A busy private practice clinic solely dedicated to pediatric dermatology provides the clinician with the unique opportunity to recognize certain trends in a specific age population. We focus this short discussion on emerging patterns of contact dermatitis seen in children and adolescents.
Nickel Allergy
Nickel has once again been named Contact Allergen of the Year by the American Contact Dermatitis Group.1 Teaching has long focused on the obvious areas of contact with nickel such as the bellybutton area from metal snaps/belts, and the earlobes/neck/wrists from jewelry. Not ignoring the aforementioned sites, the clinician should also recognize two areas that are increasingly common among nickel-allergic patients, as the first two examples illustrate.
CLASSROOM SEATS
Eruption Site: flexural aspect of the mid-upper thighs
Cause: nickel-containing screws in classroom seats
This particular contact dermatitis is a result of direct contact with the metal (nickel-containing) screws located on the surface of plastic and wooden chairs of classroom seats.
Presentation
Depending upon the sitting position of the patient, it may present both in a bilateral or unilateral fashion (Figure 1). Patients often present during the spring/summer, which corresponds to warmer temperatures when children frequently wear shorts or skirts, accounting for the increased amount of direct contact. In our practice, females tend to be more commonly affected.
Treatment
Treatment focuses on measures to decrease exposure. Thus, it is important for children to either use an alternative chair or apply duct tape directly to the metal screws to limit exposure to the allergen. This eruption seemingly disappears during the summer, only to reappear when re-exposure occurs as students return to the classroom in the fall. Like most forms of allergic contact dermatitis, topical steroids are effective.
CELL PHONES
Eruption Site: lateral cheek and pre-auricular region
Cause: nickel-plated cell phones
Presentation
An increasing trend involving contact dermatitis on the lateral cheek and pre-auricular region — especially among our teenage population —has been attributed to cell phone usage in direct contact with exposed skin. The eruption is typically unilateral, corresponding to the side where the patients most frequently hold their phones to their ears.
Data/Evidence
Cell phones may contain nickel plating, which has accounted for a few reports of allergic contact dermatitis in the literature.2-5 One recent study documents that excessive nickel release (i.e., a positive dimethyglyoxime test)6 is relatively frequent in a sample of cell phones from the Danish market. Additionally, chromate allergy has been mentioned in a case report of cellular phone dermatitis.7
Diagnosis
In our practice, many patients had a prior history of nickel allergy, which aided in the clinical diagnosis. Furthermore, many teenagers utilize cell phones for lengthy periods, which may account for the increased incidence in this population.
Treatment
Treatment focuses on decreasing exposure, either with a plastic covering on the cell phone, or with alternative “hands-free” devices.
SOCCER EQUIPMENT
Eruption site: anterior shins
Cause: soccer shin guards
Presentation
Next, we focus on an emerging pattern of contact dermatitis seen primarily in soccer players. Despite few reports in the literature,8-9 contact dermatitis to shin guards or shin pads has long been recognized by clinicians. The bilateral and fairly symmetric nature of this eruption corresponds to the exposure to that of a shin guard, with the most concentrated areas on the anterior shins (Figures 3A, 3B). The flexural aspect of the lower legs and the dorsal feet are classically spared. The presentation often corresponds with soccer season or with participation in sports where similar shin guards are worn.
Theories/Studies
There remains some controversy as to whether this contact dermatitis is allergic versus irritant in nature. In a case report by Sommer et al,8 a 10-year-old soccer player with a history of infantile atopic dermatitis presented with an eczematous eruption on both shins. After obtaining information from the manufacturer of the protective shin pad, it was found to contain urea-formaldehyde resin, a substance to which the patient demonstrated a 2+ patch test reaction. Interestingly, this patient did not react to the sample of shin pad itself.
The authors made a diagnosis of a combination of mechanical irritant and allergic contact dermatitis and concluded that it was more likely seen in aggravating conditions of heat and friction.
Another article included a retrospective analysis of eight children with shin guard dermatitis in which the authors documented all negative standard patch tests, as well as negative tests to the shin guard pieces (e.g., “use test).9 The authors concluded that irritant contact dermatitis, not allergy, was the cause of the dermatitis, and perhaps that sweating and friction contributed to the irritancy.
