Nickel metal is a common component of silver coins, belt buckles, jewelry, and many other everyday items.
Patients with nickel allergy typically develop a skin rash called contact dermatitis after exposure to the metal. Contact dermatitis causes the skin to become red, itchy, and swollen.
According to the Centers for Disease Control (CDC), the more exposure an individual has to nickel-containing products, the more likely the patient will become allergic to nickel. Patients can become allergic to nickel at any age.
There is currently no available data on the incidence rates of nickel allergy. Historically, nickel allergy has affected more women than men. Researchers believe that this is because women are more likely to get their ears pierced. Nickel is present in earrings unless the jewelry is hypoallergenic, stainless steel, solid gold, or sterling silver. However, as body piercing continues to gain popularity, an increasing number of males are reported to have nickel allergies.
Although there is no cure for allergies, antihistamines, corticosteroid creams and ointments, cool compresses, hydrocortisone creams, and moisturizing creams may help reduce allergy symptoms. In general, symptoms may last anywhere from a few hours to days.
The best way to prevent symptoms from recurring is to avoid exposure to nickel. Whenever possible, patients should purchase nickel-free items. Patients can purchase a nickel-testing kit at their local pharmacies to help them identify products that contain nickel.
General: Typically, an allergic response to nickel is not triggered the first time the body is exposed to it. The first, or several times after the body is exposed to nickel, the immune system becomes sensitized. During this process, the body's white blood cells develop immunoglobulin E (IgE) antibodies to the nickel. Once sensitized, the antibodies are able to quickly detect and bind to the nickel allergens when they enter the body. These antibodies also trigger the release of chemicals (such as histamine) that cause allergic symptoms, such as red, itchy, and swollen skin.
Triggers: Many everyday products are made with nickel. Products, such as silver coins, keys, jewelry (necklaces, earrings, bracelets, rings, and watchbands), belt buckles, zippers, buttons, bra hooks, suspender clips, pens, hair clasps, electrical shavers, paperclips, and power tools may contain nickel.
Some researchers have suggested that drinking water and eating food that contain high amounts of nickel (such as salmon, chocolate, nuts, grains, and canned fruits and vegetables) may lead to nickel allergy in extremely sensitive patients. However, these claims have not yet been confirmed by scientific evidence. Further research is needed before a firm conclusion can be reached.
HOW TO IDENTIFY NICKEL PRODUCTS
If a patient is unsure whether a product contains metal, they may call the manufacturer.
Patients can purchase a nickel testing kit (such as Spot Test for Nickel Kit™) at local pharmacies. The kit contains two bottles of clear fluid: dimethylglyoxime and ammonium hydroxide. The patient applies one drop of each solution to the object in question. Then a cotton ball or Q-tip is rubbed on the object. If the cotton ball or Q-tip turns pink, the object contains nickel.
Gender: Historically, nickel allergy has affected more women than men. Researchers believe that this increased risk may be because women are more likely to have their ears pierced than men. However, as body piercing continues to gain popularity, there have been an increasing number of reports of men with nickel allergies. When the ears or other body part is pierced, the body is exposed to nickel in the jewelry for several days until the skin heals. An allergic reaction can be prevented if the patient's skin is pierced with jewelry that is hypoallergenic, stainless steel, solid gold, or sterling silver.
Repeated exposure: Patients who are exposed to nickel on a regular basis have an increased risk of developing nickel allergies. For instance, cashiers who handle coins for extended periods of time may have an increased risk of developing the allergy.
Symptoms typically develop within 20 minutes of exposure to nickel. Symptoms may last anywhere from a few hours to days. Patients who are allergic to nickel develop contact dermatitis, which causes the skin to become red, itchy, and swollen. The severity of this skin rash varies among individuals. Some patients may develop fluid-filled blisters. In most cases, the affected skin is limited to the area that was exposed to the metal. However, it is possible for the rash to spread to other areas of the body.
