Cutaneous and Systemic Hypersensitivity Reactions to Metallic Implants

Juliana L. Basko-Plluska; Jacob P. Thyssen; Peter C. Schalock


Dermatitis. 2011;22(2):65-79. 

In This Article

Abstract and Introduction


Cutaneous reactions to metal implants, orthopedic or otherwise, are well documented in the literature. The first case of a dermatitis reaction over a stainless steel fracture plate was described in 1966. Most skin reactions are eczematous and allergic in nature, although urticarial, bullous, and vasculitic eruptions may occur. Also, more complex immune reactions may develop around the implants, resulting in pain, inflammation, and loosening. Nickel, cobalt, and chromium are the three most common metals that elicit both cutaneous and extracutaneous allergic reactions from chronic internal exposure. However, other metal ions as well as bone cement components can cause such hypersensitivity reactions. To complicate things, patients may also develop delayed-type hypersensitivity reactions to metals (ie, in-stent restenosis, prosthesis loosening, inflammation, pain, or allergic contact dermatitis) following the insertion of intravascular stents, dental implants, cardiac pacemakers, or implanted gynecologic devices. Despite repeated attempts by researchers and clinicians to further understand this difficult area of medicine, the association between metal sensitivity and cutaneous allergic reactions remains to be fully understood. This review provides an update of the current knowledge in this field and should be valuable to health care providers who manage patients with conditions related to this field.


Contact Allergy to metals such as nickel, cobalt, and chromium is prevalent in the general population. It is estimated that up to 17% of women and 3% of men are nickel allergic, and that about 1 to 2% are allergic to cobalt, chromium, or both.[1] Metal allergy is mainly caused by prolonged or repeated skin exposure to consumer items such as jewelry, cell phones,[2] clothing fasteners,[3] and leather goods.[4] In some countries, a significant proportion of metal allergy derives from occupational exposure in the metal and construction industries.[5] Independent of the primary cause of metal sensitization, the insertion of metallic implants may result in eczematous eruptions on the skin overlying the implant or in device failure caused by delayed-type hypersensitivity (DTH) (eg, chronic inflammation, pain, loosening of joint prostheses, or restenosis of cardiac stents). In an aging population, the putative association between metal allergy and device failure due to DTH may be a problem of growing significance.[6] This review aims to update the reader on the general aspects of this complex topic and to briefly discuss future challenges.


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