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Allergic contact dermatitis to isocyanate

Authors: Dr Nicholas Manuelpillai, Dermatology Resident, St Vincent’s Hospital, Melbourne, VIC, Australia; A/Prof. Rosemary Nixon, Dermatologist, Occupational Physician and Director; Skin Health Institute, Melbourne, VIC, Australia. DermNet Editor in Chief: Adjunct A/Prof. Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. March 2020.


What is allergic contact dermatitis to isocyanate?

An isocyanate is an organic compound used in the production of polyurethane foams, resins, coatings, and adhesives [1]. The major commercial isocyanates are 4,4’-diphenylmethane diisocyanate (MDI) and 2,4-toluene diisocyanate (TDI), which account for more than 95% of global isocyanate production [2].

Isocyanates are considered potent respiratory allergens and are a leading cause of occupational asthma [1]. Inhalation has long been considered the primary route of isocyanate exposure and sensitisation. Isocyanate exposure can also cause allergic contact dermatitis and irritant contact dermatitis.

The use of less volatile compounds and improvement in hygiene practices and use of personal protective equipment has increased the relative importance of skin exposure as a route of isocyanate exposure and sensitisation [3].

Resin containing isocyanate

Who gets allergic contact dermatitis to isocyanate?

The groups most at risk of allergic contact dermatitis are those involved in the manufacture of isocyanate or polyurethane foam. Others include:

What causes allergic contact dermatitis to isocyanate?

Workplace exposures can occur in the form of isocyanate vapours (resulting in airborne contact dermatitis), aerosols, or both. Exposure routes include inhalation, ingestion, skin, or eye contact [3]. Skin exposure can occur through direct contact or failure of personal protective equipment (PPE).

Skin exposure to isocyanate initiates hapten-induced contact hypersensitivity resulting in a type IV hypersensitivity reaction, resulting in allergic contact dermatitis [1,5]. However, the complete immunological mechanisms of sensitisation for isocyanate and other low-molecular-weight sensitisers are not completely understood, as exposure can result in multiple hypersensitivity pathways [5].

What are the clinical features of allergic contact dermatitis to isocyanates?

Exposure to isocyanate can result in allergic contact dermatitis, irritant contact dermatitis, contact urticaria, and generalised urticaria [6]. Isocyanate-induced allergic contact dermatitis often presents with mild symptoms and the cause may be easily missed [7].

Most patients experience mild erythema, pruritus, and vesicular dermatitis on exposed sites, such as hands, forearms, and face [2,8]. Exposure to isocyanate through the skin can induce respiratory sensitisation, with subsequent inhalation causing asthma [1].

Contact dermatitis to isocyanate

How is allergic contact dermatitis to isocyanate diagnosed?

Detailed clinical history and examination are crucial, determining which sites of the skin are affected by dermatitis and whether there are any systemic features, such as coughing, dyspnoea, and wheezing.

Commercial patch testing preparations of isocyanate are available, but are known to be unreliable and unstable leading to the possibility of false-negative results [7,9]. Patch test reactions to MDI have been reported to appear late after 7 days [10]. A reading on day 7 is therefore advisable.

When occupational allergic contact dermatitis to isocyanate is suspected, the specific isocyanates contacted at work should be tested in addition to commercial patch testing preparations [7,8].

Positive reactions to diaminodiphenylmethane (MDA) should be noted, as it may be an important marker for MDI sensitivity [6].

Positive patch test to isocyanate

What is the treatment for allergic contact dermatitis to isocyanate?

Prevention of allergic contact dermatitis in people exposed to isocyanate is critical. Engineering controls such as closed systems and ventilation and PPE to prevent dermal exposure are important critical measures to be taken at workplaces utilising isocyanates [3].

Nitrile gloves are preferable to latex gloves, but isocyanates may penetrate both types of glove [6]. Polyvinyl alcohol chemical-resistant gloves or multi-laminate gloves (Ansell™ Barrier™, Silver Shield/4H™) are likely to provide the best hand protection.

Skin contaminated with isocyanate should be washed with water, followed by an application of 30% isopropyl alcohol before washing again with soap and water.

Contact dermatitis is treated with a topical steroid, a moisturiser or barrier cream, and sometimes with oral corticosteroids or immunosuppressive drugs.

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References

  1. Bello D, Herrick CA, Smith TJ, Woskie SR, Streicher RP, Cullen MR, et al. Skin Exposure to Isocyanates: Reasons for Concern. Environ Health Perspect 2007; 115: 328–35. PubMed Central
  2. Wenk KS, Ehrlich A. Isocyanates. Dermatitis: Contact, Atopic, Occupational, Drug 2012; 23: 130–1. DOI: 10.1097/der.0b013e31824a648d. Journal
  3. CDC. Methylene bisphenyl isocyanate: The National Institute for Occupational Safety and Health (NIOSH); 2018. Available from: www.cdc.gov/niosh/npg/npgd0413.html. Updated 2018-03-28.
  4. AIHW. Occupational asthma affects thousands: Australian Institute of Health and Welfare; 2008. Available from: www.aihw.gov.au/news-media/media-releases/2008/may/occupational-asthma-affects-thousands
  5. Shane HL, Long CM, Anderson SE. Novel cutaneous mediators of chemical allergy. J Immunotoxicol 2019; 16: 13–27. PubMed
  6. Elsner P, John S-M, Maibach HI, Rustemeyer T. Kanerva's Occupational Dermatology. 2. ed. Berlin, Heidelberg: Berlin, Heidelberg : Springer Berlin Heidelberg : Imprint: Springer; 2012.
  7. Burrows D, Houle M-C, Holness DL, DeKoven J, Skotnicki S. Patch Testing Custom Isocyanate Materials From the Workplace 2015; 26: 94–8. PubMed
  8. Goossens A, Detienne T, Bruze M. Occupational allergic contact dermatitis caused by isocyanates. Contact Dermatitis 2002; 47: 304–8. PubMed
  9. Frick M, Zimerson E, Karlsson D, Marand A, Skarping G, Isaksson M, et al. Poor correlation between stated and found concentrations of diphenylmethane-4,4'-diisocyanate (4,4'-MDI) in petrolatum patch-test preparations. Contact Dermatitis 2004; 51: 73–8. PubMed
  10. Frick-Engfeldt M, Isaksson M, Zimerson E, Bruze M. How to optimize patch testing with diphenylmethane diisocyanate 2007; 57: 138–51. PubMed

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