Contact Dermatitis (CD)
(Figure 3.13A-B, Tables 3-5 to 3-8) - Acute or chronic inflammatory reaction to a substance in contact with the skin; divided into irritant and allergic CD
- Irritant contact dermatitis (ICD)
- Accounts for 80% of CD
- Due to direct local cytotoxic effect of irritant on skin
- Acute ICD: acute exposure to toxic agent; presents with pruritus and sharply localized erythema with vesicles, edematous papules or hemorrhagic blisters, ± scaling or crusting; no distant spread
- Chronic ICD: repeated exposure to mild irritants (low-grade irritation); presents with diffuse or localized but ill-defined scaly patches and plaques
- Allergic contact dermatitis (ACD)
- Accounts for 20% of all CD
- Type IV delayed hypersensitivity to contactant (to which already sensitized), onset may be delayed as long as 24–96 h after allergen exposure
- Nickel and poison ivy (urushiol) most common causes of ACD
- Patch testing (Figure 3.13C) is the gold standard for diagnosing ACD; grading system:
| | | | | Reaction | | Description | | + | | Weak reaction with erythema, infiltration, ± papules | | ++ | | Strong reaction: vesicles, erythema, infiltration, papules | | +++ | | Spreading bullous reaction |
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- Poral reaction: non-allergic reaction due to cobalt residing in acrosyringium
- Acute ACD: typically presents 24–48 h after exposure and presents with pruritus, vesicles, weeping and erythema, ± dissemination of lesions
- Subacute ACD: presents with eczematous scaly plaques or lichenification correlating to areas of contact with allergen
- Histology: spongiosis, intraepidermal vesicles and superficial perivascular infiltrate in acute setting; acanthosis, hyperkeratosis and mild superficial infiltrate in chronic setting
- Treatment: avoid exposure irritants/allergens; topical corticosteroid, patch testing (for ACD), if severe may use short-term systemic corticosteroid
| | | | | Factors | | ACD | | ICD | | Previous exposure required | | Yes | | No | | Immunologic reaction | | Yes | | No | | Distant spread | | Yes | | No | | Dose-related response | | No | | Yes | | Similar reaction in others w/ exposure | | No | | Yes |
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| | Figure 3.13 A: Allergic contact dermatitis (Courtesy of Dr. Paul Getz) B: Subacute contact dermatitis C: Patch testing, 2+ reaction (Courtesy of Dr. Sophie M. Worobec) |
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| | | | Table 3-5 Contact Allergens | Formaldehyde-Releasing Preservatives | | Quaternium-15 | | Most common cosmetic preservative to cause ACD; personal care products | | 2-Bromo-2-nitropropane-1,3-diol (Bronopol) | | Formaldehyde-releasing preservative in personal care products and variety of industrial applications | | Diazolidinyl urea (Germall II) | | Formaldehyde-releasing preservative; personal care products (especially bubble baths, baby wipes and household detergents) | | Imidazolidinyl urea (Germall 115) | | Formaldehyde-releasing antimicrobial preservative used in cosmetics | | DMDM hydantoin | | Formaldehyde-releasing antimicrobial preservative used in cosmetics like shampoo, hair conditioners and skin care products | Rubber accelerators | | Thiuram | | Rubber in shoes, rubber gloves, elastic, fungicides, paints, barrier contraceptives
{Thiuram cross reacts w/ disulfiram} | | Mercaptobenzothiazole (MBT) | | Most common cause of allergic shoe dermatitis | | | Rubber products, tires, antifreeze, anticorrosive agents, cutting oils, electrical cords, fungicides, rubber shoes (sneakers, tennis shoes, etc.) | | Carba mix | | Leather shoes, tires, fungicides, cosmetic applicators, gloves, adhesives, elastic, barrier contraceptives; may cross react with thiuram derivatives
