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A clinical study of lower leg and foot eczema and relevance of patch test in determination of its causative agents.

INTRODUCTION: Eczema of the hands and feet is one of the commonest conditions encountered in dermatologic practice affecting 1% of adults. (1) Legs and feet can be affected by both endogenous and exogenous types of eczema. Although most cases of eczema of the lower legs are secondary to venous hypertension, it must be remembered that many other types of eczema can affect this region, and in many cases there are multiple causative factors. The lower leg is particularly prone to contact allergy. (2)

In eczema, the patch test is gold standard test in detecting the etiologic factor and the only scientific proof of contact allergy. A positive reaction to a correctly prepared and applied patch test confirms the person has allergic contact sensitivity, although this doesn't necessarily mean that the substance is the cause of presenting clinical dermatitis and its relevance should always be carefully considered.

There is not much study on the patterns of lower leg and foot eczema in literature especially from India. Hence this study tries to determine the patterns of lower leg and foot eczema and also to evaluate the common allergens by patch testing using Indian Standard Series.

MATERIALS AND METHODS:

Source of Data: The study comprised of 50 clinically suspected cases of lower leg eczema above 5 years of age who attended Dermatology OPD of the hospital (Vinayaka Mission's University), Pondicherry from September 2008 to September 2010.

Method of Collection of Data: After obtaining approval and clearance from the institutional ethical committee, an informed consent was taken before involving them in the study and all the patients were patch tested. A detailed history with particular emphasis on age of onset, site of initial lesion, extent of dermatitis, seasonal variation, aggravating factors and association with atopy were noted.

Associated symptoms such as pain, pruritus, dryness, scaling, redness and oozing were observed. An occupational history with emphasis onto the common allergens that the patient may be exposed to was elicited followed by a detailed clinical examination and all the findings were recorded on a proforma. All patients were patch tested using Indian standard series approved by the Contact & Occupational Dermatoses Forum of India (CODFI).

If any positive patch test result was obtained further testing with extended set of allergens were done. Patients on steroids /immunosuppressants/ antihistamines/ UVA, UVB, phototherapy were advised to stop at least one week before the patch testing.

INDIAN STANDARD SERIES: ANTIGENS.
TABLE 1

1. Vaseline
2. Peru of balsam
3. Formaldehyde
4. Mercaptobenzothiazole
5. Potassium bichromate
6. Nickel sulphate
7. Cobalt sulphate
8. Colophony
9. Epoxy resins
10. Paraben mix
11. Paraphenylenediamine
12. Parthenium
13. Neomycin sulphate
14. Benzocaine
15. Wool alcohol
16. Chlorocresol
17. Fragrance mix
18. Thiuram mix
19. Nitrofurazone
20. Black rubber mix


FOOT WEAR SERIES: ANTIGENS.
TABLE 2

21. Hydroquinone
22. Glutaraldehyde
23. Dioctyl-phthalate
24. Disperse orange
25. Disperse blue
26. Kaathon CG


Inclusion Criteria: All patients with active predominant localized lower leg and foot eczema were included.

Exclusion Criteria:

1. Patients with widespread dermatitis along with the lower legs and feet.

2. Patients not willing to be part of the study.

3. Pregnant women (no known adverse effect, but as a precautionary method).

4. Children below 5 years of age (due to risk of non-compliance).

Statistical Methods: The data was analyzed statistically using descriptive statistics namely, Mean, Standard Deviation and 'p' value (test of significant) was noted. Wherever necessary the results are depicted in the form of graphs of percentages.

RESULTS:

DEMOGRAPHIC DATA

Age distribution:

[GRAPHIC 1 OMITTED]

Mean age of 50 patients in this study was 44.52 years with a standard deviation of 15.8 (range 07-70 years). The most common age group affected was 46- 60 years (40%), followed by 31-45 years (30%), 16-30 years (12%), 60-70 years (10%) followed by age group less than 15 years (8%).
Sex distribution:

male     64%
female   36%

Note: Table made from pie chart.


