CASE REPORT
Unilateral Hand Allergic Contact Dermatitis due to Occupational Exposure Farheen Mussani and Joel G. DeKoven
Background and Objective: H and d e rm a titis is th e m o s t c o m m o n s u b ty p e o f o c c u p a tio n -re la te d skin d isease. R egard less o f its u n d e rly in g cause, h an d d e rm a titis re su lts in s ig n ific a n t im p a irm e n t an d a n e g a tiv e im p a c t on q u a lity o f life. A n y case o f u n ila te ra l h a n d d e rm a titis s h o u ld h ave a h ig h in d e x o f su sp icion fo r an a lle rg ic c o n ta c t d e rm a titis .
Conclusion: W e re p o rt t w o cases o f u n ila te ra l h an d d e rm a titis . T h e firs t case is a 5 3 -y e a r-o ld fe m a le w ith a u n ila te ra l d e rm a titis o f th e le ft h an d . T h e second case is a 5 3 -y e a r-o ld m a le w ith d e rm a titis o f th e rig h t han d. B oth cases h ig h lig h t an in te re s tin g p re s e n ta tio n o f u n ila te ra l h an d a lle rg ic c o n ta c t d e rm a titis s e co n d a ry to an o c c u p a tio n a l ex po sure.
Contexte et object'd: La d e rm a tite d e la m a in es t le s o u s -ty p e le p lu s fre q u e n t d 'a ffe c tio n c u ta n e e p ro fess io n n e lle . Q u e lle q u 'en s o it la cause so u s -ja c e n te , la d e rm a tite d e la m a in cause des tro u b le s im p o rta n ts e t a lte re la q u a lite d e vie. II y a u ra it lieu de so u p g o n n er fo r te m e n t u ne d e rm a tite d e c o n ta c t, d e n a tu re a lle rg iq u e , d an s to u s les cas d e d e rm a tite u n i l a t e r a l d e la m a in .
Conclusions: S e ro n t expo ses d an s I'a rtic le d e u x cas d e d e rm a tite u n ila te ra le d e la m a in : I'u n ch ez u n e fe m m e d e 53 an s, d o n t la m a in g a u c h e es t affe cte e; I'a u tre ch ez un h o m m e d e 53 ans, d o n t la m a in d ro ite es t a ffe cte e. Les d e u x cas fo n t re s s o rtir un ta b le a u in te re s s a n t d e la d e rm a tite d e c o n ta c t u n ila te ra le d e la m a in , d e n a tu re a lle rg iq u e , a ttrib u a b le a u n e e x p o s itio n p ro fe s s io n n e lle a c e rta in e s su b stan ces.
Case 1 A 53-year-old female was referred for assessment of an eruption of 1.5 years’ duration involving three fingers on her left, nondominant, hand. The patient initially noted pruritus on her left hand second digit fingertip, which progressed to a vesicular eruption. Gradually over time, the rash involved the fingertips of digits 1, 2, and 3. With short periods of respite on the weekend, her eruption would improve but never fully heal. The patient’s occupation, an assembly line worker for automotive door handles, involved significant contact of her nondominant hand with rubber bumpers, steel, and cleaning supplies. The rubber bumper was a small, black, pliable, cylinder like piece resembling a small screw. She wore nitrile gloves
From the Division o f Dermatology, University o f Toronto, and Department o f Occupational and Environmental Health, St. Michael’s Hospital, Toronto, ON. Address reprint requests to: Joel DeKoven, MD, MHSc, University o f Toronto, 2075 Bayview Avenue, Suite M l-700, Toronto, O N M 4 N 3M5; e-mail: [email protected]. D O I 1 0 .2 3 1 0 /7 7 5 0 .2 0 1 3 .1 3 1 0 4
© 2014 Canadian Dermatology Association
covered with golf gloves to provide protection for her fingers. However, this did not improve her condition. She was otherwise healthy and had no history of atopy. Examination revealed an erythematous, vesicular, scaly eruption on the fingertips of digits 1, 2, and 3 of her left hand (Figure 1). No other lesions were identified. Patch testing was performed to the North American standard series (Chemotechniques, Malmo, Sweden), rubber series (Chemotechniques), melamine formalde hyde resin, and the rubber bumper used in her workplace occluded for 7 days. IQ Ultra Chambers (Dormer Laboratories Inc, Rexdale, ON) were used for the commercial allergens, and these were adhered to the patient’s back using Scanpor tape (Epitest Ltd Oy, Tuusula, Finland). The results were read using the International Contact Dermatitis Research Group grading scale at 2 days and 7 days after application. At 7 days, she showed the following positive reactions (Figure 2): • Rubber bumper sample from the workplace 2+ • N-Isopropyl-AT-phenyl paraphenylenediamine (IPPD) - standard series 2+ • N-Isopropyl-N'-phenyl paraphenylenediamine (IPPD) - rubber series 1+
DECKER^ Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 283-286
283
M ussani and DeKoven
Figure 1. Case 1 showing unilateral fingertip dermatitis.
