Indian Journal of Allergy, Asthma and Immunology

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 35  |  Issue : 2  |  Page : 61--66

Clinicodemographic and patch testing profile of patients with lower leg and feet eczema at a tertiary care center in South India


Ann Shaji Nisha, Navakumar Manickam, Kannan Gopalan, Seethalakshmi Ganga Vellaisamy 
 Department of Skin and STD, Vinayaka Mission Kirupanandha Variyar Medical College and Hospital, Salem, Tamil Nadu, India

Correspondence Address:
Dr. Navakumar Manickam
Moolapathai, Edappadi TK, Salem - 637 102, Tamil Nadu
India

Abstract

BACKGROUND: Lower legs and feet eczema may be due to exogenous causes such as allergic contact dermatitis (ACD) or endogenous cause such as atopy. Currently, patch testing is the only scientific proof of contact allergy. AIMS: The aim was to study the clinicodemographic profile and to evaluate the role of patch testing in lower leg and feet eczema. MATERIALS AND METHODS: This was a cross-sectional study conducted among 60 patients with lower leg and feet eczema. They were subjected to patch testing with Indian standard series and readings were interpreted according to the International Contact Dermatitis Research Group scoring system. RESULTS: Our study included 32 (53.3%) males and 28 (46.7%) females (M: F = 1.1:1). The mean age was 42.61 ± 13.40 years corresponding to occupationally active age group. Construction workers (10 [31.25%]) were the most common occupational group affected among males (P = 0.007). Among females, most commonly affected were housewives (10 [35.71%]) (P = 0.0002). The most common pattern of eczema seen was ACD (22 [36.7%]). Positive patch test response was recorded in 17 (28.3%) patients and the most common allergen found to be positive was potassium dichromate (6 [35.3%]). Correlating the morphology with patch test results, ACD (13 [59.1%]) was significantly positive when compared to other eczemas (4 [10.53%]) (P = 0.000). CONCLUSION: Patch testing is a valuable diagnostic aid in lower leg and feet eczema. It plays a pivotal role in identifying causative allergens associated with ACD from which allergen avoidance can be advised for a better clinical outcome and quality of life.



How to cite this article:
Nisha AS, Manickam N, Gopalan K, Vellaisamy SG. Clinicodemographic and patch testing profile of patients with lower leg and feet eczema at a tertiary care center in South India.Indian J Allergy Asthma Immunol 2021;35:61-66


How to cite this URL:
Nisha AS, Manickam N, Gopalan K, Vellaisamy SG. Clinicodemographic and patch testing profile of patients with lower leg and feet eczema at a tertiary care center in South India. Indian J Allergy Asthma Immunol [serial online] 2021 [cited 2022 Dec 2 ];35:61-66
Available from: https://www.ijaai.in/text.asp?2021/35/2/61/350072


Full Text



 Introduction



Eczema of lower legs and feet is one of the most common conditions encountered in dermatology. Various risk factors include history of eczema in childhood, female sex, occupational exposure, and history of atopy such as asthma and allergic rhinitis.[1]Lower legs and feet are more prone to allergic contact dermatitis (ACD). The feet also have a peculiar anatomical feature, such as the highest concentration of eccrine sweat glands in the plantar region, which leads to excessive maceration and increased penetration of allergens triggering ACD.[2] Stasis eczema is seen commonly affecting lower legs. Other common morphological patterns of lower leg and feet eczema include lichen simplex chronicus (LSC), nummular eczema, pompholyx, and cumulative irritant contact dermatitis. They are usually chronic, recurrent, and difficult to control.[3] There are many other common dermatological conditions which may mimic eczema such as psoriasis, dermatophytosis, lichen planus etc.[4] Thus correct identification is essential to avoid misdiagnosis and for proper management of the patient. The cause of eczema is also altered by various factors such as the geographical condition, habits of people, occupation, environmental factors, and regional variation in structure and function of the skin.[5]

The gold standard test in identifying the etiological factor for eczema is the patch test, as it is the only scientific proof of contact allergy.[6] However, patch test has often been underutilized.[7]A positive reaction to patch test combined with a proper history and clinical examination will help in identifying the allergen responsible for eczema and contact dermatitis through which we can educate the patient about avoiding the possible allergen and provide them with suitable alternatives for a good clinical outcome and preventing recurrences. Hence, this study was undertaken to assess the demographic profile and various clinical patterns of lower leg and feet eczema as well as to evaluate the role of patch test in identifying the common allergens causing eczema.

