or conform to social models.
Numerous individuals with a skin condition:
•Experience diminished feeling of self-perception
•Have lower self esteem
•Avoid circumstances where skin is uncovered
•Feel on edge about individuals passing judgment on them
•Withdraw from social co-operations
•Have sexual and relationship issues
•Feel disgrace and appal about their appearance.
Numerous individuals who have an obvious skin condition sooner or later will see a man attempting not to touch them as a result of their skin. Encounters like this can have a significant effect and make the individual feel embarrassed and furthermore more inclined to see comparative occasions later on. (21)
Psychological
Skin hypersensitive conditions, including urticaria, unfavorably susceptible contact dermatitis and atopic dermatitis, might be related with a very diminished personal satisfaction, particularly considering proficient or school exercises. Writing information recommends that patients experiencing unfavorably susceptible contact dermatitis and urticaria have a higher predominance of mental issue than the general population (for the most part anxiety disorder – fears, trailed by depressive and somatoform issue). (27)
The psychosocial outcomes of having a skin condition can bring about depression. Manifestations include:
•Feeling down, low, pitiful, or weepy
•Loss of delight or inspiration
•Sleep unsettling influence, weakness
•Appetite changes
•Trouble with memory as well as fixation
•Excessive sentiments of blame
•General absence of action and social engagement
•Suicidal thoughts.
Self-destructive contemplations are musings like “I wish that one day I just won’t wake up” or “Everybody would be in an ideal situation without me”.
Individuals that have a skin condition and are additionally discouraged may discover it particularly hard to cling to treatment proposals. Poor adherence may prompt exacerbating of the skin condition, which may then aggravate their temperament even.
Sorrow balances the impression of tingle, ie, individuals who are discouraged may encounter more terrible tingle (associated with atopic dermatitis). The more extreme the depressive symptom, the more serious tingle discernment is probably going to be. Hence, it is vital to target depressive indications while treating skin conditions. (21)
Drugs
It is a general clinical affair that systemic prednisolone in a dosage surpassing 15 mg/day may reduce or smother unfavorably susceptible patch test responses, as may topical corticoid treatment. Antihistamines and disodiumcromoglycate don’t appear to fundamentally impact the unfavorably susceptible contact dermatitis response. The impact of azathioprine and non-steroidal calming drugs on the result of fix test responses is unexplored.
Introduction to bright light, particularly UVB 78, 79 and PUVA 80, 81, may lessen danger of refinement and briefly reduce the capacity to inspire unfavorably susceptible responses in sharpened people. (9)
Clinical differences between irritant contact dermatitis and allergic contact dermatitis
The following table outlines some essential contrasts between the two sorts:
Irritant contact dermatitis Allergic contact dermatitis
Often acute in onset Acute, subacute, or chronic in onset
Appears after first exposure Sensitization necessary before the reaction occurs
Decrescendo phenomenon – reaches a rapid peak and starts to resolve Crescendo phenomenon – keeps worsening and resolves more slowly
Red swollen skin, sometimes ulcerated, in acute form Vesicles are common, but ulceration or skin necrosis is rare in acute cases
Thickening, erosion, fissuring, or shiny skin following chronic irritation Vesicles may not be found in chronic cases
Sharply delimited rash in area of contact More ill-defined boundaries but lesions usually found in areas of contact
Burning or stinging of the area, which is intensely tender Intensely pruritic lesions
(20)
Allergens from the European baseline series ?with high sensitization in Lithuania
The most prevalent allergens in atopic dermatitis and healthy groups were: nickel sulfate, chemicals, fragrances, preservatives and plants (1). The Nickel Directive in Lithuania is adopted since 2003, while a kind of restriction in nickel exposure has been present in Sweden already since 1991 when nickel-containing piercers or rings were banned if the alloy contained more than 0.05% nickel (2). Nickel was found to be the leading allergen in Lithuania, with the sex and age factors strongly influencing the prevalence of nickel sensitization (7). Preventive measures should be taken to avoid contact with potential allergens (1).
Nickel
Nickel is a silvery white lustrous, hard and ductile transition metal that is widely used in alloys to improve resistance to corrosion, wear and abrasion. Nickel comes in various forms and is the most common allergen particular in women through the use of jewelry. There are vast amount of uses of nickel in everyday life such as in batteries, coins or keys, jewelry, orthopedic plates, metal plating and wristwatch. However, there is a Dimethylglyoxime test for detecting nickel objects. Metallic nickel (only after corrosion), nickel salts gives rise to CD and sensitization is not usually occupational but through few of the components listed above (8).
Potassium Dichromate
Potassium Dichromate is a lustrous blue metal used in the manufacture of various steel and nickel alloys to enhance the resistance of other metals. Frequently aligned with causing occupational, clothing and cosmetic sensitization in CD. The uses of potassium dichromate play a vital role in everyday life like in construction, metal industry, clothing, cosmetics and even medical supplies (8).
Cobalt chloride
A grayish, hard, attractive, bendable and to some degree moldable metal, which utilized in the production of cobalt alloy and salts. The Cobalt salts are typically hued so basically utilized as shades for glass, ceramics, cosmetics and hair dyes. There are occupational related (bond, paints, gums, paint driers), metals (adornments, coins), medications (metal dental prostheses and joints, vitamin B12) causing sharpening. Be that as it may, most successive reason for sharpening to this metal is nickel-plated objects, which quite often contain cobalt (8).

Formaldehyde
Formaldehyde is a ubiquitous product due to its multiple uses and its incorporation into numerous products and reagents in chemical processes (formaldehyde releasers, plastic polymers, metalworking fluids, drugs, cosmetics and detergents). The uses of Formaldehyde are revolved around cosmetics, clothing and occupational (8).
Fragrance mix
Commercial perfumes are complex mixtures of natural essential oils and synthetic compounds. They are part of the composition of many products including cosmetics (the most frequent cause of allergic contact dermatitis due to cosmetics), topical medication, detergents, air fresheners, food. ? Fragrance mix I was developed in the late 1970s, and consist of eight ingredients, each at a concentration of 1%: Amyl cinnamal, Cinnamal, Cinnamyl alcohol, Eugenol, Evernia prunastri, Geraniol, Hydroxycitronellal, Isoeugenol. ?The uses of fragrance mix involve cosmetic, perfumes, clothing, food, household products, medication and dentistry (8).

MCI/MI
Isothiazolinones is a cosmetic perservative. Isothiazolinones are utilized broadly as powerful biocides to safeguard the water substance of beauty care products, toiletries, family unit, and modern items, for example, osmetics: shampoos, cleansers, conditioners, gels (hair and body), creams and moisturizers for the skin, confront packs, and so forth; Family items: cleansers, bubble showers, cements, pastes, wet wipes, cleansing agents, cleaning items, bathroom tissue. Stream motor fuel, latex emulsions, trimming oils, aerating and cooling, drain tests, oils and coolants, paints, pesticides, colors, varnishes, additives, printing inks, X-beams, and so on; and Others: biocides for swimming pool water (8).