Skin test: A skin test, called an epicutaneous (patch) test, is used to determine whether a patient is allergic to nickel. During the procedure, the nickel allergen is applied to a patch, which is then placed on the skin. The patch is worn on the arm or back for 48 hours. While the patch is on, the patient should not bathe, and he/she should try not to sweat heavily. The healthcare provider will remove the patch after 48 hours and observe the test site for allergic skin reactions. If the skin is red, itchy, and swollen, a positive diagnosis is made. A skin test is typically conducted in a healthcare provider's office. Skin tests cause minimal, if any, discomfort.
Allergen-specific immunoglobulin (IgE) test: An allergen-specific immunoglobulin E (IgE) test, commonly referred to as radioallergosorbent test (RAST©), may also be used to determine whether the patient is allergic to nickel. However, this test is less accurate than a skin test. It is usually performed in patients who have coexisting severe skin diseases (like eczema or psoriasis) that make it difficult to interpret a skin test.
During the procedure, a sample of blood is taken from the patient and sent to a laboratory that performs specific IgE blood tests. The nickel allergen is bound to a paper disc called an allergosorbent. Then the patient's blood is added. If the blood contains immunoglobulin antibodies that detect and bind to the nickel, the blood will bind to the allergen on the disc. A radio labeled ANTI-IgE antibody is then added to the disc to measure the level of immunoglobulin E present in the blood. The higher the radioactivity, the higher the level of IgE in the blood and the more severe the allergy.
A qualified healthcare provider will interpret the results of the test. In general, the sensitivity of these tests range from 50-90%, with the average being about 70-75%. The patient will receive test results in about seven to 14 days.
General: Although there is no cure for allergies, antihistamines, corticosteroid creams, cool compresses, hydrocortisone creams, and moisturizing creams may help reduce allergy symptoms. The best way to prevent symptoms from recurring is to avoid exposure to nickel.
Antihistamines: Antihistamines may be used to alleviate allergy symptoms, including red, itchy skin. Common nonprescription antihistamines include diphenhydramine (Benadryl©), chlorpheniramine (Chlor-Trimeton©), clemastine (Tavist©), and loratadine (Alavert© or Claritin©). Commonly used prescription medications include desloratadine (Clarinex©), fexofenadine (Allegra©), cetirizine (Zyrtec©), and hydroxyzine (Atarax© or Vistaril©).
Cool compress: Applying a cool compress to affected areas of the skin may help relieve itching, swelling, and redness.
Hydrocortisone: Hydrocortisone cream has been applied to the affected area to temporarily relieve itching. Hydrocortisone 1% cream, which is available over-the-counter, has anti-inflammatory effects and relieves swelling and redness in addition to itching. Prescription hydrocortisone has been used to relieve itching, redness, dryness, crusting, scaling, inflammation, and discomfort associated with the allergic reaction.
Moisturizing creams: Moisturizing creams and lotions like Gold Bond Medicated Moisturizing Body Lotion© may help relieve dry, itchy skin. Moisturizing creams should not be applied to open cuts, blisters, or sores on the skin.
Topical corticosteroids: Topical corticosteroid creams like clobetasol cream and ointment (Embeline© and Temovate©) have been applied to the affected skin. The cream, which is available by prescription, helps reduce redness, itching, and inflammation. Treatment with topical corticosteroids should not last longer than two weeks.
Unclear or conflicting scientific evidence :
Acupuncture : Acupuncture is commonly used throughout the world. According to Chinese medicine theory, the human body contains a network of energy pathways through which vital energy, called "chi," circulates. These pathways contain specific points that function like gates, allowing chi to flow through the body. Needles are inserted into these points to regulate the flow of chi. Acupuncture plus point-injection has been found beneficial for the treatment of hives, although more research is needed to confirm these findings.
Needles must be sterile in order to avoid disease transmission. Avoid with heart valve disease, infections, bleeding disorders, medical conditions of unknown origin, or neurological disorders. Avoid if taking drugs that increase the risk of bleeding. Avoid on areas that have received radiation therapy. Use cautiously with pulmonary disease (such as asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers. Avoid if pregnant.
Bromelain : Bromelain has been shown to decrease inflammation, regulate the immune system, and have antiviral effects and may help treat skin rash.
