A scaly rash on the hands
Cite this as: BMJ 2012;344:e2252
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We agree with Reddy et al (1) that the fingertip unit (FTU) may be useful. However, a FTU covers twice the area of a “handprint” (adult palm plus fingers) (2), not twice the area of the palm alone as suggested by Reddy et al.
A FTU (3,4) is the amount of ointment squeezed from the distal interphalangeal crease to the end of the finger. From a standard 5mm diameter tube nozzle, this weighs about 0.5g. The FTU concept can be helpful both when estimating prescription needs and when explaining to patients how much topical steroid should be used.
1. Reddy H, De Vittoris A, Wahie S. A scaly rash on the hands. BMJ 2012; 344: 46-47.
2. Long CC, Finlay AY, Averill RW. The rule of hand: 4 hand areas = 2 FTU = 1 g. Arch Dermatol 1992; 128: 1129-30.
3. Finlay AY, Edwards PH, Harding KG. “Fingertip unit” in dermatology. Lancet 1989; 2 (8655): 155.
4. Long CC, Finlay AY. The finger-tip unit – a new practical measure. Clin Exp Dermatol 1991; 16: 444-7.
Competing interests: AYF, with others, originally described the Finger Tip Unit.
Cardiff University School of Medicine, Heath Park, Cardiff CF14 4XN
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The Treasury is introducing Royal Mint nickel-plated (aRMour®) coins due to cost savings. However, it is critical that consideration is given to the potential costs to health in terms of skin disease (allergic contact dermatitis and hand dermatitis) related to nickel exposure, the financial implications to the NHS for the clinical management of affected individuals, and other costs to the taxpayer (inability of individuals to work due to nickel allergy-related hand dermatitis). There is a considerable literature to support the concerns. There has been no assessment of this by HM Treasury officials or the Royal Mint.
In the absence of responses through usual channels, under Freedom of Information the following three questions were addressed to the Royal Mint:
What is the release of nickel from the surface of the nickel-plated (aRMour®) coins (microgram/cm2/week)?
Have coin handling studies (using Royal Mint nickel-plated coins (aRMour®)) with measurements of nickel on the hands been undertaken?
Has a risk assessment been undertaken to determine the effect of exposure to nickel-plated coins (aRMour®) on those members of the UK population who have nickel contact allergy?
As anticipated, the Royal Mint has confirmed that they have no information on nickel-release from the new coins, that no coin handling studies have been undertaken and no assessment on the effects of exposure to those members of the population who have nickel allergy has been made.
However, the Swedish Riksbank has recently undertaken a review of their coinage and concluded that nickel-plated coins pose unacceptable risks to health; indeed, they will not be using nickel containing alloys in their coinage. The prevalence and implications of contact allergy to nickel in Sweden are no different to the UK.
With colleagues, one of us (IRW) met Sarah Gannaway of HM Treasury and three of her colleagues from the Royal Mint on 21st February 2012. Whilst one appreciates that HM Treasury does not have the expertise to undertake a risk assessment in relation to the potential impacts to health of the nickel-plated coins, during the discussions it was evident that the Royal Mint also does not have the competences; the representatives seemed poorly informed.
Although the Royal Mint may have adhered to all the relevant legislation and guidelines relating to the introduction of new coinage, it has proved impossible to obtain reassurance that the nickel-plated coins will have no additional potential to cause adverse effects on those members of the UK population with hand eczema (dermatitis) who have nickel contact allergy.
As the matters raised primarily relate to public health issues, perhaps Sir John Beddington, the Chief Scientific Adviser to HM Government, could be requested for a view? It should be for the public record that a competent risk assessment has formally considered the concerns.
1. Fowler JF, Ghosh A, Sung J et al. Impact of chronic hand dermatitis on quality of life, work productivity, activity impairment, and medical costs. J Am Acad Dermatol 2006; 54:448–57.
2. Josefson A, Färm G, Magnuson A, Meding B. Nickel allergy as risk factor for hand eczema: a population-based study. Br J Dermatol. 2009;160(4):828-34
3. Gawkrodger DJ, McLeod CW, Dobson K. Nickel skin levels in different occupations and an estimate of the threshold for reacting to a single open application of nickel in nickel-allergic subjects. Br J Dermatol. 2012;166(1):82-7.
4. Lidén C, Skare L, Vahter M. Release of nickel from coins and deposition onto skin from coin handling--comparing euro coins and SEK. Contact Dermatitis. 2008;59(1):31-7.
5. Swedish Riksbank REPORT FROM BANKNOTE AND COIN PROJECT Ref. no. 2008-286-ADM New banknote and coin series Formats, materials and colours MARCH 2011. http://www.riksbank.se/upload/Dokument_riksbank/Kat_sedlar/2011/SedeloMy...
Competing interests: None declared
St. John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH
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