Allergic contact dermatitis in two machinists.

Two machinists were seen whose chronic hand dermatitis was explained by allergic sensitivity to a biocide, Tris Nitro (2-[hydroxymethyl]-2-nitro-1,3-propanediol), which was added to their metalworking fluids (cutting oils) to prevent rancidity. The cause of the men's difficulty was first suspected when they had positive patch test reactions to a related biocide, Bronopol (2-bromo-2-nitropropane-1,3-diol), which we added to our standard screening tray because of its presence in more than 500 cosmetic formulations. The detective skills of the patients uncovered the chemical, Tris Nitro, related to Bronopol in their work environment. Most cases of dermatitis seen in machinists are irritant in origin. As we achieve better cooperation from the metalworking fluid industry, perhaps an increasing number of allergens will be identified. When this occurs, a cooperative manufacturer can be invaluable in directing a machinist to a replacement--a well-preserved cutting fluid free of the allergen.

Poison ivy/oak dermatitis. Use of polyamine salts of a linoleic acid dimer for topical prophylaxis.

Closed patch tests were used to evaluate the ability of 156 different preparations (based on 22 different chemicals) to prevent poison ivy dermatitis. Several polyamine salts of a linoleic acid dimer were identified that were totally able to prevent the usual dermatitis in approximately 70% of subjects. The effectiveness of the preparations improved when the antigen and the protectant were washed off within eight to 12 hours, instead of remaining on the skin for 48 hours. When washed off, and depending on the protectant, concentration, and vehicle used, several of the preparations were totally able to prevent a dermatitis in a range of 56% to 100% of subjects tested. Further work with these compounds may greatly benefit the many people currently plagued by their allergy to poison ivy and poison oak.

Contact allergy to aziridine paint hardener.

A painter experienced an extensive dermatitis when exposed to a paint primer (undercoating) used to protect wood siding. The primer was an acrylic emulsion with a polyfunctional aziridine added as a self-curing cross-linker or hardener. The polyfunctional aziridine cross-linker was made by reacting propyleneimine with a polyfunctional acrylate, trimethylolpropane triacrylate (TMPTA). Our patient reacted to the cross-linker and also reacted to TMPTA, which is present in excess in the cross-linker. He also cross-reacted to pentaerythritol triacrylate (PETA). Both TMPTA and PETA can be used in the production of aziridine hardeners and both are well known as sensitizers in radiation-dried acrylic printing inks and coatings.

Abnormal skin irritancy in atopic dermatitis and in atopy without dermatitis.

BACKGROUND AND DESIGN: Past observations have shown increased irritancy in patients with "conditioned hyperirritability" due to active dermatitis, including atopic dermatitis (AD). In less active atopic conditions, irritancy levels are less certain. We have utilized 48-hour Finn Chamber testing with graded dilutions of sodium lauryl sulfate to detect irritancy thresholds in well-defined groups of patients with AD, inactive AD, and allergic respiratory disease with no dermatitis and in normal nonatopic subjects. RESULTS: Significantly greater frequency of response to sodium lauryl sulfate in both AD groups and also in patients with allergic rhinitis with no dermatitis was seen. Effective concentrations of sodium lauryl sulfate causing irritation in 50% or more of subjects (ED50) ranged from 0.0625% to 0.31% in all atopic groups, percentages that were significantly lower than the normal ED50 of 0.60%. Response intensity was also significantly greater in each atopic group. CONCLUSIONS: Our results showed significantly greater irritant responses in atopic subjects with no skin disease or in subjects with inactive AD and confirmed past findings that showed greatly increased irritancy in patients with active AD. We hypothesize that abnormal intrinsic hyperreactivity in inflammatory cells, rather than in skin cells, in atopic individuals predisposes to a lowered threshold of irritant responsiveness.

Technical and ethical problems associated with patch testing.

When relevant allergens are identified by patch testing, and patients can avoid them in their environment, improvement of dermatitis is the rule. Some forms of chronic dermatitis may not clear completely, but patients are usually satisfied with modification of their previously more severe problem. In 1981 when asked what he felt were the five most important advances in clinical dermatology during the 20th century, Dr. Marion B. Sulzburger, an icon in American dermatology, said that, "The increased use and usefulness of the patch test and the international standardization of test concentrations and methods" was number one. Those of us who are enthusiastic patch testers and fascinated by the evaluation of patients with irritant and allergic contact dermatitis would agree. It is a thrilling clinical experience to be able to tell a machinist that he need not stop his lifelong occupation, but instead will do fine if he will simply avoid the waterless hand cleanser he has been using which is preserved with glutaraldehyde. The woman whose facial dermatitis has embarrassed her for years and clears when she stops using the Quaternium-15 preserved moisturizer that you have identified in your patch testing is grateful to you forever, and again happy in her own life. In 1991, my research assistants, Patricia Norris and Mary Lou Belozer, and I studied 30 university hospital workers who answered our advertisement asking for individuals who believed they were troubled by their rubber gloves (unreported study). By evaluating these people through history, physical examination, and patch testing, we were able to prove glove relatedness in 14 of them. Nine of the 14 had contact urticaria to latex, and only 5 had allergic contact dermatitis to rubber glove ingredients. Fifteen of our patients had irritant dermatitis. In this study, none of the patients with allergic contact dermatitis to glove ingredients had contact urticaria. However, since that time, we have observed a number of patients who had both forms of allergic reaction. Three of our patients who presented with nummular (patchy) hand dermatitis also had contact urticaria to latex, but no positive patch tests. With latex glove avoidance, their dermatitis resolved; an example of how scratching urticaria can eventuate in longer lasting dermatitis in some people ("the itch that rashes"). The patients presented to their dermatologist with dermatitis, but their true initiating event was urticaria which lasted only hours. The gratifying part of this study was that patch testing and contact urticaria testing allowed us to discover the 5 patients with allergic contact dermatitis and the 9 patients with contact urticaria who could benefit from glove alternatives. We were also able to assure patients in the remainder of the group that their hand eczema was not glove induced, but rather was related to their wet work. In most instances, therapeutic intervention helped, but in several cases job changes were required. Patch testing, when done properly, produces exciting results. When done improperly, it confuses and misleads patients and results in embarrassment to physicians who cannot properly interpret their results. Should a physician choose to include patch testing in his or her evaluation of patients with contact dermatitis it is essential, in my view, that he or she have highly developed skills in the diagnosis and treatment of skin diseases, and that these physicians be elaborately trained in the techniques of application and the methods of interpretation of patch tests.

