Substances that affect the skin Contact urticaria

Contact urticaria (1-4) refers to a wheal-and-flare response to the application of chemicals to the intact skin. Various cutaneous and extracutaneous symptoms and signs have been described, justifying the term "contact urticaria syndrome.'' The broad spectrum of clinical manifestations is classified in Table 1. The symptoms usually develop within 20-30 minutes after contact with the offending chemical, but later reactions after several hours have also been recorded.

Most cases of contact urticaria are of non-immunolo-gical origin, presumably due to the direct release of histamine, slow-reacting substance of anaphylaxis (SRS-A), bradykinin, or other vasoactive substances. Topical drugs and ingredients of cosmetics that have caused non-immunological contact urticaria are listed in Table 2.

Contact urticaria of immunological origin is less common, although many topical drugs have caused it in previously sensitized individuals. In several reports, passive-transfer tests were positive, and specific antibodies have occasionally been demonstrated, indicating an immunological phenomenon. Topical drugs and ingredients of cosmetics that have caused immunological contact urticaria are listed in Table 3; in most of these cases, the contact urticaria was of probable immunolo-gical origin.

Some cases of contact urticarial reactions cannot be ascribed with certainty to either immunological or non-immunological mechanisms; the classical example of this category of contact urticaria of uncertain mechanism is that caused by the bleaching agent ammonium persulfate. Also belonging to this category are several topical substances that have caused contact urticaria on patch-testing, the clinical significance of which is uncertain, for example nickel sulfate, butylated hydroxyanisole (BHA),

Table 2 Agents that have caused non-immunological contact urticaria (1,4)

Alcohols

Eugenol

Balsam of Peru

Formaldehyde

Benzaldehyde

Iodine

Benzocaine

Methyl green

Benzoic acid/benzoin tincture

Methyl salicylate

Camphor

Monoethyl fumarate

(SEDA-16, 153)

Cantharides

Nicotinic acid esters

(SEDA-17, 187)

Capsaicin

Parabens

Chlorocresol

Phenol

Cinnamic acid

Propylene glycol

(SEDA-19, 159)

Cinnamic aldehyde (SED-9, 249)

Resorcinol

Cinnamon oil

Sodium benzoate

Diethyl fumarate (SEDA-16, 153)

Sorbic acid

Dimethylsulfoxide (SED-9, 249)

Sulfur

Table 1 Staging and symptoms of the contact urticaria syndrome (3,4)

Cutaneous reactions only Extracutaneous reactions

Table 1 Staging and symptoms of the contact urticaria syndrome (3,4)

Cutaneous reactions only Extracutaneous reactions

Stage 1

Localized urticaria

Stage 3

Bronchial asthma

Dermatitis/dermatosis

Rhinoconjunctivitis

Non-specific symptoms

Otolaryngeal symptoms

(itching, tingling, burning, etc.)

Gastrointestinal symptoms

Stage 2

Generalized urticaria

Stage 4

Anaphylactoid reactions

Table 3 Agents known or believed to have caused immunological contact urticaria (1-4)

Acetylsalicylic acid

Acrylic acid (SEDA-18, 175)

Albendazole

Aminophenazone (aminopyrine)

Ampicillin

Amyl alcohol

Bacitracin

Balsam of Peru

Basic blue 99

Benzocaine

Benzoic acid

Benzophenone

Benzoyl peroxide

Benzyl alcohol

Buserelin acetate

Butyl alcohol

Butylated hydroxyanisole (BHA) Butylated hydroxytoluene (BHT) Caraway seed oil

Cefotiam hydrochloride (SEDA-19, 163)

Cephalosporins

Cetyl alcohol

Chamomile

Chloramine

Chloramphenicol

Chlorhexidine (SEDA-21, 166)

Chlorocresol (SEDA-12, 137)

Chlorproethazine (SEDA-17, 187)

Chlorpromazine (6)

Clioquinol (iodochlorhydroxyquinoline) (SEDA-5, 152)

Clobetasol 17-propionate (SEDA-8, 153)

Colophony

Corn starch

Denatonium benzoate

Diethyl fumarate

Diethyl toluamide (SEDA-8, 153)

1,3-Diiodo-2-hydroxypropane

Dinitrochlorobenzene

Diphenylcyclopropenone (SEDA-14, 132)

Dipyrone

Disodium cromoglicate (SEDA-12, 137) Emulgade F Estrogen cream Ethyl alcohol

Ethylenediamine dihydrochloride Etofenamate

Formaldehyde (SEDA-8, 153) Gelatine

Gentamicin (SEDA-12, 139)

