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Mark H. Lowitt, MD Clinical Associate Professor of Dermatology

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    Mark H. Lowitt, MD Clinical Associate Professor of Dermatology Mark H. Lowitt, MD Clinical Associate Professor of Dermatology Presentation Transcript

    • Mark H. Lowitt, MD Clinical Associate Professor of Dermatology University of Maryland School of Medicine Private Practice, Greater Baltimore Medical Center
    • Contact Dermatitis
      • Cases
      • Clinical Features of Allergic Contact Dermatitis
      • Mechanisms of Allergic Contact Dermatitis
      • Patch Testing
    • Case 1
      • 51 y/o F
      • Phlebotomist
      • Itchy and painful fingers and hands, worsening over years
      • Not seasonal
      • What’s the diagnosis?
      • What’s the cause?
    • Case 2
      • Same photo
      • 73 y/o F
      • Severe eyelid pain and itch worsening over weeks
      • What’s the diagnosis?
      • What’s the cause?
    • Case 3
      • 40 y/o M
      • Auto mechanic for 20 years
      • Similar eruption on feet
      • What’s the diagnosis?
      • What’s the cause?
      • Erythema
      • Edema
      • Vesiculation
      • Scaling
      • Lichenification
      • Well defined edges and Straight lines
      • Pruritus
      • History: The more you treat, the worse it gets
    • What’s new in contact dermatitis?
      • What makes a good contact allergen?
        • Low molecular weight
        • Lipophilic
        • Able to form covalent bonds with nucleophilic residues on amino acid side chains
        • Sensitizing potential may be related to chemical reactivity toward a few specific amino acids involve in sensitization
          • Esp. cysteine residues
    • North American Tray
      • Metals: Nickel, Gold, Cobalt, Copper
      • Fragrances: Fragrance mix, Balsam of Peru, Isoeugenol, Lyral
      • Preservatives: Quaternium-15, Paraben mix, Formaldehyde, Kathon CG, Propylene glycol, Thimerosol
      • Medications: Neomycin, Bacitracin, Tixocortol-21-pivalate, Budesonide
      • Dyes: P-phenylenediamine, Disperse blue
      • Rubber products: Mercaptobenzathiazole, Carba mix, thiuram mix, mixed dialkyl thiourea
      • Other: Benzocaine, Colophony, ethyl acrylate
      • Hand Dermatitis
        • Allergic Contact Dermatitis
        • Irritant Contact Dermatitis
        • Dyshidrotic Eczema
        • Palmar psoriasis
        • Tinea Manum
        • Mycosis fungoides
    • Hand Dermatitis
      • Patch test positive for Quaternium-15
        • Common preservative
    • Chronic Hand Dermatitis
      • Major Occupational Health Problem
      • 40% of all Occupational Health Claims are from skin
      • 90% of these are Dermatitis
        • 65% are Irritant Contact
        • 35% are Allergic Contact
          • THEREFORE, 12% OF ALL WORKMAN’S COMP CLAIMS ARE DUE TO ALLERGIC CONTACT DERMATITIS
    • Allergic Contact Dermatitis of the Hands
      • 22,035 patients patch tested between 1994 and 2004
      • 6953 had hand involvement
      • 959 with a solitary dx of ACD
        • Quaternium-15 17%
        • Formaldehyde 13%
        • Nickel 12%
        • Fragrance Mix 11%
        • Thiuram Mix 10%
    • Eyelid Dermatitis
      • Differential Diagnosis
        • Contact dermatitis
        • Atopic dermatitis
        • Dermatomyositis
      Atopic dermatitis Dermatomyositis (heliotrope rash)
      • Patch testing:
        • Positive for Gold sodiumthiosulfate
        • May be 10% of positive patch tests
        • More common in women
        • 8% of gold + pts have eyelid dermatitis
        • Clinical picture can be confusing due to presence of nickel in gold alloys
    • Eyelid Dermatitis
      • Most common causes of eyelid allergic contact dermatitis:
        • Gold 22%
        • Fragrance mix 19%
        • Balsam of Peru 17%
        • Nickel 16%
        • Neomycin 9%
      • Treatment with topical cortisones initially help, but then the condition worsens
      Tinea manum (dermatophyte infection)
      • Patch test positive for Budesonide
        • Cross reacts with triamcinolone, fluocinonide, fluocinolone, desonide, budesonide
      • Corticosteroids were the American Contact Dermatitis Society 2005 “Allergen of the Year”
    • Corticosteroid allergy
      • Class A Hydrocortisone and tixocortol type
        • Cortisone, hydrocortisone, methylprednisolone, prednisolone
      • Class B Triamcinolone acetate type
        • Triamcinolone, halcinonide, flucinonide, fluocinolone, desonde, budesonide, amcinonide
      • Class C Bethamethasone type
        • Betamethasone, dexamethasone, flucortolone
      • Class D Hydrocortisone-17-butyrate and clobetasol 17- butyrate
    • Patient education – CARD Database
    • Allergic Contact Dermatitis: Review
      • Have a high index of suspicion for ACD
        • Angulated lesions with straight edges and unusual shape
        • A refractory dermatitis
      • However, keep your mind open: not all dermatitis is allergic
    • Allergic Contact Dermatitis: Review
      • Patch testing can help to identify the allergen
      • Hand dermatitis most often caused by quaternium-15
      • Eyelid dermatitis most often caused by gold
      • In pts not getting better, consider contact dermatitis to topical steroids
    • www.contactderm.org American Contact Dermatitis Society (ACDS) www.dormer.com Dormer Labs (Canada) patch test materials www.allergEAZE.com patch test materials