Contact Dermatitis, Emergency Medicine

Basics

Description

Irritant:
- Immediate eczematous eruption (superficial inflammatory process primarily in epidermis)
- Most common type of dermatitis
- Trigger substance itself directly damages the skin resulting in nonimmunologic inflammatory reaction with erythema, dryness, cracking, or fissuring
- Usually owing to repeated exposure to mild irritant (e.g., water, soaps, heat, friction)
- Lesions itch or burn:
  - Usually gradual onset with indistinct borders
  - Most often seen on hands
  - May see vesicles or fissures
  - Dry, red, and rough skin
  - Common irritants include cement, hair dyes, wet diapers, rubber gloves, shampoos, frequent hand washing
Allergic:
- Delayed (type IV) hypersensitivity reaction (requires prior sensitization)
- Allergen-induced immune response
- Local edema, vesicles, erythema, pruritus, or burning
- Usually corresponds to exact distribution of contact (e.g., watchband)
- Onset usually within 12-48 hr with prior sensitization; may take 14-21 days for primary exposure
- Common sources: Nickel, gold, neomycin, bacitracin, preservatives, fragrances, dyes, poison ivy
Photocontact:
- Interaction between an otherwise harmless substance on the skin and UV light
- Common sources: Shaving lotions, sunscreens, sulfa ointments, perfumes.

Allergic contact dermatitis is less frequent in children, especially infants, than in adults
Major sources of pediatric contact allergy:
- Metals, shoes, preservatives, or fragrances in cosmetics, topical medications, and plants
- Diaper dermatitis: Prototype for irritant contact dermatitis in children
Circumoral dermatitis: Seen in infants and small children; may result from certain foods (irritant or allergic reaction)

Etiology

Irritant (80% of contact dermatitis), e.g.:
- Soaps, solvents
- Chemicals
- Certain foods
- Urine, feces
- Diapers
- Continuous or repeated exposure to moisture (hand washing)
- Course paper, glass, and wool fibers
- Shoe dermatitis: Common; identify by lesions limited to distal dorsal surface of foot usually sparing the interdigital spaces
Allergic:
- Plants, poison ivy, oak, sumac (rhus dermatitis):
  - Most common form of allergic contact dermatitis in North America
  - Direct: Reaction to oleoresin urushiol from plant
  - Indirect: Contact with pet or clothes with oleoresin on surface or fur or in smoke from burning leaves
  - Lesions may appear up to 3 days after exposure with prior sensitization (12-21 days after primary exposure) and may persist up to 3 wk
  - Fluid from vesicles is not contagious and does not produce new lesions
  - Oleoresin on pets or clothes remains contagious until removed
- Cement (prolonged exposure may result in severe alkali burn)
- Metals (especially nickel)
- Solvents, epoxy
- Chemicals in rubber (e.g., elastic waistbands) or leather
- Lotions, cosmetics
- Topical medications (e.g., neomycin, hydrocortisone, benzocaine, paraben)
- Some foods
- Ability to respond to certain antigens is probably genetically determined
Photodermatitis:
- Inflammatory reaction from exposure to irritant (frequently plant sap) and sunlight
- Typically no response in absence of sunlight

Diagnosis

Signs and Symptoms

History

Date of onset
Time course
Pattern of lesions
Relationship to work
Pruritic or not
Mucosal involvement
Exposure to new products (e.g., lotions, soaps, and cosmetics), foods, medications, and jewelry

Physical Exam

Special attention to character and distribution of rash
Acute lesions: Skin erythema and pruritus:
- May see edema, papules, vesicles, bullae, serous discharge, or crusting
Subacute: Vesiculation less pronounced
Chronic lesions: May see scaling, lichenification, pigmentation, or fissuring with little to no vesiculation; may have characteristic distribution pattern

Diagnosis Tests & Interpretation

Lab
No specific tests in ED are helpful.
Imaging
No specific tests in ED are helpful
Diagnostic Procedures/Surgery

Patch testing:
- Generally not done in ED; refer to allergist/immunologist
When tinea is suspected, may use Wood lamp for fluorescence

