Mercury-inducedsystemic allergicdermatitis caused by‘white precipitate’ in askin lightening cream

Contact Dermatitis 2009: 60: 61–63

Esen Ozkaya, Leyla Mirzoyeva andBanu Otkur

Department of Dermatology, _IstanbulMedical Faculty, _Istanbul University, _Istanbul34093, Turkey

Key words: allergic contact dermatitis;ammoniated mercury; baboon syndrome;bleaching cream; cosmetics; mercuryammonium chloride; mercury exanthema;patch test; systemic contact dermatitis; whitemercuric precipitate.

Mercurial baboon syndrome is a dis-tinct form of systemic allergic derma-titis that is mainly triggered by theinhalation ofmetallic mercury vapours(1, 2). We report an unusual casetriggered by topical use of a mercury-containing cosmetic product.

Case Report

A 32-year-old Turkish non-atopicwoman presented with erythema anditchy papulovesicular lesions on herface, neck, sides of the trunk, and ante-cubital fossae that developed 5–6 hrafter the applicationof a skin lighteningcream on her cheek and upper lip.Unintentionally, she had ingested thecream by licking her upper lip. Thecream had been borrowed from anold neighbour who had bought it 15–20 years ago.The lesions clearedwithin1 week with systemic corticosteroids.

According to product label, theskin lightening cream contained ‘pre-cip blanc’, and the patient thoughtthat it was free of mercury. Shebelieved that she had mercury allergybecause of episodes of dermatitis,affecting her anogenital area andsymmetrically on major flexures afterexposure to broken thermometers9 and 10 years previously, and use ofmercurial antiseptics had caused ery-thema and vesicles at the applicationsites 4 and 12 years previously. Shehad no dental amalgam fillings orany problem with vaccinations; therewas no other current contact withmercury compounds.

CONTACT POINTS 61

Patch testingwas performedwith anextended European baseline series(Brial Allergen, Greven, Germany)using IQ Chamber (ChemotechniqueDiagnostics, Vellinge, Sweden). Opentesting was performed with thepatient’s skin lightening cream (Fazıl�

cxil ilacı, as is, Fazıl Soysal Labo-ratuvarı _Ilacx ve Kozmetik San. veTic. Ltd. Sxti., Istanbul, Turkey) anda mercurial antiseptic (Mersol�, as is,Merkez Laboratuvarı _Ilacx San. veTic.A.S., Istanbul, Turkey) on theright and metallic mercury (0.5%pet.) on the left volar aspect of herforearms. Tests were terminated after1 D because, according to Interna-tional Contact Dermatitis ResearchGroup criteria (3),þþþ andþþ pos-itive reactions developed with the skinlightening cream and Mersol�,respectively. In addition, the patchtests showed a þþþ positive reactionto ammoniatedmercury (1%pet.) andaþ reaction to thimerosal (0.1% pet.)(Fig. 1) and metallic mercury (0.5%pet.) at D1. Flare-up reactions wereobserved on the ipsilateral axillary fold(Fig. 1) and the antecubital area. Sys-temic steroidswere given and reactionspersisted at D3 (Fig. 2) but clearedcompletely within 10 D. No newattack occurred during a 2-monthfollow-up.

Discussion

The patient had three different mani-festations ofmercury allergy: systemicallergic dermatitis (baboon syn-drome) following inhalation of me-tallic mercury vapour from broken

thermometers, and after topical useof a mercury-containing skin lighten-ing cream, localized allergic contactdermatitis from topical use of mercu-rial antiseptics, and a flare-up reac-tion during patch testing withmercurial compounds. The symmetri-cally distributed eczema on the trunk,antecubital fossae, and the neck farbeyond the application areas of theskin lightening cream suggested a pro-posed stage 3A or 3B of an allergicdermatitis syndrome (4).

Skin lightening creams containingmercury are still available in manycountries (5–7). The manufacturerin our country confirmed thatprecip blanc was the abbreviatedFrench term for ‘white precipitate’that is an old synonym for ammoni-ated mercury (8). It had been replacedby hydroquinone in 1990, but unfor-tunately, our patient used an oldproduct containing ammoniatedmercury.

Topical use of mercurial antisepticsor cosmetics is usually considered notto be a trigger for systemic allergicdermatitis, but application close tomucosal orifices might lead to sys-temic reactions via absorption (9).

The presented case is a rare exam-ple of systemic allergic dermatitiscaused by topical application of amercury-containing cosmetic to theupper lip.

References

1. NakayamaH,NikiF, ShonoM,HadaS.Mercury exanthem. Contact Dermatitis1983: 9: 411–417.

2. Andersen K E, Hjorth N, Menne; T.The baboon syndrome: systemically-induced allergic contact dermatitis.Contact Dermatitis 1984: 10: 97–100.

3. WilkinsonD S, Fregert S,Magnusson Bet al. Terminology of contact dermatitis.Acta Derm Venereol 1970: 50: 287–292.

Fig. 1. Occlusive patch test results on the back: þþþ positive reaction to ammo-niated mercury (1% pet.) and þ positive reaction to thimerosal (0.1% pet.) on D1.Note the flare-up reaction on the right axillary fold.

Fig. 2. Open test results on the right forearm: þþþ reaction to skin lighteningcream (Fazıl� cxil ilacı) and þþ reaction to mercurial antiseptic (Mersol�) at D3.Note the flare-up reaction on the antecubital area.

62 CONTACT POINTS

4. Lachapelle J M. The spectrum of dis-eases for which patch testing is re-commended. Patients who should beinvestigated. In: Patch Testing/PrickTesting. A Practical Guide, Vol. 189,Lachapelle J M, Maibach H I (eds):Berlin, Springer-Verlag, 2003: pp. 7–26.

5. MorandJ J,LyF,LightburnE,MaheA.Complications of cosmetic skin bleach-ing in Africa. Med Trops (Mars) 2007:67: 627–634.

6. Tang H L, Chu K H, Mak Y F et al.Minimal change disease followingexposure to mercury-containing skinlightening cream. Hong Kong Med J2006: 12: 316–318.

7. Tlacuilo-ParraA,Guevara-GutierrezE,Luna-Encinas J A. Percutaneous mer-cury poisoning with a beauty cream inMexico. J Am Acad Dermatol 2001: 45:966–967.

8. Young E. Poisoning by mercury inwhite precipitate treatment of skin dis-eases. Ned Tijdschr Geneeskd 1960:104: 1190–1196.

9. Tschanz C, Prins C. Drug rash witheosinophilia and systemic symptomscaused by topical application of mer-cury. Dermatology 2000: 201: 381–382.

Address:Professor Dr Esen Ozkaya_Istanbul Universitesi _Istanbul TıpFakultesi

Dermatoloji Anabilim Dalı34093 IstanbulTurkeyTel: þ90 212 6352939Fax: þ90 212 6353107e-mail: profeo@istanbul.edu.tr

CONTACT POINTS 63