dermatite purpurica

1. © 2000 European Academy of Dermatology and Venereology 101
ORIGINAL ARTICLE
JEADV (2000) 14, 101–105
Blackwell Science, Ltd
Purpuric contact dermatitis in patients with allergic reaction to
textile dyes and resins
A Lazarov,1* M Cordoba2
1Dermatology Clinic and 2Department of Pathological Anatomy, Sapir Medical Center, Meir Hospital, 44281 Kfar Saba, Israel.
*Corresponding author, tel. +972 3647 36 55; fax +972 3648 24 26; E-mail: lazarov1@netvision.net.il
ABSTRACT
Background Purpuric lesions have been described as an uncommon manifestation of allergic contact
dermatitis in individual case reports.
Objective We describe a series of patients who developed purpuric allergic contact dermatitis to textile dyes
and resins in their personal clothing. Our purpose was to study the patients clinically and histopatholo-
gically and to define the most frequent allergens, which cause purpuric allergic contact dermatitis.
Methods One hundred and three patients were clinically evaluated and tested with the Textile Color &
Finish Series (TCFS) (Chemotechnique Diagnostics) and Standard Series (TRUE Tests) because of suspected
allergic contact dermatitis (ACD) to clothing. The patients with clinical features of purpura as presenting
sign of ACD were studied. Biopsies from the purpuric lesions were performed in three patients.
Results Thirty of the 103 patients (29.1%) had positive reaction to an allergen from the TCFS. Clinically
purpuric ACD was observed in 8.7% of all the cases studied (n = 9 of 103). Nine of the 30 patch-positive
patients to the TCFS (30%) demonstrated purpuric macules, papules and patches. Patch testing of the
nine patients with purpuric contact dermatitis, with the TCFS, resulted in 26 positive patch test results.
The major causative allergens were the following: Disperse Blue 106 and Disperse Blue 124 in 26.9% each,
Disperse Blue 85 in 11.5%, and ethyleneurea melamine formaldehyde in 7.7%. Positive patch tests were
observed to dimethylol dihydroxyethyleneurea, dimethylol propyleneurea, tetramethylol acetylenediurea,
urea formaldehyde, melamine formaldehyde, Disperse Red 17, and Basic Red 46 3.8% in each. Purpuric
patch test reaction was observed in five cases. The patch test results had present relevance in all the cases.
Lesional biopsies demonstrated acanthosis, spongiosis and parakeratosis. The blood vessels were dilated,
without signs of vasculitis. The inflammatory infiltrate was composed of lymphocytes and erythrocytes.
The extravasated erythrocytes had a perivascular and interstitial distribution in the superficial and deep
plexus and were observed at the dermo–epidermal junction as well as in the epidermis.
Conclusion Purpuric contact dermatitis is not an uncommon clinical form of ACD to textile dyes and resins.
New allergens, which can evoke the development of purpuric allergic contact dermatitis and have not been
described in the literature until now include: ethyleneurea melamineformaldehyde, dimethylol dihydrox-
yethyleneurea, tetramethylol acetylenediurea, urea formaldehyde, melamine formaldehyde and Disperse
Red 17.
Key words: purpuric contact dermatitis, purpura, allergic contact dermatitis, clothing, textile dyes and resins
Received: 15 July 1999, accepted 17 February 2000
Introduction
Purpuric lesions have been described as an uncommon
manifestation of allergic contact dermatitis (ACD).1 The aetio-
logical agents that have provoked purpuric allergic contact
dermatitis are listed in Table 1.
We describe a series of patients who developed purpuric
allergic contact dermatitis to textile dyes and resins in their
apparel.
Patients and methods
During 1998, 103 patients were evaluated clinically and
tested with the Textile Color & Finish Series (TCFS)
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(Chemotechnique Diagnostics) and Standard Series (TRUE
Tests) with suspected ACD to clothing. The patch tests were
applied to unaffected skin of the upper back, removed at
2 days, read at days 2, 3, and 7 and graded according to
standard patch test definitions.
The patients with clinical features of purpura as a presenting
sign of ACD were studied. Biopsies from the purpuric lesions
were performed in three patients and from the purpuric patch
tests in five patients. Routine blood count and prothrombin
time were also performed. The patients were not taking medica-
tions affecting coagulation during the time of this study.
Results
Thirty of the 103 patients (29.1%) had positive reaction to an
allergen from the Textile Color & Finish Series. Purpuric ACD
was observed clinically in 8.7% of all the cases studied (n = 9
of 103 patients). Nine of the 30 patch-positive patients to the
TCFS (30%) presented with clinical features of purpura
namely: purpuric macules, papules and patches. Eight of the
patients with purpuric ACD were females and one was male.
None of the patients had atopic dermatitis, seasonal rhinitis
or asthma. The average duration of the skin disease prior to
fig. 1 Purpuric macules and patches on the breast after wearing a blue
coloured brassiere, in a patient with allergic reaction to Disperse Blue 106
and 124.
