causative factors for the etiology of shoe contact dermatitis supported by clinical based evidence as found in the medical literature. 2,3 Secondly, a description of the signs and symp- toms of shoe contact dermatitis will be presented in a narrative fashion. 2,3 Finally, both treatment options and preventative measures to avoid shoe dermatitis will be offered to the podi- atric clinician. Causes of Shoe “Contact” Dermatitis Allergic contact dermatitis is caused by the body’s reaction to something that directly contacts the Continued on page 190 Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Contin- uing Medical Education by the Council on Podiatric Medical Education. You may enroll: 1) on a per issue basis (at $20.00 per topic) or 2) per year, for the special introductory rate of $139 (you save $61). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the near future, you may be able to submit via the Internet. If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned cred- its. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 200. Other than those entities currently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be accept- able by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best efforts to ensure the widest acceptance of this program possible. This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts by noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected]. Following this article, an answer sheet and full set of instructions are provided (p. 200).—Editor OCTOBER 2008 • PODIATRY MANAGEMENT www.podiatrym.com 189 Continuing Medical Education Objectives 1) Appreciate the clini- cal data regarding the causes of shoe “contact” dermatitis as found in the literature. 2) Recognize key fea- tures present during the presentation of shoe dermatitis. 3) Appreciate the man- agement and prevention of shoe dermatitis. tact dermatitis caused by the contact of the foot with parts of the shoe due to these chemicals. 1-3 Despite a warm and humid environment inside shoes, shoe dermatitis is relatively uncommon. Shoe dermatitis is a di- agnostic and therapeutic challenge and is a common type of contact dermatitis affecting children and adults regardless of race. For this rea- son, it is imperative that the foot and ankle physician become familiar with recognizing signs and symp- toms of shoe dermatitis so that pa- tients can be accurately diagnosed and appropriately treated to avoid secondary infections and disability. This review will first present Shoe Dermatitis: Causes, Prevention, and Management By Robert G. Smith, DPM, MSc, RPh Introduction At least seven pairs of shoes are purchased by American families an- nually. Podiatric physicians have come to realize that there is a variety of footwear styles: casual, formal, work, and athletic shoes made all over the world from leather, rubber, and other synthetic materials. For this reason, it is impossible to identi- fy precisely all of their constituents. A vast variety of potentially sensitiz- ing chemicals are used during shoe manufacturing and finishing. A medical condition referred to as “shoe dermatitis” is a form of con- Here’s an update for the podiatric physician.
Transcript
causative factors for the etiology ofshoe contact dermatitis supported byclinical based evidence as found inthe medical literature.2,3 Secondly, adescription of the signs and symp-toms of shoe contact dermatitis willbe presented in a narrative fashion.2,3
Finally, both treatment options andpreventative measures to avoid shoedermatitis will be offered to the podi-atric clinician.
Causes of Shoe “Contact”Dermatitis
Allergic contact dermatitis iscaused by the body’s reaction tosomething that directly contacts the
Continued on page 190
Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Contin-uing Medical Education by the Council on Podiatric Medical Education.
You may enroll: 1) on a per issue basis (at $20.00 per topic) or 2) per year, for the special introductory rate of $139 (yousave $61). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the nearfuture, you may be able to submit via the Internet.
If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned cred-its. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test atno additional cost. A list of states currently honoring CPME approved credits is listed on pg. 200. Other than those entitiescurrently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be accept-able by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best effortsto ensure the widest acceptance of this program possible.
This instructional CME program is designed to supplement, NOT replace, existing CME seminars.The goal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high qualitymanuscripts by noted authors and researchers. If you have any questions or comments about this program, you can write orcall us at: Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us [email protected].
Following this article, an answer sheet and full set of instructions are provided (p. 200).—Editor
OCTOBER 2008 • PODIATRY MANAGEMENTwww.podiatrym.com 189
Continuing
Medical Education
Objectives1) Appreciate the clini-
cal data regarding thecauses of shoe “contact”dermatitis as found inthe literature.
2) Recognize key fea-tures present during thepresentation of shoedermatitis.
3) Appreciate the man-agement and preventionof shoe dermatitis.
tact dermatitis caused by the contactof the foot with parts of the shoe dueto these chemicals.1-3 Despite a warmand humid environment insideshoes, shoe dermatitis is relativelyuncommon. Shoe dermatitis is a di-agnostic and therapeutic challengeand is a common type of contactdermatitis affecting children andadults regardless of race. For this rea-son, it is imperative that the foot andankle physician become familiarwith recognizing signs and symp-toms of shoe dermatitis so that pa-tients can be accurately diagnosedand appropriately treated to avoidsecondary infections and disability.
This review will first present
ShoeDermatitis:Causes, Prevention,andManagement
By Robert G. Smith, DPM, MSc, RPh
IntroductionAt least seven pairs of shoes are
purchased by American families an-nually. Podiatric physicians havecome to realize that there is a varietyof footwear styles: casual, formal,work, and athletic shoes made allover the world from leather, rubber,and other synthetic materials. Forthis reason, it is impossible to identi-fy precisely all of their constituents.A vast variety of potentially sensitiz-ing chemicals are used during shoemanufacturing and finishing. Amedical condition referred to as“shoe dermatitis” is a form of con-
Here’s an update for the podiatric physician.
eyelets or nickel arch supports.The allergen is usually a rubber
accelerator or antioxidant used inthe manufacture of rubber ratherthan rubber or latex. Rubber contin-ues to be blamed as a common causeof shoe dermatitis, especially whenthe antioxidant monobenzyl hydro-quinone is present.3,5 This antioxi-dant may also cause hypopigmenta-tion of the skin.5
The paraphenylenediaminegroup of rubber additives are an im-portant cause of industrial dermati-tis. Shoe dermatitis is usually causedby the rubber adhesive used to gluethe parts together. Moreover, adhe-sives, both rubber and non-rubber,can cause problems so much so thateven leather shoes may containproducts that cause shoe dermatitis.
