Contact Dermatitis Due to Formaldehyde in Clothing Textiles

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					                 Contact Dermatitis Due to
             Formaldehyde in Clothing Textiles
                                Silas E.   O'Quinn, MD, and C. Barrett Kennedy, MD

   Formaldehyde resins are widely used in the textile in-         the formaldehyde-resin-impregnated materials. (4)
dustry in textile finishing. Many wrinkle-proof, crease-          The use or wearing of the fabric or tissue should
resistant, and waterproof fabrics have been treated in this       produce clinical dermatitis.
manner. Contact dermatitis due to formaldehyde con-                   During the past several months we have studied
tained in textiles has been reported from the European            three patients in whom we have been able to ful¬
countries but no authenticated cases have been reported           fill the criteria proposed by Fisher for the diagnosis
in the United States. This report describes three patients        of contact dermatitis due to formaldehyde con¬
with allergic contact dermatitis due to formaldehyde con-         tained in textiles.
tained in wearing apparel. The patients had positive patch
tests toformaldehyde and to samples of textiles shown
by chemical analysis to contain formaldehyde. There was              Patients presenting with a clinical picture com¬
correlation between the outbreaks of dermatitis and the           patible with a contact dermatitis due to clothing
use of formaldehyde-containing fabrics.                           were selected for study. The patients were patch
                                                                  tested with 2% and 5% formaldehyde solutions.
 Allergie    contact dermatitis due to formaldehyde               The patients were instructed to bring in as many
11      contained in textiles has been reported with
                                                                  samples of textiles taken from their wardrobe as
increasing frequency during the past few years.                   practical. The textile samples were tested for for¬
The majority of these reports have originated from
the Scandinavian countries, from England, and the                 maldehyde content by the Schiffs reagent method7
                                                                  and by a modification of Eegriewe's test for for¬
Netherlands.1"8 Peck's report in 1956 of sensitiza-               maldehyde." The patients were then patch tested
tion to formaldehyde contained in paper tissues is                with samples of textiles giving a positive test for
apparently the only such report from the United                   formaldehyde by the methods described above.
States.9 In 1962 Fisher and associates reviewed the
                                                                  Samples of textiles giving negative tests for for¬
problem of formaldehyde in textiles and paper as a                maldehyde were used as controls. Correlation be¬
possible cause of contact dermatitis in the United                tween the use of clothing made from formaldehyde-
States.10 In a study of 20 patients showing strongly
                                                                  containing textiles and the production of clinical
positive patch test reactions to 2% to 5% for¬                    dermatitis was obtained by actual patient use of
maldehyde solutions they could find no instances                  the clothing and by history. Correlation between
of clinical dermatitis that could be attributed to                the use of clothing made from fabrics giving a nega¬
free formaldehyde in textiles or paper to which                   tive test for formaldehyde and the ability to wear
these patients had significant clinical exposure.                 those articles of clothing without difficulty was
They further stated that there were no reports in                 similarly obtained.
the American literature of dermatitis due to for¬                     The methods used for testing for the presence of
maldehyde contained in wearing apparel.                            formaldehyde are, in brief, as follows:
     In order to establish the diagnosis of contact
 dermatitis due to formaldehyde contained in tex¬                               Schiff's Reagent Method
 tiles or paper, Fisher10 proposed the following                      1. Cut a small strip of material, approximately
 criteria should be fulfilled: (1) The paper or fabric            1   X 4 cm (or less).
 should show the presence of free formaldehyde.                      2. Immerse it in 5 ml of 0.1 N hydrochloric acid.
 (2) The patient should show a positive patch test                   3. Heat in a water bath (60 to 80 C) for ten
 reaction to 2% to 5% formaldehyde. (3) A posi¬                   minutes.
 tive patch test reaction should be obtained with                    4. Add 5 drops of Schiff's reagent for detection
  From the Department of Dermatology, Louisiana      State Uni-   of aldehydes.
versity School of Medicine, New Orleans.                             5. A violet color developing in the course of some
  Reprint requests to 1542 Tulane Ave, New Orleans   70112 (Dr.
