Contact dermatitis Presented by Athit Wutthisanwatthana, MD. April19, 2019

1. Contact Dermatitis
A Wutthisanwatthana

2. Outlines
• Irritant contact dermatitis
• Allergic contact dermatitis
• Contact urticaria
• Photocontact dermatitis
• Photoallergy
• Phototoxicity

3. Contact Dermatitis
• The most common occupational skin disorder 90-95%
Clark SC, Zirwas MJ. Management of occupational dermatitis. Dermatol Clin. 2009;27(3):365
Irritant
Allergic

4. Irritant Contact Dermatitis

5. Irritant Contact Dermatitis
• Irritant = physical or chemical agents that are capable of producing
cellular perturbation if applied to the skin for sufficient time and in
sufficient concentration
• The most common type of contact dermatitis
• 80% occupational contact dermatitis1
• The most frequent cause of hand eczema2
• Women > men
1Clark SC, Zirwas MJ. Management of occupational dermatitis. Dermatol Clin. 2009;27(3):365
2Thyssen JP, Johansen JD, Linneberg A, MennéT. The epidemiology of hand eczema in the general population--prevalence and
main findings. Contact Dermatitis. 2010;62(2):75.

6. Chemical Irritants Physical Irritants
Water
Wet work
Detergents
Surfactants
Solvents
Oxidizing agents
Acids
Alkali
Metal tools
Wood
Fiberglass
Plant parts
Paper
Dust
Soil
Dickel H, Kuss O, Schmidt A, Kretz J, Diepgen TL. Importance of irritant contact dermatitis in occupational skin disease. Am J Clin Dermatol. 2002;3(4):283

7. Highest Risk Work
• Food handlers
• Health care workers
• Mechanical industry workers
• Cleaners
• Housekeepers

8. Dickel H, Kuss O, Schmidt A, Kretz J, Diepgen TL. Importance of irritant contact dermatitis in occupational skin disease. Am J Clin Dermatol. 2002;3(4):283
Occupation Common irritants encountered
Agriculture
Oils, solvents, fertilizers and pesticides, cleansers and detergents, plants, animal hair, saliva,
secretions, wet work
Automobile industry Oils (cutting oils), solvents and paints, cleansers and detergents
Cement and construction industry Cement, wood preservatives, oils, acids and alkalis, fiberglass, adhesives and glues
Cleaners and housework Wet work, cleansers and detergents, abrasives
Electrical/electronics Solvents, soldering flux, cleansers and detergents, acids and alkalis, adhesives and glues
Food industry Wet work, cleansers and detergents, foods (especially acidic foods and food enzymes)
Hairdressing/beautician Wet work, shampoos, permanent wave solutions, oxidizing agents, bleaching agents
Health care and dental Cleansers and detergents, wet work, alcohol and other disinfectants, medications
Painting Solvents and paints, cleansers and detergents, acids and alkalis
Metal industry Solvents, cleansers and detergents, paints, glues and adhesives, oils and cutting fluids
Plastic industry Plastics, solvents, fiberglass, acids
Rubber industry Solvents, cleansers and detergents, frictional/mechanical factor
Woodwork Plastics, solvents, wood preservatives, detergents, sawdust and other

9. Pathogenesis
Genetic background + extrinsic factor
1. Disruption of the epidermal barrier
2. Damage of keratinocyte cell membranes
3. Cytotoxic effect on keratinocytes
4. Cytokine release from keratinocytes
5. Activation of innate immunity
Smith HR, Basketter DA, McFadden JP. Irritant dermatitis, irritancy and its role in allergic contact dermatitis. Clin Exp Dermatol.
2002;27(2):138

10. Pathogenesis
• Occlusion
• Chemical irritants
• Physical irritants
↑Skin permeability
↑ Transepidermal water loss (TEWL)
↓Natural moisturizing factor
Smith HR, Basketter DA, McFadden JP. Irritant dermatitis, irritancy and its role in allergic contact dermatitis. Clin Exp Dermatol.
2002;27(2):138