Allergic contact dermatitis to adhesive bandages.

More than two billion Band-Aid Brand Sheer Strips are used in the United States yearly, yet allergic contact dermatitis resulting from their use is nearly nonexistent. We report four patients with allergic reactions to these strips. One patient reacted to tricresyl phosphate, the plasticizer in the vinyl backing; another patient was allergic to 2,5-di(tertiary-amyl)hydroquinone, the antioxidant in the adhesive. In the other two patients, the allergic contact dermatitis remains unexplained.

All the things I knew were true about contact dermatitis that aren't.

Twenty-five years of experience in evaluating people with irritant and allergic contact dermatitis has taught me that many of my preconceived notions were false. No patients are more challenging and interesting to investigate or more rewarding to help than those with long-standing histories of undiagnosed contact dermatitis. Furious resolve during investigation coupled with a willingness to be proven wrong and to find the unexpected is most likely to result in a successful outcome for patients with contact dermatitis.

False-positive "poral" cobalt patch test reactions reside in the eccrine acrosyringium.

Seventy (32%) of 222 patients patch tested in our contact dermatitis clinic from 1993 to 1995 had irritant reactions to cobalt. These reactions were "poral" and seemed to reflect a unique and probably toxic effect of cobalt on the acrosyringium. The reactions are neither follicular nor petechial and we believe they are not allergic. The histopathology of the reactions is described in detail.

Use and abuse of systemic corticosteroid therapy.

Steroid-responsive acute dermatoses should be treated with a single morning dose of prednisone for approximately 2 weeks. It is necessary to "taper" a short course of oral prednisone given by this method. Chronic dermatoses should be treated whenever possible with prednisone used in the morning and on alternate days. This method is effective, is free of most side effects, and suppresses the HPA axis minimally. There are few real advantages in using intramuscular corticosteroids. TAC is an unusually strong suppressor of the HPA axis. For chronic dermatoses, a less suppressive preparation might best be chosen if the physician feels that the intramuscular route is the most reasonable one. In any event TAC should never be used more often than every two months. Finally, the time-course of HPA recovery following short courses of steroids is presently unknown. Nonetheless, some astute critics of steroid metabolism have felt obliged to advise us that individuals who have received from 1 to 4 weeks of suppressive steroid treatment should be suspect as to the integrity of their HPA axis in stressful situations for up to one year. The withdrawal from, as well as the use of, systemic corticosteroids requires a creative and critical physician.

Permanent wave contact dermatitis: contact allergy to glyceryl monothioglycolate.

Eight hairdressers and four clients were found to be allergic to glyceryl monothioglycolate (GMTG) contained in "acid" permanent waves used in American beauty salons only since 1973. Previous studies in Germany showed that compounds closely related to GMTG were strong sensitizers. In contrast, ammonium thioglycolate (ATG) has been used since 1943 in cold "alkaline" permanent waves both in homes and in salons with no clearly documented cases of contact allergy. Our allergic patients reacted to GMTG in concentrations as low as 0.25%, although their exposure in practice could reach concentrations of 20% to 80%. GMTG-allergic patients reacted to GMTG when it was tested through a variety of glove fabrics. Household-weight neoprene gloves were protective.

Para-chloro-meta-xylenol allergic contact dermatitis in seven individuals.

Seven individuals are discussed who developed allergic contact dermatitis following sensitization to the antibacterial agent parachlorometaxylenol (chloroxylenol, PCMX) contained in either medicated Vaseline or in electro-cardiogram paste. The hazard of PCMX sensitization is great in that this chemical is present in over 30 "across the counter" products. PCMX sensitive people may cross-react to chlorocresol.

Persistence of an allergen in hair after glyceryl monothioglycolate-containing permanent wave solutions.

Glyceryl monothioglycolate, a reducing agent used in permanent waving solutions, is a recognized cause of allergic contact dermatitis. Because of an unexplained persistence of dermatitis in beauty shop clients after exposure to permanent wave solutions containing glyceryl monothioglycolate, we looked for the presence of this or a cross-reacting substance in permanent-waved hair as a possible source of continued exposure to the allergen. Seventeen subjects sensitive to glyceryl monothioglycolate underwent patch testing with hair samples collected before and at various times after a permanent wave containing glyceryl monothioglycolate. None reacted to hair that had not received a permanent, while 7 of 17 showed positive reactions to the permanent-waved hair. Positive reactions were seen in hair collected as long as 3 months after the permanent. This suggests that a glyceryl monothioglycolate-related allergen is retained in hair for up to 3 months after the permanent, which may explain the long-lasting dermatitis that occurs in clients sensitive to glyceryl monothioglycolate.