atypical and unusual clinical manifestations of contact dermatitis to clothing

7/28/2019 Atypical and Unusual Clinical Manifestations of Contact Dermatitis to Clothing

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Atypical and unusual clinical manifestations of contact dermatitis to clothing

(textile contact dermatitis): Case presentation and review of the literature

Aneta Lazarov MD1, Mario Cordoba MD2, Natalia Plosk MD3, David

Abraham MD1

Dermatology Online Journal 9 (3): 1

1. Contact Dermatitis Clinic, Meir Hospital, Kfar Saba. 2. Department of Pathology, Meir

Hospital, Kfar Saba, affiliated with the Sackler School of Medicine, Tel Aviv University,

Israel. 3. Dermatology Clinic, Herzeliya. [email protected]

Abstract

Although the exact incidence of textile contact dermatitis is

unknown, recent studies demonstrate that contact dermatitis producedby allergic or irritant reactions to clothing not only is more frequent

than previously thought but also increasing. The clinical features of

contact dermatitis (CD) caused by clothing may resemble common

allergic contact dermatitis or may have atypical presentations. We

report on several cases of clothing-induced contact dermatitis with

atypical clinical presentations.

The exact incidence of textile contact dermatitis is unknown, but

recent studies demonstrate that contact dermatitis produced by

allergic or irritant reactions to clothing is more frequent than

previously thought. [1,2,3,4] It also has been shown that the

frequency of textile-dye allergy is increasing.[5,6]

The clinical features of contact dermatitis (CD) caused by

clothing may resemble common allergic contact dermatitis or may

have atypical presentations. The diagnosis of contact dermatitiscaused by clothing may be difficult in some cases because of the

wide spectrum of clinical presentations, including unusual clinical

patterns and atypical localization. In this report, we discuss severalcases of clothing-induced contact dermatitis that presented atypically.

Methods

All patients were patch tested with the standard series (TRUE

Tests), textile color and finish series (TCFS), and clothing extracts.

The TCFS was obtained from Chemotechnique Diagnostics (Malmo,

Sweden) and included 32 allergens (13 disperse dyes, 8 reactive dyes,

3 acid dyes, 1 basic dye, 1 direct dye and 6 textile-formaldehyderesins). The allergens, applied on square chambers with micropore
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tape, were placed on unaffected skin of the upper back, removed at

day 2 and read at days 2, 3, and 7, according to standard patch test

procedure.[7] Some of the patients were patch tested with extracts of

the suspected garments. The extract procedure was as follows: 2 cm

of the cloth was immersed separately in 5 cc of water, ethanol 70

percent, and acetone for 30 minutes. The clothing was removed andthe extracts with the water and alcoholic solutions were prepared for

patch testing. Acetone extract (1 cc) was diluted with 3 cc of water,

and this solution was used for patch testing. A 1 cm piece of clothing,

having been immersed in water, was also applied, unaltered, for patch

testing.

Case presentations

Erythema multiforme-like textile CD

Case 1.A 44-year-old, atopic woman presented with a pruritic,

widespread eruption on her abdomen and inner thighs, which

disseminated to the lower back and upper extremities. The present

eruption developed 1 week after the patient wore a new blue suit of

synthetic material. A large area of erythema was seen on the patient's

abdomen. This area was in direct contact with the trousers (Fig. 1).

Erythematous macules and urticarial papules and plaques, some ofthem target-like, were observed on the inner thighs, shins, and upper

extremities, in a manner resembling erythema multiforme (Fig. 2).

A lesional biopsy revealed mild focal spongiosis of the

epidermis and a mild perivascular infiltrate composed of lymphocytes

and eosinophils. The eosinophils were also conspicuous in the

interstitial areas a (Figs. 3, 4). Patch testing results are shown in

Table 1 and Figure 5. The erythema-multiforme-like eruption

resolved within 14 days after exposure to the blue synthetic suit was

discontinued.

