Case Report DKA Zamzami (Autosaved)

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Case Report

ALLERGIC CONTACT DERMATITIS

BY:

ZAMZAMI SAPUTRA

0707101010144

SUPERVISOR

DINA LIDADARI

Dermato-Venereology Department

Medical Faculty of Syiah Kuala University

Dr. Zainoel Abidin General Hospital

Banda Aceh

2012


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I. Introduction

Properly designed and conducted studies to determine the prevalence of

dermatitis in the general community are few but the point prevalence of dermatitis in

the U.K. is estimated at about 20%, with atopic eczema forming the majority. The

best studies show a point prevalence of hand dermatitis in South Sweden of 2%2 and

the lifetime risk of developing hand eczema to be 20% in women.3 Irritant contact

dermatitis is more common than allergic dermatitis; allergic dermatitis usually carries

a worse prognosis than irritant dermatitis unless the allergen is identified and

avoided. (Guidlin)

Contact dermatitis accounts for 47% of dermatological consultations.Chronicity is commonest in those allergic to nickel and chromate. The number of

reports of allergic contact dermatitis in children is increasing.5 The principle

allergens which have been identified include nickel, topical antibiotics, preservative

chemicals, fragrances and rubber accelerators. Children with eczematous eruptions

should be patch tested, particularly those with hand and eyelid eczema. Contact

allergy to specific allergens has been estimated in the general population to be 45%

for nickel,7 and 13% of the population are allergic to ingredient(s) of a

cosmetic.(Guidline)

Contact dermatitis is one of the most common skin diseases, with a great socio-

economic impact. As the outermost barrier of the human body, the skin is the first to

encounter chemical and physical factors from the environment. According to the

pathophysiological mechanisms involved, two main types of contact dermatitis may

be distinguished. Irritant contact dermatitis is due to the pro-inflammatory and toxic

effects of xenobiotics able to activate the skin innate immunity. Allergic contact

dermatitis (ACD) requires the activation of antigen specific acquired immunity

leading to the development of effector T cells which mediate the skin

inflammation.(Dermatol 2004)

Contact dermatitis may be classified into the following reaction types:

Subjective irritancyidiosyncratic stinging and smarting reactions that occur within


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minutes of contact, usually on the face, in the absence of visible changes. Cosmetic or

sunscreen constituents are common precipitants. Contact allergy is caused by skin

contact with low molecular weight haptens and may evolve to allergic contact

dermatitis (ACD) if exposure exceeds the individual threshold. ACD can be a

distressing skin problem for those who have it and may cause sick leave as well as

increase national health expenses. Consequently, there has been substantial focus on

contact allergy among patients with eczemaAllergic contact dermatitis this involves

sensitization of the immune system to a specific allergen or allergens with resulting

dermatitis or exacerbation of pre-existing dermatitis. Phototoxic, photoallergic and

photoaggravated contact dermatitissome allergens are also photoallergens. It is not

always easy to distinguish between photoallergic and phototoxic reactions. Inpractice, it is not uncommon for endogenous, irritant and allergic aetiologies to

coexist in the development of certain eczemas, particularly hand and foot eczema. It

is important to recognize and seek in the history, or by a home or workplace visit, any

recreational and occupational factors in irritant and allergic dermatitis.(guidlines)

The suspicion of ACD constitutes the first step in making a diagnosis. For ACD

to occur, the site of inflammation must have come in contact with the offending agent

in a sensitized individual. Initially, the area might itch, burn, or sting, but later

pruritus is a major symptom. The evolution and severity of the ACD lesion depend on

multiple factors, including the constitutive allergenicity/irritancy of the agent, the

integrity of the involved skin, environmental conditions, a history of prior reactions,

and the immunocompetency of the patient.

Work history must be carefully reviewed. Hobbies and nonwork activities, such

as gardening, painting, music (ie, playing stringed instruments), and photography,

may also be sources of exposure to a number of contactants. The location and clinical

appearance of the lesion may also suggest a possible ACD. Particular attention should

be given to certain anatomical sites, which include eyelids, face, neck, scalp, hands,

axillae, lower extremities, and the anogenital region. Although history can strongly

suggest the cause of ACD, it has been reported that experienced physicians accurately


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predict the sensitizer in only 10% to 20% of patients with ACD when relying solely

on the history and physical examination. Patch testing is the gold standard for

identification of a contact allergen. The number of appropriate patch tests required to

diagnose ACD may vary, depending on the nature of the clinical problem and the

potential for significant allergen exposure. Patch tests are indicated in any patient

with a chronic pruritic, eczematous lichenified dermatitis if underlying or secondary

ACD is suspected.

Considering the management of ACD, 2 phases are ofprime importance. The

acute treatment phase involves identification, withdrawal, and avoidance of contact to

offending agents. This is the key to successful treatment. Treatment of ongoing

dermatitic lesions includes both palliative and othertherapeutic measures. Coldcompresses and other measures to hydrate and soothe the skin may be helpful. The

use of topical corticosteroids (TCs) is the mainstay of treatment. Traditionally,

physicians prescribe higher-potency corticosteroids initially and then gradually

switch to medium or lower-potency corticosteroids as improvement becomes evident.

ICD does not respond as well to TCs as ACD.

The second phase of management concerns prevention. Primary prevention is

chiefly applicable to the workplace, where it is often possible to initiate surveillance

programs that are successful in bringing attention to proper skin care and helping

workers avoid undue exposure to highly sensitizing chemicals. Secondary prevention

methods are undertaken to prevent dryness and fissuring of the skin and involve the

use of emollients and moisturizers.


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CASE REPORT

Identity of patient

Name : M.Yunus

Sex : Male

Registration number : 0-92-23-92

Age : 60 years old

Address : Neuheun Aceh Besar

Examination Date : December 3th

2012

Anamnese

The MainComplaint :

Itching and watering throughout the body, especially in the feet and hands that

have been felt since 6 years ago.

History of Present Illness:

Patients come to the hospital with complaints of itching and watery in the feet,

hands and body that has been felt by the patient since 6 years ago, originally

arose in the area itchy feet starting from the feet up to the calf, the first arising

itching in area patients admitted to scratching and then gradually raised red

blotches and itchy watery after that arise in the area complained of the same

palms like in the leg but in the hands of the patient did not complain of watery

satelah only surfaced itching in the body. Previous patients never complained of

such complaints, the patient admitted itch often complained during the night,

the patient said she has worked as a construction worker and salalu exposed to

cement since 10 years ago, but new patients complained of itching since last 6

years, a history of food allergies denied.


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History of Previous Illness : Denied ever complained about the same complaints

History of Social Economy : Construction workers exposed to cement

History of Family Disease : The patient denied the family had complained the

same complaints

History of Treatment : Traditional medicine and drugs from hospital

History of Social Habits : Bath2 times a day

Physical Examination

Vital Sign : Not checked

Dermatological status :

a / r soles of the feet up to the calf, palms up to the front of the arm andabdomen are hyperpigmented patches with vesicles, papules and erosion was not

demarcated with irregular edges, plaque size, the number of multiple, discrete

arrangement, with a bilateral distribution and the surface covered with crust and

smooth squama

Clinical Test

Differential Diagnosis

1. Allergic Contact Dermatitis2. Irritans Contact Dermatitis3. Atopic Dermatitis

Diagnosis

Allergic Contact Dermatitis

Planning Diagnosis

Patch Test

Treatment

Systemic Medication:


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- Mabhidrolin Napadisilat 3 x 50mg

- Dexametason 3 x 1mg

Topical Medication:

- Asam Salisilat 3%

- Hidrocortison 1%

Education

1. Avoid the trigger factors2. Do not scratch thepart of body that free from lesions in order to prevent the

emergence of a new lesion

3. Do a regular check-up at the hospitalPrognosis

Quo ad Vitam :Dubia ad bonam

Quo Ad Functionam :Dubia ad bonam

Quo ad Sanactionam :Dubia ad bonam

Follow Up

1. November 23nd

, 2012

Dermatologic Status :


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a/r cruris dextra et sinistra, antebrachii dextra et sinistra, thorax anterior inferior et

posterior inferior. Erythematous plaque, covery thick scale that attached in centre

and release at the edge, sharply marginated, reguler, multiple in number,

confluence configuration, thedistributionis generalized.

