Allergic Contact Dermatitis

Rubber Chemical

Allergies to rubber chemicals can be caused by the raw rubber compound (latex) or the chemicals added to improve its utility. Allergy to the natural latex component is well documented as a type I (IgE) mediated response (Sussman & Beezhold, 1995). Alternatively the processing chemicals of the rubber, accelerators (carbamates, mercaptobenzothiazoles, and thiurams), and vulcanizers are known to cause the typical type IV delayed hypersensitivity reaction. Accelerators help harden and shape the latex collected from the Hevea brasiliensis tree (Mydlarski et al., 2003). Many patients will suspect a latex allergy when they experience a reaction to rubber gloves. Latex allergy testing can be performed with an allergy-specific IgE antibody test or by dermal prick testing, while testing for rubber processing chemical allergies is done by the patch test. Allergies to the rubber processing chemicals are very common among health care workers and atopic patients (Fuchs & Wahl, 1992).

Carbamates are found within the rubber components of toys, elastics, and gloves. This can present with a distinctive dermatitis in the distribution of underwear elastic and the dorsal aspect of the hands in a common locale. Mercaptobenzothiazole is one of the most common causes of shoe rubber allergies. Mercaptobenzothiazole commonly causes what is known as scuba diver dermatitis, a reaction to diving masks (Freiman, Barankin, & Elpern, 2004). These patients will present with erythema and pruritus surrounding their eyes. Thiuram, another accelerator, is the most common cause of glove allergy; however, it is also used as an antimicrobial. It can be found in fungicides and soaps (Geier, Lessmann, Uter, & Schnuch, 2003). Contraceptives including diaphragms, dental dams, and condoms may contain thiuram (DermNet.com, 2005c). Patients can react to condoms due to a latex allergy or sensitization to a rubber accelerator (Bircher, Hirsbrunner, & Langauer, 1993). There is even a case report of sensitization to thiuram from the sticky backing of a temporary tattoo (Hallai, Meirion-Hughes, & Stone, 2004).

Black rubber mix is a rubber additive used in industrial rubber products such as for belts and tubing; however, it can be found in sports equipment (TRUEtest.com, 2001a). Black rubber mix cross reacts with PPD (hair dye), so patients should avoid both allergens (Menne, White, Bruynzeel, & Dooms-Goossens, 1992). PPD is widely used in hair dye, even though the FDA prohibits its use on skin. This has not stopped companies from adding it to temporary henna tattoos to make them last longer; several case reports describe children reacting to henna tattoos (Onder, Atahan, Oztas, & Oztas, 2001). Hairstylists are at high risk for developing an allergy, but exposure may put them at risk for much worse conditions (Sosted, Rastogi, Andersen, Johansen, & Menne, 2004). Studies show an association with bladder cancer and PPD in rats (Nohynek et al., 2004). There are also notable racial differences in incidence rates. In one study, black patients had a higher incidence of sensitization to PPD than white patients. The number of people coloring their hair seems to be the same across racial and ethnic groups, but the amount of PPD in darker hair dyes is increased (Deleo et al., 2002). The patients will present with a characteristic dermatitis around their eyes, ears, and adjoining face, but sparing the scalp. PPD was recently nominated for allergen of the year because of dramatic rise in incidence.

Cite this: Allergic Contact Dermatitis: Early Recognition and Diagnosis of Important Allergens - Medscape - Oct 01, 2006.

Allergen Reference Table
Allergen	Products Allergen Found in	Foods/Drugs Allergen Found in
Nickel Sulfate	Jean snaps, metal pens, paper clips, cigarettes	Chocolate, soy, beer, oatmeal
Bacitracin	Neosporin, polysporin, polymyxin, bacitracin zinc	Animal feed
Neomycin Sulfate	Neosporin, polysporin, neomycin	N/A
Fragrance Mix	Cosmetics, detergents, soaps, deodorant	May cross react with tomato, cinnamon, vanilla
Quaternium 15	Formaldehyde-releasing preservative (FRP), baby lotion, baby wipes, cross reacts with permanent press clothing (PPC), and other FRPs	See formaldehyde
Formaldehyde	Paper products, nail polish, mascara lotion, shampoo, permanent press clothing	Jellies, preserved fruits, instant coffee, frozen cod, pollock and haddock, Italian cheeses, smoked ham skin, maple syrup, herring, caviar, diet cola, aspartame
Thimerosal	Preservative in vaccines, antifungal agents, mascara	N/A
Balsam of Peru	Flavoring agents, wound healing agent, baby care products, hemorrhoid preparations, toothpaste	Cross reacts with tomato, cinnamon, vanilla, chocolate, and cola
Cobalt Chloride	Metals: buckles, snaps, dental amalgam	Vitamin B₁₂, cocoa, liver, apricots
Sodium Gold Thiosulfate	Jewelry	Goldschlager liqueur
Thiuram Mix	Rubber accelerator: rubber gloves, syringe stoppers, toothbrushes, basketballs, shampoos	Cross reacts with antabuse and flea powder
P-phenylenediamiamine	Hair dye, henna, neoprene	Can cross react with black rubber mix, sulfonamides. Sulphonylureas, hydrochlorothiazide
Ethylene Urea/Melamine	Formaldehyde resin for textiles: permanent press, corduroy, rayon. Breakdown product of mancozeb, a fungicide, and zineb, a pesticide.	Widely used on fruit and vegetable crops.
MDBG/PE (Euxyl K)	Preservative: Nivea ^® , moist towelettes	N/A
Methylchloroisothiazolinone/ Methylisothiazolinone	Preservative: Eucerin ^® , latex paints, cleaning products, adhesives, topical medications	N/A
Bronopol	FRP, cross reacts with PPC	N/A
Carba Mix	Rubber accelerator: rubber bands, gloves, waistbands, basketballs	Cross react with disulfiram
Diazolidinyl Urea	FRP, cross reacts with other FRP and PPC	N/A
Potassium Dichromate	Metals, concrete, plaster, green pigment	Brewer's yeast, liver, bananas
DMDM Hydantoin	FRP, cross reacts with other FRP and PPC	N/A

Sources: Bohn et al., 2000; DermNet.com, 2005a; DermNet.com, 2005b; DermNet.com, 2005c; FDA, 2005; Flyvholm et al., 1984; Fuchs & Wahl, 1992; Garner, 2004; Gawkrodger, 2005; Geier et al., 2003; Gette et al., 1992; Hayashi et al., 1986; Hill & Belsito, 2003; Hogan, 2005; IPCS, 2005; Jacob & James, 2004; Menne et al., 1992; Onder et al., 2001; Rietschel & Fowler, 1995; Salam & Fowler, 2003; Saripalli et al., 2003; Schaller et al., 1989; Weiler & Russel, 1986; TRUEtest.com, 2001a, b, c

Reasons for False-Positive and False-Negative Readings
False Positives	False Negatives
Acute dermatitis during patch test	Degraded or expired testing materials
Degraded or expired testing materials	Early reading
Irritable or sensitive skin	Lack of UV light for photosensitizing allergens
Recent patch testing at same site	Narrow the scope of clinical investigation
Reaction to tape or aluminum/plastic wells	Showering or sweating during the test
Strong reaction to neighboring allergen	Sun exposure prior to the test
Inexperienced evaluator	Corticosteroids prior to the test

Sources: Bourke et al., 2001; TRUEtest.com, 2001b

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