Musical Instruments Can Throw Skin Out of Tune

Randy Dotinga

July 07, 2021

Violin and viola players can pay a price for the music they create: Many suffer from skin irritation and inflammation where the instruments touch their necks and upper bodies. Now, a new literature review offers insight into this common condition, known as "fiddler's neck."

Henry Lim

"These skin conditions are disfiguring, and they also carry so much psychological burden. Not only are these patients under constant pressure to perform at their maximum at all times, it really is troublesome when there is a barrier between you and performing art that you absolutely love," lead author Henry Lim, an osteopathic medical student at the University of North Texas Health Science Center at Fort Worth, said in an interview.

The results of the literature review were presented in a poster at the Inaugural Symposium for Inflammatory Skin Disease.

Lim, who has a special interest in skin, said his own musical experience inspired the research. "Throughout my experience as a violinist, I faced many dermatologic issues because of my violin, and it affected my performance," he said. "As time went on, I recognized that many other stringed instrumentalists were dealing with similar issues but chose to live with it because it came with the territory."

One physician told Lim that he needed to quit in order to permanently treat his skin problems. He didn't accept this answer and instead launched the literature review with colleagues Marshall Hall, MPH, also an osteopathic medical student with an interest in dermatology, and Sajid Surve, DO, codirector of the UNT Texas Center for Performing Arts Health.

Lim and colleagues evaluated 23 articles, which included case studies and literature reviews, about dermatitis in violinists, violists, cellists, bassists, guitarists and harpists. "Stringed instrumentalists are the highest at-risk population compared to performers who play other types of instruments," Lim said.

The poster he presented at the meeting largely focuses on fiddler's neck, which he defined as "simply dermatitis related to friction and allergic irritation from playing violin or viola." Many people, he noted, are allergic to nickel, and the bracket that secures the violin's chin rest "most often contains nickel. Even a very small concentration of nickel can cause massive reactions, and we found that the C string of a viola — the thickest, lowest-sounding string — contains a nickel concentration of up to 37%."

Gold-coated strings are an alternative option, he said, but they're more expensive.

Stringed instrumentalists may also be allergic to rosin applied to "bow hairs," which is the hair — typically from horses — that is used to string bows, also described in the poster. "We found that there is an overall common allergy to the main ingredient called colophony," Lim said. The legendary violin maker Antonio Stradivari "was rumored to have used colophony and another irritating ingredient called propolis in the wood varnish of his instruments. Because he was such a great influence on the art of violin crafting, his technique is still used in the modern era, which may be another contributing factor to the allergic reactions seen in stringed instrumentalists."

(In the poster, the authors refer to one of the articles in the review, which described a violin maker allergic to colophony and propolis, who was treated with cetirizine, mild corticosteroids, and avoidance.)

What should dermatologists know about skin conditions in these musicians? Hall, one of the coauthors of the report, suggested they invite the patients to play their instruments during a visit. "The musicians may not understand that they are doing certain things with their movements, but looking from a clinical lens, we are able to see how their biomechanics and posture [are] contributing to their dermatitis," he said.

Surve, the other coauthor, also suggested speaking to the patient's teacher, coach, or mentor. "Keeping that person in the loop regarding what you are seeing and recommending will go a long way towards helping your patient," he said. "If the teacher doesn't understand or agree with what you're trying to accomplish, they may try to undermine your plan of care. But if they are on board, they become a valuable tool for facilitating and reinforcing it."

As for treatments, avoidance of the instruments is the most effective, but is simply not feasible for many musicians. "Certain interventions like creating a barrier between the musician and the instrument can reduce the risk of contact dermatitis without compromising the quality [of playing] as much," Hall said. The poster reported that a handkerchief was used for this purpose in one case attributed to nickel sulfate in a 16-year-old.

Purchasing more expensive instrument materials to prevent reactions is another option, he said, and players can also purchase stands. But musicians may be resistant to any treatment that changes how the instruments sound or forces them to adjust the way they do things, he cautioned.

No funding for the study or author disclosures were reported.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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