Nickel and gold in skin lesions of pierced earlobes with contact dermatitis. A study using scanning electron microscopy and x-ray microanalysis

Abstract  Cases of contact dermatitis due to nickel and gold especially in pierced earlobes, are increasing in number the world over. However, the presence of these metal fragments has not been demonstrated in the skin lesions. The aim of this study was to demonstrate nickel and gold in contact dermatitis lesions in pierced earlobes. Skin specimens taken from such earlobe lesions were examined using scanning electron microscopy and x-ray microanalysis. The pierced earrings worn when the lesions appeared were examined by the same techniques, and their analysis confirmed. In nickel dermatitis, small, electron-dense fragments were seen in the specimens examined by scanning electron microscopy, and nickel was detected in locations corresponding to these fragments by x-ray microanalysis. In contact dermatitis due to gold, small dense fragments containing gold were observed. It is suggested that small fragments of nickel and gold remain in the skin lesions of pierced earlobes for a long time, even after the studs have been removed, and cause prolonged irritation and various cutaneous reactions. Received: 19 September 1997     

Nickel sensitivity: the influence of ear piercing and atopy

In a group of 612 consecutive patients undergoing routine patch tests for suspected allergic contact dermatitis, more than four-fifths of the 364 women had had their ears pierced, over half gave a history of cutaneous reactions to metallic jewelery and almost one-third were sensitive to nickel. The increase in the frequency of nickel sensitivity in women with pierced ears compared to those with unpierced ears was highly significant (P less than 0.001). In men, nickel sensitivity was much less frequent; occupational factors were often implicated and few cases were related to ear piercing. Jewelery dermatitis was more frequent in atopic than non-atopic women but atopy did not appear to influence the propensity for developing nickel sensitivity in either sex. Ear piercing seems to induce nickel allergy which may result in lifelong morbidity and difficulty in employment. Jewelery suppliers should be encouraged to provide nickel-free earrings to reduce the frequency of this apparently avoidable problem.     

Exposure of nickel in used and unused gold-plated earrings: a study using scanning electron microscopy and X-ray microanalysis

Nickel is the most common contact sensitizer in the female population. The aim of the present study was to examine closely the surface of both used and unused gold-plated earrings by scanning electron microscopy, and to ascertain the distribution of nickel on the surface of these earrings qualitatively and quantitatively by X-ray microanalysis. The claps of 4 sets of used earrings causing nickel dermatitis and of the 3 sets of unused earrings were examined. In backscattered electron images obtained by scanning electron microscopy, a large number of scratches and pits were found on the surface of the used earrings. Cross-sections of the surfaces confirmed that the gold plating was defective in some areas, exposing the nickel. Nickel was readily detected and quantitatively determined in the scratches and pits by X-ray microanalysis. We also found that, even in unused earrings, numerous scratch marks and pits Acre present, again exposing the nickel. Clearly, even in unused earrings, nickel exposed at the surface sensitizes the skin and causes contact dermatitis     

Contact allergy to gold sodium thiosulfate

During 1995, we added gold sodium thiosulfate and potassium dicyanoaurate to the patch test standard series. Our purpose was to compare the reactivity of the gold salts, to determine the frequency of contact allergy to gold in our country, to compare our results with those of the Malmö group and, finally, to try to clarify the clinical relevance. 2853 patients were routinely tested and 168 patients answered a questionnaire similar to that used by the Malmö group. Contact allergy to gold was found in 23 patients; all women: 22 to gold sodium thiosulfate (0.78%). only 1 to potassium dicyanoaurate and 2 to both salts. All reactors had their ears pierced and were exposed to gold jewellery (mainly earrings). Simultaneous allergies to nickel and cobalt were statistically significant in patients with positive patch tests to gold sodium thiosulfate. Atopy was no more common among these patients.     

Contact allergy to metals in adolescents. Nickel release from metal accessories 7 years after the implementation of the EU Nickel Directive in Poland

Background. Contact allergy among adolescents is an important issue. Objectives. To assess the prevalence of contact allergy to metals in adolescents aged 15 years and nickel release from metal accessories that are in direct contact with the skin. Methods. Three hundred and nine females and 219 males, all 15 years old, from randomly selected secondary schools were examined and patch tested with nickel sulfate, cobalt chloride, palladium chloride, and potassium dichromate. Three hundred and ninety-nine metal accessories were tested with the dimethylglyoxime (DMG) test. Results.'Metal dermatitis' was reported by 19.4% of females and 0.5% of males. Positive patch test reactions were found in 8.5% of the adolescents (12.9% in females; 2.3% in males), namely to: nickel (12.3% of females; 1.4% of males); palladium (5.2% of females; 0.5% of males); cobalt (3.2% of females; 1.4% of males); and chromium (1.3% of females; 0.9% of males). Allergic contact dermatitis caused by metals was diagnosed in 9.7% of females and in 0.5% of males. Of the metal items, 26.1% gave positive DMG test results: 10.0% of earrings, 11.4% of snaps, and 56.2% of belt buckles. Conclusions. Despite the implementation of the Nickel Directive in Poland, nickel still remains an important causal factor for allergic contact dermatitis. Numerous metal accessories do not comply with the Directive.     

Relationship between nickel and cobalt sensitization in hard metal workers

853 hard metal workers were examined and patch tested with 20 substances from their environment, including nickel and cobalt. Nickel sensitivity was found in 2 men and 38 women. 88% of the nickel-sensitive individuals had developed a jewelry dermatitis prior to employment in the hard metal industry or before the appearance of hand eczema. 29% of the hard metal workers gave a history of slight irritant dermatitis. In the nickel sensitized group, 40% had had severe hand eczema which generally appeared 6-12 months after starting employment. In 25% of the cases, nickel sensitive individuals developed cobalt allergy, compared with 5% in the total population investigated. Most facts indicate that nickel sensitivity and irritant hand eczema precede cobalt sensitization. Hard metal workers with simultaneous nickel and cobalt sensitivity had a more severe hand eczema than those with isolated cobalt or nickel sensitivity or only irritant dermatitis. 64% of the female population had pierced ear lobes. Among the nickel allergic women, 95% had pierced ear lobes. The use of earrings containing nickel after piercing is strongly suspected of being the major cause of nickel sensitivity. Piercing at an early age seems to increase the risk of incurring nickel sensitivity.     

Gold dermatitis due to ear piercing: correlations between gold and mercury hypersensitivities

A case of allergic contact dermatitis due to gold pierced earrings is reported. The patient developed recurring redness and swelling on her earlobes a month after the wearing of pierced-type gold earrings, which was followed by the appearance of reddish nodules around the puncture marks. Patch tests revealed positive reactions to 0.1% mercuric chloride, 1% gold sodium thiomalate and 0,2% chloroauric acid. We also demonstrated that guinea pigs contact-sensitized with a mercuric compound developed positive patch test reactions to both mercuric and gold compounds. These results suggest that there may be correlations between gold and mercury hypersensitivities.     

Lymphocytoma cutis due to pierced earrings

Abstract:  We report two cases of lymphocytoma cutis caused by pierced earrings, with the results of patch tests and X-ray microanalyses on electron microscopy. We detected zinc through scanning electron microscopy from the specimen of Case 1 and gold and titanium through transmission electron microscopy from Case 2. This is the first report to demonstrate the presence of metal fragments in the lesion, which may suggest the remanence of metal for 20 years, bringing about persistent allergic reaction.     

Assessment of nickel release from earrings randomly purchased in China and Thailand using the dimethylglyoxime test

Background: China and Thailand produce large amounts of jewellery that are sold domestically and abroad. Objective: To identify nickel release and metal content in earrings purchased in China and Thailand. Methods: A total of 557 earrings were randomly purchased from vendors in 11 markets located in Beijing, Chengdu, Bangkok, Patong Beach, and Hat Yai. Earrings were subjected to dimethylglyoxime (DMG) tests and 26 of the DMG negative earrings were further evaluated qualitatively for major and minor metal content using X‐ray fluorescence spectrometry. Results: A total of 314 Chinese earrings (31.5%) and 243 Thai earrings (29.2%) were DMG test positive. Three (11.5%) of 29 DMG negative earrings contained nickel as a major component; 7 (26.9%) of 29 DMG negative earrings contained nickel as a minor component. Discussion: Excessive nickel release was frequent. This may contribute to the high prevalence of nickel allergy in both countries. Increased public education together with the adoption of a regulatory intervention in Thailand may be warranted. In China, enforcement of the 2002 Chinese National Standard GB 11887 may assist in reducing sensitization. These initiatives may eventually result in decreased morbidity among the Chinese and Thai citizens, but can potentially benefit recipient countries of these important earring producing countries.     