Table 1 Aetiological agents causing purpuric allergic contact dermatitis
1 Rubber chemicals
1.1 IPPD in rubber clothing2
1.2 IPPD in rubber boots3
1.3 IPPD in rubber diving suits, rubberized supporting
bandage4
1.4 Elastic in underwear5
1.5 Diphenylthiourea6
2 Unprocessed wool7
3 Woolen garments8
4 Medicaments
4.1 Apronalide9
4.2 Quinidine9
4.3 Ointments containing balsam of Peru10
4.4 Proflavine11
4.5 Benzoyl peroxide12
5 Dyes and textile resins and finishes
5.1 P-Phenylenediamine13
5.2 Disperse Blue 85 (14 and present study)
5.3 Disperse Yellow 2715
5.4 Disperse Blue 106 (present study)
5.5 Disperse Blue 124 (present study)
5.6 Basic Red 46 (16 and present study)
5.7 Disperse Red 17 (present study)
5.8 Dimethylol propylene urea17
5.9 Ethyleneurea melamineformadehyde (present study)
5.10 Dimethylol dihydroxyethyleneurea (present study)
5.11 Tetramethylol acetylenediurea (present study)
5.12 Urea formaldehyde (present study)
5.13 Melamine formaldehyde (present study)
6 Occupational
6.1 Black felt millinery13
6.2 Formaldehyde resins18
fig. 2 Purpuric papules and nodules on the thighs of a woman, who wore
blue synthetic trousers and had allergic reaction to Disperse Blue 106 and 124.
fig. 3 Punctiform purpura resembling chronic pigmented purpura on both
shins caused by blue and black stockings in a patient allergic to Disperse
Blue 106 and 124. The lesions disappeared completely after stopping the
contact with the stockings.
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diagnosis was of 7.7 months. Disseminated purpuric lesions over
the trunk and the extremities were present in five patients. In
four cases the lower extremities were mainly affected.
Clinically, the purpuric lesions comprised purpuric
macules and patches in five patients (fig. 1), purpuric papules
and nodules in two (fig. 2) and punctiform pigmented
purpura on the lower extremities in two (fig. 3). In most of
the cases the purpuric eruption was present along with other
lesions, such as erythemato-squamous patches and hyperpig-
mented plaques. One patient presented with erythrodermia
sparing the face and the submammary area admixed with
purpuric macules on the folds and lower extremities. In three
patients the ACD was so severe as to require systemic steroid
treatment.
The garments provoking the purpuric ACD were personal
clothing, mainly blue and black synthetic garments and stock-
ings in six cases, red stretching trousers in one, dark personal
clothing and blue bedspreads in two patients.
Patch testing of the nine patients with purpuric contact der-
matitis, with the TCFS, resulted in 26 positive patch test results.
The causative allergens and their incidence are displayed in
Table 2. The positive patch test results persisted until the day 7
reading in seven patients. Positive results from the standard
series included allergic reaction to fragrance mix in two patients,
and nickel sulphate, potassium dichromate, quaternium, black
rubber mix, formaldehyde and colophony, respectively, in one
patient each.
Biopsies from the purpuric lesions were performed in three
cases and the results are presented on Table 3. Acanthosis,
spongiosis and dilatation of the blood vessels were observed in
all the biopsies. There was no evidence of vasculitis in any of
the specimen studied. The inflammatory infiltrate was com-
posed mainly of lymphocytes (fig. 4), and in one case some
eosinophils were seen. The extravasated erythrocytes had a
perivascular and interstitial distribution in the superficial or
superficial and deep plexuses (fig. 4). In one case erythrocytes
were present at the dermoepidermal junction (fig. 5) and in
another in the epidermis.
Purpuric macules and papules were seen at the site of the
positive patch tests in five cases. Punch biopsies from the purpuric
patch tests demonstrated generalized or focal spongiosis in the
epidemis, with or without acanthosis, dilated blood vessels,
some oedema of the endothelial cells and different degree of
Table 3 Histopathological findings in lesional biopsies from the purpuric allergic contact dermatitis
Case 1 Punctiform purpura Case 2 Purpuric patches Case 3 Purpuric nodules
Epidermis
Acanthosis + 1 + 3 + 3
Parakeratosis 0 + 1 + 1
Exocytosis 0 + 2 + 3
Generalized spongiosis + 1 + 2 + 2
Focal spongiosis + 2 + 1 + 3
Erythrocytes in the epidermis + 1 0 0
Dermis
Dilatation of blood vessels + 1 + 2 + 2
Edema of endothelial cells 0 + 1 + 1
Edema in the upper dermis 0 + 2 + 2
Vasculitis 0 0 0
Lymphocytic inflammatory infiltrate + 1 + 3 + 3
perivascular perivascular perivascular
superficial plexus superficial and deep plexus superficial and deep plexus
Perivascular erythrocytes + 1 + 1 + 3
superficial and deep plexus
Interstitial erythrocytes in the dermis 0 + 3 + 2
Erythrocytes at the Dermo-epidermal junction 0 + 1 0
+ 1 – mild; + 2 – moderate; + 3 – severe
Table 2 Positive patch test reactions
Positive results
Allergen (n = 26) %
Disperse Blue 106 7 26.9%
Disperse Blue 124 7 26.9%
Disperse Blue 85 3 11.5%
Ethyleneurea melamine formaldehyde 2 7.7%
Dimethylol dihydroxyethyleneurea 1 3.8%
Dimethylol propyleneurea 1 3.8%
Tetramethylol acetylenediurea 1 3.8%
Urea formaldehyde 1 3.8%
Melamine formaldehyde 1 3.8%
Disperse Red 17 1 3.8%
Basic Red 46 1 3.8%
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extravasated erythrocytes in the dermis as well as in the epidermis.
