Nickel contact dermatitis from hypodermic needles.

Sir,

Case 1: A 23-year-old student presented with an itchy eruption on her forearms for 2 weeks. The patient had recently recovered from typhoid fever, and while she was in hospital, she gave history of repeated blood withdrawals from the site. She did not relate any immediate itching or burning sensation following cleansing with the antiseptic solution. Also, a positive history of similar symptoms on using artificial jewellery was elicited. On examination, multiple skin colored erythematous papules in bilateral anticubital fossae were noted [Figure 1]. Few of the papules showed central crusting. Patch testing using Indian standard series of allergens revealed 2+ reaction to nickel sulfate at 48 and 72 hours [Figure 2].

Figure 1

Clinical photograph showing papular eruption in the cubital fossae

Figure 2

Strong patch test positive result to nickel sulfate

Case 2: A 21-year-old student presented with itchy hyperpigmented plaques on anticubital fossae, after 1 month of blood donation [Figure 3]. She also had a past history of itchy, scaly plaques on her left wrist, at the site of her watch. Patch testing with ISS gave a 1+ reaction for nickel sulfate at 48 hours, with the dimethyl glyoxime (DMG) test on the watch being negative.

Figure 3

Eczematous plaques seen in the cubital fossae

Nickel allergy is a common problem to which human beings are being continuously exposed, be it at home, work place or hospitals. Nickel sensitivity is common in the general population with a prevalence rate of 4–13.1%[1] and is on the increase. Nickel is an important constituent of artificial jewellery, clothing materials like metal zips, bra hooks, suspender clips, personal articles like watches, lipstick holder, knives, etc., and household utilities like kitchen utensils, machinery parts. Safety pin, due to its nickel content and ubiquitous usage across India, has proved to be a major cause of worry for its potential impact on most women across India.[2]

In both our patients, dermatitis developed following contact with hypodermic needles, which are frequently and almost ubiquitously used in the hospitals. Medical equipments such as orthopedic implants, braces, syringes and infusion pumps contain nickel in significant amounts and nickel ions released from them, on coming in contact with the human skin, cause sensitization, especially when the contact is for a prolonged period of time. Systemic contact dermatitis due to nickel release from an intravenous catheter has been reported.[3]

Romaguera et al. reported allergic contact dermatitis from a stainless steel infusion needle, and microanalysis of the needle revealed 8% nickel.[4] Koizumi et al.[5] reported a patient in whom dermatitis occurred following contact with acupuncture needles which also contained nickel. In both the above cases, dimethyl glyoxime test (DMG) test carried out on the culprit needles were negative, as was also seen in our case. Since the facility to analyze the composition of the needle was not available at our center, we failed to accurately measure the nickel content in our case.

Nickel released from nickel plated metals often induces allergic sensitization, but for stainless steels containing nickel, the effect is not well known. As laid down by the European directive, the amount of bioavailable nickel released from these metals onto the skin should be less than 0.5 µg/cm2/week. Although only a minority of nickel-sensitive individuals would react to less than 0.5 µg/cm2/week of nickel released, it may not be safe for every nickel-sensitive individual. Hence, this report reaffirms that medical equipment as an elicitor of contact dermatitis should not be overseen. Though the DMG test can be used as a first-line test for determining nickel release, DMG negative metallic articles may also induce nickel sensitization, and should by no means be advertised as safe in this respect.[6]

To conclude, any metal coming in prolonged contact with skin and releasing more than 0.5 µg/cm 2/week[7] should be prohibited as per the European directive on nickel.