A 14-year-old female came to clinic with a rash on her earlobes intermittently for several days. She had purchased a new pair of pierced earrings and the rash appeared approximately 1 day after wearing them. She removed the earrings and the rash went away, but recurred when she wore them again. With further questioning she reported that she also got rashes on her abdomen after wearing a pair of jean shorts. The intermittent rash with the jeans and jewelry was mildly pruritic/painful. She had no difficulties breathing or eating. The past medical history was positive for keratosis pilaris and seasonal allergic rhinitis that were easily controlled with emollients and oral antihistamines. The family history was positive for seasonal allergic rhinitis and “some skin problems” in maternal aunts and cousins. The review of systems was negative.
The pertinent physical exam showed a healthy female with normal growth parameters and vital signs. Bilateral earlobes showed generalized erythema of the lobe that extended to approximately 0.5 cm of the surrounding skin of the head in a semi-circular pattern. There was some mild swelling. There was no extension upwards into the helical area or into the external auditory canal. She had shoddy anterior cervical nodes. Her lateral upper arms and thighs had some mild non-erythematous papular lesions that were scattered. Her lung examination was normal. The rest of her examination was normal. The diagnosis of allergic contact dermatitis probably due to nickel was made, along with keratosis pilaris. The patient was advised to stop wearing the offending jewelry and to take antihistamines to help with the pruritis and irritation. She was also given information to purchase a nickel test kit to be able to test various items in her current wardrobe and home, and to test items before purchase in the future.
Allergic contact dermatitis (ACD) is often under-recognized but a frequent problem. Atopic dermatitis and irritant skin reactions are often difficult to distinguish from ACD. There are about 100 common sensitizers that cause ACD including nickel and poison ivy. Most are small molecules that can easily penetrate the skin and cause a delayed T-cell hypersensitivity reaction (Type IV). ACD reactions usually are linear or geometric lesions that are well demarcated and persistent.
Nickel is found in many household and wardrobe items including dental braces, jewelry, clothing fasteners such as clasps, snaps, buckles and zippers, coins, and tools (including cellphones, eating utensils, etc.). Most people require prolonged and intimate contact with items before having ACD; general contact such as handling coins or tools usually does not cause problems for most people. Nickel ACD usually results from contact with jewelry (including eyeglasses) or clothing fasteners, but an Id reaction with pruritic papules on the trunk or upper extremities can also be seen.
Nickel test kits are commercially available at many pharmacies usually for < $20. A drop of 1% dimethylglyoxime-ammonia is added to a cotton tip applicator and the applicator is rubbed against the metal. If the cotton swab turns pink the metal contains nickel in a concentration of at least 1:10,000.
Practical tips for avoiding nickel including testing but also includes barriers such as layers of clothing between the item and skin, using a coating (Nickel Guard® or electroplating of jewelry), putting plastic on handles/tools and using gloves. Decreasing contact by only wearing an item when necessary, or changing the backing of earring to stainless steel, titanium or plastic may also help. Keeping the skin in good condition to decrease concomitant atopic dermatitis can also decrease the penetration of the nickel into the skin.
Questions for Further Discussion
1. Describe the natural history of poison ivy allergic contact dermatitis?
2. What is the role of steroid treatment for allergic contact dermatitis?
- Symptom/Presentation: Eczematous Dermatitis
- Age: Teenager
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Hanks JW and Venters WJ. Nickel Allergy From a Bed-Wetting Alarm Confused With Herpes Genitalis and Child Abuse. Pediatrics. Vol. 90 No. 3 September 1992, pp. 458-460.
Militello G, Jacob SE, Crawford GH. Allergic contact dermatitis in children. Curr Opin Pediatr. 2006 Aug;18(4):385-90.
Nickel Institute. Nickel Allergic Contact Dermatitis. Available from the Internet at http://www.nickelinstitute.org/index.cfm/ci_id/99.htm (rev. 2007, cited 10/22/09).
Noble J, Ahing SI, Karaiskos NE, Wiltshire WA. Nickel allergy and orthodontics, a review and report of two cases. Br Dent J. 2008 Mar 22;204(6):297-300.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital