6 - CONTACT DERMATITIS AND DRUG ERUPTIONS Flashcards
Inflammatory reaction of the skin from exposure to a substance that causes eruptions No previous exposure necessary
Irritant contact dermatitis
Acquired sensitivity to various substances that produce inflammatory reactions only in persons who have been previously sensitized
Allergic contact dermatitis
Pain and burning more common in this type of contact dermatitis
Irritant
Alkalis penetrate and destroy deeply because they:
Dissolve keratin
Principal compounds in alkalis
Sodium Potassium Ammonium Ca hydroxide
Powerful acids are______ whereas weaker acids are _______ A. Astringent B. Corrosive
B A
What type of acid produces a brownish charring of the skin, beneath which is an ulceration that heals slowly
Sulfuric acid
This acid is used more widely than any other acid in industry
Sulfuric acid
This acid causes deep burns Tissue is stained yellow
Nitric acid
One of the strongest inorganic acids, capable of dissolving glass
Hydrofluoric acid
This acid is used in the manufacturing of pigments
Titanium hydrochloride
What to do if you come in contact with titanium hydrochloride
Wipe away Water causes burns
Acid in tear gas that can cause dermatitis
Chloroacetophenone
Petrolatum dermatitis from impure petroleum jelly or lubricating oil manifests as
Verrucous thickening of skin
What type of hypersensitivity Allergic contact dermatitis
Cell mediated Type IV
Application of substances suspected to be the cause to intact uninflamed skin usually on upper back
Patch test
Patches in patch test are removed after_____ and reevaluated after ______
48 hours Day 4 or 5
In photopatch test, a standard patch test is applied for 48h then exposed to ______ J/m2 of UVA and read after another 48 hours
5-15
Most frequent site for nail polish dermatitis
Eyelids
Earlobe dermatitis is indicative of sensitivity from ______
Nickel
Deodorant and clothing dye can cause dermatitis in the axillary area. Which part of the axilla is involved in what substance?
Deodorant-axillary vault Clothing dye- axillary fold
Most common cause of allergic contact dermatitis in florists
Peruvian lily
Difference between dermatitis and fungal infection on the foot
Toe webs involved in fungal infections
Dermatitis from metals is usually due to
Nickel and chromates
Most common cause of allergic contact dermatitis in children and adults
Nickel
Leading cause of allergic contact dermatitis associated with cosmetics
Fragrance
Chemical in hair dye that can cause dermatitis
Phenylenediamine
Hair bleaches contain ________ that can cause dermatitis
Ammonium persulfate
Chemical found in most so called natural products that is an allergen
Propolis
Most common sunscreen allergen
Oxybenzone
Least irritating antiperspirant
Aluminum chlorhydrate
Which drug induces the highest rate of allergic reactions
Clonidine
Produce sensitization of skin when applied topically, when ingested, an acute flare at site of contact dermatitis may occur
Anamnestic (recalled) eruption
Most common topical local anesthetic that can cause dermatitis
Benzocaine
Antibiotics that most commonly cause dermatitis
Neomycin Bacitracin
Wheal and flare reaction occurring when a substance is applied to the intact skin
Contact urticaria
two types of dermatitis caused by substances coming in contact with the skin
irritant dermatitis and allergic contact dermatitis
inflammatory reaction in the skin resulting from exposure to a substance that causes an eruption in most people who come in contact with it
Irritant dermatitis
an acquired sensitivity to various substances that produce inflammatory reactions only in those persons who have been previously sensitized to the allergen.
Allergic contact dermatitis
Irritant Contact Dermatitis
Many substances act as irritants that produce a nonspecific inflammatory reaction of the skin. This type of dermatitis may be induced in any person if there is contact with a sufficiently high concentration. No previous exposure is necessary, and the effect is evident within minutes, or a few hours at most. The concentration and type of toxic agent, duration of exposure, and condition of the skin at the time of exposure produce the variation in severity of the dermatitis from person to person, or from time to time in the same person. The skin may be more vulnerable because of maceration from excessive humidity or exposure to water, heat, cold, pressure, or friction. Dry skin, as opposed to wet skin, is less likely to react to contactants, although in chronic xerosis, as seen in elderly patients, increased sensitivity to irritants results. Thick skin is less reactive than thin skin. Atopic patients are predisposed to irritant hand dermatitis. Repeated exposure to some of the milder irritants may produce a hardening effect over time This process makes the skin more resistant to the irritant effects of a given substance. Symptomatically, pain and burning are more common in irritant dermatitis, contrasting with the usual itch of allergic reactions. Avoidance, substitution of nonirritating agents when possible, and protection, most often by wearing gloves or using barrier creams, are the mainstays of treatment
Irritant dermatitis is often produced by alkalis such as soaps, cement, detergents, bleaches, ammonia preparations, lye, drain pipe cleaners, and toilet bowl and oven cleansers (Fig. 6.1). Alkalis penetrate and destroy deeply because they dissolve keratin. Strong solutions are corrosive, and immediate application of a weak acid such as vinegar, lemon juice, or 0.5% hydrochloric acid solution will lessen their effects.
Fig. 6.1 Cement burns. (Courtesy Steven Binnick, MD.)
ALKALIS
The principal compounds are sodium, potassium, ammonium, and calcium hydroxides. Occupational exposure is frequent among workers in soap manufacturing. Sodium silicate (water glass) is a caustic used in soap manufacture and paper sizing and for the preservation of eggs. Alkalis in the form of soaps, bleaching agents, detergents, and most household cleansing agents figure prominently in the causes of hand eczema. Alkaline sulfides are used as depilatories. Calcium oxide (quicklime) forms slaked lime when water is added. Severe burns may be caused in plasterers.
