Download Contact allergy to compression stockings: Is this

140
Review
Contact allergy to compression
stockings: Is this possible?
E. M. Valesky; R. Kaufmann; M. Meissner
Dept. of Dermatology, Venerology and Allergology, University Hospital Frankfurt, Frankfurt am Main/Germany
Keywords
Schlüsselwörter
Compression stockings, contact allergy, latex
allergy, irritant contact dermatitis, textile
allergy
Kompressionsstrümpfe,
Kontaktallergie,
Latexallergie, irritative Kontaktdermatitis,
Textilallergie
Summary
Zusammenfassung
In the treatment of chronic venous insufficiency or lymphoedema, compression stockings are standard therapy. Nevertheless, patient compliance is relatively low. One reason
for this are symptoms such as itching, burning or redness, which are considered by patients, but also frequently by attending physicians, as an allergy to the compression
stockings. The review covers the basics of
contact allergies, shows how often allergies
to compression stockings occur and what the
causes are, and briefly describes the common
differential diagnoses, their causes and prevention.
In der Therapie der chronisch venösen Insuffizienz oder des Lymphödems sind Kompressionsstrümpfe ein Standard der Therapie. Trotzdem ist die Akzeptanz der Patienten relativ
gering. Ein Grund dafür sind unter anderem
auch Symptome wie Juckreiz, Brennen oder
Rötung, die vom Patienten, aber auch häufig
vom behandelnden Arzt als Allergie auf die
Kompressionsstrümpfe gewertet werden. Die
Übersichtsarbeit geht auf die Grundlagen der
Kontaktallergien ein, zeigt wie häufig Allergien auf Kompressionsstrümpfe auftreten,
welche Auslöser dafür in Frage kommen und
beschreibt kurz die häufigen Differenzialdiagnosen, ihre Auslöser und Prävention.
Correspondence to
Dr. med. Eva Maria Valesky
Klinik für Dermatologie, Venerologie und Allergologie
Universitätsklinikum Frankfurt
Theodor-Stern-Kai 7,
D-60590 Frankfurt am Main/Germany
Tel. +49–69/6301–5179; Fax –6466
E-Mail: [email protected]
Kontaktallergien auf Kompressionsstrümpfe:
Gibt es das?
Phlebologie 2014; 43: 140–143
DOI: http://dx.doi.org/10.12687/phleb2190-3-2014
Received: January 21, 2014
Accepted: February 12, 2014
In phlebology and lymphology, compression stockings are the therapeutic gold
standard (1). Besides the recommendations
for using compression as a routine procedure following vein surgery for a defined
period of time (2), permanent compression
remains the daily therapy for many other
oedema patients (3).
Compression stockings are often not
worn regularly by patients despite a medical need. The reasons for the avoidance of
compression stockings besides a poor fit
are symptoms such as dry skin, redness and
itching where the material touches the skin
(4, 5). Redness and itching lead patients
and their carers to suspect an allergy to the
“elastic stockings”, which consequently
makes it impossible to wear them consistently.
act as haptens and can react with bodily
peptides upon contact with the skin. A
hapten-peptide complex occurs, which is
recognised by the immune system (sensitisation phase) (6, 7).
After sensitisation and repeated contact,
an effector stage occurs in some patients in
which dendritic cells migrate from the skin
to regional lymph nodes, presenting the
antigen to the already sensitised T cells.
The thus activated T cells themselves cause
the activation of macrophages via the production of IFNα. The increased expression
of adhesion molecules on endothelial cells
in the tissue causes the effector T cells in
the circulating blood to re-migrate to the
skin, leading to an immunologically-mediated (T cell) inflammation reaction in the
skin (8).
Whether an individual reacts to a potential antigen with sensitisation and possibly allergic contact eczema depends,
among other things, on the balance of T
helper and T suppressor lymphocytes (6).
Sensitisation can last up to 15 days and
mostly takes place without clinical symptoms (7). With the help of epicutaneous
testing, such sensitisation can be proved
(▶ Fig. 1). A clinically silent sensitisation
has no disease value. The clinical picture of
allergic contact eczema besides the sensitisation includes the symptoms of the acute
phase such as redness, moistness, blisters
and scabs; and in the chronic phase redness, papulae, flaking and hardening of
skin folds.
