Diagnosis and Treatment of Dermatitis Due to Formaldehyde Resins in Clothing

Ryan M. Carlson; Mary C. Smith; Susan T. Nedorost

Disclosures

Dermatitis. 2004;15(4):169-175. 

In This Article

Abstract and Introduction

An increasing number of cases of allergic contact dermatitis secondary to formaldehyde resins used for textile finishes have been seen in our office over the last several years. Although previously reported to be more common in women, we have seen almost as many men as we have seen women with this condition. possibly because men are more likely to be occupationally sensitized to formaldehyde. We have found that patch-test reactions of only questionable strength may be clinically relevant. It has been our experience that many of these cases are of long duration before referral for patch testing. A low index of suspicion leads to a delayed diagnosis, and avoidance after diagnosis is difficult owing to the lack of labeling requirements for textile finishes. Patch testing with the textile resins Fixapret AC and Fixapret CPN most often identified patients with textile allergies. We have prepared a handout to give patients more definitive recommendations.

A Diagnosis of Allergic Contact Dermatitis (ACD) must be strongly considered for patients who present with a chronic or recurrent rash. When the rash is in a clothing (or textile) distribution, it may be due to an allergy to dyes or formaldehyde resins used in the manufacture of the clothing. Generally, textile dermatitis conforms to a pattern that coincides with places on the skin where clothing may fit tightly. Common eruption sites include the posterior neck, upper back, lateral thorax (ie, anterior and posterior axillary folds, with sparing of the axillary vault), waistband, and flexor surfaces, with relative sparing of the undergarment areas (Fig 1).

Eczematous rash involving both the posterior and anterior axillary folds. Note that the axillary vault is characteristically spared.

This pattern of textile-related ACD points out the importance of nonimmunologic factors such as pressure, friction, heat, and perspiration to the ultimate clinical response.[1] Although the face is usually spared in dermatitis caused by textile resins, patients who also react to formaldehyde-releasing preservatives may have involvement at any areas on which personal care products are used. In addition, there can be atypical presentations, such as forehead dermatitis induced by textile resins in baseball caps (Fig 2).

Figure 2.

An atypical presentation of textile dermatitis from formaldehyde resins. This eczematous scaly rash occurred after the patient wore a baseball cap containing formaldehyde resins in the inner lining.

Formaldehyde is found in many settings and frequently in materials in which it is not suspected.[2] Formaldehyde resins are the substances used in today's textile industry to make clothing that is wrinkle resistant (eg, permanent-press clothing). These resins can release significant amounts of formaldehyde.[3] Rayon, blended cotton, corduroy, wrinkle-resistant 100% cotton, and any synthetic blended polymer are likely to have been treated with such resins.[4] Textile formaldehyde resins have been used on fabrics since the mid-1920s.[5] Formaldehyde resins used in durable-press fabrics can be classified into high, medium, and low formaldehyde releasers.[5,6,7] The textile resins now in use in the United States are listed in Table 1 . Since 1961, dimethylol dihydroxyethyleneurea (DMDHEU), which is often blended with glycols, has been the most widely used permanent-press finish.[8] However, several investigators feel that the use of this resin and older high formaldehyde releasers is decreasing.[5]

Many preservatives used in cosmetics, pharmaceuticals, and industrial biocides can also release formaldehyde.[6,7] In Fowler's study, in addition to being allergic to the formaldehyde resins, 12 (70%) of his patients also were allergic to formaldehyde-releasing preservatives. Of these, quarternium-15 was the agent to which patients most reacted.[6] Clinically, these reactions may be significant because formaldehyde preservatives are frequently used in skin care products and topical corticosteroid creams.[6,7] Thus, ACD from formaldehyde can present with a variety of clinical pictures from several sources, which can be confusing to the practitioner.

Testing with formaldehyde alone identifies only about 70% of patients who are allergic to the formaldehyde resins; therefore, it is necessary to patch-test with the resins as well. It is not clear which resin or allergen is best for screening for contact dermatitis from textile formaldehyde resin. Currently, six permanent-press finishes from Chemotechnique Diagnostics, Malmö, Sweden, are available for patch testing ( Table 2 ). In 1992, Fowler and colleagues recommended that ethyleneurea/melamine formaldehyde mix in 10% petrolatum (Fixapret AC) be used to screen for ACD from permanent-press textiles as it clearly identified 14 of their 17 patients.[5,6] In 1998, Scheman and colleagues reported that testing with glycolated DMDHEU (modified, also known as Fixapret ECO) was better at detecting this allergy because all of their patients reacted to it, and this agent is the more widely used textile finish.[9] These commercially available materials for patch testing change with and reflect the evolving marketplace.[10] Reactions are often negative on the initial reading at 48 hours and may not develop until days 5 to 7.

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