Contact Dermatitis Part Contact Dermatitis Part OneOne

Boris Ioffe, D.O., Pharm.D.Boris Ioffe, D.O., Pharm.D.

08-14-0608-14-06

Irritant contact dermatitis (ICD)Irritant contact dermatitis (ICD)

Accounts for approximately Accounts for approximately 80% of all contact 80% of all contact dermatitisdermatitis

ICD is the result of a local ICD is the result of a local toxic effect when the skin toxic effect when the skin comes in contact with comes in contact with irritant chemicals such as irritant chemicals such as soaps, solvents, acids, or soaps, solvents, acids, or alkalisalkalis

This 37-year-old woman developed a contact This 37-year-old woman developed a contact irritant dermatitis from obsessive-compulsive hand irritant dermatitis from obsessive-compulsive hand washing 20-30 times a day. www.drmatlas.orgwashing 20-30 times a day. www.drmatlas.org

Introduction to Irritant Contact Introduction to Irritant Contact DermatitisDermatitis

ICD is a cutaneous inflammation resulting from a ICD is a cutaneous inflammation resulting from a direct cytotoxic effect of a chemical or physical direct cytotoxic effect of a chemical or physical agentagent

Constitutes nearly 80% of occupational contact Constitutes nearly 80% of occupational contact dermatitis (OCD)dermatitis (OCD)

OCD is a matter of public health importance, OCD is a matter of public health importance, contributing to combined direct and indirect contributing to combined direct and indirect annual costs (in the USA) of up to $1 billion annual costs (in the USA) of up to $1 billion when accounting for medical costs, workers when accounting for medical costs, workers compensation, and lost time from workcompensation, and lost time from work

Epidemiology of ICDEpidemiology of ICD The US Bureau of Labor The US Bureau of Labor

Statistics data show that Statistics data show that occupational skin diseases occupational skin diseases accounted for 10% to 15% of accounted for 10% to 15% of all occupational illnessesall occupational illnesses

High-risk occupations with High-risk occupations with frequent irritant exposure in frequent irritant exposure in caterers, furniture industry caterers, furniture industry workers, hospital workers, workers, hospital workers, hairdressers, chemical industry hairdressers, chemical industry workers, dry cleaners, metal workers, dry cleaners, metal workers, florists, and workers, florists, and warehouse workerswarehouse workers

Epidemiology of ICDEpidemiology of ICD Clinical manifestations of ICD are determined by:Clinical manifestations of ICD are determined by:

Properties of the irritating substanceProperties of the irritating substance

Host factorsHost factors

Environmental factors including concentration, mechanical pressure, Environmental factors including concentration, mechanical pressure, temperature, humidity, pH, and duration of contacttemperature, humidity, pH, and duration of contact

Cold alone may also reduce the plasticity of the horny layer, with Cold alone may also reduce the plasticity of the horny layer, with consequent cracking of the stratum corneumconsequent cracking of the stratum corneum

Occlusion, excessive humidity, and maceration increase Occlusion, excessive humidity, and maceration increase percutaneous absorption of water-soluble substancespercutaneous absorption of water-soluble substances

Bilateral shoe irritant dermatitis resulting Bilateral shoe irritant dermatitis resulting from chronic occlusive footwearfrom chronic occlusive footwear

Epidemiology of ICDEpidemiology of ICD Important predisposing characteristics of the individual include:Important predisposing characteristics of the individual include:

Age, race, sex, pre-existing skin disease, anatomic region exposed, and Age, race, sex, pre-existing skin disease, anatomic region exposed, and sebaceous activitysebaceous activity

Both infants and elderly are affected more by ICD because of their less robust Both infants and elderly are affected more by ICD because of their less robust epidermal layerepidermal layer

Patients with darkly pigmented skin seem to be more resistant to irritant reactions Patients with darkly pigmented skin seem to be more resistant to irritant reactions

Other skin disease such as active atopic dermatitis may predispose an individual Other skin disease such as active atopic dermatitis may predispose an individual to develop ICDto develop ICD

The most commonly affected sites are exposed areas such as the hands and the The most commonly affected sites are exposed areas such as the hands and the face, with hand involvement in approximately 80% of patients and face face, with hand involvement in approximately 80% of patients and face involvement in 10%involvement in 10%

Pathogenesis of ICDPathogenesis of ICD

Denaturation of epidermal keratinsDenaturation of epidermal keratins

Disruption of the permeability barrierDisruption of the permeability barrier

Damage to cell membranesDamage to cell membranes

Direct cytotoxic effectsDirect cytotoxic effects

Acute Irritant Contact DermatitisAcute Irritant Contact Dermatitis Commonly seen in occupational accidentsCommonly seen in occupational accidents Irritant reaction reaches its peak quickly, within minutes to hours Irritant reaction reaches its peak quickly, within minutes to hours

after exposureafter exposure Symptoms include stinging, burning, and soreness Symptoms include stinging, burning, and soreness Physical signs include erythema, edema, bullae, and possibly Physical signs include erythema, edema, bullae, and possibly

necrosisnecrosis Lesions restricted to the area where the irritant or toxicant damaged Lesions restricted to the area where the irritant or toxicant damaged

the tissuethe tissue Sharply demarcated borders and asymmetry pointing to an Sharply demarcated borders and asymmetry pointing to an

exogenous causeexogenous cause Most frequent irritants are acids and alkaline solutionsMost frequent irritants are acids and alkaline solutions

Acute Delayed Irritant Contact Acute Delayed Irritant Contact DermatitisDermatitis

Delayed inflammatory response characteristic of certain irritants Delayed inflammatory response characteristic of certain irritants such as anthralin, benzalkonium chloride, and ethylene oxidesuch as anthralin, benzalkonium chloride, and ethylene oxide

Visible inflammation is not seen until 8 to 24 hours after exposureVisible inflammation is not seen until 8 to 24 hours after exposure

Symptoms are more frequently burning rather than pruritusSymptoms are more frequently burning rather than pruritus

Sensitivity to touch and water are elicitedSensitivity to touch and water are elicited

This form of ICD is commonly seen during diagnostic patch testingThis form of ICD is commonly seen during diagnostic patch testing

Irritant Reaction Irritant Contact Irritant Reaction Irritant Contact DermatitisDermatitis

Type of subclinical irritant dermatitis in individuals Type of subclinical irritant dermatitis in individuals exposed to wet chemical environments such as exposed to wet chemical environments such as hairdressers, caters, or metalworkershairdressers, caters, or metalworkers

Characterized by scaling, redness, vesicles, pustules, Characterized by scaling, redness, vesicles, pustules, and erosionsand erosions

Often begins under occlusive jewelry and then spreads Often begins under occlusive jewelry and then spreads over the fingers to the hands and forearmsover the fingers to the hands and forearms

May simulate dyshidrotic dermatitisMay simulate dyshidrotic dermatitis

Cumulative Irritant Contact Cumulative Irritant Contact DermatitisDermatitis

Consequence of multiple sub-Consequence of multiple sub-threshold skin insults, without threshold skin insults, without sufficient time between them for sufficient time between them for complete barrier function repaircomplete barrier function repair

In contrast to acute ICD, the In contrast to acute ICD, the lesions of chronic ICD are less lesions of chronic ICD are less sharply demarcatedsharply demarcated

Itching and pain due to fissures of Itching and pain due to fissures of hyperkeratotic skin are symptoms hyperkeratotic skin are symptoms of chronic ICDof chronic ICD

Skin findings include Skin findings include lichenification, hyperkeratosis, lichenification, hyperkeratosis, xerosis, erythema, and vesiclesxerosis, erythema, and vesicles

Asteatotic DermatitisAsteatotic Dermatitis Exsiccation eczematid ICDExsiccation eczematid ICD

Seen mainly during the winter Seen mainly during the winter months in elderly individuals months in elderly individuals who frequently bath without who frequently bath without remoisturizingremoisturizing

Skin appears dry with Skin appears dry with ichthyosiform scale and ichthyosiform scale and patches of eczema craquelepatches of eczema craquele

Traumatic Irritant Contact Traumatic Irritant Contact Dermatitis Dermatitis

May develop after acute skin trauma, such as burns, May develop after acute skin trauma, such as burns, lacerations, or acute ICDlacerations, or acute ICD

Patients should be asked if they have cleansed with Patients should be asked if they have cleansed with strong soaps or detergentsstrong soaps or detergents

Characterized by eczematous lesions most commonly Characterized by eczematous lesions most commonly on the hands, that persist on the hands, that persist

Healing is delayed with redness, infiltration, scale, and Healing is delayed with redness, infiltration, scale, and fissuring in the affected areasfissuring in the affected areas

Pustular and Acneform Irritant Pustular and Acneform Irritant Contact DermatitisContact Dermatitis

Result to certain irritants such as Result to certain irritants such as metals, croton oil, mineral oils, metals, croton oil, mineral oils, tars, greases, cutting and metal tars, greases, cutting and metal working fluids, and naphthalenesworking fluids, and naphthalenes

Should be considered in Should be considered in conditions in which folliculitis or conditions in which folliculitis or acneform lesions develop in acneform lesions develop in setting outside of typical acnesetting outside of typical acne

Pustules are sterile and transientPustules are sterile and transient

Milia may develop in response to Milia may develop in response to occlusive clothing, adhesive tape, occlusive clothing, adhesive tape, ultraviolet and infrared radiationultraviolet and infrared radiation

Chloracne. Note heavy involvement Chloracne. Note heavy involvement of retroauricular skin with comedones of retroauricular skin with comedones and cystsand cysts

Subjective or Sensory Irritant Subjective or Sensory Irritant Contact DermatitisContact Dermatitis

Reports of stinging or burning in the absence of Reports of stinging or burning in the absence of visible cutaneous signs of irritationvisible cutaneous signs of irritation

Response to irritants such as lactic or sorbic Response to irritants such as lactic or sorbic acidacid

Airborne Irritant Contact Airborne Irritant Contact DermatitisDermatitis

Develops on irritant-exposed Develops on irritant-exposed skin of the face and periorbital skin of the face and periorbital regionsregions

Often simulates photoallergic Often simulates photoallergic reactionsreactions

Involvement of the upper Involvement of the upper eyelids, philtrum, and eyelids, philtrum, and submental regions help to submental regions help to differentiate from photoallergic differentiate from photoallergic reactionreaction

Frictional Irritant Contact Frictional Irritant Contact DermatitisDermatitis

Results from repeated low-Results from repeated low-grade frictional traumagrade frictional trauma

Plays adjuvant role in ACD Plays adjuvant role in ACD and ICDand ICD

Characterized by Characterized by hyperkeratosis, acanthosis, hyperkeratosis, acanthosis, and lichenification, often and lichenification, often progressing to hardening, progressing to hardening, thickening, and increased thickening, and increased toughnesstoughness

9 year old girl demonstrates a lichenified hyperpigmented round plaque on the top of her thumb produced by chronic thumbsucking. www.dermatlas.org

Pathology of ICDPathology of ICD Variable mix of inflammation, necrosis of epidermal keratinocytes, Variable mix of inflammation, necrosis of epidermal keratinocytes,

and mild spongiosisand mild spongiosis

Combination of an upper dermal perivascular infiltrate of Combination of an upper dermal perivascular infiltrate of lymphocytes with minimal extension of inflammatory cells into the lymphocytes with minimal extension of inflammatory cells into the overlying epidermis, and widely scattered necrotic keratinocytes is overlying epidermis, and widely scattered necrotic keratinocytes is most typical picturemost typical picture

True features of interface dermatitis are absent, and spongiosis True features of interface dermatitis are absent, and spongiosis should be focal or absent should be focal or absent

Over time additional histologic findings include acanthosis with mild Over time additional histologic findings include acanthosis with mild hypergranulosis and hyperkeratosishypergranulosis and hyperkeratosis

AcidsAcids Inorganic and organic acids can be corrosive to the skinInorganic and organic acids can be corrosive to the skin

Cause epidermal damage via protein denaturation and cytotoxicityCause epidermal damage via protein denaturation and cytotoxicity

Symptoms include erythema, vesication, and necrosisSymptoms include erythema, vesication, and necrosis

Hydrofluoric and sulfuric acid can cause the most severe burnsHydrofluoric and sulfuric acid can cause the most severe burns

Hydrofluoric acid, used in the semiconductor industry, is able to Hydrofluoric acid, used in the semiconductor industry, is able to penetrate intact skin with subsequent dissociation in deeper tissues penetrate intact skin with subsequent dissociation in deeper tissues and resultant liquefactive necrosisand resultant liquefactive necrosis

Acids Acids Chromic acid causes ulcerations Chromic acid causes ulcerations

known as ‘chrome holes’ and often known as ‘chrome holes’ and often perforates the nasal septumperforates the nasal septum

Chemical burns and irritant Chemical burns and irritant dermatitis from nitric acid can dermatitis from nitric acid can cause a distinctive yellow cause a distinctive yellow discoloration discoloration

In general, organic acids are less In general, organic acids are less irritating than inorganic acidsirritating than inorganic acids

Formic acid has the greatest Formic acid has the greatest corrosive potential of the organic corrosive potential of the organic acids acids

Examples of chrome holes www.cdc.gov/niosh/ocderm

AlkalisAlkalis Strong Alkalis include sodium, ammonium, Strong Alkalis include sodium, ammonium,

potassium hydroxide, sodium and potassium hydroxide, sodium and potassium carbonate, and calcium oxidepotassium carbonate, and calcium oxide

Found in soaps, detergents, bleaches, Found in soaps, detergents, bleaches, ammonia preparations, lye, drain pipe ammonia preparations, lye, drain pipe cleaner, toilet bowl cleansers, and oven cleaner, toilet bowl cleansers, and oven cleanercleaner

Often more painful and damaging than acidsOften more painful and damaging than acids

No vesicles, necrotic skin that appears dark No vesicles, necrotic skin that appears dark brown then black, ultimately becomes hard, brown then black, ultimately becomes hard, dry, and crackeddry, and cracked

Alkalis disrupt barrier lips and denature Alkalis disrupt barrier lips and denature proteins with subsequent fatty acid proteins with subsequent fatty acid saponificationsaponification

