Allergies of the Skin – Atopic Dermatitis
THIS IS a special type of allergic skin disease that is usually associated with asthma and hay fever. Members of the patient’s family often have some type of allergy. This might be said to be like asthma or hay fever of the skin, with the same allergic causes requiring similar methods. Usually, the causes are food, inhalant, animal danders, pollens or molds. Foods are usually most significant in infancy, and, as the child reaches adulthood, the other allergens become more significant. Special tests are often required to determine the allergens.
Atopic dermatitis has been classified by some authorities into three stages: infantile atopic dermatitis or eczema; juvenile atopic dermatitis; and adult atopic dermatitis, called by some neurodermatitis.
Infantile atopic dermatitis occurs from birth until two years of age. The rash appears usually first on the face, with small itchy blisters. It quickly spreads over the entire face and neck, but the eyes and the area about the mouth remain clear of the rash. In most cases, the rash spreads to the sides of the legs, wrists, arms and buttocks. In severe cases, it may spread over the entire body. Because of the itching, there are often many scratches, oozing and crusting. This makes the infant very restless, but, as a rule, does not appear to disturb his general well-being. In many infants, the atopic dermatitis spontaneously clears up by the age of two. However, the recovery is often only temporary, and recurrences are frequent through adolescence and adult life. It is best to make an early and determined effort to find and control the allergy during infancy.
Juvenile atopic dermatitis may be a recurrence from the infantile state or may develop independently. The areas of skin involved are the face, forehead, eyelids, around the ears, neck and chest, the bends of the forearms and the backs of the knees and wrists. The rash is usually dry, scaly, thickened, pigmented and, often, wrinkled. The itching is very severe, and, as a result of scratching and irritation, the skin thickens and secondary infection often results, with scabs and a yellowish discharge resembling impetigo.
Adult atopic dermatitis is similar in many respects to the juvenile type. The difference is largely that it has been present so much longer and the rash is more chronic, with a bluish or grayish color in the areas where the skin is thickened. There is considerable dryness and generalized flaking or scaling of the skin. There is usually considerable scratching from the rubbing and itching. There are periodic intensifications in the symptoms. Occasionally, there is an increase in the skin rash in the winter. Due to marked itching at night, the patients tend to be quite nervous, although otherwise in fairly good health.
It is usually necessary to differentiate atopic dermatitis from several skin diseases which look like it, such as seborrheic dermatitis, contact dermatitis and neurodermatitis. Except for contact dermatitis these conditions are not allergic and will not be benefited by allergic treatment. Local skin care and treatment are very vital for the ultimate “cure” of the allergy. Treatment must also include any emotional factor, as well as attention to general health, dentistry, good bowel habits, avoidance of overfatigue and excessive night life.
The skin is constantly exposed to many harmless substances, and few are primary irritants. It requires one or more exposures to a substance to prepare the skin for subsequent contact dermatitis. This form of skin disease is probably the most common type of skin allergy. Patch-testing will, in most cases, reveal the causal allergens and their removal will result in cure.
The start of contact dermatitis is usually on the exposed surfaces of the skin. A sudden appearance of redness with extreme itching is soon followed by swelling, blisters, weeping and crust formation. If infection is added, there will be pus in the blisters. This is the acute type seen in poison ivy, oak or sumac cases. With subsidence of the acute symptoms, the condition, if not cured, will reveal scaling and redness of the skin, with thickening of the affected areas due partly to the irritation and trauma of the scratching. Later, the skin will become shiny and show bluish or purplish pigmentation.
The location of the contact dermatitis will have some effect on the type of eruption, and will also enable one to suspect the possible allergic agent causing the trouble. If the face is involved, cosmetics may be suspected. Pollens, plants, and dusts tend to affect the exposed areas like the face, neck and upper and lower limbs. Clothing containing dyes and fillers diluted with perspiration causes contact dermatitis where` contact is direct. Dress dermatitis usually affects the skin of the sides of the neck, the folds of skin under the arms and the bends of the elbows and chest. Wearing shoes and socks can quite logically result in contact dermatitis on the lower part of the legs, the insteps of the feet and the toes. The backs of hands, forearms and face are usually involved in occupational contact dermatitis. Although the condition is at first localized to the area of contact absorption of many chemicals through the skin, it may result in involvement of all of the skin. Sodium dichromate, mercury, formaldehyde, quinine and many other chemicals can do this.
