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Dermatitis, Contact

para>Increased incidence of irritant dermatitis secondary to skin dryness  
Pediatric Considerations

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

 

ETIOLOGY AND PATHOPHYSIOLOGY


Hypersensitivity reaction to a substance generating cellular immunity response (4)  
  • Plants
    • Urushiol (allergen): poison ivy, poison oak, poison sumac
    • Primary contact: plant (roots/stems/leaves)
    • Secondary contact: clothes/fingernails (not blister fluid)
  • Chemicals
    • 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
  • Topical medicines
    • Neomycin: topical antibiotics
    • Thimerosal (Merthiolate): preservative in topical medications
    • Anesthetics: benzocaine
    • Parabens: preservative in topical medications
    • Formalin: cosmetics, shampoos, and nail enamel

Genetics
Increased frequency of ACD in families with allergies  

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


  • Acute
    • Papules, vesicles, bullae with surrounding erythema
    • Crusting and oozing
    • Pruritus
  • Chronic
    • Erythematous base
    • Thickening with lichenification
    • Scaling
    • Fissuring
  • Distribution
    • 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.
  • Well-demarcated area with a papulovesicular rash

DIFFERENTIAL DIAGNOSIS


  • Based on clinical impression
    • Appearance, periodicity, and localization
  • Groups of vesicles
    • Herpes simplex
  • Diffuse bullous or vesicular lesions
    • Bullous pemphigoid
  • Photodistribution
    • Phototoxic/allergic reaction to systemic allergen
  • Eyelids
    • Seborrheic dermatitis
  • Scaly eczematous lesions
    • Atopic dermatitis
    • Nummular eczema
    • Lichen simplex chronicus
    • Stasis dermatitis
    • Xerosis

DIAGNOSTIC TESTS & INTERPRETATION


Diagnostic Procedures/Other
Consider patch tests for suspected allergic trigger (systemic corticosteroids or recent, aggressive use of topical steroids may alter results).  
Test Interpretation
  • Intercellular edema
  • Bullae

TREATMENT


GENERAL MEASURES


  • Remove offending agent:
    • Avoidance
    • Work modification
    • Protective clothing
    • Barrier 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)

MEDICATION


First Line
  • Topical medications (6)[A]
    • Lotion of zinc oxide, talc, menthol 0.15% (Gold Bond), phenol 0.5%
    • Corticosteroids for ACD as well as irritant dermatitis
      • 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.
  • Calamine lotion for symptomatic relief
  • Topical antibiotics for secondary infection (bacitracin, erythromycin)
  • Systemic
    • Antihistamine
      • Hydroxyzine: 25 to 50 mg PO QID, especially useful for itching
      • Diphenhydramine: 25 to 50 mg PO QID
      • Cetirizine 10 mg PO BID-TID
  • Corticosteroids
    • 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
  • Antibiotics for secondary skin infections
    • 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)
  • Precautions
    • 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.

Second Line
Other topical or systemic antibiotics, depending on organisms and sensitivity  
Pregnancy Considerations

Usual caution with medications.

 

ISSUES FOR REFERRAL


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

COMPLEMENTARY & ALTERNATIVE MEDICINE


The use of complementary and alternative treatment is a supplement and not an alternative to conventional treatment.  
Admission Criteria/Initial Stabilization
Rarely needs hospital admission  

ONGOING CARE


FOLLOW-UP RECOMMENDATIONS


Stay active, but avoid overheating.  
Patient Monitoring
  • As necessary for recurrence
  • Patch testing for etiology after resolved

DIET


No special 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


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.

SEE ALSO


Algorithm: Rash, Focal  

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.
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