Skin Allergies

Clinical

History: A detailed history, both before and after patch testing, is crucial in evaluating individuals with ACD. Potential causes of ACD and the materials to which individuals are exposed should be patch tested. Patients with ACD require a much more detailed history compared to those with most other dermatologic disorders.

History is equally important after patch testing. Only history and questioning can determine whether the materials to which a patient is allergic are partly or wholly responsible for the current dermatitis. A positive patch reaction may indicate only a sensitivity and not the cause of current dermatitis.

• Preexisting skin diseases

   

  • Individuals with stasis dermatitis are at high risk for developing ACD to materials and agents applied to the areas of stasis dermatitis and leg ulcers. Neomycin is an important cause of ACD in these individuals because it is used frequently despite the lack of documentation of its efficacy in the treatment of stasis ulcers.

     

  • Individuals with otitis externa frequently are allergic to topical neomycin and topical corticosteroids.

     

  • Individuals with pruritus ani and pruritus vulvae may become sensitized to benzocaine and other medications applied to chronic pruritic processes.

     

  • Women with lichen sclerosus et atrophicus frequently develop ACD, complicating the severe chronic vulvar dermatosis. Patch testing these patients may provide important information that can help in the management of recalcitrant and difficult-to-manage dermatosis.

• Atopic dermatitis

   

  • Patients with a history of atopic dermatitis are at increased risk for developing nonspecific hand dermatitis and irritant contact dermatitis.

     

  • Patients with a history of atopic dermatitis do not appear to be at an increased risk for ACD, despite the wide range of topical medications and moisturizers used by individuals with chronic atopic dermatitis.

     

  • Patients with atopic dermatitis are at lower risk of ACD to poison ivy.

     

  • Some European studies indicate that patients with atopic dermatitis may have increased incidence of ACD to nickel.

• Onset of symptoms

• Eyelid dermatitis: Individuals may develop dermatitis on eyelids and other exposed skin following exposure to airborne allergens.

• Contact urticaria

• Occupational dermatitis: Contact dermatitis is 1 of the 10 leading occupational illnesses. It may prevent individuals from working. The hands are the sites exposed most intensely to contact allergens and irritants, both at work and at home. The hands are crucial for performing many work-related tasks. ACD in response to workplace materials may improve initially on weekends and during holidays, but individuals with chronic dermatitis may not demonstrate the classic history of weekend and holiday improvement. Irritant contact dermatitis is more likely if multiple workers are affected in the workplace. Most allergens rarely sensitize a high percentage of the population.

• Hobbies: Hobbies may be the source of ACD, eg, woodworking with exotic tropical woods or processing film using color-developing chemicals that may provoke cutaneous lesions of lichen planus from direct skin exposure.

• Medications: Self-prescribed and physician-prescribed medications are important causes of ACD. The workplace nurse may dispense ineffective and sensitizing topical preparations, such as Merthiolate, which may change a simple abrasion into a severe case of ACD. Individuals may develop allergy to preservatives in medications and/or to the active ingredients in topical medications, especially neomycin and topical corticosteroids.

• Iatrogenic adverse effects: Chronic use of systemic corticosteroids to treat ACD may produce severe morbidity. Individuals with ACD should not receive chronic systemic corticosteroids or immunosuppressives, unless extensive patch testing and evaluation have failed to identify remedial causes of the severe dermatitis. Chronic widespread use of potent topical corticosteroids may produce local skin atrophy and systemic adverse effects.

Physical: Acute ACD is characterized by pruritic papules and vesicles on an erythematous base. Lichenified pruritic plaques may manifest chronic ACD. Occasionally, ACD may affect the entire integument (ie, erythroderma, exfoliative dermatitis). The initial site of dermatitis often provides the best clue regarding the potential cause of ACD.

• Hands: Hands are an important site of ACD, particularly in the workplace. Common causes of allergic dermatitis on the hands include the chemicals in rubber gloves.

• Perianal: ACD is frequent in the perianal area as a result of the use of sensitizing medications and remedies (eg, topical benzocaine).

• Otitis externa: Topical medications are important causes of ACD in cases of otitis externa.

