ALLERGENFocus Sharon E. Jacob, M.D. Claudia C. Ramirez, M.D.

that affected patients should avoid, along with tips to avoid cross-reactions and exposures.

CONTACT DERMATIDES The contact dermatides include aller- gic contact dermatitis (ACD), irritant contact dermatitis and contact urticaria. Irritant contact dermatitis, the most common form, accounts for approximately 80% of environmental- occupational based dermatoses. Contact urticaria (wheal and flare reaction) represents an IgE and mast cell-mediated immediate-type hyper- sensitivity reaction that can lead to ana- phylaxis, the foremost example of this being latex protein hypersensitivity. While this is beyond the scope of this section, we acknowledge this form of hypersensitivity due to the severity of the potential reactions and direct the reader to key sources.2,3 ACD is an important disease with high impact both in terms of patient morbidity and economics. ACD repre- sents a T-helper cell Type 1 (Th1) Focus on 2000 Allergen dependent delayed-type (Type IV) hypersensitivity reaction.The instigating exogenous antigens are primarily small lipophilic chemicals (haptens) with a of the Year: Textile molecular weight less than 500 Da. On BY SHARON E. JACOB, M.D., AND CLAUDIA C. RAMIREZ, M.D. direct antigen exposure to the skin or mucosa, an immunologic cascade is ini- tiated which includes cytokines, i.e. n 1997 the Federal Drug Administration granted an indication for the use of the interleukin 2 (IL-2) and interferon thin-layer rapid-use epicutaneous (T.R.U.E.) test as a valuable, first-line screen- gamma (IFN-γ), T cells and Langerhan Iing tool in the diagnosis of allergic contact dermatitis (ACD). Many dermatolo- cells. This complex interaction leads to gists and allergists utilize this standard tool in their practice and refer to contact der- the clinical picture of ACD. matitis referral centers when the T.R.U.E test fails to identify a relevant allergen. Specifically, the T.R.U.E. test screens for 46 distinct allergens in addition to the CLINICAL ILLUSTRATION Balsam of Peru mixture. The test is thought to adequately identify an allergen in A mechanic presented to the approximately 24.5% of patients with ACD.1 This being said, many relevant allergens University of Miami Contact Dermatitis are not detected by use of this screening tool alone and, for this reason, “Allergen Clinic for evaluation of longstanding Focus” has been expanded to cover the notorious allergens that have been desig- generalized pruritus, for which he had nated by the American Contact Dermatitis Society (ACDS) as Allergens of the Year. seen multiple dermatologists and psy- “Allergen Focus” is a column designed to concentrate on common allergens chiatrists. Of note, numerous prurigo and is intended to answer some of the most frequent questions relating to their nodules and scars were present on his origin and most common uses. Each column also highlights appropriate products arms and legs and there were distinct

28 JANUARY 2007 SKIN & AGING areas of sparing in the location of his printed silks, but to his chagrin this undergarments. measure only made silks more popular.

