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SPECIAL REPORT
Dr Helen M. Horn
MD FRCP
Associate Specialist in
Dermatology
Department of
Dermatology, Royal
Infirmary of Edinburgh,
Edinburgh, UK
CONTACT DERMATiTiS
RESULTS FROM SKIN
CONTACT WITH AN
EXOGENOUS SUBSTANCE.
VARIANTS
The two most common variants are
irritant contact dermatitis (ICD) and
allergic contact dermatitis (ACD).
ICD is more common and has a worse
are the
management
options?
irritant contact dermatitis
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27
SPECIAL REPORT
CONTACT DERMATITIS
FIGURE 1 (LEFT)
Sensitisation phase
of allergic contact
dermatitis
FIGURE 2 (RIGHT)
Elicitation phase of
allergic contact
dermatitis
Hapten
Hapten
I
Allergen is
formed by
hapten-peptide
binding
/-i*r
T^^
Epidermal and
dermal dentritic
cells
Antigen complex is
transported to regional
lymph nodes by activated
dentritic cells
Hapten-specific
. , T cells form
(O) (O) and proliferate
Release of
inflammatory
mediators
Lymph node
Sources of exposure
" Can also cause airborne contact dermatitis $ Can also cause photocontact allergy
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COMMON CULPRITS
Irritants
FGURE3
Allergic contact dermatitis caused by flavouring agents
in toothpastes
FIGURE 4
Sparing of the finger webs suggests that this chronic eczema
might not be ICD. Patch testing is required
FIGURE 5
Linear streaks indicate that this bullous eruption was caused
by plants
'If eczema is
recurrent,
persistent, or
occurs in a patient
with no previous
history of eczema,
contact demratitis
should be
considered*
Sweat and caustic substances
trapped next to the skin by waterproof
gloves or protective clothing can all
cause ICD. Incontinent patients are at
risk of developing ICD of the perineum.
Cosmetics often contain abrasive
particles capable of inducing ICD.
Airborne irritants include abrasive dusts,
especially dry cement, as well as caustic
vapours. Organic solvents, acids and
alkalis, low humidity, heat and cold are
also important causes of ICD.
Allergens
FIGURE 6
Stasis eczema. Patch testing is indicated
INVESTIGATIONS
A careful history is important, enquiring
about exposure at work and at home,
hobbies, cosmetics and toiletries and
timing of the eruption.
29
SPECIAL REPORT
CONTACT DERMATITIS
FIGURE 7 (LEFT)
Exposed site
eczema,
Photosensitivity or
contact dermatitis?
FIGURE 8 (RIGHT)
Posterior auricular
involvement
suggests airborne
contact dermatitis,
in this case due to
an epoxy resin in a
floor-laying adhesive
Patch testing:
standardised
concentrations of
suspected culprits
are applied to
the skin under
occlusion and
left for 48 hours
MANAGEMENT
Accurate diagnosis, avoidance of
identified allergens and protection from
irritants are the key to successful
treatment, see table 2, below.
Patient information leaflets are
available from the British Association of
Dermatologists, see Useful information
box, p31. Formal hand dressings may be
key points
Dr Peter Saul
GP, Wrexham and Associate GP Dean for North Wales
'If contact
dermatitis
persists
a change of
occupation
maybe
necessary'
Patients with eczema that is in an
unusual distribution, recurrent or
persistent despite appropriate
management should be referred to
secondary care for investigation and
intensive treatment. Patch testing is
especially important for patients
suffering from chronic hand eczema,
facial or stasis eczema.
Treatments available in secondary
care include phototherapy, alitretinoin
for refractory hand eczema,''azathioprine
and ciclosporin. If contact dermatitis
persists a change of occupation may
be necessary.
Edinburgh. 2010
4 Ruzicka T, Lynde CW, Jemec GBE et al. Efficacy and
safety of oral alitretinoin C9-cis retinoic acid) in patients
with severe chronic hand eczema refractory to topicai
corticosteroids: results of a randomized, doube-blind.
placebo-controlled, multicentre trial. BrJ Dermatoi
2008;158(4):808-817
Useful information
British Association of Dermatologists
Patient information leaflets on hand
dermatitis and contact dermatitis
www.bad.org.uk
National Eczema Society
www.eczema.org
31
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