Corticosteroids
Contact sensitivity to corticosteroids has been progressively perceived worldwide as an issue of extensive clinical and helpful significance. The rate of corticosteroid sensitivity saw (from 0.5% to 5%) differs in each report starting with one focus then onto the next (1±6) and relies upon a few factors, for example, mindfulness and testing for corticosteroid hypersensitivity, tolerant choice, going before skin infection, endorsing propensities and kind of corticosteroids utilized as a part of every nation, and the test and perusing strategies utilized. When all is said in done, corticosteroid-delicate patients give long-standing dermatitis that neglects to react to privately connected corticosteroids. This reality may lead the doctor to recommend other, in some cases more grounded arrangements, regularly without change.
Most instances of contact sensitivities would be missed if corticosteroids were not routinely tried. Two corticosteroids have been included in numerous nations to the routinely connected standard arrangement: tixocortol pivalate (1% pet.) and budesonide (0.1% pet.). Patients with contact touchiness to corticosteroids all the time respond upon patch testing to a few corticosteroids. This may be halfway clarified by attendant sharpening because of introduction to various sorts of substances amid the long course of their skin malady. Nonetheless, obvious confirmation of the presence of cross-responses is given by responses to corticosteroids to which the patient has never been uncovered. The cross-reactivity of various corticosteroid particles has down to earth results for the recognizable proof of continuous sensitizers, and of screening specialists for corticosteroid excessive touchiness. Corticosteroid sensitivity has essential remedial outcomes, both locally and fundamentally, as has been exhibited in clinical cases. In light of the event of cross-responses between various corticosteroids, delicate patients, by and large, need to keep away from numerous corticosteroids however can in any case be treated with others. Evasion of everything except just the potentially “dangerous” corticosteroids requires a precise meaning of gatherings of cross-responding particles.
Corticosteroid affectability has since quite a while ago stayed under-analyzed, on the grounds that the calming movement of corticosteroid arrangements covers the contact-unfavorably susceptible response to the corticosteroid itself (or to another element of the readiness), prompting a clinical picture. In reality, the sores of such patients are once in a while staggering, as they are by and large perpetual and simply don’t react to neighborhood dermatologic treatment. Now and again declining of essential dermatologic side effects can be watched. At times, contact sensitivity to corticosteroids may convey what needs be as intense skin inflammation, intense neighborhood edema, prompt compose response, or an id-like spread (counting erythema multi forme-like side effects) somewhere else on the body. In addition, beforehand sharpened patients can give foundational contact dermatitis, exanthema, purpura, and urticaria after the organization of fundamental (orally or infused) corticosteroid arrangements or, in spite of the fact that this is occasional with respect to the exceptionally visit utilize, hypersensitive responses can be seen to corticosteroids directed by inward breath arrangements in the treatment of rhinitis or bronchial asthma.
Sore restriction mostly includes the hands, legs, and face. In fact, patients experiencing atopic, unfavorably susceptible, or potentially aggravation contact dermatitis on the hands, and in addition those affliction from stasis dermatitis/leg ulcers, regularly give corticosteroid hypersensitivity. (24)
Regions of body affected by ACD
Allergic contact dermatitis arises some hours after contact with the responsible material. It settles down over some days providing the skin is no longer in contact with the allergen. 
Allergic contact dermatitis is generally confined to the site of contact with the allergen, but it may extend outside the contact area or become generalised.

Transmission from the fingers can lead to dermatitis on the eyelids and genitals. 
Dermatitis is unlikely to be due to a specific allergen if the area of skin most in contact with that allergen is unaffected.

The affected skin may be red and itchy, swollen and blistered, or dry and bumpy.(19)
Patch testing
Patch testing attempts to recreate, in vivo, an allergic reaction to nonirritating concentrations of an allergen that is suspended in a vehicle. The decisions to perform patch testing, and which allergen to test depends on many factors. Some common indications for patch testing include: (1) distributions that are highly suggestive of ACD—for example, ACD of the hands, feet, face, and eyelid, as well as unilateral presentations (9). A thorough knowledge of the clinical features of the skin’s reactions to various external substances is important in making the correct diagnosis of contact dermatitis (6). Reading and grading the results of patch testing is somewhat subjective and dependent on descriptive morphology. This creates a large degree of variation in how patch tests are read by different clinicians (9). Physicians usually grade patch test reading of allergens based on the characteristics that varies between 1+ and 3+ highlighting the severity of the reaction. (Table 1)
Table 1. Classification of patch test readings according to the International Contact Dermatitis Research Group
Reaction Definition
?+ Doubtful reaction; faint erythema only?
1+ Weakly positive reaction; erythema, infiltration, and possible papules?
2+ Strongly positive reaction; erythema, infiltration, papules, and vesicles?
3+ Extreme positive reaction; intense erythema, infiltration, and coalescing vesicles
_ Negative reaction
IR
Irritant reaction: patterns include follicular, glazed erythema, and ulceration
NT
Not tested
(15)
Patch result illustration
(25)
Positive and negative patch testing
False-negative reactions can be caused by:
Failure to perform a delayed reading
Testing to an inappropriately low concentration of allergen
Poor patch test placement or loosening of patch tests
Concurrent immunosuppression.
False-positive reactions can be caused by:
Testing with borderline
Testing beyond the irritancy threshold
Excited skin syndrome
Patients with a background of dermatitis (9).
Indications
Patch tests are indicated: 
For patients with a diagnostic hypothesis of CD
Patients with other skin conditions that may be aggravated by CD (atopic dermatitis, seborrheic dermatitis and stasis, nummular eczema, psoriasis, and dyshidrosis)
Patients which chronic eczema without an established etiology
Suspected cases of occupational contact dermatitis. (15)
RESEARCH METHODOLOGY AND METHODS
272 patients were selected from Kauno 2-oji klinikine ligonine, where they were patch tested and treated for allergic contact dermatitis. All subjects were patch-tested using Finn chambers and 24 standard chemical allergens from the European standard series. Patch tests ought to be connected to the upper back, as a result of the broad territory, encouraging the arrangement of different substances. Hairy zones ought to be maintained a strategic distance from because of low adhesion. Nonetheless, if fundamental, hair might be expelled utilizing extremely sharp edges toward hair development. This mediation can prompt troubles in the translation of the outcomes, as folliculitis may happen nearby. If there should be an occurrence of oily skin, mild cleansing with ethanol or solvents, just to expel abundance oil, might be finished.
After utilization of the chambers, sticky tape can be utilized to counteract separation and loss of bond of the tests, which encourage false negative outcomes. This progression is imperative in tropical and subtropical regions because of expanded sweating. The withdrawal of the tests is completed 48 hours after application, in a sufficiently bright place and utilizing particular plaques for the sort of chamber utilized, with openings relating to the area of allergens. The back ought to be set apart with a permanent pen, permitting future readings. The patient should return for reading 72-96 hours after use of the tests. This reading is central in light of the fact that a refinement response may happen over 72 hours after contact. (15)
Results
5.1 Main characteristics of the patients who participated in the study
A total of 272 patients were selected randomly from a list of patients who were patch tested in 2015, 2016 and 2017 in Kauno 2-oji klinikine ligonine, 30, 92 and 147 patients respectably. 216 of them were female and the rest male, respectably 80% and 17%. The most common allergen was found to be textile dye (26%) in both genders followed by nickel sulphate (16.4%) as the second most prevalent allergen in women and Cobalt chloride (3.3%) in men. While the figure of women and men that were found to be hypersensitive to more than one allergen, were 35.3% and 7.8% respectably. Further more in our study from the patch test data collected there were a total of 91 negative patch test, 71 women (26.1%) and 20 male (7.4%). There were statistically significant differences of gender distribution among the group. (illustration 5.1.1)
The objectives
llustration 5.1.1
013906500
There was a significant difference in the distribution as the proportion of women was quadruple that of men. The average age for women was 42 while in men it was 40. The mode age varied among the 3 years though the data concluded women were more susceptible to a patch test at a younger age. There were mere 30 patients selected from the patch-tested list for 2015 though the results are significant to illustrate the trend. (Illustration 5.1.2
-91440044196000Illustration 5.2.1

