|
 |
  |
 |
 |
|
 |
|
 |
|
 |
|
 |
|
 |
|
 |
|
 |
|
 |
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
- Contact Dermatitis -
7/15/05 re: Sensitivity to plastics I have been asked to consult on a 64yo female pt w/ a putative hx of allergy to plastic. She claims that she gets cutaneous reactivity form contact w/ any plastic or petroleum based product (e.g., blisters on her legs from sitting on a plastic lawn chair, intraoral lesions from mucous membrane contact w/ items such as straws, plastic spoons and forks, etc). She breaks out from topical contact w/petroleum jelly. Her hx is also suggestive of latex allergy, but that's not really the isue here. Her local rritation and rashes begin almost immediately (w/in 1 hour) but she does not have a hx of true anaphylaxis at any time in the past.
The pt does not have an identifiable psychiatric hx, nad seems more annoyed than truly worried about this, stating that she's had to cope with this problem all of her adult life. Onset is poorly recalled, but sx have been recurring for the past 30-40yrs.
She needs a semi-elective gynecologic surgical proceedure. The pt is convinced she will react adversely to the endotracheal tube, IV catheter, etc. The anesthesiologist called off the procedure at the last moment, and here we areèIs there any literature/experience to support this type of allergy, any test or treatment options/recommendations?
The clinical picture you describe sounds atypical but conceivable, I suppose. There are numerous reports of contact skin and/or mucosal reactions to resins involved in making plastics, particularly epoxyresins (see enclosed abstract). Methyl methacrylate, a monomer of acrylic resin, is also a relatively common sensitizer. However, it is less clear how often true sensitivity develops to finished (polymerized) plastic materials, if at all.
In any event, systemic manifestations apparently occur rarely, if ever, in association with such contact reactions.
I would think that a pragmatic approach to this patient's situation is needed since the likelihood of identifying the offending chemical (and avoiding it completely) is small. The concern about reactions to intravenous plastic catheter may be approached by using an infusion set containing a larger bore metal needle instead of an intravenous plastic catheter for infusions/keep open the I.V. access, etc. The plastic "wings" typically present at the base of the needle in such infusion sets can be kept from contacting the skin by covering such wings with non-irritating tape. I think it highly unlikely that plastic connectors in the intravenous tubing would present a problem here.
The question of what to do if an endotracheal tube placement is needed is more complex. First, has the patient undergone previous surgical procedures that involved general anesthesia in her adult life? If so, an endotracheal tube was likely placed at a time when the patient was reportedly having problems when contacting plastic chairs, etc (as described by you). Any reaction during such surgical procedures? If not, it would seem that she is not at increased risk for a reaction to an endotracheal tube. If there is no history of previous endotracheal tube use, perhaps the anesthesiologist can explore whether metal endotracheal tubes are available/feasible here. If not, one might consider coating the outside of the endotracheal tube with a solution of human serum albumin (similar to that used for I.V.infusions), allow to dry, then sterilize the tube. This albumin "coating" may act as a barrier between the plastic on the outside of the endotracheal tube and the oropharyngeal mucosa.
Int Arch Occup Environ Health. 2005 Apr;78(3):211-7. Epub 2005 Mar 1.
Related Articles, Links
Rasmussen K, Carstensen O, Ponten A, Gruvberger B, Isaksson M, Bruze M.
Department of Occupational Medicine, Herning Hospital, 7400, Herning, Denmark.Aims: To identify workplace and individual risk factors for occupational contact allergy and dermatitis. Methods: A cross-sectional study was carried out at an international company producing wind turbine systems in Denmark . A cohort of 724 production workers at four facilities was highly exposed to epoxy resin as well as other chemicals. A screening questionnaire (participation rate 84.7%) was followed by an interview by an occupational physician and a dermatological examination, including patch testing, for a comprehensive list of potential workplace sensitizers. Results: Clinically diagnosed dermatitis was found among 214 workers (35.8%) and contact allergy to materials used in the workplace was found in 66 workers (10.9% of the total population and 20.3% of those who underwent patch testing). Of the 66 workers with a work-related allergy, 40 (60.6%) were allergic to epoxy compounds, 25 (37.9%) to hardeners and ten (15.2%) to other workplace materials, where one person showed an allergy only to these materials. Experiencing contact allergy was related to older age and longer employment in the workplace-however, neither of these risk factors was significant. The main risk factor for current dermatitis was contact allergy to materials used in the workplace, determined by patch testing, OR=5.4 (95% CI 3.9-9.9). Fewer days of absence from work was also related to current dermatitis, OR=2.0 (95% CI 1.2-3.5). Conclusions: In a cohort of workers with extensive exposure to chemicals related to epoxy-resin systems, contact dermatitis and allergy was prevalent. Older age and longer duration of employment at the workplace were individual risk factors for allergy to workplace materials, whilst work-related allergies and longer duration of employment at the workplace were significant risk factors for current dermatitis.