It is easy to recognize poison ivy dermatitis and wrist watch band or rubber glove dermatitis. There are others that are less obvious and require a most careful analysis of the present and past personal history as well as the family history of the occupational contacts and medicines that are used frequently, such as laxatives containing mercury, phenol phthalein, headache medicines, tonics containing iodine, sedatives, Fowler’s solution containing arsenic, cough mixtures and injectable medicines, such as penicillin, vitamin B and other drugs.
Contact dermatitis may resemble many other skin conditions from which it must be differentiated. There are other allergic skin diseases that require a different type of treatment and skin diseases resembling contact dermatitis which cannot be benefited from allergic management.
The allergens responsible for the contact dermatitis must be identified. Those related to seasonal occurrences, such as pollens and plants, are important. Periodic remissions or exacerbations of the dermatitis may give clues. Being away from the environment, contacting certain substances with regularity, using dyes or paints in weekend work at home, special hobbies, such as gardening, golfing and photography-all these offer suggestions for allergy. Contacts in the home, such as detergents, soaps, bleaches, turpentine, mineral spirits, furniture polishes, disinfectants, plants, pets, floor waxes, furniture, plastics, house dust, clothing, curtains, drapes, benzine and other cleaners, weeds and grasses, also offer problems.
Certain occupations involve substances likely to be causes of contact dermatitis. Telephones, business machines, dictaphones, carbon paper, pencils and dyes are sometimes implicated. Schoolteachers contact chemicals, chalk and inks; photographers contact developing solutions; beauticians contact cosmetics, waving solutions, dyes and hair tonics; bakers contact cereals, chemicals, fruits, sugar and eggs; florists contact plants and flowers and barbers contact hair tonics, soaps, metals and sterilizing solutions. Service station attendants and mechanics contact gasoline, oil, grease, soaps, chemicals and cleaning materials. A carpenter will contact woods, glue, stains and varnishes, and a bricklayer-tile-setter will contact cement, lime, clay and dyes. Printers, lithographers and engravers will contact inks, cleaning fluids, sodium bisulfide, chromates, ammonia and other chemicals. Druggists, physicians, nurses and veterinarians will contact medicines, chemicals, rubber gloves and many other substances.
Patch tests are the means of determining the cause of the dermatitis in most cases. There are, however, precautions which must be observed in using these tests, as they can produce serious scars and dangerous extensive skin disease in inexperienced hands.
The finding and removal of the causative allergen and the clearing of the rash is the certain proof that a given agent has caused the dermatitis. In the following illustrations, cases of contact dermatitis are described.
Dermatitis from Nickel
A large, well-built man stood in the center of an inferno known as open-hearth plant No. 3 of the W— Steel Works. The white-hot flames from the furnace doors cast their scorching rays upon his sweat-soaked body, which was stripped to the waist.
The man’s keen, deep-set, blue eyes shone as they focused upon a stop watch. Presently, lifting a whistle to his mouth, he blew three shrill blasts, then timed a crew of men for 60 seconds as they loosed a quantity of limestone into the bath.
Again there were three shrill blasts, and the man’s work was finished for another fifteen minutes. As he left the furnace room, he brushed perspiration from his burning body.
“Look at ’em! Look at these darned sores,” he said to a fellow worker. ‘And when I sweat, it’s just like the fire in that furnace.”
He had a nasty rash which practically covered the front of his body from the shoulders to the waistline, including both his arms.
“Hm, sure is an awful lookin’ rash ya’ got there,” remarked the other man. “Doin’ anything for it?”
“Doin’ anything!” exclaimed the large man. “I’d be the happiest guy in the world if I only knew what I could do.”
“Didja see the doctor in the front office?” asked the other.
“Yeah, he thinks it’s heat rash. Says it’ll go away by itself. Says to eat a lot of salty food.”
“Well?” said the other man expectantly.
The afflicted man shrugged his shoulders. “I eat pretzels an’ potato chips, an’ more pretzels an’ more potato chips, but, every time I go into that furnace room, these sores come out again, and, man, what I mean, they sure burn! You know, I don’t think the salt or the heat has anything to do with it.”
“Aintcha got a family doctor? Maybe he c’n tell ya what ya got,” suggested the fellow worker. “Sometimes these company doctors run into things that ain’t exactly in their line. After all, they ain’t only but human.”
