Contact Dermatitis

SAN DIEGO – The ubiquitous acrylates take home the Contact Allergen of the Year title for 2012.

"We chose them because acrylates are everywhere in the environment," said Dr. Donald V. Belsito, who announced this year’s winner at the annual meeting of the American Contact Dermatitis Society.

© Andrey Popov/iStockphoto.com

Acrylates are plastic materials that are formed by the polymerization of monomers derived from acrylic or methacrylic acid. First used in Plexiglas, these compounds have a wide range of applications, including: paints, adhesives, dental composite resins, printing inks, and artificial nails. Acrylates also are used in a number of medical devices, including contact lenses, hearing aids, and bone cement for orthopedic endoprostheses.

While monomers are very strong irritants and allergens, fully polymerized acrylates are relatively inert. "Patch testing is tricky, and I think that’s something that we’re just finding out about the acrylates," said Dr. Belsito, a professor of clinical dermatology at Columbia University in New York. "They’re very volatile. The stability of the [patch test] allergens is a major issue, and they should be frozen or refrigerated."

In addition, the concentration necessary to reveal allergic sensitization is close to the irritancy threshold. These molecules also can induce active sensitization.

The North American Standard Series (Chemotechnique screening series) has been found to identify many cases of acrylate allergy caused by the inclusion of methyl methacrylate and ethyl acrylate in the series. However, clinicians should not rule out acrylate allergy even if the initial screening is negative. (Dermatitis 2011;22:98-101).

When patch tested, acrylate-allergic patients often display multiple positive tests. Previously, this was thought to be caused by cross-reaction. However, more recent analyses have shown that most acrylate-based industrial products contain many other acrylates as impurities – and thus are not included on the material safety data sheets.

"Many of the so-called cross reactions could in fact be concomitant reactions," noted Dr. Denis Sasseville in his article on acrylates, published in the January/February issue of Dermatitis (2012;23:6-16 [doi:10.1097/DER.obo13e31823d1b81]).

Methacrylates are tested at 2%, acrylates at 0.1%, and cyanoacrylates at 10%, according to Dr. Sasseville, who is a researcher in the division of dermatology at McGill University, Montreal. It is believed that patch testing with methyl methacrylate, 2-hydrorxymethyl methacrylate, ethyl acrylate, ethylene dimethacrylate, triethylene glycol diacrylate, and ethyl cyanoacrylate will identify most acrylate allergies.

The occupational exposure for dentists in particular is quite high; classic dental acrylics (including methyl acrylate) will cross through latex and vinyl gloves within minutes. Double gloving is suggested.

In one Finnish study of dental personnel, dentists and other dental personnel were most commonly exposed to 2-hydroxyethyl methacrylate, triethylene glycol dimethacrylate, and 3,3-bis[4-(2-hydroxy-3-methacryoxypropoxy) phenyl] propane (Contact Dermatitis 2007;57:324-30).

Both Dr. Belsito and Dr. Sasseville reported that they have no relevant disclosures.

SAN DIEGO – The ubiquitous acrylates take home the Contact Allergen of the Year title for 2012.

"We chose them because acrylates are everywhere in the environment," said Dr. Donald V. Belsito, who announced this year’s winner at the annual meeting of the American Contact Dermatitis Society.

© Andrey Popov/iStockphoto.com

Acrylates are plastic materials that are formed by the polymerization of monomers derived from acrylic or methacrylic acid. First used in Plexiglas, these compounds have a wide range of applications, including: paints, adhesives, dental composite resins, printing inks, and artificial nails. Acrylates also are used in a number of medical devices, including contact lenses, hearing aids, and bone cement for orthopedic endoprostheses.

While monomers are very strong irritants and allergens, fully polymerized acrylates are relatively inert. "Patch testing is tricky, and I think that’s something that we’re just finding out about the acrylates," said Dr. Belsito, a professor of clinical dermatology at Columbia University in New York. "They’re very volatile. The stability of the [patch test] allergens is a major issue, and they should be frozen or refrigerated."

In addition, the concentration necessary to reveal allergic sensitization is close to the irritancy threshold. These molecules also can induce active sensitization.

The North American Standard Series (Chemotechnique screening series) has been found to identify many cases of acrylate allergy caused by the inclusion of methyl methacrylate and ethyl acrylate in the series. However, clinicians should not rule out acrylate allergy even if the initial screening is negative. (Dermatitis 2011;22:98-101).

