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String players, such as violinists and, violists have been known to develop dermatitis, colloquially called “Fiddler’s Neck,” either on the submandibular region (just below the jaw) or the supraclavicular (on the neck) region. The diagnosis of Fiddler’s Neck is often made based on the patient history and through observing the musician playing his/her instrument to evaluate the contact point of the dermatitis with the instrument. Of note, the submandibular presentation, aka Fiddler’s Neck Type I, primarily refers to the irritation caused by mechanical frictional secondary to prolonged contact with the instrument’s chinrest. A barrier cushion and adjustment to more horizontal positioning of the instrument has been recommended between the chinrest and submandibular neck for the prevention and treatment of Fiddler’s Neck Type I.

The supraclavicular variant, or Fiddler’s Neck Type II, primarily occurs from contact allergy to the materials in the chinrest apparatus on the instrument. Unlike the hallmark lichenified presentation of the Type I variant, Type II usually presents as a pruritic and erythematous eczematous plaques. Type II is most associated with the nickel-releasing bracket that holds the chinrest to the instrument, although less commonly it has also been reported due to allergy to the composite woods. Patch testing can provide diagnostic confirmation of contact sensitization to the individual components and support the diagnosis of allergic contact dermatitis (ACD). Sweat is thought to accelerate nickel release from the chinrest bracket, contributing to its corrosion and increasing nickel absorption by skin. To confirm nickel release, the dimethylglyoxime (DMG) test can be used1 ( Of note, the majority of professional fiddlers meet the criteria for prolonged nickel contact, given that prolonged exposure to nickel is defined as 10 minutes on three-plus occasions within two weeks,2 which places them at increased risk for the development of nickel allergic contact dermatitis (Ni-ACD).3-5

Avoidance strategies and barrier methods such as a cloth or a rhodium-plated metal bracket chinrest have been historically recommended to prevent metal sensitization;3 though musicians may hesitate to use these barrier methods due to both cost and the possible negative effects on performance quality. Our study was designed to determine the effects of recommended nickel barrier methods on sound quality and projection of stringed instruments in order to reduce exposure and subsequent sensitization to nickel in musician populations.

A computer-recorded decibel meter and studio recorder were utilized to determine differences in sound projection. Marking tape was used to ensure that the musician stayed equidistant to the recording equipment. The professional violinist played a 45-second passage using a chinrest without a barrier method as the control. This was repeated for three subsequent trials with an orchestral mute (to intentionally decrease sound projection), a cloth on top of the original chinrest, and finally, a rhodium-plated chinrest. Maximum and average volumes of all trials and videos of the overtones displaying the relative maximum dB and number of overtones were recorded.

Figure 1. Images of the four trials stopped at the same point in the 45-second passage. Letter A depicts the control, while letter B depicts the muted trial. The cloth trial and rhodium plated trial are letters C and D, respectively.

Analysis of the video graph and dB data revealed the maximum volume for the control to be 87 dB and the muted trial to be 86 dB. The control’s average volume emitted was approximately 80 dB while the muted trial was a 76 dB. A video graph of the overtones at the same point of the musical passage showed that the muted trial had a maximum relative overtone dB of +0 dB and 15 recorded columns of overtones compared to +15 dB and 22 recorded overtones in the control (See Figure 1 and Table 1). With the cloth barrier, the decibel meter measured the maximum volume emitted to be 87 dB and the overtones video graph showed a maximum relative dB of +12 and 25 recorded overtones (See Figure 1 and Table 1). On the other hand, with the rhodium plating, the decibel meter recorded the maximum volume at 86 dB and the overtones video graph showed a maximum relative dB of +14 and 25 recorded overtones (See Figure 1 and Table 1).

Based on the above findings, the use of a cloth or a rhodium-plated metal bracket chinrest in stringed instrumentalists had no audible effect on sound quality. Therefore, these barrier methods are viable recommendations for the prevention of Ni-ACD amongst stringed-instrumentalists, as they do not sacrifice sound quality.

One potential limitation to our study was slight variation in performer exertion among the various trials. That said, the difference was not significant in the recorded maximum absolute dB in the four trials. The only major difference in the four trials was between the two controls (muted and unmuted).

Jacqueline Chen, BA and Brittanya Limone, MD, MA are with the School of Medicine, Loma Linda University, Loma Linda, CA. Sharon E. Jacob, MD is with the Department of Dermatology, Loma Linda University, Dermatology Section Chief, VA Loma Linda Healthcare System, Loma Linda, CA.

This project was funded by the generous support of the Chung Grant for Dermatology Trainees, Dermatology Department of Loma Linda University School of Medicine.

Address reprint requests to Sharon E. Jacob, MD, Department of Dermatology, Loma Linda University, Faculty Medical Offices, 11370 Anderson Street, Suite 2600, Loma Linda, CA 92354. E-mail:

SEJ is the Founder and CEO of the Dermatitis Academy, a free webucation site. The other authors have no conflicts of interest to declare.

1. Limone BA, Chen J, Jacob SE. Metal detection tests: Preventive tools for “Fiddler’s Neck” [Letter]. Ear Nose Throat J. 2017 Oct-Nov;96(10-11):E56-E57.

2. Overgaard LE, Engebretsen KA, Jensen P, Johansen JD, Thyssen JP. Nickel released from children’s toys is deposited on the skin. Contact Dermatitis. 2016 Jun;74(6):380-1.

3. Gambichler T, Uzun A, Boms S, et al. Skin conditions in instrumental musicians: A self-reported survey. Contact Dermatitis 2008;58(4):217-22.

4. Myint CW, Rutt AL, & Sataloff RT. (2017). Fiddler’s neck: A review. Ear Nose Throat J. 2017;96(2): 76-79.

5. Antico, A, Soana, R. “Nickel sensitization and dietary nickel are a substantial cause of symptoms provocation in patients with chronic allergic-like dermatitis syndromes.” Allergy & Rhinology (1):56-63. 2015 Jan.

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