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Nummular Eczema and Contact Allergy: A Retrospective Study

Article in Dermatitis · July 2012

DOI: 10.1097/DER.0b013e318260d5a0 · Source: PubMed

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 Nummular eczema: relevance of contact allergy in its etiopathogenesis. A

retrospective study.

Domenico Bonamonte, Caterina Foti, Michelangelo Vestita, Luigi Davide Ranieri, Gianni

Angelini

This is not the final version of the manuscript. Full published version available at Dermatitis
23(4):153-7 · July 2012 DOI: 10.1097/DER.0b013e318260d5a0

Background: Nummular eczema, also known as discoid eczema, is defined by its clinical

appearance as coin-shaped, circular or oval lesions with distinct borders. The etiopathogenesis of

nummular eczema is obscure, and many causative factors have been proposed. In this context, only

a few studies investigated the relevance of contact allergy.

Objectives: The purpose of this retrospective study was to investigate the role of contact allergy in

the underlying mechanism of nummular eczema.

Patients and Methods: From the 29323 consecutive patients we patch-tested between January 1982

and December 2009 for eczematous dermatitis of various type, 1022 (3.5%) with nummular eczema

were enrolled in this study. Based on history and clinical data, patients were divided into 3 groups:

(i) 82 (8 %) were nummular atopic eczema patients, aged between 6 and 15; (ii) 759 (74.2%) were

non atopic adults without known causes of nummular eczema, and (iii) 181 (17.8%) were subjects

older than 65, affected by dry skin and/or venous eczema. Histological analyses of acute phase

lesions were carried out in a limited number of patients.

Results: Patients comprised of 589 (57.6%) males and 433 (42.4%) females. The peak incidence of

age at time of disease onset was found in the third decade of life, with lower figures in the first

decade and from the fifth decade onwards. The predominant sites of lesions were upper limbs

(75.8%) and dorsum of hands (35.6%), especially in the second group of patients, lower limbs
(64.5%) and trunk (45.6%), more in the third group, and face and neck (22.3%) in the atopic group.

332 out of 1022 patients (32.5%) showed positive reactions to one or more allergens. The highest

sensitization rates were found with nickel sulfate (31.3%), potassium dichromate (22.5%) and

cobalt chloride (18.6%), followed by paraphenylenediamine (17.8%) and ethylenediamine (11.1%).

Medicaments and their additives and various other substances were implicated in a smaller number

of cases. The incidence of contact allergy was higher in the group of elders (34.2%) rather than in

the atopic (26.8%) and the non-atopic adults (32.7%) groups. Additionally, incidence was overall

higher in women (54.8%) than in males (45.2%). Individuals with positive reactions showed an

increased severity of the affection. Histopathological findings showed no relevant differences

among the 3 groups of subjects. However, spongiosis and spongiotic vesicles were more

pronounced in the group of adults, rather than in atopics and elderlies.

Conclusions: Nummular eczema is usually considered an endogenous affection. This study has

demonstrated that contact allergy may both complicate and, in many cases, primarily induce

nummular eczema. Therefore, in selected instances, such dermatitis is to be considered a clinical

variant of contact dermatitis. Based on this and on the high risk of developing contact allergy,

which contributes to the severity and chronic course of nummular eczema, we recommend patch

testing for all patients with discoid eczema.

Key words: Atopic dermatitis; contact allergy; discoid eczema; nummular eczema; patch test.

Conflicts of interest: The Authors declare no conflict of interest.

Nummular eczema, also known as discoid eczema, is a clinical entity characterized by coin-shaped

or oval lesions with well-defined borders (1). Histologically, it lacks specific features (2). For this

very reason, as well as for its morphological appearance, it often overlaps with other eczema

variants.