O'Quinn).                                                         minutes indicates the presence of free aldehyde

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(released from the fabric). In textiles this will al¬          action always produced a flare-up of her dermatitis and
most  certainly represent formaldehyde.                        she was reluctant to test wear the garment again.
                                                                  CASE 3.—This 56-year-old Negro woman had had a
        Eegriewe's Test for Formaldehyde                       chronic hand eczema since 1950. In 1960 she developed
                                                               additional areas of dermatitis on the upper arms, the
  1. The sample of the fabric ifi brought to boiling           thighs, and the peripheral areas of the axillae. Since that
point with 5 ml of 1% sulphuric acid. Let it stand             time, the dermatitis in these areas has flared intermittent¬
for five minutes.                                              ly and the patient has in addition developed areas of der¬
                                                               matitis sharply localized over the breasts and in the area
   2. With a pipette, 1 drop of trie solution is trans¬        covered by her underpants. Patch testing with our screen¬
ferred to 2 ml of 72% sulphuric acid to which has              ing tray of 24 items revealed a 2+ positive patch test re¬
been added a few grains of chromotropic acid.                  action to 2% and 5% formaldehyde solutions, a 3+ patch
   3. The mixture is heated over an open flame.                test reaction to paraphenylendiamine 2% in petrolatum
                                                               and a 1+ patch test reaction to 1% mercaptobenzothiazole
   4. Positive reaction consists of an intense red¬            in petrolatum. This patient brought in only two items of
dish-purple color.                                             clothing for testing; both samples were free of formalde¬
   5. This test demonstrates not only free formalde¬           hyde. She was, however, patch tested with four textile
                                                               samples known to be strongly positive for formaldehyde
hyde, but also easily polymerizable products which             by the methods described above and a 2+ patch test re¬
appear to play a role when the textiles are stored.            action was noted with one of these samples. We have not
                                                               been able to obtain correlation between flare-ups or re¬
                    Report of Cases                            missions of this patient's dermatitis and the wearing of
   Case 1.—This 52-year-old white man had had a per¬           particular articles of clothing.
sistent dermatitis for approximately three years. The
dermatitis initially involved the posterior aspects of the
mid thighs. During the ensuing months progressive in¬
volvement was noted and included the sides of the neck,
                                                                  Among the articles in recent years dealing with
the shoulders and upper arms, the peripheral areas of the
                                                               the  problem of contact dermatitis due to formal¬
axillae, and the lower legs. Patch testing with a screening    dehyde contained in textiles there have been a
tray containing 24 patch test items revealed a 3+ positive     number of excellent and comprehensive reviews
patch test reaction to 2% and 5% lormaldehyde solutions.       discussing the use of formaldehyde in the textile
The patient brought in 16 samples of textiles taken from
his wardrobe for testing. Twelve ol these samples showed       industry and the problems which it may present
a positive test for formaldehyde ty both the Schiff and
                                                               to the dermatologist.2'5,7 The usefulness of for¬
the Eegriewe methods. Patch testing with five of the posi¬     maldehyde and formaldehyde resins in improving
tive samples gave 2+ and 3+ positive patch test reactions      the quality of textile fibers was observed as early
in all instances. Patch testing with four formaldehyde-        as 1919. However, it was not until about 1940 and
negative samples gave negative patch test reactions. The       thereafter that the use of these materials became
wearing of clothing made from textiles containing for¬
maldehyde, even in trace amounts, produced a prompt            widespread in the textile industry. Since that time,
recurrence of this patient's dermatitis. The patient was       textile finishing with formaldehyde resins has be¬
eventually restricted to wearing well-washed cotton shirts     come commonplace. Textile finishing by these
and cotton pants. At this point the patient brought in a       methods produces an improvement in the appear¬
number of samples of textiles, obtained from a tailoring
                                                               ance and ease of handling of the fabric. Cellulose
concern, for testing for the presence of formaldehyde. Only
one of these textile samples was free of formaldehyde and      fibers can thus be made crease resistant and water¬
the patient accordingly plans to have a suit made from         proof. Better dye absorption is obtained. Wool may
this material                                                  be rendered nonshrinkable and moth proof and an
   Case 2.—This 54-year-old Negro woman, who worked as
a nurse's aid, first developed a contact dermatitis of the
                                                               antiswelling and stabilizing effect is conferred on
sides of the neck in 1954. The dermatitis has persisted        rayon fibers.
