Contact Dermatitis Part Contact Dermatitis Part OneOne

Ben Adams, D.O.Ben Adams, D.O.

12-6-0512-6-05

Irritant contact dermatitis Irritant contact dermatitis (ICD)(ICD)

Accounts for Accounts for approximately 80% of approximately 80% of all contact dermatitisall contact dermatitis

ICD is the result of a ICD is the result of a local toxic effect when local toxic effect when the skin comes in the skin comes in contact with irritant contact with irritant chemicals such as chemicals such as soaps, solvents, acids, soaps, solvents, acids, or alkalisor alkalis

This 37-year-old woman developed a contact This 37-year-old woman developed a contact irritant dermatitis from obsessive-compulsive irritant dermatitis from obsessive-compulsive hand washing 20-30 times a day. hand washing 20-30 times a day. www.drmatlas.orgwww.drmatlas.org

Introduction to Irritant Introduction to Irritant Contact DermatitisContact Dermatitis

ICD is a cutaneous inflammation resulting ICD is a cutaneous inflammation resulting from a direct cytotoxic effect of a chemical from a direct cytotoxic effect of a chemical or physical agentor physical agent

Constitutes nearly 80% of occupational Constitutes nearly 80% of occupational contact dermatitis (OCD)contact dermatitis (OCD)

OCD is a matter of public health importance, OCD is a matter of public health importance, contributing to combined direct and indirect contributing to combined direct and indirect annual costs (in the USA) of up to $1 billion annual costs (in the USA) of up to $1 billion when accounting for medical costs, workers when accounting for medical costs, workers compensation, and lost time from workcompensation, and lost time from work

Epidemiology of ICDEpidemiology of ICD

The US Bureau of Labor The US Bureau of Labor Statistics data show that Statistics data show that occupational skin diseases occupational skin diseases accounted for 10% to 15% accounted for 10% to 15% of all occupational illnessesof all occupational illnesses

High-risk occupations with High-risk occupations with frequent irritant exposure in frequent irritant exposure in caterers, furniture industry caterers, furniture industry workers, hospital workers, workers, hospital workers, hairdressers, chemical hairdressers, chemical industry workers, dry industry workers, dry cleaners, metal workers, cleaners, metal workers, florists, and warehouse florists, and warehouse workersworkers

Epidemiology of ICDEpidemiology of ICD Clinical manifestations of ICD are determined by:Clinical manifestations of ICD are determined by:

Properties of the irritating substanceProperties of the irritating substance

Host factorsHost factors

Environmental factors including concentration, mechanical Environmental factors including concentration, mechanical pressure, temperature, humidity, pH, and duration of contactpressure, temperature, humidity, pH, and duration of contact

Cold alone may also reduce the plasticity of the horny layer, Cold alone may also reduce the plasticity of the horny layer, with consequent cracking of the stratum corneumwith consequent cracking of the stratum corneum

Occlusion, excessive humidity, and maceration increase Occlusion, excessive humidity, and maceration increase percutaneous absorption of water-soluble substancespercutaneous absorption of water-soluble substances

Bilateral shoe irritant dermatitis resulting from Bilateral shoe irritant dermatitis resulting from chronic occlusive footwearchronic occlusive footwear

Epidemiology of ICDEpidemiology of ICD

Important predisposing characteristics of the individual include:Important predisposing characteristics of the individual include: Age, race, sex, pre-existing skin disease, anatomic region exposed, and Age, race, sex, pre-existing skin disease, anatomic region exposed, and

sebaceous activitysebaceous activity

Both infants and elderly are affected more by ICD because of their less Both infants and elderly are affected more by ICD because of their less robust epidermal layerrobust epidermal layer

Patients with darkly pigmented skin seem to be more resistant to Patients with darkly pigmented skin seem to be more resistant to irritant reactions irritant reactions

Other skin disease such as active atopic dermatitis may predispose an Other skin disease such as active atopic dermatitis may predispose an individual to develop ICDindividual to develop ICD

The most commonly affected sites are exposed areas such as the The most commonly affected sites are exposed areas such as the hands and the face, with hand involvement in approximately 80% of hands and the face, with hand involvement in approximately 80% of patients and face involvement in 10%patients and face involvement in 10%

Practicing dentist with moderately severe irritant hand dermatitis from Practicing dentist with moderately severe irritant hand dermatitis from chronic exposure to disinfecting solutions and antisepticschronic exposure to disinfecting solutions and antiseptics. The results of . The results of patch testing, latex challenge testing, and RAST testing were negative.patch testing, latex challenge testing, and RAST testing were negative.

Pathogenesis of ICDPathogenesis of ICD

Denaturation of epidermal keratinsDenaturation of epidermal keratins

Disruption of the permeability barrierDisruption of the permeability barrier

Damage to cell membranesDamage to cell membranes

Direct cytotoxic effectsDirect cytotoxic effects

Acute Irritant Contact Acute Irritant Contact DermatitisDermatitis

Commonly seen in occupational accidentsCommonly seen in occupational accidents Irritant reaction reaches its peak quickly, within minutes to Irritant reaction reaches its peak quickly, within minutes to

hours after exposurehours after exposure Symptoms include stinging, burning, and soreness Symptoms include stinging, burning, and soreness Physical signs include erythema, edema, bullae, and Physical signs include erythema, edema, bullae, and

possibly necrosispossibly necrosis Lesions restricted to the area where the irritant or toxicant Lesions restricted to the area where the irritant or toxicant

damaged the tissuedamaged the tissue Sharply demarcated borders and asymmetry pointing to an Sharply demarcated borders and asymmetry pointing to an

exogenous causeexogenous cause Most frequent irritants are acids and alkaline solutionsMost frequent irritants are acids and alkaline solutions

Acute Delayed Irritant Acute Delayed Irritant Contact DermatitisContact Dermatitis

Delayed inflammatory response characteristic of certain Delayed inflammatory response characteristic of certain irritants such as anthralin, benzalkonium chloride, and irritants such as anthralin, benzalkonium chloride, and ethylene oxideethylene oxide

Visible inflammation is not seen until 8 to 24 hours after Visible inflammation is not seen until 8 to 24 hours after exposureexposure

Symptoms are more frequently burning rather than pruritusSymptoms are more frequently burning rather than pruritus

Sensitivity to touch and water are elicitedSensitivity to touch and water are elicited

This form of ICD is commonly seen during diagnostic patch This form of ICD is commonly seen during diagnostic patch testingtesting

Irritant Reaction Irritant Irritant Reaction Irritant Contact DermatitisContact Dermatitis

Type of subclinical irritant dermatitis in individuals Type of subclinical irritant dermatitis in individuals exposed to wet chemical environments such as exposed to wet chemical environments such as hairdressers, caters, or metalworkershairdressers, caters, or metalworkers

Characterized by scaling, redness, vesicles, Characterized by scaling, redness, vesicles, pustules, and erosionspustules, and erosions

Often begins under occlusive jewelry and then Often begins under occlusive jewelry and then spreads over the fingers to the hands and forearmsspreads over the fingers to the hands and forearms

May simulate dyshidrotic dermatitisMay simulate dyshidrotic dermatitis

Cumulative Irritant Contact Cumulative Irritant Contact DermatitisDermatitis

Consequence of multiple sub-Consequence of multiple sub-threshold skin insults, without threshold skin insults, without sufficient time between them sufficient time between them for complete barrier function for complete barrier function repairrepair

