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14. Jensen T, Novak P, Eblin KE, Gandolfi AJ, Futscher BW. Epigenetic remodeling during arsenical-induced malignant transformation. Carcinogenesis. 2008 Aug; 29(8):1500-1508.

15. Karagas M, Tosteson TD, Blum J, Klaue B, Weiss J, Stannard V, et al. Measurement of Low Levels of Arsenic Exposure: A Comparison of Water and Toenail Concentrations. American Journal of Epidemiology. 2000 July; 152(1):84-90.

16. Hall M, Chen Y, Ahsan H, Ahsan H, Slavkovich V, van Green A, et al. Blood arsenic as a biomarker of arsenic exposure: Results from a prospective study. Journal of Toxicology. 2006 May; 225(2-3):225-33.

17. Khandker S, Dey RK, Islam AM, Ahmad SA, Mahmud IA. Arsenic-safe drinking water and antioxidants for the management of arsenicosis of patients. Bangladesh J Pharmacol. 2006 Dec; 1(2):42-50.

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INTRODUCTION

llergic contact dermatitis (ACD) ranks among the most common dermatologic conditions as reported by

Philippine Dermatological Society-accredited training institutions in Metro Manila.1 ACD may

present non-classically and requires patch testing to identify the allergen and allow exposure avoidance. Impaired barrier function caused by the inflammation in ACD increases the risk for bacterial and fungal infections. This disease has a heavy impact on the patient’s quality of life2, affecting occupational, financial, and social realms.

CASE PRESENTATION

A 77-year old female physician presented with bilateral symmetrical reddish, dry, scaly, plaques on the soles and plantar aspects of the toes of six months duration (Figure 1A). She self-treated with 1% clotrimazole cream twice a day. By the end of two weeks, she noted moderate reduction in scaling, but still with residual erythema and scaling. Within 3 months, she applied a salicylic patch over the thick areas resulting in erosion and increased inflammation of the feet. She was seen by general physician, diagnosed with cellulitis hence given co-amoxiclav 625 mg per tab three times a day for 7 days and advised application of Sofra-Tulle dressing containing 1.0% framycetin sulfate.

Swelling resolved after 1 week but reddish, scaly lesions on the sides and plantar areas of the feet persisted, despite continued use of clotrimazole cream. Patient presented to our clinic with bilateral symmetrical involvement of the feet, lesions consisting of erythematous edematous scaly plaques with increased skin markings on the plantar aspect of the heels and sides of the feet (Figure 1A).

Skin and Cancer Foundation Inc. a Consultant b Resident

Source of funding: none Conflict of interest: none Corresponding author: : John Michael Dellariarte, MD Email: degustibus000@yahoo.com

Allergic contact dermatitis to propolis presenting as tinea pedis

John Michael F. Dellariarte, MDa; Shereen Reine S. Rodriguez, MDa; Vermen M. Verallo-Rowell, MD, FPDSb

Allergic contact dermatitis (ACD) is a common dermatologic condition. ACD may present with a typical clinical presentations, requiring patch testing for diagnosis. A 77-year-old Filipino female presented with a 6 month-history of bilateral symmetrical pruritic scaly plaques on both feet diagnosed and treated as a case tinea pedis unresponsive to topical antifungal treatment. Patch test result was positive for Propolis. A positive patch test result to Propolis may be associated to ACD to varnish and wood in a patient with a history of exposure to bees. Patch test was key to diagnosis and successful conservative management.

Keywords: Allergic contact dermatitis, dermatitis, Propolis, tinea pedis

A

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Acknowledgements: Dr Sonia Sarcia, Dr Verallo-Rowell’s Contact Dermatitis Clinic at VMV Skin Sciences and Research Centre + Clinics, Dr Anna Patricia Belen, Dr Karla Angela Cuenca-Luchangco

Figure 1A. Bilateral symmetrical involvement of the feet, lesions consisting of erythematous edematous scaly plaques with increased skin markings on the plantar aspect of the heels and sides of the feet

Patient was diagnosed with bacterial infection secondary to ACD probably secondary to footwear and lichen simplex chronicus. She was advised to discontinue current footwear (rubber shoes and leather shoes) and to use only white cotton socks, slippers, cloth-type shoes, natural non-dyed abaca (hemp) slippers and shoes, VCO cold compress, and apply 4% monolaurin + 0.7% monocaprin ointment (for its antibacterial and antimicrobial properties3-7) on the erythematous areas with improvement on 2 months follow up (Figure 1B). Wound culture and sensitivity revealed growth of streptococcus agalactiae and staphylococcus capitis, both methicillin sensitive.

Skin scraping showed mixed fungal spores of Candida and Pityrosporum. No septated hyphae were seen on mycology.

Patient was given Co-Amoxiclav 625 mg/tab tid for week followed and another week of Ciprofloxacin 750 mg/tab tid for the bacterial infection.

On follow up, patch test using the 80 North American Contact Dermatitis Group (NACDG) Allergens was done. At the 48 hour patch test reading, results showed a positive reaction to Propolis 10% in petrolatum (2+), Fragrance mix 6% in petrolatum (1+), Fragrance Mix II 14% in petrolatum (1+), and p-Phenylenediamine base 1% in petrolatum (1+) (Figure 2A).

At 96 hours post patch test application (Figure 2B), only

Figure 1B. Improvement of previous lesions with residual erythematous plaques on 2 months follow up

Figure 2A. 48 hours post patch test application. Results:, #3 Fragrance mix 6% in petrolatum (1+), #10 p-Phenylenediamine base 1% in petrolatum (1+), #29 Fragrance Mix II 14% in petrolatum (1+), #55 Propolis 10% in petrolatum (2+)

Figure 2B. 96 hours post patch test application. Results: #55 Propolis 10% in petrolatum (2+)

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Figure 2C. Close up comparison of allergen panel con containing #55 Propolis 10% in petrolatum 48 hours (left) and 96 hours (right) post patch test application; Note Propolis on allergen slot 55 persistently positive on 2-6 readings

Propolis retained positivity still at (+2) (Figure 2C, 4B). Patch test using specimen from patient’s footwear and

varnished wooden tiles, pulverized in petrolatum was

subsequently done (Figure 3). These revealed negative results

for footwear and positive results for the varnished and non-

varnished wooden tile samples (Figure 4A, 4B). Results

showed (1+) for varnished wood and (1+) for non-varnished

wood. On questioning, patient maintains a beehive colony

Figure 3. Patient’s footwear and wooden tiles used as allergen source for second patch test

75

Figure 4A. 48 hours and 98 hours post patch test application of the Second patch test; no changes for footwear allergens #1-#12; #13 varnished wood (1+) and #14 unvarnished wood (1+) after 48 hours persisting through 96 hours post patch test application.

Figure 4B. Close up comparison of 10% Propolis in petrolatum, varnished wood in petrolatum and unvarnished wood in petrolatum 48 hours (left) and 96 hours (right) post patch test application; and #14 unvarnished wood (1+) after 48 hours persisting through 96 hours post patch test application.

in her provincial house and has intermittent exposure to the bees.

DISCUSSION

In allergic contact dermatitis, tissue damage is mostly due to CD8+ T-cell-induced apoptosis of keratinocytes bearing the hapten protein compex on the MHC class I molecules via the perforin/granzyme of the Fas/FsL pathway.

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The induction of the keratinocyte apoptosis is accompanied by a rapid cleavage of the CH1 intercellular adhesion molecules (E-cadherins). There is loss of intercellular adhesion and the infiltration of lymphocytes in the epidermis.8 Apoptosis of keratinocytes, loss of intercellular adhesion and inflammation caused by infiltration of lymphocytes in the epidermis all contribute to the impaired skin barrier in allergic contact dermatitis making the skin susceptible to cutaneous infections such as dermatophytosis. However, despite adequate treatment of the tinea pedis, this patient remained symptomatic with a persistent symmetric eruption on both feet.

A tinea pedis unresponsive to topical antifungal and bilateral symmetrical distribution of the lesion, and 10% KOH result of 4(+) mixed spores with no hyphae have led us to consider a previously undetected allergic contact dermatitis.

Patch testing showed positive reactions to 10% Propolis in petrolatum (2+), 6% Fragrance mix in petrolatum (1+), 14% Fragrance Mix II in petrolatum (1+), and 1% p-Phenelyndiamine base in petrolatum (1+). History revealed the existence of a beehive within patient’s residence. Hence, a possible mode of sensitization could be from exposure to airborne propolis emitted from the beehive.9

Contact dermatitis from propolis are now reported from all over the world.10-13 Propolis, also known as bee glue, is a lipophilic brownish resinous substance collected by bees, mainly from trees; it is mixed with wax to seal the hives to protect the bees against invaders and cold weather.14 About 1.2 to 6.6% of patients who are patch-tested for dermatitis are sensitive to propolis.15 Propolis is often found in shampoos and conditioners, ointments, lotions, and cosmetics16 however, the patient denies use of any products on the feet. Beeswax, a propolis-related substance, is used for the seams of handmade boots and may be contaminated with propolis17; thus a patch test using materials from the patient’s foot wear, especially the seams was done but was negative. The dermatitis was observed on the soles and lateral aspects of both feet and plantar aspect of the toes. Further probe into the history revealed that patient walks around the house barefoot on a flooring made of varnished wooden tiles. Propolis is often found in varnish.18 Hausen et al19 reported that propolis has been used as an ingredient in violin varnish for centuries. There have been case reports of ACD to propolis cera in musicians and instrument makers.20-23

Because string players such as violinists and cellists as well as stringed instrument makers may be significantly exposed to propolis in varnish, the differential diagnosis of a recalcitrant, chronic eczema in these individuals must include ACD.24

Henschel and colleagues described a 50-year-old man allergic to propolis, with a 1-year history of hand dermatitis who worked in a retail store, handling untreated and finished wood products25 thus a possibility of cross-hypersensitivity of a propolis-allergic individual to wood. This is possible since resins constitute 45% to 55% of propolis26 and bees forage for resins from droplets appearing on the bark of the trunk or limbs of trees.27 A second patch test was done with pulverized samples from the wooden tile used as allergens.

Samples were taken from varnished and unvarnished sides of the wooden tile. On first reading of the patch test (48 hours post patch test application) results were positive (+1) for unvarnished and varnished wood allergens and footwear allergens showed erythema. On second reading (96 hours post patch test application), results remained positive (+1) for unvarnished and varnished wood allergens but negative for footwear supporting an allergy to varnish or wood or both.

REFERENCES

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CONCLUSION

Patient’s ACD to varnish and/or wooden tiles caused a chronic impairment of skin barrier function that predisposed the patient to a tinea pedis unresponsive to topical antifungal. A positive patch test result to Propolis may be associated with ACD to varnish, wood or other wooden products especially in a patient with a history of exposure to bees.