Tx: Remove the item, apply topical steroids
Acute episodes of nickel dermatitis are treated with topical steroid creams to break the scratch-itch cycle (which potentiates the reaction) and to reduce the inflammation. This tactic is futile, however, if the allergen remains in contact with the skin. The source of the nickel must be identified and eliminated by the patient, as was done by the 5 patients we cared for.
Clothing accessories containing nickel, such as buckles, zippers, buttons, and metal clips, must be eliminated, as well as other sources of nickel: jewelry, watches, eyeglasses, and cell phones. The situation is complicated by the fact that many patients have underlying atopic eczema/irritant dermatitis, and patients may have more than 1 form of allergic contact dermatitis. For instance, self-treatment with neomycin-containing topical antibiotics may lead to superimposed allergic contact dermatitis from this agent.
Easy preventive steps. Routine prophylactic measures should focus on eliminating exposure to nickel from all identifiable sources. You can suggest that your patient with nickel dermatitis:
- Use a clear plastic cover over the nickel-containing parts of a cell phone.
- Apply a clear coat of nail polish to the buttons and rivets on pants; this can prevent nickel release and will last through at least 2 wash and dry cycles.17 (Tucking shirts in to prevent buttons and belt buckles from touching the skin is generally ineffective; not only is the shirt unlikely to stay in place all day, but perspiration and friction can also cause problems.)
- Use other barrier coatings, such as Nickel Guard and Beauty Secrets Hardener, which may be effective in preventing contact dermatitis.18
- Replace rivets on pants with a plastic button, or cover the rivet with a sew-on denim patch. This offers a more permanent approach to eliminating nickel exposure.
- Use plastic covers for earring studs.
- Replace metal eyeglass frames with ones made out of plastic.
- Choose “hypoallergenic” or nickel-free jewelry. Of note, though: Nickel may be present in jewelry labeled hypoallergenic. The patient can perform a DMG test to verify its nickel content.
In patients who continue to react in the absence of nickel jewelry, co-sensitization to gold must be considered, as many patients do react to multiple metals. Gold is a more common allergen than previously reported and is statistically linked to allergic reactions to nickel and cobalt metals.19 Unlike nickel dermatitis, the clinical relevance of a positive gold patch test is harder to ascertain because rashing distant from areas in direct contact with gold jewelry often occurs. In fact, in some cases of eyelid dermatitis induced by contact allergy to gold, titanium dioxide particles on the skin from cosmetics and sunscreen are thought to adsorb gold particles and carry them to the eyelids.
Disclosure
Dr. Brodell reports that he receives grants/research support from Amgen Inc., Doak Dermatologics, Galderma, and OrthoNeutrogena. He serves as a consultant for, or is on the speakers bureau of, 3M/Graceway Pharmaceuticals, Allergan, CollagGenex Pharmaceuticals, Connetics Corp., Dermik/BenzaClin, Galderma, Genentech, Inc., Genentech/ Raptiva, GlaxoSmithKline, Janssen, MDsConnect.net, Medicis, Novartis Pharmaceuticals Corp., Pedinol Pharmacal, Inc., Roerig-Pfizer, Sandoz/Novartis, sanofi-aventis, Sirius Laboratories, Stiefel, Westwood-Squibb, and Upjohn. Ms. Uhlenhake and Dr. Nedorost reported no potential conflict of interest relevant to this article.
CORRESPONDENCE
Robert Brodell, MD, 2660 East Market Street, Warren, OH 44483; rtb@neoucom.edu