ChromatesChromates are compounds that
contain chromium and are com-monly responsible for allergic con-tact dermatitis from contact with ce-ment, leather, some matches, paintsand anti-rust compounds. Chro-mates are used to tan leather forshoes and clothing. Chromium isgradually liberated from leather col-lagen by the action of hydroxyl acidsin sweat, especially when shoes areworn without stockings.5
Athletic running shoes, as well asswim fins, contain rubber accelera-tors, antioxidants, and other rubberadditives that are common causes offoot dermatitis.6 These compoundsinclude: thioureas, thiurams, carba-mates, N-isopropyl-N-phenyl-p-
Continued on page 191
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Shoe Dermatitis...
skin. Many different sub-stances, called “allergens”, can
cause allergic contact dermatitis.Cronin reports that historically inthe 1930s and 1940s, leather anddyes caused most of the presentingcases of shoe contact dermatitis.4
By the 1950s and 1960s, rubberallergens became the most commonidentifiable cause of foot dermati-tis.3,4 Today, shoe dermatitis mayoccur if a person is sensitive to therubber or elastic compounds inshoes, form inserts, or elastic gluesused to bind shoe components. Theother identifiable causes of shoe der-matitis are cements, dichromatesused in tanning, dyes, anti-mildewagents, formaldehyde, and nickel
Continuing
MedicalEducation
TABLE 1The Most Common Allergens in Shoe Dermatitis
Found in the Literature
Study Year Patient # Method Common Allergens
Saha et al. 1993 50 Patch test Potassium dichromate, colophony
Shackelford and Belsito 2002 704 Patch test Rubber components, chromated leather70* adhesives
Rani et al. 2003 119 Patch test para-tert-Butylphenol formaldehyde,cobalt chloride, glues
Lazzarini et al. 2004 1027 Patch test para-tert-Butylphenol formaldehyde,53* chromate, rubber chemicals, dyes
Holden and Gawkroder 2005 3337 Patch test Chromate, rubber chemicals,230* paraphenylenediamine
Nardelli et al. 2005 8543 Patch test Potassium dichromate, cobalt chloride,474* paraphenylenediamine, rubber components
para-tert-Butylphenol formaldehyde,colophony
Chowdhuri and Ghosh 2007 640 Patch test Potassium dichromate, cobalt chloride155*
Warshaw et al. 2007 10,061 Patch test para-tert-Butylphenol formaldehyde,109* Potassium dichromate, carba mix
Bajaj et al 2007 1000 Patch test Potassium dichromate,310* mercaptobenzthiazole, mercapto mix
* Accounts for the number of patients with contact dermatitis from footwear
OCTOBER 2008 • PODIATRY MANAGEMENTwww.podiatrym.com 191
At the center of this report is theforemost intention of the investiga-tor to analyze interventional datafrom subjects retrospectively. Free-man’s patient improvement (the res-olution of symptoms of 87.5%) wasattributed to successfully finding suit-able footwear secondary to patchtesting that identified the principlecausative antigen.3,9 However, the rel-atively small representative samplesize in this study does impact themagnitude of precision as it relates tolikelihood estimates when used andapplied to generalize populations.Therefore, the effectiveness of the in-tervention of empowering patientswith allergen awareness may not befully appreciated because of bias.
Shackelford and Belsito demon-strated that rubber components werethe most common allergens con-tributing to the etiology of allergic-appearing dermatitis.3,7 The contin-ued and increased frequency withwhich rubber components act ascausative allergens in shoe dermatitisis a reflection of their continued use,further accentuated by Belsito.3,8
Shackelford and Belsito used afive-year retrospective investigationalmethod on 704 patients who werepatch-tested. Ten percent of thesepatients demonstrated a clinical pre-sentation suggestive of allergic con-tact dermatitis.7 Because this was aretrospective design, verifying theexistence of risk factors or outcomeconditions to the same degree asseen in prospective study design isdifficult. It is possible that this inves-tigation may have both elements ofrecall and or selection bias.
Most athletic shoes increase theprobability of perspiration because ofthe combination of the impermeablenature of their construction.3,8,11 Rub-ber allergens will penetrate the skinat a greater rate because of this in-crease in perspiration and will resultin increased skin exposure and sensi-tization of these materials.3,8,11
A prospective investigation con-ducted by Rani, et al. included 119patients (21 males and 98 females)suspected of having contact dermati-tis due to shoe allergens.16 Both shoeseries and European Standard seriespatches were applied on the upperback of each subject and removedafter forty-eight hours.16 Seventy-three percent (n=87) reacted posi-tively to a variety of allergens. These
phenylenediamine, and mercapto-benzothiazole.6 As with otherfootwear, the dye found in the in-soles of certain running shoes hascaused contact dermatitis in runners.
Review of the LiteratureA review of the medical literature
reveals a number of case reports, ret-rospective observations, randomcontrol trials, and practice guidelinesthat identify the potential antigensresponsible for shoe dermatitis.6-28
Shoe contact dermatitis resultingfrom shoe linings was first noted in1877 and has appeared as a recentcase report in which the cause wasattributed to para-tertiary-butylphe-nol formaldehyde.12,15,19 The mostcommon allergens responsible forcausing shoe dermatitis as found inthe literature are presented graphi-cally as Table 1.
Saha, et al. conducted a study todetermine the prevalence and clini-cal patterns of footwear dermatitis.10
Fifty patients with suspected shoedermatitis and thirty control subjectswere patch-tested with 22 allergens.10
While seventy percent of patientsshowed sensitivity to these footwearallergens, both potassium dichro-mate and colophony were identifiedas the most common sensitizers.10
The validity of this observational de-sign study is strengthened by the in-vestigators’ use of matched controlsto avoid observer bias. These investi-gators stress that there should befootwear screening to detect respon-sible allergens and call upon bothmanufacturers and research institu-tions to assist with such screeningsin order to provide non-allergenicfootwear to the public.10
Observational results reported byFreeman in 55 patients with chronicfoot dermatitis revealed “rubber” asthe most the common allergen, fol-lowed by chromate, p-teritary-butylphenol-formaldehyde resin andcolophony responsible for causingchronic footwear dermatitis.3,9 In thisstudy, the incidence of shoe dermati-tis was almost equal in both genders.A hallmark observation identified byFreeman was that during a differen-tial diagnosis, all parts of the footwere affected except the inter-digitalareas and hyperhidrosis was found inall subjects.9
Shoe Dermatitis... authors determinedquantifiably that glues andp a r a - t e r t - b u t y l p h e n o lformaldehyde resin were the lead-ing causes of shoe dermatitis.16 Glues(33.6%) were the leading cause ofshoe dermatitis, followed by leatherallergens (26.4%), rubber allergens(7.6%), and dyes (7.6%).
Rani, et al. determined that themaximum incidence of shoe der-matitis observed in this study was inthe 20-50 year age group.16 This find-ing validates Saha, et al.’s results be-cause a similar pattern of prevalencewas observed in this investigation.10
Rani, et al. acknowledge that theirobserved prevalence of footwear der-matitis may be influenced by differ-ences in geographic location, socialdisparity, and climate.16 The presentstudy indicates that patients withsuspected shoe dermatitis should bepatch-tested with the shoe series inaddition to a standard series.16
Another investigation was con-ducted by Lazzarini, et al. on fifty-three patients with eczematous der-matitis.17 Patch testing was per-formed using the Brazilian series.17
Thirty-seven (70%) had at least onepositive patch test reaction.17 Thecompounds causing positive reac-tions were rubber-vulcanizingagents, followed by either metals ortopical medications.17 This prospec-tive study detailed both inclusionand exclusion criteria for their studysubjects. Also, the presence of der-matosis on the dorsal region of thefoot in the majority of the patientswith a positive test result was statisti-cally significant.17 The use of statisti-cal data enriches this investigationby demonstrating that their resultsare not due to random chance.
