A case of textile dermatitis due to disperse blue on the surgical wound

Abstract

Disperse blue (DB) 106 and DB 124 are the most frequent fabric dye allergens inducing textile dermatitis, but contact allergy to them may easily undiagnosed because the clinical picture usually needs high index of suspicion. We present the case of a 35-year-old woman who was referred for a recurred lesion over the incision scar of right total hip replacement surgery, which did not respond to treatment with povidone–iodine, mupirocin, and rifampicin. Patch testing, conducted with a European standard series and therapeutics that were used in the treatment of the lesion, revealed a positive reaction to dispersion mix blue 106/124. The patient was questioned in detail and reported that she has been wearing dark-colored synthetic panties for long years. The correlation was done between the positive antigen in the patch test and the clinical findings. The patient was treated with a corticosteroid cream for 2 weeks. She did not wear any dark-colored synthetic panties afterward and no flare-up was seen in the follow-up period. In this report, we emphasize the importance of detailed questioning of patients and that contact dermatitis should be considered potential cause of dermatitis at skin sites where the barrier function is compromised.

Introduction

Contact dermatitis is an inflammatory response in dermis mediated by type IV hypersensitivity reaction to stimulants with allergenic features. It is one of the most common types of eczema.

Disperse blue (DB) 106 and DB 124 are the most common contact sensitizers among textile dyes.^1–3 Clinical reactivity of the DB 106 and DB 124 are similar. Therefore, a similar chemical structure has been proposed for both. ⁴

The diagnosis of contact dermatitis is not difficult in many cases, because the location and the way of occurrence of the lesions are very typical. The history and physical examination are usually enough for the diagnosis. However, patch testing should be performed to identify specific allergen that initiates the inflammation or to confirm the suspected agent. The correct interpretation of the patch testing results is the most important step in the description of the causative agent. In this article, we present a case of contact dermatitis over the incision scar of right total hip replacement surgery due to an agent that is difficult to consider.

Case

A 35-year-old woman referred to our allergy clinic because of a lesion which did not respond to the conventional treatment (Mupirocin cream 2%, application of the povidone-iodine and rifampicin-soaked dressing) and occurred repeatedly over the incision scar of right total hip replacement surgery. There was no problem in wound healing after surgery and the incision line was completely intact. But a large bullous lesion without pruritus occurred over the scar during the second postoperative month. Lesion was curettaged and empirical systemic antibiotic treatment (cefprozil 500 mg/day orally [p.o.]) was started. No growth was observed in the aerobic and anaerobic cultures taken from the bulla content. Systemic antibiotic treatment was stopped and local antibiotic treatment (Mupirocin cream 2%) was continued until the lesion disappeared completely (3 weeks).

After 2 months, she developed a flare-up of her lesion. The aerobic and anaerobic cultures were again negative and local treatment (Mupirocin cream 2%) was started. However, the severity of lesion increased gradually in time, affecting the deep layers of the dermis along with the surgical scar and surrounding skin. The physical examination revealed an erythematous, edematous lesion occupying the epidermis and dermis with partial tissue loss and discoloration associated with burning sensation and itching.

One of the differential diagnoses should be contact dermatitis for the lesion, in which infectious agents were not isolated. Therefore, patch testing was conducted with a European standard series and povidone–iodine, mupirocin, and rifampicin were used in the treatment of the lesion. Patch test was performed on healthy skin of the back using Haye’s patch test chambers (Haye's Service B.V., The Netherlands) with “European Standard series” (Brial, Allergen GmbH, D-Greven, Germany). Readings were taken at 48th, 72nd, and 96th hour. She reacted to dispersion mix blue 106/124 (1% petrolatum) at 48 hours, and this antigen was separated from the test panel. All antigens and local medications were negative at 96 hours and the test was ended.

After the dispersion mix blue 106/124 sensitivity was found with patch testing, the patient was questioned in detail and reported that she was always wearing dark-colored panties made of synthetic materials, for long years. The correlation was done between the positive antigen in the patch test and the clinical findings.

The patient was treated with a topical corticosteroid (mometasone furoate cream 0.1%). The lesion regressed during the first week and completely disappeared in the second week of the treatment. We recommended her to wear only white, 100% natural fabrics such as cotton, linen, silk, or wool, and wash them 3 times before wearing. No flare-up was seen in the follow-up period.

Discussion

The patient did not have any complaints despite the fact that she was using synthetic panties for long years. In a detailed history, she told that she sometimes had pruritus in the perianal region, which had been related to a probable Candida infection so that the contact sensitivity was not considered. During normal conditions, aforementioned textile dyes had not caused eczematous lesions over the intact skin. When the skin barrier was disrupted during surgical procedure, the amount of absorbed allergen was increased and obvious contact dermatitis reaction had occurred over the incision line that was healing. The fact that the lesions were seen on the operated hip was supporting this hypothesis. Immediately after the surgical procedure, incision line was kept closed with gauze and the patient did not wear panties. Hence, the healing of surgical wound continued without any problem and the suture line was closed.

Disperse dyes are used for coloring mixed and synthetic fibers such as acetate, acrylics, polyamide, and polyester fibers. ⁴ They have been reported to cause an allergic contact dermatitis to a variety of garments, which include underwear, blouses, pants, swimming suits, pantyhose, shoulder pads, and the velvet material of leggings, and body suits. ⁵ The newer azo dyes DB 106 and DB 124 are the most common contact sensitizers among disperse dyes. ³ Avoidance of blue textiles is irrelevant, as blue will be used in black, violet, and other colored textiles. ⁶ Disseminated contact dermatitis comprises extensive areas of the trunk and extremities, and localized contact dermatitis includes areas of friction on the trunk, such as axillary and other folds, waistband, and extremities, mainly inner and posterior thighs. ⁷

The diagnoses of the textile contact dermatitis is not difficult when the lesions are located classically, such as in the collar area, waistband area, upper thighs, and axillary folds. But the diagnosis may be difficult when the situation is complicated with other pathologies. Wound healing, suture material reaction, or allergies that are related to topical treatments would be the diagnostic probabilities initially.

Patch testing should be done in every case if contact allergy is suspected. On the other hand, all possible allergens should be added to the test panel in addition to the standard panels. Despite the fact that we do have best in vivo and in vitro diagnostic tests today, history and physical examination are still the most important steps of the diagnosis. With this case, we emphasize the importance of detailed questioning of the patients and that contact dermatitis should be considered the potential cause of dermatitis at skin sites where the barrier function is compromised.