Alkalis Alkalis

Cement mixed with water can Cement mixed with water can cause ulcerative damage due to cause ulcerative damage due to alkalinityalkalinity

Changes appear 8 to 12 hours Changes appear 8 to 12 hours after exposureafter exposure

Chronic irritant cement dermatitis Chronic irritant cement dermatitis may also develop over months to may also develop over months to yearsyears

Can accompany allergic contact Can accompany allergic contact dermatitisdermatitis

Hand dermatitis due to contact with cement dermnetnz.org/dermatitis/chrome

Metal SaltsMetal Salts

Include arsenic trioxide, beryllium compounds, calcium Include arsenic trioxide, beryllium compounds, calcium oxide, copper salts, inorganic mercury, thimerosal, and oxide, copper salts, inorganic mercury, thimerosal, and seleniumselenium

Signs ranging from ulceration to folliculitisSigns ranging from ulceration to folliculitis

SolventsSolvents

Act mainly by dissolving the intercellular lipid barrier of Act mainly by dissolving the intercellular lipid barrier of the epidermisthe epidermis

Prolonged skin contact can result in severe burns and Prolonged skin contact can result in severe burns and well as systemic toxicitywell as systemic toxicity

Examples include turpentine, benzene, toluene, xylene, Examples include turpentine, benzene, toluene, xylene, carbon tetrachloride, gasoline, and kerosenecarbon tetrachloride, gasoline, and kerosene

Professional paint and crayon illustrator with bilateral palmar dermatitis secondary to repeated contact with paint solvents. Extensive patch testing excluded allergic contact dermatitis

Detergents and CleansersDetergents and Cleansers Include any surface active agent (surfactant) that Include any surface active agent (surfactant) that

concentrates at the oil-water interfaces and has both concentrates at the oil-water interfaces and has both emulsifying and cleansing propertiesemulsifying and cleansing properties

Found in skin cleansers, cosmetics, and household Found in skin cleansers, cosmetics, and household cleaning productscleaning products

Surfactants cause protein denaturation of the stratum Surfactants cause protein denaturation of the stratum corneum, impairing barrier functioncorneum, impairing barrier function

Anionic detergents such as alkyl sulfates and alkyl Anionic detergents such as alkyl sulfates and alkyl carboxylate salts are the most irritatingcarboxylate salts are the most irritating

DisinfectantsDisinfectants Include, alcohols, aldehydes, Include, alcohols, aldehydes,

phenolic compounds, phenolic compounds, halogenated compounds, halogenated compounds, surfactants, dyes, oxidizing surfactants, dyes, oxidizing agents, and mercury agents, and mercury compoundscompounds

Weak toxic agents that can Weak toxic agents that can cause chronic ICDcause chronic ICD

Practicing dentist with moderately severe irritant hand Practicing dentist with moderately severe irritant hand dermatitis from chronic exposure to disinfecting solutions and dermatitis from chronic exposure to disinfecting solutions and antisepticsantiseptics. The results of patch testing, latex challenge testing, and . The results of patch testing, latex challenge testing, and RAST testing were negative.RAST testing were negative.

PlasticsPlastics

Three categories: thermoplastics, thermosettings, Three categories: thermoplastics, thermosettings, elastomerselastomers

Skin damage is attributed to monomer ingredients, Skin damage is attributed to monomer ingredients, hardeners, and stabilizershardeners, and stabilizers

Final hardened plastic product is generally considered Final hardened plastic product is generally considered inertinert

FoodFood Agriculture, fishing, catering, and Agriculture, fishing, catering, and

food processingfood processing

Often work without gloves, in Often work without gloves, in damp working conditions with damp working conditions with frequent hand washingfrequent hand washing

Mechanical, thermal, and climatic Mechanical, thermal, and climatic factorsfactors

Nearly 100% of exposed persons Nearly 100% of exposed persons in food handling and fishing in food handling and fishing professions may be affected by professions may be affected by chronic irritant hand dermatitischronic irritant hand dermatitis

WaterWater Ubiquitous skin irritantUbiquitous skin irritant

Tropical immersion foot, seen Tropical immersion foot, seen during Vietnam Warduring Vietnam War

Hairdressers, hospital Hairdressers, hospital cleaners, cannery workers, cleaners, cannery workers, bartendersbartenders

Irritancy of water is Irritancy of water is exacerbated by occlusionexacerbated by occlusion 9 year old is an habitual hand washer who develops a

contact irritant dermatitis every winter. At times she washes over 10 times a day. www.dermatlas.org

Fabric/man-made vitreous fibersFabric/man-made vitreous fibers Fibers larger than 3.5 um in Fibers larger than 3.5 um in

diameter cause the highly diameter cause the highly pruritic contact dermatitis pruritic contact dermatitis caused by fiberglasscaused by fiberglass

Erythematous papules with Erythematous papules with superimposed excoriations on superimposed excoriations on neck and dorsal handsneck and dorsal hands

Wool and rough clothing cause Wool and rough clothing cause dermatitis in atopic individualsdermatitis in atopic individuals

Fiberglass dermatitis www.cdc.gov/niosh/ocderm

Differential DiagnosisDifferential Diagnosis Allergic and ICD, especially in chronic stage appear similar by Allergic and ICD, especially in chronic stage appear similar by

clinical appearance, histology, and immunohistologyclinical appearance, histology, and immunohistology

Look identical with erythema, papules, xerosis, scaling, and Look identical with erythema, papules, xerosis, scaling, and lichenification with sharp borderslichenification with sharp borders

ICD has remained a diagnosis of exclusion when dermatitis is not ICD has remained a diagnosis of exclusion when dermatitis is not explained by positive patch test to a known allergenexplained by positive patch test to a known allergen

More frequent complaint of burning and stinging with ICD in contrast More frequent complaint of burning and stinging with ICD in contrast to pruritus in ACDto pruritus in ACD

TreatmentTreatment Avoidance of causative irritants at home or in the workplace is the primary Avoidance of causative irritants at home or in the workplace is the primary

TXTX

Engineering controls to reduce exposure in the workplaceEngineering controls to reduce exposure in the workplace

Shielding and personal protection such as gloves and special clothingShielding and personal protection such as gloves and special clothing

Pre-exposure protection by protective creams, removal of irritants by mild Pre-exposure protection by protective creams, removal of irritants by mild cleaning agents, and enhancement of barrier function generation by cleaning agents, and enhancement of barrier function generation by emollients and moisturizersemollients and moisturizers

Emphasizing personal and occupational hygieneEmphasizing personal and occupational hygiene

Establishing educational programs to increase awareness in the workplaceEstablishing educational programs to increase awareness in the workplace

TX Chemical BurnsTX Chemical Burns Initial tx irrigation with large volumes of water, if chemical is insoluble in water a soap Initial tx irrigation with large volumes of water, if chemical is insoluble in water a soap

solution may be usedsolution may be used

High pressure water to be avoided to prevent splashingHigh pressure water to be avoided to prevent splashing

2.5% calcium gluconate gel used to tx hydroflouric acid burns, immediate application 2.5% calcium gluconate gel used to tx hydroflouric acid burns, immediate application of a weak acid such as vinegar, lemon juice, or 0.5% hydrochloric acid will lessen the of a weak acid such as vinegar, lemon juice, or 0.5% hydrochloric acid will lessen the effect of alkali burnseffect of alkali burns

Ulcerated areas should be managed with antibacterial creams or ointments to prevent Ulcerated areas should be managed with antibacterial creams or ointments to prevent secondary infectionsecondary infection

Frequent evaluation is required because ulcers may progress over several daysFrequent evaluation is required because ulcers may progress over several days

Excision, debridement and/or grafting may speed healingExcision, debridement and/or grafting may speed healing

Monitoring of blood, liver, and kidney function may be needed when exposed to Monitoring of blood, liver, and kidney function may be needed when exposed to chemicals with potential for systemic toxicity such as hydrofluoric acid, phenolic chemicals with potential for systemic toxicity such as hydrofluoric acid, phenolic compounds, chromic acid, and gasolinecompounds, chromic acid, and gasoline

Chronic ICD TreatmentChronic ICD Treatment Tx goal is to restore normal epidermal barrier functionTx goal is to restore normal epidermal barrier function

Topical corticosteroids frequently usedTopical corticosteroids frequently used

Systemic corticosteroids although helpful in reducing inflammation, Systemic corticosteroids although helpful in reducing inflammation, are not useful in treatment of chronic ICD unless offending are not useful in treatment of chronic ICD unless offending contactants are avoidedcontactants are avoided

PUVA and Grenz ray considered for chronic dermatitis that does not PUVA and Grenz ray considered for chronic dermatitis that does not respond to other txrespond to other tx

Hyperkeratotic palmoplantar dermatitis from frictional or chronic ICD Hyperkeratotic palmoplantar dermatitis from frictional or chronic ICD may benefit from the adjunctive use of systemic retinoids such as may benefit from the adjunctive use of systemic retinoids such as acitretinacitretin

Allergic contact dermatitis Allergic contact dermatitis (ACD)(ACD)

ACD accounts for ACD accounts for approximately 20% of all approximately 20% of all contact dermatitiscontact dermatitis

ACD is a type IV, delayed or ACD is a type IV, delayed or cell-mediated immune reaction cell-mediated immune reaction that is elicited when the skin that is elicited when the skin comes in contact with a comes in contact with a chemical to which an chemical to which an individual has been previously individual has been previously sensitizedsensitized

Synonyms include contact Synonyms include contact dermatitis and contact eczemadermatitis and contact eczema

Allergic contact dermatitis. Linear streaks seen with ACD to poison ivy.

ACDACD Key FeaturesKey Features

ACD is a pruritic, eczematous ACD is a pruritic, eczematous reactionreaction

Acute ACD and many cases of Acute ACD and many cases of chronic ACD are well demarcated chronic ACD are well demarcated and located to the site of contact and located to the site of contact with the allergenwith the allergen

Prototypic reactions are ACD due Prototypic reactions are ACD due to poison ivy and nickelto poison ivy and nickel

Patch testing remains the gold Patch testing remains the gold standard for accurate and standard for accurate and consistent diagnosisconsistent diagnosis

This healthy adolescent developed an intensely pruritic vesiculobullous allergic contact dermatitis from hair dye. Dermatlas.org

Classic picture of ACD is a Classic picture of ACD is a well-demarcated erythematous well-demarcated erythematous vesicular and/or scaly patch or vesicular and/or scaly patch or plaque with well defined plaque with well defined margins corresponding to the margins corresponding to the area of contactarea of contact

Chronic allergic contact dermatitis leading to hand dermatitis. This golfer wore one leather glove and had positive patch tests to potassium dichromate and a piece of his glove. Courtesy of Kalman Watsky, M.D.

Allergic contact Allergic contact dermatitis to leather dermatitis to leather shoes.shoes. Note the Note the correspondence to sites correspondence to sites of exposure. of exposure. Courtesy of Yale Courtesy of Yale Residents Slide Collection.Residents Slide Collection.

Because ICD and ACD Because ICD and ACD are not always are not always discernable clinically, discernable clinically, patch testing is required patch testing is required to help identify an to help identify an allergen or exclude an allergen or exclude an allergy to a suspected allergy to a suspected allergen.allergen.

Allergic contact dermatitis. Chronic hand dermatitis due to ACD to mercaptobenzothiazole found in rubber gloves

Epidemiology of ACDEpidemiology of ACD Affects the old and young, individuals of all races, and both sexesAffects the old and young, individuals of all races, and both sexes

Differences in genders usually based on exposure patterns, such as Differences in genders usually based on exposure patterns, such as nickel allergy being seen more frequently in women, presumably nickel allergy being seen more frequently in women, presumably due to greater exposure to jewelrydue to greater exposure to jewelry

Occupations and avocations play an important roleOccupations and avocations play an important role

Allergens differ from region to region, e.g. preservatives used in Allergens differ from region to region, e.g. preservatives used in personal care products can vary based on government legislationpersonal care products can vary based on government legislation

Pathogenesis of ACDPathogenesis of ACD ACD is a type IV hypersensitivity responseACD is a type IV hypersensitivity response

Requires prior sensitization to the chemical in questionRequires prior sensitization to the chemical in question

Subsequent re-exposure of individual leads to allergen Subsequent re-exposure of individual leads to allergen being presented to a primed T-cell milieu leading to being presented to a primed T-cell milieu leading to release of numerous cytokines and chemotactic factors release of numerous cytokines and chemotactic factors leading to the clinical picture of eczemaleading to the clinical picture of eczema

Once sensitized a low concentration of causative Once sensitized a low concentration of causative chemical elicits a response chemical elicits a response

Induction of contact hypersensitivity. Application of contact allergens (Ag) induces the release of cytokines by keratinocytes, Langerhans cells and other cells within the skin. These cytokines in turn activate Langerhans cells which uptake the antigen and emigrate into the regional lymph nodes. During this process, the Langerhans cells mature into dendritic cells. In addition, the antigen is processed, re-expressed on the surface and finally presented to naïve T cells in the regional lymph node. Upon appropriate antigen presentation, T cells bearing the appropriate T cell receptor clonally expand and become effector T cells. These alter their migratory behavior due to the expression of specific surface molecules like CLA. Effector T cells recirculate into the periphery where they may later meet the antigen again. Ag, antigen; KC, keratinocyte.

Elicitation of contact hypersensitivityElicitation of contact hypersensitivity. Application of contact allergens (Ag) into a sensitized individual . Application of contact allergens (Ag) into a sensitized individual causes the release of cytokines by keratinocytes and Langerhans cells. These cytokines induce the causes the release of cytokines by keratinocytes and Langerhans cells. These cytokines induce the expression of adhesion molecules and activation of endothelial cells which ultimately attracts leukocytes expression of adhesion molecules and activation of endothelial cells which ultimately attracts leukocytes to the site of antigen application. Among these cells, T effector cells are present which are now activated to the site of antigen application. Among these cells, T effector cells are present which are now activated upon antigen presentation either by resident cells or by infiltrating Langerhans cells. Antigen-specific T upon antigen presentation either by resident cells or by infiltrating Langerhans cells. Antigen-specific T cell activation again induces the release of cytokines by T cells. This causes the attraction of other cell activation again induces the release of cytokines by T cells. This causes the attraction of other inflammatory cells including granulocytes and macrophages which ultimately cause the clinical inflammatory cells including granulocytes and macrophages which ultimately cause the clinical manifestation of contact dermatitis. Ag, antigen; DDC, dermal dendritic cell; KC, keratinocyte; CLA, manifestation of contact dermatitis. Ag, antigen; DDC, dermal dendritic cell; KC, keratinocyte; CLA, cutaneous lymphocyte antigen.cutaneous lymphocyte antigen.

