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Hindawi Publishing CorporationISRN AllergyVolume 2013 Article ID 361746 10 pageshttpdxdoiorg1011552013361746

Review ArticleNoneczematous Contact Dermatitis

Domenico Bonamonte Caterina Foti Michelangelo Vestita and Gianni Angelini

Department of Biomedical Science and Human Oncology Section of Dermatology University of BariPiazza Giulio Cesare 1 70124 Bari Italy

Correspondence should be addressed to Caterina Foti caterinafotiunibait

Received 7 July 2013 Accepted 12 August 2013

Academic Editors D C Cara B F Gibbs Y L Ye and Z Zhu

Copyright copy 2013 Domenico Bonamonte et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

Irritant or allergic contact dermatitis usually presents as an eczematous process clinically characterized by erythematoedematovesi-cous lesions with intense itching in the acute phase Such manifestations become erythematous-scaly as the condition progressesto the subacute phase and papular-hyperkeratotic in the chronic phase Not infrequently however contact dermatitis presentswith noneczematous features The reasons underlying this clinical polymorphism lie in the different noxae and contact modalitiesas well as in the individual susceptibility and the various targeted cutaneous structures The most represented forms of non-eczematous contact dermatitis include the erythema multiforme-like the purpuric the lichenoid and the pigmented kinds Theseclinical entities must obviously be discerned from the corresponding ldquopurerdquo dermatitis which are not associated with contact withexogenous agents

1 Introduction

Allergic contact dermatitis (ACD) is a common cutaneouseczematous disorder caused by contact (either direct or aero-mediated) with a range of environmental substances Patho-genetically ACD results from an immune reaction involvingboth innate and adaptive immunologic mechanisms In par-ticular hyperreactive response to small chemicals (haptens)penetrating the skin depends on a series of events such ashaptens capability to activate and mobilize cutaneous den-dritic cells (cDC) generation of hapten-epitopes for T-cellrecognition and hapten-cDC complex ability to prime effec-tor T cells with skin homing proprieties [1ndash3] In sensitizedindividuals skin or systemic challenge with the specific sen-sitizer determines rapid recruitment of effector T cells alongwith natural killer lymphocytes whichmediate tissue damagethrough release of proinflammatory cytokines and throughhapten-loaded keratinocytes killing

Clinics of ACD are generally polymorphic Besides theclassic eczematous form in fact different noneczematousclinical variants are possible [1 4ndash6]The causes for such vari-ability in ACD clinical aspects are many (Table 1) Accordingto our data (unpublished) considering gt30000 patch tested

individuals for contact dermatitis noneczematous forms areslightly more common (52) than the classic eczematous one(48) Various clinical patterns of noneczematous ACD havebeen described some are linked to topical use of specifichaptens and others more often dependent on allergens sys-temic administration (Table 2) The most represented formsare described as follows

2 Erythema Multiforme-LikeContact Dermatitis

Of all noneczematous clinical variants the erythema multi-forme-like (or ldquocontact erythema multiformerdquo) is the mostcommon It can be elicited by different substances par-ticularly exotic woods medicaments and ethylenediamine(Table 3)

21 Causes

Woods and plants Among exotic woods Brazilian rosewood(Dalbergia nigra) pao ferro (Machaerium scleroxylon) andEucalyptus saligna are relevant as occupational causes of ery-thema multiforme-like eruption in carpenters foresters and

2 ISRN Allergy

Table 1 Factors determining the peculiar polymorphic clinicalfeatures of allergic contact dermatitis

Eruptive polymorphismEvolutive polymorphismCausative agentPatient sensitizing levelWay of exposition (cutaneous systemic)Means of exposition (cutaneous direct cutaneous aeromediated)Tissue structures targeted by the causative agentAnatomophysiology of the cutaneous region involvedCausative agent possible concomitant irritant actionEnvironmental factors (UV temperature humidity)Itching intensity variabilityPreexisting dermatitis underlying the overlapping contact allergy

Table 2 Different types of noneczematous contact eruptions

Erythema multiforme-like contact dermatitisPurpuric contact dermatitisLichenoid contact dermatitisLymphomatoid contact dermatitisPigmented contact dermatitisPustular contact dermatitisDyshidrosiform contact dermatitis

cabinetmakers Antigens in pao ferro andBrazilian rosewoodare crossreacting quinones respectively R-3 4-di-methoxy-dalbergione and R-4-methoxy-dalbergione [7 8] Literaturealso lists extraoccupational cases from wooden bracelet [9]and pendants [10] made of D nigra M scleroxylon hasbeen described to cause a similar eruption in hobbyists whohandled this type of wood to build boxes [11]

Other reported causes of erythema multiforme-like reac-tions include Artemisia vulgaris [12 13] poison ivy [14 15]Hypericum erectum [16] and terpenes [17] Tincture of cap-sicum caused an analogous reaction in awomanwho used theconcoction to treat her knee arthritis [18] Inula heleniumcontained in a mixture to treat back pain has also inducederythema multiforme-like eruption with positive patch teststo sesquiterpene lactone mix and alantolactone [19] NotablyPrimula obconica can also induce comparable eruptions [20ndash23] We observed an erythema multiforme-like reaction in aplant nursery worker who had handled plants of P obconicaThe dermatitis involved hands forearms and face Patchtests were positive to primin (001 in pet) leaves andflower Histology showed foci of hyperkeratotic orthokerato-sis mild spongiosis exocytosis and few isolated necrotic ker-atinocytes at the superficial and mid dermis a largely peri-vascular lymphocytic infiltrate was present [24]

Topical Medicaments Numerous topical drugs are reportedas cause of erythema multiforme-like contact dermatitisthe vast majority being antimicrobials According to ourobservation pyrrolnitrin can trigger this kind of eruption

Table 3 Causative allergens in erythema multiforme-like eruption

Plants andwoods Medicaments Miscellaneous chemicals

Dalbergia nigra(Brazilianrosewood)

Ethylenediamine Brominated compounds

Toxicodendronradicans (poisonivy)

Pyrrolnitrin Phenylsulphonederivatives

Primulaobconica Sulfamide Epoxy resin

Machaeriumscleroxylon (paoferro)

Econazole Formaldehyde

Artemisiavulgaris Promethazine Disperse blue 124

Eucalyptussaligna (gum) Balsam of Peru Trichloroethylene

Inula helenium Scopolamine DinitrochlorobenzeneCapsicum Mafenide acetate DiphenylcyclopropenoneTerpenes ProflavinePyrethrum Neomycin

MephenesinVitamin EBudesonideBufexamacClioquinol(vioform)Ketoprofen

TriamcinoloneacetonideIdoxuridine

Phenylbutazone

[25 26] Other causative drugs include sulfonamide [27 28]promethazine [25] neomycin [25] mafenide acetate [29]ethylenediamine [25 30] and mephenesin [31 32] Amongnonsteroid anti-inflammatory drugs phenylbutazone [33]bufexamac [34] and mofebutazone [35] have been reportedAmong corticosteroids budesonide [36] and triamcinoloneacetonide [37] caused analogous reactions

Miscellany Erythema multiforme-like eruptions can be theexpression of contact allergy to nickel [38ndash41] and cobalt[39] 9-Bromofluorene induced a skin acute reaction inseveral chemistry students who were exposed to the productduring its synthesis [42 43] Finally many other compoundshave been associated to erythema multiforme-like reactionsalthough exceptionally [5 6]

22 Clinical Features Early lesions are eczematous in mor-phology and localized at the allergen contact site After a1 to 15 days delay the erythema multiforme-like eruptionfollows involving the area around the original lesions orrather extending to the whole cutaneous surface The latter