• N-Cyclohexyl-N'-phenyl-4-phenylenediamine (CPPD)
2+ • Nickel sulfate 2.5% Id-
Case 2
A 53-year-old male was seen for assessment of an eruption of 3 years’ duration involving the palmar surface of his right dominant hand. The patient worked at a marble company for the last 8 years. His occupation required him to measure slabs of marble and cut them on a machine.
The pieces of marble were then polished with water and a buffer. The patient used his right hand to buff the pieces, resulting in increased friction. The marble pieces were then glued together, and at this point of the manufacturing process, the patient wore rubber gloves. On occasion, while in contact with the rubber handles of certain machinery, the patient would not wear rubber gloves. As well, periodically, these gloves would tear along his palm. With periods of respite, the patient noted complete clearing of his right-handed eruption. On returning to work, his rash gradually worsened over 1 to 2 weeks. He was otherwise healthy and had no history of atopy. Examination revealed a significant dermatitic eruption on the palmar surface of his right hand, including the entire palm (Figure 3). Both the dorsal and palmar surfaces of all fingers on the right hand were affected There was marked hyperkeratosis and lichenification. The left hand was mildly affected, and his feet were bilaterally clear. No other lesions were identified. Patch testing was performed to the North American standard series (Chemotechniques), epoxy series (Chemotechniques), the patient’s personal products, and the rubber gloves and glues used in his workplace occluded for 7 days. IQ Ultra Chambers were used for the commercial allergens, and these were adhered to the patient’s back using Scanpor tape. The results were read using the International Contact Dermatitis Research Group grading scale at 2 days and 7 days after application.
Rubber BUmper Workplace Material
Figure 2. Case 1 showing patch test results at 7 days.
CPPD
284
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 283-286
Hand Dermatitis due to Occupational Exposure
Figure 3. Case 2 showing unilateral palmar dermatitis.
At 7 days, he showed the following positive reactions: • • • • •
Black rubber mix 1+ Dark blue rubber gloves 1+ Thiuram mix 1+ Carba mix 1+ Cobalt Id-
Figure 5. Case 2 showing the workplace machinery with rubber handles.
suspicion for allergic contact dermatitis is necessary. A case report in 2006 showed the use of baby wipes resulting in a unilateral palmar eruption.2 A subsequent report in 2007 described a unilateral palmar dermatitis due to contact with a rubber escalator railing, with positive patch tests to constituents of the black rubber mix.3 Regardless of the cause, hand dermatitis results in significant impair ment and a negative impact on quality of life.4
D iscussion
Skin diseases account for approximately 40% of all occupation-related diseases worldwide, and hand derma titis is the most common subtype.1 Risk factors in developing hand dermatitis include a preexisting history of atopy or contact allergy and an occupation involving wet work, irritants, sensitizers, or continuous friction.1 With unilateral hand involvement, a high index of
Case 1
This patient’s patch test showed that her reaction to the rubber bumper sample had work-related and clinical significance. Both IPPD and CPPD are antioxidants and antiozonants that are used in the production of rubber to prevent drying and cracking of rubber products.5 An indepth examination of this patient’s work environment showed that she had direct skin exposure to these substances in the exact areas of her skin eruption (Figure 4). Identification of her contact allergy facilitated a change in her job to one with no direct skin exposure to rubber bumpers. This highlights the importance of patch testing to workplace materials in the case of possible occupationrelated allergic contact dermatitis. Case 2
The positive reactions seen on this patient’s patch test also had both work-related and clinical significance. The patient tested positive to the dark blue rubber gloves that he used on a regular basis when exposed to wet work. His reaction to black rubber mix had work-related significance as the rubber handles at his workplace were made of black rubber. The constituents of black rubber mix are known to be Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 283-286
285
Mussani and DeKoven
components of rubber products and are established contact allergens. In addition, he showed positive reactions to thiuram and carba mixes. These are common rubber accelerators, and it is plausible that they would have been incorporated into his dark blue rubber gloves and could have been constituents of the rubber handles.7 Furthermore, he operated machinery with rubber handles using his right hand (Figure 5). The friction and sweat from his work activities with his right hand may have accentuated the palmar presentation of his allergic contact dermatitis. Given the nature of his work and the small size of his company, he was not able to continue working at this job site.
