Contact allergic reactions to diphenylthiourea and phenylisothiocyanate in PVC adhesive tape

28 patients reacting to a PVC adhesive tape used in routine patch testing gave positive reactions to diphenylthiourea (DPTU) and to phenylisothiocyanate (PITC) in low concentrations. DPTU is a heat stabilizer in the PVC and is partly decomposed to PITC. The two substances were also found in another type of PVC. Thioureas giving isothiocyanates are also used in certain types of rubber. Isothiocyanates are present in plants, mainly of ihe Cruciferae family, and are also formed from thiuram sulfides and thiocarbamates. The connection between isothiocyanates derived from different sources should be investigated.     

Allergic contact dermatitis from ethylene thiourea

A case of allergic contact dermatitis to the rubber additive material ethylene thiourea (ETU) is presented. Testing for cross-sensitivity gave a positive reaction to the fungicide Maneb®, manganous ethytenebisdithiocarbamte, but this reaction was probably due to ETU which was detected in Maneb® by thin-layer chromatography. Different sources of ETU arc reported.     

Allergy to rubber condom urinals and medical adhesives in male spinal injury patients

In the National Spinal Injuries Unit at Stoke Mandeville Hospital, rubber condom urinals, kept on the penis with a medical adhesive, are used for incontinent male patients where possible. However, contact allergy to rubber condoms and/or the adhesives is a common problem and can cause considerable morbidity in paralysed patients. This paper investigates the rubber chemicals and adhesives most commonly implicated in causing contact allergy. The survey was divided into two parts: 1. Patch testing symptomatic inpatients 2. A questionnaire sent to new patients from January 1974 to ascertain the overall incidence of contact allergy. It was found that allergy to mercaptobenzthiazole (MBT)- and thiuram-containing condoms was relatively common and that latex/petroleum tube medical adhesives most commonly caused adhesive allergy. It is suggested that a condom made of the least allergenic rubber and an adhesive causing the least number of allergic reactions should be used from the outset for paralysed patients requiring a condom urinal.     

Presumptive frequency of, and review of reports on, allergies to household gloves

Background  Allergies to latex or 'rubber chemicals' in medical or other occupationally used gloves are not uncommon. In contrast, very few articles have reported on latex allergy (type I) or allergic contact sensitization to additives (type IV) associated with household gloves, in spite of some 44 million pairs sold in Germany in, e.g., 2006.
Objective  We seek to determine the frequency of allergies to household gloves by providing own data and we reviewed the literature.
Methods  The study was based on 105083 consultations of patients with suspected contact allergy (Type IV) in the Information Network of Departments of Dermatology (IVDK) in Germany in the years 1995 to 2006 and on the PubMed databases (last access 7/2008).
Results  1221 patients were identified in whom protective gloves were considered as a possible cause of contact dermatitis and who did not work in occupations associated with above average risk of contact allergy to rubber chemicals. In 178 cases positive reactions to rubber components were reported, while 13 additional cases reacted only to a previously used rubber glove brand, but not to commercial allergens.
In the literature only two publications on type I and two on type IV reactions were found in which allergies to rubber household gloves were explicitly reported.
Conclusions  Allergies to rubber household gloves seem to be rare. Factors presumably counteracting contact sensitization by household gloves, compared to occupational use, comprise short intermediate use, loose fitting and the incorporation of e.g. an inner cotton surface reducing skin contact with rubber chemicals.

Conflict of interest

Ehrhardt Proksch has acted as consultant to Wirtschaftsverband der deutschen Kautschukindustrie e.V. (WDK).     

RUBBER DERMATITIS

SUMMARY.— One hundred and six rubber sensitive patients are described. Seventy had developed dermatitis from specific rubber articles such as household gloves, condoms, footwear and girdles. In the remaining 36 cases dermatitis was due to contact with rubber in various different forms.
A formidable number of chemical additives are used by the rubber industry and many of these are potential skin sensitizers. In the present series, however, sensitivity was attributed to a thiuram accelerator or mercaptobenz-thiazole in all but 2 cases     

p-tert-Butylphenol Formaldehyde Resin and Its Impact on Children

: p-tert-Butylphenol formaldehyde resin (PTBPFR) is widely used as an adhesive owing to its rapid onset of action, durability, flexibility, and heat resistance. Moreover, because of its tackiness, it is particularly useful as a glue component on both leather and rubber products. Sensitization to this resin has been increasing since the first cases of PTBPFR contact allergy in the late 1950s, and pediatric contact allergy to this resin is a significant problem. p-tert-Butylphenol formaldehyde resin has been reported as a leading cause of shoe-associated dermatitis internationally, as well as a cause of allergic contact dermatitis from its use in neoprene wet suits and sports equipment such as shin guards. In summary, patch test screening of both adults and children with PTBPFR is important, given the ubiquitous use of this chemical.     