Clinical features of ACDClinical features of ACD

Acute blistering and Acute blistering and weepingweeping

Chronic lichenified and Chronic lichenified and scaly plaquesscaly plaques

Patchy and diffuse Patchy and diffuse distributions may be seen distributions may be seen with body washes and with body washes and shampoosshampoos

Acute bullous allergic contact dermatitis due to poison ivy. This distribution is seen in patients who wear gloves. Courtesy of Yale Residents Slide Collection

Chronic allergic contact dermatitis due to glutaraldehyde. The patient was an optometrist

Pathology of ACDPathology of ACD ACD is the prototype of spongiotic dermatitisACD is the prototype of spongiotic dermatitis

Acute stage: variable degree of spongiosis with mixed Acute stage: variable degree of spongiosis with mixed dermal inflammatory infiltrate containing lymphocytes, dermal inflammatory infiltrate containing lymphocytes, histiocytes, and variable numbers of eosinophilshistiocytes, and variable numbers of eosinophils

Moderate to severe reactions show intraepidermal Moderate to severe reactions show intraepidermal vesiculationvesiculation

Subacute to chronic stages have epidermal hyperplasia, Subacute to chronic stages have epidermal hyperplasia, often psoriasiformoften psoriasiform

DDX of ACDDDX of ACD

Includes many forms of dermatitis: ICD, atopic Includes many forms of dermatitis: ICD, atopic dermatitis, stasis dermatitis, and seborrheic dermatitis, dermatitis, stasis dermatitis, and seborrheic dermatitis, as well as the erythematous form of rosaceaas well as the erythematous form of rosacea

Hand and foot ACD need to be distinguished from Hand and foot ACD need to be distinguished from psoriasis and tineapsoriasis and tinea

Widespread disease needs to be differentiated from Widespread disease needs to be differentiated from other causes of erythoderma, Sezary syndromeother causes of erythoderma, Sezary syndrome

Patch TestingPatch Testing Simple office procedure upon which the diagnosis of ACD often Simple office procedure upon which the diagnosis of ACD often

restsrests

Although the procedure is simple, deciding when and what to test Although the procedure is simple, deciding when and what to test for requires training and experiencefor requires training and experience

Patch testing is underutilizedPatch testing is underutilized

Only 50% of all residency programs in USA have a patch Only 50% of all residency programs in USA have a patch test centertest center

Past surveys show 27% of the responders did no patch testing Past surveys show 27% of the responders did no patch testing

Patch TestingPatch Testing

TRUE Test TRUE Test

Other panels include North American Contact Dermatitis Other panels include North American Contact Dermatitis Group (NACDG) Screening Series, and the European Group (NACDG) Screening Series, and the European Standard SeriesStandard Series

Other panels are unique to specific occupations such as Other panels are unique to specific occupations such as hairdressing tray, dental tray, and florist trayhairdressing tray, dental tray, and florist tray

True TestTrue Test Preimpregnated test that screens Preimpregnated test that screens

for 23 allergensfor 23 allergens

Extending testing beyond these 23 Extending testing beyond these 23 allergens has shown to be more allergens has shown to be more beneficialbeneficial

In three studies, extended testing In three studies, extended testing detected 37-76% more positive detected 37-76% more positive reactions, and 47.3% of patients reactions, and 47.3% of patients had positive reactions had positive reactions onlyonly to non- to non-screening allergensscreening allergens

Additional allergens come in Additional allergens come in multiuse syringesmultiuse syringes

Allergens contained within syringes being placed by nurse into Finn chambers

Application of TRUE test. www.truetest.com

Pre-Patch Testing QuestionsPre-Patch Testing Questions Exposures both at work and home to understand Exposures both at work and home to understand

mechanics of the work environment, Materials Safety mechanics of the work environment, Materials Safety Data Sheets (MSDS) can be helpful for workplace Data Sheets (MSDS) can be helpful for workplace exposuresexposures

Effect of vacations and time away form work or home Effect of vacations and time away form work or home should be ascertainedshould be ascertained

All personal care products should be inventoriedAll personal care products should be inventoried

All hobbies should be exploredAll hobbies should be explored

Patch TestingPatch Testing Chemicals brought in by patients should not be tested blindly, Chemicals brought in by patients should not be tested blindly,

physician should be aware of the chemical ingredients because physician should be aware of the chemical ingredients because severe burns or ulceration may occursevere burns or ulceration may occur

‘‘Leave on’ personal care products such as moisturizers and make-Leave on’ personal care products such as moisturizers and make-up may be tested ‘as is’up may be tested ‘as is’

‘‘Rinse off’ products such as soaps or shampoos need to be diluted Rinse off’ products such as soaps or shampoos need to be diluted prior to patch testingprior to patch testing

Patch TestingPatch Testing Most common site is the upper backMost common site is the upper back

Patients should not have a sunburn in Patients should not have a sunburn in test area, and should not apply topical test area, and should not apply topical corticosteroids to the patch test sites corticosteroids to the patch test sites for 7 days prior to testfor 7 days prior to test

Systemic corticosteroids should be Systemic corticosteroids should be avoided for 1 month prior to testingavoided for 1 month prior to testing

Patches are applied to back and Patches are applied to back and reinforced with Scanpor tape, patient reinforced with Scanpor tape, patient instructed to keep back dry and instructed to keep back dry and patches secured until second visit at patches secured until second visit at 48 hours48 hours Fixing allergens to patient's back using

Scanpor® tape.

Patch TestingPatch Testing When the patient returns in 48 When the patient returns in 48

hours the patches need to be hours the patches need to be inspected to ensure that the inspected to ensure that the testing technique is adequatetesting technique is adequate

As patches are removed their As patches are removed their sites of application should be sites of application should be marked in order to identify the marked in order to identify the locations of particular allergenslocations of particular allergens

Patch Test ScoringPatch Test Scoring

A positive patch test reaction to nickel. This is an example of a 3+ reaction

Patch TestingPatch Testing

Patient again asked to keep back dry until second Patient again asked to keep back dry until second reading, done from 72 hours to 1 week after the initial reading, done from 72 hours to 1 week after the initial application of the patchesapplication of the patches

This delayed reading is necessary due to patch test This delayed reading is necessary due to patch test responses to some allergens such as gold having a responses to some allergens such as gold having a delayed reactiondelayed reaction

Repeat Open Application Test Repeat Open Application Test (ROAT)(ROAT)