5/17/05 re: Contact reaction to nitrile gloves I am a home health rn who wears nitrile gloves (blue or purple) and I am ready to cut my hands off. My dermatitis/eczema is so bad that it cracks and bleeds. When I am not working, there is no dermatitis/eczema. The hospital where I work sent me to a dermatologist who would only say, "You can still work as a nurse. I'll write you a script for a steroid ointment". I am a hyperallergic person and I have allergies to preservatives in shampoos. (results from a patch test) Could there be a protein/preservative in the nitrile gloves that is specifically causing this dermatitis/eczema? I live outside Chicago, so I would gladly see someone in the city. What are the alternatives to nitrile?
I have enclosed below my response to another, recent, Ask the Expert question dealing with suspect contact sensitivity to nitrile gloves. When I had responded to a similar question about nitrile gloves in 9/04, I had not found any reports of or heard about contact allergic reactions to nitrile gloves. Since that time, I came across occasional mention of such reactions. I believe that the approaches suggested below would apply to your case as well. However, if your hand skin is quite inflamed and/or the skin is broken, it may be advisable to with hold all glove use while treating your hands intensively with a potent steroid ointment to restore integrity to your skin. Patch testing with nitrile material described below can be carried out on another skin area during that time. Once your hand skin looks reasonably normal, trials of glove made of other materials can be made.
If you wish to obtain expert consultation in this area, I suggest that you make an appointment to see Dr Kevin Kelly in the Medical College of Wisconsin in Milwaukee (Tel # 414-266-6840). Dr, Kelly is a highly respected expert in natural rubber latex sensitivity. As such, he has evaluated many patients with problems related to the use of different types of surgical gloves.
Response sent in 4/05
Since my response in 9/04 to the Ask the Expert question about nitrile glove sensitivity (to which you referred), I have come across an occasional mention of presumed sensitization to nitrile gloves. You sound convinced that your contact dermatitis is due to the nitrile gloves and not other agents used on your hands. This relationship can be confirmed by doing a patch test with a small piece of a nitrile glove appended to the skin of your inner arm with a non-irritating adhesive tape such as the Magic Tape by the 3 M company. The nitrile patch is removed after 48 hours and the site is examined over the succeeding 48 hours for persistent redness and possible small blistering.You did not mention why you have used nitrile gloves instead of natural rubber latex (NRL) gloves. Powder-free, low-protein NRL gloves are much less likely to sensitize than regular NRL gloves. If you are already sensitive to NRL and wish to avoid both NRL and nitrile gloves you may wish to consider using non-latex neoprene (polychloroprene) gloves.
6/4/02 re: Prevention measures for poison ivy dermatitis I have a number of pediatric patients with moderate allergy to poison ivy. Other than avoidance, use of IVY BLOCK and cleansing of the exposed areas shortly after exposure are there any other preventive measures available (i.e., is there immunotherapy for poison ivy allergy)? I am enclosing a brief review I wrote for this AADNC website of a lecture in March 2002 by Dr. Marks, Chair of Dermatology in the Penn State Univ/Hershey Medical Center and an expert in poison ivy/oak dermatitis. His recommendations concerning prevention were pretty much the same as described by you. With specific reference to your question about desensitization to poison ivy, there have been a number of major attempts in several institutions (including my own) to achieve this by oral or injected introduction of the offending oleoresin. There is little current enthusiasm for these approaches because of lack of efficacy and/or adverse effects (induction of a rash including a perianal rash/pruritis in those taking the extracts orally). However, with the potential advent of DNA immunization methodology, more effective desensitization approaches in poison ivy/oak may emerge in the not too distant future.
In the News
Update in poison ivy/oakSummary
At a recent Annual Meeting of the AAAAI in March 2002, Marks of the Penn State Hershey Medical Center reviewed current concepts about the clinical characteristics and treatment of poison ivy/oak (PIO) contact dermatitis. The "classic" presentation of linear papulo-vesicular lesions are not that common. A more common picture is an eczematous or cellulitic dermatitis with emerging streaks. Some less common exposures include handling wood being chopped, sitting in bushes in forests (including impromptu bathroom use), inadvertent burning leaves of PIO and skin contact with the hair of a pet which had brushed against PIO. A black streak in the middle of the dermatitis may be oxidized oleoresin of PIO. Time of onset of dermatitis after contact with PIO can vary from 4 hours to 4 days (one day most common) with peak severity at 7-9 days. Most cases take up to 21 days to resolve. Washing thoroughly within 5-10 minutes after contact can significantly reduce likelihood/severity of dermatitis. Washing after rash starts will not spread it. Ordinary hot temperature laundering will usually get rid of the PIO oleoresin. The best barrier cream is Ivy Block (quaternium-bentonite) applied as a thin layer. Rubber gloves are not protective.Individuals very allergic to PIO may have allergic reactions to cashew shell oil (commonly present in imported cashews), Indian marking nut ink (some laundries) or mango. The speaker recommends treatment of prominent PIO dermatitis with a potent topical steroid (Temovatin or Ultrabate), diphenhydramine or hydroxyzine hs for anti-pruritic and sedative effects and oral steroids (e.g. prednisone) starting with 1 mg/kg and tapering gradually over 10 days. Oral and injection protocols attempting desensitization to PIO have not been consistently successful and/or have unacceptable side effects.
Editor’s Comments
I found these comments of considerable interest and practical value in advising patients in an area in which misconceptions are common. The best prevention is recognition of PIO and appropriate avoidance.11/26/01 re: Dental bridge replacement for burning mouth syndrome I have a 59 year-old female patient who has had a one-year history of a marked burning sensation inside her cheek adjacent to a new bridge that spans only one missing tooth. The tissue appears healthy. The symptoms began only two days after the bridge was inserted. I can see a two-millimeter metal band between ceramic portion of the tooth and the gum line. The metal base of the tooth is made from gold, gallium, palladium, ruthenium, and indium. The cement used contains 2-hydroxyethel methacrylate, tartaric acid, polycarboxylic acid copolymer, and 2,6 di-tert-butyl-p-cresol. I can get patch-testing material for the methacrylate and palladium, suggesting that these two products are responsible for contact dermatitis. I need some help from here. What are the recommendations for a replacement bridge (if any) if the current bridge is removed?
The burning mouth syndrome (BMS), characterized by a burning sensation in the oral mucosa without gross signs of inflammation in the symptomatic area, is a difficult diagnostic and therapeutic problem (see enclosed abstracts below). It is understandable to investigate the possibility that such BMS symptoms result from a local contact reaction to dental appliances or other dental materials. Although it is not unusual to find positive patch test skin reactions to dental material components (see enclosed abstract below), it has often been difficult to relate reactions to the pathogenesis of oral symptomatology when there is no gross signs of mucoasal inflammation in the symptomatic area (see enclosed abstract below). As mentioned in my response to a previous Ask the Expert question about a possible reaction to a dental appliance (enclosed below). Oral mucosal patch test challenges with the suspect materials is advisable before suggesting the time-consuming and costly approach of replacing the dental bridge mentioned in your description. You might try challenging with a small amount of the metal (supplied by the patient's dentist) applied to the buccal mucosa of the opposite side of the mouth for several hours with a careful visual exam before and 48 hours after the challenge period. In a similar approach, challenge on a separate occasion the opposite mucosa with a small amount of the cement previously used by the dentist. If an impressive adverse reaction occurs, one can obtain components of the cement to carry out follow-up challenges. If there is convincing evidence of a mucosal reaction, the dentist should be advised to choose materials not containing the suspect agents in any replacement dental procedure. Contact Dermatitis 1994 Feb; 30(2): 80-4
Contact dermatitis and adverse oral mucous membrane reactions related to the use of dental prostheses.
Vilaplana J, Romaguera C, Cornellana F. Dermatology Service, Hospital Clinic, Barcelona, Spain."The latest trends in the use and composition of dental prostheses have been reviewed, and 66 patients referred by dermatologists and odontologists patch tested. The allergen series used were: TRUE Test standard series; Chemotechnique dental screening series; specially prepared metals series. The allergens found to be positive, in order of frequency, were: nickel, cobalt, potassium dichromate, rhodium, palladium, mercury, beryllium, methyl methacrylate, copper and zinc."
SADJ 2001 Aug; 56(8): 353-8
A literature review and pilot study to characterize the treatment of burning mouth syndrome.
Botha PJ, van der Bijl P, van Eyk AD.
Department of Oral Medicine and Periodontics, School of Dentistry, Faculty of Health Sciences, University of Stellenbosch, Tygerberg."Although the definition of burning mouth syndrome (BMS) can vary, the most commonly accepted is that of a burning sensation of normal appearing oral mucosa with no apparent underlying local or systemic contributing factors. The condition can be classified according to the patterns of burning experienced, the severity of the burning, as well as the pattern of onset. The management of these patients is difficult, since they are often seen by numerous clinicians and many unnecessary tests are performed in the hope of finding an underlying physical cause for the burning. No precise information pertaining to the natural history of BMS could be found. This paper consists of a selective review of the literature on BMS as well as a pilot study involving the standardized collection of data on 10 patients (9 women and 1 man) with BMS. These patients will be followed up in the long term in order to gather information pertaining to the natural history of this condition. No detectable local or systemic cause for the burning sensation could be found for any of the 10 subjects. The role of somatisation as a mechanism for burning sensation was investigated and certain proposals have been put forward regarding the management of such patients."
: Cochrane Database Syst Rev 2001; 3:CD002779
Interventions for the treatment of burning mouth syndrome (Cochrane Review).
Zakrzewska JM, Glenny AM, Forssell H.
Oral Medicine, St Bartholomew's and the Royal London, Turner Street, London, UK, E1 2AD.Background: The complaint of a burning sensation in the mouth can be said to be a symptom of other disease or a syndrome in its own right of unknown etiology. In-patients where no underlying dental or medical causes are identified and no oral signs are found; the term burning mouth syndrome (BMS) should be used. The prominent feature is the symptom of burning pain that can be localized just to the tongue and/or lips but can be more widespread and involve the whole of the oral cavity. Reported prevalence rates in general populations vary from 0.7% to 15%. Many of these patients show evidence of anxiety, depression and personality disorders.
Objectives: The objectives of this review are to determine the effectiveness and safety of any intervention versus placebo for relief of symptoms and improvement in quality of life and to assess the quality of the studies.
Search Strategy: Electronic databases (The Cochrane Library, the Cochrane Oral Health Group's Specialized Register, MEDLINE, EMBASE), Clinical Evidence Issue No. 3, conference proceedings and bibliographies of identified publications were searched to identify the relevant literature, irrespective of language of publication.
Selection Criteria: Studies were selected if they met the following criteria: study design - randomized controlled trials (RCTs) and controlled clinical trials (CCTs) which compared a placebo against one or more treatments; participants - patients with burning mouth syndrome, that is, oral mucosal pain with no dental or medical cause for such symptoms; interventions - all treatments that were evaluated in placebo-controlled trials; primary outcome - relief of burning/discomfort
Data Collection and Analysis: Articles were screened independently by two reviewers to confirm eligibility and extract data. The reviewers were not blinded to the identity of the studies. The quality of the included trials was assessed independently by two reviewers, with particular attention given to allocation concealment, blinding and the handling of withdrawals and dropouts. Due to differences in patient type, treatment and outcome measures, statistical pooling of the data was inappropriate.
Main Results: Six trials were included in the review. The interventions examined were antidepressants (two trials), cognitive behavioral therapy (one trial), analgesics (one trial), hormone replacement therapy (one trial) and vitamin complexes (one trial). The participants included in the six identified trials reported suffering from BMS from six months to 20 years. Diagnostic criteria were not always clearly reported. Out of the six trials included in the review, only two interventions demonstrated a reduction in BMS symptoms; vitamin complexes and cognitive behavioral therapy. Neither of these studies reported using blind outcome assessment. Although none of the other treatments examined in the included studies demonstrated a significant reduction in BMS symptoms, this may be due to methodological flaws in the trial design, or small sample size, rather than a true lack of effect.
Reviewer’s Conclusions: Given the chronic nature of BMS, the need to identify an effective mode of treatment for sufferers is vital. However, there is little research evidence that provides clear guidance for those treating patients with BMS. Further trials, of high methodological quality, need to be undertaken in order to establish effective forms of treatment for patients suffering from BMS.
10/30/01 re: Allergy to rhodium I am looking for information of possible allergic properties of Rhodium. I have an unexplained allergic reaction of the gums, which seems to be due to a dental bridge. I have now a hint, that the allergy could be due to Rh, do you happen to have information about cases of allergy to Rh? Allergic contact dermatitis induced by rhodium and cross-reacting metallic salts such as palladium and platinum in occupational exposures has been reported with some frequency. Whether (and how frequently) rhodium in dentures induces local allergic reactions in the oral mucosa is apparently less certain. In general, induction of allergic contact reactions occurs less frequently in the oral mucosa than in the skin. There have been reports in which positive skin patch tests to rhodium, among other constituents of dental materials, has been found in a group of individuals with oral mucosal complaints (see enclosed abstract below). Most of these individuals apparently had objective evidence of mucosal inflammation in the area of the dental prosthesis. However, there has been little evidence presented to show that application of the appropriate concentration of rhodium (equal to that present in the dental prosthesis). Would induce an adverse reaction when applied directly to the oral mucosa in such individuals. Other agents in some dentures such as certain metals, acrylics and resins may also be candidates for inducing local allergic reactions. Mucosal patch testing with rhodium and other agents in the dental prosthesis may be the most direct way to determine a pathogenic relationship. Contact Dermatitis 1994 Feb; 30(2): 80-4
Contact dermatitis and adverse oral mucous membrane reactions related to the use of dental prostheses.
Vilaplana J, Romaguera C, Cornellana F.
Dermatology Service, Hospital Clinic, Barcelona, Spain."The latest trends in the use and composition of dental prostheses have been reviewed, and 66 patients referred by dermatologists and odontologists patch tested. The allergen series used were: TRUE Test standard series; Chemotechnique dental screening series; specially prepared metals series. The allergens found to be positive, in order of frequency, were: nickel, cobalt, potassium dichromate, rhodium, palladium, mercury, beryllium, methyl methacrylate, copper and zinc."
4/18/00 re: Jobs avoiding formaldehyde I have been diagnosed with a work related contact allergic dermatitis to formaldehyde. I first had problems with only plastics and rubber products. Now I am having problems with paper products, inks, glue. It seems just about everything I touch my hands reflare. I am using proteque and clobetasol. Workers compensation doesn't want to pay, and they want me to get another job. Any suggestions on a job that doesn't come into contact with paper, ink, plastics, rubber, or chemicals. I am an RN and want to be a productive member of society, but my hands reflare so easily. I assume that appropriate patch test has confirmed your sensitivity to formaldehyde and not to other contact allergens. Formaldehyde is one of the most common contact sensitizers, likely because it is present in so many used materials. Fortunately, textiles used in clothing now apparently contain only very little formaldehyde. Although avoidance of formaldehyde by sensitive people is usually recommended, this is generally only partially successful. Yet, it may be helpful (see enclosed abstract). Unfortunately, the use of -barrier creams+ is generally not very helpful. What may be feasible in your case is the use of Nitrile gloves, which are generally well tolerated. However, I would check with a manufacturer of such gloves to determine whether they contain any formaldehyde (your hospital purchasing department can likely give the name of a nitrile glove manufacturer). Since some patients with hand eczema initially have problems from increased moisture under the glove, you may have to apply the steroid cream before donning the gloves. You may actually get more benefit from such cream used in this way.
Am J Contact Dermat 1999 Mar;10(1):12-7
Formaldehyde allergy: A follow-up study.
Agner T, Flyvholm MA, Menne T
Department of Dermatology, Gentofte University Hospital, and the Department of Allergy and Irritation, National Institute of Occupational Health, Copenhagen, Denmark.BACKGROUND: Formaldehyde is a commonly used preservative in cosmetic products, cleaning agents and industrial products, and sensitization to formaldehyde frequently occurs. OBJECTIVE: The aim of the study was to evaluate the effect of extensive information and exposure assessment of formaldehyde on the prognosis of eczema. METHODS: The present study was designed as a clinical follow-up study of formaldehyde-sensitive patients. 105 patients diagnosed as formaldehyde allergic in the period January 1 1990 to December 31 1994 were thoroughly informed about their allergy, and exposure assessment was performed as a formaldehyde analysis on the patients' products. RESULTS: At follow-up 1 to 5 years later, 57 patients accepted the invitation to attend the outpatient clinic for an interview and a skin examination by a dermatologist, and were also at this time asked to bring products to which they were currently exposed for formaldehyde analysis. Evaluated by reported number of eczema eruptions and from objective skin examination patients had generally improved from their first visit to the department. At follow-up, 38 of 49 patients bringing products for analysis were still exposed to formaldehyde, as assessed by formaldehyde analysis on their products. There was a trend that severe eczema was found more often in patients still exposed to formaldehyde, but this finding was not statistically significant. Thirty-seven patients reported that they "paid attention to their allergy" when buying and using cosmetics or consumer products. CONCLUSION: Patients who paid attention to their allergy had statistically significantly fewer eruptions than those who did not.
Contact Dermatitis 1998 Jun;38(6):332-6
Formaldehyde-related textile allergy: an update.
Scheman AJ, Carroll PA, Brown KH, Osburn AH
Northwestern University Medical Center, Chicago, Illinois, USA.Part I of this study explores whether clothing today contains formaldehyde levels likely to cause contact allergy in formaldehyde-allergic patients. Part II of this study examines whether current reactions to textiles may be due to allergy to textile resins and whether individuals with formaldehyde-related textile allergy will react to the newer low formaldehyde resins used in the textile industry. Part I: free formaldehyde was measured in 16 fabric specimens produced in the US and overseas. Additionally, since the textile industry has moved to the use of newer methods for measuring fabric formaldehyde content, the newer methodology was compared with the older methods used in the medical literature. Part II: 10 subjects with known textile contact allergy were patch tested to available Chemotechnique textile resins and 6 new low-formaldehyde resins used by the textile industry. Part I: 8 fabric specimens yielded no detectable formaldehyde and 7 specimens yielded <200 ppm free formaldehyde, using Schiff's reagent and Merck testing methods. 1 specimen showed approximately 2000 ppm formaldehyde, as measured by the Merck test, but only 24 ppm free formaldehyde when retested by the method described in Japanese Law #112. Part II: all subjects reacted strongly to formaldehyde and DMDHEU (the predominant resin currently used in textiles). 6 subjects reacted to EUMF. 2 subjects had mild reactions to the newer low-formaldehyde resins and 1 to the non-formaldehyde Fixapret NF. Our results suggest that most clothing today yields free formaldehyde levels unlikely to cause contact allergy in formaldehyde-allergic individuals. Japanese method #112 is the recommended methodology to measure free formaldehyde in future studies. DMDHEU may now represent the main cause of textile allergy and may be a better screen than EUMF for this problem. Newer resins yielding fabrics with <75 ppm free formaldehyde may cause occasional reactions, but are more likely to be tolerated by individuals with textile contact allergy. Treatment of these individuals should be directed at identification of reliable sources of garments utilizing these newer resins.
3/22/00 re: Approach to a reaction to lipstick A patient has a reaction to lipstick. Red rash and swelling of lips develops 2 days after applying red lipstick. Also some patchy red lesion perioral. Rash resolves after discontinuing lipstick but avoidance is not an option. What would you recommend. Your description makes a good case for a local contact reaction to one or more lipstick components and not an irritative reaction (e.g. - excess lip licking). Lipstick induced reactions are not rare and may be due to a variety of agents within the lipstick. However, several families of compounds (gallates ,palmitate compounds, colophony, certain esters )
appear to be major contact sensitizers. I can suggest 2 approaches:
- Pragmatic - trial of "hypoallergenic" lipsticks made by specialty companies such as Almay. These usually do not contain the major contact offenders.
- Investigative - refer the individual to a dermatologist or allergist with a particular interest in contact dermatitis to do selected patch testing with lipstick components. If a sensitizer is identified, patient inquiries can be made to major lipstick manufacturers as to which of their products do not contain this ingredient.
REFERENCE - Contact Derm 2000;42:51
2/4/00 re: Cause of rash in pathology worker 49 yrs old lady with longstanding history of hand dermatitis comes in for an allergy consultation regarding a rash on her face which began in April 99 , itchy maculo papular , recurrent and similar rash on her arms and legs which began in Nov.99 and persisting . She works in Pathology lab., Questionable history of latex allergy, latex skin tests are negative , has positive tests to pollen and dust mites. She has contact dermatitis. How does one go about looking for etiology? The clinical picture you describe sounds like contact dermatitis. You did not specify the exact duties of your patient in a Pathology department. If the activity is in the Surgical Pathology area, the most likely offender may be the tissue preservatives, particularly formaldehyde or its aldehyde analogues which are common occupational sensitizers. If the patient works in clinical laboratory activities, sensitization to chemicals used and/or latex (as suspected) may be the cause. To investigate these possibilities, I suggest:
1) Patch testing by someone experienced in this approach, using panels such as those of the North America Contact Dermatitis Working Group. If formaldehyde/glutaraldehyde reagents are not available in that physician¹s ³patch test kit², one can apply these agents (in the clinically utilized concentrations) to a small area of skin of the inner forearm or back, cover with a watertight dressing for 48 hours, remove the dressing and observe the site 48 hours later. A control patch test should be applied to the contralateral area of skin. If the patient is sensitive to these aldehydes, she must be careful about avoiding these agents present in certain cosmetics and other products (see Am J Contact Derm 1999;10:12-17)
2) If there is any question whether latex sensitivity is present with equivocal skin test/in vitro test results, do a ³finger challenge test² by appending a cut off finger from a latex glove to a relatively uninvolved finger of the patient and remove the next day. Look for rash occurrence. The latex glove finger material should be removed immediately if any systemic symptoms occur.
9/14/99 re: Treatment of contact dermatitis I have a 70 year old white female who develped acute allergic or irritant contact dermatitis (red, painful, weeping and oozing white slightly yellow but clear musky odored discharge) over her right more so than her left lower leg after wearing tight elastic socks for her varicose veins. I am in the process of patch testing. How would you treat her? Would you treat her with topical steroid over the weeping lesions (which covers most of the left lower leg) or treat her with systemic steroid? Would you add anti-staph antibiotic even though she does not appear to be secondarily infected as a precaution? Would you wet dress the lesion and what exactly is wet dressing?. The picture you describe could be due to allergic or irritant causes with the latter possibility increased in those with large circumference limbs and poor tone. Of course, appropriate patch testing will be required to determine possible allergic causes. With regard to treatment, in my experience, this is dictated by the severity and acuteness of the local inflammation.
- I use systemic steroids for relatively short periods if the reaction is severe and painful. If there are definite signs of secondary infection, I add systemic antibiotics (see below).
- If not severe but acute weeping, I recommend soaks with solution such as Burrow's solution tid to cleanse the areas.
- If there are scales/debris not so removed by solution soaks, you can use such solutions in "wet to dry dressings". Sterile 4x4 or 4x8 dressing soaked in solution placed on lesional areas, then allowed to dry, then removed gently, debriding the surface. I think that this is what your question refers to.
- After removal of the soaks (either wet or wet to dry) I would then use a potent topical steroid cream possibly in combination with topical polymyxin/bacitracin. If the lesional area becomes dry/scaly, I would switch to steroid ointment. However, I should stress that chronic application of potent steroids can lead to thinning of the skin and fragility of small skin vessels, particularly in the elderly. This may present particular problems in areas such as the pre-tibial area which have limited blood flow to begin with.
6/12/99 re: Preventive measures for contact dermatitis I am a nurse case manager. I have a patient who is a florist. She has been in this business for several years and has recently developed an allergic contact dermatitis from handling fresh flowers. She has tried to return to work, but redeveloped the dermatitis which was quite severe. She tried wearing gloves (Blu-eze/a thick glove), but cannot design with gloves on both hands. She has also tried latex gloves. The dermatitis clears once she is not in contact with the flowers. Are there any preventative measures that will allow her to continue working and not develop dermatitis? How can this be managed? I understand the condition is similar to poison ivy. I would appreciate any suggestions that you can give. The contact dermatitis problem you describe is not rare in those whose occupation deals with heavy exposure to cut flowers/plants such as chrysanthemums. Unfortunately, attempts at desensitization in contact dermatitis such as poison ivy have generally been unsuccessful. Has you patient tried close fitting, non-latex surgical gloves? Some of the newer products have allowed a lot of dexterity for surgeons in the operating room. If this approach is unsuccessful, she may consider use of a barrier cream containing bentoquatam, such as Ivy Guard, applied before each exposure to the flowers. (See review of article about poison ivy in the "What Your Patients are Reading" Section of this AADMC web site).
