Title: Contact Dermatitis Part One
1Contact Dermatitis Part One
- Boris Ioffe, D.O., Pharm.D.
- 08-14-06
2Irritant contact dermatitis (ICD)
- Accounts for approximately 80 of all contact
dermatitis - ICD is the result of a local toxic effect when
the skin comes in contact with irritant chemicals
such as soaps, solvents, acids, or alkalis
- This 37-year-old woman developed a contact
irritant dermatitis from obsessive-compulsive
hand washing 20-30 times a day. www.drmatlas.org
3Introduction to Irritant Contact Dermatitis
- ICD is a cutaneous inflammation resulting from a
direct cytotoxic effect of a chemical or physical
agent - Constitutes nearly 80 of occupational contact
dermatitis (OCD) - OCD is a matter of public health importance,
contributing to combined direct and indirect
annual costs (in the USA) of up to 1 billion
when accounting for medical costs, workers
compensation, and lost time from work
4Epidemiology of ICD
- The US Bureau of Labor Statistics data show that
occupational skin diseases accounted for 10 to
15 of all occupational illnesses - High-risk occupations with frequent irritant
exposure in caterers, furniture industry workers,
hospital workers, hairdressers, chemical industry
workers, dry cleaners, metal workers, florists,
and warehouse workers
5Epidemiology of ICD
- Clinical manifestations of ICD are determined by
- Properties of the irritating substance
- Host factors
- Environmental factors including concentration,
mechanical pressure, temperature, humidity, pH,
and duration of contact - Cold alone may also reduce the plasticity of the
horny layer, with consequent cracking of the
stratum corneum - Occlusion, excessive humidity, and maceration
increase percutaneous absorption of water-soluble
substances
6- Bilateral shoe irritant dermatitis resulting from
chronic occlusive footwear
7Epidemiology of ICD
- Important predisposing characteristics of the
individual include - Age, race, sex, pre-existing skin disease,
anatomic region exposed, and sebaceous activity - Both infants and elderly are affected more by ICD
because of their less robust epidermal layer - Patients with darkly pigmented skin seem to be
more resistant to irritant reactions - Other skin disease such as active atopic
dermatitis may predispose an individual to
develop ICD - The most commonly affected sites are exposed
areas such as the hands and the face, with hand
involvement in approximately 80 of patients and
face involvement in 10
8Pathogenesis of ICD
- Denaturation of epidermal keratins
- Disruption of the permeability barrier
- Damage to cell membranes
- Direct cytotoxic effects
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10Acute Irritant Contact Dermatitis
- Commonly seen in occupational accidents
- Irritant reaction reaches its peak quickly,
within minutes to hours after exposure - Symptoms include stinging, burning, and soreness
- Physical signs include erythema, edema, bullae,
and possibly necrosis - Lesions restricted to the area where the irritant
or toxicant damaged the tissue - Sharply demarcated borders and asymmetry pointing
to an exogenous cause - Most frequent irritants are acids and alkaline
solutions
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12Acute Delayed Irritant Contact Dermatitis
- Delayed inflammatory response characteristic of
certain irritants such as anthralin, benzalkonium
chloride, and ethylene oxide - Visible inflammation is not seen until 8 to 24
hours after exposure - Symptoms are more frequently burning rather than
pruritus - Sensitivity to touch and water are elicited
- This form of ICD is commonly seen during
diagnostic patch testing
13Irritant Reaction Irritant Contact Dermatitis
- Type of subclinical irritant dermatitis in
individuals exposed to wet chemical environments
such as hairdressers, caters, or metalworkers - Characterized by scaling, redness, vesicles,
pustules, and erosions - Often begins under occlusive jewelry and then
spreads over the fingers to the hands and
forearms - May simulate dyshidrotic dermatitis
14Cumulative Irritant Contact Dermatitis
- Consequence of multiple sub-threshold skin
insults, without sufficient time between them for
complete barrier function repair - In contrast to acute ICD, the lesions of chronic
ICD are less sharply demarcated - Itching and pain due to fissures of
hyperkeratotic skin are symptoms of chronic ICD - Skin findings include lichenification,
hyperkeratosis, xerosis, erythema, and vesicles
15Asteatotic Dermatitis
- Exsiccation eczematid ICD
- Seen mainly during the winter months in elderly
individuals who frequently bath without
remoisturizing - Skin appears dry with ichthyosiform scale and
patches of eczema craquele
16Traumatic Irritant Contact Dermatitis
- May develop after acute skin trauma, such as
burns, lacerations, or acute ICD - Patients should be asked if they have cleansed
with strong soaps or detergents - Characterized by eczematous lesions most commonly
on the hands, that persist - Healing is delayed with redness, infiltration,
scale, and fissuring in the affected areas
17Pustular and Acneform Irritant Contact Dermatitis
- Result to certain irritants such as metals,
croton oil, mineral oils, tars, greases, cutting
and metal working fluids, and naphthalenes - Should be considered in conditions in which
folliculitis or acneform lesions develop in
setting outside of typical acne - Pustules are sterile and transient
- Milia may develop in response to occlusive
clothing, adhesive tape, ultraviolet and infrared
radiation
Chloracne. Note heavy involvement of
retroauricular skin with comedones and cysts
18Subjective or Sensory Irritant Contact Dermatitis
- Reports of stinging or burning in the absence of
visible cutaneous signs of irritation - Response to irritants such as lactic or sorbic
acid
19Airborne Irritant Contact Dermatitis
- Develops on irritant-exposed skin of the face and
periorbital regions - Often simulates photoallergic reactions
- Involvement of the upper eyelids, philtrum, and
submental regions help to differentiate from
photoallergic reaction
20Frictional Irritant Contact Dermatitis
- Results from repeated low-grade frictional trauma
- Plays adjuvant role in ACD and ICD
- Characterized by hyperkeratosis, acanthosis, and
lichenification, often progressing to hardening,
thickening, and increased toughness
9 year old girl demonstrates a lichenified
hyperpigmented round plaque on the top of her
thumb produced by chronic thumbsucking.
www.dermatlas.org
21Pathology of ICD
- Variable mix of inflammation, necrosis of
epidermal keratinocytes, and mild spongiosis - Combination of an upper dermal perivascular
infiltrate of lymphocytes with minimal extension
of inflammatory cells into the overlying
epidermis, and widely scattered necrotic
keratinocytes is most typical picture - True features of interface dermatitis are absent,
and spongiosis should be focal or absent - Over time additional histologic findings include
acanthosis with mild hypergranulosis and
hyperkeratosis
22Acids
- Inorganic and organic acids can be corrosive to
the skin - Cause epidermal damage via protein denaturation
and cytotoxicity - Symptoms include erythema, vesication, and
necrosis - Hydrofluoric and sulfuric acid can cause the most
severe burns - Hydrofluoric acid, used in the semiconductor
industry, is able to penetrate intact skin with
subsequent dissociation in deeper tissues and
resultant liquefactive necrosis
23Acids
- Chromic acid causes ulcerations known as chrome
holes and often perforates the nasal septum - Chemical burns and irritant dermatitis from
nitric acid can cause a distinctive yellow
discoloration - In general, organic acids are less irritating
than inorganic acids - Formic acid has the greatest corrosive potential
of the organic acids
Examples of chrome holes www.cdc.gov/niosh/ocderm
24Alkalis
- Strong Alkalis include sodium, ammonium,
potassium hydroxide, sodium and potassium
carbonate, and calcium oxide - Found in soaps, detergents, bleaches, ammonia
preparations, lye, drain pipe cleaner, toilet
bowl cleansers, and oven cleaner - Often more painful and damaging than acids
- No vesicles, necrotic skin that appears dark
brown then black, ultimately becomes hard, dry,
and cracked - Alkalis disrupt barrier lips and denature
proteins with subsequent fatty acid
saponification
25Alkalis
- Cement mixed with water can cause ulcerative
damage due to alkalinity - Changes appear 8 to 12 hours after exposure
- Chronic irritant cement dermatitis may also
develop over months to years - Can accompany allergic contact dermatitis
