NEW YORK – In patients who develop dermatitis after implantation of a device containing materials to which they have a contact allergy, explantation is not necessarily a cure for their symptoms.
Ted Bosworth/MDedge News
Dr. Ari M. Goldminz
“It can be difficult to predict who will or will not clear when the device is removed. In addition, in some cases device explantation could lead to other issues,” cautioned Ari M. Goldminz, MD, a dermatologist at Brigham and Women’s Hospital, Boston, MA. “Offering non-surgical options and a thorough investigation of other potential causes unrelated to the implant may provide a path to avoid explantation.” However, for other patients removal of the device might be the preferred option.
During his presentation at the American Academy of Dermatology summer meeting, he described illustrative cases. These patients developed dermatitis within weeks or months after receiving a surgical implant, and tested positive for a material that was in the implanted device.
In one of these cases, the suspected problem was a metal plate containing chromium that was placed during an orthopedic repair. Subsequent patch testing revealed a reaction to chromium and the implant was eventually removed.
However, there was no improvement in dermatitis following removal of the metal plate.
“The symptoms ultimately improved after starting on a low-chromium diet and avoiding other allergens identified on patch testing, such as those found in skin care products,” Dr. Goldminz explained. He does not discount the role that the implant may have played in the onset of dermatitis,, but improvement required avoidance strategies other than device explantation.
There are studies suggesting that patch testing prior to surgery can help certain patients and surgeons select implant materials, such as when patients have a clinical history of metal sensitivity (Arch Dermatol. 2012 Jun;148[6]:687-93). However, other studies have also found that positive patch test results do not necessarily predict outcomes following surgery (J Arthroplasty. 2016 Aug;31[8]1717-21).
Although it might make sense to consider pre-operative patch testing in patients with a clinical history of rashes from metallic objects, Dr. Goldminz indicated that some patients might still need to weigh the benefits of the implant against the risks of a hypersensitivity reaction when no devices free of the allergen are available.
“In certain cases, patients might decide the risk-to-benefit ratio favors the device depending on factors such as the indication for the surgery, alternative options available, and what device removal might involve,” Dr. Goldminz said. Additionally, when patients develop rashes thought to be related to materials present in an implanted device, there are also medical treatments that can be considered if device explantation is not preferred or if it is an impractical approach.