CASE

PRESENTATION
EZEKIEL ARTETA, M.D.
MARIA ANNA DE GUZMAN, M.D.

DEPARTMENT OF DERMATOLOGY
OSPITAL NG MAYNILA MEDICAL CENTER
GENERAL DATA
A.A.
60/F
Married
Malate, Manila
CHIEF COMPLAINT
Plaque
HISTORY OF PRESENT ILLNESS
Months PTC,
(+) recurrent colds
(+) consult at a public hospital, prescribed with unrecalled
oral medication for the colds, with good compliance

3 days PTC,
(+) recurrence of the colds
Self-medicated with a mentholated ointment (Tiger Balm)
(+) relief of the symptom






HISTORY OF PRESENT ILLNESS
2 days PTC,
(+) appearance of multiple, well-defined, vesicles with
erythematous base on her infranasal and upper lip areas.
(+) burning sensation, relieved by scratching
(+) persistence of colds, relieved by applying Tiger Balm

1 day PTC,
Lesion evolved into plaques, with crusting
(+) burning sensation

PAST MEDICAL HISTORY
(+) Hypertension, maintained on Amlodipine 10 mg OD
(+) Diabetes Mellitus, maintained on Metformin 500 mg
OD
(+) Stroke [2012, OMMC]
No bronchial asthma
No PTB
No allergies to food/drugs
PREVIOUS MEDICATION
HISTORY
Unrecalled oral medication TID for colds
Tiger Balm
Furosemide 40 mg OD
Propranolol 10 mg OD
Ferrous ascorbate + Folic acid 100mg/1.5 mg OD

FAMILY HISTORY
(+) Hypertension
(+) Diabetes Mellitus
(+) Bronchial asthma

PERSONAL/ SOCIAL HISTORY
Housewife
Non-smoker
Non-alcoholic beverage drinker
Denies illicit drug use
PHYSICAL EXAMINATION
(+) multiple, well-
defined, erythematous,
confluent plaques,
topped with excoriation,
crusting and erosion,
measuring 1x2 cm to
2x3 cm on the
infranasal and maxillary
area.
SALIENT FEATURES
Chief Complaint Plaques
History of Present
Illness
(+) recurrent colds
(+) use of mentholated ointment (Tiger balm)
(+) appearance of multiple, well-defined vesicles on
erythematous base on her infranasal and upper lip
areas, which evolved into plaques
(+) burning sensation
Past Medical
History
(+) HTN, (+) DM, (+) CVD
(-) BA, (-) PTB, (-) allergy to food and drugs
Family History (+) HTN, (+) DM, (+) BA
Physical
Examination
(+) multiple, well-defined, erythematous, confluent
plaques, topped with excoriation, crusting and
erosion, measuring 1x2 cm to 2x3 cm on the
infranasal and maxillary area
ERYSIPELAS
RULE IN RULE OUT
May affect any age group
Site of infection: facial (not
uncommon and may follow
rhinitis)
Common in
immunocompromised patients
(patient is elderly with DM and
HTN; s/p CVD)
PE: (+) multiple, well-defined,
erythematous, confluent
plaques

No known portals or source of
infection (trauma, underlying
dermatoses, surgical wound,
mucosal infection)
Absence of prodrome: Malaise,
anorexia, fever, chills usually
apparent before formation of
lesion
Negative lymphadenopathy
Characteristic PE: Red, hot,
edematous and shiny plaque,
and very tender area of skin of
varying size; borders usually
sharply defined, irregular, and
slightly elevated
TINEA FACIALIS
RULE IN RULE OUT
On PE: Well-circumscribed
macule to plaque of variable
size; elevated border, scaling is
often minimal but can be
pronounced, pink to red in color
More common in children
Absence of predisposing
factors: Animal exposure,
chronic topical application of
glucocorticoids

SEBORRHEIC DERMATITIS
RULE IN RULE OUT
Sharply-demarcated
erythematous plaques with
crusting on the face
Acute onset
Presented initially as vesicles
with burning sensation
Most commonly seen on the
butterfly area of the face,
forehead, eyebrows

