Allergic contact dermatitis to the elastic bands of an N95 mask

Case report Introduction: In the wake of the COVID-19 pandemic, occupational contact dermatitis related to the use of personal protective equipment (PPE) has become increasingly prevalent. While most cases are irritant in nature, allergic contact dermatitis (ACD) remains an important cause of occupational dermatitis. We report a case of ACD to rubber accelerators in the elastic bands of an N95 mask. Informed consent was obtained from the patient for this report. Case Report: A 27-year-old healthcare worker presented with a progressive pruritic eruption over her face and neck, 1 week after she began wearing N95 masks at work. She had only worn disposable surgical masks. She had no medical history apart from hand dermatitis, which was well controlled with topical medications. Examination revealed linear eczematous plaques along her lateral cheeks and posterior neck, corresponding to contact areas between the mask bands and her skin. Patch tests revealed a positive reaction to several rubber accelerators, including Thimerosal, 2-Mercaptobenzothiazole (MBT), and Methylisothiazolinone. We performed another patch test to several N95 mask straps, to which the patient developed an eczematous reaction to the elastic bands of 2 N95 mask types with elastic bands. Clarification with the manufacturer confirmed the use of rubber accelerators similar in properties to MBT in the production of these masks. A diagnosis of allergic contact dermatitis to rubber accelerator was made. The patient's dermatitis resolved with topical corticosteroids and the avoidance of N95 masks with elastic bands. Discussion and Conclusion(s): The use of facial PPE such as masks is a recognised cause of occupational dermatitis among healthcare workers. A variety of dermatoses are associated with the use of facial PPE, with contact dermatitis being the most common. However, while the majority of contact dermatitis are irritant in nature, ACD remains an important and preventable cause of occupational dermatitis. Commonly implicated allergens associated with mask use include preservatives and adhesives used in their production, as well as metals in the nose clip. Although less common, mask elastic bands have also been reported to be a potential source of ACD, with rubber accelerators being identified as potential allergens. However, there is often a lack of declaration of such chemicals used in the production of PPE. Given the need for continued use in the occupational setting, early identification and avoidance of allergens are key. Failure to do so may result in the progression of skin lesions, ultimately affecting the patients' quality of life and work performance. With the ubiquitous use of masks in the current climate, we wish to highlight the need for greater awareness of rubber accelerators as potential allergens, and their presence in the elastic bands of frequently used PPE.

Comparison of photographic photonic assessment and conventional clinical assessment in diagnosis of contact allergy with patch testing: a pilot study

The SARS-CoV-2 (COVID-19) pandemic has led to the rapid implementation of virtual clinics across the healthcare sector. Alternatives to the conventional face-to-face patient assessment have been sought and piloted within dermatology departments. Cutaneous patch testing is traditionally assessed on days 2 and 4, and often delayed readings are required. Strategies to minimize physical attendance and the potential risk of COVID-19 transmission were required in order to maintain access to services. Photographic assessment of patch testing was introduced in our department. In addition, we employed photographic phototonics to augment the patch-test result image. Phototonics is the technology of generating, detecting and manipulating physical light, whose quantum unit is the photon. Photonics can be used to assess levels of blood flow in a clinical photograph of skin acting as a surrogate marker for cutaneous inflammation. Our aim was to assess if clinical photography and photonic image analysis can improve the detection of positive reactions in the virtual interpretation of patchtest results. Consecutive patients attending for patch testing were recruited and written consent was obtained. Photographs of patch-test results were taken using a 40-megapixel colour camera, on day 5, contemporaneous to patch-test assessment by the study investigators. The photographs were then analysed using spectral imaging technology software (HyperCube). The analysis employed principal component analysis, a technique used to reduce the dimensionality of datasets. The phototonic images were then examined to determine a combination of variables or colour patterns (red-green-blue) that would indicate a positive result and a surrogate marker for cutaneous inflammation. Thirty patients were recruited from September to November 2020. Two blinded investigators determined whether the results were positive, ?positive, irritant or other. Phototonic, photographic and clinical results were then compared. Photonic evaluation captured 59% of positive patch-test readings, while photographic assessment captured 50%. Interpretation of the results was almost identical between both investigators. This pilot study outlines the potential application of phototonic technology in the interpretation of virtual patch-test results. It is evident that physical attendance for patch-test reading is superior to both photographic phototonic assessment and photographic assessment. However, there may be role for the use of phototonics in order to augment the evaluation of virtual patch-test results. Interpretation of phototonics can be difficult and is generally modelled to validated results. Analysis using a multispectral camera to include specific wavelengths to monitor increased blood flow may have a role.

