Irritant contact dermatitis caused by specific allergens (Rook's textbook of dermatology)

1. BY DR MARIA SAEED
PGR DERMA
CMH OKARA
SPECIFIC ALLERGENS
ALLPPT.com _ Free PowerPoint Templates, Diagrams and Charts
ROOK’S
DERMATOLOGY
pg 128.19 to 1
28.27

2. SPECIFIC ALLERGENS
METALS
Woods,colophony,
turpentine
Resins and plastics Clothing
Rubber
applied
medicaments
Ultra voilet filters
anti microbial
agents and
preservatives
fragrances
,balsams,
flavoring agents
and spices
cosmetics shoes

3. Metals
 Nickel
 Cobalt
 Chromium
 Gold
 Palladium
 mercury
 aluminium
 copper

4. 1.NICKLE
Points of discussion
 Chemistry
 incidence and prevelance
 occurrence
 clinical features
 Avoidance
 Prognosis
 specific therapies
 patch test

5. CHEMISTRY
• metal itself sensitizes
• nickel chloride (NiCl2 ) and
nickel sulphate (NiSO4 ),are
readily soluble in water and
sweat and have strong
sensitizing properties.
• Some oxides (e.g Ni2O3)
and the hydroxide (Ni(OH)2)
can elicit contact dermatitis
Incidence and prevelance
• common in women
• Prevalence tends to rise in
age of 10 yrs onwards
• Ear piercing is a significant
risk factor for the
development of nickel
sensitivity
• Prevalence is higher in
occupational groups e.g in
hair dressers.

6. OCCURRENCE
 commonest sources of metallic nickel are alloys and plated objects
 sensitization from nickel plated items eg.nickel‐iron, German silver
 Chromium‐plated metal is often first nickel‐plated, and after long use the nickel may reach
the surface, for example on water taps.
 repeated exposure to occluded metal items releasing nickel
 exposure may occur from handling coins, keys, scissors, knitting needles, thimbles ,
scouring pads and other metallic tools and utensils
 Jewellery and metal components of clothing
 Platers and some metal machinists are necessarily at risk of occupational nickel allergy

7. Cont’d
Other sources include:
 pigments in glass, pottery and enamel,
 electrocautery plates
 mobile phones laptop computers
 bindi
 intravenous cannulae
 tattoo pigment
 Orthodontic appliances
 metal scouring pads
 even soaps and detergents
Nickel has been identified in some eye cosmetics
Allergic contact dermatitis to nickel
in metal studs on jeans

8. Cont’d
Systemic exposure:
 from diet (certain food and plants)
 domestic water
 nickel may also be a contaminant in
fertilizers and fungicides
 Stainless steel saucepans release
negligible nickle
Secondary eyelid dermatitis in a
patient sensitive to nickel

9. Clinical features
 patches of dermatitis at sites of contact with metal objects
 eruption may be papular, nummular, diffuse
 consist only of excoriated papules on almost normal‐looking skin
 secondary eruptions which is spread of dermatitis to distant areas
 secondary rash normally starts shortly after, or at the same time as,the primary eruption.

10. Relationship between hand eczema and nickel
Nickel‐sensitive women do appear to have a
predilection for hand eczema.
Wet work, atopy and nickel sensitivity are associated
with an increased risk of hand dermatitis.
Hand eczema is often multifactorial Common in house working
women. With vesicular palmar (dyshidrotic)pattern ,
personal care items, detergents and cleaning products do not
contain sufficient nickel
Ingestion of nickel sulphate caused a flare of vesicular hand
eczema
Hand
eczema
Nickel
sensitivity

