Allergic Contact Dermatitis

Wahyuni Taslim1, Nurhidayat2, Muhammad Ardi Munir3,4

1
Medical Profession Program, Faculty of Medicine, Tadulako University-Palu,
INDONESIA, 94118
2
Departement of Dermatovenereology, Undata General Hospital-Palu, INDONESIA,
94118
3
Departement of Social Health Science, Bioethics and Medical Law, Faculty of
Medicine, Tadulako University- Palu, INDONESIA, 94118
4
Departement of Orthopaedic and Traumatology Surgery, Undata General Hospital-
Palu, INDONESIA, 94118
*Corespondent Author : unitaslim@yahoo.com

ABSTRACT

Background: Allergic contact dermatitis (DKA) is a process of skin inflammation caused by

certain allergens and is included in type IV hypersensitivity. The clinical signs of allergic
contact dermatitis vary from macular erythematous, swelling, papulovesicles, to bullae and
ulcers in severe cases. The main symptoms are called pruritus.

Case Report: In this case report, it is a woman aged 40 years with a diagnosis of allergic
contact dermatitis. A Therapy given to these patients is a combination of topical
corticosteroid medication and antihistamine administration. Patients are also given
education to maintain cleanliness and skin moisture, avoid allergens, and not to scratch the
injured area.

Conclusion: The principle of management of these patients is to provide topical

corticosteroids, symptomatic treatment and most importantly to avoid allergens that cause
allergic reactions. Prognosis of allergic contact dermatitis is good, if you get the right
treatment right away.

Keywords: Allergic Contact Dermatitis, Type-IV Hypersensitivity, Topical Corticosteroids

1
INTRODUCTION
Allergic contact dermatitis (DKA)
is a process of inflammation of the
skin caused by certain allergens. DKA
is included in Hypersensitivity type IV
previously sensitive to allergens. The
North American Contact Dermatitis
Group (NACDG) reports from 2009-
2010 and 2011-2012, showing that the
prevalence of DKA has increased from
46.3% to 48.0%. The prevalence of
DKA patients treated at Dr. General
Hospital Mohammad Hoesin in
Palembang, in 2008 it reached 13.42%.
Allergic contact dermatitis can be
caused by several factors including
genetic, age, sex, occupation, and
other comorbidities such as irritant
contact dermatitis (DKI), dermatitis
atopic, and chronic urticaria. DKA
diagnosis can be made by history
taking and physical examination. One
of the tests used to confirm the
diagnosis is the Skin Patch Test. This
test is done by attaching a chamber /
patch that has been given these
allergen substances to patients
suspected of DKA. Positive results
from one allergen test confirm the
diagnosis. Patch test results help
doctors in patient education and
therapy. (1)
DKA is caused by a slow type
hypersensitive response to contact
allergens. The incidence of DKA is not
clearly defined, but is expected to
increase. A recent study found that all
forms of contact dermatitis, including
DKI and DKA, have a prevalence of
4.17% in the US. The latest estimated
annual medical costs in the US in 2013
for cases of atopic dermatitis and
contact dermatitis are $ 314 million
and $ 1,529 million. Allergic Contact
Dermatitis is the second most common
type of Contact Dermatitis after
Irritant Contact Dermatitis and can
appear with signs and symptoms
similar to Atopic Dermatitis. (2)
In patients with DKA in the eye
with dupilumab therapy, that eye-
related complications that occur with
dupilumab therapy are due to one
component of undiagnosed dry eye
syndrome, allergic contact dermatitis
(ACD), or atopic dermatitis that is not
fully treated with dupilumab, or a
combination from several cases. (3)
2
 Contact dermatitis is one of the sensitive individuals when challenged
most common skin diseases and is an by the same haptens. Haptens diffuse
inflammatory skin condition caused by in the skin and are taken by skin cells
exposure to environmental agents. The which are leads to activation of
skin is the first barrier to chemical and effector T cells in the dermis and
physical factors in environment. There epidermis. This triggers an
are two types of contact dermatitis: inflammatory process responsible for
Irritant Contact Dermatitis (DKI), and skin lesions and the occurrence of
Allergic Contact Dermatitis. Irritant DKA. (5)
contact dermatitis is caused by toxic Patch Test Recommendations:
effects of chemical or physical factors Avoid or reduce dose of
that activate skin's innate immunity. immunosuppressant drugs such as
Whereas, DKA requires immune systemic corticosteroids (CS) and
activation obtained by specific systemic immunosuppressants before
antigens which are lead to the patch testing. Avoid the application of
development of effector T cells, which topical corticosteroids (TCS), topical
mediate inflammation of the skin. (4) calcineurin inhibitors (TCI), or
Haptens are chemicals that can ultraviolet radiation to the skin,
form large molecules. Haptens can because this can reduce the response of
pass through the skin and reach the the Allergy Patch Test. In addition to
local lymph nodes, causing effector T using the core or basic allergen patch
cells to form. The pathophysiology of test series in evaluating DKA, consider
DKA consists of two distinct phases. using an additional series of allergen
Phase one is called the induction patch tests based on patient-specific
phase. This occurs at first contact exposure, and the patient's personal
between the skin and haptens and leads products to increase the likelihood of
to the generation of effector T cells. identifying more relevant allergens.
After phase one, phase two, the Patch testing can also be carried out
elicitation phase, is induced in using a follow-up kit using fast and

