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Featured, Skin

“Skintimate” Problems: Skin Issues Related to Underwear, Sex & Other Things That Might Embarrass You (But Shouldn’t)Featured

Skin problems can cause embarrassment. This can be especially true for skin problems affecting the “nether regions” — areas of the body that so many of us are taught to think of as shameful, not to be spoken of, or at least extremely private. Of course, they aren’t shameful and we should all know more about skin problems that appear on the genitals, or that are related to sex or our undergarments. Furthermore, we shouldn’t be shy about consulting a dermatologist to make sure that we get an accurate diagnosis and address the problem properly.

Darkening and other Skin Problems in the Groin, Stomach, and Bra Areas

Elastics, dyes, chemical processing (bleaching), scratchy fabrics, and preservatives in fabric can cause itching, rashes and, over time, darkening around the groin, scrotum, buttocks, bra area, and stomach. But it’s not just underwear that can cause these problems. Seats and lower back cushions with leather, rubber, vinyl, and other allergens can also be at fault.
While a rash, itching, or discomfort may bring you to your dermatologist, an asymptomatic condition called pigmented contact dermatitis (PCD) — a faint to mild and progressive darkening that is frequently considered “just part of aging” — might be missed. PCD can be seen around the groin, in between the buttocks, in the genital and scrotal areas, on the nipple and surrounding areola, under the breast, and/or on the stomach. It’s often missed as a type of contact dermatitis because it doesn’t start out as a rash or itching…it darkens gradually over time. While strong bleaches (some with steroids) can work to lighten the hyperpigmentation, the darkening will recur without proper prevention. Patch testing easily proves the (+) and relevant chemicals that cause the reactions.
In addition to getting a patch test so that you can practice more accurate prevention, good practices include choosing underwear that is made with elastic-free, organic (bleach and dye-free) cotton like those from Cottonique. Choose chairs with seats and lower-back surfaces that are not made of rubber or leather, or dyed. If this isn’t possible, place a barrier between you and the surface. Try a white (or, even better, uncolored) cotton towel.
Wash underwear and the barrier you use on your seat in Fawn & Launder or diluted Superwash. If you are sensitive to chlorine which is often present in tap water, rinse these items with distilled water.

Diapers

Anyone, of any age, who uses diapers can develop irritations and/or allergies on the areas of contact, especially because of the extended time of contact and in an enclosed, often humid environment. Many allergens and irritants go into the materials of diapers themselves, so try to look for unbleached options. Or consider cloth diapers or underwear with built-in pads. Pure organic virgin coconut oil (VCO) like Know-It-Oil is a great option as it cleans well without roughness, provides antimicrobial protection, and also moisturizes the area to help prevent diaper rash. Adding a purely mineral barrier might also help prevent irritations from chafing or contact with elastics.

Diseases That Can Involve the Genitals…

…include viral warts and herpes lesions (which are infectious and spread faster in ano-genital skin). Other more infectious diseases include chlamydia (the most common STI in the world), gonorrhea, syphillis, and HIV. Use a condom when having sex but get a patch test as you might be allergic to some materials commonly used in condoms. Note that not all these skin lesions are sexually transmitted. Toilet paper can cause skin problems and molluscum contagiosum can be transmitted via towels and sheets.
Don’t be shy: if you see or feel lesions in the genital areas, set a consultation with your dermatologist or gynecologist.