In the past she had developed a similar eruption at and near the

sites of metallic suture clips on her lower abdomen, after Caesarean

section. Patch testing then demonstrated hypersensitivity (+2) to

nickel sulfate. The metal clips were reported by the manufacturer as

containing nickel. She was diagnosed as having erythema-

multiforme-like CD related to nickel allergy.
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Figure 1 Figure 2

Figure 3 Figure 4

Figure 5 Figure 6

Case 2.A 32-year-old healthy woman presented with an

eruption of pruritic, erythematous macules and urticarial papules on

her shins, resembling erythema multiforme lesions (Fig. 6). An

allergic reaction to the beige synthetic stockings worn by the patient

was suspected. Patch test results, as shown in Table 1, confirmed this

relationship.
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Purpuric textile CD

Figure 7 Figure 8

Case 3.A 64-year-old healthy man presented with purpuric

papules and plaques affecting his lower extremities (Fig. 7) and arms.The lesions appeared in the winter, 1 month after he began wearing a

dark blue synthetic sportswear while playing tennis.

A lesional biopsy demonstrated spongiosis of the epidermis with

areas of acanthosis. The inflammatory infiltrate was mainly

perivascular and consisted of lymphocytes, eosinophils, and

extravasated erythrocytes (Fig. 8). Some erythrocytes were observed

in the epidermis.

Patch testing (Table 1) revealed a purpuric patch at the site of

the tested allergen, Disperse Blue 124. A biopsy at this test siterevealed spongiosis, exocytosis, and a perivascular, lymphocytic

infiltrate. Extravasated erythrocytes were seen in the dermis and the

epidermis. Complete involution, with no recurrence of the lesions,

occurred 40 days after discontinuing the use of the blue suit and other

darkly colored garments and provided further evidence for the

etiological role of hypersensitivity to textile dyes in the development

of this patient's purpuric dermatitis.
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Table 1. Contact dermatitis patch tests

and clinical presentation of cases

Allergens 1EM

2EM

3Purpuric

4Papular

5Pigmented

6Pruritus

7Atopic

Nickel Sulfate +2 +1

Formaldehyde +1 +1PPD +1

Mercapto mix +1

Quarternium 15 +1Disperse Blue

106 +1 +1 +1

Urea formaldehyde

(Kaurit S) +2 +1

Melamine

formaldehyde

(Kaurit M 70)+2 +1

Disperse Blue85 +2 +1

Disperse Blue

124 +1 +2 +1 +1

Direct Orange

34 +1

Piece of

suspected garment +1 +1 +1 +1

Alcohol extract

of garment +1 +1

Acetone extract

of garment +1 +1

Papular and purpuric textile CD

Figure 9 Figure 10

Case 4.A 58-year-old man

was evaluated because of a pruritic,

papular rash that appeared 3 weeks

after he started wearing new shirts

bought in Turkey. Multiple,

erythematous and livid papules were

seen on his lower back and flanks.

The lesions had a linear distributionat the waistband (Figs. 9, 10). Figure 11
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Patch testing results are shown in Table 1 and Figure 11.

Histopathological investigation of a papular lesion demonstrated

spongiosis and acanthosis of the epidermis. A mixed inflammatory

infiltrate consisting of lymphocytes, eosinophils, and multiple

erythrocytes were seen both perivascularly and in the interstitial area.

Similar clinical and histological findings were observed from a patch-test site positive for urea-formaldehyde. The lesions involuted

completely and did not reappear after the patient stopped wearing the

newly purchased shirts.

Pigmented textile CD

Case 5.A 23-year-old

healthy female presented withpruritic, hyperpigmented patches on

her neck, chest (Fig. 12) and arms,

which appeared some months after

she began to wear synthetic, dark-

colored, turtle-neck blouses.

Examination revealed

hyperpigmented patches at the same

areas. Patch testing (Table 1)

demonstrated a hypersensitivity reaction to Disperse Blue 106,

Disperse Blue 124, a piece of a blouse, and an acetone extract of the

garment. The lesions began to fade 1 year after exposure to dark

synthetic garments was stopped.