IRRITANT DERMATITIS SECONDARY TO ACIDS
Fig. 6.2 Drip burn from acid solution.
The powerful acids are corrosive, whereas the weaker acids are astringent. Hydrochloric acid produces burns that are less deep and more liable to form blisters than injuries from sulfuric and nitric acids (Fig. 6.2). Hydrochloric acid burns are encountered in those who handle or transport the product and in plumbers and those who work in galvanizing or tin-plate factories. Sulfuric acid produces a brownish charring of the skin, beneath which is an ulceration that heals slowly. Sulfuric acid is used more widely than any other acid in industry; it is handled principally by brass and iron workers and by those who work with copper or bronze. Nitric acid is a powerful oxidizing substance that causes deep burns; the tissue is stained yellow. Such injuries are observed in those who manufacture or handle the acid or use it in the making of explosives in laboratories. At times, nitric acid or formic acid is used in assaults secondary to interpersonal conflicts, resulting in scarring most prominently of the face, with the complication of renal failure present in a small number of cases.
Hydrofluoric acid is used widely in rust remover, in the semiconductor industry, and in germicides, dyes, plastics, and glass etching. It may act insidiously at first, starting with erythema and ending with vesiculation, ulceration, and finally necrosis of the tissue. Hydrofluoric acid is one of the strongest inorganic acids, capable of dissolving glass. Hypocalcemia, hypomagnesemia, hyperkalemia, and cardiac dysrhythmias may complicate hydrofluoric acid burns. Fluorine is best neutralized with hexafluorine solution, followed by 10% calcium gluconate solution or magnesium oxide.
Oxalic acid may produce paresthesia of the fingertips, with cyanosis and gangrene. The nails become discolored yellow. Oxalic acid is best neutralized with limewater or milk of magnesia to produce precipitation Titanium hydrochloride is used in the manufacture of pigments. Application of water to the exposed part will produce severe burns. Therefore treatment consists only of wiping away the noxious substance.
Phenol (carbolic acid) is a protoplasmic poison that produces a white eschar on the surface of the skin. It can penetrate deep into the tissue. If a large surface of the skin is treated with phenol for cosmetic peeling effects, the absorbed phenol may produce glomerulonephritis and arrhythmias. Locally, temporary anesthesia may also occur. Phenol is readily neutralized with 65% ethyl or isopropyl alcohol.
Chromic acid burns, which may be seen in electroplating and dye production occupations, may result in extensive tissue necrosis and acute renal damage. Excision of affected skin down to the fascia should be accomplished rapidly, and hemodialysis to remove circulating chromium should start in the first 24 hours. Other strong acids that are irritants include acetic, trichloracetic, arsenious, chlorosulfonic, fluoroboric, hydriodic, hydrobromic, iodic, perchloric, phosphoric, salicylic, silicofluoric, sulfonic, sulfurous, tannic, and tungstic acids.
Management of acid burns
Treatment of acid burns consists of immediate rinsing with copious amounts of water and alkalization with sodium bicarbonate, calcium hydroxide (limewater), or soap solutions. Phosphorus burns should be rinsed off with water, followed by application of copper sulfate to produce a precipitate.
Airbag Dermatitis
Airbags are deployed as a safety feature on cars when rapid deceleration occurs. Activation of a sodium azide and cupric oxide propellant cartridge releases nitrogen gas, which expands the bag at speeds exceeding 160 km/hour (96 miles/hour). Talcum powder, sodium hydroxide, and sodium carbonate are released into the bag. Abrasions, thermal, friction, and chemical burns and an irritant contact dermatitis may result. Superficial erythema may respond well to topical steroids, but full-thickness burns may occur and require debridement and grafting.
Give exampes of metal salts that act as irritants
Metal salts that act as irritants include the cyanides of calcium, copper, mercury, nickel, silver, and zinc and the chlorides of calcium and zinc.
Bromine, chlorine, fluorine, and iodine are also irritants. Occupational exposure to methyl bromide may produce erythema and vesicles in the axillary and inguinal areas. Insecticides, including 2,2-dichlorovinyl dimethyl phosphate used in roach powder and fly repellents and killers, can act as irritants.
Fiberglass Dermatitis
Fiberglass dermatitis is seen after occupational or inadvertent exposure. The small spicules of glass penetrate the skin and cause severe irritation with tiny erythematous papules, scratch marks, and intense pruritus. Usually, there is no delayed hypersensitivity reaction. Wearing clothes that have been washed together with fiberglass curtains, handling air conditioner filters, or working in the manufacture of fiberglass material may produce severe folliculitis, pruritus, and eruptions that may simulate scabies or insect bites. Fiberglass is also used in thermal and acoustic installation, the wind industry, padding, vibration isolation, curtains, draperies, insulation for automobile bodies, furniture, gasoline tanks, and spacecraft. Talcum powder dusted on the flexure surfaces of the arms before exposure makes the fibers slide off the skin. A thorough washing of the skin after handling fiberglass is helpful. Patch testing to epoxy resins should be done when evaluating workers in fiberglass and reinforced-plastics operations, because an allergic contact dermatitis may be difficult to discern from fiberglass dermatitis.
irritant derm secondary to dusts
Some dusts and gases may irritate the skin in the presence of heat and moisture, such as perspiration. The dusts of lime, zinc and arsenic may produce folliculitis. Dusts from various woods, such as teak, may incite itching and dermatitis. Dusts from cinchona bark, quinine, and pyrethrum produce widespread dermatitis. Tobacco dust in cigar factories, powdered orris roo , lycopodium, and dusts of various nutshells may cause swelling of the eyelids and dermatitis of the face, neck, and upper extremities, the distribution of an airborne contact dermatitis. Dusts formed during the manufacture of high explosives may cause erythematous, vesicular, and eczematous dermatitis that may lead to generalized exfoliative dermatitis.