Holden and Gawkrodger report-ed their experience of ten years ofpatch-testing on 230 patients toidentify which allergens are impor-tant in determining the cause ofshoe dermatitis.13 Forty-four subjectsof the group showed relative allergicpositive reactions to the allergens inthe British Contact Dermatitis Soci-ety’s standard series. Only 13 pa-tients had relevant positive results toone or more allergens from the shoeseries.13
The current shoe series consistsof 17 allergens, including two fromthe rubber series. One percent of the
Continued on page 192
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Medical Education
between 2001 to 2004.24 These inves-tigators set forth four goals as objec-tives for this study: to determine thefrequency of allergens associatedwith a shoe source in North Ameri-can Contact Dermatitis Group pa-tients with footwear allergic contactdermatitis, compare their results toallergen frequencies from other pub-lished studies, quantify the numberof shoe-related reactions that werenot identified on the North Ameri-can Contact Dermatitis Group stan-dard series, and identify relevant al-lergens not included on the NorthAmerican Contact Dermatitis Groupstandard series, based on data fromother studies.24
It was determined that in 109North American Contact Dermatitis
Group patients with allergic contactdermatitis of the foot and allergensthe most common allergen was froma shoe source p-tertiary butylphenolformaldehyde resin, an adhesive,which accounted for 24.7% of posi-tive patch test results, followed bypotassium dichromate (17.5%) andcarba mix (11.7%).24
North American Contact Der-matitis Group patients were statisti-cally more likely to have positivepatch test reactions to p-tertiarybutylphenol formaldehyde resin andstatistically less likely to have a posi-tive patch test reaction to potassiumdichromate than patients represent-ed in pooled data studies.24 A deter-mined final conclusion from theiranalysis was in North AmericanContact Dermatitis Group patients.
The most common individual shoeallergen was p-tertiary butylphenolformaldehyde resin, and as a group,rubber chemicals were most com-mon, a finding consistent with thoseof other investigations.24 This investi-gation is superior to the other inves-tigations because of its through com-parative analysis of results to previ-ously published literature findings.24
Bajaj, et al. reported their experi-ence with patch-testing of 1,000 pa-tients.25 Patients with suspected aller-gic contact dermatitis were involvedin this retrospective analysis.25 TheIndian Standard Series was used forpatch-testing. The age range of thiscohort was eight to 87 years, with amedian age of 35.9 years.25 Suspectedfootwear dermatitis was the com-monest clinical pattern found in 310patients.25 Among these 310 patients,190 (61.3%) showed positivity toone or more allergens.25
Chemicals such as potassiumdichromate (34.2%), mercaptoben-zthiazole (30%), and mercapto mix(28%) were the leading allergens inpatients with footwear dermatitis.25
Interestingly, there were no statisti-cally significant differences in sensi-tization rates between males or fe-males.25 These authors suggest thatwearing thick absorbent socks andusing other non-chromate chemicalsfor tanning and curing leather canminimize chromium exposure fromleather footwear.25
Case StudiesAs a point of completeness, case
studies describing shoe dermatitis asthey appear in the medical literatureare presented. Oztas, et al. reportshoe dermatitis from para-tertiarybutylphenol formaldehyde in a 38year old women.15 Onder, et al. fur-ther present four cases of footweardermatitis emphasizing that rubberis still the most common shoe aller-gen reported.18
Verma, et al. describe a case re-port of a 29-year-old male with pur-puric contact dermatitis fromfootwear.21 This report notes thatthere exist variations in individualallergen sensitivity with shoe der-matitis because of differences inchemical composition of footwear orindividual susceptibility.21
Interestingly, Hartmann andHunzelmann offer a case report of a
Continued on page 193
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Shoe Dermatitis...
230 cases were positive for fiveallergens.13 Chromate was identi-
fied as the top allergen during thisinvestigation. These authors con-clude from their observation thatnickel is rarely a relevant allergen forfoot dermatitis, unless an obvioussource of metal buckles is present.13
Nardelli, et al. report the resultsof a thirteen-year retrospective studythat was conducted to identify therelationship between the causativeallergens in shoes and localization offoot dermatitis.14 This study deter-mined that 474 patients presentingwith foot dermatitis had a positivereaction to one or more substancesrelated to footwear. The most com-mon allergens in decreasing order offrequency in this study were potassi-um dichromate and cobalt chloride,followed by p-phenylenediamine,rubber components, colophony, andp-tert-butylphenol formaldehyde.14
Potassium dichromate and cobaltchloride were most often found inrelation to dermatitis of the wholefoot.14 Rubber chemicals were associ-ated with dermatitis of the soles ofthe feet.14
Chowdhuri and Ghosh conduct-ed an epidemio-allergological inves-tigation of 640 patients identifying155 cases of footwear dermatitis.20
After a detailed history and clinicalexamination of a total of 640 pa-tients, patch testing was performed.20
Patch test units were comprised ofointment forms, liquid forms, strips,discs, and chambers. Those patientswith feet dermatitis only were testedfor footwear allergens with con-trols.20
Statistical analysis of data ob-tained from history, clinical features,and allegro-logical findings by corre-lation and follow up was per-formed.20 Post-patch test counselingwas employed and the results wereclinic-allergologically correlated.20
Fortunately, this later prospective in-vestigation’s results allows for valida-tion of Freeman’s earlier observa-tions on the benefit of patient aller-gen awareness. Chowdhuri andGhosh identified potassium dichoro-mate and cobalt chloride as the com-monest allergens causing footweardermatitis.20
Warshaw, et al. retrospectivelyanalyzed data from 10,061 patients
Continuing
MedicalEducation
The most common
individual shoe
allergen was p-tertiary
butylphenol
formaldehyde resin,
and as a group,
rubber chemicals were
most common,
a finding consistent
with those of other
investigations.24
OCTOBER 2008 • PODIATRY MANAGEMENTwww.podiatrym.com 193
tis caused by footwear.28 Clinical ex-amination revealed linear erythemaon the dorsum of her right footwith two flaccid blisters on the sideof her right foot.28 History revealedthe patient noticed the lesions andbelieved they were related to hershoes that had been dyed twomonths earlier.28 Patch testing wasperformed with positive results torubber and dyed leather.28 It wasconcluded that she had experiencedshoe dermatitis after the lesions re-solved when the patient stoppedusing the shoes.28 An important factacknowledged by these authors isthat the atypical presentation ofthis condition delayed this patient’sdiagnosis.28
The podiatric clinician is encour-aged to determine if these literaturecitations are relevant and valid totheir specific patient populations.First, the number of subjects is cru-cial to determine whether accuratestatistics can be generated from the
collected data. Krejcie and Morganhave suggested that a good rule ofthumb is that 400 subjects will pro-vide reliable statistics that can be ap-plied to general populations.29
Indeed, seven of the ten reviewedinvestigations have greater than 400subjects. On the other hand, whenexamining the sub-populations ofsubjects with foot dermatitis, onlyone investigation allows for the sam-ple sizes to be precisely visualized byexplaining in detail entry and exclu-sion criteria, ensuring a homogenousstudy sample population. The meth-ods of all these investigations are de-scribed in detail and were designedto answer the investigators’ researchquestion.