 Materials and Methods



This was a hospital based cross-sectional study carried out over a period of 1 year from January 2019 to January 2020 at a rural tertiary care center in South India. Ethical clearance was obtained from the institute ethics committee prior to commencing the study. A total of 60 patients with newly diagnosed lower leg and foot eczema were enrolled in our study, with the major inclusion criteria being patients above 18 years of age and those willing to undergo patch testing. The exclusion criteria were patients presenting with active eczema, those with eczema extending beyond legs and feet, pregnant and lactating females, history of prior treatment with steroids or any immunosuppressant drugs in the past 1 month, and patients with co-existent other dermatoses such as psoriasis, dermatophytosis, etc. Written informed consent was obtained from all patients after a thorough explanation regarding the nature and purpose of the study. A detailed history pertaining to the demographic data, occupation, symptoms, duration of eczema, and exposure to any external agents and cutaneous examination findings including sites affected, distribution, and morphology of the lesions were recorded in a predesigned pro forma. Correlating the history and cutaneous examination findings, clinical diagnosis of each eczema was made based on standard definitions described for each in literature.[5],[8],[9],[10] Patch testing was carried out using the battery of Indian standard series. Finn chambers with allergen in appropriate dilution were applied on upper back mounted on a micropore tape. Patients were instructed to keep the patch test in place for 48 h following application. They were advised to avoid taking a bath/wetting the back, excessive sweating and exercise, wearing tight underclothes, friction, rubbing, or lying on back during this period to prevent the patch from getting loose and displaced.

Positive patch test reactions and their intensity were recorded at 48 hours after removing the patches. Patients were advised to follow-up for a second reading at 96 h, as some allergens may elicit a delayed response. Readings were interpreted according to ICDRG (International Contact Dermatitis Research Group) scoring system.

Statistical analysis

The data were tabulated and analyzed using SPSS version 23. Descriptive data were expressed as mean ± standard deviation. Analysis was done by unpaired Student t-test for quantitative data and by Chi-square test or Fisher's exact test for qualitative data wherever required. P < 0.05 was considered statistically significant.