Systemic Medication:

- Folic Acid tab 3x1

Topical Medication:

Salysilic acid 3% + Liquor CarbonisDetergens (LCD) 5% + desoksimetason0,25% (morning)

Salysilic acid 3% + Liquor CarbonisDetergens (LCD) 5% +Vaselin Album(afternoon)

Salysilic acid 3% + Diflucortolonevalerat0,1% cream (night)

Discussion

The patient in this case was diagnosed with symptoms of Allergic Contact

Dermatitis showing hyperpigmented patches with itching on the arms, legs and the

soles of the feet to the front of the abdomen. Initially the patient complained of

itching in the feet and gradually raised black spots or patches until runny then new

patients complained of itching in 3 fingers and then spreads to the arms causing black

patches are dry and crust and squama smooth surface with a size not demarcated

plaques with irregular edges and the distribution of discrete bilateral arrangement to

arise at the front of the abdomen. history of food allergy patients and patients also

deny deny that no families have complained of the same complaints but the patient

said he has worked as a construction worker who is always exposed to the cement of

patients has been working for about 10 years, and complaints began to be felt by the

patient since the last 6 years.


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Pada kasus ini, diagnosa dermatitis kontak alergi didasarkan atas gejala yang

timbul berupa ruam kemerahan yang gatal tanpa disertai nyeri yang timbul pada

kedua kaki, kemudian ruam kemerahan berubah menjadi papul, vesikel, kemudian

pecah, dan karena digaruk ruam berubah menjadi kehitaman. Faktor pemicu

timbulnya dermatitis kontak alergi pada pasien ini berupa pekerjaan pasien yakni

seorang buruh bangunan, yang secara terus menerus terpajan oleh bahan bangunan

berupa semen. Hal ini sesuai dengan teori yang menyebutkan bahwa dermatitis

kontak alergi pada fase akut akan menimbulkan lesi berupa eritema yang disertai

keluhan subyektif berupa gatal tanpa disertai nyeri yang diakibatkan oleh terpajannya

kulit dengan kontaktan.

Pada pasien ini pemeriksaan pendukung yang harus dilakukan adalah tes tempel(patch test), namun dikarenakan waktu yang singkat, maka pemeriksaan ini tidak

dapat dilakukan pada saat hari pemeriksaan.

Supporting examination is an examination conducted by attaching a test patch

test materials specified on healthy skin then cover with a cloth or gauze after it in

plaster after 48 hours or 2 days later opened and assessed the skin is attached to the

test substance is there seems abnormalities or changes, according ICDRG

interpretation (International Contact Dermatitis Research Group) is:

- : No abnormalities : slight

+ or - : Just a weak erythema : undecided

+ : Erythema, Infiltration(edema), Papules : weak positive

++ : Erythema, Infiltration, papules, vesicles : a strong positive

+++ : Bulla : very strong positive

If necessary, for example, a strong clinical suspicion, but a negative test result,

readings were taken 72 hours after attachment, or even one week after the settlement,

no material was pressed again. It is possible to know the reaction is slow (delayed

reaction).

Terapi


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Reference

1. James WD, Berger TG, Elston DM. Andrews Disease of The Skin ClinicalDermatology. 2011. Elsevier Inc: USA. P 190-195

2. Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffel DJ. 2008.Fitzpatricks Dermathology in General Medicine. McGraw Hill Medical. New

York. P:169-185.

3. Papadopoulos L, Walker. 2003. Understanding Skin Problems: Acne, Eczema,Psoriasis and Related. Wiley Publisher: England. P: 24

4. Icen M, Crowson CS, McEvoy MT, Dann FJ, Gabriel SE, and Kremers HM.2009. Trends in Incidence of Adult-Onset Psoriasis Over Three Decades: A

Population-Based Study. J Am Acad Dermatol Vol 60. No.3; p.394.

5. Gawkrodger, D. 2007. Dermatology: An Illustrated Colour Text. United State ofAmerica :Churchill Livingstone. p.26-29.

6. Emma G, Nograles K, and Krueger J. 2011. Contrasting Pathogenesis of AtopicDermatitis and Psoriasis-Part I: Clinical and Pathologic Concepts. J Allergy

ClinImmunol Vol.127 No. 5; 1111-1112.

7. Chong YT, Tey KE, Choon SE. 2010. Local Experience on The Use ofMethotrexate in The Treatment of Psoriasis in Hospital SultanahAminah, Johor

bahru. MJD Vol 25: 1.

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Case Report DKA Zamzami (Autosaved)