When patch tested, acrylate-allergic patients often display multiple positive tests. Previously, this was thought to be caused by cross-reaction. However, more recent analyses have shown that most acrylate-based industrial products contain many other acrylates as impurities – and thus are not included on the material safety data sheets.

"Many of the so-called cross reactions could in fact be concomitant reactions," noted Dr. Denis Sasseville in his article on acrylates, published in the January/February issue of Dermatitis (2012;23:6-16 [doi:10.1097/DER.obo13e31823d1b81]).

Methacrylates are tested at 2%, acrylates at 0.1%, and cyanoacrylates at 10%, according to Dr. Sasseville, who is a researcher in the division of dermatology at McGill University, Montreal. It is believed that patch testing with methyl methacrylate, 2-hydrorxymethyl methacrylate, ethyl acrylate, ethylene dimethacrylate, triethylene glycol diacrylate, and ethyl cyanoacrylate will identify most acrylate allergies.

The occupational exposure for dentists in particular is quite high; classic dental acrylics (including methyl acrylate) will cross through latex and vinyl gloves within minutes. Double gloving is suggested.

In one Finnish study of dental personnel, dentists and other dental personnel were most commonly exposed to 2-hydroxyethyl methacrylate, triethylene glycol dimethacrylate, and 3,3-bis[4-(2-hydroxy-3-methacryoxypropoxy) phenyl] propane (Contact Dermatitis 2007;57:324-30).

Both Dr. Belsito and Dr. Sasseville reported that they have no relevant disclosures.

SAN DIEGO – The ubiquitous acrylates take home the Contact Allergen of the Year title for 2012.

"We chose them because acrylates are everywhere in the environment," said Dr. Donald V. Belsito, who announced this year’s winner at the annual meeting of the American Contact Dermatitis Society.

© Andrey Popov/iStockphoto.com

Acrylates are plastic materials that are formed by the polymerization of monomers derived from acrylic or methacrylic acid. First used in Plexiglas, these compounds have a wide range of applications, including: paints, adhesives, dental composite resins, printing inks, and artificial nails. Acrylates also are used in a number of medical devices, including contact lenses, hearing aids, and bone cement for orthopedic endoprostheses.

While monomers are very strong irritants and allergens, fully polymerized acrylates are relatively inert. "Patch testing is tricky, and I think that’s something that we’re just finding out about the acrylates," said Dr. Belsito, a professor of clinical dermatology at Columbia University in New York. "They’re very volatile. The stability of the [patch test] allergens is a major issue, and they should be frozen or refrigerated."

In addition, the concentration necessary to reveal allergic sensitization is close to the irritancy threshold. These molecules also can induce active sensitization.

The North American Standard Series (Chemotechnique screening series) has been found to identify many cases of acrylate allergy caused by the inclusion of methyl methacrylate and ethyl acrylate in the series. However, clinicians should not rule out acrylate allergy even if the initial screening is negative. (Dermatitis 2011;22:98-101).

When patch tested, acrylate-allergic patients often display multiple positive tests. Previously, this was thought to be caused by cross-reaction. However, more recent analyses have shown that most acrylate-based industrial products contain many other acrylates as impurities – and thus are not included on the material safety data sheets.

"Many of the so-called cross reactions could in fact be concomitant reactions," noted Dr. Denis Sasseville in his article on acrylates, published in the January/February issue of Dermatitis (2012;23:6-16 [doi:10.1097/DER.obo13e31823d1b81]).

Methacrylates are tested at 2%, acrylates at 0.1%, and cyanoacrylates at 10%, according to Dr. Sasseville, who is a researcher in the division of dermatology at McGill University, Montreal. It is believed that patch testing with methyl methacrylate, 2-hydrorxymethyl methacrylate, ethyl acrylate, ethylene dimethacrylate, triethylene glycol diacrylate, and ethyl cyanoacrylate will identify most acrylate allergies.

The occupational exposure for dentists in particular is quite high; classic dental acrylics (including methyl acrylate) will cross through latex and vinyl gloves within minutes. Double gloving is suggested.

In one Finnish study of dental personnel, dentists and other dental personnel were most commonly exposed to 2-hydroxyethyl methacrylate, triethylene glycol dimethacrylate, and 3,3-bis[4-(2-hydroxy-3-methacryoxypropoxy) phenyl] propane (Contact Dermatitis 2007;57:324-30).

