ARTICLE
It has been reported that erythema multiforme
occasionally occurs in conjunction with allergic contact dermatitis to
various allergens, such as nickel [1], epoxy sealant [2], agricultural
and other chemicals [3, 4], plants [5], tropical wood [6], hair dye [7],
topical medication [8], and rubber [9]. We report a rare case of erythema
multiforme-like eruption that developed in association with contact dermatitis
to a cutting mineral oil product.
Case report
A 48-year-old man had an itchy eruption on the forearms after handling
a cutting oil product, early June, 1999. The oil, whose constituents were
mineral oil and additives, was produced by Esso Oil Co., Tokyo, Japan,
and used for the honing of equipment. The eruption was mild and regressed
spontaneously after this first episode. The patient again used the oil
on two consecutive days, July 9 and 10, and developed an itchy, erythematous
eruption on the lateral aspects of forearms and the dorsa of hands in
the evening of July 10. Next day, erythematous round lesions started to
occur on his trunk and four extremities with a high temperature of 39°
C.
On July 12, the patient consulted us and presented with an erythematous
eruption on the forearms. It appeared that round, centrally purple lesions
became coalesced and evolved into diffuse erythema. It spared a wrist
watch site (Fig. 1). In
addition, variously sized, round, erythematous lesions were scattered
on the trunk and four extremities (Fig.
2). The individual lesions were well demarcated, centrally purple,
and smooth on their surfaces. Neither oral nor ocular lesions were found.
Famotidine was the only medication, which he took for a duodenal ulcer.
Laboratory tests of peripheral blood revealed: aspartate aminotransferase,
48 IU (normal, 5-35 IU); alanine aminotransferase, 39 IU (normal, 5-35
IU); gamma-glutamate transpeptidase, 80 IU/l (normal, < 57.5 IU/l);
and C-reactive protein, 5.03 mg/dl (normal, < 0.3 mg/dl). Urinalysis
showed microhematuria and proteinuria. Complete blood cell counts were
within normal levels. Serum anti-herpes simplex virus IgG and IgM titers
were 1:40 and 1:10, respectively. An anti-mycoplasma pneumoniae antibody
titer was less than 1:40. These data suggested that the occurrence of
erythema multiforme-like eruption was not caused by either of these microorganisms.
A biopsy specimen taken from an erythema multiforme-like
lesion on the left thigh showed mild liquefaction degeneration of the
basal epidermis, dermal edema, and perivascular infiltration of lymphocytes
with extravasation of erythrocytes in the upper dermis.
Topical provocation patch tests performed with the oil at 1%, 2%, 5%
and 10% gave positive reactions at 48 hours. In two normal subjects, positive
responses were observed with 100% but not 10% of the oil. He had no recurrence
of erythema multiforme-like lesions after the patch test.
Because of the occurrence of the eruption at the skin sites that were
exposed to the honing oil and the positive patch tests to the oil, he
was diagnosed as having contact dermatitis due to the oil. It was thought
that the erythematous eruption on the oil-unexposed areas with fever was
induced by a systemic response following the contact reaction. Avoidance
of exposure to the oil and topical application of a corticosteroid ointment
markedly improved his condition 2 weeks later. Since then, the eruption
has not recurred.
Discussion
The scattered skin lesions that occurred following contact dermatitis
to a cutting oil product in our case belong to a generalized erythema
multiforme-like eruption which is different from autosensitization dermatitis,
which exhibits eczematous changes. It has been reported that erythema
multiforme occasionally occurs in conjunction with allergic contact dermatitis
to various allergens [1-8]. The severity varies from mild erythema limited
to contactant-exposed areas [9] to generalized erythema multiforme or
even toxic epidermal necrolysis [10]. In several cases, the histopathologic
findings have been reported to be indistinguishable from typical erythema
multiforme. In contact dermatitis to cutting oil, it has been reported
that primary irritation is the mechanism in the vast majority of patients,
while the incidence of allergic type varies from 3 to 50% [11, 12]. The
cutting mineral oil in our case was prepared from crude petroleum by hydrogenation.
We could not identify the precise component that caused the allergic reaction
and produced the positive patch test, because the cutting oil contains
many kinds of chemicals such as biocides, corrosion inhibitors, coupling
agents and emulsifiers. The former two have been reported to be the most
common allergens [13].
The pathogenetic mechanisms of erythema multiforme-like eruption that
develops in association with allergic contact dermatitis remain unclear.
Both immune complex-mediated and T cell-mediated passways have been proposed
[5], as have been suggested in ordinary erythema multiforme. The T cell-mediated
cellular mechanism seems to be more likely, since generalized erythema
multiforme follows contact dermatitis, which is a type IV allergic reaction
mediated by T cells. In addition, the eruption at the contact sites of
our patient exhibited coalesced erythema multiforme-like appearance, suggesting
that both the contactant-exposed and -unexposed lesions are yielded via
the same immunologic mechanism. It is considered that certain contact
allergens have a potential to evoke erythema multiforme as a consequence
of systemic responses induced by local elicitation.
Article accepted on 12/1/01
REFERENCES
1. Friedman SJ, Perry HO. Erythema multiforme associated with
contact dermatitis. Contact Dermatitis 1985; 12: 21-3.
2. Whitfeld MJ, Rivers JK. Erythema multiforme after contact
dermatitis in response to an epoxy sealant. J Am Acad Dermatol
1991; 2: 386-8.
3. Imaizumi T, Tokura Y, Watanabe K. Erythema multiforme associated
with an agricultural chemicals. Hifubyo-Shinryo 1985; 7: 521-4.
4. Urano S, Tokura Y. An erythema multiforme-like eruption caused
by exposure to 1-chloromethylnaphthalene. J Dermatol 1998; 25:
13-8.
5. Cohen LM, Cohen JL. Erythema multiforme associated with contact
dermatitis to poison ivy: three cases and a review of the literature.
Cutis 1998; 62: 139-42.
6. Irvine C, Reynolds A, Finlay AY. Erythema multiforme-like
reaction to "rosewood". Contact Dermatitis 1988; 19: 224-5.
7. Tosti A, Bardazzi F, Valeri F, Toni F. Erythema multiforme
with contact dermatitis to hair dyes. Contact Dermatitis 1987;
17: 321-2.
8. Kurumaji Y. Photo-Koebner phenomenon in erythema-multiforme
like eruption induced by contact dermatitis due to Bufexamac. Dermatology
1998; 197: 183-6.
9. Foussereau J, Cavelier C, Protois JC, Sanchez M, Heid E. A
case of erythema multiforme with allergy to isopropyl-p-phenylenediamine
of rubber. Contact Dermatitis 1988; 18: 183.
10. Thompson JA, Wansker BA. A case of contact dermatitis, erythema
multiforme, and toxic epidermal necrolysis. J Am Acad Dermatol
1981; 5: 666-9.
11. De Boer EM, Van Ketel WG, Bruynzeel DP. Dermatoses in metal
workers (I). Irritant dermatitis. Contact dermatitis 1989; 20:
212-8.
12. Grattan CEH, English JSC, Foulds IS, et al. Cutting
fluid dermatitis. Contact dermatitis 1989; 20: 372-6.
13. Marks JG, DeLeo VA. Occupations commonly associated with
contact dermatitis. In: Contact and Occupational Dermatology. Mosby-Year
Book Inc., St. Louis, MO, 1992; 269-305.
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