Conclusion Any case of unilateral hand dermatitis should raise a high index of suspicion for an allergic contact dermatitis.
Acknowledgment Financial disclosure of authors and reviewers: None reported.
References 1. Lakshmi C, Srinivas C. Hand eczema: an update. Indian J Dermatol Venereol Leprol 2012;78:569-82, doi: 10.4103/0378-6323,100547. 2. Anderson B, Marks J, Clarke S. Unilateral hand dermatitis: a distinctive clinical presentation of allergic contact dermatitis. Dermatitis 2007;18:113, doi:10.2310/6620.2007.06012. 3. Weinberger L, Seraly M, Zirwas M. Palmar dermatitis due to a rubber escalator railing. Contact Dermatitis 2006;54:59-60, doi: 10,1111/j.0105-1873.2006.0729a.x. 4. Cvetkovski R, Zachariae R, Jensen H, et al. Quality of life and depression in a population of occupational hand eczema patients. Contact Dermatitis 2006;54:106-11, doi:10.1111/j.0105-1873.2006. 00783.x. 5. Herve-Bazin B, Gradiski D, Duprat P, et al. Occupational eczema from N-isopropyl -N'-phenylparaphenylenediamine (IPPD) and Ndimethy-1,3 butyl-N'-phenylparaphenylenediamine (DMPPD) in tyres. Contact Dermatitis 1977;3:1-15, doi:10.1111/j.l600-0536.1977. tb03580.x. 6. Sarma N. Occupational allergic contact dermatitis among construc tion workers in India. Indian J Dermatol 2009;54:137^1, doi: 10. 4103/0019-5154.53192. 7. Warshaw E, Kwon G, Mathias C, et al. Occupationally related contact dermatitis in North American food service workers referred for patch testing, 1994 to 2010. Dermatitis 2013;24: 22- 8 .
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 283-286
Copyright of Journal of Cutaneous Medicine & Surgery is the property of Decker Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Unilateral Hand Allergic Contact Dermatitis due to Occupational Exposure Farheen Mussani and Joel G. DeKoven
Background and Objective: H and d e rm a titis is th e m o s t c o m m o n s u b ty p e o f o c c u p a tio n -re la te d skin d isease. R egard less o f its u n d e rly in g cause, h an d d e rm a titis re su lts in s ig n ific a n t im p a irm e n t an d a n e g a tiv e im p a c t on q u a lity o f life. A n y case o f u n ila te ra l h a n d d e rm a titis s h o u ld h ave a h ig h in d e x o f su sp icion fo r an a lle rg ic c o n ta c t d e rm a titis .
Conclusion: W e re p o rt t w o cases o f u n ila te ra l h an d d e rm a titis . T h e firs t case is a 5 3 -y e a r-o ld fe m a le w ith a u n ila te ra l d e rm a titis o f th e le ft h an d . T h e second case is a 5 3 -y e a r-o ld m a le w ith d e rm a titis o f th e rig h t han d. B oth cases h ig h lig h t an in te re s tin g p re s e n ta tio n o f u n ila te ra l h an d a lle rg ic c o n ta c t d e rm a titis s e co n d a ry to an o c c u p a tio n a l ex po sure.
Contexte et object'd: La d e rm a tite d e la m a in es t le s o u s -ty p e le p lu s fre q u e n t d 'a ffe c tio n c u ta n e e p ro fess io n n e lle . Q u e lle q u 'en s o it la cause so u s -ja c e n te , la d e rm a tite d e la m a in cause des tro u b le s im p o rta n ts e t a lte re la q u a lite d e vie. II y a u ra it lieu de so u p g o n n er fo r te m e n t u ne d e rm a tite d e c o n ta c t, d e n a tu re a lle rg iq u e , d an s to u s les cas d e d e rm a tite u n i l a t e r a l d e la m a in .
