Caputo et aJ.

8, ()ol1nick H, Thies W, Taud W, et al. Intra-epidennalel1~u~rophileund eosinophile IgA-Dennatose, In: Gollnick~,$tadler R,eds. Dia-Klinik. Stuttgart: Schattauer,:~~67:68-70.

9.'pjetteW, IlurkenRR, Ray TL. Intraepidermal neutro­philic 19A dermatosis: presence of circulating pemphigus­like 19A antibody specific for monkey epithelium [Ab­stract]. J Invest DermatoI1987;88:512.

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10. Stolz W, Bieber T, Meurer M. Is the atypical neutrophilicdennatosis with subcorneal IgA deposits a variant ofpem­phigus foliaceus? Br J DermatoI1989;121:276-9.

11. Saurat J-H, Merot Y, Salomon D, et al. Pemphigus-likeIgA deposits and vesiculo-pustular dermatosis in a 10­year-old girl. Dermatologica 1987;175:96-100.

12. Johnson SAM, Cripps DJ. Subcorneal pustular dermatosisin children. Arch DermatoI1974;109:73-7.

Erythema multifonne after contact dermatitis inresponse to an epoxy sealantMargot J. Whitfe1d, MBBS, and Jason K. Rivers, MD, FRCPC Camperdown,New South Wales, Australia

A case of erythema multiforme associated with an allergic contact dermatitis in response toan epoxy-based compound is presented. Patch tests revealed a positive reaction to both theepoxy resin and the hardener. Chemicals applied directly to the skin should be considered asa potential cause of erythema multiforme. (J AM ACAD DERMATOL 1991;25:386-8.)

Epoxy resins cause more instances of occupa­tional dermatitis than anyother group ofchemicals. I

Although erythema multifonne (EM) has occasion­ally been reported in conjunction with allergic con­tact dermatitis in response to various allergens,2-27this association has been documented only once be­fore in the case of epoxy resins.2 We report anothercase of EM that developed in association with acontact dermatitis to an epoxy resin and hardener.

CASE REPORT

A 46-year-old swimming pool attendant had an in­tensely pruritic papular eruption of 24 hours' duration onher upper limbs. For the preceding 10 days, she had beenengaged in repairing and repainting the swimming pool.Although she had attempted to protect her arms, painthad splashed onto her arms daily. The "paint" was actu­ally a swimming pool sealant that contained 55% epoxyresin (molecular weight 380) and an epoxy hardener,isophoronediamine.

From the Department of Dermatology, The University of Sydney,Royal Prince Alfred Hospital.

Reprint requests: J. Rivers, MD, Division of Dermatology, Faculty ofMedicine, The University of British Columbia, 855 W. Tenth Ave.,Vancouver, B.C., Canada V5Z 1L7.

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The patient's medical history was unremarkable asidefrom previous eczematous reactions to several perfumesand cosmetics. There was no personal or family history ofatopy. Physical examination revealed an erythematouspapulovesicular and bullous eruption confined to themiddle part of the upper extremities (Fig. 1). A clinicaldiagnosis of acute allergic contact dermatitis was made,and the epoxy sealant was considered the causative agent.The patient was treated with Burow's solution compressesand betamethasone valerate 0.05% cream three timesdaily. She avoided the workplace, and her condition im­proved considerably over the next 5 days.

Nine days after the onset of the dermatitis, a neweruption developed on the patient's forearms and quicklyspread to the hands. When seen 3 days after the onset ofthe new eruption, her arms and hands were covered witherythematous papules and plaques, some with a target­like appearance (Fig. 2). The oral and ocular mucosaewere uninvolved, and the results of the remainder of thephysical examination were normal. A diagnosis of EMwas made, The eruption resolved during the next 2 weeksand has not recurred.

Patch tests with the TRUE Test standard seriesshowed positive reactions at 48 and 96 hours to epoxyresin and fragrance mix, and a positive response to balsamof Peru at 96 hours only. Further patch testing with theepoxy resin (2% in petrolatum and I%in acetone) and the

Volume 25Number 2, Part 2August 1991 Erythema multi/orme after contact dermatitis to an epoxy sealant 387

Fig. 1. Acute allergic contact dermatitis of the arm.

