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Contact Dermatitis Part Contact Dermatitis Part OneOne
Boris Ioffe, D.O., Pharm.D.Boris Ioffe, D.O., Pharm.D.
08-14-0608-14-06
Irritant contact dermatitis (ICD)Irritant contact dermatitis (ICD)
Accounts for approximately Accounts for approximately 80% of all contact 80% of all contact dermatitisdermatitis
ICD is the result of a local ICD is the result of a local toxic effect when the skin toxic effect when the skin comes in contact with comes in contact with irritant chemicals such as irritant chemicals such as soaps, solvents, acids, or soaps, solvents, acids, or alkalisalkalis
This 37-year-old woman developed a contact This 37-year-old woman developed a contact irritant dermatitis from obsessive-compulsive hand irritant dermatitis from obsessive-compulsive hand washing 20-30 times a day. www.drmatlas.orgwashing 20-30 times a day. www.drmatlas.org
Introduction to Irritant Contact Introduction to Irritant Contact DermatitisDermatitis
ICD is a cutaneous inflammation resulting from a ICD is a cutaneous inflammation resulting from a direct cytotoxic effect of a chemical or physical direct cytotoxic effect of a chemical or physical agentagent
Constitutes nearly 80% of occupational contact Constitutes nearly 80% of occupational contact dermatitis (OCD)dermatitis (OCD)
OCD is a matter of public health importance, OCD is a matter of public health importance, contributing to combined direct and indirect contributing to combined direct and indirect annual costs (in the USA) of up to $1 billion annual costs (in the USA) of up to $1 billion when accounting for medical costs, workers when accounting for medical costs, workers compensation, and lost time from workcompensation, and lost time from work
Epidemiology of ICDEpidemiology of ICD The US Bureau of Labor The US Bureau of Labor
Statistics data show that Statistics data show that occupational skin diseases occupational skin diseases accounted for 10% to 15% of accounted for 10% to 15% of all occupational illnessesall occupational illnesses
High-risk occupations with High-risk occupations with frequent irritant exposure in frequent irritant exposure in caterers, furniture industry caterers, furniture industry workers, hospital workers, workers, hospital workers, hairdressers, chemical industry hairdressers, chemical industry workers, dry cleaners, metal workers, dry cleaners, metal workers, florists, and workers, florists, and warehouse workerswarehouse workers
Epidemiology of ICDEpidemiology of ICD Clinical manifestations of ICD are determined by:Clinical manifestations of ICD are determined by:
Properties of the irritating substanceProperties of the irritating substance
Host factorsHost factors
Environmental factors including concentration, mechanical pressure, Environmental factors including concentration, mechanical pressure, temperature, humidity, pH, and duration of contacttemperature, humidity, pH, and duration of contact
Cold alone may also reduce the plasticity of the horny layer, with Cold alone may also reduce the plasticity of the horny layer, with consequent cracking of the stratum corneumconsequent cracking of the stratum corneum
Occlusion, excessive humidity, and maceration increase Occlusion, excessive humidity, and maceration increase percutaneous absorption of water-soluble substancespercutaneous absorption of water-soluble substances
Bilateral shoe irritant dermatitis resulting Bilateral shoe irritant dermatitis resulting from chronic occlusive footwearfrom chronic occlusive footwear
Epidemiology of ICDEpidemiology of ICD Important predisposing characteristics of the individual include:Important predisposing characteristics of the individual include:
Age, race, sex, pre-existing skin disease, anatomic region exposed, and Age, race, sex, pre-existing skin disease, anatomic region exposed, and sebaceous activitysebaceous activity
Both infants and elderly are affected more by ICD because of their less robust Both infants and elderly are affected more by ICD because of their less robust epidermal layerepidermal layer
Patients with darkly pigmented skin seem to be more resistant to irritant reactions Patients with darkly pigmented skin seem to be more resistant to irritant reactions
Other skin disease such as active atopic dermatitis may predispose an individual Other skin disease such as active atopic dermatitis may predispose an individual to develop ICDto develop ICD
The most commonly affected sites are exposed areas such as the hands and the The most commonly affected sites are exposed areas such as the hands and the face, with hand involvement in approximately 80% of patients and face face, with hand involvement in approximately 80% of patients and face involvement in 10%involvement in 10%
Pathogenesis of ICDPathogenesis of ICD
Denaturation of epidermal keratinsDenaturation of epidermal keratins
Disruption of the permeability barrierDisruption of the permeability barrier
Damage to cell membranesDamage to cell membranes
Direct cytotoxic effectsDirect cytotoxic effects
Acute Irritant Contact DermatitisAcute Irritant Contact Dermatitis Commonly seen in occupational accidentsCommonly seen in occupational accidents Irritant reaction reaches its peak quickly, within minutes to hours Irritant reaction reaches its peak quickly, within minutes to hours
after exposureafter exposure Symptoms include stinging, burning, and soreness Symptoms include stinging, burning, and soreness Physical signs include erythema, edema, bullae, and possibly Physical signs include erythema, edema, bullae, and possibly
necrosisnecrosis Lesions restricted to the area where the irritant or toxicant damaged Lesions restricted to the area where the irritant or toxicant damaged
the tissuethe tissue Sharply demarcated borders and asymmetry pointing to an Sharply demarcated borders and asymmetry pointing to an
exogenous causeexogenous cause Most frequent irritants are acids and alkaline solutionsMost frequent irritants are acids and alkaline solutions
Acute Delayed Irritant Contact Acute Delayed Irritant Contact DermatitisDermatitis
Delayed inflammatory response characteristic of certain irritants Delayed inflammatory response characteristic of certain irritants such as anthralin, benzalkonium chloride, and ethylene oxidesuch as anthralin, benzalkonium chloride, and ethylene oxide
Visible inflammation is not seen until 8 to 24 hours after exposureVisible inflammation is not seen until 8 to 24 hours after exposure
Symptoms are more frequently burning rather than pruritusSymptoms are more frequently burning rather than pruritus
Sensitivity to touch and water are elicitedSensitivity to touch and water are elicited
This form of ICD is commonly seen during diagnostic patch testingThis form of ICD is commonly seen during diagnostic patch testing
Irritant Reaction Irritant Contact Irritant Reaction Irritant Contact DermatitisDermatitis
Type of subclinical irritant dermatitis in individuals Type of subclinical irritant dermatitis in individuals exposed to wet chemical environments such as exposed to wet chemical environments such as hairdressers, caters, or metalworkershairdressers, caters, or metalworkers
Characterized by scaling, redness, vesicles, pustules, Characterized by scaling, redness, vesicles, pustules, and erosionsand erosions
Often begins under occlusive jewelry and then spreads Often begins under occlusive jewelry and then spreads over the fingers to the hands and forearmsover the fingers to the hands and forearms
May simulate dyshidrotic dermatitisMay simulate dyshidrotic dermatitis
Cumulative Irritant Contact Cumulative Irritant Contact DermatitisDermatitis
Consequence of multiple sub-Consequence of multiple sub-threshold skin insults, without threshold skin insults, without sufficient time between them for sufficient time between them for complete barrier function repaircomplete barrier function repair
In contrast to acute ICD, the In contrast to acute ICD, the lesions of chronic ICD are less lesions of chronic ICD are less sharply demarcatedsharply demarcated
