Case Report

IRRITANT CONTACT DERMATITIS

by:

RIDZA WISDA ARVIKA

0807101010111

Supervisor:

dr. Nanda Earlia, Sp.KK

DERMATOLOGY AND VENEROLOGY DEPARTMENT

SCHOOL OF MEDICINE SYIAH KUALA UNIVERSITY

BLUD RSUZA – BANDA ACEH

2012

INTRODUCTION

Contact dermatitis is a generic term applied to acute or chronic

inflammatory reactions to substances that come in contact with the skin1. This also

is a common problem that can be encountered in many settings. The majority of

cases are irritant-induced, with 20% being attribute to an allergic etiology2. Irritant

contact dermatitis (ICD) is a cutaneous response to contact with an external

chemical, physical, or biological agent; endogenous response such as skin barrier

function and pre-existing dermatitis also play role3. ICD account for 80 percent of

all cases of contact dermatitis, and is often occupation-related.

Contact dermatitis is especially common in the work-place, accounting for

90% of occupational skin disease or 7% of all occupational disease4. ICD is a

multi-factorial disease where both exogenous (irritant and environmental) and

endogenous (host) factors play a role.

Irritant contact dermatitis has a spectrum of clinical features which can be

divided into several different categories, depending on the irritant, exposure

pattern, mechanical, thermal, climatic, and constitutional factors. At least 10

clinical types of ICD have been described such as Acute ICD, Delayed acute ICD,

Irritant reaction, Chronic reaction, Traumatic ICD, Acneiform ICD,

Nonerythematous (suberythematous irritation), Subjective (sensory) irritation,

Friction dermatitis, Asteatotic irritant eczema, and other clinical subtypes of acute

and chronic ICD.1

Pathogenesis

Four interrelated mechanisms have been associated with ICD: (1) removal

of surface lipids and water-holding substances, (2) damage to cell membranes, (3)

epidermal keratin denaturation, and (4) direct cytotoxic effects1. There is a clearly

demonstrated immunologic-like component to the irritant response, which is

characterized by the release of pro-inflammatory mediators, particularly

cytokines, from non immune cutaneous cells (keratinocytes) in response to

chemical stimuli. This is a process that does not require previous sensitization5.

Mechanisms involved in acute and chronic phases of ICD are fundamentally

different. Acute reactions involve direct cytotoxic damage to keratinocytes.

Chronic ICD results from repeated exposures to solvents and surfactants that

cause slow damage to cell membranes, disrupting the skin barrier and leading to

protein denaturation and cellular toxicity.2

Skin Findings

May occur minutes after exposure or may be delayed up to 24

hoursmmmmm. The spectrum of changes ranges from erythema to vesiculation

and caustic burn with necrosis. Acute ICD represents sharply demarcated

erythema and superficial edema, corresponding to the application site of the toxic

substance. Lesions do not spread beyond the site of contact. In more severe

reactions vesicles and blisters arise within the erythematous lesions, followed by

erosions and/or even frank necrosis, as with acids or alkaline solutions. No

papules. Configuration often bizarre or linear ("outside job" or dripping effect).2

Diagnosis and Differential Diagnosis

Diagnosis is by history and clinical examination (lesions, pattern, site).

Rietschel6 has proposed criteria with subjective and objective features, each with

major and minor findings for the diagnosis of ICD in the table 1 below.

Table 1. Differential Diagnosis of ICD (Major types)

Most likelyLocalized

- Seborrheic dermatitis- Statis dermatitis- Atopic eczema- Tinea- Asteatosis

Diseminated- Atopic eczema- Asteatosis- Autoeczematization- Tinea corporis

ConsiderLocalized

- Lichen Simplex chronicus- Herpes simplex- Herpes zoster- Steroid acne- Rosacea- Factitial dermatitis

Diseminated- Psoriasis- Polymorphous light eruption- Nummular eczema- Parapsoriasis- Lyme disease- Drug eruption- Secondary syphilis

Always Rule OutLocalized

- Allergic contact dermatitis- Bowen disease

Diseminated- Allergic contact dermatitis- Secondary syphilis- Cutaneous T-cell lymphoma

CASE REPORT

Identity of Patient

Name : Mrs. FY

Sex : Female

Registration Number : 0-89-96-79

Age : 47 years old

Address : Lambaro Skep, Banda Aceh

Career : Trader

Hospitalized : September 14th, 2012

Examination Day : September 14th, 2012

Anamnese

1. The Chief Complaint:

Redish rash are itchy on the left foot sole since 4 days ago

2. History of Present Illness : Patient comes to hospital with chief complaint of

red rashes which is very itchy on the left foot sole since 4 days ago. At the

beginning the lesion was small and only one. The patient feel very itch in that

area so she scrapes it again and again, and next the lesion increase so much

than before. Beside that, the patient also felt that the area of lesion swell up and

getting warm. At the day she comes to the hospital, the lesion was flatting back

but still itched

3. History of Past Illness : Diabetic Mellitus

4. Family History : Denied

5. Social History : bad hygiene

6. History of medicine : drug of Diabetic mellitus, some powder to soothe

the itch, and Mikonazole zalf.

