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Skin problems associated with textiles
Abstract
Clothing is composed by textile fibers, coupling and fixer agents, finish products, dyes and complements. Contact dermatitis is produced by the contact between these clothing components and the skin. Two types of textile contact dermatitis have been reported; irritant and allergic, being irritant contact dermatitis more frequent than allergic. Dyes are the main cause of allergic contact dermatitis. Disperse dyes are the most frequent sensitizers among textile dyes, followed by the reactive dyes. Acid, direct and basic dyes are less common sensitizers. The use of the different dyes depends on the kind of fiber used in the fabric. Disperse dyes are more common in industrialized countries, because people from these countries usually wear clothes with nylon and polyester/cotton fibers. Finish products are the second most common textile sensitizers; they are used in natural and mixed fibers. Resins belong to this group, being Kaurit and Fix the most allergenic formaldehyde resins. Exact incidence of textile dermatitis is unknown because of the lack of controlled epidemiological studies. Textile dye sensitization has an estimated incidence rate from 1.4% to 5.8%. Women have a greater prevalence of allergic reactions to textile dyes and resins than men; this may be due to the use of tighter fitting synthetic and dark-colored clothing. Contact textile dermatitis is increasing, probably as a result of the wide use of new dyes in clothes production. Many clinical manifestations of textile dermatitis have been described. Usually, patients are affected by an acute or chronic dermatitis, of localized or generalized distribution of lesions. Unusual forms can also be seen: purpuric lesions, hyperpigmented patches, papular rash, papulopustular lesions, urticaria, erythema multiforme-like lesions, nummular-like lesions, lichenification and erythroderma. Topical or systemic corticosteroids can be used in the treatment of textile contact dermatitis. In addition, the patient should avoid the offending allergen or irritant source, wearing 100% natural based fabrics, use loose fitting clothing, and avoid synthetic spandex, lycra, acetate, polyester fibers and nylon. It is recommended washing clothes three times before wearing them the first time. Contact textile dermatitis may be undiagnosed because the atypical clinical manifestations do not give rise to suspicion of textile dermatitis. Clinical history, clinical findings and patch test are the best elements in the diagnosis. Therefore, the physician should suspect a contact dermatitis in patients showing suggestive clinical signs, which might lead to an early diagnosis and appropriate treatment.
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Atopic dermatitis (AD) is a chronic relapsing inflammatory skin disease which usually starts during the first years of life. In the management of AD, the correct approach requires a combination of multiple treatments to identify and eliminate trigger factors, and to improve the alteration of the skin barrier. In this article we try to explain the importance of skin care in the management of AD in relation to the use of textiles: they may be useful to improve disrupted skin but they are also a possible cause of triggering or worsening the lesions. Garments are in direct contact with the skin all day long, and for this reason it is important to carefully choose suitable fabrics in atopic subjects who have disrupted skin. Owing to their hygienic properties fabrics produced from natural fibres are preferential. Wool fibres are frequently used in human clothes but are irritant in direct contact with the skin. Wool fibre has frequently been shown to be irritant to the skin of atopic patients, and for this reason wool intolerance was included as a minor criterion in the diagnostic criteria of AD by Hanifin and Rajka in 1980. Cotton is the most commonly used textile for patients with AD; it has wide acceptability as clothing material because of its natural abundance and inherent properties like good folding endurance, better conduction of heat, easy dyeability and excellent moisture absorption. Silk fabrics help to maintain the body temperature by reducing the excessive sweating and moisture loss that can worsen xerosis. However, the type of silk fabric generally used for clothes is not particularly useful in the care and dressing of children with AD since it reduces transpiration and may cause discomfort when in direct contact with the skin. A new type of silk fabric made of transpiring and slightly elastic woven silk is now commercially available (Microair Dermasilk) and may be used for the skin care of children with AD. The presence of increased bacterial colonization has been demonstrated in patients with AD. Such colonization has been included in the group of trigger factors for eczema in AD. Silver products have recently been demonstrated to offer two advantages in the control of bacterial infections. Textiles may be used not only for clothes, but also to prevent dust mite sensitization in atopic patients. A marked clinical improvement of AD was observed in a group of adults and children with positive skin tests (not necessarily towards mites), after an intensive eradication programme for mite allergens. Skin treatment with acaricide and house dust mite control measures can decrease AD symptoms. Different textiles have various potential worsening links with allergies: e.g. clothing has been proposed as an additional source of exposure to mite and cat allergens. On the other hand, special textiles can be used to prevent dust mite sensitization.
