Core Content In Urgent Care Medicine

Transcription

1 Contact Dermatitis Susan Nedorost, MD Associate Professor of Dermatology and Environmental Health Science Case Reserve University School of Medicine University Hospitals Case Medical Center Cleveland, Ohio Disclosure: Grant/Research Support from GoJo, Inc. and Lenzing Supported by an Educational Grant from Contact Dermatitis Modified from the AAMC s MedEd Portal with permission Lauren Y. Cao, B.S., Susan T. Nedorost, M.D. Disclosures Some of the patch tests discussed are not FDA approved Consultant for GoJo Inc, Akron OH Key Concepts Diagnosis of contact dermatitis without identification of cause is useless Directing patients to appropriate subspecialty care is a critical function of urgent care physicians Allergic contact dermatitis is curable, but often treated as a chronic disease Occupational contact dermatitis is an important cause of lost time Key Points Consider allergic contact dermatitis whenever prescribing or refilling corticosteroids Identification of allergens and effective patient education are CURATIVE Face, neck, hand dermatitis with adult onset is allergic contact dermatitis until proven otherwise Our Patient Skin Exam: Vesicles, itching, oozing, scaling and fissuring on his hands and forearms, ears and lateral neck History: 65 year old retired man No prior history of skin disease Applies triple antibiotic ointment and hand lotion to his hands and forearms Recently had an ear infection, applied triple antibiotic eardrops 1

2 Question: What are the differential diagnoses? Allergic contact dermatitis Irritant contact dermatitis Dyshidrotic eczema Cellulitis Fungal infection Herpes simplex Allergic Contact Dermatitis Ask for history of outdoor/gardening exposure Other than poison ivy, all causes of contact dermatitis require patch testing to confirm the diagnosis Poison Ivy Acute presentation with linear vesicles is diagnostic New lesions present for about one week Wash tools and clothes in hot soapy water If Treating Poison Ivy - Remember That This Is Type IV, Cell-mediated For mild itch (does not interfere with sleep or concentration) use Calamine lotion For severe itch, use systemic corticosteroids for days. Need daily dose of mg. Antihistamines are of no benefit in allergic contact dermatitis. Irritant contact dermatitis Very common co-morbidity; less common reason for presentation Acute irritant contact dermatitis presents with vesicles, and can be diagnosed by history of recent contact with strong acid or alkali Chronic irritant contact dermatitis from frequent handwashing or presents with thick scales, fissures, and no vesicles 2

3 Wintertime Irritant Dermatitis Treatment is hand care Reduce wet/dry cycles Eliminate occlusion (no band-aids; use cotton under vinyl gloves) Do not use topical corticosteroids Dyshidrotic Eczema Only affects lateral fingers and palms A second diagnosis would be needed for his dermatitis on the forearms, ears and lateral neck Cellulitis Common misdiagnosis Expect pain rather than itch Expect fever, increased wbc, malaise This photo shows allergic contact dermatitis, not cellulitis Herpes Simplex Infection: Never so confluent and widespread in an immunocompetent host Fungal Infection: Bullous tinea occurs most often on the feet In an immunocompetent patient, bullous tinea would not occur on forearms, ears and neck Contact Dermatitis Among top 20 reasons for a patient visit to the physician in the U.S. 1 Large economic impact in terms of lost productivity (days away from work, job change and retraining, unemployment), disability payments, and medical care 2 Significant effects on patients quality of life 3 3

4 Irritant Contact Dermatitis Direct chemical or physical insult 4,5 May affect any individual at any time, even upon first exposure Usually high irritant concentration 2 Allergic Contact Dermatitis Type 4 delayed T cellmediated hypersensitivity 4 Affects genetically predisposed individuals who have previously been sensitized to allergen(s) Very low concentration of allergen may elicit reaction 2 History Relevant to Contact Dermatitis Face +/- neck with hand involvement without childhood eczema is highly suggestive Ask about contactants: occupational, medicament, hobbies, personal care products Irritant Contact Dermatitis 6,8 Hours to one day from exposure to onset of symptoms Faster healing process after acute exposure Example: Repeated handwashing with water and strong soap Allergic Contact Dermatitis 7,8 Several days to one week from exposure to onset of symptoms Slower to begin healing upon allergen removal Example: Poison ivy Irritant vs. Allergic Contact Dermatitis Typical Clinical Presentation 9,10 Cannot differentiate irritant from allergic contact dermatitis on clinical presentation alone Patients can often self-diagnose irritant dermatitis based on exposure history, but not allergic contact dermatitis Common Contact Irritants 5,6,11 Hand dermatitis due to frequent wet work is most common irritant dermatitis; more severe in low humidity winter conditions Water, soaps, detergents, organic solvents High-grade irritants are less common usually cause clinical dermatitis within minutes to hours Strong acids and alkalis Common Contact Allergens Nickel [metal] 2. Neomycin [antibiotic] 3. Balsam of Peru [fragrance/flavor] 4. Fragrances 5. Quaternium-15 [formaldehydereleasing preservative in personal care products] 6. Gold [metal] 7. Formaldehyde [preservative] 8. Cobalt [metal] 9. Bacitracin [antibiotic] 10. Methyldibromoglutaronitrile/phenoxy-ethanol (MDGN/PE) [preservative] 11. Para-phenylenediamine (PPD) [hair dye] 12. Thiuram mix [rubber accelerator] 13. Chromate [metal] 14. Carba mix [rubber accelerator] 15. Diazolidinylurea [formaldehydereleasing preservative] 4

5 Metals 7,13,14 Nickel Most common contact allergen: present in jewelry, coins, paperclips, clothing snaps, etc. Ear piercing is a risk factor for nickel contact allergy Gold Cobalt Chromate Present in cement, welding, gloves and shoes (potassium dichromate used in leather tanning), etc. Topical Medicaments Topical antibiotics (e.g., neomycin, bacitracin) Topical corticosteroids (e.g., clobetasol, hydrocortisone) Topical anesthetics (e.g., benzocaine) Topical antihistamines (e.g., doxepin topical) Fragrances Ubiquitous presence in cosmetics, personal care and household products. 13,14 Patch test screening: Fragrance mix (eugenol, isoeugenol, cinnamic aldehyde, cinnamic alcohol, oak moss, geraniol, hydroxycitronella, α-amylcinnamic aldehyde) detects 70-80% of fragrance sensitive persons 18 Myroxylon pereirae (balsam of Peru) (cinnamic acid, cinnamic aldehyde, mythyl cinnamate, benzyl cinnamate, benzyl benzoate, benzoic acid, benzyl alcohol, vanillin) detects around 50% of fragrance sensitive persons 18 Newer screening agents Fragrance mix II (HMPPC, citral, farnesol, coumarin, citronellol, α- hexylcinnamic aldehyde) 18 Natural fragrance mix (jasmine absolute, ylang ylang, narcissus absolute, sandalwood oil, spearmint oil) 20 Preservatives 7,13,14 Widespread presence in cosmetics, personal care products, and industrial products, etc. to control microbial growth Formaldehyde and formaldehyde-releasing preservatives (e.g., quaternium-15, imidazolidinyl urea, diazolidinyl urea, dimethylol-dimethyl [DMDM] hydantoin) Non-formaldehyde-releasing preservatives (e.g., parabens, methylchloroisothiazolinone/methylisothiazolinone [MCI/MI], methyldibromoglutaronitrile-phenoxyethanol [MDBGN-PE], iodopropynyl butyl-carbamate ) Rubber 7,13,14 Latex causes contact urticaria; contact dermatitis is primarily caused by rubber Accelerators (e.g., thiurams, carbamates, benzothiazoles) Face (makeup sponges, goggles) Hands (gloves, rubber bands) Feet (Shoes) Textile Components 7,13,14,21,22 Contact allergies are primarily caused by: Azo-aniline disperse dyes: used on synthetic fabrics Formaldehyde-releasing fabric finish resins to make textiles wrinkle-free Contact dermatitis is usually most prominent in body areas where clothing fits tightly and where sweating occurs (e.g., posterior neck, waistband, groin area, upper and inner thighs, periaxillary region) 5

