Protein Contact Dermatitis -A Case Report

Transcription

1 Protein Contact Dermatitis -A Case Report Szu-Chi Lin Mei-Eng Tu Yang-Chih Lin Protein contact dermatitis is a unique occupational dermatitis with a characteristic episodic, eczematous, itchy vesicular eruption mostly on the hands of food handlers. It usually develops several minutes after handling the offending allergens. It is either a combined type I and type IV or a type I hypersensitivity reaction alone. The diagnosis is made by skin prick or scratch test using the causative agents. We report such a case in a 28-year-old baker, a patient with chronic hand eczema, who had a 6- year history of a pruritic vesicular rash immediately after handling certain foods. A diagnosis of protein contact dermatitis was made by demonstrating positive reaction to a prick test with cucumber, egg white, and egg yolk. (Dermatol Sinica 25: 30-34, 2007) Key words: Protein contact dermatitis, Occupational contact dermatitis, Baker, Hand eczema, Prick test 28 6 ( 25: 30-34, 2007) From the Department of Dermatology, Mackay Memorial Hospital Accepted for publication: September 19, 2006 Reprint requests: Mei-Eng Tu, Department of Dermatology, Mackay Memorial Hospital, No. 92, Sec. 2, Chung-Shan N Rd., 10449, Taipei, Taiwan TEL: ext FAX: Dermatol Sinica, Mar

2 INTRODUCTION Protein contact dermatitis is a distinctive dermatitis characterized by chronic eczema with episodic acute exacerbations immediately following contact with the responsible allergens. 1 This condition results from a hypersensitivity reaction, either a simultaneous type I (IgEmediated) immediate and type IV (T-cell mediated) delayed reaction or type I reaction alone. We report a baker with protein contact dermatitis diagnosed by prick test. CASE REPORT A 28-year-old man came to us with a 6- year history of a chronic rash on his hands. He had been working as a baker for almost ten years and had had a rash since he was an apprentice. However, he hadn t been too concerned about it until recent years when it became worse. He had not previously sought medical advice, however. He stated that his hands were erythematous, swollen, dried, and fissured. The disorder was partially relieved on holidays or when he took days off. He worked with various foodstuff, including flour, flavoring agents, enzymes, butter, dairy products, eggs, meat, fruits, and vegetables. Particularly after handling cucumber, bacon, and eggs, he noted an immediate pruritic, stinging, vesicular eruption. Ingestion of these foods, however, did not cause any reaction. He more often held the offending foods with his left than with his right hand. The patient had a history of hyperhidrosis which had been treated with sympathectomy Fig. 2 Patch test with a positive reaction to brown sugar essence thirteen years previously. Nevertheless, alternating anhidrosis and hyperhidrosis were still noted postoperatively. He denied any other allergies. His father had asthma. Physical examination revealed fissures, desquamation, and hyperkeratosis on an erythematous lichenified base on the palms, fingers, and dorsum of both hands (Fig. 1). The nail folds were swollen and the cuticles were absent. These findings were most prominent on the volar aspects of fingers, followed by the palms, and then the backs of the hands. The left hand was more severely affected than the right. The patient was patch tested with a Fig. 1 (a) & (b) Fissures and desquamation on erythematous, swollen base on the fingers, palms, and dorsum of both hands, worse on the left hand than on the right. The nailfolds are swollen and cuticles are absent. Fig. 3 (a) & (b) Positive prick test results. (a) Reaction to egg white and egg yolk on the right flexural forearm. (b) Reaction to cucumber on the left flexural forearm, along with histamine as a positive control. 31 Dermatol Sinica, Mar 2007

