At first the rash didn't bother her, said Julia Omiatek, recalling the itchy red bumps that suddenly appeared one day on her palm, near the base of her first and third fingers.
It was January 2013 - the dead of winter in Columbus, Ohio - so when the area reddened and cracked a few weeks later, she assumed her problem was simply dry skin and slathered on some cream.
Omiatek, then 35, had little time to ponder the origin of her problem. An occupational therapist who works with adult patients, she was also raising two children younger than three.
A few weeks later when her lips swelled and the rash appeared on her face, she decided it was time to consult her dermatologist.
Skin problems were nothing new; Omiatek was so allergic to nickel that her mother had had to sew cloth inside her onesies to prevent the metal snaps from touching her skin and causing a painful irritation.
Over the years she had learned to avoid nickel and contend with occasional, inexplicable rashes that seemed to clear up when she used Elidel, a prescription cream that treats eczema.
But this time the perpetually itchy rash didn't go away, no matter what she did. Over the course of 11 months, she saw four doctors, three of whom said they didn't know what was causing the stubborn eruption that eluded numerous tests. The fourth specialist took one look at her hand and figured it out.
"The location was a tip-off," said Matthew Zirwas, an assistant professor of dermatology at the Ohio State University Wexner Medical Center who specialises in treating unexplained rashes.
Omiatek's case was considerably less severe than that of many of the approximately 300 other patients he has treated for the same problem.
"I can't tell you the number of people who come into my office with a horrible, weeping, itchy rash that's ruining their lives; it's all they can think about," he said. "And when I tell them the cause, they just burst into tears" of relief.
During her first visit to the dermatologist in February 2013, Omiatek said that the doctor looked at her hand and posed a series of questions.
He knew she had a seven-month-old baby and asked whether she might be washing her hands too much. Omiatek said she wasn't and was slightly put off by his next question: "Are you stressed?"
"Nooo," she said she replied.
The doctor told her he didn't know what was causing the rash or intermittent lip-swelling, but advised her to continue using the prescription cream.
When she asked him whether her nickel allergy might be responsible - there is nickel in some foods, including chocolate and bran - he told her that might be the cause.
Omiatek began avoiding foods containing nickel; her swollen lips improved somewhat, but the rash on her hand did not.
A month later, she decided to consult a family medicine physician who specialises in personalised nutrition.
Omiatek said she was increasingly convinced she had a food allergy - why else would her lips swell? - and the doctor had come highly recommended. But he had no new ideas about what she might avoid eating. A month later, Omiatek went to an allergist.
The allergist performed an extensive battery of prick tests, in which tiny amounts of allergens are placed on and just under a patient's skin to see if they trigger a reaction.
Omiatek said she was tested for varieties of nuts, fruits and other foods as well as grasses and pollens; other than confirming her known allergies to mold, nickel and dandelions, the tests revealed nothing.
The allergist suggested that Omiatek see Zirwas, who heads the Contact Dermatitis Center at OSU.
Omiatek said she called the clinic and was told that patients must commit to three appointments in a single week; the first two would take about two hours each.
Given her work schedule and responsibilities at home, Omiatek decided that she didn't have the time; she felt confident that if she kept a diary of what she ate, she could determine what was causing her vexing skin problem.
But eight months later, Omiatek still had the rash and no answer. She scheduled a series of appointments with Zirwas and was told to bring every product that touched her skin, including shampoos, face creams, sunscreen, soap, laundry detergent and makeup.
The chemicals in the products would form the basis for patch tests Zirwas would administer to determine whether Omiatek was allergic to any of the ingredients.
As she trundled her large shopping bag brimming with bottles and vials into the clinic, Omiatek had second thoughts. "I remember thinking, 'Oh, my God, this is ridiculous," she said, as her overloaded bag ripped open in the waiting room.
Zirwas said he remembers examining Omiatek's palm and feeling certain he knew what the culprit would prove to be. "I have seen this particular scenario enough over the past five years," he said.
But first he had to be sure. Small amounts of chemicals in the products Omiatek used would be applied to the skin on her back and covered with a small patch that would be left in place for several days; an itchy rash or other reaction underneath the patch signaled an allergy.
Unlike allergies to foods, animals or natural substances, which tend to show up immediately, delayed reactions to chemicals contained in personal-care products and laundry detergents typically occur 12 hours or even a day or two after exposure, just as poison ivy does.
After 24 hours wearing 116 patches, Omiatek said, her "back started to itch really bad."
At her second appointment Zirwas examined her back, confirming his hunch: The only strong reaction Omiatek displayed was to a chemical called methyllisothiazolinone, MI for short, which is used in high concentration in hundreds of beauty and personal care products.
In Omiatek's case, MI was in the new brand of "sensitive" baby wipes she had begun using a few weeks before the hand rash erupted.
The pattern of the rash, which was on her right, dominant hand, matched the way one would use a wipe. MI was also in the dishwashing soap she used as well as in her soap and shampoo.
Luckily for Omiatek, she did not use premoistened personal wipes containing MI, as have scores of Zirwas' patients.
Most, he said, arrive in his office after months of misery. Some were convinced they had a horrible sexually transmitted disease; in fact, the rash was an allergic reaction to the wipes they had been using.
"It's like wiping with poison ivy leaves," Zirwas said. "I cannot tell you the number of people just bawling in my office because they have a horribly itchy weeping rash around their anus. They've been to doctor after doctor and no one could figure it out."
Zirwas estimates that about half of the approximately 300 MI allergy patients he has seen were using wipes. Cases of allergic reactions have also been reported in babies and young children who had been exposed to baby wipes containing the preservative, and outbreaks have been reported in Europe.
Unlike shampoo or soap that is rinsed off, the substances in toilet wipes remain on the skin, in a part of the body where evaporation does not occur.
"It gets driven into the skin, perpetuating the problem," said Zirwas, noting that it takes months for the rash to clear entirely after a patient stops using the product.
Zirwas said that manufacturers are aware of the problem, and some have pledged to remove the chemical from their products.
In a statement, Kimberly-Clark, which says that its products are safe, recently introduced an MI-free line of baby wipes. The company has pledged to remove the preservative from all its wipes by the end of this year.
The concentration of MI in some personal-care products was increased about five years ago to replace other preservatives, including formaldehyde, which have been linked to health problems.
"People thought it was going to be" an effective replacement, Zirwas said, "but around two or three years ago, we started seeing an incredible increase in the number of people allergic to it."
Omiatek said she was surprised when Zirwas told her the cause of her rash.
"I said, 'Really? I would never have suspected baby wipes.' You put them on a baby, so I figured they'd be exempt from problems."
She also learned she was allergic to the brand of "sensitive baby sunscreen" she had been using on her children, although neither child developed a rash.
Avoiding MI is easy, Zirwas said; it is listed as an ingredient on a product's label. Omiatek said she is taking no chances.
She now reads labels carefully and has stopped using all baby wipes in an attempt to avoid "funky chemicals."
- The Washington Post