Both Dr. Belsito and Dr. Sasseville reported that they have no relevant disclosures.

MIAMI – Some hallmark signs of dermatologic problems in children – especially erythema and hyperpigmentation – often are less obvious in children with skin of color and can require more clinical detective work to diagnose.

Dr. Patricia A. Treadwell narrowed down the most likely dermatoses a pediatrician will encounter in this patient population at a pediatric update sponsored by Miami Children’s Hospital. Atopic and contact dermatitis, phytophotodermatitis, transient neonatal pustular melanosis, and neonatal lupus erythematosus are among the noteworthy clinical challenges, she said at the meeting.

"Children with increased pigmentation in their skin may end up testing your knowledge in terms of looking at their dermatitis and being able to diagnose that. Keep in mind it may be a little bit different in terms of the clinical presentation, but it’s important to identify it and start the proper treatment," said Dr. Treadwell, a pediatric dermatologist at Indiana University Health and Riley Hospital for Children in Indianapolis.

Overcoming this "masking" of a condition by skin pigmentation can be important, Dr. Treadwell said. She cited a patient born with a port-wine stain that went undiagnosed. The infant had subtle erythema and some asymmetry related to the overgrowth of the lesion. "This was not diagnosed based on the fact that the erythema was not apparent. The patient later developed a pyogenic granuloma, which is a complication that can be seen in patients with port-wine stains as they get older."

Photos courtesy Dr. Patricia A. Treadwell

Erythema can be missed in children of color with atopic dermatitis as well. For this reason, atopic dermatitis may be underdiagnosed in this population overall, she said. Another challenge is the common practice of grading the severity of atopic dermatitis in lighter-skinned patients based on the degree of erythema. "In children with a fair amount of pigmentation in their skin, the erythema may not be noted and the severity will not be recognized."

Similarly, you might need a higher index of clinical suspicion to diagnose a child of color with contact dermatitis. Again, the erythema can be subtle. In contrast, "contact dermatitis can be very clear in a Caucasian patient. But the lesions are the same – linear, asymmetrical, and occurring on exposed areas," Dr. Treadwell said. Pruritus is common, and edema and swelling also occur. Watch for development of vesiculobullous lesions.

Phytophotodermatitis is another dermatologic condition that may require some additional detective work in children of color. Dr. Treadwell described a girl with a unique hyperpigmentation pattern on her legs and arms. She was referred following a vacation in Cancun, Mexico, with her family, and there was a concern about an autoimmune process. "They asked if she needed blood work. I said no, she was eating a mango and went out in the sun." Some of the mango juice splashed on her legs and arms.

Phytophotodermatitis occurs when furocoumarins from tropical fruit, citrus, celery, fennel, or parsnip come into contact with skin subsequently exposed to the sun.

"This condition can have a fairly bizarre pattern of presentation," Dr. Treadwell said. "Again, if there is more pigment in the skin, hyperpigmentation can present in a less common way than might be expected."

Some dermatoses are noted more commonly in children of color, she said. For example, the hyperpigmented macules or pustules that characterize transient neonatal pustular melanosis are reported in 4.4% of African American infants and 0.2% of Caucasian infants. "The percentages here may be related to the pigmentation in the skin. This does occur in Caucasian infants, but it may not be as noticeable."

The condition can be present at birth. The macules and pustules can appear anywhere on the body, but most often on the chin, neck, upper chest, and/or lower back. The good news is they fade over time and are benign, so no treatment is necessary. The differential diagnosis from such conditions as herpes simplex and erythema toxicum is important, however, said Dr. Treadwell. One tip is to check for lesions on the palms and soles, which can be diagnostic in transient neonatal pustular melanosis, but not for erythema toxicum. A biopsy can confirm your clinical suspicions.

The cutaneous manifestations of neonatal lupus erythematosus can tip you off to this condition, she said. Skin lesions can be annular, discoid, or atrophic. Some children present with "raccoon eyes." Because this condition is related to maternal antibodies passed through the placenta during gestation, lesions generally clear by 6 months to 1 year of age.

The mother may have a diagnosis of an autoimmune disease, or she may be completely asymptomatic. In one instance, a mother brought her newborn to Dr. Treadwell’s clinic. He had annular lesions on his forehead with some erythema. The lesions were more edematous around the edges. He actually got some sun exposure between his first and second visits, and developed more-discoid lesions in his sun-exposed areas. He also presented with lesions in non–sun exposed areas.

