Contact dermatitis

CONTACT DERMATITIS

Martín GraciaFacultad de Medicina Universidad Nacional de Colombia.Dermatología.

DEFINICIÓN

Alteración inflamatoria frecuente Exposición a varios antígenos e irritantes

Mecanismos distintos tipos Eczema de contacto o dermatitis de contacto alérgica

(reacción de hipersensibilidad de tipo IV)

Dermatitis de contacto irritativa (de causa no alérgica)

Fotodermatitis de contacto (reacción de tipo IV)

Urticaria de contacto (reacción de hipersensibilidad de tipo I)

DEFINICIÓN

Presentación clínica Vesículas y bullas localizadas sobre una piel eritematosa

estadios agudos

Placas eritematosas liquenificadas estadios crónicos

Diagnóstico Localización – erupción

Historia – exposición

Pruebas epicutáneas - aplicación alergeno producirá inflamación

DEFINICIÓN

Tratamiento eliminación – agente uso de cremas esteroides antiinflamatorias antihistamínicos

casos graves corticosteroides orales

Eczema de contacto o dermatitis de contacto alérgica

Eritema

Eczema de contacto o dermatitis de contacto alérgica; fotodermatitis de contacto

Eritema, excoriación, descamación, liquenificación y edema

Eritema, excoriación, liquenificación y costras

Eritema, fisuras y descamación

Eritema y costras

fotodermatitis de contacto (reacción de tipo IV)

Eritema, hinchazón y vesículas

Eritema, edema, ampollas

Eritema, edema, ampollas, vesiculas, hinchazón

Descamación, erosiones, escoriaciones, costras

Eritema, vesiculas, descamación y edema

Epidemiology

the most common occupational disease in the United States

90% skin disorders workplace 6 million chemicals

3000 have been known to cause allergic contact dermatitis (ACD)

New chemical sensitizers are introduced annual cost $250 million

Lost productivity medical care disability payments

Epidemiology

Allergic contact dermatitis (ACD) does occur in children and infants

Allergic versus irritant contact dermatitis

Distinguishing allergic and irritant triggers Clinical and histologic examination

Both forms of contact dermatitis involve an inflammatory pathwayThe reactions of ICD are nonimmunologic

Direct epidermal keratinocyte damageconcentration irritant duration contact

ACDAffects genetically susceptible persons

Previously sensitized by allergen

FR Physical conditions

Heat Cold repeated frictional exposure Low humidity

Prior damage – skin Dehydration Trauma Compromises – integrity - epidermal barrier (stratum

corneum)

*more vulnerable to irritants

Atopic persons

Greater susceptibility ICD

phenomenon caused by ‘‘itch - scratch cycle’’ of AC

increased penetration of irritants no allergens Tendency in atopy to favor pathways of the Th2

rather than the Th1 pathways of ACD

Dermatitis de contacto alérgica

Sensitization (afferent phase)

Most allergic diseases immediate hypersensitivity response involving IgE

ACD prototypic delayed (or cell-mediated) hypersensitivity reaction

Previously sensitized T-helper cells

Haptens Contact allergens Covalently bond with

tissue proteins immunogenic initiate afferent phase

Degree of Th1 sensitization proportional to stability hapten-protein couplings

> chemically reactive haptens lipid-soluble low-molecular-weight molecules

easily penetrate the stratum corneum strongly bind carrier proteins

Haptens Within the epidermis

Pinocytosis by Langerhans cellsDegradation of the allergens

Processed peptides Displayed - Langerhans cell surface context - major histocompatibility complex class II molecules

Langerhans cells

migrate regional draining lymph nodes

processed peptides are presented to naïve Th1 cells

New peptidesSpecific T-cell receptormajor histocompatibility complex II

molecules ”found only on the Th1 cells of susceptible

patients”

*Those who have necessary repertoire receptor variable regions genetically rearranged TR-cell

Successful allergen presentation

Langerhans cells interleukin-1

Th1 cells interleukin -2Clonal proliferation newly sensitized Th1 cells

paracortical region of the lymph nodes

Patient’s initial contact

Number of responding Th1 cells is insufficient to a clinically response

But - Then - memory Th1 cells are released into the circulation

Elicitation (efferent phase)Specific memory Th1 cells – circulatingLangerhans cells Allergen

presentation expanded pool of Th1 cells occurs in:EpidermisDermisRegional draining lymph nodes

*Skin-specific homing receptors on the Th1 cells

Th1 cells release inflammatory cytokines interferon-γ chemotactic

macrophages cytotoxic T cells Natural killer cells

Granulocyte-macrophage colony–stimulating factor augments bone marrow’s production

Lymphocytes Granulocytes Monocytes

Culmination

epidermal spongiosis (intercellular edema)

dermal infiltrate*characteristic of ACD Lymphocytic

Latency periodFrom allergen contact to clinical dermatitis

time for Langerhans cells to present the allergen time for Th1 cells to

proliferate secrete cytokines Travel - site of contact

Between 12 to 48 hours - previously sensitized person

Clinical features

HistoryDetailed

Hidden sources of contact allergens

Occupational exposure - highest risk

food production construction printing metal plating (enchapado

en metal) Machine tool operation

(operarios de maquinas) engine service

(Mechanics) leather work (trabajo del

cuero) health care cosmetology forestry

Clinical features

Temporal relationship - days off and return to work recent exposures

Strong allergens poison ivy Effect - hours – days after - one exposure

long-term exposures > ƒ OACDWeak sensitizers chromate

require repeated exposures - months to years to develop sensitivity

Clinical features

Exposures ≠ workplace

Jewelry Clothing Cosmetics Fragrances Soaps Detergents household cleaning

agents paints resins rubbers (caucho y

gomas) latex adhesives topical medicines

Clinical features

One uniformly present feature of ACD is

PRURITUSwithout which the Dx of ACD is

excluded

Physical examination

Appearance - lesion in ACDcorresponds - stage at which the

patient presents.

Acute stageMarked erythemaEdemaVesicle formationEdema predominates if areas of

loose(sueltas) tissueEyelidsGenitalia

VesiclesMultipleSeveremay coalesce into bullae filled with a clear, transudative fluidRupture during the subacute stage rupture oozing(resumar) and eroded(erosion)

eczematous appearance

vesicular fluiddoes not contain appreciable amounts of

the allergendoes not spread the eruption to other

areas of the body or to othermay be replaced by papules

Crustin(Costra) and scaling(descamación) soon become more prominent than the erythema and edema

chronic stage

Papulovesicular lesions disappearLichenification

*The principles of prevention and treatment of ACD remain similar, regardless of the stage.

Differential diagnosis

the physician’s clinical suspicion of ACD may be quite(bastante) high

It is paramount(importante) consider - potentially more serious etiologies

ICD > ƒ confused

ƒ atopic dermatitis

Atopic dermatitis

onset in infancyACD is uncommon in children younger than 8

years oldDry skin and pruritus prominent - before

lesions appear - ≠ ACD afterwardsTends to be symmetrically distributed on

extensor surfaces - on flexural surfaces

Atopic dermatitis

seborrheic dermatitis

predilection for eyebrows nasal labial folds(pliegues naso-labiales) scalp (cuero cabelludo)

Mild pruritus Greasy(grasosa) or oily(oleosa) coating(capa)

with scaly(descamación) irregularly shaped(forma) erythema

seborrheic dermatitis

endogenous dermatosesMore intensely pruritic eruptionsNummular dermatitis

one or a group of coin – shaped eczematous patches 2 to 10 cm in diameter

Usually torso and extremities but not the head

Dyshidrotic dermatitis appears as multiple vesicles 1 to 2 mm in diameter

palms soles lateral aspects of the fingers and toes

endogenous dermatosesNummular dermatitis

endogenous dermatosesDyshidrotic dermatitis

Photocontact dermatitis Interaction

exogenous chemical UV component of sunlight recently ingested drug

sulfonamide Fluoroquinolone Tetracycline Oral contraceptive nonsteroidal anti-inflammatory drug topically applied substance - cold tar extract

(extracto de alquitran frio)

Photocontact dermatitisClinically

sun-exposed areas face arms upper chest

is noticeably spared skin under the chin - behind the

ears - upper eyelids

phototoxic reactions ↔ ICD subset

photoallergic reactions ↔ACD subset

phototoxic reaction

Maculartender erythema

can resemble(parecer) severe sunburn(quemaduras)

photoallergic reactiondelayed hypersensitivity reaction -

induced by UV light which chemically alters the sensitizing allergen in the skin.

