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SECOND ANNUAL NORTHERN
ONTARIO PEDIATRICS
CONFERENCE
DERMATOLOGY
Lyne Giroux BSc, MD, FRCPC dermatology
Associate professor of Medicine NOSM
Sudbury Skin Clinique Team
Disclosures
I have been a part of several advisory boards and
have given several sponsored talks for various
pharmaceutical companies in the past
I have no direct conflicts of interest for this talk
At the end of this session, participants will be able to:
Identify allergic contact dermatitis (ACD) in the
pediatric patient.
Identify potential causes of ACD
Discuss the differential diagnosis of ACD
Apply discussed treatment plans to clinical
interactions with pediatric patients
Allergic Contact Dermatitis
Type IV Delayed hypersensitivity reaction
Induction phase: Takes a minimum of 2 weeks for T-
cells to become sensitized
Elicitation phase: once sensitized it can take 1-2
days for dermatitis to appear with subsequent
exposures
Dermatitis will can last 4 weeks with one exposure
Can take multiple exposures before sensitized (can
use products many yrs before develop ACD)
Patch Testing for
Allergic Contact Dermatitis
Apply Monday Outline and remove Wednesday Read Friday
Case 1
12 y.o. female figure skater
Presents with:
Itchy vesicles, papules, swelling and crusting in areas of the tongue of her figure skates
Recreating rash with foam on tongue of
her skate
Dampened and taped on for 3 days
Potential shoe allergens
Neoprene: Mixed dialkyl thioureas
Leather tanning agents:
Chromium (most efficient tanning agent, can contain up to 5% in leather)
Glutaraldehyde
Rubber accelerators: thiurams, carbamates, mercaptobenzothiazole
Dyes for leather (paraphenylenediamine), azo
Adhesives
4-tert-butylphenol formaldehyde resin, colophony
Covington, A. “ Modern Tanning Chemistry Society Review 1997, vol 26, 111-126
Case 2
Case 2
Follicular patterned ACD
Widespread body acd causes
Preservatives or fragrance body washes, creams, Baby wipes, Gold bond
Tea tree oil
Preservatives in furniture (dimethyl fumarate)
Formadehyde preservatives in cotton clothing
Dyes (Azo type) synthetic clothing
Plants (aerosolized)
Medicaments (polysporin-neomycin, fucidin, lanacaine, Tocopheryl (vitamine E), corticosteroids
Allergic contact dermatitis
Neck dermatitis potential culprits
Metals: nickel, cobalt (used in nickel plating), gold
Fragrance: may tolerate some but not others
Careful of fragrance maskers such as benzyl alcohol
(Aveeno) as cross reacts with balsam of Peru
Azo dyes in scarves/collars (used in synthetic
fabrics)
Preservatives in creams, cleansers
Medicaments: polysporin, cortisones, fucidin,
bacitracin, topical benadryl, pramoxine…
Case 3
50 yr old woman with acute swelling itching around
upper and lower eyelids
Acute
allergic
contact
dermattis
Common causes ACD eyes
Benzaklonium chloride preservative in ophth. prep.
Nail polish (hands go to eyes)
Latex gloves
Eyelash curlers (nickel and rubber rim)
Medicaments (polysporin, bacitracin, neosporin…)
Hair dye (PPD-paraphenylenediamine)
Make-up, hairspray, shampoos (fragrance and preservatives such as:
Formaldehyde releasers ( DMDM hydantoin, quaternium 15, imidazolidinylurea, diazolidinylurea, bronopol)
Methyldibromoglutoronitrile
Methyl-isothiazinolone
Allergic contact dermatitis- eyelids
Usually upper and lower eyelid
Swelling +/- oozing going beyond area of contact
Itching
Onset delayed after exposure – can be several
weeks after first exposure but after sensitized can
take 1-2 days for dermatitis to appear
Can last up to 4 weeks
Resolves with scaling
Resolving allergic contact dermatitis
Differential diagnosis of eyelid
dermatitis
Allergic contact dermatitis
Irritant contact dermatitis
Atopic dermatitis
Psoriasis
Tinea
Irritant contact dermatitis
Acute
Lasts a few days
Red dry and scaling, no swelling or oozing
Less itch
Can just be upper or lower, less likely to be both
Does not spread beyond area in contact
Irritant contact dermatitis
Atopic dermatitis
Starts as infant
Has other areas involved (folds)
Chronic disease
Very itchy
Signs of lichenification (thickened skin)
Atopic dermatitis
Atopic Dermatitis
Psoriasis
Untreated it is usually bright red
White scaling may be present
Chronic
No swelling
Mild itch
Psoriasis
Psoriasis
Psoriasis
Pustular psoriasis
Pustular psoriasis
Pustular psoriasis
Tinea
Tinea
Tinea
Tinea
Tinea
Asymmetric
Annular hyperkeratotic border
Appears to get better but never clears with
cortisone
If treated with steroid can see follicular papules in
plaques this is called tinea incognito (Majocchi’s
granulomas due to dermatophyte infection deep in
hair follicle
Case 4
Common cause of allergic contact dermatitis
presenting in different patterns
Case 4
linear
Patchy
Case 4 Bullous
Allergic Contact Dermatitis
Poison Ivy
Delayed type IV hypersensitivity reaction to oleoresin
in Rhus toxicodendron plants
Poison ivy found east of the Rockies
Grows as shrub, vine or small plant
Allergen (urushiol) found in all parts of plant (leaf,
root, berries, stem, dead plant)
Poison Ivy-ACD
Appears 2-3 weeks after sensitization and 24-72
hrs after re-exposure
Allergen persists in the skin for weeks (need to treat
that long too!)