The "gold standard" for diagnosing allergic contact dermatitis is patch testing. Previous studies have not adequately addressed the validity and usefulness of the North American Contact Dermatitis Group (NACDG) Standard 65-allergen series alone as a screening tool in the evaluation of contact dermatitis.
The purpose of this study is to examine the usefulness of the NACDG series of 65 allergens as an exclusive screening method in the diagnosis of contact allergy.
A retrospective chart review of 794 patients referred for patch testing with the NACDG Screening Series with or without additional allergens was performed to determine the number of positive patch-test results. The study groups were analyzed to identify whether the positive reactions were to allergens in the NACDG Standard Series or to allergens in the supplementary group.
Of the 794 patients patch-tested between July 1, 2004, and July 1, 2006, 590 (74.31%) had a positive reaction to either an NACDG patch-tested allergen or a supplemental allergen; 386 (65.42%) patients testing positive for an allergen were positive to an NACDG allergen only, and 534 (90.51%) of the total positive reactors were positive for at least one NACDG test allergen.
As a screening tool, the NACDG Standard Series is substantially more efficacious than are more limited standard series when used exclusively in the evaluation of patients with allergic contact dermatitis. More extensive testing, including testing with suspected supplementary allergens determined by thorough history and physical examination, can improve upon the NACDG series as a means to investigate the full causes of contact dermatitis in any individual patient.
This is the second part of a review article on formaldehyde-releasers used as durable press chemical finishes (DPCF) in textiles. The early finishes contained large amounts of free formaldehyde, which led to many cases of allergic contact dermatitis to clothes in the 1950s and 1960s. Currently, most finishes are based on modified dimethylol dihydroxyethyleneurea, which releases less formaldehyde. Nevertheless, recent studies in the United States and Israel have identified patients reacting to DPCF, considered to have allergic contact reactions to clothes, either from formaldehyde released by the DPCF therein or from the DPCF per se (in patients negative to formaldehyde). However, all studies had some weaknesses in design or interpretation and in not a single case has the clinical relevance been proven. The amount of free formaldehyde in most garments will likely be below the threshold for the elicitation of dermatitis for all but the most sensitive patients. The amount of free cyclized urea DPCF in clothes is unlikely to be high enough to cause sensitization. Patch test reactions to formaldehyde-releasing DPCF will in most cases represent a reaction to formaldehyde released from the test material.
Although the exact incidence of textile contact dermatitis is unknown, recent studies demonstrate that contact dermatitis produced by allergic or irritant reactions to clothing not only is more frequent than previously thought but also increasing. The clinical features of contact dermatitis (CD) caused by clothing may resemble common allergic contact dermatitis or may have atypical presentations. We report on several cases of clothing-induced contact dermatitis with atypical clinical presentations.
17 male subjects are described with foot dermatitis in association with positive patch test reactions to the textile dye Basic Red 46. Chromatographic analysis of the socks of 2 affected patients confirmed the presence of Basic Red 46. Withdrawal of the acrylic blend socks suspected of having been dyed with Basic Red 46 resulted in the improvement of symptoms in 12 of 17 patients (70.6%). However, equivocal or negative patch test results to their own socks were frequently noted in those patients. A highly significant association between the presence of foot dermatitis and a positive Basic Red 46 patch test reaction was noted in 555 patients from a patch test clinic population (P < 0.001). The prevalence of positive patch test reactions to Basic Red 46 was 1.2%. We suggest that patients with foot dermatitis be routinely patch tested for textile dyes. In particular, testing with Basic Red 46 should be considered in those with a history of use of dark-coloured acrylic and/or acrylic blend socks.
