0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Observation |

Fingertip Purpura in a Dental Student An Unusual Manifestation of Methyl Methacrylate Dermatitis FREE

Lauren Strazzula, BA1; Shinjita Das, MD1; Vinod E. Nambudiri, MD, MBA1; Daniela Kroshinsky, MD, MPH1
[+] Author Affiliations
1Department of Dermatology, Massachusetts General Hospital, Boston
JAMA Dermatol. 2014;150(7):784-785. doi:10.1001/jamadermatol.2013.8520.
Text Size: A A A
Published online

Methyl methacrylate (MMA) is a well-known sensitizer commonly found in dental resins, bonding agents, prosthetics, artificial nail adhesive, and industrial glues. Allergic contact dermatitis due to MMA is often seen in individuals with occupational exposure, such as those in the dental profession.

REPORT OF A CASE

A healthy dental student in her 20s with allergies to silver, nickel, and wool presented with pruritus, pain, blistering, swelling, and numbness of the first 3 digits on her left hand. One month earlier, she had presented to her primary care physician for intense pruritus and vesicles on the left hand. Despite treatment with topical steroids for presumed eczema, her symptoms worsened, forcing her to reschedule her practical examination and present to an outside emergency department (ED) where she was treated for presumed herpetic whitlow with a 7-day course of acyclovir. Her symptoms ultimately resolved.

After resuming preparations for her practical examination, she experienced a rapid relapse of her symptoms, prompting presentation to our ED. She reported extensive handling of plastic models of teeth, and 2 months prior to her initial presentation at her primary care physician, she had begun using a new brand of powder and liquid crown resin while fashioning mold impressions of teeth. Wearing nitrile gloves, she would hold the mold with the first 3 digits of her left hand while applying the resin with her right hand.

On physical examination, we found mild edema and erythema and superficial desquamation along the palmar surfaces of the first, second, and third digits of the left hand, corresponding to areas of contact with the mold. A prominent purpuric patch with a larger area of desquamation was present distally on the first digit (Figure).

Place holder to copy figure label and caption
Figure.
Purpuric Contact Dermatitis in Reaction to Methyl Methacrylate

A, Mild edema and erythema with superficial desquamation is seen along the first, second, and third digits. B, A prominent purpuric patch located on the distal tip of the first finger was noted on the patient’s left hand.

Graphic Jump Location

Review of the resin ingredients revealed that the liquid compound contained 60% to 100% MMA, whereas the powder contained only nonsensitizing agents.1 Given the delay in the patient’s symptoms with initial use of the resin followed by a rapid relapse with reexposure as well as her history of intense pruritus, she was diagnosed as having allergic purpuric contact dermatitis (PCD) in reaction to MMA. She was treated with betamethasone, 0.05%, ointment and prednisone, 20 mg, orally for 5 days. She was instructed to discontinue using the resin.

At 10-day follow-up, her skin was clear. Patch testing was deferred in consideration of symptom resolution, a high degree of confidence in having eliminated the triggering agent, and her imminent practical final examination. She was instructed to wear 2 layers of nitrile gloves with petrolatum between them if further contact with MMA was anticipated, with glove changes every 30 minutes to minimize exposure.

DISCUSSION

An acrylic monomer, MMA can permeate latex gloves within 1 minute and nitrile gloves within 3 minutes.2 “Double gloving” does not effectively decrease MMA permeability, but the addition of a layer between pairs of glove, such as water, may decrease permeability 4-fold.2 A synthetic laminated glove (4H) appears relatively impermeable to MMA, but widespread use is limited by cost and diminished dexterity.2,3

Allergic contact dermatitis induced by MMA may result in significant discomfort and is seen frequently after occupational exposure among dentists, dental technicians, orthopedic surgeons, and other health care workers. Second- and third-digit fingertips are commonly involved.3 Nail dystrophy and fingertip paresthesias have also been reported.4 Severe cases of MMA-induced dermatitis can even necessitate profession changes.3

Purpuric contact dermatitis has been reported in patients sensitized to agents such as textile dyes, formaldehyde, and epoxy resins.5 We report herein the second case, to our knowledge, of MMA-induced PCD.6 Although patch testing is considered the diagnostic gold standard for suspected allergic contact dermatitis, this patient’s strong contact history and rapid, sustained resolution of symptoms with allergen avoidance allowed for clinical diagnosis. Fingertip purpura may appear alarming to unsuspecting clinicians and may prompt an extensive workup. We encourage physicians to consider PCD in patients with potential contact exposures.