In contrast to acute ICD, the In contrast to acute ICD, the lesions of chronic ICD are less lesions of chronic ICD are less sharply demarcatedsharply demarcated

Itching and pain due to fissures Itching and pain due to fissures of hyperkeratotic skin are of hyperkeratotic skin are symptoms of chronic ICDsymptoms of chronic ICD

Skin findings include Skin findings include lichenification, hyperkeratosis, lichenification, hyperkeratosis, xerosis, erythema, and vesiclesxerosis, erythema, and vesicles

Asteatotic DermatitisAsteatotic Dermatitis

Exsiccation eczematid ICDExsiccation eczematid ICD

Seen mainly during the Seen mainly during the winter months in elderly winter months in elderly individuals who frequently individuals who frequently bath without bath without remoisturizingremoisturizing

Skin appears dry with Skin appears dry with ichthyosiform scale and ichthyosiform scale and patches of eczema patches of eczema craquelecraquele

Traumatic Irritant Contact Traumatic Irritant Contact Dermatitis Dermatitis

May develop after acute skin trauma, such as May develop after acute skin trauma, such as burns, lacerations, or acute ICDburns, lacerations, or acute ICD

Patients should be asked if they have cleansed Patients should be asked if they have cleansed with strong soaps or detergentswith strong soaps or detergents

Characterized by eczematous lesions most Characterized by eczematous lesions most commonly on the hands, that persist commonly on the hands, that persist

Healing is delayed with redness, infiltration, Healing is delayed with redness, infiltration, scale, and fissuring in the affected areasscale, and fissuring in the affected areas

Pustular and Acneform Pustular and Acneform Irritant Contact DermatitisIrritant Contact Dermatitis

Result to certain irritants such as Result to certain irritants such as metals, croton oil, mineral oils, metals, croton oil, mineral oils, tars, greases, cutting and metal tars, greases, cutting and metal working fluids, and naphthalenesworking fluids, and naphthalenes

Should be considered in Should be considered in conditions in which folliculitis or conditions in which folliculitis or acneform lesions develop in acneform lesions develop in setting outside of typical acnesetting outside of typical acne

Pustules are sterile and transientPustules are sterile and transient

Milia may develop in response to Milia may develop in response to occlusive clothing, adhesive tape, occlusive clothing, adhesive tape, ultraviolet and infrared radiationultraviolet and infrared radiation

Chloracne. Note heavy involvement of retroauricular Chloracne. Note heavy involvement of retroauricular skin with comedones and cystsskin with comedones and cysts

Subjective or Sensory Subjective or Sensory Irritant Contact DermatitisIrritant Contact Dermatitis

Reports of stinging or burning in the Reports of stinging or burning in the absence of visible cutaneous signs of absence of visible cutaneous signs of irritationirritation

Response to irritants such as lactic or Response to irritants such as lactic or sorbic acidsorbic acid

Airborne Irritant Contact Airborne Irritant Contact DermatitisDermatitis

Develops on irritant-Develops on irritant-exposed skin of the face exposed skin of the face and periorbital regionsand periorbital regions

Often simulates Often simulates photoallergic reactionsphotoallergic reactions

Involvement of the upper Involvement of the upper eyelids, philtrum, and eyelids, philtrum, and submental regions help to submental regions help to differentiate from differentiate from photoallergic reactionphotoallergic reaction

Frictional Irritant Contact Frictional Irritant Contact DermatitisDermatitis

Results from repeated low-Results from repeated low-grade frictional traumagrade frictional trauma

Plays adjuvant role in ACD Plays adjuvant role in ACD and ICDand ICD

Characterized by Characterized by hyperkeratosis, acanthosis, hyperkeratosis, acanthosis, and lichenification, often and lichenification, often progressing to hardening, progressing to hardening, thickening, and increased thickening, and increased toughnesstoughness

9 year old girl demonstrates a lichenified hyperpigmented round plaque on the top of her thumb produced by chronic thumbsucking. www.dermatlas.org

Pathology of ICDPathology of ICD

Variable mix of inflammation, necrosis of epidermal Variable mix of inflammation, necrosis of epidermal keratinocytes, and mild spongiosiskeratinocytes, and mild spongiosis

Combination of an upper dermal perivascular infiltrate of Combination of an upper dermal perivascular infiltrate of lymphocytes with minimal extension of inflammatory cells lymphocytes with minimal extension of inflammatory cells into the overlying epidermis, and widely scattered necrotic into the overlying epidermis, and widely scattered necrotic keratinocytes is most typical picturekeratinocytes is most typical picture

True features of interface dermatitis are absent, and True features of interface dermatitis are absent, and spongiosis should be focal or absent spongiosis should be focal or absent

Over time additional histologic findings include acanthosis Over time additional histologic findings include acanthosis with mild hypergranulosis and hyperkeratosiswith mild hypergranulosis and hyperkeratosis

AcidsAcids

Inorganic and organic acids can be corrosive to the skinInorganic and organic acids can be corrosive to the skin

Cause epidermal damage via protein denaturation and Cause epidermal damage via protein denaturation and cytotoxicitycytotoxicity

Symptoms include erythema, vesication, and necrosisSymptoms include erythema, vesication, and necrosis

Hydrofluoric and sulfuric acid can cause the most severe Hydrofluoric and sulfuric acid can cause the most severe burnsburns

Hydrofluoric acid, used in the semiconductor industry, is Hydrofluoric acid, used in the semiconductor industry, is able to penetrate intact skin with subsequent dissociation able to penetrate intact skin with subsequent dissociation in deeper tissues and resultant liquefactive necrosisin deeper tissues and resultant liquefactive necrosis

Acids Acids

Chromic acid causes ulcerations Chromic acid causes ulcerations known as ‘chrome holes’ and known as ‘chrome holes’ and often perforates the nasal often perforates the nasal septumseptum

Chemical burns and irritant Chemical burns and irritant dermatitis from nitric acid can dermatitis from nitric acid can cause a distinctive yellow cause a distinctive yellow discoloration discoloration

In general, organic acids are less In general, organic acids are less irritating than inorganic acidsirritating than inorganic acids

Formic acid has the greatest Formic acid has the greatest corrosive potential of the corrosive potential of the organic acids organic acids Examples of chrome holes www.cdc.gov/niosh/ocderm

AlkalisAlkalis

Strong Alkalis include sodium, Strong Alkalis include sodium, ammonium, potassium hydroxide, ammonium, potassium hydroxide, sodium and potassium carbonate, and sodium and potassium carbonate, and calcium oxidecalcium oxide

Found in soaps, detergents, bleaches, Found in soaps, detergents, bleaches, ammonia preparations, lye, drain pipe ammonia preparations, lye, drain pipe cleaner, toilet bowl cleansers, and oven cleaner, toilet bowl cleansers, and oven cleanercleaner

Often more painful and damaging than Often more painful and damaging than acidsacids

No vesicles, necrotic skin that appears No vesicles, necrotic skin that appears dark brown then black, ultimately dark brown then black, ultimately becomes hard, dry, and crackedbecomes hard, dry, and cracked

Alkalis disrupt barrier lips and denature Alkalis disrupt barrier lips and denature proteins with subsequent fatty acid proteins with subsequent fatty acid saponificationsaponification