32 cases (64%) were males and 18 cases (36%) were females with a male to female ratio of 1.78: 1.0.
Chart 3: Incidence of Occupation:

Labourers      30%
Housewives     22%
fanners        14%
shopkeepers    10%
students       10%
teachers        4%
waiter          4%
tailor          2%
social worker   2%
conductor       2%

Note: Table made from pie chart.


Majority of the study population were laborers (15 cases- 30%), followed by housewives (10 cases-20%), farmers (7 cases- 14%), shopkeepers (5 cases- 10%) as shown in the chart.

Distribution of lesions:
Site Distribution-Chart 4

Dorsum                   82%
Ankle                    75%
Lateral Aspect Of Leg    42%
Toe                      38%
Medial Aspect Of Leg     36%
Margin                   28%
Sale                      8%

Note: Table made from bar graph.


Eczemas were bilateral in 41 cases (82%) and the rest 9 cases (18%) being unilateral. Site of involvement in decreasing order of frequency were as follows: dorsum of foot (82%), ankle (76%), lateral aspect of lower leg (42%), toes (38%), medial aspect of lower leg (36%), margin (28%), soles (8%).
Chart 5: Symptomatology:

Pruritic                98%
Hyperpigmentation       92%
oozing                  54%
dryness                 32%
pain                    26%
stalling                22%
thickening              22%
fluid filled lession    12%
swelling                 8%
raised legion            6%
hypopigmentation         6%
crusting                 6%
redness                  4%
Assuring                 2%
Ulcer                    2%

Note: Table made from bar graph.


Pruritus was the most common symptom noted in 98% of cases, followed by oozing 54% and hyperpigmentation seen in 50% of cases. Other symptoms noted included pain, dryness, redness, hypopigmentation and scaling.
Chart 6: Types of eczema:

ACD                     50%
LSC                     22%
Stasis Eczema           10%
Discoid Eczema           8%
Prurigo Nodularis        6%
Atopic DermatitiS        2%
Pomphoiyx                2%

Note: Table made from pie chart.


Allergic contact dermatitis (ACD) was the most common type seen in 25 cases (50%), followed by 11 cases of lichen simplex chronicus (22%), stasis eczema--5 cases (10%), discoid eczema 4 cases (8%), prurigo nodularis--3 cases (6%), one case each of atopic dermatitis and pompholyx. Most of the cases were of chronic type (27 cases--54%), followed by subacute type (19 cases-38%) and few of acute eczema (4 cases- 8%).

Eczemas in Various Age Groups:
Table 3

Age        ACD   LSC   STASIS   DISCOID   AD   POMPHOLYX    PRURIGO
Group                    E         E                       NODULARIS

<15        --    --      --        1      1        1           1
  years
15-30       5    --      --       --      --      --           1
31-45       8     3      2         1      --      --          --
46-60      10     5      3         2      --      --          --
>60years    2     3      --       --      --      --          --
Total      25    11      5         4      1        1           2


The common eczemas in patients less than 15 years of age were atopic dermatitis, discoid eczema, pompholyx and prurigo nodularis. The most common eczema in 15-60 years age group was allergic contact dermatitis (23 cases) and in patients more than 60 years was lichen simplex chronicus (3 cases).

Gender and type of eczema: ACD (17out of 25 cases-68%), LSC (9 out of 11 cases-81%) and stasis eczema (4 out of 5 cases-80%) were noted more commonly in males were as discoid eczema (all 4 cases) and prurigo nodularis (all 3 cases) were exclusively seen only in females in our study.
Chart 7: Duration of Eczema:

<6 months           32%
6 months -1 year    42%
>1 year             26%

Note: Table made from pie chart.


Distribution and type of eczema: Most of the cases of eczema were bilateral (41 cases-82%) were as few were unilateral (9 cases- 18%). Most of the cases of allergic contact dermatitis (23 out of 25 cases-92%) were bilateral in distribution, while discoid eczema had predominantly unilateral distribution (3 out of 4 cases-75%).

History of atopy and eczema: History of atopy was present in 8 cases (16%) of lower leg and foot eczema. History of atopy was seen in allergic contact dermatitis (2 out of 25 cases), LSC (2 out of 11 cases), similarly in one case each of atopic dermatitis, pompholyx, prurigo nodularis and stasis eczema.

