Deadline Looming

Abstract:  27 year-old woman with severe generalized contact dermatitis secondary to poison ivy, starting two weeks before her wedding.

HPI:   This 27 yo woman, whose wedding is August 4th, 2012, presented on July 19th with a one day history of a facial eruption.  She has a history of rhus allergy and had been at the beach collecting leaves for an architecture project a couple of days before the onset of symptoms.  At the time, she was wearing a bathing suit and a wrap-around towel.   The rash first appeared on her face and left lower abdomen.  She has a history of acne vulgaris which is quiescent now.  She was on prednisone 20 and 10 mg a day for a week, ~ 10 days before this episode.

O/E:  July 19th:  Marked erythema and induration on left forehead, cheek, chin.  Vesicles and small bullae scattered in the area;  A few erythematous streaky patches lsft hip.  Over the next few days, in spite of treatment the process progressed to involve abdomen, neck and fingers.  On July 23, there are new erythematous-bullous areas on the left lower abdomen and hip. (see photos).

Clinical Photos:  See below

Therapy: 
July 19th:  Prednisone 20 mg b.i.d. (her weight is 54 kg).  Cool tap water compresses.  Hydroxizine 20 - 30 mg hs.
July 21:  Because of progression of dermatitis, prednisone increased to 50 mg per day in divided doses.  Dome Boro compresses 3 x per day, Silvadene cream because of some erosions at site of bullae.  Prednisone is causing her to feel anxious and panicky.  Lunesta 1 - 2 mg added for sleep. 
July 23:  I am surprised that new lesions continue to develop in spite of an adequate dose of prednisone (see photos).  Have added a "soak and smear" protocol for body lesions and desoximetasone cream bid for dermatitis on body and once daily for face.

Diagnosis: Severe Allergic Phyto-Contact Dermatitis secondary to rhus.  We saw this at onset and in spite of a reasonable dose of prednisone and cool compresses it has progressed.  Steroid dose was limited because of CNS symptoms and initially I was reluctant to use topical steroids due to her history of acne; but have just started desoximetasone cream on 7/23.  The timeline is important as she is getting married in 12 days.  It is odd that this has progressed after what is usually an adequate dose of prednisone, and I am worried that increasing the prednisone may cause more anxiety and insomnia. Most likely this is a severe anamnestic response to urushiol and she may indeed need a higher dose of prednisone or she may not be absorbing it.

Questions:
1) How would you handle the facial erythema?

2) Topical corticosteroids as well as oral steroids can exacerbate acne.  Should we add a moderate to strong topical corticosteroid for a few days to suppress erythema?

3) She is anxious and has insomnia secondary to prednisone already.  I feel prednisoen is the key to improvement, but am reluctant to push the dose.  Your thoughts?

4) Is there a role for topical tacrolimus?

Your suggestions re: diagnosis and management will be appreciated.

Photos:

July 19

July 20

July 21

July 22

July 23

New lesions 4 d p start prednisone

July 24
Real Improvement Noted Today

7/30
Pretty Much Better

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Temple Bracelet Dermatitis

Abstract: 20 yo woman with allergic contact dermatitis to a bracelet purchased at a temple in Beijing

HPI: This young woman purchased some prayer beads at a Beijing temple in early September, 2011. Within two - three weeks she developed a rash under the bracelet. She treated this with a number of topicals including a neomycin containing cream. She was seen in an ER a few days before she presented to my office and started on prednisone and Keflex.

O/E: A well-defined area of resolving dermatitis on left wrist. It appears to have been bullous.

Clinical Photos:
The clinical picture did not come out well. Second picture is of bracelet on unaffected wrist to show how she wore it.











