Textile Contact Dermatitis: How Fabrics Can Induce Dermatitis
Purpose of the review
Textile dermatitis can sometimes be difficult to diagnose due to the fact that it is difficult to clinically suspect, and when allergic, patch test correctly and advice the patient as to what garments to avoid.
The textile fibres as such are rarely the causative agent. Allergic contact dermatitis due to textiles is primarily caused by substances that are used to give the material certain qualities or performances. The textile dye mix, now in the baseline series, has proven to be a useful tool in diagnosing allergic contact dermatitis but additional patch testing with own material is advocated. Future research will hopefully facilitate the diagnostic procedure.
This review is a short update on textile dermatitis, both irritant and allergic, the present recommendations regarding patch testing when suspecting contact allergy and the advice to give to those allergic that will hopefully help the clinician in daily work.
KeywordsTextile contact dermatitis Patch testing Textile dye mix
Contact dermatitis from textiles typically gives different clinical pictures, depending on whether the dermatitis is caused in the worker during the production of the textiles or in the consumer. Other important factors are the quality of garment, how it is worn and, when due to contact allergy, what the causative hapten is. Within the textile industry, the production process as such, in which the use of various types of chemicals seems to be ubiquitous, makes the industry a growing possible problem regarding public health as well as in the environment. From dyehouses, the wastewater discharge has serious detrimental effects on the aquatic environment. Some dyestuffs produce toxic decomposition products and the metal complex dyes release toxic heavy metals to the water. Of the dyes used in the textile industry, effluents containing reactive dyes, where considerable amounts are lost and discharged during production, are the most difficult to address [1, 2]. When investigating possible contact allergy as causative agent, it should be remembered that some of the substances used during the production can actually be found also in the finished garments such as quinolone compounds [3, 4, 5, 6]. In studies where occupational dermatoses have been investigated within the dye industry and textile industry, associations have been found with azo dyes in textile workers, and formaldehyde and chromate in those working in the leather and dyeing industries [7, 8]. In the latter study, occupational allergic contact dermatitis was found associated with lesions that were primarily on the hands and wrists of the workers. Also, those selling textiles risk hand dermatitis and even widespread occupational allergic contact dermatitis has been reported amongst this group .
Contact dermatitis in those using the garment is often diagnosed when appearing as a chronic dermatitis, i.e., there is often a delay in diagnosis. It may be found in areas preferably with close contact between skin and textile (especially where friction or perspiration occurs), but may also be widespread [10, 11•, 12]. However, textile “dermatitis” can also be found with no clinical morphology but symptomatic pruritus. Nummular dermatitis, and even a clinical picture of atopic dermatitis, involving flexures, is not infrequent [11•, 13]. The morphology of the dermatitis may differ from erythema-like or urticaria-like lesions to pigmented purpura .
Textile contact dermatitis
Textiles are made of fibres: natural wool, linen, cotton and silk and synthetic cellulose derivatives and polyamides. Other materials such as metal or rubber components may be added to give the textile a certain wanted characteristic, and for the same reason, the textile is further processed; textiles are coloured or prepared with different substances in order to produce specific effects or give the garment a certain quality . Can the fibres per se give rise to textile dermatitis? With regard to allergic reactions to wool, both type I and type IV reactions have been reported, but these publications are usually of older date. In a recent review, Zallmann et al. [12•] found that to date, there is an absence of evidence to substantiate allergy (type I and IV hypersensitivity) to wool fibres. Furthermore, allergens associated with wool processing (e.g. chemical dyes) are present at negligible levels within modern wool garments. Cutaneous irritation caused by wool garments was previously often found and most probably due to high fibre diameters. Superfine and ultrafine Merino wool garments with finer fibre diameters seem to be much better tolerated [12•].
The same is true for cotton, where the occurrence of an immediate skin reaction to textiles is extremely rare . Cotton clothing occasionally causes itchy skin or erythema, but this is usually due to skin irritation . As to silk, this material has even been tried to alleviate dermatitis symptoms ; however, there also exist occasional case reports on immunological contact urticaria from silk exposure .
Textile contact dermatitis is however not uncommon [11•] and of major concern are contact allergic reactions. The major causes for allergic reactions in textiles are thus caused by how the textile is prepared and treated [12•, 16, 17], where biocides  have also been the cause of dermatitis. In the textile, these are used for protection during manufacture or transport and to inhibit malodour, especially, for example, in textiles used in sports. Various biocides in textiles have been reported, including triclosan, zinc pyrithione, MCI/MI, dichlorooctylisothiazolinone, dimethyl fumarate, and silver particles [19, 20, 21]. Other substances remaining after dyeing (e.g. benzanthrone, an intermediate substance used in the production of vat dyes) or treating textiles (e.g. sulfites, used during bleaching) can induce allergic contact dermatitis [22, 23]. With regard to allergic contact dermatitis to formaldehyde, urea-formaldehyde resin and melamine-formaldehyde resin, used in the textile industry since the 1920s to prevent wrinkling, have been found to be causative agents. Formaldehyde release has been documented for many fibre types [24, 25, 26], and in some countries, regulative measurements have been taken. Formaldehyde content varies in studies from different countries; wool is however suggested as a secure textile material for those sensitized [12•, 26, 27, 28, 29].
