692.9 – Contact dermatitis and other eczema, unspecified cause

Allergic contact dermatitis is a delayed hypersensitivity reaction (type IV cell-mediated reaction) of sensitized individuals. The most frequent sensitizers in the general population are fragrance, nickel, neomycin, formaldehyde, chromates, rubber chemicals, lanolin, and a host of other common environmental chemicals. Poison ivy and other plants are frequent causes as well.

Nickel is found in jewelry, belt buckles, and metal closures on clothing. Chromates are found in shoe leathers. Rubber chemicals are found in gloves, balloons, and elastic in garments. Neomycin is common in triple antibiotic first aid ointments such as Neosporin® (and generic versions of Neosporin) as well as other combination preparations with antibacterials and corticosteroids. It may also be found in eye preparations, eardrops, and some vaccines. Other common allergen-containing products include cosmetics, soaps, and dyes. Allergic contact dermatitis can occur at any age.

The intense erythema and sharply demarcated plaques of contact dermatitis are easy to confuse with cellulitis or erysipelas, especially when vesiculation and bullae formation take place. Differentiating features include the presence of pruritus (often extreme) in contact dermatitis versus the skin warmth and spreading erythema of a soft tissue infection. A detailed allergen exposure history should be elicited.

In acute cases, look for a range of clinical findings, from scaling erythematous plaques to vesicles and bullae. Individual lesions have well-demarcated borders and often assume geometric shapes with straight edges and right angles. Eyelid edema is frequently seen when the allergen is innocently transferred from finger to lid. Affected areas are typically severely pruritic. Contact dermatitis can be found at any body location.

When the dermatitis is chronic, thickened plaques develop and secondary bacterial infection is possible.

Diagnosis and etiology is often based upon clinical exam and history. Individual lesions have well-demarcated borders and often assume geometric shapes with straight edges and right angles. The distribution of the rash should drive the examiner's history to possible allergen exposures.

Hand dermatitis should provoke questions regarding occupation, hobbies, and habits. There are photo-dependent allergic reactions as well.

Cellulitis – Plaque margins in cellulitis are often less distinct than those of contact dermatitis. The plaques of contact dermatitis are sharply demarcated and frequently take on bizarre geometric shapes and patterns.
Erysipelas
Irritant contact dermatitis
Dyshidrotic dermatitis (dyshidrotic eczema)
Psoriasis
Lichen simplex chronicus
Scabies
Impetigo
Orf
Erysipeloid
Herpetic whitlow
Mycobacterium marinum infection
Pasteurella multocida infection
Sporotrichosis
Urticaria
Angioedema
Sweet's syndrome
Tinea corporis
Majocchi's granuloma
Herpes virus infections (herpes simplex virus or zoster with associated lymphangitic erythema)

The diagnosis can often be made with a careful history and physical examination. Conduct patch testing to verify the allergen in cases of allergic contact dermatitis. Skin biopsy will confirm the diagnosis when there is doubt.

Identify the inciting allergen, if possible. Treatment is aimed at preventing contact with the allergen and control of symptoms, including antihistamines and topical and oral corticosteroids.

Recommend the patient avoid common triggers such as fragrance, lanolin, nickel, etc, and buy recommended soaps, cleansers, and cotton gloves (as opposed to latex gloves). Do not disregard preparations that have been used for some time since over-the-counter preparations often change ingredients. Preservatives in topical corticosteroids are common contactants as can be the corticosteroid itself. Soap substitutes (eg, Cetaphil®) and emollients (Eucerin®, Aquaphor®) are often helpful to minimize irritation and soothe the affected skin.

Do NOT prescribe a 6-day course of quickly tapering steroids, such as Medrol® "Dose Pack." The delayed hypersensitivity reaction is at least a 2-week process, and shorter courses of oral steroids will result in rebound of the dermatitis.

Use high-potency topical corticosteroids on truncal and extremity skin.

High-potency topical corticosteroids (class 2):

• Fluocinonide cream, ointment (Lidex®) – apply twice daily (15, 30, 60, 120 gm)
• Desoximetasone cream, ointment (Topicort®) – apply twice daily (15, 60, 120 gm)
• Halcinonide cream, ointment (Halog®) – apply twice daily (15, 60, 240 gm)
• Amcinonide ointment (Cyclocort®) – apply twice daily (15, 30, 60 gm)

Mid-potency topical corticosteroids (class 3–4):

• Triamcinolone cream, ointment (Kenalog®, Aristocort®) – apply twice daily (15, 30, 60, 120, 240 gm)
• Mometasone cream, ointment (Elocon®) – apply twice daily (15, 45 gm)
• Fluocinolone ointment, cream (Synalar®) – apply twice daily (15, 30, 60 gm)

Use mild-potency topical steroids on thinner skin and class 6–7 steroids on the face and intertriginous areas (desonide cream, lotion, or ointment twice daily). Use steroid ointments that have fewer preservatives in them if there seems to be flaring with multiple topical medications.

