Contact dermatitis

(pathology and treatment)

By
Srota Dawn.
M.Pharm (pharmacology)
 Meaning of dermatitis:
Dermatitis
derives from
Greek ward

derma "skin" + -itis "inflammation".

 What Is Dermatitis ?

Dermatitis is the inflammation of the

skin caused by factors such as:
1.Allergies
2.Irritants
3.Ultraviolet light
4.Foods
5.Medications
6.Hereditary
Types of Dermatitis

• SEBORRHEIC DERMATITIS [Skin eruptions on face, scalp, and

trunk of body. This symptoms will produce greasy, dry scales
and will appear reddish.]
• CONTACT DERMATITIS [The appearance of skin vesicles that
burn, itch , sting or scale. ]
• ATOPIC DERMATITIS [There will appear lesions on the face,
neck, knees, elbows, trunk of body.]
 SEBORRHEIC DERMATITIS
• affect the areas rich in sebaceous glands
• Fungal infection:
• Malassezia globosa ,
• Malassezia restricta
• Genetic,
• environmental,
• hormonal, and
immune-system factors
have been shown to be involved in the manifestation of seborrhoeic
dermatitis
Antifungals
Over-the-counter
Dermol
Other medications
betadine Antihistamines
zinc pyrithione
Coal tar
salicylic acid loratadine
selenium disulfide
Lithium gluconate
Ketoconazole cetirizine
Lithium succinate
Prescription
ciclopiroxolamine
fexofenadine
Vitamin B6 ointment
sodium sulfacetamide
terbinafine
diphenhydramine
Topical steroid
Fluconazole
Ketoconazole
chlorpheniramine
• ICD is a cutaneous inflammation resulting from a direct
cytotoxic effect of a chemical or physical agent
• Constitutes nearly 80% of occupational contact dermatitis
(OCD)
• OCD is a matter of public health importance, contributing
to combined direct and indirect annual costs (in the USA)
of up to $1 billion when accounting for medical costs,
workers compensation, and lost time from work
 Contact dermatitis:

Definition:
Contact dermatitis is a term for a skin reaction (dermatitis)
resulting from
exposure to
•ALLERGENS (ALLERGIC CONTACT DERMATITIS)
OR
•IRRITANTS(IRRITANT CONTACT DERMATITIS).
•Phototoxic dermatitis occurs when the allergen or irritant is
activated by sunlight.
 Contact
dermatitis

IRRITANT ALLERGIC PHOTOTOXIC

CONTACT CONTACT
DERMATITIS DERMATITIS DERMATITIS
Irritant contact dermatitis:
It is a form of contact dermatitis that can be divided into forms caused
by chemical irritants and those caused by physical irritants.
Contact irritant
dermatitis

(ivy poison)
Chemical irritant dermatitis occurs after doing
mehendi
 Pathogenesis of ICD
• Denaturation of epidermal keratins

• Disruption of the permeability barrier

• Damage to cell membranes

• Direct cytotoxic effects

Different types of contact dermatitis:

1. Cumulative contact dermatitis

2. Asteatotic Dermatitis

3. Traumatic Irritant Contact Dermatitis

4. Pustular and Acneform Irritant Contact Dermatitis

5. Airborne Irritant Contact Dermatitis

6. Frictional Irritant Contact Dermatitis

 Cumulative Irritant Contact Dermatitis
• Consequence of multiple sub-
threshold skin insults, without
sufficient time between them for
complete barrier function repair
• In contrast to acute ICD, the lesions
of chronic ICD are less sharply
demarcated
• Itching and pain due to fissures of
hyperkeratotic skin are symptoms
of chronic ICD
• Skin findings include
lichenification, hyperkeratosis,
xerosis, erythema, and vesicles
Asteatotic Dermatitis
• Exsiccation eczematid ICD

• Seen mainly during the winter

months in elderly individuals
who frequently bath without
remoisturizing

• Skin appears dry with

ichthyosiform scale and
patches of eczema craquele
Traumatic Irritant Contact Dermatitis
• May develop after acute skin trauma, such as burns, lacerations, or
acute ICD

