A 27-year-old woman developed the pictured lesion 2
days after wearing a new pair of earrings. What is the most likely diagnosis?
A Atopic dermatitis
B Irritant dermatitis
C. Nummular dermatitis
D Seborrheic dermatitis
E Allergic dermatitis
Option A (Atopic
dermatitis) is incorrect. Atopic dermatitis is a subacute and chronic
dermatitis that is often called an itch that
rashes. It
has dry, scaly, pruritic patches and
plaques with excoriations located in
the flexural regions.
Option B (Irritant
contact dermatitis) is incorrect. Irritant contact dermatitis is the result of direct toxic
injury to the skin and will occur in any individual given sufficient exposure.
This is in contrast to allergic contact dermatitis, where individuals with
atopy are more likely to develop it. Irritant contact dermatitis is
differentiated from allergic contact dermatitis by the acute speed of the
reaction (less than 12 hours usually), a very sharp border without spread and
an absence of papules in the acute phase.
Option C (Nummular
dermatitis) is incorrect. Nummular dermatitis presents as pruritic, coin-shaped erythematous
plaques that are dry and scaly.
Option D
(Seborrheic dermatitis) is incorrect. Seborrheic dermatitis presents with a
greasy, yellow, erythematous, scaly
plaque primarily in the perioral area or other areas rich in sebaceous glands,
such as the scalp margin and sternum.
Option
E (Allergic contact dermatitis) is correct. This patient has
allergic contact dermatitis, most likely the result of nickel in her new
earrings. Allergic contact dermatitis should be suspected when there is
exposure to an allergen and a reaction develops at least 48 hours later. As
pictured, there in an erhythematous base
and a slightly white scale with a defined border.
CONTACT
DERMATITIS
BASIC
INFORMATION
Contact dermatitis is an acute or
chronic skin inflammation, usually eczematous dermatitis resulting from
exposure to substances in the environment. It can be subdivided into
"irritant" contact dermatitis (nonimmunologic physical and chemical alteration
of the epidermis) and "allergic" contact dermatitis (delayed
hypersensitivity reaction).
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IRRITANT
CONTACT DERMATITIS:
Primary irritant dermatitis (80%) is due to direct
injury of the skin. It affects individuals exposed to specific irritants and
generally produces discomfort immediately after exposure.
· Mild exposure may result in dryness, erythema, and
fissuring of the affected area
(e.g., hand involvement in irritant
dermatitis caused by exposure to soap, genital area
involvement in irritant dermatitis
caused by prolonged exposure to wet diapers).
· Eczematous inflammation may result from chronic exposure.
ALLERGIC
CONTACT DERMATITIS:
Allergic contact dermatitis (ACD) (20%) affects only
individuals previously sensitized to the contactant. It represents a delayed
hypersensitivity reaction, requiring several hours for the cascade of cellular
immunity to be completed to manifest itself.
· Poison ivy dermatitis can present with vesicles and
blisters; linear lesions (as a result
of dragging of the resins over the
surface of the skin by scratching) are a classic
presentation.
· The pattern of lesions is asymmetric; itching, burning,
and stinging may be present.
· The involved areas are erythematous, warm to touch,
swollen, and may be confused
with cellulitis.
System(s) affected: Skin/Exocrine
Genetics: Increased frequency of ACD in families with
allergies.
Incidence/Prevalence in USA: Contact dermatitis
represents >90% of all occupational skin disorders.
Predominant age: All ages
Predominant sex: Male = Female. Variation due to
differences in exposure to offending agents as well as normal cutaneous
variation between male and female (eccrine and sebaceous gland function and
hair distribution).
SIGNS
& SYMPTOMS:
Acute
Papules, vesicles, bullae with surrounding erythema
Crusting and oozing may be present
Pruritus
Chronic
Erythematous base
Thickening with lichenification
Scaling
Fissuring
Distribution
Where
epidermis is thinner (eyelids, genitalia)
Areas
of contact with offending agent (nail polish)
Palms
and soles more resistant
Deeper
skin-folds spared
Linear
arrays of lesions
Lesions
with sharp borders and sharp angles -- pathognomonic
CAUSE
Plants
Rhus-urushiol
(poison ivy, oak, sumac)
Primary contact –
plant (roots/stems/ leaves)
Secondary contact –
clothes/fingernails (not blister fluid)
Chemicals
Nickel –
jewellery, zippers, hooks, watches
Potassium dichromate –
tanning agent in leather
Paraphenulenediamine –
hair dyes, fur dyes, industrial chemicals
Turpentine –
cleaning agents, polishes, waxes
Soaps,
detergents
×
×
Topical
medicines
Neomycin –
topical antibiotics
Thimerosal
(Menthiolate) – preservative in topical medications
Anesthetics –
benzocaine
Parabens –
preservative in topical medications
Formalin –
cosmetics, shampoo, nail enamel
SIMPLIFIED
ETHIOLOGY
· Irritant contact dermatitis: cement (construction
workers), rubber, ragweed, malathion
(farmers), orange and lemon peels
(chefs, bartenders), hair tints, shampoos
(beauticians), rubber gloves
(medical, surgical personnel)
· Allergic contact dermatitis: poison ivy, poison oak,
poison sumac, rubber (shoe
dermatitis), nickel (jewellery),
balsam of Peru (hand and face dermatitis), neomycin,
formaldehyde (cosmetics)
RISK FACTORS
×
Occupation
×
Hobbies
×
Travel
×
Cosmetics
×
Jewellery
DIAGNOSIS
LABORATORY
TESTS
· Patch testing is useful to confirm the diagnosis of
contact dermatitis; it is indicated
particularly when inflammation
persists despite appropriate topical therapy and
avoidance of suspected causative
agent; patch testing should not be used for irritant
contact dermatitis because this is a
nonimmunologic-mediated inflammatory reaction.
· Gram stain and cultures are indicated only in cases of
suspected secondary infection
or impetigo.
Patch tests for
allergic contact dermatitis (systemic corticosteroid or recent, aggressive use
of topical steroids may alter results)
TREATMENT
WORKUP
×
Medical
history: gradual onset vs. rapid onset, number of exposures, clinical
×
presentation,
occupational history
×
Physical
examination: contact dermatitis in the neck may be caused by necklaces,
×
perfumes,
after-shave lotion; involvement of the axillae is often secondary to
×
deodorants,
clothing; face involvement can occur with cosmetics, airborne allergens,
×
aftershave
lotion
General Measure
×
Removal of offending agent
×
Topical soaks with cool tap water, Burrow’s
solution (1:40 dilution), or saline ( 1 tsp/pint water), or silver nitrate solution
×
Lukewarm water baths – antipruritic
×
Aveeno (oatmeal) baths
×
Chronic – emollients (white petrolatum,
Eucerin)
×
Surgical Measures: N/A
×
Activity: Stay active, but avoid
overheating
×
Diet: No special diet
×
Patient Education:
×
Avoidance of irritating substance
×
Cleaning of secondary sources (nails,
clothes)
×
Fallacy of blister spreading disease
MEDICATION:
×
DRUG(S)
OF CHOICE
v
Topical
×
Shake lotion of zinc oxide,
talc, menthol 0.25%, phenol 0.5%
×
Corticosteroids: high
potency steroids, fl uocinonide (Lidex) 0.05% ointment 3-4 times daily. Caution
regarding face/skinfolds - use lower potency steroids and avoid prolonged
usage. Switch to lower potency topical steroid once acute phase resolved. Avoid
prolonged use.
×
Calamine lotion
×
Topical antibiotics for
secondary infection (bacitracin, gentamicin, erythromycin)
v
Systemic
Antihistamine: hydroxyzine 25-50 mg qid,
diphenhydramine 25-50 mg qid
×
Corticosteroids: prednisone.
Taper starting at 60-80 mg/d, tapered over 10-14 days.
×
Antibiotics: erythromycin
250 mg qid if secondarily infected
×
Dicloxacillin 250 mg po qid
for 7-10 days or amoxicillin- clavulanate (Augmentin) 500 mg po bid for 7-10 days
for secondary bacterial infection
×
Contraindications:
N/A
×
Precautions:
•
Drowsiness from
antihistamines
•
Local skin effects: atrophy,
stria, telangiectasia from prolonged use of potent topical steroids
×
Significant
possible interactions: N/A
×
ALTERNATIVE
DRUGS Other topical antibiotics depending
on organisms and sensitivity
FOLLOWUP
PATIENT MONITORING
×
As necessary for recurrence
×
Patch testing for etiology
after resolved
PREVENTION/AVOIDANCE
×
Avoid causative agents. Use
of protective gloves (with cotton lining) may be helpful.
POSSIBLE COMPLICATIONS
×
Generalized eruption
secondary to autosensitization
×
Secondary bacterial
infection
EXPECTED COURSE/PROGNOSIS
×
Self-limited, benign
AGE-RELATED FACTORS
×
Pediatric:
Younger individuals -
increased incidence of positive patch testing due to better delayed
hypersensitivity reactions
×
Geriatric:
Increased incidence of
irritant dermatitis secondary to skin dryness
×
Others:
N/A
×
PREGNANCY
Usual cautions with
medications
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