PruriticPapulovesicularEczematous

*similar to ACD

two types of contact urticaria subsets of contact dermatitis

nonallergic formurticaria remains localized site of

contact - caused -direct cell mediator release from:

fragrances food preservatives insect stings hairs topical medicines

Allergic contact urticaria IgE-mediated mast cell stimulation requires prior exposure to sensitizing allergens foods metals animal saliva latex industrial products topical medicines

Both forms of contact urticaria resemble noncontact urticaria

classic wheal and flare response appears within 30 minutes of exposure

allergic contact urticaria may become generalized

angioedema or anaphylaxis

Urticaria or angioedema - contact or noncontact - can be –mistaken(confundida) for ACD

*when the eyelids are involved

Both forms of contact urticaria resemble noncontact urticaria

classic wheal and flare response appears within 30 minutes of exposure

allergic contact urticaria may become generalized

angioedema or anaphylaxis

Urticaria or angioedema - contact or noncontact - can be –mistaken(confundida) for ACD

*when the eyelids are involved

Skin infections strongly considered - immunocompromised patientsCellulitis

erythema and edemaDx dif

warmth tenderness Trauma common precipitant fever and leukocytosis

Dermatophytic or tineaDryscaling erythemaannular ring and central clearing

Diagnosis scraping scales glass slide adding potassium hydroxide visualizing branching hyphae

infections present vesicular lesions

herpes simplex virus tendermay umbilicatepredilection for perioral and genital regions

varicella zoster virus

primary varicella

2- to 3-day prodrome of flu like symptoms

erythematous maculopapulesdiffuse, pruritic vesicles

varicella reactivated

few constitutional symptomslocalized pain and paresthesias 2 to

3 days before the eruptiongrouped vesicles in a dermatomal

distribution

Impetigo

all age groups, but is usually seen in young children Streptococcus pyogenes or Staphylococcus aureus involves the face has regional lymphadenopathy self-limited to 2 to 3 weeks vesicles may progress to pustules easily rupture

honey - colored crust

Impetigo

psoriasis thick(espeso) silver - scaled plaques over bright erythema extensor surfaces

mycosis fungoides (Primary cutaneous T-cell lymphoma) asymmetric finely scaled(descamadas) plaques on the trunk

and groin(ingle)

psoriasis thick(espeso) silver - scaled plaques over bright erythema extensor surfaces

mycosis fungoides (Primary cutaneous T-cell lymphoma) asymmetric finely scaled(descamadas) plaques on the trunk

and groin(ingle)

*biopsy low utility in ACD

histologic finding of spongiosis is not specific among eczematous dermatoses

Anatomic approach

Exposure to the suspect allergen - congruent - distribution of the eruption

more exposed areas the hands face

> ƒ presenting ACD

Anatomic approach

Head and neck Scalp have greater resistance than face, ears, and

neck Hair dyes(tintes) Shampoos

often spare the scalp but involve its nearby landmarks

eyelids and cheeks(mejillas) facial cosmetics products applied to the hands nail polish(esmalte)

Anatomic approach

Head and neck common triggers

Metals from jewelry piercings - face and ears

Topical antibiotics EyesEars

Anatomic approach

cosmetics and fragrancesmetalsexotic woods from necklaces (collares)musical instruments

Anatomic approach

Extremities50% involve the hands

supposed innocuous items foodsmoisturizersmusical instruments,protective gloves

> ƒ fingertips (pulpejos)

Anatomic approach

Extremitiesƒ dorsal side of the hands

the skin is thinnerdensity of Langerhans cells is greater than on

the palmar sideBracelets, watches, and rings

ACD metal exposure ICD soap and detergent accumulation under

Anatomic approach

Extremitiesphotosensitive process

hand dermatitis - contiguous with forearms - associated with a facial dermatitis

dorsal aspect - feet chrome - tanned leather (cuero) glues (pegamentos) rubber (caucho)

components of shoes

Anatomic approach

ExtremitiesStasis dermatitis - lower legs - chronic

varicose inflammation

Significantly increases the risk of ACD from topically applied products

Metals – keys - coins -match boxes(encendedores) - pants pockets upper legs

Anatomic approach

Torso and groin(ingle) Fragrances - deodorants - axillary vault formaldehyde, detergents, and dyes from

clothes torso - axillary folds - sparing vault Rubber chemicals - elastic of under garments