There was a significant difference among the patients in terms of gender in 2015, though in both genders the most prevalent allergen was textile dye. There were list of 30 patients that were patch tested and out of which 13 women were positive patch tested in comparison to only 3 men.
Illustration 5.2.2
-800100000
There were a total of 92 people patch tested in 2016 out of which 37 people resulted with a negative patch test result. From the 55 that were tested positive, among them 49 were women and 6 men. The most prevalent allergen in women was nickel sulphate whereas in men both PPD and textile dye were found to be most prevalent. (Illustration 5.2.2)
Illustration 5.2.3
-914400-10033000
There were a total of 148 people that were patch tested out which 107 resulted in positive patch test result. There were 82 women and 22 men that patch tested positive to one or more allergens. The most common allergen in women and men was textile dye, respectably 39 and 10 people. (Illustration 5.2.3)
Illustration 5.2.4
-1028700-45720000(Illustration 5.2.4) The results are the data collaborated from 2015, 2016 and 2017 data and shows the most prevalent allergen between both genders. Textile dye is found to be the most dominant allergen among women and men followed by nickel sulphate in women. In comparison cobalt chloride was found to be the 2nd most prevalent allergen in men.
5.2.1 To evaluate the frequency of people hypersensitive to one more allergens
Illustrations 5.2.1 shows the variability in both genders in all 3 years of data collected.
Illustration 5.2.1

5.3.1 To evaluate the frequency of a negative patch test results in the data
There were a significant number of people who tested negative for allergens in all 3 years, 2015, 2016 and 2017. (Table 5.2.1) The table illustrates the number of negative patch test results in each year between both genders.
Table 5.3.1

5.4.1. To evaluate the effects of age and gender and the correlation between age and gender in relation to ACD.

Evaluating the trend of age and gender in correlation to the susceptibility to allergens and evaluate which age group and gender are prone to exposure leading to hypersensitivity. The illustration 5.4.2 expresses data collected on women and illustration 5.4.3 demonstrates the trend based on results collected of men. It was determined that in both genders, age group 30 < x <49 were more prominent and had higher hypersensitivity frequency in comparison to other age groups.
Illustration 5.4.2

illustration 5.4.3

Discussion of results
The growing interest about ACD in Kauno 2-oji klinikine ligonine has motivated me to evaluate the changes in Kaunas population in regards to an increase susceptibility to allergens and to evaluate the most prevalent allergen in Kauno 2-oji klinikine ligonine. During 2015, 2016 and 2017 there were a total of 272 patients that were patch tested, among them 216 (79%) patients were women and 56 (20.6%) were men.
The disproportion between the genders was due to the availability of patients at the Kauno 2-oji klinikine ligonine, despite this the results from these patients were sufficient to accomplish my objectives and form a conclusion. There were 178 (65.2%) patients that indicated a positive reaction, from which 145 (53.1%) patients were women and 35 (12.8%) patients were men. A higher skin irritability in patients with atopic dermatitis is a conceivable clarification and it indicates out the need assess fix test comes about soon after expulsion of the strip as well as to perform late readings after day 3, which may give extra data. (1) From the 91 (33.3%) patients that resulted in a negative reaction, 71 (26%) female patients and 21 (7.7%) male patients. The overall results illustrate 91 (33.5%) patients with a negative reaction, which is around a third of the overall data collected though among them were mostly women as the data consisted of the larger proportion of women participants as indicated.
There was a significant difference in both gender and age in terms of prevalence to allergens. Overall results indicated that women and men in Kaunas region are more susceptible to textile dye as stated in the results, there were 55 (37.9%) women and 15 (42.9%) men that resulted in a hypersensitive reaction.

The Nickel Mandate in Lithuania is embraced since 2003, while a sort of limitation in nickel presentation has been available in Sweden as of now since 1991 when nickel-containing piercers or rings were restricted if the composite contained over 0.05% nickel. (2) This had an impact on the prevalence of nickel, as it has become the second most prevalent allergen in women, 44 (30.3%) women showed hypersensitivity in comparison to only 4 (11.4%) men were vulnerable.
Women under 40 years were sensitive to nickel almost four times more often than older ones. (4) Nickel is very common allergen in the group, age and sex unequivocally affecting the pervasiveness of sensitization. These outcomes allude to sex-related and age-related examples of nickel presentation, early ear piercing, and contact with nickel-discharging jewelry. Information from Finland and Poland Contact sensitivity focuses indicated sensitization rates to nickel of 21.3% and 24.3%, separately, in 2007-2008. As per Thyssen et al. the diminishing of nickel sharpening in Denmark began 16 years after the nickel direction and for the most part relied upon deferred ear penetrating time. So it could be hypothesized that sharpening to nickel in Lithuania will begin to diminish in 2020 and the moving of nickel sensitisation to the more established age (>40 years) gathering can be normal later on. (5) The second most prevalent allergen in men was found to be cobalt chloride, 9 (25.7%) men showed a positive reaction, whereas, 29 (20%) women were discovered to be sensitive to cobalt chloride. The main 10 allergens continued as before in the 9-year time frame aside from MI, which showed up in 2014 – 2015. There was no past data on contact sensitivity to MI in Lithuania, as MI was added to the European gauge arrangement in 2014 in Lithuania. (5) There were a reported 12 (8.3%) positive reactions in women and 2 (5.7%) in men over the course of three years to MCI/MI. Fragrance mix 1 was found to be one of the common allergens in women, 24 (16.6%) resulted in a positive reaction and also showed a upward trend in my data indicating a rise in prevalence. A relationship with more successive utilization of common prescription, which is connected to measurably noteworthy sensitization to fragrance mix I in older patients (5)
We evaluated the number of patients that were hypersensitive to only one allergen and patients that were sensitive to one or more allergens. It was found that there was significant rise in patients hypersensitive to one or more allergens. Comparing the data obtained from the charts indicated an upward trend from 2015 and illustrates an increase in susceptibility. Comparing the results there were 95 (65.5%) women found to hypersensitive to more than one allergen in comparison 53 (36.5%) were only hypersensitive to only allergen. On the other hand, 21 (60%) of men highly susceptible to more than one allergen and 14 (40%) were prone to only one allergen.
We evaluated the age and gender correlation among the participants; it was found that there were significantly higher percentages of female and male contributors in the age group 30 < x <49. It was found that 57 (26.4%) women tested positive while 22 (10.2%) showed a negative reaction out of the total of 216 patients. In comparison to the men, 16 (30.8%) presented with a positive reaction and 6 (11.5%) negative out of the overall 52 patients. Particular sex and age-related examples of nickel introduction, mostly by early ear piercing and the following of wearing nickel-discharging adornments, well known among ladies at a younger age. (4) In the age group 10 < x < 29 there were a total of 63 patients with 40 positive patch test results. However, in the age group 50 < x < 69 the volume of patient was lower but showed a higher positive patch test of 41 out of 60 participants. One ought to consider the altogether different situations that happen while assessing the relationship between association in young people and grown-ups as the natural presentation time clearly is any longer in grown-ups and as the insusceptible reactivity may change with age. The highest number of negative patch results were found to be in the age group 10 < x <29 in both genders, which illustrates the low exposure time in comparison to other age groups may be the reason for this.

Conclusion
Textile dye was found to be the most prevalent allergen among both gender in all age groups followed by nickel sulphate in women and cobalt chloride in men
Patients were found to be more prone to hypersensitivity to more than one allergen. Results shows almost twice the number of patient was sensitized to more than one allergen in both genders.
Age and gender played a vital role and the correlation indicated patients in the age group 30 < x < 49 in both genders were more susceptible in comparison to other age groups.
The efficiency and efficacy of the patch test was questionable as 178 (65.4%) patients developed a positive reaction out of the 272 patients. There are a few limitation in regards to patch testing, age, gender and co-morbidities can influence the result with false – negative or false positive results.
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LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
Contact sensitization profile in patients of Kaunas clinical hospital with suspected contact dermatitis; the results of patch testing
by
Rezwan Hussain
A thesis submitted in part fulfillment for the
degree of Master of Medicine
in the
Faculty of Medicine
Department of internal medicine
Kaunas
Supervisor: Palmira Leišyte
TABLE OF CONTENTS
TITLE PAGE1
TABLE OF CONTENTS2
SUMMARY3
ACKNOWLEDGEMENTS4
CONFLICT OF INTEREST5
ETHICS COMMITTEE CLEARANCE6
ABBREVIATIONS LIST7
INTRODUCTION8
AIM AND OBJECTIVES OF THE THESIS10
LITERATURE REVIEW 11
RESEARCH METHODOLOGY AND METHODS 25
RESULTS 26
DISCUSSION OF THE RESULTS 33
CONCLUSION 36
PRACTICAL RECOMMENDATIONS
LITERATURE LIST
SUMMARY
Author name: Rezwan Hussain
Title: Contact sensitization profile in patients of Kaunas clinical hospital with suspected contact dermatitis; the results of patch testing
Aim: The aim of the study was to determine Contact sensitization profile in patients with suspected contact dermatitis in the outpatient clinic of skin diseases of Kaunas clinical hospital using the standard European baseline patch testing technique.
Objectives:
To evaluate the most prevalent contact allergens in the outpatient clinic of skin diseases of Kaunas clinical hospital: in women, men and overall for both.
To evaluate the frequency of the hypersensitivity to one or more contact allergens
To evaluate the effects of age and gender and the correlation between age and gender in relation to ACD.