"The mother had a positive ANA [antinuclear antibody] test. I told her she should go to her doctor for urine and blood pressure monitoring," Dr. Treadwell said. "She had no symptoms and thought I didn’t know what I was talking about." Two years later, the woman returned with a newborn daughter who also had neonatal lupus with lesions on her face and some patchy alopecia on her scalp.

"The brother came back in, ... and he had telangiectasias already present at age 2 years."

Your evaluation can be more family centered. Consider testing the parent and affected children for anti-Rho, anti-La, and anti-RNP.

"I usually treat them with sun avoidance, sun protection, and possibly hydrocortisone," Dr. Treadwell said. She also recommends one electrocardiogram to rule out any cardiac consequences.

Dr. Treadwell reported that she had no relevant financial disclosures.

MIAMI – Some hallmark signs of dermatologic problems in children – especially erythema and hyperpigmentation – often are less obvious in children with skin of color and can require more clinical detective work to diagnose.

Dr. Patricia A. Treadwell narrowed down the most likely dermatoses a pediatrician will encounter in this patient population at a pediatric update sponsored by Miami Children’s Hospital. Atopic and contact dermatitis, phytophotodermatitis, transient neonatal pustular melanosis, and neonatal lupus erythematosus are among the noteworthy clinical challenges, she said at the meeting.

"Children with increased pigmentation in their skin may end up testing your knowledge in terms of looking at their dermatitis and being able to diagnose that. Keep in mind it may be a little bit different in terms of the clinical presentation, but it’s important to identify it and start the proper treatment," said Dr. Treadwell, a pediatric dermatologist at Indiana University Health and Riley Hospital for Children in Indianapolis.

Overcoming this "masking" of a condition by skin pigmentation can be important, Dr. Treadwell said. She cited a patient born with a port-wine stain that went undiagnosed. The infant had subtle erythema and some asymmetry related to the overgrowth of the lesion. "This was not diagnosed based on the fact that the erythema was not apparent. The patient later developed a pyogenic granuloma, which is a complication that can be seen in patients with port-wine stains as they get older."

Photos courtesy Dr. Patricia A. Treadwell

Erythema can be missed in children of color with atopic dermatitis as well. For this reason, atopic dermatitis may be underdiagnosed in this population overall, she said. Another challenge is the common practice of grading the severity of atopic dermatitis in lighter-skinned patients based on the degree of erythema. "In children with a fair amount of pigmentation in their skin, the erythema may not be noted and the severity will not be recognized."

Similarly, you might need a higher index of clinical suspicion to diagnose a child of color with contact dermatitis. Again, the erythema can be subtle. In contrast, "contact dermatitis can be very clear in a Caucasian patient. But the lesions are the same – linear, asymmetrical, and occurring on exposed areas," Dr. Treadwell said. Pruritus is common, and edema and swelling also occur. Watch for development of vesiculobullous lesions.

Phytophotodermatitis is another dermatologic condition that may require some additional detective work in children of color. Dr. Treadwell described a girl with a unique hyperpigmentation pattern on her legs and arms. She was referred following a vacation in Cancun, Mexico, with her family, and there was a concern about an autoimmune process. "They asked if she needed blood work. I said no, she was eating a mango and went out in the sun." Some of the mango juice splashed on her legs and arms.

Phytophotodermatitis occurs when furocoumarins from tropical fruit, citrus, celery, fennel, or parsnip come into contact with skin subsequently exposed to the sun.

"This condition can have a fairly bizarre pattern of presentation," Dr. Treadwell said. "Again, if there is more pigment in the skin, hyperpigmentation can present in a less common way than might be expected."

Some dermatoses are noted more commonly in children of color, she said. For example, the hyperpigmented macules or pustules that characterize transient neonatal pustular melanosis are reported in 4.4% of African American infants and 0.2% of Caucasian infants. "The percentages here may be related to the pigmentation in the skin. This does occur in Caucasian infants, but it may not be as noticeable."

The condition can be present at birth. The macules and pustules can appear anywhere on the body, but most often on the chin, neck, upper chest, and/or lower back. The good news is they fade over time and are benign, so no treatment is necessary. The differential diagnosis from such conditions as herpes simplex and erythema toxicum is important, however, said Dr. Treadwell. One tip is to check for lesions on the palms and soles, which can be diagnostic in transient neonatal pustular melanosis, but not for erythema toxicum. A biopsy can confirm your clinical suspicions.