(prendas femeninas) - bra line – waistline (cintura)

periumbilical region - metallic fasteners(cierrres) – belts(cinturones) – pants

Anatomic approach

Torso and groin(ingle)Incontinent bed – bound(obligados)

patients - urine - diaper (pañal)ƒ Contraceptive devices latex-

sensitiveMedicines, douches, spermicides

genital area - vulva and adjacent thighs(muslos) ≠ vaginal mucosa

Anatomic approach

Oral mucosa Langerhans cells are sparse(escasas) at mucosal sites contact stomatitis

contact gingivitis cheilitis

Dental metals - amalgams Nickel Palladium Mercury Gold

Anatomic approach

Oral mucosasaliva - buffering and diluting effect on the

allergen

rapid dispersal and absorption of the allergen extensive vascularity in the mouth

low incidence of contact stomatitis

Anatomic approach

Systemic involvement Systemic ACD - form of autoeczematization - known as an ‘‘id

reaction.’’ Secondary dermatitis - patients sensitized topically - subsequently

re-exposed systemically re-exposure

orally intravenously intramuscularly rectally vaginally inhalation after dental surgical devices implanted

Anatomic approach

Systemic involvement ‘‘id reaction.’’

Generalized eruption - result - hematogenous dissemination - antigen-specific Th1 cells

Common contact allergens

Allergens

Poison ivyspecie: Toxicodendron genus plant family: Anacardiaceae the most ubiquitous of four especies family includes

poison sumacpoison oak

Allergens

Poison ivy United States - responsible -more cases – ACD Strong sensitizing allergen urushiol - catechol

derivative – sap (savia)sap - difficult to wash offwashing - ideally within 10 minutes of exposure

dermatitis linear erythema and vesiclesvesicular fluid - no allergenic

Allergens

Poison ivy chronicity and spread(propagación) of symptoms

continued unintentional exposure urushiol may persist on clothing, tools, sports equipment, -

fur(piel) of pets(animals) Cross-reactions - catechol derivatives- found in other

members - Anacardiaceae family Mangoes Cashews Ginkgoes Brazilian peppers(pimienta)

Allergens

Metals

Nickel most common metal allergen prevalence women higher - early sensitization ear

piercings Other

Chromium Cobalt Gold organic forms of mercury

Allergens

Metals

Sensitivity to aluminum is quite uncommon substitution with aluminum items - workplace -

reduce the incidence metal alloys(aleación) - medical devices – implants

stainless steel contains - nickel and chromium may present - persistent - localized or generalized eczema -

loosening - implant Patch testing - metals - low specificity - moderate

sensitivity work-up - metal implant

Allergens

MedicationsTopical antibiotics

> ƒ neomycin and bacitracin*mupirocin may to be a safe alternative

Topical anestheticsester class

benzocaine and tetracaine ƒ lidocaine, dibucaine, and mepivacaine, are rare

sensitizers

Allergens

Medications Topical corticosteroids

structure may be altered to induce allergenicitymetabolism in the skindegradative reactions within the pharmaceutical

preparation topical antihistamines

known to act as sensitizers may predispose to an id reaction after systemic

administration

Allergens

MedicationsEthylenediamine

Common allergenic preservative found in

aminophyllinesome antihistaminessometopical medicines

Allergens

Medicationsthimerosal

Preservative with the highest prevalence of positive patch tests

found invaccinesnumerous topical medicines for the eyes, ears,

and nose

Allergens

Latex and rubber(caucho) chemicals Latex fluid - Brazilian rubber tree - Hevea brasiliensis Vulcanization

Chemical accelerators Antioxidants

ThiuramsCarbamatesMercaptobenzothiazole

*primary sensitizers

Allergens

Latex and rubber(caucho) chemicals

Immediate hypersensitivity reactions mediated - specific IgE against - latex protein

Responses Urticaria Rhinitis Conjunctivitis Asthma Anaphylaxis

within minutes

Allergens

Latex and rubber(caucho) chemicals

*airborne(aera) exposure proteins-Latex

latex gloves – to cause immediate-type reactionsdelayed-type reactions – ACD> ƒ ICD.