All the studies do clearly state anddefine their primary outcome andhow it was measured. Only one inves-tigation addresses confounding vari-ables regarding the presentation ofshoe dermatitis. Finally, a few of theseinvestigations specifically state statis-
47-year-old man with a vesicular der-matitis on both soles from cinna-mon as an odour-neutralizing agentin shoe insoles.22 Patch-testing re-vealed a positive reaction to cinnam-ic aldehyde and cinnamic alcohol,despite a social history described bythe patient of often eating food fla-vored with cinnamon.22
Most recently, a case report de-scribing allergic contact dermatitis toCrocs™ has been cited in the litera-ture.26 Castanedo-Tardan, et al. pre-sent the case of a 14-year-old boywith a two-year history of pruriticerythematous plaques on both thedorsal and ventral surface of hisfeet.26 Patch-testing was performed tothe North American Contact Der-matitis Standard series and to apunch plug of the patient’s Crocs™
with positive results.26
Discontinuation of the Crocs™
and the use of sneakers resulted inclearance of his foot dermatitis.26
These authors assert the importanceof testing shoe components and theneed to obtain the individual ingre-dients from the shoe product manu-facturer to enable clinicians to iden-tify potential allergens.26
Corazza, et al. describe a case pre-sentation of a 72-year-old man withthe rarely reported contact sensitiza-tion to an amputation prosthesis.27
This man presented with an erythe-mato-edematous scaly dermatitis in-volving his left foot stump extendingto the leg with extension to his rightfoot and leg.27 A cutaneous biopsyfrom his left leg was performed re-vealing histological findings consis-tent with chronic eczematous der-matitis.27
This patient wore an orthopedicshoe with its mobile plastic prosthe-sis device covered with leather.27
Patch-testing revealed positive resultsto para-tertiary-butylphenol-formaldehyde resin, cobalt chloride,nickel sulfate, and potassium dichro-mate.27 The patient’s dermatitishealed with oral antihistamines, sys-temic and topical steroids, replacingthe old prosthesis with chromate-free and para-tertiary-butylphenol-formaldehyde resin-free shoes andwearing extra pairs of socks.27
The last case report centers on a64-year-old woman with the presen-tation of unilateral contact dermati-
Shoe Dermatitis... tical significance, but itmust be remembered thatstatistical significance only min-imizes the possibility that the re-sults could have occurred by chancealone. It implies nothing about theactual importance or clinical signifi-cance of these results. The findings ofall the investigations do offer neededclinical information regarding themost common allergens responsiblefor causing shoe dermatitis.
Signs and Symptoms of ShoeDermatitis
Usually, the substances thatcause shoe contact dermatitis poseno trouble for most people, and maynot even be noticed the first time aperson is exposed. Once the skin be-comes sensitive or allergic to any ofthe etiological substances, any expo-sure will produce a rash.3,5 The rashusually does not start until a day ortwo later, but can start as soon ashours, or as late as a week.5 The his-tory of onset of symptoms and ab-sence of any previous history of skindisease and the possible temporal re-lationship to wearing new shoes canaid the healthcare professional indistinguishing shoe dermatitis fromother forms of dermatological dis-eases.
Shoe dermatitis usually shows asredness, swelling and water blisters.The size of these blisters range fromtiny to large. Also, these blisters maybreak and form crusts and scales. Un-treated, the skin may darken and be-come leathery and cracked. Allergiccontact dermatitis can be difficult todistinguish from other rashes, espe-cially after it has been present for awhile. The dermatitis can occur onthe weight-bearing parts, heels, sidesof the foot, and other pressure andfriction areas.12
The most common site first in-volved with shoe dermatitis is thedorsal surface of the big toe and onthe insteps (Figures 1a b). Later, it ex-tends by spreading to the other toesand dorsal aspect of the foot.5 Skinlesions may be acute, presenting asred, blistering, oozing, and usuallysymmetrical.3,5
The clinical symptoms of shoecontact dermatitis can range frommild, itchy rash to severe itchingwith swelling and small blisters.3 Onthe other hand, chronic lesions are
Continued on page 194
Continuing
Medical Education
Shoe dermatitis
usually shows as
redness, swelling and
water blisters.
firm the diagnosis of allergic contactdermatitis, Freeman recommendsthat all patients with foot dermatitiswhich does not respond to treatmentshould be patch tested to excludeshoe allergy.2,9
A foot and ankle physician maydetect the skin sensitizer responsiblefor shoe dermatitis by performing a“patch test.”2,5 First described by JosefJadassohn in 1895, patch testing is asafe and quick way to diagnose con-tact allergies and remains the goldstandard for diagnosing allergic con-tact dermatitis.30,31 A small amount ofthe suspected allergen is applied tothe skin for a fixed time.2,5
Commercial patches are availablethat contain common allergens thatare known to cause contact dermati-tis.2,3 Two methods for patch-testingexist. The first is the 24-component,thin layer, rapid-use, epicutaneoustest screening tool.32 The secondmethod is comprehensive patch test-ing, which involves creating cus-tomized patch-tests based on the his-
tory of the patient.32
Patch-testing can also bedone using pieces of the shoesoaked in water and appliedunder occlusion to the medialforearm or back for 48 hours. Fi-nally, patch testing of solid ob-jects may be performed by trim-ming off a small sample between0.5–1 cm2 and applying thesample to the skin. The ability toselect specific allergens givesmore power as a diagnostic toolbecause of the ability to have ahigher rate of identifying the rel-evant allergen, which wouldhave been missed by using a lim-ited screening tool.2,32
Patch testing is not the test ofchoice for diagnosis of Type-I al-lergy.30 After these patches are re-
moved, the treating physician cancheck for a positive reaction over afew days.2,3 A positive significant al-lergen will produce a reaction withpruritus, erythema, edema, and evenvesiculation. If indeed, the patienttests positive for shoe contact der-matitis, the physician must docu-ment this allergy within the patient’schart and ensure and provide patientinstructions to stop wearing theshoes causing this reaction.2,3,5
Management and Prevention ofShoe Dermatitis
Patient empowerment througheducation to assist in avoidance ofthe affecting antigen is the primarygoal as well as the cornerstone ofshoe dermatitis management.