Genital Skincare

Irritations and abrasions on or around the anus and other genitals can be helped by Boo-Boo Balm.
Know-It-Oil can also be inserted to soothe and reduce inflammation: put some into a needless syringe. Store it in the refrigerator for a few minutes. When the VCO is a cold “butter,” insert the syringe into the vagina or anus and push the plunger. The oil is quickly absorbed and does not tend to leak — if you’d like more precautions, do this before going to sleep and place a towel between you and the bed. Important: Consult your gynecologist. There are no studies on inserting VCO into the genitalia at this time. There seems to be some discussion in the medical community about whether VCO is preventive of yeast infections or has the potential to disrupt the native flora of the vagina (since it is antibacterial and antifungal) because VCO innately only treats non-commensal microbes. There are a number of well-respected hospitals (Sloan Kettering) and published doctors who do recommend using virgin coconut oil as a lube or moisturizer. But because your doctor knows your particular history best, check with them. If your doctor does give you the go-ahead, make sure that the oil you insert is pure, organic, cold-pressed VCO (not coconut oil with additives, grown with pesticides, or handled with less sanitary methods).
When using lube, look for for fragrance- and preservative-free options. VCO can also be used as a lube, but not with latex condoms as latex is broken down by oils (of any kind).
Sanitary napkins with fragrance, dyes, and preservatives are common causes of itching, irritations, and allergies. While harder to find, there are unscented and unbleached options. Feminine washes and douches are unnecessary and potentially harmful: risks include skin issues as well as offsetting the important and delicate balance of microbiota in the area.
Wash with a gentle, allergen-free liquid soap like Clark Wash instead. Pure organic virgin coconut oil like Know-It-Oil can be used for cleansing and/or barrier repair of chronically irritated and inflamed skin.

Hyperhidrosis (Sweating a LOT)

Excessive sweating that is visible and even drip from the skin may be a condition called hyperhidrosis (if it is accompanied by a bad odor, it might be bromhidrosis — see below). The sweating can be localized on the underarms, palms of the hands and soles of the feet, or generalized, affecting larger areas of the body or the whole body. All the typical things that trigger sweating (such as anxiety, heat, exercise, spicy food) worsen sweating but with hyperhidrosis, sweating can occur without triggers and even in the cold.
Hyperhidrosis can be caused by thyroid problems, menopause, diabetes, obesity; some cancers or neurological damage; or could be related to other underlying conditions. Your doctor can help you investigate the cause further. Even if unrelated to another health condition, hyperhidrosis can be frustrating. It can cause visible sweat stains and ruin fabrics. It can cause discomfort with simple social interactions like shaking hands. If severe, the sweating can cause keyboards and other electronic equipment to malfunction. And an unpleasant odor can develop.
Use a strong antiperspirant like Essence Skin-Saving Antiperspirant or Illuminants+ Axillight Treatment Antiperspirant on all affected areas. Botox® injections can stop the production of sweat in the area for several months. Consult your dermatologist for options.

Bromhidrosis (“Bad Smell”)

This perceived “bad smell” mostly occurs in the axillary or underarm area (if it is apocrine bromhidrosis). It can also be from other parts of the body (eccrine bromhidrosis). Apocrine and eccrine refer to the two types of (sweat) glands that we have.
Eccrine glands are most numerous on the palms of the hand and soles of the feet but are everywhere on the body. When the body’s temperature increases, they produce sweat that is normally odorless, more dilute, and watery. It can also begin to smell due to bacteria, some foods and medications, or alcohol.
Apocrine glands are located in the groin, breasts, and underarms and produce a thicker sweat that contains pheromones. Apocrine sweat begins without smell, with odor developing as bacteria break down the sweat.
All humans have a natural, healthy colonization of bacteria and other microorganisms that coexist in a complex, sophisticated, functional balance. Sometimes, when this balance is thrown off, one microorganism can begin to dominate and cause problems.
Odor is caused when bacteria break down sweat resulting in fatty acids and ammonia. In bromhidrosis, a higher level of bacteria break down the sweat in the apocrine areas (the most common type of bromhidrosis is in the armpits), resulting in a stronger or foul-smelling odor. If hyperhidrosis  is also a concern, it needs to be addressed as well for the bromhidrosis to be managed.
Management of bromhidrosis includes…

  • The same sweat control with Essence or Illuminants+ Antiperspirants mentioned in hyperhidrosis, above.
  • Practicing proper hygiene (wash the areas at least twice a day) with…
  • Unscented products such as Essence Superwash. While it may seem counterintuitive, a common cause of bromhidrosis is the scent of sweat interacting with perfumes in products.
  • Following antiperspirant with Id Monolaurin Gel or Kid Gloves for additional sweat control as well as antibacterial care. Id Gel and Kid Gloves can be reapplied throughout the day, too.
  • Removing hair regularly to help prevent the accumulation of bacteria and sweat on hair shafts (particularly armpit hair).

