Contact Dermatitis

Contact dermatitis is caused from skin contact with a substance that causes a rash-like reaction. People react to a variety of chemicals, including cosmetics, hair dye, metals, topical medications and dental materials. An example of a contact dermatitis is a rash from poison ivy, which is an extremely itchy and appears as blisters that ooze and crust after contact with plants of the Toxicodendron family. A contact dermatitis rash may look like atopic dermatitis, but the rash is typically located only in the area of contact with the offending chemical. Common locations include the face, especially the eyelids, neck, hands and feet. Contact dermatitis to metals, such as in jewelry or snaps/buttons/zippers on clothing, commonly occurs on the neck, wrists/hands, earlobes and at the waistline.

An example of contact dermatitis is the reaction of a sensitive person's skin to poison ivy, oak or sumac. Contact with these plants, which contain a chemical called urushiol, produces an itchy rash, redness, blisters and scaling.

What are Some Common Causes of Contact Dermatitis? Along with the evaluation for contact dermatitis, which includes patch testing, a persons history of exposure to various chemicals can help to determine the cause of the rash. The most common patch test performed in the United States is the TRUE test, and is the only test FDA approved for the diagnosis of contact dermatitis. Avoidance information is available for the chemicals tested for in this panel. The most important aspect of the treatment of contact dermatitis involves avoidance of the trigger. Find out more about the treatment of contact dermatitis. Occupational. Occupational skin diseases are second only to traumatic injuries as the most common cause of job-related diseases. Approximately 40% of Workers Compensation cases involve skin problems, and up to 95% of these involve job-induced contact dermatitis. The most common jobs associated with contact dermatitis include:

Health professions (latex allergy) Food processors Beauticians/hairdressers Machinists

 Construction workers Contact dermatitis of the hands is the most common location of disease, and common causes include:

Carba mix Thiurams Epoxy resin Formaldehyde

Nickel Plants.Plants from the Toxicodendron family is the most common cause of allergic contact dermatitis, and includes poison ivy, poison oak and poison sumac. The rash from these plants results in a linear, or streak-like, group of itchy blisters or bumps. The chemicals released from the plants, called urushiols, cause the dermatitis. Urushiol can be carried on the fur of animals, garden tools, sports equipment and clothing. The smoke from burning Toxicodendron leaves can also carry urushiol. Other plants related to Toxicodendron may contain urushiol, and cause a similar contact dermatitis. These include: Mango skin Cashew nut oil Gingko leaves Japanese lacquer Indian marking ink Patch testing is not necessary for Toxicodendron plants, since this is diagnosis made with a consistent history and physical examination. Other causes of plant contact dermatitis include contact with the Peruvian lily, a common cause of hand dermatitis in flower workers, as well as seasonal contact dermatitis from exposure to airborne pollens. Patch testing may be performed with these plants, and cross-reactivity with fragrances (on the TRUE test) is common. Cosmetics. Cosmetic induced contact dermatitis is very common, since people may apply numerous chemicals to their skin, hair and scalp on a daily basis. Typically, the rash will occur on the skin where the cosmetic was applied, although sometimes the rash will occur on another part of the body (for example, reactions to nail polish may first cause an eyelid rash as a result of touching the eyelid). Fragrances appear to be an important and common cause of contact dermatitis. Rashes can appear on the neck in a pattern consistent with spraying perfume on the area. Patch testing to fragrance mix, found in the TRUE test panel, can help identify the cause and provide important information on avoidance. Avoiding fragrances can be difficult, and use of products labeled unscented can be misleading, as a masking fragrance may be added. It is better to use products labeled as fragrance-free, and are typically tolerated by people with fragrance-induced contact dermatitis. Hair products are another common cause of

contact dermatitis. Common chemicals includephenylenediamine in hair dyes, cocamidopropyl betaine in shampoos and bath products, and glyceryl thioglycolate in permanent wave solution. Of these, only phenylenediamine is tested for in the TRUE test panel. Reactions to acrylic coatings on fingernails are a common cause of contact dermatitis on the fingers, as well as on the face and eyelids. Many people who use cosmetics on their fingernails (artificial nails or coatings on natural nails) may touch their face and eyelids with their nails. Common chemicals include acrylates and formaldehyde-based resins. Sunscreens and sun blocks, also commonly found in various moisturizers and cosmetics, can result in facial contact dermatitis, with or without activation by sunlight. Some of the chemical-free sunscreens, containing physical blocking agents such as zinc oxide and titanium dioxide, are better tolerated by people with sunscreen-induced contact dermatitis. Topical Medications. Numerous topical medications can result in contact dermatitis when applied to the skin. These include:

lanolin, found in some moisterizers such as Eucerin topical antibiotics such as neomycin (Neosporin) and bacitracin para-aminobenzoic acid (PABA), found in some sunscreens anti-itch creams containing local anesthetics topical corticosteroids, such as hydrocortisone cream topical NSAIDs, such as Aspercreme

What is Contact Dermatitis? Contact dermatitis is an itchy, blistering skin rash typically caused by the direct contact of a substance with the skin. There are 2 types of contact dermatitis: irritant and allergic. This difference is often difficult to tell apart, and is not usually an important distinction to make. Contact dermatitis results in 5.7 million doctor visits each year in the United States, and all ages are affected. Females are slightly more commonly affected than males, and teenagers and middle-aged adults seems to be the most common age groups affected.

Contact dermatitis
Definition Contact dermatitis is an inflammation of the skin caused by direct contact with an irritating substance. See also: Poison ivy - oak - sumac

Alternative Names Dermatitis - contact; Allergic dermatitis; Dermatitis - allergic Causes Contact dermatitis is an inflammation of the skin caused by direct contact with an irritating or allergy-causing substance (irritant or allergen). Reactions may vary in the same person over time. A history of any type of allergies increases the risk for this condition. Irritant dermatitis, the most common type of contact dermatitis, involves inflammation resulting from contact with acids, alkaline materials such as soaps anddetergents, solvents, or other chemicals. The reaction usually resembles a burn. Allergic contact dermatitis, the second most common type of contact dermatitis, is caused by exposure to a substance or material to which you have become extra sensitive or allergic. The allergic reaction is often delayed, with the rash appearing 24 - 48 hours after exposure. The skin inflammation varies from mild irritation and redness to open sores, depending on the type of irritant, the body part affected, and your sensitivity. Overtreatment dermatitis is a form of contact dermatitis that occurs when treatment for another skin disorder causes irritation. Common allergens associated with contact dermatitis include: Poison ivy, poison oak, poison sumac Other plants Nickel or other metals Medications Antibiotics, especially those applied to the surface of the skin (topical) Topical anesthetics Other medications Rubber or latex Cosmetics Fabrics and clothing Detergents Solvents Adhesives Fragrances, perfumes Other chemicals and substances Contact dermatitis may involve a reaction to a substance that you are exposed to, or use repeatedly. Although there may be no initial reaction, regular use (for example, nail polish remover, preservatives in contact lens solutions, or repeated contact with metals in earring posts and the metal backs of watches) can eventually cause cause sensitivity and reaction to the product. Some products cause a reaction only when they contact the skin and are exposed to sunlight (photosensitivity). These include shaving lotions, sunscreens, sulfa ointments, some perfumes, coal tar products, and oil from the skin of a lime. A few airborne allergens, such as ragweed or insecticide spray, can cause contact dermatitis. Symptoms

Itching (pruritus) of the skin in exposed areas

Skin redness or inflammation in the exposed area Tenderness of the skin in the exposed area Localized swelling of the skin Warmth of the exposed area (may occur) Skin lesion or rash at the site of exposure

