[ECZEMA/DERMATITIS] August 24, 2015

INTRODUCTION
Eczema
and
dermatitisused
interchangeably
Polymorphic inflammatory reaction
pattern of the epidermis and dermis
Various etiologies and wide range of
clinical findings
Acute eczema/dermatitis vs chronic
eczema/dermatitis
CONTACT DERMATITIS
Generic term for acute or chronic
inflammatory reactions to substances
that come in contact with the skin
Irritant contact dermatitis (ICD)caused by chemical irritants
Allergic contact dermatitis (ACD)caused by antigen that elicits a type
IV hypersensitivity reaction
IRRITANT CONTACT DERMATITIS
Caused by exposure of the skin to
chemical/physical agents capable of
irritating the skin, acute or chronic
Severe irritants cause toxic reactions
even after a short exposure
Mostly caused by chronic cumulative
exposure to one or more irritants
Hands- most commonly affected
EPIDEOMOLOGY
o Most
common
form
of
occupational
skin
disease
(80%)
o ICD need not be occupational
and not occur in anyone being
exposed to a substance irritant
or toxic to the skin
o OCCUPATIONAL EXPOSURE
Housekeeping
Medical
Veterinary services
Floral arranging
Horticulture
Food preparation and
catering
Painting
Mechanical engineering
Car maintenance

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Construction; fishing
Hairdressing
Dental
Cleaning
Agriculture
Forestry
Printing
Metal work
ETIOLOGIC AGENTS: most common
irritants/Toxic agents
o Soaps, detergents, waterless
hand cleaners
o Acid and alkalis: hydrochloric
acid, cement, phosphorous,
ethylene oxide, phenol, metal
salts
o Industrial solvents: coal tar
solvents,
petroleum,
chlorinated
hydrocarbon,
alcohol
solvents,
ethylene
glycol ether, turpentine, ethyl
ether, acetone, carbon dioxide,
DMSO, dioxane, styrene
o Plants:
Euphorbiaceae
(spurges, crotons, poinsettias,
machneel tree). Racunculaceae
(buttercup), Cruciferae (black
mustard), Urticaceae (nettles),
Solanaceae (pepper,capsaicin),
Opuntia (priddy pear)
o Others: fiberglass, wool, rough
synthetic
clothing,
fireretardant fabrics, NCR paper
o LEAD TO CHEMICAL BURNS
AND
NECROSIS,
IF
CONCENTRATED
PREDISPOSING FACTORS
o Atopies with history of atopic
dermatitishighest
risk:
majority
of
workers
with
significant occupational ICD
are atopics
o Others
White skin
Climate (low humidity)
Mechanical irritation
Temperature (low)
Occlusion
PATHOGENESIS

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[ECZEMA/DERMATITIS] August 24, 2015

o

o
o
o

Chemical and physical irritants

cause cell damage if applied
for sufficient time and in
adequate concentration
Defense or repair capacity of
the skin is unable to maintain
normal skin integrity and
function
Penetration of chemical (s)
induces
an
inflammatory
response
Lesser irritants cause reaction
after prolonged exposure
Mechanisms in acute phase
of ICD
Direct cytotoxic damage
to keratinocytes
Mechanism of chronic phase
of ICD
Slow damage to cell
membranes, disrupting
the skin barrier leading
to protein denaturation
and cellular toxicity

ACUTE ICD
SYMPTOMS
o Subjective symptoms (burning,
stinging)
o Painful
sensations
within
seconds
after
exposure
(immediate-type stinging)
o Delayed-type stinging within 12 min, peaking at 5-10 min,
fading by 30 min
PHYSICAL EXAM
o SKIN FINDINGS
ACUTE
ICDsharply
demarcated
erythema
and superficial edema,
corresponding
to
application site of toxic
substance. Lesions dont
spread beyond the site
SEVERE
REACTIONvesicles
and
blisters
arise
within
erythematous
lesions
erosions & or necrosis
CONFIGURATIONSbizarre or linear

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ICD of back, acute: croton oil: erythema and

edema on the back at sites in contact with
the irritant in 30 year old male. Croton oil
was mistakenly used as a remedy for back
pain and rubbed into the skin. Note spared
areas where contact with the irritants and
had not occurred.
ICD of hand, acute: kerosene. This airport
worker hand repeatedly spilled kerosene
over his hands and developed acute bullous
and extremely painful ICD 24h later
Acute ICD following the application of a
cream containing and nicotinic acid.
___________ ii has been prescribed for lower
back pain. The steaky pattern indicates an
outside ich, the eruption is characterized
by massive erythematous vesiculation and
blister formation and is confined to the site
exposed to the toxic agents.
Acute ICD on the hand due to an industrial
solvents. There is massive blistering on the
palm.
Acute ICD in resolution. This is a florist who
had contact with croton, poinsettias, and
buttercup so that it could not be determined
which of these was the eliciting plant. Note
the steaky pattern of the eruption on the
lefty hand.
ICD on the dorsum of the hand due to
soluble oils.
ICD due to oxalic acid in a Dressmaker.
LESIONS AND SYMPTOMS
o DISTRIBUTION
Isolated, localized to one
region or generalized,
depending on contact
with toxic agent
o DURATION
Days, weeks depending
on tissue damage
o CONSTITUTIONAL SYMPTOMS
Usually none
Widespread acute ICD

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[ECZEMA/DERMATITIS] August 24, 2015

Acute
illness
syndrome
including fever.

CHRONIC ICD
PHYSICAL EXAMINATION
o SKIN FINDINGS
Dryness,
chapping,
erythema,
hyperkeratosis
and
scaling, fissures, and
crusting
Sharp
margination
ill-defined
borders,
lichenification
Irritant reaction ICD: also
vesicles, pustules, and
erosions
ICD of hand: subacute/chronic: Erythema,
edema, scaling, fissuring, crusting of the
palmar aspect of the hand and wrist: the
other hand had similar involvement. The
patient, a housewife, is atopic and has
ignored instructions to wear gloves during
work in the kitchen and to use lubricating
creams.
Subacute/chronic irritant contact dermatitis.
Erythema, edema, scaling, vesiculation in a
housewife with atopic dermatitis who had
ignored instructions to wear protective
gloves during work.
Chronic irritant contact dermatitis in a
housewife.
There
is
a
erythema,
hyperkeratosis,
scaling,
and
fissures
particularly on the fingertips in a patients
With an atopic background.
Early chronic irritant contact dermatitis in a
housewife. This has resulted from repeated
exposure to soaps and detergents. Note
glistening fingertips (pulpitis)
Chronic irritant contact dermatitis in a 50
year old housewife and farmer. Note edema,
thickening of the skin, lichenification, and
slight scaling.

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Chronic irritants dermatitis with acute

exacerbation in a housewife. The patient
had used turpentine to clean her hands
after a paint job. Erythema, fissuring, and
scaling. Differential diagnosis is allergic
contact dermatitis and palmar psoriasis.
Patch tests to turpentine were negative.
Chronic irritant contact dermatitis in a
construction worker. There is massive
hyperkeratosis and fissuring
Chronic irritant contact dermatitis in a
mechanic who came into repeated contact
with chlorinated hydrocarbons
DISTRIBUTION
o Usually on hands, starts at
finger web spaces, spreads to
sides and dorsal hands and
palms
o Rare in other locations e.g., in
violinists on mandible or neck,
or on exposed sites as in
airborne ICD
DURATION
o Chronic: months to years
Chronic irritants contact dermatitis in a
brick layer probably due to the corrosive
effects of cement. Patch testing for
chromatase
was
negative.
Note
hyperkeratosis and fissuring. Differential
diagnosis is palmar psoriasis.
SYMPTOMS
o Stinging and itching, pain as
fissures develop OR none
except when infection occurs
o Chronic ICD (e.g., hand) can
become a severe occupational
and emotional problem
LABORATORY EXAMINATION
o HISTOPATHOLOGY
Acute ICD:
Epidermal
cell
necrosis,
neutrophils,
vrsiculation, and
necrosis
o Chronic ICD

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[ECZEMA/DERMATITIS] August 24, 2015

Acanthosis,
hyperkeratosis,
lymphocytotic
infiltrate
o PATCH TESTS
Negative in ICD unless
allergic
contact
dermatitis is also present
DIAGNOSIS
AND
DIFFERENTIAL
DIAGNOSIS
o DIAGNOSIS
History
and
clinical
examination
(lesions,
pattern, site)

DDX

ACD
Palmoplantar
psoriasis
(palms and soles)
Photoallergic
contact
dermatitis
(exposed
sites)

Difference Between Irritant and Allergic Contact Dermatitis

IRRITANCT CD
ALLERGIC CD
SYMTOMS

Acute
Chronic

LESION

Acute

Chronic
MARGINATION AND Acute
SITE

EVOLUTION

Stinging, smarting Itching

or itching
pain
Itching pain
Itching/pain
Erythema
,
Papules, Vesicles,
Erosions,
Crust,
Scaling
Papules, plaques,
fissures,
Scaling,
Crust
Sharp,
strictly
confined to site of
exposure

Chronic

Ill-defined

Acute

Rapid (few hours

after exposure)

Chronic

Months to years of
repeated exposure

CAUSATIVE AGENT

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Dependent
on
concentration
of
agent and state of
skin barrier, occurs
only
above

Erythema
,
Papules, Vesicles,
Erosions,
Crust,
Scaling
Papules, plaques,
Scaling, Crust
Sharp, confined to
site of exposure
but spreading in
the
periphery;usually
tiny papules; may
become
generalized
Ill-defines, spread
Not so rapid (1272h
after
exposure)
Months or longer;
exacerbation alter
every reexposure
Relatively
independent
of
amount
applied,
usually very low
concentrations

