CONTACT DERMATITIS GUIDE

CONTACT
DERMATITIS
CHULEEPORN KONGMEESOOK ,MD

Outline
Epidemiology
Pathophysiology
Clinical evaluation
Treatment

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

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

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-

Histology
Epidermal changes of
spongiosis
Dense lymphocytic
infiltrate in upper
dermis
Epidermal exocytosis
of lymphocytes

Middleton's allergy:principles and practice 8th edition

Differentiation between ICD and ACD

2010;125:138-

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
2010;125:138-

Pathophysiology 2
ACD and ICD frequently overlap because
many allergens at high enough centrations
can also act as irritants

2010;125:138-

Vocanson et al. et al J Allergy 2009; 64: 1699–1714
2009; 64: 1699–

Clinical evaluation
Diagnosis of ACD suspected from clinical
presentation and possible exposure to
contact allergen

2010;125:138-

Pristine W. Lee et al Current Opinion in Pediatrics 2009; 21:491–498
2009; 21:491–

Clinical presentations
Allergic contact dermatitis


Clinical presentations
Irritant contact dermatitis


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
2010;125:138-

Sources of allergens
T.R.U.E. TEST : Not US FDA approved
but recommended by CD experts

2010;125:138-

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
2010;125:138-

Richard P. Usatine et al Am Fam Physician 2010;82:249-255
2010;82:249-

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
2010;125:138-

Patch test technique


Vincent S. Beltrani et al Annals of Allergy, Asthma and Immunology 2006;97:1-30
2006;97:

Wareeporn Disphanurat J Med Assoc Thai 2010; 93 (Suppl. 7) : S7-S14
2010;
S7

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
2010;125:138-

ROAT

Contact dermatitis 5th edition

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

2010;125:138-

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

2010;125:138-

Drug induced SCD 1
Symmetric drug-related intertriginous and
drugflexural exanthema

2010;125:138-

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
2010;125:138-

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
2006;97:

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

2010;125:138-

2010;125:138-

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

2010;125:138-

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
2010;125:138-

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
2010;125:138-

Preservatives and excipients
Cosmetic preservatives
Formaldehyde releasers
Non–
Non–formaldehyde releasers : Paraben

2010;125:138-

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

2010;125:138-

Hair products
CAPB ( Cocoamidopropyl betaine )
Amphoteric surfactant often found in
shampoos, bath products, and eye and
facial cleaners

2010;125:138-

Hair products
Glycerol thioglycolate
Active ingredient in permanent wave
solution
Might remain allergenic in hair long
after rinsed out

2010;125:138-

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

2010;125:138-

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
2010;125:138-

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-

2010;125:138-

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
2006;97:

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
2010;125:138-

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

2010;125:138Vincent S. Beltrani et al Annals of Allergy, Asthma and Immunology 2006;97:1-30
2006;97:

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