Depilation or Hair Removal

Laser hair removal is a great option but — especially if you have brown skin — comes with the risk of hyperpigmentations. Make sure to see a specialist familiar with laser procedures on brown skin. Brown skin can include paler mixed skin as well. And note that laser hair removal might not not work for individuals with very light hair coloring. For this procedure, it’s clear that a specialist is important.
Waxing and sugaring are also worth considering, but hair growth will recur. Particularly when waxing (because of the heat and tearing), consider using an anti-inflammatory like Red Better Calm-The-Heck-Down Balm and ice afterwards.

Caring for Someone Who Needs to Spend Several Hours In Bed or Otherwise Not Moving Regularly

VCO is an excellent option for the daily washing of the perineal area, and can be applied at every diaper change to prevent rashes, sensitivity, and infection. This, plus regular massaging of the areas with VCO can also help prevent bed sores.

This information should not be considered medical advice. For skin problems, and certainly for those affecting sensitive areas of the body such as the genitals or that may be related to sexual activity, see your doctor.

Laura is our “dew”-good CEO at VMV Hypoallergenics and eldest daughter of VMV’s founding dermatologist-dermatopathologist. She has two children, Madison and Gavin, and works at VMV with her sister CC and husband Juan Pablo (Madison and Gavin frequently volunteer their “usage testing” services). In addition to saving the world’s skin, Laura is passionate about health, inclusion, cultural theory, human rights, happiness, and spreading goodness (like a great cream!)

Allergen, Not An Allergen, Skin

BLACK HENNA: Allergen or Not An Allergen?Featured

BLACK HENNA: Allergen or Not An Allergen?

Allergen.

Black Henna

Pure, organic henna with no additives is generally not allergenic, but black henna is. In a big way. The reason for this is that black henna has PPD or para-phenylenediamine (which is on published common allergen lists) added to it to make its color black, to make it more vivid, and to make it look more like a real tattoo. PPD is also common in hair dye and other materials like rubbers, dark-colored fabrics, and some pens. If you have patch tested positive to PPD avoid cross reactants like azo-dyes. Opt for uncolored or lighter-colored fabrics. And choose original henna without dyes or preservatives added to it to enhance its color, vibrancy, or staying power. NOTE: It can be hard to tell whether dyes or preservatives have been as this is not always clear in the ingredients list.

If you have a history of sensitive skin, don’t guess: random trial and error can cause more damage. Ask your dermatologist about a patch test.

For more:

On the prevalence of skin allergies, see Skin Allergies Are More Common Than Ever and One In Four Is Allergic to Common Skin Care And Cosmetic Ingredients.

To learn more about the VH-Rating System and hypoallergenicity, click here.

References: 

Regularly published reports on the most common allergens by the North American Contact Dermatitis Group and European Surveillance System on Contact Allergies (based on over 28,000 patch test results, combined), plus other studies. Remember, we are all individuals — just because an ingredient is not on the most common allergen lists does not mean you cannot be sensitive to it, or that it will not become an allergen. These references, being based on so many patch test results, are a good basis but it is always best to get a patch test yourself.