Avoid if allergic to bromelain, pineapple, honeybee, venom, latex, birch pollen, carrots, celery, fennel, cypress pollen, grass pollen, papain, rye flour, wheat flour, or members of the Bromeliaceae family. Use cautiously with a history of bleeding disorders, stomach ulcers, or heart, liver, or kidney disease. Use caution before dental or surgical procedures or while driving or operating machinery. Avoid if pregnant or breastfeeding.
Butterbur : Preliminary research suggests that butterbur may not suppress allergic skin disease reactions when compared to the prescription drug fexofenadine (Allegra©), which does suppress these reactions. Additional study is needed. Use caution if allergic or sensitive to Petasites hybridus or other plants from the Asteraceae/Compositae family (like ragweed, marigolds, daisies and chrysanthemums). Raw, unprocessed butterbur plant should not be eaten due to the risk of liver or kidney damage or cancer. Avoid if pregnant or breastfeeding.
Calendula : Limited early research suggests that calendula extracts may reduce skin inflammation. Human studies are lacking in this area.
Avoid if allergic to plants in the Aster/Compositae family such as ragweed, chrysanthemums, marigolds, and daisies. Use cautiously in patients taking sedatives, blood pressure medications, cholesterol medications, blood sugar-altering agents, and immunomodulators. Use cautiously with diabetes and in children. Avoid if pregnant or breastfeeding.
Jewelweed : Jewelweed has been used traditionally as a treatment for various types of contact dermatitis, including poison ivy/oak rashes and allergic dermatitis, however, human study indicates that it may not be effective for this use. Avoid if allergic or hypersensitive to jewelweed (Impatiens biflora), its constituents, or members of the Balsaminaceae family. Use cautiously if taking calcium supplements and with kidney stone disorders. Avoid consuming excess amounts of jewelweed due to reports of high mineral content, particularly calcium oxalate. Avoid if pregnant or breastfeeding.
Marshmallow : Marshmallow extracts have traditionally been used to treat inflammatory skin conditions. Several laboratory experiments, mostly in the 1960s, reported marshmallow to have anti-inflammatory activity but limited human study is available. Safety, dosing, and effectiveness compared to other anti-inflammatory agents have not been examined.
Historically, marshmallow is generally regarded as being safe in healthy individuals. However, since studies have not evaluated the safety of marshmallow, proper doses and duration in humans are not known. Allergic reactions may occur. There is not enough scientific evidence to support the safe use of marshmallow during pregnancy or breastfeeding.
Onion : Early research shows that topical application of an alcoholic onion extract significantly reduced responses to allergies, such as hives and flares. More research is needed.
Avoid if allergic or hypersensitive to onion (Allium cepa), its constituents, or members of the Lilaceae family. Use cautiously with hematologic (blood) disorders, diabetes, hypoglycemia (low blood sugar), and hypotension (low blood pressure). Use cautiously if taking anticoagulants or antiplatelets (blood thinners). Avoid medicinal doses if pregnant or breastfeeding.
Para-aminobenzoic acid : Para-aminomethylbenzoic acid (PABA) may be useful in the treatment of lichen slerosus, a benign, progressive dermatologic condition characterized by inflammation, pruritus (itching), and pain, especially in the anogenital region (involving the anus and genitals). Additional investigations are needed regarding the use of PABA for inflammatory skin disorders.
Avoid with known hypersensitivity to PABA or its derivatives. Discontinue use if rash, nausea, or anorexia occurs. Avoid oral use in children and pregnant or nursing women. Use cautiously in patients with renal or liver disease. PABA should not be given concurrently with sulfonamides. Use cautiously in patients with bleeding disorders or taking anticoagulants. Use cautiously in patients with diabetes or hypoglycemia.
Peony : Peony root may have beneficial effects on immune function. These effects may help decrease inflammation associated with allergic skin reactions such as allergic dermatitis. There is currently not enough evidence to recommend for or against the use of peony in allergic skin conditions.
Avoid if allergic or sensitive to peony. Avoid with bleeding disorders or if taking drugs, herbs, or supplements that increase bleeding risk. Use cautiously with estrogen-sensitive cancers or if taking drugs, herbs, or supplements with hormonal activity. Avoid if pregnant or breastfeeding.
Tea tree oil : Small studies show that tea tree oil applied to the skin may reduce allergic skin reactions caused by histamine-induced inflammation. Further research is needed to confirm these results.
