Nickel Allergy - Are Your Blisters Caused by Something Other Than Too Much Practice?

[srick]

I'd like this to become AGF's definitive thread on nickel allergy. There was a post earlier in the week about cracked calluses and as you'll see, not all callus issues are caused by excessive practice. I've had to break up the text into replies - it was originally a doc file and then a pdf - so hope this works for you all.
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Part 1 of 8

Guitar Players Experiencing “Finger Rot”: maybe you are allergic to your guitar!

You’re fretting or strumming hand fingers are cracked, raw and painful. You’ve been playing too much, right? After all, we all remember John Lennon crying out, “I got blisters on my fingers!”

There may be another reason – nickel allergy.

In the following set of posts, I have tried to simplify the medical terminology. When you do go see the doctor, he/she may give you the medically correct terminology. This set of posts should NOT be considered to be medical advice. It is anecdotal. While I have a medical background, I am not a dermatologist. And, a good diagnosis cannot be done over the internet. However, I hope it helps you to organize your data so that when you do see a doctor, he/she can help you find a cure for your problem.

If you see a doctor, find someone who specializes in Occupational Medicine. Try your darndest to find a doctor experienced in treating musicians. You might want to call a local university/college that has a Fine Arts program and see if anyone on the faculty can give you a recommendation. Also, local symphonies may be able to direct you in the right direction.

And you need to approach this problem like a doctor. You need to get to a baseline and take a good history. You also need to keep a journal of symptoms and impressions… dated, please. Photos will certainly help.

[srick]

My Story (History Of Present Illness):

I started playing guitar regularly at age 53 (I am now 61). My finger problem started about two years ago. At that point, I developed cracked, blistered fingers on both hands. I had no idea what was causing it and had no idea that it was related to guitar.

Both hands were involved. The peeling involved both top and bottom surfaces of the fingers, including the nails. At one point, it felt like I would lose the nail on several fingers, I tried moisturizing creams like Eucerin and Neutrogena; medicated creams like Bag Balm; tried cortisone ointment and Benadryl ointment to no avail. I tried cyanoacrylate (Krazy Glue) surgical glues (Glu-stitch, Quick Callus and Rock tips) with limited success (In fact, they may have made the problem worse)

Confusing the issue was this: Once the multi-week cycle of swelling, cracking and peeling started, it had to run its course.

Several times, I got back to a baseline and thought the problem was solved, but it wasn’t. With each iteration of the issue, I became more observant and careful about recording the progression, location and description of the symptoms. From a baseline of health, this is what happens to me:

Phase 1: 24-36 hours after exposure, rapid proliferation of the underlying dermis (skin cells) causes my finger to swell and feel warm. What is about to happen is analogous to a boiled hot dog when it bursts its casing.

Phase 2: About 24 hours after phase 1, the overlying callus feels wiggly, as if it has detached from the underlying tissue. It is only a matter of time (2-3 days) before the callus cracks and I am left with a painful fingertip.

Illustration Captions:

Figure 1.1 Initial redness and swelling occurs 24-36 hours after exposure
Figure 2.1-2.2 Left - Note swelling around the nailbed. The finger feels “fat” Right – same finger in health

[srick]

phase3 650 px.jpg

Phase 3: This phase is painful. Up until this point, the swelling has been annoying, but not painful .Peeling occurs for the next ten days or so. Throughout the peeling/cracking stage, the fingers are raw and painful. The cracks are very deep. Healing takes place layer by layer as the dead cells (stratified squamous epithelium for you histologists) build up their layers, or what we call, the callus. The course of healing can take two weeks or more. It can take several more weeks after that to get back to a healthy finger status.

Illustration Captions:

Figure 3.1-3.4 - Clockwise from the upper left: UL – painful lesion, especially in the reddest area; UR swelling around the nailbed – note how the tip of the nail appears to begin ‘detaching’ from the underlying nailbed and the nail needed to be trimmed for comfort; LR – more of the same; LL – fingertip appearance – note how the nail shape, which is normally curved, has flattened out.