Alkalis Alkalis

Cement mixed with water can Cement mixed with water can cause ulcerative damage due cause ulcerative damage due to alkalinityto alkalinity

Changes appear 8 to 12 hours Changes appear 8 to 12 hours after exposureafter exposure

Chronic irritant cement Chronic irritant cement dermatitis may also develop dermatitis may also develop over months to yearsover months to years

Can accompany allergic Can accompany allergic contact dermatitiscontact dermatitis

Hand dermatitis due to contact with cement dermnetnz.org/dermatitis/chrome

Metal SaltsMetal Salts

Include arsenic trioxide, beryllium compounds, Include arsenic trioxide, beryllium compounds, calcium oxide, copper salts, inorganic mercury, calcium oxide, copper salts, inorganic mercury, thimerosal, and seleniumthimerosal, and selenium

Signs ranging from ulceration to folliculitisSigns ranging from ulceration to folliculitis

SolventsSolvents

Act mainly by dissolving the intercellular lipid Act mainly by dissolving the intercellular lipid barrier of the epidermisbarrier of the epidermis

Prolonged skin contact can result in severe burns Prolonged skin contact can result in severe burns and well as systemic toxicityand well as systemic toxicity

Examples include turpentine, benzene, toluene, Examples include turpentine, benzene, toluene, xylene, carbon tetrachloride, gasoline, and xylene, carbon tetrachloride, gasoline, and kerosenekerosene

Professional paint and crayon illustrator with bilateral palmar dermatitis secondary to repeated contact with paint solvents. Extensive patch testing excluded allergic contact dermatitis

Detergents and CleansersDetergents and Cleansers

Include any surface active agent (surfactant) that Include any surface active agent (surfactant) that concentrates at the oil-water interfaces and has concentrates at the oil-water interfaces and has both emulsifying and cleansing propertiesboth emulsifying and cleansing properties

Found in skin cleansers, cosmetics, and Found in skin cleansers, cosmetics, and household cleaning productshousehold cleaning products

Surfactants cause protein denaturation of the Surfactants cause protein denaturation of the stratum corneum, impairing barrier functionstratum corneum, impairing barrier function

Anionic detergents such as alkyl sulfates and Anionic detergents such as alkyl sulfates and alkyl carboxylate salts are the most irritatingalkyl carboxylate salts are the most irritating

DisinfectantsDisinfectants

Include, alcohols, Include, alcohols, aldehydes, phenolic aldehydes, phenolic compounds, halogenated compounds, halogenated compounds, surfactants, compounds, surfactants, dyes, oxidizing agents, and dyes, oxidizing agents, and mercury compoundsmercury compounds

Weak toxic agents that can Weak toxic agents that can cause chronic ICDcause chronic ICD

Practicing dentist with moderately severe irritant hand Practicing dentist with moderately severe irritant hand dermatitis from chronic exposure to disinfecting solutions and dermatitis from chronic exposure to disinfecting solutions and antisepticsantiseptics. The results of patch testing, latex challenge testing, and . The results of patch testing, latex challenge testing, and RAST testing were negative.RAST testing were negative.

PlasticsPlastics

Three categories: thermoplastics, thermosettings, Three categories: thermoplastics, thermosettings, elastomerselastomers

Skin damage is attributed to monomer Skin damage is attributed to monomer ingredients, hardeners, and stabilizersingredients, hardeners, and stabilizers

Final hardened plastic product is generally Final hardened plastic product is generally considered inertconsidered inert

FoodFood

Agriculture, fishing, catering, Agriculture, fishing, catering, and food processingand food processing

Often work without gloves, in Often work without gloves, in damp working conditions with damp working conditions with frequent hand washingfrequent hand washing

Mechanical, thermal, and Mechanical, thermal, and climatic factorsclimatic factors

Nearly 100% of exposed Nearly 100% of exposed persons in food handling and persons in food handling and fishing professions may be fishing professions may be affected by chronic irritant affected by chronic irritant hand dermatitishand dermatitis

WaterWater

Ubiquitous skin irritantUbiquitous skin irritant

Tropical immersion foot, Tropical immersion foot, seen during Vietnam Warseen during Vietnam War

Hairdressers, hospital Hairdressers, hospital cleaners, cannery workers, cleaners, cannery workers, bartendersbartenders

Irritancy of water is Irritancy of water is exacerbated by occlusionexacerbated by occlusion

9 year old is an habitual hand washer who develops a contact irritant dermatitis every winter. At times she washes over 10 times a day. www.dermatlas.org

Fabric/man-made vitreous Fabric/man-made vitreous fibersfibers

Fibers larger than 3.5 um in Fibers larger than 3.5 um in diameter cause the highly diameter cause the highly pruritic contact dermatitis pruritic contact dermatitis caused by fiberglasscaused by fiberglass

Erythematous papules with Erythematous papules with superimposed excoriations superimposed excoriations on neck and dorsal handson neck and dorsal hands

Wool and rough clothing Wool and rough clothing cause dermatitis in atopic cause dermatitis in atopic individualsindividuals

Fiberglass dermatitis www.cdc.gov/niosh/ocderm

Differential DiagnosisDifferential Diagnosis

Allergic and ICD, especially in chronic stage appear similar Allergic and ICD, especially in chronic stage appear similar by clinical appearance, histology, and immunohistologyby clinical appearance, histology, and immunohistology

Look identical with erythema, papules, xerosis, scaling, and Look identical with erythema, papules, xerosis, scaling, and lichenification with sharp borderslichenification with sharp borders

ICD has remained a diagnosis of exclusion when dermatitis ICD has remained a diagnosis of exclusion when dermatitis is not explained by positive patch test to a known allergenis not explained by positive patch test to a known allergen

More frequent complaint of burning and stinging with ICD in More frequent complaint of burning and stinging with ICD in contrast to pruritus in ACDcontrast to pruritus in ACD

TreatmentTreatment

Avoidance of causative irritants at home or in the workplace is the Avoidance of causative irritants at home or in the workplace is the primary TXprimary TX

Engineering controls to reduce exposure in the workplaceEngineering controls to reduce exposure in the workplace

Shielding and personal protection such as gloves and special Shielding and personal protection such as gloves and special clothingclothing

Pre-exposure protection by protective creams, removal of irritants Pre-exposure protection by protective creams, removal of irritants by mild cleaning agents, and enhancement of barrier function by mild cleaning agents, and enhancement of barrier function generation by emollients and moisturizersgeneration by emollients and moisturizers

Emphasizing personal and occupational hygieneEmphasizing personal and occupational hygiene

Establishing educational programs to increase awareness in the Establishing educational programs to increase awareness in the workplaceworkplace

TX Chemical BurnsTX Chemical Burns Initial tx irrigation with large volumes of water, if chemical is insoluble in Initial tx irrigation with large volumes of water, if chemical is insoluble in

water a soap solution may be usedwater a soap solution may be used

High pressure water to be avoided to prevent splashingHigh pressure water to be avoided to prevent splashing

2.5% calcium gluconate gel used to tx hydroflouric acid burns, immediate 2.5% calcium gluconate gel used to tx hydroflouric acid burns, immediate application of a weak acid such as vinegar, lemon juice, or 0.5% application of a weak acid such as vinegar, lemon juice, or 0.5% hydrochloric acid will lessen the effect of alkali burnshydrochloric acid will lessen the effect of alkali burns