Itching and pain due to fissures of Itching and pain due to fissures of hyperkeratotic skin are symptoms hyperkeratotic skin are symptoms of chronic ICDof chronic ICD
Skin findings include Skin findings include lichenification, hyperkeratosis, lichenification, hyperkeratosis, xerosis, erythema, and vesiclesxerosis, erythema, and vesicles
Asteatotic DermatitisAsteatotic Dermatitis Exsiccation eczematid ICDExsiccation eczematid ICD
Seen mainly during the winter Seen mainly during the winter months in elderly individuals months in elderly individuals who frequently bath without who frequently bath without remoisturizingremoisturizing
Skin appears dry with Skin appears dry with ichthyosiform scale and ichthyosiform scale and patches of eczema craquelepatches of eczema craquele
Traumatic Irritant Contact Traumatic Irritant Contact Dermatitis Dermatitis
May develop after acute skin trauma, such as burns, May develop after acute skin trauma, such as burns, lacerations, or acute ICDlacerations, or acute ICD
Patients should be asked if they have cleansed with Patients should be asked if they have cleansed with strong soaps or detergentsstrong soaps or detergents
Characterized by eczematous lesions most commonly Characterized by eczematous lesions most commonly on the hands, that persist on the hands, that persist
Healing is delayed with redness, infiltration, scale, and Healing is delayed with redness, infiltration, scale, and fissuring in the affected areasfissuring in the affected areas
Pustular and Acneform Irritant Pustular and Acneform Irritant Contact DermatitisContact Dermatitis
Result to certain irritants such as Result to certain irritants such as metals, croton oil, mineral oils, metals, croton oil, mineral oils, tars, greases, cutting and metal tars, greases, cutting and metal working fluids, and naphthalenesworking fluids, and naphthalenes
Should be considered in Should be considered in conditions in which folliculitis or conditions in which folliculitis or acneform lesions develop in acneform lesions develop in setting outside of typical acnesetting outside of typical acne
Pustules are sterile and transientPustules are sterile and transient
Milia may develop in response to Milia may develop in response to occlusive clothing, adhesive tape, occlusive clothing, adhesive tape, ultraviolet and infrared radiationultraviolet and infrared radiation
Chloracne. Note heavy involvement Chloracne. Note heavy involvement of retroauricular skin with comedones of retroauricular skin with comedones and cystsand cysts
Subjective or Sensory Irritant Subjective or Sensory Irritant Contact DermatitisContact Dermatitis
Reports of stinging or burning in the absence of Reports of stinging or burning in the absence of visible cutaneous signs of irritationvisible cutaneous signs of irritation
Response to irritants such as lactic or sorbic Response to irritants such as lactic or sorbic acidacid
Airborne Irritant Contact Airborne Irritant Contact DermatitisDermatitis
Develops on irritant-exposed Develops on irritant-exposed skin of the face and periorbital skin of the face and periorbital regionsregions
Often simulates photoallergic Often simulates photoallergic reactionsreactions
Involvement of the upper Involvement of the upper eyelids, philtrum, and eyelids, philtrum, and submental regions help to submental regions help to differentiate from photoallergic differentiate from photoallergic reactionreaction
Frictional Irritant Contact Frictional Irritant Contact DermatitisDermatitis
Results from repeated low-Results from repeated low-grade frictional traumagrade frictional trauma
Plays adjuvant role in ACD Plays adjuvant role in ACD and ICDand ICD
Characterized by Characterized by hyperkeratosis, acanthosis, hyperkeratosis, acanthosis, and lichenification, often and lichenification, often progressing to hardening, progressing to hardening, thickening, and increased thickening, and increased toughnesstoughness
9 year old girl demonstrates a lichenified hyperpigmented round plaque on the top of her thumb produced by chronic thumbsucking. www.dermatlas.org
Pathology of ICDPathology of ICD Variable mix of inflammation, necrosis of epidermal keratinocytes, Variable mix of inflammation, necrosis of epidermal keratinocytes,
and mild spongiosisand mild spongiosis
Combination of an upper dermal perivascular infiltrate of Combination of an upper dermal perivascular infiltrate of lymphocytes with minimal extension of inflammatory cells into the lymphocytes with minimal extension of inflammatory cells into the overlying epidermis, and widely scattered necrotic keratinocytes is overlying epidermis, and widely scattered necrotic keratinocytes is most typical picturemost typical picture
True features of interface dermatitis are absent, and spongiosis True features of interface dermatitis are absent, and spongiosis should be focal or absent should be focal or absent
Over time additional histologic findings include acanthosis with mild Over time additional histologic findings include acanthosis with mild hypergranulosis and hyperkeratosishypergranulosis and hyperkeratosis
AcidsAcids Inorganic and organic acids can be corrosive to the skinInorganic and organic acids can be corrosive to the skin
Cause epidermal damage via protein denaturation and cytotoxicityCause epidermal damage via protein denaturation and cytotoxicity
Symptoms include erythema, vesication, and necrosisSymptoms include erythema, vesication, and necrosis
Hydrofluoric and sulfuric acid can cause the most severe burnsHydrofluoric and sulfuric acid can cause the most severe burns
Hydrofluoric acid, used in the semiconductor industry, is able to Hydrofluoric acid, used in the semiconductor industry, is able to penetrate intact skin with subsequent dissociation in deeper tissues penetrate intact skin with subsequent dissociation in deeper tissues and resultant liquefactive necrosisand resultant liquefactive necrosis
Acids Acids Chromic acid causes ulcerations Chromic acid causes ulcerations
known as ‘chrome holes’ and often known as ‘chrome holes’ and often perforates the nasal septumperforates the nasal septum
Chemical burns and irritant Chemical burns and irritant dermatitis from nitric acid can dermatitis from nitric acid can cause a distinctive yellow cause a distinctive yellow discoloration discoloration
In general, organic acids are less In general, organic acids are less irritating than inorganic acidsirritating than inorganic acids
Formic acid has the greatest Formic acid has the greatest corrosive potential of the organic corrosive potential of the organic acids acids
Examples of chrome holes www.cdc.gov/niosh/ocderm
AlkalisAlkalis Strong Alkalis include sodium, ammonium, Strong Alkalis include sodium, ammonium,
potassium hydroxide, sodium and potassium hydroxide, sodium and potassium carbonate, and calcium oxidepotassium carbonate, and calcium oxide
Found in soaps, detergents, bleaches, Found in soaps, detergents, bleaches, ammonia preparations, lye, drain pipe ammonia preparations, lye, drain pipe cleaner, toilet bowl cleansers, and oven cleaner, toilet bowl cleansers, and oven cleanercleaner
Often more painful and damaging than acidsOften more painful and damaging than acids
No vesicles, necrotic skin that appears dark No vesicles, necrotic skin that appears dark brown then black, ultimately becomes hard, brown then black, ultimately becomes hard, dry, and crackeddry, and cracked
Alkalis disrupt barrier lips and denature Alkalis disrupt barrier lips and denature proteins with subsequent fatty acid proteins with subsequent fatty acid saponificationsaponification
Alkalis Alkalis
Cement mixed with water can Cement mixed with water can cause ulcerative damage due to cause ulcerative damage due to alkalinityalkalinity
Changes appear 8 to 12 hours Changes appear 8 to 12 hours after exposureafter exposure
Chronic irritant cement dermatitis Chronic irritant cement dermatitis may also develop over months to may also develop over months to yearsyears
Can accompany allergic contact Can accompany allergic contact dermatitisdermatitis
Hand dermatitis due to contact with cement dermnetnz.org/dermatitis/chrome
