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Systemic Contact Dermatitis 16 Niels K 16_295_308* 05.11.2005 10:27 Uhr Seite 295 Chapter 16 Systemic Contact Dermatitis 16 Niels K. Veien, Torkil Menné Contents of stiffness, burning, heat and itching in the part 16.1 Introduction . 295 where it commences, most frequently the upper and inner surface of the thighs and about the scrotum in 16.2 Clinical Features . 295 men, but sometimes it appears first in the groin, axil- 16.3 Mechanism . 297 lae or in the bends of the arms, on the wrists and 16.4 Medicaments . 298 hands or on the neck.” In the 20th century, the systemic spread of nickel 16.5 Metals . 298 dermatitis to areas other than the sites of contact was 16.5.1 Nickel . 298 described by Schittenhelm and Stockinger in Kiel in 16.5.2 Chromium and Cobalt . 300 1925 [3]. After patch testing nickel-sensitive workers 16.5.3 Gold . 301 16.5.4 Mercury . 301 with nickel sulfate, they observed dermatitis and flares in former areas of contact dermatitis even 16.6 Other Contact Allergens . 301 when there was no current contact with nickel items 16.7 Risk-Assessment-Oriented Studies . 302 in these areas. The literature on systemic contact der- 16.8 Diagnosis . 303 matitis is now comprehensive. Reviews include Cro- nin [4], Fisher [5], Menné et al. [6] and Veien et al. [7]. 16.9 Case Reports . 303 References . 305 Core Message í Systemic contact dermatitis may occur after the systemic administration of a 16.1 Introduction hapten in persons with contact sensitivity to the hapten. Systemic contact dermatitis Systemic contact dermatitis may occur in persons may be indistinguishable from other types with contact sensitivity when these persons are ex- of contact dermatitis. posed to the hapten orally, transcutaneously, intrave- nously or by inhalation. The entity can present with clinically characteristic features or be clinically in- distinguishable from other types of contact derma- titis. Contact sensitization to ubiquitous haptens is 16.2 Clinical Features common. In a Danish population-based study, 15.2% reacted to one or more of the haptens in the Euro- The clinical features of systemic contact dermatitis pean standard patch test series [1]. Many of these are summarized in Table 1. haptens can be presented to the immune system by a A causal relationship between systemic adminis- systemic route. The total number of individuals at tration of the hapten and these clinical manifesta- risk of developing systemic contact dermatitis is tions is most easily documented in persons sensi- therefore large. tized to medicaments.For such persons,the exposure The first description of systemic contact derma- to the hapten can be controlled. This is less feasible titis can probably be ascribed to the pioneering Brit- for persons sensitized to, for example, ubiquitous ish dermatologist, Thomas Bateman [2]. His descrip- metals. tion of the mercury dermatitis called eczema rubrum Flare-up reactions at former sites of dermatitis or is similar to what we today describe as the “baboon previously positive patch test sites raise a suspicion syndrome”: “Eczema rubrum is preceded by a sense of systemic contact dermatitis [8–10]. A flare at a 16_295_308* 05.11.2005 10:27 Uhr Seite 296 296 Niels K.Veien,Torkil Menné Table 1. Clinical aspects of systemic contact dermatitis appearance of chronic hand eczema if frequent vesic- ular eruptions occur, and the dermatitis does not Dermatitis in areas Flare-up of previous dermatitis of previous exposure clear completely between eruptions. Crops of vesicles Flare-up of previously positive may be seen at the periphery of an area of dermatitis. patch test sites This type of hand eczema may be a symptom of Dermatitis on previously Vesicular hand eczema systemic contact dermatitis. unaffected skin Flexural dermatitis A flare-up of dermatitis in the elbow and the knee Baboon syndrome flexures is a common symptom of systemic contact Maculopapular rash dermatitis. Such flares are difficult to distinguish (toxicoderma) from the early lesions of atopic dermatitis [14]. Vasculitis-like lesions The “baboon syndrome” (Fig. 2) [15] is a charac- General symptoms Headache teristic, although rare, clinical manifestation of Malaise systemic contact dermatitis. It is a well-demarcated eruption on the buttocks, in the genital area and in a Arthralgia V-shape on the inner thighs, of a color ranging from Diarrhea and vomiting dark-violet to pink. It may occupy the whole area or Fever only part of it. Nakayama et al. [16] described the same clinical features as mercury exanthema.In mer- cury-sensitive patients, the baboon syndrome may previously positive patch test site following ingestion also be seen in connection with acute generalized ex- of the hapten is a fascinating and specific sign of anthematous pustulosis [17]. systemic contact dermatitis. Such reactions may be A nonspecific, maculopapular rash (toxicoderma) caused by medicaments and are also sometimes seen is often seen in systemic contact