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

detergents

• Characterized by eczematous lesions most commonly on the hands,

that persist

• Healing is delayed with redness, infiltration, scale, and fissuring in

the affected areas
Traumatic Irritant Contact Dermatitis
• Reports of stinging or burning in the absence of visible
cutaneous signs of irritation

• Response to irritants such as lactic or sorbic acid

Pustular and Acneform Irritant Contact Dermatitis
Result to certain irritants such as
metals, croton oil, mineral oils, tars,
greases, cutting and metal working
fluids, and naphthalenes
Should be considered in conditions
in which folliculitis or acneform
lesions develop in setting outside of
typical acne
Pustules are sterile and transient

Milia may develop in response to

occlusive clothing, adhesive tape,
Chloracne. Note heavy involvement of retroauricular skin
ultraviolet and infrared radiation with comedones and cysts
Airborne Irritant Contact Dermatitis

Develops on irritant-exposed skin

of the face and periorbital regions

Often simulates photoallergic

reactions

Involvement of the upper eyelids,

philtrum, and submental regions
help to differentiate from
photoallergic reaction
Frictional Irritant Contact Dermatitis
Results from repeated low-grade
frictional trauma

Plays adjuvant role in ACD and ICD

Characterized by hyperkeratosis,
acanthosis, and lichenification,
often progressing to hardening, 9 year old girl demonstrates a lichenified hyperpigmented round plaque on
thickening, and increased the top of her thumb produced by chronic thumbsucking.
www.dermatlas.org
toughness
 Pathology of ICD
Variable mix of inflammation, necrosis of epidermal keratinocytes, and mild
spongiosis
Combination of an upper dermal perivascular infiltrate of lymphocytes with
minimal extension of inflammatory cells into the overlying epidermis, and
widely scattered necrotic keratinocytes is most typical picture
True features of interface dermatitis are absent, and spongiosis should be
focal or absent
Over time additional histologic findings include acanthosis with mild
hypergranulosis and hyperkeratosis
Acids
Inorganic and organic acids can be corrosive to the skin

Cause epidermal damage via protein denaturation and cytotoxicity

Symptoms include erythema, vesication, and necrosis

Hydrofluoric and sulfuric acid can cause the most severe burns

Hydrofluoric acid, used in the semiconductor industry, is able to

penetrate intact skin with subsequent dissociation in deeper tissues
and resultant liquefactive necrosis
 Acids
 Chromic acid causes ulcerations
known as ‘chrome holes’ and often
perforates the nasal septum

 Chemical burns and irritant

dermatitis from nitric acid can cause
a distinctive yellow discoloration

 In general, organic acids are less

irritating than inorganic acids

 Formic acid has the greatest Examples of chrome holes www.cdc.gov/niosh/ocderm

corrosive potential of the organic
acids
  Strong Alkalis include sodium, ammonium,
potassium hydroxide, sodium and
Alkalis potassium carbonate, and calcium oxide

 Found in soaps, detergents, bleaches,

ammonia preparations, lye, drain pipe
cleaner, toilet bowl cleansers, and oven
cleaner

 Often more painful and damaging than

acids

 No vesicles, necrotic skin that appears dark

brown then black, ultimately becomes
hard, dry, and cracked

 Alkalis disrupt barrier lips and denature

proteins with subsequent fatty acid
saponification
 Alkalis
Cement mixed with water can cause
ulcerative damage due to alkalinity

Changes appear 8 to 12 hours after

exposure

Chronic irritant cement dermatitis

may also develop over months to
years Hand dermatitis due to contact with cement
dermnetnz.org/dermatitis/chrome

Can accompany allergic contact

dermatitis
Metal Salts
Include arsenic trioxide, beryllium compounds, calcium oxide,
copper salts, inorganic mercury, thimerosal, and selenium

Signs ranging from ulceration to folliculitis

Solvents
Act mainly by dissolving the intercellular lipid barrier of
the epidermis