The literature is still sparse regarding this condition, and it may be difficult to absolutely rule out an underlying allergic process because standard or “use” patch testing is not typically performed under the same aggravating conditions of heat and friction (under the shin guards) where possible release of allergens may be more likely.
Diagnosis
In our practice, we have not made it customary to patch test patients with shin guard or shin pad dermatitis. However, of the five patients that have been patch tested in our clinic, two patients were positive for urea-formaldehyde resin.
We have had difficulty obtaining detailed product information from the various manufactures of shin guards. Based upon the publications to date, as well as our personal clinical experience, the most likely explanation for the shin guard rash is primarily an irritant contact dermatitis.
It is worthwhile to note that shin guard dermatitis, like many forms of contact dermatitis, is increasingly common among those patients with a prior history of atopic dermatitis.
Treatment
In regards to treatment, various attempts have been made to limit exposure. In addition to the obvious (i.e., wearing the shin guard only during the game, and removing it immediately thereafter), other measures have been employed to decrease contact with the shin guards. One method that seems to have been proven effective in our practice employs covering the interior surface of the shin guard with duct tape. Along with topical steroid therapy, this eruption improves, but usually recurs with re-exposure to the shin guards.
Eruption site: various areas corresponding to contact to car seat
Cause: Car seat material
Presentation
Another newly recognized pattern of contact dermatitis is seen in infants exposed to certain car seats. Our practice first noted this eruption approximately 3 years ago, and it continues to be more recognized.
Depending upon the severity and duration of exposure, patients may present with various morphologies, ranging from acute, inflamed papules and vesicles to more chronic, eczematous plaques.
The distribution is quite unique, and typically involves seven affected sites, corresponding to skin contact with the car seat. These regions include both elbows, both upper thighs, both lateral calves, and often the occipital scalp. If a headrest or support is utilized, then the latter site may be spared as it acts a barrier to the car seat material. Additionally, the distribution is uniquely symmetric and bilateral. Although some of the aforementioned locations quite often coincide with extensor sites typical for infantile atopic dermatitis, these specific regions directly correlate with contact exposure as the infant is secured in the car seat. (Figures 4, 5) Moreover, the perfectly midline location on the occipital scalp is not a classic site for atopic dermatitis.
Discussion
As previously mentioned, contact dermatitis may be more common among atopics. Our affected patients with an atopic background have typically shown other involved sites separate from the aforementioned seven points of contact. We have also seen this car seat eruption almost equally among those without any history of atopic dermatitis. It is noteworthy that the majority of patients tend to present during the warmer months, which is likely due to less clothing worn by the infants with an increased potential for contact exposure under the setting of increased heat and sweat.
Theories
Although not limited to a certain maker of infant car seats, we have observed a common type of shiny, water-resistant type material. Currently, our practice is working directly with a large manufacturer of infant car seats in order to better elucidate potential irritant or allergic contents of the infant car seat. Similar to the shin guard dermatitis, the car seat eruption is likely primary irritant contact in nature, but more information must be gathered in order to rule out potential allergens within the car seat that may be released under the setting of sweat, heat, and friction.
Treatment
Treatment focuses on decreasing or eliminating exposure to the car seats. When infants switch to a bland, cloth type car seat or apply a thick, cloth or other similar barrier to the car seat, rapid improvement ensues.
Interestingly, atopic patients will display an impressive improvement in the areas of contact dermatitis from the car seat, but typically continue to display their baseline sites of atopic dermatitis. Those without a prior atopic background, tend to have total resolution of all affected sites.
It is important for the clinician to recognize this pattern of contact dermatitis in the infant and remove the culprit car seat. In addition to limiting exposure, topical steroids are effective.
With little or no published data thus far, our practice hopes to offer additional insight regarding infant car seat contact dermatitis.
