Allergic Contact Dermatitis

Something rubbing you the wrong way?

Dermatitis is the broad term for any inflammation of the skin -- scaling, thickening, flaking, itching, blistering, or color change. Contact dermatitis is what occurs when your skin comes into contact with an allergen (something to which you are allergic). Typical allergens include perfumes, cosmetics, rubber, plants (such as poison ivy or poison oak), gold, silver, or nickel, medicated ointments and creams, sunlight, and adhesives (such as tape).

Pronunciation

derm-a-TIE-tis

Synonyms and Abbreviations

  • Seborrheic dermatitis: seborrhea, cradle cap, dandruff
  • Stasis dermatitis: gravitational eczema, varicose eczema, venous dermatitis
  • Exfoliative dermatitis: erythroderma, pityriasis rubra
  • Diaper dermatitis: diaper rash
  • Contact dermatitis: dermatitis venenata, allergic contact dermatitis (ACD), phytodermatitis (plant dermatitis), housewives' eczema
  • Atopic dermatitis: eczema, disseminated neurodermatitis, atopic eczema, atopic neurodermatitis, constitutional dermatitis, Besnier's prurigo

Detailed Description

The good news about dermatitis is that it usually occurs only when you have had contact with a plant or chemical to which you are allergic: poison oak or ivy, for instance. As miserable as its symptoms may be, dermatitis will most likely run its course as soon as the offending agent is removed. However, there are many specific forms of dermatitis, including :

  • Contact dermatitis. A rash confined to a specific area, usually with clear boundaries. This inflammation is caused by contact with an allergen (a substance to which you are allergic). Irritant contact dermatitis results from prolonged exposure to a substance that eventually begins to irritate; even a mild soap used for years could be the cause. Allergic contact dermatitis usually occurs within a few exposures to the irritant (poison ivy, nickel in jewelry, or bandage adhesive, for instance).
  • Atopic dermatitis. Chronic, itchy inflammation of the upper layers of the skin. This condition is most likely an immune-system abnormality and occurs most commonly in children, especially those who have asthma or hay fever, or have relatives with these conditions. It can make its first appearance in the first few months of life and is usually troublesome in specific places: the upper arms, in front of the elbows, and behind the knees. It can continue into adulthood and often localizes in the hands.
  • Chronic dermatitis of the hands and feet. Itchy inflammation caused by repeated exposure to an irritant such as rubber gloves, soap, or chemicals (hands), or the warm, moist conditions of socks and shoes (feet)-- particularly black rubber sandals.
  • Seborrheic dermatitis. Commonly known as dandruff or cradle cap, this itchy inflammation also occurs on the face, ears, and chest between the breasts.
  • Generalized exfoliative dermatitis. Severe inflammation of the entire skin surface marked by extreme redness and scaling. Skin may become thickened and crusted. This serious illness results from a drug reaction, as a complication of other skin diseases, or from certain lymphomas. Sometimes no cause can be found. Loss of fluids and the possibility of infection contribute to the seriousness of this illness.
  • Nummular dermatitis. This persistent, itchy rash may come and go without any apparent reason. Small, round lesions marked by tiny blisters, scabs, and scales may ooze and form crusts. It is most commonly seen on the arms, legs, and buttocks, but it may also appear on the torso. It is more common in the winter and with dry air.
  • Stasis dermatitis. Occurs most frequently around the ankles of those suffering from varicose veins and edema (swelling). Its symptoms are chronic redness, scaling, warmth, swelling, itch, and inflammation. It culminates in dark brown skin and is caused by the pooling of blood and fluid under the skin.
  • Diaper rash. Probably the most common dermatitis, diaper rash thrives in the moist, warm, bacteria-rich environment of an infant's wet diaper. The red, raised, inflamed areas of the rash can be further irritated by urine or stool. It is characterized by small red bumps.
  • Dermatitis herpetiformis. This uncommon form of dermatitis involves intense itchiness on extensor skin surfaces.

Characteristics of Allergic Contact Dermatitis

Skin irritation after contact with an offending agent presents itself in a number of ways, but some of the more common features are itching, scales, blisters, thickened skin, flakes, and color changes. The pattern of inflammation is often the same shape as the pattern of the agent on the skin such as a rash around your wrist if the offending agent is a metal bracelet.

How Common Is Dermatitis?

