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CONTACT DERMATITIS (ALLERGIC & IRRITANT)

Introduction

Contact dermatitis is a reactive eczematous inflammation of the skin occurring after direct contact with a chemical, biologic, or physical agent. It’s a frequent problem that most people will experience at some point in their lifetime, and it accounts for 95% of all occupational skin diseases. Contact dermatitis may be either an acute or chronic issue, and it can be secondary to an allergen or irritant and categorized accordingly as allergen contact dermatitis (ACD) or irritant contact dermatitis (ICD). ICD is far more common and accounts for the majority (~80%) of all cases, most of which occur in the hands.1-3

Pathophysiology

  • The mechanism of contact dermatitis depends on its type:
    • ICD is produced by a substance exerting a direct toxic effect on the skin. It is characterized by skin damage, which could be mild to severe—depending on the causative agent—as a result of a direct, local, toxic effect on the cellular elements of the skin. This leads to removal of the lipid film, denaturation of keratin of the skin, release of lysosomal enzymes, and an inflammatory response. Examples of irritants include acids, alkalis, solvents, and detergents.1,2
    • ACD arises from a cell-mediated delayed hypersensitivity reaction, which begins after an allergen contacts the skin. This causes sensitization, which is initiated after an agent or hapten combines with skin protein to form a complete antigen. This antigen is processed by epidermal Langerhans cells, then T lymphocytes interact with these cells’ processed antigen. Eventually, the T lymphocytes release lymphokines, which serve as the mediators of inflammation and create a localized inflammatory response. There are a number of chemicals that can cause ACD, including metals, plants, medicines, cosmetics, and rubber compounds.2,4

Related Anatomy

  • Epidermis
  • Outer dermis
  • Epidermal Langerhans cells
  • Epidermal Keratinocytes

Incidence and Related Conditions

  • Contact dermatitis accounts for 95% of all occupational skin diseases.3
  • ICD is responsible for 80% of all cases of contact dermatitis.3
  • Contact dermatitis occurs twice as frequently in women as in men5and has been found to have a prevalence of 15% in 12-16 year olds.6
  • Atopic dermatitis
  • Perioral dermatitis 
  • Seborrheic dermatitis
  • Urticaria

Differential Diagnosis

  • Asteatotic eczema
  • Atopic dermatitis
  • Bacterial cellulitis
  • Contact urticaria syndrome
  • Erysipelas
  • Fungal infection
  • Lichen simplex chronicus
  • Nummular dermatitis
  • Onycholysis
  • Perioral dermatitis
  • Phytophotodermatitis
  • Prurigo nodularis
  • Psoriasis 
  • Scabies 
  • Seborrheic dermatitis
  • Tinea corporis
  • Transient acantholytic dermatosis
ICD-10 Codes

  • SKIN - COMMON HAND RASHES: CONTACT DERMATITIS

    Diagnostic Guide Name

    SKIN - COMMON HAND RASHES: CONTACT DERMATITIS

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    CONTACT DERMATITIS    
    ALLERGIC, DUE TO    
    - METALSL23.0   
    - ADHESIVESL23.1   
    - COSMETICSL23.2   
    - DRUGS IN CONTACT WITH SKINL23.3   
    - DYESL23.4   
    - OTHER CHEMICAL PRODUCTSL23.5   
    - FOOD IN CONTACT WITH SKINL23.6   
    - PLANTSL23.7   
    - ANIMAL DANDERL23.81   
    - UNSPECIFIED CAUSEL23.9   
    IRRITANT, DUE TO    
    - DETERGENTSL24.0   
    - OILS AND GREASESL24.1   
    - SOLVENTSL24.2   
    - COSMETICSL24.3   
    - DRUGS IN CONTACT WITH SKINL24.4   
    - OTHER CHEMICAL PRODUCTSL24.5   
    - FOOD IN CONTACT WITH SKINL24.6   
    - PLANTSL24.7   
    - METALSL24.81   
    - UNSPECIFIED CAUSEL24.9   

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
Patients complain of red rash, dry, cracked and scaly skin.
Patients also complain of itching, which may be severe, swelling, burning, or tenderness and uticaria.
Blistering, cracking skin, ulcerations and open sores also occur.
Typical History

