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Journal of Dermatology & Dermatologic Surgery 19 (2015) 8691

Review

Management of contact dermatitis

Sultan T. Al-Otaibi , Hatem Ali M. Alqahtani
Department of Family and Community Medicine, University of Dammam, Dammam, Saudi Arabia

Received 28 December 2014; accepted 11 January 2015

Available online 20 February 2015

Abstract

Skin disorders compromise more than 35% of all occupationally related disorders. Most of these are contact dermatitis as a result
from contact with a chemical substance. Contact dermatitis can be either irritant or allergic type. Each type has a dierent mechanism
while the clinical presentation is the same. Management of contact dermatitis must include both medical treatment and workplace
modifications as appropriate to reduce exposure to the causative agents. Physicians should be aware of this preventable medical
condition.
! 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Dermatitis; Contact; Management

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
2. Mechanism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
3. Clinical presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
4. Management of contact dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
4.1. Primary prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
4.1.1. Engineering control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
4.1.2. Personal protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
4.1.3. Personal hygiene. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
4.1.4. Work practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
4.1.5. Health education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
4.1.6. Motivation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
4.1.7. Administrative control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
4.1.8. Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Corresponding author at: University of Dammam, PO Box 2208,

Al-Khobar 31952, Saudi Arabia. Tel.: +966 13 8948964; fax: +966 13
8645612.
E-mail address: otaibist@hotmail.com (S.T. Al-Otaibi).
Peer review under responsibility of King Saud University.

http://dx.doi.org/10.1016/j.jdds.2015.01.001
2352-2410/! 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 S.T. Al-Otaibi, H.A.M. Alqahtani / Journal of Dermatology & Dermatologic Surgery 19 (2015) 8691 87

4.2. Secondary prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

4.2.1. Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
4.2.2. Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
4.3. Tertiary prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
4.3.1. Treatment and management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
4.3.2. Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Conflict of interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