Test of significance for Occupation:
Table 4

Eczemas       Laborers   Other Work Groups   Total

ACD              11             14            25
Other Types      4              21            25
Total            15             35            50

p value--0.0307. [X.sup.2] value--3.43


On comparing, the number of laborers with other work groups in cases of ACD and other endogenous eczemas, the p value was found to be 0.0307 which is significant (if p<0.05) and [X.sup.2] value of 3.43. This signifies that ACD is more common in laborers.

Allergic Contact Dermatitis: Out of the 25 patients of allergic contact dermatitis who were patch tested, 13 patients had positive results (52%), to at least one allergen. Most of the patients showed positive reaction to nickel sulfate (5 cases) and potassium bichromate (5 cases). Other allergens including paraben mix, epoxy resin, cobalt sulfate and parthenium also showed positive reactions.

PATCH TEST RELEVANCE:
Table 5

Patch Test     Positive Cases     %

Relevant             46         90.20%
Non-Relevant         5          9.80%


Significance of patch testing:
Table 6

Eczemas       Patch Test   Patch Test   Total
               Positive     Negative

ACD               13           12        25
Other Types       10           15        25
Total             23           27        50
Table 6

p value-0.5715. [X.sup.2] value- 0.32


[GRAPHIC OMITTED]

Chart 8: Patch Test Results:

DISCUSSION: Legs and feet can be affected by both endogenous and exogenous types of eczema. The lower leg is particularly prone to contact allergy.

This is a preliminary study on lower leg and foot eczema and the various allergens causing them in our population. Many studies have been done in general on eczemas or on hand eczemas, but not many studies have been done on the various types of lower leg and foot eczema especially in India.

In our study, the age of patients ranged from 7 to 70 years with a mean of 44.5 years which is comparable to that seen in most studies but the incidence of childhood eczema was very less in our study with only one child having pompholyx. Most patients with lower leg eczema belonged to 31-60 year age group. Chougule et al (3) had reported a similar mean age of 40.5 years and most of the cases in their study also belonged to 31-60 year age group. Ertam et al (4) had also reported a mean age of 40.38 years with a standard deviation of 14.69 years.

The occurrence of more allergic reactions in the adult females of 31-60 years is probably due to more exposure of these women to wet work and detergents domestically which damages the skin barrier function predisposing to eczemas. In the males more allergic reactions were seen in 46-60 years age group probably because occupational sensitization commonly occurs only after decades of exposure to allergens, and also due to the fact that the number of allergies acquired increasingly accumulate with age. (5)

In contrast to other studies in general, the number of male patients was significantly more as compared to females in our study. However, Saha et al (6) and Freeman S7 had reported slightly higher prevalence for males than females. Vani et al (5) also reported a male to female ratio of 1.77:1 in cases of hand and foot dermatitis, which is coinciding with our study. This may be due to the fact that, males in general have more of occupational exposure and they wear more of occlusive footwear than females.

In study done by Vani et al (5) eczemas were commonly seen in semiskilled workers followed by housewives. This was similar to our findings in which laborers were the most commonly affected cases, followed by housewives. Saha Met al (6 )had reported that the mean duration in 80% of patients was more than 6 months. This is same as in our study were mean duration of eczema was 15 months and only 16 cases (32%) of cases had duration less than 6 months.

Chougule et al (3) had noted history of atopy in 3 out of 29 cases (10%) of ACD which was similar to our result of 2 out of 25 cases (8%) and most of these cases had atopic diathesis clinically presenting as prurigo nodularis, pompholyx, atopic dermatitis and ACD to nickel sulphate.

Most of the cases had a bilaterally symmetrical involvement of lower legs with the commonest sites of involvement being the dorsum of the legs, ankle, lateral and medial aspect of the lower legs and toes. Saha Met al (6) had found similar distribution with dorsum of foot being the commonest site of involvement seen in 90% of the cases, which is comparable to our study of 82% incidence in dorsum of feet.

Most common type of eczema affecting lower legs and feet in our study was ACD followed by LSC, Stasis Eczema, Discoid Eczema in that order. Chougule et al (3) had found the most common eczema involving the lower legs to be lichen simplex chronicus (36%) followed by discoid eczema (18.5%), allergic contact dermatitis (14.5%) and stasis eczema (7.5%).