6 Colophony (Rosin, Pine Resin) 13,14 Present in: Some mascaras Shoe glues Athletic uses: gymnastics grip powder, rosin for bowling balls Medical products: ulcer bandages, dentistry supplies Synthetic Plastic Resins 13,23 Fingertip dermatitis with involvement of eyelids, face and neck Often found in glues and adhesives Include (meth)acrylate resins, epoxy resins, polyurethane resins, phenolformaldehyde resins Lanolin/Wool Wax Alcohol 13,14 Greasy yellow substance produced by sebaceous glands of sheep Often present in topical medicaments Weak contact allergen, so usually sensitizes and elicits contact allergies only on diseased skin (e.g., stasis dermatitis) Botanicals Increasing use in cosmetics, massage oils, aromatherapy 20,24 Tea tree oil 25,26 Complex mixture of chemicals extracted from Australian Melaleuca alternifolia plant Possesses anti-microbial (even against some antibioticresistant species) and anti-inflammatory properties Most common botanical reported to cause allergic contact dermatitis Other botanicals 20,24 Arnica, chamomile, common mugwort, lavender, peppermint, ylang ylang, etc. Dermatitis Locations and Likely Exposure(s) for our Patient Question: What are the likely exposure(s) given the locations of patient s dermatitis? Dermatitis Locations and Likely Exposure(s) Hands, Forearms, Face, Ears and Neck 7,27 Transfer from hands/nails is likely with this pattern This patient is retired, so occupational exposures are unlikely Ask about hobbies, use of glue, etc. This patient gives history of application of antibiotics to affected sites, making allergic contact dermatitis to medicament most likely 6

7 Next Step in Management Question: Once allergic contact dermatitis is suspected, what is the next step in management? Patch Testing Gold standard for diagnosis of allergic contact dermatitis Experienced and knowledgeable specialist physicians are required for proper performance, reading and interpretation of this in vivo test Only U.S. FDA-approved patch test allergens are those in the thin-layer rapid-use epicutaneous (T.R.U.E.) test 29 Has low sensitivity due to limited number of allergens (28 preloaded allergens) 30 Hence often supplemented with other allergens (e.g., occupation specific test series) Patch Testing Procedure Patch Application (Day 1): Apply patch tests to an area of the patient s upper back or mid back that is not affected by dermatitis Remove patches after 48 hours First Reading (Days 2-4): Obtain first reading to allow assessment of strengthening (allergic) or diminishing (irritant) response at second reading Second Reading (Days 4-7): Educate patient on nature of positive and relevant allergen(s) and avoidance strategies Patch Test Readings Results 35,36 Results at both readings are scored based on intensity of the reaction covering at least 50% of the patch test site: [-]: negative reaction [?]: doubtful reaction only faint erythema [1+]: weak positive reaction erythema, infiltration, possible discrete papules [2+]: strong positive reaction erythema, infiltration, papules, vesicles [3+]: extreme positive reaction erythema, infiltration, bullous reaction made by confluence of vesicles [IR]: irritant reaction scorched appearance with little surrounding infiltration Patient #1 underwent patch testing, with the following positive reactions: Patch Test Allergens First Reading Second Reading Thimerosal Determining Relevance Question: Which positive reaction(s) are relevant to patient s dermatitis? Neomycin? 2+ Bacitracin

8 Patch Test Readings Relevance of Positive Reactions 7,34,37 When an allergen is patch test positive, it means that the patient has contact allergy to this chemical, but expertise is needed to determine if this allergen is relevant to (i.e., the cause of) patient s present or past dermatitis Neomycin and Bacitracin are positive reactions which are relevant to our patient s dermatitis Present in triple antibiotic ointment patient has been applying to his hands and forearms relevant to hand and forearm dermatitis Also present in triple antibiotic eardrops patient has been applying for ear infection relevant to ear and lateral neck dermatitis Thimerosal Possible or Past Relevance Could be relevant to patient s ear and lateral neck dermatitis if present in his eardrops (read eardrop label to find out) If not present in eardrops, thimerosal is not relevant Patient may have been asymptomatically sensitized to thimerosal by childhood vaccines Patient Was Shown On Patch Testing To Have Contact Allergies To Neomycin And Bacitracin Question: Are there other substances he should avoid in the future? Avoidance Education for Patient Answer: Yes, he should avoid Structurally-related substances (e.g., streptomycin, gentamicin, tobramycin) which may cross-react with neomycin Would A Skin Biopsy Have Helped To Diagnose This Patient? Can be used to confirm that dermatitis is eczematous (spongiotic with intercellular edema), and to rule out differential diagnoses (e.g., psoriasis, cutaneous T-cell lymphoma) Cannot differentiate irritant contact dermatitis vs. allergic contact dermatitis 8