Unfortunately, patient avoidanceof these antigens is often difficult toimplement, which ultimately resultsin a presentation of shoe dermatitis.Once a diagnosis of shoe dermatitishas been confirmed, treatment man-agement goals include alleviation ofpruritis and treating the inflamma-tion. The podiatric physician shouldemphasize basic good skin care withthe use of soap-free hydrating clean-ers and emollients to patients as animportant adjunct to the treatmentof shoe dermatitis.32
Treatment should begin with anon-pharmacological approach andincorporate prescription medica-tions, when necessary. In order totreat shoe dermatitis, the physicianmust achieve an understanding ofthe mechanism and pathophysiolo-gy of allergic contact dermatitis.First, contact dermatitis results fromexposure to exogenous agents. ThenZellar and Warshaw’s classificationsystem for contact dermatitis can beused to identify if the reaction is oneof two types: nonimmunologic andimmunologic.30
Shoe dermatitis has been identi-fied as allergic contact dermatitiswhich is a delayed, cell-mediated,immunologic reaction requiringprior sensitization to the offendingantigen.30
Allergens are processed by anti-gen-presenting cells known asLangerhans cells with receptors spe-cific for the antigen which recognizethe antigen, bind to it, and becomeactivated.30 Subsequent contact be-tween the antigen and the skin trig-
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Shoe Dermatitis...
dry, lichenified, and in severecases, open sores may present and
can result in secondary bacterial in-fections.3,5
Finally, an important diagnosticparameter used by physicians is thepresence of normal skin not in con-tact with shoes between eczematousareas.3 The design of the footwear de-termines to a large extent the ap-pearance of shoe dermatitis.12 Thepodiatric physician may keep thisobservation in mind when referred apatient for medical evaluation. If un-treated, a secondary infection mayresult, which presents as swelling,tenderness and pus formation.
Diagnosis of Shoe DermatitisThe physician and patient will
discuss the materials that touch theperson’s skin at work and home, andtry to identify the allergen. Giventhat history and physical examina-tion alone are not sufficient to con-
Continuing
MedicalEducation
Continued on page 195
Figures 1a and b:The most commonsite first involvedwith shoe dermati-tis is the dorsal sur-face of the big toeand on the insteps.Later, it extends byspreading to theother toes and dor-sal aspect of thefoot. (Photo Cour-tesy of G. DockDockery, DPM, Seat-tle, WA.)
1A
1B
OCTOBER 2008 • PODIATRY MANAGEMENTwww.podiatrym.com 195
shoe dermatitis.2,3 Corticosteroids areknown to interfere with inflammato-ry response. The major therapeuticrole of corticosteroids in treating al-lergic contact dermatitis is their abili-ty to inhibit T-cell activation andleukocyte migration.33
A recently published literatureaccount using contact hypersentivi-ty mouse models has suggested thatcorticosteroid therapeutic effectsand cell targets for immune sup-pression in contact allergies, mayalso involve both macrophages andneutrophils.32,34
Topical glucocorticoids (corticos-teroids) are adrenocorticosteroidderivatives incorporated into a vehi-cle formulated to be applied to theskin and external mucous mem-branes.2,3 Corticosteroids tend topenetrate human skin slowly, lead-ing to a reservoir effect.2,3,35
The absorption of the drug intothe skin is a function of the nature of
the drug, the behavior of the vehicle,and the status of the skin. Drug ab-sorption is increased with an in-crease of water content of the stra-tum corneum.2,3
The differences in rate of absorp-tion of different topical drugs, or thesame drug in a different vehicle, relyon three variables: the concentrationof drug in the vehicle, the partitioncoefficient of the drug between thestratum corneum and the vehicle,and the diffusion coefficient of thedrug in the stratum corneum.3
The diffusion coefficient is theextent to which the matrix of thebarrier restricts the mobility of thedrug.3 Increases in molecular size ofthe drug will increase the frictionalresistance and decrease the diffusioncoefficient.3
Topically applied corticosteroidsdiffuse across cell membranes to in-teract with cytoplastic receptors lo-cated in both dermal and intrader-mal cells. The primary therapeutic
gers an inflammatory cascade thatmanifests clinically within 24 to 72hours.30
Skin affected by allergic contactdermatitis will demonstrate inflam-mation corresponding to the degreeof potency and immune reactionfrom the allergen.32 Summaries ofboth non-pharmacological and phar-macological approaches will be of-fered with an emphasis on mecha-nism of actions, potential adverse ef-fects, and patient consideration.2,3,32-37
First, moist compresses may beused to enhance the drying of well-localized, acute, weeping lesions.Cool moist soaks applied for five toten minutes, followed by air-drying,may significantly reduce drainagefrom the affected foot. Secondly,even though the exact mechanism isunknown, an absorbent cloth moist-ened with isotonic physiologicsaline, aluminum sulfate-calcium ac-etate astringent solution, silver ni-trate or tap water applied for 20-30minutes, several times a day, can beutilized to reduce inflammation andprovide relief from the irritatingsymptoms of shoe dermatitis.2,32
Finally, inflamed lower extremityskin that is dry, hot, and induratedmay benefit from a thin layer ofwhite petrolatum followed by a coldcompress.2,32
Moisturizing emollients havebeen prescribed to treat shoe der-matitis, providing both occlusionand humectance.32 The occlusionproperty of emollients provides asealant layer on the surface of theskin to reduce water loss.32 On theother hand, the humectance proper-ty is one of increasing the “water-holding capacity” of the stratumcorneum and therefore increasingskin hydration.2,32 Lipids known asceramides have been added to mois-turizing emollients to improve theskin barrier in inflamed skin by en-hancing the structural lipid bilayerof the stratum corneum.2,32
Finally, urea, glycerin, pyrroli-done carboxylic acid, alpha-hydroxyacids, as in lactic acid and glycolicacid are examples of low molecularweight humectants that have beenadded to emollients.2,32
The prescribing and applicationof topical corticosteroids is a medicalstandard of care in the treatment of
Shoe Dermatitis... effects of topical corticos-teroids are due to their non-specific anti-inflammatory ac-tivity. Glucocorticoids enhance orrepress the transcription of genescontained in almost every cell in-volved in the immune and inflam-matory responses through interac-tion of cell receptors located in thecell membrane and its cytoplasm.3,36
The anti-inflammatory action ofsteroids is mediated by its action ofcortisol, as it induces production oflipocortins through the glucorticoidreceptor mechanism to inhibit theactivity of phospholipase A2.3 Thisaction impairs production ofpostagladins and leukotrienes, themediators of inflammation, throughthe action of cyclooxygenase onarachidonic acid.3,36
A variety of topical corticos-teroids are available in various po-tency and vehicles. The relative po-tency of a product depends on sev-eral factors including the character-istics and concentration of the drugand vehicle used.2,3 Vasoconstrictionassays are used to measure the rela-tive potency of available commer-cial products.2,3 The podiatristshould be familiar with the classifi-cations of relative potencies ofavailable products as they are pre-sented in Table 2.
