The value of pantomiming for allergic contact dermatitis

Abstract

To the Editor: Pantomiming enables humans to communicate through mimicry in a context in which the physical tools of reference are not present.1Broadbent R. History of Pantomime. International Business Publications, Alexandria, VA2018Google Scholar,2Lausberg H. Kazzer P. Heekeren H.R. Wartenburger I. Pantomiming tool use with an imaginary tool in hand as compared to demonstration with tool in hand specifically modulates the left middle and superior temporal gyri.Cortex. 2015; 71: 1-14Crossref PubMed Scopus (7) Google Scholar Pantomime in dermatology can be useful to help understand the pattern of allergic contact dermatitis (ACD). For example, Alstroemeria, the Peruvian lily, is a well-documented occupational allergen for florists (Fig 1).3McGovern T.W. Alstroemeria L. (Peruvian lily).Am J Contact Dermat. 1999; 10: 172-176Crossref PubMed Scopus (10) Google Scholar The distribution of ACD can be clarified when a florist pantomimes how he or she places the hand on the flower to strip the stem.3McGovern T.W. Alstroemeria L. (Peruvian lily).Am J Contact Dermat. 1999; 10: 172-176Crossref PubMed Scopus (10) Google Scholar Garlic is another well-recognized cause of ACD; pantomime can help explain a distribution involving the nondominant thumb and index finger, which hold the garlic as the dominant hand cuts it (Fig 2).4Hughes T.M. Varma S. Stone N.M. Occupational contact dermatitis from a garlic and herb mixture.Contact Dermatitis. 2002; 47: 48Crossref PubMed Scopus (17) Google ScholarFig 2Allergic contact dermatitis. A classic distribution of a rash due to garlic allergen involving the nondominant hand.View Large Image Figure ViewerDownload Hi-res image Download (PPT) We present 3 cases for which pantomime was useful in diagnosing ACD. Case 1: Explaining rash distribution. A patient presented with sharply demarcated dermatitis of the left side of the neck. She had positive reactions on patch tests to gold, neomycin, and budesonide. Pantomiming the application of topical medications was helpful in understanding the distribution of her ACD (Fig 3). If the hands are spared (and, therefore, the relevance of topical medicament is questioned), it can be useful to ask what was used to apply the medication (eg, fingertips, cotton applicators, gauze, tissues). Sparing of fingertips may be explained if an applicator was used or if the hands were washed immediately after application. Case 2: Guiding selection of patch test allergens. An auto body shop worker presented with bilateral dorsal hand dermatitis. When pantomiming daily work tasks, the patient demonstrated using the dorsal aspect of his hands to put pressure on panels after applying an adhesive. Possible exposure to acrylate adhesive residue on the panels prompted testing an acrylate adhesive series. He showed allergy to ethylene glycol dimethacrylate and other acrylates that may have been missed on testing with only a standard screening series. Case 3: Identifying the primary source of relevance. A pipefitter presented with dermatitis of the left hand and periumbilical region. Overlying the rash were splotches of dried white material on his shirt, which prompted a request for him to pantomime how that substance got there. The patient pantomimed holding a paint tray with his left hand lodged against his periumbilical region while using a paintbrush to dip into the tray. The lubricant substance in the tray would splash over the edge onto his left hand and the clothing over his abdomen. The patch testing result was positive for lanolin, relevant to the lubricant and to the medicament used to treat the dermatitis. When using pantomime, prompt the patient by saying, “Let's pretend” or “Show me,” referring to the use of an object. Statements such as “How do you use this?” should be avoided because they may confuse the patient and make the process awkward. It may be helpful to hand any object to the patient that approximates the size of the item he or she is pretending to handle. Pantomiming can be very helpful in understanding unusual patterns of dermatitis. Pantomiming can be a powerful diagnostic modality that allows the physician to observe how patients may interact with various products to better diagnose ACD.