In the world of modern dermatology, treating contact dermatitis may not have the cache of phototherapy or the challenge of skin cancer treatment. However, patients with undiagnosed and untreated dermatitis can suffer life-altering, even debilitating symptoms. While some cases of contact dermatitis can be relatively easy to diagnose and are typically treated by simply removing the source of the dermatitis, some patients have difficult-to-detect or unexpected sources for their dermatitis. For most of these patients, months, and sometimes years, of frustration are lifted when their dermatologist finally uncovers the offending allergen responsible for all their grief. The Dancer’s Feet The image of a dancer is supposed to be one of grace and flawless beauty. However, it’s difficult to be graceful or project beauty when your feet itch constantly for nearly a year. This was the case with a 12-year-old dancer who was referred to Andrew Scheman, M.D., a dermatologist in private practice in North-Brook, IL. “The interesting thing about the case was the perfect triangle-shape of the eczema.” (See photos.) Dr. Scheman ran the array of tests that the location of the dermatitis would suggest. “We ran the shoe and textile trays, but these were negative. We looked at her dance shoes, and she had one pair that had neoprene instep panels that matched her eczema.” We therefore tested for the ingredients that went into the manufacture of neoprene, and she came up positive to diethylthiourea. Thiourea compounds are often used as accelerators in the neoprene industry. Patch testing could be done with the specific thiourea compounds or with the dialkyl thiourea mix, but testing with material from the suspected products may be negative. Neoprene allergy commonly occurs from athletic shoes, especially slip-on athletic shoes with elastic neoprene uppers. Neoprene is also found in sports padding (hockey, football and so on) and in orthopedic braces and corsets. In addition, this material is also commonly found in wetsuits, swim masks and some other types of swimming gear. A Soldier’s Story Matthew J. Darling, D.O., a flight surgeon who had served in the armed services in the United Arab Emirates, encountered an intriguing case of contact dermatitis that resulted from henna tattoos. “One of our female solders got a henna tattoo applied by a local vendor,” explains Dr. Darling. “About 3 or 4 days later, she experienced intense itching. The location of the tattoo and the subsequent dermatitis made it difficult to wear the clothes and the equipment that she needed for her daily job.” Dr. Darling was unable to identify the vendor and therefore the exact ingredients that he had used, but he treated her with a moderate potency topical steroid to control the itching and irritation. Within several weeks, the contact dermatitis had largely cleared. While the henna itself is typically non-irritating, many ingredients can be added to the henna to change the color of the tattoo or to make it last longer on the skin. One ingredient that can cause severe reactions in a large percentage of individuals, and likely the one that caused the severe dermatitis in this soldier, is para-phenylenediamine (PPD), an agent that darkens the henna, making it last longer. “I think physicians in general, and dermatologists in particular, need to be aware of the problems with henna tattoos because PPD is not the only questionable ingredient added to the henna,” warns Dr. Darling. “Although the dermatitis will likely clear in a few weeks, the potential for significant permanent scarring in severe cases is large.” Dr. Darling goes on to warn that allergic reactions aside, one of the key ingredients in henna, Lawsone, can cause hemolytic anemia in children (if they are G6PD deficient), which is a life- threatening condition. “With the growing popularity of henna tattoos, I think we need to be more concerned with this issue,” says Dr. Darling. “When a popular singer gets a henna tattoo on her daughter, many folks will emulate that and I think that we may see many more cases of this.” The Waitress and Her Fingernails Often, physicians must look beyond the obvious and delve deeper into the patient’s activities to determine the true source of the dermatitis. When a waitress came to Christen Mowad, M.D., Assistant Professor and Director of the Contact Dermatitis Clinic at the Geisinger Medical Center in Danville, PA, Dr. Mowad’s immediate reaction was that something in this woman’s workplace was the likely source of the dermatitis. After running the standard tray of tests for the types of irritants and allergens that a waitress would typically contact, Dr. Mowad was surprised to find that the patient had no reactions to any of the standard chemicals. “It makes sense to test for the most obvious sources, but when those tests don’t uncover anything, that’s when the skill of the dermatologist really comes into play.” Dr. Mowad began to run additional testing. “The problem with additional testing is that it can be very inconvenient for the patient, and when you start getting into more exotic testing, things that are