A case of allergic contact dermatitis due to application of synthetic

East J Med 22(4): 224-226, 2017

DOI: 10.5505/ejm.2017.43531

Corresponding Author: Uzm. Dr. Tülin TÜRKÖZÜ, Şerefiye Mah. Ordu Cad. Ümitkent Sitesi B Blok No: 16 İpekyolu/VAN

Tlf: +90(432) 215 76 01-08, Faks: +90(432) 212 19 54, Cep Tel: 0 530 922 27 03, E-mail: dktrtulin@gmail.com

Received: 27.02.2017, Accepted: 10.05.2017

CASE REPORT

A case of allergic contact dermatitis due to

application of synthetic casting which mimics the

manifestation of cellulitis

Tülin Türközü

and Necip Güven

Republic of Turkey Ministry of Health, Health Sciences University, Van Education and Research Hospital Department

of Trauma and Orthopedic Surgery, Van, Turkey

Introductıon

Allergic contact dermatitis is an allergic or

inflammatory skin reaction that may occur due to

contact effect with external foreign substances. Acute

phase is characterized by erythematous, scaly plaques.

In severe cases vesiculation and bullae in exposed

areas are very characteristic.

Cellulitis is a common bacterial skin infection.

Cellulitis may first appear as a red, swollen area that

feels hot and tender to the touch. The redness and

swelling often spread rapidly. Cellulitis is usually

painful.

Case report

The 27-year-old male patient admitted to the

orthopaedic outpatients department due to sprain

the complaint of ankle. The patient has swelling,

diffuse ecchymosis and increased sensitivity in the

circumference of left lateral malleolus. The

performed radiography revealed nondisplaced

fracture in the lateral malleolus. No pathology was

found in the examination of syndesmosis.

Conservative treatment was planned for the

fracture and a synthetic short leg cast was applied.

The patient was recommended immobilization for

about 45 days using a crutch, without putting on

weight on the broken foot. The patient was

performed limb elevation because of the risk for

compartment syndrome and he was initiated

Clexane 0.6 sc 1x1 for prophylaxis of deep venous

thrombosis. The patient who had interdigital tinea

pedis was recommended to visit the Dermatology

Outpatients Department and dated due to visit the

Orthopaedic Outpatients Department one week

later for control examination.

The patient readmitted to our outpatient

department due to the complaint of intolerable

sensation of burning and pain 4 days later. It was

determined that no swelling of the fingers and

painful finger movement was present. The short

leg cast of the patient was replaced with a splint

and ankle circumference was evaluated. There was

diffuse swelling, edema, redness and increased

temperature in his ankle and especially around

lateral malleolus (Figure 1). In accordance with the

findings of the physical examination, the patient

was admitted in the ward due to prediagnosis of

cellulitis. Test of the infection markers was

ordered and antibiotic treatment was initiated. A

consultation of Department of Dermatology was

ordered because of tinea pedis and the treatment

regime recommended by Department of

Dermatology was initiated. Extremity elevation

was ordered while wet and cold dressing was

started. Of the whole blood and infections tested

in the first admission day; WBC: 9.9 K/mcL,

ABSTRACT

Casting application is one of the essential aspects with respect to conservative treatment of fractures in Orthopaedics and

it may be applied after surgical treatment when needed. In the recent years, common use of synthetic cast (45%

polyurethane resin and 55% fiberglass) and also undercast cotton padding (synthetic fiber) caused an increased incidence

of allergic contact dermatitis. It may develop an allergic reaction progressing accompanied by eruptions and itching as

commonly experienced in our daily orthopaedic practice. We have pre sented a case of allergic contact dermatitis which

mimics an unusual manifestation of cellulitis in routine clinical practice.

Key Words: Synthetic cast, Allergic contact dermatitis, cellulitis, mimic

Türközü and Güven / Allergic contact dermatitis due to application of synthetic casting

East J Med Volume:22, Number:4, October-December/2017

225

GRAN: 7.7 K/mcL, LYM: 1.7 K/mcL, CRP: 20

mg/L, SED: 13 mm/hour. In the second

admission day, no change was encountered in the

physical findings of his ankle however cold and

wet dressing reduced the sensation of burning.