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[ECZEMA/DERMATITIS] August 24, 2015

threshold level

INCIDENCE

May
occur
practically
everyone

COURSE AND PROGNOSIS

o Healing within 2 wks of
removal
of
noxious
stimuli
o Chronic cases heals in 6 weeks
o Occupational ICD
1/3 of cases have
complete
remission
May
require
allocation
to
another job
o Atopics
With
worse
prognosis
o Chronic subcritical levels
or irritant
Some
workers
develop tolerance
or hardening
MANAGEMENT
o PREVENTION
Avoid irritant or
caustic chemicals
by
wearing
protective clothing
(i.e.
goggles,
shields, gloves)
If contact occurs,
wash with water
or
weak
neutralizing
solution
Barrier creams
In
occupation
al ICD that
persists in
spite of the
adherence
to
the

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in

sufficient
but
depends
on
degree
of
sensitization
Occurs only in the
sentizied

above
measures,
change of
job may be
necessary.
TREATMENT
o ACUTE
Identify and remove
the etiologic agents
Wet dressing with
gauze
soaked
in
Burrows
solution
changed q 2-3h
Larger vesicles may
be drained but tops
shoud
not
be
removed
Topical
Class
I
glucocorticoids
preparations
In
severe
cases,
systemic
glucocorticoids
(Prednisone: 2 wk
course, 60 mg and
tampering by steps
of 10mg)
o SUBACUTE AND CHRONIC
Identify and remove
the etiologic agents
Potent
topical
glucocorticoid
preparation
and
adequate lubrication
As healing occurs,
continue lubricating
protective
cream
ointments
Chronic ICD of the
hands
Hardening
effect
by

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[ECZEMA/DERMATITIS] August 24, 2015

topical (soak
or
bath)PUVA therapy
Topical
antiinflammatory
agents
(pimecrolimus
and
tacrolimus)
still
being
evaluated

ALLERGIC CONTACT DERMATITIS

An eczematous dermatitis due to
re-exposure to a substance of
previously sensitized individuals
EPIDEMIOLOGY
o 7%
of
occupationally
related illness (US)
o Non-occupational ACD is
3X occupational ACD
o Age of onset
Uncommon in young
children and >70yrs
Occupation
One of the
most

important
causes
disability
industry

of
in

PATHOGENESIS
o SENSITIZATION
Strong sensitizer- in
a week or so
Weak
allergenmonths to years
o Ag taken up by Langerhans
cells
in
epidermis,
processed, migrates to the
draining LN
Ag with
MHC class II molecules
presented to T cells which
proliferate
sensitized T
cells enter circulation and
home to skin
o Langerhans cells with the
same
specific
Ag
sensitized T cells
(-)
cytokines, skin become
hypersensitive to contact
allergens,
will
react
wherever
the
specific
allergen is (+)

Top Ten Contact Allergens (North American Contact Dermatitis Group) and other
Common Contact Allergen
ALLERGENS
PRINCIPAL SOURCES OF CONTACT
Nickel sulfate
Metals, metals in clothing, jewelry,
catalyzing agents
Neomycin sulfate
Usually contained in creams, ointment
Balsam of Peru
Topical medication
Fragrance
Fragrance, cosmetics
Aerosol???
antiseptics
Sodium gold thiosulfate
Medication
Formaldehyde
Disinfectant, curing agents, plastics
Quarter????
Disinfectant
Cobalt chloride
Cement, galvanization, industrial oils,
cooling agents, eyeshades
Bacitracin
Ointment, powder
Methyldihydroxy?????

Preservative and cosmetics

PHYSICAL EXAMINATION
o SIN LESIONS
ACUTE

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[ECZEMA/DERMATITIS] August 24, 2015

Well demarcated erythema and edema on top of which are

closely spaced, non-umbilicated vesicles and /or papules
In severe reactions, bullae, confluent erosions exuding serum
and crusts
SUBACUTE
Erythematous plaques with small, dry, scale, sometimes
associated with small, red, pointed or rounded, firm papules
CHRONIC
Lichenified plaques, scaling with small satellite papules,
excoriations, erythema and pigmentation
LABORATORY EXAMINATIONS
o DERMATOPATHOLOGY
ACUTE
Inflammation
with
intraepidermal
intercellular
edema
(spongiosis), lymphocytes and eosinophils in E. monocytes and
histiocyte infiltration in D
CHRONIC
Spongiosis, acanthosis, elongation of rete ridges, elongation
and broadening of papillae, hyperkeratosis and lymphocytic
infiltrate
o PATCH TEST
(-) IN ACD
Should be delayed until the dermatitis has subsuded for at least 2
weeks and should be performed on a previously involved site.

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