Hand dermatitis due to contact with cement
dermnetnz.org/dermatitis/chrome
26Metal Salts
- Include arsenic trioxide, beryllium compounds,
calcium oxide, copper salts, inorganic mercury,
thimerosal, and selenium - Signs ranging from ulceration to folliculitis
27Solvents
- Act mainly by dissolving the intercellular lipid
barrier of the epidermis - Prolonged skin contact can result in severe burns
and well as systemic toxicity - Examples include turpentine, benzene, toluene,
xylene, carbon tetrachloride, gasoline, and
kerosene
28- Professional paint and crayon illustrator with
bilateral palmar dermatitis secondary to repeated
contact with paint solvents. Extensive patch
testing excluded allergic contact dermatitis
29Detergents and Cleansers
- Include any surface active agent (surfactant)
that concentrates at the oil-water interfaces and
has both emulsifying and cleansing properties - Found in skin cleansers, cosmetics, and household
cleaning products - Surfactants cause protein denaturation of the
stratum corneum, impairing barrier function - Anionic detergents such as alkyl sulfates and
alkyl carboxylate salts are the most irritating
30Disinfectants
- Include, alcohols, aldehydes, phenolic compounds,
halogenated compounds, surfactants, dyes,
oxidizing agents, and mercury compounds - Weak toxic agents that can cause chronic ICD
Practicing dentist with moderately severe
irritant hand dermatitis from chronic exposure to
disinfecting solutions and antiseptics. The
results of patch testing, latex challenge
testing, and RAST testing were negative.
31Plastics
- Three categories thermoplastics, thermosettings,
elastomers - Skin damage is attributed to monomer ingredients,
hardeners, and stabilizers - Final hardened plastic product is generally
considered inert
32Food
- Agriculture, fishing, catering, and food
processing - Often work without gloves, in damp working
conditions with frequent hand washing - Mechanical, thermal, and climatic factors
- Nearly 100 of exposed persons in food handling
and fishing professions may be affected by
chronic irritant hand dermatitis
33Water
- Ubiquitous skin irritant
- Tropical immersion foot, seen during Vietnam War
- Hairdressers, hospital cleaners, cannery workers,
bartenders - Irritancy of water is exacerbated by occlusion
9 year old is an habitual hand washer who
develops a contact irritant dermatitis every
winter. At times she washes over 10 times a day.
www.dermatlas.org
34Fabric/man-made vitreous fibers
- Fibers larger than 3.5 um in diameter cause the
highly pruritic contact dermatitis caused by
fiberglass - Erythematous papules with superimposed
excoriations on neck and dorsal hands - Wool and rough clothing cause dermatitis in
atopic individuals
Fiberglass dermatitis www.cdc.gov/niosh/ocderm
35Differential Diagnosis
- Allergic and ICD, especially in chronic stage
appear similar by clinical appearance, histology,
and immunohistology - Look identical with erythema, papules, xerosis,
scaling, and lichenification with sharp borders - ICD has remained a diagnosis of exclusion when
dermatitis is not explained by positive patch
test to a known allergen - More frequent complaint of burning and stinging
with ICD in contrast to pruritus in ACD
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37Treatment
- Avoidance of causative irritants at home or in
the workplace is the primary TX - Engineering controls to reduce exposure in the
workplace - Shielding and personal protection such as gloves
and special clothing - Pre-exposure protection by protective creams,
removal of irritants by mild cleaning agents, and
enhancement of barrier function generation by
emollients and moisturizers - Emphasizing personal and occupational hygiene
- Establishing educational programs to increase
awareness in the workplace
38TX Chemical Burns
- Initial tx irrigation with large volumes of
water, if chemical is insoluble in water a soap
solution may be used - High pressure water to be avoided to prevent
splashing - 2.5 calcium gluconate gel used to tx
hydroflouric acid burns, immediate application of
a weak acid such as vinegar, lemon juice, or 0.5
hydrochloric acid will lessen the effect of
alkali burns - Ulcerated areas should be managed with
antibacterial creams or ointments to prevent