The cutaneous manifestations of neonatal lupus erythematosus can tip you off to this condition, she said. Skin lesions can be annular, discoid, or atrophic. Some children present with "raccoon eyes." Because this condition is related to maternal antibodies passed through the placenta during gestation, lesions generally clear by 6 months to 1 year of age.

The mother may have a diagnosis of an autoimmune disease, or she may be completely asymptomatic. In one instance, a mother brought her newborn to Dr. Treadwell’s clinic. He had annular lesions on his forehead with some erythema. The lesions were more edematous around the edges. He actually got some sun exposure between his first and second visits, and developed more-discoid lesions in his sun-exposed areas. He also presented with lesions in non–sun exposed areas.

"The mother had a positive ANA [antinuclear antibody] test. I told her she should go to her doctor for urine and blood pressure monitoring," Dr. Treadwell said. "She had no symptoms and thought I didn’t know what I was talking about." Two years later, the woman returned with a newborn daughter who also had neonatal lupus with lesions on her face and some patchy alopecia on her scalp.

"The brother came back in, ... and he had telangiectasias already present at age 2 years."

Your evaluation can be more family centered. Consider testing the parent and affected children for anti-Rho, anti-La, and anti-RNP.

"I usually treat them with sun avoidance, sun protection, and possibly hydrocortisone," Dr. Treadwell said. She also recommends one electrocardiogram to rule out any cardiac consequences.

Dr. Treadwell reported that she had no relevant financial disclosures.

MIAMI – Some hallmark signs of dermatologic problems in children – especially erythema and hyperpigmentation – often are less obvious in children with skin of color and can require more clinical detective work to diagnose.

Dr. Patricia A. Treadwell narrowed down the most likely dermatoses a pediatrician will encounter in this patient population at a pediatric update sponsored by Miami Children’s Hospital. Atopic and contact dermatitis, phytophotodermatitis, transient neonatal pustular melanosis, and neonatal lupus erythematosus are among the noteworthy clinical challenges, she said at the meeting.

"Children with increased pigmentation in their skin may end up testing your knowledge in terms of looking at their dermatitis and being able to diagnose that. Keep in mind it may be a little bit different in terms of the clinical presentation, but it’s important to identify it and start the proper treatment," said Dr. Treadwell, a pediatric dermatologist at Indiana University Health and Riley Hospital for Children in Indianapolis.

Overcoming this "masking" of a condition by skin pigmentation can be important, Dr. Treadwell said. She cited a patient born with a port-wine stain that went undiagnosed. The infant had subtle erythema and some asymmetry related to the overgrowth of the lesion. "This was not diagnosed based on the fact that the erythema was not apparent. The patient later developed a pyogenic granuloma, which is a complication that can be seen in patients with port-wine stains as they get older."

Photos courtesy Dr. Patricia A. Treadwell

Erythema can be missed in children of color with atopic dermatitis as well. For this reason, atopic dermatitis may be underdiagnosed in this population overall, she said. Another challenge is the common practice of grading the severity of atopic dermatitis in lighter-skinned patients based on the degree of erythema. "In children with a fair amount of pigmentation in their skin, the erythema may not be noted and the severity will not be recognized."

Similarly, you might need a higher index of clinical suspicion to diagnose a child of color with contact dermatitis. Again, the erythema can be subtle. In contrast, "contact dermatitis can be very clear in a Caucasian patient. But the lesions are the same – linear, asymmetrical, and occurring on exposed areas," Dr. Treadwell said. Pruritus is common, and edema and swelling also occur. Watch for development of vesiculobullous lesions.

Phytophotodermatitis is another dermatologic condition that may require some additional detective work in children of color. Dr. Treadwell described a girl with a unique hyperpigmentation pattern on her legs and arms. She was referred following a vacation in Cancun, Mexico, with her family, and there was a concern about an autoimmune process. "They asked if she needed blood work. I said no, she was eating a mango and went out in the sun." Some of the mango juice splashed on her legs and arms.

Phytophotodermatitis occurs when furocoumarins from tropical fruit, citrus, celery, fennel, or parsnip come into contact with skin subsequently exposed to the sun.