intermittently since that time. In 1957 an eczematous der¬        A number of formaldehyde resins are used in
matitis of the feet and hands was noted. This dermatitis       textile finishing but resins in more common use
has persisted intermittently to the present time. In June      include urea-formaldehyde, melamine-formalde-
of 1964, the patient first developed a dermatitis involving
the periphery of the axillae. Pat:h testing at this time       hyde, and phenol-formaldehyde. The material to
revealed a 2+ patch test reaction to 2% and 5% for¬            be treated is soaked in an aqueous mixture of the
maldehyde solutions and 3+ patch test reactions to both        resin and a curing agent. The material is then heat-
mercaptobenzothiazole 1% in petrolatum and tetramethyl-        cured at a temperature of approximately 140 C.
thiuram disulfide (thiram) 1% in petrolatum. The patient       This is followed by washing to remove any excess
stated that she could not wear rubber next to her skin:
wearing rubber gloves made her hands break out in blis¬        resin, free formaldehyde, or other residue. This
ters. She had noted that wearing new unwashed clothing         treatment produces polymer formation and com¬
made the dermatitis of her neck and axillae worse. She         bination of the polymers within the textile fiber.
had used a formaldehyde-containing anhidrotic four or
five years previously but did not recall if this deodorant
                                                               Polymerization involves the joining of urea residues
preparation had produced a dermatitis of the axillae. Four
                                                               together by means of méthylène linkages, each
samples of clothing were brought in for formaldehyde
                                                               chain or branch being terminated by a methylol
testing. Only one of these samples was positive for for¬       group. The méthylène linkages are stable and are
maldehyde and patch testing with this material produced        unlikely to be a source of free formaldehyde in
a 3+ positive patch test reaction. Patch testing with the      resin-treated cloth. The methylol groups are more
negative textiles was negative except for one sample of        labile. Polymers of this type structure may be dis¬
brown and black wool material which gave a positive patch
test reaction. The patient stated that the fabric containing   solved in water and formaldehyde that are slowly
formaldehyde and producing the positive patch test re-         liberated over several days.5 These groups may

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thus be percursors of free formaldehyde in such           be of sufficient degree to allow the development of
treated textiles. Berrens and co-workers speculate        contact dermatitis on exposure to textiles con¬
that the hydrolysis of textile-finishing resins may       taining very low concentrations of formaldehyde.
liberate a glycine-formaldehyde product in addition       Marcussen1 included the following in his criteria
to free formaldehyde.6 They point out that formal¬        for the diagnosis of contact dermatitis due to form¬
dehyde reacts readily with free amino groups and          aldehyde in textiles: (1) typical localization of the
that a glycine-formaldehyde product may be formed         condition, (2) positive patch test with 4% aqueous
by the contact of free formaldehyde with the human        formaldehyde, (3) positive patch test with at least
skin. The antigenicity of such intermediate prod¬         one textile of the clothing and (4) failing reaction
ucts might account for the development of some            to patch test with paraphenylendiamine, rubber,
formaldehyde hypersensitivity reactions.                  and possibly dress preservers. We question the
   It thus appears that there are two possible            necessity of including the fourth criteria. Two of
sources of free formaldehyde in formaldehyde-resin        our patients had long-standing dermatitis with
treated textiles. The first of these is free formal¬      positive patch tests to substances commonly con¬
dehyde persisting after the finishing process and         tained in rubber. It seems possible to us that
inadequately removed by washing. This free form¬          chronic dermatitis might provide a fertile ground
aldehyde should be removed after an article of            for the development of additional sensitivities and
clothing has received several launderings. The            that possibly in this way the patient may become
second source of formaldehyde is from polymer             sensitized to formaldehyde.
