CD08 Double bubble trouble

Abstract

Abstract A 29-year-old woman of Lithuanian heritage was referred to dermatology with a 3-year history of recurrent blistering to the hands and, occasionally, feet. The patient’s own photographs revealed small, tense blisters on the sides of her fingers and one on the foot. In the general dermatology clinic, she was noted to have acrylic nails, which she had been applying at home with her own gel nail kit for over 5 years. In recent years, the patient had noticed that use of the acrylic nail kit exacerbated her blistering. There was no prior history of skin disease or atopy. She was otherwise well, with no known allergies. She worked in the food-packing industry where she wore nonlatex gloves. In light of her frequent, prolonged use of acrylic nails and exacerbation of blistering on use of the home kit, she was suspected to have allergic contact dermatitis (ACD) to acrylates and was referred to the patch test clinic. Patch testing was performed to the British standard, facial, rubber and acrylate series. She had positive reactions to five different acrylates, confirming a clinical diagnosis of ACD relevant to her use of acrylic nails and gel polish. However, she was noted to have several unusual features. Clinically, she had small round scars on the dorsum of both hands. On questioning, she described scars occurring after each blister. Blisters occurred all year round but were significantly more frequent in the summer months. Exposure of her gel nails to ultraviolet (UV) light was felt to trigger the blistering. This prompted additional tests to investigate possible photosensitivity. Both urine and plasma porphyrin levels were significantly elevated, confirming cutaneous porphyria. This is an unusual case of a dual pathology causing blistering of the hands: ACD to acrylates and cutaneous porphyria. In most circumstances, it is ACD that is the overlooked diagnosis, but here, an important general medical diagnosis may have been missed. It is important to remember that blistering caused by gel nail kits may be multifactorial, with acrylates causing ACD and UV light possibly triggering cutaneous porphyria.