11. Pathogenesis
• Keratinocyte
• IL-1ɑ
• IL-1β
• IL-6
• TNF-ɑ
• Anti-inflammatory cytokines
• IL-10
• IL-1RA
CCL20, CCL21, CXCL8
↑ICAM-1 on keratinocyte
Smith HR, Basketter DA, McFadden JP. Irritant dermatitis, irritancy and its role in allergic contact dermatitis. Clin Exp Dermatol.
2002;27(2):138

12. Hardening Phenomenon
• Adaptation of the skin to repeated
irritant exposure
Watkins SA, Maibach HI. The hardening phenomenon in irritant contact dermatitis: an interpretative update. Contact Dermatitis.
2009;60(3):123

13. Watkins SA, Maibach HI. The hardening phenomenon in irritant contact dermatitis: an interpretative update. Contact Dermatitis.
2009;60(3):123

14. Predisposing Factors - Host
• Age – Highest in infant
• Sex – Women > men
• Body site – Face, dorsum of the hands, and finger webs
• Atopy - Chronically impaired barrier function
• Genetic factors
• TNFA gene polymorphism à sodium lauryl sulfate and benzalkonium chloride
• SNP in genes involved in inflammation and skin homeostasis
Nixon RL, Diepgen T. Contact Dermatitis. In: Adkinson NF, Jr, Bocher BS, Burks AW, Busse WW, Holgate ST, Lemanske RF, et al. Middleton’s allergy principles and
practice. Philadelphia; Elsevier Saunders; 2014

15. Predisposing Factors – Environmental Factors
• High temperature
• Air flow
• Cold temperature
• Low ambient humidity
Nixon RL, Diepgen T. Contact Dermatitis. In: Adkinson NF, Jr, Bocher BS, Burks AW, Busse WW, Holgate ST, Lemanske RF, et al. Middleton’s allergy principles and
practice. Philadelphia; Elsevier Saunders; 2014
↓ Skin barrier function
↑ Penetration of irritants
↑ TEWL
↑ Skin susceptibility to irritants

16. Histopathology
• Acute ICD
• Mild spongiosis
• Intraepidermal vesicles or bullae
• Necrosis of keratinocyte
• Perivascular mononuclear cell infiltrate
• Chronic ICD
• Hyperkeratosis
• Parakeratosis
• Acanthosis
http://www.dermaamin.com

17. Mechanism of Action of Irritants
• Level of irritancy
• Chemical properties (acid dissociation constant, ionization status, molecular
size, liposolubility)
• Duration of contact
• May act synergistically
• Solvents remove lipids
• Detergent remove lipids and hygroscopic substances
Slodownik D1, Lee A, Nixon R. Irritant contact dermatitis: a review. Australas J Dermatol. 2008 Feb;49(1):1-9

18. Water and Wet Work
• Water
• Hypotonic
• Cytotoxic on eroded skin
• Wet work
• Skin exposure to liquids or wearing occlusive gloves more than two hours
daily or hand washing or disinfection more than 20 times daily
Swelling of stratum corneum
Disruption of intercellular lipid
↑ skin permeability and susceptibility to irritants
Slodownik D1, Lee A, Nixon R. Irritant contact dermatitis: a review. Australas J Dermatol. 2008 Feb;49(1):1-9

19. Detergents and Surfactants
• Remove lipids and hygroscopic substances
• Denature proteins
• Damage the cell membranes
Solvents
• Remove lipids and hygroscopic substances
• Damage cell membranes
• Aromatic solvent are stronger irritants than alcohols or ketones
Slodownik D1, Lee A, Nixon R. Irritant contact dermatitis: a review. Australas J Dermatol. 2008 Feb;49(1):1-9

