Contact Dermatitis

By admin On Nov 18, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Contact Dermatitis

Jennifer J. Mitchell

Kirk Tiemann

Basics

Allergic contact dermatitis (ACD)
Irritant contact dermatitis (ICD): Causes about 80% of contact dermatitis

Description

ACD:
- Delayed cell-mediated hypersensitivity reaction
- Requires previous exposure and sensitization
- Indirect exposure to allergen from pet, clothing, smoke, dust
- Cross-sensitization when exposed to chemically related antigen
- Entire skin becomes hypersensitive to the contact allergen
- Pruritic erythematous lesions usually rapid but can be delayed for days following exposure and may appear to spread over time
ICD:
- Inflammatory response to contact with irritant (chemical and physical)
- Requires no previous exposure
- Direct injury to skin usually limited to the site of contact
- Erythematous lesions may occur minutes to days from exposure.

Epidemiology

Predominant age:
- All ages
- Extremes of age less likely to sensitize to plants.
Pediatric considerations:
- ACD less frequent in young children than adults
- Major sources of pediatric contact allergy:
  - Metals (nickel most common)
  - Shoes
  - Preservatives
  - Fragrances
  - Topical medications
  - Plants

Risk Factors

Increased activities related to contact or exposure to irritant or allergen
Common sports-related contact dermatitis (1):
- Baseball: Friction and/or moisture with clothing and gear
- Basketball: “Pebble fingers” associated with ball surface
- Canyoning: “Canyoning hand”:
  - ICD
  - Irritation of hands from cold water and rock abrasions
- Cycling: Friction or moisture with clothing and gear
- Fishing:
  - Epoxy or resin in rod
  - Fish bait
  - Nickel
- Football:
  - Moisture
  - Friction
  - Adhesives and athletic tape
  - Chemicals associated with equipment
- Golf: Chemicals in glove, club grip
- Hockey:
  - Gloves
  - Epoxy or resin in equipment
  - Moisture with clothing and gear (“gonk”)
- Running:
  - Friction or moisture with clothing and gear
  - Shoe dermatitis associated with synthetic rubber, glues, dyes in athletic shoes
- Skiing:
  - Clothing
  - Epoxy or resin
  - Metals: Nickel, cobalt
  - Formaldehyde
- Soccer:
  - Friction or moisture with gear
  - Resin in shin guards
  - “Cement burns” associated with alkaline lime of field markings
- Swimming/snorkeling/diving:
  - Brominated pool water
  - Formaldehyde or synthetic rubber compounds in goggles, head caps, and wet suits
  - Larvae of parasitic flatworm schistosomes from snails; “swimmer's itch”
  - Red coral
  - Seawater
  - Seaweed
- Tennis: “Tennis player's thigh”:
  - Friction or moisture with clothing
  - Epoxy or resin in equipment
- Weightlifting:
  - Chalk
  - Gloves
  - Metal: Nickel/chromium in weights/bar
- Disabled athletes (2): Prosthetic equipment, including:
  - Epoxy resin
  - Friction
  - Formaldehyde
  - Moisture
  - Plastic
  - Synthetic rubber
  - Clothing and gear

General Prevention

Avoidance of irritants or causative agents (3):

ACD prevention:
- No good-quality studies
- Toxicodendron (Rhus): Severity reduced or prevention: Quaternium-18-bentonite (organoclay) lotion
- Nickel, cobalt, copper prevention and reduction of reaction: Diethylenetriamine pentaacetic acid
ICD prevention: Good evidence from good-quality studies:
- Barrier creams
- Moisturizing creams, high-lipid content
- Fabric softeners
- Cotton glove liners (fair quality)

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Etiology

Common causes include (3,4):

