Allergic Contact Dermatitis to Gold Mervyn L. Elgart, MD, and Robert S. Higdon, MD, Washington, DC

Allergic Contact Dermatitis to Gold Mervyn L. Elgart, MD, and Robert S. Higdon, MD, Washington, DC Gold sensitivity (the eighth reported case, and the...
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Allergic Contact Dermatitis to Gold Mervyn L. Elgart, MD, and Robert S. Higdon, MD, Washington, DC Gold sensitivity (the eighth reported case, and the seventh proved case) occurred in a 27-year\x=req-\ old woman. This is the first instance where a dental appliance was involved. The gingival mucosa sloughed following contact with a gold crown, and previous sites of contact dermatitis to jewelry flared. The cutaneous lesions subsided

when the crown was removed. Patch tests to gold salts were positive, but those to metallic gold (leaf) were negative. Four months after the crown was removed, the skin test to gold trichloride was still positive, although diminished in intensity.

x\.LLERGIC

the ring, the erythema did not subside (Fig 2). Triamcinolone acetonide cream, 0.1%, was used on the skin of the hands for two weeks, and the dermatitis decreased. The oral mucosa was only slightly improved with the use of triamcinolone in an adhesive base (Orábase). Patch tests were done at that time to the following: nickel sulfate, 10% aqueous; mercu¬

reactions to gold are exceed¬ ingly rare, only seven cases have been re¬ ported. Allergic contac stomatitis is gener¬ ally uncommon, and contact stomatitis to metallic gold has not previously been de¬ scribed. The following case illustrates both these unusual features.

ry biochloride, 1:1,000; potassium dichromate, 0.5% aqueous; copper sulfate, 1% aqueous; A 27-year-old woman had no allergic prob¬ ammoniated mercury, 10% petrolatum; acrylic lems until 1967, when her ears were pierced. monomer; procaine, 1% aqueous; gold leaf; nitrate, 0.5% Following this, she developed an eczematous metallic nickel; and silver reaction to gold earrings, and had to stop aqueous. All these tests were negative. Gold available, and a wearing them. She then found that she could solution was not immediately with therefore done was test patch gold sodium no longer wear her gold rings or wristwatch. In each instance, the reaction was characterized thiomalate (Myochrysine), an organic gold salt by an erythematous, scaly, and weeping derma¬ used in the treatment of rheumatoid arthritis. titis. It was noted to subside a few days after A severe response, with vesicles and a flare, was she stopped wearing the offending jewelry. The seen within 24 hours (Fig 3). At the same time, 4), as did the problem seemed more severe during the sum¬ the hand lesions worsened (Fig mu¬ the

Report of a Case

months. In October 1969, a gold crown was placed on a left lower bicuspid. Within a few days, there was irritation of the gingival mucosa around it (Fig 1), and an eczematous dermatitis again appeared under her ring. When she removed mer

Accepted for publication Dec 23, 1970. From the Department of Dermatology, George Washington University School of Medicine, Washington, DC. Reprint requests to 2150 Pennsylvania Ave NW, Washington, DC 20037 (Dr. Elgart).

condition of the earlobes and gingival cosa. The reaction around the patch test site remained intense after one week of topical treatment with triamcinolone acetonide, 0.1%, and required the intralesional injection of triamcinolone acetonide, 10 mg/ml, for relief. After two additional weeks, the patch test site began resolving, as did the dermatitis on the hands. After the reaction had completely subsided, the patient was tested with gold (auric) trichlor¬ ide, 0.5% aqueous. A positive response was

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Fig 1.—Irritation

and

gival mucosa adjacent cuspid.

superficial ulcération of gin¬ gold crown, left lower bi¬

to

Fig 2.—Eczematous dermatitis

hand.

on

ring finger of each

Fig 3.—Erythema, edema, and vesiculation 24 hours after patch test to gold sodium thiomalate on patient's back.

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noted within 24 hours (Fig 5), with vésicules, severe erythema, and edema. Exacerbation of previous locations of her dermatitis again oc¬ curred. In July 1970, because of repeated episodes of difficulty with her gums and hand dermatitis, the gold crown was removed. Within a week, the oral lesions had improved, and at the end of a month, all traces of irritation of the gingival mucosa (Fig 6) and of the hands (Fig 7) had disappeared. Repeat patch testing to gold chloride in Nov¬ ember 1970 showed a papulovesicular reaction with erythema and edema, with no flare, and required two days to produce pruritus, rather than one day, as was noted previously.