Lesions of any type: redness, rash, papules (pimple-like), vesic les, and bullae(blisters) May involve oozing, draining, or crusting May become scaly, raw, or thickened Exams and Tests The diagnosis is primarily based on the skin appearance and a history of exposure to an irritant or an allergen. According to the American Academy of Allergy, Asthma, and Immunology, "patch testing is the gold standard for contact allergen identification." Allergy testing with skin patches may isolate the suspected allergen that is causing the reaction. Patch testing is used for patients who have chronic, recurring contact dermatitis. It requires three office visits and must be done by a clinician with detailed experience in the procedures and interpretation of results. On the first visit, small patches of potential allergens are applied to the skin. These patches are removed 48 hours later to see if a reaction has occurred. A third visit approximately 2 days later is to evaluate for any delayed reaction. You should bring suspected materials with you, especially if you have already tested those materials on a small area of your skin and noticed a reaction. Other tests may be used to rule out other possible causes, including skin lesion biopsy or culture of the skin lesion (see skin or mucosal biopsy culture). Treatment Initial treatment includes thorough washing with lots of water to remove any trace of the irritant that may remain on the skin. You should avoid further exposure to known irritants or allergens. In some cases, the best treatment is to do nothing to the area. Corticosteroid skin creams or ointments may reduce inflammation. Carefully follow the instructions when using these creams, because overuse, even of low-strength over-the-counter products, may cause a troublesome skin condition. In severe cases, systemiccorticosteroids may be needed to reduce inflammation. These are usually tapered gradually over about 12 days to prevent recurrence of the rash. In addition to or instead of corticosteroid skin treatment, your doctor may prescribe tacrolimus ointment or pimecrolimus cream. Wet dressings and soothing anti-itch (antipruritic) or drying lotions may be recommended to reduce other symptoms. Outlook (Prognosis) Contact dermatitis usually clears up without complications within 2 or 3 weeks, but may return if the substance or material that caused

it cannot be identified or avoided. A change of occupation or occupational habits may be necessary if the disorder is caused by occupational exposure. Possible Complications Secondary bacterial skin infections may occur. When to Contact a Medical Professional Call your health care provider if symptoms indicate contact dermatitis and it is severe or there is no improvement after treatment. Prevention Avoid contact with known allergens. Use protective gloves or other barriers if contact with substances is likely or unavoidable. Wash skin surfaces thoroughly after contact with substances. Avoid overtreating skin disorders.

How is Contact Dermatitis Diagnosed? The diagnosis of contact dermatitis should be considered when a person has any acute or chronic rash that typically itches, but may also sting or burn. The rash classically has small blisters containing clear fluid, but can swell, crust, ooze or peel in other cases. The diagnosis is made with a patch test, which involves the placement of various chemicals on the back for approximately 48 hours (it is not the same as allergy testing). This typically is done with a paper tape system, such as the TRUE test. The TRUE test is the only FDA approved test for contact dermatitis in the United States, although some allergists and dermatologists will develop more extensive patch test panels with chemicals purchased from Canada or Europe. The results of the test are interpreted at 48 hours after placement, and again at 72 or 96 hours after placement. A positive test is confirmed when there are blisters, redness, and mild swelling at the site of the particular chemical in question. The site of the positive test usually itches, although the reaction size is typically limited to the site of contact, and therefore is usually smaller than a dime.

How is the Cause of Contact Dermatitis Determined? It may be difficult to determine the cause of contact dermatitis, since some common chemicals that cause contact dermatitis are found in many substances. For example, many perfumes, lotions, creams and other toiletries may contain various fragrances which cause contact dermatitis. It must be realized that a reaction can develop to a cosmetic, hair dye, toiletry or any other trigger even if the substance has been used for years without problems. A persons job or hobby may give clues to the cause of contact dermatitis. If a work trigger is

suspected, it is important to know the effects of vacation, weekends, and varied work schedules on the rash. Contact with chemicals in a hobby, such as painting, ceramics, photography, and gardening may be important clues. http://allergies.about.com/od/skinallergies/a/ski nallergyhub.htm

Contact Dermatitis When certain substances come into contact with your skin, they may cause a rash called contact dermatitis. Irritant contact dermatitis is often more painful than itchy, and is caused by a substance damaging the part of your skin it comes into contact with. The longer your skin is in contact with the substance, or the stronger the substance is, the more severe your reaction will be. These reactions appear most often on the hands and are frequently work-related. Allergic contact dermatitis is best known by the itchy, red, blistered reaction experienced after you touch poison ivy. This allergic reaction is caused by a chemical in the plant called urushiol. You can have a reaction from touching other items the plant has come into contact with. However, once your skin has been washed, you cannot get another reaction from touching the rash or blisters. Allergic contact dermatitis reactions can happen 24 to 48 hours after contact. Once a reaction starts, it takes 14 to 28 days to go away, even with treatment. Nickel, perfumes, dyes, rubber (latex) products and cosmetics also frequently cause allergic contact dermatitis. Some ingredients in medications applied to the skin can cause a reaction, most commonly neomycin, an ingredient in antibiotic creams. For irritant contact dermatitis, you should avoid the substance causing the reaction. You should also avoid spilling chemicals on your skin. Gloves can sometimes be helpful. Since these reactions are nonallergic, avoiding the substance will relieve your symptoms and prevent lasting damage to your skin. Treatment for allergic contact dermatitis depends on the severity of symptoms. Cold soaks and compresses can offer relief for the acute, early, itchy blistered stage of your rash. You may also be prescribed topical corticosteroid creams. To prevent the reaction from returning, avoid contact with the offending substance. If you and your allergist cannot determine the substance that caused the reaction, your allergist may conduct a series of patch tests to help identify it. http://www.aaaai.org/conditions-and-treatments/library/at-a-glance/allergic-skin-conditions.aspx