Occupational dermatoses during the second COVID-19 pandemic wave: an audit of 401 healthcare workers

Healthcare workers (HCWs) assessed by dermatologists during the first wave of the COVID-19 pandemic had high rates of irritant hand dermatitis, facial dermatitis and acne triggered by wearing personal protective equipment (PPE) (Ferguson FJ, Street G, Cunningham L et al. Occupational dermatology in the time of the COVID-19 pandemic: a report of experience from London and Manchester, UK. Br J Dermatol 2021;184: 180-2). We report data from a tertiary National Health Service trust during the second COVID-19 wave in winter 2020-21. At its peak, the Trust had 835 COVID-positive inpatients and 263 intensive care unit (ICU) beds - one of the largest ICUs in Europe. Building on the published experience of dermatology units, we ran 30 dermatology pop-up clinics over 3 weeks in allocated rest areas across the Trust: 08.00-09.00 h and 13.00-14.00 h on weekdays, from 18 January 2021. HCWs requiring formal dermatology referral were provided with letters to their line managers. In 3 weeks, 401 HCWs were assessed: 327 females and 74 males (mean age 35 2 years). The most frequently seen occupation was nurses (n = 130;32 4%) followed by doctors (n = 74;18 4%). On average, staff spent 9 5 h in PPE per shift. Consistent with the existing literature, the most common diagnosis was irritant hand dermatitis (n = 186;46 4%). There was an increased incidence of acne (n = 171;42 6%) vs. the first wave, where the reported incidence was 17% in a multicentre study (O'Neill H, Narang I, Buckley DA et al. Occupational dermatoses during the COVID-19 pandemic: a multicentre audit in the UK and Ireland. Br J Dermatol 2021;184: 575-7). Less common in the second wave was facial eczema (n = 50, 12 5%) and pressure injury (n = 30;7 5%). Thirty-one (16 7%) of the HCWs with hand dermatitis required the prescription of potent topical corticosteroids, suggesting at least moderate symptoms. The majority received emollient samples. It was rare for HCWs to require formal referral (n = 11;2 7%). In our cohort, at least four (1 0%) HCWs required time off work owing to their skin problems. Our data support previous reports of increased occupational dermatoses in HCWs during the COVID-19 pandemic. We highlight the sheer scale of the issue, with 401 HCWs presenting for dermatological assessment in only 3 weeks in one trust. Compared with our experience during the first wave, acne exacerbated or precipitated by masks is increasingly common, which may be due to emollient use to prevent facial eczema or injury when wearing masks.

Fragranced hand gels: beware the risk of contact allergy

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.