Diagnosis and Discussion: This contact dermatitis is most likely secondary to wooden beads. There are a few pertinent references (see below). The patient also applied neosporin so we can't rule out that this may have played a role. She does not live near my office and is in college far away. My approach would be to treat with a topical corticosteroid and warn her about neomycin. If this recurs she can be patch tested. At this point, I do not know what kind of wood the bracelet is made of. The references I found were mostly about cocobolo wood. This may prove difficult to determine. Your comments will be welcome. Note: A number of our readers favor rosewood as the culprit (see reference # 3)

References:
1. Hausen BM. Allergic contact dermatitis from a wooden necklace. Am J Contact Dermat. 1997 Sep;8(3):185-7.
Abstract
A 36-year-old female kitchenworker twice developed eczematous lesions corresponding exactly to the area around her neck where she had worn a wooden necklace. Contact dermatitis lasted longer than 1 week. The necklace consisted of 42 brown wooden beads and 63 other wooden parts, 0.5 to 3 cm diameter. Most parts could be identified as Cocobolo wood, Brazilian and East Indian rosewood, and teak. Patch tests with the pure constituents gave +3-reactions to three dalbergions and obtusaquinone, which are known to be the sensitizers of Cocobolo and the above-mentioned rosewoods. Because of these test results, the identification of the species by eye examination could be corroborated. Further detailed questioning revealed that the patient had played a recorder, probably made from Cocobolo (Dalbergia retusa), when a child, to which she unknowingly became allergic.


2. Moratinos MM, Tevar E, Conde-Salazar L. Contact allergy to a cocobolo bracelet. Dermatitis. 2005 Sep;16(3):139-41.
Abstract
Tropical woods are highly valued because of their strength, hardness, and resistance to moisture. These characteristics make them easy to work with and extremely durable, and that is why they have been used in the manufacture of wooden jewelry, musical instruments, furniture, and handles of many different objects. We present a case of a 44-year-old man who developed pruritus, erythema, and blistering around his right wrist, corresponding exactly to the area where he had worn a wooden bracelet. Thin-layer chromatography performed with the extract of the shavings revealed (R)-4-methoxydalbergione and obtusaquinone (the main components of cocobolo wood) and (S)-4'-hydroxy-4-methoxydalbergione (in lower amounts). Patch-testing with sawdust from the bracelet resulted in a very strong reaction. Patch tests with the pure constituents yielded +++ reactions to the main sensitizers of cocobolo, including obtusaquinone, but also to sensitizers present in other rosewoods. This last fact can be explained by cross-reactivity between different dalbergiones. Contact dermatitis from tropical woods is more frequent than thought, owing to their high sensitizing properties. An exhaustive search can identify the allergen responsible in many cases.

3. Hausen BM. [Rosewood allergy due to an arm bracelet and a recorder]. Derm Beruf Umwelt. 1982;30(6):189-92. [Article in German]
Abstract
A 40-year-old woman developed dermatitis of the left forearm after wearing a bracelet manufactured from Brazilian rosewood (Dalbergia nigra All.). Swelling of the lips, itching and vesicles recurred when she played a recorder made from the same timber some years later. Epicutaneous tests were strongly positive after 120 h with 2 of the wood constituents: R-4-methoxydalbergione and S-4,4'-dimethoxydalbergione. The third quinone (S-4'-hydroxy-4-methoxydalbergione) only elicited a weak reaction. Shavings of the wooden bracelet extracted with benzene and ethanol and separation of the residues by thin layer chromatography yielded all 3 dalbergiones in remarkable amounts (congruent to 0,8%). Cross-reactions to the chemically near related R-3,4-dimethoxydalbergione, known as the strongest sensitiser of the dalbergione group, were not obtained, although guinea pig experiments had revealed cross-reactivities. Of the racemic

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Post-Operative Contact Dermatitis

Abstract: 63 yo woman with 5 day history of a dermatitis

HPI: A 63 yo woman developed a dermatitis 2 d post surgery. An arterial line had been placed in the L. radial artery pre-op. The area was first prepped with chlorhexidine, the line was placed, and the area covered with 6 x 7 cm Tegaderm Film. A venous line was placed in the R. external jugular vein and covered with Tegaderm w/o dermatitis.



O/E: An 8 x 8 cm erythematous vesicular and hemorrhagic plaque is seen in the area under the Tegaderm. Island of sparing in center of patch is where angiocath resided. This plaque is cool to touch. Neck completely clear.

Clinical Photos:



Lab and Pathology: Not deemed necessary at this time.



