Is Contact Allergy to Disperse Dyes and Related Substances Associated With Textile Dermatitis?

K. Ryberg; A. Goossens; M. Isaksson; B. Gruvberger; E. Zimerson; F. Nilsson; J. Björk; M. Hindsén; M. Bruze

Disclosures

The British Journal of Dermatology. 2009;160(1):107-115. 

In This Article

Discussion

Individual patients with contact allergy to DDs are regularly traced by patch testing with commercially available textile patch test screening series. On the other hand, there is little knowledge of the clinical relevance of positive patch tests to DDs. In the previous study performed at the department in Malmö, 1.5% of 3325 patch tested patients tested positively to the TDM.[8] The European Society of Contact Dermatitis recommends a sensitizer to be considered for inclusion in the baseline patch test series when routine testing of patients with suspected contact dermatitis results in a contact allergy rate exceeding 0.5-1%.[10] The contact allergy rate found in the Malmö study raised the question of whether or not a TDM should be included in the baseline series. In the present study 2% of 982 consecutively patch tested patients tested positively to the TDM ( Table 1 ). Accordingly, the contact allergy rate found in this study supports the idea of including the TDM in the baseline series. However, besides the contact allergy rates, other factors such as clinical relevance have to be considered before inclusion in a baseline series.[10] Thus, the present study was undertaken to clarify the connection between textile-related clinical manifestations and contact allergy to DDs.

History, clinical findings and exposure are the major elements in the assessment of clinical relevance in an allergic individual. The questioning on exposure and assessment of its significance for the dermatitis under investigation is easily biased when the contact allergy is known to the dermatologist and the patient. To use a questionnaire answered by the patient prior to patch testing makes it possible to avoid the bias that the knowledge of a contact allergy to the chemicals of interest could give, and hence one would obtain information on various factors more objectively. In the present study we, therefore, used a questionnaire to investigate the association between textile problems and contact allergy to TDM and chemically related substances. Thus, the present study was not an epidemiological investigation aimed at determining the true prevalence of textile dermatitis, but a study in which an epidemiological instrument, the questionnaire, was used to explain a possible connection between patient-reported textile-related skin problems and contact allergies to a TDM and chemically related substances, formaldehyde and various risk factors.

As several crease-resistant textiles contain textile finish resins of the formaldehyde type, patients with contact allergy to formaldehyde would possibly report more textile-related skin problems. However, no statistically significant association could be found between contact allergy to formaldehyde, sex or textile-related skin problems ( Table 5 ). These findings are supported by an article by Scheman et al.[11] who consider that most clothing today does not contain enough free formaldehyde to cause skin problems in formaldehyde-allergic individuals.

The question 'Have you ever had a rash/itch that you suspect is caused by textiles?' did not pick out the patients testing positively to the TDM, whereas the study demonstrated contact allergy to PPD to be an independent risk factor for textile-related skin problems ( Table 4 ). On the other hand, although not statistically significant, 3% of the patients suspecting textiles as a cause of their skin problems tested positively to the TDM and/or its ingredients compared with 2% of the patients answering negatively to this question. Furthermore, a statistically highly significant association was seen between the patients testing positively to both PPD and TDM.

From our clinical experience there are obvious cases with textile dermatitis and contact allergy to the DDs included in the present TDM. There may be several explanations for the fact that no statistically significant association was found in the present study between the patients answering that they had had a rash/itch possibly caused by textiles and having allergic test reactions to the TDM. One important reason may be that only 2% of the patients who answered the questionnaire tested positively to the TDM. The low prevalence of patients with contact allergy to the DDs tested makes it difficult to demonstrate a statistically significant association between the test results and reported skin problems due to textiles. More positive reactors may have been found by patch testing with the eight DDs at higher concentrations in the mix. In commercially available textile series the concentrations of the DDs are double those used in the TDM, with the exception of DB 106 and 124, which are commercially available at 10 times higher concentrations. In the present study only two patients tested positively to DB 106 and 124 ( Table 2 ). One of these patients answered positively to the question about textile-related skin problems. Many studies on contact allergy to DDs also emphasize DB 106 and 124 as the DDs of most interest.[12,13]

Furthermore, only 13 of the 20 TDM-positive patients tested positively to any of the ingredients in the mix. Possible explanations could be that the penetration into the skin of the TDM is higher, compared with the penetration of the ingredients when tested separately. Other possible explanations are a compound allergy, additive or synergistic effects of the different substances, as has been demonstrated when testing other mixes such as fragrance mix.[14,15]

To obtain a higher number of participating patients the study was performed at departments in both Malmö and Leuven. The patch testing of the patients followed the routine of the respective departments, and accordingly the methodologies used at the two centres differed. However, because of our experience, the patch test results using Finn Chambers® and Van der Bend Square Chambers® were comparable. Furthermore, only the patch test reactions registered on day 3 or 4, the common reading occasion, could be used for registration in the present study. A late reading on day 7 may have detected more patients with contact allergy to the DDs. In Malmö, the reading on day 7 revealed three more patients with allergic reactions to the TDM and four patients with positive reactions to at least one ingredient in the mix (results not shown). These findings support the importance of late readings, as reported in several studies.[16,17]

Another explanation for the fact that no association was found between the patients answering that they had had a rash/itch possibly caused by textiles, and having allergic test reactions to the TDM, may be that the DDs used are not the best screening dyes to detect clinically relevant textile-related skin problems caused by DDs. This statement is supported by a study by Hatch et al.,[18] who demonstrated that the DDs to which the patients were patch test allergic when testing with commercial patch test series, were only infrequently identified among the DDs found in the fabrics suspected to be the cause of the skin lesions. However, in our clinics, we have seen patients with textile-related skin problems due to contact allergy to the DDs used in our study, especially to DB 106 and 124 (unpublished observations).

