Contact dermatitis

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Contact dermatitis

Presented by Chuleeporn Kongmeesook, MD,

2013

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Contact dermatitis

  1. 1. CONTACT DERMATITIS CHULEEPORN KONGMEESOOK ,MD
  2. 2. Outline Epidemiology Pathophysiology Clinical evaluation Treatment
  3. 3. Introduction Common inflammatory skin disease Occurs after direct or indirect contact with substances Major cause of occupational skin disease Middleton's allergy:principles and practice 8th edition; 2013
  4. 4. Classification Allergic contact dermatitis Inflammation caused by allergen specific T lymphocytes Prior sensitization necessary Irritant contact dermatitis Prolonged and repeated exposure to irritants Prior sensitization not necessary www.worldallergy.org
  5. 5. Epidemiology In USA Overall prevalence 24,400 /100,000 24, 100, people Cohort population-based studies in Europe populationPrevalence 0.7% - 18.6% for ACD 18. Incidence of OCD in other countries 1.3 19 cases per 10,000 10, Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  6. 6. Histology Epidermal changes of spongiosis Dense lymphocytic infiltrate in upper dermis Epidermal exocytosis of lymphocytes Middleton's allergy:principles and practice 8th edition
  7. 7. Differentiation between ICD and ACD Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  8. 8. Pathophysiology 1 ACD Prototype of type IV cell-mediated cellhypersensitivity reaction ICD Nonimmunologic, multifactorial, Nonimmunologic, multifactorial, direct tissue reaction T cells activated by nonimmune, irritant, nonimmune, or innate mechanisms release proinflammatory cytokines DoseDose-dependent inflammation Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  9. 9. Differentiation between ICD and ACD Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  10. 10. Pathophysiology 2 ACD and ICD frequently overlap because many allergens at high enough centrations can also act as irritants Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  11. 11. Vocanson et al. et al J Allergy 2009; 64: 1699–1714 2009; 64: 1699–
  12. 12. Vocanson et al. et al J Allergy 2009; 64: 1699–1714 2009; 64: 1699–
  13. 13. Vocanson et al. et al J Allergy 2009; 64: 1699–1714 2009; 64: 1699–
  14. 14. Clinical evaluation Diagnosis of ACD suspected from clinical presentation and possible exposure to contact allergen Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  15. 15. www.uptodate.com
  16. 16. Pristine W. Lee et al Current Opinion in Pediatrics 2009; 21:491–498 2009; 21:491–
  17. 17. Clinical presentations Allergic contact dermatitis Middleton's allergy:principles and practice 8th edition
  18. 18. Clinical presentations Irritant contact dermatitis Middleton's allergy:principles and practice 8th edition
  19. 19. Differentiation between ICD and ACD Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  20. 20. Investigation : Patch testing 1 Indicated in patients with chronic, pruritic eczematous or lichenified dermatitis in whom ACD is suspected Affected by Oral corticosteroid [>20 mg of prednisolone/day or [>20 prednisolone/day equivalent] Cancer chemotherapy or immunosuppressive drug Topical corticosteroid should be discontinued for 5-7 days before patch testing Not affected by antihistamines Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  21. 21. Investigation : Patch testing 2 Sources of allergens T.R.U.E. TEST : Not US FDA approved but recommended by CD experts Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  22. 22. Investigation : Patch testing 3 Numbers of allergens Ideal number remains controversial T.R.U.E. Test contains 29 allergens Higher false-negative reactions to falseneomycin, thiuram mix, balsam of Peru, fragrance mix, cobalt and lanolin NACDG series range from 65-70 allergens 65T.R.U.E test serve as screening tool in allergist practice Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  23. 23. Richard P. Usatine et al Am Fam Physician 2010;82:249-255 2010;82:249-