11. AVOIDANCE
• Nickel cannot be entirely avoided in daily life.
• Waterproof tape and metal lacquer can be used to cover nickel‐plated objects
• Protection with rubber gloves may be insufficient
• Heavy‐duty vinyl gloves have been suggested as an alternative
PROGNOSIS
• Excellent prognosis in case of jewellery and clothing
• Once the hands are involved, the eczema may remain chronic, persistent or intermittent
SPECIFIC THERAPIES
•Barrier creams and cleansers containing chelating agents
•Dietary reduction of nickle
•Clioquinol is known to chelate nickel
•topical clioquinol–steroid combination
•Treatment with tetraethylthiuramdisulphide (disulfiram; Antabuse

12.  Nickel sulphate 5% in petrolatum is used for patch tests
 False negative reactions are common with 2.5% nickel in petrolatum
 May produce irritant false positive reactions with a deep erythema and
pustulation
 Some follicular reactions are irritant, but those with raised papules are
often truly allergic
Patch testing

13. 2. COBALT
Points of discussion
 Chemistry
 incidence and prevelance
 occurrence
 clinical features
 Avoidance
 Prognosis
 patch test

14. chemistry
• Cobalt metal and its
oxides (e.g. Co2O3 and
CoO) and salts (e.g. CoCl2
and CoSO4) are
sensitizers.
• heated CoO elicits positive
patch test reactions
(unlike NiO).
Prevalence
• females predominating
• Of patients with
dermatitis, 4.6–9% were
patch test positive

15. OCCURRENCE
 Metallic cobalt is present in ‘hard metal used for metal cutting and drilling.
 used in magnets and jewellery.
 It is always present as a contaminant in nickel.
 It occurs in alloys, for example vitallium used in dentures and in nails for pinning fractures.
 Cobalt oxides present as traces in cement, are sensitizers.
 Cobalt salts are used for plating ,unlike nickel salts, although cobalt chloride has sensitized in
a metal‐etching solution.
 Organic compounds(e.g cobalt naphthenate, resinate, stearate)are used as driers in paints and
varnishes, bonders of rubber to metal and accelerators for unsaturated polyester resin
They may also be present as additives in lubricating oils.

16. Cont’d
Cobalt compounds are found in:
 paints
 Glass
 Pottery
 Ceramics
 enamel (blue)
 coloured crayons
 animal feed additives
 multivitamin pills
 textile dyes
 tattoos
 soaps
 cosmetic
 pigments, hair dye and detergents

17. Clinical features
 clinical features of cobalt allergy can be identical to those of nickel allergy
 its presence in cement may induce a clinical pattern identical to allergy from chromate
 Isolated cobalt allergy is seen in hard‐metal workers and in the pottery and glass
industries when it is usually associated with hand dermatitis
 Stomatitis
 Allergic granulomatous reactions to tattoo pigment
 Animal feed may induce contact allergy
 Photocontact dermatitis
 An oral lichenoid eruption to a chrome/cobalt prosthesis
 Vitamin B 12 is a cobalt‐containing compound and can cause cheilitis

18. •depend on identifying a
relevant cause and
eliminating contact
•Reduction of the dietary
intake of cobalt
(monitoring plasma
vitamin B12 if prolonged)
Avoidance
•Concomitant cobalt and
chromate sensitivity cause
troublesome dermatitis
•Same goes for cobalt
nickel sensitivity
Prognosis •Cobalt chloride 1% in
petrolatum is reliable for
testing
•False positive, irritant,
purpuric reactions are
common ,especially in
atopics
Patch testing

19. 3. Chromium
Points of discussion
 Chemistry
 incidence and prevelance
 occurrence
 clinical features
 Avoidance
 Prognosis
 patch test

20. Chemistry
•The metal itself, if not dissolved in
oil or acids or as a salt, seems to
be non‐sensitizing, unlike nickel
and cobalt.
•Hexavalent chromate, trioxide
(CrO3),dichromates of potassium,
sodium and ammonium are
common sensitizers
• less soluble lead chromate, barium
chromate and zinc chromate
(ZnCrO4) are also allergenic
•.trivalent chromium compounds
(occurring as cations), for example
chromium trichloride (CrCl3), are
sensitizers
Prevalence
•Commoner in men than in
women
•Incidence higher with
occupational dermatitis