Conclusions: S e ro n t expo ses d an s I'a rtic le d e u x cas d e d e rm a tite u n ila te ra le d e la m a in : I'u n ch ez u n e fe m m e d e 53 an s, d o n t la m a in g a u c h e es t affe cte e; I'a u tre ch ez un h o m m e d e 53 ans, d o n t la m a in d ro ite es t a ffe cte e. Les d e u x cas fo n t re s s o rtir un ta b le a u in te re s s a n t d e la d e rm a tite d e c o n ta c t u n ila te ra le d e la m a in , d e n a tu re a lle rg iq u e , a ttrib u a b le a u n e e x p o s itio n p ro fe s s io n n e lle a c e rta in e s su b stan ces.
Case 1 A 53-year-old female was referred for assessment of an eruption of 1.5 years’ duration involving three fingers on her left, nondominant, hand. The patient initially noted pruritus on her left hand second digit fingertip, which progressed to a vesicular eruption. Gradually over time, the rash involved the fingertips of digits 1, 2, and 3. With short periods of respite on the weekend, her eruption would improve but never fully heal. The patient’s occupation, an assembly line worker for automotive door handles, involved significant contact of her nondominant hand with rubber bumpers, steel, and cleaning supplies. The rubber bumper was a small, black, pliable, cylinder like piece resembling a small screw. She wore nitrile gloves
From the Division o f Dermatology, University o f Toronto, and Department o f Occupational and Environmental Health, St. Michael’s Hospital, Toronto, ON. Address reprint requests to: Joel DeKoven, MD, MHSc, University o f Toronto, 2075 Bayview Avenue, Suite M l-700, Toronto, O N M 4 N 3M5; e-mail: [email protected]. D O I 1 0 .2 3 1 0 /7 7 5 0 .2 0 1 3 .1 3 1 0 4
© 2014 Canadian Dermatology Association
covered with golf gloves to provide protection for her fingers. However, this did not improve her condition. She was otherwise healthy and had no history of atopy. Examination revealed an erythematous, vesicular, scaly eruption on the fingertips of digits 1, 2, and 3 of her left hand (Figure 1). No other lesions were identified. Patch testing was performed to the North American standard series (Chemotechniques, Malmo, Sweden), rubber series (Chemotechniques), melamine formalde hyde resin, and the rubber bumper used in her workplace occluded for 7 days. IQ Ultra Chambers (Dormer Laboratories Inc, Rexdale, ON) were used for the commercial allergens, and these were adhered to the patient’s back using Scanpor tape (Epitest Ltd Oy, Tuusula, Finland). The results were read using the International Contact Dermatitis Research Group grading scale at 2 days and 7 days after application. At 7 days, she showed the following positive reactions (Figure 2): • Rubber bumper sample from the workplace 2+ • N-Isopropyl-AT-phenyl paraphenylenediamine (IPPD) - standard series 2+ • N-Isopropyl-N'-phenyl paraphenylenediamine (IPPD) - rubber series 1+
DECKER^ Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 283-286
283
M ussani and DeKoven
Figure 1. Case 1 showing unilateral fingertip dermatitis.
• N-Cyclohexyl-N'-phenyl-4-phenylenediamine (CPPD)
2+ • Nickel sulfate 2.5% Id-
Case 2
A 53-year-old male was seen for assessment of an eruption of 3 years’ duration involving the palmar surface of his right dominant hand. The patient worked at a marble company for the last 8 years. His occupation required him to measure slabs of marble and cut them on a machine.
The pieces of marble were then polished with water and a buffer. The patient used his right hand to buff the pieces, resulting in increased friction. The marble pieces were then glued together, and at this point of the manufacturing process, the patient wore rubber gloves. On occasion, while in contact with the rubber handles of certain machinery, the patient would not wear rubber gloves. As well, periodically, these gloves would tear along his palm. With periods of respite, the patient noted complete clearing of his right-handed eruption. On returning to work, his rash gradually worsened over 1 to 2 weeks. He was otherwise healthy and had no history of atopy. Examination revealed a significant dermatitic eruption on the palmar surface of his right hand, including the entire palm (Figure 3). Both the dorsal and palmar surfaces of all fingers on the right hand were affected There was marked hyperkeratosis and lichenification. The left hand was mildly affected, and his feet were bilaterally clear. No other lesions were identified. Patch testing was performed to the North American standard series (Chemotechniques), epoxy series (Chemotechniques), the patient’s personal products, and the rubber gloves and glues used in his workplace occluded for 7 days. IQ Ultra Chambers were used for the commercial allergens, and these were adhered to the patient’s back using Scanpor tape. The results were read using the International Contact Dermatitis Research Group grading scale at 2 days and 7 days after application.
Rubber BUmper Workplace Material
Figure 2. Case 1 showing patch test results at 7 days.