Irritant derm secondary to capsaicin
Hand irritation produced by capsaicin in hot peppers used in Korean and North Chinese cuisine (Hunan hand) may be severe and prolonged, sometimes necessitating stellate ganglion blockade and gabapentin Pepper spray, used by police in high concentrations and by civilians in less concentrated formulas, contains capsaicin and may produce severe burns. Cold water is not much help; capsaicin is insoluble in water. Acetic acid 5% (white vinegar) or antacids (Maalox) may completely relieve the burning, even if applied an hour or more after the contact. Application should be continued until the area can be dried without return of the discomfort.
Tear Gas Dermatitis
Fig. 6.3 Mustard gas burn
Lacrimators such as chloroacetophenone in concentrated form may cause dermatitis, with a delayed appearance about 24–72 hours after exposure. Irritation or sensitization, with erythema and severe vesiculation, may result. Treatment consists of lavage of the affected skin with sodium bicarbonate solution and instillation of boric acid solution into the eyes. Contaminated clothing should be removed.
Sulfur mustard gas, also known as yperite (dichlorodiethyl sulfide), has been used in chemical warfare. Erythema, vesicles, and bullae result from mild to moderate exposure (Fig. 6.3). Toxic epidermal necrolysis (TEN)–like appearance may follow more concentrated contact. The earliest and most frequently affected sites are areas covered by clothing and humidified by sweat, such as the groin, axillae, and genitalia.
Mace is a mixture of tear gas (chloroacetophenone) in trichloroethane and various hydrocarbons resembling kerosene. It is available in a variety of self-defense sprays. Mace is a potent irritant and may cause allergic sensitization (Fig. 6.4). Treatment consists of changing clothes, then washing with oil or milk, followed by washing with copious amounts of water
Fig. 6.4 Mace-induced reaction.
Chloracne
Workers in the manufacture of chlorinated compounds may develop chloracne, with small, straw-colored follicular plugs and papules, chiefly on the malar crescent, retroauricular areas, earlobes, neck, shoulders, and scrotum. Histologically, there is a loss of sebaceous glands and the formation of cystic structures. The synthetic waxes chloronaphthalene and chlorodiphenyl, used in the manufacture of electric insulators and in paints, varnishes, and lacquers, predispose workers engaged in the manufacture of these synthetic waxes to chloracne. Exposure to 2,6-dichlorobenzonitrile during the manufacture of a herbicide, and to 3,4,3′,4′-tetrachloroazooxybenzene, which is an unwanted intermediate byproduct in the manufacture of a pesticide, may also produce chloracne.
A contaminant in the synthesis of herbicides and hexachlorophene, 2,3,7,8-tetracholorodibenzo-p-dioxin, produces a chemical burn in the acute stage, but chloracne, hyperpigmentation, hirsutism, and skin fragility (with or without criteria for porphyria cutanea tarda) are manifestations of chronic toxicity. Gastrointestinal tract cancer and malignancies of the lymphatic and hematopoietic systems are suspected to result. Although direct contact is the usual method of exposure, inhalation, ingestion, or contact with contaminated clothing may also result in chloracne. Chloracne may persist for long periods because dioxin is stored in the liver and released slowly into the circulation. Treatment is with medications used in acne vulgaris, including isotretinoin.
Hydrocarbons that produce skin eruptions
Many hydrocarbons produce skin eruptions. Crude petroleum causes generalized itching, folliculitis, or acneiform eruptions The irritant properties of petroleum derivatives are directly proportional to their fat-solvent properties and inversely proportional to their viscosity. Oils of the naphthalene series are more irritating han those of the paraffin series. Refined fractions from petroleum are less irritating than the unrefined products, although benzene, naphtha, and carbon disulfide may cause a mild dermatitis
Lubricating and cutting oils are causes of similar cutaneous lesions. They represent a frequent cause of occupational dermatoses in machine tool operators, machinists, layout men, instrument makers, and setup men. Insoluble (neat) cutting oils are responsible for a follicular acneiform eruption on the dorsa of the hands, the forearms, face, thighs, and back of the neck. Hyperpigmentation, keratoses, and scrotal cancer have been found in those exposed to insoluble cutting oils. Soluble oils and synthetic fluids used in metalworking do not result in acne, but rather an eczematous dermatitis, usually of the dorsal forearms and hands. Approximately 50% of the time it is irritant and in the remainder it is allergic. Allergic contact dermatitis arises from various additives, such as biocides, coloring agents, and deodorizers.
Coal briquette makers develop dermatitis as a result of a tarry residue from petroleum used in their trade. Paraffin exposure leads to pustules, keratoses, and ulcerations Shale oil workers develop an erythematous, follicular eruption that eventually leads to keratoses, which may become the sites of carcinoma. It is estimated that 50% of shale oil workers have skin problems.