Topical calcineurin inhibitors (pimecrolimus 1% cream, tacrolimus 0.1% ointment) applied twice daily may be an alternative to topical corticosteroids in the treatment of the inflammatory response, if the patient tolerates them.

Antihistamines:

• Diphenhydramine hydrochloride (Benadryl®) – 25–50 mg every 6 to 8 hours as needed
• Hydroxyzine (Atarax®) – 25 mg every 6 hours as needed
• Cetirizine hydrochloride (ZYRTEC®) – 5–10 mg daily
• Loratadine (Claritin®) – one 10 mg tablet or RediTab® daily

In severe cases involving large body areas, use a 14-day course of oral prednisone 0.5 mg/kg each morning and taper only slightly during the interval. For example, start at 40 mg/day and taper by 10 mg every 3 days to 0 mg.

Antibiotics may be indicated when there is evidence of impetiginization. Topical mupirocin or an oral cephalosporin (eg, cephalexin) or penicillinase-resistant penicillin (eg, dicloxacillin) will often suffice.

Treatment with PUVA/UVB or certain immune-modulating drugs (azathioprine, cyclosporine, methotrexate) has also been tried.

Fleischer AB. Diagnosis and management of common dermatoses in children: atopic, seborrheic, and contact dermatitis. Clin Pediatr (Phila). 2008 May;47(4):332-46. PubMed Id: 18057146

Martellotta D, Di Costanzo L, Cafiero M, La Bella S, Balato A. Contact allergy to p-tert-butylphenol formaldehyde resin and zinc diethyldithiocarbamate in a wet suit. Dermatitis. 2008 Mar-Apr;19(2):E3-4. PubMed Id: 18413101

Cohen DE, Jacob SE. Allergic Contact Dermatitis. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick's Dermatology in General Medicine. 7th ed. New York, NY: McGraw-Hill; 2008:135-146.

American Academy of Allergy, Asthma and Immunology, American College of Allergy, Asthma and Immunology. Contact dermatitis: a practice parameter. Ann Allergy Asthma Immunol. 2006 Sep;97(3 Suppl 2):S1-38. PubMed Id: 17039663

James WD, Berger TG, Elston DM. Contact Dermatitis and drug eruptions. In: James WD, Berger TG, Elston DM, Odom RB, eds. Andrews' Diseases of the Skin: Clinical Dermatology. 10th ed. Philadelphia, PA: Saunders Elsevier; 2006:91-115.

Belsito DV. Occupational contact dermatitis: etiology, prevalence, and resultant impairment/disability. J Am Acad Dermatol. 2005 Aug;53(2):303-13. PubMed Id: 16021126

Krob HA, Fleischer AB, D'Agostino R, Haverstock CL, Feldman S. Prevalence and relevance of contact dermatitis allergens: a meta-analysis of 15 years of published T.R.U.E. test data. J Am Acad Dermatol. 2004 Sep;51(3):349-53. PubMed Id: 15337975

Gudi VS, White MI, Ormerod AD. Allergic contact dermatitis from dibutylthiourea in a wet suit. Dermatitis. 2004 Mar;15(1):55-6. PubMed Id: 15573652

Cohen DE, Heidary N. Treatment of irritant and allergic contact dermatitis. Dermatol Ther. 2004;17(4):334-40. PubMed Id: 15327479

Vaswani SK, Collins DD, Pass CJ. Severe allergic contact eyelid dermatitis caused by swimming goggles. Ann Allergy Asthma Immunol. 2003 Jun;90(6):672-3. PubMed Id: 12839329

Belsito DV. The diagnostic evaluation, treatment, and prevention of allergic contact dermatitis in the new millennium. J Allergy Clin Immunol. 2000 Mar;105(3):409-20. PubMed Id: 10719287

Corazza M, Virgili A. Allergic contact dermatitis due to nickel in a neoprene wetsuit. Contact Dermatitis. 1998 Nov;39(5):257. PubMed Id: 9840264

