contact dermatitis

CONTACT CONTACT CONTACT CONTACT CONTACT CONTACT CONTACT CONTACT DERMATITISDERMATITISDERMATITISDERMATITISDERMATITISDERMATITISDERMATITISDERMATITISDERMATITISDERMATITISDERMATITISDERMATITISDERMATITISDERMATITISDERMATITISDERMATITIS

CHULEEPORN KONGMEESOOK ,MDCHULEEPORN KONGMEESOOK ,MD

Outline Outline

�� EpidemiologyEpidemiology

� PathophysiologyPathophysiology� PathophysiologyPathophysiology

��Clinical evaluationClinical evaluation

��TreatmentTreatment

IntroductionIntroduction

�� Common inflammatory skin diseaseCommon inflammatory skin disease

�� Occurs after direct or indirect contact with Occurs after direct or indirect contact with �� Occurs after direct or indirect contact with Occurs after direct or indirect contact with substancessubstances

�� Major cause of occupational skin diseaseMajor cause of occupational skin disease

Middleton's Middleton's allergy:principlesallergy:principles and practice and practice 88th edition; th edition; 20132013

ClassificationClassification

�� Allergic contact dermatitisAllergic contact dermatitis

�� Inflammation caused by allergen specific Inflammation caused by allergen specific T lymphocytesT lymphocytes

�� Prior sensitization necessaryPrior sensitization necessary

�� Irritant contact dermatitisIrritant contact dermatitis

�� Prolonged and repeated exposure to Prolonged and repeated exposure to irritantsirritants

�� Prior sensitization not necessaryPrior sensitization not necessarywww.worldallergy.orgwww.worldallergy.org

EpidemiologyEpidemiology

�� In USA In USA

�� Overall prevalence Overall prevalence 2424,,400 400 //100100,,000 000 peoplepeople

�� Cohort populationCohort population--based studies in Europebased studies in Europe

�� Prevalence Prevalence 00..77% % -- 1818..66% for ACD% for ACD

�� Incidence of OCD in other countries Incidence of OCD in other countries 11..3 3 --19 19 cases per cases per 1010,,000000

Luz S. Luz S. FonacierFonacier et al et al J Allergy Clin Immunol 2010;125:138J Allergy Clin Immunol 2010;125:138--4949

Histology Histology

�� Epidermal changes of Epidermal changes of spongiosisspongiosis

�� Dense lymphocytic Dense lymphocytic infiltrate in upper infiltrate in upper infiltrate in upper infiltrate in upper dermisdermis

�� Epidermal Epidermal exocytosisexocytosisof lymphocytesof lymphocytes

Middleton's Middleton's allergy:principlesallergy:principles and practice and practice 88th editionth edition

Differentiation between ICD and ACDDifferentiation between ICD and ACD

Luz S. Luz S. FonacierFonacier et al et al J Allergy Clin Immunol J Allergy Clin Immunol 20102010;;125125::138138--4949

PathophysiologyPathophysiology 11�� ACD ACD

�� Prototype of type IV cellPrototype of type IV cell--mediated mediated hypersensitivity reactionhypersensitivity reaction

�� ICD ICD �� ICD ICD

�� NonimmunologicNonimmunologic, , multifactorialmultifactorial, direct , direct tissue reactiontissue reaction

�� T cells activated by T cells activated by nonimmunenonimmune, irritant, , irritant, or innate mechanisms release or innate mechanisms release proinflammatoryproinflammatory cytokinescytokines

�� DoseDose--dependent inflammation dependent inflammation Luz S. Luz S. FonacierFonacier et al et al J Allergy Clin Immunol J Allergy Clin Immunol 20102010;;125125::138138--4949

PathophysiologyPathophysiology 22

�� ACD and ICD frequently overlap because ACD and ICD frequently overlap because

many allergens at high enough many allergens at high enough centrationscentrations

can also act as irritantscan also act as irritantscan also act as irritantscan also act as irritants


VocansonVocanson et al. et al et al. et al J J Allergy Allergy 20092009; ; 6464: : 16991699––1714 1714

