ContaCt Dermatitis Dermatologic Manifestations of Musicians: A Case Report and Review of Skin Conditions in Musicians Kathleen Vine, MD; Vincent DeLeo, MD Chronic practice and performance with a musi- musician with a unique allergic contact dermatitis cal instrument predisposes musicians to several to nickel sulfate and possibly palladium and cobalt unique and characteristic dermatoses, reflecting chloride in his tuba. We also review several der- the hours of dedication to practice to advance matologic manifestations of musical instrument– their artistic skill. This article briefly discusses related dermatitides. a case of a professional musician with a unique allergic contact dermatitis to nickel sulfate Case Report and possibly palladium and cobalt chloride in A 23-year-old man with a medical history of his tuba. We also review several dermatologic asthma as a child presented with an itchy rash on causes and manifestations of musical instrument– his bilateral arms and chest of 6 months’ duration related dermatitides. CUTIS(Figure). He was in good general health, was not tak- Cutis. 2011;87:117-121. ing any medications, and had no known medication allergies. The patient was a full-time music student who specialized in playing the tuba. His daily routine usicians, both amateur and professional, included several hours of practice with his tuba to are a unique subpopulation of dermatology perfect his art. On physical examination, the patient M patients, as their skin and mucosal surfaces exhibited well-demarcated, erythematous, scaling are exposedDo to mechanical forcesNot and chemical sub- plaques Copy on his bilateral forearms, bilateral upper stances characteristic to the instrument of their spe- arms, and chest. cialty. Often these skin findings are manifestations To rule out allergic contact dermatitis, the patient of countless hours of dedication to both practice and underwent patch testing using the standard North performance with their musical instrument. Several American Contact Dermatitis Group contact aller- dermatologic findings with names identifying the gens as well as allergens from a supplemental tray culprit instrument coupled with the characteris- containing several metals (ie, titanium, molyb- tic distribution of skin lesions have been coined, denum, chromate, gold, silver, platinum, tin, including fiddler’s neck, flautist’s chin, guitarist’s copper). It was believed that the patient was likely nipple, and harpist’s finger. The underlying process allergic to one of the metals he was exposed to triggering the skin manifestations may be related in his tuba. The patch tests results revealed that to localized pressure, friction-induced mechanical the patient had a positive reaction to nickel sul- shearing forces, allergic or irritant contact dermatitis, fate, palladium, and cobalt chloride. The tuba infections (bacterial or viral), psychological factors was made of brass, which does not contain any of (anxiety), or excessive saliva or sweat production. these metals. The possibility of the patient having This article briefly discusses a case of a professional an allergic contact dermatitis to one or several of the metal connectors and posts on the tuba, which were not brass, was then suspected. On further investiga- From the Department of Dermatology, St. Luke’s-Roosevelt Hospital tion, a dimethylglyoxime test revealed that several of Center, New York, New York. The authors report no conflict of interest. the nonbrass metal connectors and posts on the tuba Correspondence: Kathleen Vine, MD, 1090 Amsterdam Ave, Ste 11B, did in fact contain nickel. The patient was given New York, NY 10025 ([email protected]). a diagnosis of allergic contact dermatitis to nickel WWW.CUTIS.COM VOLUME 87, MARCH 2011 117 Copyright Cutis 2011. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Contact Dermatitis Table 1. Mechanisms Contributing to Dermatologic Conditions in Musicians Trauma (ie, pressure/friction) Blisters Calluses Erosions Hemorrhage Onycholysis A 23-year-old man with well-demarcated, erythematous, Allergic Contact Dermatitis scaling plaques on his bilateral forearm and bilateral upper arm, corresponding to areas of contact with Exotic woods his tuba. Metals Resins sulfate and possibly palladium and cobalt chloride Stains that he was exposed to in the nonbrass parts and Varnishes connections of his tuba. He was instructed to wear protective clothing on his arms while practicing and Irritant Contact Dermatitis performing to minimize his exposure to nickel. The Acne mechanica patient was relieved to discoverCUTIS the etiology of his Cheilitis skin lesions. Following use of a mild topical corti- costeroid and protective clothing, his