Dermatology Case Challenge: An Accountant on a Weight-Loss Program Has a Rash, Poor Sleep

Melba Estrella, MD; John Plante; Andraia Li; Margaret LaPorte; Dirk M. Elston, MD


January 24, 2023


This patient's clinical presentation is consistent with allergic contact dermatitis due to clothing. The appearance of an eczematous eruption involving the periphery of the axillary vault suggests textile contact dermatitis. Tightly covered posterior axillary folds are subject to friction and perspiration. Perspiration in the absence of evaporation may lead to dye leakage from fabrics, triggering allergen sensitization.[1,2] The axillary vault is typically involved in deodorant dermatitis, whereas the periphery of the vault suggests clothing dermatitis. Clothing dermatitis may be caused by dyes or resins within the fabric.

Patch testing was performed and revealed positive reactions to resins used in textile manufacturing. The remaining differential diagnoses presented were excluded based on the patient's history and physical examination findings. The key factor that pointed away from a diagnosis of deodorant contact dermatitis was the distribution of the rash. In this patient, the axillary vault was spared. Although deodorant contact dermatitis is also a form of allergic contact dermatitis, and therefore may appear with a similar morphology, this diagnosis would be more likely if the patient's axillary vault was affected.[3]

Although textile contact dermatitis may mimic atopic dermatitis, this condition characteristically involves the flexor surfaces in adults. In addition, adults with atopic dermatitis typically have a history of childhood eczema.[4]

This patient occasionally takes ibuprofen, a medication that is commonly implicated in fixed-drug eruptions. However, a progressively darkening, erythematous, and sharply demarcated oval patch that recurs at the same skin sites with each exposure would be expected. Also, eruptions secondary to the use of nonsteroidal anti-inflammatory drugs commonly involve the oral mucosa.[3,4] Although this patient does have a history of chickenpox, herpes zoster is less likely to be the diagnosis because it typically appears as a painful vesicular rash that follows a unilateral dermatomal distribution.[4]

Contact dermatitis can be divided into irritant and allergic contact dermatitis. The inflammatory response in irritant contact dermatitis does not require prior sensitization and is due to nonimmune mediated mechanisms.[4,5] Examples of irritants include acids, alkalis, and detergents.[3,4] Numerous substances, including neomycin, formaldehyde, and poison ivy, can cause allergic contact dermatitis. Prior sensitization to an allergen is required because the pathogenesis involves a cell-mediated delayed (type IV) hypersensitivity reaction.[3] Textile contact dermatitis is a subtype of allergic contact dermatitis.


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