DERMATITIS, Vol 25 ¡ Number 1 ¡ January/February, 2014
44
Ingrid Herskovitz, MD Bridgit Virginia Nolan, MD Antonella Tosti, MD Department of Dermatology and Cutaneous Surgery, University of Miami, Miami, FL
REFERENCES 1. Baran R, Dawber RPR, Richert B. In: Baran R, Dawber RPR, de Berker DAR, et al, eds. Baran and Dawber’s Diseases of the Nails and Their Management. 3rd ed. Oxford, England: Blackwell Science; 2001:48Y103. 2. Tosti A, Daniel CR III, Piraccini BM, et al. Color Atlas of Nails. Berlin, Germany: Springer-Verlag; 2010:60Y61. 3. Maibach HI, Kligman AM. Dihydroxyacetone: a sun-tan-simulating agent. Arch Dermatol 1960;82:505Y507. 4. Wittgenstein E, Berry KH. Reaction of dihydroxyacetone (DHA) with human skin callus and amino compounds. J Invest Dermatol 1961;36: 283Y286. 5. Draelos ZD. Self-tanning lotions: are they a healthy way to achieve a tan? Am J Clin Dermatol 2002;3(5):317Y318.
Allergic Contact Dermatitis to Lyofoam Polyurethane Dressing Used as Padding by a Patient With Above-Knee Amputation To the Editor: A 36-year-old nonatopic man with above-knee traumatic amputation presented with a history of an eczematous rash in his left groinVthe site where his prosthesis had been causing frictional damage to the skin. To reduce skin friction, he had for some years been placing a polyurethane foam dressing (Lyofoam; Mo¨lnlycke Health Care, Bedfordshire, UK) between the end rim of the prosthesis and his groin. Before he was referred to our department, various topical medicaments had been prescribed by his general practitioner for him to apply to the groin rash. He reported that the latter had virtually cleared after he stopped using both the Lyofoam dressing and the topical medicaments. He was patch tested to the British Society of Cutaneous Allergy Standard Series and also to our departmental medicament and isocyanates series (Chemotechnique Diagnostics, Vellinge, Sweden). The patches were applied to the back of the patient using Finn Chambers on Scanpore tape (Vitaflo
TABLE 1. Patch Test Results Patch Test Results Allergen PPD 1.00% pet Benzocaine 5% pet MDA 0.5% pet TDI 2% pet Lanolin 30% pet Amerchol 50% pet Benzalkonium chloride 0.1% aq
Day 2
Day 4
Relevance
+ + + j + +/j +/j
++ + ++ ++ ++ ++ +
Cross-sensitization Cross-sensitization Current Current Current Current Current
Aq, aqueous; pet, petrolatum.
Scandinavia AB, Go¨teborg, Sweden). Readings were taken according to the International Contact Dermatitis Research Group criteria, being read at day 2 and day 4 with results as shown in Table 1. He was also patch tested to the Lyofoam dressing, with both ‘‘foam’’ and ‘‘backing’’ surfaces separately applied to the skin. These latter patch test results were positive (+) and equivocal (+/j), respectively, at day 4 only, as shown in Figure 1. Polyurethanes are synthetically produced polymers formed by a condensation or adduction reaction between isocyanates and multifunctional alcohols (polyols), which are usually polyesters or polyethers. Polyurethanes are most commonly produced using 1 of 2 isocyanates, namely, diphenylmethane diisocyanate or less frequently toluene diisocyanate (TDI). Isocyanates are well-known to cause occupational allergic contact dermatitis (ACD).1 The ‘‘curing’’ process for such polymers can be modified by the addition of a catalyst such
Address reprint requests to Avad A. Mughal, MRCP, MRCPDerm, Dermatology Department, Singleton Hospital, Sketty Lane, Swansea SA2 8QA, United Kingdom. E-mail: [email protected]. The authors have no funding or conflicts of interest to declare. DOI: 10.1097/DER.0b013e3182a5d852 * 2014 American Contact Dermatitis Society. All Rights Reserved.
FIGURE 1. Positive (+) and equivocal (+/j) patch test results at day 4 only.