CONCLUSION
In conclusion, emerging patterns of contact dermatitis are becoming increasingly common among pediatric patients. In addition to nickel dermatitis, shin guards and car seats should be added to the list of potential causes
A busy private practice clinic solely dedicated to pediatric dermatology provides the clinician with the unique opportunity to recognize certain trends in a specific age population. We focus this short discussion on emerging patterns of contact dermatitis seen in children and adolescents.
Nickel Allergy
Nickel has once again been named Contact Allergen of the Year by the American Contact Dermatitis Group.1 Teaching has long focused on the obvious areas of contact with nickel such as the bellybutton area from metal snaps/belts, and the earlobes/neck/wrists from jewelry. Not ignoring the aforementioned sites, the clinician should also recognize two areas that are increasingly common among nickel-allergic patients, as the first two examples illustrate.
CLASSROOM SEATS
Eruption Site: flexural aspect of the mid-upper thighs
Cause: nickel-containing screws in classroom seats
This particular contact dermatitis is a result of direct contact with the metal (nickel-containing) screws located on the surface of plastic and wooden chairs of classroom seats.
Presentation
Depending upon the sitting position of the patient, it may present both in a bilateral or unilateral fashion (Figure 1). Patients often present during the spring/summer, which corresponds to warmer temperatures when children frequently wear shorts or skirts, accounting for the increased amount of direct contact. In our practice, females tend to be more commonly affected.
Treatment
Treatment focuses on measures to decrease exposure. Thus, it is important for children to either use an alternative chair or apply duct tape directly to the metal screws to limit exposure to the allergen. This eruption seemingly disappears during the summer, only to reappear when re-exposure occurs as students return to the classroom in the fall. Like most forms of allergic contact dermatitis, topical steroids are effective.
CELL PHONES
Eruption Site: lateral cheek and pre-auricular region
Cause: nickel-plated cell phones
Presentation
An increasing trend involving contact dermatitis on the lateral cheek and pre-auricular region — especially among our teenage population —has been attributed to cell phone usage in direct contact with exposed skin. The eruption is typically unilateral, corresponding to the side where the patients most frequently hold their phones to their ears.
Data/Evidence
Cell phones may contain nickel plating, which has accounted for a few reports of allergic contact dermatitis in the literature.2-5 One recent study documents that excessive nickel release (i.e., a positive dimethyglyoxime test)6 is relatively frequent in a sample of cell phones from the Danish market. Additionally, chromate allergy has been mentioned in a case report of cellular phone dermatitis.7
Diagnosis
In our practice, many patients had a prior history of nickel allergy, which aided in the clinical diagnosis. Furthermore, many teenagers utilize cell phones for lengthy periods, which may account for the increased incidence in this population.
Treatment
Treatment focuses on decreasing exposure, either with a plastic covering on the cell phone, or with alternative “hands-free” devices.
SOCCER EQUIPMENT
Eruption site: anterior shins
Cause: soccer shin guards
Presentation
Next, we focus on an emerging pattern of contact dermatitis seen primarily in soccer players. Despite few reports in the literature,8-9 contact dermatitis to shin guards or shin pads has long been recognized by clinicians. The bilateral and fairly symmetric nature of this eruption corresponds to the exposure to that of a shin guard, with the most concentrated areas on the anterior shins (Figures 3A, 3B). The flexural aspect of the lower legs and the dorsal feet are classically spared. The presentation often corresponds with soccer season or with participation in sports where similar shin guards are worn.
Theories/Studies
There remains some controversy as to whether this contact dermatitis is allergic versus irritant in nature. In a case report by Sommer et al,8 a 10-year-old soccer player with a history of infantile atopic dermatitis presented with an eczematous eruption on both shins. After obtaining information from the manufacturer of the protective shin pad, it was found to contain urea-formaldehyde resin, a substance to which the patient demonstrated a 2+ patch test reaction. Interestingly, this patient did not react to the sample of shin pad itself.
The authors made a diagnosis of a combination of mechanical irritant and allergic contact dermatitis and concluded that it was more likely seen in aggravating conditions of heat and friction.
Another article included a retrospective analysis of eight children with shin guard dermatitis in which the authors documented all negative standard patch tests, as well as negative tests to the shin guard pieces (e.g., “use test).9 The authors concluded that irritant contact dermatitis, not allergy, was the cause of the dermatitis, and perhaps that sweating and friction contributed to the irritancy.