1. Introduction 2. Mechanism

Skin is the most commonly injured organ in industry
today, whereas skin disorders compromise more than
35% of all occupationally related disorders (Diepgen and
Kanverva, 2006). Contact dermatitis is the most common
occupational disease in many countries. A challenge is that
contact dermatitis is under reported as work related illness.
Health care worker should be aware of this occupational
illness. It will also require appropriate diagnosis and
management.
Contact dermatitis (CD) is defined as a reactive eczema-
tous inflammation of the skin which occurs after the direct
contact with a chemical but occasionally by biologic or
physical agents (Holness, 2014; Chew and Maibach,
2003). Contact dermatitis can be either due to irritation
from direct exposure to a substance, irritant contact
dermatitis (ICD) or as a result of exposure to allergic
substance, allergic contact dermatitis (ACD) (Chew and
Maibach, 2003; McFadden, 2014). ICD is the most com-
mon form of occupational skin disease which accounts
for nearly 80% of CD (McFadden, 2014; Cahill et al.,
2004; Lau et al., 2011).
ICD can be either acute type due to single exposure of
a material such as chemical burns (e.g. hydrofluoric acid,
hydrochloric acid, alkali) and also phototoxic ICD
(require ultraviolet light A to elicit it) or could be chronic
type from cumulative and repetitive exposure to irritant
substance (such as solvents, water, soap, detergents, acid,
alkali, etc.).
ACD includes contact urticaria which is type I hyper-
sensitivity as an immediate but transient localized swelling
and redness that occurs on the skin after direct contact
with an oending substance such as latex, food (beans,
egg, fish), antibiotics (penicillin, neomycin), ingredients of
cosmetics and medicaments such as Balsam of Peru and
Benzoic acid. ACD also includes contact dermatitis which
is type IV hypersensitivity (dermatitis begins within 24
48 h after contact) e.g. chrome, nickel, epoxy resin, rubber
additives, etc. Sometimes ACD could be photoallergic that
requires UV light after exposure to allergen. Atopic skin
remains the single most important risk factor in an occupa-
tional setting (Holness, 2011; Holness et al., 2013; Diepgen,
2006; Keegel et al., 2009; Ibler et al., 2012; Luk et al., 2011;
Lysdal et al., 2012).
The mechanism of contact dermatitis depends on its
type (Cahill et al., 2004; Keegel et al., 2009).
ICD is characterized by skin damage which could be
mild to severe depending on the causative agent as a result
of direct, local, toxic eect on the cellular elements of the
skin. This leads to removal of the lipid film, denaturation
of keratin of the skin, release of lysosomal enzymes and
inflammatory response.
Contact urticaria occurs through either allergic
(immunologic) or non-allergic (non-immunologic) mechan-
ism. Allergic contact urticaria is mediated by an IgE
mechanism leading to a cascade of events causing inflam-
mation of the skin. In non-immunologic contact urticaria
a direct eect on the blood vessel wall occurs with release
of vasoactive substances leading to hives (McFadden,
2014).
Allergic contact dermatitis arises from a cell mediated
delayed hypersensitivity reaction. Sensitization is initiated
after an agent or hapten combines with skin protein to
form a complete antigen. This antigen is processed by epi-
dermal Langerhans cells, then T lymphocytes interact with
Langerhans cell processed antigen. Later on T lympho-
cytes release lymphokines which serve as mediators of
inflammation (Holness, 2014).
3. Clinical presentation
It is impossible to dierentiate between ICD and ACD
clinically (Chew and Maibach, 2003).
However, acute ICD is manifested by red, swollen,
itchy, painful and ulcerated skin. Hydrofluoric acid burns
are associated with hypocalcemia, and hypomagnesemia.
While chronic ICD is characterized by eczematous skin
eruption, erythema, dryness, cracking and fissuring of the
skin. Secondary infection may supervene. It mainly
involves the back of the hands including the fingers and
the finger webs and subsequent involvement of the palm
(Ibler et al., 2012; Luk et al., 2011; Lysdal et al., 2012).
Contact urticaria appears as hives occurring within a
few minutes up to an hour of skin exposure to the oending
agent. Allergic contact dermatitis is characterized by red-
ness, itching and scaling of the skin at the site of the con-
tact, but very frequently involvement of the eyelids
88 S.T. Al-Otaibi, H.A.M. Alqahtani / Journal of Dermatology & Dermatologic Surgery 19 (2015) 8691
occurs. Later on vesiculation and oozing of the aected
part occur (McFadden, 2014).
4. Management of contact dermatitis
Information on the workplace health and safety hazards
and prevention measures is the key component of modern
occupational medicine policies and practice. The occur-
rence of contact dermatitis serves as a warning that preven-
tive measures at the workplace likely need to be improved.
Prevention of contact dermatitis includes the following:
4.1. Primary prevention
4.1.1. Engineering control
It aims to enclose, contain or isolate the potential
irritant or allergens. Such measures should receive the
top priority wherever feasible (Geier et al., 2011). Chemical
substitution is an alternative way to replace the allergen
and irritant agents with less noxious substance (required
by law) Schnuch et al., 2012. Also work practice which uses
stainless steel (hardly release nickel), nickel, tin, and white
gold causes very few reactions in nickel sensitive patients,
so these patients can work in these jobs (Keegel et al.,
2009). If skin exposure occur through air in the form of
particulate, dust, mist or vapor, local and general ventila-
tion may be sucient.
4.1.2. Personal protection
4.1.2.1. Protective clothing. Protective clothing such as
gloves, boots and aprons is available in a number of fabrics