ARTICLE INFORMATION

Corresponding Author: Daniela Kroshinsky, MD, MPH, Department of Dermatology, Massachusetts General Hospital, 50 Staniford St, 200, Boston, MA 02114 (dkroshinsky@partners.org).

Published Online: May 21, 2014. doi:10.1001/jamadermatol.2013.8520.

Conflict of Interest Disclosures: None reported.

REFERENCES

America  GC. Alike Temporary Crown Bridge and Resin: Material Safety Data Sheets.http://www.gcamerica.com/products/operatory/alike/msds.php. Accessed July 1, 2013.
Lönnroth  EC, Wellendorf  H, Ruyter  E.  Permeability of different types of medical protective gloves to acrylic monomers. Eur J Oral Sci. 2003;111(5):440-446.
PubMed   |  Link to Article
Kanerva  L, Estlander  T, Jolanki  R, Tarvainen  K.  Occupational allergic contact dermatitis caused by exposure to acrylates during work with dental prostheses. Contact Dermatitis. 1993;28(5):268-275.
PubMed   |  Link to Article
Bjorkner  B. Plastic materials. In: Frosch  PJ, Menne  T, Lepoittevin  JP, eds. Contact Dermatitis.4th ed. Berlin, Germany: Springer; 2006:583-621.
Lazarov  A, Cordoba  M.  Purpuric contact dermatitis in patients with allergic reaction to textile dyes and resins. J Eur Acad Dermatol Venereol. 2000;14(2):101-105.
PubMed   |  Link to Article
Koch  P, Baum  HP, John  S.  Purpuric patch test reaction and venulitis due to methyl methacrylate in a dental prosthesis. Contact Dermatitis. 1996;34(3):213-215.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Purpuric Contact Dermatitis in Reaction to Methyl Methacrylate

A, Mild edema and erythema with superficial desquamation is seen along the first, second, and third digits. B, A prominent purpuric patch located on the distal tip of the first finger was noted on the patient’s left hand.

Graphic Jump Location

Tables

References

America  GC. Alike Temporary Crown Bridge and Resin: Material Safety Data Sheets.http://www.gcamerica.com/products/operatory/alike/msds.php. Accessed July 1, 2013.
Lönnroth  EC, Wellendorf  H, Ruyter  E.  Permeability of different types of medical protective gloves to acrylic monomers. Eur J Oral Sci. 2003;111(5):440-446.
PubMed   |  Link to Article
Kanerva  L, Estlander  T, Jolanki  R, Tarvainen  K.  Occupational allergic contact dermatitis caused by exposure to acrylates during work with dental prostheses. Contact Dermatitis. 1993;28(5):268-275.
PubMed   |  Link to Article
Bjorkner  B. Plastic materials. In: Frosch  PJ, Menne  T, Lepoittevin  JP, eds. Contact Dermatitis.4th ed. Berlin, Germany: Springer; 2006:583-621.
Lazarov  A, Cordoba  M.  Purpuric contact dermatitis in patients with allergic reaction to textile dyes and resins. J Eur Acad Dermatol Venereol. 2000;14(2):101-105.
PubMed   |  Link to Article
Koch  P, Baum  HP, John  S.  Purpuric patch test reaction and venulitis due to methyl methacrylate in a dental prosthesis. Contact Dermatitis. 1996;34(3):213-215.
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

896 Views
1 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Jobs