• Airborne ACD: Chemicals in the air may produce airborne ACD. This dermatitis usually occurs maximally on the eyelids, but it may affect other areas exposed to chemicals in the air, particularly the head and the neck.

• Ophthalmologic: Allergy to chemicals in ophthalmologic preparations may provoke dermatitis around the eyes.

• Hair dyes: Individuals allergic to hair dyes typically develop the most severe dermatitis on the ears and adjoining face rather than on the scalp.

• Stasis dermatitis and stasis ulcers: Individuals with stasis dermatitis and stasis ulcers are at high risk for developing ACD to topical medications applied to inflamed or ulcerated skin (see Image 1). The chronicity of this condition and the frequent occlusion of applied medications contribute to the high risk of ACD to medicament (eg, neomycin) in these patients. Individuals may develop widespread dermatitis from topical medications applied to leg ulcers or from cross-reacting systemic medications administered intravenously. For example, a patient allergic to neomycin may develop systemic contact dermatitis if treated with intravenous gentamicin.

• Erythema multiforme: Erythema multiforme (EM) is a severe cutaneous reaction with targetoid lesions that occurs primarily after exposure to certain medications or is triggered by infection, most commonly by herpes simplex virus. Rare cases of EM have been reported after ACD resulting from exposure to poison ivy, tropical woods, nickel, and hair dye (see Image 2).

Causes: Approximately 25 chemicals appear to be responsible for as many as one half of all cases of ACD.

• Poison ivy is the classic example of acute ACD in North America. ACD from poison ivy is characterized by linear streaks of acute dermatitis that develop where plant parts have been in direct contact with the skin.

• Nickel is the leading cause of ACD in the world. ACD to nickel typically is manifested by dermatitis at the sites where earrings or necklaces (see Image 3) containing nickel are worn or where metal objects containing nickel are in contact with the skin. Nickel may be considered a possible occupational allergen. Workers in whom nickel may be an occupational allergen primarily include hairdressers, retail clerks, caterers, domestic cleaners, and metalworkers. Individuals allergic to nickel occasionally may develop vesicles on the sides of the fingers (dyshidrotic hand eczema or pompholyx) from nickel in the diet.

• Allergy to 1 or more chemicals in rubber gloves is suggested in any individual with chronic hand dermatitis who is wearing them, unless patch testing demonstrates otherwise. ACD to chemicals in rubber gloves typically occurs maximally on the dorsal aspects of the hand. Usually, a cutoff of dermatitis occurs on the forearms where skin is no longer in contact with the gloves. Individuals allergic to chemicals in rubber gloves may develop dermatitis from other exposures to the chemicals (eg, under elastic waistbands).

• Individuals allergic to dyes and permanent press and wash-and-wear chemicals added to textiles typically develop dermatitis on the trunk, which occurs maximally on the lateral sides of the trunk but spares the vault of the axillae. Primary lesions may be small follicular papules or may be extensive plaques. Individuals in whom this ACD is suggested should be tested with a series of textile chemicals, particularly if routine patch testing reveals no allergy to formaldehyde. New clothing is most likely to provoke ACD, since most allergens decrease in concentration in clothing following repeated washings.

• Preservative chemicals added to cosmetics, moisturizers, and topical medications are major causes of ACD (see Image 4). The most widely used preservatives include parabens, which are not a frequent cause of ACD despite their wide use. The risk of ACD appears to be highest to quaternium-15, followed by ACD to isothiazolinones (Kathon CG).

• Formaldehyde is a major cause of ACD (see Image 5). Certain preservative chemicals widely used in shampoos, lotions, other moisturizers, and cosmetics are termed formaldehyde releasers (ie, quaternium-15 [Dowicil 200], imidazolidinyl urea [Germall 115]).

• Individuals may develop allergy to fragrances. Fragrances are found not only in perfumes, colognes, aftershaves, deodorants, and soaps, but also in numerous other products, often as a mask to camouflage an unpleasant odor. Unscented products may contain fragrance chemicals used as a component of the product and not labeled as fragrance. Individuals allergic to fragrances should use fragrance-free products. Unfortunately, the exact chemicals responsible for a fragrance in a product are not labeled. Four thousand different fragrance molecules are available to formulate perfumes. The fragrance industry is not required to release the names of ingredients used to compose a fragrance, even when individuals develop ACD to fragrances found in topical medications. Deodorants may be the most common cause of ACD to fragrances because they are applied to occlude skin. They often abrade in American women.

