Contact Dermatitis
Contact Dermatitis: Excerpt from The 5-Minute Pediatric Consult
Kara N. Shah, MD
Contact Dermatitis - BASICS
Contact Dermatitis - description
- An acute or chronic eczematous eruption that may result from either direct irritation to the skin (irritant contact dermatitis) or from a delayed hypersensitivity reaction to a contact allergen (allergic contact dermatitis).
- Most cases of contact dermatitis are irritant contact dermatitis (>80%).
Contact Dermatitis - general prevention
Minimize contact exposure to known or potential allergens.
Contact Dermatitis - incidence
The incidence of contact dermatitis in children is not known.
Contact Dermatitis - prevalence
- The prevalence of allergic contact dermatitis increases with age.
- Contact dermatitis can occur at any age but is relatively uncommon in infants.
- Infants are more likely to develop an irritant contact dermatitis.
- In children, the overall prevalence of allergic contact dermatitis is ~20%.
Contact Dermatitis - risk factors
- Susceptibility to certain contact allergens for delayed hypersensitivity is in part genetically determined.
- It is unclear whether atopic dermatitis is associated with an increased risk of developing contact dermatitis.
- Increased exposure to potential allergens and the chronic or intermittent development of an impaired skin barrier are predisposing factors.
Contact Dermatitis - pathophysiology
- Allergic contact dermatitis requires initial exposure and sensitization to an allergen and only occurs in susceptible individuals. Repeated exposure to the allergen leads to the development of a T-cell mediated delayed-type hypersensitivity reaction.
- Irritant contact dermatitis does not involve an immunologic response and can occur in anyone, even after the 1st exposure to the irritant. It commonly results from frequent or chronic exposure to moisture and/or friction such as from water, saliva, or urine or to acidic or alkaline chemicals such as soaps and detergents.
- Both processes result in nonspecific findings of dermal and epidermal edema and inflammation, and may be indistinguishable from other forms of eczematous dermatitis.
Contact Dermatitis - etiology
- Irritant contact dermatitis:
- Frequent handwashing or water immersion
- Soaps and detergents
- Saliva (lip licking)
- Urine and feces (diaper dermatitis)
- Allergic contact dermatitis:
- Nickel and other metals
- Fragrances (e.g., Balsam of Peru)
- Clothing dyes
- Formaldehydes
- Lanolin
- Topical antibiotics (neomycin, bacitracin)
- Rubber and rubber accelerators
- Plants (Toxicodendron species, e.g., poison ivy, poison oak, and poison sumac, which contain the allergen urushiol)
Contact Dermatitis - DIAGNOSIS
Contact Dermatitis - signs & symptoms
Contact Dermatitis - history
- Patients may present with either the acute development of a pruritic rash or with the chronic persistence of a localized, mildly pruritic dermatitis.
- Many patients are unable to associate a specific allergen with the development of symptoms. With regard to acute allergic contact dermatitis, this is often due to the latency between the exposure and the development of symptoms (usually 48–72 hours but occasionally as long as several days).
- Patients with either an irritant contact dermatitis or a chronic contact dermatitis should be asked about all chemicals and other potential contact allergens to which they are intermittently or frequently exposed.
Contact Dermatitis - physical exam
- Acute allergic contact dermatitis manifests as erythematous edematous papules and plaques, often with vesicles and crusting.
- Chronic allergic contact dermatitis manifests as erythematous often hyperpigmented patches and plaques, usually with lichenification (accentuation of skin markings) as a result of chronic rubbing.
- Irritant contact dermatitis more commonly manifests as erythematous papules and patches with less prominent edema, vesiculation, and crusting.
- The morphology of contact dermatitis commonly consists of geometric, angulated, or asymmetric lesions that correlate with the pattern of allergen exposure.
- The distribution of the dermatitis may suggest particular allergens, such as the dorsum of the feet (shoe rubber) or earlobes and/or periumbilical (nickel).
- In older children a perioral rash often signifies an irritant contact dermatitis from lip licking.
Contact Dermatitis - tests
Contact Dermatitis - lab
In general, routine laboratory testing is not helpful in confirming the diagnosis of contact dermatitis.