"This condition can have a fairly bizarre pattern of presentation," Dr. Treadwell said. "Again, if there is more pigment in the skin, hyperpigmentation can present in a less common way than might be expected."

Some dermatoses are noted more commonly in children of color, she said. For example, the hyperpigmented macules or pustules that characterize transient neonatal pustular melanosis are reported in 4.4% of African American infants and 0.2% of Caucasian infants. "The percentages here may be related to the pigmentation in the skin. This does occur in Caucasian infants, but it may not be as noticeable."

The condition can be present at birth. The macules and pustules can appear anywhere on the body, but most often on the chin, neck, upper chest, and/or lower back. The good news is they fade over time and are benign, so no treatment is necessary. The differential diagnosis from such conditions as herpes simplex and erythema toxicum is important, however, said Dr. Treadwell. One tip is to check for lesions on the palms and soles, which can be diagnostic in transient neonatal pustular melanosis, but not for erythema toxicum. A biopsy can confirm your clinical suspicions.

The cutaneous manifestations of neonatal lupus erythematosus can tip you off to this condition, she said. Skin lesions can be annular, discoid, or atrophic. Some children present with "raccoon eyes." Because this condition is related to maternal antibodies passed through the placenta during gestation, lesions generally clear by 6 months to 1 year of age.

The mother may have a diagnosis of an autoimmune disease, or she may be completely asymptomatic. In one instance, a mother brought her newborn to Dr. Treadwell’s clinic. He had annular lesions on his forehead with some erythema. The lesions were more edematous around the edges. He actually got some sun exposure between his first and second visits, and developed more-discoid lesions in his sun-exposed areas. He also presented with lesions in non–sun exposed areas.

"The mother had a positive ANA [antinuclear antibody] test. I told her she should go to her doctor for urine and blood pressure monitoring," Dr. Treadwell said. "She had no symptoms and thought I didn’t know what I was talking about." Two years later, the woman returned with a newborn daughter who also had neonatal lupus with lesions on her face and some patchy alopecia on her scalp.

"The brother came back in, ... and he had telangiectasias already present at age 2 years."

Your evaluation can be more family centered. Consider testing the parent and affected children for anti-Rho, anti-La, and anti-RNP.

"I usually treat them with sun avoidance, sun protection, and possibly hydrocortisone," Dr. Treadwell said. She also recommends one electrocardiogram to rule out any cardiac consequences.

Dr. Treadwell reported that she had no relevant financial disclosures.

NAPA, CALIF. – There is little risk that patients with orthopedic metal implants will have a skin reaction or joint pain from the device, said Dr. Joseph F. Fowler.

"I do patch test patients ... who have concerns about a metal allergy or are going to have an implant. I tell them if they have a positive patch test, they may have a skin reaction," said Dr. Fowler. However, there is a small chance they will have a cutaneous reaction, and a smaller chance they will have problems with the joint.

Metals used in orthopedic implants include stainless steel, which is composed of an iron-chromium alloy plus nickel and molybdenum, and sometimes a little chromium and titanium; nitinol (55% nickel and 45% titanium); vitallium (iron cobalt plus chromium 30% and molybdenum 5%); and titanium. Two of the four metals contain nickel, a common contact allergen, noted Dr. Fowler, a dermatologist at the University of Louisville (Ky.).

When it comes to joint pain from implants, findings from a small German study of 15 patients showed that levels of the inflammatory marker interleukin-17 (IL-17) were increased in only those patients with nickel containing replacement joints who both had a positive patch test to nickel and complaints of joint pain. IL-17 levels were not increased in patients with a positive patch test to nickel who did not complain of joint pain (Contact Dermatitis 2010;63:15-22).

In an unpublished study, Dr. James Taylor of the Cleveland Clinic found that 60% of a small group of patients (10) with a metal implant who had a positive patch to metal experienced resolution of joint pain after the metal was replaced. "There is getting to be more and more of a suggestion that metal allergies and joint problems do go hand in hand," said Dr. Fowler.

If you just had to guess what would be the best material to put in a patient who with a chance of a metal allergy, titanium is the best bet, he said. "It comes down to a medical legal question. Will doctors and patients accept a small amount of risk if there is an implant that is better than titanium?"

He said that he will patch test patients if requested by the physician who will be performing the implant surgery, but it is not normally done because there is less than a 1% chance that even if they do have a positive patch test to metal, dermatitis will occur. There have been reports, although rare, that a metal allergy may cause joint failure, but prospective studies are needed, he said.

