AIRBORNE-CONTACT DERMATITIS OF NON-PLANT ORIGIN: AN OVERVIEW

Abstract

Airborne-contact dermatitis (ABCD) represents a unique type of contact dermatitis originating from dust, sprays, pollens or volatile chemicals by airborne fumes or particles without directly touching the allergen. ABCD in Indian patients has been attributed exclusively by pollens of the plants like Parthenium hysterophorus, etc., but in recent years the above scenario has been changing rapidly in urban and semiurban perspective especially in developing countries. ABCD has been reported worldwide due to various type of nonplant allergens and their clinical feature are sometimes distinctive. Preventive aspect has been attempted by introduction of different chemicals of less allergic potential.

Introduction

Airborne-contact dermatitis (ABCD) denotes an unique type of contact dermatitis originating from dust, sprays, pollens or volatile chemicals by airborne fumes or particles without directly handling this allergen.[1] This form of dermatitis commonly involves face, neck, v-area of chest and eyelids. Exposed as well as nonexposed skin can be affected. Axillae and waist lines can also be the target of this disease. This form of dermatitis can sometimes also be generalized.[2,3]

Airborne dermatoses often cause diagnostic problems and create a puzzle not only to the patient but also to the doctor.[4] The incidence of airborne dermatoses has increased considerably in recent years.[5]

As per previous reports[6,7] ABCD in Indian patients has been attributed exclusively by pollens of the plants like Parthenium hysterophorus, Xanthium strumarium, Chrysanthemum coronarium, Helianthus annus (sunflower) and Dahlia pimrata.

In recent years the above scenario has been changing rapidly in urban and semi\urban perspective especially in developing countries.[8] Organic compounds that are used or generated anthropogenically in large quantities in the cities can be the source of human contact allergens.[9]

Nonplant etiology

ABCD[10] may be caused by: a) cement and wood dust, causing irritant as well as sensitization reactions b) fibrous materials like grain dust, glass fiber and rock wool causing mechanical dermatitis c) aerosols of mineral oils inducing irritant reaction d) pollens or dust containing particles from plants such as Parthenium hysterophorus, ragweed or certain types of woods or medicaments by the process of delayed hypersensitivity.

In a study by Ghosh[8] among 64 patients(36 M, 28 F) age ranging from 10 to 67 years suffering from ABCD in urban perspective 64.1% (n=41) had urban residency whereas 35.9% (n= 23) had semiurban. Pattern of allergens contributory to ABCD detected in the study were as follows: potassium dichromate 39.7% (n=25), fragrance mix 28.1% (n=18), epoxy resin 26.6% (n=17), colophony 17.8% (n=12), formaldehyde 13.2% (n=7) and parthenium 9.4% (n=6). Cement, perfumes or deodorants, volatile paints and synthetic glues have become commonest allergens contributing to ABCD in urban and semiurban areas.[8]

In urban and semiurban area of India incidence of ABCD due to parthenium has been gradually become lowered as compared to previous reports[6,7] due to rapid urbanization and reduction in open land required for the growth of these plants.[8]

ABCD to cement (chromate) has been already published by different workers.[11–14] Extensive housing development projects and construction works in recent years in developing country like India have caused very high allergic sensitivity rate to potassium dichromate contained in the cement. Even by ‘non-occupational’ contact housewives are also commonly involved.[8,15] In China a high proportion (19%) of patch test positive reaction to chromate has been reported possibly reflecting the exposure to cement due to China's very active construction programs.[13]

Fragrance allergy leading to ABCD has been reported by many authors.[16–18] In the recent years increased self-image and beauty consciousness due to media and film influence has contributed to the increased use of perfume, deodorants, room fresheners among urban and semiurban people.[8]

Increased incidence of epoxy resins and colophony allergy has been caused by increased household decoration, newer occupations and various newer personal hobbies. ABCD originated by paints, epoxy resin, colophony and formaldehyde has been reported by some previous workers.[19–22] Epoxy resin systems are important sensitizers and often responsible for occupational airborne dermatitis. Vitiligo, both to epoxy resins and reactive diluents have been reported.[23]

