•
Introduction
Chromium
exists in every one of the oxidation states from -(II) to +(VI), but
only the valencies of (0), (II), (III) and (VI) are common. Only the
trivalent and hexavalent salts are sufficiently stable to act as haptens,
therefore able to form covalent bonds with proteins(1,
2) and cause allergy. This protein-binding capacity is
the general precondition of immunogenic activity of a hapten, already
shown 60 years ago(3).
It is generally accepted that chromium metal itself does not act as
a hapten and is accordingly non-sensitising(1,
2). Theoretically, sweat or plasma could transform metallic
chromium into allergenic chromium salts. Saliva could have a similar
action on chromium-containing intraoral devices. Chromium released
from household utensils could also transform into chromium salts.
Accordingly, ingestion of chromium compounds may induce systemic contact
dermatitis (see below). Data on the above aspects are anecdotal. Some
aspects of chromium allergy in relation to the skin are reviewed in
this article.
•
Chromium salts as skin sensitizers
The
bivalent salts are unstable and therefore not used commercially(4).
The trivalent compounds include chromic oxide, chromic sulphate and
chromium trichloride, of which the last two are skin sensitizers(1,
2). Soluble trivalent chromium salts penetrate the skin
poorly, so they are not used for patch testing(5),
although patch testing with trivalent chromium salts may elicit allergic
reactions. The hexavalent chromium compounds, including chromates,
dichromates and chromic acid, are widely used in industry and are
the most sensitising of the chrome compounds(1,
2). Allergic contact dermatitis caused by chromium salts
has been known since 1925(6)
and is common(1, 2).
A maximisation test was used by Kligman(7)
to assess the skin sensitising potential of trivalent and hexavalent
chromium compounds; about half of a group of 23 human subjects were
sensitised with trivalent chromium salts, whereas each one of 23 subjects
was sensitised to potassium dichromate. On a scale of 1 to 5, in which
5 is the most potent allergen, trivalent chromium was graded as 3
and hexavalent as 5, i.e. extreme sensitizer. In a guinea pig maximisation
test, potassium chromate was graded as 4 on the same scale(8).
In 1982, Nethercott reviewed the world literature on routine patch
testing for chromium salts (17,021 cases) and found an incidence of
7.9 % positivity to potassium dichromate(12).
However, the incidence of chromium dermatitis has decreased over the
period 1980 - 1990(13).
In industrialised countries, chromium salts have been one of the most
common skin sensitizers(1, 2).
They are a more common sensitizer in men than in women(1,
2), although the ratio of women to men has been increasing(9).
The difference probably depends on the pattern of employment. The
causes of allergy to chromium salts vary from country to country,
depending on the industry and the chemical environment.
•
Cement industry
Cement
is the most common cause of chromium dermatitis(1,
2, 9). The greatest hazard from cement occurs on building
and construction sites, but workers are also at risk in the preparation
of cement, including cement mixing at home for “do-it-yourself”
jobs(1, 2, 9). Dermatitis
is most commonly localised on the hands(1,
2, 9). A diagnosis of cement dermatitis (allergic or irritant)
must be considered in all patients working with cement or plaster.
Cement dermatitis carries a bad prognosis(1,
2, 9, 10; see below).
•
Dental and orthopaedic implants
Humans
often have multiple sensitivity to metals. As regards simultaneous
reactivity to chromium and cobalt, a recent guinea pig maximisation
test showed that chromium and cobalt do not cross-react(11).
It is not often clear whether chromium or other metals have caused
the allergic skin reactions elicited by dental metals(21
- 25). Hubler reported on a patient with generalised eczematoid
dermatitis which was believed to have been caused by allergy to chromium
liberated from a metal dental plate(22).
In another report, a woman had severe dermatitis and allergic reactions
to several metals; she recovered only after removal of a cast chrome-cobalt
partial denture(23).
Foussereau and Laugier cite a case of generalised dermatitis that
occurred after a chromium-nickel denture had been fitted(21);
skin tests were strongly positive to nickel and chromium and the dermatitis
subsided after the denture was removed(21).
According to Rietschel and Fowler, metallic dental chromium is a rare
sensitizer(21). In
most instances in which an allergic reaction is attributed to a metallic
chrome object, nickel is the actual sensitizer. Nickel readily penetrates
the micropores in chrome-plated objects(21).
Allergic reactions from exposure to chromium have been reported from
orthopaedic metals(26 - 28)
and acupuncture needles(29).
Burrows considered it quite clear that chromium allergy is not a factor
in the rejection of hip prosthesis (metal head, plastic cup), even
in those containing chromium and made of stainless steel or chrome-cobalt
(vitallium 26 to 30 %)(30 - 33).
•
Stainless steel and stainless steel welding
Stainless
steel became popular more than 80 years ago when Brearley discovered
that a ferrous mixture containing at least 12 % chromium was resistant
to corrosion and oxidation(20).