A typical patient is a 32-year-old, female physician assistant, who recently started a new job at a hospital. The woman served under an orthopedic surgeon, which required her to “scrub up” with soap prior to each surgical procedure. A few hours after her first time scrubbing up, she noticed that a rash had developed over all the areas her hands and wrists that had been washed with soap. The development of the rash was followed by some pain, burning, and a stinging sensation, as well as discomfort, which led her to consult a dermatologist for an evaluation.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Identify the diagnosis accurately
  • Successful treat the lesion
Conservative

The most definitive treatment of ACD, whenever possible, is the identification and removal of the offending agent. 1,4,7

  • Topical corticosteroids
    • Indicated for milder localized cases of contact dermatitis. On areas such as the hands and forearms, use of a mid- to high-potency topical steroid, such as 0.1% triamcinolone and 0.05% halobetasol (respectively) creams or ointments
    • Systemic corticosteroids
      • A short course may be needed – and should be reserved – for acute, severe, generalized cases
      • Prednisone: 40-60 mg for a minimum of five days, with or without tapering
      • Triamcinolone suspension: 1 mL, administered intramuscularly
      • Systemic antihistamines 
        • Helpful for pruritus
        • Hydroxyzine
        • Diphenhydramine 
        • Astringent dressings and soothing baths
          • Reduces weeping and itching
          • Emollients
          • Topical calcineurin inhibitors
Operative
  • Surgery is rarely indicated for contact dermatitis.
Complications
  • Acne7
  • Folliculitis
  • Irritant reactions
  • Erythema
  • Skin atrophy
  • Tachyphylaxis
Outcomes
  • Acute ACD typically subsides within 3-4 weeks, but chronic contact dermatitis may develop if the patient is repeatedly exposed to the allergen, thus complicating the recovery process.1
  • The prognosis often depends on the patient’s ability to avoid the allergen or irritant. Individuals with a long duration of hand eczema before diagnosis, respiratory atopy, skin atopy, and those who remain with the same job have been found to be more likely to have a long-term continuation of dermatitis.7
Key Educational Points
  • It is extremely difficult—if not impossible—to clinically differentiate between ICD and ACD, but it may be possible to distinguish acute ICD from chronic ICD. Acute ICD is manifested by red, swollen, itchy, painful, and ulcerated skin, while chronic ICD features eczematous skin eruption, erythema, dryness, cracking, and fissuring of the skin.2
  • Generally speaking, patients with ICD will report burning as their primary symptom, while patients with ACD will describe itching as their primary symptom.
  • There is no standard testing method for diagnosing ICD. Obtaining a thorough inventory of occupational and environmental exposures may identify culprit agents.
  • Patch testing is a gold standard for diagnosing ACD
  • Skin biopsies provide limited value in diagnosing contact dermatitis, as findings depend on the stage of the process and the nature of the contactant.
  • Fungal, bacterial, and viral smears and cultures may help in evaluating patients with suspected ICD.
  • The use of topical corticosteroids for ICD is somewhat controversial and may be effective for treating inflammation in contact dermatitis if the underlying irritant is avoided.3
  • Clinicians should explain to patients that there is a possibility contact dermatitis may persist and require long-term management, even after initial treatment and workplace modifications.7
References

New and Cited Articles

  1. Marks JG, Miller JJ. Lookingbill and Marks’ Principles of Dermatology. Fifth Ed. London, New York: Saunders Elsevier; 2013.
  2. Al-Otaibi, ST. Review management of contact dermatitis. J Derm & Derm Surg 2015;19:86-91.
  3. Bains SN, Nash P, Fonacier L. Irritant Contact Dermatitis. Clin Rev Allergy Immunol 2019;56(1):99-109. PMID: 30293200
  4. Murphy PB, Hooten JN, Atwater AR. Allergic Contact Dermatitis. In: StatPearls.Treasure Island (FL) 2019. PMID: 30422461
  5. Thyssen JP, Linneberg A, Menne T, Johansen JD. The epidemiology of contact allergy in the general population--prevalence and main findings. Contact Dermatitis 2007;57(5):287-299. PMID: 17937743
  6. Mortz CG, Lauritsen JM, Bindslev-Jensen C, Andersen KE. Contact allergy and allergic contact dermatitis in adolescents: prevalence measures and associations. The Odense Adolescence Cohort Study on Atopic Diseases and Dermatitis (TOACS). Acta Derm Venereol 2002;82(5):352-358. PMID: 12430734
  7. Rashid RS, Shim TN. Contact dermatitis. BMJ 2016;353:i3299.PMID: 27364956

Review

  1. Rashid RS, Shim TN. Contact dermatitis.  BMJ 2016;353:i3299. PMID: 27364956
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