Contact allergy to disperse dyes in textiles is documented in prevalence studies from southern Europe. To evaluate the prevalence of allergic patch test reactions to different textile dyes in southern Sweden, and to look at the sites of dermatitis in individuals hypersensitive to textile dyes, we retrospectively investigated 3325 consecutively patch-tested patients. They had all been patch tested with the standard test series supplemented with a textile dye mix (TDM) consisting of 8 disperse dyes, i.e. Disperse (D) Blue 35, 106 and 124, D Yellow 3, D Orange 1 and 3 and D Red 1 and 17. All but 3 of the TDM-positive patients were additionally tested with the separate dyes included in the mix. The frequency of contact allergy to TDM was 1.5%, which is comparable with studies from southern Europe. The most common dye allergen was D Orange 1. The high prevalence of allergic reactions to D Orange 1 was unexpected, whereas test reactions to D Blue 106 and 124 were lower than expected from other studies. Compared to all tested patients, the TDM-positive patients more often had dermatitis on their arms, face, neck and axillary folds, and women also had a higher frequency of hand dermatitis.
The prevalence of contact allergy to fragrance ingredients increased during the last part of the 20th century with the consequence that a substantial number of individuals are at risk of experiencing allergic contact dermatitis (ACD) if they have a sufficient degree of skin exposure to the chemical to which they have become sensitized. Such exposure does not necessarily have to arise from the type of source that originally induced the sensitization. A number of sources of exposure are clearly associated with risk of elicitation of ACD, but the role of fragrance deposited on fabrics, for example as a result of laundry processes, also can be questioned. In this article, firstly, the risk of the induction of fragrance-related ACD from exposure to fragrance via fabric is considered. Using a quantitative risk-assessment approach, the risk appears to be extremely low. The possibility that fragrance residues on laundered fabrics might elicit reactions in those already sensitized by a different route is also discussed. Clinically, clothing pattern dermatitis associated with fragrance allergy is almost never observed, although this could be investigated clinically by exposing sensitized individuals to the relevant fragrance allergen.
Chlorothalonil (tetrachloro-1,3-benzenedicarbonitrile, CAS 1897-45-6) is a pesticide that has been on the market for many years. It is used as a fungicide in agriculture, horticulture, and floriculture; as a wood preservative; and in paint. We report an epidemic of airborne irritant contact dermatitis, conjunctivitis, and upper airway complaints among seamstresses in a Portuguese trailer tent factory, which we attribute to chlorothalonil. All exposed workers had work-related skin symptoms. After patch testing, we showed that none of these were of allergic origin. Instead of allergic reactions, we noticed a delayed type of irritation after 72 hr to chlorothalonil and to the textile extracts containing high concentrations of chlorothalonil. Although allergic and irritant contact dermatitis from chlorothalonil has been described before, this is, as far as we know, the first time that a delayed type of dermatitis, conjunctivitis, and upper airway irritation after exposure to chlorothalonil in tent-cloth is described.
The type of fabric worn by sufferers from atopic dermatitis should not exacerbate the condition but, if possible, help to control it. Synthetic fabrics and wool tend to produce itching and irritate the skin. Cotton is traditionally recommended but its structure contains short fibres which expand and contract, causing a rubbing movement that can irritate delicate skin. Dyes used in cotton garments can increase the potential of a sensitivity reaction. Cotton is also prone to bacterial and fungal attack. Silk garments are often closely woven which impedes the flow of air, and some people are allergic to the sericin protein in silk. Published studies suggest that a specially treated silk material (DermaSilk), which is loosely knitted, has had the sericin removed and has a microbial agent (AEM 5772/5) permanently bonded to it, is well tolerated and has beneficial effects on the skin of children and adults with atopic dermatitis. Atopic dermatitis often becomes infected, commonly with Staphylococcus aureus. Some studies have investigated the use of clothing materials impregnated with substances such as silver, which has antimicrobial properties. However, these are still unproven and there are concerns about bacterial resistance and the local and environmental effects of silver. The use of the antimicrobial AEM 5772/5, which does not transfer to the skin of the patient, is a new development in the control of atopic dermatitis. Further studies are needed to determine whether an antimicrobial shield bonded to clothing material will reduce the colonisation of atopic skin by S. aureus.