BIRD’S EYE VIEW ON THE HISTORY OF BLEACHING IS DISCOVERED TEXTILE DYES In 1774 the bleaching properties of The earliest written record of the use chlorine (by destroying vegetable colors) of natural dyes was found in China, was first employed by Scheele, a Swedish dated 2600 BC.4 These early records chemist. He had noted the bleaching denote the ancient Chinese methods effect on a cork in a bottle of hydrochlo- for silk using various dyes ric acid and this discovery was of enor- obtained from plants.These plants were mous commercial importance. selected and harvested by the dyer and The practical application of this new boiled in water to form the dyebath. chemical in bleaching cloth soon sup- (metal salts such as tin, planted the Old Dutch process of chrome, iron, copper, alum, etc. used to “crafting” — that is, extended sun- fix natural dyes to fabric) were also uti- bleaching by spreading the cloth upon lized to broaden the range of colors the grass. within the same dyebath base.5 This discovery was paramount to tex- In early documented European his- tile manufacturers, as the old process of tory, the Phoenicians used their bleaching consumed an entire summer renowned dyeing skills and beautifully to whiten a single piece of linen. The colored fabrics to enhance trade with new process reduced the period to a other countries. few hours.6 Colors were also used for sociological Until this time, the great subject of classification. For example, in ancient organic chemistry had remained practi- Rome yellow was only used for dyeing cally unexplored. Under Scheele’s bridal garments5 and Caesar identified direction, new methods of isolating and his status with the color purple. The THE VENETIANS studying animal and vegetable Venetians further developed the art of products were introduced, and a large FURTHER DEVELOPED dyeing with imported indigo and Brazil number of previously unknown acids wood from India.5 Of interest, the THE ART OF DYEING WITH and other organic compounds were Portuguese later used the Brazil-tree to IMPORTED INDIGO AND BRAZIL able to be reproducibly prepared.6 name the newly discovered South Prior to Scheele’s advances, older green WOOD FROM INDIA.5 American country where many of these pigments were based on copper carbonate. trees had also been found. With Scheele’s new methodologies, During the tenth century, the first THE LAW OF THE DIET he was able to create a new spectrum of syndicate of dyers was created in green based on the properties of the OF 1577 PROHIBITED THE USE Germany, the Wool Dyer’s Guild.5 The compound arsenic. discovery by Pizarro and Cortez of cot- OF INDIGO (FROM INDIA) These favored green dyes were used for ton in Central and South America IN GERMANY, coloring paper, cotton and linen.7 (c. 1519) brought to Spain brightly Interestingly, the wallpapers containing IT BEING DESCRIBED AS A printed fabrics from the natives.4 Scheele’s Green were implicated in the “PERNICIOUS AND arsenic poisoning of Napoleon Bonaparte!8 THE DYEING INDUSTRY BOOMS CORROSIVE DYE”.5 The discovery of the Americas gave a THE ERA OF SYNTHETIC DYES IS BORN great impetus to the art of dyeing, intro- In 1856 during Easter vacation from the ducing logwood, fustic and Royal College of Chemistry, an English (vegetable coloring matters). import of logwood dye in 1620 to chemistry student, William H. Perkin, Thereafter, the dyeing industry restrict commerce with Spain, who had accidentally synthesized mauve (an aniline boomed, guilds formed and regulations been importing it from the Americas,5 basic dye, derived from coal tar).4 and laws were created to protect local but dyers managed to acquire it under While attempting to create a possible industry. For example, the Law of the Diet other names. cure for malaria, he chemically synthe- of 1577 prohibited the use of indigo (from On the other hand, King James II pro- sized quinine, which when oxidized India) in Germany, it being described as a hibited exportation of undyed cloth to help yielded a beautiful violet-colored mat- “pernicious and corrosive dye”.5 reinforce the home industry for English ter with great tinctorial powers (ability Kings passed laws to protect com- dyers (over Scottish dyers) in 1688.4 to impart color on another object). merce and direct taxation. For example, Furthermore, in 1708, William III This was the beginning of the era of James I of England prohibited the signed a law banning the importation of synthetic dyestuffs and an important

JANUARY 2007 SKIN & AGING 29 AT THE NEW YORK WORLD FAIR PREMIER IN 1939, THE FIRST PAIR OF NYLON STOCKINGS, WHICH WERE THOUGHT TO HAVE BEEN DYED WITH FEDERAL DYESTUFF DISPERSE DYES, WERE FORMALLY INTRODUCED TO THE COMMERCIAL MARKET.14 WITHIN A YEAR, THE NYLON STOCKING CRAZE WAS IN FULL FORCE, WITH 64 MILLION PAIRS SOLD!

