Medication Summary
Therapy depends on the etiology and severity of contact dermatitis. Mild-to-moderate acute allergic contact dermatitis responds to topical care with astringents in a wet compress, topical corticosteroids, and systemic antipruritics. Acute severe allergic contact dermatitis with marked edema and bullae should receive the same treatment but may also require the addition of systemic corticosteroids.
Chronic allergic contact dermatitis should be treated with midpotency topical corticosteroids and general skin care with emollients.
Numerous emollients are available as creams, ointments, or lotions. Use ointments on dry or cracked skin and creams on inflamed or weeping lesions. Most patients prefer creams. These may be helpful in subacute and chronic contact dermatitis because they help add moisture to skin, minimize moisture loss, or both. Brand names include Eucerin, Lubriderm, Moisturel, and Vaseline Intensive Care, among many others.
Wet compresses with an astringent
Class Summary
These agents are used to reduce pain, pruritus, and serous drainage in acute weeping contact dermatitis.
Aluminum acetate solution (Burow solution, Domeboro)
Moist compresses are soothing, have a mild antipruritic effect, reduce serous drainage, and gently débride the wound. They are effective in the early stages of acute contact dermatitis when serous drainage is most severe.
Antihistamines
Class Summary
These agents may be used as adjunctive therapy to relieve pruritus. They are used to treat minor allergic reactions and anaphylaxis and may be used to pretreat patients with prior documentation of minor allergic reactions. These agents may control itching by blocking effects of endogenously released histamine.
Hydroxyzine HCl (Vistaril, Atarax)
Hydroxyzine antagonizes H1 receptors in the periphery. It may suppress histamine activity in subcortical region of the central nervous system. This agent is available in 10 mg/5 mL syrup and as 10- and 25-mg tablets.
Diphenhydramine (Benadryl, Allerdryl)
Diphenhydramine is used for symptomatic relief of allergic symptoms caused by released histamine.
Topical corticosteroids
Class Summary
These agents decrease the inflammatory reaction associated with allergic contact dermatitis.
Triamcinolone topical (Triderm, Kenalog)
Use ointments on dry or cracked skin and creams on inflamed or weeping lesions. Most patients prefer creams. A moderate-potency topical corticosteroid, triamcinolone is available in both ointment (0.1%) and cream (0.1% or 0.5%). This agent decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.
Hydrocortisone topical (Cortaid, Dermarest, Westcort)
Lower-potency topical steroids such as hydrocortisone are useful on the face and intertriginous areas.
Superpotent topical corticosteroids
Class Summary
Low- or moderate-strength topical corticosteroids are useless as therapy for moderate-to-severe allergic contact dermatitis. Superpotent topical corticosteroids, such as clobetasol propionate (Temovate) or betamethasone dipropionate (Diprolene), applied 2-3 times daily for 1-2 weeks may be effective in small areas of acute allergic contact dermatitis or in lichenified areas of chronic contact dermatitis.
Clobetasol propionate (Temovate)
Clobetasol decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Betamethasone dipropionate (Diprolene, Celestone, Luxiq)
Betamethasone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Systemic corticosteroids
Class Summary
These agents are reserved for severe cases of allergic contact dermatitis with involvement of more than 20% of the total body surface area (TBSA), significant bullae, or significant facial involvement. They have anti-inflammatory (glucocorticoid) and salt-retaining (mineralocorticoid) properties. Glucocorticoids cause profound and varied metabolic effects and modify the body's immune response.
Prednisone (Deltasone)
Approximately 7-10 d of therapy is usually adequate and does not require a tapering dosage schedule. Lesions occasionally recur following a course of therapy, and an additional few days of therapy may be required.
Prednisone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.
Prednisolone (Pedia-Pred, Delta-Cortef)
Prednisolone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.
Betamethasone (Betamethasone IM/PO, Betaject, Celestone)
In adolescents and adults, an alternative to oral therapy is an IM dose of betamethasone sodium phosphate (Celestone) mixed with triamcinolone (Kenalog). This provides rapid onset and prolonged action over 2-4 weeks.