The total process can take 3-4 weeks to complete. It’s not always linear, either. Sometimes the steps get repeated several times before resolving fully. If you are tempted to play guitar before the resolution is complete, you will likely have a worse recurrence as the skin is already damaged and frail. If this is the case, consider playing with a glove.

[srick]

before-after.jpg

Images of before and after

[srick]

Diagnosing the Problem

Step Zero: Is it Really an Allergy?

Perhaps the most annoying aspect of this problem is the diagnosis. An allergic reaction can look like a dozen other things and a dozen other things can look like an allergy.

Since most of us don’t play our guitar every day, or for the same amount of time, the problem is intermittent and of varying intensity. Also, we tend to play multiple guitars: not only our own instruments, but foreign guitars at a music store or a friend’s house. There are many other reasons that your fingers may have problems. You could have: a bacterial infection, a fungal infection, diabetes, dry hands, chemical exposure or psoriasis. And I’m sure there are many more potential causes that a dermatologist can help you track down.

Step One: Establish a Baseline:

Before doing anything else, you need to establish a baseline of healthy hands. Discontinue playing any guitar for as long as it takes to establish healthy fingers again. A healthy finger has a uniform color, tissue thickness, with no peeling or layers evident. The callus should be firm and not movable. During this healing period, feel free to use hand creams like Aquaphor or Neutrogena. Wear protective gloves as much as possible, especially if you are doing heavy work or are out in the cold. Use a high-fat, glycerin bar soap (like Neutrogena) and avoid soft soap/liquid soaps (they have a high detergent content). Hand sanitizers tend to be loaded with alcohol and will sting chapped hands. You probably should avoid them if you can. A multi-vitamin can’t hurt.

Healing may take a month or more. If your hands are not healing, then stop reading and get to the doctor – this is not a problem caused by your guitar.

[srick]

Step Two: Is it the frets or is it the strings? Is it both?

Switch to Elixir Polyweb strings and only play this one guitar. They are coated with Teflon. The top strings in a set of Elixirs are uncoated, but are treated with a corrosion resistant substance. I have no idea what that substance is or if it can initiate an allergic response, but IMO, this is probably as close as we can get to hypo-allergenic strings.

Record the amount of time/date you are playing and any symptoms. Record when the symptoms occur and their nature ie) location, size, itching, redness, swelling, blistering, bleeding. Photos help.

Do this for one week. If all is ok at the end of the week, do one more week. If you have no problems, you are partway there. In this step, we have eliminated the variable of the strings.

If you still have symptoms of allergy, what’s the pattern? If you have an allergy due to nickel in the frets, your thumb (if you wrap around like me), index, middle and ring of your fretting hand will be most affected – the pinky not as much. If the allergy is due to the strings (or strings and frets), then both hands will be affected.

Guitar frets vary in their nickel content. Many fret materials contains 18% nickel. Guitar strings have varying contents of nickel, but generally in the 7% range (if it is present). Plus, many guitar strings are coated with nickel or a nickel based alloy.

Once you develop a reaction, the cycle of cell growth, cracking, peeling and healing wants to take its course. It is often a several week or month long process. If you cheat and pick up your guitar before your fingers have fully healed, you are setting yourself up for more problems. This is because sensitivity to nickel increases over time. Plus, when the skin is abraded or cracked, it’s much easier to develop an allergic reaction.

Important: Symptoms are often delayed by 24-36 hours after the exposure. You may go to Guitar Center and pick up several instruments only to find that a couple of days later you are back in the reaction cycle. Likely, you will fail to put two and two together. You may have thought you were cured and now you’re back to square one. (ask me how I know that)

Step Three: Confirming: Was it “Really” the Strings?

If no problems with two weeks of playing Elixirs, then change strings to whatever brand you prefer. Give it the two week test. If you develop the rash and cracking, you have discovered that the strings are a part of your problem. Let the hands heal and try the Elixirs again. This may be one of the many changes you will have to make in order to be able to continue playing guitar.

[srick]

Step Four: Is it the Frets?

