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Severe urticaria due to recombinant interferon beta‐1a

SIR, A 7-year-old boy with mild eczema was treated with Oilatum Plus (Stiefel, High Wycombe, U.K) and intermittent application of mometasone furoate ointment. He developed an unusual eruption on his neck, axillae, popliteal and antecubital fossae and groin. He had three separate episodes of this rash over a 2-year period, each coinciding with the use of Oilatum Plus bath additive and settling with its withdrawal. The recommended dose of a capful of Oilatum Plus had been added in a standard size bath and the amounts used were therefore not excessive. However, he had repeated prolonged contact with Oilatum Plus from soaking in the bath for 20 min daily for 2 weeks. Examination revealed localized areas of brown-staining skin, severe erythema and extensive desquamation symmetrically involving flexural sites (Fig. 1). Full blood count, erythrocyte sedimentation rate, C-reactive protein and antistreptolysin-O titres, serum zinc, fungal culture and skin swabs were normal or negative. Patch test to the European standard battery, cream constituents, steroid battery and constituents of Oilatum Plus showed no reaction. Skin biopsy showed focal spongiosis, a mild perivascular lymphocytic dermal infiltrate and necrotic keratinocytes consistent with an irritant response. We believe our patient had developed an irritant reaction to Oilatum Plus . Prolonged immersion in the bath may have increased penetration of Oilatum Plus into the skin. Our patient had atopic eczema associated with increased skin sensitivity and decreased skin barrier function, and the prolonged contact with Oilatum Plus resulted in an extensive erythematous reaction and subsequent painful desquamation. In addition, the accentuation in skin folds suggests that local factors such as friction, skin temperature and eccrine gland distribution may have contributed to the development of this rash. Another possible factor may be incomplete mixing of the Oilatum Plus in the bath. Irritant reactions to Oilatum Plus have been reported previously in a case series involving seven patients. Irritant dermatitis can occur even with adherence to the manufacturer’s recommendations and not just with prolonged exposure or excessive use of Oilatum Plus . Oilatum Plus contains the antiseptics triclosan and benzalkonium chloride, which may be the causative agents. Benzalkonium chloride is a known irritant, and is corrosive at a concentration of 10%. Oilatum Plus contains a significantly higher concentration of benzalkonium chloride (6%) than most antiseptic bath emollients; the concentration of this antimicrobial agent is only 0Æ5% in Emulsiderm (Dermal, Hitchin, U.K) and Dermol 600 (Dermal) bath emollients. The acute skin irritation potential and allergenicity of triclosan is very low considering its widespread use in the cosmetic industry. It therefore seems less likely that the reactions were attributable to triclosan. Unlike previous cases that were essentially asymptomatic, in our patient the rash was associated with severe pain and discomfort. These symptoms and the distribution of the rash were different from his usual experience of eczema. In addition, patch testing and skin biopsies were not performed in previous cases. In our patient, the clinical diagnosis was supported by patch testing which ruled out an allergic contact dermatitis and a skin biopsy that showed histological features consistent with an irritant dermatitis. This bath emollient is widely used for the treatment of eczema. Although rare, clinicians should be aware of its potential in causing irritant dermatitis.