A 50-year-old woman is seen in the allergy clinic for rash.
For the last year, she reported a rash (fine bumps) when wearing "permanent press" clothing in high temperature environment. She works in a warehouse. The rash is less pronounced in lower temps. No rash with cotton clothing. She has to wear protective clothes at to work as part of the work rules. The rash is sometimes itchy but does not last longer than a day. No hives, angioedema or systemic symptoms. She thinks the rash is caused by polyesther.
What is the most likely diagnosis?
Clothing Dermatitis. Differential diagnosis includes miliaria rubra (heat rash), or contact dermatitis.
Polyesther is not a common cause of contact dermatitis. In fact, it is so uncommon for polyesther to cause allergy that is used as a negative control in the TRUE patch test (the test base is made of polyesther). Patients who report polyesther allergy are typically allergic to the dyes used to color the material.
What happened?
The most likely diagnosis is miliaria rubra (heat rash).
Regarding dermatitis, see instructions below. For mild exacerbations, use topical hydrocortisone 1% for up to 1-3 weeks. For more severe exacerbations, I recommended topical triamcinolone 0.1% for up to 1-2 weeks.
TRUE patch was ordered to rule out contact dermatitis.
Any patient information handouts?
Yes, see the Educational Handout for Patients with Textile Finish/Formaldehyde Resin Allergic Contact Dermatitis by University Hospitals Health System University Hospitals of Cleveland.
For Textile Finish/Formaldehyde Resin Allergic Dermatitis, it is recommended:
1. WEAR clothes with labels that say:
- 100% silk
- 100% linen (if it wrinkles easily)
- 100% polyester
- 100% acrylic
- 100% nylon
- spandex
- flannel (if soft)
- denim (jeans)
- wool (may cause irritation)
2. DO NOT WEAR clothes with labels that say:
- Permanent press
- Wrinkle resistant
- Color-fast
- Stain-resistant
- "Blends" (including rayon, polyester-cotton)
- corduroy or shrink-proof wool
3. It may be helpful to remember this:
-Soft, easily wrinkled fabrics = SAFE
-Heavy, stiff fabrics = UNSAFE
4. Things that cause rubbing, pressure or sweating could cause your condition to flare. So, loose fitting clothes are helpful and you may be able to tolerate more kinds of fabrics in cooler temperatures than you can in higher temperatures (in the summer).
5. Start by READING THE LABELS IN YOUR CLOSET. Put to one side all the clothes that are safe to wear. See 1 above. Wear only these clothes for one month.
6. If you need to buy new clothes, remember that clothing made in Japan may be the safest choice for imported textiles. Japan enforces the strictest standards for formaldehyde release from the textile finishes. Also, the companies that market in or out of Japan meet acceptable standards and are generally safe.
7. Clothing made by GAP, OLD NAVY, BANANA REPUBLIC, LIZ CLAIBORNE, EDDIE BAUER, CUDDL DUDS, and LEVI STRAUSSS is recommended. Also, products from VERMONT COUNTRY STORE and AVANTAL U.S. claim to use very low amounts of formaldehyde resins in finishing their textiles (amounts below the U.S. industry standard.
8. Do note that washing clothing will not significantly reduce the levels of formaldehyde resins in your clothing necessary for an allergic reaction. Use of dry cleaning fluids and spray starch are okay. Washing your family's clothes is okay if you do not develop fingertip dermatitis.
9. If exposure to formaldehyde resins in your clothes cannot be avoided, then you may consider wearing undergarments to protect your skin. Silk is an acceptable choice for an undergarment.
10. If you have been told that you are also allergic to formaldehyde preservatives, you also need to check your personal care products such as cosmetic creams, medication, nail products and shampoo. The Contact Allergen Replacement Database (CARD) printout provided by your doctor can be your shopping list for products that do not contain the allergens.
11. You may also come in contact with fabrics containing formaldehyde in other than clothes, such as bed sheets, upholstered furniture and craft fabrics. Use of knitting yarns and needlework floss is acceptable.
12. Keep in mind that you MUST AVOID FORMALDEHYDE RESINS AT ALL TIMES. Even exposure once a month would be enough to cause a rash to continue. "Dress clothes" only worn on weekends is enough to maintain your dermatitis.
13. Also, realize that since you have had an allergic reaction, now even low levels of formaldehyde may be enough to cause flares. Try to add only one new product per week. If you have a flare after a new product, STOP FOR 3 WEEKS until clear.
14. Remember this is a difficult process. Be patient and call with questions.
What are the panel allergens in the patch test?
Panel Allergens - T.R.U.E. TEST is used as a patch test for contact allergies to the common allergens shown below. For more information about where each allergen can be found and how to avoid it, check the manufacturer's website: http://www.truetest.com/panelallergens.aspx
Panel 1.2
Nickel sulfate
Wool alcohols
Neomycin sulfate
Potassium dichromate
Caine mix
Fragrance mix
Colophony
Paraben mix
Negative control
Balsam of Peru
Ethylenediamine dihydrochloride
Cobalt Dichloride
Panel 2.2
p-tert-Butylphenol formaldehyde resin
Epoxy resin
Carba mix
Black rubber mix
Cl+ Me- isothiazolinone (MCI/MI)
Quaternium-15
Methyldibromo glutaronitrile
p-Phenylenediamine
Formaldehyde
Mercapto mix
Thimerosal
Thiuram mix
Panel 3.2
Diazolidinyl urea
Quinoline mix
Tixocortol-21-pivalate
Gold sodium thiosulfate
Imidazolidinyl urea
Budesonide
Hydrocortizone-17-butyrate
Mercaptobenzothiazole
Bacitracin
Parthenolide
Disperse blue 106
2-Bromo-2-nitropropane-1,3-diol (Bronopol)
References:
Diagnosis and Treatment of Dermatitis Due to Formaldehyde Resins in Clothing - Medscape, 2004. http://buff.ly/1DTrISb
Contact Dermatitis | Symptoms and Treatment | ACAAI http://buff.ly/1tAFyWj
Clothing dermatitis - WA.org http://buff.ly/1tAFB49
Textile contact dermatitis. DermNet NZ http://buff.ly/1tAFCp0
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