Clinical evaluationClinical evaluation

�� Diagnosis of ACD suspected from clinical Diagnosis of ACD suspected from clinical

presentation and possible exposure to presentation and possible exposure to

contact allergencontact allergencontact allergencontact allergen


www.uptodate.comwww.uptodate.com

Pristine W. Lee et al Current Opinion in Pediatrics Pristine W. Lee et al Current Opinion in Pediatrics 20092009; ; 2121::491491––498498

Clinical presentationsClinical presentations

�� Allergic contact dermatitisAllergic contact dermatitis


Clinical presentationsClinical presentations

�� Irritant contact dermatitisIrritant contact dermatitis


Investigation : Patch testing Investigation : Patch testing 11

�� Indicated in patients with chronic, Indicated in patients with chronic, pruriticpruriticeczematous or eczematous or lichenifiedlichenified dermatitis in whom dermatitis in whom ACD is suspectedACD is suspected

�� Affected by Affected by �� Affected by Affected by

�� Oral corticosteroid [>Oral corticosteroid [>20 20 mg of mg of prednisoloneprednisolone/day or /day or equivalent] equivalent]

�� Cancer chemotherapy or immunosuppressive drug Cancer chemotherapy or immunosuppressive drug

�� Topical corticosteroid should be discontinued for Topical corticosteroid should be discontinued for 55--7 7 days before patch testingdays before patch testing

�� Not affected by antihistaminesNot affected by antihistamines



�� Sources of allergensSources of allergens

T.R.U.E. TEST : Not US FDA approved T.R.U.E. TEST : Not US FDA approved but recommended by CD expertsbut recommended by CD experts



�� Numbers of allergensNumbers of allergens

�� Ideal number remains controversialIdeal number remains controversial

�� T.R.U.E. Test contains T.R.U.E. Test contains 29 29 allergensallergensT.R.U.E. Test contains T.R.U.E. Test contains 29 29 allergensallergens

�� Higher falseHigher false--negative reactions to negative reactions to neomycin, neomycin, thiuramthiuram mix, balsam of Peru, mix, balsam of Peru, fragrance mix, cobalt and lanolinfragrance mix, cobalt and lanolin

�� NACDG series range from NACDG series range from 6565--70 70 allergensallergens

�� T.R.U.E test serve as screening tool in T.R.U.E test serve as screening tool in allergist practiceallergist practice


Richard P. Richard P. UsatineUsatine et al Am et al Am FamFam Physician Physician 20102010;;8282::249249--255255

Patch test techniquePatch test technique�� Applied to upper or middle back areas (Applied to upper or middle back areas (22..5 5 cm cm

lateral to lateral to midspinalmidspinal reference point) free of reference point) free of dermatitis and hairdermatitis and hair

�� Kept in place for Kept in place for 48 48 hourshours

Read Read 30 30 minutes after removal of patches minutes after removal of patches �� Read Read 30 30 minutes after removal of patches minutes after removal of patches

�� Second reading should be done Second reading should be done 3 3 to to 5 5 days after days after initial application initial application

�� Metals , topical antibiotics , topical Metals , topical antibiotics , topical orticosteroidsorticosteroids, , and PPD can elicit positive reactions after and PPD can elicit positive reactions after 7 7 daysdays

�� NonstandardizedNonstandardized patch tests tested at patch tests tested at 11::10 10 to to 11::100 100 dilutionsdilutions


Patch test techniquePatch test technique


Vincent S. Vincent S. BeltraniBeltrani et al et al Annals of Annals of Allergy, Asthma and ImmunologyAllergy, Asthma and Immunology 20062006;;9797::11--3030

www.truetest.com/global/patch

www.uptodate.comwww.uptodate.com

WareepornWareeporn DisphanuratDisphanurat J Med Assoc Thai J Med Assoc Thai 20102010; ; 93 93 (Suppl. (Suppl. 77) : S) : S77--SS1414

Investigation : ROATInvestigation : ROAT

�� Improving reliability of interpreting tests for Improving reliability of interpreting tests for leaveleave--on productson products