   

• Massage and physical therapists and geriatric nurses are at higher risk of occupational ACD to fragrances.

• In the last decade, it has become clear that many individuals with chronic dermatitis develop allergy to topical corticosteroids. Most affected individuals can be treated with some topical corticosteroids, but an individual can be allergic to all topical and systemic corticosteroids. Budesonide and tixocortol pivalate are useful patch test corticosteroids for identifying individuals allergic to topical corticosteroids.

• The risk of allergy to neomycin is related directly to the extent of its use in a population. The risk of allergy to neomycin is much higher when it is used to treat chronic stasis dermatitis than when it is used as a topical antibiotic on cuts and abrasions in children. Assume that individuals allergic to neomycin are allergic to chemically related aminoglycoside antibiotics (eg, gentamicin, tobramycin). Avoid these drugs both topically and systemically in individuals allergic to neomycin.

• Avoid topical use of benzocaine. Benzocaine is included in most standard patch test trays. Individuals allergic to benzocaine may safely use or be injected with Xylocaine, which does not cross-react with benzocaine.

• Many individuals complain of adverse reactions to sunscreens, but many of these individuals are not allergic to the sunscreen materials. They may be allergic to preservatives in these products (see Image 4) or may have nonspecific cutaneous irritation from these products.

• Occasionally, individuals develop photo ACD. ACD may be accentuated by ultraviolet (UV) light, or patients may develop an allergic reaction only when a chemical is present on the skin and when the skin is exposed sufficiently to ultraviolet light A (UV-A; 320-400 nm).

Differentials

Asteatotic Eczema
Atopic Dermatitis
Berloque Dermatitis
Contact Dermatitis, Irritant
Cutaneous T-Cell Lymphoma
Dermatomyositis
Drug-Induced Bullous Disorders
Drug-Induced Photosensitivity
Erythema Multiforme
Folliculitis
Id Reaction (Autoeczematization)
Intertrigo
Lichen Nitidus
Lichen Simplex Chronicus
Nummular Dermatitis
Onycholysis
Perioral Dermatitis
Phytophotodermatitis
Pigmented Purpuric Dermatitis
Prurigo Nodularis
Seborrheic Dermatitis
Stasis Dermatitis
Tinea Corporis
Tinea Cruris
Tinea Pedis
Transient Acantholytic Dermatosis
Urticaria, Contact Syndrome

Other Problems to be Considered:

Mycosis fungoides

Workup

Lab Studies:

• Potassium hydroxide preparation and/or fungal culture to exclude tinea are often indicated for dermatitis of the hands and feet.

Procedures:

• Patch testing

• Repeat open application test: For individuals who develop weak or 1+ positive reactions to a chemical, the repeat open application test (ROAT) is useful in determining whether the reaction is significant. ROAT is most useful when an individual has a 1+ reaction to a chemical found in a leave-on consumer product. For example, an individual with a weak reaction to a preservative found in a moisturizer may apply the moisturizer twice a day for a week to the side of the neck or behind an ear. If the individual applies it twice a day for a week without developing clinical dermatitis, the 1+ reaction likely was not meaningful. Conversely, if the individual develops dermatitis following a few days of repeated application of the suspected product, then the weak patch test reaction is highly relevant.

• Dimethylgloxime test: The dimethylgloxime test is a useful and practical way to identify metallic objects that contain enough nickel to provoke allergic dermatitis in individuals allergic to nickel. Dermatology staff may test suspected metal products in the office, or the individual may purchase a test kit and test objects at home or at work, particularly jewelry or metallic surfaces. Other chemical tests are available for other suspected allergens (eg, formaldehyde, chromate). Occasionally, chemical analyses may be necessary to determine whether a material contains a suspected allergen or to identify new unknown allergens.

• Skin biopsy may help exclude other disorders, particularly tinea, psoriasis, and cutaneous lymphoma. Skin biopsy of skin lesions of the palms and soles has several potential pitfalls, which include the following:

   

  • The stratum corneum and epidermis are particularly thick on the palms and soles. This makes the histologic diagnosis of psoriasis more difficult and increases the possibility that the biopsy specimen will lack sufficient dermis for optimal diagnosis.