Plants: Toxicodendron (formerly Rhus) genus:
- Poison ivy, most common
- Poison sumac
- Poison oak, 2 types
- Most common cause of ACD in U.S.
- More common than all other causes combined
- Allergen: Urushiol:
  - Pentadactyl catechol from plant sap
  - Cross-reaction with similar catechol derivatives in several other plants
  - Contact may be:
    - Primary with plant (leaves/roots/stems)
    - Secondary via clothing, pets, equipment
Chemicals:
- Alkaline lime for field marking (rarely used now)
- Cement
- Formaldehyde: Clothing, gear, paper products
- Fiberglass: Equipment
- Fragrances/perfumes: Cosmetics, soaps, lotions, sunscreen, insect repellant
- Glues and adhesives: Epoxy, resins, colophony (tree sap resin)
- Latex: Natural compounds; may cause immediate hypersensitivity reaction
- Mercaptobenzothiazole: Athletic shoe rubber
- Paraphenylenediamine (PPD): Dyes, henna, hair dye, neoprene
- Potassium dichromate: Leather tanning
- Preservatives:
  - Thimerosal, methylchloroisothiazolinone, parabens
  - Lotions, cosmetics, cleaning agents, moisturizers
- Soaps, strong detergents
- Solvents (eg, turpentine): Cleaning agents, polishes, waxes
- Thiuram (rubber accelerator): Black rubber, gloves, basketballs, tubing, waistbands, contraceptive devices
- Waterless hand cleaners
Metals:
- Chromium: Cement, pigments in tattoos, vitamins, chrome-covered metals/equipment
- Cobalt: Buckles, snaps, dental amalgams, jewelry
- Copper: Jewelry, equipment, IUD
- Gold: Jewelry, some liqueurs, some food items
- Mercury: Organic forms, dental amalgams
- Nickel:
  - Most common cause of metal dermatitis
  - Snaps, clips, jewelry, earrings
Topical medications:
- Merthiolate: Preservative in topical medications
- Topical antibiotics: Neomycin, bacitracin, polymyxin
- Topical anesthetic:
  - Ester class (benzocaine, tetracaine)
  - Amide class (lidocaine, dibucaine), less frequent
Shoe dermatitis:
- Allergic or irritant
- Dorsal aspect of foot, sparing interdigit spaces
- Chemicals/dyes from processing of leather, adhesives, or rubber compounds
Photocontact dermatitis:
- Inflammatory reaction from exposure to an irritant
- Frequently plant sap or photoallergic drug and sunlight

Diagnosis

Typically made from history and physical exam
Often difficult to distinguish between ACD and ICD

History

Lesion characteristics: Vesicles, pruritus, rash (5)[B]
Date of onset
Time course
Treatment
Possible exposure to irritating substance:
- Acute or chronic
- New skin products: Cosmetics, sunscreen, soaps, perfumes, hygiene products
- New equipment use: Braces, clothing, shoes
- New jewelry, body piercing
Recent use of medications:
- Topical
- Systemic
- Recent travel: Camping, hiking, mountain biking
- Recent change in environment: Running, hiking, snorkeling
- Recent change in occupation
- Keep in mind cross-sensitization: Reaction to different allergen with similar properties

Physical Exam

Acute lesions:
- Erythematous rash
- Fever
- Edema
- Pruritus
- Stinging
- Pain
- Papules
- Vesicles
- Erosions
- Serous drainage
Subacute lesions:
- Erythema
- Pruritus
- Scaling
- Firm papules
Chronic lesions:
- Erythema
- Scaling
- Firm papules
- Excoriations
- Plaques of lichenification
- Pigmentation changes
Appearance of lesions:
- Borders of lesions: Sharp demarcated, linear when caused by rubbing against plant
- Edema
- Erythema and rubor associated with secondary infection
- Vesicles may coalesce into bullae, rupture, or ooze.
- Lichenification/scaling/fissures in chronic exposure

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Common clues to causative agents associated with distribution:
- Head: Hair dyes, shampoos, sunscreen, cosmetics, body piercing, jewelry, medications, swim caps, headgear
- Oral mucosa: Piercing, dental appliances
- Neck: Perfumes, cosmetics, jewelry, clothing
- Torso: Clothing, elastic in bra line or waistline
- Extremities: Environmental exposure, insect repellant, metal in rings or watches, pocketed items (coins, keys) in striking area of thighs, shoe components, sunscreen