Dr. Fowler reported financial conflicts of interest with multiple pharmaceutical companies.

NAPA, CALIF. – There is little risk that patients with orthopedic metal implants will have a skin reaction or joint pain from the device, said Dr. Joseph F. Fowler.

"I do patch test patients ... who have concerns about a metal allergy or are going to have an implant. I tell them if they have a positive patch test, they may have a skin reaction," said Dr. Fowler. However, there is a small chance they will have a cutaneous reaction, and a smaller chance they will have problems with the joint.

Metals used in orthopedic implants include stainless steel, which is composed of an iron-chromium alloy plus nickel and molybdenum, and sometimes a little chromium and titanium; nitinol (55% nickel and 45% titanium); vitallium (iron cobalt plus chromium 30% and molybdenum 5%); and titanium. Two of the four metals contain nickel, a common contact allergen, noted Dr. Fowler, a dermatologist at the University of Louisville (Ky.).

When it comes to joint pain from implants, findings from a small German study of 15 patients showed that levels of the inflammatory marker interleukin-17 (IL-17) were increased in only those patients with nickel containing replacement joints who both had a positive patch test to nickel and complaints of joint pain. IL-17 levels were not increased in patients with a positive patch test to nickel who did not complain of joint pain (Contact Dermatitis 2010;63:15-22).

In an unpublished study, Dr. James Taylor of the Cleveland Clinic found that 60% of a small group of patients (10) with a metal implant who had a positive patch to metal experienced resolution of joint pain after the metal was replaced. "There is getting to be more and more of a suggestion that metal allergies and joint problems do go hand in hand," said Dr. Fowler.

If you just had to guess what would be the best material to put in a patient who with a chance of a metal allergy, titanium is the best bet, he said. "It comes down to a medical legal question. Will doctors and patients accept a small amount of risk if there is an implant that is better than titanium?"

He said that he will patch test patients if requested by the physician who will be performing the implant surgery, but it is not normally done because there is less than a 1% chance that even if they do have a positive patch test to metal, dermatitis will occur. There have been reports, although rare, that a metal allergy may cause joint failure, but prospective studies are needed, he said.

Dr. Fowler reported financial conflicts of interest with multiple pharmaceutical companies.

NAPA, CALIF. – There is little risk that patients with orthopedic metal implants will have a skin reaction or joint pain from the device, said Dr. Joseph F. Fowler.

"I do patch test patients ... who have concerns about a metal allergy or are going to have an implant. I tell them if they have a positive patch test, they may have a skin reaction," said Dr. Fowler. However, there is a small chance they will have a cutaneous reaction, and a smaller chance they will have problems with the joint.

Metals used in orthopedic implants include stainless steel, which is composed of an iron-chromium alloy plus nickel and molybdenum, and sometimes a little chromium and titanium; nitinol (55% nickel and 45% titanium); vitallium (iron cobalt plus chromium 30% and molybdenum 5%); and titanium. Two of the four metals contain nickel, a common contact allergen, noted Dr. Fowler, a dermatologist at the University of Louisville (Ky.).

When it comes to joint pain from implants, findings from a small German study of 15 patients showed that levels of the inflammatory marker interleukin-17 (IL-17) were increased in only those patients with nickel containing replacement joints who both had a positive patch test to nickel and complaints of joint pain. IL-17 levels were not increased in patients with a positive patch test to nickel who did not complain of joint pain (Contact Dermatitis 2010;63:15-22).

In an unpublished study, Dr. James Taylor of the Cleveland Clinic found that 60% of a small group of patients (10) with a metal implant who had a positive patch to metal experienced resolution of joint pain after the metal was replaced. "There is getting to be more and more of a suggestion that metal allergies and joint problems do go hand in hand," said Dr. Fowler.

If you just had to guess what would be the best material to put in a patient who with a chance of a metal allergy, titanium is the best bet, he said. "It comes down to a medical legal question. Will doctors and patients accept a small amount of risk if there is an implant that is better than titanium?"

He said that he will patch test patients if requested by the physician who will be performing the implant surgery, but it is not normally done because there is less than a 1% chance that even if they do have a positive patch test to metal, dermatitis will occur. There have been reports, although rare, that a metal allergy may cause joint failure, but prospective studies are needed, he said.

Dr. Fowler reported financial conflicts of interest with multiple pharmaceutical companies.