Impure and low-grade paraffins and mineral oils cause similar skin eruptions. Initially, the skin changes are similar to those in chloracne. Over time, a diffuse erythema with dappled pigmentation develops. Gradually, keratoses appear, and after many years, some of these are the sites of carcinoma. Melanoderma may occur from exposure to mineral oils and lower-grade petroleum from creosote, asphalt, and other tar products. Photosensitization may play a role. Creosote is a contact irritant, sensitizer, and photosensitizer. Allergy is demonstrated by patch testing with 10% creosote in oil.
Petrolatum dermatitis may appear as a verrucous thickening of the skin caused by prolonged contact with impure petroleum jelly or, occasionally, lubricating oil. A follicular-centered process may occur in which erythematous horny nodules are present, usually on the anterior and inner aspects of the thighs. There are no comedones, and the lesions are separated by apparently normal skin.
Acne corne consists of follicular keratosis and pigmentation resulting from crude petroleum, tar oils, and paraffin. The dorsal aspects of the fingers and hands, the arms, legs, face, and thorax are the areas usually involved. The lesions are follicular horny papules, often black, and are associated at first with a follicular erythema and later with a dirty brownish or purplish spotty pigmentation, which in severe cases becomes widespread and is especially marked around the genitals. This syndrome may simulate pityriasis rubra pilaris or lichen spinulosus.
Coal tar and pitch and many of their derivatives produce photosensitization and an acneiform folliculitis of the forearms, legs, face, and scrotum. Follicular keratoses (pitch warts) may
develop and later turn into carcinoma. Soot, lamp black, and the ash from peat fires produce dermatitis of a dry, scaly character, which over time forms warty outgrowths and cancer. Chimney sweep’s cancer occurs under a soot wart and is usually located on the scrotum, where soot, sebum, and dirt collect in the folds of the skin. This form of cancer has virtually disappeared.
Acquired perforating disease may occur in oil field workers who use drilling fluid containing calcium chloride. Patients develop tender, umbilicated papules of the forearms that microscopically show transepidermal elimination of calcium.
Solvents that cause dermatitis
The solvents cause approximately 10% of occupational dermatitis. When solvents are applied to the hands o cleanse them, the surface oil is dissolved, and a chronic fissured dermatitis results. Additionally, peripheral neuropathy and chemical lymphangitis may occur after the solvents are absorbed through the fissured skin. Solvent sniffers may develop an eczematous eruption around the mouth and nose; erythema and edema occur. This is a direct irritant dermatitis caused by the inhalation of the solvent placed on a handkerchief.
Trichloroethylene is a chlorinated hydrocarbon solvent and degreasing agent also used in the dry-cleaning and refrigeration industry. Inhalation may produce exfoliative erythroderma, mucous membrane erosions, eosinophilia, and hepatitis.
Allergic contact dermatitis caused by alcohol is rarely encountered with lower-aliphatic alcohols. A severe case of bullous and hemorrhagic dermatitis on the fingertips and deltoid region was caused by isopropyl alcohol. Although rare, ethyl alcohol dermatitis may also be encountered. Cetyl and stearyl alcohols may provoke contact urticaria.
Pathophysiology of allergic contact dermatitis
Allergic contact dermatitis results when an allergen comes into contact with previously sensitized skin. It is caused by a specific acquired hypersensitivity of the delayed type, also known as cell-mediated (type IV) hypersensitivity. These sensitizers do not cause demonstrable skin changes on initial contact.
Persons may be exposed to allergens for years before finally developing hypersensitivity. Genetic variability in the immunologic processes leading to sensitization and other factors, such as concentration of the allergen applied, its vehicle, timing and site of the exposure, presence of occlusion, age, gender, and race of the patient, and presence of other skin or systemic disorders, likely determine whether any given exposure will result in sensitization. Once sensitized, however, subsequent outbreaks may result from extremely slight exposure.
Childhood exposures do result in allergy, and the frequency of allergy in this age group is increasing. The most common relevant allergens in young children are nickel, cobalt, fragrance, lanolin, and neomycin. In adolescents potassium dichromate and Myroxylon pereirae become significant. Sensitivity is rarely lost over the years; older patients have similar rates of allergy as adults.
Occasionally, dermatitis may be induced when the allergen is taken internally by a patient first sensitized by topical application, as with substances such as cinnamon oil or various medications. The anamnestic response is termed systemic contact dermatitis. It may appear first at the site of the prior sensitization or past positive patch test, but may spread to a generalized morbilliform or eczematous eruption. Additional morphologic patterns include vesicular hand eczema, urticaria, erythema multiforme, vasculitis, or symmetric drug-related intertriginous and flexural exanthema (SDRIFE). Formerly called baboon syndrome, SDRIFE is a deep-red-violet eruption on the buttocks, genital area, inner thighs, and sometimes the axillae.
The most common causes of contact dermatitis in the United States are toxicodendrons (poison ivy, oak, or sumac), nickel, balsam of Peru (Myroxylon pereirae), neomycin, fragrance, formaldehyde and the formaldehyde releasing preservatives, bacitracin, and rubber compounds. Frequent positive reactions to gold and thimerosal do not often correlate with the clinical exposure history. Gold reactions, which may be prolonged, can be correlated in some cases with oral gold exposure or occupational dermatitis, but in most cases, the relevance is questionable. Thimerosal reactions are probably related to its use as a preservative in common vaccines and skin-testing material. It also serves as a marker for piroxicam photosensitivity.
