Ch. 34 Contact Dermatitis Flashcards
1
Q
Contact Dermatitis
A
- Inflammation, redness, itching, stinging, vesicle/pustule formation
- Occurs due to exposure from an irritant or antigenic
- Types: Irritant Contact Dermatitis (ICD) or Allergic Contact Dermatitis (ACD)
- Differ by etiology and presentation
2
Q
ICD
A
- Common when working in personal services or health care
- Those who must wash hands frequently, handle foods, or are repeatedly in contact with irritants are at an increased risk
- Usually occur on exposed skin surfaces like hands, face, arms, and can occur at first exposure or after multiple exposures
- Mechanisms: disrupts skin barrier, changes epidermal cells, and released of proinflammatory cytokines
- Quantity, concentration, tight clothing, diapers, humidity, warm climates, and other skin conditions can increase its severity
- Chemical irritants, acids, and alkalis can have immediate, severe reactions
- Mild irritants like detergents, soaps, and solvents tend to cause reactions after repeat exposures
3
Q
ICD Clinical Presentation
A
- Skin becomes inflamed, swollen, and turns erythematous with irritant exposure
- Often a delayed reaction
- Primarily dry/macerated, painful, cracked, inflamed skin
- Itching, stinging, burning are also common
- Inflammation can range from slight swelling to ulcers to local necrosis
- Resolves when irritant is avoided but can take several days
- IF chronically exposed, may develop fissures, scales, lichenification, leathering/thickening of skin, and hypo or hyperpigmented skin; some resolve completely
4
Q
ICD Treatment Goals
A
- Remove offending agent and prevent exposure
- Relieve inflammation, dermal tenderness, and irritation
- Educate patient on self-management to prevent or treat recurrences
5
Q
ICD General Treatment
A
- Avoid irritant
- Preventative measures
- Patient education
6
Q
ICD Nonpharmacologic
A
- Wash area of exposure with lots of tepid water and mild or hypoallergenic soap
- Will decrease contact times with irritant and decrease the reaction or lessen the symptoms
7
Q
ICD Preventative Measures
A
- Educating in techniques to reduce exposure
- Protective clothing, gloves, other equipment, and limiting time skin is occluded by changing coverings often to decrease exposure
- Emollients, moisturizers, and barrier creams (esp. dimethicone) are recommended to treat and prevent ICD since they repair epidermal barrier
8
Q
ICD Pharmacologic
A
- Liberal applications of emollients help moisturize stratum corneum and protect from further exposure
- Colloidal oatmeal baths can relive itching
- Topical corticoids have questionable efficacy and are not recommended
- Topical “caine” anesthetics should be avoided since they can cause ACD
9
Q
ACD
A
- Poison ivy, oak, or sumae = common ACD inducers
- Metal allergy, particularly to nickel is also very common (19%)
- Latex is also a common reaction in health care workers
- Fragrances, cosmetics, and skin care can also cause ACD
10
Q
ACD Pathophysiology
A
- Inflammatory dermal reaction activates sensitized T cells which go to the site of contact and release inflammatory mediators
- Doesn’t occur on first contact usually
- Initial exposure sensitizes immune system (induction)
- Next exposure induces type IV allergic reactions where cell mediated reaction occurs, can take 24 hours to 21 days to develop (dermatitis symptoms)
- Rash/symptoms usually occur in 24-48 hours
11
Q
Urushiol-Induced ACD
A
- 4 species of Toxicodendron plants - primary dermatoses causers in plants
- 80% of population may be sensitive to urushiol
- Enters skin in about 10 minutes and starts sensitivity process
- Poison ivy/oak/sumac reactions are reported in as young as 3 year olds, increased incidence in adulthood and drops back down in the elderly
- Usually allergic to all plants if allergic to one
- “Leaves of three, leave them be” (more consistent with ivy)
- Produce small, waxy, white, five-petaled flowers in spring and green/white/pale yellow berries in fall
- Urushiol is sensitive to oxidation and changes from clear fluid to a black, inky, tar like substance
- Only released from plant damage, usually contained
- Not volatile, but can still cause dermatitis from smoke exposure if burned
- Unwashed, contaminated hands can also transfer urushiol to other parts of body, causing reaction
12
Q
Poison Ivy
A
- Most common Toxicodendron plant in the U.S.
- Climbing shrub or hairy vine that grows up poles, tress, and walls
- Radicans - shrub or vine, main type, throughout U.S.
- Rydbergil - dwarf shrub with large spoon-like leaves, 2nd main type and found in northern U.S.