1. Warshaw, E.M., Maibach, H.I., Taylor, J.S., et al. North American contact dermatitis group patch test results: 2011-2012. Dermatitis. 2015; 26: 49-59
2. W Uter et al. The European Baseline Series in 10 European Countries, 2005/2006–Results of the European Surveillance System on Contact Allergies (ESSCA). Contact Dermatitis 61 (1), 31-38.7 2009
3. Wetter, DA et al. Results of patch testing to personal care product allergens in a standard series and a supplemental cosmetic series: An analysis of 945 patients from the Mayo Clinic Contact Dermatitis Group, 2000-2007. J Am Acad Dermatol. 2010 Nov;63(5):789-98.
4. Verallo-Rowell VM. The validated hypoallergenic cosmetics rating system: its 30-year evolution and effect on the prevalence of cosmetic reactions. Dermatitis 2011 Apr; 22(2):80-97
5. Ruby Pawankar et al. World Health Organization. White Book on Allergy 2011-2012 Executive Summary.
6. Misery L et al. Sensitive skin in the American population: prevalence, clinical data, and role of the dermatologist. Int J Dermatol. 2011 Aug;50(8):961-7.
7. Warshaw EM1, Maibach HI, Taylor JS, Sasseville D, DeKoven JG, Zirwas MJ, Fransway AF, Mathias CG, Zug KA, DeLeo VA, Fowler JF Jr, Marks JG, Pratt MD, Storrs FJ, Belsito DV. North American contact dermatitis group patch test results: 2011-2012.Dermatitis. 2015 Jan-Feb;26(1):49-59.
8. Warshaw, E et al. Allergic patch test reactions associated with cosmetics: Retrospective analysis of cross-sectional data from the North American Contact Dermatitis Group, 2001-2004. J AmAcadDermatol 2009;60:23-38. 
9. Foliaki S et al. Antibiotic use in infancy and symptoms of asthma, rhinoconjunctivitis, and eczema in children 6 and 7 years old: International Study of Asthma and Allergies in Childhood Phase III. J Allergy Clin Immunol. 2009 Nov;124(5):982-9.
10. Kei EF et al. Role of the gut microbiota in defining human health. Expert Rev Anti Infect Ther. 2010 Apr; 8(4): 435–454.
11. Thavagnanam S et al. A meta-analysis of the association between Caesarean section and childhood asthma. Clin Exp Allergy. 2008;38(4):629–633.

12. Marks JG, Belsito DV, DeLeo VA, et al. North American Contact Dermatitis Group patch-test results, 1998 to 2000. Am J Contact Dermat. 2003;14(2):59-62.
13. Warshaw EM, Belsito DV, Taylor JS, et al. North American Contact Dermatitis Group patch test results: 2009 to 2010. Dermatitis. 2013;24(2):50-99.
Want more great information on contact dermatitis? Check out the American Contact Dermatitis SocietyDermnet New Zealand, and your country’s contact dermatitis association.

Skin

Could Your Skin's Patterns Be The Map To Its Cure?

Patterns aren’t just for understanding behavior. Your skin problem’s pattern can be the very roadmap to its solution!

Look at your skin. Really look at it. If you observe your acne, rashes, dry patches, and dark splotches as carefully as you would an inkblot test, you might be surprised at how much your skin is telling you about the causes of its problems…and how to fix them.

Face

You indulged in a new moisturizer and all you got was an angry, red rash? Curse you, moisturizer! Before you take a pitchfork to that tube, study the pattern of the redness carefully. For the moisturizer to be a good suspect, the redness should appear over most of the entire face, which is how you normally apply a moisturizer. If you notice that the reaction is concentrated in specific areas, you’re better off looking at another product that you tend to use on those areas, even if you’ve never had a problem with that product before (irritations and allergies can develop over time).
If you notice that the skin reaction is worse on one side of the face, think about where you normally sit in the car, on the bus, at home, and in the office. Does that side tend to face a window or be closer to a lamp? You might be looking at a photosensitive reaction — redness or darkening due to exposure to sun or light, or from allergens in your skincare or makeup reacting to sun or light.
Your bedsheets could also be a problem: if you tend to sleep on one side more than another, allergy- or acne-causing materials in your pillowcase or ingredients in your laundry detergent could be causing your skin reaction.

Forehead, Cheeks, Upper Back

Is your acne concentrated on the forehead, cheeks, or upper back? It might be caused by your shampoo, conditioner, and hair styling products. Comedogens (ingredients that clog pores) and allergens (which can irritate pores and lead to infection, then acne) in some of these products could trickle down onto the skin (particularly with sweat) to cause acne and other skin problems.
If you use helmets for biking or sports, or headscarves or hats, consider them, too. Many contain rubber, dyes, bleaches, and preservatives, which can all cause skin problems.