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
DERMATITIS, Vol 25 ¡ Number 1 ¡ January/February, 2014
as diaminodiphenylmethane (MDA), which itself can be a significant cause of ACD.2 A positive patch test result to MDA has also been stated to be a good marker for diphenylmethane diisocyanate sensitivity. Toluene diisocyanate, which our patient patch tested positive to, was the isocyanate stated to have been used in the manufacture of Lyofoam. The manufacturers of Lyofoam (Mo¨lnlycke Health Care) were contacted with regards to the ingredients of the product. They confirmed that the dressing may contain TDI, some of which may not have been used up forming the polyurethane. Our results would confirm that small amounts of TDI were present in this dressing. Diaminodiphenylmethane, being a 4,4-substituted compound, may potentially cross-react with other para-amino chemicals, such as paraphenylenediamine (PPD) and benzocaine. Approximately a third of patients with a positive patch test result to MDA will show a concomitant reaction to PPD.1 Our patient did not report a history of dyeing his hair, had never had a temporary black henna tattoo applied to his skin, and had no history of using benzocaine-containing medicaments. The positive patch test reactions to amerchol and lanolin were accounted for by the fact that the patient had been applying a moisturizer, known to contain lanolin, onto the groin rash when the skin had been inflamed. The positive patch test result to the benzalkonium chloride would likely be because of another topically applied medicament. Our patient did not give an occupational history that would account for the stated positive patch test results. We were not made aware of any history of the patient coming into contact with items containing either MDA or TDI that could have resulted in such sensitizations. Polyurethane foam dressings are highly absorbent3 and are often used to treat skin conditions such as ulcers and cavities, when there is significant wound exudation. In our patient, because of its foam structure, the Lyofoam dressing had been used as padding to try and reduce the frictional skin contact with his prosthesis. It is likely that the frictional skin irritancy/inflammation caused by the prosthesis rim onto the flexural skin of the groin resulted in optimal conditions for the production of ACD to the polyurethane foam dressing and constituents of some of the topical medicaments that had been applied to the rash. Polyurethanes have a variety of industrial uses, such as surface coatings and paints, glues and adhesives, and soft and hardened foams. Allergic contact dermatitis due to polyurethane chemicals has mainly been reported from occupational exposure.4 Allergic contact dermatitis due to polyurethane foams has also previously, but not frequently, been reported from nonoccupational causes.5 To the best of our knowledge, ACD to a polyurethane foam dressing, such as the Lyofoam, has not previously been reported.
45
Avad A. Mughal MRCP, MRCPDerm Dermatology Department Singleton Hospital Swansea, United Kingdom T. Meirion Hughes, MB BCh, DPD Natalie M. Stone, FRCP Dermatology Department St. Woolos Hospital Stow Hill Newport, United Kingdom
REFERENCES 1. Aalto-Korte K, Suuronen K, Kuuliala O, et al. Occupational contact allergy to monomeric isocyanates. Contact Dermatitis 2012; 67:78Y88. 2. van Joost T, Heule F, de Boer J, et al. Sensitization to methylenedianiline and para-structures. Contact Dermatitis 1987;16:246Y248. 3. Steen A, Williamson DJ. Dressings and wound care. In: Finlay AY, Chowdhury MMU, eds. Specialist Training in Dermatology, 2007. China: Elsevier; 151Y171. 4. Estlander T, Keskinen H, Jolanki R, et al. Occupational dermatitis from exposure to polyurethane chemicals. Contact Dermatitis 1992; 27:161Y165. 5. Turan H, Saricao?lu H, Turan A, et al. Polyurethane toilet seat contact dermatitis. Pediatr Dermatol 2011;28(6):731Y732.
Audit of Patch Testing Services in Wales To the Editor: Contact dermatitis accounts for 4% to 7% of dermatology consultations.1 Occupational dermatitis makes up 70% of occupationalskin diseases. Accurate and effective testing with education about the outcome is beneficial and can lead to a lifestylechange that is overall beneficial to the patient’s condition.2 There is a statistically significant improvement in the quality of life after patch testing.3 The expertise of the clinicians performing the test and their ability to place the result in context are invaluable to the
FIGURE 1. Presence or absence of particular audit points as laid out in the guidelines. LD indicates lead dermatologist.