ISRN Allergy 3

Table 4 Differential diagnosis between true erythema multiforme (EM) and erythema multiforme-like contact dermatitis

Criteria EM EM-like contact dermatitisEtiology Viruses bacteria systemic drugs Various topical chemicals

Clinical featuresErythematoedematous lesions with cockadeappearance sometimes bullous with acrallocalization (face hands forearms thighs)

Polymorphic lesions located peripherally tothe contact site with the sensitizing agent

Fever Often present AbsentMucosal involvement Frequent Rare

HistologyEpidermis basal cells necrosissubepidermal vesicobullaeDermis edema capillary vasodilationvasculitis signs

Epidermis spongiosisDermis edema lymphohistiocytic infiltrate

Pathogenesis Immunocomplexes Type IV hypersensitivityPatch tests Negative PositiveCourse Self-limited in 3 weeks Favorable after allergen withdraw

occurrence generally ensues systemic exposition to drugswhich the patient had previously been sensitized to topicallyTarget-like erythematovesicular or urticarial lesions arecharacteristic Resolution is slow-paced these manifestationspersist usually much longer than the original eczematouslesions (or sometimes appearing after regression of the latter)Itching sensation is also typically present in polymorphicreactions [1] Patch tests generally elicit eczematous positivereactions with the exceptional vesico-bullous or urticariallesions

Differential diagnosis is set out with true erythemamultiforme (Table 4) the latter showing almost all target-likelesions with typical acral distribution and crops-like onset

23 Histopathology The histology is generally aspecific Epi-dermis shows spongiosis and exocytosis Mild upper dermisedema and perivascular lymphohistiocytic infiltration arenoticeable Vacuolar degeneration of basal cells is rarelypresent while epidermal necrosis is very mild or absentWhen bullae are present they are intraepidermal [1]

The histopathology of true erythema multiforme showsfrank epidermal necrosis and vacuolar basal cells degenera-tion while bullae are subepidermal [1]

3 Purpuric Contact Dermatitis

This particular form of noneczematous contact dermatitis isof unusual observation andmany cases remain undiagnosedThe eruption evolves in several weeks after the withdrawal ofthe offending agent and resolves with more or less persistentpigmentation The purpuric aspects of contact dermatitisand the respective patch test reactions can be secondary toirritant or more frequently allergic mechanisms [44]

31 Causes The most frequent causative factors are listedin Table 5 Certain components of rubber and textile arerecurrently reported in the literature

RubberFirst reported cases date back to 1968 9womendevel-oped purpura from cloth elastic inserts in every instance

patch tests turned positive to N-isopropyl-N-phenyl-para-phenylenediamine (IPPD) a rubber antioxidant [45] Other2 cases showing diffuse purpuric reactions with negativebloodwork were associated to IPPD and specifically to theuse of rubber boots [46] Fisher reported 3 cases respectivelyfrom rubber diving suit elasticized shorts and rubberizedsupport leg bandage in all 3 patients patch tests turnedpositive to IPPD [47 48] The author therefore fashionedthe ldquoPPPP syndromerdquo defined as an ACD characterized bypruritus petechiae and purpura caused by IPPD IPPD alsoprompted similar eruption in a woman in the pattern of herbrassiere [49] and in a man at rubber boots contact sites[50] PPPP syndrome has also been described following useof orthopedic elastic bandages [51] and rubber gloves [52]in the latter case patch tests were positive not just to IPPDbut to N-cyclohexyl-N1015840-phenyl-paraphenylenediamine andNN1015840-diphenyl-para-phenylenediamine as well

Textile From 1969 to 1972 Osmundsen gathered 167 casesof purpuric reactions from an optical whitener contained inwashing powders [53 54] The petechial and itchy dermatitisinterested those areas which are typically subject to tightercontact with clothes (armpits arms upper limbs folds neckand thighs)Theoffending agentwasTinopalCH3566 amix-ture of 2 noncrossreactive pyrazolines (monochlorobiphenyl-pyrazoline and dichloro diphenyl pyrazole) Tinopal CH3566was used to bleach nylon fibers and caused a similar epidemicoutbreak in Spain where 103 were collected [55] From thattime on the product was discontinued with no more casesreported As of today risk-free stilbene-based optical whiten-ers are employed

A sailor developed generalized purpuric lesion withpigmentary outcomes at sites of contact with themilitary blueuniform Patch tests evidenced positive reaction to DisperseBlue 85 while histology demonstrated Schamberg diseasesign [56] We directly observed a case of purpuric ACD toDisperse Yellow 27 (Serisol Fast Yellow 6DW) an azoic dyeused in acetate and polyester fibers a result of para-amino-acetanilide and paraphenylphenol The dye was part of a pairof trousers inner lining and the dermatitis while interesting

4 ISRN Allergy

Table 5 Causative agents in purpuric contact dermatitis

Rubber compounds Textile compounds Plants MiscellanyN-isopropyl-N1015840-phenyl-paraphenylenediamine Optical whiteners (Tinopal CH 3566) Agave americana L ParaphenylenediamineMercaptobenzothiazole Azoic dyes Zea mais Fiberglass

Rubber compounds Frullania Peru balsamFormaldehyde resins d-Limonene Epoxy resin

OxyquinolineProflavineCobaltBenzoyl peroxide

the whole skin surface started from and was particularlymanifest at the thighs Thin layer chromatography fromtextile extract demonstrated only one component DisperseYellow 27 Histology proved traditional aspects of ACD withlymphocytic infiltrate and intense perivascular edema asso-ciated to noticeable erythrocyte extravasation [57] Purpuriceruptions have also been described in a black hats vendorfrom paraphenylenediamine [58] in British soldiers fromformaldehyde resins contained in kakiwool shirts [59] and ina man assigned to mixed wool-synthetic residues harvesting[60]

Plants Frullania induced a diffuse purpuric reaction histol-ogy showed signs of leukocytoclastic vasculitis however cir-culating immune complex and complement deposition assayswere also positive [61] Agave americana L of Agavaceaefamily can determine purpuric contact dermatitis with his-tological features of leukocytoclastic vasculitis [62] We alsoobserved a similar case secondary to plant latex contact [63]Zea mais (corn) has been shown to induce irritant purpuricphytodermatitis some hours after contact to green leavesPatch photopatch and scratch tests with alcoholic extracts ofdifferent plant parts (leaves trunk efflorescences) all resultednegative [64] Two-hour experimental exposition to 98 d-limonene resulted in a severe and several week persistentpurpuric reaction 6 hours after contact [65]

Miscellany Fiberglass can induce direct or aeromediatedcontact dermatitis with pruriginous 01ndash05mm diametermostly follicular purpuric papules Exposed and nonexposedareas are both affected since these fibers are able to passthrough clothing [66 67] Clothes contaminated by beingwashed together with fiberglass curtains can also inducepurpuric dermatitis [68]

Vasculitic purpuric eruptions to Peru balsam [25 69]ethylenediamine [70 71] benzoyl peroxide [72] and pro-flavine [73] have also been reported

32 Patch Tests Purpuric Reactions As is well known amongthose who practice dermatoallergology petechial reactions tocobalt patch test without edema vesicles and infiltration canbe observed These are toxic in nature rather than allergicSchmidt et al in a 4-year time span observed 123 cases(47) of cobalt petechial reactions out of a total of 2594

patch-tested patients Twenty-three patients were retestedand developed new petechial responses in 60 of casesBased on these authors data the incidence of positive allergicreactions to cobalt was lower (29) than the incidence ofprimary irritant reactions [74] Judging on our practice casesof petechial nonallergic reactions to cobalt and chrome areindeed rather numerous and frequently reproducible