Localized argyria caused by silver earrings

We report a patient with localized cutaneous argyria following the wearing of silver earrings in pierced ears.     

P24Increasing prevalence of sensitization to preservatives in children

Objective:  The first Spanish patch‐test study of patients with contact dermatitis was performed in 1977. We aimed to determine the prevalence of hypersensitivity for Spanish standard allergens in patients suspected of contact dermatitis in 2001.
Methods:  A total of 3832 patients of 13 dermatological centers were patch‐tested with Spanish standard series. Age, gender, occupation, dermatitis site and type, and positive patch test were tabulated.
Results:  2300 female and 1532 male patients, aged 0 to 70 years were observed with contact dermatitis. Origin of eczema was occupational in 16.66% of patients. Eczema was located on hands in 54.34% of cases. Allergic contact dermatitis in 31.02% and irritative contact dermatitis in 15.88% were the most frequent diagnosis. Positive patch tests was observed in 55.11% of patients. Prevalence of positives reaction was obtained with nickel (26.64%), cobalt (9.89%), chrome (8.66%), PPDA (5.27%), thimerosal (5.21%), fragance mix (5.03%), Kathon CG (4.04%) and thiuram mix (2.87%).
Conclusions:  The results emphasize that nickel, cobalt, chrome are by far the most common allergens. A increase in the frequency of allergic patch test reactions to nickel has been noted (18,78 in 1977; 26,64 in 2001). However the contact sensitivity to cobalt, chrome and thiuram mix has decreased. Currently, allergy to cosmetics constitutes a significant portion of the cases of contact dermatitis.     

Nickel and cobalt allergy before and after nickel regulation--evaluation of a public health intervention

Over the 20th century, the frequent use of nickel in consumer products resulted in an increasing prevalence of nickel allergy. Risk items included suspenders in the 1950s-1960s; buttons, zippers and rivets in the 1970s; and ear-piercing jewellery in the 1980s. When subjects allergic to nickel were exposed to nickel in high concentrations, it often resulted in allergic nickel contact dermatitis and hand eczema. In 1990, the Danish government began to regulate consumer nickel exposure as a response to the increasing nickel allergy problem. In 1994, the EU Nickel Directive was passed, a regulation that was based on the Danish and Swedish nickel regulations. These major public health interventions were expected to change the epidemiology of nickel allergy and dermatitis in Europe. Furthermore, it was debated whether nickel would be replaced by cobalt in inexpensive jewellery and result in higher prevalence of cobalt allergy. An evaluation of the possible effects of the European nickel regulations is of importance to ensure protection of consumers and dermatitis patients. This doctoral thesis aimed to evaluate the effects of regulatory interventions on nickel exposure by investigating the development of nickel allergy and dermatitis before and after nickel regulation. Furthermore, a change in the association between nickel allergy and hand eczema was evaluated. The nickel spot test was validated to determine its value when used for screening purposes. Possible explanations for the persistence of nickel allergy were explored including genetic predisposition and consumer nickel exposure from jewellery and accessories. A cobalt spot test was developed and validated. Finally, it was evaluated whether a cobalt allergy epidemic had replaced the nickel allergy epidemic after nickel regulation in terms of increasing cobalt sensitization and cobalt exposure. The thesis showed that the prevalence of nickel allergy decreased significantly after nickel regulation in young Danish women from the general population (18-35 years) and in young Danish female dermatitis patients from a university patch test clinic (0-30 years). Stratification by ear-piercing status revealed that women ear pierced before 1990 had a significantly higher prevalence of nickel allergy and dermatitis than women ear pierced after 1990. Furthermore, the association between hand eczema and nickel allergy decreased in young women aged 18-35 years when a comparison was made between women who were patch tested and questioned in, respectively, 1990 and 2006. Despite the decreasing prevalence of nickel allergy, this condition remains prevalent in young Danish women, as about 10% are nickel allergic. Genetic predisposition to nickel allergy was evaluated by investigating the possible association between filaggrin null mutation status and nickel allergy. A positive association was found but it was also concluded that environmental nickel exposure is of much greater importance. Thus, of 354 consumer items purchased from 36 different stores in Copenhagen, 22% released nickel in concentrations that may result in nickel dermatitis in sensitized subjects. Therefore excessive consumer nickel exposure remains common in Denmark and may be an important explanation for the persistence of nickel allergy. Excessive nickel release was also frequent when samples of earrings purchased in Warsaw and London were examined with the nickel spot test, in particular earrings purchased from street markets and shops with independent ownership. Only very weak indications of an emerging cobalt allergy epidemic were found, as the prevalence of cobalt allergy has not yet increased in young people and only four of 354 consumer items purchased in Copenhagen released cobalt in concentrations that may result in cobalt dermatitis in sensitized individuals. The specificity of the nickel spot test was 98% and the sensitivity 59%. Also, a cobalt spot test was developed and validated and seemed to be a useful diagnostic tool. In conclusion, the Danish nickel regulation and the EU Nickel Directive have changed the epidemiology of nickel allergy in Denmark. However, the Nickel Directive and its reference methods need to be revised to better protect consumers and dermatitis patients.     