�� Suspected allergens are applied to Suspected allergens are applied to antecubitalantecubitalfossafossa twice daily for twice daily for 7 7 days and observed for days and observed for fossafossa twice daily for twice daily for 7 7 days and observed for days and observed for dermatitisdermatitis

�� Absence of reaction makes CD unlikelyAbsence of reaction makes CD unlikely

�� If eyelid dermatitis is considered If eyelid dermatitis is considered

�� ROAT can be performed on back of earROAT can be performed on back of ear


ROATROAT

Contact dermatitis Contact dermatitis 55th editionth edition

Systemic contact dermatitis Systemic contact dermatitis 11

�� Localized or generalized inflammatory skin Localized or generalized inflammatory skin

disease in contactdisease in contact--sensitized individuals sensitized individuals

exposed to exposed to haptenhapten orally, orally, transcutaneouslytranscutaneously, , exposed to exposed to haptenhapten orally, orally, transcutaneouslytranscutaneously, ,

intravenously or by means of inhalationintravenously or by means of inhalation


Systemic contact dermatitis Systemic contact dermatitis 22

�� CauseCause

�� Metal Metal (cobalt, copper, chromium, gold, mercury, nickel, (cobalt, copper, chromium, gold, mercury, nickel,

zinc)zinc)

�� Medications Medications corticosteroids, antihistamines corticosteroids, antihistamines �� Medications Medications corticosteroids, antihistamines corticosteroids, antihistamines

((diphenhydraminediphenhydramine, , ethylenediamineethylenediamine, , hydroxyzinehydroxyzine, , doxepindoxepin), ), miconazolemiconazole, , terbinafineterbinafine, , neomycin,gentamicinneomycin,gentamicin, , erythromycin, pseudoephedrine, erythromycin, pseudoephedrine, benzocainebenzocaine, , tetracainetetracaine, , oxycodoneoxycodone, IVIG, , IVIG, aminopenicillinsaminopenicillins, , 55--aminosalicylic acid, aminosalicylic acid, naproxen, naproxen, allopurinolallopurinol, , mitomycinmitomycin C, C, 55--FUFU

�� Herbal medicineHerbal medicine


Drug induced SCD Drug induced SCD 11

�� Symmetric drugSymmetric drug--related related intertriginousintertriginous and and

flexural exanthemaflexural exanthema


Drug induced SCD Drug induced SCD 2 2

�� Criteria for diagnosisCriteria for diagnosis

�� Exposure to systemic drug at first or repeated Exposure to systemic drug at first or repeated dosing (contact allergens excluded)dosing (contact allergens excluded)

�� ErythemaErythema of of glutealgluteal//perianalperianal area, Varea, V--shaped shaped �� ErythemaErythema of of glutealgluteal//perianalperianal area, Varea, V--shaped shaped erythemaerythema of inguinal/of inguinal/perianalperianal area, or botharea, or both

�� Involvement of at least Involvement of at least 1 1 other other intertriginousintertriginous/flexural localization/flexural localization

�� Symmetry of affected areasSymmetry of affected areas

�� Absence of systemic signs and symptomsAbsence of systemic signs and symptoms


Occupational contact dermatitisOccupational contact dermatitis

�� 4 4 of of 7 7 criteria must be positive to conclude OCDcriteria must be positive to conclude OCD

�� Clinical appearance consistent with CDClinical appearance consistent with CD

�� CutaneousCutaneous irritants or allergens present in workplaceirritants or allergens present in workplace

�� Anatomic distribution of dermatitis consistent with skin Anatomic distribution of dermatitis consistent with skin exposure to chemicals in course of various job tasksexposure to chemicals in course of various job tasksexposure to chemicals in course of various job tasksexposure to chemicals in course of various job tasks

�� Temporal relationship between exposure and onset of Temporal relationship between exposure and onset of symptoms consistent with CDsymptoms consistent with CD

�� NonoccupationalNonoccupational exposures excluded as probable causes exposures excluded as probable causes of dermatitisof dermatitis

�� Dermatitis improves away from work exposure and Dermatitis improves away from work exposure and reexposurereexposure causes exacerbationcauses exacerbation

