[Dermatology] Atlas of Contact Dermatitis

These are pictures of Contact Dermatitis. This is a part in the Atlas of Geriatric Dermatology book

Clinical Description

In the elderly, allergic and irritant contact dermatitis presents as variable, patchy erythema, often without vesicles (in contrast to younger patients) but with pruritus and/or burning.

Etiology and Pathophysiology

Contact dermatitis is a generic term applied to acute or chronic inflammatory reactions to substances that come in contact with the skin. Irritant contact dermatitis (ICD) is caused by a chemical irritant. Since ICD is a toxic phenomenon, it is confined to the area of exposure and is therefore sharply marginated and remains localized. Allergic contact dermatitis (ACD) occurs by an antigen (allergen) that elicits a type IV (cell-mediated or delayed) hypersensitivity reaction. ACD is an immunologic reaction that involves the surrounding skin and may spread beyond affected sites.

Topical preparations containing ingredients such as vitamin E, aloe vera, fragrances, parabens. quarternium 15, diphenhydramine (Benadryl spray, Caladryl lotion), neomycin (Neosporin). and PABA (para-amino benzoic acid) are common allergenic offenders [1, 2]. Overuse of soaps, cleansers, moisturizers, and cosmetics can produce irritation [3].

Histopathology

Histopathologic investigation reveals subacute dermatitis with spongiosis and lymphocytic (allergic) and/or neutrophilic (irritant) exocytosis. 

Diagnosis

Patch testing can be of value when properly performed [4, 5]. The site of contact dermatitis suggests possible causes.

Differential Diagnosis 

Because inflammation is attenuated in the elderly, other causes of generalized pruritus, including metabolic, infectious, and neoplastic conditions, must be considered. Unusual or persistent eczematous eruptions in the elderly warrant a careful search for neoplasms, infections, metabolic diseases, and drug ingestion. Sulfa-related medications are a common cause of contact dermatitis and phototoxic reactions.

Therapy

1. Discontinue use of offending topical agent(s) [15, 16]

2. Mild or mid-strength steroids are preferable to highpotency topical steroids in the elderly to avoid atrophy

3. Apply soothing, cool compresses, followed by bland emollients.

Prognosis

The prognosis is good once the offending agent(s) has been identified and removed. 

Fig. 2.1 Linear vesicles and erythema are characteristic of poison oak
and poison ivy (Rhus) dermatitis  

Fig. 2.2 Generalized poison oak or poison ivy dermatitis  

Fig. 2.3 Hyperpigmented streaks suggested berloque dermatitis 

(phytophotodermatitis) caused by citrus furocoumarins in perfume, cologne,
and certain lemon and lime peel oils  

Fig. 2.4 Rubber dermatitis from elastic stockings  

Fig. 2.5 Factitial (self-induced) dermatitis, also called dermatitis 

artefacta in a patient with delusion of parasitosis  

Fig. 2.6 Stasis dermatitis complicated by application of topical
Neosporin ointment  

Fig. 2.7 Contact allergic dermatitis from artificial acrylic nails  

Fig. 2.8 Vesicular contact allergic dermatitis from shoe materials
(leather, rubber, or glue)  

Fig. 2.9 Nickel dermatitis from an underwire bra  

Fig. 2.10 Second-degree hot water burn from a pressure cooker  

Fig. 2.11 Hair dye (paraphenylenediamine) dermatitis affects the ears,
neck, and hands  

Fig. 2.12 Hatband dermatitis  

Fig. 2.13 Contact dermatitis from nitropaste (nitroglycerin transdermal patch)  

Fig. 2.14 Acute exudative contact dermatitis of the scrotum from
Bounce fabric softener  

Fig. 2.15 Palm eczema may be aggravated by various topical
allergens or irritants and by overwashing, certain foods
(citrus, shellfish), emotional stress, infections (tinea pedis)
or, occasionally, internal malignancies  

Fig. 2.16 Cheilitis venenata, contact dermatitis of the lips, caused by
lip balm containing PABA, vitamin E, and aloe vera, three common
allergens  

Fig. 2.17 Erythema ab igne (“redness from the fire”). This poikilodermatous 

(hyperpigmentation and hypopigmentation, telangiectasia, and
atrophy) contact dermatitis is caused by excessive use of a heating pad  

Fig. 2.18 Contact allergic dermatitis from Steri-Strip adhesive.
(Reproduced with permission from Newcomer and Young [17])  

Fig. 2.19 Irritant dermatitis on the neck  

References

1. Adams RM. Occupational skin disease. New York: Grune & Stratton; 1983.

2. Fisher AA. Contact dermatitis. 3rd ed. Philadelphia: Lea & Pebiger; 1986.

3. Newcomer VD, Young Jr EM. Recognition and treatment of contact dermatitis. Drug Ther. 1991;21(3):211–7.

4. Nethercott JR. Practical problems in the use of patch testing in the evaluation of patients with contact dermatitis. Curr Probl Dermatol. 1990;2:95.

5. Adams RM. Patch testing: a recapitulation. J Am Acad Dermatol. 1981;5:629.

6. Thestrup-Pedersen K, Larsen CG, Ronnevig J. The immunology of contact dermatitis: a review with special reference to the pathophysiology of eczema. Contact Dermatitis. 1989;20:81.

7. Bourke J, Coulson I, English J. Guidelines for the management of contact dermatitis: an update. Br J Dermatol. 2009;160(5):946–54.

8. Ale Iris S, Maibachl HA. Diagnostic approach in allergic and irritant contact dermatitis. Expert Rev Clin Immunol. 2010;6(2):291–310. 9. Modi GM, Doherty CB, Katta R, Orengo IF. Irritant contact dermatitis from plants. Dermatitis. 2009;20(2):63–78.

10. Goossens A, Medeiros S. Allergic contact dermatitis from topical medicaments. Expert Rev Dermatol. 2008;3(1):37–42.

11. Rajpara A, Feldman SR. Cell phone allergic contact dermatitis: case report and review. Dermatol Online J. 2010;16(6):9.

12. Glick ZR, Saedi N, Ehrlich A. Allergic contact dermatitis from cigarettes. Dermatitis. 2009;20(1):6–13.

13. Alikhan A, Maibach HI. Allergic contact dermatitis: the future. Dermatitis. 2009;20(6):327–33.

14. Munoz CA, Gaspari A, Goldner R. Contact dermatitis from a prosthesis. Dermatitis. 2008;19(2):109–11.

15. Adams RM, Fisher AA. Contact allergen alternatives: 1986. J Am Acad Dermatol. 1986;14:951.

16. McLelland J, Shuster S, Matthews JNS. “Irritants” increase the response to an allergen in allergic contact dermatitis. Arch Dermatol. 1991;127:1016.

17. Newcomer VD, Young Jr EM. Geriatric dermatology: clinical diagnosis and practical therapy. New York: Igaku-Shoin; 1989