Triamcinolone (Aristospan, Kenalog IV, Trivaris)
In adolescents and adults, an alternative to oral therapy is an IM dose of betamethasone sodium phosphate (Celestone) mixed with triamcinolone (Kenalog). This provides rapid onset and prolonged action over 2-4 weeks.
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Dry, fissured, pruritic eczema is frequently the result of excessive washing and very low humidity in cold climates. Irritant contact dermatitis is due to direct injury of the skin. In this patient, frequent handwashing and use of soap is the cause of damage to the protective layers of the upper epidermis. Patients should be educated about the cause of the dermatitis and instructed in methods of skin protection and care with emollients.
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Nickel is the most frequent contact allergen in females older than 8 years, and allergy occurs in as many as 25% of females 14 years or older. Allergens, such as nickel, are impossible to completely avoid. Exposure can be reduced with careful instruction, but occult exposures may produce chronic or recurrent symptoms. Nickel in the watch and watch band produced this episode of allergic contact dermatitis.
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Allergic reactions to rubber products are usually caused by antioxidants and accelerators added in the manufacturing process, rather than the rubber itself. Antioxidants help preserve the rubber, and accelerators help in the vulcanization process. Exposure to rubber in gloves, shoes, undergarments, tires, heavy-duty rubber goods, and sport goggles is common.
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The typical eruption from poison ivy includes erythema, edema, papules, vesicles, and bullae. Linear streaks as in this patient are characteristic but are not always present. Initial yellow crusts are dried serum from ruptured bullous lesions and not evidence of infection. Oleoresin (urushiol), which exudes from damaged areas of poison ivy, poison oak, and poison sumac, turns black after exposure to air. Fresh oleoresin on the skin dries and may be observed as black smudges or spots.
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When limes are squeezed into beverages, excess juice remains on the skin. Many other foods can cause similar reactions, i.e. the phytophotodermatitis. Sun exposure of this lime juice produces areas of dermatitis or hyperpigmentation. Perfumes are also common sources of photo contact dermatitis.
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Most common moisturizers contain various additives and preservatives. The list of ingredients on this bottle is not uncommon, and most of these agents are capable of causing allergic contact dermatitis. Patch testing with dilute concentrations of the individual ingredients can be used to identify the agent that is a problem for any particular patient.
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Areas of acute contact dermatitis respond well to cool compresses and wound care. Moist compresses are soothing, have a mild antipruritic effect, reduce serous drainage, and gently debride the wound. Clean water, isotonic sodium chloride solution, and Burow solution all can be used. Compresses should be kept moist at all times. Wet-to-dry compresses are painful and destroy fragile tissues. Following moist compress applications for 5-10 minutes, affected sites should be gently cleared of loose crusts and a thin coat of Vaseline or antibacterial ointment should be applied.
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Urticaria, also known as hives or whelps, involves edematous pale or pink plaques. Agents can produce urticaria by immunologic reactions, by nonimmunologic reactions, or by unknown mechanisms. Nonimmunologic reactions are most common. Other types of environmentally associated urticaria must be excluded. This is an example of cold urticaria produced by application of an ice cube to the dorsum of the arm.
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Prolonged use of moderate- to high-potency topical steroids may cause skin atrophy or steroid acne. This patient used a moderate-strength steroid, triamcinolone 0.1%, in this area for several weeks. Steroid acne, also called steroid rosacea, has a classic appearance with monomorphic erythematous papules. If the steroid is discontinued, the condition usually worsens. Patients must understand that symptoms worsen before they improve, and several weeks or months are required to taper off this steroid.
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This purpuric reaction was noted after application of eutectic mixture of local anesthetics (EMLA) for 1 hour. EMLA cream is widely used as a local anesthetic for superficial procedures. Blanching and redness are commonly observed side effects. Dramatic purpuric reactions to EMLA, as in this patient, have been reported. Patch test results in these patients with the individual ingredients of EMLA cream, EMLA cream itself, placebo cream, and Tegaderm are negative. Apparently, the purpuric reaction is not of an allergic nature, but the cream may have a toxic effect on the capillary endothelium.