or materials. Protective clothing should be guided by consid-
ering the physical and chemical resistance properties, flex-
ibility and skin surface to be exposed. Gloves often protect
well but many organic substances and solvents penetrate
them readily, therefore this issue should be taken into con-
sideration when selecting the appropriate gloves for a par-
ticular work practice (Ibler et al., 2012). Clothing should
be periodically inspected and discarded if holes and tears
are found. Disposable clothing is required for protection
against allergens and irritant substances. Protective clothing
may occasionally cause contact dermatitis rather than
prevent it, through nonspecific irritation from sweat entrap-
ment and friction of clothing against the skin (Holness et al.,
2013). Occlusion of chemical allergen beneath the protective
clothing enhances cutaneous absorption of the substance
leading to ACD (e.g. allergy to accelerator and antioxidants
in rubber from wearing rubber gloves). Gloves should
always be worn over clean hands to avoid accidental
occlusion of the allergen and irritants against the skin.
Protective clothing should not be used unless engineering
controls are feasible (Holness et al., 2013).
4.1.2.2. Barrier creams. The clinical eectiveness of such
preparation is controversial and unsupported by clinical
studies. Water resistant barrier creams contain hydropho-
bic substance such as silicone, which protects against water
soluble substances such as acids, alkali and dye. On other
hand, oil or solvent resistant barrier creams protect against
dust, oils, greases and solvents. The manufacturers
instruction should be followed when these barrier creams
are applied. Many barrier creams facilitate the removal
of sticky oils, greases, thus decrease the need to wash with
irritating water and soap (Uter et al., 2012).
Barrier creams should be used on normal skin as they
cause aggravation of dermatitis if applied to inflamed skin
(Geier et al., 2011). Qaternium-18 bentonite lotion was
found to be eective in preventing or diminishing
experimentally produced poison ivy and poison oak
(Arrandale et al., 2012).
4.1.3. Personal hygiene
Washing hands with mild soap and water suce to
remove allergen and irritants from the skin. Sometimes
abrasive soap which works by peeling the stratum corneum
is used to remove oil and greases from the skin or waterless
hand cleaners which contain organic solvents are used in
these situations. Abrasive and waterless soap should be
only applied to the palm where the skin is thick and should
be restricted if simple water and mild soap do not suce
(Nicholson et al., 2010; Smedley, 2010). Overuse or misuse
of skin cleaning agents can cause or aggravate contact der-
matitis (Adisesh et al., 2013). Industrial solvents should not
be used for skin cleansing.
Eating, drinking and smoking at the workplace should
be prohibited except in the designated resting area to avoid
contamination with allergen and irritant substances.
Personal hygiene should also include regular washing or
cleaning protective clothing because of the risk of skin con-
tact with allergen or irritant especially when clothing is
soiled (Adisesh et al., 2013).
4.1.4. Work practice
It includes covering the work surface with protective or
absorbent towels or sheets, cleaning the work surface with
appropriate industrial cleaner and sweeping or vacuuming
of dust and particulate (Holness et al., 2013).
Application of skin moisturizer is advised where the
work practice exposes the individual to water based irri-
tants such as cutting oils or solvents. White petroleum is
an excellent skin moisturizer and is as eective as any other
type of barrier cream but has the disadvantage of greasi-
ness which makes gripping the tools dicult if applied lib-
erally to the palm.
Cross reactions occur between many chemically related
substances, hence important in the prevention of allergic
contact dermatitis (Nicholson et al., 2010).
4.1.5. Health education
It aims to promote awareness and identify work activ-
ities in which exposure to allergens and irritants is likely.
Job training should teach recognition of early symptoms
and signs of contact dermatitis, proper use of protective
clothing and barrier cream and personal and work hygiene.
 S.T. Al-Otaibi, H.A.M. Alqahtani / Journal of Dermatology & Dermatologic Surgery 19 (2015) 8691
Instruction of employees in the emergency procedure is
necessary in case of accidental contamination from high
risk work. Training involves the use of videotape, lectures
and others. Worker education should be initiated before
placement in the job and should be periodically repeated.
Supervisors should be included in the education program
with intensive education and safety training to serve as
on the job teachers and reinforcing safety issues. It was
found that workers understanding of the diagnosis and
patient education is essential to improving the outcome
of contact dermatitis (Lysdal et al., 2012; Bourke et al.,
2009).
4.1.6. Motivation
It is an important but frequently neglected aspect of pre-
vention program. So, despite education, some workers are
not motivated to observe preventive practice because they
do not consider themselves at risk for contact dermatitis.
Eorts should be aimed to stimulate self motivation and
consider personal life style and convince exposed workers
that they are at risk. The active support of union and safety
ocials is a critical element of motivational eorts
(Schnuch et al., 2012).
On the other hand, employer motivation should aim
that safe work will increase worker satisfaction and pro-
ductivity or decrease cost from worker compensation point
of view (Schnuch et al., 2012).
4.1.7. Administrative control
This includes work shift rotation or spreading the high