Review of Literature Of the seven cases of gold allergy pre¬ viously reported in the literature, four in¬ volved gold rings or other gold jewelry. Three women and one man comprise this group. As in nickel sensitivity,1 the predomi¬ nance of women who are affected probably reflects their increased contact with jewelry rather than an increased susceptibility. One of these cases was not confirmed by patch testing.2 In the other three,134 patch tests were positive to gold salts. Gaul's1 patient only had difficulty when the weather was warm and she perspired. He found a reac¬ tion to gold sodium thiosulfate, 1%, as well as to 22-karat gold metal. In the case report¬ ed by Comaish,3 patch testing to metallic gold was negative, although 2% gold chlo¬ ride produced a positive test reaction. Fox et al4 reported the case of a man who had a reaction to gold rings and medallions. He was able to wear this jewelry for four days in cold weather before

a

reaction

began, but

only for two days in warm weather. Patch tests to gold (auric) chloride, as well as to gold sodium thiomalate were positive, but testing with golf foil was negative. Shelley and Epstein5 reported the case of a patient whose problem was initiated by contact with crystals of gold trichloride on a laboratory bench. This substance is some¬ what irritating, and the irritation may have initiated the response, although patch tests later proved the existence of both dermal and epidermal sensitivity. A case report by Rostenberg and Perkins6 described a patient with a long history of

Fig 4.—Following patch testing, dermatitis

of hands

worsened.

metal

sensitivity who had strongly positive patch tests to both cobalt and nickel. A weakly positive reaction to gold (auric) chloride, 2%, was noted, and this was felt to be an independent sensitivity There was no evidence that the gold sensitivity was of significance clinically. A curious case of sensitivity to a gold-ball orbital implant was described by Forster and Dickey.7 In this patient, a purulent reaction developed within her eye, and an

eczematous reaction around it two years

after the 14-karat gold ball was implanted. The ball was made up of 60% fine gold, 35% copper, and 5% silver and tin. Patch tests to gold sodium thiosulfate, 0.5%, as well as to gold leaf and to the gold-ball implant, were positive. Symptoms subsided within a week after the gold-ball implant was removed. No mention was made of cuta¬ neous problems with rings or other jewelry. Allergic contact stomatitis is uncommon. This is felt to be due to the fact that poten¬ tial allergens are rapidly diluted and re¬ moved by saliva. The extensive vascularization of the oral mucosa contributes to rapid dispersal and absorption of the allergen. The absence of a keratin layer, which may provide specific proteins capable of combi¬ ning with the allergen to form a complete antibody, may be an additional factor.8

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Fig

5.—Reaction to

gold (auric) trichloride, 0.5%

solution, 24 hours after patch test.

Dental appliances, however, maintain contact with the oral mucosa for extended periods öf time. The con¬ tinued presence of saliva may help to dissolve highly insoluble substances, such as gold and mercury, from crowns or

Fig 6.—One month after gold crown was replaced with plastic prosthesis, gum appeared completely normal.

Fig 7.—One month after gold crown had been removed, dermatitis of fingers had completely resolved.

fillings.

In the case of fillings, this type of reaction is appar¬

ently

more

common

after

fillings have been im¬ planted.9 Localized irritation

new

well as urticaria have been described.10 In a case re¬ ported by Juhlin and Ohman,11 a patient with red tattoos and mercury fillings developed inflammation in the red areas 19 months after the tattoos were acquired. At the same time, he developed a sore tongue. Patch tests to mercuric chloride were positive, as were tests with cinnabar, the usual ingredient in red tattoos. The red portions of the tattoos as

No

previous reports of allergic

stomatitis to gold

were

contact

discovered.