Airborne dermatitis resulted from exposure to metaproterenol (Alupent) used by respiratory therapist to treat patients.[24]

Airborne dermatitis and asthma reported in a psyllium factory worker. Psyllium, primarily used as a stool softener, comes from the seed of the genus Plantago.[25]

Clinical Aspects

ABCD appears on areas of the skin where the dust or fibers can be trapped, e.g., on the eyelids, neck (under a shirt collar), forearms (under cuffs) or lower legs (inside trouser legs).[26]

Contact dermatitis from prolonged, repeated exposure to relatively small quantities of airborne allergens, such as pollens, dusts and vapors, produces diffuse, dry and lichenified eruptions with vesiculations. The exposed portions of the body as well as wrinkles and folds are most markedly involved.[27]

Household sprays, insecticides, animal hairs and occupational volatile chemicals can produce eyelid dermatitis.[27]

Benzoyl peroxide has been used to bleach candles white. Intense exposure to burning candles in a church has caused facial dermatitis.[28]

Chronic ABCD occasionally may simulate photocontact dermatitis. Even sometimes a combination of these two forms of dermatitis may also be seen.[29]

The handling of large amounts of carbonless copy paper and laser printed paper can cause irritation of the mucous membrane of the nose and eyes and pruritus on exposed skin.[10]

Various cutaneous symptoms, including pruritus and paresthesia, have been described after long-term exposure to computer screens, but few patients exhibit diagnostic skin lesions.[30]

A chronic eczema on exposed areas is usually not due to photosensitivity but is the result of ABCD. ABCD characteristically involves the upper eyelids and extends below the chin and behind the ears, but does not always do so. A further source of diagnostic confusion is that ACD can be photoexacerbated.[31]

Airborne and photoallergic contact dermatitis have a similar clinical expression –acute or subacute dermatitis on exposed areas. They differ from toxic dermatitis because they have a more polymorphic clinical picture, not precisely limited to exposed areas. However, as stated with irritant type, there are some locations spared in photodermatitis, which may be affected in airborne type, such as upper eyelids, under the chin, behind the ears, the back of neck, or even the scalp.[32]

Airborne irritant contact dermatitis predominates in exposed areas, but, as opposed to photosensitive dermatitis it does not spare areas such as the upper eyelids, retroauricular folds or submental area.[32]

ABCD may result from exposure to sawdust—even associated with leukoderma,[33] cutting oils[34] and even jewellery[35]

The airborne MCI/MI (Chloromethyl- and Methylisothiazolinone) dermatitis may appear in the face of sensitized individuals who stay in newly painted rooms, and the diagnosis is easily missed unless specifically considered.[36]

Dental practitioners and their associates may develop dermatitis on face, eyelids and other exposed skin areas by airborne contact.[37]

Airborne contact urticaria can be associated with rhinitis, conjunctivitis or asthma. These have been largely reported as an occupational problem in health workers with hypersensitivity to latex proteins from rubber gloves made with natural latex (usually derived from Hevea brasiliensis Muell. Arg., family Euphorbiaceae). Airborne transmission of latex allergens is enhanced by their adsorption onto the cornstarch (derived from Zea mays L., family Gramineae) used as glove powder.[38]

Airborne contact urticaria reported in a warehouseman resulted from exposure to dust derived from cinchona bark (Cinchona spp., family Rubiaceae).[39]

Preventive Management

The allergic capacity of chromium salts is really intriguing and deserves special mention. The sensitizing potential of trivalent chromium salts remains high as they form complexes with proteins in the upper layers of the skin. The trivalent salts are, however, not common sensitizers due to their low penetration into the skin. In contrast hexavalent chromium salts, a nonsensitizer by nature, can penetrate the skin and could be reduced to trivalent salts subsequently and the latter may lead to sensitization by acting as hapten. In some countries ferrous sulphate is added to cement to transform hexavalent chromates into trivalent ones to reduce the incidence of sensitization. Otherwise a special type of cement namely Portland blast furnace slag cement (PBFSC) of low hexavalent chromate content may be used to reduce cement sensitivity.[40]