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Dermatitis, Contact

Doctor123.org

Dermatitis, Contact

para>Increased incidence of irritant dermatitis secondary to skin dryness

Hypersensitivity reaction to a substance generating cellular immunity response (4)

Increased frequency of ACD in families with allergies

Consider patch tests for suspected allergic trigger (systemic corticosteroids or recent, aggressive use of topical steroids may alter results).

Other topical or systemic antibiotics, depending on organisms and sensitivity

May need referral to a dermatologist or allergist if refractory to conventional treatment

Admission Criteria/Initial Stabilization

Rarely needs hospital admission

Stay active, but avoid overheating.

11 Ale IS, Maibacht HA. Diagnostic approach in allergic and irritant contact dermatitis. Expert Rev Clin Immunol. 2010;6(2):291-310.22 Tan CH, Rasool S, Johnston GA. Contact dermatitis: allergic and irritant. Clin Dermatol. 2014;32(1):116-124.33 Admani S, Jacob SE. Allergic contact dermatitis in children: review of the past decade. Curr Allergy Asthma Rep. 2014;14(4):421.44 Martin SF. Contact dermatitis: from pathomechanisms to immunotoxicology. Exp Dermatol. 2012;21(5):382-389.55 Tuchman M, Silverberg JI, Jacob SE, et al. Nickel contact dermatitis in children. Clin Dermatol. 2015;33(3):320-326.66 Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician. 2010;82(3):249-255.

Increased incidence of positive patch testing due to better delayed hypersensitivity reactions (3)

ETIOLOGY AND PATHOPHYSIOLOGY

  • PlantsUrushiol (allergen): poison ivy, poison oak, poison sumacPrimary contact: plant (roots/stems/leaves)Secondary contact: clothes/fingernails (not blister fluid)
  • ChemicalsNickel: jewelry, zippers, hooks, and watches (5)Potassium dichromate: tanning agent in leatherParaphenylenediamine: hair dyes, fur dyes, and industrial chemicalsTurpentine: cleaning agents, polishes, and waxesSoaps and detergents
  • Topical medicinesNeomycin: topical antibioticsThimerosal (Merthiolate): preservative in topical medicationsAnesthetics: benzocaineParabens: preservative in topical medicationsFormalin: cosmetics, shampoos, and nail enamel
  • Urushiol (allergen): poison ivy, poison oak, poison sumac
  • Primary contact: plant (roots/stems/leaves)
  • Secondary contact: clothes/fingernails (not blister fluid)
  • Nickel: jewelry, zippers, hooks, and watches (5)
  • Potassium dichromate: tanning agent in leather
  • Paraphenylenediamine: hair dyes, fur dyes, and industrial chemicals
  • Turpentine: cleaning agents, polishes, and waxes
  • Soaps and detergents
  • Neomycin: topical antibiotics
  • Thimerosal (Merthiolate): preservative in topical medications
  • Anesthetics: benzocaine
  • Parabens: preservative in topical medications
  • Formalin: cosmetics, shampoos, and nail enamel

RISK FACTORS

  • Occupation
  • Hobbies
  • Travel
  • Cosmetics
  • Jewelry

GENERAL PREVENTION

  • Avoid causative agents.
  • Use of protective gloves (with cotton lining) may be helpful.

DIAGNOSIS

HISTORY

  • Itchy rash
  • Assess for prior exposure to irritating substance.

PHYSICAL EXAM

  • AcutePapules, vesicles, bullae with surrounding erythemaCrusting and oozingPruritus
  • ChronicErythematous baseThickening with lichenificationScalingFissuring
  • DistributionWhere epidermis is thinner (eyelids, genitalia)Areas of contact with offending agent (e.g., nail polish)Palms and soles relatively more resistant, although hand dermatitis is common.Deeper skin folds sparedLinear arrays of lesionsLesions with sharp borders and sharp angles are pathognomonic.
  • Well-demarcated area with a papulovesicular rash
  • Papules, vesicles, bullae with surrounding erythema
  • Crusting and oozing
  • Pruritus
  • Erythematous base
  • Thickening with lichenification
  • Scaling
  • Fissuring
  • Where epidermis is thinner (eyelids, genitalia)
  • Areas of contact with offending agent (e.g., nail polish)
  • Palms and soles relatively more resistant, although hand dermatitis is common.
  • Deeper skin folds spared
  • Linear arrays of lesions
  • Lesions with sharp borders and sharp angles are pathognomonic.

DIFFERENTIAL DIAGNOSIS

  • Based on clinical impressionAppearance, periodicity, and localization
  • Groups of vesiclesHerpes simplex
  • Diffuse bullous or vesicular lesionsBullous pemphigoid
  • PhotodistributionPhototoxic/allergic reaction to systemic allergen
  • EyelidsSeborrheic dermatitis
  • Scaly eczematous lesionsAtopic dermatitisNummular eczemaLichen simplex chronicusStasis dermatitisXerosis
  • Appearance, periodicity, and localization
  • Herpes simplex
  • Bullous pemphigoid
  • Phototoxic/allergic reaction to systemic allergen
  • Seborrheic dermatitis
  • Atopic dermatitis
  • Nummular eczema
  • Lichen simplex chronicus
  • Stasis dermatitis
  • Xerosis

DIAGNOSTIC TESTS & INTERPRETATION

  • Intercellular edema
  • Bullae

TREATMENT

GENERAL MEASURES

  • Remove offending agent:AvoidanceWork modificationProtective clothingBarrier creams, especially high-lipid content moisturizing creams (e.g., Keri lotion, petrolatum, coconut oil)
  • Topical soaks with cool tap water, Burow solution (1:40 dilution), saline (1 tsp/pt water), or silver nitrate solution
  • Lukewarm water baths
  • Aveeno oatmeal baths
  • Emollients (white petrolatum, Eucerin)
  • Avoidance
  • Work modification
  • Protective clothing
  • Barrier creams, especially high-lipid content moisturizing creams (e.g., Keri lotion, petrolatum, coconut oil)

MEDICATION

  • Topical medications (6)[A]Lotion of zinc oxide, talc, menthol 0.15% (Gold Bond), phenol 0.5%Corticosteroids for ACD as well as irritant dermatitisHigh-potency steroids: fluocinonide (Lidex) 0.05% gel, cream, or ointment TID-QIDUse high-potency steroids only for a short time, then switch to low- or medium-potency steroid cream or ointmentCaution regarding face/skin folds: use lower potency steroids, and avoid prolonged usage. Switch to lower potency topical steroid once the acute phase is resolved.
  • Calamine lotion for symptomatic relief
  • Topical antibiotics for secondary infection (bacitracin, erythromycin)
  • SystemicAntihistamineHydroxyzine: 25 to 50 mg PO QID, especially useful for itchingDiphenhydramine: 25 to 50 mg PO QIDCetirizine 10 mg PO BID-TID
  • CorticosteroidsPrednisone: taper starting at 60 to 80 mg/day PO, over 10 to 14 daysUsed for moderate to severe casesMay use burst dose of steroids for up to 5 days
  • Antibiotics for secondary skin infectionsDicloxacillin: 250 to 500 mg PO QID for 7 to 10 daysAmoxicillin-clavulanate (Augmentin): 500 mg PO BID for 7 to 10 daysErythromycin: 250 mg PO QID in penicillin-allergic patientsTrimethoprim-sulfamethoxazole (Bactrim DS): 160 mg/800 mg (1 tablet) PO BID for 7 to 10 days (suspected resistant Staphylococcus aureus)
  • PrecautionsAntihistamines may cause drowsiness.Prolonged use of potent topical steroids may cause local skin effects (atrophy, stria, telangiectasia).Use tapering dose of oral steroids if using >5 days.
  • Lotion of zinc oxide, talc, menthol 0.15% (Gold Bond), phenol 0.5%
  • Corticosteroids for ACD as well as irritant dermatitisHigh-potency steroids: fluocinonide (Lidex) 0.05% gel, cream, or ointment TID-QIDUse high-potency steroids only for a short time, then switch to low- or medium-potency steroid cream or ointmentCaution regarding face/skin folds: use lower potency steroids, and avoid prolonged usage. Switch to lower potency topical steroid once the acute phase is resolved.
  • High-potency steroids: fluocinonide (Lidex) 0.05% gel, cream, or ointment TID-QID
  • Use high-potency steroids only for a short time, then switch to low- or medium-potency steroid cream or ointment
  • Caution regarding face/skin folds: use lower potency steroids, and avoid prolonged usage. Switch to lower potency topical steroid once the acute phase is resolved.
  • AntihistamineHydroxyzine: 25 to 50 mg PO QID, especially useful for itchingDiphenhydramine: 25 to 50 mg PO QIDCetirizine 10 mg PO BID-TID
  • Hydroxyzine: 25 to 50 mg PO QID, especially useful for itching
  • Diphenhydramine: 25 to 50 mg PO QID
  • Cetirizine 10 mg PO BID-TID
  • Prednisone: taper starting at 60 to 80 mg/day PO, over 10 to 14 days
  • Used for moderate to severe cases
  • May use burst dose of steroids for up to 5 days
  • Dicloxacillin: 250 to 500 mg PO QID for 7 to 10 days
  • Amoxicillin-clavulanate (Augmentin): 500 mg PO BID for 7 to 10 days
  • Erythromycin: 250 mg PO QID in penicillin-allergic patients
  • Trimethoprim-sulfamethoxazole (Bactrim DS): 160 mg/800 mg (1 tablet) PO BID for 7 to 10 days (suspected resistant Staphylococcus aureus)
  • Antihistamines may cause drowsiness.
  • Prolonged use of potent topical steroids may cause local skin effects (atrophy, stria, telangiectasia).
  • Use tapering dose of oral steroids if using >5 days.