Possible cross reactions with :
Cashew nuts Mango rind
Ginko biloba Japanese laquer tree
Indian marking nut
Poison Ivy-ACD
Allergen can persist on clothes if not washed (ie. Shoelaces, shoes…)
Blister fluid does not spread rash
Presentations:
Linear (most common)
Airborne/photodistribution (from smoke)
Patchy (indirectly from pets or clothing)
Treatment
Antihistamines
Calamine lotion
Cool compresses (water/milk)
Aveeno bath
Wash all clothes, pets…
Avoid exposure, wash with soap/water or rubbing alcohol if in contact
Barrier creams available (Ivy block)
Treatment
Potent topical corticosteroid if mild/localized
(use for 3 weeks)
Clobetasol-17 proprionate 0.05% TID body
Betamethasone valerate 0.1% for face/folds
Often need oral prednisone 1 mg/kg
(taper over 1 month)
Other local plants -ACD
Compositae plants (sesquiterpene lactone)
> 200 are known to cause ACD (20,000 species)
Common ones: chrysanthemums, daisies, sunflowers, dandelions, lettuce, artichokes, endives, chamomile, arnica, yarrow, feverfew, ragweed, sunflower
Some can be photo-induced allergy
Can get systemic contact with teas or oral supplements
Used in “natural creams”, natural insecticides
Not to be confused with phytophoto
toxic reactions
Furocoumarins (psoralens) exposed to UV light causes a chemical burn which leads to a post inflammatory hyperpigmentation that lasts for months
Giant hogweed
Parsnip
Lime, oranges
Carrot
Celery
dill
Tatoo ACD
RED –mercuric sulfide (cinnebar) most common
Also reported with black, blue, purple, green
Henna non permanent tatoo often mixed with PPD
paraphenylinediamine (used in hair dye)
Photo aggravated –yellow >red– cadmium sulfide
Tatoo ACD
Tatoo ACD
Most prevalent causes in pediatrics
Nickel 16.3%
Cobalt 6.9%
Kathon CG 5.4% (methyl(chloro)isothiazolinone- MCI/MI)
Potassium dichromate 5.1%
Fragrance mix 4.3%
Neomycin 4.3%
One third also had atopic dermatitis
Cohort study 349 children over 7 yrs
Allergic contact dermatitis in children with and without atopic dermatitis., Schena D et al,
Dermatitis 2012 Nov 23(6)
Nickel or cobalt ACD
Nickel test kit available
Dimethylglioxime added to cotton tip turns pink with
contact with Ni
Cobalt test kit available
Safe OTC products
Petrolatum
Mineral oil
ceraVe (cream, cleanser)
Cliniderm (shampoo, conditionner, spf, hairspray,
cream, cleanser)
Epiceram (ceramide containing prescription cream-
apply 2 min pre or post other Rx products)
Treatment- ACD face/folds
For actute flares:
hydroval or hydrocortisone oint 1-2.5% x 1-2 weeks
For chronic use or to prevent flares:
-protopic 0.03% oint pediatric
-protopic 0.1% oint adults (or peds if 0.03% fails)
-elidel cream (if cr is preferred)
Protopic (tacrolimus), Elidel (pimecrolimus)
-work best on thin skin areas
(large macromolecule has difficulty penetrating)
-elidel less effective, but it is in a cream form
that some prefer
-can sting when used on acute flares, improves
with use (some keep in fridge or take
asa/acetominophen 1 hr prior)
-wine can also trigger flare of redness in some
Position statement protopic/elidel by
Canadian Dermatoloy Assoc. 2006
-Black box warning not based on good evidence
-Clinical studies in 38,000 people (14,000 children)
2 cases non-lymphoma cancer, none in children
Would expect at least 3 among such a large group based on
population risk
-At time of statement, 7 million pts using in US, spontaneous reporting
programs showed 25 cases of malignancies (4 children and 13 were
lymphoma). Reviewers did not feel likely to be linked.
Based on pop risk would expect 61 cases.
Corticosteroids for acd body
Ointments
More effective and potent than cream
Increased hydration
Stings less on acutely flared skin
For body areas use stronger steroid such as
clobetasol 0.05% (up to 4 weeks)
If suspecting steroid to be culprit ACD then use
topicort (desoximethasone 0.25 % or o.05%)
Steroid induced striae
Periorificial dermatitis
Periorificial dermatitis
ACD treatment
Antihistamines- help pruritus due to their sedative
properties
Consider antibiotics if secondarily infected
Case 5
Vigamox
moxifloxacin
Delayed hypersensitivity reaction to moxifloxcin
eye drops
16 yo girl with a diffuse papular rash
developped 2 weeks after starting the eyedrops for an eye infection
Resolved after 4 weeks of stopping it.
Gave topical betaderm 0.1% cr
Should avoid all forms of moxifloxacin (topical or po) in future
Drug patch testing available at SunnyBrook Hospital
Case 6
urticaria
Type 1 reaction IgE
Immediate
Acute type
Chronic type (autoimmune or physical triggers)
Physical triggers (sun, water, cold, heat, vibration,
exercise)
Treatment urticaria
Avoidance of triggers
Avoidance asa, ibuprofen, etoh
Non sedating antihistamines
Sedating antihistamines
Type 2 antihistamines’
Mast cell stabilizer- montelukast (singulair)
Rarely course pred,
Only severe cases 6 months Cyclosporin (Neoral)
Erythema ab igne – heat induced
discoloration from laptop computer
Erythema ab igne – heat from computer
Spot the dermatologist!
