ABSTRACT
An 11-year-old boy presented to the children's Emergency Department in Autumn 2020 with acute blistering of his palms. No other parts of the body or mucosal surfaces were involved. He was systemically well, with no significant past medical history except for eczema in early childhood. He had recently started back at school and was using hand gel regularly as part of precautions to reduce SARS-CoV-2 (COVID-19) transmission during the pandemic. There had been no other contact with chemicals, plants, crafting materials, glues, paints or homemade slime. Clinical photographs showed swelling and large bullae on the thenar eminence and lateral fingers. There was no erythema, nail involvement or significant scaling. The clinical diagnosis was acute pompholyx that was either irritant or allergic in origin. Testing to the standard series showed inconclusive results to some fragrances in the standard series. The patch testing to fragrance in the standard series was repeated and the fragrance series was added. The repeat test confirmed allergic contact dermatitis to fragrance with a positive to Myroxylon pereirae, linalool, limonene, sandalwood oil and majantol. The hand gels were found to contain linalool and limonene. To curb the spread of COVID-19, regular handwashing and the use of alcohol-based hand sanitizers/gels are part of everyday hygiene guidance for the general public. Therefore, the incidence of hand dermatitis is likely to rise. The World Health Organization and the Food and Drugs Administration advise that a minimum alcohol content of 60% is required to inactivate viral particles;however, it is also important to be aware that hand sanitizers/gels may also contain other constituents, including thickeners, humectants (e.g. propylene glycol) and fragrance. Research into the ingredients of 10 widely used hand sanitizers recently investigated by an independent watchdog for their alcohol content found that six had their ingredients listed online and five contained fragrance. The patient responded to topical treatment with a superpotent topical steroid cream (Dermovate) twice daily, white soft paraffin 50 : 50, an antiseptic emollient (Dermol 500) to wash the hands and allergen avoidance. We highlight to other dermatologists that contact allergy to fragrance or other components in hand sanitizer/gels may present acutely with pompholyx and to consider testing to the standard and fragrance series if this is suspected.