landmark in industrial chemistry. In fact, perous history of producing non-sensi- Around this time, Harvard chemist, most of the labor-intensive vegetable tizing pants. Wallace Hume Carothers at DuPont pigment processes have now been In addition, this American-based developed their most notorious innova- replaced by the various synthetic coal-tar company is notable for being one the tion, Fiber 66 (a.k.a. Nylon).13 And, colors, because they were faster coloring first and few to use American-based even though it took more than a decade and easier to apply.This allowed for mass dyes and produce their product to bring this fiber to the consumer mar- production of standardized materials and domestically, which allowed them to ket, its debut was hallmarked. At the the boom of the garment industry. maintain production despite changing New York World Fair premier in 1939, The Post Office Department, the world events. the first pair of nylon stockings, which predecessor of the United States Postal In 1914, for example, 90% of the notably are thought to have been dyed Service, was founded in 1775, but offi- dyestuffs used by North American man- with Federal Dyestuff disperse dyes, cial uniforms weren’t worn until after ufacturers were imported. This specifi- were formally introduced to the com- 1868, when Congress passed legislation cally became a problem during WWI, as mercial market.14 Within a year, the authorizing use of uniforms by letter many of the dyes came from Germany.4 nylon stocking craze was in full force, carriers. These uniforms were cadet The limited availability of dyes during with 64 million pairs sold! blue-gray with black trim.9 These dark- the War, led Congress to pass a protec- In 1942, production of nylon stock- colored uniforms, especially those made tive duty on homeland dyestuffs to ings ground to a halt, as nylon resources from synthetic or blended fabrics, were encourage domestic manufacture. were re-directed to World War II and are significant sources of exposure efforts, (e.g. parachutes, aircrafts tires to some of the most allergenic dyes.10 THE AMERICAN DYE INDUSTRY THRIVES and tent production). People began As good fortune would have it for In October 1915, the Federal Dyestuff paying almost 20 times the original the Levi Strauss Company, they select- and Chemical Corporation was incor- price on the black market.15 ed vat blue 1 (indigo) to color their porated in Delaware.12 Their strategic At the end of the war, nylons did patented and very popular copper riv- acquisition of 200 land acres in become available again, but the supply eted denim pants in 1873. Kingsport,TN, bordered by the Holston didn’t meet the demand. Thousands of The vat dyes were very water-insolu- River and accessible by the Carolina, women who learned of the sales of the ble and had to be treated in order to Clinchfield, and Ohio Railroads served stockings by word of mouth showed up secure binding to the fibers. Once as the optimal supply house for the pro- to stores to purchase the meager sup- bound, however, they were virtually cessing of U.S.-based coal tar dye raw plies, only to find that the stockings impossible to remove.11 materials: coal, sulfur and salt. were all sold out. In Pittsburgh, for This “fastness” of the dyes rendered The dye quality produced here was example, 40,000 women waited to buy the vat dyes one of the least allergenic equated to that of the best European the available 13,000 pairs of stockings.16 dye families.As a result, the Levi Strauss dyestuffs, and the American Dye Industry Scenarios such as this led to the out- Company has enjoyed a long and pros- gained a new independence.12 break of The Nylon Riots Of 1945.15

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To Come TABLE 1 which gives useful information on the usually require various “after” treatments AVOIDANCE IN TEXTILE DYE optimal fiber composition of the fabric (e.g.: copper, chrome, formaldehyde). DERMATITIS10,11,20 for dyeing and establishes the general • Vat dyes are named as such because conditions (temperature, pH,) under of original storage in wooden vats.Vat • Use lightly colored garments which the fabric accepts the dye. dyes are water insoluble, which requires • Use 100% natural fibers (cotton, linen, silk, wool) Moreover, the application groups often they be reduced in a soluble form and describe the degree of fastness (quality then re-oxided once absorbed into the • Wear loose-fitting clothing of being fixed) of the dye.18 For fiber.They are commonly used on cot- • Avoid dark linens, towels instance, disperse blue 106 is a disperse ton, flax and rayon fibers.18 • Use “safe” undergarments dye (application class) and an azo dye Since vat