Metal SaltsMetal Salts
Include arsenic trioxide, beryllium compounds, calcium Include arsenic trioxide, beryllium compounds, calcium oxide, copper salts, inorganic mercury, thimerosal, and oxide, copper salts, inorganic mercury, thimerosal, and seleniumselenium
Signs ranging from ulceration to folliculitisSigns ranging from ulceration to folliculitis
SolventsSolvents
Act mainly by dissolving the intercellular lipid barrier of Act mainly by dissolving the intercellular lipid barrier of the epidermisthe epidermis
Prolonged skin contact can result in severe burns and Prolonged skin contact can result in severe burns and well as systemic toxicitywell as systemic toxicity
Examples include turpentine, benzene, toluene, xylene, Examples include turpentine, benzene, toluene, xylene, carbon tetrachloride, gasoline, and kerosenecarbon tetrachloride, gasoline, and kerosene
Professional paint and crayon illustrator with bilateral palmar dermatitis secondary to repeated contact with paint solvents. Extensive patch testing excluded allergic contact dermatitis
Detergents and CleansersDetergents and Cleansers Include any surface active agent (surfactant) that Include any surface active agent (surfactant) that
concentrates at the oil-water interfaces and has both concentrates at the oil-water interfaces and has both emulsifying and cleansing propertiesemulsifying and cleansing properties
Found in skin cleansers, cosmetics, and household Found in skin cleansers, cosmetics, and household cleaning productscleaning products
Surfactants cause protein denaturation of the stratum Surfactants cause protein denaturation of the stratum corneum, impairing barrier functioncorneum, impairing barrier function
Anionic detergents such as alkyl sulfates and alkyl Anionic detergents such as alkyl sulfates and alkyl carboxylate salts are the most irritatingcarboxylate salts are the most irritating
DisinfectantsDisinfectants Include, alcohols, aldehydes, Include, alcohols, aldehydes,
phenolic compounds, phenolic compounds, halogenated compounds, halogenated compounds, surfactants, dyes, oxidizing surfactants, dyes, oxidizing agents, and mercury agents, and mercury compoundscompounds
Weak toxic agents that can Weak toxic agents that can cause chronic ICDcause chronic ICD
Practicing dentist with moderately severe irritant hand Practicing dentist with moderately severe irritant hand dermatitis from chronic exposure to disinfecting solutions and dermatitis from chronic exposure to disinfecting solutions and antisepticsantiseptics. The results of patch testing, latex challenge testing, and . The results of patch testing, latex challenge testing, and RAST testing were negative.RAST testing were negative.
PlasticsPlastics
Three categories: thermoplastics, thermosettings, Three categories: thermoplastics, thermosettings, elastomerselastomers
Skin damage is attributed to monomer ingredients, Skin damage is attributed to monomer ingredients, hardeners, and stabilizershardeners, and stabilizers
Final hardened plastic product is generally considered Final hardened plastic product is generally considered inertinert
FoodFood Agriculture, fishing, catering, and Agriculture, fishing, catering, and
food processingfood processing
Often work without gloves, in Often work without gloves, in damp working conditions with damp working conditions with frequent hand washingfrequent hand washing
Mechanical, thermal, and climatic Mechanical, thermal, and climatic factorsfactors
Nearly 100% of exposed persons Nearly 100% of exposed persons in food handling and fishing in food handling and fishing professions may be affected by professions may be affected by chronic irritant hand dermatitischronic irritant hand dermatitis
WaterWater Ubiquitous skin irritantUbiquitous skin irritant
Tropical immersion foot, seen Tropical immersion foot, seen during Vietnam Warduring Vietnam War
Hairdressers, hospital Hairdressers, hospital cleaners, cannery workers, cleaners, cannery workers, bartendersbartenders
Irritancy of water is Irritancy of water is exacerbated by occlusionexacerbated by occlusion 9 year old is an habitual hand washer who develops a
contact irritant dermatitis every winter. At times she washes over 10 times a day. www.dermatlas.org
Fabric/man-made vitreous fibersFabric/man-made vitreous fibers Fibers larger than 3.5 um in Fibers larger than 3.5 um in
diameter cause the highly diameter cause the highly pruritic contact dermatitis pruritic contact dermatitis caused by fiberglasscaused by fiberglass
Erythematous papules with Erythematous papules with superimposed excoriations on superimposed excoriations on neck and dorsal handsneck and dorsal hands
Wool and rough clothing cause Wool and rough clothing cause dermatitis in atopic individualsdermatitis in atopic individuals
Fiberglass dermatitis www.cdc.gov/niosh/ocderm
Differential DiagnosisDifferential Diagnosis Allergic and ICD, especially in chronic stage appear similar by Allergic and ICD, especially in chronic stage appear similar by
clinical appearance, histology, and immunohistologyclinical appearance, histology, and immunohistology
Look identical with erythema, papules, xerosis, scaling, and Look identical with erythema, papules, xerosis, scaling, and lichenification with sharp borderslichenification with sharp borders
ICD has remained a diagnosis of exclusion when dermatitis is not ICD has remained a diagnosis of exclusion when dermatitis is not explained by positive patch test to a known allergenexplained by positive patch test to a known allergen
More frequent complaint of burning and stinging with ICD in contrast More frequent complaint of burning and stinging with ICD in contrast to pruritus in ACDto pruritus in ACD
TreatmentTreatment Avoidance of causative irritants at home or in the workplace is the primary Avoidance of causative irritants at home or in the workplace is the primary
TXTX
Engineering controls to reduce exposure in the workplaceEngineering controls to reduce exposure in the workplace
Shielding and personal protection such as gloves and special clothingShielding and personal protection such as gloves and special clothing
Pre-exposure protection by protective creams, removal of irritants by mild Pre-exposure protection by protective creams, removal of irritants by mild cleaning agents, and enhancement of barrier function generation by cleaning agents, and enhancement of barrier function generation by emollients and moisturizersemollients and moisturizers
Emphasizing personal and occupational hygieneEmphasizing personal and occupational hygiene
Establishing educational programs to increase awareness in the workplaceEstablishing educational programs to increase awareness in the workplace
TX Chemical BurnsTX Chemical Burns Initial tx irrigation with large volumes of water, if chemical is insoluble in water a soap Initial tx irrigation with large volumes of water, if chemical is insoluble in water a soap
solution may be usedsolution may be used
High pressure water to be avoided to prevent splashingHigh pressure water to be avoided to prevent splashing
2.5% calcium gluconate gel used to tx hydroflouric acid burns, immediate application 2.5% calcium gluconate gel used to tx hydroflouric acid burns, immediate application of a weak acid such as vinegar, lemon juice, or 0.5% hydrochloric acid will lessen the of a weak acid such as vinegar, lemon juice, or 0.5% hydrochloric acid will lessen the effect of alkali burnseffect of alkali burns
Ulcerated areas should be managed with antibacterial creams or ointments to prevent Ulcerated areas should be managed with antibacterial creams or ointments to prevent secondary infectionsecondary infection
Frequent evaluation is required because ulcers may progress over several daysFrequent evaluation is required because ulcers may progress over several days
Excision, debridement and/or grafting may speed healingExcision, debridement and/or grafting may speed healing