33 Clinical Features Purpuric contact dermatitis can beeither toxic or allergic in nature From a clinical-morpholog-ical perspective differential diagnosis is not straightforwardboth present palpable purpuric elements evolve slowly andare followed by variably intense and persistent pigmentationAt times clinical extension represents a useful feature indifferentiating the 2 forms the irritant being strictly limitedto contact sites Moreover lesional elements resolve morerapidly and are less infiltrated in the irritant form comparedto the allergic one

Diffuse contact irritation from fiberglass must be dis-cerned from scabies eczema (prurigo-like) animal andvegetal acariasis and if persistent fromHodgkin diseaseTheanamnestic data of epidemic bursts in industries or bureaus(fibers dispersed from defective air conditioners) greatly aiddiagnosis [75]

The allergic form of purpuric contact dermatitis generallyfeatures diffuse and polymorphic manifestations papulop-urpuric and papulovesicular lesions parallel classic eczema-tous foci The latter are limited to the original contact sitewith the offending noxa Secondary distant lesions can alsopresent polymorphic or vasculitic aspects as we have directlyobserved Purpuric patch tests reactions are obviously vesic-ular and infiltrated [44]

34 Pathogenesis and Histopathology The pathogeneticmechanism of purpuric contact dermatitis is currentlyunknown Hemostasis or complement system alterations arenot generally described in reported cases nor are immunecomplexes commonly isolated In every case we observedamong which 3 severe cases from Peru balsam with franklyvasculitic and bullous lesions and various cases fromethylenediamine (in which the rash had followed systemicadministration of aminophylline) specific laboratory examsfell into normal range [25 44]

ISRN Allergy 5

Table 6 Histopathological characteristics of purpuric contactdermatitis (PCD) and vasculitis (V)

Criteria PCD VSpongiosis ++ NegativeSubpapillary edema + ++Leukocytoclasis Negative ++Erythrocyte extravasation + +++Neutrophilic perivascular infiltrate + +++Vasal involvement + +++C3-direct immunofluorescence Negative ++

Since endothelial cells degeneration is evident at electronmicroscopy a selective effect on these cells has been hypoth-esized In detail specific toxic or allergic substances as wellas certain mechanical stimuli (fiberglass) would exhibit anaffinity for vessels endothelium [47 57 58] Alternatively aprimary lymphocytic reaction in response to the antigen atthe perivascular site would free toxic lymphokines ultimatelyresponsible of endothelial damage [72]

Histopathology has been described with comparableresults in most reported cases In the epidermis spongiosisand lymphocytic exocytosis are constant features along withpossible bulla formation In the upper dermis the signsof leukocytoclastic vasculitis (vessels fibrinoid degenerationedematous endothelium scarce perivascular lymphomono-cytic and neutrophilic infiltrate erythrocytes extravasationand karyorrhexis) are visible The same features are presentwhen examining a patch test response lesion (Table 6) [4774]

Bloodwork histologic and patch test examinations arevalid to differentiate the condition from vascular hemostaticand idiopathic purpuric affections

4 Lichenoid Contact Dermatitis

A particularly uncommon form of noneczematous contactdermatitis presents with clinical features resembling those oflichen planus It affects both skin and mucosal membranes

41 Causes Color developers substances derived from para-phenylenediamine are the most common cause of allergiccontact lichenoid eruption Among these compounds KodakCD2 (4-N N-diethyl-2 methylphenylenediamine) KodakCD3 (4-N-ethyl-N-2-methanesulfonylaminoethyl-2-methyl-phenylenediamine sesquisulfate monohydrate) Kodak CD4(2-amino-5-N-ethyl-N-(hydroxyethyl)-aminotoluenesulfate) Ilford MI 210 (N-ethyl-N (5-hydroxy-amyl) para-phenylenediamine hydrogen sulphate) and Agfa TSS(4-amino-N-diethylaniline sulfate) [75]

Other cases of lichenoid contact dermatitis have beenreported byMandel in 9 out of 11 workerswith contact allergyto a color developer [76] and by Fry in 7 out of 20 patientswith analogous sensitization [77] High speed black-and-white film processing implies the use of similar chemicalswhich can induce lichenoid reactions [78] As a general rulethe eruption from color developers spares the oral mucosa[79] Cases from paraphenylenediamine in hair dyes [80]

Table 7 Histopathological characteristics of lichenoid contactdermatitis (LCD) and lichen planus (LP)

Criteria LCD LPSpongiosis ++ NegativeHypergranulosis minus+ +++Basal cells vacuolardegeneration + +++

Incontinentia pigmenti + +++Civatte bodies Negative ++

Dermal papillae Lengthened Broaden domeshaped

Lymphohistiocytic infiltrate Mild perivascular Band-like

P obconica [81] nickel [82] epoxy resins [83] aminoglycosideantibiotics [84] andmethacrylic acid esters for industrial use[85] have also been described Oral mucosae involving formsare due to copper [86] zinc [87] andmercury [88] containedin dental restorations

42 Clinical Features Eczematous lesions evolve or associatewith papulous lesions with peculiar lilac-red gradation Theeruption mostly involves contact sites later widely spreadingwith mucosal sparing Course is prolonged and leaves vari-ably intense pigmentary changes lasting up to some monthsLichenoid contact dermatitis has to be differentiated fromlichen planus with its characteristic papulous polygonal lilaclesions The onset of lichenoid contact dermatitis is almostinvariably acute and the eruption spreads rapidly Franklyeczematous lesions at the primitive site are noticeable inmanycases

Positive reactions to patch tests are eczematous in naturebut might turn lichenoid

43 Pathogenesis and Histopathology Pathogenesis of con-tact lichenoid dermatitis is unclear Systemic absorption ofoffending agents can elicit skin lesions far from the originalsite of contact In 5 cases we observed (3 from color filmdevelopers and 2 fromparaphenylenediamine) histology dis-played lack of hypergranulosis foci of moderate spongiosisand focal basal stratum vacuolization A patchymononuclearinfiltrate was evident in the upper dermis [86] Basal cellvacuolization is the cause of incontinentia pigmenti whichcould explain skin lesions peculiar color a blend of red fromflogosis with blue from dermalmelanin Table 7 compares thedifferent histopathological characteristic of lichenoid contactdermatitis and lichen planus

5 Lymphomatoid Contact Dermatitis

This uncommon dermatitis manifests with the clinical fea-tures of plaque parapsoriasis or an early stage mycosis fun-goides [1 70] There are no specific causing haptens [89ndash95]the most frequently reported being paraphenylenediaminepara-tertyl-butyl phenol resin gold ethylenediamine andnickel Patch test reaction to these is eczematous in nature

6 ISRN Allergy

Table 8 Histopathological characteristics of lymphomatoid contactdermatitis (LCD) and mycosis fungoides (MF)

Criteria LCD MFSpongiosis +++ +

Exocytosisminus+++

Inflammatorycells

+++Atypical lymphoid

cells(microabscesses)

Lymphocytic infiltrate Perivascular Band-typeLymphocytes withcerebriform nuclei minus+ +++

and can persist for several days Lymphomatoid contact der-matitis and mycosis fungoides alike present with infiltrativepatches the former however demonstrates a bright erythe-matous color and undefined margins