CPPD
284
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 283-286
Hand Dermatitis due to Occupational Exposure
Figure 3. Case 2 showing unilateral palmar dermatitis.
At 7 days, he showed the following positive reactions: • • • • •
Black rubber mix 1+ Dark blue rubber gloves 1+ Thiuram mix 1+ Carba mix 1+ Cobalt Id-
Figure 5. Case 2 showing the workplace machinery with rubber handles.
suspicion for allergic contact dermatitis is necessary. A case report in 2006 showed the use of baby wipes resulting in a unilateral palmar eruption.2 A subsequent report in 2007 described a unilateral palmar dermatitis due to contact with a rubber escalator railing, with positive patch tests to constituents of the black rubber mix.3 Regardless of the cause, hand dermatitis results in significant impair ment and a negative impact on quality of life.4
D iscussion
Skin diseases account for approximately 40% of all occupation-related diseases worldwide, and hand derma titis is the most common subtype.1 Risk factors in developing hand dermatitis include a preexisting history of atopy or contact allergy and an occupation involving wet work, irritants, sensitizers, or continuous friction.1 With unilateral hand involvement, a high index of
Case 1
This patient’s patch test showed that her reaction to the rubber bumper sample had work-related and clinical significance. Both IPPD and CPPD are antioxidants and antiozonants that are used in the production of rubber to prevent drying and cracking of rubber products.5 An indepth examination of this patient’s work environment showed that she had direct skin exposure to these substances in the exact areas of her skin eruption (Figure 4). Identification of her contact allergy facilitated a change in her job to one with no direct skin exposure to rubber bumpers. This highlights the importance of patch testing to workplace materials in the case of possible occupationrelated allergic contact dermatitis. Case 2
The positive reactions seen on this patient’s patch test also had both work-related and clinical significance. The patient tested positive to the dark blue rubber gloves that he used on a regular basis when exposed to wet work. His reaction to black rubber mix had work-related significance as the rubber handles at his workplace were made of black rubber. The constituents of black rubber mix are known to be Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 283-286
285
Mussani and DeKoven
components of rubber products and are established contact allergens. In addition, he showed positive reactions to thiuram and carba mixes. These are common rubber accelerators, and it is plausible that they would have been incorporated into his dark blue rubber gloves and could have been constituents of the rubber handles.7 Furthermore, he operated machinery with rubber handles using his right hand (Figure 5). The friction and sweat from his work activities with his right hand may have accentuated the palmar presentation of his allergic contact dermatitis. Given the nature of his work and the small size of his company, he was not able to continue working at this job site.
Conclusion Any case of unilateral hand dermatitis should raise a high index of suspicion for an allergic contact dermatitis.
Acknowledgment Financial disclosure of authors and reviewers: None reported.
References 1. Lakshmi C, Srinivas C. Hand eczema: an update. Indian J Dermatol Venereol Leprol 2012;78:569-82, doi: 10.4103/0378-6323,100547. 2. Anderson B, Marks J, Clarke S. Unilateral hand dermatitis: a distinctive clinical presentation of allergic contact dermatitis. Dermatitis 2007;18:113, doi:10.2310/6620.2007.06012. 3. Weinberger L, Seraly M, Zirwas M. Palmar dermatitis due to a rubber escalator railing. Contact Dermatitis 2006;54:59-60, doi: 10,1111/j.0105-1873.2006.0729a.x. 4. Cvetkovski R, Zachariae R, Jensen H, et al. Quality of life and depression in a population of occupational hand eczema patients. Contact Dermatitis 2006;54:106-11, doi:10.1111/j.0105-1873.2006. 00783.x. 5. Herve-Bazin B, Gradiski D, Duprat P, et al. Occupational eczema from N-isopropyl -N'-phenylparaphenylenediamine (IPPD) and Ndimethy-1,3 butyl-N'-phenylparaphenylenediamine (DMPPD) in tyres. Contact Dermatitis 1977;3:1-15, doi:10.1111/j.l600-0536.1977. tb03580.x. 6. Sarma N. Occupational allergic contact dermatitis among construc tion workers in India. Indian J Dermatol 2009;54:137^1, doi: 10. 4103/0019-5154.53192. 7. Warshaw E, Kwon G, Mathias C, et al. Occupationally related contact dermatitis in North American food service workers referred for patch testing, 1994 to 2010. Dermatitis 2013;24: 22- 8 .
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 283-286
Copyright of Journal of Cutaneous Medicine & Surgery is the property of Decker Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