degradation and especially from breakdown of                 Malten reported a group of 66 patients suspected
methylol groups. Release of free formaldehyde from        of suffering from a textile-finish hypersensitivity.8
this breakdown process may occur while the textile        These patients were patch tested with 37 different
is stored or under conditions of use by the wearer.       substances which may be used in the textile finish¬
   Allergic contact dermatitis due to sensitivity to      ing process. In 27 patients positive patch test re¬
formaldehyde contained in clothing presents a fair¬       actions were obtained to various textile finishing
ly characteristic clinical picture. In the early stages   materials and additives. Only seven of these pa¬
there is an acute eczematous dermatitis presenting        tients reacted to formaldehyde and this formalde¬
as a    pruritic, erythematous, papulovesicular   erup¬   hyde hypersensitivity never occurred alone. Malten
tion. As the process becomes subacute and chronic,        considers that formaldehyde sensitivity may be of
scaling and lichenification may predominate. The          secondary importance in textile-finish contact hy¬
areas   involved include the peripheral portions of       persensitivity. He feels that positive patch test
the axillae, the sides of the neck, the arms and legs,    reactions to formaldehyde may be due either to
especially in the fold areas, the inner and posterior     group specificity of the textile-finishing compounds
aspects of the thighs, and the gluteal clefts. Thus,      and additives or to impurities contained in indus¬
in general, those areas of the skin in close contact      trially used finishes.
with the responsible clothing and especially those           The frequency of the occurrence of contact der-
areas where the skin is apt to be damp from sweat¬
ing are commonly involved (Figure). Women are                Areas involved in contact dermatitis due to formalde¬
said to be involved much more frequently than men.           hyde contained in clothing textiles.
   It is not uncommon to see patients who attribute
the outbreak of a dermatitis to the wearing of par¬
ticular items of clothing. Such a dermatitis might
be due to the textile fiber, to soaps or detergents
carried on the material, or to a number of sub¬
stances contained in textiles such as dyes, rubber,
formaldehyde, or other textile-finishing compounds.
Even when a patient demonstrates a positive patch
test reaction to formaldehyde solution and when it
can be demonstrated that formaldehyde-containing
textiles are in the patient's wardrobe, positive patch
test reactions to the samples of textiles can only be
obtained infrequently.
   A large number of patients reported in the lit¬
erature give positive patch test reactions to 4%
or 5% formaldehyde solutions but fail to react to
patch tests of formaldehyde-containing textiles or
fail to develop clinical dermatitis when wearing
clothing made from such textiles.1,3"5 Such patients
with positive patch tests to formaldehyde solutions
may represent false positive reactors or a latent
hypersensitivity to formaldehyde. In some of these
patients the sensitivity to formaldehyde may not

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matitis due to hypersensitivity to textile finishing                hyde-impregnated clothing. During      the course of
compounds and additives is not known. It is pos¬                    four months we have seen three cases that appear
sible that it is more common than we generally                      to be true examples of contact dermatitis due to
think. In the New Orleans area the climate is hot                   sensitivity to textile finishes. For the patient, the
and humid during many months of the year. A local                   problem is both a chronic and a distressing one. In
concern manufactures a formaldehyde-containing                      the patient presenting with a clinical picture com¬
anhidrotic which is in fairly common use in this                    patible with a clothing contact dermatitis, careful
area. It would seem that such conditions would                      and diligent investigation including patch testing
afford an optimal opportunity for the development                   may be fruitful, both in establishing a precise etio¬
of such dermatitis. Once sensitivity has been es¬                   logic diagnosis and in guiding the patient towards
tablished by contact with a formaldehyde-contain¬                   relief of the problem.
ing anhidrotic, the dermatitis might be perpetuated                   Kathryn Isbell performed   the chemical   analyses   for formalde¬
or recur at intervals upon exposure to formalde-                    hyde in textiles.
