Ean Low-Nickel Diet Scoring System for Systemic Nickel Allergy Mona Mislankar, BS" and Matthew J, Zirwas, MDt Background: Consumation of nickel inthe diet leads to sponglatic dermatitis ina dose-related fashion in individuals who are allergic to nickel. Dietary modification to reduce nickel intake leads to resolution ofthis dermatitis. Objective: This study aims to create an evidence-based, user-friendly diet to assist pa nickel intake, Methods: Food and Drug Administration data on the nickel content of foods were combined with serving size Information to calculate the upper limit of nickel per serving for a variety of foods. Based on these calculations, a point system was created that allows patients to reduce their nickel intake below the typical threshold for elicitation of the spongiotic dermatitis. Conclusions: A simplified point-based let can help patients with dermatitis due te dietary nickel consumption. nts in reducing dietary Ithough nickel has long been acknowledged as a cause of lergie contact dermatitis, it has more recently become ‘widely recognized that pruritic dermatoses can arise fom dietary nickel consumption ip a dosedependent fashion The most common systemic reactions in nickel-allergle patients include vesicular and dermatitis andlor a generalized eczematous ‘reaction. Less common, but wel described, presentations include a papuloerythrode:ma-like eruption and prurtis ani. Seudies demonstrate that the use of dietary nickel modifcetion in these nicke.allergc patients can result in improversent of euch ext neous manifestations." OBJECTIVE/METHODS Following an avoldance-based diet without specific recommen: dations regardig allowable amounts of nckel-containing foods is extremely dificult To providea more user-friendly diet that would ‘increase compliance, the authors sought to develop a point-based sytem, smile to successful cornmercal weight contel systems, A similar scoring system was recently developed for dietary cobalt avoidance Fra he Colige of Medina Unveriy of Carats and Phan of Dor rata, The Ohi Ste Unnriy Wear Medal Canter Calum Aiea repre russ Mathew |. Zine, MD, Dion of ermal ‘he Ohio State Unrerty Ween bd Cover, $40 Oana, Gahanna, OH 43250 Ema mat rwaronu The autos have o finding a enn of ere dele, OK: 10.1097/DER 0013318293781 (©2013 by the Amarean Contact Drie Scien, Al Rights Reve. ‘The Total Diet Study published by the Food and Drug ‘Administration (FDA) repores the mean concentration of sical in many of the focds and food groups representing the major component of the typial US dit.” Using FDA-approved mete serving szes! the authors converted the mean nickel concentra tion (reported in miligrams pe kilogram) into absolute amounts (microgram per standard serving size), Hated on the assumption ‘that Americans frequently consume larger porons than I standard serving size, ths original nickel content (microgram per standard serving size) was doubled to arrive at microgram per serving Each ood was then assigned a score from 0 0 10:0 ifles than 1 yay serving, Lift 10 ugfserving,21f11 1020 e/serving. and soon, up 10 10 1f 90 to 100 jpleerving Any foods with more than 100 gy serving are listed as “avid” (Table). In addition, instructions based ‘on the authors experiance were developed to be given with the diet. RECOMMENDATIONS ‘The estimated average dally intake of aickel with a normal diet, «anges from 220 to 350 ug dally, and 1% of ickel-llerge patients will have a cutaneous reaction to 220 ig Therefore, the authors recommend that patients who are experiencing cutaneous reactions thought to be due to dietary aickel limit their con- sumption to less than 150 gid. Because children have a lower body weight than adults and there are no data regurding dose. response in children, the authors empiticlly recommend no ‘more than 100 ugid for children. Given that reponse to dietary nickel are on a dose-response curve, thee will be rare patients who reac to less than 150 ug/é, The authors opinion is thatthe lowest ‘reasonably posible nicl intake per day would be 5 points, otis cutolf was st as the most restictve level DERMATITIS, Val 24 # No JuAsgust 2013 Copyright © 2013 American Contact Deematie Society Unauthorized rprecucton ofthis ate is chibi,ane Zr LoveNicel Dit Scoring Ste fr Mickel Aergy 191 BEER structions tor Low-Nickel Diet 1. thmay take op to 2 Tarts tose the benefits fom folowny tis Gel 2. Adults should consume ne more than 18 points par day. 8. Chldan younger than 12 years should coneume no more than 10 points per dy. 4 Very rare incivduals are even more sensitive than tis ond may need to stay under 8 points par day. In genera, even i not sted specfcaly, avd anyhing with beana, chocolate, peanuts, soy, ostmedl, or granola 8. Onl bottedicstiled water should be conaumed, ether by inking erin cooking 7. Avoid cooking acigic fos in stainless steel cookware, Act foods include toratces, vinegar, and cit. Types ofcookvare that are ‘ale: nonatick coated of any ype, aluminum, copper, cast ion 8 Do not take any vitanins or supplements except for vitmin C. However, this dat is relatively low i be, 80 if you ar prone to Constipation it may be beneficial to take a stool satener, such as cocusate sodium, 8, Take a chewable 800mg or 1000-mg vitamin Ctabet wih every meal—ths helps to provet nickal kom being absorbed. must be taken a the beginning, midl,or end of each meal I doesnot do any good to take tat mes otherthan when exing the viecin G ‘must be inthe stomach atthe same tine asthe food. The information on which the diet ia based can be found at this Web ste: hp:/wor. fda gov/downlosds/Fcod/FeodSatety/ FoodContaminants Aduiterstion/TotalDietStucy/UOM124301 pdf Nickel Diet Foods Listed by Point Value (Page 1) pole ° (Cheese, American, srosaseed 1 Boer ° Chicken breast, ied with en 1 utero margarine o ‘Chicken lg, ie with sin + Candy, hava ° Chicken, roasted shinies 1 CChease, cheddar ° (Chuck roast, beet 1 Cheese, Si ° Cofee 1 Chicken breast, kin romoved ° Coes, decaeinates 1 Goes cramer, nondairy ° Calesiewe 1 Conage cnoess ° Colares 1 ‘Cream chasse ° Cookies, suger 1 Eogplent ° Comhominy site 1 Fags ° Comoreac 1 Frit ink ° CCrackrs(nor-whele wheat) 1 Half 2 hal ream ° Cranbery juice cocks 1 Honey ° Cucumber 1 lee era, vail ° Engish muffin, lan 1 Jel ° Fait ica bend 1 4 ° Grape ice 1 Lunch meat (ehicken, turkey, or ham) 0 Grapotut 1 Maple syrup a repo 1 Mayonnaise o Gea, canna or boted 1 Mi, white ° Ham, cures, bakes 1 Mushrooms ° Hotdog 4 Olive ai 0 Lam chop 1 Popsicle ° Lemonade 1 Suiad dressing ° Live (beta) 1 Soda/popiecla ° Lunch meat, salar 1 Sour eream ° Macaroni and chesse 1 Steak ° Macareei elas 1 Sugie ° Moatost 1 Tuna, carved ° Matin ut or pin 1 Vogatabe ci ° Noose, og 1 Apa