Contact sensitization in patients with leg dermatitis
M. Nečas, E. Dastychová
I st dept. of dermatovenereology of the Masaryk’s University and
St. Anna Faculty Hospital, Brno, Czech Republic

Leg (lower extremity) dermatitis
urelatively common diagnosis
uddg : broader ddg:
u stasis dermatitis    superfic. phlebitis
u microbial eczema vasculitis
u atopic dermatitis streptodermia
u asteatotic dermatitis lichen
u allergic contact dermatitis      ACA
uirritant contact dermatitis pretibial myxoedema
u
u

I~000034
Microbial eczema


   Asteatotic eczema
I~000036


I~000041
Atopic eczema


Differential diagnosis - feet
uAllergic contact dermatitis
uDyshidrosis
uTinea pedum – inflamed
uTinea pedum with microbial eczema
uPlantar psoriasis
uPlantar keratoderma
uOthers
u
u
u
u

    Inflamed tinea pedum
I~000003


Tinea pedum with microbial eczema
I~000080


        Plantar keratoderma
I~000073


        Plantar keratoderma
I~000053


       Leg contact dermatitis
uPrimary allergic contact dermatitis
u       - relatively rare
u
uSecondary ACD – common
u     in the terrain of stasis dermatitis, inflamed interdigital
u        mycosis, around chronic leg ulcer or less often in any dermatosis
u        treated with topical medical preparations (ATBs, corticosteroids etc.)

Allergic contact dermatitis
 caused by ketoprophene
I~000038

Allergic contact dermatitis
Kořínková Marie 19-7-06 078


     Leg contact dermatitis
upromoting factors:
u   chronicity of the disease
u   prolonged application of topical medication
u   disturbance of the skin surface
u                in leg ulcers or interdigital mycosis
u   impaired skin barrier
u                in stasis dermatitis, asteatotic or atopic  eczema

Source of potential allergens
umedical preparations:
u
u1) active:      topical ATBs (neomycine, gentamycine, fusidic ac.)
u                                   disinfectants ( PVP iodine)
u                       natural substances (balsam of
Peru,colophony

u                                                                                      chamomile
etc.)
u                       topical corticosteroids
u                       antifungal substances
u                       antiinflammatory agents
u                                  ( kebuzone, ketoprophene etc. )
u
u

Source of potential allergens
u2)  adjuvants:   preservatives: formaldehyde
u                                                          Quaternium 15
u                                                          bronopol
u                                                          kathon CG
u                                                          chloracetamide
u                                                          chlorhexidine
u                                                          benzalkoniumchloride
u                                                          thimerosal
u                                                          paraben mix
u                                antioxidants:   gallates
u                                                          butylhydroxianisole, butylhydroxitoluene
u                                                          sorbic acid
u                                emulsifiers:     wool alcohols
u                                                          triethanolamine
u                                                          propylene glycol
u

Sources of potential allergens
ucosmetic products – mostly fragrances, natural
u                                                     substances and adjuvants
ufolk medicine – mostly natural substances
u                                   propolis, tea tree oil,
u                                               asteraceae extracts
uother sources - chromium (chromic leather boots)
u                                          IPPD (black rubber boots)
u                                          rubber in elastic bandages
u                                          textile dyes in socks etc.

Contact sensitization in leg dermatitis
          authors
allergens
I
II
III
IV
V
VI
VII
%
%
%
%
%
%
%
Balsam of Peru
29
21,3
30,0
15,6
20,0
38,0
22,8
Wool alcohols
30
8
9,0
?
?
30,0
17,2
Nickel sulphate
?
4
11,0
?
1,6
8,0
?
Fragrance mix
2,7
?
20,0
11,1
16
20,0
3,3
Colophony
?
13,3
NT
8,8
3,3
6,0
3,3
Neomycin sulphate
29
10,7
13,0
?
23,3
20,0
11,1
Fusidic acid
9
17,3
4,0
?
NT
NT
NT
Carba-mix
24
18,7
11,0
?
5
NT
NT
Paraben mix
?
12,0
?
?
18,3
20,0
13,9
PVP iodine
?
NT
NT
20
NT
NT
NT
Clioquinol
?
?
?
?
?
10,0
?
Budesonide
3
?
?
?
?
20,0
?
I – Tavadia et al.                                      IV – Freise et al.
     VII – Ficova et al.
II – Jankievič et al.                                  V – Tomljanovič et
al                                   ?  - frequency not available
III – Saap et al.                                        VI  – Zmudzinska et
al.                                 NT – not tested
.
        .