Eczematous delayed-type hypersensitivity reaction, as exemplified by allergic contact dermatitis and the patch test, must be distinguished from immediate-type hypersensitivity reaction. The latter presents within minutes of exposure with urticaria and is proved with a scratch test. It should be kept in mind, however, that persons who develop contact urticaria to a substance may concomitantly have a type IV delayed-type sensitization and eczema from the same allergen.
In some patients, impetigo, pustular folliculitis, and irritation or allergic reactions from applied medications are superimposed on the original dermatitis. A particularly vexing situation is when allergy to topical corticosteroids complicates an eczema, in which case the preexisting dermatitis usually does not flare, but simply does not heal as expected. The cutaneous reaction may also provoke a hypersusceptibility to various other, previously innocuous substances, which continues the eczematous inflammatory response indefinitely.
These eruptions resolve when the cause is identified and avoided. For acute generalized allergic contact dermatitis, treatment with systemic steroidal agents is effective, beginning with 40–60 mg/ day of prednisone in a single oral dose, and tapering slowly to topical steroids. When the eruption is limited in extent and severity, local application of topical corticosteroid creams, lotions, or aerosol sprays is preferred.
used to detect hypersensitivity to a substance that is in contact with the skin so that the allergen may be determined and corrective measures taken
Patch Test.
Fig. 6.5 Positive patch test reaction.
So many allergens can cause allergic contact dermatitis that it is impossible to test a person for all of them. In addition, a good history and observation of the pattern of the dermatitis, its localization on the body, and its sta e of activity are helpful in determining the cause. The patch test is confirmatory and diagnostic, but only within the framework of the history and physical findings; it is rarely helpful if it must stand alone. Interpretation of the relevance of positive tests and the subsequent education of patients are challenging in some cases. The Contact Allergen Management Program (CAMP) provides names of alternative products that may be used by patients when an allergen is identified. This is available through the American Contact Dermatitis Society.
The patch test consists of application of substances suspected to be the cause of the dermatitis to intact uninflamed skin. Patch testing may be administered by the thin-layer rapid-use epicutaneous (TRUE) test or by individually prepared patches The TRUE test has resulted in more screening for allergic contact dermatitis than in the past, but if it does not reveal the allergen for a highly suspect dermatitis, testing with an expanded series will on average yield relevant allergens in more than half of these patients. Dermatitis originating in the workplace will almost always require individualized testing.
Test substances are applied usually to the upper back, although if only one or two are applied, the upper outer arm may be used. Each patch should be numbered to avoid confusion. The patches are removed after 48 hours (or sooner if severe itching or burning occurs at the site) and read. The patch sites need to be evaluated again at day 4 or 5 because positive reactions may not appear earlier. Some allergens may take up to day 7 to show a reaction, and the patient should be advised to return if such a delayed reaction occurs. Erythematous papules and vesicles with edema are indicative of allergy (Fig. 6.5). Occasionally, patch tests for potassium iodide, nickel, or mercury will produce pustules at the
site of the test application. Usually no erythema is produced; therefore the reaction has no clinical significance.
Strong patch test reactions may induce a state of hyperirritability (“excited skin syndrome”) in which adjacent tests that would otherwise be negative appear as weakly positive. Weakly positive tests in the presence of strong tests do not prove sensitivity. The skin and mucous membranes vary widely in the ability to react to antigens. The oral mucosa is more resistant to primary irritants and is less liable to be involved in allergic reactions. This may be because the keratin layer of the skin more readily combines with haptens to form allergens. Also, the oral mucosa is bathed in saliva, which cleanses and buffers the area and dilutes irritants. However, patch testing for various types of oral signs and symptoms, such as swelling, tingling and burning, perioral dermatitis, and the appearance of oral lichen planus, is useful in determining a cause in many cases.
Potent topical corticosteroids, ultraviolet (UV) light, prednisone, and the acquired immunodeficiency syndrome (AIDS) have been reported to interfere with the reliability of patch testing. Expert opinion regarding patch testing while on other immunosuppressants (e.g , methotrexate, azathioprine, biologics) is that these are less likely to produce unreliable testing. However, with all of these, false-negative reactions may result; the value of testing in such circumstances is that if a positive reaction occurs, a diagnosis may be made. Vitiliginous skin is less reactive than normally pigmented adjacent skin.
test that may be used to screen products used by the patient
Provocative Use Test
Products that are made to stay on the skin once applied (as opposed to shampoos or soaps) are rubbed on normal skin of the inner aspect of the forearm several times da ly for 5 days. A pink itchy patch will indicate the need to avoid the product. Further testing to its individual ingredients will help identify replacement products. This test may also confirm a positive closed patch test reaction to ingredients of the personal care product.
test used to evaluate for contact photoallergy to such substances as sulfonamides, phenothiazines, p-aminobenzoic acid, oxybenzone, 6-methyl coumarin, musk ambrette, and tetrachlorosalicylanilide
Photopatch Test
A standard patch test is applied for 48 hours; this is then exposed to 5 to 15 J/m2 of UVA and read after another 48 hours. To test for 6-methyl coumarin sensitivity, the patch is applied in the same manner but for only 30 minutes before light exposure, rather than for 48 hours. A duplicate set of nonirradiated patches is used in testing for the presence of routine delayed hypersensitivity reactions. Also, a site of normal skin is given an identical dose of UVA to test for increased sensitivity to light without prior exposure to chemicals. There is a steady increase in incidence of photoallergy to sunscreening agents and a decreasing incidence of such reactions to fragrance.