Diagnostic Tests & Interpretation

Diagnosis based on history and physical findings; no specific acute testing helpful (6)[A]
Potassium hydroxide slide: Rule out possible fungal causes.
Patch testing: Placement of known concentrations of common antigens on the skin to help identify responsible causes
Serum IgE: Radioallergosorbent test (RAST) helps to identify specific causes; safer than patch test because performed with blood in lab
Skin prick: Small quantities of antigen (eg, latex) introduced into skin via small needle

Differential Diagnosis

Atopic dermatitis: Associated family history of atopy, scaly eczematous lesion
Bullous pemphigoid: Diffuse bullous lesions
Cellulitis: Warm, blanching, painful lesion
Erythrasma: Pink patches may turn brown and scale, red fluorescence with Wood's lamp
Herpes simplex: Groups of vesicles, painful, burning lesions
Herpes zoster: Painful vesicular lesions following dermatome
Impetigo: Yellow crusting lesions
Infectious eczematous dermatitis: Usually associated with secondary bacterial infection, typically Staphylococcus aureus
Intertrigo: Dermatitis in areas where skin is in apposition
Lichen simplex: Scaly eczematous lesions
Molluscum contagiosum: Skin-colored papule with central umbilication, caused by poxvirus
Nummular dermatitis: Coinlike lesions
Pityriasis alba: Discrete asymptomatic hypopigmented lesions
Psoriasis: Silvery adherent scaling lesions, well demarcated, typically on extensor surfaces, scalp, and genital regions
Scabies: Intensely pruritic lesions, frequently interdigital or in waistband regions, associated “tracks” from mite sometimes noted
Seborrheic dermatitis: Scaly or crusting “greasy” lesions
Tinea (corpus, pedis): Maximal involvement at margins of lesion, fluoresces with Wood's lamp
Urticaria: Pruritic raised lesions (wheal) frequently with surrounding erythema (flare)

Treatment

General measures (3)[A],(7)[A]:
- Primarily directed at symptomatic relief
- Avoidance of irritants or causative agents: Wash and clean any possible irritant-containing clothing or equipment with nonallergenic cleaners.
- Protective barriers if irritant or allergen cannot be avoided
- Mild nonallergenic soap and water cleansing with cool to tepid water; avoid hot water.
- Cool, wet compresses: Especially effective during acute blistering phase
- Burrow's solution soaks
- Calamine- or oatmeal-containing creams: May soothe acute lesions
- Nonallergenic, high-lipid-content barrier moisturizing creams may be applied.
Acute treatment:
- Follow general measures plus:
  - Aseptic aspiration of larger vesicles or bullae with tops left in place may relieve discomfort.
  - Severe reaction: Systemic corticosteroids for 2–3 wks with gradual taper
- Premature termination of corticosteroid therapy may result in rapid rebound of symptoms.
Shoe dermatitis: Follow general measures plus:
- Wear open-toe, canvas, or vinyl shoes.
- Control perspiration: Change socks; use absorbent powder.