skin lesions Fiddler’s neck greatly improved. The patient is considering the purchase of a new tuba made of silver. Infection Abscess Comment Bacterial infections Long-termDo practice and performance Not with a musical Copy instrument predisposes musicians to several unique Folliculitis and characteristic dermatoses reflecting the hours Herpes labialis of dedication to practice to advance their artistic Paronychia skill. The mechanisms contributing to the resulting dermatologic condition(s) include one or a combina- Psychological-Related Skin Disorders tion of the following causes: trauma, allergic contact (ie, anxiety) dermatitis, irritant contact dermatitis, infection, and psychological effects (Table 1). Hyperhidrosis In a self-reported survey of 412 musicians con- Hypersalivation 1 ducted by Gambichler et al, roughly 21% of musi- Xerostomia cians described an instrument-related skin disorder. Trauma and contact dermatitis were among the main reasons for development of instrument-related dermatoses and findings were significantly associated with both high practice frequency (P5.022) and professional musician status (P5.001).1 marks,’ which may denote the occupation of the One of the most common causes of skin conditions person.” For instance, Garrod pads are calluses often in musicians is repetitive physical trauma. According found on the dorsal proximal interphalangeal joints to Adams,2 “formation of calluses in instrumentalists of the index or middle fingers of violinists from long- may provide protection against additional trauma term skin trauma.3 Adams2 also discusses chronic and can thus be considered valid ‘occupational paronychia of pianists and harpists and onycholysis 118 CUTIS® WWW.CUTIS.COM Copyright Cutis 2011. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Contact Dermatitis with subungual hemorrhage that develops secondary to repeated nail trauma from plucking string instru- Table 2. ments. Finger callosities of harpists and drummers Common Allergens Used for Patch as well as lip callosities of clarinet, oboe, and horn 2-4 players also are fairly common among both amateur Testing in Musicians and professional musicians.2 Multiple etiologies (ie, traumatic and allergic Chromium contact mechanisms) often overlap and contribute to Cobalt instrument-associated dermatitis. Cohen3 addressed both traumatic and allergic causes of skin lesions on Colophony (rosin) the fingertips of musicians of string instruments. He Exotic woods (Makassar ebony, Cocobolo, discussed the case of a 6-year-old girl who developed African Blackwood, Brazilian and Indian a left index finger blister while learning to play the rosewood, ebony wood) harp. The blister was attributed to repeated trauma from contact with taut harp strings; however, in addi- Nickel sulfate tion to trauma-induced lesions, Cohen3 added that string instrumentalists may develop allergic contact Paraphenylenediamine dermatitis to chromium and nickel present in the Propolis (bee glue) cello, guitar, harp, sitar, and violin. Electric guitarists are exposed to chromium in the strings, bridge, frets, Wood alcohols and chromate leather guitar accessories. Cellists and violinists are exposed to nickel in the handles and clamp components of their instruments.3 Exposure to these allergic substances in addition to chronic trauma leads to development of a characteristic instrument-related dermatitis. Musicians also may developCUTIS allergic contact der- skin conditions were seen in violin and viola players. matitis to nonmetal components of their instruments Most responders reported fiddler’s neck, a localized including paraphenylenediamine, which is found in lichenification of the left side of the neck just below black-dyed stringed bows and instrument chin rests; the angle of the jaw. A combination of factors were propolis (bee glue) used in violin varnish; cane reed attributed to development of fiddler’s neck, includ- found in mouthpieces of saxophones; and rare woods ing increased pressure, friction, and occlusion on the (ie, Brazilian, Indian, and East Indian rosewood, and skin from the instrument; a poorly fitted chin rest; ebony)Do used to construct fingerboardsNot and structural poor hygiene;Copy and excessive perspiration.5 components of string instruments.3 A literature Moreno et al6 also discussed allergic and irri- search conducted by Lombardi et al4 found that the tant contact dermatitis–induced fiddler’s neck in most frequently reported allergic contact sensitizers 2 female viola players. Each musician exhibited affecting string and wind instrument players were well-demarcated, erythematous, scaling, infiltrated colophony, exotic woods (Makassar ebony found in plaques on