not generally included in standard trays, it can be a bit expensive.” After several fruitless rounds of testing, the patient tested positive for primula, or primrose, which isn’t on the standard T.R.U.E. Test. Since the patient did not garden or have contact with flowers very often, Dr. Mowad was puzzled by the continued dermatitis. Finally, the patient remarked that she had a small plant at home that she’d occasionally prune by snipping dead flowers and shoots using her fingernails. The plant proved to be a primrose. The woman stopped pinching the plant and her dermatitis resolved. Even with a careful look at a patient’s lifestyle, it can be easy to overlook something, especially when relying on a patient’s memory of all of the details of his or her daily routine. Or, in this case, the waitress may have known the plant as a cowslip and even when told that she was allergic to primrose, might not have made the connection. The Case of the Swollen Eyelids When a white woman in her fifties with chronic eyelid dermatitis was referred to Dr. Mowad’s office, she had endured many months of swollen and irritated eyelids. “The first thing you think about with this type of eyelid dermatitis is the cosmetics the patient is using,” says Dr. Mowad. “Or you might look at the items that she uses to apply makeup, the brushes, sponges, and so on.” Initially, the patient applied over- the-counter topical cortisone cream in an unsuccessful attempt to relieve the dermatitis. The physician who initially treated her had also attempted to treat with prescription-strength cortisone cream, which proved ineffective. By the time Dr. Mowad examined this patient, prior testing had already revealed the agent for her dermatitis to be sensitivity to nickel, but there had been no success in identifying the source for the allergy. The patient had stopped using all of her cosmetics, moisturizers and other facial products. “Even after she eliminated all her cosmetics and related chemicals, the chronic eyelid dermatitis persisted. She was clearly frustrated and was really quite uncomfortable. We wanted to resolve this for her.” Dr. Mowad and the patient painstakingly catalogued every item used daily to determine the source for the nickel allergy. Finally, the patient revealed that she used an eyelash curler. The curler proved to be made of nickel-plated metal. “We immediately told her to stop using that curler,” says Dr. Mowad. “Within a few weeks, the dermatitis resolved and when the patient began to use a plastic curler, the dermatitis didn’t return.” Comprehensive testing of the patient coupled with a close look at the patient’s habits and activities, allowed Dr. Mowad to uncover the source for the allergy and successfully treat this patient. The Hidden Hot Tub Allergen With more people installing hot tubs and public pools and spas and switching to alternative sanitizing agents such as bromine, there appears to be an up-tick in the number of patients with contact dermatitis related to pool and spa chemicals. One such patient came to Dr. Scheman for treatment and exhibited the classic symptoms of sensitivity to pool chemicals. “This patient would develop rashes after being in his hot tub,” says Dr. Scheman. “The rashes were always below the neck line, which is a pretty clear indicator of the source.” When this 38-year-old patient presented to Dr. Scheman, patch testing was done to various chemicals used in pools and spas. More and more cases of allergic reactions to bromine pool and spa chemicals (in the form of bromo-chloro-dimethylhydantoin) are being reported as the use of these chemicals increases. “I have seen many cases of allergic contact dermatitis from sensitivity to bromine-based sanitizers,” says Dr. Scheman. “If someone comes in with dermatitis and he or she has a hot tub or spa, bromine is always going to be the number-one suspect.” “We tested for chlorine, bromo-chloro-dimethylhydantoin, ammonium persulfate, sodium metabisulfite (used to adjust pH), and fragrances because they’re often added to spa water,” says Dr. Scheman. “The patient did not react to the chlorine or bromide, which the typical patient would. However, he did react to the sodium metabisulfite and ammonium persulfate. Ammonium persulfate was used to screen for contact allergy to the potassium persulfate used as shock treatment in the patient’s spa (and it’s also used in many bromine-based pool and spa chemical systems).” The patient switched to a chlorine-based sanitizer and shock treatment and began to use other chemicals to adjust the pH levels in his spa. Soon after, his condition cleared. Finding a Solution for the Solution In another case of hidden sources that had an additional twist, Dr. Scheman treated a 36-year-old female with an 8-month history of dermatitis of the face and neck, especially around the eyes. “We had lots of suspects since she used hair dye as well as botanical haircare products. She also swam often and was using Patanol eye drops.” “We did a patch test to the North American Contact Dermatitis Group standard tray, a cosmetic tray, a botanical tray and a pool chemical tray,” explains