The next step is to pick up a box of fitted nitrile surgical gloves (finger cots may also work - they are available in most pharmacies). Play with them on the fretting hand. Even though the glove takes away much of the joy of playing, the barrier will help you diagnose the problem further. If your fretting hand heals, you have found the problem – your frets.

Fret materials vary in their nickel content. There are hypo-allergenic frets (Jescar EVO), but you will need to have your instrument re-fretted. It’s an expensive cure, but it will most likely work. Not every guitar uses the same frets. Your fingers may be able to tolerate the frets on the Martin, but go crazy when you play the Taylor. This is also why it is important during diagnosis to only play one guitar. Note that the glove barrier should make this a moot point. Which brings us to:

Step Five: Is it Something Else?

The variability of the problem is maddening. While on vacation, I played my Voyage-Air daily for two weeks without any issues. When I returned to work, the problem came back within three days.

What most likely happened is this: co-factors made my problem worse. I am in the medical field and wash my hands some 30-40 times daily. Soft/liquid soap contains more detergent and likely contributed to the problem. I now use a bar soap like Dove or Neutrogena as much as possible. Also, wearing gloves all day long led to swelling of my fingers in the evening, which led to cracking of the callus. And as much as I’d like to blame all of my problems on work, work pays for my guitar habit, so work comes first!

So, if after trying the strings and trying the barrier you still have the problem, please, please, please, see a doctor.

(“A physician who treats himself has a fool for a patient” - Sir William Osler )

[srick]

My Treatment

I previously listed a bunch of ointments and treatments that didn’t work. First, if the cause of the swelling is still present in your environment, nothing is going to work. You have to start using a barrier (glove) until you figure out the problem. I recommend a nitrile or neoprene glove. BTW, Latex gloves can cause an allergy, so avoid them. It’s annoying to play with gloves, but it works.

Once the allergy is evident, I have found that a foot cream containing urea (I have used Target’s Up and Up brand) will gently soften the callus and remove the topmost layer. This has helped a lot to relieve the extent and depth of the cracking. It’s counterintuitive, but thinning and softening the callus with urea, allows it to flex and the underlying finger to swell. Urea provides a more controlled exfoliation as opposed to pumice or sandpaper.

Some websites would have you believe that you can control your nickel allergy through dietary means. I sincerely doubt that. Even if this is true, you don’t have enough information about your food’s ingredients to make a good and consistent choice as to what works and what doesn’t. There is some evidence that Vitamin D helps (from sun exposure). But, there is controversy as to whether Vitamin D capsules help much.

Over the counter cortisone ointments may or may not help; Benadryl may or may not help; Prescription strength medicines would likely work better, but again, if the cause of the allergy is not under control, then you are just covering up the source of the problem and becoming dependent on these medications.

Ultimately, I had my guitar re-fretted with JESCAR EVO wire. This alloy was originally developed for eyeglass frames and is designed to be hypo-allergenic. This, plus coated strings, has done the trick. I am very careful not to play other guitars without a glove, and if I do, I limit the playing time to a brief exposure.

Nail Care

You need to be meticulous with your nail care during an attack, especially at the corners of the nail (round the corners, but don’t trim them short). Resist the urge to peel the skin around or from under the nail – let it come off in its own time. I keep some very precise iris scissors available to gently trim any loose peeling skin. Keep your nails long enough to be seen from the palm side. Use emery boards followed by a nail stone to create a really smooth surface. Note that the emery board can abrade your skin at the fingertip, so be meticulous.

How do you find out about nickel content in Musical Instruments?

Good luck – there’s information out there and then there isn’t. Search away and you ”may” find it. Some folks have had good luck contacting manufacturers, others not so much. IMO, the frets and the strings are where the action is. I don’t think you have to worry about tuning knobs, metal plates, etc. I can go to a music store and play for a brief period of time and have no problems playing a strange guitar for a half hour or so. But the issue comes to the surface with intensity and time.

Summary

For me, the solution was to have the guitar re-fretted – a $300-$400 solution. And it was worth every penny. I hope that I have provided you with good advice and the tools to take care of the problem. Best of luck.

srick

-- END --

PS - THIS IS THE ULTIMATE CURE FOR G.A.S.! If every attractive guitar that you meet will need a re-fret in order to be played, you will become very selective about the guitars you fall in love with!