secondary infection - Frequent evaluation is required because ulcers
may progress over several days - Excision, debridement and/or grafting may speed
healing - Monitoring of blood, liver, and kidney function
may be needed when exposed to chemicals with
potential for systemic toxicity such as
hydrofluoric acid, phenolic compounds, chromic
acid, and gasoline
39Chronic ICD Treatment
- Tx goal is to restore normal epidermal barrier
function - Topical corticosteroids frequently used
- Systemic corticosteroids although helpful in
reducing inflammation, are not useful in
treatment of chronic ICD unless offending
contactants are avoided - PUVA and Grenz ray considered for chronic
dermatitis that does not respond to other tx - Hyperkeratotic palmoplantar dermatitis from
frictional or chronic ICD may benefit from the
adjunctive use of systemic retinoids such as
acitretin
40Allergic contact dermatitis (ACD)
- ACD accounts for approximately 20 of all contact
dermatitis - ACD is a type IV, delayed or cell-mediated immune
reaction that is elicited when the skin comes in
contact with a chemical to which an individual
has been previously sensitized - Synonyms include contact dermatitis and contact
eczema
- Allergic contact dermatitis. Linear streaks seen
with ACD to poison ivy.
41ACD
- Key Features
- ACD is a pruritic, eczematous reaction
- Acute ACD and many cases of chronic ACD are well
demarcated and located to the site of contact
with the allergen - Prototypic reactions are ACD due to poison ivy
and nickel - Patch testing remains the gold standard for
accurate and consistent diagnosis
This healthy adolescent developed an intensely
pruritic vesiculobullous allergic contact
dermatitis from hair dye. Dermatlas.org
42- Classic picture of ACD is a well-demarcated
erythematous vesicular and/or scaly patch or
plaque with well defined margins corresponding to
the area of contact
- Chronic allergic contact dermatitis leading to
hand dermatitis. This golfer wore one leather
glove and had positive patch tests to potassium
dichromate and a piece of his glove. Courtesy of
Kalman Watsky, M.D.
43- Allergic contact dermatitis to leather shoes.
Note the correspondence to sites of exposure.
Courtesy of Yale Residents Slide Collection.
44- Because ICD and ACD are not always discernable
clinically, patch testing is required to help
identify an allergen or exclude an allergy to a
suspected allergen.
- Allergic contact dermatitis. Chronic hand
dermatitis due to ACD to mercaptobenzothiazole
found in rubber gloves
45Epidemiology of ACD
- Affects the old and young, individuals of all
races, and both sexes - Differences in genders usually based on exposure
patterns, such as nickel allergy being seen more
frequently in women, presumably due to greater
exposure to jewelry - Occupations and avocations play an important role
- Allergens differ from region to region, e.g.
preservatives used in personal care products can
vary based on government legislation
46Pathogenesis of ACD
- ACD is a type IV hypersensitivity response
- Requires prior sensitization to the chemical in
question - Subsequent re-exposure of individual leads to
allergen being presented to a primed T-cell
milieu leading to release of numerous cytokines
and chemotactic factors leading to the clinical
picture of eczema - Once sensitized a low concentration of causative
chemical elicits a response
47- Induction of contact hypersensitivity.
Application of contact allergens (Ag) induces the
release of cytokines by keratinocytes, Langerhans
cells and other cells within the skin. These
cytokines in turn activate Langerhans cells which
uptake the antigen and emigrate into the regional
lymph nodes. During this process, the Langerhans
cells mature into dendritic cells. In addition,
the antigen is processed, re-expressed on the
surface and finally presented to naïve T cells in
the regional lymph node. Upon appropriate antigen
presentation, T cells bearing the appropriate T
cell receptor clonally expand and become effector
T cells. These alter their migratory behavior due
to the expression of specific surface molecules
like CLA. Effector T cells recirculate into the
periphery where they may later meet the antigen
again. Ag, antigen KC, keratinocyte.
48- Elicitation of contact hypersensitivity.
Application of contact allergens (Ag) into a
sensitized individual causes the release of
cytokines by keratinocytes and Langerhans cells.
These cytokines induce the expression of adhesion
molecules and activation of endothelial cells
which ultimately attracts leukocytes to the site
of antigen application. Among these cells, T
effector cells are present which are now
activated upon antigen presentation either by
resident cells or by infiltrating Langerhans
cells. Antigen-specific T cell activation again
induces the release of cytokines by T cells. This
causes the attraction of other inflammatory cells
including granulocytes and macrophages which
ultimately cause the clinical manifestation of
contact dermatitis. Ag, antigen DDC, dermal
dendritic cell KC, keratinocyte CLA, cutaneous
lymphocyte antigen.
49Clinical features of ACD
- Acute blistering and weeping
- Chronic lichenified and scaly plaques
- Patchy and diffuse distributions may be seen with
body washes and shampoos
- Acute bullous allergic contact dermatitis due to
poison ivy. This distribution is seen in patients
who wear gloves. Courtesy of Yale Residents Slide
Collection
- Chronic allergic contact dermatitis due to
glutaraldehyde. The patient was an optometrist
50Pathology of ACD
- ACD is the prototype of spongiotic dermatitis
- Acute stage variable degree of spongiosis with
mixed dermal inflammatory infiltrate containing
lymphocytes, histiocytes, and variable numbers of
eosinophils - Moderate to severe reactions show intraepidermal
vesiculation - Subacute to chronic stages have epidermal
hyperplasia, often psoriasiform
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52DDX of ACD
- Includes many forms of dermatitis ICD, atopic
dermatitis, stasis dermatitis, and seborrheic
dermatitis, as well as the erythematous form of
rosacea - Hand and foot ACD need to be distinguished from
psoriasis and tinea - Widespread disease needs to be differentiated
from other causes of erythoderma, Sezary syndrome
53Patch Testing
- Simple office procedure upon which the diagnosis
of ACD often rests - Although the procedure is simple, deciding when
and what to test for requires training and
experience - Patch testing is underutilized
- Only 50 of all residency programs in USA have a
patch - test center
- Past surveys show 27 of the responders did no
patch testing
54Patch Testing
- TRUE Test
- Other panels include North American Contact
Dermatitis Group (NACDG) Screening Series, and
the European Standard Series - Other panels are unique to specific occupations
such as hairdressing tray, dental tray, and
florist tray
55True Test
- Preimpregnated test that screens for 23 allergens
- Extending testing beyond these 23 allergens has
shown to be more beneficial - In three studies, extended testing detected
37-76 more positive reactions, and 47.3 of
patients had positive reactions only to
non-screening allergens - Additional allergens come in multiuse syringes
Application of TRUE test. www.truetest.com
- Allergens contained within syringes being placed
by nurse into Finn chambers
56Pre-Patch Testing Questions
- Exposures both at work and home to understand
mechanics of the work environment, Materials
Safety Data Sheets (MSDS) can be helpful for
workplace exposures - Effect of vacations and time away form work or
home should be ascertained - All personal care products should be inventoried
- All hobbies should be explored
57Patch Testing
- Chemicals brought in by patients should not be
tested blindly, physician should be aware of the
chemical ingredients because severe burns or
ulceration may occur - Leave on personal care products such as
moisturizers and make-up may be tested as is - Rinse off products such as soaps or shampoos
need to be diluted prior to patch testing
58Patch Testing
- Most common site is the upper back
- Patients should not have a sunburn in test area,
and should not apply topical corticosteroids to
the patch test sites for 7 days prior to test - Systemic corticosteroids should be avoided for 1
month prior to testing - Patches are applied to back and reinforced with
Scanpor tape, patient instructed to keep back dry
and patches secured until second visit at 48 hours
- Fixing allergens to patient's back using Scanpor
tape.
59Patch Testing
- When the patient returns in 48 hours the patches
need to be inspected to ensure that the testing
technique is adequate - As patches are removed their sites of
application should be marked in order to
identify the locations of particular allergens
60Patch Test Scoring
- A positive patch test reaction to nickel. This is
an example of a 3 reaction
61Patch Testing
- Patient again asked to keep back dry until second
reading, done from 72 hours to 1 week after the
initial application of the patches - This delayed reading is necessary due to patch
test responses to some allergens such as gold
having a delayed reaction
62Repeat Open Application Test (ROAT)
- Poor mans patch test
- Patient applies the product in question to the
same location (where there is not dermatitis),
e.g. antecubital fossa, BID for 1-2 weeks - If dermatitis develops, it can be concluded that
the patient is reacting to the product - Downside to this approach is that individual
problem ingredients are not identified
63Treatment and Patient Education
- Once allergens are positively identified, patient
should be given written information on all of
these chemicals - Patient should be instructed on how to read
labels on old or new products to avoid future
exposure
64Treatment of ACD
- Involves identification of causative allergens
- Clear the dermatitis with topical, or if
necessary systemic corticosteroids - Complete and prolonged clearing can take up to 6
weeks or more, even when allergens are being
avoided
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66Nickel
- Most common allergen tested by the NACDG, with
14 of patients reacting to it - Relevance has been estimated to be 50
- Commonly used in jewelry, buckles, snaps, and
other metal-containing objects - High rate of sensitivity attributed to ear
piercing - Dimethylglyoxime test to determine if a
particular item contains nickel - Individuals with nickel allergy should avoid
custom jewelry, and can usually wear stainless
steel or gold
67Nickel Dermatitis
- Common presentations are dermatitis on the ears,
under a necklace or a watch back, or on the
mid-abdomen caused by a belt buckle, zipper, or
snap - Eyelid dermatitis from metal eyelash curlers can
be seen
- Photos from dermatlas.org
68Neomycin Sulfate
- Most commonly used topical antibiotic
- Most common sensitizer among topical antibiotics
- Found in many OTC preparations bacterial
ointments, hemorrhoid creams, and otic and
opthalmic preparations - Frequently used with other antibacterial agents,
such as bacitracin and polymyxin, as well as
corticosteroids - Co-reactivity is commonly seen with neomycin and
bacitracin
13 year old boy developed an itchy allergic
contact dermatitis from a topical antibiotic.
www.dermatlas.org
69Balsam of Peru
- Naturally occurring fragrance material
- Prior to introduction of fragrance mix in the
1970s, balsam of Peru was used to screen for
fragrance allergy - Capable of identifying 50 of those allergic to
fragrance - Seen in those with allergies to spices, in
particular cloves, Jamaicin pepper, and cinnamon - Patients with a positive reaction need to avoid
fragrances, occasionally spices, and other
sources such as colas, tobacco, wines, and
vermouth
70Fragrance Mix
- Contains eight different components cinnamic
etoh, cinnamic aldehyde, hydroxycitronellal,
isoeugenol, eugenol, oak moss absolute,
alpha-amyl cinnamic aldehyde, and geraniol - Detects 70-80 of fragrance allergies
- Patients need to read product labels and avoid
anything that lists a fragrance, is labeled
unscented, or has an obvious scent - Patients need to look for fragrance-free
products
- ACD to fragrance found in cologne. A Patient with
ACD to fragrance found in his cologne. B Patient
after avoidance of fragrances and his cologne.
71Thimerosal
- Thimerosal is a combination of thiosalicylic acid
and ethylmercuric chloride, and is used as a
preservative - Most sensitization may be due to its use as a
preservative in vaccines - Other exposures include contact lens solution,
otic and opthalmic solutions, antiseptics, and
cosmetics - Positive reactions are common, relevance is low
and therefore routine testing to this allergen
should be reconsidered
72Gold
- NACDG found a positive rate of 9.5
- NACDC found 90 of gold-allergic patients were
women, and there was a higher rate of nickel
(33.5) and cobalt allergy (18) in this group - Most common clinical picture is hand, facial, or
eyelid dermatitis - Systemic reactions to gold in patients whom it
was used to tx RA, SLE, or pemphigus. - Cutaneous findings of lichen planus-like
reactions to pityriasis rosea-like reactions and
papular eruptions with systemic reactions
73Formaldehyde
- Is a ubiquitous, colorless gas found in the
workplace, cosmetics, medications, textiles,
paints, cigarette smoke, paper, and formaldehyde
resins in plastic bottles - Commonly seen in association with
formaldehyde-releasing presevatives, such as
quarternuim-15 imidazolidinyl urea, diazolidinyl
urea, DMDM hydantoin, 2-bromo-2-nitropropane-1-3,d
iol, and tris(hydroxymethyl)nitromethane - ICD is most common, ACD, contact urticaria, and
mucous membrane irritation can occur - Textile dermatitis due to formaldehyde resins in
wash-and-wear and wrinkle resistant clothes - Another source of formaldehyde is
formaldehyde-free products that are packaged in
containers coated with formaldehyde resins - So widespread that avoidance is difficult and
clinical relevance should be determined
74Quaternium-15
- Preservative that is an effective biocide against
Pseudomonas, as well as other bacteria and fungi - Most common preservative to cause ACD
- Found in shampoos, moisturizers, conditioners,
and soaps - 80 of those reacting to quarternium-15 are also
formaldehyde sensitive
Hand dermatititis due toquaternium-15 in a
moisturiser dermnetnz.org/dermatitis/quaternium
75Cobalt
- Metal that is used in association with other
metals to add hardness and strength - Frequently combined with nickel, chromium,
molybdenum, and tungsten - 80 of individuals with a cobalt sensitivity have
a co-sensitivity to chromate (more common in men)
or nickel (more common in women) - Exposure through jewelry snaps, buttons, tools,
cosmetics, hair dyes, joint replacements,
ceramics, enamel, cement, paints , and resins
76Bacitracin
- Topical antibiotic with activity against
Gram-positive bacteria and spirochetes - Commonly used in combination with other
antibiotics such as neomycin and with
corticosteroids - In addition to ACD, also rarely causes
anaphylaxis and contact urticaria
Chronic ulcerations on the lower extremity are
particularly likely to develop allergic contact
dermatitis. This eruption resulted from
sensitization to bacitracin. www.worldallergy.org
77Corticosteroids
- Have been shown to cause ACD in anywhere from
0.2 to 5.98 - It is suspected that ACD to these agents is
underdiagnosed, due to insufficient testing - Clinical scenarios that should raise suspicion
include chronic dermatitis, failure to clear
with corticosteroids, and exacerbations of
dermatitis after use of corticosteroids - Tixocortol-21-pivalate and budesonide used for
screening, with 91.3 of corticosteroid allergic
reactions detected - Complicates patch test interpretation, due to
edge effect (first reading may have erythema only
at the rim of the Finn chamber)
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79Systemic Contact Dermatitis
- Systemic exposure to a chemical may result in a
diffuse dermatitis - Patient has had a prior contact allergy and then
becomes exposed through a systemic route, such as
injection, oral, intravenous, or intranasal
administration - One of most common examples is patient with
ethylenediamine allergy and subsequent reaction
to aminophylline
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81Airborne Contact Dermatitis
- Airborne allergens result in several different
reactions including ICD and ACD - PhotoACD, photoICD, photoxicity, and photoallergy
to systemic medications clinically resemble
airborne contact dermatitis - Ragweed dermatitis is a classic example
- Clinically, lichenified and dry skin located in
the exposed portions of the skin face, V of the
neck, arms and legs - Most common causative agents are plants, natural
resins, woods, plastics, rubbers, glues, metals,
pharmaceutical chemicals, insecticides and
pesticides
8255-year-old farm worker developed a chronic
allergic contact dermatitis to airborn allergens
(compositae).
83Anacardiacea Dermatitis
- Poison Ivy vine growing up a tree
www.dermatlas.org
84Anacardiacea ACD
- Members of the Anacardiaceae cause more contact
dermatitis that all other plant families combined - Most allergenic members belong to the genus
Toxicodendron, including poison ivy, poison oak,
and poison sumac - Tocicodendron leaves are compound, possessing
three or more leaflets. Flowers and fruit arise
in an axillary positions in the angle between the
leaf and the twig from which it arises - Black dots of urushiol often present on leaves
and fruit
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86Anacardiacae Allergens
- Urushiol derives its name form the Japanese word
for the sap (kiurushi) of the Japanese lacquer
tree - Urushiol contains a mixture of catechols
(1,2-dihydroxybenzenes) and resorcinols
(1,3-dihydroxybenzenes) - Urushiol self-melanizes on exposure to oxygen
- Avidly binds to skin but is readily degraded by
water
- Poison Ivy www.dermatlas.org
87Clinical Features Anacardiacea Dermatitis
- Damage is generally required for plants to
release urushiol - In late fall plants release urushiol
spontaneously - Urushiol may be spread by contaminated clothing,
dogs, cats, lacquered furniture, sawdust, and
smoke - Allergen-containing smoke can cause severe
respiratory tract inflammation, severe
dermatitis, and even temporary blindness
88Clinical Features Anacardiacea Dermatitis
- After contact with urushiol, a sensitized person
typically develops and pruritic , erythematous
eruption within 2 days (4-96 hours) that peaks
within 1-14 days - Dermatitis may last up to 3 weeks after primary
contact or within hours of secondary contact - Streaks of erythema and edematous papules
typically precede vesicles and bullae - Although ACD is the most common cause of streaky,
vesicular dermatitis, plants may cause this same
picture by other means e.g. chemical irritant
dermatitis, or the initial phase of
phytodermatitis
89- Clinical manifestations of Anacardiaceae
dermatitis. A Acute, streak-like edematous and
erythematous dermatitis without vesicles after
poison ivy brushed across the face. Courtesy of
Fitzsimons Army Medical Center Dermatology slide
teaching library. B Acute, streak-like vesicular
dermatitis after poison ivy (Toxicodendron
radicans) contact. Courtesy of Fitzsimons Army
Medical Center Dermatology slide teaching
library. C Widespread erythema and edema
associated with intense pruritus after carrying
logs of the poisonwood tree (Metopium toxiferum)
of the family Anacardiaceae. D Black-spot
poison ivy dermatitis note the black
discoloration in the central portion of the
edematous plaques due to plant resin.
90Clinical Features Anacardiacea Dermatitis
- Eruption progresses to new areas because of
variability in antigen concentration and stratum
corneum/epidermis thickness, not because of
bullae fluid - Over 70 of the US population reacts to poison
ivy allergens after patch testing, but only 50
react to plants in the field - Only 15 atopic patients are sensitive to poison
ivy - Uncommonly, eruptions resemble erythema
multiforme, measles, scarlatina, or urticaria - Prolonged postinflammatory hyperpigmentation may
occur in darkly pigmented individuals
91Treatment
- Entire body should be washed with copious amounts
of water as soon as possible after exposure - Soap may be used afterwards, but early use of
soap may expand the area of resin on the body - As mentioned before, urushiol is water
degradable, After 10 minutes only 50 can be
removed, after 15 minutes only 25 can be
removed, after 30 minutes only 10 can be
removed, and after 60 minutes none of it can be
removed
www.dermatlas.org
92Treatment
- Weepy lesions are best treated with tepid baths,
wet-to-dry soaks, or bland shake lotions
(calamine) - Stringent such as Burows solution (aluminum
subacetate) works to cool and dry lesions when
applied as a wet-to-dry dressing - Topical antihistamines, anesthetics containing
benzocaine, and antibiotics should be avoided to
prevent sensitization
93Treatment
- Most potent topical corticosteroids only help if
applied during the earliest stages of the
outbreak, when vesicles and blisters are not yet
present - Systemic steroids are effective when given at a
dose of 1-2 mg/kg/day, slowly tapered over 2-3
weeks - Many patients are referred for a recurrence of
their poison ivy dermatitis after completing a
short, 6 day course of oral corticosteroids - Oral antihistamines may decrease pruritus