Neck cellulitis complicating spectacle frames’ contact dermatitis: A case report

Abstract

Neck cellulitis occurs as a result of dental, pharyngeal or ear infections or following trauma, but rarely via a cutaneous entry point. A 34-year-old female patient consulted with a left-sided, painful cervical swelling with limited head rotation and trismus, accompanied by a painful, oozing, retroauricular contact dermatitis (CD). Clinical examination confirmed the left cervical cellulitis with superinfected retroauricular CD. A computed tomography scan of the neck revealed no abscess. Systemic antibiotic therapy against streptococci and staphylococci for 8 days, combined with hygiene care for the CD lesions and the avoidance of glasses with metal frames, resulted in complete recovery without recurrence. Patch tests revealed sensitization to several metals, particularly nickel. Eyeglasses may cause allergic CD, an inflammatory skin disease caused by a delayed-type hypersensitivity reaction. Metal spectacle frames are particularly prone to causing CD, mainly due to the presence of nickel. Because of the skin breakdown it entails, spectacle frames’ CD may lead to skin infections and neck cellulitis. Spectacle frame CD should be investigated in patients presenting with retroauricular eczema. To our knowledge, the case of neck cellulitis induced by spectacle frame-allergic CD has never been reported.

Introduction

A break in the skin barrier on the occasion of an infectious, traumatic or inflammatory dermatosis is a well-known trigger for cellulitis. ¹ Allergic contact dermatitis (CD) is an inflammatory skin disease caused by a delayed-type hypersensitivity reaction, which can also constitute a port of entry for germs and lead to soft tissue infection. ² Most cases of neck cellulitis result from an untreated dental, throat or ear infection that has spread to the surrounding subcutaneous tissue or from trauma, but a cutaneous starting point is rarely incriminated,^3–6 and, to our knowledge, no case of neck cellulitis induced by allergic CD has ever been reported. In cases of neck cellulitis, a deep underlying infection of the cervical space constitutes a surgical emergency and should be sought.^4,6 We present the case of a young myopic patient who presented with spectacle frames’ CD complicated by neck cellulitis, even though she was not immunosuppressed, had good dental health, and had not used any medication or other drugs beforehand.

Case

A 34-year-old woman with no previous medical history presented with a painful left cervical swelling with reddening of the skin that had appeared the previous day, accompanied by limited rotation of the head to the left and trismus (Figure 1). On the left ear, there was oedema of the lobule and retroauricular erythema with vesicles and yellowish oozing. There was no chest pain, dysphagia or dyspnoea. The body mass index was 22.4 kg/m² (weight: 61 kg); the blood pressure was 126/82 mmHg; the heart rate was 66 beats per minute; the respiratory rate was 14/min; the body temperature was 37°C; and the pain was moderate to severe (a numerating rating scale of 6–8). The first-line medication included exclusively a gram of paracetamol three times a day and the application of moisturising cream to the retroauricular area. Ten months previously, she had bought new eyeglasses with metallic spectacle frames. The protective lacquer progressively disappeared at the contact point with the skin, exposing the left retroauricular area to direct contact with the metal. Erythema and oedema, accompanied by symptoms of itching, tingling and burning, had progressively appeared. For the past 4 days, the injured retroauricular area has become painful and oozing. The patient did not have any sick family members, had not recently travelled, and had no recent interaction with animals. She had no dental pain and had regular dental check-ups. She drank alcohol occasionally but did not smoke or use any other drugs. Furthermore, she reported no previous symptoms suggestive of CD in her life. On clinical examination, the swelling measured 3 cm in diameter and was warm and very painful at palpation. An erythematous and erosive skin lesion on the right malar was noted at the point of contact with the spectacle frame (Figure 1), and posterior auricular lymph nodes were palpable. The endobuccal examination revealed no lesions or dental caries, while the tonsils were normal in size; auricle and ear canal examinations were unremarkable; and palpation of the sinuses was painless. The rest of the skin examination was normal, as was the chest auscultation. The hemogram was normal, and the C-reactive protein was less than 10 mg/l. A head-and-neck computed tomography (CT) scan revealed frank infiltration of the subcutaneous soft tissues opposite the left parotid gland, extending to the ear lobule, as well as discrete infiltration of the parenchyma of the parotid gland. There was no abscess (Figure 2), and the lowest CT images showed no abnormalities in the superior mediastinal space. Spectacle frame CD-inducing non-complicated neck cellulitis was diagnosed, so the treatment consisted of antibiotic therapy with amoxicillin-clavulanic acid (1 g every 8 h), avoiding wearing metal-rimmed glasses, local hygiene care with soap and water, and fusidic acid cream. The patient exchanged her metal-rimmed glasses for plastic-rimmed glasses, and after 8 days of treatment, the neck cellulitis and retroauricular CD had healed. Three months later, the patient underwent patch tests to identify potential allergens. The substances included in the European baseline series, ⁷ benzisothiazolinone (an isothiazolinone derivative present as a biocide in the glasses’ cleansing product), an additional battery dedicated to metals, and the eyeglass cleaning wipe were tested. The patch tests (IQ Ultimate™, Laboratoire Destaing, Grasse, France) were positive for nickel, copper, palladium, titanium and vanadium when read at 48 and 96 h (Figure 3), highlighting a frank sensitization to metals. The cleaning wipe and all the other substances tested remained negative on both the first and second readings. Given the diagnosis of a severe contact allergy to metals, avoiding all metal accessories and contact with metal surfaces of any kind was advised. A year later, the left ear CD had not recurred.