Contact allergies and
chronic venous
Pathophysiology of contact insufficiency
allergy
Contact allergens are low-molecular compounds that are foreign to the body, which
Patients with chronic venous insufficiency
and venous leg ulcers have significantly
higher sensitisation rates than the normal
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141
E. Valesky: Contact allergy to compression stockings
Risk factors for allergy
development
The most important risk factor for allergy
onset is the allergenic potential of the substances, which can be determined using a
lymph node assay (17). Moreover, the frequency and duration of contact, the concentration of the substance, and the area
and permeability of the exposed skin play a
significant role (18).
a
b
Fig. 1
Epicutaneous testing
of stocking materials.
a. Application of the
different stocking materials using the Finn
Chambers®; b. Marking of the areas on the
skin and careful attaching of the
samples; c. Applied
epicutaneous test.
c
population (9–12). Increased long-term application of topical products that can be
used for existing varicose eczema or ulcers
are probably responsible for this, as well as
damage to the barrier function of the epidermis, which facilitates the infiltration of
allergens (13, 14). Pathologically altered
lymph drainage may also play a role, enabling prolonged contact with allergens (15).
Common contact allergens are balsam
of Peru, Amerchol L101 (liquid paraffin,
emulsifier), mixed fragrance, lanolin alcohol, rosin, aminoglycoside antibiotics and
povidone-iodine (10). In rare cases, contact
allergy is also a possible cause of leg ulcers
(16).
Allergen
Allergic relevance
Elastane
extremely low
Polyamide
extremely low
Nylon
isolated reports
Untreated cotton
none
Treated cotton
(e.g. formaldehyde)
present
(primarily type IV reactions)
Natural rubber latex
present
(primarily type I reactions)
Vulcanisation accelerators
present
(thiuram, dithiocarbamate, etc.) (primarily type IV reactions)
for latex manufacture
Azo dyes DP blue 124/DP blue
106
isolated reports, since not approved
in Germany
Tab. 1
List of potential allergens in compression
stockings.
Allergenicity of compression stocking materials
Medical compression stockings today are
generally made of elastane (elastic core
fibres) and polyamide (weaving material
that especially comes into contact with
the skin) (19). There are currently no systematic tests for allergic reactions to compression materials. Immediate reactions
(e.g. urticaria) or delayed reactions (contact eczema) to the materials commonly
used today in compression stockings,
elastane and polyamide, are rare. There
are single reports of contact reactions to
nylon (20).
Other components such as cotton and
natural rubber latex are used increasingly
less often in compression stockings (19).
Untreated cotton or linen fibres are not
known to cause contact allergic reactions.
Latex allergies and
compression stockings
Natural latex is problematic in many respects. Multiple allergens can be found in
latex (n>15). These water-soluble latex proteins with different molecular weights are
activators of immediate-type (IgE-mediated) allergic reactions. These can lead
via intensified skin/mucosa contact (percutaneous) or via the airways to contact urticaria or allergic bronchial asthma. Systemic reactions are also possible in the
form of anaphylaxis (21).
To guarantee long wearing life, product
quality and product stability, several substances have been added to the natural
latex. In particular, vulcanisation acceler-
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E. Valesky: Contact allergy to compression stockings
ators have a high sensitisation potential
compared with natural rubber latex. These
added substances are mainly responsible
for delayed-type allergic reactions (contact
allergies) (21).
Natural latex (elastodiene) has only limited use today in compression therapy in
flat–knit and circular-knit products. In patients with previously known latex allergy,
and when there is no clear indication that
the product is “latex free”, in view of the
wide range of products direct contact with
the manufacturer is recommended. Selfadhesive cohesive support and compression bandages, which are often used in
compression dressings with multiple components, may have a hidden latex source
(22, 23). The presence of latex in the bandages results in the adhesive turns of the
bandage being more adhesive to each
other, without the bandages sticking to the
skin or hair. Latex-free cohesive bandages
are also available on the market. Respecting labeling is necessary.
Further possibilities of
textile allergy
Allergic reactions to textiles are generally
not caused by the synthetic textile fibres
themselves, but rather by dyes and textile
enhancing substances, which are added to
the fibres.
Disperse dyes such as azaquinone and
anthraquinone are the most common
causes of allergic textile eczema. The azo
dyes DP blue 124 and DP blue 106 (24)
are of particular allergic significance.
