P6171Sulfur spring dermatitis

Yen-Jen Wang, MD, Mackay Memorial Hospital, Taipei City, Taiwan; Pei-Lun Sun,MD, Mackay Memorial Hospital, Taipei, Taiwan; Yu-Hung Wu, MD, MackayMemorial Hospital, Taipei, Taiwan

Hot spring bath is a common leisure activity. Peitou, located in northern area ofTaiwan, has been well known for its two kinds of spring water: green sulfur springand white sulfur spring. Green sulfur spring is unique due to its strong acidity (pH¼1), high content of soluble sulfur and chloride and only been found in Peitou,Tamagawa in Japan, and Chile. It is undrinkable. We report a case developed sulfurspring dermatitis which turned into second degree burn. A 65-year-old man, who is aresident in Peitou, developed skin lesions soon after he took the green sulfur bath ina hotel. He denied any preexisting skin diseases. He spent about 25 minutes in thespring water and he stood near the plughole, where the temperature was higher. Hedescribed that he scratched his legs because of the tickling sensation during soak inthe hot spring. After an hour, there were pinhead sized pitted erosions withperipheral erythema on his lower limbs. These lesions became confluent andpunched-out ulcers, covered with brownish crusts 1 day later. The ulcers wereextensive and very painful and he was admitted to our ward for wound care. Nomicroorganisms were grown on culture from the wound. Skin biopsy specimentaken from the thigh revealed sharply demarcated homogenous necrosis in theepidermis and papillary dermis with many neutrophils underneath. He wasdischarged after 1 week but the wounds healed slowly in the next few monthsand became mild hypertrophic scars. The pH value of green sulfur spring decreaseswith raising temperature. The patient may develop irritant contact dermatitis fromacidity and soluble sulfur, and resulting large area of skin injury similar to seconddegree chemical burn. Patient with skin defect or pre-existing dermatitis shouldavoid high temperature of green sulfur spring bath.

AB84

cial support: None identified.

Commer

P6882Two cases of allergic contact dermatitis caused by rubber additives ofunusual origin

Patricia Garcia-Martin, MD, Hospital Universitario De La Princesa, Madrid, Spain;Almudena Godoy-Trapero, MD, Hospital Universitario De La Princesa,Madrid, Spain; Amaro Garcia-Diez, MD, Hospital Universitario De LaPrincesa, Madrid, Spain; Elena Sotomayor, MD, Hospital Universitario De LaPrincesa, Madrid, Spain; Javier Sanchez-Perez, MD, Hospital Universitario DeLa Princesa, Madrid, Spain; Maria Jose Concha-Garzon, MD, HospitalUniversitario De La Princesa, Madrid, Spain

Background: Sensitization to rubber additives was traditionally observed amongrubber industry workers, and in the last years among users of products made fromrubber generally in their workplaces.

Case 1: A 59-year-old man, gardener, consulted for outbreaks mainly in spring andsummer of eczematous lesions initially located on both feet, 4 years ago, and later onthe right forearm and right hand palm. During the last outbreak it has also spread tofacial region and rest of the body. The patient reported the use of a rubber hose thatheld with his right forearm and in his right hand. He also travelled by subway forabout 2 hours daily, leaning his right forearm and hand on the black conveyor. Patchtests were performed with standard, cosmetics, fragrance and plant batteries.Standard battery was positive at 48 and 96 hours for black rubber mix andparaphenylenediamine. In addition at 96 hours we observed positivity for mercaptomix andmercaptobenzothiazole. Patch testswith rubber battery and a piece of blackrubber conveyor from the subway escalator were positive at 48 and 96 hours for N-phenyl-N’-cyclohexyl-p-phenylenediamine (CPPD), N, N’-diphenyl-p-phenylenedi-amine (DPPD), N-isopropyl-N-phenyl-p-phenylenediamine (IPPD), morpholinylmercaptobenzothiazole (MOR), diphenylguanidine, N-phenyl-2-naphthylamineand the conveyor. In addition, at 96 hours positivity for 2-mercaptobenzothiazole,hexamethylenetetramine and diaminodiphenylmethane was also observed.

Case 2: A 59-year-old man, early retiree, consulted for the presence of eczematouslesions on the right ventral forearm since 2 months ago. The patient also claimedtravelling by subway from his youth. Patch tests with standard battery were positiveat 48 and 96 hours for black rubber mix. He was tested with rubber battery and apiece of black rubber conveyor from the subway escalator, showing positivity at 48and 96 hours for CPPD, DPPD, IPPD, 2-mercaptobenzothiazole and the black rubberconveyor.

Discussion: Nonoccupational sensitization to rubber additives is unusual. We report2 cases of allergic contact dermatitis by rubber additives in relation to exposure toblack rubber conveyor from the subway escalator in both cases, although in one casean occupational exposure to rubber was also confirmed.

cial support: None identified.