Gentian violet Glyceryl trinitrate Hamamelis Henna Hexanetriol

Hydrolysed protein (SEDA-21, 166) Isopropyl alcohol Isopropyl dibenzoylmethane Labetalol

Lanolin alcohol (SEDA-5, 152) Latex

Lidocaine (SEDA-15, 149) Lindane

Mechlorethamine hydrochloride (SEDA-22, 172)

Menthol

Merbromin

Mercurochrome (SEDA-19, 163) Metamizole Methotrimeprazine Methylethylketone

Mexiletine hydrochloride (SEDA-18, 175)

Mezlocillin (SEDA-15, 149)

Monoamylamine

Myrrh

Neomycin

Nickel sulfate

Nicotine

Nicotinyl alcohol Nifuroxime Orthophenylphenate Oxyphenbutazone

Para-aminodiphenylamine (SEDA-5, 152) Parabens

Parahydroxybenzoic acid

Paraphenylenediamine derivatives (SEDA-21, 166) Penicillin

Pentamidine isethionate

Phenylmercuric salts

Polyethylene glycol

Polypropylene (Polysorbate 60)

Povidone iodine (SEDA-20, 157)

Pristinamycin

Procaine hydrochloride

Promethazine hydrochloride

Propipocaine hydrochloride (SEDA-15, 149)

Propyl alcohol

Propylene glycol

Protein hydrolysate (SEDA-15, 149) Pyrazolone derivatives (SEDA-9, 139) Pyrethrin (SEDA-15, 149) Rifamycin (SEDA-17, 191) Salicylic acid

Sisomycin (SEDA-12, 139) Sodium hypochlorite Sodium sulfite

Sorbitan laurate (SEDA-9, 139)

Squaric acid dibutyl ester

Steartrimonium hydrolysed animal protein

Stearyl alcohol

Streptomycin

Sulfur

Tetracycline (SEDA-9, 139)

Thiomersal

Thuja a-Tocopherol Tropicamide Vanillin Virginiamycin butylated hydroxytoluene (BHT), ethyl vanillin, potassium bichromate, parabens, and ethylenediamine (5).

The diagnosis of contact urticaria can usually be confirmed by an open test. However, such tests should be performed with great caution, since anaphylactoid reactions due to the testing procedure have been described (3,4).

Reports of contact urticaria to ingredients of drugs and cosmetics are listed in Table 4 and Table 5 (7-11).

Table 4 Contact urticaria to ingredients of topical drugs and cosmetics

Allergen

Allergen-containing product

20-minute patch test

Skin prick test

Reference

Cyclopentolate hydrochloride

Di(2-ethylhexyl)

phthalate

Glyceryl thioglycolate Panthenol

Wheat hydrolysate

Eye drops (Colircursi cicloplejico 1%) PVC grip cotton gloves

Hair permanent fluid Hair conditioner

Eyedrops + Not performed (12)

Rubbing with PVC grip+ Gas chromatography extracts + (13)

Body cream

1% in petrolatum +

Hair conditioner Panthenol 30% in petrolatum Body cream ++

Di-n-butylmaleate +

Not performed

Hair conditioner + Panthenol +++

Wheat hydrolysate ++

Table 5 Contact urticaria to relatively rare antigens in drugs and cosmetics

Allergen Allergen-containing Patch tests Skin prick tests Reference product

Benzophenone 3

Benzyl alcohol

Cyclopentolate hydrochloride Di-(2-ethylhexyl) phthalate (DOP)

Geraniol

Glyceryl thioglycolate

Panthenol

Phenoxyethanol

Sunscreens

Bacteriostatic saline

Eye drops

PVC grip cotton gloves

Various cosmetics

Hair permanent fluid

Hair conditioner Body lotion

Benzophenone 3 + (concentration not stated)

10cm wheal after 24 hours (concentration not stated) Eye drops 1% +

Rubbing with PVC +

Geraniol + (concentration not stated)

1% in petrolatum +

Panthenol 30% in petrolatum -

Phenoxyethanol 1% pet + Euxyl K 400 1.5% + Own cosmetics + Not done

Not done

Not done

Not done

Potassium persulfate Hair dye Wheat hydrolysate Body cream

Nickel sulfate Body cream ++

Gas chromatography extracts + (13) DOP +

Di-n-butylmaleate

Hair conditioner + (15)

Phenoxyethanol 1%+ (20)

Body lotion +++ Euxyl K 400 ++ Phenoxyethanol 1%+, 5%+,10%++

Potassium persulfate (dilution (22) not stated) 5 mm wheal

Wheat hydrolysate ++ (16)

+, ++, +++ indicate increasing intensity of reaction.

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