Cutaneous and Systemic Hypersensitivity Reactions to Metallic Implants

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

Disclosures

Dermatitis. 2011;22(2):65-79. 

In This Article

Conclusions

Most information regarding putative sensitivity reactions to endovascular, cardiovascular, orthopedic, and dental metal implants are based either on anecdotal case reports or on data gathered from relatively small cohorts. Very few prospective data are available. For decades, it was believed that only selected highly susceptible patients (< 1%) developed skin complications due to metal implants; however, a recent case study showed that a significantly higher number of patients (5%) developed eczematous reactions directly associated with metallic implants.[21] Those individuals with a preexisting metal sensitivity who receive an implant containing the offending metal had a higher rate of cutaneous dermatitis compared to those without metal allergy. Another study examining this exact situation suggests that there may be no adverse reactions to implanting the allergenic metal.[115] Further prospective and well-powered studies are needed to definitively answer this question.

In the majority of cases, the removal of the allergenic metal device results in clearing of the skin condition. Based on these data, we recommend that patients who develop a cutaneous eruption months to years after receiving a metal implant should be patch-tested with an appropriate series of metals. If relevant allergens are identified and corticosteroid therapy is insufficient to clear the eruption, removal of the implant may be considered. A perfectly functioning dynamic implant causing no pain and without evidence of loosening should not be removed in most cases, despite a positive patch-test result.

Although removal of offending devices may clear the dermatitis, prevention of reactions and complications is preferable. There is no general support for preimplantation patch-test evaluation, but it may be considered for individuals who are suspected of having a strong metal allergy. One study suggested that patients with a history of metal reactions prior to implantation may have an increased risk of arthroplasty failure, but this study had methodologic limitations.[16] In comparisons of 22 individuals before, and 22 individuals after, the implantation of orthopedic devices, 5 individuals were identified as being allergic to the alloy in their proposed device, whereas none (0 of 22) of the symptomatic individuals had positive reactions when tested.[43] Another approach was suggested by Carlsson and Moöller, who reported that no patients had adverse reactions to metal implants to which they were sensitized prior to implantation,[20] and by Bruze, who reports that no preimplantation testing is performed in Sweden.[116] The reason some patients develop cutaneous complications in association with metal implants and others do not remains a puzzle. Prospective longitudinal studies are strongly needed to shed further light on this subject. We also need better insight into the diagnostic performance of patch testing and in vitro test methods.

It is hoped that our knowledge about the associations between metal allergy, allergic contact dermatitis, and device failure will expand. At present, it is unknown whether the risk of device failure and allergic contact dermatitis is increased in metal-allergic persons. With aging populations in Western Europe and the United States, there is an urgent need for greater insight. The use of metal implants is expected to grow rapidly. At the same time, the generations of people who became metal allergic in great numbers from the 1960s to the 1980s either from industrial metal exposure or from exposure to consumer products and cosmetic procedures (such as wristwatches, jean buttons, inexpensive jewelry, and ear piercing) are gradually aging. As dermatologists are often consulted about the possible role of metal allergy in patients awaiting implantation, this collision course warrants our full attention.

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