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
44
Ingrid Herskovitz, MD Bridgit Virginia Nolan, MD Antonella Tosti, MD Department of Dermatology and Cutaneous Surgery, University of Miami, Miami, FL
REFERENCES 1. Baran R, Dawber RPR, Richert B. In: Baran R, Dawber RPR, de Berker DAR, et al, eds. Baran and Dawber’s Diseases of the Nails and Their Management. 3rd ed. Oxford, England: Blackwell Science; 2001:48Y103. 2. Tosti A, Daniel CR III, Piraccini BM, et al. Color Atlas of Nails. Berlin, Germany: Springer-Verlag; 2010:60Y61. 3. Maibach HI, Kligman AM. Dihydroxyacetone: a sun-tan-simulating agent. Arch Dermatol 1960;82:505Y507. 4. Wittgenstein E, Berry KH. Reaction of dihydroxyacetone (DHA) with human skin callus and amino compounds. J Invest Dermatol 1961;36: 283Y286. 5. Draelos ZD. Self-tanning lotions: are they a healthy way to achieve a tan? Am J Clin Dermatol 2002;3(5):317Y318.
Allergic Contact Dermatitis to Lyofoam Polyurethane Dressing Used as Padding by a Patient With Above-Knee Amputation To the Editor: A 36-year-old nonatopic man with above-knee traumatic amputation presented with a history of an eczematous rash in his left groinVthe site where his prosthesis had been causing frictional damage to the skin. To reduce skin friction, he had for some years been placing a polyurethane foam dressing (Lyofoam; Mo¨lnlycke Health Care, Bedfordshire, UK) between the end rim of the prosthesis and his groin. Before he was referred to our department, various topical medicaments had been prescribed by his general practitioner for him to apply to the groin rash. He reported that the latter had virtually cleared after he stopped using both the Lyofoam dressing and the topical medicaments. He was patch tested to the British Society of Cutaneous Allergy Standard Series and also to our departmental medicament and isocyanates series (Chemotechnique Diagnostics, Vellinge, Sweden). The patches were applied to the back of the patient using Finn Chambers on Scanpore tape (Vitaflo
TABLE 1. Patch Test Results Patch Test Results Allergen PPD 1.00% pet Benzocaine 5% pet MDA 0.5% pet TDI 2% pet Lanolin 30% pet Amerchol 50% pet Benzalkonium chloride 0.1% aq
Day 2
Day 4
Relevance
+ + + j + +/j +/j
++ + ++ ++ ++ ++ +
Cross-sensitization Cross-sensitization Current Current Current Current Current
Aq, aqueous; pet, petrolatum.
Scandinavia AB, Go¨teborg, Sweden). Readings were taken according to the International Contact Dermatitis Research Group criteria, being read at day 2 and day 4 with results as shown in Table 1. He was also patch tested to the Lyofoam dressing, with both ‘‘foam’’ and ‘‘backing’’ surfaces separately applied to the skin. These latter patch test results were positive (+) and equivocal (+/j), respectively, at day 4 only, as shown in Figure 1. Polyurethanes are synthetically produced polymers formed by a condensation or adduction reaction between isocyanates and multifunctional alcohols (polyols), which are usually polyesters or polyethers. Polyurethanes are most commonly produced using 1 of 2 isocyanates, namely, diphenylmethane diisocyanate or less frequently toluene diisocyanate (TDI). Isocyanates are well-known to cause occupational allergic contact dermatitis (ACD).1 The ‘‘curing’’ process for such polymers can be modified by the addition of a catalyst such
Address reprint requests to Avad A. Mughal, MRCP, MRCPDerm, Dermatology Department, Singleton Hospital, Sketty Lane, Swansea SA2 8QA, United Kingdom. E-mail: [email protected]. The authors have no funding or conflicts of interest to declare. DOI: 10.1097/DER.0b013e3182a5d852 * 2014 American Contact Dermatitis Society. All Rights Reserved.
FIGURE 1. Positive (+) and equivocal (+/j) patch test results at day 4 only.