3
precise thin films or with individually
loaded antigen panels recommended
by NACDG. Reading and
interpretingthe Patch Test compliance
with the grading system is developed
by The International Contact
Dermatitis Research Group. Complete
the use of Patch Test about 48 hours
after the test. The second reading is
carried out between 3 and 7 days after
application. Recognize the possibility
of a false negative reaction can be
caused by inadequate allergens the
concentration needed to obtain a
response; the inability of the patch test
to release sufficient allergens; reduced
responsive skin due to previous
exposure to ultraviolet light (sun,
concurrent immunosuppressive
therapy; or inadequate methodological
testing errors, failure to read Patch
Test photos. Determine the relevance
of Patch Test results based on clinical
history and exposure when interpreting
Patch Tests. Consult with a doctor
with expertise in patch testing for
household or industrial cleaning
products if testing for actual products
that are suspected to contain allergens
is necessary because false positive
irritations and severe irritation
reactions occur. (6)
CASE REPORT
The 40-year-old female patient
was consulted to the skin and genitals
in Undata District Hospital with
complaints of itching and redness in
the area of both lower legs. The
complaint was said by the patient had
been experienced since 1 week ago.
The itching is felt to occur
continuously. The patient also feels
pain in his legs so the patient cannot
walk. At the beginning,this patient's
feet swollen since 5 years ago when
the patient had heart disease. This
patient said because the swelling in his
leg did not go down and only
disappeared. Then, the patient gave
massage oil to his feet, then when
given the massage oil the patient felt
his legs red and felt very hot, then over
time his skin turned red and his skin
turned black and felt very sore and
itchy. Other information, the patient
has a history of hypertension.
4
 From the physical examination it
was found that the patient's blood
pressure was 130/90 mmHg, pulse
80x/min, Respiration 24x/min, and
Body Temperature 36.8oC. The results
of dermatological examination showed
the appearance of skin abnormalities in
the lower extremities: erosion,
erythema and bullae in the regiopedis
dextra and sinistra.
The patient works as a housewife.
The patient lives with her husband and
family. None of the patient’s family
members suffer from the same illness
and complaints
Figure 1. The appearance of the skin
disorders in the lower extremities, in
the form of erosions, erythema and
bullae in the regio of the pedis sinistra.
Figure 2. The appearance of skin in
the lower extremities is abnormalities,
erosions, erythema and bullae in regio
of the pedis dextra.
The patient was diagnosed with
allergic contact dermatitis, with a
differential diagnosis of irritant contact
dermatitis, and atopic dermatitis.
Management in these patients is to
compress the lesion with a moist gauze
of 0.9% NaCl solution, topical drug
given Desoximetasone 0.25% cream
2x1, systemic medication given oral
antihistamines namely Cetirizine 10
mg 1x1 tablet.Patients are also given
education to maintain cleanliness and
skin moisture, avoid allergens, and do
not scratch the injured area.
DISCUSSION
A 40-year-old female patient was
consulted to the skin and genitals in
5
Undata District Hospital with exposed to a suspected substance or a
complaints of itching and redness in substance that can cause a cross
the area of both lower legs. This reaction, the time needed to induce an
complaint was said by the patient had allergic reaction can be faster, which is
been experienced since 1 week ago. around 24-48 hours. Typical
The itching is felt to occur symptoms of DKA include pruritus
continuously. The patient also feels and ecematous dermatitis which are
pain in his legs so the patient cannot confined to the site of allergen
walk. The patient also has a history of exposure. The main complaint of the
hypertension. At the beginning, this patient is itchy red spots, burning
patient's feet were swollen since 5 sensation and blisters on the skin after
years ago when the patient had heart rubbing oil on the swollen feet.
disease. The patient said because the Patients also have a history of previous
swelling in his legs did not go down sensitization with allergens suspected.
and only disappeared, the patient then DKA lesion features eczematous
gave oil to his feet, then when given dermatitis consisting of multiple
the oil the patient felt his feet red and vesicles and bullae above the
felt very hot, then over time his skin erythematous macules, pus, exudation,
turned red and his skin turned black and erosion. (7)
and felt very sore and itchy. Contact dermatitis can be divided
Dermatological examination into irritant contact dermatitis (DKI)
results show the appearance of skin and allergic contact dermatitis (DKA).
disorders in the lower extremities: in DKA is an immune-mediated antigen-
the form of erosion, erythema and specific skin reaction to allergic
squama in the regio of pedis dextra & chemicals that are in accordance with
sinistra. the Type Hypersensitivity Delay
The time required for DKA Response (type IV reaction). The Gold
induction is generally 7-20 days. If the Standard for diagnosis is the Patch
patient has a previous history of being Test. This test has a sensitivity and