Once the selection of a topicalcorticosteroid agent is considered,the clinician must decide on themost appropriate delivery system;thus the choice of vehicle in a topicalformulation is of great importance.2,3
The ideal vehicle has the follow-ing characteristics: easy to applyand remove, acceptable cosmetical-ly without odor and non-greasy,non-irritating, compatible with theactive ingredient, and readily releas-ing the active drug.3 Topical corti-costeroids are available in vehiclessuch as gels, lotions, solutions,creams, and ointments.3,36
An advantage of using creams oroil-in-water emulsions is that theyare absorbable and are vehicles thatmay be drying.2,3 Water-misciblecreams may be more appropriate formoist or weeping lesions.2,3 Oint-ment bases are compounded as ei-ther water-insoluble bases like petro-latum or water-soluble bases likepolyethylene glycol, or they can beemulsified with water.2,3
Continued on page 196
Continuing
Medical Education
A variety of
topical corticosteroids
are available
in various potency
and vehicles.
penetration when compared to lo-tions. Gels are most useful when ap-plied to hairy areas or other areaswhere it is considered cosmeticallyunacceptable to have residue of a ve-hicle remain on the skin.2,3
Both gels and ointment formula-tions are considered more potentthan creams and lotions, becauseointments and gels restrict water lossand preserve hydration of the stra-tum corneum.2,3
Although topical corticosteroidsare generally well-tolerated for shortterm use, the sophisticated methodof delivering topical corticosteroidsis not void of producing adverse ef-fects. Long-term widespread use canresult in adverse effects groupedinto four categories: cutaneous
changes, cutaneous infections andinfestations, eye effects, and sys-temic effects.2,3
Systemic adverse effects includehypothalamic-pituitary-axis suppres-sion, hyperglycemia, and avascularnecrosis.2,3,32 Therefore, alternativetherapeutic interventions for treatingshoe dermatitis must be considered.
Topical immune modulatorshave been investigated as a treat-ment option for inflammatory skindisorders.2,32 Both tacrolimus oint-ment and pimecrolimus cream actby inhibiting the protein cal-cineurin, which subsequently pre-vents the dephosphorylation of thenuclear factor of activated T-cells, atranscription factor. This causes sig-nal transduction pathways in T-cellsto be blocked and inflammatory cy-tokine production is inhibited.2,32,37
Experimentally, both tacrolimusand pimecrolimus have demonstrat-ed efficacy in treating allergic con-tact dermatitis induced by nickel.2,32
Tacrolimus and pimecrolimusshould be limited to short-term use.Adverse reactions associated withtacrolimus included pruritis, a sensa-tion of burning skin, and alopecia.Adverse effects associated with pime-crolimus use include a sensation ofburning skin, headache, and risk ofinfection. These agents should beconsidered when conventional ther-apies have failed. Both these agentsdo carry a block box warning em-phasizing their potential for cancerrisks.2,32
Systemic therapy may be re-served for severe and chronic allergiccontact shoe dermatitis. Systemictreatments may include the use ofthe following oral agents: H1-anti-histamines, systemic corticosteroid,azathioprine, methotrexate, and my-cophenolate mofetil.2,32
Oral antihistamines have an ef-fect on severe pruritis by competingwith free histamine for binding atH1-receptor sites. The most commonantihistamines used to treat allergicdermatitis include cetirizine, hydrox-yzine, diphenhydramine, chlor-pheniramine, and loratadine. Ad-verse effects of antihistamines in-clude dry mouth and drowsiness.
Systemic corticosteroid therapyhas demonstrated high efficacy inthe treatment of acute allergic der-matitis by dramatically improving
Continued on page 197
196 www.podiatrym.comPODIATRY MANAGEMENT • OCTOBER 2008
Shoe Dermatitis...
An ointment is a water-in-oilemulsion. It is noted as being the
most effective hydrating agent. It isconsidered more potent and effec-tive due to its occlusive, nature-en-hancing corticosteroid penetra-tion.2,3 Ointments are the most effec-tive vehicle for treating thick, fis-sured, lichenified and dry, scalyeruptions.2,3
Lotions are formulated as a pow-der in a water suspension and areconsidered less lipophilic suspendingagents.2,3 Lotions are used to treat su-perficial dermatoses, especially ifthere is slight oozing. Gels are semi-solid polymers containing pockets ofliquids that tend to allow for greater
Very High Betamethasone dipropionate (augmented) 0.05Clobetasol propionate 0.05Diflorasone diacetate 0.05Halobetasol propionate 0.05
OCTOBER 2008 • PODIATRY MANAGEMENTwww.podiatrym.com 197
tively inhibits the enzyme inosine 5’-monophosphate dehydrogenase,preferentially blocking the type IIisoform, in the de novo purine syn-thesis pathway. Both methotrexateand mycophenolate mofetil havebeen recognized as effective treat-ment options for immune-mediatedskin disease.2,32
The foremost part of a treat-ment plan for shoe dermatitis isthe avoidance of the sensitizer (al-lergen), once it is known. The po-diatric physician can offer expertisein footwear by providing educationto patients with the selection offootwear without materials thatmay cause shoe dermatitis. Substi-tute products made of differentmaterials that do not cause allergicreactions will lessen the likelihoodof future episodes of shoe dermati-tis. Treatment and managementsuggestions are summarized inTable 3.
Secondly, the podiatric physi-cian may offer an educational initia-tive to the patient to avoid re-dyedshoes.2,3,5 Patients with shoe dermati-tis can use special types of shoes pre-pared from non-sensitizing sub-
skin inflammation; however, theyalso cause the same adverse effectsas topical corticosteroids. In the at-tempt to avoid adverse effectsfrom repeated doses of corticos-teroids in patients with chronicdermatitis, steroid-sparing sys-temic immunosuppressant therapywas investigated.2,32
The selection of these agents de-pends on the clinical presentation ofthe patient as well as the patient’sgeneral health and presenting con-tra-indications. Azathioprine is a cellcycle-specific antimetabolite that af-fects natural killer cell function, T-cell signaling, prostaglandin produc-tion and neutrophil activity. Aza-thioprine has been studied in allergiccontact dermatitis induced byparthenium revealing resolution ofdisease.2,32
Methotrexate exerts cytotoxic ac-tivity through a cell cycle, S-phase-specific antimetabolite, which causesinhibition of neutrophil chemotaxisand inhibition of TNF-alpha, IL-1,IL-6, and IL-8. Mycophenolatemofetil selectively and non-competi-
stances. Adams suggeststhat measures to controlsweating may be very helpfulfor the patient who suffers fromshoe dermatitis.12
Medicated powders, adminis-tered once or twice a day to controlfoot perspiration, may be helpful inpreventing shoe dermatitis. Podiatricclinicians can suggest stockingsmade of absorbent cotton thatshould always be worn by the pa-tient who is recovering from anepisode of shoe dermatitis.2,3 Further,the foot and ankle physician couldsuggest changing socks two or threetimes a day, and the wearing of dif-ferent shoes for work and home toprevent dermatitis.12
An insight may be gleaned froma recent report by Borghesan andBellotti describing successful treat-ment of a contact allergic dermatitisin a fifty year old construction work-er with “barrier socks.”38 These au-thors describe both an improvementin their patient’s quality of life aswell as a comparative reduction incosts incurred when comparing theirobservations with traditional topicaltherapy.38
Finally, Srinivas, et al. offer amethod to reduce the allergenic hex-avalent chromium in leather.39 Theseauthors acknowledge their perspec-tive that chromium is the most com-mon allergen in leather footwear.10,39
Further, they recount that hexava-lent chromium pentrates the skinand causes an allergic reaction; how-ever, as the reduced trivalentchromium form, it is less allergenic.39
These investigators prepared a 5% vi-tamin C solution to be used as asoaking solution for a piece ofleather overnight.