Azurdia RM, King CM. Allergic contact dermatitis due to phenol-formaldehyde resin and benzoyl peroxide in swimming goggles. Contact Dermatitis. 1998 Apr;38(4):234-5. PubMed Id: 9565314

Drake LA, Dorner W, Goltz RW, Graham GF, Lewis CW, Pariser DM, Salasche SJ, Skouge JW, Turner ML, Lowery BJ, et al. Guidelines of care for contact dermatitis. Committee on Guidelines of Care. J Am Acad Dermatol. 1995 Jan;32(1):109-13. PubMed Id: 7822498

Appearance
No Acute Distress

Body Location
Abdomen
Anterior Lower Leg
Arm
Axilla
Buttocks
Cheek
Chin
Corona
Crural or Inguinal Fold
Dorsum of Foot
Dorsum of Hand
Ear
Eyelids
Face
Female Genital
Fingers
Foot (Feet) or Toes
Foreskin
Frontal Scalp
Glans of Penis
Hand or Fingers
Inferior Eyelid
Inferior Lip
Labia Majora
Lateral Neck
Leg
Lips
Lower Leg
Neck
Nose
Occipital Scalp
Palm
Penis
Periungual Fingers
Periungual Toes
Plantar Foot (Sole)
Post Auricular Scalp
Scalp
Scrotum
Shaft of Penis
Shoulder
Superior Eyelid
Superior Lip
Suprapubic/Mons Pubis
Trunk
Web Spaces of Fingers
Wrist

Configuration
Geometric
Round

Distribution
All Fingernails or Distal Fingers
Bilateral
Bite or Trauma Site
Diaper Area
Extensor
Genitals, Buttocks, Perineum
Intertriginous
Scattered Haphazard
Scattered Nails or Distal Digits
Unilateral
Widespread Male Genital

Exposures
Acrylates
Artificial Nails
Condom Use
Cosmetics
Fragrance Containing Skin Care Products
Jewelry
Lanolin Containing Skin Care Products
Metal Compounds
Nail Polish
Preservative Containing Skin Care Products
Rubber Gloves
Soaps or Detergents
Water

Lesion
Blanching Patch
Erythema and Edema
Eyelid Edema
Onycholysis - Lifting Nail
Penile Edema
Plaque
Scale Fine
Scaly Papule
Scaly Plaque
Scrotal Edema
Tense Bullae
Tense Vesicle
Transverse Lines
Vesicle

Medications
5-Aminolaevulinic Acid Methyl Ester
Acetaminophen
Albendazole
Alprazolam
Aminocaproic Acid
Amyl Nitrite
Apraclonidine
Ascorbic Acid
Atropine Sulfate
Auranofin
Azithromycin
Bacitracin
Benzocaine
Betaxolol
Buspirone
Calcipotriene
Carmustine
Carteolol
Celestone Chronodose
Chloramphenicol
Chlorhexidine
Clemastine
Clonidine
Clotrimazole
Cloxacillin
Cromolyn
Cyanocobalamin
Cyproheptadine
Diclofenac
Dimenhydrinate
Diphenhydramine
Dorzolamide
Doxepin
Estradiol
Fluorouracil
Flurbiprofen
Furazolidone
Gentamicin
Gold & Gold Compounds
Kanamycin
Ketoconazole
Ketotifen
Latanoprost
Levobunolol
Lidocaine + Prilocaine
Meropenem
Metipranolol
Metronidazole
Minoxidil
Neomycin
Nicotine
Nitroglycerin
Penicillamine
Pentazocine
Phenoxybenzamine
Phenylephrine
Praziquantel
Prednisolone
Promethazine
Propantheline
Quinine
Scopolamine
Spectinomycin
Succinylcholine
Terbinafine
Testosterone
Tetracycline
Thiabendazole
Timolol
Tiopronin
Tobramycin
Tolazoline
Trientine
Vitamin A
Vitamin E

Occupations
Baker
Bartender
Building Industry
Construction Worker
Cosmetologist
Dishwasher
Dye Worker
Florist
Food Production or Service
Health Care Worker (Medical)
Janitor
Laboratory Worker or Researcher
Military
Oil Industry
Painter
Photographic Processing Worker
Rubber Worker
Tanning Leather Worker

Signs and Symptoms
No Fever (Afebrile, Apyrexial)
Pruritus (Itching)

Social History
Elementary School (K-5)
Middle/High School (6-12)
Scuba Diving/Snorkeling/Ocean Swimming
Swimmer

Temporal
Developed Acutely Over Days to Weeks
Eruption 0 to 5 Days After Drug

Medical History
Paronychia