{Repeated washing of elastic (ie. undergarments) with hypochlorite (bleach) causes elastic to become more allergenic (due to ↑ availability of carbamates), which may result in ‘elastic dermatitis’ or ‘bleached rubber syndrome’ (but patch test negative for rubber accelerators)} | | Mercapto mix | | Tires, elastic, rubber gloves, electrical cords, rubber soles of shoes, etc. | | Black rubber mix | | Heavy-use rubber products such as tires, hoses, cables and belts | | Mixed dialkyl thioureas | | Neoprene rubber (wetsuit), goggles, elastic, paint remover, shoe insoles | Textiles | | Disperse blue 106 | | Clothing dye (bed linens, blue dye, clothing, tights, garment lining) | | Ethylene urea melamine formaldehyde mix | | Permanent press clothing (wrinkle-resistant)
{Textile dermatitis typically occurs where clothing fits tightly (posterior neck, upper back, lateral thorax, axillae, waistband, flexor surfaces); ± purpuric contact dermatitis} | Adhesives | | Epoxy resin (bisphenol A) | | Glues, plastics, electrical insulation, paint and primer | | Colophony (rosin, abietic acid) | | Paper, cosmetics, paint, adhesives, waxes, chewing gum, used in baseball/ ballet/musical instruments to ↑ friction | | Cyanoacrylate (methyl or ethyl) | | Fast-acting adhesive (Super or Krazy Glue), liquid bandages, Dermabond | | Ethyl acrylate | | Artificial nail (adhesive) | | Methacrylate (methyl or ethyl) | | Adhesive, artificial nails, dental fillings/sealants, hearing aids, hard contact lenses, glue (bone cement) for artificial joints, acrylic denture material
{May diffuse through intact surgical glove and cause paresthesias (i.e. most commonly seen in either dentist or orthopedic surgeon)} | | p-tert-butylphenol formaldehyde resin | | Leather/rubber adhesive | Sunscreen components | | Benzophenone-3 | | Sunscreens, rubber products, cosmetics | | PABA (Padimate O) | | Sunscreen (UVB)
{PABA ± cross react w/ sulfonamides, azo dyes, benzocaine, PPD} | | Oxybenzone | | Sunscreen (UVA)
{Oxybenzone: most common sunscreen agent to cause photoallergic contact dermatitis} | Corticosteroids | | Tixocortol-21-pivalate | | Group A (hydrocortisone acetate, prednisone, methylprednisolone) | | Budesonide | | Group B (triamcinolone acetonide, desonide, fluocinolone acetonide, fluocinonide, halcinonide)
{Budesonide also marker for some Gr. D steroids} | | Hydrocortisone-17-butyrate | | Group D (hydrocortisone-17-valerate/butyrate, clobetasone-17-butyrate clobetasol proprionate, betamethasone valerate/diproprionate) | Hair preparations | | Paraphenylenediamine (PPD) | | Permanent hair dye, ‘black henna’ (not natural henna from plant), photographic developer, printing inks, black rubber, temporary tattoos | | | ACD typically on eyelids/ear helices/hairline or hands
{May cross react with: PABA, sulfonamides (including thiazide and furosemide), para-aminosalicylic acid, benzocaine and procaine (ester anesthetics), azo dyes (temporary/semi-permanent hair dye, pen ink, coloring agent)} | | Monothioglycolate | | Permanent wave preparations; typically in glycerol monothioglycolate | | Ammonium persulfate | | Hair bleach, bleaching agent in flour | Others | | Bacitracin | | Topical antibiotic ointment, otic and ophthalmic preparations | | Balsam of Peru | | Naturally occurring fragrance material, found in topical medications | | Benzalkonium chloride | | Skin disinfectant (ophthalmic solutions), cosmetics | | Benzocaine, tetracaine | | Local anesthetic (ester)
{May cross-react with PABA, PPD, and sulfonamides} | | Cobalt | | Added to other metals to ↑ hardness; found in jewelry, buttons, cosmetics, hair dye, joint replacements, ceramics, enamel, cement, paint, and pottery | | Cocamidopropyl betaine | | Hair and bath products like shampoo (surfactant) | | Ethylenediamine | | Medical creams, antifreeze, paint