Patients´ demographic data
I st. dept of DV St. Anna Faculty Hosp., Brno,CZ (2001 - 2007)
n
f age
CVI without
current leg ulcer
current leg
ulcers
n
f age
n
f age
Total
462
49,1
148
59,2
73
63,5
Men
196
49,6
87
53,6
32
60,7
Women
266
48,7
61
63,0
41
64,3

Methods
uHistory
uClinical investigation
uPatch tests
uOther: laboratory
u                bacteriology
u                mycology
u                biopsy

Methods
uPatch tests: allergens of Chemotechnique diagnostic
u
uEuropean standard series
uSpecial series: 19 constituents (adjuvants)
u                              5  natural substances
uAdditional tests according to the anamnesis
u                (tested individually)
u
u                                  patch strips of Lohman & Rauscher company

Methods
uApplication & readings accordig to ICDRG rules:
uupper back skin
uleft for 48 hours
uevaluation at 48, 72, 96 hours, or 1 week (CS)
u       strength of reaction:     -      negative
u                                                                 ?+     doubtfull reaction, only
u                                                                          erythema
u                                                                 +       erythema with
infiltration
u                                                                 ++     papules, vesicles
u                                                                 +++   coalescing papulovesicles
u
u
u
u
u

       Patch tests results
*   CS +         contact sensitisation detected
** CS-        contact  sensitisation  detected
n
%
n
%
CS + *
218
47,2
 >  1
     1
110
108
23,8
23,4
CS - **
244
52,8




Frequency of contact sensitization (ESS)
u
u
u

                allergen
n
%
1.
Potassium dichromate O,5 % pet.
15
3,2
2.
Neomycin sulphate 20 % pet.
17
3,5
3.
Thiuram mix 1% pet.
4
0,9
4.
Paraphenylenediamine 1% pet.
3
0,7
5.
Cobalt chloride 1% pet.
22
4,8
6.
Benzocaine 5% pet
2
0,4
7.
Formaldehyde 1% aq.
11
2,4
8.
Colophony 20% pet.
29
6,3
9.
Clioquinol 5% pet.
6
1,3
10.
Balsam of Peru 25 % pet.
44
9,5
11.
N-isopropyl-N-phenyl-4-phenylenediamine 0,1% pet.
13
2,8
12.
Wool alcohol 20% pet.
41
8,7
13.
Mercapto mix 2% pet.
4
0,9
14.
Epoxy resin 1% pet.
4
0,9
15.
Paraben mix 16% pet.
14
3,0
16.
4-t- butylphenol formaldehyd resin 1% pet.
8
1,7
17.
Fragrance mix 8% pet.
34
7,4
18.
Quaternium 15 1% pet.
3
0,6
19.
Nickel sulphate 5% pet.
39
14,9
20.
Kathon CG 0,01% aq.
4
0,9
21.
Mercaptobenzothiazole 2% pet.
3
0,7
22.
Sesquiterpenlactone mix 0,1% pet.
1
0,2
23.
Primin 0,01% pet.
0
0
24.
Tixocortol-21-pivalate 0,1% pet.
0
0
25.
Budesonide 0,01% pet.
4
0,9
26.
Methyldibromoglutaronitrile
(1,2-dibromo-2,4-dicyanobutane)*
27
28
Fragrance II **
Lyral**
*   included in ESS in 2005
** included in ESS in 2007
•

