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Indian J Dermatol Venereol Leprol March-April 2005 Vol 71 Issue 2 96
INTRODUCTION
It is generally believed that allergic contact dermatitis
(ACD) is less common in persons with atopic dermatitis
(AD) than in normal persons. This is thought to be due
to decreased lymphocyte-mediated hypersensitivity
response in atopics.
[1]
It has also been observed that
patients with AD are not readily sensitized by repeated
application of dinitrochlorobenzene (DNCB).
[2]
However,
there is no total agreement in this respect. It has been
documented that a poor response to DNCB occurs only
in severe AD. Once the AD improves, DNCB challenges
are positive. During the remission period most of the
atopics respond to contact allergens like the normal
How to cite this article: Sharma AD. Allergic contact dermatitis in patients with atopic dermatitis: A clinical study. Indian J Dermatol Venereol
Leprol 2005;71:96-8.
Received: October, 2004. Accepted: November, 2004. Source of Support: Nil. Conflict of Interest: None declared.
Study
Allergic contact dermatitis in patients with atopic dermatitis: A clinicalAllergic contact dermatitis in patients with atopic dermatitis: A clinical
Allergic contact dermatitis in patients with atopic dermatitis: A clinicalAllergic contact dermatitis in patients with atopic dermatitis: A clinical
Allergic contact dermatitis in patients with atopic dermatitis: A clinical
studystudy
studystudy
study
A. D. SharmaA. D. Sharma
A. D. SharmaA. D. Sharma
A. D. Sharma
Consultant Dermatologist, Bongaigaon, Assam, India
Address for correspondence: Dr. A. D. Sharma, MM Singha Road, Bongaigaon, Assam - 783380, India.
E-mail: dradsharma_bngn@rediffmail.com
ABSTRACT
Background: Atopic dermatitis (AD) is a chronically relapsing dermatitis with no known cure. Due to the chronic nature
of the condition, frequent and long term topical therapy is used. This may lead to sensitization, resulting in allergic
contact dermatitis (ACD). Aims: The aim of the study was to observe the frequency of ACD in atopic patients in this part
of the country using Indian standard battery. Methods: A total number of 30 cases of AD were taken for the study.
Diagnosis of AD cases was based on the criteria of Hannifin and Rajka (1980). All the selected cases of AD had mild to
moderate grade of severity. All these cases were treated and patch tested during the remission period. The duration of
the study was 12 months. Results: Out of the 30 AD cases, 7 cases showed positive ACD with patch test allergens.
Conclusion: This study shows that ACD is not uncommon amongst atopic individuals.
KEY WORDS: Atopic dermatitis, Patch test, Allergic contact dermatitis
population.
[3]
In an American study, where 410 cases
underwent allergic and irritant patch test reactions, it
was observed that atopics were at least as likely to have
contact allergy as were non-atopics.
[4]
Similarly, several
authors have noted different types of ACD occurring
in atopic individuals in different studies— contact
allergy to latex,
[5]
topical steroid,
[6]
clothing,
[7]
etc. Even
more, several cases of contact dermatitis complicating
atopic dermatitis have been documented.
[8]
The study was designed to note the frequency of ACD
in atopic patients in this part of the country, the western
end of Assam, using Indian standard battery of Patch
Test Allergens approved by the Contact and
Indian J Dermatol Venereol Leprol March-April 2005 Vol 71 Issue 297
Occupational Dermatoses Forum of India (CODFI). It
was a hospital-based study. AD is not uncommon in
this region. The estimated incidence rate of AD is 3.47
per 1000 patients according to a study conducted by
this author
[9]
in the past.
METHODS
Thirty cases of AD were taken for this study during
2003-2004. Diagnosis of AD was based on the criteria
of Hanifin and Rajka (1980).
[1]
All the selected cases of
AD had mild to moderate grade of severity (Severity
grading of AD: Rajka and Langeland).
[1]
There were 22
male patients and 8 female patients, in the age range
of 7 to 50 years. The youngest patient was a boy, 7
years old; the oldest patient was a 50-year-old male.
Almost all these cases were treated previously with
different drugs with frequent remissions and relapses.
All the cases were controlled by conventional therapy,
and corticosteroids were used whenever necessary.