   1. Marcussen, P.V.: Contact Dermatitis Due to Formaldehyde       hyde in Textiles in Relation to Formalin Contact Sensitivity,
in Textiles 1934-1958: Preliminary Report, Acta Dermatovener        Brit J Derm 76:110-115,1964.
39:348-356, 1959.                                                      7. Wereide, K.: Formaldehyde as a Contact Allergen in Tex-
  2. Hovding, G: Free Formaldehyde in Textiles: A Cause of          tiles: Formaldehyde Clothing Dermatitis. A Ten Year Period
Contact Eczema, Acta Dermatovener 39:357-368, 1959.                 In-Patient Series (1953-1962), Acta Allerg 19:351-352, 1964.
  3. Hovding, G: Contact Eczema Due to Formaldehyde in Resin           8. Malten, K.E.: Textile Finish Contact Hypersensitivity, Arch
Finished Textiles, Acta Dermatovener 41:194-200, 1961.              Derm 89:215-221,1964.
                                                                       9. Peck, S.M., and Palitz, L.L.: Sensitization to Facial Tissues
   4. Marcussen, P.V.: Dermatitis Caused by Formaldehyde Res-
                                                                    With Urea-Formaldehyde Resin, JAMA 160:1226-1227 (April 7)
ins in Textiles, Dermatologica 125:101-111, 1962.
   5. Cronin, E.: Formalin Textile Dermatitis, Brit J Derm            10.Fisher, A.A., Kanof, N.B.; and Biondi, B.S.: Free Formal-
75:267-273,1963.                                                    dehyde in Textiles and Paper: Clinical Significance, Arch Derm
  6. Berrens, L.; Young, E.; and Jansen, L.H.: Free Formalde-       86:753-756, 1962.

                                              Medicine has      a   history. So has physics. So have            re¬

                 Just Words              ligion, philosophy, and in fact all the real and all the
                                         stipulated subunits of man's restive comportment.
                                             But this is a peculiar thing. I do not quite know what
                                          philosophy is. And if I make a soundly systematic
                                          effort—I might almost say, a philosophically sound effort
                 —to improve ray understanding in this matter, there is but one way of
                 going about it: I must study the history of philosophy.
                    In this lies a paradox which fails to strike us as such because it is so
                 evident that we prefer to call it a truism: The entity philosophy is not a
                 thing that is lout a thing that becomes. It evolves toward a progressively
                 more definable integration and integrity. And one reason I do not quite
                 know what philosophy is, is precisely that it is not as yet. It is still becoming.
                    This is not so in the case of physics. This is not so in the case of medicine.
                 In fact, we have here a criterion that permits the grouping of all subdivisions
                 of man's relent ess questing in two categories. There are disciplines which have
                 a subject matter which would be even if they were not; and there are disciplines
                 whose subject matter is their own history.
                    The history of medicine is very interesting, very significant, and very im¬
                 portant. But medicine can be visualized other than historically. To study medicine
                 is not synonymous with studying the history of medicine. The history of litera¬
                 ture is not just interesting, significant, and important. It is literature. Literature
                 can be visuali2ed only historically.
                    All this has one dramatic implication: history is documents, and documents
                  (with but slight restrictive qualifications) and words. Words are surely im¬
                 portant in medicine, but the subject matter of medicine is not words. On the
                 other hand, the subject matter of literature is words. The subject matter of
                 philosophy is words. The subject matter of religion (I trust I shan't be mis¬
                 understood) is words.
                    All of which makes me observe dryly: I am amazed at the number of medical
                 men who write; well and still more at the number of men in the history- and
                 word-constituted disciplines who write badly.
                                                                             Alexander Gode, PhD

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