As mentioned before, PPD historically has been considered to be a screening allergen for textile dye dermatitis[7] and the results in the present study raise the question of whether or not contact allergy to PPD is a better indicator for textile-related skin problems than the TDM. Contact allergy to PPD may also indicate that the patient has been sensitized by hair dye, temporary 'black henna' tattoo dye or by PPD derivatives in BRM. However, the present study could not demonstrate any statistically significant association between contact allergy to PPD and having used hair dye or having had temporary tattoos ( Table 3 ). On the other hand, some other studies consider PPD to be a good screening agent for contact allergy to hair dye, but not for DD sensitivity.[12,19] Nevertheless, simultaneous sensitivity to PPD and DDs, especially DO 3, has been described repeatedly.[19,20] In the present study PPD-positive patients significantly more often tested positively to both the TDM and DO 3 separately (P < 0.001 and P < 0.019, respectively). Possible explanations for simultaneous allergy to PPD and DDs could be cross-reactivity or sensitization to a common metabolite.[20,21] Accordingly, at least some of the patients allergic to the TDM may initially have been sensitized to PPD and then reacted to DDs due to cross-reactivity, or they may have been sensitized due to exposure to a common metabolite, rather than sensitized due to primary exposure to DDs in textiles.

Synthetic material was regarded as the most common textile to give rash/itch, followed by wool, cotton and silk. The good properties of silk, especially for atopic children, have been described by Ricci et al.[22] and silk has been recommended as a useful tool in the management of atopic dermatitis. The well-known relationship between patients having a history of eczema as a child and intolerance to wool[23] was also found in the present study. It is more difficult to explain why women reacted significantly more often to wool than men and more seldom to cotton. However, as many textiles are produced from mixed natural and synthetic fibres today, some of the patients answering the questionnaire may believe that they use pure cotton textiles when, in reality, they use clothes containing mixed natural and synthetic material. This circumstance may lead to more unreliable answers to this question.

When evaluating the overall answers to the questionnaire, women more often had eczema as a child, they more often dyed their hair and more often had worked with textiles. In the present study, women also tended to suspect textiles as a cause of skin problems more often than men. Possible explanations could be that women are more prone to skin irritation, or perhaps are more observant of skin manifestations than the average man, and that women have a tendency to wear more tight-fitting underwear made from synthetic textile materials, leading to increased friction and sweating. Women also use more hair dyes, cosmetics and other skin-care products which can cause skin irritation and/or contact allergies. According to several studies, women are more prone to become sensitized to DDs.[1,2,24] However, the present study could not demonstrate any statistically significant sex difference in patch test results to the TDM or to PPD, although women suspecting intolerance to synthetic materials were statistically more often allergic to PPD compared with women without skin problems from such textiles. Furthermore, there was a tendency for PPD-positive patients as a whole to report intolerance to synthetic fibres more often than PPD-negative patients.

Most skin sites have been involved in textile dermatitis.[4,25] In this study no statistically significant associations were found between skin site and contact allergy to TDM or chemically related substances.

Childhood eczema was found to be an independent, statistically highly significant risk factor for textile-related skin problems ( Table 4 ). Although the question 'Have you had eczema as a child?' may overestimate the prevalence of atopic eczema in childhood,[26] it is highly unlikely that this will change the conclusion that childhood eczema is a risk factor for textile-related skin problems. Previous childhood eczema most likely reflects general skin sensitivity, as no association could be found between childhood eczema and contact allergy either to TDM, or to PPD or BRM ( Table 3 ).

Although not statistically significant, there was a tendency for patients working with production or with finished textiles to have more textile-related problems than patients answering negatively to these questions, but no statistically significant association was found between working with textiles or dyes and contact allergy to TDM, PPD or BRM ( Table 3 and Table 5 ). Nowadays very little textile manufacturing is found in Belgium or Sweden, while there is a lot of occupational exposure to finished textile products.

In conclusion, 18% of 858 dermatitis patients suspected textiles to be the cause of their past or present skin problems. Female sex, increasing age, previous childhood eczema and contact allergy to PPD were found to be important risk factors with an OR ∼2. Contact allergy to TDM was not demonstrated as a significant risk factor, but simultaneous contact allergy to PPD and TDM was statistically highly significant. The present TDM was currently inferior to PPD to trace textile-related skin problems; thus TDM with its present composition is not recommended for inclusion in a baseline patch test series. A change in the composition may justify such an inclusion. Ongoing studies with simultaneous patch testing with the DDs in different concentrations will possibly give us more information on optimal patch test concentrations for tracing patients with contact allergy to DDs. However, for the time being, whenever a patient has a positive patch test reaction to PPD, the history must be scrutinized for the possibility of textile-related skin problems, and testing with textile dyes should be considered.


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