The whole blood and infection markers in the

third admission day was measured such as WBC:

7.3 K/mcL, GRAN: 5.5 K/mcL, LYM: 1.4

K/mcL, CRP: 42.3 mg/L and SED: 47 mm/hour.

In the 4th admission day; since no change was

monitored in the swelling, edema and redness in

the ankle and also the marker tests resulted: WBC:

8.7 K/mcL, GRAN: 7.7 K/mcL, LYM: 0.7

K/mcL, CRP: 39 mg/L and SED: 51 mm/hour; it

was considered that the lesion around lateral

malleolus may be allergic contact dermatitis due to

use of synthetic cast and under cast cotton

therefore a consultation by the Department of

Dermatology was reordered. The steroid and

antihistaminic treatment initiated in the 4th

admission day provided a dramatic improvement

in the clinical condition of the patient in the 5th

admission day (Figure 2). Whole blood and

infection markers were measured as WBC: 12.1

K/mcL, GRAN: 10.6 K/mcL , LYM: 1.1 K/mcL,

CRP: 17.7 mg/L and SED: 57 mm/hour. The

slightly increased leukocytosis was considered

associated with administration of steroids. In the

6th admission day; whole blood and infection

markers were measured as WBC: 10.1 K/mcL,

GRAN: 8.2 K/mcL, LYM: 1.4 K/mcL, CRP: 6.3

mg/L and SED: 48 mm/hour. The clinical picture

of the patient was improved and the patient was

discharged and dated for a control examination

one week later.

At the control examination in the polyclinic one

week later; the physical condition of ankle was

found completely recovered. Whole blood and

infection markers were measured as WBC: 11.2

K/mcL, GRAN: 7.9 K/mcL, LYM: 2.6 K/mcL,

CRP: 3.5 mg/L and SED: 14 mm/hour and

fracture in his ankle was applied 100% cotton

under cast stocking and followed-up by

application of splint.

Fig. 2. The appearance of the ankle after steroid and antihistaminic treatment .

Fig. 1. The appearance of patient’s ankle after

removal of the synthetic cast.

Türközü and Güven / Allergic contact dermatitis due to application of synthetic casting

East J Med Volume:22, Number:4, October-December/2017

226

Discussion

The most common complication associated with

casting application is pressure or friction injuries.

Beside these, other complications may include

compartment syndrome, thermal injuires and skin

infection. Long-term use of a casting may cause

more severe complications such as chronic pain,

joint stiffness, muscular atrophy, complex regional

pain syndrome or venous thrombosis and further

pulmonary embolism (1,2,3).

Allergic contact dermatitis is an itchy dermatitis

condition. The clinical picture may vary depending

upon strength of allergen, contact duration,

reaction site and sensitivity degree of the subject

(4-9). In the acute period; erythematous macule,

papules, vesicles and bullae may be monitored.

Lesions have regular margins and are localized at

the contact site. Dilution may decrease in one or

two weeks. In the subacute period, vesicles change

to crusts, desquamation is remarkable. It may

become chronic if contact with the allergen

proceeds or the allergen is not removed. In the

chronic term; completely dry skin, thickening of

the skin, lichenification and fissures form (4,7,9).

Allergic contact dermatitis secondary to casting

application is commonly observed in the daily

orthopaedic practice. There is a limited number of

studies on this subject in the literature. In this

case; absence of leukocytosis in the laboratory test

results corroborated the conclusion that the

present condition may be due to allergic contact

dermatitis secondary to use of sythetic cast or

under cast cotton although the clinical findings of

the patient were exactly compatible with cellulitis.

After dramatically positive response of the patient

to steroid treatment and absence of leukocytosis, a

definite diagnosis of allergic contact dermatitis

could be established. In this case of allergic

contact dermatitis, present clinical symptoms were

different from the general findings and mimicked

cellulitis. The clinical picture of cellulitis should be

certainly supporeted by the laboratory results. It

should be also beard in mind that allergic contact

dermatitis may develop resulting from the use of

synthetic casting and undercast cotton padding.

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