CHLORINE GAS EXPOSURE AND OBSTRUCTIVE AIRWAY DISEASE: A CASE REPORT AND CASE-BASED DISCUSSION

SESSION TITLE: Occupational and Environmental Lung Disease Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Chlorine gas is a pulmonary irritant with pungent odor that damages the respiratory tract. Chlorine gas exposure occurs in industrial or household exposures,Chlorine gas has two forms either a liquid or gas, toxicity of chlorine gas depends on the dose and duration of exposure. Chlorine gas used in manufacturing products like paper, insecticides, Chlorine is used to treat bottled and swiming pool water. CASE PRESENTATION: A 37 Y.O Male, no PMH presents with progressive dyspnea for three days worse with activity,decreases with rest, denied cough fever or chest pain he is vaccinated for COVID,no smoking history. The patient worked at a chlorine gas factory in the Dominican Republic for 15 years. Exam: Vitals: BP 124/72 mmHg. HR 100 BPM. RR 21 BPM. SpO2 84%. General: acute distress. Heart: normal S1, S2. RRR. Lung: wheeze bilaterally. Abdomen: Soft. Musculoskeletal: no pitting edema. he was placed on 6 LPM NC saturation improved to 90%. CBC and Chemistry were unremarkable, he was started on steroid, breathing treatment with antibiotics. ABG showed hypoxemia. he was placed on Venturi mask and his saturation improved to 95%.CTA was negative for PE. EKG, troponin were unremarkable. A proBNP normal. The antibiotics were discontinued because of a negative workup. A TTE study was normal. HRCT scan of the chest, showed atelectasis and infiltrates of lower lobes. No interstitial fibrosis.A PFT showed obstructive airway disease. He was discharged on oral and inhaled steroids.Hi new onset obstructive airway could be due to chlorine gas exposure. DISCUSSION: Chlorine gas causes cellular injury through oxidative damage but further damage results from activation and recruitment of inflammatory cells with subsequent release of oxidants and proteolytic enzymes. Humans can detect chlorine gas odor at a concentration between 0.1-0.3 ppm. At 1-3 ppm,it causes irritation of oral,eye mucosal membranes. At 30-40 ppm causes cough, chest pain, and SOB. At 40-60 ppm, toxic pneumonitis and pulmonary edema and can be fatal at 430 ppm concentration or higher within thirty minutes. Chronic exposure to chlorine gas lead to chest pain, cough, sore throat, hemoptysis, recurrent asthma. Physical exam findings include tachypnea cyanosis, wheezing, intercostal retractions, decreased breath sounds. Pulmonary function tests may reveal obstructive lung function disease. Chronic exposure to a low level was found to be associated with an increased risk of asthma in swimmers. CONCLUSIONS: Chlorine exposure results in direct chemical toxicity to the airways with acute airways obstruction or airways hyperreactivity, presentation varies from acute overwhelming intoxication with acute lung injury and or death, occupational exposure increase the likelihood of chronic bronchitis or isolated wheezing attacks. Treatment for chlorine exposure is largely supportive. Reference #1: 1- Center of disease control and prevention website/emergency preparedness and response/ https://emergency.cdc.gov/agent/chlorine/basics/facts.asp Reference #2: 2- C- Morim A, Guldner GT. Chlorine Gas Toxicity. [Updated 2021 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537213/. Reference #3: A- Gummin DD, Mowry JB, Beuhler MC, et al. 2020 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 38th Annual Report. Clin Toxicol (Phila). 2021;59(12):1282-1501. doi:10.1080/15563650.2021.1989785 DISCLOSURES: No relevant relationships by Abdallah Khashan No relevant relationships by Samer Talib no disclosure on file for Matthew Yotsuya;

Piloting Photographic Photonic Patch Testing: Pioneering Equitable Diagnosis of Contact Dermatitis

Objectives: Due to restricted access to cutaneous patch testing (PT) during the SARS-CoV-2 pandemic innovative strategies were necessary to promote equitable healthcare. Photonics generates, detects and manipulates physical light (photons) which can assess blood-flow in a clinical photograph and potentially act as a surrogate marker for cutaneous inflammation. We wished to assess if clinical photography and photonic image analysis could improve the virtual interpretation of PT results. Methods: PT photographs of 30 consecutive patients were taken using a 40- megapixel colour camera contemporaneous to PT assessment by study investigators. Photographs were then analysed using HyperCube using Principal Component Analysis (PCA), a technique used to reduce the dimensionality of datasets. Photonic images were then examined to determine a combination of variables or colour patterns indicating a positive result. Results: Thirty patients were recruited from September-November 2020. Two blinded investigators determined whether the results were positive, ?positive, irritant or other. Photonic, photographic and clinical results were compared. Initial blinded photonic evaluation captured 40% of positive PT while photographic assessment captured 51%. Unblinded evaluation captured 90% of both PCA and clinically positive results. Conclusions: The SARS-CoV-2 pandemic catalysed many changes in healthcare delivery and introduced opportunities to produce patient centred care. This pilot study employs innovative technology to improve rural accessibility to PT, promote inclusivity and reduce carbon emissions by reducing patient travel. Further development is necessary as while PCAanalysis of digital images improves pick-up of positive PTvirtually it remains inferior to face-to-face assessment. Multispectral imaging has the potential to expand the range of wavelengths further.