  24. 24. Patch test technique Applied to upper or middle back areas (2.5 cm (2 lateral to midspinal reference point) free of dermatitis and hair Kept in place for 48 hours Read 30 minutes after removal of patches Second reading should be done 3 to 5 days after initial application Metals , topical antibiotics , topical orticosteroids, orticosteroids, and PPD can elicit positive reactions after 7 days Nonstandardized patch tests tested at 1:10 to 1:100 dilutions Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  25. 25. Patch test technique Middleton's allergy:principles and practice 8th edition
  26. 26. Vincent S. Beltrani et al Annals of Allergy, Asthma and Immunology 2006;97:1-30 2006;97:
  27. 27. www.truetest.com/global/patch
  28. 28. www.uptodate.com
  29. 29. Pristine W. Lee et al Current Opinion in Pediatrics 2009; 21:491–498 2009; 21:491–
  30. 30. Wareeporn Disphanurat J Med Assoc Thai 2010; 93 (Suppl. 7) : S7-S14 2010; S7
  31. 31. Investigation : ROAT Improving reliability of interpreting tests for leaveleave-on products Suspected allergens are applied to antecubital fossa twice daily for 7 days and observed for dermatitis Absence of reaction makes CD unlikely If eyelid dermatitis is considered ROAT can be performed on back of ear Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  32. 32. ROAT Contact dermatitis 5th edition
  33. 33. Systemic contact dermatitis 1 Localized or generalized inflammatory skin disease in contact-sensitized individuals contactexposed to hapten orally, transcutaneously, transcutaneously, intravenously or by means of inhalation Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  34. 34. Systemic contact dermatitis 2 Cause Metal (cobalt, copper, chromium, gold, mercury, nickel, zinc) Medications corticosteroids, antihistamines (diphenhydramine, ethylenediamine, hydroxyzine, diphenhydramine, ethylenediamine, hydroxyzine, doxepin), miconazole, terbinafine, neomycin,gentamicin, doxepin), miconazole, terbinafine, neomycin,gentamicin, erythromycin, pseudoephedrine, benzocaine, tetracaine, benzocaine, tetracaine, oxycodone, oxycodone, IVIG, aminopenicillins, 5-aminosalicylic acid, aminopenicillins, naproxen, allopurinol, mitomycin C, 5-FU allopurinol, Herbal medicine Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  35. 35. Drug induced SCD 1 Symmetric drug-related intertriginous and drugflexural exanthema Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  36. 36. Drug induced SCD 2 Criteria for diagnosis Exposure to systemic drug at first or repeated dosing (contact allergens excluded) Erythema of gluteal/perianal area, V-shaped gluteal/ Verythema of inguinal/perianal area, or both inguinal/perianal Involvement of at least 1 other intertriginous/flexural intertriginous/flexural localization Symmetry of affected areas Absence of systemic signs and symptoms Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  37. 37. Occupational contact dermatitis 4 of 7 criteria must be positive to conclude OCD Clinical appearance consistent with CD Cutaneous irritants or allergens present in workplace Anatomic distribution of dermatitis consistent with skin exposure to chemicals in course of various job tasks Temporal relationship between exposure and onset of symptoms consistent with CD Nonoccupational exposures excluded as probable causes of dermatitis Dermatitis improves away from work exposure and reexposure causes exacerbation There are positive-reaction and relevant patch tests positiveperformed according to established guidelines Vincent S. Beltrani et al Annals of Allergy, Asthma and Immunology 2006;97:1-30 2006;97:
  38. 38. Selected contact dermatitis : Metals 1 Nickel 18. 18.7% positive patch test reaction to nickel Female sensitization to nickel higher 1% of nickel allergy have systemic reactions to nickel content of normal diet Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  39. 39. Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  40. 40. www.online.epocrates.com
  41. 41. www.mmc.tn.gov.in
  42. 42. www.flipper.diff.org