The condition is not a precise etiological entity and, as a matter of fact, a number of agents acting

individually or in a combined fashion have been assessed and suggested as the likely etiological
factors; the most frequently quoted are nutritional (3,4), infective (3,5-7) and emotional (8,9)

etiologies, together with excessive alcohol intake (10) and dry skin, particularly in the elderly (11-

13). In some patients, nummular eczema has also exceptionally been induced by methyldopa (14),

gold (15) and peginterferon alfa-2b and ribavirin (16). Contact irritation or contact sensitivity are

uncommonly reported as etiological causes. In particular, anecdotal reports have described

nummular eczema as a result of hypersensitivity to aloe (17), ethylenediamine hydrochloride (18),

depilatory creams (19), mercury (20), soluble oils (21) and scabies treatment (22). Relatively larger

observations, focusing on the incidence of contact allergy in nummular eczema patients, are scarce

in number and have been usually carried out in limited cohorts of subjects (23-27).

We present the results of a retrospective epidemiological and allergological study in a large series

of patients with nummular eczema. The aim of the study was to assess two specific aspects: (i) the

incidence of contact allergy in a large patient series with nummular eczema, regardless of the

primary cause of affection, and (ii) the possibility that nummular eczema might represent, in

selected cases, a clinical variant of contact dermatitis with specific morphological aspects. Our data

show a noticeably high incidence of contact allergy in nummular eczema and demonstrate that

contact dermatitis can primarily manifest with nummular and well-defined borders lesions.

PATIENTS AND METHODS

Study population

Between January 1982 and December 2009, a total of 29323 consecutive patients with eczematous

dermatitis of various type underwent patch testing at our Service of Allergological and

Occupational Dermatology. For the present study, we selected every case of nummular eczema,

diagnosed following standardized clinico-morphological criteria: presence of single or often

multiple coin-shaped or ovalar patches, with either an oozing crusted surface in acute lesions or dry,

scaly and lichenified aspects in chronic ones. Moreover, an essential criterion was a clearly
demarcated lesional edge, crucial in differentiating nummular from other types of eczema, in which

lesions are irregularly shaped and exhibit unclear margins.

Prior to testing, patients had completed a questionnaire which included demographic, medical and

occupational information. Patients were asked to report a detailed history of the eczematous

nummular dermatitis, as well as personal and familial atopy history, if any. Particular attention was

put in recognizing patients affected by atopic dermatitis, as defined by the criteria set forth by

Hanifin and Rajka (28). Based on such clinical and anamnestic data, in order to try and correlate

nummular eczema with a relevant etiology, patients were classified into 3 different groups: (i)

subjects with personal or familial atopy history and current clinical manifestations of atopic

nummular dermatitis; (ii) non atopic individuals with primitive idiopathic nummular eczema, and

(iii) patients showing nummular eczema associated to cutaneous xerosis and/or stasis dermatitis of

the lower limbs. As a result of such classification, the first group comprised of pediatric patients

aged between 6 and 15, the second included young-adults ranging from 16 to 65 years old, while

the third consisted of elder individuals (aged >65). In each patient, nummular eczema dated back in

time at least 6 months and showed chronic or chronic recurrent course.

It has to be underlined that cases of nummular eczema with a clear endogenous etiology, other than

atopic eczema and cutaneous xerosis, were not included in our analysis. Clinical forms secondary to

intestinal parasitosis, systemic drugs or alcohol intake, bacterial infections acting directly or through

a sensitizing effect, as well as other known causes, were also excluded (29). In particular, in our

second group of patients, only those without significant clinical, anamnestic and laboratory data

pointing to specific etiologies, were included.

The results we obtained were analyzed with special reference to the following: the incidence of

nummular eczema in the context of the entire patch-tested patients pool, the sex and age

distribution, the correlation with atopic dermatitis, the involvement sites and the incidence of

relevant contact allergy. Finally, wherever technically possible, follow-up data was recorded, in
order to evidence a possible regression of nummular eczema following preventive measures, which

were adopted congruously to patch testing results.

