Clinical Study and Patch Testing in Contact Dermatitis due to Metals

Rokini, N (2012) Clinical Study and Patch Testing in Contact Dermatitis due to Metals. Masters thesis, Madras Medical College, Chennai.


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INTRODUCTION : Metals are the most frequent contact allergens and sensitivity found both in occupational and non occupational group. Contact dermatitis to metals are increasing due to the rapid growth of industrialization and due to the vast increase in occupations in the construction industry. Most of the metals cause some form of skin reactions as allergic or irritant contact dermatitis. Allergic contact dermatitis to metals occurs only if the metal salts are in solution, as occurs with perspiration or exposure with body fluids. In addition to direct skin contact with metals, dermatitis to metals can occur due to ingestion or implantation of metals. Allergic sensitivity to a metal is highly specific, but crosssensitivity with other metals can occur. Many of the cross reactions between metals are actually co- reactions, which occur due to simultaneous exposure to two or more metals. Co-reactions are more common among cobalt, nickel and chromium. Polysensitization, which is considered to represent susceptibility to delayed-hypersensitivity in general, is also associated with the concurrent reactions to the metals. Hence, not only coupled exposure, but also individual susceptibility may be responsible for concurrent reactions to metals in man. AIMS OF THE STUDY : 1. To study the incidence of sensitization to metals like chromium, nickel, and cobalt among patients with a presumptive diagnosis of contact dermatitis to metal antigens. 2. To study the age and sex incidence among patients of contact dermatitis to metals antigens. 3. To study the association of contact dermatitis to metal antigens with atopy. 4. To find the incidence of occupational and nonoccupational causes of metal contact dermatitis. 5. To study the association between the duration of exposure to metal antigens required for clinical manifestation in the occupational group. 6. To study the various combinations of presentations among chromium, nickel and cobalt and to compare the results with the literature. STUDY DESIGN : Prospective, observational study. MATERIALS AND METHODS : SAMPLE: 277 cases of contact dermatitis with a history of exposure to metals attending the OPD of occupational contact dermatitis section, department of dermatology, Rajiv Gandhi Government General Hospital (RGGGH), Chennai from October 2009 to October 2010 were included in the study. The study was approved by the institutional ethical committee, RGGGH & Madras medical college, chennai. A written consent form was signed by all. METHODS: A detailed history of the patients including the age, sex, chief complaints, the type of occupation and the duration of exposure to metals in their occupation were noted. Based on the morphology and distribution of the lesions patients were diagnosed as allergic contact dermatitis, irritant contact dermatitis and photocontact dermatitis. Clinical pattern’s of the distribution of the contact dermatitis was noted. History, symptoms and signs suggestive of atopy, past history of similar illness and any drug intake both prior and after the onset of lesions were noted. Patients with history and clinical features compatible with contact dermatitis due to metals were patch tested Procedure: PATCH TESTING was done for all the patients with the three metal antigens available in the Indian standard series. - 0.1% Potassium dichromate. - 5 % Nickel sulphate. - 5 % Cobalt sulphate. Patch testing was deferred in patients with *Active disease (Acute Eczema) *on Systemic Steroids. *on Antimetabolites. Inclusion Criteria: All the patients of allergic contact dermatitis and photoallergic contact dermatitis with positive patch test results and all patients of irritant contact dermatitis with irritant reaction were included for analysis. Exclusion Criteria: Patients with contact dermatitis and who patch tested negative for the metals antigens. STATISTICAL ANALYSIS: Analysis was done using the SPSS software. Whereever required Pearsons chi square was used to calculate the P value. Two by two tables were evaluated by Fisher’s exact two tailed test. OBSERVATION : A total of 277 patients with a history of an exposure to metal antigens were recruited for the study. Based on the history and clinical morphology, they were diagnosed as allergic contact dermatitis, irritant contact dermatitis and photo allergic contact dermatitis. All cases were patch tested with three metal antigens: chromium, nickel and cobalt. Patients with history of exposure to other allergens were patch tested with appropriate antigens from the Indian standard series. 237 patients with positive patch test reaction to the metal antigens were included for analysis. 40 patients who tested negative to all three metals antigens were excluded from the analysis. CONCLUSION : 1. Allergic contact dermatitis to metal antigens was the commonest clinical pattern observed in 88.6 percent cases of the study. 2. Male to female ratio of the total cases was 1.21:1 with males predominating in the cement exposure group (ratio = 5.4:1) and females predominating in the ornaments & metallic objects exposure group (ratio = 1:20.5). 3. Most of the cases of metal contact dermatitis due to ornamental jewels were in the age group below 40 years, in comparision to older ages of 30-50 years in the cement exposed group. 4. Occupational exposure to metals was more common in the study with ratio of occupational to nonoccupational cases as 1.69:1. 5. Occupation wise, cement exposure was the commonest cause of metal contact dermatitis. 6. The mean duration of exposure to develop metal contact dermatitis in the occupational group was 4.7 years, with the cement exposure group having the longer latency of 5.2 years. 7. 19.8% of the study group was atopic. In our study, atopy did not significantly influence the propensity for developing metal sensitivity. 8. The commonest distribution of metal contact dermatitis was in the extremities in 30.8% of the total, followed by cement dermatitis in extremities in 42.6%. This emphasises the need for protective clothing, use of gloves and proper footwear to avoid occupational exposure and sensitization to metals. 9. The commonest distribution of dermatitis in ornaments & metal group was in the region of head, neck and shoulders in 51.2%. In our study the most common ornamental jewellery to cause nickel sensitization was neckchains, followed by earrings, safety pins and bangles. 10. Chromium was the commonest metal in the study to present as an isolated allergen in 46.8% of the total. 11. Cobalt sensitivity was predominantly associated with other metals in 24.9% of the study group. 12. Parthenium was the commonest allergen to be associated with metal sensitization, presenting as an airborne contact dermatitis or photodermatitis pattern. As this plant is wide spread and rampant, this has to be suspected in all cases of airborne contact and photocontactdermatitis. 13. Sensitivity to detergents, turmeric and PPD was more in the ornaments & metallic objects exposure group, especially in housewives and housemaids. This explains the leaching effect of wet works leading to more sensitization. 14. To conclude, chromium was the commonest metal allergen, in our study found positive in 77.6% of the total. • Chromium sensitivity was predominant in the groups occupationaly exposed to metal antigens, especially cement workers. • Nickel sensitivity was predominant in the nonoccupationally exposed group, especially housewives. • Cobalt sensitivity was most commonly associated with concurrent sensitivity to chromium and nickel. 15. This study emphasises the need for standardization in the chrome content of cement and nickel content of ornamental jewels in the market. 16. Limitation of the study was that, spot test for nickel and chromium has not been done for ornaments and consumer articles. Patch test has not been done for other metals like silver as antigens were not available for them.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Clinical Study ; Patch Testing ; Contact Dermatitis ; Metals.
Subjects: MEDICAL > Dermatology Venereology and Leprosy
Depositing User: Subramani R
Date Deposited: 01 Mar 2018 17:19
Last Modified: 03 Mar 2018 07:46

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