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

Textiles are any kind of fabric formed by natural and synthetic fibers or a combination of both.[6] Most fibers themselves rarely cause immune-mediated sensitization, whereas the primary cause of textile allergy arises from textile preparation and its treatment processes. The most common sensitizing agents include dyes, finishing resins, and rubber additives. These substances serve the functions of improving clothing durability and appearance.

Several finishing chemicals, including urea-formaldehyde and melamine-formaldehyde, have been used for decades to prevent wrinkles. These compounds trigger sensitization because formaldehyde eludes from the bound fibers.[6] Textile dyes are by far the most common overall cause of textile contact dermatitis.[1,7] In a study of 154 patients with textile contact dermatitis, dyes accounted for 79.8% of all positive results on patch tests.[1] Approximately 13% of the cohort was sensitized to several compounds that included rubber additives, whereas the remainder were allergic to formaldehyde and finishing resins.

Reactive dyes are primarily used to color the natural fiber found in cotton, wool, and silk. Sensitization to these dyes are quite rare.[6] Disperse dyes are commonly used to dye synthetic fabrics, such as polyester, acetate, nylon, and fiber mixtures, and they account for more than 20% of all dyes. The prevalence of allergy to these dyes is estimated to be 0.4% to 6.7% and includes dyes such as disperse blue 106, disperse blue 124, and disperse yellow 3.[1,8] These dyes only partially bind to textile fibers, possibly explaining their strong sensitizing properties. Furthermore, their propensity to leak from fabric increases in the presence of friction and moisture, thereby enhancing their immunogenic potential.[6,7]

Due to the wide variety of textiles, numerous body areas may be involved. Thus, distribution is a crucial diagnostic clue to the identity of the sensitizing compound.[3] Textile contact dermatitis typically appears in the fifth decade in women and fourth decade in men. Textile contact dermatitis may mimic or exacerbate atopic dermatitis if the antecubital or popliteal fossae are involved. A higher incidence of textile contact dermatitis is also observed in those with a prior history of atopic dermatitis because disruption of the skin barrier increases the likelihood of sensitization.[1,2] Secondary infection is common.[3]

The clinical presentation can range from an acute flare with erythema and vesicles to chronic manifestations such as lichenification.[5] In a study of 211 patients, most (79.9%) had a pruritic eczematous dermatitis with oozing vesicles; 20% of patients had atypical presentations including lichenoid, purpuric, lymphomatoid, psoriasiform, pustular, and nummular variations.[1] Most patients (95.3%) in a 277-patient cohort also had eczematous eruptions, and the remainder (4.7%) had atypical presentations.[1]

Body areas subject to heat, friction, and sweating are more likely to experience sensitization.[2] The neck, trunk, abdomen, lower limbs, and axillary folds, where clothing is often tight, are common locations of nonoccupational textile contact dermatitis. Occupational textile contact dermatitis due to dyeing practices most commonly involves the hands. However, the eyelids, abdomen, and upper limbs may be involved as well. No evidence to date suggests a correlation between the clinical pattern and distribution of textile contact dermatitis and the responsible allergens.[1]

Due to the diverse manifestations of textile contact dermatitis, the differential diagnosis is broad and may include dyshidrotic eczema, atopic dermatitis, tinea corporis, inverse psoriasis, scabies, palmoplantar psoriasis, nummular dermatitis, seborrheic dermatitis, irritant contact dermatitis, and other causes of allergic contact dermatitis.[5] Eczematous drug eruptions caused by calcium channel blockers can be widespread on the trunk and extremities but are usually not accentuated at the periphery of the axillary vault. This is also true of allergy to cocamidopropyl betaine in soaps and body washes.

A high index of suspicion is warranted. The diagnosis is often suggested by a detailed history and physical examination. If textile contact dermatitis is suspected, the next step is to obtain patch testing, which is confirmatory in the appropriate clinical context.[3,9] In patients with suspected textile contact dermatitis, supplementing the standard panel with the textile dyes may be helpful.[6] A suspected fabric may also be placed under a patch for 3-4 days.[3]


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