These dyes have a relatively high sensitisation potential and are used in large
quantities for dark colour tones (blue,
black). Although they are no longer approved in Germany, they are partly still
manufactured in England and indirectly
reach consumers in Germany (25). A current study of textiles from various countries could demonstrate that the commonly suspected disperse dyes are only
rarely used (26; ▶ Tab. 1).
medication, consisting of fatty (salve) topical products with natural ingredients such
as eucalyptus oil, menthol, chamomile, arnica (composite plant family), bears not
only the risk of a toxic irritant reaction (e.g.
fat irritation), but also the danger of sensitisation with resulting contact allergy to
the ingredients used (▶ Fig. 2).
In high-risk patients, all potential contact
allergens should be avoided for the purposes of allergy prevention.
a
b
Fig. 2 Toxic irritant contact dermatitis from a
topical product (marmot salve) under a compression stocking. a. front view and b. rear view of the
lower leg with sharply defined red swelling and
partial blistering.
Differential diagnosis of
irritant contact dermatitis
Allergic contact dermatitis has a tendency
to spread away from the area of allergen
contact, unlike irritant reactions. In everyday clinical practice the difference is sometimes difficult to see. Epicutaneous testing
with the suspected materials can answer
the question. In general, allergic reactions
to compression stockings are rare. Irritations arising from unspecified damage to
the epidermis are more common. Material
properties such as the roughness of the fabric with the associated rubbing on the skin,
reduced moisture absorption of the compression materials, as well as added chemicals, play an important role in toxic irritant
contact dermatitis.
Problematic locations are the extensor
sides of the lower leg and at the border of
the topband on the thigh. Skin hypersensitivity can often be explained in terms of
skin composition (e.g. atopic diathesis). To
minimise adverse effects, patients must
clearly be told about appropriate skin care
during compression therapy (27). Self-
Oinments and creams in accordance with
the German New Drug Formulary (NRF)
are recommended because of good tolerability. They are manufactured without
preservation substances and stabilisers.
Rehydrating topical products with a tolerable not too greasily basis, e.g. base cream
(DAC) with 2–5 % added carbamide (NRF
11.71) or dexpanthenol 5 % (NRF 11.28)
are suitable for this (28).
The problem of the
topband
Most topbands are made of polyamide,
elastane, silicone and polyester. Natural
rubber latex is not used. Contact allergies
to the components used are rare. If there is
a clinical suspicion of contact allergy, an attempt should be made to prove this using
an epicutaneous test.
Irritation due to the topbands is much
more common. The occlusive border
caused by the material as well as the additive effect of pressure and rubbing is responsible for this. The goal when using
topbands on sensitive skin is to minimise
the silicone-skin contact area while maintaining an optimal hold. A good compromise is a topband with a slub finish (29). If
irritation continues, alternative fastening
methods (hip fastening, one-legged panty,
diagonal upper border, thigh stockings
without a topband or tights instead of
thigh stockings) should be considered
(29).
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142
143
E. Valesky: Contact allergy to compression stockings
References
Conclusion for clinical practice
If there is a clinical suspicion of contact allergy in a patient with chronic venous insufficiency, epicutaneous testing is recommended. Recognising the triggering allergen is decisive in allergic contact eczema,
since only by avoiding the recognised allergen can the disease be healed.
As well as the standard series of tests,
specimens of the textiles that patients have
brought along are also useful. After being
soaked in ethanol, these are placed dry on
the patient’s back. Regarding isolated textile allergies, besides natural rubber latex,
textile ingredients (e.g. formaldehyde) and
dyes play the most important role (32).
Allergic reactions to compression stockings remain rare. Irritant, unspecified contact dermatitis is considerably more common. To avoid this and to increase compliance for compression therapy, a clarification of the potential adverse effects and the
need for consistent skin care are essential.
Prospects
Because of the increasing number of
people who suffer from hypersensitive
skin, the textile industry is striving to develop materials or textile refinement methods that include even greater wearing comfort. It is hoped that future material innovations will further improve compliance
with compression therapy (30, 31).
Ethical guidelines
The author declares no conflicts of interest.
All data on humans in the manuscript were
conducted in accordance to national laws,
the Helsinki Declaration and informed
consent from all patients.
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