Prolonged skin contact can result in severe burns and well

as systemic toxicity

Examples include turpentine, benzene, toluene, xylene,

carbon tetrachloride, gasoline, and kerosene
Professionalpaint and crayon illustrator with bilateral palmar dermatitis secondary to
repeated contact with paint solvents. Extensive patch testing excluded allergic contact
dermatitis
Detergents and Cleansers
Include any surface active agent (surfactant) that concentrates at the
oil-water interfaces and has both emulsifying and cleansing
properties

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

Surfactants cause protein denaturation of the stratum corneum,

impairing barrier function

Anionic detergents such as alkyl sulfates and alkyl carboxylate salts

are the most irritating
Disinfectants
• Include, alcohols, aldehydes,
phenolic compounds, halogenated
compounds, surfactants, dyes,
oxidizing agents, and mercury
compounds

• Weak toxic agents that can cause

chronic ICD

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

Three categories: thermoplastics, thermosettings,

elastomers

Skin damage is attributed to monomer ingredients,

hardeners, and stabilizers

Final hardened plastic product is generally considered

inert
Food
 Agriculture, fishing, catering, and food
processing

 Often work without gloves, in damp

working conditions with frequent hand
washing

 Mechanical, thermal, and climatic factors

 Nearly 100% of exposed persons in food

handling and fishing professions may be
affected by chronic irritant hand
dermatitis
Water
Ubiquitous skin irritant

Tropical immersion foot, seen

during Vietnam War

Hairdressers, hospital cleaners,

cannery workers, bartenders
9 year old is an habitual hand washer who
develops a contact irritant dermatitis every winter.
Irritancy of water is exacerbated by At times she washes over 10 times a day.

occlusion
 Fabric/man-made vitreous fibers
Fibers larger than 3.5 um in
diameter cause the highly pruritic
contact dermatitis caused by
fiberglass

Erythematous papules with

superimposed excoriations on neck
and dorsal hands
Fiberglass dermatitis www.cdc.gov/niosh/ocderm

Wool and rough clothing cause

dermatitis in atopic individuals
Differential Diagnosis
Allergic and ICD, especially in chronic stage appear similar
by clinical appearance, histology, and immunohistology

Look identical with erythema, papules, xerosis, scaling,

and lichenification with sharp borders

ICD has remained a diagnosis of exclusion when dermatitis

is not explained by positive patch test to a known allergen

More frequent complaint of burning and stinging with ICD

in contrast to pruritus in ACD
 Treatment
 Avoidance of causative irritants at home or in the workplace is the primary TX

 Engineering controls to reduce exposure in the workplace

 Shielding and personal protection such as gloves and special clothing

 Pre-exposure protection by protective creams, removal of irritants by mild cleaning agents,

and enhancement of barrier function generation by emollients and moisturizers

 Emphasizing personal and occupational hygiene

 Establishing educational programs to increase awareness in the workplace

 Allergic contact dermatitis (ACD)

• ACD accounts for approximately 20% of all

contact dermatitis

• ACD is a type IV, delayed or cell-mediated

immune reaction that is elicited when the skin
comes in contact with a chemical to which an
individual has been previously sensitized

• Synonyms include contact dermatitis and

contact eczema

Allergic contact dermatitis. Linear streaks seen with ACD to poison ivy.
 Acute Contact Dermatitis
• Key Features

 ACD is a pruritic, eczematous reaction

 Acute ACD and many cases of chronic

ACD are well demarcated and located to
the site of contact with the allergen

 Prototypic reactions are ACD due to

poison ivy and nickel

 Patch testing remains the gold standard This healthy adolescent developed an intensely pruritic
for accurate and consistent diagnosis vesiculobullous allergic contact dermatitis from hair dye.
 Classic picture of ACD is a well-demarcated
erythematous vesicular and/or scaly patch or
plaque with well defined margins
corresponding to the 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 dermatitis to
leather shoes. Note the
correspondence to sites of exposure.
Courtesy of Yale Residents Slide Collection.
Because ICD and ACD are not
always differentiable clinically,
patch testing is required to help
identify an allergen or exclude an
allergy to a suspected allergen.