Dr. Scheman. “She came up positive to benzalkonium chloride, which is a preservative present in almost all prescription eyedrop medications.” The woman used two products that contained the chemical preservative. “We were happy to uncover the source of the allergy. However, we now faced the problem of how to deal with this,” says Dr. Scheman. “Fortunately, we have a pharmacy we frequently use that was able to compound a preservative-free copy of the patient’s medication,” says Dr. Scheman. “The patient was able to use the new formulation with no signs of allergy.” Dr. Scheman routinely contacts eyecare providers in the area to make them aware that he offers patch testing for suspected contact allergy to ophthalmic medications. In this instance, Dr. Scheman not only had to isolate the allergen but also find an acceptable solution to the problem since simply eliminating the contact lens solution wasn’t an option for the patient. Knowing what resources are available and being able to take advantage of them can be as important as testing when trying to resolve particular cases. Persistence Pays Although the T.R.U.E. Test panel of 23 common allergens can pick up some simple cases of contact allergy, there are many other chemical compounds that can cause dermatitis in particular individuals. If the common tests do not yield an agent, the dermatologist must carefully expand the testing or refer the patient to a patch test center that can do so. To successfully treat intractable dermatitis, you must be persistent and use every available resource. Also, it pays to avoid making easy assumptions about the cause or the appropriate response for the dermatitis.
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Cracking Tough Cases of Contact Dermatitis
In the world of modern dermatology, treating contact dermatitis may not have the cache of phototherapy or the challenge of skin cancer treatment. However, patients with undiagnosed and untreated dermatitis can suffer life-altering, even debilitating symptoms. While some cases of contact dermatitis can be relatively easy to diagnose and are typically treated by simply removing the source of the dermatitis, some patients have difficult-to-detect or unexpected sources for their dermatitis. For most of these patients, months, and sometimes years, of frustration are lifted when their dermatologist finally uncovers the offending allergen responsible for all their grief. The Dancer’s Feet The image of a dancer is supposed to be one of grace and flawless beauty. However, it’s difficult to be graceful or project beauty when your feet itch constantly for nearly a year. This was the case with a 12-year-old dancer who was referred to Andrew Scheman, M.D., a dermatologist in private practice in North-Brook, IL. “The interesting thing about the case was the perfect triangle-shape of the eczema.” (See photos.) Dr. Scheman ran the array of tests that the location of the dermatitis would suggest. “We ran the shoe and textile trays, but these were negative. We looked at her dance shoes, and she had one pair that had neoprene instep panels that matched her eczema.” We therefore tested for the ingredients that went into the manufacture of neoprene, and she came up positive to diethylthiourea. Thiourea compounds are often used as accelerators in the neoprene industry. Patch testing could be done with the specific thiourea compounds or with the dialkyl thiourea mix, but testing with material from the suspected products may be negative. Neoprene allergy commonly occurs from athletic shoes, especially slip-on athletic shoes with elastic neoprene uppers. Neoprene is also found in sports padding (hockey, football and so on) and in orthopedic braces and corsets. In addition, this material is also commonly found in wetsuits, swim masks and some other types of swimming gear. A Soldier’s Story Matthew J. Darling, D.O., a flight surgeon who had served in the armed services in the United Arab Emirates, encountered an intriguing case of contact dermatitis that resulted from henna tattoos. “One of our female solders got a henna tattoo applied by a local vendor,” explains Dr. Darling. “About 3 or 4 days later, she experienced intense itching. The location of the tattoo and the subsequent dermatitis made it difficult to wear the clothes and the equipment that she needed for her daily job.” Dr. Darling was unable to identify the vendor and therefore the exact ingredients that he had used, but he treated her with a moderate potency topical steroid to control the itching and irritation. Within several weeks, the contact dermatitis had largely cleared. While the henna itself is typically non-irritating, many ingredients can be added to the henna to change the color of the tattoo or to make it last longer on the skin. One ingredient that can cause severe reactions in a large percentage of individuals, and likely the one that caused the severe dermatitis in this soldier, is para-phenylenediamine (PPD), an agent that darkens the henna, making it last longer. “I think physicians in general, and dermatologists in particular, need to be aware of the problems with henna tattoos because PPD is not the only questionable ingredient added to the henna,” warns Dr. Darling. “Although the dermatitis will likely clear in a few weeks, the potential for significant permanent scarring in severe cases is large.” Dr. Darling goes on to warn that allergic reactions aside, one of the key ingredients in henna, Lawsone, can cause hemolytic anemia in children (if they are G6PD deficient), which is a life- threatening condition. “With the growing popularity of henna tattoos, I think we need to be more concerned with this issue,” says Dr. Darling. “When a popular singer gets a henna tattoo on her daughter, many folks will emulate that and I think that we may see many more cases of this.” The Waitress and Her Fingernails Often, physicians must look beyond the obvious and delve deeper into the patient’s activities to determine the true source of the dermatitis. When a waitress came to Christen Mowad, M.D., Assistant Professor and Director of the Contact Dermatitis Clinic at the Geisinger Medical Center in Danville, PA, Dr. Mowad’s immediate reaction was that something in this woman’s workplace was the likely source of the dermatitis. After running the standard tray of tests for the types of irritants and allergens that a waitress would typically contact, Dr. Mowad was surprised to find that the patient had no reactions to any of the standard chemicals. “It makes sense to test for the most obvious sources, but when those tests don’t uncover anything, that’s when the skill of the dermatologist really comes into play.” Dr. Mowad began to run additional testing. “The problem with additional testing is that it can be very inconvenient for the patient, and when you start getting into more exotic testing, things that are not generally included in standard trays, it can be a bit expensive.” After several fruitless rounds of testing, the patient tested positive for primula, or primrose, which isn’t on the standard T.R.U.E. Test. Since the patient did not garden or have contact with flowers very often, Dr. Mowad was puzzled by the continued dermatitis. Finally, the patient remarked that she had a small plant at home that she’d occasionally prune by snipping dead flowers and shoots using her fingernails. The plant proved to be a primrose. The woman stopped pinching the plant and her dermatitis resolved. Even with a careful look at a patient’s lifestyle, it can be easy to overlook something, especially when relying on a patient’s memory of all of the details of his or her daily routine. Or, in this case, the waitress may have known the plant as a cowslip and even when told that she was allergic to primrose, might not have made the connection. The Case of the Swollen Eyelids When a white woman in her fifties with chronic eyelid dermatitis was referred to Dr. Mowad’s office, she had endured many months of swollen and irritated eyelids. “The first thing you think about with this type of eyelid dermatitis is the cosmetics the patient is using,” says Dr. Mowad. “Or you might look at the items that she uses to apply makeup, the brushes, sponges, and so on.” Initially, the patient applied over- the-counter topical cortisone cream in an unsuccessful attempt to relieve the dermatitis. The physician who initially treated her had also attempted to treat with prescription-strength cortisone cream, which proved ineffective. By the time Dr. Mowad examined this patient, prior testing had already revealed the agent for her dermatitis to be sensitivity to nickel, but there had been no success in identifying the source for the allergy. The patient had stopped using all of her cosmetics, moisturizers and other facial products. “Even after she eliminated all her cosmetics and related chemicals, the chronic eyelid dermatitis persisted. She was clearly frustrated and was really quite uncomfortable. We wanted to resolve this for her.” Dr. Mowad and the patient painstakingly catalogued every item used daily to determine the source for the nickel allergy. Finally, the patient revealed that she used an eyelash curler. The curler proved to be made of nickel-plated metal. “We immediately told her to stop using that curler,” says Dr. Mowad. “Within a few weeks, the dermatitis resolved and when the patient began to use a plastic curler, the dermatitis didn’t return.” Comprehensive testing of the patient coupled with a close look at the patient’s habits and activities, allowed Dr. Mowad to uncover the source for the allergy and successfully treat this patient. The Hidden Hot Tub Allergen With more people installing hot tubs and public pools and spas and switching to alternative sanitizing agents such as bromine, there appears to be an up-tick in the number of patients with contact dermatitis related to pool and spa chemicals. One such patient came to Dr. Scheman for treatment and exhibited the classic symptoms of sensitivity to pool chemicals. “This patient would develop rashes after being in his hot tub,” says Dr. Scheman. “The rashes were always below the neck line, which is a pretty clear indicator of the source.” When this 38-year-old patient presented