3 Table 1. Results of Patch Testing Tested substances (Number of substances) Conc. Veh. Results 48 hours 72 hours 1 week European standard series (25) All (-) All (-) All (-) Fragrance series (24) All (-) All (-) All (-) Sorbic acid 2.0% pet (-) (-) (-) Propyl gallate 1.0% pet (-) (-) (-) Dodecyl gallate 0.25% pet (-) (-) (-) Ammonium persulfate 2.5% pet (-) (-) (-) Hydroquinone 1.0% pet (-) (-) (-) Benzoyl peroxide 1.0% pet (-) (-) (-) 2-tert-butyl-4-methoxyphenol (BHA) 2.0% pet (-) (-) (-) 2,6-ditert-butyl-4-cresol (BHT) 2.0% pet (-) (-) (-) Personal series a (11) Brown sugar b as is Others All (-) All (-) All (-) a Personal series included various flours, enzyme, flavors, yeasts, and butter b Control tests of five healthy volunteers were all negative All above substances except those in personal series were obtained from Chemotechnique Diagnostics, Malmö, Sweden European standard series, fragrance series, and common bakery allergens, as well as other substances frequently used at his workplace (Table 1). Prick tests on the flexural aspect of the forearms with material commonly used at work were also performed (Table 2). The patch tests were all negative except for a reaction to brown sugar essence (Fig. 2). Positive reactions to cucumber, egg white, and egg yolk were demonstrated by prick tests (Fig. 3). 2 MAST examination of a blood sample showed a class 1 reaction to egg white and egg yolk. The results suggested diagnoses of irritant contact dermatitis, allergic contact dermatitis, and protein contact dermatitis. We prescribed topical steroids and instructed the patient to wear gloves at work as often as possible, especially when processing the offending foods. The dermatitis had improved considerably 3 weeks later. DISCUSSION Occupational hand dermatitis is commonly seen in food handlers. 3-5 Exposure to irritants, wet work, and frequent hand washing as well as an atopic diathesis are all risk factors for the development of hand dermatitis. 3 Though irritant contact dermatitis is by far the most common diagnosis, other forms may also be seen. The term protein contact dermatitis was introduced in 1976 by Hjorth and Roed- Petersen for a particular form of chronic recurrent occupational dermatitis observed in thirtythree Danish food handlers. 1 Since then, many cases have been reported, mostly in individuals handle meat. Chefs, butchers, bakers, fishermen, and even veterinary surgeons are especially at risk. 6-8 Usually, the lesions are confined to the hands and forearms and consist of pruritic eczematous vesicles associated with burning, stinging or pain that appear within minutes on the skin in contact with the specific allergens. The causative agent of protein contact dermatitis is thought to be a larger protein molecule rather than a hapten, the type of lowmolecular-weight substance which causes clas- Dermatol Sinica, Mar

4 Table 2. Results of Prick Test Tested substance Conc. Prick test Patch test /Veh. 20 min 40 min 60 min 48 hr 72 hr 1 wk Histamine 10 mg/ml as is Normal saline 0.9% as is Bacon as is NT NT NT Ham as is NT NT NT Pork as is NT NT NT Tuna (canned) as is NT NT NT Tuna (commercial extract)* NT NT NT Milk (commercial extract)* NT NT NT Egg white (commercial extract)* NT NT NT Egg white (raw) as is Egg yolk (raw) as is Wheat (commercial extract)* NT NT NT Wheat flour 50% aq Wheat flour 30% aq Cucumber as is Potato as is Lettuce as is Garlic as is NT NT NT Onion as is NT NT NT Kiwi as is NT NT NT NT: not tested, -: negative. Positive results of the prick test were graded according to Dreborg 2 : diameter of the wheal 3 to 5mm (+), 5 to 10mm (++), 10 to 15mm (+++) * The commercial extracts were obtained from Greer Laboratories, Inc. (Lenoir, NC, USA) sic contact dermatitis. Subsequently, Janssens et al. further classified the causative proteins into four groups: fruits, vegetables, spices, and plants; animal proteins; grains; and enzymes. Patch tests are usually negative, but skin prick or scratch testing with the offending proteins or proteinaceous allergens result in an urticarial reaction within 20 minutes. 9 The skin serves as a protective barrier preventing access of foreign substances to the body. It has been suggested that only extremely small compounds (<500Da) are able to penetrate the stratum corneum. 10 Therefore, a defective barrier is necessary for a high-molecularweight allergen to penetrate or bypass the stratum corneum and enter the epidermis or dermis. This may explain why atopy, skin abrasions, pre-existing dermatitis, and irritation may facilitate the development of protein contact dermatitis. 11 Only about 50% of reported patients have had an atopic diathesis. In these individuals, it is thought that in a preexisting inflammatory skin condition, reduced ceramide levels, and increased ceramidase expressed by staphylococcal bacteria may then predispose them to protein contact 9, 11 dermatitis. In some patients, serum specific IgE is detectable, but its absence does not exclude the diagnosis. According to recent studies, it may be that IgE bound to Langerhans cells in the epidermis and dermis, a mechanism similar to that of atopic dermatitis, is responsible for this 33 Dermatol Sinica, Mar 2007