Comment In the present case, several remarkable

eventually ulcerated, extruding pigmented features are present. The patient developed cells. Following this, treatment with fluocino- sensitivity to gold following ear piercing. lone acetonide (Synalar) caused the skin to While common with nickel sensitivity,12 this heal, and the oral lesions disappeared with¬ is the first time such a reaction has been out treatment. After patch testing, cutaneous reported with gold allergy. The patient experienced continuous dif¬ sites flared again, although the mouth was ficulty wearing gold jewelry, with increased asymptomatic.

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sensitivity to the metal during

warm, humid weather. Gold is a relatively insoluble sub¬ stance, and it can be assumed that little, if any, gold salt is produced by exposure of the metal to the skin. While it has never beenshown that sweat is capable of dissolving gold on prolonged contact, the presence of moisture and maceration, combined with warmer temperatures, must be presumed to increase the liberation of soluble salt from the metal. Even though the amounts involved must be minimal, this may explain the in¬ creased severity during the summer. Patch testing to the metallic gold was negative, but an intense reaction was pro¬ duced with gold salts. It is interesting to note that patch testing with the pure metal may not sufficiently reproduce the condi¬ tions of the original exposure, thereby re¬ sulting in a false negative patch test. In performing a patch test with gold (au¬ ric) chloride, 0.5% solution, two reactions were seen in other patients who were clini¬ cally not sensitive to gold. Most patients developed a yellow-brown color in the area of the test, which appeared to be precipitat¬ ed by gold. In addition, some patients de¬ veloped a slight pustular response, without edema or erythema, similar to that seen with patch testing with nickel salts. Both these changes were considered to be nega¬ tive.

A strongly positive patch test reaction will sometimes cause a flare of previously involved cutaneous sites, and this was true for our patient. However, a flare of a mucosal site is quite unusual. When she was tested after the crown was removed, and showed a diminished sensitivity to gold, nei¬ ther the cutaneous nor the mucosal flare was evident. Prior to the time that the gold crown was placed in her mouth, our patient was able to stop the reaction by removing the offending jewelry. Healing occurred within a few days. In some of the reported cases, persistence of eczematous dermatitis in exposed sites for several weeks or even months was the rule.3 Persistent dermatitis at the previously in¬ volved areas occurred only after she began to react to her gold crown. Within a few weeks after the crown had been removed, the skin lesions subsided. Nevertheless, she retained her cutaneous reactivity to gold and would have difficulty if she tried to wear her gold rings. Patch testing four months after the crown had been removed confirmed a per¬ sistent, but diminished sensitivity.

Nonproprietary and Trade Names of Drug Triamcinolone acetonide—Aristocort Topical Foam, Aristocort Topical Ointment. Aristoderm Foam. Kenalog.

References 1. Gaul LE: Incidence of

nickel, gold, silver, and

sensitivity to chromium, compared to reacincluding cobalt sulfate.

copper

tions to their aqueous salts Ann Allerg 12:429-444, 1954. 2. Chenworth E: Contact dermatitis from 18-karat gold. Med J Aust 2:20, 1957. 3. Comaish S: A case of contact hypersensitivity to metallic gold. Arch Derm 99:720-723, 1969. 4. Fox JM, Kennedy R, Rostenberg A Jr: Eczematous contact-sensitivity to gold. Arch Derm 83:956\x=req-\ 959, 1961. 5. Shelley WB, Epstein E: Contact-sensitivity to gold as a chronic papular eruption. Arch Derm 87:388-391, 1963. 6. Rostenberg A Jr, Perkins AJ: Nickel and cobalt dermatitis. J Allerg 22:466-474, 1951.

7. Forster HW Jr, Dickey RF: A case of sensitivto gold-ball orbital implant. Amer J Ophthal

ity

32:659-662, 1949.

8. Fisher AA: Contact Dermatitis. Philadelphia, Lea & Febiger, 1967. 9 Frykholm KO: On mercury from dental amalgam: Its toxic and allergic effects. Acta Odont Scand 15(suppl 22):1-108, 1957. 10. Markow H: Urticaria following a dental silver filling. New York J Med 43:1648-1652, 1943. 11. Juhlin L, Ohman S: Allergic reactions to mercury in red tattoos, and in mucosa adjacent to

amalgam fillings. Acta Dermatovener 48:103-105, 1968. 12. Gaul LE: Development of allergic nickel dermatitis from earrings. JAMA 200:176-178, 1967.

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