Patch tests

All patients were patch-tested with the SIDAPA (Società Italiana di Dermatologia Allergologica

Professionale e Ambientale) baseline series (FIRMA Diagent, Florence, Italy). The tests were

applied on the back and left in occlusion for 2 days, using the Al-test® (Imeco ab, Södertälje,

Sweden) secured with Scanpor® tape (Norgesplaster A/S, Vennesla, Norway). Readings were

performed at D2 and D4. Reactions were scored according to the International Contact Dermatitis

Research Group guidelines (23).

The relevance of positive patch tests was arbitrarily defined as follows: 1=definite and present

(patient presented a positive reaction to a substance, he or she had been exposed to during

professional or personal activities, along with current relevant clinical symptoms); 2=past (patient

had prior clinical events of allergic contact dermatitis, non-directly related to the current

dermatological problems); 3=unknown (related to no-known exposure in the past and the present)

(30).

Further examinations

In 13 subjects (3 belonging to the first, 5 to the second and 5 to the third group), biopsy samples

were taken for histological examination from acute phase lesional skin and stained with

hematoxylin and eosin.

While initially of uniform quality throughout, nummular eczema patches can possibly evolve

towards central clearing, leading to morphological aspects that resemble superficial fungal

infections. Hence, in cases showing central clearing, direct and cultural (Sabouraud dextrose agar)

mycological examinations by skin scraping were performed.

RESULTS

Study population characteristics

Between January 1982 and December 2009, 29323 eczema patients have been patch-tested at our

Clinic. Among these patients, 1022 (3.5%) were affected by nummular eczema: 589 males (57.6%)

e 433 females (42.4%). Thus, given our data, the condition seems prevalent in the male gender.

Distribution of subjects by age at time of disease onset is shown in Fig.1. The peak incidence has

been found in the third decade, with lower figures in the first decade and from the fifth decade

onwards. Some interesting considerations can be drawn by incidence per age analysis. Nummular

eczema represents a disease of the adult, being much less frequent in the first decade of life. In

younger aged individuals the affection occurs more frequently in females; with rising age it

becomes prevalent in males. There were 82 patients (8% of the total) aged between 6 and 15, all of

them affected by atopic nummular dermatitis. 759 (74.2%) of our cohort were non atopic and aged

between 16 and 65, while the remaining 181 (17.8%) were older than 65.

The data presented in Table 1 show that any part of the body may be affected. In our series, lesions

were mainly found on the upper and lower limbs (75.8% and 64.5% respectively), followed by the

trunk (45.6%), dorsum of the hands (35.6%), and face and neck (22.3%). In younger women the

first lesions usually developed on the hands and remained localized for a long time. The same site

of onset, though less frequently, was also recorded in men. The lower limbs were primarily affected

in elder patients, first lesions on the trunk were prevalent in adults and elderlies, whereas face and

neck were mainly involved in the atopic group of subjects.

The patient occupational distribution, carried out in the second group of patients, showed the

disease to be more frequent in workmen, housewives and hairdressers. Our data further showed

that nummular eczema improved at summer time in atopic and elder patients. Follow up at 1-2

years after patch testing has been feasible in only about half of patients (n=137) showing positive

patch tests reactions. However, relevant data evidence resolution of nummular eczema in most adult
subjects, as a result of the specific preventive measures advised for after patch testing. On the other

hand, irrespective of preventive measures, nummular eczema persisted in atopic as well as elder

subjects, albeit with noticeable signs of improvement.

Patch testing

Of the 1022 subjects with nummular eczema, patch-tested with a large series of haptens, one or

more positive reactions were observed in 332 cases, 182 females (54.8%) and 150 males (45.2%),

i.e. in 32.5% of the study population. The most frequently involved antigens were nickel sulfate

(31.3%), potassium dichromate (22.5%) and cobalt chloride (18.6%), followed by

paraphenylenediamine (17.8%) and ethylenediamine (11.1%). Topical medicaments and their

additives and various other substances were implicated in smaller proportions of cases (Table 2).