risk activities of work more evenly among employees to
minimize exposure to allergen and irritant substance. A
job change, unless it means complete avoidance of specific
allergen such as epoxy resin is unlikely to lead to clearing of
contact dermatitis (Adisesh et al., 2013; Bourke et al.,
2009). This should be the last thing to be tried if all the
above preventive strategies are not feasible.
4.1.8. Regulation
Warning signs or labels should be placed in all contain-
ers or products in which hazardous chemical or substances
may be encountered. The health hazard should be
described clearly in the Material Safety Data Sheet
(MSDS). There is no present regulatory requirement gov-
erning skin exposure to potential hazards (Holness, 2004;
Adisesh et al., 2002; Cahill et al., 2005; Johnansen et al.,
2011).
4.2. Secondary prevention
4.2.1. Diagnosis
The diagnosis of ICD is made by exclusion, based on
accurate, thorough medical history and careful clinical
examination of the patient. It is important to obtain expo-
sure history from work, from home and hobbies.
Patch tests with a standard tray and a special environ-
mental allergen will verify or rule out allergic components
89
of contact dermatitis. Also correct, pure and stable patch
test material is essential for accurate patch test results
and can form the basis for prevention of allergic contact
dermatitis through screening (Goulden and Wilkinson,
2000).
If the patch test gives a positive result, a determination
should be made to decide whether the allergen is relevant
to the work environment.
If the patch test gives a negative result, and if ACD
suspected, the clinical history should be reviewed and
questioned whether or not the appropriate allergen has
been tested. Systemic steroids can suppress the result of
the patch test if the dose of prednisone is more than
30 mg daily taken by the patient prior to patch testing.
Other possibilities for negative patch test include: incor-
rect concentration of the allergen used for testing, contact
urticaria and photo-contact dermatitis (Johnston, 2009;
Geier et al., 2006; Wang et al., 2011).
A visit to the workplace may be needed to identify phy-
sical irritants such as temperature, humidity or mechanical
irritants and/or chemical allergens and irritants. Work-
place provocation test can be carried out if the patch test
is still negative and ACD is suspected (Aalto-Korte et al.,
2012; Geier et al., 2004; Houle et al., 2012; Slodowink
et al., 2009).
Pre-placement screening to exclude a new employee at
risk of developing contact dermatitis (such as atopy as a
risk factor for ICD) is a waste of time, money and eort
and even ethically unaccepted. The American with Dis-
ability Act discourages employer from denying work to
persons with skin diseases as long as they are able to do
the job. Patch testing of healthy new employees without a
history of contact dermatitis has no value and is even dan-
gerous with respect to patch test sensitization (Saary et al.,
2005).
On the other hand, vocational guidance should be con-
sidered and the choice of career should begin in children
with atopy as early as age of 10 years. At the age of 14 most
youngsters have a good idea about their choice of occupa-
tion. Therefore, parents should attempt to direct children
with atopy away from most irritating occupations such as
hairdressing and auto-mechanics (Saary et al., 2005).
4.2.2. Surveillance
Surveillance centers of contact dermatitis clinic should
be accessible to those who suer from contact dermatitis.
Such centers can cooperate for collection of the patients
data and identify new problem at an early stage through
health questionnaire and medical examination of the skin
for prevention of contact dermatitis (Nicholson et al.,
2010; Smedley, 2010).
4.3. Tertiary prevention
4.3.1. Treatment and management
The treatment of contact dermatitis depends on its
stage. The acute phase is best treated with astringent soak
90 S.T. Al-Otaibi, H.A.M. Alqahtani / Journal of Dermatology & Dermatologic Surgery 19 (2015) 8691
and topical or systemic steroids and an antihistamine.
Surgical debridement and skin grafting may be needed in
very rare cases specifically when big ulcers develop as a
result of strong acid or alkali accidents at work. The chronic
phase is managed by moisturizing creams for skin dryness in
addition to topical steroids. Antibiotics may be needed if
there is evidence of secondary infection. In all cases protec-
tion and avoidance of irritants and allergens should be
implemented (Diepgen et al., 2009; John et al., 2011).
4.3.2. Rehabilitation
When preventive and therapeutic measures fail, assess-
ment of skin impairment and disability should be carried
out. Rehabilitation eorts should be aimed to restore eco-
nomic and vocational usefulness of the worker. The worker
may need to receive workers compensation and disability
benefit after establishing occupational causation while con-
sidering retraining for a new job. The cost of early consid-
eration for rehabilitation may be financially beneficial
(Weisshaar et al., 2013; Van Gils et al., 2012a,b; Gomez
et al., 2011; Holness, 2003).
To sum up, prevention of contact dermatitis is a
multidisciplinary approach. Primary prevention of contact
dermatitis is the single most important preventive measure
to reduce employees exposure to irritant or allergen
substance. Once a prevention program is in place, work
practice must be reviewed to ensure protective clothing
being used.
On the other hand, secondary and tertiary preventive
measures have not proved particularly eective.
Conflict of interest
None declared.
Acknowledgments
The authors are most grateful to Dr. Sarah Hasan
Al-Breiki, Dermatology Consultant at King Fahad
Hospital of the University, Al-Khobar, Saudi Arabia for
reviewing this manuscript.
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