In order to identify a possible culprit, colour identification of the agent is necessary; however, the classification of dyes is complicated since they can be classified either according to chemical structure or according to method of application. Classification according to the colour (the Colour Index, C.I.) is compiled and edited by the Society of Dyers and Colourists and by the American Association of Textile Chemists and Colorists. In the lists, there are thousands of dyes, but since every generic name covers all colourants with the same structure, they are not necessarily identical with regard to possible additives or impurities. This has also been a problem with regard to patch testing where test substances, thought to be defined, have been found to contain impurities .
Usage classification of dyes according to K. Hunger  with modifications by the authors
Dye class according to application
Dye classes according to chemical structure
Described as allergens
Nylon, wool, silk (also paper, inks, leather)
Azo, anthraquinone, triphenylmethane, azine, xanthenes, nitro, nitroso
Cotton, rayon, cellulose acetate, PET
Polyacrylonitrile, modified nylon, PET (also paper, inks)
Cyanine, hemicyanine, diazahemicyanine, diphenylmethane, triarylmethane, azo, azine, xanthene, acridine, oxazine, anthraquinone
Rare (Basic Red 46—important allergen in acrylic socks)
Cotton, rayon, nylon (also paper, leather)
Azo, phthalocyanine, stilbene, oxazine
Rare (some cases of immediate type allergic reaction)
PET, polyamide, acetate, acrylic (also plastics)
Azo, anthraquinone, styryl, nitro, benzodifuranone
Wool (also leather)
Azo and anthraquinone
Cotton, wool, silk, nylon
Azo, anthraquinone, phthalocyanine, formazan, oxazine, basic
Described only as occupational allergens
Plastics, fuels, varnishes, lacquers, inks, oils, waxes
Azo, triphenylmethane, anthraquinone, phthalocyanine
Cotton, rayon, wool
The mix was recommended at 6.6% in 2015 for the European Baseline Series [48•]. The mix has also been recommended for the international baseline series . The composition of the 6.6% wt/wt pet. mix should be as follows: Disperse Blue 35 (DB 35), Disperse Yellow 3 (DY3), Disperse Orange 1 (DO1), Disperse Orange 3 (DO 3), Disperse Red 1 (DR 1) and Disperse Red 17 (DR 17), all at 1.0% wt/wt, and Disperse Blue 106 (DB 106) and Disperse Blue 124 (DB 124), both at 0.3% wt/wt [48•, 51]. With the Finn Chambers® technique, a standardised amount of 20 mg of the pet., preparation should be used , corresponding to a dose equivalent to 2.2 mg TDM/cm2.
Studies performed in Europe and the USA [48•, 51] showed that 2.1–6.9% of consecutively tested dermatitis patients reacted to a 6.6% wt/wt textile dye mix consisting of eight disperse dyes. The clinical relevance was ascertained in > 30% of the positive cases. DO 3 and PPD had a high frequency of simultaneous sensitivity. It has even been argued that the textile dye mix within the baseline series might even be with five colours, omitting DO 3 as the impression is that these patients are actually caught by patch testing with PPD and suggestions have been made that the concentration of the mix could then actually be lower . However, such consideration requires that PPD is patch tested in the correct concentration . In testing with DDs, late reactions are sometimes reported, and in some studies, active sensitization has been suggested [11•], while in other studies, no signs of active sensitization has been found . In reports on contact allergy to DDs, there is usually a higher contact allergy rate to DDs noted in females compared to men . In one study , a significant association was seen in females regarding contact allergy to PPD and self-reported skin problems arising from synthetic textile materials. The increased female frequency rate may be explained by a different exposure to synthetic fabrics or by the association between PPD contact allergy and allergy to DO 3 which in a large number of cases give simultaneous reactions in those sensitized . From a chemical point of view, most DDs contain an azo structure. As a consequence, high frequencies of simultaneous sensitivity to DO 3, TDM and PPD, to TDM and black rubber mix and to DO 3 and PPD [56, 57] are often seen.
In summary, textile contact dermatitis often looks like endogenous eczema which localisation depends on intimate contact with the garment and often seen in skin folds. Such reactions are most commonly seen to disperse azo dyes, but other substances present in clothes can occasionally also induce contact allergy with exception of the fibres themselves. Testing for textile dermatitis is recommended using the European baseline series including TDM, Textile series and own material “as is”, as well as with extracts made from it. If possible, performing chemical investigation of the textiles which is positive on patch testing can prove clinical relevance of positive tests and find new emerging allergens.
Compliance with Ethical Standards
Conflict of Interest
Cecilia Svedman declares that she has no conflict of interest, Malin Engfeldt declares that she has no conflict of interest, Laura Malinauskiene declares that she has no conflict of interest.
Human and Animal rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance
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