20. Acids
• Protein coagulation
• Cell necrosis
Alkalis
• Saponify the surface lipid
• Dissolve water-holding substances
• Break the cross-linkages of keratin
• Cause swelling of cells
Soap
Soda
Ammonia
Potassium
Sodium hydroxides
Cement,
Chalk
Slodownik D1, Lee A, Nixon R. Irritant contact dermatitis: a review. Australas J Dermatol. 2008 Feb;49(1):1-9

21. Physical Irritants
• Chronic microtrauma or friction damage the stratum corneum
• Impairs the skin barrier
Slodownik D1, Lee A, Nixon R. Irritant contact dermatitis: a review. Australas J Dermatol. 2008 Feb;49(1):1-9

22. Spectrum of Disease
• Acute disease
• Single exposure to a severe irritant
• Chronic disease
• Chronic exposure to a mild irritant
Watkins SA, Maibach HI. The hardening phenomenon in irritant contact dermatitis: an interpretative update. Contact Dermatitis.
2009;60(3):123

23. Clinical Manifestation
• Acute ICD
• Erythema, edema, vesicles, bullae,
epidermal necrosis
• Chronic ICD
• Erythema and dryness that
progress to hyperkeratosis,
fissuring, and lichenification
Watkins SA, Maibach HI. The hardening phenomenon in irritant contact dermatitis: an
interpretative update. Contact Dermatitis. 2009;60(3):123
Nixon RL, Diepgen T. Contact Dermatitis. In: Adkinson NF, Jr, Bocher BS, Burks AW, Busse WW,
Holgate ST, Lemanske RF, et al. Middleton’s allergy principles and practice. Philadelphia; Elsevier
Saunders; 2014

24. Allergic Contact Dermatitis

25. Allergic Contact Dermatitis
• T cell-mediated, delayed-type hypersensitivity response to exogenous
agents
• Epidemiology
• NA and Europe (1966-2007)
• Prevalence 21.2% (12.5-40.5)
• The Odense Adolescence Cohort Study
• Point prevalence 0.7%
• Life lifetime prevalence 7%
Thyssen JP, Linneberg A, Menné T, Johansen JD: The epidemiology of contact allergy in the general population—prevalence and main findings. Contact Dermatitis.
2007:57:287-299
Mortz CG, Lauritsen JM, Bindslev-Jensen C, Andersen KE: Prevalence of atopic dermatitis, asthma, allergic rhinitis, and hand and contact dermatitis in adolescents. The
Odense Adolescence Cohort Study on Atopic Diseases and Dermatitis. Br J Dermatol. 2001;144:523-532

26. Rick Factors
• Occupation
• Health professionals
• Chemical industry workers
• Beauticians and hairdressers
• Machinists
• Construction workers
• Age – increases with age
• Atopy

27. Common Contact Allergens in the United States
Zug KA, Warshaw EM, Fowler JF Jr, et al. Patch test results of the North American Contact Dermatitis Group 2005-2006. Dermatitis 2009;20:149-60

28. Fragrance
• >2,500 fragrance ingredients
• Fragrance mix I
• Cinnamyl alcohol, cinnamal, amyl cinnamal, geraniol, hydroxycitronellal,
eugenol, isoeugenol, and oakmoss absolute
• Fragrance mix II
• HICC (hydroxyisohexyl-3-cyclohexene carboxaldehyde, also known as lyral),
citral, citronellol, coumarin, farnesol, α-hexyl-cinnamal, and Myroxylon
pereirae resin
Nixon RL, Diepgen T. Contact Dermatitis. In: Adkinson NF, Jr, Bocher BS, Burks AW, Busse WW, Holgate ST, Lemanske RF, et al. Middleton’s allergy principles and
practice. Philadelphia; Elsevier Saunders; 2014

