Environmental Toxicology and Pharmacology 20 (2005) 381–382
Short communication
A case of contact urticaria due to adigraf, a PVC-made material P.L. Minciullo a , M. Patafi a , B. Ferlazzo a , A. Saija b , M. Cristani b , S. Gangemi a, ∗ a
Division and School of Allergy and Clinical Immunology, Department of Human Pathology, University of Messina, Italy b Department Farmaco-Biologico, University of Messina, Italy Received 21 September 2004; accepted 23 January 2005 Available online 25 February 2005
Abstract Adigraf is a plastic material applied as thin sheets that may be incised and are used, also by children, to produce artistic drawing. The principal component of adigraf is polyvinyl chloride (PVC). Di-(2-ethylhexyl) adipate is added as a plasticizer. Herein we describe a case of a 14-year-old boy with facial angioedema and widespread urticaria, occurring 1 h after contact with an adigraf sheet. Open patch-test with adigraf sheet showed swelling of the application site and widespread urticaria. To our knowledge, there are no similar reports of urticaria and angioedema from adigraf or similar PCV items. © 2005 Elsevier B.V. All rights reserved. Keywords: Adigraf; PVC; Additives; Allergy; Contact urticaria
1. Introduction Adigraf is a plastic material widely used to produce artistic drawing. It is produced as thin sheets that may be incised by a nib and then covered with a paint, so that the drawing can be printed. Due to its softeness, adigraf may be incised more easily than linoleum, so that its use is widely diffused, especially in Italy, also among children for recreational and scholastic activities. The principal component of adigraf is polyvinyl chloride (PVC), to which di-(2-ethylhexyl) adipate (DEHA) is added. Other components are calcium carbonate, silicon dioxide, pigment Green 7 and a mixture of Ca/Zn soaps in epoxidated soy oil. PVC is obtained by polymerization of vinyl chloride monomers and is added with different additives, including plasticizers, heat stabilizers and radical initiators. DEHA, as well as di-(2-ethylhexyl) phthalate (DEHP), is a plasticizer widely used in making PVC products for flexibility (Castle et al., 1987; Startin et al., 1987). Despite such widespread use, contact dermatitis from PVC or PVC additives seems to be rare. Herein we describe ∗
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the case of a 14-year-old boy with facial angioedema and widespread urticaria, occurring 1 h after contact with an adigraf sheet.
2. Case report A 14-year-old boy was referred to our Operative Unit for facial angioedema and widespread urticaria developing 1 h approximately after contact with an adigraf sheet during scholastic activities. The patient was treated with intramuscular corticosteroids and antihistaminics. A complete remission of symptoms was obtained within 24 h. Past medical history revealed rhinitis and asthma due to house dust mite allergy. There were no previous episodes of urticaria, food allergy or adverse drug reactions. Prick tests with common inhalants were positive for dermatophagoides pteronyssinus (+++) and dermatophagoides farinae (+++) and negative for food allergens. Physical examination findings were unremarkable and routine laboratory exams (complete blood cell count, sedimentation rate, seric iron, routine biochemical parameters, such as hepatic and kidney functionality indexes, and urine and parasitical stool exams) were in the normal range. Before the appearance of symptoms,
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the patient had consumed no drugs, nutraceuticals or dietary supplements. Suspecting involvement of adigraf, the patient underwent an open patch test, by applying a little piece not incised of the adigraf sheet on the volar surface of the arm. Twenty minutes later, he developed swelling of the site of application, extending to the arm, and widespread urticaria. He was treated with methylprednisolone and chlorpheniramine maleate. Because of the severe reaction caused by the open test and the possibility to easily avoid contact with adigraf, the patient’s parents refused to subject their son to patch tests with the single chemicals obtained from adigraf. Ten months after the reported episode of urticaria, the patient had not shown any similar manifestation.
3. Discussion Although the exact causative chemical agent was not identified, the temporal relationship between the use of the adigraf sheet and the onset of urticaria, the recurrence of urticaria after the open patch test with adigraf, the absence of other identifiable causative factors or other explanations for the skin reaction, and the absence of other episodes of urticaria without contact with adigraf strongly support the diagnosis of contact urticaria from a chemical present in adigraf. To our knowledge, there are no other reports concerning urticaria and angioedema from adigraf or similar PVC items. Health hazards from PVC have been recently reviewed by Hayakawa et al. (2000), but there have been few reports of allergic contact dermatitis or urticaria to PVC or PVC additives. Some cases of contact allergy from PVC gloves were reported by Estlander et al. (1986). A case of contact urticaria syndrome due to DEHP in work clothes (Sugiura et al., 2002) has been recently reported. DEHA, the plasticizer present in adigraf, is classified as a skin irritating agent; however no data on allergic reactions to DEHA are reported in literature, although Guin (2001) has described a case of dermatitis due to adipic acid used in polyester synthesis. Interestingly, migration of DEHA from plasticized PVC films into the wrapped goods could be demonstrated (Castle et al., 1987; Startin et al., 1987). Aalto-Korte et al. (2003) have reported a case of allergic contact dermatitis from bisphe-
nol A (used as an antioxidant and inhibitor of end polymerization in PVC plastics) in PVC gloves. Finally, a case of allergic contact dermatitis and mercury exanthem due to mercury chloride in PVC boots was reported by Koch and Nickolaus (1996), and a case of severe allergic contact dermatitis caused by a pyridine derivative used as an antifungal agent in PVC leather was described by Huh et al. (2001). However, there is no known evidence of allergic reactions due to the other chemicals contained in adigraf (calcium carbonate, silicon dioxide, pigment Green 7n soaps in epoxidated soy oil). In our opinion, this report is of interest because skin hazards due to PVC and PVC additives, in particular cases of contact allergy, are very likely to increase, due to the wide employment of PVC-made items in daily life and in working environment and to the difficulty to avoid them.
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