�� There are positiveThere are positive--reaction and relevant patch tests reaction and relevant patch tests performed according to established guidelinesperformed according to established guidelines


Selected contact dermatitis : Metals Selected contact dermatitis : Metals 11

NickelNickel

�� 1818..77% positive patch test reaction to % positive patch test reaction to nickelnickel

�� Female sensitization to nickel higherFemale sensitization to nickel higher

�� 11% of nickel allergy have systemic % of nickel allergy have systemic reactions to nickel content of normal dietreactions to nickel content of normal diet


www.online.epocrates.com

www.mmc.tn.gov.inwww.mmc.tn.gov.in

www.flipper.diff.orgwww.flipper.diff.org

Selected contact dermatitis : Metals Selected contact dermatitis : Metals 22

GoldGold

�� NACDG reported that NACDG reported that 389389//41014101((99..55%) %) positive patch test reactions to goldpositive patch test reactions to gold

�� Hands (Hands (2929..66%), face with %), face with seborrheicseborrheicdistribution (distribution (1919..33%) and eyelids (%) and eyelids (77..55%)%)

�� Used for fashion appeal, antiUsed for fashion appeal, anti--inflammatory inflammatory medication, used in electroplating industry, medication, used in electroplating industry, part of dental appliancespart of dental appliances


Selected contact dermatitis : Cosmetics Selected contact dermatitis : Cosmetics 11

FragranceFragrance

�� Most common cause of ACD from Most common cause of ACD from cosmetics cosmetics

�� Positive patch test reactions in Positive patch test reactions in 1010..44% of % of �� Positive patch test reactions in Positive patch test reactions in 1010..44% of % of patientspatients

�� ‘‘Unscented’’ and ‘‘Fragrance‘‘Unscented’’ and ‘‘Fragrance--free’’free’’

�� Fragrance mix I Fragrance mix I containscontains allergensallergens foundfound1515%%--100100% of cosmetic products and % of cosmetic products and might detect ~might detect ~8585% of subjects with % of subjects with fragrance allergyfragrance allergy



Preservatives and Preservatives and excipientsexcipients

�� Lanolin Lanolin

�� Common component of consumer Common component of consumer Common component of consumer Common component of consumer productsproducts

�� Weak sensitizer on normal skin but Weak sensitizer on normal skin but stronger sensitizer on damaged skinstronger sensitizer on damaged skin

�� Stasis dermatitis, higher risk of lanolin Stasis dermatitis, higher risk of lanolin sensitivitysensitivity


Selected contact dermatitis : Cosmetics 3Selected contact dermatitis : Cosmetics 3

Preservatives and Preservatives and excipientsexcipients

�� Cosmetic preservatives Cosmetic preservatives

�� Formaldehyde releasers Formaldehyde releasers Formaldehyde releasers Formaldehyde releasers

�� NonNon––formaldehyde releasers : formaldehyde releasers : ParabenParaben



Hair productsHair products

�� PPD (PPD (ParaphenylenediamineParaphenylenediamine) )

�� Most common cause of CD in Most common cause of CD in Most common cause of CD in Most common cause of CD in hairdressershairdressers

�� PPD crossPPD cross--reacts with COXreacts with COX--2 2 inhibitor inhibitor ((celecoxibcelecoxib), sunscreens, and ), sunscreens, and antioxidants used in manufacture of antioxidants used in manufacture of rubber productsrubber products




�� CAPB ( CAPB ( CocoamidopropylCocoamidopropyl betainebetaine ))

�� AmphotericAmphoteric surfactant often found in surfactant often found in AmphotericAmphoteric surfactant often found in surfactant often found in shampoos, bath products, and eye and shampoos, bath products, and eye and facial cleanersfacial cleaners




�� Glycerol Glycerol thioglycolatethioglycolate

�� Active ingredient in permanent wave Active ingredient in permanent wave Active ingredient in permanent wave Active ingredient in permanent wave solutionsolution

�� Might remain allergenic in hair long Might remain allergenic in hair long after rinsed outafter rinsed out


