EDITORIAL
Transference in Contact Dermatitis: New Name for Underappreciated Cause of Eczema
Craig G. Burkhart1, *
Article Information
Identifiers and Pagination:
Year: 2023Volume: 17
E-location ID: e18743722272472
Publisher ID: e18743722272472
DOI: 10.2174/0118743722272472231129100746
Article History:
Received Date: 15/7/2023Revision Received Date: 29/10/2023
Acceptance Date: 23/11/2023
Electronic publication date: 7/12/2023
Collection year: 2023
open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Transference is the action of conveying something. In dermatology, that would be transferring irritating and/or allergic substances from the hands to other body parts. The fact that this specific area of the body itches leads to a more repetitive transportation of these chemicals to that specific area.
In an analogous situation, bacterial pathogens have been shown to be transferred via contaminated hands of healthcare workers, such as in neonatal patients [1]. In another outbreak, Malassezia pachydermatis was transmitted from a nurse’s pet dogs to infants in an intensive care nursery via the hands of the nurse [2]. Other studies have shown bacterial transfer from moist fabrics [3]. Friction increased the level of transfer from fabrics to finger pads as much as fivefold [3].
Possibly, the best way to demonstrate the importance of transference is by thoroughly examining the example of nickel dermatitis. Nickel is a malleable, silvery white metal that is capable of taking a high polish, imparting durability and hardness to metal objects, particularly the precious metals and stainless steel. It is used widely in metal production and humans are exposed to the metal almost continuously throug hout the day. It is also used extensively in industry.
Nickel also is one of the most common causes of allergic contact dermatitis. Sweating has a pronounced effect on dermatitis in nickel-sensitive individuals. The chloride radical in sweat dissolves the metallic nickel from nickel-plated objects, permitting the soluble salts of this metal to act. Indeed, perspiration, pressure and friction affect the occurrence and severity of the reaction with nickel in sensitized individuals [4].
A puzzling feature of nickel dermatitis is that the eruption occurs in three forms [4]. First, there is the area in direct contact with the metal. Secondly, in some patients, a symmetrical outbreak occurs, often involving the extremities.
This has been considered an id phenomenon in the past [4]. Occasionally one sees cases in which a dermatitis appears that appears to have no relationship to nickel sensitivity. In my humble opinion, the answer to these last two categories is transference from the hands to other body parts. The palms are so thick that they are almost impervious to contact allergies, but they can carry the metal to other body parts by transference. Such transference would be exacerbated if the fingers were transpiring.
This method of conveyance of nickel by means of hand contact is poorly appreciated. For example, the American Academy of Dermatology [5] and the American Academy of Allergy, Asthma, and Immunology [6] both only discuss direct contact with nickel in disease causation. The North American Contact Dermatitis Group also failed to acknowledge this form of disease transfer [7]. Even a book released this year on the topic suggests that nickel dermatitis only occurs by direct contact with the metal, period [8]. Without an understanding of this transference, part of the treatment of this condition is not fully addressed [7-9]. Transference has been discussed for eyelid dermatitis [10].
The most definitive work in transference is by Isnardo et al. [11]. Using mass spectrometry, they documented that high concentrations of nickel can be transferred to the fingers from touching metal objects; additionally, by touching the face with those hands, sufficient quantities of nickel are achieved to cause allergic dermatitis in people with nickel allergy. Their study gave more credence to previous reports of nickel dermatitis after handling metal objects such as coins [12], keys, and mobile phones [13]. The authors [11] found that hand-to-face transference of metal is much more likely to be the cause of facial rashes in such patients than finding nickel in their cosmetic products [14].
In short, transference is ectopic allergic dermatitis due to conveyance of a substance from the patient's hands to some other body part with otherwise no direct contact to metal. In contrast to introducing an allergenic product directly to the eyes, face, or extremities through conscious application of a product to these areas, the patient introduces the allergen inadvertently when touc hing or rubbing the eyes, face, or extremities. In a patient who has naturally sensitive skin, the involvement can be extensive.