Histology is crucial in differentiating the above two con-ditions Spongiosis is much clearer and exocytosis is typicallylymphocytic in contact dermatitisMycosis fungoides insteadshows atypical lymphocytes in focal abscess-like aggregations(ie the pathognomonic Pautrierrsquos microabscesses) and aband-like subepidermal infiltration of large lymphoid cellswith cerebriform nuclei (Table 8)

6 Pigmented Contact Dermatitis

Described by Osmundsen in 1970 it is a melanic primitivehyperpigmentation usually observed in dark phototypes andmostly occupational [96]The author observed an intense andbizarre skin hyperpigmentation due to contact with an opticalwhitener (Tinopal CH 3566) used in washing powders andmade by a combination of two pyrazolone derivatives as ofnow discontinued

Clinically involved sites were those of textile contact der-matitis with brown-blue to grayish hyperchromia The sameoccurred at patch test application sites Histology evidencedmelanin deposits inside and out melanophages in the upperdermis

Pigmented contact dermatitis can also be prompted byazoic dyes An epidemic outburst from contact to naphtholAShas been reported in a textile business [97]Hyperpigmen-tation was noticeable in dark skinned individuals while fairskinned ones showed the signs of classical eczema Sudan IVacanceine Red [98] and Brilliant Lake Red R [99] are otheroffending colorants which have been reported Isolatedoccupational cases from insoluble cutting oils [100] para-phenylenediamine [101] and other substances are alsodescribed (Table 9) [102] Riehlrsquos melanosis is nowadaysalso considered a pigmented contact dermatitis mostly fromcosmetic sensitizing fragrances and chemicals [103]

7 Pustular Contact Dermatitis

Pustules are usually associated with irritant reactions Nev-ertheless allergic pustular reactions are known from nitro-furazone [104] black rubber [105] and minoxidil [106]The latter has been described in a woman who developeda vesicopustular eruption on the forehead after applying 2

Table 9 Causative agents in pigmented contact dermatitis

Optical whiteners Tinopal CH 3566

Dyes

Naphthol ASSudan IBrilliant Lake RedVacanceine RedSolvent orange 8

Cosmetics

PigmentsPigment orange 3Pigment red 3Pigment red 49Pigment red 53Pigment red 64

Azoic solventsSolvent orange 2Solvent orange 8

Fragrances

JasmineHydroxycitronellalYlang-ylangPatchouliCananga

Antiseptics Carbanilide

Miscellany

FormaldehydeNickelRubberPrimula obconicaMusk ambrette

minoxidil solution Histology showed perifollicular lympho-cytes histiocytes and eosinophils Patch test response waserythematovesicopustular Patch test was strongly eczema-tous in another case of pustular allergic contact dermatitisfrom isoconazole nitrate [107]

The implication of such rare pustular reactions remainsuncertain Pustules are sterile and transient and can displacesubcorneally as observed in a case from trichloroethylene[108]

71 Pustular Patch Test Reactions Pustular reactions to con-tactants are frequently observed in patch test reading Hjorthstated that atopics are predisposed to such reactions [109]Metal salts particularly nickel copper arsenic and mercuryrepresent the most common causes of these reactions whichare irritant in nature [110 111] As a matter of fact pustularresponses to nickel patch test are widely observed when test-ing atopics on lesional skin with follicular papules erythemaor lichenification [112] This further supports the irritantnature of the phenomenon

In subjects affected by atopic dermatitis we oftenobserved such pustular follicular reactions when patch test-ing with nickel but also with potassium bichromate Pus-tules are always sterile dry promptly and resolve rapidlyErythema is mild and the reaction is not pruriginous His-tology documented in various cases has always evidencedintraepidermial aggregations of neutrophils without signs oflymphomonocytic exocytosis or spongiosis We have alwaysconsidered these reactions we directly observed irritant innature [113 114]

ISRN Allergy 7

Table 10 Differential diagnosis between dyshidrosiform ACD andpompholyx

Characteristics Dyshidrosiform ACD PompholyxPalmssoles +++ +++Handsfeet dorsum +++ +Erythema +++ +Hemorrhagic vesicles + minus

Bullae +plusmn ++++ACD primary locus Present AbsentSpongiosis +++ +Exocytosis +++ +Vesicles Minute Large from coalescing

8 Dyshidrosiform Contact Dermatitis

Certain authors include this condition among noneczema-tous allergic contact forms [6] In our opinion this dermatitisretains frankly clinicohistologic eczematous aspects and aproper differential diagnosis would have to be made with theendogenous eczema pompholyx As per our observationsdyshidrosiform allergic contact dermatitis can be primitiveor secondary [70 115 116] The latter is defined as a contactsensitivity which complicates a preexisting primitive palmo-plantar pompholyx The latter tends to a chronic recurrentcourse thus constituting a predisposing factor to occupa-tional and extraoccupational contact allergy [117 118] Fromstudies we carried out on 354 subjects with pompholyxgenuine lesions observed during a 5-year period incidenceof relevant positive patch tests reactions was 296 Topicalmedicaments (used to treat the original pompholyx) andother substances amongwhich paraphenylenediamine (315positive reactions) chrome (25) cobalt (102) mer-captobenzothiazole (93) nickel (65) and para-tert-butylphenol formaldehyde resin (27) were the most oftenimplicated haptens Patch tests relevance was related tospecific occupational activities use of peculiar gloves ratherthan shoes [115] More recently a study we conducted on 45individuals affected by palmoplantar pompholyx confirmedan ACD incidence of 31 [116]

Primitive dyshidrosiform ACD is instead an expressionof systemic contact allergy of common observation in nickelsensitized patients Oral challenge test with nickel reproducesthe dyshidrosiform eruption in these subjects [119ndash122]although this phenomenon has not been widely confirmed[123 124]

Table 10 designates differential diagnosis betweendyshidrosiform ACD and pompholyx Intense erythema andconstant hand dorsum involvement in the former representuseful discerning characteristics Histologically spongiosisand exocytosis are much more marked in ACD than inpompholyx

References

[1] D Bonamonte A Cavani and G Angelini ldquoAllergic contactdermatitisrdquo in Textbook of Dermatology amp Sexually Transmitted

Diseases A Giannetti and C Del Forno Eds vol 2 pp 933ndash961 Piccin Padova Italy 2013

[2] A Cavani O De Pita and G Girolomoni ldquoNew aspects of themolecular basis of contact allergyrdquo Current Opinion in Allergyand Clinical Immunology vol 7 no 5 pp 404ndash408 2007

[3] S F Martin and T Jakob ldquoFrom innate to adaptive immuneresponses in contact hypersensitivityrdquoCurrent Opinion in Allergy and Clinical Immunology vol 8 no 4 pp 289ndash293 2008

[4] G Angelini and G A Vena ldquoDermatite allergica da contattordquoin Dermatologia Professionale e Ambientale G Angelini and GA Vena Eds vol 2 pp 483ndash512 ISED Brescia Italy 1999

[5] C L Goh ldquoNon-eczematous contact reactionsrdquo in Textbook ofContact Dermatitis R J G Rycroft T Menne P J Frosh andJ-P Lepoittevin Eds pp 413ndash431 Springer Berlin Germany3rd edition 2001

[6] R L Rietschel and J F Fowler ldquoNoneczematous contact derma-titisrdquo in Fisherrsquos Contact Dermatitis 6 Hamilton R L Rietscheland J F Fowler Eds pp 88ndash109 BC Decker 2008

[7] R Holst J Kirby and B Magnusson ldquoSensitization to tropicalwoods giving erythema multiforme like eruptionsrdquo ContactDermatitis vol 2 no 5 pp 295ndash296 1976