After soaking this piece ofleather, as well as a control piece ofleather soaked in distilled water,these samples were stuck to theinner surface of the heels of twovolunteers’ shoes and to the innersurface of the sandal strap of a thirdvolunteer.39 The pieces of leatherwere left in place for one week.39The results of this observationalcase control study proved thatfreshly prepared vitamin C solutionwas capable of making leatherhypo-allergic by converting thehexavalent chromium to trivalentchromium.33
Continued on page 198
Continuing
Medical EducationTABLE 3
Management and Preventionof Shoe Dermatitis
Non-pharmacological
Moist compressions or cool moist soaks
Moisturizing emollients or humectants
Pharmacological
Topical corticosteroids
Topical immune modulators
Systemic corticosteroids
Oral antihistamines
Steroid-sparing systemic immunosuppresant therapy
The foremost part of treatment plan for shoe dermatitis is avoidance ofthe sensitizer (allergen) once known
Offer an educational initiative
Shoe Dermatitis...
14 Nardelli A, Taveirne M, Drieghe A,et al. The relation between the localiza-tion of foot dermatitis and causative al-lergens in shoes: a 13-year retrospectivestudy. Contact Dermatitis 2005; 53(4):201-206.
24 Warshaw EM, Schram SE, BelsitoDV, et al. Shoe allergens: retrospectiveanalysis of cross-sectional data from thenorth American contact dermatitisgroup, 2001-2004. Dermatitis 2007; 18(4): 191-202.
25 Bajaj AK, Saraswat A, Mukhija G,et al. Patch testing experience with 1000patients. Indian J dermatol Venerol Lep-rol. 2007; 73 (5): 313-318.
27 Corazza M, Lauriola MM, Manto-vani L, et al. Allergic contact dermatitisdue to orthopedic shoes and a prosthesisfor amputated foot. Contact Dermatitis2006; 55 (2): 115-117.
28 Laguna-Argente C, Roche E, VilataJ, et al. Unilateral contact dermatitiscaused by foot wear. Actas Dermosifiliogr2007; 98 (10): 718-719.
29 Krejcie RV, Morgan DW. Deter-mining sample size for research activi-ties. Educational and Psychological Man-agement 1970; 30: 607-610.
30 Zeller S, Warshaw E. Allergic con-
198 www.podiatrym.comPODIATRY MANAGEMENT • OCTOBER 2008
Shoe Dermatitis...
ConclusionShoe contact dermatitis pre-
sents as a diagnostic and thera-peutic challenge for the podiatricphysician. Rubber compoundscontinue to be blamed as a com-mon cause of shoe dermatitis. Asan important member of thehealthcare team, the podiatricphysician must be familiar withrecognizing signs and symptomsof shoe dermatitis so patients canavoid secondary infections anddisability. This review presentscausative factors for the etiology ofshoe contact dermatitis supportedby clinical-based evidence asfound in the medical literature. �
References1 Dockery GL, Crawford ME. Con-
tact Dermatitis In: Color Atlas of Footand Ankle Dermatology. Philadelphia-New York: Lippincott-Raven; 1999. 29-41.
2 Smith RG. Shoe Dermatitis: A re-view of current concepts. The Foot 2008;18 (1):40-47.
3 Smith RG. A review of topical corti-costeroids. Podiatry Management 2006;25 (3): 207-216.
4 Cronin E. Shoe dermatitis. Br. JDermatol 1966; 78 (12):617-625.
5 Principles of Pediatric DermatologyChapter 26 Skin sensitization due toother irritantswww.drmhijazy.com/english/chapters/Chapter26.htm accessed July 21, 2007.
6 Caselli, M A. Sports Medicine: Howto handle contact dermatitis in athletes.Podiatry Today 2003; (16): 68—70.
7 Shackelford KE, Belsito DV. The eti-ology of allergic-appearing foot dermati-tis: a 5 year retrospective study J AmAcad Dermatol 2002; 47(5): 715-721.
8 Belsito DV. Common shoe aller-gens undetected by commercial patchtesting kits: dithiodimorphorpholine andisocyanates. Am J Contact Dermatitis2003; 14(2): 95-96.
9 Freeman S. Shoe dermatitis. Con-tact Dermatitis 1997; 36(5): 247-251.
10 Saha M, Srinivas CR, Shenoy SD,et al. Footwear dermatitis. Contact Der-matitis 1993; 28(5): 260-264.
11 Roberts JL, Hanifin JM. Athleticshoe dermatitis JAMA 1979; 241(3): 275-277.
13 Holden CR, Gawkrodger DJ. 10years’ experience of patch testing with ashoe series in 230 patients: which aller-gens are important? Contact Dermatitis2005; 53(1): 37-39.
Continuing
MedicalEducation
Dr. Smith com-pleted his post-graduate train-ing with theCollege ofMedicine at theUniversity ofWales, Cardiff,Wales, UK inwound careand tissue re-pair. He is a member of the AmericanProfessional Wound Care Associationand a consultant to National Board ofPodiatric Medical Examiners. He is acontributing editor and reviewer toJAPMA in the area of podiatric clini-cal pharmacology and has authored50 refereed journal articles in the dis-ciplines of pharmacy, podiatry, andwound care. He currently practices inOrmond Beach, FL.
tact dermatitis. Minn Med 2004; 87 (3):38-42.
31 Warshaw EM, Moore JB, Nelson D.Patch-testing practices of American con-tact dermatitis society members: cross-sectional survey. Am J Contact Dermat2003; 14 (1): 5-11.