Ulcerated areas should be managed with antibacterial creams or ointments Ulcerated areas should be managed with antibacterial creams or ointments to prevent secondary infectionto prevent secondary infection

Frequent evaluation is required because ulcers may progress over several Frequent evaluation is required because ulcers may progress over several daysdays

Excision, debridement and/or grafting may speed healingExcision, debridement and/or grafting may speed healing

Monitoring of blood, liver, and kidney function may be needed when Monitoring of blood, liver, and kidney function may be needed when exposed to chemicals with potential for systemic toxicity such as exposed to chemicals with potential for systemic toxicity such as hydrofluoric acid, phenolic compounds, chromic acid, and gasolinehydrofluoric acid, phenolic compounds, chromic acid, and gasoline

Chronic ICD TreatmentChronic ICD Treatment

Tx goal is to restore normal epidermal barrier functionTx goal is to restore normal epidermal barrier function

Topical corticosteroids frequently usedTopical corticosteroids frequently used

Systemic corticosteroids although helpful in reducing Systemic corticosteroids although helpful in reducing inflammation, are not useful in treatment of chronic ICD inflammation, are not useful in treatment of chronic ICD unless offending contactants are avoidedunless offending contactants are avoided

PUVA and Grenz ray considered for chronic dermatitis that PUVA and Grenz ray considered for chronic dermatitis that does not respond to other txdoes not respond to other tx

Hyperkeratotic palmoplantar dermatitis from frictional or Hyperkeratotic palmoplantar dermatitis from frictional or chronic ICD may benefit from the adjunctive use of chronic ICD may benefit from the adjunctive use of systemic retinoids such as acitretinsystemic retinoids such as acitretin

Allergic contact dermatitis Allergic contact dermatitis (ACD)(ACD)

ACD accounts for ACD accounts for approximately 20% of all approximately 20% of all contact dermatitiscontact dermatitis

ACD is a type IV, delayed ACD is a type IV, delayed or cell-mediated immune or cell-mediated immune reaction that is elicited reaction that is elicited when the skin comes in when the skin comes in contact with a chemical to contact with a chemical to which an individual has which an individual has been previously sensitizedbeen previously sensitized

Synonyms include contact Synonyms include contact dermatitis and contact dermatitis and contact eczemaeczema

Allergic contact dermatitis. Linear streaks seen with ACD to poison ivy.

ACDACD

Key FeaturesKey Features

ACD is a pruritic, eczematous ACD is a pruritic, eczematous reactionreaction

Acute ACD and many cases of Acute ACD and many cases of chronic ACD are well chronic ACD are well demarcated and located to demarcated and located to the site of contact with the the site of contact with the allergenallergen

Prototypic reactions are ACD Prototypic reactions are ACD due to poison ivy and nickeldue to poison ivy and nickel

Patch testing remains the gold Patch testing remains the gold standard for accurate and standard for accurate and consistent diagnosisconsistent diagnosis

This healthy adolescent developed an intensely pruritic vesiculobullous allergic contact dermatitis from hair dye. Dermatlas.org

Classic picture of ACD is a Classic picture of ACD is a well-demarcated well-demarcated erythematous vesicular erythematous vesicular and/or scaly patch or and/or scaly patch or plaque with well defined plaque with well defined margins corresponding to margins corresponding to the area of contactthe area of contact

Chronic allergic contact dermatitis leading to hand dermatitis. This golfer wore one leather glove and had positive patch tests to potassium dichromate and a piece of his glove. Courtesy of Kalman Watsky, M.D.

Allergic contact Allergic contact dermatitis to dermatitis to leather shoes.leather shoes. Note Note the correspondence to the correspondence to sites of exposure. sites of exposure. Courtesy of Yale Residents Slide Courtesy of Yale Residents Slide Collection.Collection.

Because ICD and ACD Because ICD and ACD are not always are not always discernable clinically, discernable clinically, patch testing is patch testing is required to help required to help identify an allergen or identify an allergen or exclude an allergy to a exclude an allergy to a suspected allergen.suspected allergen.

Allergic contact dermatitis. Chronic hand dermatitis due to ACD to mercaptobenzothiazole found in rubber gloves

Epidemiology of ACDEpidemiology of ACD

Affects the old and young, individuals of all races, and both Affects the old and young, individuals of all races, and both sexessexes

Differences in genders usually based on exposure patterns, Differences in genders usually based on exposure patterns, such as nickel allergy being seen more frequently in such as nickel allergy being seen more frequently in women, presumably due to greater exposure to jewelrywomen, presumably due to greater exposure to jewelry

Occupations and avocations play an important roleOccupations and avocations play an important role

Allergens differ from region to region, e.g. preservatives Allergens differ from region to region, e.g. preservatives used in personal care products can vary based on used in personal care products can vary based on government legislationgovernment legislation

Pathogenesis of ACDPathogenesis of ACD

ACD is a type IV hypersensitivity responseACD is a type IV hypersensitivity response

Requires prior sensitization to the chemical in Requires prior sensitization to the chemical in questionquestion

Subsequent re-exposure of individual leads to Subsequent re-exposure of individual leads to allergen being presented to a primed T-cell milieu allergen being presented to a primed T-cell milieu leading to release of numerous cytokines and leading to release of numerous cytokines and chemotactic factors leading to the clinical picture chemotactic factors leading to the clinical picture of eczemaof eczema

Once sensitized a low concentration of causative Once sensitized a low concentration of causative chemical elicits a response chemical elicits a response

Induction of contact hypersensitivity. Application of contact allergens (Ag) induces the release of cytokines by keratinocytes, Langerhans cells and other cells within the skin. These cytokines in turn activate Langerhans cells which uptake the antigen and emigrate into the regional lymph nodes. During this process, the Langerhans cells mature into dendritic cells. In addition, the antigen is processed, re-expressed on the surface and finally presented to naïve T cells in the regional lymph node. Upon appropriate antigen presentation, T cells bearing the appropriate T cell receptor clonally expand and become effector T cells. These alter their migratory behavior due to the expression of specific surface molecules like CLA. Effector T cells recirculate into the periphery where they may later meet the antigen again. Ag, antigen; KC, keratinocyte.

Elicitation of contact hypersensitivityElicitation of contact hypersensitivity. Application of contact allergens (Ag) into a . Application of contact allergens (Ag) into a sensitized individual causes the release of cytokines by keratinocytes and Langerhans cells. sensitized individual causes the release of cytokines by keratinocytes and Langerhans cells. These cytokines induce the expression of adhesion molecules and activation of endothelial These cytokines induce the expression of adhesion molecules and activation of endothelial cells which ultimately attracts leukocytes to the site of antigen application. Among these cells which ultimately attracts leukocytes to the site of antigen application. Among these cells, T effector cells are present which are now activated upon antigen presentation either cells, T effector cells are present which are now activated upon antigen presentation either by resident cells or by infiltrating Langerhans cells. Antigen-specific T cell activation again by resident cells or by infiltrating Langerhans cells. Antigen-specific T cell activation again induces the release of cytokines by T cells. This causes the attraction of other inflammatory induces the release of cytokines by T cells. This causes the attraction of other inflammatory cells including granulocytes and macrophages which ultimately cause the clinical cells including granulocytes and macrophages which ultimately cause the clinical manifestation of contact dermatitis. Ag, antigen; DDC, dermal dendritic cell; KC, manifestation of contact dermatitis. Ag, antigen; DDC, dermal dendritic cell; KC, keratinocyte; CLA, cutaneous lymphocyte antigen.keratinocyte; CLA, cutaneous lymphocyte antigen.