[8] P Martin H Bergoend and F Piette ldquoErythema multiforme-like eruption from Brazilian rosewoodrdquo in Proceedings of the5th International Symposium on Contact Dermatitis BarcelonaSpain March 1980

[9] A A Fisher ldquoErythemamultiforme-like eruptions due to exoticwoods and ordinary plants part 1rdquo Cutis vol 37 no 2 pp 101ndash104 1986

[10] A A Fisher and J Bikowski Jr ldquoAllergic contact dermatitis dueto awooden crossmade ofDalbergia nigrardquoContact Dermatitisvol 7 no 1 pp 45ndash46 1981

[11] C Irvine A Reynolds andA Y Finlay ldquoErythemamultiforme-like reaction to ldquorosewoodrdquordquo Contact Dermatitis vol 19 no 3pp 224ndash225 1988

[12] G Kurz andM J Rapaport ldquoExternalinternal allergy to plants(Artemesia)rdquo Contact Dermatitis vol 5 no 6 pp 407ndash4081979

[13] S L Moschella ldquoErythema multiformerdquo in Dermatology vol 1WB Saunders Philadelphia Pa USA 1975

[14] S B Mallory O F Miller III and W B Tyler ldquoToxicodendronradicans dermatitis with black lacquer deposit on the skinrdquoJournal of the American Academy of Dermatology vol 6 no 3pp 363ndash368 1982

[15] R S Schwartz and T F Downham II ldquoErythema multiformeassociated with Rhus contact dermatitisrdquo Cutis vol 27 no 1pp 85ndash86 1981

[16] W Torinuki ldquoGeneralized erythema-multiforme-like eruptionfollowing allergic contact dermatitisrdquo Contact Dermatitis vol23 no 3 pp 202ndash203 1990

[17] J D Kirby and C R Darley ldquoErythema multiforme associatedwith a contact dermatitis to terpenesrdquo Contact Dermatitis vol4 no 4 p 238 1978

[18] A A Raccagni F Bardazzi U Baldari and M G RighinildquoErythema-multiforme-like contact dermatitis due to cap-sicumrdquo Contact Dermatitis vol 33 no 5 pp 353ndash354 1995

[19] M P G Mateo M Velasco F J Miquel and J de la CuadraldquoErythema-multiforme-like eruption following allergic contactdermatitis from sesquiterpene lactones in herbal medicinerdquoContact Dermatitis vol 33 no 6 pp 449ndash450 1995

[20] N Hjorth ldquoPrimula dermatitisrdquo Transactions of the St JohnrsquosHospital Dermatological Society vol 52 pp 207ndash219 1966

8 ISRN Allergy

[21] AVirgili andMCorazza ldquoUnusual primin dermatitisrdquoContactDermatitis vol 24 no 1 pp 63ndash64 1991

[22] F LengrandA S TellartM Segard YDejobert andPThomasldquoErythema multiforme-like eruption an unusual presentationof primula contact allergyrdquo Contact Dermatitis vol 44 no 1 p35 2001

[23] R Gallo S Sorbara and F Rongioletti ldquoContact erythemamul-tiforme fromPrimula obconicardquoContact Dermatitis vol 53 no6 pp 351ndash352 2005

[24] D Bonamonte R Filotico V Mastrandrea C Foti and GAngelini ldquoErythema multiforme-like contact dermatitis frompriminrdquo Contact Dermatitis vol 59 no 3 pp 174ndash176 2008

[25] C L Meneghini and G Angelini ldquoSecondary polymorphiceruptions in allergic contact dermatitisrdquo Dermatologica vol163 no 1 pp 63ndash70 1981

[26] C L Meneghini and G Angelini ldquoContact dermatitis frompyrrolnitrinrdquo Contact Dermatitis vol 8 no 1 pp 55ndash58 1982

[27] H R Gottschalk and O J Stone ldquoStevens Johnson syndromefrom ophthalmic sulfonamiderdquo Archives of Dermatology vol112 no 4 pp 513ndash514 1976

[28] Z Rubin ldquoOphthalmic sulfonamide induced Stevens JohnsonsyndromerdquoArchives of Dermatology vol 113 no 2 pp 235ndash2361977

[29] H S Affee and D P Dressler ldquoTopical application of mafenideacetate Its association with erythema multiforme and cuta-neous reactionsrdquo Archives of Dermatology vol 100 no 3 pp277ndash281 1969

[30] A A Fisher ldquoErythema multiforme-like eruptions due to top-ical medications part IIrdquo Cutis vol 37 no 3 pp 158ndash161 1986

[31] H Degreef A Bonamie D van Derheyden and A Dooms-Goossens ldquoMephenesin contact dermatitis with erythemamul-tiforme featuresrdquoContact Dermatitis vol 10 no 4 pp 220ndash2231984

[32] A Schulze-Dirks and P J Frosch ldquoContact allergy to Mephen-esinerdquo Hautarzt vol 44 no 6 pp 403ndash406 1993

[33] S Kerre A Busschots and A Dooms-Goossens ldquoErythema-multiforme-like contact dermatitis due to phenylbutazonerdquoContact Dermatitis vol 33 no 3 pp 213ndash214 1995

[34] P Koch and F A Bahmer ldquoErythema-multiforme-like urticar-ial papular and plaque eruptions from bufexamac report of 4casesrdquo Contact Dermatitis vol 31 no 2 pp 97ndash101 1994

[35] M Walchner F Rueff and B Przybilla ldquoDelayed-type hyper-sensitivity to mofebutazone underlying a severe drug reactionrdquoContact Dermatitis vol 36 no 1 pp 54ndash55 1997

[36] L Stingeni S Caraffini D Assalve V Lapomarda and P LisildquoErythema-multiforme-like contact dermatitis from budes-oniderdquo Contact Dermatitis vol 34 no 2 pp 154ndash155 1996

[37] R Valsecchi A Reseghetti P Leghissa L Cologni and RCortinovis ldquoErythema-multiforme-like lesions from triamci-nolone acetoniderdquo Contact Dermatitis vol 38 no 6 pp 362ndash363 1998

[38] C D Calnan ldquoNickel dermatitisrdquo British Journal of Dermatol-ogy vol 68 pp 229ndash232 1956

[39] L J Cook ldquoAssociated nickel and cobalt contact dermatitispresenting as erythema multiformerdquo Contact Dermatitis vol 8no 4 pp 280ndash281 1982

[40] S J Friedman and H O Perry ldquoErythema multiforme associ-ated with contact dermatitisrdquo Contact Dermatitis vol 12 no 1pp 21ndash23 1985

[41] A A Fisher ldquoErythema multiforme-like eruptions due totopical miscellaneous compounds part IIIrdquo Cutis vol 37 no4 pp 262ndash264 1986

[42] E W Powell ldquoSkin reactions to 9-bromofluorenerdquo British Jour-nal of Dermatology vol 80 no 8 pp 491ndash496 1968

[43] J Roed-Petersen ldquoErythema multiforme as an expression ofcontact dermatitisrdquo Contact Dermatitis vol 1 no 4 pp 270ndash271 1975

[44] D Bonamonte and G Angelini ldquoDermatite da contatto pur-puricardquo Annali Italiani di Dermatologia Allergologica vol 55pp 53ndash61 2001

[45] B Batschvarov and D M Minkov ldquoDermatitis and purpurafrom rubber in clothingrdquo Transactions of the St Johnrsquos HospitalDermatological Society vol 54 no 2 pp 178ndash182 1968

