We all know someone who is reactive to poison ivy, and when exposed to the “leaves of three” plants gets a nasty rash, which doctors call a contact dermatitis. Most of these victims find out where this itch comes from, and will learn to avoid the plants, and the rash. A lesser known, but surprisingly common cause of a similar rash that is at times hard to diagnose is the metal nickel.
It turns out that over 20% of those with a dermatitis who are evaluated by patch testing are reactive to nickel. In the general public, it is found five times more likely in women, affecting up to as much as 15-25% of the female population. It is thought that this imbalanced gender ratio may be due in part to prolonged exposure to inexpensive jewelry, like piercings, often starting at a relatively young age, although some men are starting to catch up in this category.
Nickel induced rashes can be as simple as a reddening of the skin, which may progress to dry, itching or thickened skin which can even become raw or scaly. In more severe cases you can see local fluid filled blisters. Most often, the location the skin reactions occur is obviouswhere nickel touches the skin; like earlobes, on the wrist under a watch, or on the low belly under a jeans button. Sometimes, however, nickel which has been ingested in small amounts over time can react with the immune system, causing skin reactions “from the inside out”, and these rashes can be notoriously hard to identify. You can find an extensive list of the more common objects or occupations that increase nickel exposure in the Resources section at the end of this article.
I’d like to tell you about such a situation where a ‘hard to diagnose or fix’ rash had a less than obvious nickel source. Hopefully, you won’t recognize a similar situation in you or a friend, and if not you may want to pause this article right here. Otherwise, read on to hear how we found solutions for one patient’s ‘never ending itch and rash’ problem.
Sandy was a 45 year lady who had been having a problem with a dry and reddened skin irritation, mostly on the arms, but also including the chest and back for ~4 years. It was very itchy at times. And not surprisingly, scratching at it only made it worse and thickened the irritated skin. The problem was getting steadily worse, and she was increasingly frustrated, as she was otherwise an active and healthy person. She had been to a dermatologist, a rheumatologist, and then then an allergist. Her workup was negative for most everything, except for patch testing, which showed a high reactivity to nickel. But because she did not have any specific outbreak where metals might normally touch the skin, this had been generally discounted as the primary source of the problem. Her allergist did advise her to try a low nickel diet, and over a 3 month trial she thought it helped “maybe 10 or 20 %”.
When we met and discussed her past history, she reflected that the jewelry she had worn in younger years were dime store cheap, starting when she had her ears pierced at age 11. The pieces she had worn in the last 5-10 years were of higher quality and had no known nickel element to them. We reviewed many of the other potential sources of nickel (see Resources) and I was very interested to find that she had worked as a hairdresser since her late teens. I explained that trace amounts of nickel can be present in many hair care products, and we decided to check on her cumulative metals exposure. We ran a test we call a ‘six hour urine for heavy metals’ where we administer an IV chelator to bind and remove heavy metals, excreted primarily through the kidneys. We collect that urine during and after the test and send it out a lab which shows what heavy metals were removed, as an estimate of one’s ‘total body load’.
And yes…you guessed it, when this test came back it showed that she had a relatively large load of nickel on board! The nickel was interacting with her immune system and promoting a skin reaction ‘from the inside out’. We followed a plan to reduce her nickel levels and her reactivity, and within 4 months she had nearly cleared virtually all of the symptoms of her 4 years of ‘never ending rash’. I’ve summarized the elements of her therapy plan below, with details on each of them in the Resource section of this article. You may also need to find an integrative minded physician to implement some of the tests or therapy we’ll discuss. I’ve also referenced some resources for finding these physicians9.
It is very frustrating to have a very real problem that doesn’t have a ‘diagnosed explanation’. While at times it can be hard to ferret them out, every real health problem has biochemical roots that are waiting to be uncovered. Don’t ever give up on educating yourself about your options for both effective self-care and enlightened science based alternatives to solving your healthcare dilemmas!
How Sandy* cleared her rash
-note the referenced resources
- A key element of her earlier workup was the allergy testing, particularly patch testing for contact allergens, which revealed the nickel reaction.
- A history of occupational risks1 and a review of common sources of nickel exposure2 was essential to suggest going on to testing her body’s nickel load.
We gave Sandy a standardized IV EDTA provocative test for heavy metals3 to evaluate her total body load of nickel. This test would also uncover other potentially problematic heavy metals. This showed that she had accumulated high levels of nickel over time, most likely from her occupation as a hair stylist, and that it almost certainly would have continued to provoke her immune system, and her skin, if left unaltered. We followed this up with several methods of reducing her nickel load:
1) She had several sessions of IV EDTA3 to substantially reduce her tissue nickel levels. In between these sessions, she also took an oral prescription chelator called Disulfram4 to additionally clear the nickel. Disulfram was approved in 1951, originally and still used in the treatment of alcohol abuse.
2) She re-started the low nickel diet 5 to minimize additional nickel stores while we were doing the cleanup. She also took daily Vitamin C 6 to further reduce nickel absorption.
3) Sandy started using a sauna after her workouts ~3 times a week to further hasten the excretion of nickel through the skin.7 As she loved her work, and was really quite talented, we researched the products and chemicals she routinely encountered in the workplace to remove nickel containing offenders, and to find effective alternatives. In the process, her clients were happy to hear how proactive she was in using more natural, and less toxic hair care alternatives.