The literature is still sparse regarding this condition, and it may be difficult to absolutely rule out an underlying allergic process because standard or “use” patch testing is not typically performed under the same aggravating conditions of heat and friction (under the shin guards) where possible release of allergens may be more likely.
Diagnosis
In our practice, we have not made it customary to patch test patients with shin guard or shin pad dermatitis. However, of the five patients that have been patch tested in our clinic, two patients were positive for urea-formaldehyde resin.
We have had difficulty obtaining detailed product information from the various manufactures of shin guards. Based upon the publications to date, as well as our personal clinical experience, the most likely explanation for the shin guard rash is primarily an irritant contact dermatitis.
It is worthwhile to note that shin guard dermatitis, like many forms of contact dermatitis, is increasingly common among those patients with a prior history of atopic dermatitis.
Treatment
In regards to treatment, various attempts have been made to limit exposure. In addition to the obvious (i.e., wearing the shin guard only during the game, and removing it immediately thereafter), other measures have been employed to decrease contact with the shin guards. One method that seems to have been proven effective in our practice employs covering the interior surface of the shin guard with duct tape. Along with topical steroid therapy, this eruption improves, but usually recurs with re-exposure to the shin guards.
Eruption site: various areas corresponding to contact to car seat
Cause: Car seat material
Presentation
Another newly recognized pattern of contact dermatitis is seen in infants exposed to certain car seats. Our practice first noted this eruption approximately 3 years ago, and it continues to be more recognized.
Depending upon the severity and duration of exposure, patients may present with various morphologies, ranging from acute, inflamed papules and vesicles to more chronic, eczematous plaques.
The distribution is quite unique, and typically involves seven affected sites, corresponding to skin contact with the car seat. These regions include both elbows, both upper thighs, both lateral calves, and often the occipital scalp. If a headrest or support is utilized, then the latter site may be spared as it acts a barrier to the car seat material. Additionally, the distribution is uniquely symmetric and bilateral. Although some of the aforementioned locations quite often coincide with extensor sites typical for infantile atopic dermatitis, these specific regions directly correlate with contact exposure as the infant is secured in the car seat. (Figures 4, 5) Moreover, the perfectly midline location on the occipital scalp is not a classic site for atopic dermatitis.
Discussion
As previously mentioned, contact dermatitis may be more common among atopics. Our affected patients with an atopic background have typically shown other involved sites separate from the aforementioned seven points of contact. We have also seen this car seat eruption almost equally among those without any history of atopic dermatitis. It is noteworthy that the majority of patients tend to present during the warmer months, which is likely due to less clothing worn by the infants with an increased potential for contact exposure under the setting of increased heat and sweat.
Theories
Although not limited to a certain maker of infant car seats, we have observed a common type of shiny, water-resistant type material. Currently, our practice is working directly with a large manufacturer of infant car seats in order to better elucidate potential irritant or allergic contents of the infant car seat. Similar to the shin guard dermatitis, the car seat eruption is likely primary irritant contact in nature, but more information must be gathered in order to rule out potential allergens within the car seat that may be released under the setting of sweat, heat, and friction.
Treatment
Treatment focuses on decreasing or eliminating exposure to the car seats. When infants switch to a bland, cloth type car seat or apply a thick, cloth or other similar barrier to the car seat, rapid improvement ensues.
Interestingly, atopic patients will display an impressive improvement in the areas of contact dermatitis from the car seat, but typically continue to display their baseline sites of atopic dermatitis. Those without a prior atopic background, tend to have total resolution of all affected sites.
It is important for the clinician to recognize this pattern of contact dermatitis in the infant and remove the culprit car seat. In addition to limiting exposure, topical steroids are effective.
With little or no published data thus far, our practice hopes to offer additional insight regarding infant car seat contact dermatitis.