“We haven’t got a family doctor, but my wife’s been takin’ the youngest girl to a doctor for hay fever. Maybe next time I’ll go along. Who knows, maybe I got hay fever.” He laughed.
“Naw!” replied the other man seriously. “That’s with weeds. They ain’t no weeds in here.”
“Aw, I’m only kiddin’,” apologized the large man.
So, the next time Mike D.’s wife took young Elsa for a hay-fever treatment, Mike went along. At the doctor’s office, he remarked to the physician about his trouble.
“What sort of trouble?” asked the doctor.
Mike laughed. “I got hay fever of the skin.”
“Wait,” interrupted the doctor. “It may not be as funny as it sounds.”
“You said it, Doctor!” exclaimed Mike. “Right now, it only itches, but, when I get to work at the hearth, it really burns!”
“What itches and burns?” asked the doctor.
“All around here,” replied Mike, demonstratively pointing to the affected regions of his body.
The physician insisted upon examining Mike. After a lengthy questioning, he said: “The joke’s on you, Mike. You have hay fever—a different kind of hay fever—and I’d like to find out what’s causing it.”
Mike needed little persuasion, and the physician began immediately to test for specific sensitivities. Row upon row of tests were made during the next few weeks. Not a single positive reaction resulted.
Then came the contact irritants. There was not a pollen in the world that reacted against Mike. Nor was his body averse to the numerous kinds of dust.
The long list of standard test items having been exhausted to no avail, the doctor braced himself for another of those battles with the unknown.
“Mike,” he began, “I’m going to find out what causes your trouble, but we’ll have to be patient.”
“That’s all right, Doctor,” Mike replied in his good-natured manner. “Take as long as you like.”
When Mike went to the plant that night, the physician accompanied him. “You see, Mike,” explained the doctor, “I’ve got to know what things you work with at the plant. If your rash gets worse when you go to work, there is obviously something in the place that doesn’t agree with you.”
“Maybe it’s the boss,” joked Mike.
“Maybe,” agreed the doctor. “We’ll know soon enough.”
Both men stripped to the waist before entering the open-hearth plant for the late shift. As they checked into the torrid room, Mike paused long enough to introduce the doctor to the night superintendent.
“Boss, meet my private doctor. He’s gonna find out what’s makin’ me itch all day and burn all night.”
There was a cool nod from the superintendent. “You’ll find it awful hot in here, Doctor,” he remarked. “Stay away from the furnace. There’s canned Hell inside.” He handed Mike his whistle and stop watch.
Inside the furnace room, the doctor asked many questions. He learned that there were at least eight kinds of metal being used in the room. He also noted a number of other things. Several hours of this was all the doctor could stand, even with periodic rest periods. He felt that he had secured the information he wanted.
“Be at my office next Friday, Mike,” he told his patient.
“Why so long?” asked Mike.
“I’ll need tune to prepare some extracts,” explained the physician.
The doctor was sure he would soon know the source of
his patient’s trouble. The following five days were spent in preparing extracts of iron, vanadium, chromium, aluminum and several other metals.
The next Friday when Mike appeared at the office, he was tested with each metal, but one by one, they showed negative results after a 72-hour period.
Believing that he was on the right track, the doctor continued to make patch tests with the different metals until suddenly his face beamed. “That’s it! Mike, we have it!”
“What?” asked the patient.
“The metal that’s been causing your trouble.”
“Gee,” said Mike, “what is it?”
“Nickel,” was the brief reply.
The light faded from Mike’s face. “Are ya sure, Doctor?” he asked.
“Sure as you’re alive,” replied the doctor, indicating a large red area surrounding the point where the metal extract was placed against the man’s arm.
“I don’t know,” said Mike skeptically.
“What don’t you know?”
“Well, you see, we don’t use any nickel in the plant. There ain’t a thing we mix that’s got nickel in it,” he explained.
“There must be.” said the doctor convincingly. “I’m going with you tonight, and we’re going to locate that nickel.”
That night, with the assistance of the superintendent and Mike, the doctor scrutinized the plant carefully for traces of nickel. There were none. The doctor watched Mike work. In his bewilderment, he subconsciously noticed Mike preparing to give the signal for pig iron. Whistle in his mouth, and his eyes glued to the stop watch in his hand, he stood motionless for a moment, then let out three shrill blasts.