21. Occurrence
 main source of hexavalent chromium is cement
 antirust paints (lead chromate and zinc chromate)
 including dust liberated by drilling, cutting or sandpapering of painted metals.
 plating salts
 metal alloys
 lithography/offset printing materials,
 Anticorrosive oil, cutting oils, cooling water, foundry sand
 polysulphide sealants
 matches
 photographic chemicals
 chemicals for fat determination in milk
 welding fumes

22. Cont’d
 wood preservatives,wood ashes, wood pulp
 mordant in wool dyeing
 stains in glass
 glazing enamels
 catgut
 violin strings
 Coating on zinc‐galvanized iron sheets
 textiles
 glass polishing
 flour
 tyre‐fitting solution
 colour television manufacture
 soaps and detergents and dental prostheses.
 household bleach
 chromium sulphate used as a tanning agent for leather

23. Clinical features
 Dry insidious eruption, which tends to fissure, particularly on the hands
 Secondary lichenification is often a feature.
 Widespread eruptions may occur from cement dust, with flexural accentuation and
involvement of the ankles and dorsa of the feet.
 Palmar vesicular eruptions have been blamed on traces of chromate in the diet
 Exposure to leather furniture has induced eczematous flares on the back,calves, arms and
feet in sensitized subjects
 An oral lichenoid eruption to a chrome/cobalt prosthesis
 Contact with leather footwear, gloves, belts and other clothing, or even handbags and
purses, may produce dermatitis in those areas in contact with the material

24. Avoidance
• Avoidance of contact with
sources of
chromate,including leather
footwear and gloves
• Ferrous sulphate added to
cement,thus preventing
chromium sensitization
• Various reducing agents,
chelating compounds and
ion exchangers have been
recommended as
components of hand creams
to prevent dermatitis in
chromate‐sensitive individuals
Prognosis
• In men, allergy to chromate
carries a worse prognosis
than does sensitization to
other allergens
• Chronicity and frequent
relapses are the rule
• affected individuals have
been labelled as ‘chrome
cripples’
• superimposed shoe
dermatitis may prevent by
using chromate free shoes
Patch test
• Sensitivity is demonstrated
by a closed patch test with
potassium dichromate 0.5%
in petrolatum.

25. 4. Palladium
Points of discussion
 Chemistry
 incidence and Prevalence
 occurrence
 clinical features
 Patch test

26. Chemistry
•Palladium is a
relatively
inexpensive metal of
the platinum group
of elements
Prevalence
•cross‐reactivity or
contamination of
palladium chloride
by nickel sulphate
•There is
concomitant
sensitivity to nickel,
and guinea pig
Occurrence
• used in dental
alloys, prostheses
and industry .
• It can be used as a
whitener in white
gold.
• Its main uses are in
electrical
components and as
a catalyst

27. Clinical features
 Its a reflection of nickel allergy.
 Stomatitis and lichen planus due to palladium in dental materials ( i.e prostheses or dental
alloys )
 A granulomatous reaction after ear piercing.
PATCH TESTING : Palladium chloride is normally tested at 1% in petrolatum.

28. 5. Gold
Points of discussion
 Chemistry
 incidence and Prevalence
 occurrence
 clinical features
 Patch test

29. chemistry
•Metallic gold is
soft, malleable
and ductile
•It is stable and
resistant to
corrosion
•Gold salts, such as
gold trichloride
and potassium
dicyanoaurate are
sensitizing as well
as irritating
prevalence
• Female
predominance
• due to context of
jewellery or gold
dental work.
• increase
incidence due to
use of gold‐plated
cardiac stents
occurrence
• Jewellery
•stents and dental
materials.
• Gold salts are
used in the
plating,
electronics,
photographic,
glass and
porcelain
industries

30. Clinical features
 A seborrhoeic eczema pattern has been described.
 Persistent papules and nodules on the ear lobes with lymphomatoid or granulomatous
histology.
oral manifestations of allergy have included erythema, burning mouth, erosions,ulceration,
oro‐facial granulomatosis and lichen planus‐like lesions.
Acral dermatitis
Sodium aurothiomalate injections for rheumatoid arthritis have induced systemic contact
dermatitis and ‘fever’ in those previously sensitized to gold.