Around the Eyes

Do you wear glasses with metal parts? Nickel is regularly at the top of published lists of common allergens, and reactions on the nose, ears, and around the eyes could point to a nickel sensitivity. Eyewear without metal parts may not be entirely safe for you either if they contain allergens like benzophenones in the plastic or thiuram in rubberized parts.
A case study was presented where a woman was erroneously diagnosed with vitiligo (loss of pigment in the skin) due to whitened patches around her eyes. A dermatologist suspicious of the symmetry of the whitening ordered a patch test. The results showed that the patient was sensitive to rubber. As the patient worked in a laboratory, the doctor asked if she used protective eyewear. It turns out that the patient had developed hypo-pigmentation (loss of pigmentation) as a reaction to the rubber on her lab goggles.
Eye makeup and eye serums can also be an issue, of course, and a reaction to this would normally be concentrated on the areas of application.

Mouth, Lips, Chin, Jaw

If you have chronic dryness and blisters on the lips, check out this case study showing how simple avoidance — in this case, of mint and nickel (the patient’s allergens) — can be powerful at clearing up a problem entirely! If you share this patient’s allergies, avoiding mint may seem simple but allergens often cross-react or are related to other allergens…so we’d suggest avoiding flavors altogether.
Nickel can be present in braces. If you’ve tested positive for a nickel allergy, make sure to tell your dentist and orthodontist about it.
Some colors used in lipsticks can contain nickel. Ask the manufacturer about the concentration of nickel in their dyes or pigments to be sure (note that a nickel sensitivity often comes with a cobalt sensitivity, too).
Nickel can also be present in mordants, or metals in fabrics. If you tend to use scarves, opt for natural, uncolored fabrics because mordants are used to help dyes adhere to cloth.
There are other allergens present in fabrics. If your problems seem to be where your skin tends to come into contact with clothing, ask your doctor about a patch test with clothing allergens included. Safer scarf options include pale, natural colors and non-scratchy, non-stretchy fabrics.
We also regularly see acne, dryness, darkening, rashes and other problems around the mouth and on the chin, lips, and/or jawline as a result to a sensitivity to fluoride and flavors in toothpastes and oral care products (peri-oral dermatitis) which also responds dramatically to simple avoidance. A halogen sensitivity also benefits from avoiding iodides, bromides, chlorine, and similar substances (check out this halogen-Free Diet for a great guide).

Hands & Feet

Notice some random, and stubborn, dryness on your fingers? If it’s on the the thumb and the index finger, it could be from holding coffee mugs with metals or rubbers on the handles. Or, as in the case of one psoriasis patient, from touching paper! This patient’s psoriasis was finally well controlled. Part of her successful management was her disciplined avoidance of her allergens: dyes and preservatives. Still, she had dry, scaly patches on one hand that just wouldn’t go away.
Her dermatologist grilled her about what she was using that could be causing the patches. The patient was adamant: nothing! Because she was so happy about her therapy’s success, she was exacting about avoiding dyes and preservatives, and was (rightfully, in our opinion…it’s not easy) proud of it. The doctor persisted, asking if the patient had begun working again (she was retired) or had any other changes in her life that could be sources of accidental exposure. They finally got to new hobbies. The patient said that she had recently started playing weekly bingo. Delving deeper, the dermatologist asked the patient to show him what she used when playing the game. The patient returned with an ink-stained marker and paper. Sure enough, where her skin came into contact with the ink and where she rested her hand on the paper (thiourea, one of her allergens, is related to dyes and preservatives and is common in paper) matched the pattern of her dry, scaly patches. After just a few weeks of minimizing contact with the pen and paper, the patient was scale-free from head to toe.
Problems on the feet can be due to elastics in socks, as well as rubbers, colorants, metals, or glues in shoes. Laundry detergent could also be a factor.
An interesting case we are monitoring is of a patient whose irritations are on the soles of the feet, and who is mostly allergic to propolis. His doctor is narrowing in on the possibility of the wooden floors of the patient’s home possibly containing propolis from floor wax…or even as a transfer from bees!
For either hands or feet, if the nails or webbing between the toes are involved, make sure to consult a dermatologist to rule out other skin conditions.
IMPORTANT: If you notice a dark spot that looks almost like a bruise on the fingers or toes, don’t dismiss it so easily. Show it to your dermatologist at your next skin cancer screening as it could be an early sign of some skin cancers (even in non-white skin).

