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8, ()ol1nick H, Thies W, Taud W, et al. Intra-epidennalel1~u~rophileund eosinophile IgA-Dennatose, In: Gollnick~,$tadler R,eds. Dia-Klinik. Stuttgart: Schattauer,:~~67:68-70.
9.'pjetteW, IlurkenRR, Ray TL. Intraepidermal neutrophilic 19A dermatosis: presence of circulating pemphiguslike 19A antibody specific for monkey epithelium [Abstract]. J Invest DermatoI1987;88:512.
Journal of theAmerican Academy of
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10. Stolz W, Bieber T, Meurer M. Is the atypical neutrophilicdennatosis with subcorneal IgA deposits a variant ofpemphigus foliaceus? Br J DermatoI1989;121:276-9.
11. Saurat J-H, Merot Y, Salomon D, et al. Pemphigus-likeIgA deposits and vesiculo-pustular dermatosis in a 10year-old girl. Dermatologica 1987;175:96-100.
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Erythema multifonne after contact dermatitis inresponse to an epoxy sealantMargot J. Whitfe1d, MBBS, and Jason K. Rivers, MD, FRCPC Camperdown,New South Wales, Australia
A case of erythema multiforme associated with an allergic contact dermatitis in response toan epoxy-based compound is presented. Patch tests revealed a positive reaction to both theepoxy resin and the hardener. Chemicals applied directly to the skin should be considered asa potential cause of erythema multiforme. (J AM ACAD DERMATOL 1991;25:386-8.)
Epoxy resins cause more instances of occupational dermatitis than anyother group ofchemicals. I
Although erythema multifonne (EM) has occasionally been reported in conjunction with allergic contact dermatitis in response to various allergens,2-27this association has been documented only once before in the case of epoxy resins.2 We report anothercase of EM that developed in association with acontact dermatitis to an epoxy resin and hardener.
CASE REPORT
A 46-year-old swimming pool attendant had an intensely pruritic papular eruption of 24 hours' duration onher upper limbs. For the preceding 10 days, she had beenengaged in repairing and repainting the swimming pool.Although she had attempted to protect her arms, painthad splashed onto her arms daily. The "paint" was actually a swimming pool sealant that contained 55% epoxyresin (molecular weight 380) and an epoxy hardener,isophoronediamine.
From the Department of Dermatology, The University of Sydney,Royal Prince Alfred Hospital.
Reprint requests: J. Rivers, MD, Division of Dermatology, Faculty ofMedicine, The University of British Columbia, 855 W. Tenth Ave.,Vancouver, B.C., Canada V5Z 1L7.
16/4/24613
386
The patient's medical history was unremarkable asidefrom previous eczematous reactions to several perfumesand cosmetics. There was no personal or family history ofatopy. Physical examination revealed an erythematouspapulovesicular and bullous eruption confined to themiddle part of the upper extremities (Fig. 1). A clinicaldiagnosis of acute allergic contact dermatitis was made,and the epoxy sealant was considered the causative agent.The patient was treated with Burow's solution compressesand betamethasone valerate 0.05% cream three timesdaily. She avoided the workplace, and her condition improved considerably over the next 5 days.
Nine days after the onset of the dermatitis, a neweruption developed on the patient's forearms and quicklyspread to the hands. When seen 3 days after the onset ofthe new eruption, her arms and hands were covered witherythematous papules and plaques, some with a targetlike appearance (Fig. 2). The oral and ocular mucosaewere uninvolved, and the results of the remainder of thephysical examination were normal. A diagnosis of EMwas made, The eruption resolved during the next 2 weeksand has not recurred.
Patch tests with the TRUE Test standard seriesshowed positive reactions at 48 and 96 hours to epoxyresin and fragrance mix, and a positive response to balsamof Peru at 96 hours only. Further patch testing with theepoxy resin (2% in petrolatum and I%in acetone) and the
Volume 25Number 2, Part 2August 1991 Erythema multi/orme after contact dermatitis to an epoxy sealant 387
Fig. 1. Acute allergic contact dermatitis of the arm.
Fig. 2. Erythema multiforme developing 9 days later in area of resolving dermatitis.
hardener (0.5% and 1% in petrolatum) from the sealantto which the patient had been exposed showed positiveresponses at 48, 96, and 168 hours to both substances. Inaddition, the patient was tested with a modified Trolabplastics-and-glue series that included two epoxy hardeners (triethylenetetramine, 0.5% in petrolatum, and diaminodiphenylmethane, 0.5% in petrolatum). Results fromall test sites were negative at 48 and 96 hours. She had norecurrenceofthe EM during or after the patch test period.
DISCUSSION
This case illustrates the occurrence of EM in aperson sensitized to both an epoxy resin and a hardener. To our knowledge, there has been only one
previous report of this phenomenon, and in that instance the hardener alone was thought to haveinduced the EM.2
Occasionally, EM has been reported to occur inassociation with allergic contact dermatitis to othersubstances (Table I). In those cases the EM hasranged from a mild localized exanthem3-5 to lifethreatening toxic epidermal necrolysis.6,7 As in ourpatient, the EM is often initially localized to the areaof contact dermatitis. 5, 8, 9 EM may develop withouta primary eczematous component,10, 11 concurrentlywith the acute allergic contact dermatitis12,13 or,most commonly, during resolution of acute allergic
388 Whitfeld and Rivers
Table. I. Substances reported to cause erythemamultiforme in;:l.sSociation with allergic contactdermatitis
9-ai'ornofluorene19, 20
Balsam of Peru21
Econazole22
Hair dyes I2
Isopropyl-p-phenylenediamine5
Mephenesin23
Nickell I, 14.15
Proflavine24
Promethazine21
Pyrrolnitrin2,5
Rhus16
Spray cologne7
Sulfonamide21
Terpenes26
Tropical woods6•17
Vitamin E27
contact dermatitis. 6, 12, 14 In addition, reexposure toan allergen several months after an episode of EMmay cause the reappearance of EM.15
The pathogenesis of EM in relation to allergiccontact dermatitis remains unclear, but it may represent an Arthus-type reaction. 16 A circulating an~
tibody to the absorbed allergen could result inimmune complex formation and its subsequent deposition in the microvasculature. I? However, biopsyspecimens from positivepatch testsites showchangesconsistent with a delayed type of hypersensitivityreaction.
Prevention of contact sensitization to epoxy resinsand their hardeners is important. 1 Warning labelsshould appear on epoxy resin containers, and protective clothing and gloves should be worn. Soap,waterless cleansers, and solvents have been suggested to remove epoxy resins from the skin,1.18 butoveruse of the latter agents can result in an irritantdermatitis. I It has also been suggested that the epoxy oligomers of molecular weights 340 and 624 beavoided and higher molecular weight epoxy resinsused because they are less allergenic. I
REFERENCES
1. Fisher A. Contact dermatitis. 3rd ed. Philadelphia: Lea &Febiger, 1986:549-53.
2. Chanial G, Wertheimer J, Tolot F. Dermite par inducteurepicote, a type d'erytheme polymorphe. Arch Mal Prof1961 ;22:171.
Journal of theAmerican Academy of
Dermatology
3. Fisher A. Erythema multiforme-like eruptions due to exoticwoods and ordinary plants. Part I. Cutis 1986;34:101-4.
4. Fisher AA, Bikowski 1. Allergic contact dermatitis due toa wooden cross made of Dalbergia nigra. Contact Dermatitis 1981;7:45.
5. Foussereau J, Caveler C, Protois JC, et al. A case oferythema multiforme with allergy to isopropyl-p-phenylenediamine of rubber. Contact Dermatitis 1988;18:183.
6. Holst R, Kirby J, Magnusson B. Sensitization to tropicalwoods giving erythema multiforme-like eruptions. ContactDermatitis 1976;2:295-6.
7. Thompson JA Jr, Wansker BA. A case of contact dermatitis, erythema multiforme, and toxic epidermal necrolysis.JAM ACAD DERMATOL 1981;5:666-9.
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9. Fisher AA. Erythema multiforme-like eruptions due totopical miscellaneous compounds. Part III. Cutis 1986;37:262-4.
10. Cronin E. Contact dermatitis. 2nd ed. Edin burgh: ChurchillLivingstone, 1980:29.
11. Cook LJ. Associated nickel and cobalt contact dermatitispresenting as erythema multiforme. Contact Dermatitis1982;8:280-1.
12. Tosti A, Bardazzi F, Valeri F, et al. Erythema multiformewith contact dermatitis to hair dyes. Contact Dermatitis1987;17:53-4.
13. Fisher A. Erythema multiforme-like eruptions due to topical medications. Part II. Cutis 1986;37:158-60.
14. Calnan CD. Nickel dermatitis. Br J DermatoI1956:68:22936.
IS. Friedman SJ, Perry HO. Erythema multiforme associatedwith contact dermatitis. Contact Dermatitis 1985;12:21-3.
16. Schwartz RS, Downham TF. Erythema multiforme associated with Rhus contact dermatitis. Cutis 1987;27:85-6.
17. Irvine C, Reynolds A, Finlay A. Erythema multiforme-likereaction to "rosewood." Contact Dermatitis 1988;3:224-5.
18. Cronin E. Contactdermatitis. 2nd ed. Edinburgh: ChurchillLivingstone 1980:609-13.
19. Cavernish A. A case of dermatitis from 9-bromo-f1uoreneand a peculiar reaction to a patch test. Br J Dermatol1940;52:155-64.
20. De Feo CPJ. Erythema multiforme bullosum caused by 9bromofluorene. Arch Dermatol 1966;94:545-5 J.
21. Meneghini CL, Angelini G. Secondary polymorphic eruptions in allergic contact dermatitis. Dermatologica 1981;163:63-70.
22. Valsecchi R, Tornaghi A, Ribbia G, et al. Contact dermatitis from econazole. Contact Dermatitis 1982;8:422.
23. Degreef H, Conamie A, Van Derheyden D, et al. Mephenesin contact dermatitis with erythema multiforme features.Contact Dermatitis 1984;10:220-3.
24. Goh CL. Erythema multiforme-like and purpuric eruptiondue to contact allergy to proflavine. Contact Dermatitis1987;17:53-4.
25. Meneghini CL, Angelini G. Contact dermatitis from pyrrolnitrin. Contact Dermatitis 1982;8:55-8.
26. Kirby DJ, Darley CR. Erythema multiforme associatedwith a contact dermatitis to terpenes. Contact Dermatitis1987;4:238.
27. Saperstein H, Rapaport M, Rietschel RL. Topical vitaminE as a cause of erythema multiforme-like eruptions. ArchDermatol 1984;120:906-9.