vice 1 Os 1 Apolesauce l ves 1 Bacon 1 Onion 1 Bagel, ian 1 Orange 1 Banare 1 Cxange tice 1 Bests 1 icles, al 1 Bologna 1 Prk chop 1 TCO FT PES) [Copyright 62013 Amencan Contact Dematis Society. Unauthorized reproduction otis ace pronto(Continved) Ate Seer ECP TE ED, Bread, white Brocect Brussel sprouts Cabbage Carat Cauitower Caley (Ceres), com fakes Geral cream of wheat Cereal, raisin bran caret (Cereal. seeded wheat Squash, summer Sweet and cour sauce Tomato Tomato osteup Tomato salsa, eotied Toria chins, eae Tuthay breast Turnip Wine, rede Yellow mustard Ale pie ‘Avocado Biecute Bread, whast or ye Cate, ylow with cing Candy ber, chocolate, nougat, nuts Cantaloupe Cates Cera, creped ree (Chicken fot sandwich broad Chocolate chip cookies Cookiss (Oree pe) Com Engish mutfin—egg, cheese, ham Fish sancvich, fst food Fah sticks & patty Grapefruit ice Groan beans Hamburger Lestuce Parcavee Peanuts Pear Pooper, grean Popcom Poptaritoaster pasty Potato salad Potato, baked or boiled Puding, not chocolate ‘Soup, chicken noodle, canned DERMATITIS, Vol 24 « No Juh/Augas, 013, Pork roast, Potato one Prot Rating Fics, white Sausage Sherbet Shrimp ‘Soup, ental necclas amen Spaghetti ‘Spaghet with meat sauce Asparagus Beet stroganot with nodes Coral fat favored Chicken nugget, fast food (Chicken with vegetables in sauce Doughnut Meal replacemant shake Peach Peanut butter Pioeapole Pra, cheesa and pepperoni Pumpin se Fico, ed and mestioss Scup,vagetabo boo, canned ‘Staw-—beo! anc vegetable “Tacoltostada with bast and cheese Tomato sauce, batted Tuna rocele casserole Vegetables, mized ‘Watermelon ‘eel wih vegetables in sauce Chicken pote, roan (am chowéer Franch ties Fut eootesi cannes il choco ese, tazen ‘Soup, tomato, earned Tomato juice Granola bar wth ralsing Bears, white Brownie Corea, granola with sina Chocolate CChocelate sy Prneapale juice Lasagna wih moat Prune ice Burrito with beet, beans, chesee Mak hake, chocolate Spinacn aime) ‘Squash, winter ‘Soup, bean, bacon, porecanned y Strawbrise| Cake, chocolate wih ing Avsid (Contd on RR pe) CCooyright © 2018 American Contact Dermatitis Society Unauthorized reproduction ofthis ate is proibiedisla a Zee Low Nick ut Scoring Syste for Mik len (Continued) Smerpoxtaee 2 Coos oa tre Tra Snes Dah pasty 2 hth ean eae td Ten cwcaterted 2 Lima beans, fro Teno ee bg 2 Patou ow Teri, ow 2 Pork an bore ee Yenst 2 Tati boar fie roves 3 Sartor sente hled ses Nickel Det Foods Listed Alphabetcaly Page 1) ope ° Chan pti, ox ‘ sone i can wih vegatin nice 3 ove ie 2 hte oad shoves ‘ ope sauce t Chiba, canned ci spice 3 Chocle 3 pepe 3 Choc chi oois 2 seats 2 Groce ome : econ ‘ ruck ot eet ' rp! pan ‘ ‘Sn chor ‘ auune 1 . Conee i ean white : Cote csene nnciy ° Beet sagan wih odes 5 Cotes coterie ‘ Bet wih wots oma ‘ ‘consien ' Bee ° Cotacs i Bross ‘ Coste Oro ye) 2 Bons 2 Cooke sur i Bioore i on 2 Sn wht oF 98 2 conten ts ‘ Brn i Contre ‘ Sonecl i cotage cute ° aon : acta occ nes ‘ Bunce sous ‘ Cancer fice cecal ‘ Bio wih bebe 2 ‘rar chess ° Baterormargebe 6 Conuner : Cattage : Dowprct 3 Cae choca wih cng ot Ceci ° Cae ytow win hg 2 tom ° Cay by sheet rouge ua 2 Engle min, cheese han 2 any het 6 nfoh mal pt ‘ cancun 2 ranean a od 2 Care : rat ech or pay 2 caren 2 neh ‘ Calter ‘ Fro cca, eames ‘ ey ' Curae ‘ Cor co fakes i Felt hie ee : Gora eam aft, i Gra bar thre : Gora ieee tee 2 Grape ce ‘ Cons rattan 2 Caageut 1 Goma, gare wah iin 3 osha ice 2 Com ou cis Srpet ‘ ‘ Gray, came betfed ‘ ‘ oo sane 2 : vat andhatomam é ° am, ue, bated ‘ ° anburger 2 Scan reas eg thn t ore c (Continued on want page) (Copyright ©2013 American Contact Dermatils Socley. Unauthorized reproduction o this ace i prohibited,(Continued) Mickel Diet Fowds Listed atprayencany aye TZ) Chicken breast, skin removed DERMATITIS Vol 24 « No 4» fgvaapust 2013 ° Hor cog 1 (Chicken tet sancwieh-boled 2 lee cream, varia ° (Chicken leg, red wth akin + elo 7 Chicken nuggets, fastfood 3 Jely ° Lamb chop 1 Pudding, not chocolate 2 Lasagna wth mast 7 Pumkin pie a Lemenads 1 Raising 1 Letuce 2 Rotied beans Avia ima beens Avoid Rice, ted and meatess a vor foetal) 1 ee, white 1 Lunch mest chicken, turkey or ham ° ‘Saad drasting ° Lunch mest, salami 1 ‘Sausage 1 Macaroni ard che 1 Sherer 1 Nacaron sala 1 ‘Shame 1 Maple sya ° Soda/pop/ecla ° Mayonnaise ° ‘Soup, bean, bacon, porkeanned 10 Meal replacement thake 3 Soup, chickonnocdle, canned 2 Meatiat 1 Soup, oriental reedes—ramen 1 Mik shake, enacoite 8 ‘Soup, tomato, canned 4 Mil, chocolate | 4 ‘Sova, vegetable boet, canned 3 Mik hi ° Sour cream ° Mati, fat or pain ‘ Snaghatt 1 Muchrooms| a Spaghet wih mast eauce 1 Noodes, ogg 1 Spintch 2 Oates! ° ‘Squash summer 1 Obra 1 Squash, winter 2 ive oi ° Steak ° Gives 1 ‘Stew —bee! and vegetable 2 nian 1 Strawberies 2 Orange 1 Suge: ° range juice 1 Suntowar soees, shld avoid Pancakes 2 ‘Sweet and sour eauce ' Peach 8 Sweet potaon 2 Peart buter 8 Sweotol/Darish pasty 2 Parte 2 “Tacoltostaca wih beet and cheese 2 Pear 2 Tea, decaeinared 2 Peas, tozen ‘ Tea, rom tea bag 2 Pepoer, green a Tomato 1 Picks, ai 1 Tomato catsus 1 Pinespoie 3 Tomato juice “ Pineapoe juice 6 Tomato asaa, voting 1 Pinta boars void Temato sauce, botted a axa, cheese and pepperoni 3 Tomila chips, con 1 Popcom 2 Toni, tour 2 Popsicle ° ‘Tuna rendlecxssercle 3 PPoptettcaster pastry 2 “Tuna, canned ° Pork and beans Avoid “Turkey east 1 Perk chop 1 Tania 1 Pork roast 1 Vegetabe cil a Potato chipe 1 Vegetabes, mixed a Potato asl 2 Waterton 2 Potato, baked or boiled 2 Wine, reaite 1 Protos 1 Yellow mustard 1 rane juice 1 Yogurt 2 (Copyright ©2013 American Contact Dermatis Socity. authorized reproduction of his arse is poniesseach ane Zewas « Lowi Det Sing Sten for Nally REFERENCES Jensen CS, Menné 7, Johansen JD. Symemic coat dermis aero spot ica a ew witha malfed means Coin Drmatig 20217945 Zewas Di, Molenda MA. Diary sick a «cast of sree cone leat. Clin Aether Dermat! 3000216) 3949, Svea DL, Barmene 8, Puts aia a mannaton of sec cn ‘act derma: reclution wih deary neal reson, Dermat 2011 uses, Kato K Soh T, Tanaka Tet aL Syemic al ley prenting a lor yhodermalke erpins. Ate Dem Venerol 2016906)855 30 5 once 1. Nickel allergy. itary Mancenent of foal drm hina tampon Guid. Vo. I. Por Cogan, Bee Ph Hal Pubcans 1995247-261 6 Sct Nedrot§, Lowe et for dsr etna patents Conte Derma 200859(6) 361-36, 7. Toa Dat iy Stic on een Rested 206-2008 US end and ‘rg Admiisreion Market aes. Avail at btn gona ‘eoaftyFoodCocaminusAddtrson/TotDeSndam 60h ‘cs on Oatber 30,2012 {US Food and Dog admnisraon CER Code of Feder Regulations Tle 21, Avudable at: hep aceiata a govlerpuctetdeed cet (RSet 12 Aceon October 30212 Coorght ©2013 Amarcan Contact Demalis Society. Unautherzed reproduction ofthis aces prohised I