Article
Allergic contact dermatitis due to green permanent marker: a case report
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Published: | August 16, 2017 |
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Objective: We want to demonstrate the case of a 51-year-old woman who presented herself with skin lesions on her left breast after nipple sparing mastectomy with sentinel node excision and immediate reconstruction with a DIEP-flap. Important anatomical landmarks were initially marked with a green permanent marker (EDDING 3300) one day prior to surgery. The second day after surgery, pruritic, erythematous and infiltrated plaques, with vesicules and papular spread strictly limited to the surgical markings, developed (Figure 1 [Fig. 1]). Elocom ointment (Mometasone furoate) was applied as therapy for several days. The patient recovered completely.
To track down the cause for the skin lesions, a dermatologic examination and consecutive patch test was performed.
Methods: We contacted the manufacturer of the marker. Standardized patch testing was performed with the declared contents, which were provided by the manufacturer already diluted and ready for testing. The readings were performed on day two and day three.
Results: During testing, the patient presented with a strong eczematous reaction on day two and day three on the site where alkyd resin was attached (Table 1 [Tab. 1]).
Conclusion: At our department, we usually use black, green or blue permanent markers to mark prior to surgery. Allergic reactions due to ingredients of permanent markers are rare, but have been observed and published before. This is the first time that alkyd resin was identified as the allergy-causing component of a permanent marker. It should be noted that the manufacturer strongly emphasizes that those markers are not intended to be used on skin. According to the WHO, preoperative markings preventing "wrong side, wrong patient"-surgery should be made with a permanent marker. On the other hand, the Association of perioperative Registered Nurses does not recommend using such standard office-type pens to mark on patients" skin. There is no real consensus about what kind of marker pen should be used, and of course preoperative markings in plastic surgery differ from the ones to mark the right side of the patient. While permanent markers typically contain nontoxic inks that are considered to have no long-term toxicity effects, they technically are not approved for direct, intentional use on human skin. We recommend using specialized skin markers whenever possible.