Causes of contact allergies on the head and neck
The scalp is relatively resistant to the d ment of contact allergies; however, involvement may be caused by hair dye, hair spray, shampoo, or permanent wave solutions. The surrounding glabrous skin, including the ear rims and backs of the ears, may be much more inflamed and suggestive of the cause. Persistent otitis of the ear canal may be caused by sensitivity to neomycin, an ingredient of most aural medications. The eyelids are the most frequent site for nail polish dermatitis. Volatile gases, false-eyelash adhesive, fragrances, eye medications, preservatives, mascara, rubber in sponges used to apply cosmetics, and eye shadow are also frequently implicated (Fig. 6.6). Perioral dermatitis and cheilitis may be caused by flavoring agents in dentifrices and gum, as well as fragrances, shellac, medicaments, and sunscreens in lipstick and lip balms. Perfume dermatitis may cause redness just under the ears or on the neck. Earlobe dermatitis is indicative of nickel sensitivity. Photocontact dermatitis may involve the entire face and may be sharply cut off at the collar line or extend down on to the sternum in a V shape. There is a typical clear area under the chin where there is little or no exposure to sunlight. The left cheek and left side of the neck (from sun exposure while driving) may be the first areas involved.
Fig. 6.6 Eyelid dermatitis.
Causes of contact allergies on the trunk
The trunk is an infrequent site; however, the dye or finish of clothing may cause dermatitis. The axilla may be the site of deodorant dermatitis and clothing-dye dermatitis; involvement of the axillary vault suggests the former; of the axillary folds, the latter. In women, brassieres cause dermatitis from the material itself, the elastic, or the metal snaps or underwires.
Causes of contact allergies on the arms
The wrists may be involved because of jewelry or the backs of watches and clasps, all of which may contain nickel. Wristbands made of leather are a source of chrome dermatitis.
Causes of contact allergies on the hands
Innumerable substances may cause allergic contact dermatitis of the hands, which typically occurs on the backs of the hands and spares the palms. Florists will often develop fingertip or palmar lesions. A hand dermatitis that changes from web spaces to fingertips or from palms to dorsal hands should trigger patch testing. Poison ivy and other plant dermatitides frequently occur on the hands and arms. Rubber glove sensitivity must be kept constantly in mind. Usually, irritancy is superimposed on allergic contact dermatitis of the hands, altering both the morphologic and histologic clues to the diagnosis.
Causes of contact allergies on the abdomen
The abdomen, especially the waistline may be the site of rubber dermatitis from the elastic in pants and undergarments The metallic rivets in blue jeans may lead to periumbilical dermatitis in nickel-sensitive patients, as may piercings of the umbilicus.
Causes of contact dermatitis on the groin
The groin is usually spared, but the buttocks and upper thighs may be sites of dermatitis caused by dyes. The penis is frequently involved in poison ivy dermatitis. Condom dermatitis may also occur. The perianal region may be involved from the “caine” medications in suppositories, as well as preservatives and fragrances in cleansing materials. Almost half of women with pruritus vulvae have one or more relevant allergens; often these are medicaments, fragrances, or preservatives.
Causes of contact dermatitis on the lower extremities
The shins may be the site of rubber dermatitis from elastic stockings. Feet are sites for shoe dermatitis, most often attributable to rubber sensitivity, chrome-tanned leather, dyes, or adhesives. Application of topical antibiotics to stasis ulcers frequently leads to sensitivity and allergic contact dermatitis.
Dermatitis Resulting From Plants
A large number of plants, including trees, grasses, flowers, vegetables, fruits, and weeds, are potential causes of dermatitis. Eruptions from them vary considerably in appearance but are usually vesicular and accompanied by marked edema. After previous exposure and sensitization to the active substance in the plant, the typical dermatitis results from reexposure. The onset is usually a few hours or days after contact. The characteristic linearly grouped lesions are probably produced by brushing the skin with a leaf edge or a broken twig or by carriage of the allergen under the nails. Contrary to popular belief, the contents of vesicles are not capable of producing new lesions
Toxicodendron (Poison Ivy)
Fig. 6.7 Acute poison ivy reaction.
Toxicodendron dermatitis includes dermatitis from members of the Anacardiaceae family of plants: poison ivy (T. radicans, or Rhus radicans), poison oak (T. diversilobum, R. diversaloba), poison sumac (T. vernix, R. vernix), Japanese lacquer tree, cashew nut tree (allergen in nutshell), mango (allergen in rind, leaves, or sap), Rengas tree, and Indian marking nut tree. The ginkgo (allergen in fruit pulp), spider flower or silver oak, Gluta species of trees and shrubs in Southeast Asia, Brazilian pepper tree, also known as Florida holly, and poisonwood tree contain almost identical antigens.
Toxicodendron dermatitis appears within 48 hours of exposure of a person previously sensitized to the plant. It usually begins on the backs of the fingers, interdigital spaces, wrists, and eyelids, although it may begin on the ankles or other parts that have been exposed. Marked pruritus is the first symptom; inflammation, vesicles, and bullae may then appear. The vesicles are usually grouped and often linear (Fig. 6.7). Large bullae may be present, especially on the forearms and hands. The eyelids are puffy and worse in the morning, improving as the day progresses (Fig. 6.8). Pruritus ani and involvement of the genital areas occur frequently. A black lacquer deposit may occur in which the sap of the plant has been oxidized after being bound to the stratum corneum (Fig. 6.9) Untreated Toxicodendron dermatitis usually lasts 2–3 weeks.