to Dr. Scheman, patch testing was done to various chemicals used in pools and spas. More and more cases of allergic reactions to bromine pool and spa chemicals (in the form of bromo-chloro-dimethylhydantoin) are being reported as the use of these chemicals increases. “I have seen many cases of allergic contact dermatitis from sensitivity to bromine-based sanitizers,” says Dr. Scheman. “If someone comes in with dermatitis and he or she has a hot tub or spa, bromine is always going to be the number-one suspect.” “We tested for chlorine, bromo-chloro-dimethylhydantoin, ammonium persulfate, sodium metabisulfite (used to adjust pH), and fragrances because they’re often added to spa water,” says Dr. Scheman. “The patient did not react to the chlorine or bromide, which the typical patient would. However, he did react to the sodium metabisulfite and ammonium persulfate. Ammonium persulfate was used to screen for contact allergy to the potassium persulfate used as shock treatment in the patient’s spa (and it’s also used in many bromine-based pool and spa chemical systems).” The patient switched to a chlorine-based sanitizer and shock treatment and began to use other chemicals to adjust the pH levels in his spa. Soon after, his condition cleared. Finding a Solution for the Solution In another case of hidden sources that had an additional twist, Dr. Scheman treated a 36-year-old female with an 8-month history of dermatitis of the face and neck, especially around the eyes. “We had lots of suspects since she used hair dye as well as botanical haircare products. She also swam often and was using Patanol eye drops.” “We did a patch test to the North American Contact Dermatitis Group standard tray, a cosmetic tray, a botanical tray and a pool chemical tray,” explains Dr. Scheman. “She came up positive to benzalkonium chloride, which is a preservative present in almost all prescription eyedrop medications.” The woman used two products that contained the chemical preservative. “We were happy to uncover the source of the allergy. However, we now faced the problem of how to deal with this,” says Dr. Scheman. “Fortunately, we have a pharmacy we frequently use that was able to compound a preservative-free copy of the patient’s medication,” says Dr. Scheman. “The patient was able to use the new formulation with no signs of allergy.” Dr. Scheman routinely contacts eyecare providers in the area to make them aware that he offers patch testing for suspected contact allergy to ophthalmic medications. In this instance, Dr. Scheman not only had to isolate the allergen but also find an acceptable solution to the problem since simply eliminating the contact lens solution wasn’t an option for the patient. Knowing what resources are available and being able to take advantage of them can be as important as testing when trying to resolve particular cases. Persistence Pays Although the T.R.U.E. Test panel of 23 common allergens can pick up some simple cases of contact allergy, there are many other chemical compounds that can cause dermatitis in particular individuals. If the common tests do not yield an agent, the dermatologist must carefully expand the testing or refer the patient to a patch test center that can do so. To successfully treat intractable dermatitis, you must be persistent and use every available resource. Also, it pays to avoid making easy assumptions about the cause or the appropriate response for the dermatitis.
In the world of modern dermatology, treating contact dermatitis may not have the cache of phototherapy or the challenge of skin cancer treatment. However, patients with undiagnosed and untreated dermatitis can suffer life-altering, even debilitating symptoms. While some cases of contact dermatitis can be relatively easy to diagnose and are typically treated by simply removing the source of the dermatitis, some patients have difficult-to-detect or unexpected sources for their dermatitis. For most of these patients, months, and sometimes years, of frustration are lifted when their dermatologist finally uncovers the offending allergen responsible for all their grief. The Dancer’s Feet The image of a dancer is supposed to be one of grace and flawless beauty. However, it’s difficult to be graceful or project beauty when your feet itch constantly for nearly a year. This was the case with a 12-year-old dancer who was referred to Andrew Scheman, M.D., a dermatologist in private practice in North-Brook, IL. “The interesting thing about the case was the perfect triangle-shape of the eczema.” (See photos.) Dr. Scheman ran the array of tests that the location of the dermatitis would suggest. “We ran the shoe and textile trays, but these were negative. We looked at her dance shoes, and she had one pair that had neoprene instep panels that matched her eczema.” We therefore tested for the ingredients that went into the manufacture of neoprene, and she came up positive to diethylthiourea. Thiourea compounds are often used as accelerators in the neoprene industry. Patch testing could be done with the specific thiourea compounds or with the dialkyl thiourea mix, but testing