Poor man’s patch testPoor man’s patch test

Patient applies the product in question to the same Patient applies the product in question to the same location (where there is not dermatitis), e.g. antecubital location (where there is not dermatitis), e.g. antecubital fossa, BID for 1-2 weeksfossa, BID for 1-2 weeks

If dermatitis develops, it can be concluded that the If dermatitis develops, it can be concluded that the patient is reacting to the productpatient is reacting to the product

Downside to this approach is that individual problem Downside to this approach is that individual problem ingredients are not identifiedingredients are not identified

Treatment and Patient EducationTreatment and Patient Education

Once allergens are positively Once allergens are positively identified, patient should be identified, patient should be given written information on all given written information on all of these chemicalsof these chemicals

Patient should be instructed on Patient should be instructed on how to read labels on old or how to read labels on old or new products to avoid future new products to avoid future exposureexposure

Treatment of ACDTreatment of ACD

Involves identification of causative allergensInvolves identification of causative allergens

Clear the dermatitis with topical, or if necessary systemic Clear the dermatitis with topical, or if necessary systemic corticosteroidscorticosteroids

Complete and prolonged clearing can take up to 6 weeks Complete and prolonged clearing can take up to 6 weeks or more, even when allergens are being avoidedor more, even when allergens are being avoided

NickelNickel Most common allergen tested by the Most common allergen tested by the

NACDG, with 14% of patients reacting NACDG, with 14% of patients reacting to itto it

Relevance has been estimated to be Relevance has been estimated to be 50%50%

Commonly used in jewelry, buckles, Commonly used in jewelry, buckles, snaps, and other metal-containing snaps, and other metal-containing objectsobjects

High rate of sensitivity attributed to ear High rate of sensitivity attributed to ear piercingpiercing

Dimethylglyoxime test to determine if a Dimethylglyoxime test to determine if a particular item contains nickelparticular item contains nickel

Individuals with nickel allergy should Individuals with nickel allergy should avoid custom jewelry, and can usually avoid custom jewelry, and can usually wear stainless steel or goldwear stainless steel or gold

Nickel DermatitisNickel Dermatitis Common presentations are Common presentations are

dermatitis on the ears, under a dermatitis on the ears, under a necklace or a watch back, or necklace or a watch back, or on the mid-abdomen caused on the mid-abdomen caused by a belt buckle, zipper, or by a belt buckle, zipper, or snapsnap

Eyelid dermatitis from metal Eyelid dermatitis from metal eyelash curlers can be seen eyelash curlers can be seen

Photos from dermatlas.orgPhotos from dermatlas.org

Neomycin SulfateNeomycin Sulfate Most commonly used topical antibioticMost commonly used topical antibiotic

Most common sensitizer among topical Most common sensitizer among topical antibioticsantibiotics

Found in many OTC preparations: Found in many OTC preparations: bacterial ointments, hemorrhoid bacterial ointments, hemorrhoid creams, and otic and opthalmic creams, and otic and opthalmic preparationspreparations

Frequently used with other Frequently used with other antibacterial agents, such as bacitracin antibacterial agents, such as bacitracin and polymyxin, as well as and polymyxin, as well as corticosteroidscorticosteroids

Co-reactivity is commonly seen with Co-reactivity is commonly seen with neomycin and bacitracin neomycin and bacitracin

13 year old boy developed an itchy allergic contact

dermatitis from a topical antibiotic. www.dermatlas.org

Balsam of PeruBalsam of Peru Naturally occurring fragrance material Naturally occurring fragrance material

Prior to introduction of fragrance mix in the 1970’s, balsam of Peru Prior to introduction of fragrance mix in the 1970’s, balsam of Peru was used to screen for fragrance allergywas used to screen for fragrance allergy

Capable of identifying 50% of those allergic to fragranceCapable of identifying 50% of those allergic to fragrance

Seen in those with allergies to spices, in particular cloves, Jamaicin Seen in those with allergies to spices, in particular cloves, Jamaicin pepper, and cinnamonpepper, and cinnamon

Patients with a positive reaction need to avoid fragrances, Patients with a positive reaction need to avoid fragrances, occasionally spices, and other sources such as colas, tobacco, occasionally spices, and other sources such as colas, tobacco, wines, and vermouthwines, and vermouth

Fragrance MixFragrance Mix Contains eight different components: Contains eight different components:

cinnamic etoh, cinnamic aldehyde, cinnamic etoh, cinnamic aldehyde, hydroxycitronellal, isoeugenol, hydroxycitronellal, isoeugenol, eugenol, oak moss absolute, alpha-eugenol, oak moss absolute, alpha-amyl cinnamic aldehyde, and geraniolamyl cinnamic aldehyde, and geraniol

Detects 70-80% of fragrance allergiesDetects 70-80% of fragrance allergies

Patients need to read product labels Patients need to read product labels and avoid anything that lists a and avoid anything that lists a fragrance, is labeled ‘unscented’, or fragrance, is labeled ‘unscented’, or has an obvious scenthas an obvious scent

Patients need to look for ‘fragrance-Patients need to look for ‘fragrance-free’ productsfree’ products

ACD to fragrance found in cologne. A Patient with ACD to fragrance found in his cologne. B Patient after avoidance of fragrances and his cologne.

ThimerosalThimerosal Thimerosal is a combination of thiosalicylic acid and ethylmercuric Thimerosal is a combination of thiosalicylic acid and ethylmercuric

chloride, and is used as a preservativechloride, and is used as a preservative

Most sensitization may be due to its use as a preservative in Most sensitization may be due to its use as a preservative in vaccinesvaccines

Other exposures include: contact lens solution, otic and opthalmic Other exposures include: contact lens solution, otic and opthalmic solutions, antiseptics, and cosmeticssolutions, antiseptics, and cosmetics

Positive reactions are common, relevance is low and therefore Positive reactions are common, relevance is low and therefore routine testing to this allergen should be reconsideredroutine testing to this allergen should be reconsidered

GoldGold NACDG found a positive rate of 9.5%NACDG found a positive rate of 9.5%

NACDC found 90% of gold-allergic patients were women, and there NACDC found 90% of gold-allergic patients were women, and there was a higher rate of nickel (33.5%) and cobalt allergy (18%) in this was a higher rate of nickel (33.5%) and cobalt allergy (18%) in this groupgroup

Most common clinical picture is hand, facial, or eyelid dermatitisMost common clinical picture is hand, facial, or eyelid dermatitis

Systemic reactions to gold in patients whom it was used to tx RA, Systemic reactions to gold in patients whom it was used to tx RA, SLE, or pemphigus. SLE, or pemphigus.