Generalized pruritus with excoriation

Figure 13 Figure 14

Figure 12
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Case 6.A 56-year-old, atopic

woman presented because of severe

generalized pruritus. Areas of

excoriation could be seen on her

trunk and extremities (Fig. 13, 14).

A lesional biopsy demonstrated mildspongiosis and a mild perivascular

lymphocytic infiltrate. Multiple

eosinophils were seen in the

perivascular and interstitial area. A

diagnosis of atopic dermatitis was considered. Medications

(conjugated estrogens and atrovastatin) were withdrawn in order to

rule out drug-induced pruritus. No improvement resulted. The

patient's pruritus worsened despite treatment with antihistamines.

Systemic steroids produced clinical improvement but relapse

occurred after withdrawal of therapy. A thorough workup for

generalized pruritus, including liver, renal, and thyroid function tests,bacteriology, and chest X-ray, was performed but rendered no

relevant information. Positive patch-test results to Disperse Blue 106,

85, and 124 persisted for 3 weeks( Fig. 15). The pruritus appeared to

be related to a hypersensitivity reaction to textile dyes and resins, and

so the patient began to wear only white and beige cotton garments.

By 1 months, the pruritus was diminished and was completely

resolved in 2 months.

Atopic dermatitis-like textile CD

Case 7.A 10-year-old boy with suspected atopic dermatitis

was referred to our clinic for investigation of environmental contact

allergens. He had been suffering from pruritus on his palms, wrists,

and shins for several months. The boy had participated in a soccer

team for 3 years as a goal keeper. He had been wearing special gloves

and shin shields consisting of an external hard plastic cover, rubber

padding, and a dark textile lining on the inside, that came in contact

with the skin. Lichenification on the wrists, shins, and popliteal areas

was observed.

Patch testing with standard textile and rubber additive series, as

well as extracts and pieces of the rubber part of the gloves and shields

and parts of the textile lining was carried out. Hypersensitivity

reactions occurred at the sites of the alcohol extracts of the textile and

pieces of the black textile used in the lining. No hypersensitivity

reactions were observed to any of the standard textile and colorsfinish

allergens. The lesions resolved after changing the shield to another

brand.

Figure 15
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Discussion

Chronic subacute and acute dermatitis are the most frequent

presentations of textile contact dermatitis according to previous

studies.[2,3,4,6] Erythematous patches with or without finedesquamation are a common form of textile dermatitis. Usually these

lesions develop at sites where the garments fit tightly, such as inner

and posterior thighs, popliteal fossae, buttocks, waistband area, and

anterior and posterior axillary folds, sparing the vault (Figs. 16, 17).

Textile dermatitis can also assume other clinical appearances that are

atypical and thus delay the correct diagnosis of CD produced by

clothing.

Figure 16 Figure 17

Erythema-multiforme-like lesions can be an atypical

manifestation of hypersensitivity to disperse dyes, as reported in theliterature and observed in two of our patients.[8,9,10,11] Erythema-

multiforme-like CD related to hypersensitivity to the azo dye,

Disperse blue 124, was reported even in a child.[12] In our cases, the

erythema-multiforme-like CD lacked the typical target lesion and the

histopathological findings resembled those of contact dermatitis,

including the admixture of multiple eosinophils in the inflammatory

infiltrate. In the first case, erythema-multiforme-like CD was

provoked by exposure to two different types of allergens, nickel and

azo dyes. This finding shows that erythema-multiforme-like reactions

are not allergen specific but rather represent a pattern of response to

delayed-type hypersensitivity to topical agents.