My clinical pearl is to consider patients that whose palms of the hands have thick skin and do not develop allergic reactions to nickel. However, after touching something metallic (like utensils, pens, cell phones, or exercise equipment), one has to avoid transferring this from the hands to other body areas. Patients must wash their hands, free of this nickel from handling metal objects prior to touching other body parts. I have treated patients with extensive atopic dermatitis, as well as erythroderma, in which patch testing revealed that only one allergen (namely nickel) respond to these directives.
The same scenario also applies to other contact irritant s and allergic substances. Directing patients to avoid hand to skin contact will diminish the transference and can be curative by itself. Transference should be a basic tenet in the treatment of contact dermatitis.
CONFLICT OF INTEREST
Craig G. Burkhart is the Editors-in-Chief of The Open Dermatology Journal.
ACKNOWLEDGEMENTS
Declared none.
DISCLAIMER
The above article has been published, as is, ahead-of-print, to provide early visibility but is not the final version. Major publication processes like copyediting, proofing, typesetting and further review are still to be done and may lead to changes in the final published version, if it is eventually published. All legal disclaimers that apply to the final published article also apply to this ahead-of-print version.
REFERENCES
| [1] | Foca M, Jakob K, Whittier S, et al. Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit. N Engl J Med 2000; 343(10): 695-700. |
| [2] | Chang HJ, Miller HL, Watkins N, et al. An epidemic of Malassezia pachydermatis in an intensive care nursery associated with colonization of health care workers’ pet dogs. N Engl J Med 1998; 338(11): 706-11. |
| [3] | Sattar SA, Springthorpe S, Mani S, et al. Transfer of bacteria from fabrics to hands and other fabrics: development and application of a quantitative method using Staphylococcus aureus as a model. J Appl Microbiol 2001; 90(6): 962-70. |
| [4] | Fisher AA. Contact dermatitis. 2nd ed. Philadelphia: Lea & Febiger 1975. |
| [5] | American Academy of Dermatology. Nickel allergy: how to avoid exposure and reduce symptoms https://www.youtube.com/watch?v=8OUO4QOAPeI |
| [6] | Two Cents about Nickel Allergy. Available from: https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/nickel |
| [7] | Warshaw EM, Zhang AJ, DeKoven JG, et al. Epidemiology of nickel sensitivity: Retrospective cross-sectional analysis of North American Contact Dermatitis Group data 1994-2014. J Am Acad Dermatol 2019; 80(3): 701-13. |
| [8] | Rishor CR, Gnugnoli DM. Nickel allergy. In: StatPearls. Treasure Island (FL): StatPearls Publishing 2023. |
| [9] | Menne T, Kaaber K, Tjell JC. Treatment of nickel dermatitis. (The influence of tetraethylthiuramdisulfide (Antabuse) on nickel metabolism). Ann Clin Lab Sci 1980; 10(2): 160-4. |
| [10] | Zirwas MJ. Pearls for the diagnosis and management of eyelid and lip dermatitis. Pract Dermatol 2009; 10: 90-2. |
| [11] | Isnardo D, Vidal J, Panyella D. Nickel transfer by fingets. Actas Dermosifiliogr 2015; 106: e23-6. |
| [12] | Thyssen JP, Gawkrodger DJ, White IR, Julander A, Menné T, Lidén C. Coin exposure may cause allergic nickel dermatitis: A review. Contact Dermat 2013; 68(1): 3-14. |
| [13] | Aquino M, Mucci T, Chong M, Lorton MD, Fonacier L. Mobile phones: Potential sources of nickel and cobalt exposure for metal allergic patients. Pediatr Allergy Immunol Pulmonol 2013; 26(4): 181-6. |
| [14] | Zemba C, Romaguaera C, Vilaplana J. Allergic contact dermatitis from nickel in an eye pencil. Contact Dermat 1992; 27(2): 116. |