Fig. 2. Erythema multiforme developing 9 days later in area of resolving dermatitis.

hardener (0.5% and 1% in petrolatum) from the sealantto which the patient had been exposed showed positiveresponses at 48, 96, and 168 hours to both substances. Inaddition, the patient was tested with a modified Trolabplastics-and-glue series that included two epoxy harden­ers (triethylenetetramine, 0.5% in petrolatum, and diami­nodiphenylmethane, 0.5% in petrolatum). Results fromall test sites were negative at 48 and 96 hours. She had norecurrenceofthe EM during or after the patch test period.

DISCUSSION

This case illustrates the occurrence of EM in aperson sensitized to both an epoxy resin and a hard­ener. To our knowledge, there has been only one

previous report of this phenomenon, and in that in­stance the hardener alone was thought to haveinduced the EM.2

Occasionally, EM has been reported to occur inassociation with allergic contact dermatitis to othersubstances (Table I). In those cases the EM hasranged from a mild localized exanthem3-5 to life­threatening toxic epidermal necrolysis.6,7 As in ourpatient, the EM is often initially localized to the areaof contact dermatitis. 5, 8, 9 EM may develop withouta primary eczematous component,10, 11 concurrentlywith the acute allergic contact dermatitis12,13 or,most commonly, during resolution of acute allergic

388 Whitfeld and Rivers

Table. I. Substances reported to cause erythemamultiforme in;:l.sSociation with allergic contactdermatitis

9-ai'ornofluorene19, 20

Balsam of Peru21

Econazole22

Hair dyes I2

Isopropyl-p-phenylenediamine5

Mephenesin23

Nickell I, 14.15

Proflavine24

Promethazine21

Pyrrolnitrin2,5

Rhus16

Spray cologne7

Sulfonamide21

Terpenes26

Tropical woods6•17

Vitamin E27

contact dermatitis. 6, 12, 14 In addition, reexposure toan allergen several months after an episode of EMmay cause the reappearance of EM.15

The pathogenesis of EM in relation to allergiccontact dermatitis remains unclear, but it may rep­resent an Arthus-type reaction. 16 A circulating an~

tibody to the absorbed allergen could result inimmune complex formation and its subsequent dep­osition in the microvasculature. I? However, biopsyspecimens from positivepatch testsites showchangesconsistent with a delayed type of hypersensitivityreaction.

Prevention of contact sensitization to epoxy resinsand their hardeners is important. 1 Warning labelsshould appear on epoxy resin containers, and pro­tective clothing and gloves should be worn. Soap,waterless cleansers, and solvents have been sug­gested to remove epoxy resins from the skin,1.18 butoveruse of the latter agents can result in an irritantdermatitis. I It has also been suggested that the ep­oxy oligomers of molecular weights 340 and 624 beavoided and higher molecular weight epoxy resinsused because they are less allergenic. I

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2. Chanial G, Wertheimer J, Tolot F. Dermite par inducteurepicote, a type d'erytheme polymorphe. Arch Mal Prof1961 ;22:171.

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22. Valsecchi R, Tornaghi A, Ribbia G, et al. Contact derma­titis from econazole. Contact Dermatitis 1982;8:422.

23. Degreef H, Conamie A, Van Derheyden D, et al. Mephen­esin contact dermatitis with erythema multiforme features.Contact Dermatitis 1984;10:220-3.

24. Goh CL. Erythema multiforme-like and purpuric eruptiondue to contact allergy to proflavine. Contact Dermatitis1987;17:53-4.

25. Meneghini CL, Angelini G. Contact dermatitis from pyr­rolnitrin. Contact Dermatitis 1982;8:55-8.

26. Kirby DJ, Darley CR. Erythema multiforme associatedwith a contact dermatitis to terpenes. Contact Dermatitis1987;4:238.

27. Saperstein H, Rapaport M, Rietschel RL. Topical vitaminE as a cause of erythema multiforme-like eruptions. ArchDermatol 1984;120:906-9.