Comparison of diagnostic methods in latex surgical glove contact urticaria

Surgical rubber gloves contain allergens derived from natural rubber latex which may sensitize, causing contact urticaria and even systemic reactions. We examined 15 hospital employees allergic to latex surgical gloves, using various skin tests and RAST, to determine the most reliable diagnostic method and to investigate coexistent allergy to glove powder and rubber chemicals. Prick testing using a stock solution made from one brand of latex glove yielded positive (2+ to 4+) reactions in all 15 employees: 8 retained positive reactions at a 1/10 dilution, 1 at 1/100 and 4 at 1/1000. A prick test using rubber-tree sap (Hevea brasiliensis) was positive in 12/15 employees and a scratch-chamber test using crushed rubber-tree leaf was positive in 13/15. A latex glove use test was positive in 12/13 employees and a latex RAST detected measurable amounts of specific IgE in 8/15. No positive prick test reactions were obtained using glove powder. On patch testing, 2/15 employees showed delayed allergy to rubber chemicals but no immediate reactions were detected. The present results indicate that in addition to the use test, prick testing with a stock solution prepared from latex surgical gloves is an adequate test method for routine practice when diagnosing latex glove contact urticaria. The correlation between prick tests and whole glove use tests was good, but latex RASTs yielded some negative results.     

Dermatitis and urticaria from rubber and plastic gloves

The number and nature of allergic occupational glove dermatoses were analysed. 542 cases of allergic contact dermatosis were diagnosed during 1974-1983. Amongst these, 68 (12.5%) were caused by rubber or plastic gloves. 2 patients had contact urticaria due to rubber gloves. Gloves were the main cause of occupational allergic rubber eczema, inducing 63 (58.3%) of 108 rubber eczema cases. 38 of them had positive reactions to rubber chemicals and glove material, 14 to glove material only, and 11 to rubber chemicals. 5 cases of allergic eczema from plastic gloves were diagnosed, all due to polyvinyl chloride (PVC). 2 cases of contact urticaria from natural rubber gloves were diagnosed by a provocation test. Epicutaneous testing with material of natural rubber gloves and rubber chemicals was negative. The present study shows that allergy to rubber gloves is usual, while allergy to plastic gloves is rare. Thus, plastic gloves should be used, when possible. Patch testing with protective gloves should always be used when patients develop prolonged hand dermatitis and where the possibility of glove eczema exists.     

The utility of cytokeratin 5/6 in the recognition of cutaneous spindle cell squamous cell carcinoma

BACKGROUND: Cutaneous spindle cell squamous cell carcinoma (SSCC) is a challenging diagnosis since it may be difficult to distinguish from spindle cell melanoma, leiomyosarcoma and atypical fibroxanthoma. Furthermore, it may be difficult to demonstrate epithelial differentiation by a traditional immunohistochemical panel. We performed an expanded immunohistochemical evaluation of ultrastructurally documented SSCC to assess its utility in diagnosing this entity. METHODS: We identified 16 cases of SSCC that were composed predominantly of spindle-shaped cells and with ultrastructural evidence of epithelial differentiation (i.e. at least rudimentary cell junctions). Immunohistochemical analysis using antibodies to a variety of cytokeratins (AE1/3, K903, CK5/6) and S-100 protein was performed. The extent of immunostaining was graded on a scale of 0 to 4+ (0: no staining; 1+: < or =25%; 2+: 26-50%; 3+: 51-75%; 4+: >75%). RESULTS: Of the 16 cases, 6 expressed AE1/3 (38%), 8 expressed K903 (50%) and 11 (69%) expressed CK5/6. Six cases were positive for all three CK markers and two cases were positive for both K903 and CK5/6 but negative for AE1/3. Three cases (19%) stained for CK5/6 without any staining for AE1/3 or K903. Five cases (31%) were negative for all epithelial markers. The extent of CK5/6 staining was either similar to or greater than K903 staining in 7 of 8 cases that stained with both markers. All 16 cases were negative for S-100 protein. CONCLUSIONS: Including CK5/6 in the initial battery of immunostains performed on a cutaneous spindle cell neoplasm can help demonstrate epithelial differentiation in SSCC, even in the absence of AE1/3 or K903 staining. However, some cases of cutaneous SSCC can only be confirmed ultrastructurally, as up to one-third may not show evidence of epithelial differentiation using an expanded immunohistochemical panel.     