ACD was the most common type of eczema in our study (50%), this is similar to a study done by Waranya B. et al (8) in Thailand, who had reported an incidence of 57% cases of ACD.

The most common allergens noted by him were potassium bichromate (27%), nickel sulfate (26%) followed by fragrance mix and paraben mix. These were coinciding with our study, were we got potassium bichromate (20%), nickel sulfate (20%), followed by paraben mix and epoxy resin as the common allergens positive on patch testing.

In our study, stasis eczema was observed in 5 cases (10%). Most of the cases seen in our study were shopkeepers (3 cases), as they are involved in standing for long duration. 4 cases (80%) of stasis eczema had a positive patch test, all to multiple allergens. The common allergen seen in our study in cases of stasis eczema included perubalsam, benzocaine, nitrofurazone, fragrance mix, black rubber mix, potassium dichromate, PPD, and paraben mix.

In a study done by Jindal et al (9) on contact sensitization on venous eczema, positive patch test results were noted in 50% of the cases with most of them being males (M:F, 16:1). Common allergens were fragrance mix, PPD, nickel, balsam of Peru, cobalt chloride, potassium dichromate, epoxy resin and thiuram mix.

The most common allergens in our study in total on patch testing were potassium bichromate (30%) and paraben mix (30%), followed by nickel sulphate (21%), epoxy resin (17%) and fragrance mix (17%). This was in accordance to a study done by Anyur A et al (10) on various types of eczema, the most frequent allergens being nickel sulphate, cobalt chloride and potassium dichromate (metal allergens).

Recently, study done by Waranya Bet al (8) in Thailand, the most frequent allergen found was potassium bichromate with an incidence of 27%, which is comparable to our study (30%).

In another study, the frequency of contact allergy to fragrance mix was reported to be 20.7% (8) which was compatible with our study where we got positive reactions in 17% cases. The high incidence is attributed to the widespread use of perfumes in cosmetics and house hold products. The overall prevalence of footwear dermatitis among contact dermatitis cases in our study was 24% (6/25) which is higher than that seen by Saha et al (6)(11.7%) but similar to that seen by Chowdhuri S et al (24.22%).n

Positive patch test reactions to footwear allergens were found in 53.3%, which was similar to a study done by Angelini et al (12) who had reported an incidence of 65.4%. The probable reasons for this higher prevalence are indiscriminate use of footwear chemicals, lack of quality control of footwear, and hot climate associated with profuse sweating. The most common site involved was on the dorsum of the feet corresponding to the shape of the footwear (v-shaped chapels). This type of footwear is usually worn without socks and is preferred by people living in warm and humid climates as in this coastal town.

None of the cases reported any flare up of the disease on patch testing. No delayed reactions were noted in any of the patients. Thus patch testing was helpful in finding the incriminating cause of the dermatitis, avoidance of which may result in resolution of the disease. Also on basis of patch testing we can suggest alternative advice and at the same time, it is a very safe "in vivo" test independent of any laboratory procedure.

CONCLUSION: In this clinical study of lower leg and foot eczema including 50 cases, the following analysis is made after analyzing the data:

* Mean age of 50 patients in this study was 44.52 years with a standard deviation of 15.8 (range 7 years to 70 years).

* The most common age group affected was 46- 60 years (40%), followed by 31-45 years (30%).

* 32 cases (64%) were males and 18 cases (36%) were females with a male to female ratio of 1.78: 1.0.

* History suggestive of atopy was noted in 8 cases.

* Eczemas were bilateral in 82% of cases. Site of involvement in decreasing order of frequency were as follows: dorsum of foot, ankle, lateral aspect of lower leg, toes, medial aspect of lower leg, margin, soles.

* Pruritus was the most common symptom noted in 98% of cases. This was followed by oozing which was noted in 54% of cases and hyperpigmentation seen in 50% of cases.

* Allergic contact dermatitis (ACD) was the most common type of lower leg eczema (50%), followed by lichen simplex chronicus (22%), stasis eczema (10%), discoid eczema (8%), prurigo nodularis (6%), atopic dermatitis and pompholyx (2%) each.