The fingers transfer the allergen to other parts, especially the forearms and the male prepuce, which become greatly swollen. However, once the causative oil has been washed off, there is no spreading of the allergen. Some persons are so susceptible that direct contact is not necessary, the allergen apparently being carried by objects with prior exposure to the catechol. Occasionally, eating the allergen, as occurred in a patient who ingested raw cashew
nuts in an imported pesto sauce, may result in SDRIFE (see earlier) or a systematized allergic contact dermatitis with the morphology of a generalized erythematous papular eruption.
The cause is an oleoresin known as urushiol, of which the active agent is a mixture of catechols. This and related resorcinol allergens are present in many plants and also in Philodendron species, wood from Persoonia elliptica, wheat bran, and marine brown algae.
The most striking diagnostic feature is the linearity of the lesions. It is rare to see vesicles arranged linearly except in plantinduced dermatitis. A history of exposure in the country or park to plants that have shiny leaves in groups of three, followed by the appearance of vesicular lesions within 2 days, usually establishes the diagnosis.
Eradication of plants having grouped “leaves of three” growing in frequented places is one easy preventive measure, as is recognition of the plants to avoid. An excellent resource is a pamphlet available from the American Academy of Dermatology. If the individual is exposed, washing with soap and water within 5 minutes may prevent an eruption. Protective barrier creams are available tha are somewhat beneficial. Quaternium-18 bentonite has been shown to prevent or diminish experimentally produced poison ivy dermatitis.
Innumerable attempts have been made to immunize against poison ivy dermatitis by oral administration of the allergen or subcutaneous injections of oily extracts. To date, no accepted method of immunization is available. Repeated attacks do not confer immunity, although a single severe attack may achieve this by what has been called massive-dose desensitization.
When the diagnosis is clear and the eruption severe or extensive, systemic steroidal agents are effective, beginning with 40–60 mg of prednisone in a single oral dose daily, tapered off over a 3-week period. When the eruption is limited in extent and severity, local application of topical corticosteroid creams, lotions, or aerosol sprays is preferred. Time-honored calamine lotion without phenol is helpful and does no harm. Antihistaminic ointments should be avoided because of their sensitization potential. This also applies to the local application of the “caine” topical anesthetics.
Other Toxicodendron-Related Dermatitides
Lacquer dermatitis is caused by a furniture lacquer made from the Japanese lacquer tree, used on furniture, jewelry, or bric-a-brac. Antique lacquer is harmless, but lacquer less than 1 or 2 years old is highly antigenic. Cashew oil is extracted from the nutshells of the cashew tree (Anacardium occidentale). This vesicant oil contains cardol, a phenol similar to urushiol in poison ivy. The liquid has many commercial applications, such as the manufacture of brake linings, varnish, synthetic glue, paint, and sealer for concrete.
Mango dermatitis is uncommon in natives of mango-growing countries (e.g., Philippines, Guam, Hawaii, Cuba) who have never been exposed to contact with Toxicodendron species. Many persons who have been so exposed, however, whether or not they had dermatitis from it, are sensitized by one or a few episodes of contact with the peel of the mango fruit. The palms carry the allergen, so the eyelids and the male prepuce are often early sites of involvement.
Ginkgo tree dermatitis simulates Toxicodendron dermatitis with its severe vesiculation, erythematous papules, and edema. The causative substances are ginkgolic acids from the fruit pulp of the ginkgo tree. Ingestion of the ginkgo fruit may result in perianal dermatitis. Ginkgo biloba given orally for cerebral disturbances is made from a leaf extract so it does no elicit a systemic contact allergy when ingested.
Flowers and Houseplants that causes dermatitis.
Among the more common houseplants, the velvety-leafed philodendron, Philodendron crystallinum (and its several variants), known in India as the “money plant,” is a frequent cause of contact dermatitis. The eruption is often seen on the face, especially the eyelids, carried there by hands that have watered or cared for the plant. English ivy follows philodendron in frequency of cases of occult contact dermatitis. Primrose dermatitis affects the fingers, eyelids, and neck with a punctate or diffuse erythema and edema. Formerly found most frequently in Europe, the primrose is now a common U.S. houseplant. Primin, a quinone, is the causative oleoresin abounding in the glandular hairs of the plant Primula obconica.
The popular cut flower, the Peruvian lily, is the most common cause of allergic contact dermatitis in florists. When handling flowers of the genus Alstroemeria, the florist uses the thumb and second and third digits of the dominant hand. Because it is chronic, fissured hyperkeratotic dermatitis results, identical to the “tulip fingers” seen among sensitized tulip workers (see Fig. 6.10). Testing is done with the allergen tuliposide A. It does not penetrate nitrile gloves. The geranium, scorpion flower (Phacelia crenulata or P. campanularia), hydrangea, creosote bush (Larvia tridentata), Heracula, daffodil, foxglove, pooja, lisianthus, lilac, lady slipper, magnolia, and tulip and narcissus bulbs are other flowers that commonly cause allergic reactions among florists. The poinsettia and oleander almost never cause dermatitis, despite their reputation for it, although they are toxic if ingested.
Chrysanthemums frequently cause dermatitis, with the hands and eyelids of florists most often affected. The α-methylene portion of the sesquiterpene lactone molecule is the antigenic site, as it is in the other genera of the Compositae family.
A severe inflammatory reaction with bulla formation may be caused by the prairie crocus (Anemone patens L.), the floral emblem of the province of Manitoba. Several species of ornamental “bottle
brush” from Queensland (Grevillea banksii, G. Robyn Gordon, G. robusta), may cause allergic contact dermatitis. It is exported to the United States and other Western countries. The allergen is a long-chain alkyl resorcinol. Cross-sensitivity to Toxicodendron has been demonstrated. Treatment of all these plant dermatitides is the same as that recommended for toxicodendron dermatitis.