Nickel Sensitivity in Singapore

Nickel is the most common cause of allergic contact dermatitis in Singapore, resulting in positive reactions in patch tests between 7 and 14%. Women are more commonly affected and have an earlier mean age of onset than men (21 compared with 32). Wrist watches, earrings, buttons, and necklaces are the common source of nickel allergy. Twenty-five percent of patients also had some form of associated hand eczema. Thirty-six percent of patients had a history of atopy showing a higher incidence than the normal populations. Thirty-seven percent of patients had an associated positive reaction to cobalt.     

Nickel release from ear piercing kits and earrings

Ear piercing with nickel-alloyed studs/clasps involves considerable risk of nickel sensitisation. Stainless steel studs/clasps for ear piercing and different types of earring were stored in synthetic sweat for 1 week. The nickel release was determined. One "hypoallergenic" stud/clasp released 0.005 microgram Ni; 21 unused studs/clasps and earrings released 0.05-3 microgram Ni, and 11 unused studs/clasps and earrings released 6-25 micrograms Ni. 6 earrings which caused dermatitis released 14-442 micrograms Ni. Thus, all studs/clasps and earrings released nickel. Neither gold nor silver plating prevented the nickel release. Nickel-sensitive women were asked to wear studs/clasps releasing various amounts of nickel. The most sensitive of them showed eczematous reactions to studs/clasps releasing nickel down to 0.05 micrograms. The dimethylglyoxime test was positive only when more than 10 micrograms Ni was released.     

A Case of Double Cancer: A Squamous Cell Carcinoma Arising from a Long Pierced Site on the Left Earlobe and a Solid Tubular Carcinoma of the Left Breast

A 43-year-old woman presented with a well differentiated squamous cell carcinoma of the left earlobe where a small hole for pierced type earrings had been made about 20 years earlier. A year after the removal of the tumor, a metastasis of a moderately differentiated squamous cell carcinoma to the left cervical lymph nodes was detected. A month later, a solid tubular carcinoma of the left breast was found. A modified radical neck dissection and a quadrantectomy with an axillary lymph node dissection were performed. A total of 5 courses of peplomycine-mitomycine combinated therapy with 26 Gy of radiotherapy was administered for the cervical lesion. A month of postoperative chemotherapy with tegafur-uracil and medroxyprogesterone acetate and a total of 56 Gy of radiotherapy to the mammary lesion were added. She has been well without recurrence for about a year after the operations. This case is not only a rare double cancer, a combination of a squamous cell carcinoma and a solid tubular carcinoma, but may also be the first case of a squamous cell carcinoma arising at a long pierced site on an earlobe for pierced type earrings.     

