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Chapter 4: Allergic and Irritant Contact Dermatitis

Nathan Egge; Jake E. Turrentine; Ponciano D. Cruz,

ALLERGIC AND IRRITANT CONTACT DERMATITIS

Therapeutic Approach

Contact dermatitis (CD) is a common eczematous disorder caused by chemical contact with the skin and, rarely, a systemic reaction to an ingested contact allergen. Depending on the nature of the causative chemical, CD is either allergic (ACD) or irritant (ICD). Due to immune involvement, ACD has an incubation period of several hours to days, whereas ICD manifests almost immediately after exposure to the culprit chemical except in cases of cumulative irritant CD where exposure to the culprit chemical gradually and additively over months to years will manifest itself (eg, water). Effective treatment of CD depends on identifying and avoiding relevant chemicals. Patch testing may help diagnose ACD but is limited by the scope of allergens tested and the expertise and experience of the provider. Importantly, in the initial evaluation, contact urticaria should be excluded. Regardless of type of dermatitis, patients benefit from knowing the sources of the offending chemicals, alternative products they can substitute, and protective equipment they may use. While the treatments listed below may be used to help clear eruptions, it must be emphasized that continued exposure to offending chemicals can perpetuate the dermatitis. See Table 4-1.

Table 4-1Contact Dermatitis Treatment Table
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Table 4-1 Contact Dermatitis Treatment Table
MEDICATION NAME MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING AND SUPPLEMENTATION LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy
Highest potency corticosteroids Anti-inflammatory, immunosuppressant Clobetasol butyrate or propionate 0.05% cream/ointment Skin atrophy, telangiectasia, hypertrichosis, hypopigmentation; rarely ACD None IB1-3
Moderate-high potency corticosteroids Anti-inflammatory, immunosuppressant Triamcinolone 0.1% ointment, mometasone furoate 0.1% ointment, betamethasone valerate 0.1% cream, fluticasone propionate 0.05% cream

Skin atrophy, telangiectasia, hypopigmentation;

rarely ACD;

cataracts, glaucoma (if applied near eyes)

 None IB3-7
Calcineurin inhibitors Immunosuppressant Tacrolimus 0.1% ointment, pimecrolimus 1% cream Burning sensation, theoretical lymphoma risk None IB8-10
Emollients/emollient-containing cleansers Humectant, physical barrier Petrolatum or lipid-rich moisturizers; it may be helpful to substitute harsh soaps with emollient-containing cleansers (eg, emulsifying ointment, Cetaphil cleanser, eucerin cleanser, etc) ACD, ICD None

IV (ACD),

IB11,12 (ICD)
Barrier cream/gel Physical barrier Perfluoropolyether 5% gel, dimethicone 2% cream, stokoderm, taktosan, kerodex Exacerbation of skin irritation None IA13,14
Gloves Physical barrier Appropriate gloves should be selected for anticipated exposure (not all gloves confer protection to all chemicals) Exacerbation of skin irritation None IV15
Systemic Therapy
Corticosteroids Anti-inflammatory, immunosuppressant Prednisone PO starting at up to 1 mg/kg/d, then tapered over a specific duration or triamcinolone IM up to 1 mg/kg/d Weight gain, hyperglycemia, sleep disturbance, changes in energy level, osteopenia/osteoporosis, infection; glaucoma, cataracts; peripheral neuropathy; growth impairment; acne, striae; hyperlipidemia; GI ulcers and reflux For chronic use: blood pressure, body weight, blood glucose, and lipids (baseline, after 1 mo, then q2-3mo); baseline TB test; annual DEXA/bone marrow density; annual eye exam. Supplemental vitamin D 1200 IU and calcium 1000 mg/d; consider bisphosphonates; ...

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