Avoid allergic or hypersensitive to tea tree oil (Melaleuca alternifolia), any of its constituents, balsam of Peru, benzoin, colophony (rosin) tinctures, eucalyptol, or members of the Myrtle (Myrtaceae) family. Avoid taking tea tree oil by mouth. Avoid if taking antineoplastic agents. Use tea tree oil applied to the skin cautiously in patients with previous tea tree oil use. Avoid if pregnant or breastfeeding.
Thyme : Historically, thyme has been used topically for a number of inflammatory skin disorders. Results are mixed. Additional study is needed in this area.
Avoid with known allergy/hypersensitivity to members of the Lamiaceae (mint) family or to any component of thyme, or to rosemary (Rosmarinus officinalis). Avoid oral ingestion or non-diluted topical application of thyme oil due to potential toxicity. Avoid topical preparations in areas of skin breakdown or injury, or in atopic patients, due to multiple reports of contact dermatitis. Use cautiously in patients with gastrointestinal irritation or peptic ulcer disease due to anecdotal reports of gastrointestinal irritation. Use cautiously in patients with thyroid disorders due to observed anti-thyrotropic effects in animal research of the related species Thymus serpyllum. Avoid if pregnant or breastfeeding.
Traditional or theoretical uses lacking sufficient evidence :
Burdock : Burdock is a plant that is native to Europe and northern Asia. The root is most often used in herbal preparations. Traditionally, burdock has been used to treat hives. However, there is currently no human evidence on its safety and effectiveness for this use.
Avoid if allergic to burdock or other plants of the Asteraceae/Compositae family (such as ragweed, chrysanthemums, marigolds, or daisies). Avoid with a history of dehydration, diabetes, heart disease, cancer, high blood pressure, or HIV. Stop use before and immediately after surgeries or dental or diagnostic procedures with bleeding risks. Avoid if pregnant or breastfeeding.
Chamomile : Although chamomile has traditionally been used to treat hives, scientific evidence is lacking.
Avoid if allergic to chamomile or any related plants, such as aster, chrysanthemum, mugwort, ragweed, or ragwort. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures with bleeding risks. Use cautiously if driving or operating machinery. Avoid if pregnant or breastfeeding.
Detoxification therapy (cleansing) : Detoxification is a broad concept that encompasses many different modalities and substances used in cleansing the body's systems and organs. Detoxification has been suggested as a possible treatment for hives. However, there is currently no scientific evidence of its safety or effectiveness for this use.
In cases of illness, the various forms of detoxification should be used under professional guidance. See specific monographs for precautions and warnings associated with modalities of detoxification.
Ephedra : Ephedra is a natural stimulant. Traditionally, ephedra has been used to treat hives. However, there is currently no evidence on the safety and effectiveness of ephedra for this use.
Even though this herb has been suggested as a potential treatment for hives, it is unsafe for humans. Serious reactions, including heart attack, stroke, seizure, and death have occurred. The U.S. Food and Drug Administration (FDA) has banned sales of ephedra dietary supplements. The FDA has collected more than 800 reports of serious toxicity, including more than 22 deaths. Avoid use in individuals younger than 18 years old. Avoid use for prolonged periods (longer than seven days) due to risk of abuse or toxicity. Discontinue use at least one week prior to major surgery or diagnostic procedures. Use cautiously with cardiovascular disease, including structural heart disease, arrhythmia, coronary artery disease, high blood pressure, cerebrovascular disease, and a history of stroke or transient ischemic attack. Use cautiously with depression, anxiety disorders, anorexia/bulimia, a history of suicidal ideation, insomnia, tremors, urinary retention, enlarged prostate, diabetes, kidney disease, glaucoma, thyroid disease, and peptic ulcer disease. Use cautiously with monoamine oxidase inhibitor (MAOI) or stimulant use. Avoid if pregnant or breastfeeding.
Kudzu : Kudzu is an herb that has been used in Chinese medicine for many years. Traditionally, kudzu has been used to treat hives. However, there is currently no scientific evidence on the safety and efficacy for this use.