Clinical features of ACDClinical features of ACD

Acute blistering and Acute blistering and weepingweeping

Chronic lichenified and Chronic lichenified and scaly plaquesscaly plaques

Patchy and diffuse Patchy and diffuse distributions may be distributions may be seen with body seen with body washes and shampooswashes and shampoos

Acute bullous allergic contact dermatitis due to poison ivy. This distribution is seen in patients who wear gloves. Courtesy of Yale Residents Slide Collection

Chronic allergic contact dermatitis due to glutaraldehyde. The patient was an optometrist

Pathology of ACDPathology of ACD

ACD is the prototype of spongiotic dermatitisACD is the prototype of spongiotic dermatitis

Acute stage: variable degree of spongiosis with Acute stage: variable degree of spongiosis with mixed dermal inflammatory infiltrate containing mixed dermal inflammatory infiltrate containing lymphocytes, histiocytes, and variable numbers lymphocytes, histiocytes, and variable numbers of eosinophilsof eosinophils

Moderate to severe reactions show Moderate to severe reactions show intraepidermal vesiculationintraepidermal vesiculation

Subacute to chronic stages have epidermal Subacute to chronic stages have epidermal hyperplasia, often psoriasiformhyperplasia, often psoriasiform

Irregular psoriasiform epidermal hyperplasia with slight spongiosis. A The thick compact orthokeratotic stratum corneum is due to the acral location of the specimen. B Spongiotic, vesicular psoriasiform dermatitis due to contact dermatitis. The intraepidermal vesiculation is a consequence of marked spongiosis. C Spongiotic, psoriasiform dermatitis with areas of spongiotic microvesiculation within the epidermis. D Higher magnification of C showing eosinophils within a spongiotic microvesicle at the tip of a rete ridge. Eosinophils were also present in the dermal infiltrate.

DDX of ACDDDX of ACD

Includes many forms of dermatitis: ICD, atopic Includes many forms of dermatitis: ICD, atopic dermatitis, stasis dermatitis, and seborrheic dermatitis, stasis dermatitis, and seborrheic dermatitis, as well as the erythematous form of dermatitis, as well as the erythematous form of rosacearosacea

Hand and foot ACD need to be distinguished from Hand and foot ACD need to be distinguished from psoriasis and tineapsoriasis and tinea

Widespread disease needs to be differentiated from Widespread disease needs to be differentiated from other causes of erythoderma, Sezary syndromeother causes of erythoderma, Sezary syndrome

Patch TestingPatch Testing

Simple office procedure upon which the diagnosis of ACD Simple office procedure upon which the diagnosis of ACD often restsoften rests

Although the procedure is simple, deciding when and what Although the procedure is simple, deciding when and what to test for requires training and experienceto test for requires training and experience

Patch testing is underutilizedPatch testing is underutilized

Only 50% of all residency programs in USA have a patch Only 50% of all residency programs in USA have a patch test centertest center

Past surveys show 27% of the responders did no patch Past surveys show 27% of the responders did no patch testing testing

Patch TestingPatch Testing

TRUE Test TRUE Test

Other panels include North American Contact Other panels include North American Contact Dermatitis Group (NACDG) Screening Series, and Dermatitis Group (NACDG) Screening Series, and the European Standard Seriesthe European Standard Series

Other panels are unique to specific occupations Other panels are unique to specific occupations such as hairdressing tray, dental tray, and florist such as hairdressing tray, dental tray, and florist traytray

True TestTrue Test

Preimpregnated test that Preimpregnated test that screens for 23 allergensscreens for 23 allergens

Extending testing beyond Extending testing beyond these 23 allergens has shown these 23 allergens has shown to be more beneficialto be more beneficial

In three studies, extended In three studies, extended testing detected 37-76% more testing detected 37-76% more positive reactions, and 47.3% positive reactions, and 47.3% of patients had positive of patients had positive reactions reactions onlyonly to non- to non-screening allergensscreening allergens

Additional allergens come in Additional allergens come in multiuse syringesmultiuse syringes

Allergens contained within syringes being placed by nurse into Finn chambers

Application of TRUE test. www.truetest.com

Pre-Patch Testing QuestionsPre-Patch Testing Questions

Exposures both at work and home to understand Exposures both at work and home to understand mechanics of the work environment, Materials mechanics of the work environment, Materials Safety Data Sheets (MSDS) can be helpful for Safety Data Sheets (MSDS) can be helpful for workplace exposuresworkplace exposures

Effect of vacations and time away form work or Effect of vacations and time away form work or home should be ascertainedhome should be ascertained

All personal care products should be inventoriedAll personal care products should be inventoried

All hobbies should be exploredAll hobbies should be explored

Patch TestingPatch Testing

Chemicals brought in by patients should not be tested Chemicals brought in by patients should not be tested blindly, physician should be aware of the chemical blindly, physician should be aware of the chemical ingredients because severe burns or ulceration may occuringredients because severe burns or ulceration may occur

‘‘Leave on’ personal care products such as moisturizers and Leave on’ personal care products such as moisturizers and make-up may be tested ‘as is’make-up may be tested ‘as is’

‘‘Rinse off’ products such as soaps or shampoos need to be Rinse off’ products such as soaps or shampoos need to be diluted prior to patch testingdiluted prior to patch testing

Patch TestingPatch Testing

Most common site is the upper Most common site is the upper backback

Patients should not have a Patients should not have a sunburn in test area, and should sunburn in test area, and should not apply topical corticosteroids to not apply topical corticosteroids to the patch test sites for 7 days the patch test sites for 7 days prior to testprior to test

Systemic corticosteroids should be Systemic corticosteroids should be avoided for 1 month prior to avoided for 1 month prior to testingtesting

Patches are applied to back and Patches are applied to back and reinforced with Scanpor tape, reinforced with Scanpor tape, patient instructed to keep back patient instructed to keep back dry and patches secured until dry and patches secured until second visit at 48 hourssecond visit at 48 hours

Fixing allergens to patient's back using Scanpor® tape.