Underarm & Body

A doctor shared a fascinating case of a patient whose underarm darkening would not go away. The patient had already switched over to our allergen-free Essence Skin-Saving Antiperspirant, Essence Skin-Saving Body Washes and Fawn & Launder Hypoallergenic Laundry, and was conscientious about not using any other products on the area.

The doctor reviewed her case in detail. The patient’s patch test showed an allergic reaction to metals and nothing else. She asked the patient to come in again so that she could take another look at the darkened area. The doctor noticed that the darkened skin was in a pattern: the darkening was limited to a circle at the perimeter of the underarm, and there was no darkening in the center. This perimeter area is where the skin would most come into contact with shirt sleeve openings and the sides of a bra. Thinking back to the patch test results, the doctor asked the patient to use only white or otherwise un-dyed materials in bras and shirts. It took a few months but the darkening subsided significantly.

Why did this darkening happen if the patient was primarily allergic to metals? In addition to causing redness, dryness, scaling, itching and other abnormal symptoms, an allergy to metal can also cause darkening…and there are often hidden metals in clothing. As mentioned above, mordants are chemicals that are added to clothing to help dyes adhere to fabric. This is why, when the patient stopped using fabrics with color, the darkening subsided.

Due to their function, mordants are common in colored clothing, including denim. The photo below shows a man’s metal allergy on the upper thigh due to the mordants in his jeans (for other people, a common problem the blue colorant, indigo). This patient was highly allergic to nickel, and his pattern revealed that he was also reacting to the nickel in his cell phone, which he tended to keep in his pocket:

If the itching, redness or darkening is on your knees or around the groin area where clothing tends to gather or crease, you could be reacting to your clothing or underwear. Use allergen-free body cleansers, wash your clothing in hypoallergenic laundry soap, and choose clothing that is less stretchy and as un-colored as possible.

Patterns Matter

If you have stubborn darkening, redness, dryness, itching, acne or other skin problems, pay close attention to where they occur. Patterns can be helpful in determining the causes of skin problems, as can a patch test and an investigative dermatologist.

In addition to our allergen-free products, if you have clothing contact dermatitis we suggest browsing through dye, latex and rubber-free clothing like those offered by Cottonique. Fun fact: one of Cottonique’s founders was a patient of our founding dermatologist-dermatopathologist — he started the company after her diagnosis of his clothing contact dermatitis.

Disclosure: VMV has no commercial or other relationship with Cottonique except having done a clinical study for how their allergen-free clothing can help those with clothing contact dermatitis.


“Dew” More:

To shop our selection of validated hypoallergenic products, visit vmvhypoallergenics.com. Need help? Leave a comment below, contact us by email, or drop us a private message on Facebook.

If you have a history of sensitive skin, don’t guess: random trial and error can cause more damage. Ask your dermatologist about a patch test.

Learn more:

On the prevalence of skin allergies, see Skin Allergies Are More Common Than Ever and One In Four Is Allergic to Common Skin Care And Cosmetic Ingredients.

To learn more about the VH-Rating System and hypoallergenicity, click here.

Allergen, Not An Allergen, Featured, Skin

COBALT: Allergen or Not An Allergen?Featured

COBALT: Allergen or Not An Allergen?

Allergen.

Cobalt

A strong, common allergen, cobalt is a naturally-occurring metal, frequently found with nickel, and was Allergen of the Year in 2016. If your patch test showed an allergy to cobalt, avoid it in cosmetics as an ingredient (frequently used as a colorant for makeup), in pottery and cement, as well as in colored and treated fabrics (opt for raw, natural, pure cotton), tattoo inks, paints (including blue or green watercolor and crayons), as well as some leathers and hair dyes. You may also want to steer clear of metals that may contain nickel (such as buttons, zippers, snaps, metal eating utensils, and some jewelry) as there have been reports of people who are allergic to one tending to be allergic to the other.

If you have a history of sensitive skin, don’t guess: random trial and error can cause more damage. Ask your dermatologist about a patch test.

For more:

On the prevalence of skin allergies, see Skin Allergies Are More Common Than Ever and One In Four Is Allergic to Common Skin Care And Cosmetic Ingredients.

To learn more about the VH-Rating System and hypoallergenicity, click here.

References: 

Regularly published reports on the most common allergens by the North American Contact Dermatitis Group and European Surveillance System on Contact Allergies (based on over 28,000 patch test results, combined), plus other studies. Remember, we are all individuals — just because an ingredient is not on the most common allergen lists does not mean you cannot be sensitive to it, or that it will not become an allergen. These references, being based on so many patch test results, are a good basis but it is always best to get a patch test yourself.

1. Warshaw, E.M., Maibach, H.I., Taylor, J.S., et al. North American contact dermatitis group patch test results: 2011-2012. Dermatitis. 2015; 26: 49-59
2. W Uter et al. The European Baseline Series in 10 European Countries, 2005/2006–Results of the European Surveillance System on Contact Allergies (ESSCA). Contact Dermatitis 61 (1), 31-38.7 2009
3. Wetter, DA et al. Results of patch testing to personal care product allergens in a standard series and a supplemental cosmetic series: An analysis of 945 patients from the Mayo Clinic Contact Dermatitis Group, 2000-2007. J Am Acad Dermatol. 2010 Nov;63(5):789-98.
4. Verallo-Rowell VM. The validated hypoallergenic cosmetics rating system: its 30-year evolution and effect on the prevalence of cosmetic reactions. Dermatitis 2011 Apr; 22(2):80-97
5. Ruby Pawankar et al. World Health Organization. White Book on Allergy 2011-2012 Executive Summary.
6. Misery L et al. Sensitive skin in the American population: prevalence, clinical data, and role of the dermatologist. Int J Dermatol. 2011 Aug;50(8):961-7.
7. Warshaw EM1, Maibach HI, Taylor JS, Sasseville D, DeKoven JG, Zirwas MJ, Fransway AF, Mathias CG, Zug KA, DeLeo VA, Fowler JF Jr, Marks JG, Pratt MD, Storrs FJ, Belsito DV. North American contact dermatitis group patch test results: 2011-2012.Dermatitis. 2015 Jan-Feb;26(1):49-59.
8. Warshaw, E et al. Allergic patch test reactions associated with cosmetics: Retrospective analysis of cross-sectional data from the North American Contact Dermatitis Group, 2001-2004. J AmAcadDermatol 2009;60:23-38. 
9. Foliaki S et al. Antibiotic use in infancy and symptoms of asthma, rhinoconjunctivitis, and eczema in children 6 and 7 years old: International Study of Asthma and Allergies in Childhood Phase III. J Allergy Clin Immunol. 2009 Nov;124(5):982-9.
10. Kei EF et al. Role of the gut microbiota in defining human health. Expert Rev Anti Infect Ther. 2010 Apr; 8(4): 435–454.
11. Thavagnanam S et al. A meta-analysis of the association between Caesarean section and childhood asthma. Clin Exp Allergy. 2008;38(4):629–633.

12. Marks JG, Belsito DV, DeLeo VA, et al. North American Contact Dermatitis Group patch-test results, 1998 to 2000. Am J Contact Dermat. 2003;14(2):59-62.
13. Warshaw EM, Belsito DV, Taylor JS, et al. North American Contact Dermatitis Group patch test results: 2009 to 2010. Dermatitis. 2013;24(2):50-99.