CONCLUSION
In conclusion, emerging patterns of contact dermatitis are becoming increasingly common among pediatric patients. In addition to nickel dermatitis, shin guards and car seats should be added to the list of potential causes
A busy private practice clinic solely dedicated to pediatric dermatology provides the clinician with the unique opportunity to recognize certain trends in a specific age population. We focus this short discussion on emerging patterns of contact dermatitis seen in children and adolescents.
Nickel Allergy
Nickel has once again been named Contact Allergen of the Year by the American Contact Dermatitis Group.1 Teaching has long focused on the obvious areas of contact with nickel such as the bellybutton area from metal snaps/belts, and the earlobes/neck/wrists from jewelry. Not ignoring the aforementioned sites, the clinician should also recognize two areas that are increasingly common among nickel-allergic patients, as the first two examples illustrate.
CLASSROOM SEATS
Eruption Site: flexural aspect of the mid-upper thighs
Cause: nickel-containing screws in classroom seats
This particular contact dermatitis is a result of direct contact with the metal (nickel-containing) screws located on the surface of plastic and wooden chairs of classroom seats.
Presentation
Depending upon the sitting position of the patient, it may present both in a bilateral or unilateral fashion (Figure 1). Patients often present during the spring/summer, which corresponds to warmer temperatures when children frequently wear shorts or skirts, accounting for the increased amount of direct contact. In our practice, females tend to be more commonly affected.
Treatment
Treatment focuses on measures to decrease exposure. Thus, it is important for children to either use an alternative chair or apply duct tape directly to the metal screws to limit exposure to the allergen. This eruption seemingly disappears during the summer, only to reappear when re-exposure occurs as students return to the classroom in the fall. Like most forms of allergic contact dermatitis, topical steroids are effective.
CELL PHONES
Eruption Site: lateral cheek and pre-auricular region
Cause: nickel-plated cell phones
Presentation
An increasing trend involving contact dermatitis on the lateral cheek and pre-auricular region — especially among our teenage population —has been attributed to cell phone usage in direct contact with exposed skin. The eruption is typically unilateral, corresponding to the side where the patients most frequently hold their phones to their ears.
Data/Evidence
Cell phones may contain nickel plating, which has accounted for a few reports of allergic contact dermatitis in the literature.2-5 One recent study documents that excessive nickel release (i.e., a positive dimethyglyoxime test)6 is relatively frequent in a sample of cell phones from the Danish market. Additionally, chromate allergy has been mentioned in a case report of cellular phone dermatitis.7
Diagnosis
In our practice, many patients had a prior history of nickel allergy, which aided in the clinical diagnosis. Furthermore, many teenagers utilize cell phones for lengthy periods, which may account for the increased incidence in this population.
Treatment
Treatment focuses on decreasing exposure, either with a plastic covering on the cell phone, or with alternative “hands-free” devices.
SOCCER EQUIPMENT
Eruption site: anterior shins
Cause: soccer shin guards
Presentation
Next, we focus on an emerging pattern of contact dermatitis seen primarily in soccer players. Despite few reports in the literature,8-9 contact dermatitis to shin guards or shin pads has long been recognized by clinicians. The bilateral and fairly symmetric nature of this eruption corresponds to the exposure to that of a shin guard, with the most concentrated areas on the anterior shins (Figures 3A, 3B). The flexural aspect of the lower legs and the dorsal feet are classically spared. The presentation often corresponds with soccer season or with participation in sports where similar shin guards are worn.
Theories/Studies
There remains some controversy as to whether this contact dermatitis is allergic versus irritant in nature. In a case report by Sommer et al,8 a 10-year-old soccer player with a history of infantile atopic dermatitis presented with an eczematous eruption on both shins. After obtaining information from the manufacturer of the protective shin pad, it was found to contain urea-formaldehyde resin, a substance to which the patient demonstrated a 2+ patch test reaction. Interestingly, this patient did not react to the sample of shin pad itself.
The authors made a diagnosis of a combination of mechanical irritant and allergic contact dermatitis and concluded that it was more likely seen in aggravating conditions of heat and friction.
Another article included a retrospective analysis of eight children with shin guard dermatitis in which the authors documented all negative standard patch tests, as well as negative tests to the shin guard pieces (e.g., “use test).9 The authors concluded that irritant contact dermatitis, not allergy, was the cause of the dermatitis, and perhaps that sweating and friction contributed to the irritancy.
