- D3.497 - Allergic Contact Dermatitis with Multiple Sensitizations in a Professional Viola Player

Introduction: Occupational diseases in musicians most commonly manifest as musculoskeletal disorders related to repetitive movements and as skin lesions resulting from direct contact with musical instruments. Among players of string instruments, Fiddler’s neck, which develops due to friction of the instrument against the submandibular region, is the most frequently described condition; however, allergic contact dermatitis may also accompany this presentation. Nickel-containing strings, the wood of the instrument itself or its varnish, as well as exposure to rosin, have all been implicated as potential causative agents. Here, we present a case of allergic contact dermatitis involving multiple body sites, in which patch testing revealed multiple sensitizations.

Case Report: A 41-year-old female professional viola player presented with dermatitis affecting the left palm, fingertips, and the left side of the face which are the areas exposed to rosin dust, occurring 48-72 hours after playing the viola. She reported that she started playing the viola at the age of 11, with symptom onset three years later and gradual worsening over a 30-year period. Facial symptoms became more pronounced following orchestra rehearsals and performances, likely due to increased exposure to rosin dust from other string instruments. After 3-4 hours of contact with the instrument, palmar and fingertip lesions required treatment with topical corticosteroids.

Patch testing was performed in our clinic using the European Standard Series (ESS). Positive reactions were observed to nickel (++); which is consistent with exposure from viola strings, colophonium (+++); with violin bow rosin, and fragrance mix I (+++). In addition, the patient’s own rosin (+++) and the wood oil/varnish (+) she used were positive. These findings confirmed the diagnosis of allergic contact dermatitis induced by viola-related exposure and established a clear occupational causal relationship.

Conclusion: Allergic contact dermatitis resulting from exposure to string instruments, particularly due to nickel, rosin, and wood-derived materials, has been previously reported. This case emphasizes the importance of patch testing in the diagnosis of occupational allergic contact dermatitis and highlights the need to include suspected allergens not routinely present in standard patch test series to identify multiple sensitizations.