Cutaneous findings of lichen planus-like reactions to pityriasis Cutaneous findings of lichen planus-like reactions to pityriasis rosea-like reactions and papular eruptions with systemic reactionsrosea-like reactions and papular eruptions with systemic reactions

FormaldehydeFormaldehyde Is a ubiquitous, colorless gas found in the workplace, cosmetics, medications, Is a ubiquitous, colorless gas found in the workplace, cosmetics, medications,

textiles, paints, cigarette smoke, paper, and formaldehyde resins in plastic bottlestextiles, paints, cigarette smoke, paper, and formaldehyde resins in plastic bottles

Commonly seen in association with formaldehyde-releasing presevatives, such as Commonly seen in association with formaldehyde-releasing presevatives, such as quarternuim-15 imidazolidinyl urea, diazolidinyl urea, DMDM hydantoin, 2-bromo-2-quarternuim-15 imidazolidinyl urea, diazolidinyl urea, DMDM hydantoin, 2-bromo-2-nitropropane-1-3,diol, and tris(hydroxymethyl)nitromethanenitropropane-1-3,diol, and tris(hydroxymethyl)nitromethane

ICD is most common, ACD, contact urticaria, and mucous membrane irritation can ICD is most common, ACD, contact urticaria, and mucous membrane irritation can occuroccur

Textile dermatitis due to formaldehyde resins in ‘wash-and-wear’ and wrinkle resistant Textile dermatitis due to formaldehyde resins in ‘wash-and-wear’ and wrinkle resistant clothesclothes

Another source of formaldehyde is ‘formaldehyde-free’ products that are packaged in Another source of formaldehyde is ‘formaldehyde-free’ products that are packaged in containers coated with formaldehyde resinscontainers coated with formaldehyde resins

So widespread that avoidance is difficult and clinical relevance should be determinedSo widespread that avoidance is difficult and clinical relevance should be determined

Quaternium-15Quaternium-15 Preservative that is an effective Preservative that is an effective

biocide against biocide against PseudomonasPseudomonas, as , as well as other bacteria and fungiwell as other bacteria and fungi

Most common preservative to Most common preservative to cause ACDcause ACD

Found in shampoos, moisturizers, Found in shampoos, moisturizers, conditioners, and soapsconditioners, and soaps

80% of those reacting to 80% of those reacting to quarternium-15 are also quarternium-15 are also formaldehyde sensitiveformaldehyde sensitive

Hand dermatititis due toquaternium-15 in a moisturiser dermnetnz.org/dermatitis/quaternium

CobaltCobalt Metal that is used in association with Metal that is used in association with

other metals to add hardness and other metals to add hardness and strengthstrength

Frequently combined with nickel, Frequently combined with nickel, chromium, molybdenum, and tungstenchromium, molybdenum, and tungsten

80% of individuals with a cobalt 80% of individuals with a cobalt sensitivity have a co-sensitivity to sensitivity have a co-sensitivity to chromate (more common in men) or chromate (more common in men) or nickel (more common in women)nickel (more common in women)

Exposure through jewelry snaps, Exposure through jewelry snaps, buttons, tools, cosmetics, hair dyes, buttons, tools, cosmetics, hair dyes, joint replacements, ceramics, enamel, joint replacements, ceramics, enamel, cement, paints , and resinscement, paints , and resins

BacitracinBacitracin Topical antibiotic with activity Topical antibiotic with activity

against Gram-positive bacteria against Gram-positive bacteria and spirochetesand spirochetes

Commonly used in Commonly used in combination with other combination with other antibiotics such as neomycin antibiotics such as neomycin and with corticosteroidsand with corticosteroids

In addition to ACD, also rarely In addition to ACD, also rarely causes anaphylaxis and causes anaphylaxis and contact urticariacontact urticaria

Chronic ulcerations on the lower extremity are particularly likely to develop allergic contact dermatitis. This eruption resulted from sensitization to bacitracin. www.worldallergy.org

CorticosteroidsCorticosteroids Have been shown to cause ACD in anywhere from 0.2% to 5.98%Have been shown to cause ACD in anywhere from 0.2% to 5.98%

It is suspected that ACD to these agents is underdiagnosed, due to It is suspected that ACD to these agents is underdiagnosed, due to insufficient testinginsufficient testing

Clinical scenarios that should raise suspicion include: chronic Clinical scenarios that should raise suspicion include: chronic dermatitis, failure to clear with corticosteroids, and exacerbations of dermatitis, failure to clear with corticosteroids, and exacerbations of dermatitis after use of corticosteroidsdermatitis after use of corticosteroids

Tixocortol-21-pivalate and budesonide used for screening, with Tixocortol-21-pivalate and budesonide used for screening, with 91.3% of corticosteroid allergic reactions detected91.3% of corticosteroid allergic reactions detected

Complicates patch test interpretation, due to edge effect (first Complicates patch test interpretation, due to edge effect (first reading may have erythema only at the rim of the Finn chamber)reading may have erythema only at the rim of the Finn chamber)

Systemic Contact DermatitisSystemic Contact Dermatitis Systemic exposure to a chemical Systemic exposure to a chemical

may result in a diffuse dermatitismay result in a diffuse dermatitis

Patient has had a prior contact Patient has had a prior contact allergy and then becomes allergy and then becomes exposed through a systemic route, exposed through a systemic route, such as injection, oral, such as injection, oral, intravenous, or intranasal intravenous, or intranasal administration administration

One of most common examples is One of most common examples is patient with ethylenediamine patient with ethylenediamine allergy and subsequent reaction to allergy and subsequent reaction to

aminophyllineaminophylline

Airborne Contact DermatitisAirborne Contact Dermatitis Airborne allergens result in several different reactions including ICD Airborne allergens result in several different reactions including ICD

and ACDand ACD

PhotoACD, photoICD, photoxicity, and photoallergy to systemic PhotoACD, photoICD, photoxicity, and photoallergy to systemic medications clinically resemble airborne contact dermatitismedications clinically resemble airborne contact dermatitis

Ragweed dermatitis is a classic exampleRagweed dermatitis is a classic example

Clinically, lichenified and dry skin located in the exposed portions of Clinically, lichenified and dry skin located in the exposed portions of the skin: face, V of the neck, arms and legsthe skin: face, V of the neck, arms and legs

Most common causative agents are plants, natural resins, woods, Most common causative agents are plants, natural resins, woods, plastics, rubbers, glues, metals, pharmaceutical chemicals, plastics, rubbers, glues, metals, pharmaceutical chemicals, insecticides and pesticidesinsecticides and pesticides

55-year-old farm worker developed a chronic allergic contact dermatitis to airborn allergens (compositae).

Anacardiacea DermatitisAnacardiacea Dermatitis

Poison Ivy vine growing up a tree Poison Ivy vine growing up a tree www.dermatlas.orgwww.dermatlas.org

Anacardiacea ACDAnacardiacea ACD Members of the Anacardiaceae cause Members of the Anacardiaceae cause

more contact dermatitis that all other more contact dermatitis that all other plant families combinedplant families combined

Most allergenic members belong to the Most allergenic members belong to the genus genus Toxicodendron, Toxicodendron, including including poison ivy, poison oak, and poison poison ivy, poison oak, and poison sumacsumac

Tocicodendron leaves are compound, Tocicodendron leaves are compound, possessing three or more leaflets. possessing three or more leaflets. Flowers and fruit arise in an axillary Flowers and fruit arise in an axillary positions in the angle between the leaf positions in the angle between the leaf and the twig from which it arises and the twig from which it arises

Black dots of urushiol often present on Black dots of urushiol often present on leaves and fruitleaves and fruit

Anacardiacae AllergensAnacardiacae Allergens Urushiol derives its name form the Urushiol derives its name form the