29. Allergenicity
• Capacity to penetrate the outer layer
• Lipophilicity
• Chemical reactivity
IL-1β
TNF-ɑ
GM-CSF
Nixon RL, Diepgen T. Contact Dermatitis. In: Adkinson NF, Jr, Bocher BS, Burks AW, Busse WW, Holgate ST, Lemanske RF, et al. Middleton’s allergy principles and
practice. Philadelphia; Elsevier Saunders; 2014
Saint-Mezard P, Rosieres A, Krasteva M, Berard F, Dubois B, Kaiserlian D, Nicolas JF. Allergic contact dermatitis. Eur J Dermatol. 2004 Sep-Oct;14(5):284-95.
Sensitization lasts 10 to 15 days
Specific CD8+ T cell activated
Infiltration of leucocytes
CD4+ T cell subsets with down-regulatory activities
(Th2 cells, Th3 cells, Tr1 cells, CD4+25+ cells)
The efferent phase takes 72 hours
CCR10 bind to CCL27 on keratinocyte
IFN-ɣ, IL-2, IL-17

30. Clinical Feature - Acute
• Erythematous, indurated, scaly plaque, vesiculation, bullae
UpToDate

31. Clinical Feature - Chronic
• Dry, scaly, and thicker as a result of acanthosis, hyperkeratosis,
edema, and cellular infiltration in the dermis, lichenification and
fissuring
Nixon RL, Diepgen T. Contact Dermatitis. In: Adkinson NF, Jr, Bocher BS, Burks AW, Busse WW, Holgate ST, Lemanske RF, et al. Middleton’s allergy principles and
practice. Philadelphia; Elsevier Saunders; 2014

32. Lesion Distribution
• Localized to the skin areas that come in contact with the allergen
• Secondary transfer
• Facial lesion – tools, eyelid ACD from nail polish
• Diffuse/patchy dermatitis at trunk, axillary fold – cloth dyes, textiles

33. Fonacier L, Bernstein DI, Pacheco K, Holness DL, Blessing-Moore J, Khan D, el al. Contact dermatitis: a practice parameter-update 2015. J Allergy Clin Immunol Pract.
2015 May-Jun;3(3 Suppl):S1-39

34. Phototoxic Dermatitis
• Exposure to UV radiation
• Medication – diuretics, NSAIDs,
tetacylines, amiodarone, phenothiazines
• Plant containing furocoumarin (celery,
carrot, citrus fruits)
Nixon RL, Diepgen T. Contact Dermatitis. In: Adkinson NF, Jr, Bocher BS, Burks AW, Busse WW, Holgate ST, Lemanske RF, et al. Middleton’s allergy principles and
practice. Philadelphia; Elsevier Saunders; 2014
UpToDate

35. Photoallergy
• Delayed-type hypersensitivity reaction
• Antigenicity has changed after exposure to UV radiation
• Eczematous eruptions in sun-exposed areas of skin that develop 24 to
48 hours after sun exposure
• Topical agent
• Sunscreen
• NSAIDs (ketoprofen, diclofenac)
• Fragrances
• Systemic Medication
• Griseofulvin
• Sulfonamides
• Piroxicam
Nixon RL, Diepgen T. Contact Dermatitis. In: Adkinson NF, Jr, Bocher BS, Burks AW, Busse WW, Holgate ST, Lemanske RF, et al. Middleton’s allergy principles and
practice. Philadelphia; Elsevier Saunders; 2014

36. Airborne Contact Dermatitis
• Airborne pattern of ACD
• Inspection of the skin will reveal no sparing of shaded areas
Nixon RL, Diepgen T. Contact Dermatitis. In: Adkinson NF, Jr, Bocher BS, Burks AW, Busse WW, Holgate ST, Lemanske RF, et al. Middleton’s allergy principles and
practice. Philadelphia; Elsevier Saunders; 2014

37. Handa S, De D, and Mahajan R. Ariborne contact dermatitis - current perspectives in etiopathogenesis and management. Indian J Dermatol. 2011 Nov-Dec; 56(6):
700–706