Contact dermatitis
Dermatitis - contact; Allergic dermatitis; Dermatitis - allergic Last reviewed: November 1, 2009. Contact dermatitis is an inflammation of the skin caused by direct contact with an irritating substance. See also: Poison ivy - oak - sumac

Causes, incidence, and risk factors

Contact dermatitis is an inflammation of the skin caused by direct contact with an irritating or allergy-causing substance (irritant orallergen). Reactions may vary in the same person over time. A history of any type of allergies increases the risk for this condition. Irritant dermatitis, the most common type of contact dermatitis, involves inflammation resulting from contact with acids, alkaline materials such as soaps and detergents, solvents, or other chemicals. The reaction usually resembles a burn. Allergic contact dermatitis, the second most common type of contact dermatitis, is caused by exposure to a substance or material to which you have become extra sensitive or allergic. The allergic reaction is often delayed, with the rash appearing 24 - 48 hours after exposure. The skin inflammation varies from mild irritation and redness to open sores, depending on the type of irritant, the body part affected, and your sensitivity. Overtreatment dermatitis is a form of contact dermatitis that occurs when treatment for another skin disorder causes irritation. Common allergens associated with contact dermatitis include: Poison ivy, poison oak, poison sumac Other plants Nickel or other metals Medications Antibiotics, especially those applied to the surface of the skin (topical) Topical anesthetics Other medications Rubber or latex Cosmetics Fabrics and clothing Detergents Solvents Adhesives Fragrances, perfumes Other chemicals and substances Contact dermatitis may involve a reaction to a substance that you are exposed to, or use repeatedly. Although there may be no initial reaction, regular use (for example, nail polish remover, preservatives in contact lens solutions, or repeated contact with metals in earring posts and the metal backs of watches) can eventually cause cause sensitivity and reaction to the product. Some products cause a reaction only when they contact the skin and are exposed to sunlight (photosensitivity). These include shaving lotions, sunscreens, sulfa ointments, some perfumes, coal tar products, and oil from the skin of a lime. A few airborne allergens, such as ragweed or insecticide spray, can cause contact dermatitis. Symptoms

Itching (pruritus) of the skin in exposed areas Skin redness or inflammation in the exposed area
Tenderness of the skin in the exposed area Localized swelling of the skin Warmth of the exposed area (may occur) Skin lesion or rash at the site of exposure Lesions of any type: redness, rash, papules (pimple-like), vesicles, and bullae (blisters) May involve oozing, draining, or crusting May become scaly, raw, or thickened Signs and tests The diagnosis is primarily based on the skin appearance and a history of exposure to an irritant or an allergen. According to the American Academy of Allergy, Asthma, and Immunology, "patch testing is the gold standard for contact allergen identification." Allergy testing with skin patches may isolate the suspected allergen that is causing the reaction.