To determine the efficacy and efficiency of positive patch testing.

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Methods: 272 patients were selected from Kauno 2-oji klinikine ligonine, where they were patch tested and treated for allergic contact dermatitis. All subjects were patch-tested using Finn chambers and 24 standard chemical allergens from the European standard series. Patch tests ought to be connected to the upper back, as a result of the broad territory, encouraging the arrangement of different substances. Hairy zones ought to be maintained a strategic distance from because of low adhesion. Nonetheless, if fundamental, hair might be expelled utilizing extremely sharp edges toward hair development. This mediation can prompt troubles in the translation of the outcomes, as folliculitis may happen nearby. If there should be an occurrence of oily skin, mild cleansing with ethanol or solvents, just to expel abundance oil, might be finished.
After utilization of the chambers, sticky tape can be utilized to counteract separation and loss of bond of the tests, which encourage false negative outcomes. This progression is imperative in tropical and subtropical regions because of expanded sweating. The withdrawal of the tests is completed 48 hours after application, in a sufficiently bright place and utilizing particular plaques for the sort of chamber utilized, with openings relating to the area of allergens. The back ought to be set apart with a permanent pen, permitting future readings. The patient should return for reading 72-96 hours after use of the tests. This reading is central in light of the fact that a refinement response may happen over 72 hours after contact. (15)
Acknowledgements
Conflict of interest
Ethics committee clearance
Abbreviation list
ACD: Allergic contact dermatitis?
AD: Atopic dermatitis?
APT: Atopy patch test
?LTT: Lymphocyte transformation test?
MCI: Methylchloroisothiazolinone?
MI: Methylisothiazolinone?
ICD: Irritant contact dermatitis
IL: Interleukin
Tumor necrosis factor: TNF
OxS: Oxadative pressure
Ros: Reactive oxygen species
SCD: Systemic contact dermatitis
Introduction
Allergic contact dermatitis (ACD) is an induced hypersensitivity to a specific allergen/allergens, which occurs when a persons skin surface comes in contact with antigen, resulting in an allergic reaction. The inflammatory reaction takes place in the skin after percutaneous absorption of antigen resulting in recruitment of previously sensitized, antigen-specific T lymphocytes into the skin (1). It starts as normal cell-mediated response to intracellular pathogen such as bacteria, fungi and virus however the persistence of allergen sensitizes TDTH cells, causing secretion of inflammatory cytokines. The cytokines then activate the phagocytic cells resulting in non-specific tissue destruction and induce inflammation where symptoms usually take 24 – 72 hours to develop (13). The site of the inflammatory reaction, which came in contact with an allergen in a sensitized individual results in redness, papules and vesicles, followed by scaling and dry skin, these symptoms is Lithuania are most commonly caused by Nickel, cobalt chloride, Potassium dichromate, Formaldehyde and MCI/MI (2,11).
There are 2 types of Contact dermatitis, Allergic contact dermatitis and Irritant contact dermatitis (ICD), easily distinguishable based on the characteristics of symptoms and mechanism of response. ICD is a non-immune related physical and chemical modification of the skin due to pro-inflammatory and lethal effects of organic solvents, soaps, environmental factors and acids. ACD corresponds to type IV immune response, with an induction phase (afferent pathway) and an elicitation phase (efferent pathway), involving a complex series of events (12). The induction phase involves the Langerhans cells to uptake, processing, and presentation of the antigen by local antigen-presenting cells, and migrate to the limb node where they activate the T cells and activate production of memory T cells and in the elicitation phase, TH1 cells that have been primed by the previous exposure to the antigen which migrate and become activated because these cells are rare so there is little inflammation to attract the specific memory T cells to the site of dermis (14). ACD is very common in communities however, hard to determine the actual rate of incidence as patients often self-diagnose and self treat and are bought to a medical practitioners attention at various points, such as the emergency room, general practice, and urgent care clinics (10).
Patch testing is a gold standard technique discovered by Jozef Jadassohn in 1985 that revolutionised the way of identifying the explicit allergens triggering ACD.

When performing patch testing it must be recalled that the patch test is a biological incitement test and in that capacity the result is subject to different variables including the test framework and test material, the organic/functional status of the tested individual, and the dependable dermatologist. To get desired bioavailability of a hapten, one can impact the accompanying five factors. (15)
Intrinsic penetration capacity?
Concentration, dose?
Vehicle?
Occlusivity of patch test system and tape
Exposure time
Patch testing is a complex but very effective mean to establish contact allergy although the diagnosis of allergic contact dermatitis comes from the combination of patch-test results and clinical data. However, different countries and centers usually have their own patch test traditions despite the efforts to standardize the procedure by international societies. This makes it difficult to compare results obtained in different countries (2). 2
The the European standard series is commonly used across Lithuania, which is the baseline series of most frequently appearing allergens and the choice of test concentration is based on reading and interpretation of complex test results that requires training and experience with clinical history of contact dermatitis (8, 16).
The diagnosis of ACD is based on clinical history and patch testing. The patch test determines whether a specific substance causes allergic inflammation of a patient’s skin. The positive patch test indicates contact sensitization of present or past relevance. However, sometimes the test gives false-positive and false-negative results, which can be correctly interpreted only by experienced allergists (3).
AIM AND OBJECTIVES OF THESIS
The aim of the study was to determine Contact sensitization profile in patients with suspected contact dermatitis in the outpatient clinic of skin diseases of Kaunas clinical hospital using the standard European baseline patch testing technique.
Objectives
To evaluate the most prevalent contact allergens in the outpatient clinic of skin diseases of Kaunas clinical hospital: in women, men and overall for both.
To evaluate the frequency of the hypersensitivity to one or more contact allergens
To evaluate the effects of age and gender and the correlation between age and gender in relation to ACD.

To determine the efficacy and efficiency of positive patch testing.