Patch TestingPatch Testing

When the patient returns When the patient returns in 48 hours the patches in 48 hours the patches need to be inspected to need to be inspected to ensure that the testing ensure that the testing technique is adequatetechnique is adequate

As patches are removed As patches are removed their sites of application their sites of application should be marked in order should be marked in order to identify the locations of to identify the locations of particular allergensparticular allergens

Patch Test ScoringPatch Test Scoring

A positive patch test reaction to nickel. This is an example of a 3+ reaction

Patch TestingPatch Testing

Patient again asked to keep back dry until second Patient again asked to keep back dry until second reading, done from 72 hours to 1 week after the reading, done from 72 hours to 1 week after the initial application of the patchesinitial application of the patches

This delayed reading is necessary due to patch This delayed reading is necessary due to patch test responses to some allergens such as gold test responses to some allergens such as gold having a delayed reactionhaving a delayed reaction

Repeat Open Application Test Repeat Open Application Test (ROAT)(ROAT)

Poor man’s patch testPoor man’s patch test

Patient applies the product in question to the Patient applies the product in question to the same location (where there is not dermatitis), e.g. same location (where there is not dermatitis), e.g. antecubital fossa, BID for 1-2 weeksantecubital fossa, BID for 1-2 weeks

If dermatitis develops, it can be concluded that If dermatitis develops, it can be concluded that the patient is reacting to the productthe patient is reacting to the product

Downside to this approach is that individual Downside to this approach is that individual problem ingredients are not identifiedproblem ingredients are not identified

Treatment and Patient Treatment and Patient EducationEducation

Once allergens are Once allergens are positively identified, positively identified, patient should be given patient should be given written information on all written information on all of these chemicalsof these chemicals

Patient should be Patient should be instructed on how to read instructed on how to read labels on old or new labels on old or new products to avoid future products to avoid future exposureexposure

Treatment of ACDTreatment of ACD

Involves identification of causative allergensInvolves identification of causative allergens

Clear the dermatitis with topical, or if necessary Clear the dermatitis with topical, or if necessary systemic corticosteroidssystemic corticosteroids

Complete and prolonged clearing can take up to 6 Complete and prolonged clearing can take up to 6 weeks or more, even when allergens are being weeks or more, even when allergens are being avoidedavoided

NickelNickel

Most common allergen tested by the Most common allergen tested by the NACDG, with 14% of patients reacting NACDG, with 14% of patients reacting to itto it

Relevance has been estimated to be Relevance has been estimated to be 50%50%

Commonly used in jewelry, buckles, Commonly used in jewelry, buckles, snaps, and other metal-containing snaps, and other metal-containing objectsobjects

High rate of sensitivity attributed to High rate of sensitivity attributed to ear piercingear piercing

Dimethylglyoxime test to determine if Dimethylglyoxime test to determine if a particular item contains nickela particular item contains nickel

Individuals with nickel allergy should Individuals with nickel allergy should avoid custom jewelry, and can usually avoid custom jewelry, and can usually wear stainless steel or goldwear stainless steel or gold

Nickel DermatitisNickel Dermatitis

Common presentations are Common presentations are dermatitis on the ears, dermatitis on the ears, under a necklace or a under a necklace or a watch back, or on the mid-watch back, or on the mid-abdomen caused by a belt abdomen caused by a belt buckle, zipper, or snapbuckle, zipper, or snap

Eyelid dermatitis from Eyelid dermatitis from metal eyelash curlers can metal eyelash curlers can be seen be seen

Photos from dermatlas.orgPhotos from dermatlas.org

Neomycin SulfateNeomycin Sulfate

Most commonly used topical Most commonly used topical antibioticantibiotic

Most common sensitizer among Most common sensitizer among topical antibioticstopical antibiotics

Found in many OTC preparations: Found in many OTC preparations: bacterial ointments, hemorrhoid bacterial ointments, hemorrhoid creams, and otic and opthalmic creams, and otic and opthalmic preparationspreparations

Frequently used with other Frequently used with other antibacterial agents, such as antibacterial agents, such as bacitracin and polymyxin, as well bacitracin and polymyxin, as well as corticosteroidsas corticosteroids

Co-reactivity is commonly seen Co-reactivity is commonly seen with neomycin and bacitracin with neomycin and bacitracin

13 year old boy developed an itchy allergic contact

dermatitis from a topical antibiotic. www.dermatlas.org

Balsam of PeruBalsam of Peru

Naturally occurring fragrance material Naturally occurring fragrance material

Prior to introduction of fragrance mix in the 1970’s, balsam Prior to introduction of fragrance mix in the 1970’s, balsam of Peru was used to screen for fragrance allergyof Peru was used to screen for fragrance allergy

Capable of identifying 50% of those allergic to fragranceCapable of identifying 50% of those allergic to fragrance

Seen in those with allergies to spices, in particular cloves, Seen in those with allergies to spices, in particular cloves, Jamaicin pepper, and cinnamonJamaicin pepper, and cinnamon

Patients with a positive reaction need to avoid fragrances, Patients with a positive reaction need to avoid fragrances, occasionally spices, and other sources such as colas, occasionally spices, and other sources such as colas, tobacco, wines, and vermouthtobacco, wines, and vermouth

Fragrance MixFragrance Mix

Contains eight different Contains eight different components: cinnamic etoh, components: cinnamic etoh, cinnamic aldehyde, cinnamic aldehyde, hydroxycitronellal, isoeugenol, hydroxycitronellal, isoeugenol, eugenol, oak moss absolute, eugenol, oak moss absolute, alpha-amyl cinnamic aldehyde, alpha-amyl cinnamic aldehyde, and geranioland geraniol

Detects 70-80% of fragrance Detects 70-80% of fragrance allergiesallergies

Patients need to read product Patients need to read product labels and avoid anything that labels and avoid anything that lists a fragrance, is labeled lists a fragrance, is labeled ‘unscented’, or has an obvious ‘unscented’, or has an obvious scentscent

Patients need to look for Patients need to look for ‘fragrance-free’ products‘fragrance-free’ products

ACD to fragrance found in cologne. A Patient with ACD to fragrance found in his cologne. B Patient after avoidance of fragrances and his cologne.

ThimerosalThimerosal

Thimerosal is a combination of thiosalicylic acid and Thimerosal is a combination of thiosalicylic acid and ethylmercuric chloride, and is used as a preservativeethylmercuric chloride, and is used as a preservative

Most sensitization may be due to its use as a preservative Most sensitization may be due to its use as a preservative in vaccinesin vaccines

Other exposures include: contact lens solution, otic and Other exposures include: contact lens solution, otic and opthalmic solutions, antiseptics, and cosmeticsopthalmic solutions, antiseptics, and cosmetics

Positive reactions are common, relevance is low and Positive reactions are common, relevance is low and therefore routine testing to this allergen should be therefore routine testing to this allergen should be reconsideredreconsidered

GoldGold

NACDG found a positive rate of 9.5%NACDG found a positive rate of 9.5%

NACDC found 90% of gold-allergic patients were women, NACDC found 90% of gold-allergic patients were women, and there was a higher rate of nickel (33.5%) and cobalt and there was a higher rate of nickel (33.5%) and cobalt allergy (18%) in this groupallergy (18%) in this group

Most common clinical picture is hand, facial, or eyelid Most common clinical picture is hand, facial, or eyelid dermatitisdermatitis

Systemic reactions to gold in patients whom it was used to Systemic reactions to gold in patients whom it was used to tx RA, SLE, or pemphigus. tx RA, SLE, or pemphigus.

