Allergic contact dermatitis

Essentials

  • It is often not possible to differentiate allergic contact dermatitis from other types of dermatitis on the basis of clinical presentation alone.
  • The diagnostic cornerstones are established contact allergy, clinical picture of an eczema and temporally-related exposure to the allergen in question.
  • The possibility of allergic contact dermatitis should be borne in mind where dermatitis is not resolving despite appropriate treatment.

Aetiology

  • Delayed cell-mediated allergy (skin contact allergy)
  • Usually results from a long-standing exposure.
  • The most common causative agents are nickel (picture 1) as well as perfumes and preservatives used in cosmetics and hygiene products.
  • Other causative agents include chemicals found in rubber, ingredients of plastics and glues (picture 2), chromium and cobalt compounds as well as ingredients used in skin care products.

Symptoms

  • The rash first appears at the site of exposure but may become more widespread (pictures 3 4).
  • After subsequent exposure, the symptoms will redevelop within 1–2 days and will gradually resolve as the exposure ceases.

Diagnosis

  • The site of the rash should prompt a suspicion of allergic contact dermatitis, particularly when located at the following sites:
    • armpits (deodorants)
    • hands and wrists (metal, leather, working tools, chemicals; picture 5).
  • Allergic dermatitis may, however, occur anywhere on the body. Typical sites include:
    • face (pictures 6 7) and neck (picture 8; skin care products, cosmetics)
    • waist (leather, metal; pictures 9 10)
    • gluteal cleft (haemorrhoid creams and suppositories)
    • thighs and legs (socks, rubber boots, topical treatments for leg ulcers)
    • feet (metals, rubber, leather, dyes, contact glue, chromium, antimycotics).

Investigations

  • Patch testing is usually not indicated if the history clearly identifies the causative allergen, for example nickel.
  • The diagnostics of skin contact allergy and allergic dermatitis use epicutaneous tests (patch testing 1), which demonstrate possible sensitisation to allergens.
  • However, a positive test result does not always prove the causal relationship with the patient’s dermatitis.
  • Testing is carried out and interpreted by a dermatologist.

Treatment

  • The definitive treatment of allergic contact dermatitis is the avoidance or removal of the allergen (personal protective equipment, changing substances or methods used at the workplace, change of employment).
  • Topical glucocorticoid creams
  • Immunosuppressive medication is used occasionally in chronic cases at the discretion of a dermatologist.
Topical treatment

  • Treatment of allergic hand dermatitis: see 2.
  • Moderately potent to potent glucocorticoid creams once or twice daily until the skin has healed, for 2–6 weeks as appropriate to the severity of dermatitis. A follow-up appointment is indicated if the condition has not resolved.
  • In acute vesicular dermatitis relief can often be obtained with moist compresses (10–20 minutes twice or thrice daily).

Systemic treatment

  • In cases of severe and spreading allergic dermatitis a short course of systemic glucocorticoids may be indicated, e.g. prednisolone 20–40 mg once daily for 1–2 weeks.
  • Antimicrobials are very rarely needed in allergic dermatitis, and they do not replace topical treatment. If the rash is clearly infected (picture 11), an antimicrobial may be indicated (cephalexin 500 mg three times daily for 7–10 days).

Immediate contact dermatitis

  • Based on an immediate, IgE-mediated allergy
  • Contact urticaria and protein contact dermatitis
  • Redness, pruritus and/or urticaria develop immediately (less than 30 minutes) at the site of the allergen contact. Allergens include natural rubber (latex), cat or dog (dander or hair), root and other vegetables.
  • Clearly more rare than allergic contact dermatitis, but in its chronic state its appearance may resemble that of allergic dermatitis.

Specialist consultation

  • Particularly severe and extensive cases as well as chronic forms of the conditions
  • Patch testing and the verification of diagnosis
  • A suspicion of occupational allergic contact dermatitis or hand dermatitis

References

1. Johansen JD, Aalto-Korte K, Agner T et al. European Society of Contact Dermatitis guideline for diagnostic patch testing - recommendations on best practice. Contact Dermatitis 2015;73(4):195-221.  [PMID:26179009]

2. Fonacier L, Bernstein DI, Pacheco K et al. Contact dermatitis: a practice parameter-update 2015. J Allergy Clin Immunol Pract 2015;3(3 Suppl):S1-39.  [PMID:25965350]

3. Boonstra MB, Christoffers WA, Coenraads PJ et al. Patch test results of hand eczema patients: relation to clinical types. J Eur Acad Dermatol Venereol 2015;29(5):940-7.  [PMID:25220568]


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TY - ELEC T1 - Allergic contact dermatitis ID - 454418 BT - Evidence-Based Medicine Guidelines UR - https://evidence.unboundmedicine.com/evidence/view/EBMG/454418/all/Allergic_contact_dermatitis PB - Duodecim Medical Publications Limited DB - Evidence Central DP - Unbound Medicine ER -