Contact allergy investigations in healthcare workers with face mask-related skin disease

Background: In the last 10 year prior to the COVID-19 pandemic approximately 1 healthcare worker (HCW) per year has been investigated for suspected occupational facial skin disease at our department. In contrast, during the present pandemic several HCWs has been investigated because of suspected occupational facial skin disease. Objectives: To report the findings in consecutively investigated HCWs with occupational facial skin disease. Methods: More than 40 HCWs has been investigated including patch test with their own face mask as is and with acetone extracts of the masks. Chemical analyses of potential allergens been performed in a number of different brands of face masks. Results: In all cases the skin disease was of recent onset. The most common diagnoses were irritant dermatitis and acne or acne-like eruptions including perioral dermatitis. No occupational contact allergies were found, and all patch tests with face masks were negative. Chemical analysis indicated colophonium-related substances in one brand of face mask. Conclusions: Based on referral pattern there has been increase of occupational facial dermatitis during the pandemic. Irritant factors like occlusion and friction appears to be the most common cause while contact allergy to the masks were not detected in this population.

Occupational skin dermatoses as a result of Covid-19 prevention practices

Introduction: Occupational skin diseases (OSD) account for a significant proportion of occupational disease. High risk occupations for OSD include workers in the healthcare, food service, metal-working, hairdressing and construction industries. The prevention of the COVID-19 virus has increased the use of personal protective equipment (PPE), handwashing and cleaning practices globally. Methods: We will cover the first hand experiences gained during the pandemic, by reviewing the presentations of OSD at a dermatology clinic as result of COVID-19 practices. Results: During the pandemic, the use of PPE created occlusive and humid environments particularly exacerbating underlying skin conditions. This phenomenon was not exclusive to high risk OSD occupations. Atopic individuals at risk of OSD had an increased susceptibility to irritant contact dermatitis (ICD) as a consequence of using hand sanitizers and additional hand washing. Furthermore more exacting cleaning practices provided exposures to additional irritants and allergens, such as laundry rinses containing benzalkonium chloride (BAK) and fragrances in personal care products. Patch testing proved useful in diagnosing and treating patients, which allowed workers to return to work. Conclusions: Personal protective practices adopted during the pandemic adversely affected workers, especially those with underlying skin conditions. This included the use of PPE, increased hand washing and sanitizing practices as well as increased cleaning practices. Treatment of underlying skin disorders as well as education on skin protection has been pertinent during this time.

Cinnamomum camphora: A long history for epidemics control

Camphor (C10H16O) is a white crystalline solid exist in enantiomeric form R and S camphor. It is a terpenoid obtained from turpentine oil. Synthetically it is synthesized by catalytic process as alpha pinene. Naturally camphor is obtained by steam distillation of woods of Cinnamomum camphora tree, also known as Camphor tree, camphor laure and camphor wood. Camphor has many pharmacological properties. It acts as antiviral, anticancerous, antimicrobial, insecticidal, anticoccidial, anti-nociceptive and antitussive drug. In addition, it can be used as skin penetrating enhancer. Camphor gives a soothing and cooling effect, which helps to reduce pain. The reason behind its soothing effect is camphor act as a counter-irritant by activating heat sensitive transient receptor potential vanilloid subtype 1 and transient receptor potential vanilloid subtype 3 receptors and inhibits the transient receptor potential melastatin-subfamily member 8 receptor. As a result, these receptors provide a sensation of scalding heat and pain (nociception) and could be used to treat neuropathic pain associated with multiple sclerosis, chemotherapy, or amputation, as well as pain associated with the inflammatory response of damaged tissue such as in osteoarthritis. Camphor has a history of epidemics cure. During leishmaniosis (kala-azar) pandemic in 14th century, camphor was used as fumigant to control the spread of plague in European countries. In 19th century when cholera, small pox and influenza spreads, camphor was used as mothballs in Indian subcontinent as a (cough reliever) agent. During 18th century Russian influenza “flu pandemic” founder of Homeopathy Hahnemann in 1831, published his research work on camphor and suggested camphor as a “divine remedy” for influenza given in extremely small doses. In the same year, several companies launched to sell menthol rub as natural rub ointment consisting camphor as prevention measures for spread of influenza. As the recent epidemic of COVID-19 arises, prevention and control of spread of disease is an alarming issue. This article covered the glimpse of uses and importance of camphor in the history of epidemic cure.