Literature review
In Lithuania as in the most Eastern European countries atopic dermatitis is considered to be mainly an allergic disease (both by patients and clinicians). Thus, almost all patients diagnosed with atopic dermatitis are referred firstly to allergologists and later to dermatologists. In Scandinavia and most Western European countries atopic dermatitis is diagnosed and treated mostly by dermatologists (2).
The frequencies of sensitization to allergens of the European baseline series, often supplemented by region-specific contact allergens, are continuously analyzed in most European countries. On the basis of resulting findings, the composition of the European baseline series is constantly revised (last modified in 2008) and the relevance to allergen exposure is maintained (4). Monitoring time trends of contact allergy allows evaluation of the need for, and effectiveness of, preventive measures (5).
Pathophysiology of ACD
ACD is a type IV, delayed-type reaction that is caused by skin contact with allergens that activate antigen-specific T cells in a sensitized individual. The sensitized T cells are primarily T-helper 1 (TH1) type. In the sensitization phase, innate immunity is activated through keratinocyte release of interleukin (IL)-1a, IL-1b, tumor necrosis factor alpha, granulocyte-macrophage colony-stimulating factor, and ILs-8 and -18. Langerhans and dermal dendritic cells uptake the allergen and migrate to the regional lymph nodes to activate antigen- specific T cells. These T cells then proliferate and enter the circulation and site of exposure. When exposed to the allergen again, antigen-specific T cells are activated through the release of cytokines and induce an inflammatory process. We now also recognize that patients with atopic dermatitis (AD) have barrier dysfunction that contributes to ACD in that population. Dermal dendritic cells, as opposed to epidermal Langerhans cells, play an important role in educating naive T cells in the lymph node to become antigen-specific effector cells during cutaneous sensitization. The recognition of skin resident T cells has enlightened our understanding of the role of Langerhans cells. Langerhans cells have now been shown to interact with skin resident T cells and generally promote tolerance when encountering antigens by stimulating Treg cells (9).
Top 5 most frequent allergens in Lithuania
Consecutive patients with suspected ACD were tested in Lithuania in the years 2010–2012. A ?Positive patch test reaction to at least one allergen was observed. The top 5 most frequent allergens in Lithuania were as follows: nickel sulphate, methylchloroisothiazolinone/methylisothiazolinone (MCI/MI), cobalt chloride, potassium dichromate, formaldehyde (2). Nickel is the leading allergen in Lithuania, with the sex and age factors strongly influencing the prevalence of nickel sensitization. Refer to sex-related and age-related patterns of nickel exposure, early ear piercing, and contact with nickel-releasing jewelry (5). Women under 40 years are more sensitive to nickel than older ones (7).
Factors with correlation to delayed hypersensitivity
Influence of age
Allergic contact dermatitis (ACD) in children appears to be on the increase, and contact sensitization may already begin in infancy (6). It has been reported children with atopic dermatitis have tested positive to more than one allergen and statistically more girls than boys (1). Younger patients were patch test-positive to nickel sulfate almost two times more often than older ones (5). Allergic contact dermatitis (ACD) in children appears to be on the increase (9).