Patch testing is used for patients who have chronic, recurring contact dermatitis. It requires three office visits and must be done by a clinician with detailed experience in the procedures and interpretation of results. On the first visit, small patches of potential allergens are applied to the skin. These patches are removed 48 hours later to see if a reaction has occurred. A third visit approximately 2 days later is to evaluate for any delayed reaction. You should bring suspected materials with you, especially if you have already tested those materials on a small area of your skin and noticed a reaction. Other tests may be used to rule out other possible causes, including skin lesion biopsy or culture of the skin lesion (see skin or mucosal biopsy culture). Treatment Initial treatment includes thorough washing with lots of water to remove any trace of the irritant that may remain on the skin. You should avoid further exposure to known irritants or allergens. In some cases, the best treatment is to do nothing to the area. Corticosteroid skin creams or ointments may reduce inflammation. Carefully follow the instructions when using these creams, because overuse, even of low-strength over-the-counter products, may cause a troublesome skin condition. In severe cases, systemiccorticosteroids may be needed to reduce inflammation. These are usually tapered gradually over about 12 days to prevent recurrence of the rash. In addition to or instead of corticosteroid skin treatment, your doctor may prescribe tacrolimus ointment or pimecrolimus cream. Wet dressings and soothing anti-itch (antipruritic) or drying lotions may be recommended to reduce other symptoms. Expectations (prognosis) Contact dermatitis usually clears up without complications within 2 or 3 weeks, but may return if the substance or material that caused it cannot be identified or avoided. A change of occupation or occupational habits may be necessary if the disorder is caused by occupational exposure. Complications Secondary bacterial skin infections may occur. Calling your health care provider Call your health care provider if symptoms indicate contact dermatitis and it is severe or there is no improvement after treatment. Prevention Avoid contact with known allergens. Use protective gloves or other barriers if contact with substances is likely or unavoidable. Wash skin surfaces thoroughly after contact with substances. Avoid overtreating skin disorders. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001872/

Contact dermatitis
From Wikipedia, the free encyclopedia

Contact dermatitis

Classification and external resources

Rash resulting from skin reactions. ICD-10 L25.9 ICD-9 692.9 DiseasesDB 29585 eMedicine emerg/131 ped/2569oph/480 MeSH D003877 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.
[edit]Symptoms

Contact dermatitis is a localized rash or irritation of the skin caused by contact with a foreign substance. Only the superficial regions of the skin are affected in contact dermatitis. Inflammation of the affected tissue is present in the epidermis (the outermost layer of skin) and the outer dermis (the layer beneath the epidermis).[1] Unlike contact urticaria, in which a rash appears within minutes of exposure and fades away within minutes to hours, contact dermatitis takes days to fade away. Even then, contact dermatitis fades only if the skin no longer comes in contact with the allergen or irritant.[2] Contact dermatitis results in large, burning, and itchy rashes, and these can take anywhere from several days to weeks to heal. Chronic contact dermatitis can develop when the removal of the offending agent no longer provides expected relief.
[edit]Causes

In North and South America, the most common causes of allergic contact dermatitis are plants of the Toxicodendron genus: poison ivy, poison oak, and poison sumac. Specific plant species that can induce such contact dermatitis include Western Poison Oak, a widespread plant in the western USA. [3] Common causes of irritant contact dermatitis are harsh (highly alkaline) soaps, detergents, and cleaning products.[4]

[edit]Types

There are three types of contact dermatitis: irritant contact dermatitis, allergic contact dermatitis, and photocontact dermatitis. Photocontact dermatitis is divided into two categories that is, phototoxic and photoallergic.
[edit]Irritant

contact dermatitis

Main article: Irritant contact dermatitis Irritant contact dermatitis can be divided into forms caused by chemical irritants and those caused by physical irritants. Common chemical irritants implicated include solvents (alcohol, xylene,turpentine, esters, acetone, ketones, and others); metalworking fluids (neat oils, waterbased metalworking fluids with surfactants); latex; kerosene; ethylene oxide; surfactants in topical medications and cosmetics (sodium lauryl sulfate); alkalies (drain cleaners, strong soap with lye residues). Physical irritant contact dermatitis may most commonly be caused by low humidity from air conditioning.[5] Also, many plants directly irritate the skin.
[edit]Allergic

contact dermatitis

Main article: Allergic contact dermatitis Although less common than ICD, ACD is accepted to be the most prevalent form of immunotoxicity found in humans.[6] By its allergic nature, this form of contact dermatitis is a hypersensitive reaction that is atypical within the population. The mechanisms by which these reactions occur are complex, with many levels of fine control. Their immunology centres around the interaction of immunoregulatory cytokines and discrete subpopulations of T lymphocytes. Allergens include nickel, gold, balsam of Peru (Myroxylon pereirae), chromium and the oily coating from plants of theToxicodendron genus: poison ivy, poison oak, and poison sumac.
[edit]Photocontact