5 8, 9, distinct type of contact dermatitis. Before accepting a diagnosis of protein contact dermatitis, contact urticaria, allergic contact dermatitis, irritant dermatitis, and atopic dermatitis should be ruled out. Prick or scratch tests remain the gold standard of diagnosis. Patch tests are helpful in excluding allergic contact dermatitis. In our patient, the variety of potential allergens he worked with, the fact that his hands were frequently wet (because of the working conditions, frequent hand washing, and his hyperhidrosis), and an atopic predisposition may all have contributed to the development of chronic eczema on his hands. Evidence of allergic contact dermatitis to brown sugar essence was demonstrated by the patch test, while the immediate clinical response plus the positive prick test reactions to cucumber, egg white, egg yolk were all consistent with protein contact dermatitis. The class I reaction to egg white and egg yolk on the MAST assay is consistent with circulating IgE against the causative allergens. Although protein contact dermatitis is thought to be rare, it is probably in fact underdiagnosed. The characteristic history ought to raise consideration of the diagnosis, as patients themselves are quite likely recognize the association between their skin response and a particular environmental contact. Protective measures such as wearing gloves and avoiding direct contact with allergens cannot be overemphasized. 15 Use of emollients and barrier creams as well as daily skin care is important to reestablish an intact skin barrier. Educating the patients to recognize initial skin changes may reduce the exacerbations and chronicity of their disease. 16 Protein contact dermatitis, then, is a disorder which should be suspected in individuals with occupational exposure to likely allergens. A correct diagnosis allows institution of effective therapeutic and prophylactic measures. Had this entity been recognized earlier in our patient, he might have been saved several years of discomfort. REFERENCES 1. Hjorth N, Roed-Petersen J: Occupational protein contact dermatitis in food handlers. Contact Dermatitis 2: 28-42, Dreborg S: Skin test used in type I allergy testing. Allergy 44: 22-30, Bauer A, Bartsch R, Hersmann C, et al.: Occupational hand dermatitis in food industry apprentices: results of a 3-year follow-up cohort study. Int Arch Occup Environ Health 74: , Nethercott JR, Holness DL: Occupational dermatitis in food handlers and bakers. J Am Acad Dermatol 21: , Chan EF, Mowad C: Contact dermatitis to food and spices. Am J Contact Dermat 9: 71-79, Iliev D, Wuthrich B: Occupational protein contact dermatitis with type I allergy to different kinds of meat and vegetables. Int Arch Occup Environ Health 71: , Tosti A, Cuerra L: Protein contact dermatitis in food handlers. Contact Dermatitis 19: , Kanerva L, Pajari-Backas M: IgE-mediated RAST-negative occupational protein contact dermatitis from taxonomically unrelated fish species. Radioallergosorbent test. Contact Dermatitis: 41: , Janssens V, Morren M, Dooms-Goossens A, et al.: Protein contact dermatitis: myth or reality? Br J Dermatol 132: 1-6, Bos JD, Meinardi MM: The 500 Dalton rule for the skin penetration of chemical compounds and drugs. Exp Dermatol 9: , Smith Pease CK, White IR, Basketter DA: Skin as a route of exposure to protein allergens. Clin Exp Dermatol 27: , Tosti A, Fanti PA, Guerra L, et al.: Morphological and immunohistological study of immediate contact dermatitis of the hands due to foods. Contact Dermatitis 22: 81, Fruynzeel-Koomen C: IgE on Langerhans' cells: New insights into the pathogenesis of atopic dermatitis. Dermatologica 172: , Withrich B: Food-induced cutaneous adverse reactions. Allergy 53: , Bauer A, Kelterer D, Bartsch R, et al.: Skin protection in baker's apprentices. Contact Dermatitis 46: 81-85, Bauer A, Bartsch R, Hersmann C, et al.: The prevention of occupational hand dermatitis in bakers, confectioners and employees in the catering trades. Contact Dermatitis 44: 85-88, Dermatol Sinica, Mar