 Allergic contact dermatitis. Chronic hand dermatitis due to ACD to mercaptobenzothiazole found
in rubber gloves
 Epidemiology of ACD
Affects the old and young, individuals of all races, and both sexes

Differences in genders usually based on exposure patterns, such as nickel

allergy being seen more frequently in women, presumably due to greater
exposure to jewelry

Occupations and avocations play an important role

Allergens differ from region to region, e.g. preservatives used in personal care
products can vary based on government legislation
 Pathogenesis of ACD
ACD is a type IV hypersensitivity response

Requires prior sensitization to the chemical in question

Subsequent re-exposure of individual leads to allergen being presented to a

primed T-cell milieu leading to release of numerous cytokines and
chemotactic factors leading to the clinical picture of eczema

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

• Elicitation of contact hypersensitivity. Application of contact allergens (Ag) into a sensitized
individual causes the release of cytokines by keratinocytes and Langerhans cells. 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, 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
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
manifestation of contact dermatitis. Ag, antigen; DDC, dermal dendritic cell; KC, keratinocyte;
CLA, cutaneous lymphocyte antigen.
Clinical features of ACD
• Acute blistering and weeping
 Acute bullous allergic
contact dermatitis due to
poison ivy. This
distribution is seen in

• Chronic lichenified and scaly patients who wear gloves.

Courtesy of Yale Residents

plaques Slide Collection

• Patchy and diffuse distributions

may be seen with body washes and  Chronic allergic contact dermatitis
shampoos due to glutaraldehyde. The patient was
an optometrist
 Pathology of ACD
• ACD is the prototype of spongiotic dermatitis

• Acute stage: variable degree of spongiosis with mixed dermal

inflammatory infiltrate containing lymphocytes, histiocytes, and
variable numbers of eosinophils

• Moderate to severe reactions show intraepidermal vesiculation

• Subacute to chronic stages have epidermal hyperplasia, often

psoriasiform
Treatment of ACD

• Involves identification of causative allergens

• Clear the dermatitis with topical, or if necessary systemic

corticosteroids

• Complete and prolonged clearing can take up to 6 weeks or

more, even when allergens are being avoided
Nickel
• Most common allergen tested by the
NACDG, with 14% of patients
reacting to it
• Relevance has been estimated to be
50%
• Commonly used in jewelry, buckles,
snaps, and other metal-containing
objects
• High rate of sensitivity attributed to
ear piercing
• Dimethylglyoxime test to determine
if a particular item contains nickel
• Individuals with nickel allergy
should avoid custom jewelry, and
can usually wear stainless steel or
 Neomycin Sulfate
• Most commonly used topical antibiotic

• Most common sensitizer among topical

antibiotics

• Found in many OTC preparations: bacterial

ointments, hemorrhoid creams, and otic and
opthalmic preparations

• Frequently used with other antibacterial agents,

such as bacitracin and polymyxin, as well as
corticosteroids
13 year old boy developed an itchy allergic contact dermatitis from a topical antibiotic.
www.dermatlas.org

• Co-reactivity is commonly seen with neomycin

and bacitracin
 Balsam of Peru
• Naturally occurring fragrance material

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

• Capable of identifying 50% of those allergic to fragrance

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

• Patients with a positive reaction need to avoid fragrances, occasionally spices,

and other sources such as colas, tobacco, wines, and vermouth
 Thimerosal
• Thimerosal is a combination of thiosalicylic acid and ethylmercuric
chloride, and is used as a preservative

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

vaccines

• Other exposures include: contact lens solution, otic and opthalmic

solutions, antiseptics, and cosmetics

• Positive reactions are common, relevance is low and therefore

routine testing to this allergen should be reconsidered
 Gold
• Gold allergy is found a positive rate of 9.5%

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

• Most common clinical picture is hand, facial, or eyelid dermatitis

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

pemphigus.