Occupational allergic contact dermatitis caused by thiourea compounds

Thiourea compounds are mainly used as accelerators in the rubber industry, but also in other industries, e.g., as antioxidants in the graphics industry. Thiourea compounds may provoke allergic contact dermatitis, although the number of reported cases is relatively low. During 1985–1991, we had 5 patients with allergic patch test reactions caused by thiourea compounds. 1 of our patients had to use a knee brace after an occupational accident. He developed allergic contact dermatitis caused by the knee brace, probably because he had become sensitized to diethylthiourea. 2 patients were probably sensitized by diphenylthiourea in neoprene gloves. A florist had an allergic patch test reaction to diphenylthiourea and might have been sensitized by fungicides or pesticides, which break down into thioureas. It is often difficult, however, to detect the source of thiourea compound sensitization. If the patient has contact dermatitis and has been exposed to products that may contain thiourea compounds (or compounds that break down into thiourea compounds), such as rubber, PVC plastic or adhesive, diazo paper, paints or glue remover, anticorrosive agents, fungicides or pesticides, patch testing with a series of thiourea compounds needs to be performed. If patch testing with thiourea compounds is not performed, allergic contact dermatitis caused by thiourea compounds is not likely to be diagnosed.     

Cutaneous reactions to surgical preparations and dressings

A prospective study of 100 surgical patients was undertaken to identify causes of contact dermatitis. Patch testing with the North American Contact Dermatitis Standard Series and additional agents used in the surgical preparation and dressing was performed in 11 patients with post-operative dermatitis or a history of tape allergy. 12 patients were diagnosed as having irritant (mechanical) contact dermatitis. One patient had allergic contact dermatitis to benzoin postoperatively; another patient with a history of an adhesive tape reaction had a positive patch test to thiuram mix, rubber accelerators formerly present in adhesive tapes. Our findings indicate that irritant contact dermatitis is a common problem in the surgical patient. Allergic contact dermatitis is less common, occurring in 2 of the 100 patients.     

Results of patch testing with a special series of rubber allergens

The purpose of this study was to examine the results of patch testing with the rubber components on a standard screening tray and compare them with the results of testing with a special series of 27 rubber components (rubber tray). 1670 patients were patch tested with the screening tray and 317 of these were also tested with the rubber tray 16% of those tested with the rubber tray had a positive response to at least 1 of the rubber allergens on the screening tray and 22% had a positive response to at least 1 of the allergens on the rubber tray. The most common positive response to the rubber tray allergens was to tetramethylthiuram monosulfide. There were no responses to 3 of the components on the rubber tray and there was only 1 positive response to a further 4 components. The diagnostic test characteristics of the rubber components on the screening tray were examined using the rubber tray as the gold standard. The sensitivity of the screening tray was 94%, specificity 51%, positive predictive value 87%, and negative predictive value 71% Of the 317 tested. 11%, were found to have a positive to a substance on the rubber tray that was not evident from the results of the screening tray patch testing technique: allergic contact dermatitis; rubber allergens: false-negative reactions: fake-positive reactions.     