Excessive nickel release from earrings purchased from independent shops and street markets – a field study from Warsaw and London

Background Nickel allergy is frequent and cause morbidity and increased health care costs. Objective The aim of this study was to determine the proportion of inexpensive earrings randomly purchased from stores and street markets in two capitals that gave positive dimethylglyoxime (DMG) test reactions and to determine whether the degree of nickel release was related to shop category. Methods Random inexpensive metallic earrings were purchased from stores and vendors in London and Warsaw. A qualitative investigation of nickel release by using the DMG test was performed. Results DMG testing revealed that respectively 15.1% (n = 205) and 18.4% (n = 206) of earrings purchased in London and Warsaw released nickel as indicated by positive test outcomes. Stratification by store category showed that DMG test‐positive jewellery were mainly purchased from street markets and from stores that were not part of national or international chains. Conclusions Despite the EU Nickel Directive having resulted in decreasing prevalence of nickel allergy, a large proportion of inexpensive earrings still release nickel in concentrations that may result in nickel allergy and dermatitis. Authorities should prioritize information campaigns and random inspections as a legislation that is not followed is of limited value.     

Nickel dermatitis in medical workers

The incidence of contact allergy to nickel in medical workers has increased from 9.4 to 26.2 per cent during the past decade. Despite the many occupational nickel sources in a hospital or outpatient department, the incidence and prevalence of hypersensitivity to this metal are no higher in female medical workers than in the female population in general. Also, most of the cases of nickel allergy have been acquired before working life or are attributable to nonoccupational sources such as earrings, wristwatches, and clothing buckles. Occupational nickel sensitization is rare. Nickel allergy is a handicap in many medical jobs, and persons suffering from it need career advice.     

Exposure to metallic gold in patients with contact allergy to gold sodium thiosulfate

Gold allergy is common, with approximately 10% of patients patch tested because of eczematous disease being positive to gold sodium thiosulfate (GSTS). However, clinical relevance seems to be rare. The aim of this prospective double-blind study was to demonstrate the effects of exposure to metallic gold, in this case earrings, in gold-positive patients. 60 female patients with pierced earlobes test-positive to GSTS were included in the study. The patients were randomized into 2 groups, 30 patients receiving earrings with a surface layer consisting of 24-carat gold and 30 patients earrings with a surface layer of titanium nitride, virtually indistinguishable from gold. The patients wore the earrings for 8 weeks. During the study, any dermatitis on the earlobes, as well as on other body sites, was registered. The skin reactions observed were weak but, in total, 17 of the 60 patients had a skin reaction (local or remote) during the study, 12 of whom had received gold earrings and 5 titanium (p<0.05). 11 patients had a reaction on the earlobes, 7 of whom had received gold earrings and 4 titanium (NS). With these facts it is hard to exclude that exposure to gold jewelry can be clinically relevant in persons hypersensitive to gold.     

Contact sensitivity to metals (chromium, cobalt and nickel) in childhood

Metals, especially nickel, are the most common contact allergens in children. Recent data has shown increased incidence of allergy in industrialized countries. Sensitization can occur at any age, even in neonates. Costume jewelry, particularly earrings, is linked to increased sensitization to nickel. Sensitization to cobalt often occurs by the use of costume jewelry. The most common source of sensitization to chromium is leather. Due to the absence of a specific therapy, the main treatment is to identify and avoid the responsible allergens. This article presents an updated view on the epidemiological and clinical aspects of contact allergy to metals, focusing on prevention strategies and risk factors, and warns about possible and new sources of contact.     

The epidemiology of contact allergy in the general population--prevalence and main findings

A substantial number of studies have investigated the prevalence of contact allergy in the general population and in unselected subgroups of the general population. The aim of this review was to determine a median prevalence and summarize the main findings from studies on contact allergy in the general population. Published research mainly originates from North America and Western Europe. The median prevalence of contact allergy to at least 1 allergen was 21.2% (range 12.5-40.6%), and the weighted average prevalence was 19.5%, based on data collected on all age groups and all countries between 1966 and 2007. The most prevalent contact allergens were nickel, thimerosal, and fragrance mix. The median nickel allergy prevalence was 8.6% (range 0.7-27.8%) and demonstrates that nickel was an important cause of contact allergy in the general population and that it was widespread in both men and women. Numerous studies demonstrated that pierced ears were a significant risk factor for nickel allergy. Nickel was a risk factor for hand eczema in women. Finally, heavy smoking was associated with contact allergy, mostly in women. Population-based epidemiological studies are considered a prerequisite in the surveillance of national and international contact allergy epidemics.