6
specificity of between 70% and 80%. depend on the potential of steroids and
The treatment of choice for DKA is percutaneous penetration capacity.
topical corticosteroids, and various Patients cannot be given oral
symptomatic treatments can be used to corticosteroids with the consideration
relieve itching. However, the that the patient has a history of
identification and elimination of each hypertension, and the size of the lesion
potential causative agent is very is not extensive. (10)
important. (8) This study shows desoximetasone
The clinical manifestations of cream is significantly more active in
DKA vary from macular reducing erythema and overall lesion
erythematous, swelling, improvement compared with
papulovesicles, to bullae and ulcers in betamethasone valerate. The difference
severe cases. Pruritus is the main was most apparent 4 days after
symptom found in DKA patients. (1) treatment began and desoximetasone
Research conducted at Soetomo cream was considered better in 27.5%
District Hospital in 2017 showed that of cases. This difference was not
the most complaints were itching in statistically significant.
214 (74%) patients. Itching is the Desoximetasone has a faster effect on
problem most often complained of by psoriatic lesions compared to 0.05%
patients with dermatitis. One cause of betamethasone dipropionate. (10)
itching is increased Transepidermal Second-generation antihistamines
Water Loss (TEWL) and decreased are also widely used, because they are
water levels in the stratum corneum. (9) less lipophilic, do not affect the central
Topical corticosteroids are the nervous system, and have the
drugs most often used for the treatment advantage of anti-inflammatory
of patients with inflammatory skin effects. Loratadine regulates cytokine
diseases. The risks associated with the release, specifically IL-6 and IL-8,
use of corticosteroids are directed whereas cetirizine has the effect of
more than therapeutic benefits, and inhibiting eosinophil chemotaxis,

7
release, and expression of endothelial on Patch Test. amj. 2017
adhesion molecules. This study shows Dec;4(4):541–5.
that loratadine and cetirizine are the 2. Owen JL, Vakharia PP, Silverberg
second generation of antihistamines JI. The Role and Diagnosis of
that are often used. (9) Allergic Contact Dermatitis in
Patients with Atopic Dermatitis.
CONCLUSION
Allergic contact dermatitis (DKA) Am J Clin Dermatol. 2018

is included in type IV hypersensitivity Jun;19(3):293–302.

previously sensitive to allergens. The 3. Raffi J, Suresh R, Fishman H,

basic principle of management of this Botto N, Murase JE. Investigating

patient is to provide topical the role of allergic contact

corticosteroids, symptomatic treatment dermatitis in residual ocular

and most importantly to avoid surface disease on dupilumab

allergens causing the reaction. The (ROSDD),,. International Journal

prognosis of DKA is good, if you get of Women’s Dermatology. 2019

the right treatment right away. Dec;5(5):308–13.

4. Zhang Z, Malewicz NM, Xu X,
APPROVAL Pan J, Kumowski N, Zhu T, et al.
In this case report, the author has
Differences in itch and pain
received consent from the patient in
behaviors accompanying the
the form of informed consent.
irritant and allergic contact
CONFLICTS OF INTEREST dermatitis produced by a contact
The author states that in this allergen in mice: PAIN Reports.
writing there is no conflict of interests
in this paper. 2019;4(5):e781.
5. Kim JH, Kim HJ, Kim SW.
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