ALLERGIC CONTACT
DERMATITIS
RULE IN RULE OUT
(+) history of application of a
mentholated ointment prior to
appearance of lesion
(+) multiple, well-defined,
erythematous, confluent
plaques with crusting on the
face
No history of atopy
Initially presented with vesicles
(+) burning sensation
Lesion confined to the site of
exposure; lesion does not
spread
IRRITANT CONTACT DERMATITIS
RULE IN RULE OUT
Onset of symptoms within
minutes to hours of exposure
Pain, burning, stinging or
discomfort exceeding pruritus
Well-defined, erythematous
Does not extend beyond the
site of exposure
Cannot be totally ruled out
DIAGNOSIS
Irritant Contact Dermatitis
secondary to Tiger Balm
PLAN
Discontinue offending agent
Rx:
Desloratadine 5 mg/tab, 1 tab OD prn
Triamcinolone acetonide 0.1% cream BID x 1 week
Mupirocin 2% ointment BID x 1 week (on erosions)
Mild soap
Advised
TCB after 1 week
DISCUSSION
IRRITANT CONTACT DERMATITIS
(ICD)
Accounts for
approximately 80% of
all contact dermatitis
ICD is the result of a
local toxic effect
when the skin comes
in contact with irritant
chemicals such as
soaps, solvents,
acids, or alkalis
This 37-year-old woman developed a contact irritant
dermatitis from obsessive-compulsive hand washing 20-
30 times a day. www.drmatlas.org
IRRITANT CONTACT DERMATITIS
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

EPIDEMIOLOGY OF ICD
The US Bureau of Labor
Statistics data show that
occupational skin diseases
accounted for 10% to 15% of
all occupational illnesses
High-risk occupations with
frequent irritant exposure in
caterers, furniture industry
workers, hospital workers,
hairdressers, chemical industry
workers, dry cleaners, metal
workers, florists, and
warehouse workers

EPIDEMIOLOGY OF ICD
Clinical manifestations of ICD are determined by:
Properties of the irritating substance
Host factors
Environmental factors including concentration, mechanical
pressure, temperature, humidity, pH, and duration of
contact
Cold alone may also reduce the plasticity of the horny
layer, with consequent cracking of the stratum corneum
Occlusion, excessive humidity, and maceration increase
percutaneous absorption of water-soluble substances


Bilateral shoe irritant dermatitis resulting from chronic occlusive footwear
EPIDEMIOLOGY OF ICD
Important predisposing characteristics of the individual
include:
Age, race, sex, pre-existing skin disease, anatomic region
exposed, and sebaceous activity
Both infants and elderly are affected more by ICD
because of their less robust epidermal layer
Patients with darkly pigmented skin seem to be more
resistant to irritant reactions
Other skin disease such as active atopic dermatitis may
predispose an individual to develop ICD
The most commonly affected sites are exposed areas
such as the hands and the face, with hand involvement in
approximately 80% of patients and face involvement in
10%

PATHOGENESIS OF ICD
Denaturation of epidermal keratins
Disruption of the permeability barrier
Damage to cell membranes
Direct cytotoxic effects


ACUTE IRRITANT CONTACT
DERMATITIS
Commonly seen in occupational accidents
Irritant reaction reaches its peak quickly, within minutes to
hours after exposure
Symptoms include stinging, burning, and soreness
Physical signs include erythema, edema, bullae, and possibly
necrosis
Lesions restricted to the area where the irritant or toxicant
damaged the tissue
Sharply demarcated borders and asymmetry pointing to an
exogenous cause
Most frequent irritants are acids and alkaline solutions


ACUTE DELAYED IRRITANT
CONTACT DERMATITIS
Delayed inflammatory response characteristic of certain
irritants such as anthralin, benzalkonium chloride, and
ethylene oxide
Visible inflammation is not seen until 8 to 24 hours after
exposure
Symptoms are more frequently burning rather than
pruritus
Sensitivity to touch and water are elicited
This form of ICD is commonly seen during diagnostic
patch testing


IRRITANT REACTION IRRITANT
CONTACT DERMATITIS
Type of subclinical irritant dermatitis in individuals
exposed to wet chemical environments such as
hairdressers, caters, or metalworkers
Characterized by scaling, redness, vesicles,
pustules, and erosions
Often begins under occlusive jewelry and then
spreads over the fingers to the hands and forearms
May simulate dyshidrotic 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

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,
ultraviolet and infrared radiation

Chloracne. Note heavy involvement of
retroauricular skin with comedones and
cysts
SUBJECTIVE OR SENSORY
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


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,
thickening, and increased
toughness

9 year old girl demonstrates a lichenified hyperpigmented
round plaque on the top of her thumb produced by chronic
thumbsucking. www.dermatlas.org
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

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