[Pitar]

Blisters? We never got any blisters. I did pass out once and came to in intensive care after fingering some coated strings. Never know what's in that coating. It isn't named Elixir for nothing.

[Wade Hampton]

Thanks for going to the effort, srick. I'm fortunate in not having that particular allergy, but I do have other allergies, so I know how frustrating it can be trying to ferret out any information about them, or to even know what's going on in the first place.

Hopefully others with the same problem you have can learn from your efforts.


Wade Hampton Miller

[Vol46]

Thanks for the In depth analysis & discussion. I have had a nickel allergy for years, diagnosed by a neighbor who was a dermatologist - he taped a nickel to my upper arm for a day & it caused a significant localized inflammation under the coin.
I am unable to wear any watch bands except stainless steel or 24K gold ( lesser gold alloys are hardened with nickel). Cheap jewelry, buckles, etc. usually contain nickel & will cause rashes, scab formation, etc. on the skin under the bracelet, chain, buckle, or whatever. I have learned over the years and generally try to avoid prolonged skin contact with any metals other than stainless or pure gold.
Knock on wood, I have not had a problem with my hands from playing guitar ( usually at least an hour a day). I have not had to re- fret my guitars, and I use Elixer nanoweb PB strings on one of my primary guitars, and John Pearse PBs on the other - usually play them on alternate days. Martin strings ( even the coated Lifespans) seem to cause more discomfort/irritation to my fingertips than either the Elixers or the John Pearse, so I don't use them, even though I like their sound - possible that they are worse for my nickel allergy.

[srick]

Vol - that's really interesting regarding the Martin strings. I had that happen with some D'Addario EJ16s a few weeks ago (uncoated). Once they oxidized, my problems lessened. A thread awhile back talked in depth about the coatings and the treatment of the wound vs. the unwound strings. I wouldn't doubt for an instant that your symptoms were related to the nickel allergy.

Best,

Rick

PS - thanks for the kind words Wade. I've been meaning to post this for well over a year and fimally got around to it.

[Paraclete]

I definitely have a problem with nickel. I didn't figure it out until I started developing sores on the sides of my head from my eyeglasses. Then the whole thing clicked for me. I don't think my allergy is severe. I have EJ16s on my acoustics, and no problems. But playing electric is a challenge for sure, as all my preferred strings have been nickel wound.

[jaymarsch]

Thanks for taking the time to post this important information. I have a sensitivity to both aluminum and nickel. The aluminum is really the worst for me. I cannot use the Ernie Ball Aluminum Bronze strings at all for obvious reasons and discovered (through experimentation since SC wouldn't confirm or deny to me the presence of aluminum in their strings) that I cannot play the Santa Cruz or the Straight Up Strings either. Nickels I can play for a bit but not every guitar every day. John Pearse Nickels seem to be the ones that give me the least problems though. I have found a good alternative in the GHS Signature Bronze strings - they have good tone. My all mahogany guitars sound great with these so I haven't had to use the nickels very much. Much better to not push the envelope when it comes to allergies.

It did take me a while to discover the allergies because at first the sensitivity feels a lot like when your fingertips are sore from playing too much or you callouses get a bit ragged. I have known about my metal allergies before playing a lot of guitar because I could never wear most jewelry without having reactions.

It is great to have a thread to reference if folks think they may be having metal sensitivity issues. Thanks again for posting!

Best,
Jayne

[srick]

Originally Posted by jaymarsch

It did take me a while to discover the allergies because at first the sensitivity feels a lot like when your fingertips are sore from playing too much or you callouses get a bit ragged.

Jayne - yes - this! Sorry to hear that the Santa Cruz strings are out of the picture. Y'know, the frets are a known quantity, but the string treatments and formulations are held close to the vest. And as you mentioned, I think that everyone's allergy profile is different. I often wonder about the uncoated strings- several months ago when we were kicking around the SCGC strings on the forum, someone authoritative confimed that most unwound strings were the same. And yes they're made with nickel.

Rick