Monitoring of blood, liver, and kidney function may be needed when exposed to Monitoring of blood, liver, and kidney function may be needed when exposed to chemicals with potential for systemic toxicity such as hydrofluoric acid, phenolic chemicals with potential for systemic toxicity such as hydrofluoric acid, phenolic compounds, chromic acid, and gasolinecompounds, chromic acid, and gasoline
Chronic ICD TreatmentChronic ICD Treatment Tx goal is to restore normal epidermal barrier functionTx goal is to restore normal epidermal barrier function
Topical corticosteroids frequently usedTopical corticosteroids frequently used
Systemic corticosteroids although helpful in reducing inflammation, Systemic corticosteroids although helpful in reducing inflammation, are not useful in treatment of chronic ICD unless offending are not useful in treatment of chronic ICD unless offending contactants are avoidedcontactants are avoided
PUVA and Grenz ray considered for chronic dermatitis that does not PUVA and Grenz ray considered for chronic dermatitis that does not respond to other txrespond to other tx
Hyperkeratotic palmoplantar dermatitis from frictional or chronic ICD Hyperkeratotic palmoplantar dermatitis from frictional or chronic ICD may benefit from the adjunctive use of systemic retinoids such as may benefit from the adjunctive use of systemic retinoids such as acitretinacitretin
Allergic contact dermatitis Allergic contact dermatitis (ACD)(ACD)
ACD accounts for ACD accounts for approximately 20% of all approximately 20% of all contact dermatitiscontact dermatitis
ACD is a type IV, delayed or ACD is a type IV, delayed or cell-mediated immune reaction cell-mediated immune reaction that is elicited when the skin that is elicited when the skin comes in contact with a comes in contact with a chemical to which an chemical to which an individual has been previously individual has been previously sensitizedsensitized
Synonyms include contact Synonyms include contact dermatitis and contact eczemadermatitis and contact eczema
Allergic contact dermatitis. Linear streaks seen with ACD to poison ivy.
ACDACD Key FeaturesKey Features
ACD is a pruritic, eczematous ACD is a pruritic, eczematous reactionreaction
Acute ACD and many cases of Acute ACD and many cases of chronic ACD are well demarcated chronic ACD are well demarcated and located to the site of contact and located to the site of contact with the allergenwith the allergen
Prototypic reactions are ACD due Prototypic reactions are ACD due to poison ivy and nickelto poison ivy and nickel
Patch testing remains the gold Patch testing remains the gold standard for accurate and standard for accurate and consistent diagnosisconsistent diagnosis
This healthy adolescent developed an intensely pruritic vesiculobullous allergic contact dermatitis from hair dye. Dermatlas.org
Classic picture of ACD is a Classic picture of ACD is a well-demarcated erythematous well-demarcated erythematous vesicular and/or scaly patch or vesicular and/or scaly patch or plaque with well defined plaque with well defined margins corresponding to the margins corresponding to the area of contactarea of contact
Chronic allergic contact dermatitis leading to hand dermatitis. This golfer wore one leather glove and had positive patch tests to potassium dichromate and a piece of his glove. Courtesy of Kalman Watsky, M.D.
Allergic contact Allergic contact dermatitis to leather dermatitis to leather shoes.shoes. Note the Note the correspondence to sites correspondence to sites of exposure. of exposure. Courtesy of Yale Courtesy of Yale Residents Slide Collection.Residents Slide Collection.
Because ICD and ACD Because ICD and ACD are not always are not always discernable clinically, discernable clinically, patch testing is required patch testing is required to help identify an to help identify an allergen or exclude an allergen or exclude an allergy to a suspected allergy to a suspected allergen.allergen.
Allergic contact dermatitis. Chronic hand dermatitis due to ACD to mercaptobenzothiazole found in rubber gloves
Epidemiology of ACDEpidemiology of ACD Affects the old and young, individuals of all races, and both sexesAffects the old and young, individuals of all races, and both sexes
Differences in genders usually based on exposure patterns, such as Differences in genders usually based on exposure patterns, such as nickel allergy being seen more frequently in women, presumably nickel allergy being seen more frequently in women, presumably due to greater exposure to jewelrydue to greater exposure to jewelry
Occupations and avocations play an important roleOccupations and avocations play an important role
Allergens differ from region to region, e.g. preservatives used in Allergens differ from region to region, e.g. preservatives used in personal care products can vary based on government legislationpersonal care products can vary based on government legislation
Pathogenesis of ACDPathogenesis of ACD ACD is a type IV hypersensitivity responseACD is a type IV hypersensitivity response
Requires prior sensitization to the chemical in questionRequires prior sensitization to the chemical in question
Subsequent re-exposure of individual leads to allergen Subsequent re-exposure of individual leads to allergen being presented to a primed T-cell milieu leading to being presented to a primed T-cell milieu leading to release of numerous cytokines and chemotactic factors release of numerous cytokines and chemotactic factors leading to the clinical picture of eczemaleading to the clinical picture of eczema
Once sensitized a low concentration of causative Once sensitized a low concentration of causative chemical elicits a response chemical elicits a response
Induction of contact hypersensitivity. Application of contact allergens (Ag) induces the release of cytokines by keratinocytes, Langerhans cells and other cells within the skin. These cytokines in turn activate Langerhans cells which uptake the antigen and emigrate into the regional lymph nodes. During this process, the Langerhans cells mature into dendritic cells. In addition, the antigen is processed, re-expressed on the surface and finally presented to naïve T cells in the regional lymph node. Upon appropriate antigen presentation, T cells bearing the appropriate T cell receptor clonally expand and become effector T cells. These alter their migratory behavior due to the expression of specific surface molecules like CLA. Effector T cells recirculate into the periphery where they may later meet the antigen again. Ag, antigen; KC, keratinocyte.
Elicitation of contact hypersensitivityElicitation of contact hypersensitivity. Application of contact allergens (Ag) into a sensitized individual . Application of contact allergens (Ag) into a sensitized individual causes the release of cytokines by keratinocytes and Langerhans cells. These cytokines induce the causes the release of cytokines by keratinocytes and Langerhans cells. These cytokines induce the expression of adhesion molecules and activation of endothelial cells which ultimately attracts leukocytes expression of adhesion molecules and activation of endothelial cells which ultimately attracts leukocytes to the site of antigen application. Among these cells, T effector cells are present which are now activated to the site of antigen application. Among these cells, T effector cells are present which are now activated upon antigen presentation either by resident cells or by infiltrating Langerhans cells. Antigen-specific T upon antigen presentation either by resident cells or by infiltrating Langerhans cells. Antigen-specific T cell activation again induces the release of cytokines by T cells. This causes the attraction of other cell activation again induces the release of cytokines by T cells. This causes the attraction of other inflammatory cells including granulocytes and macrophages which ultimately cause the clinical inflammatory cells including granulocytes and macrophages which ultimately cause the clinical manifestation of contact dermatitis. Ag, antigen; DDC, dermal dendritic cell; KC, keratinocyte; CLA, manifestation of contact dermatitis. Ag, antigen; DDC, dermal dendritic cell; KC, keratinocyte; CLA, cutaneous lymphocyte antigen.cutaneous lymphocyte antigen.
Clinical features of ACDClinical features of ACD
Acute blistering and Acute blistering and weepingweeping
Chronic lichenified and Chronic lichenified and scaly plaquesscaly plaques
Patchy and diffuse Patchy and diffuse distributions may be seen distributions may be seen with body washes and with body washes and shampoosshampoos
Acute bullous allergic contact dermatitis due to poison ivy. This distribution is seen in patients who wear gloves. Courtesy of Yale Residents Slide Collection
Chronic allergic contact dermatitis due to glutaraldehyde. The patient was an optometrist
Pathology of ACDPathology of ACD ACD is the prototype of spongiotic dermatitisACD is the prototype of spongiotic dermatitis
Acute stage: variable degree of spongiosis with mixed Acute stage: variable degree of spongiosis with mixed dermal inflammatory infiltrate containing lymphocytes, dermal inflammatory infiltrate containing lymphocytes, histiocytes, and variable numbers of eosinophilshistiocytes, and variable numbers of eosinophils
Moderate to severe reactions show intraepidermal Moderate to severe reactions show intraepidermal vesiculationvesiculation
Subacute to chronic stages have epidermal hyperplasia, Subacute to chronic stages have epidermal hyperplasia, often psoriasiformoften psoriasiform
DDX of ACDDDX of ACD
Includes many forms of dermatitis: ICD, atopic Includes many forms of dermatitis: ICD, atopic dermatitis, stasis dermatitis, and seborrheic dermatitis, dermatitis, stasis dermatitis, and seborrheic dermatitis, as well as the erythematous form of rosaceaas well as the erythematous form of rosacea
Hand and foot ACD need to be distinguished from Hand and foot ACD need to be distinguished from psoriasis and tineapsoriasis and tinea
Widespread disease needs to be differentiated from Widespread disease needs to be differentiated from other causes of erythoderma, Sezary syndromeother causes of erythoderma, Sezary syndrome
Patch TestingPatch Testing Simple office procedure upon which the diagnosis of ACD often Simple office procedure upon which the diagnosis of ACD often
restsrests
Although the procedure is simple, deciding when and what to test Although the procedure is simple, deciding when and what to test for requires training and experiencefor requires training and experience
Patch testing is underutilizedPatch testing is underutilized
Only 50% of all residency programs in USA have a patch Only 50% of all residency programs in USA have a patch test centertest center
Past surveys show 27% of the responders did no patch testing Past surveys show 27% of the responders did no patch testing
Patch TestingPatch Testing
TRUE Test TRUE Test
Other panels include North American Contact Dermatitis Other panels include North American Contact Dermatitis Group (NACDG) Screening Series, and the European Group (NACDG) Screening Series, and the European Standard SeriesStandard Series
Other panels are unique to specific occupations such as Other panels are unique to specific occupations such as hairdressing tray, dental tray, and florist trayhairdressing tray, dental tray, and florist tray
True TestTrue Test Preimpregnated test that screens Preimpregnated test that screens
for 23 allergensfor 23 allergens
Extending testing beyond these 23 Extending testing beyond these 23 allergens has shown to be more allergens has shown to be more beneficialbeneficial
In three studies, extended testing In three studies, extended testing detected 37-76% more positive detected 37-76% more positive reactions, and 47.3% of patients reactions, and 47.3% of patients had positive reactions had positive reactions onlyonly to non- to non-screening allergensscreening allergens
Additional allergens come in Additional allergens come in multiuse syringesmultiuse syringes
Allergens contained within syringes being placed by nurse into Finn chambers
Application of TRUE test. www.truetest.com
Pre-Patch Testing QuestionsPre-Patch Testing Questions Exposures both at work and home to understand Exposures both at work and home to understand
mechanics of the work environment, Materials Safety mechanics of the work environment, Materials Safety Data Sheets (MSDS) can be helpful for workplace Data Sheets (MSDS) can be helpful for workplace exposuresexposures
Effect of vacations and time away form work or home Effect of vacations and time away form work or home should be ascertainedshould be ascertained
All personal care products should be inventoriedAll personal care products should be inventoried
All hobbies should be exploredAll hobbies should be explored
Patch TestingPatch Testing Chemicals brought in by patients should not be tested blindly, Chemicals brought in by patients should not be tested blindly,
physician should be aware of the chemical ingredients because physician should be aware of the chemical ingredients because severe burns or ulceration may occursevere burns or ulceration may occur
‘‘Leave on’ personal care products such as moisturizers and make-Leave on’ personal care products such as moisturizers and make-up may be tested ‘as is’up may be tested ‘as is’
‘‘Rinse off’ products such as soaps or shampoos need to be diluted Rinse off’ products such as soaps or shampoos need to be diluted prior to patch testingprior to patch testing
Patch TestingPatch Testing Most common site is the upper backMost common site is the upper back
Patients should not have a sunburn in Patients should not have a sunburn in test area, and should not apply topical test area, and should not apply topical corticosteroids to the patch test sites corticosteroids to the patch test sites for 7 days prior to testfor 7 days prior to test
Systemic corticosteroids should be Systemic corticosteroids should be avoided for 1 month prior to testingavoided for 1 month prior to testing
Patches are applied to back and Patches are applied to back and reinforced with Scanpor tape, patient reinforced with Scanpor tape, patient instructed to keep back dry and instructed to keep back dry and patches secured until second visit at patches secured until second visit at 48 hours48 hours Fixing allergens to patient's back using
Scanpor® tape.