On complete remission, the patients were tested with
the Indian standard battery of allergens. The results
were read after 48 and 72 hours. Patch test unit
comprised 24 antigens in ointment form, 4 antigens
in liquid form and 3 plant antigens as antigens-
impregnated discs; aluminum patch test chambers
prefixed on micropore tape and filter paper discs
(Watman’s No. 5)
RESULTS
Out of the 30 AD cases, 7 patients (23%) showed positive
reactions with the patch test allergens. Amongst them,
5 were male and 2 were female. The youngest patient
was an 8-year-old girl and the oldest patient was a 38-
year-old male who tested positive in this series.
Out of the 7 patients, 6 cases were suffering from AD
for more than 12 years; the last one had the disease
for 7 years. All of them had a history of receiving drugs
(both oral and topical) frequently for their ailment in
the past. Four patients showed contact allergy to
multiple allergens (i.e. 2 different antigens each) in this
series. The remaining 3 cases showed contact allergy
to a single antigen each.
A total of 31 allergens were used in this study of which
7 allergens were tested positive. While many of the
allergens were antibacterial agents (neomycin sulfate,
gentamicin and chinoform), the rest (nickel sulfate,
chlorocresol and balsam of Peru) were used in a variety
of consumer items. Neomycin was the most common
allergen in this study; 3 out of 7 cases were tested
positive with neomycin sulfate. The only plant allergen
that tested positive was Chrysanthemum.
While recording the grade of patch test reaction, it was
noted that one patient showed (++) ve reaction to
neomycin sulfate; the rest of the cases showed (+) ve
reaction to other allergens in this series.
DISCUSSION
This study shows that ACD is not uncommon in atopics;
7 cases (23%) out of 30 patients of AD showed positive
patch test reactions with different antigens. The most
common contact allergen was neomycin sulfate
followed by gentamicin. Neomycin is a potent sensitizer
all over the world and the reported incidence varies
between 2.5%-6%.
[10-12]
In India, the incidence is said to
be much higher.
[13,14]
The incidence of contact allergy
due to gentamicin was found to be 8.3%
[15]
in India. But
in UK the incidence is much higher and was found to
be 31% in one study.
[16]
This is probably because
gentamicin is used more than neomycin in the UK.
Cross-reactivity between gentamicin and neomycin has
been observed to be 40% in different studies.
[17]
The
incidence of contact allergy to chinoform was found
to be 10.9%
[18]
in the UK. In India, however, the
prevalence of contact allergy to chinoform is less
because of its infrequent use. Similarly, chlorocresol,
which is used as a preservative, has a low sensitizing
potential and is an infrequent sensitizer.
[19]
It cross-
reacts with chloroxylenol.
Allergen profile and outcome of patch test
Name of the Pattern of positive patch test Total no.
allergens 1+ 2+ 3+ 4+ of cases
Positive Positive Positive Positive
Gentamycin 2 —- —- —- 2
Chrysanthemum 1 —- —- —- 1
Nickel 1 —- —- —- 1
Neomycin 2 1 —- —- 3
Chlorocresol 1 —- —- —- 1
Balsum of Peru 1 —- —- —- 1
Chinoform 1 —- —- —- 1
Fragrance mix 1 —- —- —- 1
Sharma AD: Atopic dermatitis and allergic contact dermatitis
Indian J Dermatol Venereol Leprol March-April 2005 Vol 71 Issue 2 98
It is to be noted that many of these antigens, which
tested positive in the present study, are generally used
in local ointments applied for atopic conditions. Almost
all these cases were treated previously with different
topical drugs. This study indicates that the haphazard
use of common antibiotic / common antibiotic-steroid
(topical) preparations may cause sensitization in AD
patients. It is a fact that the skin of the AD patient is
frequently colonized with Staph. aureus, but this
colonization is secondary rather than primary and it
regresses when treated with corticosteroid alone.
[20]
Specific anti-staphylococcal drugs (topical) should only
be used when there is evidence of infection. Routine
use of common antibiotic/antiseptic is not only
ineffective, but may cause sensitization.
It has also been observed that all those atopic patients
who had ACD in this series had a longer duration of
disease period (more than 12 years in 6 cases and 7
years in one case). This may be related to the fact that
due to the chronic and relapsing nature of the disease,
the patients used more topical medicines in an attempt
to cure or control the disease; this made them more
vulnerable to developing ACD.
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