Allergic Contact Dermatitis

At a glance:

 A cell-mediated (type IV), delayed type, hypersensitivity reaction caused by skin contact with an
environmental allergen.
 Prior sensitization to a chemical is required for allergy to develop.
 The clinical manifestation of ACD is an eczematous dermatitis.
o The acute phaseis characterized by pruritus, erythema, edema, and vesicles usually confined to
the area of direct exposure.
o Recurrent contact to the allergen in a sensitized individual will result in chronic disease,
characterized by lichenified erythematous plaques with variable hyperkeratosis and fissuring that
may spread beyond the areas of direct exposure.
 Itch and swelling are key components of the history and can be a clue to allergy.
 The hands, feet, and face (including the eyelids) are some of the common sites for ACD.
 Patch testing is fundamental for the identification of causal allergens and is indicated for patients with
persistent or recurrent dermatitis in whom ACD is suspected.
 Avoidance is the mainstay of treatment for ACD. Educating patients about avoidance of the allergen and
its potentially related substances, and providing suitable alternatives are crucial to a good outcome.

Clinical Presentation
History
A detailed history, both before and after patch testing, is crucial in evaluating individuals with allergic
contact dermatitis. Potential causes of allergic contact dermatitis and the materials to which individuals are
exposed should be included in patch testing. Evaluation of allergic contact dermatitis requires a much more
detailed history than 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 allergic contact dermatitis to materials
and agents applied to the areas of stasis dermatitis and leg ulcers. Neomycin and bacitracin are important causes
of allergic contact dermatitis in these individuals because they are used frequently despite the lack of
documentation of their 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 allergic contact dermatitis, 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. They are at lower risk of allergic contact dermatitis to poison ivy. An
inverse association was found between contact sensitization and severe atopic dermatitis. Inverse associations
were found for all groups of allergenic chemicals and metals, except for sensitization to fragrances and topical
drugs, for which positive associations were identified.

Onset of symptoms
Individuals with allergic contact dermatitis typically develop dermatitis, within a few days of exposure,
in areas that were exposed directly to the allergen. Certain allergens (eg, neomycin) penetrate intact skin poorly,
and the onset of dermatitis may be delayed up to a week following exposure.
A minimum of 10 days is required for individuals to develop specific sensitivity to a new contactant. For
example, an individual who never has been sensitized to poison ivy may develop only a mild dermatitis 2 weeks
following the initial exposure but typically develops severe dermatitis within 1-2 days of the second and
subsequent exposures.
Remember that removing the poison ivy allergen from the skin is difficult, and unless, an individual
washes exposed skin within 30 minutes of exposure, allergic contact dermatitis will develop. The hallmark of
the diagnosis of poison ivy is linear dermatitic lesions. The possibility of an external cause of dermatitis always
must be considered if the dermatitis is linear or sharply defined.
The immediate onset of dermatitis following initial exposure to material suggests either a cross-sensitization
reaction, prior forgotten exposure to the substance, or nonspecific irritant contact dermatitis provoked by the
agent in question.

Eyelid dermatitis
Individuals may develop dermatitis on eyelids and other exposed skin following exposure to airborne allergens
or allergens transferred to that site by the fingers. Contact dermatitis may also result from allergy to eyelid
makeup.
Contact urticaria
Immediate reactions, ie, visible lesions developing less than 30 minutes after exposure, indicate contact
urticaria (not allergic contact dermatitis). This is particularly true if the lesions are urticarial in appearance and
if the skin reaction is associated with other symptoms, such as distant urticaria, wheezing, ophthalmedema,
rhinorrhea, or anaphylaxis.

Latex
Rubber latex currently is the most important source of allergic contact urticaria (see Latex Allergy). The term
hypoallergenic may refer to gloves that do not contain sensitizing chemicals added to rubber latex but may not
indicate whether the gloves are rubber latex free.
Some individuals may have delayed specific contact sensitivity to rubber latex, but contact urticaria to rubber
latex is much more common than allergic contact dermatitis to latex. Individuals with hand dermatitis, hospital
workers, children with spina bifida, and atopic individuals are at increased risk of developing contact urticaria
to rubber latex. Individuals may have allergic contact dermatitis to chemicals added to rubber gloves and have
contact urticaria to latex. Individuals wearing rubber gloves should be evaluated carefully for both possibilities.
Rare reports exist of immediate anaphylactic reactions to topical antibiotics (eg, bacitracin).

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. Allergic contact dermatitis 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 allergic contact dermatitis. Examples include 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
Medications (both self-prescribed and physician-prescribed) are important causes of allergic contact dermatitis.
The workplace nurse may dispense ineffective and sensitizing topical preparations, such as thimerosal
(Merthiolate), which may change a simple abrasion into a severe case of allergic contact dermatitis. Individuals
may develop allergy to preservatives in medications and/or to the active ingredients in topical medications,
especially neomycin and topical corticosteroids. [17, 18]
Patients with dermatitis that does not clear with topical corticosteroid treatment should be considered for
patch testing with a corticosteroid series and the commercial preparations of corticosteroids and their vehicles.

Physical Examination
Acute allergic contact dermatitis is characterized by pruritic papules and vesicles on an erythematous base.
Lichenified pruritic plaques may indicate chronic allergic contact dermatitis. Occasionally, allergic contact
dermatitis may affect the entire integument (ie, erythroderma, exfoliative dermatitis). The initial site of
dermatitis often provides the best clue regarding the potential cause of allergic contact dermatitis. Note the
following.
Hands
Hands are an important site of allergic contact dermatitis, particularly in the workplace. Common
causes of allergic dermatitis on the hands include the chemicals in rubber gloves.
Topical medication sites
Allergic contact dermatitis is frequent in the perianal area as a result of the use of sensitizing
medications and remedies (eg, topical benzocaine). Topical medications are also important
causes of allergic contact dermatitis in cases of otitis externa. Allergy to chemicals in
ophthalmologic preparations may provoke dermatitis around the eyes.
Airborne allergic contact dermatitis
Chemicals in the air may produce airborne allergic contact dermatitis. 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.
Hair dyes
Hair dye—in particular, the component p-phenylenediamine (PPD)—may trigger allergic contact
dermatitis. 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 allergic contact
dermatitis to topical medications applied to inflamed or ulcerated skin (see the image below).
The chronicity of this condition and the frequent occlusion of applied medications contribute to
the high risk of allergic contact dermatitis 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.

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.

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 allergic
contact dermatitis resulting from exposure to poison ivy, [19] tropical woods, nickel, and
hair dye (see the image below).
Intraoral metal contact allergy may
result in mucositis that mimics lichen
planus, which has an association with
intraoral squamous cell carcinoma.
Intraoral squamous cell carcinoma
adjacent to a dental restoration
containing a metal to which the patient
was allergic has been reported. [20]
Allergic contact dermatitis may be a
direct trigger for skin ulceration in
patients with venous insufficiency. Early diagnosis and treatment of allergic contact
dermatitis may prevent the development of venous ulcers.
Diagnosis
Diagnostic studies for allergic contact dermatitis include the following:
 Potassium hydroxide preparation and/or fungal culture: To exclude tinea; these tests are often indicated
for dermatitis of the hands and feet
 Patch testing: To identify external chemicals to which the person is allergic
 Repeat open application test (ROAT): To determine whether a reaction is significant in individuals who
develop weak or 1+ positive reactions to a chemical
 Dimethylgloxime test: To determine whether a metallic object contains enough nickel to provoke
allergic dermatitis
 Skin biopsy: May help to exclude other disorders, particularly tinea, psoriasis, and cutaneous lymphoma