Patch TestingPatch Testing When the patient returns in 48 When the patient returns in 48
hours the patches need to be hours the patches need to be inspected to ensure that the inspected to ensure that the testing technique is adequatetesting technique is adequate
As patches are removed their As patches are removed their sites of application should be sites of application should be marked in order to identify the marked in order to identify the locations of particular allergenslocations of particular allergens
Patch Test ScoringPatch Test Scoring
A positive patch test reaction to nickel. This is an example of a 3+ reaction
Patch TestingPatch Testing
Patient again asked to keep back dry until second Patient again asked to keep back dry until second reading, done from 72 hours to 1 week after the initial reading, done from 72 hours to 1 week after the initial application of the patchesapplication of the patches
This delayed reading is necessary due to patch test This delayed reading is necessary due to patch test responses to some allergens such as gold having a responses to some allergens such as gold having a delayed reactiondelayed reaction
Repeat Open Application Test Repeat Open Application Test (ROAT)(ROAT)
Poor man’s patch testPoor man’s patch test
Patient applies the product in question to the same Patient applies the product in question to the same location (where there is not dermatitis), e.g. antecubital location (where there is not dermatitis), e.g. antecubital fossa, BID for 1-2 weeksfossa, BID for 1-2 weeks
If dermatitis develops, it can be concluded that the If dermatitis develops, it can be concluded that the patient is reacting to the productpatient is reacting to the product
Downside to this approach is that individual problem Downside to this approach is that individual problem ingredients are not identifiedingredients are not identified
Treatment and Patient EducationTreatment and Patient Education
Once allergens are positively Once allergens are positively identified, patient should be identified, patient should be given written information on all given written information on all of these chemicalsof these chemicals
Patient should be instructed on Patient should be instructed on how to read labels on old or how to read labels on old or new products to avoid future new products to avoid future exposureexposure
Treatment of ACDTreatment of ACD
Involves identification of causative allergensInvolves identification of causative allergens
Clear the dermatitis with topical, or if necessary systemic Clear the dermatitis with topical, or if necessary systemic corticosteroidscorticosteroids
Complete and prolonged clearing can take up to 6 weeks Complete and prolonged clearing can take up to 6 weeks or more, even when allergens are being avoidedor more, even when allergens are being avoided
NickelNickel Most common allergen tested by the Most common allergen tested by the
NACDG, with 14% of patients reacting NACDG, with 14% of patients reacting to itto it
Relevance has been estimated to be Relevance has been estimated to be 50%50%
Commonly used in jewelry, buckles, Commonly used in jewelry, buckles, snaps, and other metal-containing snaps, and other metal-containing objectsobjects
High rate of sensitivity attributed to ear High rate of sensitivity attributed to ear piercingpiercing
Dimethylglyoxime test to determine if a Dimethylglyoxime test to determine if a particular item contains nickelparticular item contains nickel
Individuals with nickel allergy should Individuals with nickel allergy should avoid custom jewelry, and can usually avoid custom jewelry, and can usually wear stainless steel or goldwear stainless steel or gold
Nickel DermatitisNickel Dermatitis Common presentations are Common presentations are
dermatitis on the ears, under a dermatitis on the ears, under a necklace or a watch back, or necklace or a watch back, or on the mid-abdomen caused on the mid-abdomen caused by a belt buckle, zipper, or by a belt buckle, zipper, or snapsnap
Eyelid dermatitis from metal Eyelid dermatitis from metal eyelash curlers can be seen eyelash curlers can be seen
Photos from dermatlas.orgPhotos from dermatlas.org
Neomycin SulfateNeomycin Sulfate Most commonly used topical antibioticMost commonly used topical antibiotic
Most common sensitizer among topical Most common sensitizer among topical antibioticsantibiotics
Found in many OTC preparations: Found in many OTC preparations: bacterial ointments, hemorrhoid bacterial ointments, hemorrhoid creams, and otic and opthalmic creams, and otic and opthalmic preparationspreparations
Frequently used with other Frequently used with other antibacterial agents, such as bacitracin antibacterial agents, such as bacitracin and polymyxin, as well as and polymyxin, as well as corticosteroidscorticosteroids
Co-reactivity is commonly seen with Co-reactivity is commonly seen with neomycin and bacitracin neomycin and bacitracin
13 year old boy developed an itchy allergic contact
dermatitis from a topical antibiotic. www.dermatlas.org
Balsam of PeruBalsam of Peru Naturally occurring fragrance material Naturally occurring fragrance material
Prior to introduction of fragrance mix in the 1970’s, balsam of Peru Prior to introduction of fragrance mix in the 1970’s, balsam of Peru was used to screen for fragrance allergywas used to screen for fragrance allergy
Capable of identifying 50% of those allergic to fragranceCapable of identifying 50% of those allergic to fragrance
Seen in those with allergies to spices, in particular cloves, Jamaicin Seen in those with allergies to spices, in particular cloves, Jamaicin pepper, and cinnamonpepper, and cinnamon
Patients with a positive reaction need to avoid fragrances, Patients with a positive reaction need to avoid fragrances, occasionally spices, and other sources such as colas, tobacco, occasionally spices, and other sources such as colas, tobacco, wines, and vermouthwines, and vermouth
Fragrance MixFragrance Mix Contains eight different components: Contains eight different components:
cinnamic etoh, cinnamic aldehyde, cinnamic etoh, cinnamic aldehyde, hydroxycitronellal, isoeugenol, hydroxycitronellal, isoeugenol, eugenol, oak moss absolute, alpha-eugenol, oak moss absolute, alpha-amyl cinnamic aldehyde, and geraniolamyl cinnamic aldehyde, and geraniol
Detects 70-80% of fragrance allergiesDetects 70-80% of fragrance allergies
Patients need to read product labels Patients need to read product labels and avoid anything that lists a and avoid anything that lists a fragrance, is labeled ‘unscented’, or fragrance, is labeled ‘unscented’, or has an obvious scenthas an obvious scent
Patients need to look for ‘fragrance-Patients need to look for ‘fragrance-free’ productsfree’ products
ACD to fragrance found in cologne. A Patient with ACD to fragrance found in his cologne. B Patient after avoidance of fragrances and his cologne.
ThimerosalThimerosal Thimerosal is a combination of thiosalicylic acid and ethylmercuric Thimerosal is a combination of thiosalicylic acid and ethylmercuric
chloride, and is used as a preservativechloride, and is used as a preservative
Most sensitization may be due to its use as a preservative in Most sensitization may be due to its use as a preservative in vaccinesvaccines
Other exposures include: contact lens solution, otic and opthalmic Other exposures include: contact lens solution, otic and opthalmic solutions, antiseptics, and cosmeticssolutions, antiseptics, and cosmetics
Positive reactions are common, relevance is low and therefore Positive reactions are common, relevance is low and therefore routine testing to this allergen should be reconsideredroutine testing to this allergen should be reconsidered
GoldGold NACDG found a positive rate of 9.5%NACDG found a positive rate of 9.5%
NACDC found 90% of gold-allergic patients were women, and there NACDC found 90% of gold-allergic patients were women, and there was a higher rate of nickel (33.5%) and cobalt allergy (18%) in this was a higher rate of nickel (33.5%) and cobalt allergy (18%) in this groupgroup
Most common clinical picture is hand, facial, or eyelid dermatitisMost common clinical picture is hand, facial, or eyelid dermatitis
Systemic reactions to gold in patients whom it was used to tx RA, Systemic reactions to gold in patients whom it was used to tx RA, SLE, or pemphigus. SLE, or pemphigus.