Commer

J AM ACAD DERMATOL

P6566Use of allopurinol for the treatment of the reaction to red tattoo pigments:Case report

Laila Klotz De Almeida Balassiano, Policlinica Geral Do Rio De Janeiro, Rio DeJaneiro, Brazil; Caroline Nabarrete Mour~ao, Policlinica Geral Do Rio De Janeiro,Rio De Janeiro, Brazil; Fernanda Carvalho Rocha Lima, Policlinica Geral Do RioDe Janeiro, Rio De Janeiro, Brazil; Marina Bombardelli, Policlinica Geral Do RioDe Janeiro, Rio De Janeiro, Brazil; Nathalia Carvalho Delcourt, Policlinica GeralDo Rio De Janeiro, Rio De Janeiro, Brazil; Paula Periquito Cosenza Vieira,Policlinica Geral Do Rio De Janeiro, Rio De Janeiro, Brazil

Cutaneous reactions to tattoos are not uncommon. With the growing popularity ofthis practice, several side effects have been observed. The treatments, however, areinconsistent. Studies have shown allopurinol therapy in granulomatous reactions totattoo pigments. The aim of this paper is to present a case of delayed hypersensitivityreaction type IV Gell and Coombs, to the red pigment, treated with allopurinol.Female, 24 years, with lichenified pruritic nodular lesions in the ankle and dorsum ofthe left foot, where used the red-colored pigment for tattooing, about two years ago.Two other sites tattooed, each of which contains the red pigment, initially withoutlesions, after completion of the third, there were changes in the integumentprimarily exposed. Histopathology revealed hyperkeratosis, irregular acanthosis,ulceration niche, tuberculoid granulomatous infiltrate with Langerhans cells,epithelioid cells and numerous pigmented corpuscles, and endothelial hyperplasiawith thickening of vessels walls, consistent with foreign body granulomatousreaction and vasculopathy. Patch test with standard battery was initially negative.Was chosen to perform the technique of abrasion of the same, using mercury andtattoo pigments brought by the patient (745 Mars color Natic Staldther, Ink),positive for both pigments. Started topical steroids and allopurinol 400mg daily. Thepatient is responding adequately to treatment. The reactions to the pigments used inmaking tattoos are diverse. The prevalence of reactions to red occurs for unknownreasons. The reaction is a granulomatous foreign body reaction with type IVGell andCoombs immune mechanism of the use of pigment, related to metals such asmercury (red), chromium (green), cobalt (blue) and manganese (purple). Thelesions are limited to sites with the pigment. The therapy requires multipleprocedures, and there is no guarantee of complete withdrawal, which may causethe risk of dispersion of antigen, worsening the lesion. Another option is the use oftopical and intralesional corticosteroids, but with frequent recurrences. Theantiinflammatory and antioxidant allopurinol has been used in the treatment ofgranulomatous reactions of the foreign body type, as observed in this case.

cial support: None identified.

Commer

DERMATOPATHOLOGY

P6767A case of multinucleate cell angiohistiocytoma

Neil Patel, MBBS, St. Mary’s Hospital, London, United Kingdom; James Carton,MBChB, St. Mary’s Hospital, London, United Kingdom; Parvin Shahrad, MD, St.Mary’s Hospital, London, United Kingdom

Multinucleate cell angiohistiocytoma (MCAH) was first described in 1985 and is arare, benign lesion, with fewer than 100 reported cases to date. It most frequentlyoccurs in middle-aged females, and male cases are particularly uncommon. Ittypically presents with indolently progressive, asymptomatic, grouped, red-brownpapules, most commonly on the dorsum of the hand or the leg. The characteristichistologic features are dermal proliferation of small blood vessels associated withfibrohistiocytic cells and multinucleate cells with scalloped borders. We present a64-year-old man with a 10-year history of slowly enlarging, asymptomatic lesions onthe dorsum of the right hand. Examination revealed a cluster of 5 discrete, red-brown, firm papulonoduleswith a smooth surface, and ranging in diameter from 7 to12 mm. Histologic analysis demonstrated a proliferation of small blood vessels in thepapillary and mid dermis, with dilated lumina and plump endothelial cells, and amild perivascular lymphocytic infiltrate. The vessels were surrounded by a numberof spindle-shaped fibrohistiocytic cells and scattered, bizarre, multinucleate cellswith scalloped edges. The clinical and histologic findings were characteristic ofMCAH. The histogenesis of MCAH is poorly understood but it is generally consideredto be a reactive lesion, with dermal fibrohistiocytic and vascular proliferation.Important histologic differential diagnoses to consider include atrophic vasculardermatofibroma, fibrous papule variant of angiofibroma, and Kaposi sarcoma. Thepaucity of reported cases of MCAH may suggest that the lesion is commonlymisdiagnosed, and we present this case in order to highlight MCAH as a distinctivecondition with typical clinicopathologic features. Spontaneous regression mayoccur infrequently. There is no consensus on the optimal form of treatment, butsurgical excision, argon laser, cryotherapy and intense pulsed light have beensuccessful in reported cases.

cial support: None identified.

Commer

APRIL 2013