Chandler W. Rundle, Sharon E. Jacob
  1. School of Medicine, Loma Linda University, Loma Linda, CA, USA
  2. Department of Medicine (Dermatology), Veterans Affairs Hospital, Loma Linda and Department of Dermatology, Loma Linda University, Loma Linda, CA, USA

Correspondence Address:
Sharon E. Jacob
Department of Medicine (Dermatology), Veterans Affairs Hospital, Loma Linda and Department of Dermatology, Loma Linda University, Loma Linda, CA, USA


Copyright: © 2016 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Rundle CW, Jacob SE. Nickel release and surveying in surgical clip alopecia. Surg Neurol Int 26-Oct-2016;7:97

How to cite this URL: Rundle CW, Jacob SE. Nickel release and surveying in surgical clip alopecia. Surg Neurol Int 26-Oct-2016;7:97. Available from:

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We read with interest the article by Ono et al. in which a woman experienced onset of redness, itching, and focal hair loss 3 weeks after clipping surgery of her cerebral aneurysm.[ 3 ] It was noted that the four metal pins of the Sugita head holder contain allergens such as cobalt, nickel, chromium, and mercury. It was later determined that the woman had a history of contact dermatitis to metal jewelry, supporting the nickel in the etiology.

While this patient did not receive confirmatory patch testing, the authors made several key observations that are notable because contact alopecia is a rarely reported entity. First, the eczematous inflammatory response preceding the alopecia is a hallmark of contact alopecia. Whereas, in alopecia areata, round, smooth patches occur where hair once was. Second, the authors astutely state that the symptoms occurred 3 weeks after the surgery and re-growth occurred at 6 months; this time course of contact associated telogen effluvium has been previous described by Tosti et al.[ 4 ]

That said, it is important (and easy) to test that nickel release from the surgical stainless steel in question to have a more definitive answer. While the percentage of nickel in the alloy is important, the amount of free release nickel in direct and prolonged contact is critical [ Table 1 ].[ 2 ] We suggest surgical metals including stainless steel be tested for free nickel release using the dimethylglyoxime (DMG) nickel spot test. DMG, often dissolved in ethanol, is a colorless liquid in its unchelated state. When two molecules come into contact with a free nickel ion, a chelate forms that is red/pink in color [Figures 1 and 2 ]. The higher the releasable amount of nickel, the greater the pink precipitate.[ 1 ] We do agree that patch testing is the gold standard for diagnostic confirmation of sensitization, but have also had patients refuse the testing.

Table 1

Grades of stainless steel and their compositions


Figure 1

Reaction of dimethylglyoxime with free nickel ion


Figure 2

Dimethylglyoxime test in a paper clip


Financial support and sponsorship

Loma Linda School of Medicine for support in publication fees.

Conflicts of interest

There are no conflicts of interest.


1. Herro EM, Jacob SE. A nickel for your thoughts: determining relative nickel content using an analog color scale. Dermatitis. 2012. 23: 183-4

2. Mehta V, Vasanth V, Balachandran C. Nickel contact dermatitis from hypodermic needles. Indian J Dermatol. 2011. 56: 237-8

3. Ono H, Takasuna H, Tanaka Y. Alopecia due to an allergic reaction to metal head-pins used in a neurosurgical operation. Surg Neurol Int. 2016. 7: S5-7

4. Tosti A, Piraccini BM, van Neste DJ. Telogen Effluvium After Allergic Contact Dermatitis of the Scalp. Arch Dermatol. 2001. 137: 187-90


Hajime Ono
  1. Division of Neurosurgery, St. Marianna University School of Medicine, Toyoko Hospital, Kanagawa, Japan E-mail:

Metal allergy in the medical field

I read a very interesting report regarding the accuracy of the dimethylglyoxime (DMG) nickel spot test by the authors. Basically, the patch test is the most important inspection item for the evaluation of allergic patients. In addition, DMG nickel spot test[ 2 ] can be added to the evaluation of medical equipment. It is an effective inspection method in the medical field.

Even in SUS316L, nickel is present in the content of 12–15%. In patients with metal allergy, the possibility of allergic reactions.

Therefore, considering the frequency of occurrence of metal allergies in patients, allergic reactions caused by medical instruments seems to occur more often.

In the European Union countries, the nickel content of medical stainless steel has been severely limited as a countermeasure for serious metal allergies; it cannot be sold as medical biological material if it is not tailored according to the criterion.[ 1 ]

In other words, there are no legal restrictions on nickel allergy in Japan; there is a gap in the regulation compared with other countries. Standard maintenance and management of nickel-free stainless steel is not determined as a national policy. It is necessary to establish a global criterion for metal allergy, including medical equipment in the future.

Finally, I emphasize that checking the history of a patient's allergy is most important as a method of preventing the metal allergic reaction in the medical field.


1. Garg S, Thyssen JP, Uter W, Schnuch A, Johansen JD, Menné T. Nickel allergy following European Union regulation in Denmark, Germany, Italy and the U.K. Br J Dermatol. 2013. 169: 854-8

2. Thyssen JP, Skare L, Lundgren L, Menné T, Johansen JD, Maibach HI. Sensitivity and specificity of the nickel spot (dimethylglyoxime) test. Contact Dermatitis. 2010. 62: 279-88

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