The literature is still sparse regarding this condition, and it may be difficult to absolutely rule out an underlying allergic process because standard or “use” patch testing is not typically performed under the same aggravating conditions of heat and friction (under the shin guards) where possible release of allergens may be more likely.
Diagnosis
In our practice, we have not made it customary to patch test patients with shin guard or shin pad dermatitis. However, of the five patients that have been patch tested in our clinic, two patients were positive for urea-formaldehyde resin.
We have had difficulty obtaining detailed product information from the various manufactures of shin guards. Based upon the publications to date, as well as our personal clinical experience, the most likely explanation for the shin guard rash is primarily an irritant contact dermatitis.
It is worthwhile to note that shin guard dermatitis, like many forms of contact dermatitis, is increasingly common among those patients with a prior history of atopic dermatitis.
Treatment
In regards to treatment, various attempts have been made to limit exposure. In addition to the obvious (i.e., wearing the shin guard only during the game, and removing it immediately thereafter), other measures have been employed to decrease contact with the shin guards. One method that seems to have been proven effective in our practice employs covering the interior surface of the shin guard with duct tape. Along with topical steroid therapy, this eruption improves, but usually recurs with re-exposure to the shin guards.
Eruption site: various areas corresponding to contact to car seat
Cause: Car seat material
Presentation
Another newly recognized pattern of contact dermatitis is seen in infants exposed to certain car seats. Our practice first noted this eruption approximately 3 years ago, and it continues to be more recognized.
Depending upon the severity and duration of exposure, patients may present with various morphologies, ranging from acute, inflamed papules and vesicles to more chronic, eczematous plaques.
The distribution is quite unique, and typically involves seven affected sites, corresponding to skin contact with the car seat. These regions include both elbows, both upper thighs, both lateral calves, and often the occipital scalp. If a headrest or support is utilized, then the latter site may be spared as it acts a barrier to the car seat material. Additionally, the distribution is uniquely symmetric and bilateral. Although some of the aforementioned locations quite often coincide with extensor sites typical for infantile atopic dermatitis, these specific regions directly correlate with contact exposure as the infant is secured in the car seat. (Figures 4, 5) Moreover, the perfectly midline location on the occipital scalp is not a classic site for atopic dermatitis.
Discussion
As previously mentioned, contact dermatitis may be more common among atopics. Our affected patients with an atopic background have typically shown other involved sites separate from the aforementioned seven points of contact. We have also seen this car seat eruption almost equally among those without any history of atopic dermatitis. It is noteworthy that the majority of patients tend to present during the warmer months, which is likely due to less clothing worn by the infants with an increased potential for contact exposure under the setting of increased heat and sweat.
Theories
Although not limited to a certain maker of infant car seats, we have observed a common type of shiny, water-resistant type material. Currently, our practice is working directly with a large manufacturer of infant car seats in order to better elucidate potential irritant or allergic contents of the infant car seat. Similar to the shin guard dermatitis, the car seat eruption is likely primary irritant contact in nature, but more information must be gathered in order to rule out potential allergens within the car seat that may be released under the setting of sweat, heat, and friction.
Treatment
Treatment focuses on decreasing or eliminating exposure to the car seats. When infants switch to a bland, cloth type car seat or apply a thick, cloth or other similar barrier to the car seat, rapid improvement ensues.
Interestingly, atopic patients will display an impressive improvement in the areas of contact dermatitis from the car seat, but typically continue to display their baseline sites of atopic dermatitis. Those without a prior atopic background, tend to have total resolution of all affected sites.
It is important for the clinician to recognize this pattern of contact dermatitis in the infant and remove the culprit car seat. In addition to limiting exposure, topical steroids are effective.
With little or no published data thus far, our practice hopes to offer additional insight regarding infant car seat contact dermatitis.
CONCLUSION
In conclusion, emerging patterns of contact dermatitis are becoming increasingly common among pediatric patients. In addition to nickel dermatitis, shin guards and car seats should be added to the list of potential causes
