Occupational allergic contact dermatitis from alkylammonium amidobenzoate

ARTICLE

Quaternary ammonium compounds are effective, water-soluble antimicrobials which are widely used in hospitals as disinfectants, sterilizers and skin cleansers [1]. They are also used in antiseptic creams and shampoos, and as algicides and slimicides in swimming pools, water reservoirs, and farm ponds [1, 2]. They are usually not used in cosmetics because of incompatability with other ingredients, e.g. non-ionic and ionic surfactants [1]. One quaternary ammonium compound, alkylammonium amidobenzoate (Osmaron B^®) has for decades been used by dairy farmers in udder ointments and has caused sensitization [3-10]. Here we report on occupational allergic contact dermatitis from alkylammonium amidobenzoate in a ship technician.

Case report and methods

A 54-year-old ship technician had had hand eczema for 7 years when he was sent to us for tests. His hand eczema started on the back of the hands and wrists and spread to the fingerwebs as a vesicular dermatitis. The hand dermatitis improved or disappeared during a 1-month period of sick leave but relapsed while at work. As a ship technician the patient was exposed to many different motor, lubrication, diesel and combustion oils. The patient was patch tested according to the recommendations of the International Contact Dermatitis Research Group (ICDRG). Nickel sulfate (5% pet) provoked a 1+ reaction in a modified European standard series, and dodecyl-di-(aminoethyl)glycine (Ampholyte 103 G) a 1+ reaction in an antimicrobial series. The rubber chemical series and the series of oils and cutting fluids were negative. When patch testing the patient with his personal creams and other materials used at work, one hand ointment (Nelisan^®, FinnLacto Oy, Seinäjoki, Finland) provoked a 2+ allergic patch test reaction (tested as is). It turned out that this was an udder ointment, which had been approved at the work site for use as a hand ointment. The product declaration label suggested that the ointment is "good/suitable for treatment of the skin". Prick tests with standard environmental allergens were negative. The manufacturer then kindly supplied us with the ingredients (N = 7) of the ointment. One component, alkylammonium amidobenzoate (Osmaron B^®) provoked strong allergic patch test reactions in petrolatum (1%, 3+; 0.1 and 0.01% 2+ (Fig. 1). The hand dermatitis of the patient cleared completely when he was on sick leave. It was concluded that irritant factors, frequent hand washing and sensitization to Osmaron B^® caused a combined allergic and irritant occupational contact dermatitis.

Discussion

Alkylammonium amidobenzoate (CAS 68526-65-8, Osmaron B^®) is a quaternary ammonium compound (quat) with a long hydrophobic alkyl side-chain (Fig. 2), and is used as a disinfectant. The ointment used by our patient is also used as an udder antiseptic ointment and its antimicrobial chemical, alkylammonium amidobenzoate has previously been reported to cause sensitization in Finland [7]. Interestingly, the producers have recommended milking fats for the treatment of atopic eczema, neurodermatitis, psoriasis and other skin care [5], as in our patient. Milking fats have also become popular remedies and cosmetics in the so-called organic pharmacy [6]. Alkylammonium amidobenzoate should not be used in cosmetics as it is not included in the INCI (International Nomenclature of Cosmetic Ingredients) list [7] and also because of its tendency to sensitization. Hausen and Post [5] had nine, and Goldermann et al. [4] had three patients who had used "udderfats" for various non-occupational reasons. Occupational cases have been reported in farmers since the 1950s [6]. Hausen and Post [5] reported a masseur who was occupationally sensitized by Osmaron B^®. More recently Schnuch and coworkers [8-10] showed that 2 to 5% of patients in selected populations have an allergic patch test reaction to Osmaron B^® in Germany. These high numbers indicate that Osmaron B^® needs to be tested more often than previously believed.

Our study emphasizes the importance of patch testing to a patient's personal set of materials [11]. Our patient had suffered from dermatitis for years, and had been treated by a dermatologist but an important etiological factor had not been clarified because patch testing had not been performed with the patient's personal substances. It is not easy to suspect that an udder ointment could be the cause of sensitization in a ship technician. Our report also shows that it is important to select non-allergenic hand creams, not udder creams, for use in work places.

Quaternary ammonium compounds are irritants but also weak sensitizers ([1-10, 12-26]) (Table I). Allergic reactions are rare, except to quaternium 15 which is also a formaldehyde releaser [1, 2]. The interpretation of patch test results is often difficult, and it is easy to label an irritant response as sensitization [1]. Low patch test concentrations need to be used. None of the 20 controls in the study by Goldermann and coworkers [4] reacted to 0.1% Osmaron B^®. Schubert [6] had 10 controls with negative patch tests to 0.1-1% Osmaron B^® in liquid paraffin. Our patient reacted to 0.01% Osmaron B^® in petrolatum (Fig. 1), and lower concentrations were not tested. Accordingly, Osmaron B^® can be patch tested in petrolatum and the correct patch test concentration seems to be 0.1-0.01%.

Article accepted on 15/03/01

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