D. S. Wilkinson

HAND DERMATITIS IN HOUSEWIVES

SUMMARY.— In a series of 4000 patients patch tested in 5 European clinics, 1000 were engaged in domestic work only; they included 281 women with contact dermatitis of the hands. There were no significant differences between the 2 groups as regards age, duration of dermatitis and patch test results.

CONTACT DEKMATITIS I

Photocontact Dermatitis from Antibacterial Agents in Toilet Soap Since the outbreak of photocontact dermatitis from tetrachlorosalicylanilide (TCSA) in toilet soap in 1961 (Wilkinson, 1961) the popular brands of deodorant soaps in Britain have contained trichlorocarbanilide (TCC) as an antiseptic agent, and this has caused virtually no trouble. Several Australian, American, Italian (Midana et al., 1967) and German reports have noted the sporadic occurrence of photodermatitis from other halogenatcd salicylanilides, bithionol, and even hexachlorophane in soaps and toilet preparations, and in some antifungal preparations (Burry, 1967). Recently, two large series of patients with photodermatitis due to tribromosalicylanihde (TBS) have been studied in the U.S.A.* (Harber et al, 1968) and in Denmarkf (Osmundsen, 196S). In tho U.S.A. 55% of the population, and in Denmark about 20%, prefer soaps containing antibacterial agents. In the U.S.A. the brands which claim to possess antibacterial properties must state the content of antiseptics on the wrapping. Other brands of soap, however, make no such claims, and the contents may vary, unlmown to the public and the dermatologists. The antiseptics preferred are TBS, TCC, and hexachlorophane. In relation to the number of consumers, the incidence of photodermatitis from soap seems to be quite low in the U.S.A. In Denmark during the recent summer, however, Osmundsen has seen 40 cases in a few months. He estimates the incidence to be about 1 in 1000 consumers. Since the relative number of consumers and the daily photo-lux index are much higher in the U.S.A. than in Denmark, the extent of the Danish outbreak should provide the soap industry with valuable information. Differences in the incidence of sensitization might be due to the soap bases, impurities in the TBS used, or the concentration of this employed. It is noteworthy that American toilet soaps contain 0 • 75% TBS or less, while the Danish soap responsible for the photodermatitis had a TBS content of 2%. This may explain the difference in the incidence. The Danish soap manufacturers have taken immediate steps to substitute TCC for TBS in the soap concerned. Harber et al. have recently provided the decisive proof that photosensitivity from halogenated salicylanilides depends on an allergic mechanism. With lymphocytes from guinea-pigs highly sensitive to TCSA they passively transferred photosentitivity to non-sensitive guinea-pigs. The immunological mechanism in photocontact dermatitis is thus identical with that of simple contact dermatitis with the proviso that the hapteneprotein conjugate requires light energy for its formation. As in simple contact dermatitis, the spectrum of sensitivity is increased by testing with potential secondary photoallergens, a further indictation that the mechanism is allergic. Photocontact dermatitis from TBS is elicited by long UV-light with a maximum around 360 nm. Photo-patch testing should accordingly be performed mth UV-light screened by window glass. Woods light (of high intensity), or, most conveniently, by the use of black light fluorescent tubes. False negative patch test reactions are apt to occur with a high pressure mercury arc lamp without a glass screen, since the light emitted in the sunburn range hmits the energy at 360 nm. given to the patch tests. Natural sun may be used in appropriate climatic regions (Burry, 1967).

CONTACT DERMATITIS IV Tulip Fingers, Hyacinth Itch and Lily Rash

The term tuhp fingers though long in popular use first appeared in medical literature in 1935 (Bertwistle). Popular names applied to plants are sometimes confusing. In Great Britain the term daffodil is used for trumpet narcissi and the unqualified term narcissi for the remainder. There is no reason to separate these two groups in regard to their sensitizing capacity, though this may vary within each group. This review deals for the most part with recent Continental—especially Dutch—work, where the bulb industry is of great economic importance. Though at present expanding, the main centres in Great Britain still remain the Scilly Isles (narcissi) and north Cambridgeshire and Lincolnshire (tulips) and cases of dermatitis are rarely seen elsewhere. Tulip bulbs may cause a painful, dry, fissured and hjrperkeratotic eczema, at first underneath the free margin of the nails, then extending to the finger-tips and periungual region. Sometimes an irritable dermatitis spreads to the face, hands and forearms and the genital region. Tulip fingers may develop after many years of recurrent seasonal work; once started the condition relapses with each further exposure, even if a patient has been removed from the work for many years. Tulip fingers are very common but, as with other occupational dermatoses in plant growers, are seldom seen by dermatologists. A search through the combined files of the University Clinic of Leyden and the Municipal Hospital of the Hague in 1962 revealed only two cases. The number of persons exposed can be estimated from the export figures of 1200 million bulbs in 1967. Dermatitis from bulbs has recently been reviewed by Verspyck Mijnssen (1968a) in a Dutch monograph in which he reports his detailed studies on the pathogenesis and aetiology of tulip dermatitis. He accomplished the isolation of the pure tulip allergen, later identified by the chemist Brongersma-Oosterhoff (1967). In the bulb industry the fiower is removed from the stem, manually or by machine, in April or at the beginning of May. A few workers engaged in this work may develop dermatitis from it. The bulbs are taken up in June or July either by hand or by machine. Subsequently they are peeled manually to remove the daughter bulbs from the remnants of the parent bulb. The friction and trauma this causes is the major source of primary sensitization. Dermatitis may develop during the collection of the bulbs and their peeling or during packing and inspection in August and September before they are planted in late autumn. Persons highly sensitized by bulbs may develop dermatitis on the index finger and the dorsum of the hand when cutting tulip fiowers (Verspyck Mijnssen, 19686). Another mode of sensitization is described by Klaschka et al. (1964). This occurs in March or April from the harvesting of fiowers. The tulips are pulled out of the ground with the bulbs attached and in Denmark are brought to the market in this way. But in Germany and Sweden the bulbs are split with a knife to give a longer stem. This gave rise to dermatitis in 8 of 12 workers employed.

