Heavy Metal Is Not for Everyone: Skin Allergies and the Professional Musician

December 30, 2019

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The professional musician has much to contend with in terms of health. The grind of sitting and standing for prolonged periods of time and holding an instrument in contortionist fashion naturally results in daily aches and pains. Equally problematic—though much less examined—are skin ailments.

Because of the intensity of repeated rehearsals and performances, orchestral players are among the most susceptible to various types of skin issues. The composition of string instruments such as cellos, violas, violins, and the products used with these instruments may contain allergens that cause contact dermatitis.

For reed instruments—bassoon, clarinet, oboe, and saxophone—cane reeds, chromium, cobalt, nickel, and exotic woods are all culprits. For strings, add to the list paraphenylenediamine (staining agent for wood), rosin (or colophony), and propolis (a component of Italian varnishes used in all Stradivarius violins). 

The cloth that some violinists and violists use over their chin rest provides a barrier to an allergic wood component, namely rosewood or ebony. Chronic exposure to nickel sulfate in the bracket of the chinrest also may cause callosities (fiddler’s neck) or a blemish-like mark on the left side of the neck, below the angle of the jaw. Often referred to as a battle scar, mark of greatness, “violin hickey,” or in medical terms, erythema, the wound and subsequent scarring can be problematic, especially for young players just developing their form. For the professional (or would-be professional), custom-fitted chin rests are an important investment. In addition, a shoulder rest may be recommended to reduce pressure below the jaw.

Beyond the natural and temporary irritation that can occur after extended playing sessions, cheilitis (inflammation of lips) can lead to long-term problems for clarinetists, trumpeters, horn and harmonica players, who are either sensitive to or allergic to nickel and chromate. Saliva and sweat between the skin/lip and mouthpiece contribute to the release of metal from the mouthpiece. The condition can be significantly improved by replacing the mouthpiece, such as substituting a nickel mouthpiece for one made of gold. Less expensive options include brass and non-metal wood or plastic mouthpieces, which have additional advantages. They are less likely to freeze or burn the lips in very cold or hot environments. 

Flutists have their own issues. The flute rests on the chin, often leaving increased pigmentation, a black mark or an acne-like rash. It’s what some flutists affectionately call the “Flutist’s Goatee.” To reduce the potential for an allergic reaction, seasoned flutists suggest leaving the part of skin that comes into contact with the flute free of all products, including moisturizer. You could also use a headjoint with a gold or wood lip plate. Another simple fix: lip plate patches. These are simple decals with a mild adhesive backing that attach to the lip plate.

Allergic reactions to composite wood are not unusual, especially since component materials are exotic woods. One study describes the case of a recorder player who presented with an erosive cheilitis (eczema) of one third of his lower lip. When a patch test to sawdust (10% in petrolatum) from the wooden recorders was performed, the result was positive reactions to African blackwood (Dalbergia melanoxylon) and rosewood that resulted in a cross reaction.

In cases of reed allergies, patch testing/prick testing can be performed using fine shavings from a cane reed. (The reed, made from Arundo donax, belongs to the family Gramineae, subfamily Poaceae.) Research suggests that the reaction is due to cross-reactivity with allergens causing grass pollen allergies. Simply replacing the cane reed with a plastic one showed rapid improvement in reported cases. (It should be noted that synthetic reeds may lack the warm register a player gets from natural cane. That said, synthetic reeds are a durable and consistent alternative.)

Treating Contact Dermatitis

• At the first sign of irritation, seek early intervention and evaluation by a dermatologist. Specific tests can quickly indicate whether it’s simply an irritant or an allergen.
• Treatment, along with modifying playing technique, can reduce further damage.
• It’s recommended to suspend playing the instrument while skin heals.
• Topical corticosteroids or calcineurin inhibitors, such as tacrolimus or pimecrolimus, allow the dermatitis to heal.
• If the musician has irritant contact dermatitis caused by friction or pressure, modifying the area of contact with the instrument, such as wearing protective gloves, may help improve the condition.
• If allergic contact dermatitis is the culprit, substituting the offending component of the instrument with another material is recommended. For example, mouthpieces and guitar strings are available in different compositions.
• If a change is not made, the dermatitis will recur more rapidly with each exposure.
• Keep instruments clean and replace worn or damaged parts in intimate contact with the body.
• Reeds and mouthpieces should never be shared.

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