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

© Schattauer 2014

Phlebologie 3/2014 Downloaded from www.phlebologieonline.de on 2017-10-29 | IP: 69.16.147.93 For personal or educational use only. No other uses without permission. All rights reserved.

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-

Phlebologie 3/2014

© Schattauer 2014 Downloaded from www.phlebologieonline.de on 2017-10-29 | IP: 69.16.147.93 For personal or educational use only. No other uses without permission. All rights reserved.

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).

© Schattauer 2014

Phlebologie 3/2014 Downloaded from www.phlebologieonline.de on 2017-10-29 | IP: 69.16.147.93 For personal or educational use only. No other uses without permission. All rights reserved.

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.

1. Partsch H, Flour M, Smith PC. Indications for compression therapy in venous and lymphatic disease consensus based on experimental data and scientific evidence. Under the auspices of the IUP. Int Angiol 2008; 27: 193–219. 2. Nüllen H, Noppeney T. Kompressionstherapie nach invasiven Maßnahmen in der Phlebologie. Phlebologie 2011; 40: 15–19. 3. Stout N, et al. Chronic edema of the lower extremities: international consensus recommendations for compression therapy clinical research trials. Int Angiol 2012; 31: 316–329. 4. Reich-Schupke S, et al. Quality of life and patients’ view of compression therapy. Int Angiol 2009; 28: 385–393. 5. Duque MI, et al. Itch, pain, and burning sensation are common symptoms in mild to moderate chronic venous insufficiency with an impact on quality of life. J Am Acad Dermatol 2005; 53: 504–508. 6. Niebuhr M, Kapp A, Werfel T. Allergien der Haut. In: Heppt W, Bachert K (eds.). Praktische Allergologie. Stuttgart: Thieme Verlag 2011: 64–77. 7. Averbeck M, Gebhardt C, Emmrich F, et al. Immunologische Grundlagen der Allergien. J Dtsch Dermatol Ges 2007; 11: 1115–1128. 8. Martin SF. Immunologie der Kontaktallergie. Hautarzt 2011, 62: 739–734. 9. Reich-Schupke S, et al. Patch testing in patients with leg ulcers with special regard to modern wound products. Hautarzt 2010; 61: 593–597. 10. Freise J, Kohaus S, Korber A, et al. Contact sensitization in patients with chronic wounds. J Eur Acad Dermatol Venereol 2008; 22: 1203–1207. 11. Zmudzinska M, et al. Contact allergy in patients with chronic venous leg ulcers – possible role of chronic venous insufficiency. Contact Dermatitis 2006; 54: 100–105. 12. Lehnen M, et al. Contact allergies in patients with chronic wounds: results of a study from 1999 to 2004. Hautarzt 2006; 57: 303–308. 13. Scharffetter-Kochanek K, Schüller J, Meewes C, et al. Chronic venous venous ulcus cruris. Pathogenesis and the significance of „aggressive micro-milieus“. J Dtsch Dermatol Ges 2003; 1: 58–67. 14. Gallenkemper G, Schultz-Ehrenburg U. Kontaktallergisierung bei chronisch venöser Insuffizienz. Phlebologie 1999; 28: 27–39. 15. Thomas PRS, et al. White cell accumulation in dependent legs of patients with venous hypertension: a possible mechanism for trophic changes in the skin. Br Med J 1988; 18; 296: 1693–1695.

16. Klode D, Grabbe S, Dissemond J. Allergisches Kontaktekzem als seltene Ursache eines Ulcus cruris. Phlebologie 2005; 34: 109–111. 17. Basketter DA, Gerberick F, Kimber I. The local lymph node assay and the assessment of relative potency: status of validation. Contact Dermatitis 2007; 57(2): 70–75. 18. Bahmer FA. Bedeutung lokaler Faktoren für die Entstehung kontaktallergischer Reaktionen bei Patienten mit chronisch venöser Insuffizienz. Z Hautkr 1987; 62: 1662–1664. 19. Thomä HJ. Die Materialien. In: Reich-Schupke S, Stücker M. Moderne Kompressionstherapie. Köln: Viavital Verlag 2013; 17–19. 20. Dooms-Goossens A, et al. Contact urticaria due to nylon. Contact Dermatitis 1986; 14: 63. 21. Nettis E, et al. Type I allergy to natural rubber latex and type IV allergy to rubber chemicals in health care workers with glove-related skin symptoms. Clin Exp Allergy 2002; 32: 441–447. 22. Cravo M, Gonçalo M, Figueiredo A. Allergic contact dermatitis to rubber-containing bandages in patients with leg ulcers. Contact Dermatitis 2008; 58: 371–372. 23. Hann S, Hughes TM, Stone NM. Self-adherent wrap bandages- a hidden source of natural rubber latex. Contact dermatitis 2006; 55: 194–195. 24. Pratt M, Taraska V. Disperse blue dyes 106 and 124 are common causes of textile dermatitis and should serve as screening allergens for this condition. Am J Contact Dermat 2000; 11: 30–41. 25. Moreau L, Goossens A. Allergic contact dermatitis associated with reactive dyes in a dark garment: a case report. Contact Dermatitis 2005; 53:150–4. 26. Malinauskiene L, Zimerson E, Bruze M, et al. Are allergenic disperse dyes used for dyeing textiles? Contact Dermatitis 2012; 67: 141–148. 27. Murmann F. Nebenwirkungen der Kompressionstherapie. In: Reich-Schupke S, Stücker M. Moderne Kompressionstherapie. Köln: Viavital Verlag 2013; 45–52. 28. Bundesvereinigung Deutscher Apothekerverbände (Hrsg). Neues Rezeptur-Formularium (NRF). Govi, Eschborn; Stuttgart: Deutscher Apothekerverlag 2003. 29. Reich-Schupke S. Praktische Hinweise In: ReichSchupke S, Stücker M. Moderne Kompressionstherapie. Köln: Viavital Verlag, 2013; 152–164. 30. Strese H, et al. Influence of finishing textile materials on the reduction of skin irritations. Skin Res Technol 2013; 19: e409–416. 31. Ricci G, et al. Silk fabrics in the management of atopic dermatitis. Skin Therapy Lett 2012; 17: 5–7. 32. Lazarov A. Textile dermatitis in patients with contact sensitization in Israel: a 4-year prospective study. J Eur Acad Dermatol Venereol 2004; 18: 531–537.

Phlebologie 3/2014

© Schattauer 2014 Downloaded from www.phlebologieonline.de on 2017-10-29 | IP: 69.16.147.93 For personal or educational use only. No other uses without permission. All rights reserved.