Allergic contact dermatitis from chromium after vein sclerosis with chromated glycerin

Chromium can still provoke irritant and allergic contact dermatitis from its presence in (some) cements, yet it can nowadays also be found in other sources, for example, leather items, mobile phones and even cosmetics.1 Several complications after sclerotherapy have been reported, yet allergic reactions are considered rare and are characteristically related to polidocanol.2 We here report a case of allergic contact dermatitis from chromated glycerin (CG) used during sclerotherapy. A 57-year-old female lawyer presented to our department suffering from hyperpigmented skin lesions in the left leg (pretibial area) lasting 3 months (Figure 1A). History revealed that these were the result of a skin reaction following sclerotherapy for varicose veins. The procedure was initially well tolerated, but 2 days after it had been performed, an erythematous and pruritic skin eruption appeared over the sclerotherapy-treated area. Photographs showed an erythemato–edematous rash clinically indicative of allergic contact dermatitis (Figure 1B). Further inquiry showed that the sclerotherapy had been performed using CG. In May 2023, patch tests were performed with the Spanish Contact Dermatitis Research Group Research Group (Grupo Español de Investigación en Dermatitis de Contacto y Alergia Cutánea [GEIDAC]) baseline series (TRUE-Test, AllergEaze, SmartPractice, Calgary, Canada).3 Occlusion time was 2 days and readings were performed on Days (D) 2 and 4. The patch test showed a + reaction to nickel sulphate hexahydrate 5% and potassium dichromate 0.5% on D2 and a ++ reaction to both haptens on D4 (Figure 1C). All other patch tests remained negative. A diagnosis of contact allergy to chromium as a part of CG used in sclerotherapy was thus made. Sclerotherapy can be performed using different agents (detergents, osmotic solutions and chemical irritants) by injecting these into a vessel to cause an inflammatory reaction with thrombosis formation and fibrosis due to endothelial damage. CG is a chemical irritant widely used for this purpose. Chromium is mixed with glycerin, as it is a potent coagulating factor, to enhance the glycerin sclerosing properties of glycerin.4 Although it has not been approved by the Food and Drug Administration (FDA) for this use, it is widely used and it has been suggested to have a higher efficacy compared to polidocanol and sodium tetradecyl sulphate, which are alternative and FDA-approved agents for sclerotherapy.5, 6 Allergic skin reactions following sclerotherapy may manifest as allergic contact dermatitis, but also contact urticaria and (a vaguely described) ‘erythema’.7 Rather exceptionally, also anaphylactic shock has been reported as an extremely rare complication. In all such cases, commonly polidocanol (laureth-9) has been considered as the culprit cause of these reactions.2, 8 Surprisingly, regarding CG, there is only one single case report detailing cutaneous hypersensitivity.9 In that particular case, the patient developed a similar skin eruption as our patient, consisting of an erythemato–edematous and pruritic rash over the injection sites, occurring 3 days after the procedure; however, patch tests to potassium dichromate, GC and glycerol remained negative, thus not being able to confirm the allergic origin of the reaction as we did in the current case. In conclusion, our report serves to raise awareness that CG may preferably need to be avoided for conducting sclerotherapy procedures in patients contact-allergic to chromium. Álvaro Aguado Vázquez: Conceptualization; writing – original draft; methodology. José María Sánchez Motilla: Writing – review and editing; validation; visualization; supervision. Cecilia Alonso Díez: Writing – review and editing; validation; visualization. Pilar Villodre Lozano: Validation; visualization; writing – review and editing. Almudena Mateu Puchades: Writing – review and editing; visualization; validation; supervision. The authors report there are no conflicts of interest to declare related to this manuscript. Written consent was obtained from the patient to include the images. Data are available on request from the authors.

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