     

  • An overly deep skin biopsy of the thenar area can cut the motor nerve, which is the recurrent branch of the median nerve.

     

  • A biopsy from the sole may leave a chronic painful scar on which the patient must walk.

Histologic Findings: Histology of ACD is similar to that found in other forms of eczematous dermatitis. A pattern of subacute chronic dermatitis or acute dermatitis may be seen. The inflammatory infiltrate in the dermis predominately contains lymphocytes and other mononuclear cells. Epidermal edema (ie, spongiosis and microvesicle formation) may be seen, but these changes may be absent in long-standing dermatitis in which thickening of the epidermis (acanthosis) with hyperkeratosis and parakeratosis may be seen in the epidermis and stratum corneum. ACD is provokes atypical T-cell infiltrates, simulating mycosis fungoides.

Treatment

Medical Care: The cause of ACD must be identified; otherwise, the patient is at increased risk for chronic or recurrent dermatitis. The Contact Allergan Replacement Database of the American Contact Dermatitis Society allows the physician to create a list of products free of allergens to which the patient is allergic.

• Symptomatic treatment

   

  • Cool compresses with saline or aluminum acetate solution are helpful for acute vesicular dermatitis (eg, poison ivy).

     

  • Some individuals with widespread vesicular dermatitis may obtain relief from lukewarm oatmeal baths.

     

  • Sedating oral antihistamines may help diminish pruritus.

     

  • Patients should avoid using topical antihistamines, including topical doxepin, because of the apparently high risk of iatrogenic ACD to these agents.

• Corticosteroids

• Topical immunomodulators: Topical immunomodulators (TIMs) are approved for atopic dermatitis and are prescribed for cases of ACD when they offer safety advantages over topical corticosteroids. TIMs do not cause cutaneous atrophy or glaucoma or cataracts when applied near the eye. Pimecrolimus (Elidel cream) is a topical treatment often helpful for ACD of the face. Tacrolimus (Protopic 0.1% ointment) appears to be the most helpful TIM for ACD of the hands.

   

• Psoralen plus UV-A: Individuals with chronic ACD that is not controlled well by topical corticosteroids may benefit from psoralen plus UV-A (PUVA) treatments.

• Immunosuppressive agents: Rarely, chronic immunosuppressive agents, such as azathioprine (Imuran) or cyclosporine (Neoral), are used in recalcitrant cases of severe chronic widespread ACD or severe hand dermatitis that prevents the individual from working or performing daily activities. Biologicals active on T cells may be helpful in the future.

• Disulfiram: Occasionally, an individual who is highly allergic to nickel with severe vesicular hand dermatitis benefits from treatment with disulfiram (Antabuse). The chelating effect of disulfiram is helpful in reducing the body's nickel burden. Alcohol ingestion may produce severe adverse reactions in patients taking disulfiram.

Consultations: Many primary care physicians treat individuals with typical poison ivy dermatitis who respond well to a 2-week treatment course using topical or systemic corticosteroids and subsequently avoid poison ivy and related plants. Acute dermatitis that resolves with short-term treatment does not require further evaluation. Individuals with chronic dermatitis, particularly if it possibly is related to work, require detailed history and patch testing to standard screening sets and additional allergens as indicated by history, occupation, hobbies, and results on initial patch testing.

Diet: Some chemicals tested by the TRUE test may be present in the diet. Individuals with severe dermatitis, particularly if it is a disabling vesicular dermatitis of the hands, may be treated with diets low in minerals and chemicals to which the individual is allergic. A low-nickel diet is the most common, but published diets are available that are low in chromate, cobalt, or balsam of Peru. These diets may be attempted for the occasional allergic patient with severe chronic vesicular dermatitis.

Activity: Individuals with severe acute ACD may be incapacitated temporarily and unable to work. Most individuals with ACD may require light duties or restrictions of duties. They should avoid further contact with the chemicals to which they are allergic or chemicals that cross-react with these materials. Patients also should minimize exposure to irritant chemicals, particularly if the dermatitis is active or recently resolved. They should use mild cleansing agents on the skin, such as Aquanil, Cetaphil cleanser, or Oilatum-AD, and should apply bland protective emollients, such as SBR Lipocream, Cetaphil cream or Neutrogena hand cream, to help minimize relapse of ACD or development of irritant contact dermatitis of ceramide cream (eg, Impruv).

Medication

The goal of pharmacotherapy is to reduce morbidity and to prevent complications. Topical glucocorticosteroids are the mainstay of therapy. When choosing a topical glucocorticosteroid, match the potency to the location of the dermatitis and the vehicle to the morphology (ointment for dry scaling lesions; lotion or cream for weeping areas of dermatitis).

For severe acute ACD (eg, rhus dermatitis, erythroderma), systemic glucocorticosteroids or other immunosuppressive medications may be needed.

In some cases, ACD may prove persistent despite avoidance of the allergen. In some of these cases (eg, nickel), ingestion of minute amounts of the allergen is believed to drive the process, and chelation therapy with disulfiram can be beneficial. In other instances, the cause of persistence remains enigmatic; many allergens penetrate through rubber gloves. PUVA can be helpful in these cases.

For details of some of these therapies, which are by no means all inclusive, see the drug tables below.

Drug Category: Topical immunomodulators -- These agents modify immune processes that promote inflammation.

Drug Category: Corticosteroids -- Have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.

Drug Category: Antihistamines -- Act by competitive inhibition of histamine at the H1 receptor. May control itching by blocking effects of endogenously released histamine. Have no effect in treating ACD beyond possibly decreasing pruritus via sedating effects.

Drug Category: Tricyclic antidepressants -- Used in contact dermatitis for its sedative and antihistaminic properties. May consider oral doxepin (10-25 mg at night in adults if other oral antihistamines are not helpful). Maximum dose is 75 mg/d PO for dermatoses. This is achieved by increasing the initial dosage gradually. Topical doxepin should be avoided because of the risk of iatrogenic ACD.

Drug Category: Chelation agents -- Although marketed as a treatment for alcoholism, disulfiram chelates nickel, which then is excreted in the urine. Lowering systemic levels of nickel has been reported to benefit individuals with pompholyx and demonstrated hypersensitivity to the metal. Consider this therapy only for severe disabling dyshidrosis refractory to all other treatment in a patient proven allergic to nickel who does not drink alcohol and who consents to regular blood tests to identify liver toxicity from the medication.

Follow-Up

Further Inpatient Care:

• Inpatient care rarely is required for ACD unless the dermatitis is so severe that patients cannot care for themselves. Examples may include severe ACD with marked eyelid swelling that impairs vision or severe ACD of the penis, which may impede urination. If patients develop chronic severe allergic reactions to their home or workplace, they may require a temporary change of environment until the cause of the dermatitis is identified.

Further Outpatient Care:

• Individuals may develop new allergies. An individual who develops a relapse or a worsening of the dermatitis may require further history and, possibly, further patch testing.

Deterrence/Prevention:

• To prevent recurrence of ACD, instruct patients thoroughly concerning allergen(s) and the types of products likely to contain allergen(s).

   

  • For many patients with allergic reactions to fragrances, preservatives, vehicles, and medicaments, reading cosmetic labels and package inserts of topical/systemic medicaments may be sufficient to avoid allergens.

     

  • For patients allergic to nickel, the dimethylgloxime test can alert them the presence of the metal.

     

  • For many other patients with allergic reactions to chemicals that are unlikely to be labeled on consumer products (eg, rubber accelerators), suitable allergen alternatives (eg, gloves specifically known to be accelerator free) must be provided by the practitioner.

• Many cases of ACD, especially of the hands, occur in the occupational setting. Proper worker education and hygiene may prevent allergic reactions. For example, glutaraldehyde is a known sensitizer with widespread use as a cold sterilizing agent in medicine and dentistry. Needless cases of ACD to this biocide occur because of the lack of proper education regarding the appropriate use of gloves and other barriers to cutaneous contact.

• Advise patients to avoid identified chemicals to which they are allergic to minimize the risk of relapse, the risk of chronic contact dermatitis, and the risk of adverse effects from chronic use of nonspecific suppressive treatments (eg, topical and systemic corticosteroids, cyclosporine).

