What is known about this subject in regard to women and their families?
- Generally, the fact that this kind of product can cause contact dermatitis is underrecognized by women and their families, even though absorbent hygiene products are in widespread use.
What is new from this article as messages for women and their families?
- This case shows that intimate hygiene products, despite being approved and having passed quality controls, may contain more than one substance that can potentially be the cause of contact dermatitis. Vulvar contact allergic dermatitis should always be suspected in cases of recurrent genital discomfort, pruritus, or similar conditions, and those patients should be referred to a dermatologist to perform patch testing.
Dear Editors,
Allergic contact dermatitis (ACD) is an important diagnosis to be considered when examining patients presenting with genital symptoms, notably in female population. Though the real incidence of contact sensitization in the vulvar area is unknown; it is linked to the use of absorbent hygiene products (AHPs) and it was originally described in 1979.1
Herein, we report the case of a 23-year-old woman who visited our consultation complaining of itching and generalized erythema and desquamation in the vulvar area for the last 8 years, coinciding with her menstruation. However, these inconveniences disappeared during the last months since she started using a menstrual cup, and consequently, she stopped using AHPs.
When ACD was suspected due to acrylates used in AHPs, we performed an allergy patch test (APT), which included a standard battery (T.R.U.E. TEST Allergen Patch Test) and a more specific methacrylate battery (Marti Tor Alergia S.L.). After 48- and 96-hour readings, the following compounds were positive (Fig. 1): Quaternium-15 (100 µg/cm2 hydroxypropyl cellulose), p-phenylenediamine (90 µg/cm2 povidone), formaldehyde (180 µg/cm2 povidone), Hydroxyethyl methacrylate (1% vaseline), hydroxyethyl acrylate (0.1% vaseline), hydroxypropyl methacrylate (2% vaseline), ethylene glycol dimethacrylate (2% vaseline), ethyl acrylate (0.1% vaseline), and tetrahydrofuryl methacrylate (2% vaseline).
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Fig. 1.: Positive allergy patch test in our patient after 96 hours, including a standard battery (T.R.U.E. TEST Allergen Patch Test) and a more specific methacrylate battery (Marti Tor Alergia S.L.). (A) Hydroxyethyl methacrylate (1% vaseline), (B) hydroxyethyl acrylate (0.1% vaseline), (C) hydroxypropyl methacrylate (2% vaseline), (D) ethylene glycol dimethacrylate (2% vaseline), (E) ethyl acrylate (0.1% vaseline), (F) tetrahydrofuryl methacrylate (2% vaseline), (G) Quaternium-15 (100 µg/cm2 hydroxypropyl cellulose), (H) p-phenylenediamine (90 µg/cm2 povidone), (I) formaldehyde (180 µg/cm2 povidone).
Acrylates are synthetic resins which represent an important cause of both occupational and nonoccupational ACD. Probably, the most known nonoccupational source of acrylates are nail products, even though acrylate allergy associated with other sources are well described.
Most AHPs are made of cellulose and contain adhesives, fragrances, and superabsorbent polymers, such as acrylates. In turn, all these materials can polymerize into other substances under specific conditions. This occurs in the genital area at occlusion, making it difficult to identify exactly which substance a patient has been exposed to.
On the other hand, we should also consider that vulvar tissue is more permeable than other anatomical sites of the skin due to differences in structure, occlusion, hydration, and susceptibility to friction, so there is a higher risk of skin contact.2 This would explain the wide range of allergens to which our patient was sensitized.
Despite the widespread use of AHPs, the literature on the subject is paradoxically sparse, with only a few case reports linking AHPs to ACDs due to different substances (colophonium, methyldibromo glutaronitrile, acrylates, Magnolia officinalis…).3,4 One reason for this low reporting rate could be that consumers are generally unaware that AHPs can contain allergens.5 Another reason could be that the first medical contact of these patients is with general practitioners or gynecologists who are probably not sufficiently trained on the subject.
In our view, it would be important for AHP users, general practitioners, and gynecologists to be aware of this problem to enable better detection and treatment.
Accordingly, if there is recurrent genital discomfort, itching or similar conditions, contact allergic vulvar dermatitis should always be suspected, and these patients should be referred to a dermatologist for APT.
Additionally, as alternatives to traditional AHPs (eg, menstrual cups) will become popular, we will see also ACD for other materials.
Conflicts of interest
None.
Funding
None.
Study approval
Written informed consent was obtained from the patient for the publication of this article and any accompanying images.
Author contributions
NR-M: participated in research design, performance of the research, data analysis, and writing of the paper. VE-S, MS, MG, CL-L, and MR: participated in research design, performance of the research and data analysis.
References
1. Larsen WG. Sanitary napkin dermatitis due to the perfume. Arch Dermatol 1979;115:363. doi:10.1001/archderm.1979.04010030065027
2. Farage M, Maibach HI. The vulvar epithelium differs from the skin: implications for cutaneous testing to address topical vulvar exposures. Contact Dermatitis 2004;51:201–9. doi:10.1111/j.0105-1873.2004.00444.x.
3. Amat-Samaranch V, López-Sánchez C, Tubau C, et al. Vulvar allergic contact dermatitis caused by
Magnolia officinalis bark extract. Contact Dermatitis 2022; 87:96–97.
4. Williams JD, Frowen KE, Nixon RL. Allergic contact dermatitis from methyldibromo glutaronitrile in a sanitary pad and review of Australian clinic data. Contact Dermatitis 2007;56:164–7. doi:10.1111/j.1600-0536.2007.01040.x.
5. Desmedt B, Marcelis Q, Zhilivoda D, Deconinck E. Sensitizing fragrances in absorbent hygiene products. Contact Dermatitis 2020;82:279–82. doi:10.1111/cod.13472.