Figure 1.

(a) Left cervical cellulitis with intense erythema under the left ear. (b) Side view of the lesion. (c) Temple of the glasses placed on the left ear. Erythema and desquamation of the retroauricular skin around the frame. (d) Break in the cutaneous barrier in the left retroauricular area, vesicles on erythematous epidermis with yellowish oozing.

Figure 2.

Axial section of the brain computed tomography scan showing a frank infiltration of the subcutaneous soft tissue opposite the left parotid gland and discrete infiltration of the parotid gland at the contact point (white arrow).

Figure 3.

Patch tests placed on the patient’s back (a). Positive patch tests for nickel (b), copper, palladium (c), titanium (d) and vanadium (e) at 96-h reading.

Discussion

CD is caused by irritation in 80% of cases. Clinical examination, exposure assessment and evaluation using patch tests or skin prick tests help to distinguish allergic CD from other causes. ² Management includes patient education, strategies for avoiding particular substances, and topical treatments. ² Cases of retroauricular eczema induced by metal spectacle frames in contact with the temporal temples have already been described. ⁸ Changing the frame material is still often the only option. Hypoallergenic spectacle frames are available for purchase and should be recommended to the patient. Although CD is well-known for constituting a port of entry for germs, neck cellulitis complicating a spectacle frame-induced CD has never been reported. Only one case of recurrent facial erysipelas complicating allergic CD has been documented. ⁹ Our clinical observation is also peculiar in that none of the risk factors known to favour the development of severe infection (use of non-steroidal anti-inflammatory drugs, alcoholism, active smoking, diabetes, obesity or chronic illness)^5,6,10 were present.

An extension of the infection to the mediastinum may complicate deep cervical cellulitis. When the deep spaces of the neck are affected, a thoracic CT scan should be performed to look for evidence of mediastinitis, all the more so as the suggestive clinical signs (dyspnoea, dysphagia, chest pain or chest erythema) may be delayed.^4,6,11–13 In our observation, although the restricted head rotation and the trismus suggested a deep neck space involvement, the infection was confined to the left parotid space on the CT scan. Therefore, according to the current guidelines, ¹⁴ the treatment consisted of antibiotics active against streptococci and staphylococci, per os, for 5–10 days, with analgesics and local hygiene.

A spectacle frame is a structure that encloses or supports ophthalmic lenses. It can be made of plastic, metal, wood or composite materials. Metal frames may be preferred because of their rigidity, their ability to retain their shape or for aesthetic reasons. However, they are much more likely to cause CD. ¹⁵ The most common metals used for spectacle frames are nickel-silver (an alloy of copper with nickel and zinc), monel (a nickel and copper alloy with iron, manganese, carbon and silicon), other nickel-based alloys, stainless steel, gold, beryllium, titanium or aluminium. ¹⁶ In our case, while the spectacle frame was only made of nickel-silver, the patch tests were positive for nickel, copper, palladium, titanium and vanadium. Given the high prevalence of nickel allergy, there was strong evidence that it was the main cause of our patient’s CD. The patch tests’ positivity for copper was more equivocal, as documented true copper allergies are rare. ¹⁷ Spectacle frames made of palladium or titanium have been associated with allergic CD,^18,19 and one patient developed hand eczema after handling vanadium-containing tools, ²⁰ but neither palladium, titanium, nor vanadium was used in the composition of our patient’s eyeglasses. In our opinion, the epicutaneous tests’ positivity for these metals was due to metal polysensitization, a frequent phenomenon in cases of nickel allergy. ²¹ As nickel is ubiquitous (clothing, tools, medical devices, jewellery or food), the prevalence of nickel allergy is high, ranging from 8% to 19% in adults and 8% to 9% in children and adolescents, with 4–10 times more women than men affected. ²² Unsurprisingly, it is the most frequent culprit in cases of spectacle frame CD.^15,16 Spectacle frames available on the market can also be made from or at least contain allergens such as plastics (cellulose acetate, acrylates or epoxy resins), plasticisers (phosphates and phthalates), solvents (acetone and ethylene acetate), dyes (p-phenylenediamine and anthraquinone), rubber (silicone), cosmetics (tosyl/amide formaldehyde resin), waxes or antioxidants.^15,16

Conclusion

Spectacle frame-induced allergic CD may result in severe consequences. Based on our information, neck cellulitis complicating spectacle frame-induced allergic CD has never been reported. Although spectacle frames’ CD is uncommon, it should be looked at in patients with retroauricular dermatitis, particularly if the spectacle frames are made with known allergens such as metal.