Contact Dermatitis

Contact dermatitis refers to a group of common eczematous conditions in which an inflammatory reaction in the skin is triggered by direct contact with an environmental agent. Here, we discuss the two major forms of contact dermatitis and a treatment approach.

Irritant Contact Dermatitis
Irritant contact dermatitis is the most common type (representing 80 percent of contact dermatitis) and results from a direct cytotoxic effect on the skin from an irritant chemical agent. With irritant contact dermatitis, any individual with long enough exposure to the irritant will eventually develop a reaction. The rash usually occurs within minutes, is itchy and consists of erythema (redness or rash), edema (swelling), vesicles and crusts. Common irritants include acids, alkalis and hydrocarbons. Patients with atopic dermatitis are more predisposed to develop irritant contact dermatitis because of the disturbed barrier function of the skin.

Irritant dermatitis can occur for a number of reasons and in different locations on the body. In infants, a rash can form around the mouth secondary to chronic occlusion of saliva by a pacifier against the facial skin. This type of dermatitis is generally eczematous with a fine, red scale on the perioral area (skin around the mouth) and often involving the red border. It is treated with thick emollients and behavior modification when appropriate. Likewise, “lip-licker’s” dermatitis is an irritant contact dermatitis resulting from the chronic wet-to-dry cycle caused by lip licking . Irritant dermatitis may also be seen in adults, especially those whose occupations or personal behaviors cause them to over-wash their hands.

Allergic Contact Dermatitis
Allergic contact dermatitis is a delayed hypersensitivity reaction that occurs when the skin comes in contact with a chemical (antigen) to which the individual is already sensitized. Initial sensitization takes days to weeks, but repeat exposures cause a more rapid reaction occurring within hours to days.

The acute rash is identical in form to that of irritant contact dermatitis; however, the rash of allergic contact dermatitis may also become chronic, depending on how quickly the inciting agent is identified. In chronic cases, findings are similar to those of chronic atopic dermatitis: lichenification (thickened and leathery skin), scaling and pigmentary changes. Common contact allergens include plants (poison ivy, oak and sumac), nickel, rubber, glues, dyes (often in shoes), and other chemicals found in clothing. Neomycin (topical antibiotic) is also a common sensitizer. Protein contact dermatitis is commonly seen in children; common inciting agents include latex, insects and food substances.

Rhus dermatitis (poison ivy, poison oak, poison sumac) is the most common allergic contact dermatitis in the United States. The rash consists of linear streaks of erythematous (redness or rash) papules and vesicles (see picture) that appear where the plant has brushed against the skin. Significant edema (swelling) is sometimes seen, particularly when the face or genitals are involved.

The dermatitis is produced by both direct contact with the poison sap and by indirect contact (such as with an animal or clothing that has had contact with the plant). The rash is not spread by the fluid contained within the vesicles. Antigen retained on the skin may initiate new lesions, but once on the skin for about 20 minutes, the allergen becomes fixed and cannot spread further. Thorough washing of the skin after a known exposure may decrease the amount of remaining sap and therefore reduce the severity of the eruption. Additionally, barrier creams applied prior to exposure may be protective.

Treatment
In both irritant and allergic contact dermatitis, history of an inciting agent helps to make the diagnosis; consequently, removal of the agent should result in clearing of the dermatitis. In difficult cases, patients may be referred to a specialist for patch testing in an attempt to isolate the allergen.

Mid-potency topical corticosteroids are generally used to control itching and hasten healing for lesions not involving the face, axilla or groin. In these areas, low-potency preparations such as 1 percent hydrocortisone cream or topical calcineurin inhibitors (Elidel or Protopic) should be used. Oral corticosteroids are indicated for treatment of severe cases. When used, oral corticosteroids should be taken for approximately one week and then tapered over one to two additional weeks to prevent rebound flaring of the dermatitis.