Gender related patterns
One of the main allergens in the group is nickel, age and sex strongly influencing the prevalence of sensitization. These results refer to sex-related and age-related patterns of nickel exposure, early ear piercing, and contact with nickel-releasing jewelry (5). While the proportion of positive patch tests is significantly lower among men than women (7). Women were significantly more often patch test-positive to nickel sulfate than men (5). The correlation between positive patch test in men being lower than women could be related to fashion related jewelry. The more than two-crease higher prevalence in women is because of various exposures, for example, nickel through piercing. Nonetheless, regardless of whether nickel isn’t considered, women still have a higher pervasiveness for ACD. This higher powerlessness is likely caused by hormonal impacts. (26)
Ladies have higher immunoglobulin levels (IgM and IgG) than men, and more grounded cell-intervened immune reactions. Both in animal studies and in people, there is a prevalence of immune system illness in ladies contrasted with men. The fundamental explanation behind female dominance in clinical patch test contemplates is the high number of nickel and cobalt-delicate ladies. This is undoubtedly an outcome of various introductions, with ear puncturing the primary hazard factor for nickel hypersensitivity in ladies. A current investigation of nickel hypersensitivity in men with pierced ears affirmed the part of ear puncturing as a hazard factor for nickel sharpening additionally in men, yet the recurrence of nickel sensitivity in men with pierced ears was lower than the recurrence announced in ladies. The impact of sex hormones on enlistment and elicitation of contact sensitivity is to a great extent obscure. In a pilot study, think about the reaction to DNCB was improved in ladies getting oral prophylactic hormones and a preparatory report shows that the cutaneous reactivity to fix testing varies inside the menstrual cycle. The restricted information in this field is uncertain, and merits encourage efficient assessment. (17)
Atopy
Atopics down regulate Th1 cells, which discloses their inclination to serious viral contaminations, especially with herpes simplex. In view of this Th1-cell down regulation, a diminished affinity to contact dermatitis is normal. Clinical investigations tending to this issue are conflicting, yet most locate a diminished propensity to contact sharpening. A few investigations propose that particularly patients with extreme atopic dermatitis have a diminished capacity to create contact sensitivities. In a population-based examination no relationship, either positive or negative, was found between the nearness of a positive patch test and IgE affectability. Respiratory side effects may likewise be of significance, and distinctive subgroups of atopic patients concerning contact sharpening may exist. Another conceivable inclination is the expanded number of aggravation patch test brings about atopic patients, particularly when testing metals, e.g., nickel, cobalt, and chromate. Late examinations do, in any case, demonstrate that atopics appear to have an expanded recurrence of nickel refinement. As a result of these vulnerabilities, patch test results ought to determine the quantity of patients included with atopy. (17)
Stress
There has been an investigation found to help aggravation and oxidative pressure, coming about because of overproduction of receptive oxygen and also responsive nitrogen species nearby with associative inadequacy of against oxidative resistances of an individual, is indivisibly identified with physiological and infection states. Introductory allergen refinement and in addition advancement of pathogenic insusceptible reaction has been identified with an ascent in foundational interleukin – IL-6, IL-1, and furthermore tumor corruption factor (TNF-irritation and oxidative pressure (OxS)), the last characterized as an overproduction of receptive oxygen and in addition nitrogen species (ROS and RSN, resp.) with corresponding inadequacy of antioxidative resistances of the body, have been observed to be inseparably associated in physiological and also ailment states. In hypersensitive contact dermatitis, hoisted fundamental levels of IL-6, IL-1, and tumor necrosis factor (TNF) and ROS are proposed to take an interest in the underlying allergen sharpening and in addition in the advancement of pathogenic unfavorably susceptible reactions.
Both, OxS and inflammatory mediators, for example, cytokines and CRP have an impact on the adipokine status. Adiponectin, a cytokine created exclusively by fat tissue, has antidiabetic, antiatherogenic, and powerful mitigating exercises. As per its mitigating character, adiponectin levels are expanded, instead of diminished, in various chronic inflammatory and autoimmune diseases. Opposite correlations of adiponectin with markers of OxS and aggravation have been already found. The second most vital adipokine leptin is known fundamentally by its capacity to direct sustenance admission and vitality use. Leptin has overwhelmingly pro-inflammatory capacities, advancing, for instance, the initiation and generation of oxidative burst of fiery cells. (18)
Dietary
While both ACD and systemic contact dermatitis (SCD) are interceded by White blood cells, the pathogenesis of SCD isn’t surely understood. A key inquiry is the reason just a subset of patients with ACD will respond to allergens upon dietary presentation. No research center test is accessible to decide whether a patient with ACD is likewise influenced by SCD. In this manner, if a patient with ACD to nickel or another all around perceived dietary allergen does not enhance shirking of cutaneous contact, dietary evasion would be prescribed for a time of 6 weeks to two months. It is additionally essential to take note of that SCD may happen in conjunction with Promotion. In these cases, dermatitis may enhance with allergen evasion, however not resolve, because of the underlying AD. (22)
Implants
Complex immune responses that occur around the implants may bring about torment, irritation, and relaxing of the implant. Nickel, cobalt, and chromium are considered as the most common metals inspiring both cutaneous and extracutaneous unfavorably susceptible responses from unending inner presentation. Sporadically, other metal particles and bone bond segments cause excessive touchiness responses. (27)
Concomitant diseases (atopic dermatitis)
In spite of the way that audits have shown conflicting results, the standard appreciation is that contact sharpening is less ceaseless in patients with atopic dermatitis, inferable from a prevented cell safe response of the skin provoking a lessened ability to fight skin defilements and raise Type IV sensitivities.
Latest studies, be that as it may, have demonstrated that contact sharpening may vary with the seriousness of atopic dermatitis, proposing an additionally confusing relationship. An exploratory examination found that solitary 33% of patients with outrageous atopic dermatitis could be honed with the intense sensitizer dinitrochlorobenzene, as differentiated and 95% and 100% of patients with direct and gentle atopic skin inflammation, separately. Similarly, an observational examination found a decreased transcendence of contact refinement in patients with outrageous atopic dermatitis, yet not in patients with gentle to direct disease. Conflicting results have in like manner been appropriated, uncovering a higher repeat of positive fix test response in patients with extraordinary atopic dermatitis than in those with direct infection and mellow ailment. (23)
Quality of life
Skin conditions can diminish personal satisfaction, characterized by the World Wellbeing Association as a condition of finish physical, mental, and social prosperity. This can regularly be ascribed to feeling constrained to look ordinary or conform to social models.
Numerous individuals with a skin condition:
•Experience diminished feeling of self-perception
•Have lower self esteem
•Avoid circumstances where skin is uncovered
•Feel on edge about individuals passing judgment on them
•Withdraw from social co-operations
•Have sexual and relationship issues
•Feel disgrace and appal about their appearance.
Numerous individuals who have an obvious skin condition sooner or later will see a man attempting not to touch them as a result of their skin. Encounters like this can have a significant effect and make the individual feel embarrassed and furthermore more inclined to see comparative occasions later on. (21)
Psychological
Skin hypersensitive conditions, including urticaria, unfavorably susceptible contact dermatitis and atopic dermatitis, might be related with a very diminished personal satisfaction, particularly considering proficient or school exercises. Writing information recommends that patients experiencing unfavorably susceptible contact dermatitis and urticaria have a higher predominance of mental issue than the general population (for the most part anxiety disorder – fears, trailed by depressive and somatoform issue). (27)
The psychosocial outcomes of having a skin condition can bring about depression. Manifestations include:
•Feeling down, low, pitiful, or weepy
•Loss of delight or inspiration
•Sleep unsettling influence, weakness
•Appetite changes
•Trouble with memory as well as fixation
•Excessive sentiments of blame
•General absence of action and social engagement
•Suicidal thoughts.
Self-destructive contemplations are musings like “I wish that one day I just won’t wake up” or “Everybody would be in an ideal situation without me”.
Individuals that have a skin condition and are additionally discouraged may discover it particularly hard to cling to treatment proposals. Poor adherence may prompt exacerbating of the skin condition, which may then aggravate their temperament even.
Sorrow balances the impression of tingle, ie, individuals who are discouraged may encounter more terrible tingle (associated with atopic dermatitis). The more extreme the depressive symptom, the more serious tingle discernment is probably going to be. Hence, it is vital to target depressive indications while treating skin conditions. (21)
Drugs
It is a general clinical affair that systemic prednisolone in a dosage surpassing 15 mg/day may reduce or smother unfavorably susceptible patch test responses, as may topical corticoid treatment. Antihistamines and disodiumcromoglycate don’t appear to fundamentally impact the unfavorably susceptible contact dermatitis response. The impact of azathioprine and non-steroidal calming drugs on the result of fix test responses is unexplored.
Introduction to bright light, particularly UVB 78, 79 and PUVA 80, 81, may lessen danger of refinement and briefly reduce the capacity to inspire unfavorably susceptible responses in sharpened people. (9)
Clinical differences between irritant contact dermatitis and allergic contact dermatitis
The following table outlines some essential contrasts between the two sorts:
Irritant contact dermatitis Allergic contact dermatitis
Often acute in onset Acute, subacute, or chronic in onset
Appears after first exposure Sensitization necessary before the reaction occurs
Decrescendo phenomenon – reaches a rapid peak and starts to resolve Crescendo phenomenon – keeps worsening and resolves more slowly
Red swollen skin, sometimes ulcerated, in acute form Vesicles are common, but ulceration or skin necrosis is rare in acute cases
Thickening, erosion, fissuring, or shiny skin following chronic irritation Vesicles may not be found in chronic cases
Sharply delimited rash in area of contact More ill-defined boundaries but lesions usually found in areas of contact
Burning or stinging of the area, which is intensely tender Intensely pruritic lesions
(20)
Allergens from the European baseline series ?with high sensitization in Lithuania
The most prevalent allergens in atopic dermatitis and healthy groups were: nickel sulfate, chemicals, fragrances, preservatives and plants (1). The Nickel Directive in Lithuania is adopted since 2003, while a kind of restriction in nickel exposure has been present in Sweden already since 1991 when nickel-containing piercers or rings were banned if the alloy contained more than 0.05% nickel (2). Nickel was found to be the leading allergen in Lithuania, with the sex and age factors strongly influencing the prevalence of nickel sensitization (7). Preventive measures should be taken to avoid contact with potential allergens (1).
Nickel
Nickel is a silvery white lustrous, hard and ductile transition metal that is widely used in alloys to improve resistance to corrosion, wear and abrasion. Nickel comes in various forms and is the most common allergen particular in women through the use of jewelry. There are vast amount of uses of nickel in everyday life such as in batteries, coins or keys, jewelry, orthopedic plates, metal plating and wristwatch. However, there is a Dimethylglyoxime test for detecting nickel objects. Metallic nickel (only after corrosion), nickel salts gives rise to CD and sensitization is not usually occupational but through few of the components listed above (8).
Potassium Dichromate
Potassium Dichromate is a lustrous blue metal used in the manufacture of various steel and nickel alloys to enhance the resistance of other metals. Frequently aligned with causing occupational, clothing and cosmetic sensitization in CD. The uses of potassium dichromate play a vital role in everyday life like in construction, metal industry, clothing, cosmetics and even medical supplies (8).
Cobalt chloride
A grayish, hard, attractive, bendable and to some degree moldable metal, which utilized in the production of cobalt alloy and salts. The Cobalt salts are typically hued so basically utilized as shades for glass, ceramics, cosmetics and hair dyes. There are occupational related (bond, paints, gums, paint driers), metals (adornments, coins), medications (metal dental prostheses and joints, vitamin B12) causing sharpening. Be that as it may, most successive reason for sharpening to this metal is nickel-plated objects, which quite often contain cobalt (8).

Formaldehyde
Formaldehyde is a ubiquitous product due to its multiple uses and its incorporation into numerous products and reagents in chemical processes (formaldehyde releasers, plastic polymers, metalworking fluids, drugs, cosmetics and detergents). The uses of Formaldehyde are revolved around cosmetics, clothing and occupational (8).
Fragrance mix
Commercial perfumes are complex mixtures of natural essential oils and synthetic compounds. They are part of the composition of many products including cosmetics (the most frequent cause of allergic contact dermatitis due to cosmetics), topical medication, detergents, air fresheners, food. ? Fragrance mix I was developed in the late 1970s, and consist of eight ingredients, each at a concentration of 1%: Amyl cinnamal, Cinnamal, Cinnamyl alcohol, Eugenol, Evernia prunastri, Geraniol, Hydroxycitronellal, Isoeugenol. ?The uses of fragrance mix involve cosmetic, perfumes, clothing, food, household products, medication and dentistry (8).

MCI/MI
Isothiazolinones is a cosmetic perservative. Isothiazolinones are utilized broadly as powerful biocides to safeguard the water substance of beauty care products, toiletries, family unit, and modern items, for example, osmetics: shampoos, cleansers, conditioners, gels (hair and body), creams and moisturizers for the skin, confront packs, and so forth; Family items: cleansers, bubble showers, cements, pastes, wet wipes, cleansing agents, cleaning items, bathroom tissue. Stream motor fuel, latex emulsions, trimming oils, aerating and cooling, drain tests, oils and coolants, paints, pesticides, colors, varnishes, additives, printing inks, X-beams, and so on; and Others: biocides for swimming pool water (8).