Usual caution with medications.

ISSUES FOR REFERRAL

COMPLEMENTARY & ALTERNATIVE MEDICINE

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • As necessary for recurrence
  • Patch testing for etiology after resolved

DIET

PATIENT EDUCATION

  • Avoidance of irritating substance
  • Cleaning of secondary sources (nails, clothes)
  • Fallacy of blister fluid spreading disease

PROGNOSIS

  • Self-limited
  • Benign

COMPLICATIONS

  • Generalized eruption secondary to autosensitization
  • Secondary bacterial infection

REFERENCES

SEE ALSO

CODES

ICD10

  • L25.9 Unspecified contact dermatitis, unspecified cause
  • L23.9 Allergic contact dermatitis, unspecified cause
  • L25.5 Unspecified contact dermatitis due to plants, except food
  • L25.3 Unsp contact dermatitis due to other chemical products
  • L25.4 Unsp contact dermatitis due to food in contact with skin
  • L25.8 Unspecified contact dermatitis due to other agents
  • L25.0 Unspecified contact dermatitis due to cosmetics
  • L25.1 Unsp contact dermatitis due to drugs in contact with skin
  • L25.2 Unspecified contact dermatitis due to dyes

ICD9

  • 692.9 Contact dermatitis and other eczema, unspecified cause
  • 692.6 Contact dermatitis and other eczema due to plants [except food]
  • 692.4 Contact dermatitis and other eczema due to other chemical products
  • 692.89 Contact dermatitis and other eczema due to other specified agents
  • 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
  • 692.81 Dermatitis due to cosmetics
  • 692.83 Dermatitis due to metals
  • 692.0 Contact dermatitis and other eczema due to detergents
  • 692.8 Contact dermatitis and other eczema due to other specified agents
  • 692.2 Contact dermatitis and other eczema due to solvents
  • 692.5 Contact dermatitis and other eczema due to food in contact with skin
  • 692.82 Dermatitis due to other radiation
  • 692.84 Contact dermatitis and other eczema due to animal (cat) (dog) dander

SNOMED

  • 40275004 Contact dermatitis (disorder)
  • 238575004 Allergic contact dermatitis (disorder)
  • 200821000 Contact dermatitis due to plants
  • 3226008 Contact dermatitis due to non-medicinal chemical
  • 78755001 Contact dermatitis due to cosmetics
  • 30451004 Contact dermatitis due to detergents
  • 267796002 Contact dermatitis due to metal
  • 6888008 Contact dermatitis due to dye
  • 86062001 Contact dermatitis due to drugs AND/OR medicine (disorder)

CLINICAL PEARLS

  • Anyone exposed to irritants or allergic substances is predisposed to contact dermatitis, especially in occupations that have high exposure to chemicals.
  • The most common allergens causing contact dermatitis are plants of the Toxicodendron genus (poison ivy, poison oak, poison sumac).
  • Poison-ivy dermatitis typically requires 10 to 14 days of topical or oral steroid therapy to prevent recurrent eruption.
  • The usual treatment for contact dermatitis is avoidance of the allergen or irritating substance and temporary use of topical steroids.
  • A contact dermatitis eruption presents in a nondermatomal geographic fashion due to the skin being in contact with an external source.