Contact Dermatitis - diag proced-surgery
Formal skin patch testing to evaluate suspected contact allergens may be performed by a dermatologist or allergist. The patch test involves the controlled exposure of multiple allergens to the skin. Positive reactions manifest with the development of erythema, edema and vesicles at the site of exposure, usually within 48–96 hours. It may be performed using a standard panel of allergens (the T.R.U.E. Test) or by the application of selected allergens at the discretion of the specialist.
Contact Dermatitis - pathological findings
- Skin biopsy findings may not be specific and often overlap with other eczematous dermatoses.
- Acute contact dermatitis shows edema of the epidermis and dermis with a mixed inflammatory infiltrate. There may be intraepidermal vesicles and a prominence of eosinophils in the dermal inflammatory infiltrate.
- Chronic contact dermatitis usually shows prominent hyperkeratosis (thickening) of the stratum corneum and epidermal rete ridges with minimal edema. A sparse inflammatory infiltrate may be present.
Contact Dermatitis - differencial diagnosis
- Infection:
- Impetigo and cellulitis: Bacterial infections of the skin, usually caused by Staphylococcus or Streptococcus, may manifest as erythematous, edematous crusted patches and plaques. They are usually associated more with pain and tenderness than with pruritus.
- Scabies: Intensely pruritic papules and nodules with a predilection for the hands and feet (especially the web spaces), the axillae, and the groin. There are often multiple affected family members.
- Neoplastic:
- Langerhans cell histiocytosis: The skin manifestations may present as scaling red-brown papules and petechial macules that favor the scalp and the intertriginous areas, including the diaper area. Affected infants and children may also manifest gingival lesions, hepatosplenomegaly, and adenopathy.
- Metabolic:
- Acrodermatitis enteropathica: A genetic or acquired deficiency of zinc that usually presents with characteristic bullae and erosions involving the hands and feet and periorificial areas (perioral, periocular, and perineal). These patients also develop failure to thrive, diarrhea, and alopecia.
- Immunologic
- Atopic dermatitis: Infantile atopic dermatitis usually begins within the 1st 6 months of life. It may favor the face and extremities or occur more diffusely with truncal involvement but usually spares the diaper area and the perinasal area. It is associated with erythematous, excoriated, and crusted papules, patches, and plaques and with chronic pruritus, which is often worse at night. Atopic dermatitis is often accompanied by a personal or family history of atopy (reactive airways disease and/or allergic rhinitis).
- Seborrheic dermatitis: Usually affects infants <1 year of age or adolescents. It manifests as erythema and greasy yellow, scaling patches that favor the scalp, face, ears and intertriginous areas. It is usually asymptomatic.
- Nummular eczema: A chronic, often intensely inflammatory and pruritic dermatitis that presents with multiple round, crusted, edematous, erythematous patches and plaques. Lesions often favor the extremities.
- Psoriasis vulgaris: A chronic dermatitis that presents with recurrent well-defined erythematous plaques with silvery scale. Commonly affected areas include the scalp, elbows, knees, and genital regions.
Contact Dermatitis - TREATMENT
Contact Dermatitis - general measures
- The most effective treatment involves identification and elimination of the offending allergens or exposures. This often requires extensive education of the patient and family regarding potential sources of exposure.
- Mild cases of acute contact dermatitis may not require treatment and will resolve within 1–2 weeks.
- Moderate to severe cases of acute contact dermatitis and most case of chronic contact dermatitis often require treatment in order to reduce symptoms and hasten resolution.
- Prompt bathing with soap and water immediately after exposure to poison ivy, poison oak, or poison sumac may help to reduce exposure to the allergen in susceptible individuals. Zanfel is an OTC cleanser that reportedly binds to and eliminates the urushiol allergen from the skin if used immediately after contact with poison ivy, poison oak, and poison sumac.
- Acute allergic contact dermatitis: Application of cool compresses and shake lotions with drying properties (i.e., Caladryl) can be helpful. Products containing colloidal oatmeal, such as Aveeno oatmeal bath and Aveeno lotion, may also be helpful in soothing inflamed skin.
Contact Dermatitis - medication
Contact Dermatitis - first line
- Topical corticosteroids help with the pruritus and inflammation associated with both acute and chronic contact dermatitis. Use of a medium-to-high potency topical corticosteroid (class 2–4) for a short duration (1–2 weeks) is usually more effective that prolonged treatment with low-potency topical corticosteroids. The use of medium-high potency fluorinated topical corticosteroids should be avoided on the face, axillae, and groin. The skin of these areas is thinner and more susceptible to side effects. A low-potency topical corticosteroid such as hydrocortisone (class 6–7) should be used instead.