Epicutaneous natural rubber latex sensitization induces T helper 2-type dermatitis and strong prohevein-specific IgE response

In addition to immediate type I allergy symptoms, natural rubber latex allergy may manifest as protein contact dermatitis on the hands of health-care workers and other natural rubber latex glove users. We examined whether repeated application of natural rubber latex on mouse skin causes sensitization to natural rubber latex and dermatitis. Epicutaneous sensitization with natural rubber latex produced a significant influx of mononuclear cells, CD4+ CD3+ cells, and eosinophils to the sensitized skin sites. The number of degranulated mast cells in natural rubber latex-sensitized skin sites was significantly higher compared with control sites treated with phosphate-buffered saline. The expression of interleukin-1beta and interleukin-4 mRNA was markedly increased in natural rubber latex-sensitized skin sites. Moreover, significant increases in the mRNA expression of chemokines CCL2 (monocyte chemoattractant protein-1), CCL11 (eotaxin-1), CCL3 (macrophage inflammatory protein-1alpha), and CCL4 (macrophage inflammatory protein-1beta) were found. In addition to the cutaneous inflammatory response, epicutaneous sensitization with natural rubber latex induced a striking increase in the total and specific immunoglobulin E levels but not in the immunoglobulin G2a levels. Intraperitoneal immunization with natural rubber latex induced a strong natural rubber latex-specific immunoglobulin G2a response, but only a weak immunoglobulin E response. We also studied the role of two major natural rubber latex allergens, the highly hydrophilic prohevein and the hydrophobic rubber elongation factor. Cutaneous application of natural rubber latex elicited a strong immunoglobulin E response against prohevein, but not against rubber elongation factor. On the contrary, intraperitoneal immunization with natural rubber latex elicited strong immunoglobulin G2a production to rubber elongation factor but not to prohevein. These results demonstrate that epicutaneous sensitization with natural rubber latex induces T helper 2-dominated dermal inflammation and strong immunoglobulin E response in this murine model of natural rubber latex induced protein contact dermatitis. Epicutaneous sensitization to natural rubber latex proteins eluting from latex gloves may therefore contribute to the development of hand dermatitis and also natural rubber latex-specific immunoglobulin E antibodies.     

Allergic contact dermatitis from the adhesive remover wipe of stoma bags

Skin disorders at ostomy sites are common and include irritant contact dermatitis from the draining fluid and/or the ostomy devices, intertrigo, and bacterial and mycotic infection (1). Allergic contact dermatitis has also been described, from a karaya seal ring (2), stoma adhesive paste (3), and rubber (4). The allergens causing contact dermatitis from ostomy bags, have been defined as epoxy resin (5–7), diaminodiphenylmethane (8) and polyisobutylene (9).     

Chemical leucoderma: a clinico-aetiological study of 864 cases in the perspective of a developing country

Background  Chemical leucoderma, often clinically mimicking idiopathic vitiligo and other congenital and acquired hypopigmentation, has been increasing rapidly in incidence in developing countries such as India.
Objectives  This study attempts to detect clinical and epidemiological patterns of chemical leucoderma.
Methods  Detailed history-taking, especially of exposure to contributory chemicals, clinical examination, relevant investigations, data recording and analysis were done.
Results  In a total of 864 cases of chemical leucoderma, 65·6% cases started de novo and vitiligo patches were pre-existing in the remaining cases. Patches were limited to the contact area in 73·7% but had spread to remote areas in 26·3% cases. The face (41·1%) and scalp (5·9%) were the commonest and least involved sites. Confetti macules were seen in 89% and pruritus was complained of in 21·8%. Aetiological agents identified were hair dye 27·4% (21% self-use; 6·4% not self-use), deodorant and spray perfume 21·6%, detergent and cleansers 15·4%, adhesive bindi 12%, rubber chappal 9·4%, black socks and shoes 9·1%, eyeliner 8·2%, lipliner 4·8%, rubber condoms 3·5%, lipstick 3·3%, fur toys 3·1%, toothpaste 1·9%, insecticides 1·7%, 'alta' 1·2%, amulet string colour 0·9%. Therapeutic response was much better in 'pure' chemical leucoderma (73·4%) than in those with co-existing vitiligo (20·9%).
Conclusions  Chemical leucoderma, a disease of mostly industrial origin in developed countries, may be induced by common domestic products in developing countries. Diagnosis and differentiation from other causes of hypopigmentation can be done confidently by following the clinical criteria as proposed. The therapeutic response of chemical leucoderma is better than that of vitiligo.     