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
DERMATITIS, Vol 25 ¡ Number 1 ¡ January/February, 2014
as diaminodiphenylmethane (MDA), which itself can be a significant cause of ACD.2 A positive patch test result to MDA has also been stated to be a good marker for diphenylmethane diisocyanate sensitivity. Toluene diisocyanate, which our patient patch tested positive to, was the isocyanate stated to have been used in the manufacture of Lyofoam. The manufacturers of Lyofoam (Mo¨lnlycke Health Care) were contacted with regards to the ingredients of the product. They confirmed that the dressing may contain TDI, some of which may not have been used up forming the polyurethane. Our results would confirm that small amounts of TDI were present in this dressing. Diaminodiphenylmethane, being a 4,4-substituted compound, may potentially cross-react with other para-amino chemicals, such as paraphenylenediamine (PPD) and benzocaine. Approximately a third of patients with a positive patch test result to MDA will show a concomitant reaction to PPD.1 Our patient did not report a history of dyeing his hair, had never had a temporary black henna tattoo applied to his skin, and had no history of using benzocaine-containing medicaments. The positive patch test reactions to amerchol and lanolin were accounted for by the fact that the patient had been applying a moisturizer, known to contain lanolin, onto the groin rash when the skin had been inflamed. The positive patch test result to the benzalkonium chloride would likely be because of another topically applied medicament. Our patient did not give an occupational history that would account for the stated positive patch test results. We were not made aware of any history of the patient coming into contact with items containing either MDA or TDI that could have resulted in such sensitizations. Polyurethane foam dressings are highly absorbent3 and are often used to treat skin conditions such as ulcers and cavities, when there is significant wound exudation. In our patient, because of its foam structure, the Lyofoam dressing had been used as padding to try and reduce the frictional skin contact with his prosthesis. It is likely that the frictional skin irritancy/inflammation caused by the prosthesis rim onto the flexural skin of the groin resulted in optimal conditions for the production of ACD to the polyurethane foam dressing and constituents of some of the topical medicaments that had been applied to the rash. Polyurethanes have a variety of industrial uses, such as surface coatings and paints, glues and adhesives, and soft and hardened foams. Allergic contact dermatitis due to polyurethane chemicals has mainly been reported from occupational exposure.4 Allergic contact dermatitis due to polyurethane foams has also previously, but not frequently, been reported from nonoccupational causes.5 To the best of our knowledge, ACD to a polyurethane foam dressing, such as the Lyofoam, has not previously been reported.
45
Avad A. Mughal MRCP, MRCPDerm Dermatology Department Singleton Hospital Swansea, United Kingdom T. Meirion Hughes, MB BCh, DPD Natalie M. Stone, FRCP Dermatology Department St. Woolos Hospital Stow Hill Newport, United Kingdom
REFERENCES 1. Aalto-Korte K, Suuronen K, Kuuliala O, et al. Occupational contact allergy to monomeric isocyanates. Contact Dermatitis 2012; 67:78Y88. 2. van Joost T, Heule F, de Boer J, et al. Sensitization to methylenedianiline and para-structures. Contact Dermatitis 1987;16:246Y248. 3. Steen A, Williamson DJ. Dressings and wound care. In: Finlay AY, Chowdhury MMU, eds. Specialist Training in Dermatology, 2007. China: Elsevier; 151Y171. 4. Estlander T, Keskinen H, Jolanki R, et al. Occupational dermatitis from exposure to polyurethane chemicals. Contact Dermatitis 1992; 27:161Y165. 5. Turan H, Saricao?lu H, Turan A, et al. Polyurethane toilet seat contact dermatitis. Pediatr Dermatol 2011;28(6):731Y732.
Audit of Patch Testing Services in Wales To the Editor: Contact dermatitis accounts for 4% to 7% of dermatology consultations.1 Occupational dermatitis makes up 70% of occupationalskin diseases. Accurate and effective testing with education about the outcome is beneficial and can lead to a lifestylechange that is overall beneficial to the patient’s condition.2 There is a statistically significant improvement in the quality of life after patch testing.3 The expertise of the clinicians performing the test and their ability to place the result in context are invaluable to the
FIGURE 1. Presence or absence of particular audit points as laid out in the guidelines. LD indicates lead dermatologist.
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