Comparing the 3 groups of patch-tested patients, the incidence of contact allergy was higher in the

third (34.2%) rather than in the first (26.8%) and the second (32.7%) group. In the first and third

group a higher frequency of positive reactions to medicaments and their additives was found, while

sensitization to metals and other agents was prevalent in the second group. Overall, positive

reactions relevance was registered as high (89.7%). Increased severity of the affection, with a

higher number of discrete lesions in multiple body areas in those resulted positive to patch testing,

represents a further important observation which can be drawn from our data.

Further examinations

Skin biopsies from acute phase lesions of nummular eczema did not show any significant difference

among the 3 groups of patients. In each case, epidermal intercellular edema with spongiotic vesicles

of variable size was paralleled by a predominantly lymphohistiocytic infiltrate in the superficial

dermis, mainly perivascularly. However, as noted on a clinico-morphological level, spongiosis and

consequent spongiotic vesicles were more pronounced in the second group rather than in atopic and

elder subjects. Given the exiguous number of biopsied patients, this finding could be non-

significant and should be confirmed by further studies.

Direct and cultural mycological examinations turned back negative in every case of central clearing

lesions.

DISCUSSION

Nummular eczema has been first described by Devergie in 1857 (31), but clinical aspects of the

condition had been roughly outlined already in 1845 by Rayer (32). According to Chipman, other

historical clinical descriptions, such as Ormshy orbicular eczema, Brocq neurotic eczema and

Pollitzer recurrent eczematoid affection, are similar and refer to the same disease, namely

nummular eczema, under different eponyms (33). Nummular eczema is not a disease per se, but a

morphological entity in which many factors concur. While its clinical aspects, such as coin-shaped

or ovalar plaques with clearly defined margins, are well known, the same cannot be stated for its

pathogenesis. Nummular eczema is usually considered endogenous in nature in most cases.

However, the present study and other recent observations show that exogenous agents, such as

irritant and/or sensitizing agents, may both complicate (through impaired cutaneous barrier) and

primarily induce the affection.

Clinical considerations

Among the 29323 eczema patients we patch-tested between January 1982 and December 2009, only

3.5% presented nummular cutaneous lesions. The pertinent literature data are few; Horn recorded

an incidence of nummular eczema of 7% among all types of eczema (34). Our figures show that the

disease is prevalent in males; literature data on this are discordant: in different observations, both

genders are affected with the same frequency (35).

Regarding age correlation, nummular eczema is mainly a disease of adults and, atopic children

excluded, it rarely seems to occur in the first decade of life. Overall, in younger subjects, the disease

arises more frequently in females, becoming prevalent in males with rising age.

The relationship of nummular eczema to atopy is a controversial one. The majority of studies

evidence no association between discoid eczema and atopy (3, 4, 29, 36, 37), partly based on the

observation of lower IgE serum levels in the former than in the latter (38). Nevertheless, atopic

dermatitis can manifest with nummular lesions, albeit generally not very exudative and usually just

scaly, both in children and adults, with a respective incidence of 9% and 12% (39).

Contact allergy

There are few studies on contact allergy in nummular eczema, specifically on the primary role of

sensitizing agents in its pathogenesis. In a series of 4825 patients, patch-tested by 10 dermatologists

in 7 European countries, 100 subjects (2.1%) had nummular dermatitis and 17% of these had

relevant positive reactions (23). Others have reported variable incidence of contact allergy in

nummular eczema, ranging from 30.1% (24), 40.6% (27), 50% (25,26), up to 77.9% (40).

Regardless of such variability from one case series to another, likely consequence of different

patient selection criteria, the above data suggest that contact allergy is common in persistent discoid

eczema.