Stainless steel often contains nickel, and, in addition to chromium
and nickel, may contain carbon, nitrogen, manganese, magnesium, phosphorous,
sulphur, cobalt, copper, silicon and molybdenum(17,
20, 21). Accordingly, there are many types of stainless
steel: the austenitic stainless steels (containing 8 to 34 % nickel)
are the most widely used(20);
the commonly used 18/8-stainless steel contains 18 % chromium and
8 % nickel. Stainless steel is reviewed here from a dermato-allergological
point of view. Allergic contact dermatitis caused by stainless steel
is generally considered to be due to nickel(14
- 21). High-quality stainless steel is not regarded by
dermatologists to be a health hazard(21),
but some types of stainless steel release enough nickel to provoke
dermatitis in nickel-sensitive patients(14
- 21). Recently, Haudrechy and co-workers showed that 14
% of nickel-allergic patients reacted on patch testing to high sulphur
stainless steel (AISI 303 grade), whereas low sulphur stainless steel
(AISI 304, 316L and 430) did not elicit allergic reactions(17).
Chromium may be present in the electrode rods used in electric arc
welding. During welding chromium may be oxidised to the hexavalent
form and be present in the fumes as a result of the combination of
temperature, oxygen and of alkali metals commonly present in welding
rod coatings. Airborne exposure to these chromium-containing aerosols
may cause an allergic contact dermatitis of the face(40)
or the hands(41).
Inhalation of aerosols during welding may cause asthma and urticaria,
but the putative allergen has not been identified(42,
43).
•
Galvanising and electroplating
Iron
sheets are best protected from rusting by galvanising them with zinc
applied either by electroplating or by dipping them in molten zinc.
To prevent the zinc corroding, oxidising or whitening with moisture,
the metal is coated with chromate. This surface chromate can induce
skin sensitisation or exacerbate chromate dermatitis(34
- 37). Wass and Wahlberg calculated that the mean release
of hexavalent chromium from chromed parts should not exceed 0.3 mg/cm2/20
minutes in order to prevent elicitation of allergic contact dermatitis(38).
Electroplating consists of coating one metal with a layer of another
metal by means of an electric current. In chromium plating, the bath
contains chromic acid and sulfuric acid. Chrome ulcerations of the
nose and perforation of the septum have been reported(39).
There is no relationship between chrome ulcers and skin sensitisation(1,
2).
•
Oral exposure
Hexavalent,
but not trivalent, chromium is well absorbed from the gut. Since the
acidity of gastric juices encourages the rapid reduction of ingested
hexavalent chromium to the trivalent form, it is likely that in a
normal person little hexavalent chromium is absorbed(44).
However, some may be absorbed and chromium-sensitive patients have
developed exacerbation of their dermatitis after oral administration
of chromium salts(45 - 49).
Accordingly, it is possible that the accidental ingestion of chromium
in food plays a part in the chronicity of the dermatitis in chromium-sensitive
patients. On the other hand, McMillan (cited by Burrows and Adams(2))
was unable to confirm that ingestion of chromium made any difference
in chromium dermatitis. The contribution made by stainless steel cooking
utensils to nickel in the diet is very small and within the normal
day-to-day variation of nickel intake(51),
although some older reports claim that nickel release from cooking
utensils may be significant(52
- 56). Stainless steel cookware has also been reported
to be a significant source of chromium(54),
but another investigation of actual cooking operations using real
foods found that both the nickel and chromium contents of spinach,
sauerkraut and rhubarb, cooked in 19 Cr/9 Ni stainless steel saucepans
(unified numbering system S30400) were within the normal range of
values found in these foods in the raw state(56).
On first use, new saucepans may release nickel(51).
No leaching of chromium could be detected from old or new stainless
steel bowls into coffee, milk or fruit juice(57).
•
Photosensitivity
Sunlight
sensitivity has been said to develop in patients with chromium dermatitis(58
- 60), but according to Burrows it remains to be proved
that there is a connection between light sensitivity an chromium dermatitis(2).
•
Patch testing for chromium sensitivity
Patch
testing to 0.5 % potassium dichromate in petrolatum is a routine part
of the standard patch test
series. Accordingly, patients with allergic contact dermatitis to
chromium compounds will be diagnosed
if patch testing is performed.
•
Prognosis
Allergy
to chromium compounds carries in men a worse prognosis than does sensitisation
to other allergens(45, 46, 61).
The reason is not known. Continued contact with unrecognised chromium
compounds in the environment or possibly ingestion of chromium compounds
have been considered as possible explanations.
•
Conclusions
Allergic
contact dermatitis caused by chromium compounds has been known since
1925 and is still common. Whilst some trivalent chromium compounds
are known skin sensitizers, hexavalent chromium compounds are considered
as the strongest sensitizers; according to maximisation tests, they
are strong to extreme sensitizers. On the other hand, it is generally
accepted that chromium metal itself and chromium
in low-sulphur stainless steels are non-sensitising.
•
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