Frequency of contact sensitization (special tests)
1.
 propolis 10%
35
7,6
2.
 Chamomile extr. 0,5%
28
6,1
3.
 Arnica extr. 0,5%
28
6,1
4.
 Tea tree 10%
21
4,5
5.
 Calendula extr- 2,5%
12
2,6
         allergen
 n
 %
 1.
 Dodecyl Gallate (Lauryl
 Gallate)0,3%
26
5,6
 2.
 Chloroacetamide 0,2%
20
4,3
 3.
 Dibromodicyanobutane/Phenoxye
 thanol (1:1) 1%
17
3,7
 4.
 Chlorhexidine Digluconate
 (In water) 0,5%
15
3,2
 5.
 Diazolidinyl Urea (GemallII)
 2%
14
3
 6.
 Benzalkonium Chloride 0,1%
11
2,3
 7.
 Trolamine (Triethanolamine)
9
1,9
 8.
 Triclosan 2%
8
1,7
 9.
 Imidazolodinyl Urea (Germall 115)2%
6
1,3
10.
 Glutar(di)aldehyde 0,3%
6
1,3
11.
 Cocamidopropyl betaine 1%
6
1,3
12.
 Butylhydroxyanisole 2,0%
5
1,1
13.
 Propyl Gallate 0,5%
5
1,1
14.
 DMDM Hydantoin (In water) 2%
4
0,9
 15.
 Phenoxyethanol 1%
3
0,7
 16.
 Chloro cresol 1%
3
0,7
 17.
 Sorbic Acid 2%
3
0,7
 18.
 Propylene glycol 5%
2
0,4
 19.
 Butylhydroxytoluene 2%
2
0,4

The most frequent allergens
Allergen
n
%
1.
Balsam of Peru
44
9,5
2.
Wool alcohols
41
8,9
3.
Nickel sulphate
39
8,4
4.
Propolis
35
7,6
5.
Fragrance MIX
34
7,4
6.
Colophony
29
6,3
7.
Chamomile extr.
Arnica extr.
28
6,1

CS in leg ulcers:  65,4%
                ( n=73)
Allergen
n
%
1.
Balsam of Peru
21
26,9
2.
Wool alcohols
18
23,1
3.
Colophony
Propolis
Fragrance mix
8
10,3
4.
Neomycine sulphate
Paraben mix
Chamomile extr.
7
8,9

CS in tinea pedum:  52,4%
                  (n=21)
Allergen
n
%
1.
Tea tree
3
14,3
2.
Econazole
Cyclopiroxolamine
2-aminotridekanadipate (Mykodecidin)
2
9,5
3.
Formaldehyde
Colophony
Wool alcohols
Fragrance mix
Nickelsulphate
undecylenic acid (Mycoseptin)
2-chloro-4-nitrophenol (Nitrofungin)
1
4,8

Final diagnosis
Final diagnosis
n
%
Allergic contact dermatitis
                           primary
                           secondary
138
25
113
29,9
Microbial eczema/varicous dermatitis
112
24,2
Atopic dermatitis
108
23,4
Irritant contact dermatitis
39
8,4
Keratoderma/Hyperkeratotic eczema
23
5,0
 Other:  Tinea pedum
         Palmoplantar pustulosis
         Prurigo
         Lichen ruber planus
         Other

13
12
5
3
9
2,8
2,6
1,1
0,7
1,9

Conclusion
uSpectrum of allergens unchainged:
u   top allergens: balsam of Peru
u                            wool alcohols, parabens
u                            colophony, fragrances
u                            neomycin sulphate
u                            corticosteroids
uFrequency of contact sensitization still high
u

Conclusion
u         primary prevention: reduction of the usage of
u                                              potent contact  allergens
u                                                     (balsam of Peru, neomycine… )
u
u      secondary prevention: suspicion of ACD
u                                                          -> patch tests
u
u      tertiary prevention: modification of topical
u                                             treatment according to PT,
u                                             labeled ingredients
u
u                                                                supported by the grant NR
9203-3/2007
u

  Thanks for your attention
I~000076
St. Peter´s cathedral
           Brno
   Czech Republic