CHAPTER 22

 
Cold and hot humid weather may exacerbate the skin problem. It is important to keep the infant's skin in its optimum condition both in winter and summer. It is not meant by any way to occlude the skin surfaces with heavy and several layers of wool and other garments as these may play an important role in exacerbating dermatitis.

The sensitizers in clothing are: the fabrics, the finish of the clothes , dyes as azodyes or to the " Para" groups as paraphenylenediamine which have an irritating effect that increases with overheating of the child and with increased sweating .

Fabrics:

Cotton is rarely considered a sensitizing agent but the dyes and finish may cause sensitization.

Wool may be a primary irritant.

Silk silk is rarely a sensitizer.

Polyesters - Plastic or synthetic fibers as acrylic, orlon, polyvinyl resins or spandex are used in diapers, socks and girdles. The irritant may be due to mercaptobenzothiazole causing contact dermatitis due to the material itself, the dye or due to the finish of the fabric.

Spandex-This is a non-rubber, stretchable, polyurethane fiber which is used for socks, brassieres, and girdles. The sensitizer in these fabrics is mercaptobenzothiazole.

Formaldehyde :

Formaldehyde and its resins are used in the preparation of fabrics, facial tissues, toilet papers and in certain types of clothes to make them wrinkle free. The coll that is made of certain type of fabrics such as wool or polyesters used to cover the neck and upper chest of the infant during feeding may cause contact dermatitis .

Formaldehyde, chromate and tannin used for shoe finish are an important cause of contact dermatitis.

Paraphenylene diamine is used in fur manufacture. This may act as a sensitizer.

Remnants of bar soaps or powdered soaps on washed clothing is an important cause of dermatitis especially the underwear. Some types of dermatitis especially those at the intertriginous areas sometimes exhaust the patient and the physician‘s efforts to identify this simple common cause.

Predisposing Factors

1. Tender and sensitive skin such as that of infants

2. Obesity

3. Hyperhidrosis: tends to leach dyes from the fabrics to the skin surface causing dermatitis.

4. Moisture: causes more hydration of the epidermis, which enhances more penetration of the sensitizers.

5. Increased skin surface lipids

6. Tight clothes causes more occlusion

7. Constitutional factors: individual susceptibility is an important factor.

8. Skin Condition: repeated friction, trauma, chaffing, abrasion and damaged skin. All these facilitate and predispose to clothing dermatitis.

9. Patients with past history of dermatitis or having dermatitis are more susceptible to sensitization.

10. Skin structure and its reactivity. Thin skin as that of the eyelids or skin with pilosebaceous follicles are more susceptible to sensitization.

Clinical Features of Clothing Dermatitis

Clothing dermatitis is of the delayed type hypersensitivity. The reaction is due to contract of clothing to the skin. The eczematous reaction is either primary irritant or delayed type hypersensitivity.

Itching at the site of contact is a common manifestation. Erythematous reaction will appear at the site of contact of the cloth to the skin. There may be a papulovesicular reaction, especially in sensitive children.

Contact dermatitis to certain types of fabrics such as wool has a seasonal prevalence, where it is more in winter season.

The mother, if she can observe her child well, will notice that itching and the eczematous reaction exacerbates when she dresses the child certain types of clothing, and his condition is much improved when such type of dress is changed.

Socks dermatitis is also common in children. The lesion will be confined to the area covered by socks. The eczematous reaction may be related to the rubber part of the socks. The dermatitis will be in a ring form, encircling the upper part of the socks. The whole area covered may be eczematous if the reaction is due to the fabric of the socks.

The same is also applied to pants or diapers. It should be noted that contact dermatitis may spread to involve the uncovered area by the sensitizing material.

Not all types of dermatitis occurring on areas covered by the cloth is caused by the fabric.

General Considerations:

1. Remnants of detergents such as soap and other chemicals as formaldehyde resins used in "wrinkle-free" clothing may be also blamed to cause irritant or contact sensitivity.

2. Hyperhidrosis, sebum, lack of cleanliness, overheating of the skin surface have also an important effect in cloth dermatitis.

3. Different layers or thick occlusive types of cloth have the same effect.

4. Certain dyes, chemicals, coloring, paints or metals in certain dresses may cause eczematous reaction.

5. Moisture, occlusion and friction are important factors enhancing penetration of the sensitizers through the epidermis and hence increases the allergic reaction.

6. Some types of clothe such as khaki cloth may cause purpuric or lichenoid dermatitis in the areas covered by the fabric. This type of dermatitis may be due to the azo dyes, formaldehyde and finishes rather than to the type of cloth. The reaction may start on the inner side of the thighs or arms and spread to affect most covered areas by the sensitizing cloth.

Diagnosis of Clothing Dermatitis

1. Clinical Picture : the eczematous reaction may be localized at the beginning to the areas covered by the cloth. The signs and symptoms improve when the irritating clothing is not used and exacerbation of the lesions occur when the child is dressed with such irritating fabrics.

2. Patch test - patch tests are not always reliable in diagnosing cloth dermatitis due to the high rate of false-negative reaction. In spite of that, patch test may detect certain fabric sensitizers.
   Technique of patch testing for dye sensitivity :
   Soak the fabric in water, then add 2 drops of vinegar. This solution can be used for patch testing which is kept on the skin for 24 hours.
   In testing for axillary dermatitis, the fabric is soaked in water to which a drop of sodium hydroxide has been added and then applied to the skin for 48 hours.

3. Exclusion and elimination test.
   This test may have good effects to monitor the type of cloth causing dermatitis. If itching is increased after dressing, it should be suspected that such type of cloth may be the cause. The patient is requested not to use such cloth for few days. If the condition is improved, he tries again that cloth. If itching recurs, this means that fabric is the cause of sensitization.