13
Q
Poison Oak
A
- Two species indigenous in U.S.: diversilobum (West Coast) and toxicarium (East Coast)
- Both leaves are similar to oak tress, 3 leaves per stem, unlobed leaves
- Leaves and berries are covered in fine hairs
- Usually a non-climbing shrub but can climb up to 13 ft
- Western poison oak: 3-11 leaflets/stem, similar to California oak leaves
- Better at altitudes <4000-5000 ft
14
Q
Poison Sumac
A
- Vernix, grows in remote areas in eastern third of U.S., usually in bogs and swamps
- Usually a shrub or small tree, can grow ~9.8 ft
- May resemble elder or ash trees
- Leaves: odd numbered, pinnate, ~16” long potentially, with 7-13 leaflets/stem
- Leaves are smooth and come to a tip
15
Q
ACD Clinical Presentation
A
- Distribution and presentation of rash is the main difference
- Both occur where irritant touched, but ICD usually only on hands are arms from occupational exposure
- ACD usually limited to areas contacted by antigen, but can spread to broader areas of body form transferring contaminant from the hands to objects/self
- ACD: papules, small vesicles, significant itching, large bullae over inflamed, swollen skin sometimes too
- Chronic presentation: lichenification
16
Q
Urushiol Presentation
A
- Highly variable depending on sensitivity and exposure extent
- Intense itching followed by erythema
- Vesicles or bullae may form with reaction progression depending on the individual’s sensitivity, these can break and release fluid (sometimes for days)
- Papules and plaques may develop in addition or instead of bullae or vesicles
- Fluid can’t cause further reaction or dermatitis
- Streaks of vesicles where antigen was exposed suggests poison ivy or oak exposure
- Affected areas will crust and dry at the end of the dermatitis
17
Q
Severity of ACD Reaction
A
- Mild: linear streaks, localized to unprotected areas of body, minimal itching
- Moderate: erythema, bullae, papules, vesicles, and inflammation of exposed skin in addition to pruritis
- Severe: Extensive involvement and edema of extremities or face, swollen eyelids, contaminated hands, extreme itching, irritation, formation of multiple vesicles and bullae
- Dermatitis involving the eyes, lungs, face or genitalia should be immediately referred to medical practitioners
18
Q
Poison Ivy/Oak/Sumac Complications
A
- Scratching for several days after exposure and excoriate surface dermal layer - lesions and potential secondary wound infections
- Staph, group A Strep., and E. Coli commonly infect poison ivy dermatitis, but not only these
19
Q
ACD Treatment Goals
A
- Remove and avoid offending agent
- Treat the inflammation
- Relieve itching and excessive scratching that could increase secondary infection risk
- Relieve accumulation of debris arising from oozing, crusting, and scaling or vesicle fluids
Usually resolves with or without treatment in 10-21 days, but topicals can help relieve symptoms
20
Q
ACD General Treatment
A
- Removing antigen ASAP
- Shower/wash AA with tepid water and mild soap
- Treatment depends on severity
- Hydrocortisone 1% - good for local patches and rashes application with intense pruritis and erythema
- Can use astringent compresses and baths to dry oozing vesicles
- Calamine and colloidal oatmeal good for nonweeping lesions
- Calamine dries poison ivy lesions and colloidal relieves itching associated with rash
- Refer to PCP if patient < 2 y.o. and involes eyes, eyelids, genitals, or more than 20% of skin
- Signs of infection, large bullae, and 7 days of self-treatment with unresolved rash should be refered to PCP
21
Q
ACD Prevention
A
- Familiarize oneself with identifying toxicodexdron plants
- Survey areas when outside to determine risk
22
Q
ACD Protective Clothing
A
- Remove and wash post-exposure
- Use ordinary laundry detergent and separate from non-contaminated clothing when washing (also wash linens)
23
Q
ACD Barrier Products - Nonpharm.
A
- IvyBlock - only FDA approved against poison ivy/oak/sumac exposure
- Active ingredients: quaternium-19 bentonite (bentoquatam), 5% of that and has alcohol
- Nonsensitizing and nonirritating organoclay with little antigenicity or toxicity when applied
- Believed to physically block urushiol absorption
- Shake vigorously and apply generously to dry, clean skin
- Blocks exposure at least 15 minutes before exposure
- Leaves a faint, white coating on skin, reapply every 4 hours or as needed
- Remove with soap and water, avoid eyes, flammable, don’t apply to a preexisting poison ivy rash
- Not recommended for < 6 y.o.
24
Q
Toxicodendron Eradication
A
- Recommended when extremely sensitive individuals are in close proximity of plant
- Methods: mechanically removing or applying a herbicide
- If having an ACD reaction in an off-season or in winter, may have a urushiol-contaminated object
- Objected can hold onto antigenicity on inanimate objects through entire winter season
25
ACD Antigen Removal - Nonpharm.
- Wash exposed areas immediately, best within 10 minutes to reduce reaction
- Don't vigorously scrub area with harsh soaps, alcohol, or hand sanitizers
- Use mild face soap and water to wash exposed area, be sure to wash under nails and be meticulous
- Zanfel: non-Rx wash to relieve urushiol rash, reduces redness and blistering after exposure, expensive
- Good for spot treatment and washing inanimate objects
- Tecnu Outdoor Skin Cleaner: can also be used for urushiol, can use up to 8 hour post-exposure, cleanse for at least 2 minutes and water isn't necessary
- Use before eating smoking, or using the bathroom to reduce contamination exposure
- Tecnu, Dial, and Goop are all equally effective in cleansing urushiol exposed skin
26
ACD Itching Relief - Nonpharm.
- Primary nonpharmacologic is cold or tepid, soapless showers
- Hot showers could intensify pruritis
- Use hypoallergenic soap to maintain cleanliness
- Don't use harsh soaps or vigorous scrubbing
- Trim fingernails and use topicals
27
ACD Pharmacologic - Itching
- Topical ointments or creams containing anesthetics, antihistamines, or antibiotics SHOULD NOT be used
- Non-Rx 1st generation, oral antihistamines can assist with itching and sedation at night, use 2nd generation if sedation isn't desired
- Refer to PCP if antihistamines doesn't relieve itching
28
ACD Pharmacologic - Weeping
- Astringents slow weeping, oozing, discharge, or bleeding from dermatitis
- Decrease edema, exudation, and inflammation be decreasing cell permeability and hardening cellular cement
- Vasoconstriction and decreased blood flow to inflamed tissue
- Clean skin of exudates, crusts, and debris
- Aluminum acetate solution 5% (Burrow's Solution) - astringent agent that affects protein's ability to swell and hold water
- Soak area for 15-30 minutes 2-4 times per day or soak with dressing 4-6 times per day to soften crusts and have mild anti-pruritic effects
- Make fresh solution for each application
- Less expensive alternatives: saline, tap water, diluted white vinegar, unchlorinated water
- Hydrocortisone decreases weeping by treatment immune-mediated inflammation
- Don't use ointment for open lesions since it could be hard to remove and increase infection risk
29
ACD Pharmacologic - Inflammation
- Hydrocortisone is the most effected for mild to moderate ACD
- Decrease inflammation from vasoconstriction and decrease pruritis associated with ACD
- 0.5% or 1% available OTC and is approved for aczema, psoriasis, insect bites, SD, ACD
- Safe to all parts of the body except eyes/eyelids
- Systemic absorption can occur when applied to large areas, prolonged use, use with occlusive dressing, or open/cut skin
- Can apply 2-4 times per day
- Usually well tolerated with limited ADR
- ASE: irritation, burning
- Don't use dressings and bandages in self-care
- Don't use in <2 y.o. unless recommended by PCP
- Don't use if dermatitis persists after more than 7 days or clears and reappears (PCP)
- If 20% or more of body is involved, refer to PCP
30
ICD/ACD Special Population
- Similar in kids and adults
- Nonpharmacologic Emollients, barrier creams, and topical corticosteroids are okay for kids
- Only use pharmacologic therapy if older than 2 y.o. unless recommended by the doctor
- Topicals are safe for preggo as long as its not used on large areas of the body of for extended times
- Hydrocortisone: Preg. Category C, okay with low potency, OTC formations
- Other topicals don't have preggo categories but use same precautions as adults
- Any other treatments, refer to PCP
- Avoid 1st generation antihistamines in the elderly
- Itching: concern for elderly due to increased risk of skin tears and secondary infection
31
ICD/ACD Patient Factors and Preferences
- Severity of dermatitis and presence of vesicles effects dosage form choice
- Don't apply ointment to open lesions, but good for dry or cracked skin since it holds moisture in
- Cream better for weeping lesions and letting them dry out, also more cosmetically appealing
- Some gels have alcohol or organic solvents that cause irritation or burning to open lesions
- Spray - easiest administration, even distribution, convenient, doesn't require touching the area and can curtail scratching
- BUT sprays can have propellants that cause inflammation, drying, or irritation
32
ICD/ACD Assessment
Distinguishing factors between ACD/ICD:
1. History or irritant or allergen exposure
2. History of known sensitivity and exposure
3. Time of exposure to rash appearance
4. Distribution/appearance of lesions
5. Severity of symptoms
6. Improvement of dermatitis with irritant avoidance
- Must of these are from patient history, lesions are the only possible visible factor
- Knowing if previous treatments were used and worked will help pick a non-Rx product
33
ICD/ACD Counseling
- Review possible chemicals and allergens likely to cause dermatitis if unknown
- Preventative, protective, and non-Rx pharmacologics should be explained
- Include purpose, appropriate use, ASE, time to relief, and times to see PCP
34
ICD/ACD Evaluation
- Follow-up: 5 to 7 days
- Encourage to call it itching hasn't significantly subsided within 5-7 days
- If rash has increased in size, affected eyes or genitals, or covers extensive area of the face, see PCP
- Complete remission may take up to 3 weeks, but should see a slow and steady reduction after 5-7 days of therapy
