Allergic Contact Dermatitis Case Reviews
Dermatitis Due to Stoma Equipment
Numerous cases involving different types of peristomal skin dermatitis have been documented in the literature. Stevenson described seven patients who presented with peristomal rashes. Three of the patients had undergone ileostomies, three had undergone cystectomies, and one had undergone a thoracostomy. The patients were all patch-tested, but only three displayed positive reactions-one to lanolin, another to rubber in the stoma bag, and the last to strapping. In each case, the dermatitis cleared after the problematic factor was removed. Two of the patients were diagnosed with psoriasis; treatment of the psoriasis (along with surgical revision of a poorly formed stoma in one case) led to the eventual clearance of the rash. One patient presented with a poorly created surgical stoma that resulted in maceration of the skin; this cleared after surgical revision of the stoma. The last patient was diagnosed with a psychoneurosis that prevented proper treatment of the peristomal rash.
Mann and colleagues described a 41-year-old woman who presented with a 1-month history of erythematous and acute eczematous eruptions around her urostomy stoma, arms, abdomen, and right thigh. Patch testing at 48 and 96 hours yielded positive reactions to epoxy resins that were components of the ostomy bag. Mann and colleagues postulated that although frictional irritant dermatitis and "prickly heat" could also have contributed to the dermatologic reaction, the role of the epoxy resins must also be considered.
Fregert and colleagues described the case of a 77-year-old woman who developed dermatitis due to a plastic urostomy pouch. Patch testing showed a strong positive reaction to the epoxy resin that was a known component of the pouch. Fregert and colleagues also used thin-layer chromatography (TLC) and high-performance liquid chromatography (HPLC) to identify the specific components of stoma bags from different companies. TLC showed the presence of epoxy resin oligomers MW 340, 624, and 908; HPLC revealed the same oligomers. The oligomer with a molecular weight of 340 is a known component of bisphenol A (BPA) epoxy resins and has been shown to be the main allergen in these resins. These specific resins can migrate to the surface of the equipment, causing allergic reactions in patients who undergo prolonged skin exposure. BPA epoxy resins make up about 90% of commercial epoxy resins.
Van Ketel and colleagues also described a very similar case in which a 47-year-old woman developed dermatitis around the ileostomy site for 2 months. Patch testing yielded a positive reaction to an epoxy resin that was a component of the bag. Further analysis showed that BPA was present in the ileostomy bag.
Beck and colleagues described six patients who developed peristomal eczematous reactions around the skin covered by their ostomy bags. Patch testing with a series of known contact allergens (Trolab, Hermal, Reinbek, Germany) and with 1/2-inch squares of the ostomy bags yielded positive reactions to epoxy resin at 48 hours and 96 hours. In addition, five of the patients had positive reactions to the ostomy bags at both the 48- and 96-hour readings. The bags were analyzed with TLC; results indicated the presence of BPA epoxy resins. Five of the patients were using an ostomy bag manufactured by Squibb (Bristol Meyers Squibb, New York) whereas the last patient used one manufactured by Simpla Plastics Limited (Cardiff, England).
Camarasa and Alomar described the case of a 40-year-old woman suffering from an itchy dermatitis around the opening of her colostomy. She was using a polyethylene bag containing a karaya gum seal ring; patch testing yielded positive reactions to the karaya gum ring. Karaya gum, a natural resin obtained from the plant Sterculia urens, is often mixed with glycerin and parabenzoin to make the adhesive sealing ring more effective.
Van Hecke and Vossaert reported on a 57-year-old man who had a monthlong history of dermatitis around his colostomy opening. The dermatitis appeared in the areas where the ostomy bag was touching the skin on his right thigh and right abdomen. Patch testing yielded positive results for 2-benzotriazol (Tinuvin P, Ciba, Ludwigshafen, Germany). Information from the manufacturer of the ostomy bag stated that Tinuvin P was present at a concentration of less than 0.5%. It was also found that Tinuvin P migrated from the inner core of the plastic to the surface, where it could make contact with the skin. The patient was advised to switch to a Tinuvin P–free bag.