32 Jacob SE. Castanedo-Tardan MP.Pharmacotherapy for allergic contact der-matitis. Expert Opin Pharmacother 2007;8 (16): 2757-2774.
33 Cohen DE, Heidary N. Treatmentof irritant and allergic contact dermatitis.Dermatol Ther 2004; 17 (4): 334-340.
34 Tuckermann JP, Kleiman A,Moriggl R et al. Macrophages and neu-trophils are the targets for immune sup-pression by glucocorticoids in contact al-lergy. J Clin Invest 2007; 117 (5): 1381-1390.
35 Han NH, Nowakowski PA andWest D. Acne and Psoriasis DermatologicDisorders. In: Dipiro JT, editor Pharma-cotherapy: a pathophysiologic approacheditor 4th edition Stamford, CN1999;1489-1504.
36 Anti-inflammatory Agents Corti-costeroids, Topical. In Drugs Facts andComparsions Novak CH ed., et al., StLouis MO 2005; 1633-1642.
37 Bornhovd E, Burgdorf WH, Wol-lenberg A. Macrolactam immunomodu-lators for topical treatment of inflamma-tory skin diseases J Am Acad Dermatol2001; 45 (5): 736-743.
38 Borghesan F, Bellotti M. Use ofnew “barrier socks” in contact allergicdermatitis. Allerg Immunol (Paris) 2007;39 (6): 202-203.
39 Srinivas CR, Sundaram VS, SelvarajK. Reducing the allergenic hexavalentchromium in leather to hypoallergenictrivalent chromium for prevention ofleather dermatitis. Indian J DermatolVenereol Lepro 2007; 73 (6):428-429.
OCTOBER 2008 • PODIATRY MANAGEMENTwww.podiatrym.com 199
B) contact isolationC) broad spectrum antibioticsD) systemic corticosteroids
6) Which of the following corticos-teroid(s) have the lowest relativepotency?
A) Dexamethasone sodium0.10%B) Hydrocortisone acetate0.5%, 1%C) Methylprednisolone 0.25%-1%D) All of the above productshave low potency.
7) In shoe dermatitis, allergens areprocessed by antigen-presentingcells, known as ____________.
A) KeratinocytesB) FibroblastsC) Langerhans cellsD) Platelets
8) According to this review, whatmay determine, to a large extent,the appearance of shoe dermatitis?
A) The patient’s ageB) The patient’s social historyC) The design of the footwearD) The patient’s physiology
9) Patch-testing is not the test ofchoice for diagnosis of _________.
A) Type II allergyB) Type I allergyC) Type III allergyD) Type IV allergy
10) Topical corticosteroids’primary therapeutic effects aredue to their ___________.
A) Moisturizing emollientactivityB) Anti-infective propertiesC) Water-holding capacityD) Non-specific anti-inflamma-tory activity
1) According to this review whatsubstance is not among the mostcommon allergens responsible forcausing shoe dermatitis?
A) Potassium dichromateB) Para-tert-ButylphenolformaldehydeC) ThiamineD) Rubber components
2) Cronin reports that historicallyin the 1930s and 1940s _______and ______ caused most of the pre-senting cases of shoe contact der-matitis.
A) Rubber and elasticB) Leather and dyesC) Rubber and leatherD) Dyes and Rubber
3) What was a hallmark observa-tion identified by Freeman’s obser-vations during a differential diag-nosis?
A) No subjects had hyperhidro-sis.B) 50% of subjects had hyper-hidrosis.C) 33% of subjects had hyper-hidrosis.D) 100% of subjects had hyper-hidrosis.
4) A safe and quick way to diagno-sis contact allergies, which remainsthe gold standard for diagnosingallergic contact dermatitis is________?
A) antibioticsB) radiologyC) patch testD) family history
5) Treatment of shoe “contact”dermatitis should begin with a_______.
A) non-pharmacological ap-proach
11) Chowdhuri and Ghosh identi-fied ____ and ______ in their inves-tigation as the most common aller-gens causing footwear dermatitis.
A) Potassium dichromate andcobalt chlorideB) Rubber components andcolophonyC) Potassium dichromate andleatherD) Cobalt and leather
12) Two topical immune modula-tors investigated as treatmentoptions for inflammatory skindisorders are ________ and____________.
A) Humectants and emollientsB) Azathioprine and mycophe-nolateC) Tacrolimus ointment andpimecrolimusD) Methotrexate andhydroxyzine
13) Shoe “contact” dermatitis skinlesions may be acute, presentingas red, blistering, oozing and____________.
A) Always contagiousB) Usually symmetricalC) Never itchD) Always interdigital
14) Castanedo-Tardan, et al. pre-sent the case of a 14-year-old boywith a two-year history of pruriticerythematous plaques on both thedorsal and ventral surface of hisfeet from _______.
A) Contact sensitization to theamputation prosthesisB) Dyed leather shoesC) Crocs™ with positive patchtest resultsD) Positive reaction to cinnamicaldehyde and cinnamic alcohol
Continuing
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E X A M I N A T I O N
See answer sheet on page 201.
Continued on page 200
200 PODIATRY MANAGEMENT
15) Borghesan and Bellotti describe successfultreatment of a contact allergic with __________.
A) Systemic emollientsB) Systemic corticosteroidsC) Collagenase productsD) Barrier socks
16) All of the following are common antihis-tamines used to treat allergic dermatitis except_______.
A) DiphenhydramineB) Fluocinolone acetaonideC) LoratadineD) Hydroxyzine
17) Srinivas, et al. offer a method to reduce theallergenic hexavalent chromium in leather byusing a 5% solution of __________.
A) ThiamineB) PyridoxineC) Ascorbic acidD) Folic acid
18) The patch test was first described by_____________ in 1895.
A) Josef JadassohnB) Shanmuga SundaramC) A.K. BajajD) Abir Saraswat
19) Chromates are compounds that contain_________ and are commonly responsible forallergic contact dermatitis.
A) SilverB) MercuryC) ChromiumD) Lead
20) Long-term widespread use of topical corticos-teroids can produce which of the following ad-verse effects:
A) Hypothalamic-pituitary axis suppression.B) Hyperglycemia.C) Avascular necrosis.D) All the above are adverse effects.
E X A M I N A T I O N
(cont’d)
See answer sheet on page 201.
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202 www.podiatrym.comPODIATRY MANAGEMENT • OCTOBER 2008
E N R O L L M E N T F O R M & A N S W E R S H E E T (cont’d)Continuing
MedicalEducation
LESSON EVALUATION
Please indicate the date you completed this exam
_____________________________
How much time did it take you to complete the lesson?
______ hours ______minutes
How well did this lesson achieve its educationalobjectives?
_______Very well _________Well
________Somewhat __________Not at all
What overall grade would you assign this lesson?
A B C D
Degree____________________________
Additional comments and suggestions for future exams:
