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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

- 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

- 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

  • Irritant:Immediate eczematous eruption (superficial inflammatory process primarily in epidermis)Most common type of dermatitisTrigger substance itself directly damages the skin resulting in nonimmunologic inflammatory reaction with erythema, dryness, cracking, or fissuringUsually owing to repeated exposure to mild irritant (e.g., water, soaps, heat, friction)Lesions itch or burn:Usually gradual onset with indistinct bordersMost often seen on handsMay see vesicles or fissuresDry, red, and rough skinCommon 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 responseLocal edema, vesicles, erythema, pruritus, or burningUsually 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 exposureCommon sources: Nickel, gold, neomycin, bacitracin, preservatives, fragrances, dyes, poison ivy
  • Photocontact:Interaction between an otherwise harmless substance on the skin and UV lightCommon 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 plantsDiaper 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, solventsChemicalsCertain foodsUrine, fecesDiapersContinuous or repeated exposure to moisture (hand washing)Course paper, glass, and wool fibersShoe 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 AmericaDirect: Reaction to oleoresin urushiol from plantIndirect: Contact with pet or clothes with oleoresin on surface or fur or in smoke from burning leavesLesions may appear up to 3 days after exposure with prior sensitization (12-21 days after primary exposure) and may persist up to 3 wkFluid from vesicles is not contagious and does not produce new lesionsOleoresin on pets or clothes remains contagious until removedCement (prolonged exposure may result in severe alkali burn)Metals (especially nickel)Solvents, epoxyChemicals in rubber (e.g., elastic waistbands) or leatherLotions, cosmeticsTopical medications (e.g., neomycin, hydrocortisone, benzocaine, paraben)Some foodsAbility to respond to certain antigens is probably genetically determined
  • Photodermatitis:Inflammatory reaction from exposure to irritant (frequently plant sap) and sunlightTypically 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
  • Dyshidrotic dermatitis (eczema)Drug rashStevens-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 skinSystemic: 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 potencyArms, legs, and trunk: Medium potencyHands 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 contagiousOatmeal baths can provide soothing reliefAseptic aspiration of bullae may relieve discomfortSevere 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 aquaphorChange 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 PRNLoratadine: 10 mg PO BIDFor 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 dailyCaution: 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)