Japanese word for the sap Japanese word for the sap (kiurushi) of the Japanese lacquer (kiurushi) of the Japanese lacquer treetree

Urushiol contains a mixture of Urushiol contains a mixture of catechols (1,2-catechols (1,2-dihydroxybenzenes) and dihydroxybenzenes) and resorcinols (1,3-resorcinols (1,3-dihydroxybenzenes)dihydroxybenzenes)

Urushiol self-melanizes on Urushiol self-melanizes on exposure to oxygenexposure to oxygen

Avidly binds to skin but is readily Avidly binds to skin but is readily degraded by waterdegraded by water

Poison Ivy www.dermatlas.orgPoison Ivy www.dermatlas.org

Clinical Features Anacardiacea Clinical Features Anacardiacea DermatitisDermatitis

Damage is generally required for Damage is generally required for plants to release urushiolplants to release urushiol

In late fall plants release urushiol In late fall plants release urushiol spontaneouslyspontaneously

Urushiol may be spread by Urushiol may be spread by contaminated clothing, dogs, cats, contaminated clothing, dogs, cats, lacquered furniture, sawdust, and lacquered furniture, sawdust, and smokesmoke

Allergen-containing smoke can Allergen-containing smoke can cause severe respiratory tract cause severe respiratory tract inflammation, severe dermatitis, inflammation, severe dermatitis, and even temporary blindnessand even temporary blindness

www.dermatlas.orgwww.dermatlas.org

Clinical Features Anacardiacea Clinical Features Anacardiacea DermatitisDermatitis

After contact with urushiol, a sensitized person typically develops After contact with urushiol, a sensitized person typically develops and pruritic , erythematous eruption within 2 days (4-96 hours) that and pruritic , erythematous eruption within 2 days (4-96 hours) that peaks within 1-14 dayspeaks within 1-14 days

Dermatitis may last up to 3 weeks after primary contact or within Dermatitis may last up to 3 weeks after primary contact or within hours of secondary contacthours of secondary contact

Streaks of erythema and edematous papules typically precede Streaks of erythema and edematous papules typically precede vesicles and bullaevesicles and bullae

Although ACD is the most common cause of streaky, vesicular Although ACD is the most common cause of streaky, vesicular dermatitis, plants may cause this same picture by other means e.g. dermatitis, plants may cause this same picture by other means e.g. chemical irritant dermatitis, or the initial phase of phytodermatitischemical irritant dermatitis, or the initial phase of phytodermatitis

Clinical manifestations of Anacardiaceae dermatitis. AClinical manifestations of Anacardiaceae dermatitis. A Acute, streak-like edematous and Acute, streak-like edematous and erythematous dermatitis without vesicles after poison ivy brushed across the face. Courtesy of erythematous dermatitis without vesicles after poison ivy brushed across the face. Courtesy of Fitzsimons Army Medical Center Dermatology slide teaching library. Fitzsimons Army Medical Center Dermatology slide teaching library. BB Acute, streak-like vesicular Acute, streak-like vesicular dermatitis after poison ivy (dermatitis after poison ivy (Toxicodendron radicansToxicodendron radicans) contact. Courtesy of Fitzsimons Army Medical ) contact. Courtesy of Fitzsimons Army Medical Center Dermatology slide teaching library. Center Dermatology slide teaching library. CC Widespread erythema and edema associated with Widespread erythema and edema associated with intense pruritus after carrying logs of the poisonwood tree (intense pruritus after carrying logs of the poisonwood tree (Metopium toxiferumMetopium toxiferum) of the family ) of the family Anacardiaceae. Anacardiaceae. DD ‘Black-spot’ poison ivy dermatitis: note the black discoloration in the central ‘Black-spot’ poison ivy dermatitis: note the black discoloration in the central portion of the edematous plaques due to plant resin. portion of the edematous plaques due to plant resin.

Clinical Features Anacardiacea Clinical Features Anacardiacea DermatitisDermatitis

Eruption ‘progresses’ to ‘new areas’ because of variability in antigen Eruption ‘progresses’ to ‘new areas’ because of variability in antigen concentration and stratum corneum/epidermis thickness, not concentration and stratum corneum/epidermis thickness, not because of bullae fluidbecause of bullae fluid

Over 70% of the US population reacts to poison ivy allergens after Over 70% of the US population reacts to poison ivy allergens after patch testing, but only 50% react to plants in the fieldpatch testing, but only 50% react to plants in the field

Only 15% atopic patients are sensitive to poison ivyOnly 15% atopic patients are sensitive to poison ivy

Uncommonly, eruptions resemble erythema multiforme, measles, Uncommonly, eruptions resemble erythema multiforme, measles, scarlatina, or urticariascarlatina, or urticaria

Prolonged postinflammatory hyperpigmentation may occur in darkly Prolonged postinflammatory hyperpigmentation may occur in darkly pigmented individualspigmented individuals

TreatmentTreatment Entire body should be washed Entire body should be washed

with copious amounts of water as with copious amounts of water as soon as possible after exposuresoon as possible after exposure

Soap may be used afterwards, but Soap may be used afterwards, but early use of soap may expand the early use of soap may expand the area of resin on the bodyarea of resin on the body

As mentioned before, urushiol is As mentioned before, urushiol is water degradable, After 10 water degradable, After 10 minutes only 50% can be minutes only 50% can be removed, after 15 minutes only removed, after 15 minutes only 25% can be removed, after 30 25% can be removed, after 30 minutes only 10% can be minutes only 10% can be removed, and after 60 minutes removed, and after 60 minutes none of it can be removed none of it can be removed

www.dermatlas.orgwww.dermatlas.org

TreatmentTreatment Weepy lesions are best treated Weepy lesions are best treated

with tepid baths, wet-to-dry soaks, with tepid baths, wet-to-dry soaks, or bland shake lotions (calamine)or bland shake lotions (calamine)

Stringent such as Burow’s solution Stringent such as Burow’s solution (aluminum subacetate) works to (aluminum subacetate) works to cool and dry lesions when applied cool and dry lesions when applied as a wet-to-dry dressingas a wet-to-dry dressing

Topical antihistamines, Topical antihistamines, anesthetics containing anesthetics containing benzocaine, and antibiotics should benzocaine, and antibiotics should be avoided to prevent sensitizationbe avoided to prevent sensitization

www.dermatlas.orwww.dermatlas.orgg

TreatmentTreatment Most potent topical corticosteroids only Most potent topical corticosteroids only

help if applied during the earliest help if applied during the earliest stages of the outbreak, when vesicles stages of the outbreak, when vesicles and blisters are not yet presentand blisters are not yet present

Systemic steroids are effective when Systemic steroids are effective when given at a dose of 1-2 mg/kg/day, given at a dose of 1-2 mg/kg/day, slowly tapered over 2-3 weeksslowly tapered over 2-3 weeks

Many patients are referred for a Many patients are referred for a ‘recurrence’ of their poison ivy ‘recurrence’ of their poison ivy dermatitis after completing a short, 6 dermatitis after completing a short, 6 day course of oral corticosteroidsday course of oral corticosteroids

Oral antihistamines may decrease Oral antihistamines may decrease prurituspruritus

www.dermatlas.orgwww.dermatlas.org