38. Systemic Contact Dermatitis
• Cutaneously sensitized to an allergen
• React via a different route
• Allergic contact dermatitis syndrome, Baboon
syndrome, SDRIFE (symmetrical drug-related
intertriginous and flexural exanthema)
Aquino M, Rosner G. Systemic Contact Dermatitis. Clin Rev Allergy Immunol. 2019 Feb;56(1):9-18

39. Aquino M, Rosner G. Systemic Contact Dermatitis. Clin Rev Allergy Immunol. 2019 Feb;56(1):9-18

40. Contact Urticaria
• Immediate hypersensitivity reaction
• Repeated episodes can lead to protein contact dermatitis
• Causes
• Latex
• Ammonium persulfate (hairdressing bleach)
• Food proteins
Amaro C, Goossens A. Immunological occupational contact urticaria and contact dermatitis from proteins: a review. Contact Dermatitis. 2008 Feb;58(2):67-75

42. Patch Testing
• Gold standard for ACD
• Patient preparation
• Avoid/reduce dose of immunosuppressant medication
• Avoid topical corticosteroid, topic calcineurin inhibitor
• Avoid UV radiation
Fonacier L, Bernstein DI, Pacheco K, Holness DL, Blessing-Moore J, Khan D, el al. Contact dermatitis: a practice parameter-update 2015. J Allergy Clin Immunol Pract.
2015 May-Jun;3(3 Suppl):S1-39

43. Patch Testing
• Core or baseline series
• North American Contact Dermatitis Group (NACDG) Research Group
• American Contact Dermatitis Society (ACDS)
• TRUE Test (TT; SmartPractice, Phoenix, Ariz)
• Supplementary series
• Rubber chemicals, adhesives, and leather components of footwear in patients
presenting with unexplained chronic dermatitis involving the lower
extremities, feet and/or soles
• Cosmetics
• Machinists
Fonacier L, Bernstein DI, Pacheco K, Holness DL, Blessing-Moore J, Khan D, el al. Contact dermatitis: a practice parameter-update 2015. J Allergy Clin Immunol Pract.
2015 May-Jun;3(3 Suppl):S1-39

45. Schalock PC, Dunnick CA, Nedorost S, Brod B, Warshaw E, Mowad C. American Contact Dermatitis Society Core Allergen Series: 2017 Update. Dermatitis. 2017
Mar/Apr;28(2):141-143

46. Patch Testing
• Remove and read at
• 48 h
• 3(4)-7 days
Fonacier L, Bernstein DI, Pacheco K, Holness DL, Blessing-Moore J, Khan D, el al. Contact dermatitis: a practice parameter-update 2015. J Allergy Clin Immunol Pract.
2015 May-Jun;3(3 Suppl):S1-39

47. International Contact Dermatitis Research
Group Scoring • Increasing reaction – ACD
• Waning reaction - irritative
Fonacier L, Bernstein DI, Pacheco K, Holness DL, Blessing-Moore J, Khan D, el al. Contact dermatitis: a practice parameter-update 2015. J Allergy Clin Immunol Pract.
2015 May-Jun;3(3 Suppl):S1-39
Kostner L, Anzengruber F, Guillod C, Recher M, Schmid-Grendelmeier P, Navarini AA. Allergic Contact Dermatitis. Immunol Allergy Clin North Am. 2017 Feb;37(1):141-
152

48. False Positive
• Irritating higher concentrations
• Pressure reaction from the filling chamber
• Angry back syndrome
• Patch testing on skin with active dermatitis

49. Angry Back Syndrome
• Strong positive patch test reaction
• Hyper-reactive to other patch test challenges
• DDx polysensitization
• Repeat testing of selected allergens about 2 months later
Kostner L, Anzengruber F, Guillod C, Recher M, Schmid-Grendelmeier P, Navarini AA. Allergic Contact Dermatitis. Immunol Allergy Clin North Am. 2017 Feb;37(1):141-
152