dyes are the least allergenic • Wash clothes before wearing (2 to 3 times) (chemical class). dyes, blue jeans colored with a vat blue Among chemical structures, azo dyes dye may be used by disperse dye- • Avoid nylon stockings, spandex and lycra are the most relevant. They comprise allergic individuals. exercise clothing around 40% of all the dyes used by the • Avoid or decrease use of hair dyes textile industry. Furthermore, they have CLINICAL PRESENTATION OF TEXTILE containing PPD a 20% cross-reactivity with para- DYE ALLERGY • Avoid henna tattooing with black henna (natural phenylenediamene, an allergen in hair The textbook presentation of dye 19 henna laced with PPD) dyes, black henna tattoos, and inks. dermatitis is in the distribution of con- They are the most common cause of tact with the inciting garment. This is allergic textile dye dermatitis.11 generally a good rule of thumb with the A description of the principal appli- areas of increased friction and sweating TABLE 2 cation classes follows: being more likely to be affected.20 UNEXPECTED EXPOSURE SOURCES OF • Disperse dyes are primarily used to When the responsible dye is in a DISPERSE DYES color , acetate fibers and nylon shirt or dress, the neck, upper trunk fibers (particularly garments and stockings). and the axillary borders are typically • Diapers These are the most common dye sen- involved, whereas the vault is spared. • Hosiery sitizers, due to their partial water solu- In trousers dermatitis, areas of • Shoulder pads bility, resulting in significant leaching increased friction are most likely • Synthetic wigs out of fabrics in the normal wear, tear affected, e.g: the anteromedial aspects • Swimsuits and wash life of the garment and ulti- of the thighs, buttocks and popliteal mately absorption by the skin. Disperse fossae tend to be affected.11,23 • Underwear blue 124 and disperse blue 106 are the Furthermore, a pearl to diagnosis is the most frequently positive dye sensitizers. clinical observation of spared areas, They are related structurally and com- corresponding to skin protected by People waiting in lines became so dis- monly used together, and thus may brassieres or undershirts. In addition, ruptive that police force was needed to present as concomitant positive reac- textile dye contact sensitivity may disperse the crowds.15 tions on patch testing.10 present as hand dermatitis in occupa- Finally,by March of 1946, DuPont was In two studies published in 2000, tionally exposed individuals.23 back in full swing with a production of 18%20 and 40%21 of the patients suspect- All this being said, dye allergy may pres- 30 million pairs a month in the U.S.A!15 ed of having a textile ACD had positive ent as a chronic generalized pruritus skin This is most notable, as to this day,nylon patch tests to textile dyes (with the dermatitis, a.k.a Dr. Kligman’s invisible stockings and hosiery represent a signifi- most common allergens being disperse dermatosis24 or as prurigo nodularis. cant source of disperse dye exposure (the blue 124, disperse blue 106 and disperse most allergenic family of dyes).16 blue 85). This finding led to the desig- TESTING FOR TEXTILE DYES SENSITIVITY nation of disperse blue dyes as the Confirming a contact sensitivity to CLASSIFICATION OF TEXTILE DYES Contact Allergen of the Year in 2000.22 dye is an algorithmic process based on More than 1,200 dye pigments are • Basic dyes represent the second clinical index of suspicion. used in the textile industry,17 making it largest group of dye allergens. These First, there are more than a thousand difficult to trace possible sensitizing have a high affinity for wool, silk and textile dyes to choose from, thus those dyes. Dyes may be classified by their cotton (natural) fibers. And, they have most encountered by the specific chemical structure including azo reasonably good wet fastness (ability to patient should be considered. (subclasses: monoazo, diazo, and triazo), stay fixed when exposed to water) for Second, one must consider the fact anthraquinone, azine, indigoide, nitro, nylon, polyester and acrylics. that a specific textile color is often the quinoline and triarylmethane. • Acidic dyes work on nylon, wool and result of a compilation mixture of sev- Dyes may also be grouped (within silk, particularly well. Interestingly, they eral dyes. For example, serisol black l their chemical class), by their appli- are also used to color foods as well.11 1944, used to dye black velvet clothes, cation, based on the procedure • Direct dyes are directly applied to contains five dispersed dyes: blue 1, 106, involved in applying dyes to the fabric, fibers, have poor wet fastness, and thus 124, red 1 and yellow 3.25