In 1992, de Pablo and colleagues reported the case of a 74-year-old man who had had a colostomy for 14 years. After using a new colostomy bag for 3 days, the patient developed an pruritic dermatitis around the stoma. The patient was tested with the Grupo Español de Investigación de la Dermatitis de Contacto standard series and with the plastic and glues series from Chemotechnique (Malmö, Sweden). At 96 hours, he had positive reactions to diaminodiphenylmethane 0.5% (++) and the rubber seal surrounding the bag (++). Diaminodiphenylmethane is used as a rubber antioxidant, as an epoxy resin hardener, and as an intermediate in germicides, surface-active agents, pharmaceuticals, corrosion inhibitors, and phosphate insecticides. The authors obtained no information about the components of the rubber seal from the manufacturer.
Parslew and colleagues described the case of a 48-year-old woman who had a colectomy and ileostomy following a long history of Crohn's disease. Shortly after she started wearing her ostomy bag, she noticed an eczematous reaction around the stoma. Cutaneous Crohn's disease was excluded, and further skin biopsy results confirmed the diagnosis of allergic contact dermatitis. Patch tests yielded a positive reaction to colophony, benzyl peroxide, and the adhesive ring around the bag. Further testing of the individual components of the adhesive ring resulted in contact urticaria due to polyisobutylene after 10 minutes. The polyisobutylene was then diluted to concentrations of 0.1%, 0.5%, 1.0%, and 5.0%. These were applied to the patient and five controls. Positive reactions occurred with the 5% solution on the patient, but the controls had no reactions. Polyisobutylene, a polymer of isobutylene, is available in various molecular weights. The stabilizer involved during processing is 2,6-di-tert-butyl-4-methylphenol (BHT), but the patient tested negatively to BHT during patch testing. Polyisobutylene is an ingredient in rubber and a component of hydrocolloids and chewing gum. In hydrocolloid dressings, it functions as an adhesive to allow proper placement and attachment on the skin. Parslew and colleagues were surprised by the patient's allergic reaction to polyisobutylene, given its large molecular weight, but considered the possibility that an impurity or additive was the true culprit.
Dermatitis Due to Topical Adhesives
There have also been a few reported cases of allergic contact dermatitis due to topicals that are often applied to improve stoma bag adhesion (Figure 2). In 1987, Heskel described the case of a 48-year-old woman who developed an eczematous reaction after 1 month of using her colostomy bag. Patch testing yielded positive reactions to balsam of Peru 25%, cinnamic aldehyde 2%, geraniol 5%, benzyl alcohol 5%, and isoeugenol 4%. Further testing resulted in positive reactions to Gantrez ES-225 (International Specialty Products, Wayne, NJ) 5%, Stomadhesive wafer (Bristol Meyers Squibb), and Stomadhesive paste (ConvaTec, Skillman, NJ). Discontinuation of the Stomadhesive wafer and paste led to the resolution of the dermatitis reaction.
Patch tests for allergic contact dermatitis: positive reactions to Adapt Paste (Hollister, Inc., Libertyville, IL) and Stomahesive paste.
Gantrez (N-butyl monoester of polymethyl vinyl ether maleic acid in an ethanol solution) is described as a series of copolymers with altering chemical structures. Besides being a component of the Stomadhesive paste, Gantrez is found in hair sprays, shoe polishes, spray bandages, and textile dyes and finishes. The function of Gantrez is to improve the "wet grab" and adhesion of the stoma equipment by creating a highly polar film. The specific polymer of Gantrez that is present in Stomadhesive paste is Gantrez ES-225.
In 2000, Scalf and Fowler Jr described the case of a 14-year-old girl who had undergone a total colostomy for an ulcerative colitis. She had been experiencing a severe peristomal dermatitis since she began using an ostomy bag. The bag she used was secured to the stoma site with Stomahesive paste (ConvaTec). Patch testing yielded positive results at 48 hours for Stomahesive paste (++) and Gantrez (+). At 96 hours, positive results for Myroxilon pereirae (balsam of Peru) 25% in petrolatum and propylene glycol 30% aqueous were also seen. The most relevant allergen was determined to be Gantrez.
In 2002, Gallo and colleagues also reported a patient who had a peristomal allergic contact dermatitis reaction to Stomahesive paste. A 76-year-old man with a colectomy underwent patch testing and had positive reactions (+) to Stomahesive paste and rosin. There was no reaction to Gantrez in this case, and further testing of Stomahesive paste in 20 control subjects yielded negative results. Shortly after stopping the patient's use of Stomahesive paste, the erythematous excoriated papules and scaling disappeared. Stomahesive paste is composed of pectin, gelatin, sodium carboxymethylcellulose, ethyl alcohol, Triacetin FFC, glyceryl tris(12-hydroxystearate), and Gantrez ES-425. The specific component of Stomahesive paste that caused this second case could not be determined due to the manufacturer's noncompliance. It is important to note that Stomahesive paste manufactured by ConvaTec contains Gantrez ES-425, whereas Stomadhesive paste manufactured by Bristol Meyers Squibb contains Gantrez ES-225, a different form.
In 2005, Martin and colleagues described the case of a 63-year-old woman who had undergone a total colectomy with an ileostomy several years prior to developing a peristomal blistering reaction over a period of 12 months. The patient had used both Dansac Soft Paste (Dansac A/S, Fredensborg, Denmark) and Stomahesive paste to improve the adhesion of her appliance. Patch testing yielded positive reactions to both the Dansac Soft Paste and the Stomahesive paste. The components of Dansac Soft Paste include Gantrez ES, silica, allantoin, butylparaben, methylparaben, gelatin, pectin, polysorbate, and polyacrylamide. When the patient was patch-tested with the components of the Dansac paste, she had positive reactions to Gantrez ES. These studies imply that the components of Stomahesive paste and Dansac Soft Paste, particularly Gantrez), can be potential allergens in ostomy patients.
Dermatitis Due to Other Ostomy Products
Peristomal allergic contact dermatitis has also been shown to result from various cleansers and anesthetics that are frequently used on the affected area. Davies and colleagues presented the case of a patient who was experiencing allergic contact dermatitis due to an ostomy deodorant. The patient was a 69-year-old male presenting with dermatitis primarily on his right thumb and fingertips. He was using DOR ostomy deodorant (Simpla Plastics Ltd., Cardiff, England) around his colostomy, and patch tests yielded positive reactions to the deodorant and to balsam of Peru. Davies and colleagues found that the main component of DOR deodorant was citronella oil; however, the patient refused any further testing. The authors also patch-tested 10 volunteers with DOR deodorant as is and saw that all subjects had positive reactions, thus indicating primary irritant properties of DOR deodorant. Also, the product's instructions specifically recommend avoiding contact with the skin. This indicates that to avoid stomal complications with this product, patients should be properly educated on its use.
In 1998, Lazarov and Trattner presented the case of a 58-year-old psoriatic woman who had undergone a colostomy after resection of colon cancer. Two weeks after she started using the ostomy equipment, the patient developed an erythematous papular eruption around the stoma. Patch testing yielded positive reactions to the adhesive remover wipe after 2 and 4 days. Additional patch testing was refused, but after usage of the wipes was terminated, the peristomal irritation resolved. In a second case, a 57-year-old woman with a urostomy due to carcinoma of the bladder developed an acute dermatitis around the stoma. Patch testing resulted in positive reactions to nickel sulfate 5% and to the adhesive cleanser wipes (ConvaCare, ConvaTec). The components of the wipes were C12-C15 benzoate alcohol, d-limonene, high-purity hydrocarbons, ethoxylated alkylaryl alcohol, coconut diethanolamide, 2,4-dichlorobenzyl alcohol, and butylated hydroxytoluene. Further testing of this second patient yielded a positive reaction to d-limonene.
Fernandez-Redondo and colleagues reported the case of a 58-year-old man with a urostomy who presented with a 2-month history of severe pruritus, erythema, and scaly exudative plaques. He noticed these reactions after he used Braum Monodose ointment (Braum Medical, Barcelona, Spain). The ointment contains tetracaine hydrochloride (.045 g) and glycerin (5.955 g). Patch testing resulted in positive reactions to the ointment, caine mix (+++), and fragrance mix (++). Further tests resulted in positive reactions to tetracaine, cinchocaine (also known as dibucaine), and lavender oil absolute 2%. These case reports indicate that certain cleansers, ointments, and wipes can pose as allergens for ostomy patients.
Table 2 summarizes the allergic contact dermatitis (ACD) cases that have been reported in the literature.
Dermatitis. 2010;21(3):138-147. © 2010 American Contact Dermatitis Society
Cite this: Stoma Dermatitis: Prevalent but Often Overlooked - Medscape - Jun 01, 2010.