Titanium: An Unusual Allergen With Various Presentations-A Retrospective Cohort Study.

Background: Titanium, a rare allergen tested within a designated metal series, has a unique exposure profile, warranting evaluation in specific clinical scenarios. Our study aims to characterise the clinical features of patients with Titanium sensitisation.

Methods: A retrospective cohort analysis was conducted on 255 patients patch tested with the metal series at a tertiary contact dermatitis clinic between 2012 and 2024. Clinical characteristics and sensitisation patterns were evaluated.

Results: The metal series was performed in several main indications: occupational scenarios, exposure to jewellery, post-dental or orthopaedic implants and tattoo-related dermatitis. The cohort predominantly comprised Caucasian females (57%) with a mean age of 51. Only ~20% of cases with occupational exposure and post-orthopaedic implant elicited a positive reaction to metals. 67% of patients in the latter group and all patients with tattoo-induced dermatitis would have been missed unless the metal series was performed. A positive relevant reaction to titanium oxalate was evoked in 5% of cases; 38% were associated with jewellery. Co-sensitisation with other metals including nickel, cobalt and vanadium was common. Titanium typically caused dermatitis adjacent to the contact site, mainly involving fingers and hands. Two cases associated with medical implants developed a generalised rash, 1 of whom was diagnosed with Bullous pemphigoid (BP), confirmed by immunofluorescence.

Conclusions: While nickel, cobalt and chrome are considered common allergens, we hypothesise that sensitisation to other metals, including titanium, will become more prevalent in the following years through exposure via medical devices and implants as well as recreationally via 'nickel free' jewellery and tattoos. Titanium-induced BP is an intriguing phenomenon that should be further investigated, on the verge between allergology and immunology.