Dermatologic Status:

Location: a/r dorsum pedis sinistra

Patch erythematous, plaque size, with irregular margin, sharply demarcated, and

in it’s surface there are vesicles and papules lesion spread localized at the region.

Differential Diagnosis:

1. Irritant Contact Dermatitis

2. Atopic Dermatitis

3. Sebhorrheic Dermatitis

4. Tinea Pedis

Supporting Examination:

Patch testing

Clinical Diagnosis

Irritant Contact Dermatitis

Treatment

Systemic: Anti allergic, Mebhidrolin napadisilat (ex. Interhistin)

Topical: Thyamicin 2% / Inerson oint and Asam fusidat (ex. Fuson cream)

Education

Avoid yourself from any irritant materials and Do not scratch the lesion.

Prognose:

- Quo ad vitam : dubia ad bonam

- Quo ad functionam : dubia ad bonam

- Quo ad sanctionam : dubia ad bonam

DISCUSSION

ICD can occur in anyone being exposed to a substance irritant or toxic to

the skin1. It may occur minutes after exposure or may be delayed up to 24 hours2.

These are some etiologic agents that caused irritant contact dermatitis based on

table 3.

Table 3 Most Common Irritant/Toxic Agents

Soaps, detergents, waterless hand cleaners

Acids and alkalis*: hydrofluoric acid, cement, chromic acid, phosphorus,

ethylene oxide, phenol, metal salts.

Industrial solvents: coal tar solvents, petroleum, chlorinated hydrocarbons,

alcohol solvents, ethylene glycol ether, turpentine, ethyl ether, acetone, carbon

dioxide, dioxane, styrene.

Plants: Euphorbiaceae (spurges, crotons, poinsettias, machneel tree).

Racunculaceae (buttercup), Cruciferae (black mustard), Urticaceae (nettles),

Solanaceae (pepper, capsaicin), Opuntia (prickly pear).

Others: fiberglass, wool, rough synthetic clothing, fire-retardant fabrics, "NCR"

paper.

* Lead to chemical burns and necrosis, if concentrated.

In this case the patient said that four days ago the lesion was only small,

soliter, as a vesicle, then she scratch it (because it felt so itchy), so next day the

lesion were multiple and swelling. But on the day the patient comes to hospital,

the lesion had been flattened but it still multiple. The lesion occur after exposure.

ICD is often diagnosed by excluding other cause for the dermatitis,

including ACD. A detailed inquiry, including occupational, recreational (hobbies)

and past medical histories, and a meticulous clinical examination are important for

making diagnosis. When an allergic component is considered, diagnostic patch

testing should be performed.1 If the reaction after this test decreased, that is an

ICD, but if the reaction increased that will be clue for ACD. The standard method

involves the application of antigen to the skin at standardized concentration in

appropriate vehicle and under occlusion. Back is commonly used principally for

convenience. The optimum timing of the patch test readings is probably days 2

and 4.

In this case patient comes to hospital with chief complaint of redish rash

which is very itchy at the left foot sole since 4 days ago. She said that was the first

time she got the rash. It is similar to the theory which is that ICD does not require

previous sensitization5. Bourke (2011) also explained the reaction types of contact

dermatitis such as acute irritant contact dermatitis that often the result of a single

overwhelming exposure or a few brief exposures to strong irritants or caustic

agents and chronic (cumulative) irritant contact dermatitis that occurs following

repetitive exposure to weaker irritants that may be either ‘wet’ such as detergens,

organic, solvents, soaps, weak acids and alkalis, or ‘dry’, such as low humidity

air, heat, powders, and dusts. 4

Patient felt the area of lesion was very itchy, no painful. But many theories

explain that Irritant contact dermatitis usually more painful than itchy4. I think it

just individual perception which is so subjective.

The patient did not try patch testing. But if she did, we will see irritant

patch test reaction which is present as erythema with or without papules and often

remain confined to the test site and are sharply demarcated. The margin and site

are sharp, strictly confined to site of exposure.1 

The images of irritant contact dermatitis between case report and theory

(An erythema, oedema, bullae and necrosis, leading to a burning and

stinging senzation7,9.)