Signs of vasculitis were not observed in any of the biopsies.
There was a striking resemblance in the histopathological find-
ings between the lesional biopsies and those taken from the
purpuric patch tests.
The patch test results were relevant in all the cases. The skin
eruption cleared on an average period of 45 days after stopping
the contact with the incriminated textile. Most of the patients
have stayed free of lesions for more than a year, wearing
mainly light-coloured clothes. In two patients recidives were
observed, when having been in contact with dark synthetic
textiles.
Discussion
Several authors have reported purpuric contact dermatitis
caused by clothing in the past.2,4,5,13–15 Textile dyes namely
p-phenylenediamine,13 Disperse Blue 85,14 Disperse Yellow
2715, Basic Red 4616 and formaldehyde resins17,18 have been
described as the cause of purpuric ACD in only individual
case reports.
In our series, purpuric macules, papules and plaques were
observed in 8.7% of all the patients studied. Purpuric lesions
along with other manifestations of ACD were seen in up to
30% of our patch-positive patients. This comparatively high
frequency demonstrates that textile dyes and resins are cap-
able of inducing purpuric ACD and purpuric patch tests. In
our experience purpuric contact dermatitis was not an
uncommon, but a rather frequent manifestation of ACD to
azo dyes. This phenomenon could be due in part, to the
climatic factors in Israel, characterized by very high tem-
peratures and humidity lasting for 6–9 months per year. The
hot and humid climate favours profuse sweating and thus
enhances the exposure to the allergens and increases their
penetration.
Purpuric contact dermatitis (CD) may be of toxic19 or allergic
origin.13–18 In all our patients the purpuric CD was a mani-
festation of an allergic reaction to textile dyes and resins, as
demonstrated by the positive patch tests, which persisted in
the majority of the cases until the day 7 reading. Furthermore,
the patch test was relevant in all of the patients.
The correlation between the clinically observed purpuric
lesions, and the development of purpuric patch test in some
patients with purpuric contact dermatitis, suggests the involve-
ment of allergic mechanisms rather than a toxic reaction as
well.
The histopathological findings in our cases, depicted
marked similarity between the lesional biopsies and the pur-
puric patch test biopsies. On one hand all the lesional biopsies
displayed the features of acute eczema, with extravasated
erythrocytes at different levels of the dermis and epidermis.
On the other hand the purpuric patch test biopsies demon-
strated the characteristics of an allergic patch test namely:
focal or disseminated spongiosis in the epidermis, with forma-
tion of spongiotic vesicles in some cases, mainly perivascular
lymphocytic infiltrate in the superficial and deep plexuses,
with the admixture of eosinophils, and extravasated erythro-
cytes as described elsewhere.21 This histopathological correla-
tion between the relevant patch test and the lesional biopsies
also implies the involvement of an allergic reaction, rather
than a toxic one. The extravasated erythrocytes in the lesional
and patch test biopsies were observed mainly perivascularly
but also interstitially in the dermis at the dermo–epidermal
junction as well as the epidermis. Cytokines released by
immunocompetent cells in the epidermis and dermis, during
the allergic reaction, which have vasodilating effect, could be
one of the triggering factors, leading to the extravasation of
erythrocytes.
Vasculitis was not observed in contrast to the findings of
Bruynzeel,10 who described leukocytoclastic vasculitis in a
fig. 4 Parakeratosis, acanthosis, spongiosis, exocytosis and dilated blood
vessels surrounded by inflammatory infiltrate composed mainly of lym-
phocytes and intermingled erythrocytes. HE × 40.
fig. 5 The extravasated erythrocytes are seen surrounding the blood ves-
sels, interstitially, and at the dermoepidermal junction. HE × 100.
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purpuric vasculitic-like eruption ascribed to contact allergy to
Balsam of Peru in an antirheumatic ointment.
The most frequent allergens triggering the purpuric allergic
reaction in our series were Disperse Blue 106, 124 and 85.
These allergens are potent and are capable of inducing pur-
puric ACD. Other allergens that can evoke the development
of purpuric allergic contact dermatitis and have not been
described in the literature until now include: ethyleneurea
melamineformaldehyde, dimethylol dihydroxyethyleneurea,
tetramethylol acetylenediurea, urea formaldehyde, melamine
formaldehyde and Disperse Red 17.
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