9 Patient Has Been Diagnosed With Allergic Contact Dermatitis To Neomycin, Bacitracin And Thimerosal Question: How will you treat him? Allergic Contact Dermatitis Treatment Allergen Avoidance Teach patient various names of allergen(s), cross-reacting chemicals, products which contain the allergen(s), non-sensitizing alternatives American Contact Dermatitis Society members can access Contact Allergy Replacement Database (CARD): produces lists of products which are free of allergen(s) and cross-reacting substances 38 ) CARD Website Allergic Contact Dermatitis Treatment Allergen Avoidance American Contact Alternative Group recently published an article describing each allergen found on the 2007 North American Contact Dermatitis Group (NACDG) standard tray, and alternatives which may be used in place of the allergen 14 Allergic Contact Dermatitis Treatment Avoidance of identified irritant(s)/allergen(s) is curative, but signs and symptoms of contact dermatitis may take weeks to resolve In the meantime, topical and/or systemic therapies are used to treat the signs and symptoms Long-term use of topical steroids, especially in skin folds, may cause skin atrophy, striae and telangiectasia; use on face may cause steroid rosacea Allergic Contact Dermatitis Treatment Systemic Therapy 9,10 Patients with >25% body surface area involvement of contact dermatitis, or with severe vesiculobullous eruptions of hands/feet/face may require systemic corticosteroids Side effects of systemic steroids include hypertension, hyperglycemia, and peptic ulcers Long-term side effects of systemic steroids include immunosuppression, glaucoma, osteoporosis, etc. Oral cyclosporine is a more expensive alternative for short-term, systemic treatment 9

10 References 1. Soni BP, Sherertz EF: Evaluation of previously patch-tested patients referred to a contact dermatitis clinic. Am J Contact Dermat 1997; 8: Mark BJ, Slavin RG. Allergic contact dermatitis. Med Clin North Am 2006; 90: Kadyk DL, McCarter K, Achen F, et al. Quality of life in patients with allergic contact dermatitis. J Am Acad Dermatol 2003; 49: Fyhrquist-Vanni N, Alenius H, Lauerma A. Contact dermatitis. Dermatol Clin 2007; 25: SlodownikD, Lee A, Nixon R. Irritant contact dermatitis: a review. AustralasJ Dermatol 2008; 49: Amado A, Taylor JS, Sood A. Irritant contact dermatitis. Fitzpatrick s Dermatology in General Medicine, 7 th ed. Wolff K, Goldsmith LA, Katz SI, et al (eds): McGraw-Hill, New York, 2008, p Cohen DE, Jacob SE. Allergic contact dermatitis. Fitzpatrick s Dermatology in General Medicine, 7 th ed. Wolff K, Goldsmith LA, Katz SI, et al, (eds): McGraw-Hill, New York, 2008, p Rietschel RL. Clues to an accurate diagnosis of contact dermatitis. Dermatol Ther 2004; 17: Warshaw EM, Lee G, Storrs FJ. Hand dermatitis: a review of clinical features, therapeutic options, and long-term outcomes. Am J Contact Dermat : Belsito DV. The diagnostic evaluation, treatment, and prevention of allergic contact dermatitis in the new millennium. J Allergy clin Immunol2000; 105: References 11. Frosch PJ, John SM. Clinical Aspects of Irritant Contact Dermatitis. Contact Dermatitis, 4 th ed. Frosch PJ, Menne T, Lepoittevin JP (eds): Berlin, Heidelberg, New York, Springer Verlag, 2006: WarshawEM, BelsitoDV, DeLeoVA, et al. North American Contact Dermatitis Group Patch- Test Results, study period. Dermatitis 2008; 19: Andersen KE, White IR, Goossens A. Allergens from the standard series. Contact Dermatitis, 4 th ed. Frosch PJ, Menne T, Lepoittevin JP (eds): Berlin, Heidelberg, New York, Springer Verlag, 2006: Scheman A, Jacob S, Zirwas M, et al. Contact allergy: alternatives for the 2007 North American Contact Dermatitis Group (NACDG) standard screening tray. DisMon 2008; 54: Jacob SE, Steele T. Corticosteroid classes: a quick reference guide including patch test substances and cross-reactivity. J Am Acad Dermol 2006; 54: Warshaw EM, Schram SE, Belsito DV, et al: Patch-test reactions to topical anesthetics: retrospective analysis of cross-sectional data, 2001 to Dermatitis 19:81-5, Szolar-Platzer C, Maibach H. Allergic contact dermatitis to topically applied antihistamines. Dermatosen 1996, 44: Biebl KA, Warshaw EM. Allergic contact dermatitis to cosmetics. Dermatol Clin 2006; 24: MowadCM. Allergens of new and emerging significance. Dermatol Nurs 2006; 18: Ortiz KJ, Yiannias JA. Contact dermatitis to cosmetics, fragrances, and botanicals. 2004; DermatolTher 17: References 21. Hatch KL, Maibach HI. Textile dye dermatitis. J Am Acad Dermatol 1995; 32: Pratt M, Taraska V. Disperse blue dyes 106 and 124 are common causes of textile dermatitis and should serve as screening allergens for this condition. Am J Contact Dermat 2000; 11: Bjorkner B, Ponten A, Zimerson E, et al. Plastic materials. Contact Dermatitis, 4 th ed. Frosch PJ, Menne T, Lepoittevin JP (eds): Berlin, Heidelberg, New York, Springer Verlag, 2006: p Aberer W: Contact allergy and medicinal herbs. Dtsch Dermatol Ges 6:15-24, Carson CF, Hammer KA, Riley TV: Melaleuca alternifolia (Tea Tree) oil: a review of antimicrobial and other medicinal properties. Clin Microbiol Rev 19:50-62, Hammer KA, Carson CF, Riley TV, et al: A review of the toxicity of Melaleuca alternifolia (tea tree) oil. Food Chem Toxicol 44:616-25, Belsito DV. A sherlockian approach to contact dermatitis. Dermatol Clin 1999; 17: Rycroft RJG, Frosch PJ. Occupational Contact Dermatitis. Contact Dermatitis, 4 th ed. Frosch PJ, Menne T, Lepoittevin JP (eds): Berlin, Heidelberg, New York, Springer Verlag, 2006: T.R.U.E. test website. Available at : Accessed October 2, References 30. Saripalli YV, Achen F, Belsito DV. The detection of clinically relevant contact allergens using a standard screening tray of twenty-three allergens. J Am Acad Dermatol 2003; 49: Wahlberg JE, Lindberg M. Patch testing. Contact Dermatitis, 4 th ed. Frosch PJ, Menne T, Lepoittevin JP (eds): Berlin, Heidelberg, New York, Springer Verlag, 2006: Belsito DV. Patch testing with a standard allergen ( screening ) tray: rewards and risks. Dermatol Ther 2004; 17: Marrakchi S, Maibach HI. What is occupational contact dermatitis? An operational definition. Dermatol Clin 1994; 12: Wilkinson DS, Fregert S, Magnusson B, et al. Terminology of contact dermatitis. Acta Derm Venereol 1970; 50: Goossens A. Art and science of patch testing. Indian J Dermatol Venereol Leprol 2007; 73: El-Azhary RA, Yiannias JA. A new patient education approach in contact allergic dermatitis: the Contact Allergen Replacement Database (CARD). Int J Dermatol 2004; 43: