LAUSR

An electronic cigarette or e-cigarette is a handheld device that vaporises a liquid, usually containing nicotine, propylene glycol, glycerine and flavourings, which is then inhaled. They were first patented in 2003, and there are now thousands of different brands. Use of the e-cigarette has risen exponentially in recent years as an alternative to prescription nicotine replacement products, both by smokers and by previous nonsmokers. There are reportedly over 2.6 million users in the UK. A 37-year-old woman presented with a history of 4–5 episodes of facial, lip and eyelid swelling, erythema and itching over a 6-month period. Each time the symptoms had come on over hours, and lasted around a week before resolving. She had a several-year history of mild hand dermatitis particularly affecting her right (dominant) hand, and a self-reported allergy to nickel, with reactions to costume jewellery and belt buckles, which she now avoided. Her medical history also included depression and hayfever, for which she took regular venlafaxine and fexofenadine. She had no known drug allergies. She was a current smoker but had recently been trying to stop. Physical examination at presentation showed mild dermatitis of the right hand. Photographs taken during a previous episode showed erythema and swelling of the eyelids and cheeks bilaterally, with generalized lip swelling (Fig. 1), consistent with a contact dermatitis. Patch testing to standard, medicament and facial series demonstrated a strongly positive reaction to nickel (2+), and positive (+) reactions to hydroxycitronellal and iodopropynyl butylcarbonate. On further questioning, the patient reported using metal eyelash curlers intermittently, and a metal e-cigarette (VIP Electronic Cigarettes, Manchester, UK) around the time of onset of the rash. Testing of both of these products using a dimethyl glyoxime (DMG) nickel spot test revealed positive reactions (Fig. 2). After 2 months of avoidance, the patient reported she had experienced no further episodes of facial rash/ swelling and there was an improvement in her hand dermatitis. We contacted the companies manufacturing the two vaping fluids used by our patient. In addition to the usual ingredients of vaping fluid, the products contained benzyl alcohol and methanol flavourings in concentrations of 0.03–0.1%, and other (nonspecified) ingredients at < 0.03%. Neither these or current cosmetic products used by the patient were known to contain hydroxycitronellal or iodopropynyl butylcarbamate. In the literature, there is one previous case report of nickel allergy to an e-cigarette, in a patient presenting with scaly, erythematous skin on the right (dominant) thumb and index finger, and a strongly positive DMG nickel spot test to the e-cigarette. The authors of that report tested 11 different e-cigarette models, each at three body locations, and found that 3 of the 11 e-cigarettes produced a positive reaction with the DMG spot test. Use of e-cigarettes is likely to keep rising. Dermatologists and other clinicians should be aware of these devices as potential sources of nickel release, in order to elicit the necessary history from patients presenting with possible contact allergy to the hand or face, and to educate patients to avoid nickel containing devices in those with confirmed allergy on patch testing. Vaping fluid should be also be considered as a potential allergen. Figure 1 Picture during a symptomatic episode showing erythema and swelling of the eye, and generalized lip swelling.