[46] C D Calnan and R D C Peachey ldquoAllergic contact purpurardquoClinical Allergy vol 1 no 3 pp 287ndash290 1971

[47] A A Fisher ldquoAllergic petechial and purpuric rubber dermatitisthe PPPP syndromerdquo Cutis vol 14 pp 25ndash27 1974

[48] A A Fisher ldquoPurpuric contact dermatitisrdquo Cutis vol 33 no 4pp 346ndash351 1984

[49] C Romaguera and F Grimalt ldquoPPPP syndromerdquo Contact Der-matitis vol 3 no 2 pp 102ndash103 1977

[50] C Romaguera F Grimalt and J Vilaplana ldquoEczematous andpurpuric allergic contact dermatitis from bootsrdquo Contact Der-matitis vol 21 no 4 p 269 1989

[51] L Carlsen K E Andersen and H Egsgaard ldquoIPPD contactallergy from an orthopedic bandagerdquo Contact Dermatitis vol17 no 2 pp 119ndash121 1987

[52] J Roed-Petersen O J Clemmensen T Menne and E LarsenldquoPurpuric contact dermatitis from black rubber chemicalsrdquoContact Dermatitis vol 18 no 3 pp 166ndash168 1988

[53] P E Osmundsen ldquoContact dermatitis due to an opticalwhitener in washing powdersrdquo British Journal of Dermatologyvol 81 no 11 pp 799ndash803 1969

[54] P E Osmunsden ldquoContact dermatitis from an optical whitenerin washing powdersrdquo Cutis vol 10 pp 59ndash66 1972

[55] J Pinol Aguade F Grimalt C Romaguera et al ldquoDermatitis porblanqueadores opticosrdquoMedicina Cutanea vol 5 p 249 1971

[56] J P Van der Veen H Neering P de Haan and D P BruynzeelldquoPigmented purpuric clothing dermatitis due to Disperse Blue85rdquo Contact Dermatitis vol 19 no 3 pp 222ndash223 1988

[57] C Foti G Elia R Filotico and G Angelini ldquoPurpuric clothingdermatitis due to Disperse Yellow 27rdquo Contact Dermatitis vol39 no 5 p 273 1998

[58] E Shmunes ldquoPurpuric allergic contact dermatitis to para-phenylenediaminerdquo Contact Dermatitis vol 4 no 4 pp 225ndash229 1978

[59] F F Hellier ldquoDermatitis purpurica after contact with textilesrdquoDer Hautarzt Zeitschrift fur Dermatologie Venerologie undverwandte Gebiete vol 11 pp 173ndash174 1960

[60] C Romaguera F Grimalt and M Lecha ldquoOccupational pur-puric textile dermatitis from formaldehyde resinsrdquo ContactDermatitis vol 7 no 3 pp 152ndash153 1981

[61] M Faure C Dambuyant G Chabeau P Souteyrand and JTguviket ldquoImmune complex vasculitis and contact dermatitisto Frullaniardquo Contact Dermatitis vol 7 no 6 pp 320ndash325 1981

[62] M R Ricks P S Vogel D M Elston and C Hivnor ldquoPulpuricagave dermatitisrdquo Journal of the American Academy of Derma-tology vol 40 no 2 pp 356ndash358 1999

ISRN Allergy 9

[63] V Petruzzellis G Angelini and G A Vena ldquoLa dermatite arte-fattardquo Bollettino di Dermatologia Allergologica e Professionalevol 3 pp 23ndash34 1988

[64] MGrandolfo C Foti G A Vena andG Angelini ldquoFitoderma-tite da contatto irritante con granturcordquoBollettino diDermatolo-gia Allergologica e Professionale vol 9 pp 225ndash229 1994

[65] A Falk T Fischer and M Hagberg ldquoPurpuric rash caused bydermal exposure to d-limonenerdquoContactDermatitis vol 25 no3 pp 198ndash199 1991

[66] G Angelini and G A Vena ldquoAirborne contact dermatitisrdquoClinics in Dermatology vol 10 no 2 pp 123ndash131 1992

[67] G Angelini and G A Vena ldquoDermatosi aerorasmesserdquo in Der-matologia Professionale e Ambientale G Angelini and G AVena Eds vol 1 pp 107ndash128 ISED Brescia Italy 1997

[68] R Abel ldquoWashing machine and fiberglassrdquo Archives of Derma-tology vol 93 no 1 p 78 1966

[69] D P Bruynzeel H M van den Hoogenband and F KoedijkldquoPurpuric vasculitis-like eruption in a patient sensitive tobalsam of Perurdquo Contact Dermatitis vol 11 no 4 pp 207ndash2091984

[70] C Foti ldquoDermatite allergica da contatto non eczematosardquo inDermatologia Professionale e Ambientale G Angelini and G AVena Eds vol 2 pp 345ndash356 ISED Brescia Italy 1999

[71] C L Meneghini and G Angelini ldquoEczemas de contact allergi-ques et reactions par voie generale a lrsquoallergenerdquo Medecine etHygiene vol 43 pp 879ndash886 1985

[72] T Van Joost J van Ulsen V D Vuzevski B Naafs and B TankldquoPurpuric contact dermatitis to benzoyl peroxiderdquo Journal of theAmerican Academy of Dermatology vol 22 no 2 pp 359ndash3611990

[73] C L Goh ldquoErythema multiforme-like and purpuric eruptiondue to contact allergy to proflavinerdquo Contact Dermatitis vol 17no 1 pp 53ndash54 1987

[74] H Schmidt F S Larsen PO Larsen andH Sogaard ldquoPetechialreaction following patch testing with cobaltrdquo Contact Derma-titis vol 6 no 2 pp 91ndash94 1980

[75] C L Goh S F Kwok and V S Rajan ldquoCross sensitivity incolour developersrdquo Contact Dermatitis vol 10 no 5 pp 280ndash285 1984

[76] E H Mandel ldquoLichen planus-like eruptions caused by a color-film developerrdquo Archives of Dermatology vol 81 pp 516ndash5191960

[77] L Fry ldquoSkin disease from colour developersrdquoTheBritish Journalof Dermatology vol 77 no 8 pp 456ndash461 1965

[78] J Roed Petersen and T Menn ldquoAllergic contact dermatitis andlichen planus from black and white photographic developingrdquoCutis vol 18 no 5 pp 699ndash700 1976

[79] E A Knudsen ldquoLichen planus-like eruption caused by colordeveloperrdquo Archives of Dermatology vol 89 pp 357ndash359 1964

[80] V K Sharma S K Mandal G Sethuraman and N A BakshildquoPara-phenylenediamine-induced lichenoid eruptionsrdquo Con-tact Dermatitis vol 41 no 1 pp 40ndash41 1999

[81] K Lapiere L Matthieu L Meuleman and J Lambert ldquoPrimuladermatitis mimicking lichen planusrdquo Contact Dermatitis vol44 no 3 p 199 2001

[82] P Lombardi P Campolmi andA Sertoli ldquoLichenoid dermatitiscaused bynickel saltsrdquoContactDermatitis vol 9 no 6 pp 520ndash521 1983

[83] M Lichter D Drury and K Remlinger ldquoLichenoid dermatitiscaused by epoxy resinrdquoContact Dermatitis vol 26 no 4 p 2751992

[84] G Lembo N Balato and C Patruno ldquoLichenoid contact der-matitis due to aminoglycoside antibioticsrdquo Contact Dermatitisvol 17 no 2 pp 122ndash123 1987