{Cross-reacts with hydroxyzine and aminophylline} | | Euxyl K400 | | Cosmetic and household products (preservative) | | Fragrance mix | | Several components (cinnamic aldehyde), detects 70% fragrance allergies | | Formaldehyde | | Textile resins (wrinkle-free clothing), cosmetics, tissue fixative, embalming solution, paints, disinfectants, and medications | | Gold | | Jewelry, dentistry, electronics, treatment of certain diseases (RA, SLE, etc.) | | Glutaraldehyde | | Cold sterilization (medical/dental equipment), disinfectant, tan shoe leather | | Lanolin (wool alcohol) | | Cosmetics and some topical creams | | Methylchloroisothiazolinone (Kathon CG) | | Preservative in cosmetics and shampoos (antibacterial properties) | | Neomycin sulfate | | Antibiotic ointment, hemorrhoidal cream, otic and ophthalmic preparations | | | Co-sensitivity often between neomycin and bacitracin | | Nickel sulfate | | Costume jewelry, buckles, and snaps; dimethylglyoxime test detects nickel (positive if turns pink); ± co-sensitivity seen with nickel and cobalt | | Paraben mix | | Cosmetics, topical medications, food, textiles, antiperspirants | | Potassium dichromate | | Cement, leather (footwear), plaster, wood finishes, green felt of card tables | | Propylene glycol | | Cosmetics, topical medications (vehicle), antifreeze | | Thimerosal | | Preservative in contact lens solution, vaccines, otic/ophthalmic solution, antiseptic
{↑ photosensitivity with piroxicam if patient with positive reaction to thimerosal} | | Tocopherol acetate | | Vitamin E | | Toluene sulfonamide
{Also known as tosylamide sulfonamide formaldehyde resin} | | Nail polish (typically appears as eyelid dermatitis or periungual dermatitis) | | | | |
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| | | | Table 3-6 Plant Allergens | | Allergen | | Plant (Common Name) | | Scientific Name | | Urushiol (includes pentadecacatechol in oleoresin) | | Poison ivy, poison sumac, poison oak
{May cross react with Japanese lacquer tree (sap), cashew tree, mango tree, Indian marking nut (black juice), Brazilian Pepper tree (sap), gingko (seed pulp)} | | Family: Anacardiaceae | | | | Genus: Toxicodendron; Species: Rhus | | Sesquiterpene lactone | | Chrysanthemum, ragweed, sunflower, artichoke, arnica, daisy, marigold, arnica
{Dermatitis may be airborne (face, neck) or direct contact (hands)} | | Family: Asteraceae or Compositae
{May cross react with permethrin} | | Primin | | Primrose | | Family: Primulaceae | | | | | Species: Primula obconica | | Diallyl disulfide, allylpropyl disulfide | | Garlic, onion, chives | | Family: Alliaceae | | | | Genus: Allium | | Allicin | | Garlic, onion, chives | | Family: Alliaceae | | | | Genus: Allium | | Tuliposide A | | Peruvian lily | | Family: Alstroemeriaceae | | | Tulip, hyacinth | | Family: Liliaceae | | d -Usnic acid | | Lichens | | Several genera including Parmelia | | Colophony (Abietic acid, rosin) | | Pine tree (resin) | | Family: Pinaceae | | | | Species: Pinus species | | Tea tree oil (Limonene) | | Ti or tea tree | | Family: Myrtaceae | | | | Species: Melaleuca alternifolia | | 3-carene | | Turpentine | | Family: Pinaceae | | | | | | |
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| | | | Table 3-7 Plant Irritants (ICD) | | Irritant | | Plant | | Bromelin | | Pineapple (Ananas comosus) | | Calcium oxalate | | Dumb cane (Araceae), daffodils (Narcissus spp.), hyacinth (Liliaceae), pineapple | | Phorbol esters (in milky latex) | | Poinsettias, spurges, crotons (Euphorbiaceae)
{May cause temporary blindness if latex contacts eye} | | Capsaicin | | Chili peppers (Solanaceae) | | Thiocyanates (Allyl isothiocyanate) | | Garlic (Alliaceae) | | | Black mustard and radish (Brassicaceae) | | Protoanemonin (Ranunculin) | | Buttercups (Ranunculaceae)
{Causes intense linear vesiculation} {Ranunculin converts to protoanemonin after plant injury} | | | | |
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| | | | Table 3-8 Pigment Reactions from Tattoos | | Tattoo Color | | Chemical | | Black | | Carbon, iron oxide | | Blue | | Cobalt | | Brown | | Ferric oxide | | Green | | Chromic oxide | | Purple | | Manganese | | Red | | Cinnabar (mercury sulfide), cadmium red | | White | | Titanium dioxide | | Yellow | | Cadmium sulfide | | | | | | | | | | | | | | | | | | | Most common allergic reaction seen from red tattoo pigment | | | | | | | |
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