Each blast seemed to say to the doctor: “Here—here—here,” and finally it came to him. That whistle! “Mike,” he called, hurrying toward the man. “Mike, when you said it might be your boss that didn’t agree with you, you weren’t far off.”
“What do you mean?” asked Mike.
“I mean that the boss has been giving you a nickel-plated whistle and a nickel-plated stop watch to work with every
time you come in here. That’s where the poison is coming from.”
“Well, I’ll be—” was all that Mike said.
The doctor’s theory was checked and found to be correct.
Mike’s request for a wooden whistle and a silver-plated stop watch was quickly fulfilled, and, within a very short time, the rash disappeared completely from his body.
Dermatitis from Canary Feathers
The case of 45-year-old Lewis R. was one of pure stubbornness.
Lewis’ first trip to the physician’s office was not his first experience with the ugly, itching rash that covered his face and arms. This first visit merely represented Mrs. R.’s first successful attempt to induce her husband to investigate the cause of the rash.
Although the irritation seemed obviously to be the result of a contact irritant, the physician checked first on the foods. Finding nothing significant, he continued with the tests for contact irritants, but nothing appeared. A similar result with the bacterial group convinced the doctor that there was some detective work to be done.
“How often does this rash appear?” the physician asked.
“I can hardly say that it ever disappears,” answered the patient. “There are some days when it seems to be worse than others.”
“It is quite obvious, then, that whatever is irritating your skin must be constantly present. In that case, I must find out about everything you come into contact with regularly. It may be wise for me to visit your home,” explained the physician.
Mr. R. exchanged glances with his wife. “Oh, I don’t think that will be necessary,” said Mr. R. boldly.
“I hope not but, if new evidence doesn’t show up, I’ll have no other alternative.”
With this, the doctor referred to the autobiographical history of the case as obtained during the initial consultation,
and questioned Mr. R. in detail about each individual point.
All through this tedious questioning, Mr. and Mrs. R. constantly exchanged those cryptic glances.
“Mr. R.,” the doctor began after several silent moments, “if I’m to help you, I’ll need your full cooperation. Are you sure there isn’t something you have overlooked? Something you may have forgotten to tell me?”
“Not that I know of,” Lewis said hesitantly.
“Then,” began the doctor with an air of finality, “there is only one thing left for me to do. I’ll have to come to your home and see for myself.”
Mr. R.’s reaction indicated that he was not anxious for the doctor to come to his home. He was momentarily silent, then suddenly: “That’s all right with me, Doctor, but, if you think 111 give up my canaries, you are mistaken,” he warned.
The physician laughed. “Let’s cross that bridge when we come to it. You hadn’t told me about a canary, even though I asked whether you had any pets.”
“Well, canaries aren’t exactly pets,” Lewis explained.
The physician’s visit to his patient’s home revealed that the man had not one or two canaries, but 40 of them in all parts of the house.
Mr. R. had felt all along that the birds were causing his trouble, but, like so many people, he could not bear to face the problem squarely. Raising canaries was his hobby, and what person likes to be told that his hobby is ruining his health?
A minimum of testing proved conclusively that the constant presence of canary dander in the air was the cause of the rash.
The irony of the whole case lies in the fact that it took the physician days to persuade Mr. R. to get rid of the birds in the interest of his own health. Uncomfortable and unpleasant as the ailment was to the man, he was not easily persuaded.
Today, less than a year after sacrificing his hobby, Lewis R. is no longer ashamed of his appearance, for his rash has
cleared up completely. His hobby? Well, he now derives a great deal of pleasure from writing authoritative articles on canaries for the various bird publications, as well as from collecting photographs of these birds.
Dermatitis from Goat Hair
Christmas had brought joy—and pain—to five-year-old Mary Lou. Under the Christmas tree stood that big rocking horse she had ordered from the department store Santa Claus.
It was a beautiful toy, and, for the first few days, Mary Lou spent most of her time on it. On the evening of the third day, the child complained about an itching sensation about her thighs and her backside. The frightened mother learned, after calling the physician, that Mary Lou was sensitive to the goat hair of which the rocking horse was made. Mary Lou reluctantly parted with her rocking horse, and the itching sensation disappeared. Written By: Jack A. Rudolph, M.D. & Burton M. Rudolph. M.D., Continue Reading, Urticaria and Angioedema