Allergens

FormaldehydeFormaldehyde itselfformaldehyde–releasers = quaternium-

15, are the most common ƒ preservative ≠ thimerosal ACD

cosmeticsmoisturizers fabrics (telas)

Allergens

FragrancesCosmeticsFabrics topical medicines flavorings (aromatizantes) of foodsdrinksspices (especias)oral hygiene productsperfumes and colognes

Allergens

FragrancesBalsam of Peru >ƒ ACD - nonallergic

contact urticaria*In addition to mentioned products

Sunscreens Shampoos

beneficial actions - side effects stimulate capillary beds increase local

circulation

Patch testing

gold standard – Dx ACD first use

1895 Josef Jadassohn suspected - rash - result - mercury sensitivity

refined- simple reproducing – ACD

allergen - same or cross-reactingsmall area – back

Patch testing

Standardized allergens- delivery vehiclesACD eruption appears - 2 to 3 days of

sufficient allergen contactpatch testing - performed - at least a 3-day

periodnumber of allergens - depends

physician’s clinical suspicion likely culprits

Patch testing

Screening panels - 20 to 30 - most prevalent allergens>ƒ TRUE Test (Mekos Laboratories A/S,

Hillerød, Denmark)23 allergensone negative control

gel delivery system

Identifies about 70% - clinically relevant

allergens

Patch testing

*Another option assortments(diversidad) of allergens

Filter paper in 8-mm aluminum disks ‘‘Finn Chambers’’ (Epitest Ltd Oy, Tuusula, Finland)allergen dispersion -Along - 5-mm ribbon of

petrolatum -

Patch testing

Techniques

Applied Allergens togetherhairless regionupper backbetween - spine and scapulazone washed

Patch testing

TechniquesAn adhesive keeps the allergens

securedEdges(bordes) - marked with a pen.Patients - return - physician’s office - 48

to 72 hoursRemoved patch - Waiting 20 to 30 minutes

reactions are gradedThird visit 24 to 96 hours later

Patch testing

Techniqueslonger allergic response

Elderly patientsallergens - late phase reactions

cobalt neomycin topical corticosteroids

Patch testing

PrecautionsNot be performed in - acute or

widespread(extendida) contact dermatitisPositive patch test reaction may progress to

autoeczematizationPruritus within minutes of application

suspicions - contact urticaria - possibility anaphylaxis if patch is not removed

Patch testing

to consider bacitracin and gold are not TRUE Test panels

prevalent allergens Poison ivy also is not included urushiol’s

sensitizing may cause severe reactions May need to be delayed - potent topical

steroids -near test site Systemic steroids

doses of 20 mg or less of prednisone daily - not inhibit positive reactions

Patch testing

to consider bacitracin and gold are not TRUE Test panels

prevalent allergens Poison ivy also is not included urushiol’s

sensitizing may cause severe reactions May need to be delayed - potent topical

steroids -near test site Systemic steroids

doses of 20 mg or less of prednisone daily - not inhibit positive reactions

MANAGEMENT

treating the active case Prevention

treatment Topical corticosteroids Soap substitutes Emollients

Second line treatments topical PUVA azathioprine cyclosporin

steroid resistant chronic dermatitis

MANAGEMENT

PREVENTION workplace eliminating harmful exposures

substitution of chemicals less irritating or allergenic

introduction of engineering controls Organization of work all employees are exposed

to the same degree Uses of personal protection

Gloves

Selection of less susceptible individuals

MANAGEMENT

correct selection of glovesCotton gloves

allow the skin to ‘‘breathe’’could be used for dry workWet work thin cotton gloves

absorb sweat inside rubber or vinyl gloves

MANAGEMENT

Barrier creamsquestionable value in protecting against

contact with irritantsAfter-work creams

Controlled clinical trials have shown benefit reducing the incidence and prevalence

approved industrial skin cleansers

MANAGEMENT

PRE-EMPLOYMENT SCREENING

predisposing factorsAtopic dermatitishand eczemaxerosis

MANAGEMENT

WORK RELATED EDUCATIONAL PROGRAMMESHalf OCDs appear first two years of

employment recognition of early signs and symptoms proper use of protective clothingafter-work creamspersonal and environmental hygiene

Contact dermatitis

Documents

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