Corticosteroids
Contact sensitivity to corticosteroids has been progressively perceived worldwide as an issue of extensive clinical and helpful significance. The rate of corticosteroid sensitivity saw (from 0.5% to 5%) differs in each report starting with one focus then onto the next (1±6) and relies upon a few factors, for example, mindfulness and testing for corticosteroid hypersensitivity, tolerant choice, going before skin infection, endorsing propensities and kind of corticosteroids utilized as a part of every nation, and the test and perusing strategies utilized. When all is said in done, corticosteroid-delicate patients give long-standing dermatitis that neglects to react to privately connected corticosteroids. This reality may lead the doctor to recommend other, in some cases more grounded arrangements, regularly without change.
Most instances of contact sensitivities would be missed if corticosteroids were not routinely tried. Two corticosteroids have been included in numerous nations to the routinely connected standard arrangement: tixocortol pivalate (1% pet.) and budesonide (0.1% pet.). Patients with contact touchiness to corticosteroids all the time respond upon patch testing to a few corticosteroids. This may be halfway clarified by attendant sharpening because of introduction to various sorts of substances amid the long course of their skin malady. Nonetheless, obvious confirmation of the presence of cross-responses is given by responses to corticosteroids to which the patient has never been uncovered. The cross-reactivity of various corticosteroid particles has down to earth results for the recognizable proof of continuous sensitizers, and of screening specialists for corticosteroid excessive touchiness. Corticosteroid sensitivity has essential remedial outcomes, both locally and fundamentally, as has been exhibited in clinical cases. In light of the event of cross-responses between various corticosteroids, delicate patients, by and large, need to keep away from numerous corticosteroids however can in any case be treated with others. Evasion of everything except just the potentially “dangerous” corticosteroids requires a precise meaning of gatherings of cross-responding particles.
Corticosteroid affectability has since quite a while ago stayed under-analyzed, on the grounds that the calming movement of corticosteroid arrangements covers the contact-unfavorably susceptible response to the corticosteroid itself (or to another element of the readiness), prompting a clinical picture. In reality, the sores of such patients are once in a while staggering, as they are by and large perpetual and simply don’t react to neighborhood dermatologic treatment. Now and again declining of essential dermatologic side effects can be watched. At times, contact sensitivity to corticosteroids may convey what needs be as intense skin inflammation, intense neighborhood edema, prompt compose response, or an id-like spread (counting erythema multi forme-like side effects) somewhere else on the body. In addition, beforehand sharpened patients can give foundational contact dermatitis, exanthema, purpura, and urticaria after the organization of fundamental (orally or infused) corticosteroid arrangements or, in spite of the fact that this is occasional with respect to the exceptionally visit utilize, hypersensitive responses can be seen to corticosteroids directed by inward breath arrangements in the treatment of rhinitis or bronchial asthma.
Sore restriction mostly includes the hands, legs, and face. In fact, patients experiencing atopic, unfavorably susceptible, or potentially aggravation contact dermatitis on the hands, and in addition those affliction from stasis dermatitis/leg ulcers, regularly give corticosteroid hypersensitivity. (24)
Regions of body affected by ACD
Allergic contact dermatitis arises some hours after contact with the responsible material. It settles down over some days providing the skin is no longer in contact with the allergen. 
Allergic contact dermatitis is generally confined to the site of contact with the allergen, but it may extend outside the contact area or become generalised.

Transmission from the fingers can lead to dermatitis on the eyelids and genitals. 
Dermatitis is unlikely to be due to a specific allergen if the area of skin most in contact with that allergen is unaffected.

The affected skin may be red and itchy, swollen and blistered, or dry and bumpy.(19)
Patch testing
Patch testing attempts to recreate, in vivo, an allergic reaction to nonirritating concentrations of an allergen that is suspended in a vehicle. The decisions to perform patch testing, and which allergen to test depends on many factors. Some common indications for patch testing include: (1) distributions that are highly suggestive of ACD—for example, ACD of the hands, feet, face, and eyelid, as well as unilateral presentations (9). A thorough knowledge of the clinical features of the skin’s reactions to various external substances is important in making the correct diagnosis of contact dermatitis (6). Reading and grading the results of patch testing is somewhat subjective and dependent on descriptive morphology. This creates a large degree of variation in how patch tests are read by different clinicians (9). Physicians usually grade patch test reading of allergens based on the characteristics that varies between 1+ and 3+ highlighting the severity of the reaction. (Table 1)
Table 1. Classification of patch test readings according to the International Contact Dermatitis Research Group
Reaction Definition
?+ Doubtful reaction; faint erythema only?
1+ Weakly positive reaction; erythema, infiltration, and possible papules?
2+ Strongly positive reaction; erythema, infiltration, papules, and vesicles?
3+ Extreme positive reaction; intense erythema, infiltration, and coalescing vesicles
_ Negative reaction
IR
Irritant reaction: patterns include follicular, glazed erythema, and ulceration
NT
Not tested
(15)
Patch result illustration
(25)
Positive and negative patch testing
False-negative reactions can be caused by:
Failure to perform a delayed reading
Testing to an inappropriately low concentration of allergen
Poor patch test placement or loosening of patch tests
Concurrent immunosuppression.
False-positive reactions can be caused by:
Testing with borderline
Testing beyond the irritancy threshold
Excited skin syndrome
Patients with a background of dermatitis (9).
Indications
Patch tests are indicated: 
For patients with a diagnostic hypothesis of CD
Patients with other skin conditions that may be aggravated by CD (atopic dermatitis, seborrheic dermatitis and stasis, nummular eczema, psoriasis, and dyshidrosis)
Patients which chronic eczema without an established etiology
Suspected cases of occupational contact dermatitis. (15)
RESEARCH METHODOLOGY AND METHODS
272 patients were selected from Kauno 2-oji klinikine ligonine, where they were patch tested and treated for allergic contact dermatitis. All subjects were patch-tested using Finn chambers and 24 standard chemical allergens from the European standard series. Patch tests ought to be connected to the upper back, as a result of the broad territory, encouraging the arrangement of different substances. Hairy zones ought to be maintained a strategic distance from because of low adhesion. Nonetheless, if fundamental, hair might be expelled utilizing extremely sharp edges toward hair development. This mediation can prompt troubles in the translation of the outcomes, as folliculitis may happen nearby. If there should be an occurrence of oily skin, mild cleansing with ethanol or solvents, just to expel abundance oil, might be finished.
After utilization of the chambers, sticky tape can be utilized to counteract separation and loss of bond of the tests, which encourage false negative outcomes. This progression is imperative in tropical and subtropical regions because of expanded sweating. The withdrawal of the tests is completed 48 hours after application, in a sufficiently bright place and utilizing particular plaques for the sort of chamber utilized, with openings relating to the area of allergens. The back ought to be set apart with a permanent pen, permitting future readings. The patient should return for reading 72-96 hours after use of the tests. This reading is central in light of the fact that a refinement response may happen over 72 hours after contact. (15)
Results
5.1 Main characteristics of the patients who participated in the study
A total of 272 patients were selected randomly from a list of patients who were patch tested in 2015, 2016 and 2017 in Kauno 2-oji klinikine ligonine, 30, 92 and 147 patients respectably. 216 of them were female and the rest male, respectably 80% and 17%. The most common allergen was found to be textile dye (26%) in both genders followed by nickel sulphate (16.4%) as the second most prevalent allergen in women and Cobalt chloride (3.3%) in men. While the figure of women and men that were found to be hypersensitive to more than one allergen, were 35.3% and 7.8% respectably. Further more in our study from the patch test data collected there were a total of 91 negative patch test, 71 women (26.1%) and 20 male (7.4%). There were statistically significant differences of gender distribution among the group. (illustration 5.1.1)
The objectives
llustration 5.1.1
013906500
There was a significant difference in the distribution as the proportion of women was quadruple that of men. The average age for women was 42 while in men it was 40. The mode age varied among the 3 years though the data concluded women were more susceptible to a patch test at a younger age. There were mere 30 patients selected from the patch-tested list for 2015 though the results are significant to illustrate the trend. (Illustration 5.1.2
-91440044196000Illustration 5.2.1