CONTACT DEEMATITIS III

Despite their extensive use in agriculture and horticulture, dermatitis from pesticides is regarded as rare (Fregert and Hjorth, 1968). Rubber dermatitis from thiurams (TMTD and TETD) is common and most dermatologists will warn sensitive patients to avoid contact with rose powders and sprays, which usually contain these substances. But even enthusiastic gardeners rarely suffer any irritation from them, although cases are occasionally observed in professional ch i-ysanthemum growers. Similarly, dermatitis from Zineb and Maneb (respectively zinc and manganese ethylene fcis-dithiocarbamate) has been reported (Laborie and Dedieu, 1964), but it appears to be uncommon, as is sensitivity to other zinc-dithiocarbamates used as pesticides and rubber accelerators. Impurities eause more trouble than the active pesticides. Positive ]>atch test reaction to technical DDT were found to be negative when repeated with the pure substanee (Beerbohm, 1960). Dermatitis from gamma-hexachlorocyclohexane ( Lindane ) has been encountered mainly at the stage of manufacture and is caused exclusively by delta-heptachlorocyclohexane (Hegyi and Stota, 196.5). Even after decades of use of the jmvG gamma-isomer for scabies and lice in the United States untoward reactions are exceptional. While several isomers have insecticidal properties, allergie sensitization is more exclusive. Experimentally the organo-phosphorus compounds Malathion (Milby and Epstein, 1964; Kligman, 1967) and Parathion (Palmienteri, 1964) have been shown to be strong sensitizers in man. Clinical dermatitis from Malathion , liowever, occurred only after repeated heavy exposure over a period of years (Milby and Epstein, 1964), although it may be assumed that many eases pass vuidiagnosed. Even with Malathion the sensitizing properties are due to an impurity, diaethjlfumarate (Kligman, 1967) the content of which can be reduced by refining.

CONTACT DERMATITIS V

Essential Cryoglobulinaemia. A Kjaii ai^ed i);). Hlslonj-—(,.)nset ni I.K)!). First sei>ii m i!Hi(i with hlotehy, ej-ytliematoTfs. ecchymotic a])]^earaner oi the skin ot the face, hacks cif tlic hands and jtarts of the IOWIT liirihs. NcciTitic areas r»n helices. (»vcr some (>f the small joints of thi. liands, elhows, rJiiht cheek und some ot the loes. In Ma> P.Hi4 he decloped more i:anirrcnous areas. IMafiy toes have separate<l s])ontaneons|y. (General healtli ^ood. Became worse iUi |irednisolone. Oil rxdti/iiKifioii.—All toes absent ece])t for the left, tirst and titth toes. All i*erij theral judses ])resent. H P . 110/70. l.)iisk . t(danii:icctatic ap i icarancc of face and hands . Marked atn.^pliy ?f sJcm of slnns. Inri:sfi(ffi(ii)ii-^. — Pa])er Fleet roplioi-esis ; di^ise enmnact hand m i^amma reiiifHi. A