Medications 1Medications 1

Antibiotics and antisepticsAntibiotics and antiseptics

�� Neomycin and Neomycin and nitrofurazonenitrofurazone potent potent sensitizerssensitizers

�� Neomycin sulfate crossNeomycin sulfate cross--sensitize with sensitize with gentamicingentamicin, , kanamycinkanamycin, streptomycin, , streptomycin, spectinomycinspectinomycin, , tobramycintobramycin and and paromomycinparomomycin


Medications Medications 22

CorticosteroidCorticosteroid

�� Patients with worsening of previous Patients with worsening of previous dermatitis or initial improvement followed dermatitis or initial improvement followed by deterioration of dermatitis after by deterioration of dermatitis after by deterioration of dermatitis after by deterioration of dermatitis after application of corticosteroids should be application of corticosteroids should be evaluated for corticosteroid allergyevaluated for corticosteroid allergy

�� CrossCross--reactivity between groups A and Dreactivity between groups A and D2 2 and groups B and Dand groups B and D2 2 has been reportedhas been reported

�� 3030% of ACD to corticosteroids be missed if % of ACD to corticosteroids be missed if delayed delayed 77--day reading not doneday reading not done


Surgical implant devices Surgical implant devices 11

�� Use of nickel in biomedical Use of nickel in biomedical devices,leddevices,led to to increasing concern about safety in increasing concern about safety in suspected nickelsuspected nickel--sensitized patientssensitized patients

No large, evidenceNo large, evidence--based guidelinesbased guidelines�� No large, evidenceNo large, evidence--based guidelinesbased guidelines


Surgical implant devices Surgical implant devices 22�� Criteria for diagnosis of Criteria for diagnosis of cutaneouscutaneous

implantimplant––induced reactioninduced reaction

�� Dermatitis (localized/generalized) Dermatitis (localized/generalized) appearing after implant surgeryappearing after implant surgery

Persistent dermatitis Persistent dermatitis ((resistant to resistant to �� Persistent dermatitis Persistent dermatitis ((resistant to resistant to appropriate therapiesappropriate therapies))

�� Positive patch test Positive patch test ((history to metallic history to metallic component of implant or to commonly component of implant or to commonly used acrylic gluesused acrylic glues))

�� Resolution of dermatitis after removal of Resolution of dermatitis after removal of implantimplant


Treatment Treatment 11

�� Allergen identification to improve contact Allergen identification to improve contact avoidanceavoidance

�� Alternatives and substitutes to cosmetics Alternatives and substitutes to cosmetics should be offered to patient to increase should be offered to patient to increase should be offered to patient to increase should be offered to patient to increase compliancecompliance

�� Supportive care and relief of Supportive care and relief of prurituspruritus

�� Excessive Excessive handwashinghandwashing and nonirritating and nonirritating or sensitizing moisturizers must be used or sensitizing moisturizers must be used after washingafter washing


Treatment Treatment 22

�� TC is firstTC is first--line treatment for ACDline treatment for ACD

�� Extensive(>Extensive(>2020% BSA) and severe CD, % BSA) and severe CD, systemic corticosteroids might offer faster systemic corticosteroids might offer faster relief (relief (1212--2424hr)hr)relief (relief (1212--2424hr)hr)

�� Recommended dose is Recommended dose is 00..5 5 to to 1 1 mg/kg daily mg/kg daily for for 5 5 to to 7 7 days, and only if patient is days, and only if patient is comfortable at that time is dose reduced by comfortable at that time is dose reduced by 5050% for next % for next 5 5 to to 7 7 daysdays

Luz S. Luz S. FonacierFonacier et al et al J Allergy Clin Immunol J Allergy Clin Immunol 20102010;;125125::138138--4949Vincent S. Vincent S. BeltraniBeltrani et al et al Annals of Annals of Allergy, Asthma and ImmunologyAllergy, Asthma and Immunology 20062006;;9797::11--3030

THANK YOUTHANK YOUTHANK YOUTHANK YOUTHANK YOUTHANK YOUTHANK YOUTHANK YOU

contact dermatitis

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