There was a significant difference among the patients in terms of gender in 2015, though in both genders the most prevalent allergen was textile dye. There were list of 30 patients that were patch tested and out of which 13 women were positive patch tested in comparison to only 3 men.
Illustration 5.2.2
-800100000
There were a total of 92 people patch tested in 2016 out of which 37 people resulted with a negative patch test result. From the 55 that were tested positive, among them 49 were women and 6 men. The most prevalent allergen in women was nickel sulphate whereas in men both PPD and textile dye were found to be most prevalent. (Illustration 5.2.2)
Illustration 5.2.3
-914400-10033000
There were a total of 148 people that were patch tested out which 107 resulted in positive patch test result. There were 82 women and 22 men that patch tested positive to one or more allergens. The most common allergen in women and men was textile dye, respectably 39 and 10 people. (Illustration 5.2.3)
Illustration 5.2.4
-1028700-45720000(Illustration 5.2.4) The results are the data collaborated from 2015, 2016 and 2017 data and shows the most prevalent allergen between both genders. Textile dye is found to be the most dominant allergen among women and men followed by nickel sulphate in women. In comparison cobalt chloride was found to be the 2nd most prevalent allergen in men.
5.2.1 To evaluate the frequency of people hypersensitive to one more allergens
Illustrations 5.2.1 shows the variability in both genders in all 3 years of data collected.
Illustration 5.2.1

5.3.1 To evaluate the frequency of a negative patch test results in the data
There were a significant number of people who tested negative for allergens in all 3 years, 2015, 2016 and 2017. (Table 5.2.1) The table illustrates the number of negative patch test results in each year between both genders.
Table 5.3.1

5.4.1. To evaluate the effects of age and gender and the correlation between age and gender in relation to ACD.

Evaluating the trend of age and gender in correlation to the susceptibility to allergens and evaluate which age group and gender are prone to exposure leading to hypersensitivity. The illustration 5.4.2 expresses data collected on women and illustration 5.4.3 demonstrates the trend based on results collected of men. It was determined that in both genders, age group 30 < x <49 were more prominent and had higher hypersensitivity frequency in comparison to other age groups.
Illustration 5.4.2

illustration 5.4.3

Discussion of results
The growing interest about ACD in Kauno 2-oji klinikine ligonine has motivated me to evaluate the changes in Kaunas population in regards to an increase susceptibility to allergens and to evaluate the most prevalent allergen in Kauno 2-oji klinikine ligonine. During 2015, 2016 and 2017 there were a total of 272 patients that were patch tested, among them 216 (79%) patients were women and 56 (20.6%) were men.
The disproportion between the genders was due to the availability of patients at the Kauno 2-oji klinikine ligonine, despite this the results from these patients were sufficient to accomplish my objectives and form a conclusion. There were 178 (65.2%) patients that indicated a positive reaction, from which 145 (53.1%) patients were women and 35 (12.8%) patients were men. A higher skin irritability in patients with atopic dermatitis is a conceivable clarification and it indicates out the need assess fix test comes about soon after expulsion of the strip as well as to perform late readings after day 3, which may give extra data. (1) From the 91 (33.3%) patients that resulted in a negative reaction, 71 (26%) female patients and 21 (7.7%) male patients. The overall results illustrate 91 (33.5%) patients with a negative reaction, which is around a third of the overall data collected though among them were mostly women as the data consisted of the larger proportion of women participants as indicated.
There was a significant difference in both gender and age in terms of prevalence to allergens. Overall results indicated that women and men in Kaunas region are more susceptible to textile dye as stated in the results, there were 55 (37.9%) women and 15 (42.9%) men that resulted in a hypersensitive reaction.

The Nickel Mandate in Lithuania is embraced since 2003, while a sort of limitation in nickel presentation has been available in Sweden as of now since 1991 when nickel-containing piercers or rings were restricted if the composite contained over 0.05% nickel. (2) This had an impact on the prevalence of nickel, as it has become the second most prevalent allergen in women, 44 (30.3%) women showed hypersensitivity in comparison to only 4 (11.4%) men were vulnerable.
Women under 40 years were sensitive to nickel almost four times more often than older ones. (4) Nickel is very common allergen in the group, age and sex unequivocally affecting the pervasiveness of sensitization. These outcomes allude to sex-related and age-related examples of nickel presentation, early ear piercing, and contact with nickel-discharging jewelry. Information from Finland and Poland Contact sensitivity focuses indicated sensitization rates to nickel of 21.3% and 24.3%, separately, in 2007-2008. As per Thyssen et al. the diminishing of nickel sharpening in Denmark began 16 years after the nickel direction and for the most part relied upon deferred ear penetrating time. So it could be hypothesized that sharpening to nickel in Lithuania will begin to diminish in 2020 and the moving of nickel sensitisation to the more established age (>40 years) gathering can be normal later on. (5) The second most prevalent allergen in men was found to be cobalt chloride, 9 (25.7%) men showed a positive reaction, whereas, 29 (20%) women were discovered to be sensitive to cobalt chloride. The main 10 allergens continued as before in the 9-year time frame aside from MI, which showed up in 2014 – 2015. There was no past data on contact sensitivity to MI in Lithuania, as MI was added to the European gauge arrangement in 2014 in Lithuania. (5) There were a reported 12 (8.3%) positive reactions in women and 2 (5.7%) in men over the course of three years to MCI/MI. Fragrance mix 1 was found to be one of the common allergens in women, 24 (16.6%) resulted in a positive reaction and also showed a upward trend in my data indicating a rise in prevalence. A relationship with more successive utilization of common prescription, which is connected to measurably noteworthy sensitization to fragrance mix I in older patients (5)
We evaluated the number of patients that were hypersensitive to only one allergen and patients that were sensitive to one or more allergens. It was found that there was significant rise in patients hypersensitive to one or more allergens. Comparing the data obtained from the charts indicated an upward trend from 2015 and illustrates an increase in susceptibility. Comparing the results there were 95 (65.5%) women found to hypersensitive to more than one allergen in comparison 53 (36.5%) were only hypersensitive to only allergen. On the other hand, 21 (60%) of men highly susceptible to more than one allergen and 14 (40%) were prone to only one allergen.
We evaluated the age and gender correlation among the participants; it was found that there were significantly higher percentages of female and male contributors in the age group 30 < x <49. It was found that 57 (26.4%) women tested positive while 22 (10.2%) showed a negative reaction out of the total of 216 patients. In comparison to the men, 16 (30.8%) presented with a positive reaction and 6 (11.5%) negative out of the overall 52 patients. Particular sex and age-related examples of nickel introduction, mostly by early ear piercing and the following of wearing nickel-discharging adornments, well known among ladies at a younger age. (4) In the age group 10 < x < 29 there were a total of 63 patients with 40 positive patch test results. However, in the age group 50 < x < 69 the volume of patient was lower but showed a higher positive patch test of 41 out of 60 participants. One ought to consider the altogether different situations that happen while assessing the relationship between association in young people and grown-ups as the natural presentation time clearly is any longer in grown-ups and as the insusceptible reactivity may change with age. The highest number of negative patch results were found to be in the age group 10 < x <29 in both genders, which illustrates the low exposure time in comparison to other age groups may be the reason for this.

Conclusion
Textile dye was found to be the most prevalent allergen among both gender in all age groups followed by nickel sulphate in women and cobalt chloride in men
Patients were found to be more prone to hypersensitivity to more than one allergen. Results shows almost twice the number of patient was sensitized to more than one allergen in both genders.
Age and gender played a vital role and the correlation indicated patients in the age group 30 < x < 49 in both genders were more susceptible in comparison to other age groups.
The efficiency and efficacy of the patch test was questionable as 178 (65.4%) patients developed a positive reaction out of the 272 patients. There are a few limitation in regards to patch testing, age, gender and co-morbidities can influence the result with false – negative or false positive results.
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