CONTACT DERMATITIS VIII

oii1;M-t < i f T i i i a t i t i s ( l i j )on ( l i i p d i i t h i c l i c r n i o a l I h c e ; i u > e > o f a l H r . U K e wlueh r-. ifiainl>de t e rmined by t he decree of indus t r i a l deve lopment and tlie tlierapc habi ts ol tlie piiysicians. T recent s tudies , l iowever, indicate t h a t less than alleri:cu>^ are tlie predotn inant causes oi r ontact dennatiti. ^ in Europe (.Ia2nn> J aLl!)(fS: Fni^ert rl fi. l!Hi.l), In Scand inav ia anrl F inland t he 20 mtjst ctnninoti contact aller iens were ideniieaL althoULdi tlie ineidenee of sensi t i i ty to individual Mibstanecs differed from i:)ne c o u n t r y t o anothf/r . T h e 2t) subs tances were nickel. cobah . notassuim ilichrouuitr . 4 r u b b e r chemieals . S t e rosan . ioform. iicnzocaine wnol aleohiils ami to iu ia idchyde a n d var ious n a t u r a l s i ibs tanecs—colophony, balsam nl .peril, wdol taj-s. t u r p e n t i n e and coal tai*. 1be same series oi t.est subs tances Aas used in an invest igat ion of 4X2) ]iatient.v in S clinic-^ in Eni : land. (-Germany. Hollantl . l t a l , Sweden and Denmark , Forty ]K-r eent of the nai icnts test ed hail posit ive reac t ions to one or scvei-al s i ibstances of the battiM-v Aux test sei*ies !s bouud to iiivfpositi(^ redactions a p p a r e n t l y unre la ted to the ]irisciit deiuiatifis but . tin an average , .»*>,, of tli<: pos i t ive reac t ions to tlie ba t tery tests wnv cojjsidcred relevajit. Sensit ivitx t o eln-oinatc a n d cobal t was considered relevant morr often in men t h a n in women. Tliis j ioints t o u n k n o w n sources of contact with thcM meta ls in the env i ronment of females. P>alsam of Peru , colojtliony. and tuqientiiic an (bltienh lo t race in the envi rormient aiid tln^ sonrees (jf t he sensitizing Contacts seem tn uni-it fiuther s tudy , yriivlv all ]>atic()ts iti t he s t u d y were also t(^sted with addi t iona l allergens am] (;,^ had a jiositive reh;vant reaction to substances n(:)t included in the battery. In the tiiia) analysis, rto-,, of all pa t io t t s examined suffered from coutact dermatitis, and of thî r?>y, had alleigic contact dermat i t is . It-Vv, irr i tant dcrjiiatitis. and 4,, a mixture nf allergic an<i irritant dermati t is . Jn spite of the arying clientele of the elinies and thi diHerin,ii conccfits of the <:[eroiat(.(iogist.s (jii the statf, allergic contact dermatitis uas mere eoijjnion than iiiitant (h^-matitis in all tli(^ particij^ating depar tments . Thu-ty ])er cent of the nicn and 12,-, of the women had occupational dermatitis, w hieh was strikingly common, not only in de]>artment.s especially interested Ijiit also in general ilermatological dcjiaitments. Fifteen ]ier cent of tlie ])atients had dermat i t i s from a])]>lied medicaments. This was e([i)al]y common in both sexes, l.nit ]>a3tienlarly .so in ]>atient.s with ,sta.sis ejr leg ulcer flermalitis. 5X-, of whom had sensitivity causnig or com])licating their primary complaint. Dermatitis of the bauds is a common indication for testing. P^ifty-nine per cent of the patients liad some affection of th.e hands, and in 32n these were the only site of dermatitis. Aboul half the ]iatierits wilh hand i lermati t is have a reie-ant sensitivity. iSineeoiily a fraction of the relevant sensiti^dties would have been detected hy aimed pateh tests seleeted for the ii)di itlual pat ient , the two eompreheii.sive studies cited stress the usetulness of a series of s tandard test sul.>sfanees. Aet i e pati-li test sensitizatiou is ]!articularly frei.|uent with the use itf high ctmcentrations of test substanees, whieh must be ada])ted to the degree of occlusiveiiess of the test unit. It cs])eciaily occurs in ]>atients who are ])redisposod liy previous cxjiositrc to the re,sjMnisib!e allergen.

Detergents and the Skin

flux were used in the 3 Boards under examination. Twenty-four skin cases and 3 chest cases were discovered in the period of the survey. As a result of that investigation the need for care in aluminium jointing was established and a code of practice evolved. The report of the investigation and the code of practice were widely circulated among medical staff, throughout both sides of the industry and to the Jointers themselves. The statement that the Electricity Board and their medical advisers were unaware of the existence of a dermatitis problem is untrue. Furthermore the magnitude of the problem should be considered. It would be interesting to know the epidemiological methods employed by Crow and his colleagues in selecting their small sample of seventeen jointers from one Area Board, as each Area Board employs about 1000 men on this work. Further, Crow implies criticism of the Area Boards for not making use of the patch testing facilities available . We would venture to ask whether routine patch testing is the best course to adopt in these situations. This view has been reinforced by the recent paper Sensitization induced by patch testing (Br. J. Derm. (1968), 80, 361). Furthermore hi the opinion of some dermatologists Kynal fiux can act as a primary irritant and in consequence patch testing is not appropriate. The table produced by the authors shows that Bical fiux produces no cross sensitization with previous fiuxes. We accept with caution however the inference made by the authors that this new fiux will not pose a future dermatitis hazard . The Research Department of the Electricity Council has also evolved for a fiux aluminium jointing free from A.E.E. base which together with Bical is undergoing practical tests in the field. If the engineers and those responsible for our electricity supply are convinced of the efiicacy of the new fiuxes they will be considered for use in the industry. However, the medical hazards of other amines will have to be carefully watched lest we repeat with them the experience of Holden with A.E.E. That is, no cases among 250 aluminium cable jointers in 1961 (McCann, 1964) and a 10% incidence 7 years later.