with material from the suspected products may be negative. Neoprene allergy commonly occurs from athletic shoes, especially slip-on athletic shoes with elastic neoprene uppers. Neoprene is also found in sports padding (hockey, football and so on) and in orthopedic braces and corsets. In addition, this material is also commonly found in wetsuits, swim masks and some other types of swimming gear. A Soldier’s Story Matthew J. Darling, D.O., a flight surgeon who had served in the armed services in the United Arab Emirates, encountered an intriguing case of contact dermatitis that resulted from henna tattoos. “One of our female solders got a henna tattoo applied by a local vendor,” explains Dr. Darling. “About 3 or 4 days later, she experienced intense itching. The location of the tattoo and the subsequent dermatitis made it difficult to wear the clothes and the equipment that she needed for her daily job.” Dr. Darling was unable to identify the vendor and therefore the exact ingredients that he had used, but he treated her with a moderate potency topical steroid to control the itching and irritation. Within several weeks, the contact dermatitis had largely cleared. While the henna itself is typically non-irritating, many ingredients can be added to the henna to change the color of the tattoo or to make it last longer on the skin. One ingredient that can cause severe reactions in a large percentage of individuals, and likely the one that caused the severe dermatitis in this soldier, is para-phenylenediamine (PPD), an agent that darkens the henna, making it last longer. “I think physicians in general, and dermatologists in particular, need to be aware of the problems with henna tattoos because PPD is not the only questionable ingredient added to the henna,” warns Dr. Darling. “Although the dermatitis will likely clear in a few weeks, the potential for significant permanent scarring in severe cases is large.” Dr. Darling goes on to warn that allergic reactions aside, one of the key ingredients in henna, Lawsone, can cause hemolytic anemia in children (if they are G6PD deficient), which is a life- threatening condition. “With the growing popularity of henna tattoos, I think we need to be more concerned with this issue,” says Dr. Darling. “When a popular singer gets a henna tattoo on her daughter, many folks will emulate that and I think that we may see many more cases of this.” The Waitress and Her Fingernails Often, physicians must look beyond the obvious and delve deeper into the patient’s activities to determine the true source of the dermatitis. When a waitress came to Christen Mowad, M.D., Assistant Professor and Director of the Contact Dermatitis Clinic at the Geisinger Medical Center in Danville, PA, Dr. Mowad’s immediate reaction was that something in this woman’s workplace was the likely source of the dermatitis. After running the standard tray of tests for the types of irritants and allergens that a waitress would typically contact, Dr. Mowad was surprised to find that the patient had no reactions to any of the standard chemicals. “It makes sense to test for the most obvious sources, but when those tests don’t uncover anything, that’s when the skill of the dermatologist really comes into play.” Dr. Mowad began to run additional testing. “The problem with additional testing is that it can be very inconvenient for the patient, and when you start getting into more exotic testing, things that are not generally included in standard trays, it can be a bit expensive.” After several fruitless rounds of testing, the patient tested positive for primula, or primrose, which isn’t on the standard T.R.U.E. Test. Since the patient did not garden or have contact with flowers very often, Dr. Mowad was puzzled by the continued dermatitis. Finally, the patient remarked that she had a small plant at home that she’d occasionally prune by snipping dead flowers and shoots using her fingernails. The plant proved to be a primrose. The woman stopped pinching the plant and her dermatitis resolved. Even with a careful look at a patient’s lifestyle, it can be easy to overlook something, especially when relying on a patient’s memory of all of the details of his or her daily routine. Or, in this case, the waitress may have known the plant as a cowslip and even when told that she was allergic to primrose, might not have made the connection. The Case of the Swollen Eyelids When a white woman in her fifties with chronic eyelid dermatitis was referred to Dr. Mowad’s office, she had endured many months of swollen and irritated eyelids. “The first thing you think about with this type of eyelid dermatitis is the cosmetics the patient is using,” says Dr. Mowad. “Or you might look at the items that she uses to apply makeup, the brushes, sponges, and so on.” Initially, the patient applied over- the-counter topical cortisone cream in an unsuccessful attempt to relieve the dermatitis. The physician who initially treated her had also attempted to treat with prescription-strength cortisone cream, which proved ineffective. By the time Dr. Mowad examined this patient, prior testing had