Differential Diagnosis

Atopic dermatitis: Associated with family history of atopy
Seborrheic dermatitis: Scaly or crusting "greasy" lesions
Nummular dermatitis: Coin-like lesions
Intertrigo: Dermatitis in which skin is in apposition (axillae, groin area)
Infectious eczematous dermatitis: Dermatitis with secondary bacterial infection, usually Staphylococcus aureus
Cellulitis: Warm, blanching, painful lesion
Impetigo: Yellow crusting
Scabies: Intensely pruritic, frequently interdigital with tracks
Psoriasis: Silvery adherent, scaling, lesions well delineated, affecting extensor surfaces, scalp, and genital region
Herpes simplex: Groups of vesicles, painful, burning
Herpes zoster: Painful, follows dermatomal pattern
Bullous pemphigoid: Diffuse bullous lesions
Tinea: Maximal involvement at margins, fluoresces under Wood lamp
Pityriasis alba: Discrete, asymptomatic, hypopigmented lesions
Urticaria: Pruritic raised lesions (wheal) frequently with surrounding erythema (flare)
Acrodermatitis enteropathica: Vesiculobullous lesion of hands and feet, associated with failure to thrive, diarrhea, and alopecia
- Due to zinc deficiency
Dyshidrotic dermatitis (eczema)
- Drug rash
- Stevens-Johnson syndrome (SJS)
- Toxic epidermal necrolysis (TEN)
- Erythema nodosum (EN)

Treatment

Initial Stabilization/Therapy

Rarely required in absence of concomitant pathology

Ed Treatment/Procedures

General:

Primarily symptomatic
Wash area with mild soap and water
Remove or avoid offending agent (including washing clothes)
Cool, wet compresses; especially effective during acute blistering phase
Antipruritic agents:
- Topical:
  - Calamine lotion, corticosteroids (do not penetrate blisters); avoid benzocaine or hydrocortisone-containing products, which may further sensitize skin
- Systemic: Antihistamines, corticosteroids
Aluminum acetate (Burrows) solution: Weeping surfaces

Irritant dermatitis:

Remove offending agent
Wash well with soap and warm water
Decrease wet/dry cycles (hand washing)
- Alcohol-based cleansers decrease repetitive trauma
Bland emollient
Topical steroids for severe cases (ointment preferred), medium to high potency (hands), BID for several weeks

Allergic dermatitis:

Topical steroids (ointment preferred) BID for 2-3 wk:
- Face: Low potency
- Arms, legs, and trunk: Medium potency
- Hands and feet: High potency
Oral steroids for severe cases

Rhus dermatitis:

Follow general measures plus:
- Wash all clothes and pets that have come in contact with the plant; oil persists and is contagious
- Oatmeal baths can provide soothing relief
- Aseptic aspiration of bullae may relieve discomfort
- Severe reaction (>10% TBSA): Systemic corticosteroids for 2-3 wk with gradual taper:
  - Premature termination of corticosteroid therapy may result in rapid rebound of symptoms

Shoe dermatitis:

Follow general measures plus:
- Wear open-toe, canvas, or vinyl shoes.
- Control perspiration: Change socks, use absorbent powder.

Diaper dermatitis:

Follow general measures plus:
- Topical zinc oxide, petrolatum ointment, or aquaphor
- Change diapers after each soiling

Medication

Systemic:

Antihistamine (H1-receptor antagonist, 1st and 2nd generation):
- Cetirizine: Adults and children >6 yr, 5-10 mg PO daily (peds: Age 2-6 yr, 2.5 mg PO daily BID)
- Diphenhydramine hydrochloride: 25-50 mg IV/IM/PO q6h PRN (peds: 5 mg/kg/24h div. q6h PRN)
- Fexofenadine: 60 mg PO BID or 180 mg PO daily (peds: Age 6-12 yr, 30 mg PO BID)
- Hydroxyzine hydrochloride: 25-50 mg PO IM up to QID PRN (peds: 2 mg/kg/24h PO div. q6h or 0.5 mg/kg IM q4-6h PRN
- Loratadine: 10 mg PO BID
- For refractory pruritus: Doxepin: 75 mg PO daily may be effective.
Corticosteroid:
- Prednisone: 40-60 mg PO daily (peds: 1-2 mg/kg/24h, max. 80 mg/24h) div. daily/BID
For refractory pruritis:
- Doxepin: 75 mg PO daily may be effective.