- Systemic antihistamines are generally not necessary for treating contact dermatitis, but can be considered if pruritus is extreme. The use of topical antihistamines is not recommended.
- In severe cases involving a large body surface area or associated with significant facial edema, a short course (14–21 days) of systemic corticosteroids may be appropriate, with tapering over 1–2 weeks to avoid a rebound of the dermatitis.
Contact Dermatitis - second line
The intermittent use of a topical calcineurin inhibitor such as tacrolimus ointment or pimecrolimus cream, which have anti-inflammatory and steroid-sparing properties, may be considered as adjunctive therapy in patients with chronic contact dermatitis.
Contact Dermatitis - FOLLOW UP
Contact Dermatitis - prognosis
Complete resolution can be expected after appropriate treatment and elimination of further exposure to the allergen.
Contact Dermatitis - complications
Generally, there are no long-term complications, although secondary bacterial infections may occur. Exposure to certain substances, such as latex, can cause reactions ranging from a mild contact dermatitis to life-threatening anaphylaxis.
Contact Dermatitis - patient monitoring
- Follow-up depends on the severity of the dermatitis and elimination of continued exposure to the allergen.
- Patients who do not improve after 1–2 weeks of therapy should be re-evaluated.
Contact Dermatitis - bibliography
- Bruckner AL, Weston WL. Beyond poison ivy: Understanding allergic contact dermatitis in children. Pediatr Ann. 2001;30(4):203–206.
- Mortz CG, Andersen KE. Contact Dermatitis. 1999;41(3):121–130.
- Weston WL. Contact dermatitis in children. Curr Opin Pediatr. 1997;9(4):372–376.
- Weston WL, Bruckner A. Allergic contact dermatitis. Pediatr Clin North Am. 2000;47:4.
Contact Dermatitis - CODES
Contact Dermatitis - icd9
692.9 Contact dermatitis and other eczema (unspecified cause)
Contact Dermatitis - PATIENT TEACHING-MED
Contact Dermatitis - prevent
- Patients should be instructed on allergen avoidance, including the use of protective gloves, clothing where appropriate.
- Ivy Block contains quaternium-18 bentonite (bentoquatam 5%), a barrier lotion that prevents exposure to the allergen in poison ivy if applied prior to anticipated exposure.
Contact Dermatitis - FAQ
- Q: Can the fluid from blisters caused by poison ivy spread the rash to other parts of the body?
- A: The contents of the vesicles and bullae from rhus dermatitis are not contagious. After exposure to poison ivy is eliminated, new lesions appear because of the variable sensitivity of various areas of the body to the allergen.
- Q: After making lemonade at a picnic on the beach, my child developed a red, blistering rash on his face. What was the cause?
- A: A phototoxic form of contact dermatitis can result from exposure to plant compounds (psoralens) and ultraviolet light (sunlight). Called phytophotodermatitis, the plants that can cause this include lime and lemons, celery, dill, parsnip, and carrot juices.
- Q: Is it possible to avoid contact dermatitis using protective clothing or skin barrier creams?
- A: Yes. Proper fitting protective gloves and clothing are a highly effective means of decreasing irritant exposure. However, gloves permeable to irritants such as organic solvents may increase the exposure to the irritant. Some contact allergens can also permeate rubber gloves, which therefore are of no benefit. Rubber gloves are contraindicated in individuals with immediate and delayed-type allergy to latex and rubber additives. With the exception of Ivy Block lotion, the use of barrier creams in the prevention of contact dermatitis is not effective.
- Q: How does saliva cause a perioral rash in some kids? Is there something unusual in the saliva that is causing this?
- A: “Lip-licker dermatitis” is an irritant dermatitis that results from chronic and/or excessive exposure to moisture. It is not caused by any specific substances in the saliva.
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
More About Contact dermatitis
More Medical Textbooks Online about Contact dermatitis
Review other book chapters online related to Contact dermatitis:
Medical Books Excerpts
- Dermatitis
- "Professional Guide to Diseases (Eighth Edition)" (2005)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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