Recurrent toxin-mediated perineal erythema: eleven pediatric cases

BACKGROUND: Recurrent toxin-mediated perineal erythema is a cutaneous disease mediated by superantigens made by staphylococci and streptococci, which, to our knowledge, has only been reported in young adults. We describe recurrent toxin-mediated perineal erythema in 11 children and outline the differences between recurrent toxin-mediated perineal erythema and Kawasaki disease in this age range. OBSERVATIONS: Eleven children (7 male and 4 female) presented with the sudden appearance of asymptomatic erythema, which was salmonlike in color and rapidly desquamating, involving the perineum in 10 patients and extending to the perianal area in 1 patient. At the onset of the rash, all patients were in good health, although 9 had mild fever for 1 to 2 days before its appearance. Physical examination also revealed an erythema of the hands and feet in 4 patients and strawberry tongue in 7. Two patients had a facial impetigo, and another showed a perianal streptococcal dermatitis. A group A beta-hemolytic streptococcus was isolated from the throat in 10 cases and from a perianal culture in 1 case. In 8 cases, resolution was spontaneous, but all patients were treated with systemic antimicrobial therapy for 10 days. Three patients had a personal history of cutaneous rashes on the perineal area during the last years before consultation. Rash recurrence was observed in 3 of the 11 patients at the follow-up examination. Conclusion Recurrent toxin-mediated perineal erythema can be observed not only in young adults but also in childhood.     

Prick and use tests with 6 glove brands in patients with immediate allergy to rubber proteins

20 patients with contact urticaria from rubber gloves were prick tested using eluates from 4 latex (Triflex, Ansell Gammex, Exona, Armi) and 2 non-latex (Tactylon, Elastyren) glove brands. All patients showed a positive prick test reaction to at least 2 latex glove eluates. A hypoallergenic glove (Ansell Gammex) gave a positive prick test reaction in 1 patient, but non-latex gloves were negative in all cases. All patients showed a positive result in the use test with a latex surgical glove (Triflex), whereas none did with a non-latex glove (Tactylon). Non-latex gloves and, in some cases, also hypoallergenic latex gloves, are a good alternative to rubber gloves for patients with immediate latex allergy.     

Contact dermatitis due to rubber boots worn by Japanese farmers, with special attention to 6-ethoxy-2,2,4-trimethyI-,1,2-dihydroquinoline (ETMDQ) sensitivity

An investigation was conducted as follows in 9 farmers with contact allergy due to rubber boots: (i) patch tests with 19 rubber additives: (ii) chemical analysis of additives in 6 pairs of rubber bouts: (iii) use tests on a hypoallergenic trial product in 5 patients. The following results were obtained: (i) in the patch tests, all 9 patients showed positive reactions to 1 or more of the nitrogen(N)-containing antioxidants (IPPD. DMRPPD. ETMDQ): (ii) ETMDQ was detected in 1 pair rubber boots, and IPPD and DMBPPD in another pair: (iii) no patient using hypoallergenic boots during rice-planting had recurrent dermatitis. N-containing antioxidants. such as IPPD. DMBPPD and ETMDQ, were thus considered as the main causative agents and the trial product was found useful for managing contact dermatitis. Contact allergy due to ETMDQ in rubber is reported here for the 1st time.     

D-penicillamine in the treatment of localized scleroderma

Localized scleroderma has no recognized internal organ involvement but may be disfiguring and disabling when the cutaneous lesions are extensive or affect children. There is no accepted or proven treatment for localized scleroderma. Case reports of 11 patients with severe, extensive localized scleroderma who were treated with D-penicillamine are summarized in this article. This drug was judged to have a favorable effect on the disease course in 7 (64%) of 11 patients. Improvement began within 3 to 6 months and consisted of cessation of active cutaneous lesions in all 7 patients, skin softening in 5, and more normal growth of the affected limb in 2 of 3 children. Joint stiffness and contractures also improved. The dose of D-penicillamine associated with a favorable response was as low as 2 to 5 mg/kg per day given over a period ranging from 15 to 53 months. D-Penicillamine caused nephrotic syndrome in 1 patient and milder reversible proteinuria in 3 other patients; none developed renal insufficiency. These data suggest that D-penicillamine may be effective in severe cases of localized scleroderma.