Diagnosis: Irritant vs. Allergic Contact Dermatitis. Not likely Tegaderm since area under patch on neck is clear. I am considering a toxic burn from chlorhexidine under wrist patch. (see Addendum)



Questions: What are your thoughts?



Addendum: The anesthesiologist reviewed his notes and found that he applied Tincture of Benzoin to the area around the arterial line to help keep the Tegaderm in place, but not on the neck for the venous line. Allergic Contact Dermatitis to Benzoin is well-reported. This seems to be the culprit here. Hopefully, wet compresses followed by clobetasol 0.05% ointment will be helpful. We are indebted to the anesthesiologist for reviewing the operative record and educating us! We will patch test her once her eruption has quieted down.



References: (Free Full Text)

1. Indian J Dermatol Venereol Leprol. 2006 Jan-Feb;72(1):62-3.

Contact dermatitis to compound tincture of benzoin applied under occlusion.

Lakshmi C, Srinivas CR.



2. BMC Dermatol. 2004 Mar 31;4:1.

Severe facial dermatitis as a late complication of aesthetic rhinoplasty; a case report.

Rajabian MH, Sodaify M, Aghaei S.

Department of Plastic Surgery Shiraz University of Medical Sciences, Shiraz

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Recurrent Cheilitis in a 37 yo Woman

Abstract: 37 yo woman with 18 year recurrent cheilitis

HPI: This 37 yo woman has had recurrent cheilitis for 18 – 20 years. She works as a medical assistant. At one time, she was thought to be latex sensitive because blowing up balloons makes her feel sick, but a RAST test was negative. The episodes last five to six days. The day before the present episode she had eaten a “Mediterranean Dip” which included cucumber, garlic, feta, tomato, and horseradish. She noted nothing till the next morning when there was mild erythema of upper lip. She may have a history of mild atopic dermatitis. She can recall no meds she took before this or other episodes.

O/E: Erythema and mild crusting of lips and adjacent glabrous skin. Remainder of exam normal. Occasionally she’ll have mild erythema around outer canthi.

Photos:




Lab/Path: N/A

Diagnosis: ? Allergic Cheilitis. Role of Foods? Doubt Fixed Drug Eruption. To me this looks like an allergic contact cheilitis.

Questions: What would be the best way to work this up? This woman has 3 - 4 episodes per year, so it is unlikely that her cheilitis is related to something whe uses daily, and she does not recall anything she applies only intermittently.

Reference:
Allergic contact cheilitis in the United Kingdom: a retrospective study.
Strauss RM, Orton DI.
Am J Contact Dermat. 2003 Jun;14(2):75-7.

Abstract: Environmental and Contact Dermatitis Unit, Amersham Hospital, Whielden Street,
Amersham, Buckinghamshire, HP7 0JD, United Kingdom. strauss@strauss.karoo.co.uk

BACKGROUND: To date, only a few cohorts of patients with allergic cheilitis have
been described, most of them from Australia and Asia. OBJECTIVE: To establish the
prevalence of cheilitis in a UK specialist contact dermatitis clinic and to
identify the most common allergens. METHOD: We analyzed our patch-test database
in a tertiary referral center in the United Kingdom, retrospectively. All
patients presenting with cheilitis over a 19-year period (1982 to 2001) were
included. RESULTS: Data were available from a total of 146 patients. A positive
allergic patch-test reaction was thought to be relevant in 15% of the patients (n
= 22) and to be of possible relevance in 6.8% (n = 10). Of the 22 patients with
relevant allergic results, 95% (n = 21) were women. The most common allergens
included fragrance mix (mainly cinnamaldehyde, oak moss, and isoeugenol) in 41%
of patients, shellac in 18%, colophony in 18%, and Myroxylon pereirae in 14%. For
half of the patients, the allergen was believed to stem from lipsticks or lip
products. Eighteen percent of patients with allergic cheilitis reacted to only
their own products. CONCLUSIONS: Patients should be tested to extended
lipstick/cosmetic vehicle series in addition to standard series. As a significant
percentage of patients react to their own products only, a thorough clinical
history and testing to patients' own products are important.

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