Cutaneous findings of lichen planus-like reactions to pityriasis Cutaneous findings of lichen planus-like reactions to pityriasis rosea-like reactions and papular eruptions with systemic reactionsrosea-like reactions and papular eruptions with systemic reactions
FormaldehydeFormaldehyde Is a ubiquitous, colorless gas found in the workplace, cosmetics, medications, Is a ubiquitous, colorless gas found in the workplace, cosmetics, medications,
textiles, paints, cigarette smoke, paper, and formaldehyde resins in plastic bottlestextiles, paints, cigarette smoke, paper, and formaldehyde resins in plastic bottles
Commonly seen in association with formaldehyde-releasing presevatives, such as Commonly seen in association with formaldehyde-releasing presevatives, such as quarternuim-15 imidazolidinyl urea, diazolidinyl urea, DMDM hydantoin, 2-bromo-2-quarternuim-15 imidazolidinyl urea, diazolidinyl urea, DMDM hydantoin, 2-bromo-2-nitropropane-1-3,diol, and tris(hydroxymethyl)nitromethanenitropropane-1-3,diol, and tris(hydroxymethyl)nitromethane
ICD is most common, ACD, contact urticaria, and mucous membrane irritation can ICD is most common, ACD, contact urticaria, and mucous membrane irritation can occuroccur
Textile dermatitis due to formaldehyde resins in ‘wash-and-wear’ and wrinkle resistant Textile dermatitis due to formaldehyde resins in ‘wash-and-wear’ and wrinkle resistant clothesclothes
Another source of formaldehyde is ‘formaldehyde-free’ products that are packaged in Another source of formaldehyde is ‘formaldehyde-free’ products that are packaged in containers coated with formaldehyde resinscontainers coated with formaldehyde resins
So widespread that avoidance is difficult and clinical relevance should be determinedSo widespread that avoidance is difficult and clinical relevance should be determined
Quaternium-15Quaternium-15 Preservative that is an effective Preservative that is an effective
biocide against biocide against PseudomonasPseudomonas, as , as well as other bacteria and fungiwell as other bacteria and fungi
Most common preservative to Most common preservative to cause ACDcause ACD
Found in shampoos, moisturizers, Found in shampoos, moisturizers, conditioners, and soapsconditioners, and soaps
80% of those reacting to 80% of those reacting to quarternium-15 are also quarternium-15 are also formaldehyde sensitiveformaldehyde sensitive
Hand dermatititis due toquaternium-15 in a moisturiser dermnetnz.org/dermatitis/quaternium
CobaltCobalt Metal that is used in association with Metal that is used in association with
other metals to add hardness and other metals to add hardness and strengthstrength
Frequently combined with nickel, Frequently combined with nickel, chromium, molybdenum, and tungstenchromium, molybdenum, and tungsten
80% of individuals with a cobalt 80% of individuals with a cobalt sensitivity have a co-sensitivity to sensitivity have a co-sensitivity to chromate (more common in men) or chromate (more common in men) or nickel (more common in women)nickel (more common in women)
Exposure through jewelry snaps, Exposure through jewelry snaps, buttons, tools, cosmetics, hair dyes, buttons, tools, cosmetics, hair dyes, joint replacements, ceramics, enamel, joint replacements, ceramics, enamel, cement, paints , and resinscement, paints , and resins
BacitracinBacitracin Topical antibiotic with activity Topical antibiotic with activity
against Gram-positive bacteria against Gram-positive bacteria and spirochetesand spirochetes
Commonly used in Commonly used in combination with other combination with other antibiotics such as neomycin antibiotics such as neomycin and with corticosteroidsand with corticosteroids
In addition to ACD, also rarely In addition to ACD, also rarely causes anaphylaxis and causes anaphylaxis and contact urticariacontact urticaria
Chronic ulcerations on the lower extremity are particularly likely to develop allergic contact dermatitis. This eruption resulted from sensitization to bacitracin. www.worldallergy.org
CorticosteroidsCorticosteroids Have been shown to cause ACD in anywhere from 0.2% to 5.98%Have been shown to cause ACD in anywhere from 0.2% to 5.98%
It is suspected that ACD to these agents is underdiagnosed, due to It is suspected that ACD to these agents is underdiagnosed, due to insufficient testinginsufficient testing
Clinical scenarios that should raise suspicion include: chronic Clinical scenarios that should raise suspicion include: chronic dermatitis, failure to clear with corticosteroids, and exacerbations of dermatitis, failure to clear with corticosteroids, and exacerbations of dermatitis after use of corticosteroidsdermatitis after use of corticosteroids
Tixocortol-21-pivalate and budesonide used for screening, with Tixocortol-21-pivalate and budesonide used for screening, with 91.3% of corticosteroid allergic reactions detected91.3% of corticosteroid allergic reactions detected
Complicates patch test interpretation, due to edge effect (first Complicates patch test interpretation, due to edge effect (first reading may have erythema only at the rim of the Finn chamber)reading may have erythema only at the rim of the Finn chamber)
Systemic Contact DermatitisSystemic Contact Dermatitis Systemic exposure to a chemical Systemic exposure to a chemical
may result in a diffuse dermatitismay result in a diffuse dermatitis
Patient has had a prior contact Patient has had a prior contact allergy and then becomes allergy and then becomes exposed through a systemic route, exposed through a systemic route, such as injection, oral, such as injection, oral, intravenous, or intranasal intravenous, or intranasal administration administration
One of most common examples is One of most common examples is patient with ethylenediamine patient with ethylenediamine allergy and subsequent reaction to allergy and subsequent reaction to
aminophyllineaminophylline
Airborne Contact DermatitisAirborne Contact Dermatitis Airborne allergens result in several different reactions including ICD Airborne allergens result in several different reactions including ICD
and ACDand ACD
PhotoACD, photoICD, photoxicity, and photoallergy to systemic PhotoACD, photoICD, photoxicity, and photoallergy to systemic medications clinically resemble airborne contact dermatitismedications clinically resemble airborne contact dermatitis
Ragweed dermatitis is a classic exampleRagweed dermatitis is a classic example
Clinically, lichenified and dry skin located in the exposed portions of Clinically, lichenified and dry skin located in the exposed portions of the skin: face, V of the neck, arms and legsthe skin: face, V of the neck, arms and legs
Most common causative agents are plants, natural resins, woods, Most common causative agents are plants, natural resins, woods, plastics, rubbers, glues, metals, pharmaceutical chemicals, plastics, rubbers, glues, metals, pharmaceutical chemicals, insecticides and pesticidesinsecticides and pesticides
55-year-old farm worker developed a chronic allergic contact dermatitis to airborn allergens (compositae).