31. PATCH TESTING :
 Gold sodium thiosulphate 0.5% in petrolatum.
 Late reactions are common and an additional 7‐day
 or even 2‐ or 3‐week reading has been advised.
 The appearance of a positive patch test may be ‘dermal’, with erythema and
edema but no vesiculation.

32. 6. Mercury
Points of discussion
 Chemistry
 Occurrence
 Clinical features
 Patch test

33. chemistry
•Corrosive sublimate (HgCl2),
calomel (HgCl), fulminate
(Hg(CNO)2)
• ammoniated mercury
(HgCl·2NH 4Cl) and organic
compounds (e.g.
mercurochrome, thimerosal
and phenylmercuric) may all
sensitize
occurrence
•used in instruments and amalgam filling
teeth
•used in disinfectants, fungicides,
herbicides,
•insecticides, detonators, emulsion paints
and jewellery
•in the production of caustic soda and
chlorine
•Ammoniated mercury has been used in
the topical treatment of psoriasis.
•Mercury and ammoniated mercury have
been used in skin‐lightening creams
•Red mercuric sulphide is used in red
tattoos

34. Clinical features
 local mucosal reactions and stomatitis
 Hypertrophic amalgam dermatitis simulating carcinoma of the tongue
 Perioral dermatitis after dental filling
 oral lichen planus in association with amalgam fillings
 Oro‐facial granulomatosisi n association with mercury allergy
 Generalized exanthems and erythema multiforme from mercury exposure, including inhalati
on, dental fillings, following the breakage of thermometers in the mouth
 use of an antiparasitic powder for the treatment of crab lice
 systemic reactions from amalgam seem to develop a few hours after insertion or removal
and settle after 10–14 days
 Red mercuric sulphide (cinnabar) in a tattoo may induce granulomatous reactions in
allergic subjects.

35. PATCH TESTING :
Mercury is normally tested at 0.5% in petrolatum,
mercurochrome 2% in petrolatum or aqueous, mercuric chloride
0.1% in petrolatum and ammoniated mercury 2% in petrolatum.
Patch testing to amalgam is also possible and is
available commercially at 5% pet. and as amalgam alloying metals
at 20% pet.

36. 7. Aluminium
Points of discussion
 Occurrence
 Clinical features
 Patch test

37. occurrence
•Aluminium is widely used
in (kitchen utensils,window
frames,foils etc ) but
contact allergy is very rare.
• Aluminium Adsorbed
vaccines and parenteral
solutions
•Antiperspirant
Clinical features
• granulomatous
reactions at the injection
site in case of
vaccination and
parenteral solution for
hyposensitization
• Axillary dermatitis due
to the use of
antiperspirant

38. PATCH TESTING :
Pure aluminium metal or salts, for example aluminium acetate 10% aqueous or
aluminium chloride 2% aqueous, can be used for testing.
a positive patch test,often annular in configuration.

39. 8. copper
 Copper is a ubiquitous metal found especially in coinage, jewellery,pipes, electrical equipment
and wiring.
 Its salts are used in insecticides, fungicides, wood preservatives, food processing,
 Fertilizers and fur dyes.
 Contact allergy is very rare.
 Dermatitis has been reported from copper intrauterine contraceptive devices.
Other metals used in dentistry may have the potential to cause contact allergy, including
platinum, rhodium, indium and iridium.