already revealed the agent for her dermatitis to be sensitivity to nickel, but there had been no success in identifying the source for the allergy. The patient had stopped using all of her cosmetics, moisturizers and other facial products. “Even after she eliminated all her cosmetics and related chemicals, the chronic eyelid dermatitis persisted. She was clearly frustrated and was really quite uncomfortable. We wanted to resolve this for her.” Dr. Mowad and the patient painstakingly catalogued every item used daily to determine the source for the nickel allergy. Finally, the patient revealed that she used an eyelash curler. The curler proved to be made of nickel-plated metal. “We immediately told her to stop using that curler,” says Dr. Mowad. “Within a few weeks, the dermatitis resolved and when the patient began to use a plastic curler, the dermatitis didn’t return.” Comprehensive testing of the patient coupled with a close look at the patient’s habits and activities, allowed Dr. Mowad to uncover the source for the allergy and successfully treat this patient. The Hidden Hot Tub Allergen With more people installing hot tubs and public pools and spas and switching to alternative sanitizing agents such as bromine, there appears to be an up-tick in the number of patients with contact dermatitis related to pool and spa chemicals. One such patient came to Dr. Scheman for treatment and exhibited the classic symptoms of sensitivity to pool chemicals. “This patient would develop rashes after being in his hot tub,” says Dr. Scheman. “The rashes were always below the neck line, which is a pretty clear indicator of the source.” When this 38-year-old patient presented to Dr. Scheman, patch testing was done to various chemicals used in pools and spas. More and more cases of allergic reactions to bromine pool and spa chemicals (in the form of bromo-chloro-dimethylhydantoin) are being reported as the use of these chemicals increases. “I have seen many cases of allergic contact dermatitis from sensitivity to bromine-based sanitizers,” says Dr. Scheman. “If someone comes in with dermatitis and he or she has a hot tub or spa, bromine is always going to be the number-one suspect.” “We tested for chlorine, bromo-chloro-dimethylhydantoin, ammonium persulfate, sodium metabisulfite (used to adjust pH), and fragrances because they’re often added to spa water,” says Dr. Scheman. “The patient did not react to the chlorine or bromide, which the typical patient would. However, he did react to the sodium metabisulfite and ammonium persulfate. Ammonium persulfate was used to screen for contact allergy to the potassium persulfate used as shock treatment in the patient’s spa (and it’s also used in many bromine-based pool and spa chemical systems).” The patient switched to a chlorine-based sanitizer and shock treatment and began to use other chemicals to adjust the pH levels in his spa. Soon after, his condition cleared. Finding a Solution for the Solution In another case of hidden sources that had an additional twist, Dr. Scheman treated a 36-year-old female with an 8-month history of dermatitis of the face and neck, especially around the eyes. “We had lots of suspects since she used hair dye as well as botanical haircare products. She also swam often and was using Patanol eye drops.” “We did a patch test to the North American Contact Dermatitis Group standard tray, a cosmetic tray, a botanical tray and a pool chemical tray,” explains Dr. Scheman. “She came up positive to benzalkonium chloride, which is a preservative present in almost all prescription eyedrop medications.” The woman used two products that contained the chemical preservative. “We were happy to uncover the source of the allergy. However, we now faced the problem of how to deal with this,” says Dr. Scheman. “Fortunately, we have a pharmacy we frequently use that was able to compound a preservative-free copy of the patient’s medication,” says Dr. Scheman. “The patient was able to use the new formulation with no signs of allergy.” Dr. Scheman routinely contacts eyecare providers in the area to make them aware that he offers patch testing for suspected contact allergy to ophthalmic medications. In this instance, Dr. Scheman not only had to isolate the allergen but also find an acceptable solution to the problem since simply eliminating the contact lens solution wasn’t an option for the patient. Knowing what resources are available and being able to take advantage of them can be as important as testing when trying to resolve particular cases. Persistence Pays Although the T.R.U.E. Test panel of 23 common allergens can pick up some simple cases of contact allergy, there are many other chemical compounds that can cause dermatitis in particular individuals. If the common tests do not yield an agent, the dermatologist must carefully expand the testing or refer the patient to a patch test center that can do so. To successfully treat intractable dermatitis, you must be persistent and use every available resource. Also, it pays to avoid making easy assumptions about the cause or the appropriate response for the dermatitis.