4. Chemical analysis of the cloth. This is useful to detect formaldehyde resins and other sensitizers.

Treatment of Clothing Dermatitis

1. Exclusion of the blamed cloth and should be replaced by suitable types.

2. Active treatment: The same as that applied to other types of contact dermatitis.

3. proper washing and rinsing of clothes to get red of remnants of detergents and other chemicals in the cloth.

   I have seen patients suffering from intertriginous dermatitis particularly on the crural area for months and even years with temporary improvement due to the medications they receive  but the problem recurs again after stopping treatment.

   Such patients are instructed simply to have their clothes especially the underwears free from remnants of the powdered soaps used in laundering the clothes. A convenient method for that is to wash the clothes after machine washing by plain water thoroughly and then dried or put in the drier. An effective method to get rid of the remnants of soaps in the clothes after washing is to soak the clothes after removing them from the washing machine and soak them again in a container added to water few drops of lemon or white vinegar. The soak is left for few hours and then washed again with plain water and dried.

REFRENCES

1. Cronin E. Studies in contact dermatitis. 18. Dyes in clothing. Trans St John‘s Hosp Derm Soc 1960; 54: 156-64.

2. Cronin E. Contact Dermatitis. Edinburgh: Churchill Livingstone, 1980.

3. Edman B. Sites of contact dermatitis in relationship to particular allergens. Contact Derm 1985; 13: 120-35.

4. Hodgson CA, Hellier FF. Dermatitis caused by shirts in B.L.A. J Roy Army Med Corps 1946; 87: 110-17.

5. Epstein E, Maibach HI. Ethylenediamine allergic contact dermatitis. Arch Dermatol 1968; 92: 476-7.

6. Frosch PJ, Kligman AM. A method for appraising the stinging capacity of topically applied substances. J Soc Cosmet Chm
   1977; 28: 197-209.

7. Christophersen J, MennÈ TM, Tanghof P et al. Clinical patch test data evaluated by multivariate analysis. Contact Derm
   1989; 21: 291-9.

8. Kirton V, Wilkinson DS. Sensitivity to cinnamic aldehyde in a toothpaste. Contact Derm 1975; 1: 77-80.

9. Berger C, Muscleman M, Meekness Brandao F et al. Thin layer chromatography search for Disperse Yellow 3 and Disperse

10. Orange 3 in 52 stockings and pantyhose. Contact Derm 1984; 10: 154-7.

11. Cronin E. Formal in textile dermatitis. Br J Dermatol 1963; 75: 267-73.

12. Cronin E. Studies in contact dermatitis: XVIII. Dyes in clothing. Trans St John‘s Hosp Derm Soc 1968; 54: 156-64.

13. Fregert S, Greenberger B, Grandson K et al. Allergic contact dermatitis from chromate in military textiles. Contact Derm 1978; 4: 223-4.

14. Hjorth N, M"ller H. Phototoxic textile dermatitis (‘Bikini dermatitis‘). Arch Dermatol 1976; 112: 1445-7.

15. Jordan WP. Clothing and shoe dermatitis. Postgrad Med 1972; 52: 143-8.

16. Lundkofoed M. Contact dermatitis from formaldehyde in fabric softeners. Contact Derm 1984; 11: 254.

17. Dahl MV. Allergic dermatitis from footwear. Minnesota Med 1975; 58: 871-4.

18. De Groot AK, Gerkens F. Contact urticaria from a chemical textile finish. Contact Derm 1989; 20: 63-4.

19. Farli M, Gasperini M, Giorgini S et al. Clothing dermatitis. Contact Derm 1986; 14: 316-17.

20. Fisher AA. How to obtain shoes free of common sensitizers. Cutis 1973; 12: 678.

21. Fisher AA, Kanof NB, Bionchi EM. Free formaldehyde in textiles and paper. Arch Dermatol 1962; 36: 753-6.

22. Foussereau J, Dallara JM. Purity of standardized textile dye allergens - a thin layer chromotography study. Contact Derm 1986; 14: 303-6.

23. Hatch KL, Maibach HI. Textile chemical finish dermatitis. Contact Derm 1986; 14: 1-13.

24. HODGSON G. & HELLIER F. (1946) J. roy. Army. Med. Corps. 87, 110.

25. Hatch KL, Maibach HI. Textile fiber dermatitis. Contact Derm 1985; 12: 1-11.

26. Hjorth N, M"ller H. Phototoxic textile dermatitis (‘Bikini dermatitis‘). Arch Dermatol 1976; 112: 1445-7.

27. Jordan WP. Clothing and shoe dermatitis. Postgrad Med 1972; 52: 143-8.

28. Lundkofoed M. Contact dermatitis from formaldehyde in fabric softeners. Contact Derm 1984; 11: 254.

29. Hatch KL, Maibach HI. Textile chemical finish dermatitis. Contact Derm 1986; 14: 1-13.

30. Hatch KL, Maibach HI. Textile fiber dermatitis. Contact Derm 1985; 12: 1-11.

31. Cronin E. Studies in contact dermatitis. 18. Dyes in clothing. Trans St John‘s Hosp Derm Soc 1960; 54: 156-64.

32. Cronin E. Contact Dermatitis. Edinburgh: Churchill Livingstone, 1980.

33. Hodgson CA, Hellier FF. Dermatitis caused by shirts in B.L.A. J Roy Army Med Corps 1946; 87: 110-17.

34. Epstein E, Maibach HI. Ethylenediamine allergic contact dermatitis. Arch Dermatol 1968; 92: 476-7.

35. Osmundsen P.E. (1968) Br. J. Derm 81, 789

36. Osmundsen P.E. (1970) Br. J. Derm 831, 296

Top