Anacardiacea DermatitisAnacardiacea Dermatitis
Poison Ivy vine growing up a tree Poison Ivy vine growing up a tree www.dermatlas.orgwww.dermatlas.org
Anacardiacea ACDAnacardiacea ACD Members of the Anacardiaceae cause Members of the Anacardiaceae cause
more contact dermatitis that all other more contact dermatitis that all other plant families combinedplant families combined
Most allergenic members belong to the Most allergenic members belong to the genus genus Toxicodendron, Toxicodendron, including including poison ivy, poison oak, and poison poison ivy, poison oak, and poison sumacsumac
Tocicodendron leaves are compound, Tocicodendron leaves are compound, possessing three or more leaflets. possessing three or more leaflets. Flowers and fruit arise in an axillary Flowers and fruit arise in an axillary positions in the angle between the leaf positions in the angle between the leaf and the twig from which it arises and the twig from which it arises
Black dots of urushiol often present on Black dots of urushiol often present on leaves and fruitleaves and fruit
Anacardiacae AllergensAnacardiacae Allergens Urushiol derives its name form the Urushiol derives its name form the
Japanese word for the sap Japanese word for the sap (kiurushi) of the Japanese lacquer (kiurushi) of the Japanese lacquer treetree
Urushiol contains a mixture of Urushiol contains a mixture of catechols (1,2-catechols (1,2-dihydroxybenzenes) and dihydroxybenzenes) and resorcinols (1,3-resorcinols (1,3-dihydroxybenzenes)dihydroxybenzenes)
Urushiol self-melanizes on Urushiol self-melanizes on exposure to oxygenexposure to oxygen
Avidly binds to skin but is readily Avidly binds to skin but is readily degraded by waterdegraded by water
Poison Ivy www.dermatlas.orgPoison Ivy www.dermatlas.org
Clinical Features Anacardiacea Clinical Features Anacardiacea DermatitisDermatitis
Damage is generally required for Damage is generally required for plants to release urushiolplants to release urushiol
In late fall plants release urushiol In late fall plants release urushiol spontaneouslyspontaneously
Urushiol may be spread by Urushiol may be spread by contaminated clothing, dogs, cats, contaminated clothing, dogs, cats, lacquered furniture, sawdust, and lacquered furniture, sawdust, and smokesmoke
Allergen-containing smoke can Allergen-containing smoke can cause severe respiratory tract cause severe respiratory tract inflammation, severe dermatitis, inflammation, severe dermatitis, and even temporary blindnessand even temporary blindness
www.dermatlas.orgwww.dermatlas.org
Clinical Features Anacardiacea Clinical Features Anacardiacea DermatitisDermatitis
After contact with urushiol, a sensitized person typically develops After contact with urushiol, a sensitized person typically develops and pruritic , erythematous eruption within 2 days (4-96 hours) that and pruritic , erythematous eruption within 2 days (4-96 hours) that peaks within 1-14 dayspeaks within 1-14 days
Dermatitis may last up to 3 weeks after primary contact or within Dermatitis may last up to 3 weeks after primary contact or within hours of secondary contacthours of secondary contact
Streaks of erythema and edematous papules typically precede Streaks of erythema and edematous papules typically precede vesicles and bullaevesicles and bullae
Although ACD is the most common cause of streaky, vesicular Although ACD is the most common cause of streaky, vesicular dermatitis, plants may cause this same picture by other means e.g. dermatitis, plants may cause this same picture by other means e.g. chemical irritant dermatitis, or the initial phase of phytodermatitischemical irritant dermatitis, or the initial phase of phytodermatitis
Clinical manifestations of Anacardiaceae dermatitis. AClinical manifestations of Anacardiaceae dermatitis. A Acute, streak-like edematous and Acute, streak-like edematous and erythematous dermatitis without vesicles after poison ivy brushed across the face. Courtesy of erythematous dermatitis without vesicles after poison ivy brushed across the face. Courtesy of Fitzsimons Army Medical Center Dermatology slide teaching library. Fitzsimons Army Medical Center Dermatology slide teaching library. BB Acute, streak-like vesicular Acute, streak-like vesicular dermatitis after poison ivy (dermatitis after poison ivy (Toxicodendron radicansToxicodendron radicans) contact. Courtesy of Fitzsimons Army Medical ) contact. Courtesy of Fitzsimons Army Medical Center Dermatology slide teaching library. Center Dermatology slide teaching library. CC Widespread erythema and edema associated with Widespread erythema and edema associated with intense pruritus after carrying logs of the poisonwood tree (intense pruritus after carrying logs of the poisonwood tree (Metopium toxiferumMetopium toxiferum) of the family ) of the family Anacardiaceae. Anacardiaceae. DD ‘Black-spot’ poison ivy dermatitis: note the black discoloration in the central ‘Black-spot’ poison ivy dermatitis: note the black discoloration in the central portion of the edematous plaques due to plant resin. portion of the edematous plaques due to plant resin.
Clinical Features Anacardiacea Clinical Features Anacardiacea DermatitisDermatitis
Eruption ‘progresses’ to ‘new areas’ because of variability in antigen Eruption ‘progresses’ to ‘new areas’ because of variability in antigen concentration and stratum corneum/epidermis thickness, not concentration and stratum corneum/epidermis thickness, not because of bullae fluidbecause of bullae fluid
Over 70% of the US population reacts to poison ivy allergens after Over 70% of the US population reacts to poison ivy allergens after patch testing, but only 50% react to plants in the fieldpatch testing, but only 50% react to plants in the field
Only 15% atopic patients are sensitive to poison ivyOnly 15% atopic patients are sensitive to poison ivy
Uncommonly, eruptions resemble erythema multiforme, measles, Uncommonly, eruptions resemble erythema multiforme, measles, scarlatina, or urticariascarlatina, or urticaria
Prolonged postinflammatory hyperpigmentation may occur in darkly Prolonged postinflammatory hyperpigmentation may occur in darkly pigmented individualspigmented individuals
TreatmentTreatment Entire body should be washed Entire body should be washed
with copious amounts of water as with copious amounts of water as soon as possible after exposuresoon as possible after exposure
Soap may be used afterwards, but Soap may be used afterwards, but early use of soap may expand the early use of soap may expand the area of resin on the bodyarea of resin on the body
As mentioned before, urushiol is As mentioned before, urushiol is water degradable, After 10 water degradable, After 10 minutes only 50% can be minutes only 50% can be removed, after 15 minutes only removed, after 15 minutes only 25% can be removed, after 30 25% can be removed, after 30 minutes only 10% can be minutes only 10% can be removed, and after 60 minutes removed, and after 60 minutes none of it can be removed none of it can be removed
www.dermatlas.orgwww.dermatlas.org
TreatmentTreatment Weepy lesions are best treated Weepy lesions are best treated
with tepid baths, wet-to-dry soaks, with tepid baths, wet-to-dry soaks, or bland shake lotions (calamine)or bland shake lotions (calamine)
Stringent such as Burow’s solution Stringent such as Burow’s solution (aluminum subacetate) works to (aluminum subacetate) works to cool and dry lesions when applied cool and dry lesions when applied as a wet-to-dry dressingas a wet-to-dry dressing
Topical antihistamines, Topical antihistamines, anesthetics containing anesthetics containing benzocaine, and antibiotics should benzocaine, and antibiotics should be avoided to prevent sensitizationbe avoided to prevent sensitization
www.dermatlas.orwww.dermatlas.orgg
TreatmentTreatment Most potent topical corticosteroids only Most potent topical corticosteroids only
help if applied during the earliest help if applied during the earliest stages of the outbreak, when vesicles stages of the outbreak, when vesicles and blisters are not yet presentand blisters are not yet present
Systemic steroids are effective when Systemic steroids are effective when given at a dose of 1-2 mg/kg/day, given at a dose of 1-2 mg/kg/day, slowly tapered over 2-3 weeksslowly tapered over 2-3 weeks
Many patients are referred for a Many patients are referred for a ‘recurrence’ of their poison ivy ‘recurrence’ of their poison ivy dermatitis after completing a short, 6 dermatitis after completing a short, 6 day course of oral corticosteroidsday course of oral corticosteroids
Oral antihistamines may decrease Oral antihistamines may decrease prurituspruritus
www.dermatlas.orgwww.dermatlas.org