No well-designed studies on the long-term effects of kudzu are available. Avoid if allergic or hypersensitive to Pueraria lobata or members of the Fabaceae/Leguminosae family. Use cautiously with blood thinners and blood pressure-lowering agents, hormones, antiarrhythmics, benzodiazepines, bisphosphonates, diabetes medications, drugs that are metabolized by the liver's cytochrome P450 enzymes, mecamylamine, neurologic agents, and methotrexate. Avoid if pregnant or breastfeeding.
Moxibustion : Moxibustion is a therapeutic method in traditional Chinese medicine, classical (five element) acupuncture, and Japanese acupuncture. During the therapy, an herb (usually mugwort) is burned above the skin or on the acupuncture points in order to introduce heat into an acupuncture point and alleviate symptoms. There is limited evidence suggesting that moxibustion may help treat hives. Additional research is needed to evaluate the safety and efficacy of moxibustion for this use.
Use cautiously over large blood vessels and thin or weak skin. Avoid with aneurysms, any kind of "heat syndrome," heart disease, convulsions, cramps, diabetic neuropathy, extreme fatigue and/or anemia, fever, or inflammatory conditions. Avoid use over allergic skin conditions, ulcerated sores, skin adhesions, or inflamed areas or organs. Do not use on contraindicated acupuncture points, the face, genitals, head, or nipples. Use cautiously in patients who have just finished exercising or taking a hot bath or shower. Use cautiously in elderly people with large vessels. Not advisable to bathe or shower for up to 24 hours after a moxibustion treatment. Avoid if pregnant or breastfeeding.
Peppermint oil : Peppermint is a flowering plant that grows throughout Europe and North America. Peppermint is usually grown for its fragrant oil. Historically, peppermint has been used to treat hives. Further research is needed to determine whether peppermint is safe and effective for this use.
Avoid if allergic or hypersensitive to peppermint or menthol. Peppermint is generally considered safe in non-allergic adults when taken in small doses. Use cautiously with G6PD deficiency or gallbladder disease. Menthol, which makes up part of peppermint oil, is generally considered safe in non-allergic adults. However, doses of menthol greater than 1 gram per kilogram of body weight may be deadly in humans. Avoid if pregnant or breastfeeding.
Probiotics : Probiotics are beneficial bacteria that are sometimes called friendly germs. They help maintain a healthy intestine and help the body digest foods. They also help keep harmful bacteria and yeasts in the gut under control. Most probiotics come from food sources, especially cultured milk products. Although probiotics have been suggested as a possible treatment for hives, there is insufficient scientific evidence on its safety and efficacy for this use.
Probiotics are generally considered safe and well tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant.
Avoid products that contain nickel: The only way to prevent allergy symptoms from recurring is to avoid nickel. The metal is present in many products that are commonly used. Patients should avoid or minimize contact with silver coins, keys, jewelry (necklaces, earrings, bracelets, rings, and watchbands), belt buckles, zippers, buttons, bra hooks, suspender clips, pens, hair clasps, electrical shavers, paperclips, and power tools that contain nickel.
Patients can purchase alternative products that are not made from nickel. For instance, patients can safely use colored paper clips that are coated with plastic. Patients can wear hypoallergenic, stainless steel, solid gold, sterling silver, or plastic jewelry. Patients should look for clothing with plastic-coated or painted metal zippers, buttons, or clasps.
Avoiding foods that contain nickel: Some healthcare providers may recommend that patients avoid eating food that contains high amounts of nickel (such as salmon, chocolate, nuts, grains, or canned fruits and nuts). However, it remains unclear whether these foods can trigger an allergic reaction. Further research is needed before a firm conclusion can be reached.
Creating a barrier: If contact with nickel is unavoidable, patients can wear plastic gloves. For instance, patients who are cashiers and handle silver coins regularly may benefit from gloves. Also, if a patient is unsure whether a piece of jewelry, hair clasp, zipper, or other similar product contains nickel, clear nail polish can be applied to the item. This creates a barrier between the patient's skin and the product. Patients can also purchase plastic covers for earrings that contain nickel. These covers, available at jewelry stores, prevent the nickel from touching the skin and causing an allergic reaction.
This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).
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