[85] T Kawamura S Fukuda N Ohtake M Furue and K TamakildquoLichen planus-like contact dermatitis due to methacrylic acidestersrdquo British Journal of Dermatology vol 134 no 2 pp 358ndash360 1996

[86] K O Frykholm L Frithiof A I Fernstrom G Moberger SG Blohm and E Bjorn ldquoAllergy to copper derived from dentalalloys as a possible cause of oral lesions of lichen planusrdquo ActaDermato-Venereologica vol 49 no 3 pp 268ndash281 1969

[87] T Ido M Kumakiri T Kiyohara T Sawai and Y HasegawaldquoOral lichen planus due to zinc in dental restorationsrdquo ContactDermatitis vol 47 no 1 p 51 2002

[88] J Laine K Kalimo H Forssell and R-P Happonen ldquoReso-lution of oral lichenoid lesions after replacement of amalgamrestorations in patients allergic to mercury compoundsrdquo BritishJournal of Dermatology vol 126 no 1 pp 10ndash15 1992

[89] P Calzavara-Pinton R Capezzera C Zane et al ldquoLymphoma-toid allergic contact dermatitis from para-phenylenediaminerdquoContact Dermatitis vol 47 no 3 pp 173ndash174 2002

[90] A V Evans P Banerjee J P McFadden and E CalonjeldquoLymphomatoid contact dermatitis to para-tertyl-butyl phenolresinrdquoClinical and Experimental Dermatology vol 28 no 3 pp272ndash273 2003

[91] F Ayala N Balato P Nappa G De Rosa and G Lembo ldquoLym-phomatoid contact dermatitisrdquo Contact Dermatitis vol 17 no5 pp 311ndash313 1987

[92] W B Shelley and E Epstein ldquoContact-sensitivity to gold as achronic papular eruptionrdquo Archives of Dermatology vol 87 pp388ndash391 1963

[93] J Gomez Orbaneja L Iglesias Diez J L Sanchez Lozano andL Conde Salazar ldquoLymphomatoid contact dermatitis A syn-drome produced by epicutaneous hypersensitivity with clinicalfeatures and a histopathologic picture similar to that of mycosisfungoidesrdquo Contact Dermatitis vol 2 no 3 pp 139ndash143 1976

[94] A A Fisher ldquoChronic allergic contact dermatitis simulatingmycosis fungoidesrdquo Bollettino di Dermatologia Allergologica eProfessionale vol 2 pp 13ndash16 1987

[95] L MWall ldquoLymphomatoid contact dermatitis due to ethylene-diamine dihydrochloriderdquo Contact Dermatitis vol 8 no 1 pp51ndash54 1982

[96] P E Osmundsen ldquoPigmented contact dermatitisrdquo British Jour-nal of Dermatology vol 83 no 2 pp 296ndash301 1970

[97] A Ancona Alayon R EscobarMarques A GonzalezMendozaJ A Bernal-Tapia E Macotela-Ruız and J Jurado-MendozaldquoOccupational pigmented contact dermatitis from naphtholASrdquo Contact Dermatitis vol 2 no 3 pp 129ndash134 1976

[98] K Fujimoto S Hashimoto T Kozuka M Tashiro and S SanoldquoOccupational pigmented contact dermatitis from azo-dyesrdquoContact Dermatitis vol 12 no 1 pp 15ndash17 1985

[99] T Kozuka M Tashiro and S Sano ldquoBrilliant Lake Red R as acause of pigmented contact dermatitisrdquoContact Dermatitis vol5 no 5 pp 297ndash304 1979

[100] R B Fountain ldquoOccupational melanodermardquo British Journal ofDermatology vol 79 no 1 pp 59ndash60 1967

[101] THamada and SHoriguchi ldquoChronicmelanodermatitis due tothe rubber peephole of a ship radarscoperdquo Contact Dermatitisvol 4 no 4 pp 245ndash246 1978

[102] A Bonamonte and G Angelini ldquoDisordini pigmentari da con-tattordquo Annali Italiani di Dermatologia Allergologica vol 55 pp1ndash15 2001

10 ISRN Allergy

[103] L Wattanakrai L Miyamoto and J S Taylor ldquoOccupationalpigmentary disordersrdquo inHandbook of Occupational Dermatol-ogy L Kanerva P Elsner J E Wahlberg and H I MaibachEds pp 280ndash294 Springer Berlin Germany 2000

[104] C G Burkhart ldquoPustular allergic contact dermatitis a distinctclinical and pathological entityrdquo Cutis vol 27 no 6 pp 630ndash638 1981

[105] V J Schoel and B J Frosch ldquoAllergisches Kontaktekzem durchGummiin-haltsstoffe unter demBild einer Pustulosis palmarisrdquoDermatosen vol 38 pp 178ndash180 1990

[106] J M Sanchez-Motilla V Pont E Nagore M Rodrıguez-SernaJ L Sanchez andAAliaga ldquoPustular allergic contact dermatitisfromminoxidilrdquo Contact Dermatitis vol 38 no 5 pp 283ndash2841998

[107] A Lazarov and A Ingber ldquoPustular allergic contact dermatitisto isoconazole nitraterdquo American Journal of Contact Dermatitisvol 8 no 4 pp 229ndash230 1997

[108] L Conde Salazar D Guimaraens L V Romero and E SanchezYus ldquoSubcorneal pustular eruption and erythema from occupa-tional exposure to trichloroethylenerdquoContact Dermatitis vol 9no 3 pp 235ndash237 1983

[109] N Hjorth ldquoDiagnostic patch testingrdquo in Dermatoxicology andPharmacology F Marzulli and H I Maibach Eds pp 344ndash351John Wiley amp Sons New York NY USA 1977

[110] A A Fisher L Chargrin R Fleischmayer and A HymanldquoPustular patch test reactions with particular reference to thoseproduced by ammoniumfluoriderdquoArchives of Dermatology vol80 pp 742ndash752 1959

[111] J E Wahlberg and H I Maibach ldquoSterile cutaneous pustulesa manifestation of primary irritancy Identification of contactpustulogensrdquo Journal of Investigative Dermatology vol 76 no5 pp 381ndash383 1981

[112] M Uehara C Takahashi and S Ofuji ldquoPustular patch testreactions in atopic dermatitisrdquoArchives of Dermatology vol 111no 9 pp 1154ndash1157 1975

[113] G Angelini andMGrandolfo ldquoTest diagnosticirdquo inDermatolo-gia Allergologica e Professionale G Angelini and G A VenaEds vol 2 pp 572ndash592 ISED Brescia Italy 1997

[114] D Bonamonte C Foti A Carpentieri and G Angelini ldquoDer-matite allergica da contatto in eta pediatricardquo Annali Italiani diDermatologia Allergologica vol 64 article 1 2010

[115] C L Meneghini and G Angelini ldquoContact and microbialallergy in pompholyxrdquo Contact Dermatitis vol 5 no 1 pp 46ndash50 1979

[116] G A Vena S Mazzoccoli and G Angelini ldquoStudio epidemio-logico clinico ed eziopatogenetico della disidrosirdquo Bollettino diDermatologia Allergologica e Professionale vol 7 pp 259ndash2731992

[117] M Reichenberger ldquoDieDyshidrosis als Schrittmacher fur beru-fliche Dermatosenrdquo Berufdermatosen vol 29 pp 127ndash130 1975

[118] T Menne and N Hjorth ldquoPompholyxmdashdyshidrotic eczemardquoSeminars in Dermatology vol 2 no 1 pp 75ndash80 1983

[119] O B Christensen and H Moller ldquoNickel allergy and handeczemardquo Contact Dermatitis vol 1 no 3 pp 129ndash135 1975