50. False Negative
• Inadequate concentration
• Inability of the vehicle to release sufficient allergen
• Reduced skin responsiveness
• Methodological testing errors such as insufficient occlusion, failure to
perform delayed readings, and failure to perform a photo PT

51. Photo Patch Test
• Duplicate sample
• 5 joules of UVA after 48 h
• Read after (at least) 2 days
Nixon RL, Diepgen T. Contact Dermatitis. In: Adkinson NF, Jr, Bocher BS, Burks AW, Busse WW, Holgate ST, Lemanske RF, et al. Middleton’s allergy principles and
practice. Philadelphia; Elsevier Saunders; 2014

52. Management

53. Management
• Avoidance
• Contact Allergen Management
program
• SkinSAFE database
• Protection
Johnston GA, Exton LS, Mohd Mustapa MF, Slack JA, Coulson IH, English JS, Bourke JF. British Association of Dermatologists' guidelines for the management of contact
dermatitis 2017. Br J Dermatol. 2017 Feb;176(2):317-329

54. Emollient or Moisturizing Agent
• Should be used in all patient
• Benefit
• Provide barrier protection
• Prevent itching
• Reduce frequency of flare
• Restore lipid balance
Nixon RL, Diepgen T. Contact Dermatitis. In: Adkinson NF, Jr, Bocher BS, Burks AW, Busse WW, Holgate ST, Lemanske RF, et al. Middleton’s allergy principles and
practice. Philadelphia; Elsevier Saunders; 2014

55. Topical Corticosteroid
• First line for localized ACD
• Data in ICD is controvosial
• Not been evaluated in randomized trials
• Side effect
• Skin atrophy and epidermal barrier damage
Nixon RL, Diepgen T. Contact Dermatitis. In: Adkinson NF, Jr, Bocher BS, Burks AW, Busse WW, Holgate ST, Lemanske RF, et al. Middleton’s allergy principles and
practice. Philadelphia; Elsevier Saunders; 2014

56. Topical Corticosteroid
• Severe (not face or flexural areas)
• Super-high potency: Betamethasone, 0.05% Clobetasol bid x2-4 wks
• Milder form
• High-potency (group 2, 3): 0.025% Clobetasol OD, bid x2-4 wks
• Face, flexural area
• Medium-, low-potency (group 5, 6): 0.1% TA OD, bid –2 wks
Nixon RL, Diepgen T. Contact Dermatitis. In: Adkinson NF, Jr, Bocher BS, Burks AW, Busse WW, Holgate ST, Lemanske RF, et al. Middleton’s allergy principles and
practice. Philadelphia; Elsevier Saunders; 2014

57. Topical Calcineurin Inhibitors
• Tacrolimus, pimecrolimus
• Use
• Chronic, localized ACD
• Localized ACD resistant to topical corticosteroid
• ACD involving the face or intertriginous areas
• ACD induced by topical corticosteroids
• Onset of tacrolimus is slower than potent corticosteroid
• Side effect
• Burning, stinging sensation

58. Phototherapy
• Chronic ACD that is unresponsive to topical or oral corticosteroids
• Hand eczema
• Narrow band UVB – fewer side effect
• Psoralens + UVA
Kostner L, Anzengruber F, Guillod C, Recher M, Schmid-Grendelmeier P, Navarini AA. Allergic Contact Dermatitis. Immunol Allergy Clin North Am. 2017 Feb;37(1):141-
152

59. Systemic Corticosteroids
• Acute severe contact dermatitis
• >20 percent of the body surface
• 0.5 MKD prednisolone equivalent, max 3 weeks
Kostner L, Anzengruber F, Guillod C, Recher M, Schmid-Grendelmeier P, Navarini AA. Allergic Contact Dermatitis. Immunol Allergy Clin North Am. 2017 Feb;37(1):141-
152

60. Systemic Immunosuppressive Agents
• Rarely used
• Airborne compositae dermatitis
• Photodermatitis
• Azathioprine
• Mycophenolate mofetil
• Cyclosporine