Allergic and irritant contact dermatitis can be difficult to distinguish,

because the resulting rashes are very similar. The pattern and location of the rash

on the skin help distinguish whether it was caused by an allergen or irritant.

Table 2 Differences Between Irritant and Allergic Contact Dermatitis*

    Irritant CD Allergic CD

Symptoms Acute Stinging, smarting ⇛ itching 

Itching ⇛ pain 

  Chronic Itching/pain Itching/pain

Lesions Acute Erythema ⇛ vesicle ⇛ erosion ⇛ crust ⇛ scaling

Erythema ⇛ papules ⇛ vesicles ⇛ erosions ⇛ crust ⇛ scaling 

  Chronic Papules, plaques, fissures, scaling, crusts

Papules, plaques, scaling, crusts

Margination and site

Acute Sharp, strictly confined to site of exposure 

Sharp, confined to site of exposure but spreading in the periphery; usually tiny papules; may become generalized 

  Chronic Ill-defined Ill-defined, spreads 

Evolution Acute Rapid (few hours after exposure) 

Not so rapid (12 to 72 hours after exposure) 

  Chronic Months to years of repeated exposure

Months or longer; exacerbation after every re-exposure

Causative agents

  Dependent on concentration of agent and state of skin barrier; occurs only above threshold level 

Relatively independent of amount applied, usually very low concentrations sufficient but depends on degree of sensitization 

Incidence   May occur in practically everyone 

Occurs only in the sensitized 

* Differences are printed in bold.

Management

The management of ICD principally involves the protection of the skin

from irritants or avoid caustic chemical(s) by wearing protective clothing (i.e.,

goggles, shields, gloves). If contact does occur, wash with water or weak

neutralizing solution.

Beside that we can use barrier creams to protect skin from irritants. There

are controlled clinical showing benefit in the use of soap substitutes and after-

work creams in reducing the incidence and prevalence of contact dermatitis. They

should be encouraged and made readily available in the workplace. In

occupational ICD that persists in spite of adherence to the above measures,

change of job may be necessary.

Course and Prognosis

Healing usually occurs within 2 weeks of removal of noxious stimuli; in

more chronic cases, 6 weeks or longer may be required. In the setting of

occupational ICD, only one-third of individuals have complete remission and may

require allocation to another job. Several studies have confirmed that the long-

term prognosis for occupational contact dermatitis is often very poor.7 Atopic

individuals have a worse prognosis too. In cases of chronic subcritical levels or

irritant, some workers develop tolerance or "hardening."2 The point is if the patient

can avoid the cause of contact dermatitis then dermatitis will clear. 7

REFERENCES

1. Wolff, K., Johnson, Richard A, Suurmond, Dick. 2007. Fitzpatrick’s Color

Atlas & Synopsis of Clinical Dermatology. New York: Mc Graw Hill

Companies.

2. Amrol, D., Keitel, D., Hagaman, D., Murray, J. 2003. Topical pimecrolimus in

the treatment of human allergic dermatitis. Annals of Allergic, Asthma, &

Immunology, Volume 91, 563-6.

3. Wolff, K., Goldsmith, L., Katz, S. I., Gilchrest, B., Paller, A., & Leffeell, D. J.

2008. Fitzpatrick's Dermatology in General Medicine. New York: Mc Craw

Hill Companies.

4. Jennifer, E. C; Philip, R.C. 2012. Fiddler’s neck: Chin res-associated irritant

contact dermatitis and allergic contact dermatitis in a violin player. Texas:

Dermatology Online Journal.

http://dermatology.cdlib.org/1809/05_vgn/10_12-00157/article.html

[Retrieved on September 16th, 2012]

5. Smith H. R., Basketter, D. A., McFadden J. P. 2002. Irritant dermatitis,

irritancy and its role in allergic contact dermatitis. Clin Exp Dermatol,

Volume 27, 138.

6. Rietschel, R. L., 2004. Clues to an accurate diagnosis of contact dermatitis.

Dermatol Ther, Volume 17, 224.\

7. Bourke I, Coulson I, English I. Guidelines for Care of Contact Dermatitis.

British Journal of Dermatology. 2001: 877-85.

8. Little, Frederic F. 2009. Contact Dermatitis. Chicago: Boston University.

http://health.rush.edu/HealthInformation/Pediatric%20Center/28/000011.aspx

[Retrieved on September 16th,2012].

9. http://eczema.dermis.net/content/e03typesof/e02irritant/e419/f_zoomImage?

key=imghires&lang=eng&manage_lang=eng