Cutaneous findings of lichen planus-like reactions to Cutaneous findings of lichen planus-like reactions to pityriasis rosea-like reactions and papular eruptions with pityriasis rosea-like reactions and papular eruptions with systemic reactionssystemic reactions

FormaldehydeFormaldehyde

Is a ubiquitous, colorless gas found in the workplace, cosmetics, medications, Is a ubiquitous, colorless gas found in the workplace, cosmetics, medications, textiles, paints, cigarette smoke, paper, and formaldehyde resins in plastic textiles, paints, cigarette smoke, paper, and formaldehyde resins in plastic bottlesbottles

Commonly seen in association with formaldehyde-releasing presevatives, such Commonly seen in association with formaldehyde-releasing presevatives, such as quarternuim-15 imidazolidinyl urea, diazolidinyl urea, DMDM hydantoin, 2-as quarternuim-15 imidazolidinyl urea, diazolidinyl urea, DMDM hydantoin, 2-bromo-2-nitropropane-1-3,diol, and tris(hydroxymethyl)nitromethanebromo-2-nitropropane-1-3,diol, and tris(hydroxymethyl)nitromethane

ICD is most common, ACD, contact urticaria, and mucous membrane irritation ICD is most common, ACD, contact urticaria, and mucous membrane irritation can occurcan occur

Textile dermatitis due to formaldehyde resins in ‘wash-and-wear’ and wrinkle Textile dermatitis due to formaldehyde resins in ‘wash-and-wear’ and wrinkle resistant clothesresistant clothes

Another source of formaldehyde is ‘formaldehyde-free’ products that are Another source of formaldehyde is ‘formaldehyde-free’ products that are packaged in containers coated with formaldehyde resinspackaged in containers coated with formaldehyde resins

So widespread that avoidance is difficult and clinical relevance should be So widespread that avoidance is difficult and clinical relevance should be determineddetermined

Quaternium-15Quaternium-15

Preservative that is an Preservative that is an effective biocide against effective biocide against PseudomonasPseudomonas, as well as , as well as other bacteria and fungiother bacteria and fungi

Most common preservative to Most common preservative to cause ACDcause ACD

Found in shampoos, Found in shampoos, moisturizers, conditioners, moisturizers, conditioners, and soapsand soaps

80% of those reacting to 80% of those reacting to quarternium-15 are also quarternium-15 are also formaldehyde sensitiveformaldehyde sensitive

Hand dermatititis due toquaternium-15 in a moisturiser dermnetnz.org/dermatitis/quaternium

CobaltCobalt

Metal that is used in association Metal that is used in association with other metals to add hardness with other metals to add hardness and strengthand strength

Frequently combined with nickel, Frequently combined with nickel, chromium, molybdenum, and chromium, molybdenum, and tungstentungsten

80% of individuals with a cobalt 80% of individuals with a cobalt sensitivity have a co-sensitivity to sensitivity have a co-sensitivity to chromate (more common in men) chromate (more common in men) or nickel (more common in women)or nickel (more common in women)

Exposure through jewelry snaps, Exposure through jewelry snaps, buttons, tools, cosmetics, hair buttons, tools, cosmetics, hair dyes, joint replacements, ceramics, dyes, joint replacements, ceramics, enamel, cement, paints , and enamel, cement, paints , and resinsresins

BacitracinBacitracin

Topical antibiotic with Topical antibiotic with activity against Gram-activity against Gram-positive bacteria and positive bacteria and spirochetesspirochetes

Commonly used in Commonly used in combination with other combination with other antibiotics such as antibiotics such as neomycin and with neomycin and with corticosteroidscorticosteroids

In addition to ACD, also In addition to ACD, also rarely causes anaphylaxis rarely causes anaphylaxis and contact urticariaand contact urticaria

Chronic ulcerations on the lower extremity are particularly likely to develop allergic contact dermatitis. This eruption resulted from sensitization to bacitracin. www.worldallergy.org

CorticosteroidsCorticosteroids

Have been shown to cause ACD in anywhere from 0.2% to Have been shown to cause ACD in anywhere from 0.2% to 5.98%5.98%

It is suspected that ACD to these agents is underdiagnosed, It is suspected that ACD to these agents is underdiagnosed, due to insufficient testingdue to insufficient testing

Clinical scenarios that should raise suspicion include: chronic Clinical scenarios that should raise suspicion include: chronic dermatitis, failure to clear with corticosteroids, and dermatitis, failure to clear with corticosteroids, and exacerbations of dermatitis after use of corticosteroidsexacerbations of dermatitis after use of corticosteroids

Tixocortol-21-pivalate and budesonide used for screening, with Tixocortol-21-pivalate and budesonide used for screening, with 91.3% of corticosteroid allergic reactions detected91.3% of corticosteroid allergic reactions detected

Complicates patch test interpretation, due to edge effect (first Complicates patch test interpretation, due to edge effect (first reading may have erythema only at the rim of the Finn reading may have erythema only at the rim of the Finn chamber)chamber)

Systemic Contact DermatitisSystemic Contact Dermatitis

Systemic exposure to a chemical Systemic exposure to a chemical may result in a diffuse dermatitismay result in a diffuse dermatitis

Patient has had a prior contact Patient has had a prior contact allergy and then becomes allergy and then becomes exposed through a systemic exposed through a systemic route, such as injection, oral, route, such as injection, oral, intravenous, or intranasal intravenous, or intranasal administration administration

One of most common examples One of most common examples is patient with ethylenediamine is patient with ethylenediamine allergy and subsequent reaction allergy and subsequent reaction

to aminophyllineto aminophylline

Airborne Contact DermatitisAirborne Contact Dermatitis

Airborne allergens result in several different reactions Airborne allergens result in several different reactions including ICD and ACDincluding ICD and ACD

PhotoACD, photoICD, photoxicity, and photoallergy to PhotoACD, photoICD, photoxicity, and photoallergy to systemic medications clinically resemble airborne contact systemic medications clinically resemble airborne contact dermatitisdermatitis

Ragweed dermatitis is a classic exampleRagweed dermatitis is a classic example

Clinically, lichenified and dry skin located in the exposed Clinically, lichenified and dry skin located in the exposed portions of the skin: face, V of the neck, arms and legsportions of the skin: face, V of the neck, arms and legs

Most common causative agents are plants, natural resins, Most common causative agents are plants, natural resins, woods, plastics, rubbers, glues, metals, pharmaceutical woods, plastics, rubbers, glues, metals, pharmaceutical chemicals, insecticides and pesticideschemicals, insecticides and pesticides

Airborne contact dermatitis. Example of the airborne contact dermatitis pattern seen in a patient allergic to sesquiterpene lactones. Note involvement on the anterior neck, which would not be expected if this were a photodermatitis. Courtesy of Dirk Elston, M.D.

55-year-old farm worker developed a chronic allergic contact dermatitis to airborn allergens (compositae).