 Results



Of the total 60 patients, 32 (53.3%) males were affected as compared to 28 (46.7%) females, and the male: female ratio was 1.1:1. Majority of the study subjects were in the age group of 41–60 years (27 [45.0%]) and 21–40 years (22 [36.6%]). The mean age of the study population was 42.61 ± 13.40 years, corresponding to the occupationally active age group. There was no statistical significance when comparing the mean age of males (44.15 ± 16.34 years) and females (39.11 ± 10.92 years) (P = 0.17, unpaired t-test). The mean duration of the disease was 19.71 ± 23.26 months. Construction workers (10 [31.25%]) were the most common occupational group affected among males (P = 0.007, Fisher's exact test), followed by farmers in 8 patients. Among females, most commonly affected were housewives (10 [35.71%]) (P = 0.0002, Fisher's exact test), followed by daily laborers and teachers in 4 patients each and 3 textile workers. [Figure 1]. The most common pattern of eczema seen was ACD [22 (36.7%)], followed by lichen simplex chronicus (10 [16.7%]), discoid eczema (9 [15%]), and stasis eczema (6 [10.0%]). Regarding the sex-wise distribution, the most common pattern seen in males was ACD (13 [40.6%]), followed by discoid eczema (7 [21.88%]), LSC, and asteatotic eczema in 4 patients each (12.5%). In females, the most common pattern seen was ACD (9 [32.14%]), followed by LSC (6 [21.43%]), stasis eczema (4 [14.3%]), and cumulative ICD (3 [10.71%]) [Table 1]. The bulk of ACD patients (90.9%) belonged to 41–60 years of age (10 [45.45%]) and 21–40 years of age (10 [45.45%]). LSC (7 [70%]) and discoid eczema (6 [100%]) patients were commonly seen in the age group of 41–60 years. Stasis eczema (4 [44.4%]) was commonly seen in 21–40 years of age, and all cases of asteatotic eczema (4 [100%]) were seen in the elderly above 61 years of age. Pruritus was the predominant symptom noted in 27 patients (45%). The distribution of eczema was unilateral in 23 patients (38.3%) and bilateral in 37 patients (61.7%), and the most common sites affected were dorsum of foot followed by anterior aspect of ankle, medial aspect of lower leg with ankle, and lateral aspect of lower leg with ankle and sole. Majority of ACD patients had involvement of dorsum of feet (17 [77.3%]). The most common site of involvement of LSC was lateral aspect of lower leg with ankle (6 [60%]). Medial aspect of ankle with lower leg (5 [83.3%]) was commonly affected in stasis eczema [Figure 2]. Positive patch test response was recorded in 17 (28.3%) patients which included 9 males and 8 females. Fourteen patients showed positive responses and 3 patients showed doubtful responses at 48 h, which later turned out to be positive at 96 h. The most common allergen found to be positive in our study was potassium dichromate in 6 patients (35.3%), followed by parthenium and nickel in 4 patients each (23.5%) and Mercaptobenzothiazole(MBT), fragrance, and black rubber mix in 1 each (5.9%). Each patient with footwear eczema showed positivity to MBT and black rubber mix [Figure 3]a and [Figure 3]b. The list of positive allergens among males and females relevant to occupation and morphology is shown in [Table 2]. Correlating the morphology with patch test results, a significant number of ACD patients (13 [59.1%]) was positive when compared to other eczema subtypes (4 [10.53%]). Among the other eczema subtypes, patch test was positive in discoid eczema in 2 patients, LSC and cumulative ICD in 1 patient each. With regard to the distribution, among 37 patients with bilateral distribution, 16 had a positive patch test compared to only one positive response among the total 23 patients with unilateral distribution. Comparative analysis of patch test results with sex, distribution, and morphology is shown in [Table 3]. There was a significant association seen between patch test results and site affected, with 14 out of 31 patients with dorsum of feet involvement showing patch test positivity [Table 4].{Figure 1}{Figure 2}{Figure 3}{Table 1}{Table 2}{Table 3}{Table 4}

 Discussion



The most common cause for lower leg and foot eczema is ACD which occurs due to c onstant exposure to several allergens in day-to-day life and also in the occupational setting. The prevalence of contact dermatitis is high in tropical country like India due to multiple contributing factors such as humidity, high temperature, and occlusive footwear. It has a chronic relapsing and remitting course. Thus, identifying and avoidance of the external agents is of paramount importance in the management of contact dermatitis.[11] Patch test can be employed to determine the causative allergens in refractory cases in order to devise a better management strategy.[12] A positive patch test does not necessarily mean that the allergen is the cause for eczema and its relevance should always be carefully considered.[6]

There was a male predominance in previous studies done by Aithal V and Jacob MA[13] [1.78:1] and Kumar et al.[14] (M: F-1.3:1). In contrast, females were commonly affected in studies conducted by Priya et al.[15] and Mohanty et al.[16] and they have attributed it to the usage of variety of footwear and increased exposure to soap, water, and detergents among Indian women. In our study, we observed no sex predilection with the male: female ratio of 1.1:1. The most common age group affected in our study population was 41–60 years (45%), with the mean age of patients being 42.61 ± 13.4 years in accordance with a study by Kumar et al.[14] This mainly constitutes the working and active age group who are more prone to get exposed to multiple allergens.

Majority of patients in our study were construction workers (11 [18.3%]), followed by farmers (10 [16.7%]) and housewives (10 [16.7%]). In contrast, farmers (28.75%) were commonly affected in a study by Kumar et al.[14], whereas Aithal and Jacob[13] and Mohanty et al.[16] observed office workers (50%) and housewives (31%) as the common occupation groups affected in their studies, corroborating the findings of Mohanty et al.[16] This may be due to increased penetration of allergens following epidermal barrier damage due to excessive exposure to water, vegetable juices, detergents, and other cleansing agents.[17]

We observed ACD as the major pattern of eczema seen in 22 (36.7%) patients, consistent with previous studies.[13],[18] This may be due to more number of outdoor workers like construction workers, farmers, and daily laborers getting exposed to allergens in their workplace and subsequently developing ACD. They are also more prone to trauma which further enhances the penetration of allergens. Dorsum of feet (51.7%) was the common site affected in our study which was in accordance with various Indian studies conducted previously.[3],[13],[14],[15] More than half of patients (54.8%) with dorsum of feet involvement had ACD as the major pattern of eczema.

The most common allergen in our study was potassium dichromate seen in 6 (35.3%) patients. Majority of potassium dichromate positivity was seen in males compared to females and all of them were construction workers. Among 11 construction workers, 6 (54.5%) showed patch test positivity to potassium dichromate. Previous studies also have reported similar findings.[14],[19],[20] However, contrasting observations were made by Aithal and Jacob[13] and Priya et al.[15] where parthenium and MBT were the common sensitizers.

In our study, parthenium was seen positive mainly among farmers (4 [40%]) owing to their engagement in a variety of outdoor activities. Their skin is more prone to trauma which can lead to dysfunction of skin barrier, thus leading to a high degree of sensitization with parthenium. Mercaptobenzothiazole and black rubber mix were the common sensitizers in 2 patients with footwear dermatitis in accordance with the studies by Priya et al.[15] and Mohanty et al.[16] They have attributed it to the greater usage of rubber chappals among the Indian population.

Positive patch test results were seen in 17 (28.3%) patients, and the overall prevalence of patch test positivity in our study was relatively low when compared to previous studies. This may be due to the fact that patch testing was conducted mainly among patients with ACD in previous studies, whereas we have included all patients with lower leg and foot eczema irrespective of the morphology which might have reduced its sensitivity. However, patch test results were significantly higher in ACD (13 [59.1%]) when compared to other eczema subtypes consistent with the findings by Aithal and Jacob[13] (60%) and Kumar et al.[14] (57%). The summary of patch test positive percentages and common positive allergens found in previous studies along with our study is shown in [Table 5].{Table 5}

In the present study, bilateral involvement of eczemas was seen in 37 patients (61.7%), contrasting to the observations made by Aithal and Jacob[13] and Priya et al.[15] (90%). Among the 37 patients with bilateral involvement, 16 were patch test positive. Furthermore, positive patch test results were noted more among patients with dorsum of feet involvement. ACD was seen more bilaterally distributed and also commonly affecting the dorsum of feet which could explain the higher positivity rate with respect to site and distribution.

The major limitation of our study was the relatively small sample size and the overall sensitivity of patch test was reduced due to inclusion of less number of patients with ACD. Furthermore, there was a minimal number of patients with footwear eczema in our study.

 Conclusion



The most common sensitizer identified in our study was potassium dichromate. There was a significant correlation seen between patch test positivity and ACD, distribution, and site of involvement. Our study stresses the importance of patch test as a major tool in the diagnosis of lower leg and foot eczema. It plays a pivotal role in identifying the common sensitizers associated with ACD from which possible advice regarding allergen avoidance and occupational and lifestyle modifications can be given for better symptomatic relief and for preventing recurrences. The allergens keep on varying from time to time due to changes in lifestyle and urbanization, thereby necessitating the need for such studies to be conducted frequently to know the trend in allergen patterns.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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