Topical:

Aluminum acetate (Burrows) solution: Apply topically for 20 min TID until skin is dry.
Calamine lotion: q6h PRN
Topical corticosteroid: Triamcinolone ointment 0.025, 0.1%; cream 0.025, 0.1%; lotion 0.025, 0.1% TID or QID daily
- Caution: Do not apply to face or eyelids

First Line

Topical steroids
Oral antihistamines

Second Line
Oral steroids

Follow-Up

Disposition

Admission Criteria
Rarely indicated unless severe systemic reaction or significant secondary infection
Discharge Criteria

Symptomatic relief
Adequate follow-up with primary care physician or dermatologic specialist

Follow-Up Recommendations

Follow up with primary care physician in 2-3 days for recheck
Return to ED for: Facial swelling, difficulty breathing, mucosal involvement causing decreased PO intake

Pearls and Pitfalls

Remove offending agent
Beware of progression to systemic anaphylaxis (e.g., latex allergy)
Watch out for concurrent bacterial infections
Rhus dermatitis wounds are no longer contagious after washed with soap and water:
- Be sure to wash all clothes and animals that have come in contact with plant as oil remains contagious.

Additional Reading

Goldner R, Tuchinda P (2012). Irritant Contact Dermatitis in Adults, Up To Date, retrieved Jan 13, 2013 from http://www.uptodate.com/contents/irritant-contact-dermatitis-in-adults.
Hogan DJ, ed. (2011). Allergic Contact Dermatitis, Medscape. Retrieved Dec 12, 2012 from http://emedicine.medscape.com/article/1049216-overview.
Hogan DJ, ed. (2011). Irritant Contact Dermatitis, Medscape. Retrieved Dec 12, 2012 from http:emedicine.medscape.com/article/1049353-overview.
Marx JA, Hockberger RS, Walls RM, et al., eds. Rosens Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2009.
Rietschel RL, Fowler JF, eds. Fisher's Contact Dermatitis. 6th ed. Ontario, ON: BC Decker; 2008.

Codes

ICD9

692.2 Contact dermatitis and other eczema due to solvents
692.9 Contact dermatitis and other eczema, unspecified cause
692.81 Dermatitis due to cosmetics
692.5 Contact dermatitis and other eczema due to food in contact with skin
691.0 Diaper or napkin rash
692.1 Contact dermatitis and other eczema due to oils and greases
692.3 Contact dermatitis and other eczema due to drugs and medicines in contact with skin
692.4 Contact dermatitis and other eczema due to other chemical products
692.6 Contact dermatitis and other eczema due to plants [except food]
692.83 Dermatitis due to metals
692.84 Contact dermatitis and other eczema due to animal (cat) (dog) dander
692.89 Contact dermatitis and other eczema due to other specified agents

ICD10

L25.0 Unspecified contact dermatitis due to cosmetics
L25.2 Unspecified contact dermatitis due to dyes
L25.9 Unspecified contact dermatitis, unspecified cause
L25.4 Unsp contact dermatitis due to food in contact with skin
L22 Diaper dermatitis
L23.0 Allergic contact dermatitis due to metals
L23.1 Allergic contact dermatitis due to adhesives
L23.2 Allergic contact dermatitis due to cosmetics
L23.3 Allergic contact dermatitis due to drugs in contact w skin
L23.4 Allergic contact dermatitis due to dyes
L23.5 Allergic contact dermatitis due to other chemical products
L23.6 Allergic contact dermatitis due to food in contact w skin
L23.7 Allergic contact dermatitis due to plants, except food
L23.81 Allergic contact dermatitis due to animal (cat) (dog) dander
L23.89 Allergic contact dermatitis due to other agents
L23.8 Allergic contact dermatitis due to other agents
L23.9 Allergic contact dermatitis, unspecified cause
L23 Allergic contact dermatitis
L25.1 Unsp contact dermatitis due to drugs in contact with skin
L25.3 Unsp contact dermatitis due to other chemical products
L25.5 Unspecified contact dermatitis due to plants, except food
L25.8 Unspecified contact dermatitis due to other agents
L25 Unspecified contact dermatitis

SNOMED

40275004 Contact dermatitis (disorder)
78755001 Contact dermatitis due to cosmetics
6888008 Contact dermatitis due to dye
67445002 contact dermatitis due to food in contact with skin (disorder)
110979008 Irritant contact dermatitis (disorder)
200821000 Contact dermatitis due to plants
238575004 Allergic contact dermatitis (disorder)
30451004 Contact dermatitis due to detergents
86062001 Contact dermatitis due to drugs AND/OR medicine (disorder)
91487003 Diaper rash (disorder)

Home

Erectile Dysfunction

Doctor123.org