4) While working through the above therapy, Sandy applied some low potency topical steroid sparingly to the worst of the rash, and also took quercetin 500 mg twice daily6 for its histamine reducing benefits.
*not her real name, of course.
1 Occupations at risk for nickel exposure
-cashiers handling coins.
-domestic house cleaners
-those who have regular exposure to nickel while doing “wet work” — as a result of either sweat or frequent contact with water — may be more likely to develop nickel allergy. The nickel salts (nickel sulfate) that are produced when nickel is exposed to perspiration is the form most likely to activate an immune response.
2 Common sources of nickel to assess and minimize
-inexpensive jewelry, as well as clothing fasteners, such as zippers, snaps, belt buckles and bra hooks
-cigarette smoke, either as a tobacco user or by second hand exposure
-nickel ingested from tap water, especially if it has been sitting in the pipe for long periods between use. Let the water run a few seconds before using for coffee, cooking pasta, etc.
-from stainless steel cookware when cooking with acidic foods like tomato or lemon.
-metal tools or keys
-cellphones, laptops, tablets like iPads
-cold-wave hair permanent, cosmetics, hair spray, shampoos
-dental and orthodontic materials, even some medical implants
-foods that may contain nickel (chocolate, cocoa hydrogenated oils, nuts, food grown near industrial areas), see list below related to low nickel diet.
-having lived in proximity to industrial waste, metal refineries or solid-waste incinerators
3 Provocative testing for excess ‘nickel on board’
If your patch testing for nickel sensitivity is significant, it may be worth getting a provocative test to gauge your body load of heavy metals, which would include nickel. At our clinic, we give a 3 hour IV with EDTA, an amino acid designed to bind heavy metals in the body. The IV allows it to percolate through and find those bad boys, bringing them out through the urine. We collect all the urine produced during and for the 3 hours after the IV, and send it out to a specialty lab for mass spectrometry analysis. This gives a snapshot of what heavy metals may be present body wide, including nineteen others besides nickel. If further therapy for removal is indicated, we can use this same IV to sequentially reduce the total body load of the offending heavy metal.
4 Using oral chelation to remove excess tissue nickel stores
Disulfiram, an oral nickel chelator, has also been shown to be both an effective initial adjunct to IV chelation in clearing persistent dermatitis as well as an effective monotherapy in clearing nickel stores. Keep in mind that this agent (also known as Antabuse) is also used to help alcoholics not drink, by inducing nausea when taken at the same time as alcohol. So, a word to the wise, if you ever use this chelator for nickel detox, do not ingest adult beverages! Also keep in mind that some over the counter cough remedies have a meaningful alcohol content, so one would avoid those as well.
5 Low nickel diet
Some nickel-allergic patients have skin reactions when they consume a high nickel diet. In one large study, 80% of patients on a low nickel diet for 4 weeks had a complete or near-complete recovery from dermatitis 8 This is probably most useful when the person does not have a more significant cumulative load of the metal.
- First off: a) run any tap water for a few seconds before washing, drinking, or cooking to flush out nickel that may have leached from pipes or fixtures. b) avoid stainless steel cookware and utensils when cooking acidic foods like tomato or lemon c) in general, avoid canned foods, especially fruit
- Minimize intake of the following foods:
-grains in general, especially whole grains
-beans such as lentils, peas, bean sprouts, soy beans, and soy products (tofu, soy sauce)
-chocolate in all forms (sorry ‘bout that one…)
-commercial salad dressings
Additional low nickel diet resources you can find online:
-Rebelytics: “Low Nickel Diet Scoring System”: a website that rates nickel content of foods, see http://www.rebelytics.ca/lownickeldiet.html
-The Nickel Navigator: an Android app to track potential food nickel sources, find at: www.rebelytics.ca/nickelnavigator.html
6 Supplementing Vitamin C and Quercetin
Vitamin C taken with food will decrease the absorption of dietary nickel. To augment a low nickel diet, take 500 mg of Vitamin C with each meal. For most of us, a daily dose of 1500-2000 mg is a very safe range of usage. If this irritates the bowel or makes your elimination too loose, reduce the dose by 30-50%
Quercetin is a citrus bioflavonoid that can reduce inflammation and itch by reducing excess histamine release in the skin. A dose of 500-1000 mg/day can be helpful as you implement the other measures discussed.
7 Sauna and sweating as a route for heavy metal detoxification
Sweating is an additional pathway to rid the body of excess nickel. Saunas, hot baths and exercise all can increase sweat production. It is important to wash the sweat off afterward, so that the skin doesn’t react to the excreted nickel.
8 Finding an integrative minded physician
There are several ways to find a physician who practices what we call integrative, or functional medicine. Some good online sources include:
-the Physician Link page at the web site for the American College for the Advancement of Medicine, at: www.acam.org/search/custom.asp?id=1758
-the Find a Practitioner page at the Institute for Functional Medicine site: www.ifm.org/find-a-practitioner/
-call a local compounding pharmacy. They usually know the integrative minded physicians in your area.