title: Shoe contact dermatitis from dimethyl fumarate: clinical manifestations, patch test results, chemical analysis, and source of exposure.
abstract: BACKGROUND
  The methyl ester form of fumaric acid named dimethyl fumarate (DMF) is an effective mould-growth inhibitor. Its irritating and sensitizing properties were demonstrated in animal models. Recently, DMF has been identified as responsible for furniture contact dermatitis in Europe.
  
  
  OBJECTIVE
  To describe the clinical manifestations, patch test results, shoe chemical analysis, and source of exposure to DMF-induced shoe contact dermatitis.
  
  
  METHODS
  Patients with suspected shoe contact dermatitis were studied in compliance with the Declaration of Helsinki. Patch test results obtained with their own shoe and the European baseline series, acrylates and fumaric acid esters (FAE), were recorded according to international guidelines. The content of DMF in shoes was analysed with gas chromatography and mass spectrometry.
  
  
  RESULTS
  Acute, immediate irritant contact dermatitis and non-immunological contact urticaria were observed in eight adults and two children, respectively. All the adult patients studied developed a delayed sensitization demonstrated by a positive patch testing to DMF < or = 0.1% in pet. Cross-reactivity with other FAEs and acrylates was observed. At least 12 different shoe brands were investigated. The chemical analysis from the available shoes showed the presence of DMF.
  
  
  CONCLUSIONS
  DMF in shoes was responsible for severe contact dermatitis. Global preventive measures for avoiding contact with DMF are necessary.
authors.affiliation: Department of Dermatology, Hospital del Mar IMAS, Universitat Autònoma, Barcelona, Spain. 22505aga@comb.es
authors.forename: Ana
authors.initials: A
authors.lastname: Giménez-Arnau
authors.forename: Juan Francisco
authors.initials: JF
authors.lastname: Silvestre
authors.forename: Pedro
authors.initials: P
authors.lastname: Mercader
authors.forename: Jesus
authors.initials: J
authors.lastname: De la Cuadra
authors.forename: Isabel
authors.initials: I
authors.lastname: Ballester
authors.forename: Fernando
authors.initials: F
authors.lastname: Gallardo
authors.forename: Ramón M
authors.initials: RM
authors.lastname: Pujol
authors.forename: Erik
authors.initials: E
authors.lastname: Zimerson
authors.forename: Magnus
authors.initials: M
authors.lastname: Bruze
mesh_terms: D000328:Adult; D000368:Aged; D000935:Antifungal Agents / Q000009:adverse effects* / Q000737:chemistry; D003877:Dermatitis, Contact / Q000209:etiology*; D000069462:Dimethyl Fumarate; D005260:Female; D005533:Foot Dermatoses / Q000139:chemically induced*; D005650:Fumarates / Q000009:adverse effects* / Q000737:chemistry; D008401:Gas Chromatography-Mass Spectrometry; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D015394:Molecular Structure; D010328:Patch Tests; D012775:Shoes; D014581:Urticaria / Q000139:chemically induced
chemical_list: D000935:Antifungal Agents; D005650:Fumarates; D000069462:Dimethyl Fumarate