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Medication

Topical (3)[A],(7)[A]:
- Aluminum acetate (Burrow's) solution: Apply topically for 20 min t.i.d. until skin is dry.
- Calamine lotion: q.i.d. PRN
- Corticosteroid: Low- to medium-high-potency for both ACD and ICD; beneficial for:
  - Mild to moderate localized lesions
  - <20% body surface area involved
  - Avoid in thinner skin areas (eyelids, face, flexural surfaces) and prolonged use
- Hydrocortisone:
  - Forms: Cream (c)/lotion (l)/ointment (o)/solution (s)/spray (sp)
  - Low potency: Hydrocortisone acetate 0.5% (c/o) or 1% (c/o/sp) b.i.d., t.i.d., or q.i.d.
  - Medium potency:
    - Hydrocortisone butyrate 0.1% (c/o/s) b.i.d. or t.i.d.
    - Hydrocortisone valerate 2% (c/o) b.i.d. or t.i.d.
- Triamcinolone:
  - Forms: Cream (c)/lotion (l)/ointment (o)/solution (s)
  - Medium potency: Triamcinolone (Kenalog) 0.1% (c/l/o/s) b.i.d., t.i.d.
  - High potency: Triamcinolone (Kenalog) 0.5% (c/o) b.i.d., t.i.d.
  - Topical tacrolimus 0.03–0.1% b.i.d.
  - Effective with ACD
  - Carries a black box warning for potential risk for developing malignancies
  - Not recommended for children <2 yrs old
- Topical antibacterial ointment for secondary infections
- OTC meds:
  - No good information on efficacy
  - Examples: Mean Green hand scrub, Tecnu, Zanfel
  - Avoid benzocaine-containing products.
  - May further sensitize skin
Systemic:
- Antihistamine (H₁-receptor antagonist, 1st and 2nd generation)
- Diphenhydramine hydrochloride:
  - Adult: 12.5–50 mg PO/IM q6h PRN
  - Children: 5 mg/kg/24 hr divided q6h PRN
- Hydroxyzine hydrochloride:
  - Adult: 25–50 mg PO/IM up to q.i.d. PRN
  - Children: 2 mg/kg/24 hr PO divided q.i.d. or 0.5 mg/kg IM q4–6h PRN
- Loratadine:
  - Adult and children >6 yrs of age: 10 mg PO daily
  - Children ages 2–5 yrs: 5 mg PO daily
- Cetirizine:
  - Adult and children >6 yrs of age: 5–10 mg PO daily
  - Children ages 2–5 yrs: 2.5 mg PO daily b.i.d.
- Fexofenadine:
  - Adult and children >12 yrs of age: 60 mg PO b.i.d. or 180 mg PO daily
  - Children ages 6–12 yrs: 30 mg PO b.i.d.
- Corticosteroids useful in extensive lesions, >20% body surface area: Oral adult dose 0.5–2 mg/kg, depending on severity, daily ×5–7 days, tapered by 50% over next 5–7 days, tapered thereafter depending on severity and duration
- Methylpreclnisolone:
  - Solu-Medrol: Dose varies 4–48 mg PO daily.
  - Medrol Dosepack: Taper from 24 mg over 6 days.
- Prednisone: Dose varies 5–60 mg PO daily.
- Sterapred 5-mg tablets: Taper 30–5 mg over 6 days.
- Sterapred DS 10-mg tablets: Taper 60–10 mg over 6 days.
- Oral pediatric dose 0.04–1 mg/kg/24 hr, depending on severity, divided b.i.d. or t.i.d.
- Orapred: Suspension 5 mg/5 mL, 15 mg/5 mL; orally disintegrating tablets 10, 15, 30 mg
- Oral antibiotics for secondary infections against Staphylococcus or β-hemolytic Streptococcus bacterial infections until culture results obtained

Ongoing Care

Return to play:

Athlete stable with symptomatic relief
Dressing may be applied:
- Reduce irritation, if needed.
- May be required for aesthetics
Contagious causes for lesion ruled out
If contagious agent suspected:
- Prompt treatment
- Isolation from skin contact to inhibit spread to others

References

1. Kockentiet B, Adams BB. Contact dermatitis in athletes. J Am Acad Dermatol. 2007.

2. Meulenbelt H, Geertzen J, Dijkstra P, et al. Skin problems in lower limb amputees: an overview by case reports. J Eur Acad Dermatol Venereol. 2007;21:147–155.

3. Saary J, Qureshi R, Palda V, et al. A systematic review of contact dermatitis treatment and prevention. J Am Acad Dermatol. 2005;53:845.

4. Mark BJ, Slavin RG. Allergic contact dermatitis. Med Clin North Am. 2006;90:169–185.

5. Slodownik D, Lee A, Nixon R. Irritant contact dermatitis: A review. Australas J Dermatol. 2008;49:1–11.

6. Bourke J, Coulson I, English J. Guidelines for the management of contact dermatitis: an update. Br J Dermatol. 2009.

7. Beltrani VS, Bernstein IL, Cohen DE, et al. Contact dermatitis: a practice parameter. Ann Allergy Asthma Immunol. 2006;97:S1–S38.

Codes

ICD9

692.0 Contact dermatitis and other eczema due to detergents
692.1 Contact dermatitis and other eczema due to oils and greases
692.9 Contact dermatitis and other eczema, unspecified cause