* Out of 50 cases, 23 patients (46%) showed positive patch test result to at least a single allergen. To the 26 allergens in Indian standard series tested, around 19 allergens were found to be positive. Some were having positivity to multiple allergens, giving a total of 51 positive results. Out of which 46 were relevant (90.20%) against which only 5 cases were non-relevant (9.80%) according to the history.

* Most of the patients in footwear series (7 cases -30.43%) were found to have positive patch test result to potassium bichromate. All the patients who showed positive reactions to potassium bichromate were males, with the majority of the cases being labourers, coming in contact with cement on a regular basis.

* Patients were found to be positive to paraben mix (7 cases- 30.43%), with most of the cases being relevant.

* The most common allergen in females was nickel sulfate (5 cases- 21.74%), with all patients having history of use of jewellery.

* Epoxy resin (4 cases-17.39%) and fragrance mix was also found to be other common allergens on patch testing.

DOI: 10.14260/jemds/2014/3849

BIBLIOGRAPHY:

(1.) Valia RG, Valia AR. Eczema. In: Valia RG. IADVL Textbook of dermatology, 3rd ed. Bhalani Publishing House; 2008.p.490-519.

(2.) Beck M.H, Wilkinson S.M. Contact Dermatitis Allergic. In: Tony Burns, Stephen Breathnack, Neil Cox, Christopher Griffiths, editors. Rook's Text book of dermatology; vol.1.7th ed. Malden: Blackwell; 2004.p 20.23.

(3.) Chougule A, Thappa DM. Patterns of lower leg and foot eczema in South India. Indian J Dermatol Venerol Leprol 2008; 74: 458-61.

(4.) Ertam I, Turkmen M et al. Patch test results of an academic department in Izmir, Turkey. Dermatitis. 2008 Jul-Aug; 19(4):213-5.

(5.) Vani G, Gnaneshwar R et al. Allergic contact dermatitis of the hands and/or feet--common sensitizers. Contact Points 2002: 50-2. 2008; vol 19(4): 213-15.

(6.) Saha M, Srinivas S, Shenoy D et al. Footwear dermatitis. Contact dermatitis, 1993; 28: 260-64.

(7.) Freeman S. Shoe dermatitis. Contact Dermatitis.1997; 36: 247-51.

(8.) Waranya B, Pacharee I et al. Prevalence of allergic contact dermatitis in Thailand. Dermatitis, 2007; 19(3): 142-45.

(9.) Jindal R, Sharma NL et al. Contact sensitization in venous eczema: preliminary results of patch testing with Indian standard series and topical medicaments. Indian J Dermatol Venerol Leprol 2009; 75: 136-41.

(10.) Aynur A, Erbak G et al. Evaluation of the patch test results with standard antigens in various types of eczema. Contact Dermatitis.1996; 35; 303.

(11.) Chowdhuri S, Ghosh S. Epidemio-allergological study in 155 cases of footwear dermatitis. Indian J Dermatol Venerol Leprol 2007; 73: 319-22.

(12.) Angelini G, Vena A, Meneghini L. Shoe contact dermatitis. Contact Dermatitis.1980; 6: 279-83.

Vinita John [1], Srinivas M [2]

AUTHORS:

[1.] Vinita John

[2.] Srinivas M.

PARTICULARS OF CONTRIBUTORS:

[1.] Consultant Dermatologist, Department of Dermatology, Caritas Hospital, Kottayam, Kerala.

[2.] Assistant Professor, Department of Dermatology, Akash Institute Medical Sciences & Research Centre, Devanahalli, Bengaluru.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Srinivas M, Bloom Super Speciality Skin, Laser and Cosmetic Surgery Clinic, #19, 1st Main, Judge's Colony, R. T. Nagar, Bangalore-560032. Email: drshreeniderm@gmail.com

Date of Submission: 04/07/2014.

Date of Peer Review: 05/07/2014.

Date of Acceptance: 18/11/2014.

Date of Publishing: 18/11/2014.
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Title Annotation:ORIGINAL ARTICLE
Author:John, Vinita; Srinivas, M.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Clinical report
Geographic Code:9INDI
Date:Nov 20, 2014
Words:3424
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