• Cutaneous findings of lichen planus-like reactions to pityriasis rosea-like

reactions and papular eruptions with systemic reactions
 Formaldehyde
• Is a ubiquitous, colorless gas found in the workplace, cosmetics, medications, textiles, paints,
cigarette smoke, paper, and formaldehyde resins in plastic bottles
• Commonly seen in association with formaldehyde-releasing presevatives, such as
quarternuim-15 imidazolidinyl urea, diazolidinyl urea, DMDM hydantoin, 2-bromo-2-
nitropropane-1-3,diol, and tris(hydroxymethyl)nitromethane
• ICD is most common, ACD, contact urticaria, and mucous membrane irritation can occur

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

clothes
• Another source of formaldehyde is ‘formaldehyde-free’ products that are packaged in
containers coated with formaldehyde resins
• So widespread that avoidance is difficult and clinical relevance should be determined
 Quaternium-15
• Preservative that is an effective biocide
against Pseudomonas, as well as other
bacteria and fungi

• Most common preservative to cause ACD

• Found in shampoos, moisturizers,

conditioners, and soaps

Hand dermatititis due to

• 80% of those reacting to quarternium-15
quaternium-15 in a moisturiser
are also formaldehyde sensitive dermnetnz.org/dermatitis/quaternium
 Cobalt
• Metal that is used in association with other
metals to add hardness and strength

• Frequently combined with nickel, chromium,

molybdenum, and tungsten

• 80% of individuals with a cobalt sensitivity

have a co-sensitivity to chromate (more
common in men) or nickel (more common in
women)

• Exposure through jewelry snaps, buttons, tools,

cosmetics, hair dyes, joint replacements,
ceramics, enamel, cement, paints , and resins
 Bacitracin
• Topical antibiotic with activity
against Gram-positive bacteria and
spirochetes

• Commonly used in combination

with other antibiotics such as
neomycin and with corticosteroids

Chronic ulcerations on the lower extremity are particularly likely to

• In addition to ACD, also rarely develop allergic contact dermatitis. This eruption resulted from
sensitization to bacitracin. www.worldallergy.org
causes anaphylaxis and contact
urticaria
 Systemic Contact Dermatitis
• Systemic exposure to a chemical may
result in a diffuse dermatitis

• Patient has had a prior contact

allergy and then becomes exposed
through a systemic route, such as
injection, oral, intravenous, or
intranasal administration

• One of most common examples is

patient with ethylenediamine allergy
and subsequent reaction to
aminophylline
55-year-old farm worker developed a chronic allergic contact
dermatitis to airborn allergens (compositae).
Patch test:
1. A patch test relies on the principle of a type IV hypersensitivity reaction.

2. When the skin is exposed to an allergen, the antigen presenting cells (APCs) -
also known as Langerhans cell or Dermal Dendritic Cell - eat up substance
(phagocytoze) and break it into smaller pieces. his is where a substance is
recognized by immune cells in the skin.

3. They then put parts of the substance onto their surface (technically holds the
part of the molecule on the surface in the major histocompatibility complex type
two (MHC-II).

4. Once this is done the APC moves down the lymphatic system to a lymph node
where it presents this part of the substance (what we now call an antigen) to a
particular immune cell called a CD4+ T-cell or T-helper cell.
5.The T-cell, if it recognizes the substance as dangerous, expands in number
and sends out more of itself to the skin, at the site of antigen exposure.

6. When the skin is again exposed to the antigen, the memory t-cells in the
skin recognize the antigen and produce cytokines (chemical signals)
which cause more T-cells to migrate from blood vessels. This starts a
complex immune cascade leading to skin inflammation, itching and the
typical rash of contact dermatitis.

7.In general, it takes 2 to 4 days for a response in patch testing to develop. The
patch test is really just induction of a contact dermatitis in a small area
Interestingly, the size of the molecule necessary to be picked up and
recognized is ten times the size of the largest molecule that can pass
through the skin. Therefore, it is likely that an antigen (like nickel) when it
has passed through the skin, combines with something else before it is
recognized.