dermatitis. General in experimental oral provocation studies. This symp- symptoms such as headache and malaise are rarely tom is hapten specific and can be seen years after the seen in sensitized individuals following oral provo- original patch testing [11, 12]. cation with gold and medicaments. In patients sensi- Vesicular hand eczema (Fig. 1) [13] is a pruritic tive to neomycin [8] and chromate [18], oral provoca- eruption on the palms, volar aspects and sides of the tion with the hapten can cause nausea, vomiting, and fingers, around the nails and occasionally on the diarrhea. A few patients have complained of arthral- plantar aspects of the feet with deep-seated vesicles gia. Systemic administration of gold to gold-sensi- and sparse or no erythema. If the periungual area is tized individuals has led to toxicoderma and slight involved, transverse ridging of the fingernails can be fever [19, 20]. Malaise, leukocytosis, and pyrexia have a consequence. Vesicular hand eczema is a common also been seen in patients with systemic contact der- disease,often with unknown etiology.It may have the matitis from mercury [21]. 16 Fig. 1. Vesicular eruption in the thenar region after oral chal- lenge with 4 mg nickel 16_295_308* 05.11.2005 10:27 Uhr Seite 297 Systemic Contact Dermatitis Chapter 16 297 suggests that circulating immune complexes play a role [7]. Flares at sites of previous dermatitis or previously positive patch test sites are probably caused by spe- cifically sensitized T-cells, either resting at the site or homing to the area after specific hapten exposure [12, 22, 23]. A reduction of CD4+ cells, CD4+ CD45Ro+ and CD8+ cells was seen in the peripheral blood of nickel-sensitive women after oral challenge with nickel. The oral challenge induced maturation of naive T-cells into memory cells. Memory cells were seen particularly in the intestinal mucosa [24]. A reduction of the number of CLA+ CD45Ro+ CD3+ and CLA+ CD45Ro+ CD8+ but not CLA+ CD45Ro+ CD4+ cells was seen in the peripheral blood of nickel-sensitive patients after oral challenge with nickel [25]. CD4+ T-cell clones reacted to cobalt but not to nickel in a patient following the removal of a cobalt- containing metal joint prosthesis [26]. Flexural eczema, vesicular hand eczema, the ba- boon syndrome, and toxicoderma may be caused by nonspecific cytokine release [27]. Möller et al. [19] recorded a significant increase of cytokines such as IL-ra, interferon-γ (IFN-γ), tumor necrosis factor α (TNF-α), type-1 TNFα receptor (TNF-R1), IL-6 and acute phase reactants during systemic contact reac- tions to gold. In a patient with systemic contact der- matitis from prednisolone, elevated serum values of Fig. 2. Baboon syndrome in a patient sensitive to balsam of Pe- the IL-5, IL-6, and IL-10 were seen [28]. ru after the use of suppositories that contained balsam of Peru Antigen-specific tolerance to nickel has been demonstrated in guinea pigs [29]. Flares of derma- titis are frequently seen in clinical hyposensitization experiments when the hapten is given orally. Of 20 Core Message Parthenium-sensitive patients, 6 had to stop oral hy- posensitization therapy due to aggravation of their dermatitis [30]. í The clinical features of systemic contact dermatitis include flare-up of previous dermatitis or previously positive patch test sites, vesicular palmar and/or plantar Core Message dermatitis, flexural dermatitis, and the baboon syndrome. í The mechanism of systemic contact der- matitis includes both specifically sensitized T-cells and nonspecific cytokine release. The latter could explain nonspecific symp- toms such as flexural dermatitis and the 16.3 Mechanism baboon syndrome. Based on human and animal experiments, it appears that both the humoral and the cellular immune sys- tems are activated in systemic contact dermatitis. The histopathology of flare-up reactions is similar to that seen in ordinary contact dermatitis,while the ac- cumulation of neutrophils in the baboon syndrome 16_295_308* 05.11.2005 10:27 Uhr Seite 298 298 Niels K.Veien,Torkil Menné 16.4 Medicaments Core Message Most diagnosed cases of systemic contact dermatitis í Drugs used both topically and systemically have occurred as a consequence of systemic exposure may cause systemic contact dermatitis to medicaments in specifically contact-sensitized in- either as a flare-up of dermatitis in previ- dividuals.Such cases were common in the early era of ous areas of dermatitis or as a widespread the use of antibiotics, when drugs such as streptomy- rash. cin and penicillin were given both topically and systemically. Medicaments known to cause systemic contact dermatitis are summarized in Chap.35 and elsewhere [7]. Many case reports are available, and while the list 16.5 Metals illustrates the wide range of possibilities, it is not complete. Any drug is probably capable of causing systemic contact dermatitis if cutaneous sensitiza- 16.5.1 Nickel tion precedes systemic exposure.
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