In our study, in a large population of nummular eczema patients, we registered an incidence of

contact sensitization of 32.5%. The highest sensitization rates were found with nickel sulfate

(31.3%), potassium dichromate (22.5%) and cobalt chloride (18.6%), followed by

paraphenylenediamine (17.8%) and ethylenediamine (11.1%). Medicaments, their additives and

various other substances were implicated less frequently. The incidence of contact allergy was

higher in the group of elders (34.2%) rather than in the atopic (26.8%) and the non-atopic adults

(32.7%) groups. Additionally, incidence was overall higher in women (54.8%) than in males

(45.2%). Concerning specific allergens, women had a higher rate of positive reactions to nickel
sulfate (76.9% vs 23.1% in males), cobalt chloride (77.4% vs 22.6% in males) and

paraphenylenediamine (91.5% vs 8.5% in males); conversely men displayed higher positive rates

for potassium dichromate (89.3% vs 10.7% in females). Moreover, increased severity of dermatitis

in sensitized patients was noted, along with a higher incidence of positive reactions to medicaments

and their additives in the atopic as well as in the elder groups. Finally, limited follow-up data, at 1-2

years after patch testing, showed that avoidance of offending allergens eventually led to dermatitis

resolution in most young-adult subjects.

Based on the results of this study, we propose a series of diagnostic signs which might be useful in

differentiating, clinically and etio-pathologically, the most common types of endogenous and

exogenous nummular eczema (Table 3).

CONCLUSIONS

Many factors have been noted and therefore suspected as etiological agents in patients with

nummular eczema. Our study, albeit hampered by limitations dependent on its retrospective nature,

shows that contact allergy can definitely complicate the course of nummular eczema, regardless of

its nature, and can also possibly represent the primary cause of discoid eczema in a relevant

percentage of cases. Based on this consideration, nummular eczema might constitute, in selected

cases, a clinico-morphological subtype of contact dermatitis. On this ground, we advise for patch

testing in all cases of persistent nummular eczema; indeed if contact allergy is demonstrated,

avoidance of offending allergens proves of substantial benefit to the patients.

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Table 1. Localization of lesions of nummular eczema in 1022 patients.

Site of lesions %
Upper limbs 75.8
Lower limbs 64.5
Trunk 45.6
Dorsum of hands 35.6
Face and neck 22.3

Table 2. Results of patch testing with most common relevant allergens in nummular eczema.

Allergen Males Females Total (%)

Nickel sulfate 24 80 104 (31.3)

Potassium dichromate 67 8 75 (22.5)

Cobalt chloride 14 48 62 (18.6)

Paraphenylenediamine 5 54 59 (17.8)

Ethylenediamine 17 20 37 (11.1)

Neomycin 7 9 16 (4.8)

Mercury ammoniated 8 8 16 (4.8)

Parabens 10 5 15 (4.5)

Benzocaine 9 6 15 (4.5)

Thiuram mix 7 3 10 (3.0)

Fragrance mix 1 9 10 (3.0)

Wool alcohols 6 3 9 (2.7)

Formaldehyde 4 5 9 (2.7)

Balsam of Peru 1 7 8 (2.4)

Colophony 7 1 8 (2.4)

Propylene glycol 1 5 6 (1.8)

Table 3. Differential diagnosis in nummular eczema of various type, based on predominant clinical and
histopathological aspects.

NCD NAE ENE

Age Middle Childhood Elder

Itching ++ +++ +++

Cutaneous lesions

Shape Ovalar/irregular Round Round

Number Few/Several Few Several

Arrangement Asymmetric Symmetric Symmetric

Primary sites Hands dorsum Face, upper limbs Lower limbs

Central clearing + +/++ -

Morphology Papulo-vesicular Dry scaly Dry scaly

Cutaneous xerosis -/+ ++/+++ ++/+++

Varicosities -/+ - +/+++

Histopathology

Spongiosis ++/+++ + +

Vesiculation ++/+++ + +

NCD, nummular contact dermatitis; NAE, nummular atopic eczema; ENE, endogenous nummular eczema.
 Fig. 1. Age distribution of 1022 selected subjects at the onset of nummular eczema.
NAE, nummular atopic eczema; NCD, nummular contact dermatitis; ENE, endogenous nummular eczema.

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