PREVIOUS CASE - DISCUSSION
Chrome Ulcers

John Cienki
Florida Poison Center
Miami, FL

Int J Med Toxicol 1998; 1(2): 18


See also NEW CASE - SUMMARY - 1998; 1(1): 5

Discussion

Chromium is a hard metal, of various oxidative states, most commonly encountered in the electroplating, pigment manufacturing, and leather tanning industries. Other smaller industries that also utilize chromium include photographic developing, etching, textile production, and television picture tube manufacture. Chromium compounds have two distinct and unrelated actions on the skin. Sensitization produces an allergic contact dermatitis and irritation produces chrome ulcers. Chrome ulcers were first described in 1827 by William Cummin of Scotland.(1) They are the direct result of the action of chromic acid or other chromium compounds on the skin.Vapors liberated when chromic acid is heated or the reddish brown mist that is released at electrodes in the chrome electroplating process can also cause ulcers of the nose or oropharynx when inhaled. A Brazilian study on the incidence of chrome ulcers found the brilliant chrome finish to be four times more likely to produce skin lesions than the hard chrome finish. The hard chrome process was more likely to produce mucous membrane lesions and up to 90% of all workers were affected in some way in this study.(2) Contact between chromium compounds and the skin only results in an ulcer if there is a cut abrasion, or any other defect, in the protective dermis. The development of a chrome ulcer is also not pH dependent. A guinea pig study produced ulcers regardless of pH, even using buffered chromium solutions.(3) Studies that used various vehicles with chromium found different penetration dependent on the vehicle. Petrolatum was found to be most penetrating, not explained by its occlusiveness alone.(4) Initially, chrome ulcers appear as a small papular lesion. They usually occur on exposed areas of the hands, forearms and feet. After a few days a central ulceration develops with an intense inflammatory reaction at the margins. At this stage, pain is not usually a major complaint, although intense itching is often related, especially at night. If there is no further chromium contact the ulcer will heal spontaneously, but over a few weeks time. There usually is permanent scarring with a characteristic "hole punch" appearance. If continued exposure persists the ulcers can penetrate deeply, even to the bone. Superinfection of the ulcers can also occur.(5) Specific treatment is based largely on animal data. A guinea pig study using various chromium solutions found that trivalent preparations are not ulcerogenic even in concentrations three times greater than hexavalent solutions. Prompt washing or applications of ascorbic acid solutions which reduce the hexavalent chromium to the tetravalent state will prevent the formation of chrome ulcers. Late application of chelating agents or reducing solutions such as ascorbic acid had no effect on healing once the ulcer had formed.(3) The patient whose photograph is above worked in an auto body repair shop and reported that plating solution often got into his boots. He had experienced the ulcers on and off since the beginning of his employment there.

References

  1. Cummin W: Remarks on the medicinal properties of madar and the effects of potassium dichromate on the body. Edin Med J: 1827;28:295.
  2. Gomes ER: Incidence of occupational chromium induced lesions among electroplating workers in Brazil Indust Med 1972;41:21-25.
  3. Samitz MH, Epstein E: Experimental cutaneous chrome ulcers in guinea pigs Arch Environ Health 1962;5:463-468.
  4. Liden S, Lundberg E: Penetration of chromium in intact human skin in vivo J Invest Dermaol 1979;72:42-45.
  5. Williams N: Occupational skin ulceration in chrome platers. Occup Med 1997;47:309-310.

If you have a case you would like to submit, please send the clinical information and the appropriated image (photograph, x-ray, or ECG) to: 777 E. Park Drive, P.O. Box 8820, Harrisburg, PA 17105-8820. Images (as tif, gif, jpg files) and clinical information may be sent by e-mail to bobhoff@pol.net. If the image shows an actual patient or part of a patient's body, please include a cover letter indicating that the patient has given you permission to take and use their photograph.



Int J Med Toxicol 1998; 1(2): 18

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