  43. 43. Selected contact dermatitis : Metals 2 Gold NACDG reported that 389/4101(9.5%) 389/4101( positive patch test reactions to gold Hands (29.6%), face with seborrheic (29. distribution (19.3%) and eyelids (7.5%) (19. (7 Used for fashion appeal, anti-inflammatory antimedication, used in electroplating industry, part of dental appliances Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  44. 44. Selected contact dermatitis : Cosmetics 1 Fragrance Most common cause of ACD from cosmetics Positive patch test reactions in 10.4% of 10. patients ‘‘Unscented’’ and ‘‘Fragrance-free’’ ‘‘FragranceFragrance mix I contains allergens found 15% 100% 15%-100% of cosmetic products and might detect ~85% of subjects with ~85% fragrance allergy Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  45. 45. Selected contact dermatitis : Cosmetics 2 Preservatives and excipients Lanolin Common component of consumer products Weak sensitizer on normal skin but stronger sensitizer on damaged skin Stasis dermatitis, higher risk of lanolin sensitivity Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  46. 46. Selected contact dermatitis : Cosmetics 3 Preservatives and excipients Cosmetic preservatives Formaldehyde releasers Non– Non–formaldehyde releasers : Paraben Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  47. 47. Vincent S. Beltrani et al Annals of Allergy, Asthma and Immunology 2006;97:1-30 2006;97:
  48. 48. Selected contact dermatitis : Cosmetics 4 Hair products PPD (Paraphenylenediamine) (Paraphenylenediamine) Most common cause of CD in hairdressers PPD cross-reacts with COX-2 inhibitor crossCOX(celecoxib), sunscreens, and celecoxib), antioxidants used in manufacture of rubber products Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  49. 49. Selected contact dermatitis : Cosmetics 5 Hair products CAPB ( Cocoamidopropyl betaine ) Amphoteric surfactant often found in shampoos, bath products, and eye and facial cleaners Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  50. 50. Selected contact dermatitis : Cosmetics 6 Hair products Glycerol thioglycolate Active ingredient in permanent wave solution Might remain allergenic in hair long after rinsed out Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  51. 51. Medications 1 Antibiotics and antiseptics Neomycin and nitrofurazone potent sensitizers Neomycin sulfate cross-sensitize with crossgentamicin, kanamycin, gentamicin, kanamycin, streptomycin, spectinomycin, spectinomycin, tobramycin and paromomycin Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  52. 52. Medications 2 Corticosteroid Patients with worsening of previous dermatitis or initial improvement followed by deterioration of dermatitis after application of corticosteroids should be evaluated for corticosteroid allergy CrossCross-reactivity between groups A and D2 D2 and groups B and D2 has been reported D2 30% 30% of ACD to corticosteroids be missed if delayed 7-day reading not done Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  53. 53. Pristine W. Lee et al Current Opinion in Pediatrics 2009; 21:491–498 2009; 21:491–
  54. 54. Surgical implant devices 1 Use of nickel in biomedical devices,led to increasing concern about safety in suspected nickel-sensitized patients nickelNo large, evidence-based guidelines evidence- Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  55. 55. Surgical implant devices 2 Criteria for diagnosis of cutaneous implant– implant–induced reaction Dermatitis (localized/generalized) appearing after implant surgery Persistent dermatitis (resistant to appropriate therapies) therapies) Positive patch test (history to metallic component of implant or to commonly used acrylic glues) glues) Resolution of dermatitis after removal of implant Vincent S. Beltrani et al Annals of Allergy, Asthma and Immunology 2006;97:1-30 2006;97:
  56. 56. Treatment 1 Allergen identification to improve contact avoidance Alternatives and substitutes to cosmetics should be offered to patient to increase compliance Supportive care and relief of pruritus Excessive handwashing and nonirritating or sensitizing moisturizers must be used after washing Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138-
  57. 57. Treatment 2 TC is first-line treatment for ACD firstExtensive(>20% Extensive(>20% BSA) and severe CD, systemic corticosteroids might offer faster relief (12-24hr) (12-24hr) Recommended dose is 0.5 to 1 mg/kg daily for 5 to 7 days, and only if patient is comfortable at that time is dose reduced by 50% 50% for next 5 to 7 days Luz S. Fonacier et al J Allergy Clin Immunol 2010;125:138-49 2010;125:138Vincent S. Beltrani et al Annals of Allergy, Asthma and Immunology 2006;97:1-30 2006;97:
  58. 58. THANK YOU

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