Purpuric CD related to hypersensitivity to textile dyes and resins

has been previously described.[3,13,14,15,16,17,18] Although

purpuric CD is not among the common clinical presentations of

textile CD, it is not an atypical and extraordinary manifestation. In

our experience, purpuric CD to clothing is more frequent than

previously reported.[3,19,20] This phenomenon could be due in part

to the climatic factors in Israel, where the hot and humid climate

favors profuse sweating and thus enhances the exposure to the

allergens.
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Papular CD to textiles is a rare phenomenon. Follicular and

papular lesions are reported in two patients with textile dermatitis

causes by formaldehyde,[21] and a dermal reaction is noted with

Disperse Blue 106.[22] It is of interest that in our patient the papular

eruption also has purpuric features. The purpura is demonstrated

histologically both in a lesional biopsy and in the biopsy from apositive patch test to Kaurit S. Admixture of purpura with papules is

observed also in our patient with purpuric contact dermatitis (Case 3).

Similar features of papules and purpura are described in the patients

observed by Khanna.[23] It can be speculated that under certain

circumstances strong allergens trigger an influx not only of

lymphocytes but also of erythrocytes in the inflammatory infiltrate.

Textile dermatitis with purpuric papules can resemble granuloma

annulare, papular dermatitis, dermatitis herpetiformis, and mycosis

fungoides and has to be differentiated from these entities.

Pigmented CD is an atypical manifestation of textile CDoccasionally described in case reports.[25,26,27] Pigmented

clothing dermatitis has been related to hypersensitivity to dispersedyes [3,16,18,28] and to an azo dye coupling component agent,

Naphthol AS.[29] In our case, the pigmented patches are pruritic and

appear without previously discernible eczematous lesions, in contrast

with the findings of Ancona Alayon et al.[29] In their series the

Naphthol AS pigmented CD presents with spotted hyperpigmentation

on the exposed areas but without pruritus. The hyperpigmentation is

most pronounced in individuals with dark complexions, as we also

observe. The histological features included melanocyte proliferation,

incontinence of pigment, and various degrees of damage to the basal

layer.

In the literature, phototoxic reactions to textiles[30] and contact

depigmentation from the textile azo dye, Solvent Yellow 3, have been

reported.[31]

Apart from fiberglass, which can contaminate clothes and induce

irritant, pruritic, contact dermatitis,[33] pruritus and excoriations are

seldom mentioned as a part of the clinical manifestation of clothing

CD.[3,33] Our patient demonstrates that pruritus and excoriationwithout dermatitis in the initial stages may also be a rare form of

hypersensitivity to textile dyes and resins. Indeed she has undergone

a thorough and expensive workup for generalized pruritus prior to

patch testing.

Although intolerance to wool and synthetic fibers are well

known in atopic dermatitis,[34] childhood atopic dermatitis-like,

allergic, CD reactions with lichenification, related to hypersensitivity

to textile dyes or resins, are not documented. Our patient displays the

features of chronic dermatitis with lichenification at areas reminiscent

of the distribution of lesions in atopic patients. The triggering agentin the incriminated textile cannot be defined, but the clinical course
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demonstrates the relevance of the suspected clothing.

Other unusual forms of textile dermatitis to dyes and resins

described in the literature include pustular lesions[3] and large,

erythematous patches with desquamation.[6] Textile CD presenting

as lichen amyloidosis, with hyperkeratotic papules and plaques andpositive patch tests to fragrance mix, formaldehyde, and

formaldehyde resins has been described recently.[25]

Our series of patients with allergic textile contact dermatitis

demonstrates the atypical and unusual clinical presentations of

allergic contact dermatitis to clothing. It should be noted that apart

from the well-delineated clinical forms such as EM-like contact

dermatitis, pigmented contact dermatitis, pruritus, and excoriation,

mixed forms including papular and purpuric lesions, and purpuric and

pigmented lesions can be also present. Being familiar with the typical

and unusual forms of textile contact dermatitis allows more rapid andprecise diagnosis of clothing-related, contact dermatitis, which is not

uncommon.

References

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atypical and unusual clinical manifestations of contact dermatitis to clothing

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