2/17/99 re: Control/preventive measures for nickel sensitivity I am a licensed medical assistant and also am a workers' compensation claims representative for an Insurance Companies. I have the following questions:
- What is the potential for recurrence of nickel allergy reactions once the patient is taken away from the exposure?
- Is there any possibility of treatment for nickel allergies?
- What are the potential future treatment needs of a person with an allergy to nickel once they are no longer exposed to the chemical? Is there the chance that if the patient is kept away from high doses of nickel solvent that she will no longer need any future treatment?
This is the rundown of the case. A 35 year old woman had long term exposure to liquid nickel in the workplace. She developed a sensitivity to the chemical and began having breakouts on her hands and forearms. Several days out of the workplace would correct the problem. We attempted to get this woman back to work with the use of surgical gloves/gown to prevent exposure to the nickel. Unfortunately, this reasonable accomodation was not effective and the woman has been unable to work since that time in her previous occupation. I, as the claims representative and a NRMA, would like to know the future ramifications of this allergy and what we could possibly be exposed to as far as future medical treatment.
Nickel is the most common cause of contact allergic reactions in the USA, with increasing prevalence, likely associated with the increasing use of "body piercing" with nickel-containing earrings and other less traditional decorative items. Once an individual becomes highly sensitized, reactions may be elicited by very small amounts of nickel
commonly present in jewelry and other items in prolonged contact with the the skin. Whether reactions are elicited in such sensitive individuals by small amounts of nickel in some ingestants or in dental amalgams or orthopedic implants is still debated .Occupational exposure to nickel represents a particular problem. The usual gloves worn in medical practice are often not a sufficient barrier. Creams and ointments that are more effective barriers to nickel contact/absorption in the skin have been described (Enclosed below are abstracts of articles which you may want to read).
Occup Med 1994 Jan-Mar;9(1):81-95
Nickel sensitivity and occupational skin disease.
Veien NK
Dermatology Clinic, Aalborg, Denmark.
One of the earth's most common metals, nickel, is present in items ranging from uniform buttons to semiconductors. Nickel also represents the most frequently occurring contact allergen. This chapter describes numerous ways that nickel is used industrially and details the clinical features,diagnosis, and prevention of this sensitivity.
Contact Dermatitis 1995 May;32(5):257-65
Published erratum appears in Contact Dermatitis 1995 Oct;33(4):288The prevention of nickel contact dermatitis. A review of the use of binding agents and barrier creams.
Gawkrodger DJ, Healy J, Howe AM
Department of Dermatology
Royal Hallamshire Hospital
Sheffield, UK.
Chelating agents and other substances can be used to bind nickel or reduce its penetration through the skin, and hence to reduce the symptoms in subjects with nickel sensitivity. Topical usage is mostly described but, in some studies, chelating agents have been given systemically. The most effective ligand for nickel so far described is 5-chloro-7-iodoquinolin-8-ol. Although normally regarded as safe, its usage in some situations may be limited by concerns about its toxicity. Other ligands with demonstrable effect include ethylenediaminetetraacetic acid in various forms, diphenylglyoxime and dimethylglyoxime. Cation exchange resins can effectively bind nickel and work both in vitro and in vivo. Propylene glycol, petrolatum and lanolin reduce the absorption of nickel through the skin. Corticosteroids and cyclosporin work in nickel dermatitis by suppressing the immunological reaction rather than through an effect on nickel. Studies of the oral administration of ligands such as tetraethylthiuram disulphide have given conflicting results but the use of these agents is limited by hepatoxicity in any case. Some compounds offer potential for use in the prophylaxis of nickel dermatitis. Further work is required to develop the existing agents and to look at the use of novel combinations, such as that of a cation exchanger with a ligand.