[120] O B Christensen and H Moller ldquoExternal and internal expo-sure to the antigen in the hand eczema of nickel allergyrdquoContactDermatitis vol 1 no 3 pp 136ndash141 1975

[121] E Cronin A D Di Michiel and S S Brows ldquoOral challenge innickel sensitive womenwith hand eczemardquo inNickel ToxicologyS S Brown and F W Sunderman Jr Eds pp 149ndash152Academic Press New York NY USA 1980

[122] K Kaaber N K Veien and J C Tjell ldquoLow nickel diet in thetreatment of patients with chronic nickel dermatitisrdquo BritishJournal of Dermatology vol 98 no 2 pp 197ndash201 1978

[123] D Burrows S Creswell and J D Merrett ldquoNickel hands andhip prosthesesrdquo British Journal of Dermatology vol 105 no 4pp 437ndash443 1981

[124] W P Jordan Jr and S E King ldquoNickel feeding in nickel-sensitivepatients with hand eczemardquo Journal of the American Academy ofDermatology vol 1 no 6 pp 506ndash508 1979

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


MEDIATORSINFLAMMATION

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Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

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Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

2 ISRN Allergy

Table 1 Factors determining the peculiar polymorphic clinicalfeatures of allergic contact dermatitis

Eruptive polymorphismEvolutive polymorphismCausative agentPatient sensitizing levelWay of exposition (cutaneous systemic)Means of exposition (cutaneous direct cutaneous aeromediated)Tissue structures targeted by the causative agentAnatomophysiology of the cutaneous region involvedCausative agent possible concomitant irritant actionEnvironmental factors (UV temperature humidity)Itching intensity variabilityPreexisting dermatitis underlying the overlapping contact allergy

Table 2 Different types of noneczematous contact eruptions

Erythema multiforme-like contact dermatitisPurpuric contact dermatitisLichenoid contact dermatitisLymphomatoid contact dermatitisPigmented contact dermatitisPustular contact dermatitisDyshidrosiform contact dermatitis

cabinetmakers Antigens in pao ferro andBrazilian rosewoodare crossreacting quinones respectively R-3 4-di-methoxy-dalbergione and R-4-methoxy-dalbergione [7 8] Literaturealso lists extraoccupational cases from wooden bracelet [9]and pendants [10] made of D nigra M scleroxylon hasbeen described to cause a similar eruption in hobbyists whohandled this type of wood to build boxes [11]

Other reported causes of erythema multiforme-like reac-tions include Artemisia vulgaris [12 13] poison ivy [14 15]Hypericum erectum [16] and terpenes [17] Tincture of cap-sicum caused an analogous reaction in awomanwho used theconcoction to treat her knee arthritis [18] Inula heleniumcontained in a mixture to treat back pain has also inducederythema multiforme-like eruption with positive patch teststo sesquiterpene lactone mix and alantolactone [19] NotablyPrimula obconica can also induce comparable eruptions [20ndash23] We observed an erythema multiforme-like reaction in aplant nursery worker who had handled plants of P obconicaThe dermatitis involved hands forearms and face Patchtests were positive to primin (001 in pet) leaves andflower Histology showed foci of hyperkeratotic orthokerato-sis mild spongiosis exocytosis and few isolated necrotic ker-atinocytes at the superficial and mid dermis a largely peri-vascular lymphocytic infiltrate was present [24]

Topical Medicaments Numerous topical drugs are reportedas cause of erythema multiforme-like contact dermatitisthe vast majority being antimicrobials According to ourobservation pyrrolnitrin can trigger this kind of eruption

Table 3 Causative allergens in erythema multiforme-like eruption

Plants andwoods Medicaments Miscellaneous chemicals

Dalbergia nigra(Brazilianrosewood)

Ethylenediamine Brominated compounds

Toxicodendronradicans (poisonivy)

Pyrrolnitrin Phenylsulphonederivatives

Primulaobconica Sulfamide Epoxy resin

Machaeriumscleroxylon (paoferro)

Econazole Formaldehyde

Artemisiavulgaris Promethazine Disperse blue 124

Eucalyptussaligna (gum) Balsam of Peru Trichloroethylene

Inula helenium Scopolamine DinitrochlorobenzeneCapsicum Mafenide acetate DiphenylcyclopropenoneTerpenes ProflavinePyrethrum Neomycin

MephenesinVitamin EBudesonideBufexamacClioquinol(vioform)Ketoprofen

TriamcinoloneacetonideIdoxuridine

Phenylbutazone

[25 26] Other causative drugs include sulfonamide [27 28]promethazine [25] neomycin [25] mafenide acetate [29]ethylenediamine [25 30] and mephenesin [31 32] Amongnonsteroid anti-inflammatory drugs phenylbutazone [33]bufexamac [34] and mofebutazone [35] have been reportedAmong corticosteroids budesonide [36] and triamcinoloneacetonide [37] caused analogous reactions

Miscellany Erythema multiforme-like eruptions can be theexpression of contact allergy to nickel [38ndash41] and cobalt[39] 9-Bromofluorene induced a skin acute reaction inseveral chemistry students who were exposed to the productduring its synthesis [42 43] Finally many other compoundshave been associated to erythema multiforme-like reactionsalthough exceptionally [5 6]

22 Clinical Features Early lesions are eczematous in mor-phology and localized at the allergen contact site After a1 to 15 days delay the erythema multiforme-like eruptionfollows involving the area around the original lesions orrather extending to the whole cutaneous surface The latter

ISRN Allergy 3




















4 ISRN Allergy















ISRN Allergy 5





















6 ISRN Allergy



Exocytosisminus+++

Inflammatorycells














Dyes


Cosmetics



Fragrances



Miscellany






ISRN Allergy 7








References






















8 ISRN Allergy











































ISRN Allergy 9









































10 ISRN Allergy




























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















ISRN Allergy 3




















4 ISRN Allergy















ISRN Allergy 5





















6 ISRN Allergy



Exocytosisminus+++

Inflammatorycells














Dyes


Cosmetics



Fragrances



Miscellany






ISRN Allergy 7








References






















8 ISRN Allergy











































ISRN Allergy 9









































10 ISRN Allergy




























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















4 ISRN Allergy















ISRN Allergy 5





















6 ISRN Allergy



Exocytosisminus+++

Inflammatorycells














Dyes


Cosmetics



Fragrances



Miscellany






ISRN Allergy 7








References






















8 ISRN Allergy











































ISRN Allergy 9









































10 ISRN Allergy




























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















ISRN Allergy 5





















6 ISRN Allergy



Exocytosisminus+++

Inflammatorycells














Dyes


Cosmetics



Fragrances



Miscellany






ISRN Allergy 7








References






















8 ISRN Allergy











































ISRN Allergy 9









































10 ISRN Allergy




























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















6 ISRN Allergy



Exocytosisminus+++

Inflammatorycells














Dyes


Cosmetics



Fragrances



Miscellany






ISRN Allergy 7








References






















8 ISRN Allergy











































ISRN Allergy 9









































10 ISRN Allergy




























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















ISRN Allergy 7








References






















8 ISRN Allergy











































ISRN Allergy 9









































10 ISRN Allergy




























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















8 ISRN Allergy











































ISRN Allergy 9









































10 ISRN Allergy




























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















ISRN Allergy 9









































10 ISRN Allergy




























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















10 ISRN Allergy




























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















review article noneczematous contact dermatitisdownloads.hindawi.com/archive/2013/361746.pdf ·...

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