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To Come tact urticaria from natural rubber latex in healthcare Last, textile-based chemicals, other and non-healthcare workers. Contact Dermatitis. 2004; than the dyes, could be the culprit aller- 50(4): 222-4. gen and should therefore be considered 3.Warshaw E. Latex allergy. Skinmed. 2003 Nov- Dec;2(6):359-66. in the algorithm. A comprehensive 4. Druding CS. Dye History from 2600 BC to the evaluation for textile-based allergy 20th Century. http://www.straw.com/sig/dyehist.html should also include patch testing to 5. Matthews JM.. Application of Dyestuffs To Textiles, Paper, Leather and Other Materials. Available at dyes, textile fibers and resins, rubber http://www.straw.com/tan/dyeing additives, glues, cleansers and softeners. /ApplicationDyes2.html, accessed in July, 2006. As with any diagnosis of ACD, clinical 6. HS Williams. A History of Science:Volume IV,Part V, Karl Wilhelm Scheele. Available at relevance should be assigned. http://www.worldwideschool.org/library/books/sci/hi If there is a high index of suspicion story/AHistoryofScienceVolumeIV/chap7.html, for textile dyes, the dye allergens in accessed on August 2006. 7. Scheele’s Green. Available at: petrolatum or aqueous solution may be http://en.wikipedia.org/wiki/Scheele’s_Green, obtained from chemotechnique, or a accessed on August 2006. swatch extraction test may be per- 8. Ball H. Arsenic poisoning and Napoleon's death. Available at: http://www.victorianweb.org/history formed on a suspect textile. The gar- /arsenic.html, accessed on August 2006. ment in question may be soaked in sol- 9. Postal History-Clothing. Available at vents such as 4-methoxy-4-methenyl-2- http://www.usps.com/postalhistory/clothing.htm , 26 accessed in July, 2006. pentanol, and the eluate used for test- 10. Le Coz, CJ. Clothing. In Rycroft RJG, Menné T, ing along with the solvent as a control. Frosch PJ, Lepoittevin JP (eds): Textbook of Contact Dermatitis, ed 3. Berlin, Springer, 2001, pp 725-749. 11.Textile and shoe dermatitis. In: Rietschel RL, THE VALUE OF THIS PATIENT CASE Fowler JF Jr, eds. Fisher’s contact dermatitis, 5th edition. Our patient tested positive for dis- Lippincott Williams & Williams, Philadelphia, PA. perse dyes 106 and 124. Notably, these 2001; p. 279-319. 12. Federal Dyestuff and Chemical Corporation were used in his blue-green mechanic’s Kingsport,Tennessee. Available at http://www.col- overall garments. The prurigo nodules orantshistory.org/FederalDyestuff.html, accessed in corresponded to the areas where the August 2006. 13.The Lemelson Center for the Study of Invention overalls were in direct contact with the and Innovation, National Museum of American patient’s skin. With discontinuation of History, Smithsonian Institution.The Nylon Drama. the overalls and substitution with non- Accessible on the internet at: http://www.kathysnos- talgiabilia.com/lemelson.htm. dyed 100% cotton overalls, this patient’s 14. Falco M. Nylon Stockings - The History of dermatitis resolved. Nylons. Available at http://searchwarp.com/swa This patient underscores the impor- 7795.htm, accessed April 2006. 15.The History of Household Wonders-Nylon Riots. tance of appropriate allergen patch testing OUR PATIENT, Available at: http://www.historychannel.com and post patch test education. Once the WHO WAS A MECHANIC, /exhibits/hometech/nylon.html, accessed in July 2006. culprit allergen was identified, the patient 16. Nylon Riots. Available at http://en.wikipedia.org PRESENTED WITH NUMEROUS /wiki/Nylon_riots, accessed in August 2006. was counseled on exposure risks and pro- 17. Fregert S.Trulsson L. Difficulties in tracing sensitiz- vided with alternative safe products.This is PRURIGO NODULES AND SCARS ing textile dyes. Contact Dermatitis 1978;4:174. of the utmost importance, as the mainstay 18. Hatch KL, Maibach HI.Textile dye dermatitis. J Am ON HIS ARMS AND LEGS. Acad Dermatol. 1995;32:631-9. of treatment for ACD is avoidance. n 19. Seidenari S, Manzini BM, Danese P.Contact sensi- THERE WERE DISTINCT AREAS tization to textile dyes: description of 100 subjects. Sharon E. Jacob, M.D. is the Director of OF SPARING IN THE LOCATION Contact Dermatitis. 1991;24:253-8. 20. Pratt M,Taraska V.Disperse blue dyes 106 and 124 the Contact Dermatitis Clinic at the OF HIS UNDERGARMENTS. are common causes of textile dermatitis and should University of Miami. serve as screening allergens for this condition. Am J HE TESTED POSITIVE FOR Contact Dermat. 2000;11:30-41. 21. Lazarov A,Trattner A, David M, Ingber A.Textile Claudia Ramirez, M.D., is a second-year DISPERSE DYES 106 AND 124 dermatitis in Israel: a retrospective study. Am J Contact resident at the Department of Dermatology, — WHICH WERE USED IN HIS Dermat. 2000 Mar;11:26-9. University of Chile. She completed an 22. Storrs FJ. Disperse Blue Dyes. Am J Contact Dermat. BLUE-GREEN 2000;11:1-2. ACDS Mentorship in Contact Dermatitis 23. Giusti F,Mantovani L, Martella A, Seidenari S. at the University of Miami. MECHANIC’S OVERALLS. Hand dermatitis as an unsuspected presentation of tex- tile dye contact sensitivity. Contact Dermatitis. 2002;47:91-5. For more information on the educational 24. Kligman AM. Subclinical patch test reactions in programs offered by the ACDS, see contact sensitization. Jadassohn Centenary Congress, www.contactderm.org. References London, Oct 9-12,1996. 1. Saripalli YV,Achen F,Belsito DV.The detection of 25. Hausen BM. Contact allergy to disperse blue 106 and blue 124 in black “velvet” clothes. Contact DISCLOSURE: The authors have no con- clinically relevant contact allergens using a standard screening tray of twenty-three allergens. J Am Acad Dermatitis. 1993;28:169-73. flict of interest with any subject matter dis- Dermatol. 2003 July;49(1):65-9. 26. Clothing and textiles. In: Cronin E, ed. Contact cussed in this month’s column. 2.Valks R, Conde-Salazar L, Cuevas M. Allergic con- Dermatitis. Churchill Livingstone, New York,NY.1980; p.36-92.

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