Complications:

• Occasionally, ACD is complicated by secondary bacterial infection, which may be treated by the appropriate systemic antibiotic.

• Darkly pigmented individuals may develop areas of hyperpigmentation or hypopigmentation from ACD. Occasionally, they may develop depigmentation at sites of ACD to certain chemicals.

Prognosis:

• Individuals with ACD may have persistent or relapsing dermatitis, particularly if the material(s) to which they are allergic is not identified or if they continue to practice skin care that is no longer appropriate (ie, they continue to use harsh chemicals to wash their skin, they do not apply bland emollients to protect their skin).

• The longer an individual has severe dermatitis, the longer it is believed it will take the dermatitis to resolve once the cause is identified.

• Some individuals have persistent dermatitis following ACD, which appears to be true especially in individuals allergic to chrome.

• A particular problem is neurodermatitis (lichen simplex chronicus), in which individuals repeatedly rub or scratch an area initially affected by ACD.

• The TRUE test can provide accurate basic information on common allergens (T.R.U.E. TEST). The Contact Allergan Replacement Database of the American Contact Dermatitis Society is particularly valuable for allergens to topical skin care products (database restricted to American Contact Dermatitis Society members).

Patient Education:

• Patients have the best prognosis when they are able to remember the materials to which they are allergic and how to avoid further exposures.

• Provide patients with as much information as possible concerning the chemical to which they are allergic, including all known names of the chemical.

• Web sites, standard textbooks, and the TRUE test kit contain basic information about the chemicals.

• Susceptible individuals need to read the list of ingredients before applying American cosmetic products to their skin, since preservative chemicals are used widely in consumer, medical, and workplace products. The same chemical may have different names when used for consumer or industrial purposes.

• Provide pamphlets with color pictures of poison ivy to individuals allergic to the plant. The American Academy of Dermatology also has pamphlets on ACD and hand eczema.

• For excellent patient education resources, visit eMedicine's Skin, Hair, and Nails Center. Also, see eMedicine's patient education article Contact Dermatitis.

Caption: Picture 1. Chronic stasis dermatitis with allergic contact dermatitis to quaternium-15, a preservative in moisturizer. Allergic contact dermatitis produces areas of erythema in areas of atrophie blanche and varicose veins.

 

Picture Type: Photo

Caption: Picture 2. Erythema multiformelike reaction that developed acutely following hair dying

Picture Type: Photo

 

Caption: Picture 3. Allergic contact dermatitis to nickel in a necklace

Picture Type: Photo

 

Caption: Picture 4. Severe allergic contact dermatitis resulting from preservatives in sunscreen. Patch testing was negative to the active ingredients in the sunscreen. Picture Type: Photo Caption: Picture 5. Onycholysis developing from allergic contact dermatitis to formaldehyde used to harden nails Picture Type: Photo

Bibliographty

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• Cohen LM, Cohen JL: Erythema multiforme associated with contact dermatitis to poison ivy: three cases and a review of the literature. Cutis 1998 Sep; 62(3): 139-42[Medline].
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• Marks JG, Belsito DV, DeLeo VA, et al: North American Contact Dermatitis Group patch test results for the detection of delayed-type hypersensitivity to topical allergens. J Am Acad Dermatol 1998 Jun; 38(6 Pt 1): 911-8[Medline].
• Rajagopalan R, Anderson RT, Sarma S, et al: An economic evaluation of patch testing in the diagnosis and management of allergic contact dermatitis. Am J Contact Dermat 1998 Sep; 9(3): 149-54[Medline].
• Rietschel RL, Fowler JR Jr: Fisher's Contact Dermatitis . 5th ed. Lippincott, Williams & Wilkins: 2001.
• Shaffer MP, Belsito DV: Allergic contact dermatitis from glutaraldehyde in health-care workers. Contact Dermatitis 2000 Sep; 43(3): 150-6[Medline].
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DISCLAIMER: The information contained in this site is for educational purposes only, and should not be used as a substitute for personal care by a licensed physician. Please see your physician for diagnosis and treatment of any concerning symptoms or medical condition.

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