40. Fragrances, balsams, flavouring agents and spices
 General description
 Prevalence
 Occurrence
 Clinical features
 Avoidance
 Patch test

41. How perfumes cause allergic reaction ?
Natural
sources
synthetic
fixatives
Natural sources include extracts from plants, tree
lichens and animals (e.g. musk, civet)
mixture of essential oils from the natural sources
‘Fixatives’ are added to delay evaporation.e.g balsams,
benzyl benzoate, benzyl salicylate and synthetic musks

42. What is balsam?
An aromatic and usually oily and resinous substance
flowing from various plants
e.g: balsam of Peru,balsam of Tolu, balsam of spruce, gum
benzoin and storax.
 Tree balsams contain many different fragrance and
flavouring Components
 Balsam of Peru comes from a tree, Myroxylon pereirae,
that grows in Central America (not Peru!)
 widely used earlier for treating wounds, and scabies
composition: balsam does contain benzyl benzoate,
benzyl cinnamate, cinnamic acid, alcohol and aldehyde,
benzoic acid, vanillin, farnesol and nerolidol
 It may cross‐sensitize with resorcinol monobenzoate
 used in cellulose ester plastics

43. Flavours:
• Flavours may similarly be of natural or synthetic origin. Examples of natural flavours include
citrus fruit peel, peppermint oil,spearmint and vanilla
Natural spices
• Natural spices include nutmeg, mustard,
• cinnamon, cloves and oil of juniper. In the modern food industry
Prevalence
fragrances are the second most common allergen (after nickel)
Routine patch testing with balsam of Peru as a marker of allergy to perfume and certain flavours has shown
a positive rate of allergy

44. Occurrence
 Fragrances are ubiquitous. Perfumes, cosmetics,
 moisturizers, deodorants, aftershaves, soaps, bath additives, aromatherapy, oils and toilet
tissues and wipes are typical sources.
 Medicaments and work creams and cleansers often contain perfume
 domestic environment cleansers, fabric conditioners, candles, pot pourri, air fresheners and
polishes.
 coolant oils may contain a masking perfume.
 Flavours and spices are found in foods, beverages, lipsalves and dental products, including
toothpastes.

45. Clinical features
 In women: hands, face and neck.
 In men: hands, face and lower legs.
 Allergic reaction to axillae in both sexes.
 Allergy to lavender applied to a pillow.
 Aromatherapists and their clients are liable to
sensitization in sites where there is contact with the
essential oils.
 Allergic occupational hand dermatitis in d‐limonene
in its oxidized state
 Dermatitis in bakers and chefs as a result of contact
with sensitizing flavouring agents
An urticated contact dermatitis in a patient
allergic to fragrance

46. Cont’d
 Peeling of citrus fruit may induce allergic hand dermatitis.
 Cheilitis may be a reflection of allergy to flavouring agents in toothpastes ,lip salves and
food and drink
 Gingivitis has occurred from allergy to eugenol in dental cement
 Cinnamon has induced oral blisters, erosions and lichen planus.
 Balsam of Peru is still used as a medicament, particularly in haemorrhoid preparations, and
allergy is therefore relevant to perianal problems
 Sensitizing balsams are used in medicaments and balms for wounds, sprains and joint pains.
 Tincture of benzoin is used in a similar way, and may also be used under orthopaedic plaster
casts.
 Vesicular hand dermatitis has been related to dietary intake of flavours related to balsam of
Peru
 Musk ambrette is a synthetic perfume component responsible for photoallergy.
 Fragrance‐allergic subjects appear to be at an increased risk of more frequent and more
severe eye and respiratory symptoms.

47. Avoidance :
 In the domestic situation,perfume‐containing sprays such as air fresheners,
insect repellents and hairsprays should be avoided.
 Fragrance allergic patients with ongoing problems should also be counselled
 Other perfumed skin products to be avoided include deodorants,aftershave,
talcum powders, soaps.
PATCH TESTING :
The main recommended marker for perfume allergy was balsam of
Peru, which is still advised.

48. THANK YOU