Anacardiacea DermatitisAnacardiacea Dermatitis

Poison Ivy vine growing up a tree Poison Ivy vine growing up a tree www.dermatlas.orgwww.dermatlas.org

Anacardiacea ACDAnacardiacea ACD

Members of the Anacardiaceae Members of the Anacardiaceae cause more contact dermatitis cause more contact dermatitis that all other plant families that all other plant families combinedcombined

Most allergenic members belong Most allergenic members belong to the genus to the genus Toxicodendron, Toxicodendron, including poison ivy, poison oak, including poison ivy, poison oak, and poison sumacand poison sumac

Tocicodendron leaves are Tocicodendron leaves are compound, possessing three or compound, possessing three or more leaflets. Flowers and fruit more leaflets. Flowers and fruit arise in an axillary positions in the arise in an axillary positions in the angle between the leaf and the angle between the leaf and the twig from which it arises twig from which it arises

Black dots of urushiol often Black dots of urushiol often present on leaves and fruitpresent on leaves and fruit

Anacardiacae AllergensAnacardiacae Allergens

Urushiol derives its name Urushiol derives its name form the Japanese word for form the Japanese word for the sap (kiurushi) of the the sap (kiurushi) of the Japanese lacquer treeJapanese lacquer tree

Urushiol contains a mixture of Urushiol contains a mixture of catechols (1,2-catechols (1,2-dihydroxybenzenes) and dihydroxybenzenes) and resorcinols (1,3-resorcinols (1,3-dihydroxybenzenes)dihydroxybenzenes)

Urushiol self-melanizes on Urushiol self-melanizes on exposure to oxygenexposure to oxygen

Avidly binds to skin but is Avidly binds to skin but is readily degraded by waterreadily degraded by water

Poison Ivy www.dermatlas.orgPoison Ivy www.dermatlas.org

Clinical Features Anacardiacea Clinical Features Anacardiacea DermatitisDermatitis

Damage is generally required Damage is generally required for plants to release urushiolfor plants to release urushiol

In late fall plants release In late fall plants release urushiol spontaneouslyurushiol spontaneously

Urushiol may be spread by Urushiol may be spread by contaminated clothing, dogs, contaminated clothing, dogs, cats, lacquered furniture, cats, lacquered furniture, sawdust, and smokesawdust, and smoke

Allergen-containing smoke Allergen-containing smoke can cause severe respiratory can cause severe respiratory tract inflammation, severe tract inflammation, severe dermatitis, and even dermatitis, and even temporary blindnesstemporary blindness

www.dermatlas.orgwww.dermatlas.org

Clinical Features Anacardiacea Clinical Features Anacardiacea DermatitisDermatitis

After contact with urushiol, a sensitized person typically After contact with urushiol, a sensitized person typically develops and pruritic , erythematous eruption within 2 days develops and pruritic , erythematous eruption within 2 days (4-96 hours) that peaks within 1-14 days(4-96 hours) that peaks within 1-14 days

Dermatitis may last up to 3 weeks after primary contact or Dermatitis may last up to 3 weeks after primary contact or within hours of secondary contactwithin hours of secondary contact

Streaks of erythema and edematous papules typically Streaks of erythema and edematous papules typically precede vesicles and bullaeprecede vesicles and bullae

Although ACD is the most common cause of streaky, Although ACD is the most common cause of streaky, vesicular dermatitis, plants may cause this same picture by vesicular dermatitis, plants may cause this same picture by other means e.g. chemical irritant dermatitis, or the initial other means e.g. chemical irritant dermatitis, or the initial phase of phytodermatitisphase of phytodermatitis

Clinical manifestations of Anacardiaceae dermatitis. AClinical manifestations of Anacardiaceae dermatitis. A Acute, streak-like Acute, streak-like edematous and erythematous dermatitis without vesicles after poison ivy brushed edematous and erythematous dermatitis without vesicles after poison ivy brushed across the face. Courtesy of Fitzsimons Army Medical Center Dermatology slide across the face. Courtesy of Fitzsimons Army Medical Center Dermatology slide teaching library. teaching library. BB Acute, streak-like vesicular dermatitis after poison ivy Acute, streak-like vesicular dermatitis after poison ivy ((Toxicodendron radicansToxicodendron radicans) contact. Courtesy of Fitzsimons Army Medical Center ) contact. Courtesy of Fitzsimons Army Medical Center Dermatology slide teaching library. Dermatology slide teaching library. CC Widespread erythema and edema associated with Widespread erythema and edema associated with intense pruritus after carrying logs of the poisonwood tree (intense pruritus after carrying logs of the poisonwood tree (Metopium toxiferumMetopium toxiferum) of the ) of the family Anacardiaceae. family Anacardiaceae. DD ‘Black-spot’ poison ivy dermatitis: note the black discoloration ‘Black-spot’ poison ivy dermatitis: note the black discoloration in the central portion of the edematous plaques due to plant resin. in the central portion of the edematous plaques due to plant resin.

Clinical Features Anacardiacea Clinical Features Anacardiacea DermatitisDermatitis

Eruption ‘progresses’ to ‘new areas’ because of variability Eruption ‘progresses’ to ‘new areas’ because of variability in antigen concentration and stratum corneum/epidermis in antigen concentration and stratum corneum/epidermis thickness, not because of bullae fluidthickness, not because of bullae fluid

Over 70% of the US population reacts to poison ivy Over 70% of the US population reacts to poison ivy allergens after patch testing, but only 50% react to plants allergens after patch testing, but only 50% react to plants in the fieldin the field

Only 15% atopic patients are sensitive to poison ivyOnly 15% atopic patients are sensitive to poison ivy

Uncommonly, eruptions resemble erythema multiforme, Uncommonly, eruptions resemble erythema multiforme, measles, scarlatina, or urticariameasles, scarlatina, or urticaria

Prolonged postinflammatory hyperpigmentation may occur Prolonged postinflammatory hyperpigmentation may occur in darkly pigmented individualsin darkly pigmented individuals

TreatmentTreatment

Entire body should be washed Entire body should be washed with copious amounts of water with copious amounts of water as soon as possible after as soon as possible after exposureexposure

Soap may be used afterwards, Soap may be used afterwards, but early use of soap may but early use of soap may expand the area of resin on the expand the area of resin on the bodybody

As mentioned before, urushiol As mentioned before, urushiol is water degradable, After 10 is water degradable, After 10 minutes only 50% can be minutes only 50% can be removed, after 15 minutes only removed, after 15 minutes only 25% can be removed, after 30 25% can be removed, after 30 minutes only 10% can be minutes only 10% can be removed, and after 60 minutes removed, and after 60 minutes none of it can be removed none of it can be removed www.dermatlas.orgwww.dermatlas.org

TreatmentTreatment

Weepy lesions are best Weepy lesions are best treated with tepid baths, wet-treated with tepid baths, wet-to-dry soaks, or bland shake to-dry soaks, or bland shake lotions (calamine)lotions (calamine)

Stringent such as Burow’s Stringent such as Burow’s solution (aluminum solution (aluminum subacetate) works to cool and subacetate) works to cool and dry lesions when applied as a dry lesions when applied as a wet-to-dry dressingwet-to-dry dressing

Topical antihistamines, Topical antihistamines, anesthetics containing anesthetics containing benzocaine, and antibiotics benzocaine, and antibiotics should be avoided to prevent should be avoided to prevent sensitizationsensitization

www.dermatlas.orwww.dermatlas.orgg

TreatmentTreatment

Most potent topical corticosteroids Most potent topical corticosteroids only help if applied during the only help if applied during the earliest stages of the outbreak, earliest stages of the outbreak, when vesicles and blisters are not when vesicles and blisters are not yet presentyet present

Systemic steroids are effective Systemic steroids are effective when given at a dose of 1-2 when given at a dose of 1-2 mg/kg/day, slowly tapered over 2-mg/kg/day, slowly tapered over 2-3 weeks3 weeks

Many patients are referred for a Many patients are referred for a ‘recurrence’ of their poison ivy ‘recurrence’ of their poison ivy dermatitis after completing a dermatitis after completing a short, 6 day course of oral short, 6 day course of oral corticosteroidscorticosteroids

Oral antihistamines may decrease Oral antihistamines may decrease prurituspruritus

www.dermatlas.orgwww.dermatlas.org