dermatitis

Sometimes termed "photoaggravated",[7] and divided into two categories, phototoxic and photoallergic, PCD is the eczematous condition which is triggered by an interaction between an otherwise unharmful or less harmful substance on the skin and ultraviolet light (320-400 nm UVA) (ESCD 2006), therefore manifesting itself only in regions where the sufferer has been exposed to such rays. Without the presence of these rays, the photosensitiser is not harmful. For this reason, this form of contact dermatitis is usually associated only with areas of skin which are left uncovered by clothing, and it can be soundly defeated by avoiding exposure to sunlight.[8] The mechanism of action varies from toxin to toxin, but is usually due to the production of a photoproduct. Toxins which are associated with PCD include the psoralens. Psoralens are in fact used therapeutically for the treatment of psoriasis, eczema and vitiligo. Photocontact dermatitis is another condition where the distinction between forms of contact dermatitis is not clear cut. Immunological mechanisms can also play a part, causing a response similar to ACD.

[edit]Symptoms

Allergic dermatitis is usually confined to the area where the trigger actually touched the skin, whereas irritant dermatitis may be more widespread on the skin. Symptoms of both forms include the following: Red rash. This is the usual reaction. The rash appears immediately in irritant contact dermatitis; in allergic contact dermatitis, the rash sometimes does not appear until 2472 hours after exposure to the allergen. Blisters or wheals. Blisters, wheals (welts), and urticaria (hives) often form in a pattern where skin was directly exposed to the allergen or irritant. Itchy, burning skin. Irritant contact dermatitis tends to be more painful than itchy, while allergic contact dermatitis often itches. While either form of contact dermatitis can affect any part of the body, irritant contact dermatitis often affects the hands, which have been exposed by resting in or dipping into a container (sink, pail, tub, swimming pools with high chlorine) containing the irritant.
[edit]Treatment [edit]Self-care

at home

Immediately after exposure to a known allergen or irritant, wash with soap and cool water to remove or inactivate most of the offending substance. Weak acid solutions [lemon juice, vinegar] can be used to counteract the effects of dermatitis contracted by exposure to basic irritants. If blistering develops, cold moist compresses applied for 30 minutes 3 times a day can offer relief. Calamine lotion and cool colloidal oatmeal baths may relieve itching. Oral antihistamines such as diphenhydramine (Benadryl, Ben-Allergin) can also relieve itching. For mild cases that cover a relatively small area, hydrocortisone cream in nonprescription strength may be sufficient. Avoid scratching, as this can cause secondary infections. A barrier cream such as those containing zinc oxide (e.g. Desitin, etc.) may help to protect the skin and retain moisture.
[edit]Medical

care

If the rash does not improve or continues to spread after 2-3 of days of selfcare, or if the itching and/or pain is severe, the patient should contact a dermatologist or other physician or physician assistant. Medical treatment usually consists of lotions, creams, or oral medications. Corticosteroids. A corticosteroid medication similar to hydrocortisone may be prescribed to combat inflammation in a localized area. This medication may be applied to the skin as a cream or ointment. If the reaction covers a relatively large portion of the skin or is severe, a corticosteroid in pill or injection form may be prescribed. Antihistamines. Prescription antihistamines may be given if nonprescription strengths are inadequate.

[edit]Prevention

Since contact dermatitis relies on an irritant or an allergen to initiate the reaction, it is important for the patient to identify the responsible agent and avoid it. This can be accomplished by having patch tests, a method commonly known as allergy testing. The patient must know where the irritant or allergen is found to be able to avoid it. It is important to also note that chemicals sometimes have several different names.[9] In an industrial setting the employer has a duty of care to the individual worker to provide the correct level of safety equipment to mitigate the exposure to harmful irritants. This can take the form of protective clothing, gloves or barrier cream depending on the working environment. http://en.wikipedia.org/wiki/Contact_dermatitis
[edit]Summary

The distinction between the various types of contact dermatitis is based on a number of factors. The morphology of the tissues, the histology, and immunologic findings are all used in diagnosis of the form of the condition. However, as suggested previously, there is some confusion in the distinction of the different forms of contact dermatitis.[10] Using histology on its own is insufficient, as these findings have been acknowledged not to distinguish, [10] and even positive patch testing does not rule out the existence of an irritant form of dermatitis as well as an immunological one. It is important to remember, therefore, that the distinction between the types of contact dermatitis is often blurred, with, for example, certain immunological mechanisms also being involved in a case of irritant contact dermatitis.