Contact dermatitis may be caused by handling many other flowers, such as the geranium, scorpion flower (Phacelia crenulata or P. campanularia), hydrangea, creosote bush (Larvia tridentata), Heracula, daffodil, foxglove, lilac, lady slipper, magnolia, and tulip and narcissus bulbs. The poinsettia and oleander almost never cause dermatitis, despite their reputation for it, although they are toxic if ingested.
Parthenium hysterophorus is a photosensitizing weed. The welldeserved reputation for harmfulness of dieffenbachia, a common, glossy-leafed house plant, rests on the high content of calcium oxalate crystals in its sap, which burn the mouth and throat severely if any part of the plant is chewed or swallowed. Severe edema of the oral tissues may result in complete loss of voice, thus its common nickname, “dumb cane.” It does not appear to sensitize. The castor bean, the seed of Ricinus communis, contains ricin, a poisonous substance (phytotoxin). Its sap contains an antigen that may cause anaphylactic hypersensitivity and also dermatitis.
Fruit and Vegetables that cause dermatitis
Many vegetables may cause contact dermatitis, including asparagus, carrot, celery, cow-parsnip, cucumber, garlic, Indian bean, mushroom, onion, parsley, tomato, and turnip. Onion and celery, among other vegetables, have been incriminated in the production of contact urticaria and even anaphylaxis. Several plants, including celery, fig, lime, and parsley, can cause a phototoxic dermatitis because of the presence of psoralens. Phototoxic contact dermatitis from plants is discussed more fully in Chapter 3.
Trees that cause dermatitis
Fig. 6.11 Tea tree oil dermatitis.
Trees with timber and sawdust that may produce contact dermatitis include ash, birch, cedar, cocobolo, elm, Kentucky coffee tree, koa, mahogany, mango, maple, mesquite, milo, myrtle, pine, and teak. The latex of fig and rubber trees may also cause dermatitis, usually of the phototoxic type. Melaleuca oil (tea tree oil), which may be applied to the skin to treat a variety of maladies, can cause allergic contact dermatitis, primarily through the allergen D-limonene (Fig. 6.11). The exotic woods, especially cocobolo and rosewood are prominent among allergens that may produce erythema multiforme (EM) after cutaneous exposure. Toxicodendron, tea tree oil, various medicaments, and a variety of other allergens may induce this reaction.
Tree-Associated Plants that cause dermatitis
Foresters and lumber workers can be exposed to allergenic plants other than trees. Lichens are a group of plants composed of symbiotic algae and fungi. Foresters and wood choppers exposed to these lichens growing on trees may develop severe allergic contact dermatitis. Exposure to the lichens may also occur from firewood, funeral wreaths, and also fragrances added to aftershave lotions (oak moss and tree moss). Sensitization is produced by d-usnic acid and other lichen acids contained in lichens. The leafy liverwort (Frullania nisquallensis), a forest epiphyte growing on tree trunks, has produced allergic dermatitis in forest workers The eruption is commonly called “cedar poisoning.” It resembles Toxicodendron dermatitis; its attacks are more severe during wet weather. The allergen is sesquiterpene lactone.
Pollens and Seeds that cause dermatitis
The pollens in ragweed are composed of two antigens. The protein fraction causes the respiratory symptoms of asthma and hay fever, and the oil-soluble portion causes contact dermatitis. Ragweed oil dermatitis is a seasonal disturbance seen mainly during the ragweed growing season from spring to fall. Contact with the plant or with wind-blown fragments of the dried plant produces the typical dermatitis. The oil causes swelling and redness of the lids and entire face, and a red blotchy eruption on the forearms that, after several attacks, may become generalized, with lichenification. It closely resembles chronic atopic dermatitis, with lichenification of the face, neck, and major flexures, and severe pruritus. The distribution also mimics that of photodermatitis, with ragweed dermatitis differentiated by its involvement of the upper eyelids and the retroauricular and submental areas. Chronic cases may continue into the winter, although signs and symptoms are most severe at the height of the season. Sesquiterpene lactones are the cause. Coexisten sensitization to pyrethrum may account for prolongation of ragweed dermatitis. Men outnumber women in hypersensitivity reactions; farmers outnumber patients of all other occupations.
Marine Plants that cause dermatitis
Numerous aquatic plants are toxic or produce contact dermatitis. Algae are the worst offenders. Freshwater plants are rarely of concern. Seaweed dermatitis is a type of swimmer’s eruption produced by contact with a marine blue green alga, Lyngbya majuscula Gomont. The onset is within a few minutes of leaving the ocean, with severe itching and burning, followed by dermatitis, blisters, and deep, painful desquamation that affects the areas covered by the bathing suit, especially the scrotum, perineum, and perianal areas and occasionally the breasts in women). Patch tests with the alga are neither necessary nor helpful because it is a potent irritant. Bathing in fresh water within 10 or 15 minutes of leaving the ocean may prevent the dermatitis. The Bermuda fire sponge may produce contact erythema multiforme. Trawler fishermen in the Dogger Bank area of the North Sea develop allergic dermatitis after contact with Alcyonidium hirsutum. This seaweed-like animal colony becomes caught in nets and produces erythema, edema, and lichenification on the fishermen’s hands and wrists.