No predominant age or age group is more affected by dermatitis than another, however, different forms of dermatitis can affect different ages, such as infants diagnosed with diaper rash to adults with atopic dermatitis. Either sex is equally likely to be afflicted with dermatitis, variations seen are likely due to either individual differences in exposure to the allergen or normal skin variations between men and women.

What You Can Expect

Some types of dermatitis have a self-limiting course of a few days or weeks once the allergen has been removed (contact dermatitis). However, the irritating agent may not be obvious. Until it can be identified and you can avoid it, the symptoms may persist. Prolonged exposure to the irritant can lead to chronic contact dermatitis. Others types are chronic or recurring (atopic dermatitis, chronic dermatitis of the hands and feet, seborrheic dermatitis). Others may occur just once (generalized exfoliative dermatitis). Atopic dermatitis is most common in children, and 90% of cases clear up on their own by puberty. All forms of dermatitis can be managed with treatment.

If you currently have severe, chronic contact dermatitis, you may develop exfoliative dermatitis, a much more serious illness that causes the skin to peel. This peeling, in turn, disrupts the skin's integrity and barrier function leading to thermoregulatory problems, electrolyte imbalances, protein and iron losses, and secondary infection. This is very rare.


Established Causes

The myriad of causes are as diverse as the population allergic contact dermatitis afflicts. In certain cases, dermatitis is idiopathic -- that is, the cause is unknown. In most cases, the cause has been established due to some form of allergen, trauma, familial disposition, internal disorder, diet, or environmental factor.

The three main categories of allergens can be identified as:

  • Plants, including primary contact with Rhus-urushiols (poison ivy, oak, sumac). Even secondary contact (not directly with the plant itself) may elicit a cutaneous reaction.
  • Chemicals, including turpentine-containing agents, gold and nickel metal, soaps, detergents, and potassium dichromate.
  • Topical preparations, such as the antibiotic neomycin, the anesthetic benzocaine, and formalin in shampoos and nail enamel.

Risk Factors

Because contact dermatitis is caused by exposure to an allergen or irritant, risk factors depend on a person's exposure to specific allergens. Thus, risk factors can include:

  • Occupational exposures
  • Certain hobbies that may involve working with a known or possible allergen
  • Traveling to foreign environments
  • Burns (due to scalding or sunburn)
  • An environment that affects cutaneous moisture levels (i.e., constant exposure to hot water, detergents)
  • Genetics
  • Age
  • Diet
  • Pregnancy
  • Stress
  • Medication use
  • Improper laundering
  • Sensitivities to chemicals and metals

Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.

Symptoms

How do you know you have dermatitis? There are three established signs that signify dermatitis: immediate manifestations, long-term manifestations, and finally, diagnosis based on characteristic descriptions and distribution of the lesions.

  • Acute
    • Itching (usually the first symptom)
    • Oozing and crusting of lesions
    • Formation of papules or vesicles with redness on the skin
  • Chronic
    • c
    • Scratching may cause hyperkeratosis (thickening of the skin)
    • Cutaneous erythema (redness)
  • Lesions
    • Form in areas of direct contact with irritant (often in a pattern that is in the same shape as the distribution of irritant on the skin)
    • Are arrayed linearly
    • Have sharp borders and angles
    • Form more easily on regions where the epidermis is thinner
    • Do not form as much on palms, feet, or deeper skin-fold areas

Conditions That May Be Mistaken for Allergic Contact Dermatitis

Though the diagnosis of contact dermatitis is usually based on a clinical impression (appearance, localization, frequency), many of the signs and symptoms can be found in other cutaneous disorders creating confusion in the diagnosis. Certain similarities between skin disorders include the appearance of:

  • Scaly, eczema-like lesions that can be found in atopic dermatitis, lichen simplex chronicus, xerosis, and stasis dermatitis
  • Lesions on eyelids similarly found in seborrheic dermatitis
  • Scattered vesicular (bullous) lesions as found in bullous pemphigoid

How Dermatitis Is Diagnosed

Diagnostic methods may include a patch test (allergic contact dermatitis), blood work, tests on scraping of skin, or even skin biopsy. The diagnostic work-up varies, depending on the specific condition.

The signs and symptoms of dermatitis vary with the different forms. In all cases, the clinical picture involves physical manifestations of the skin, such as:

  • Flaking
  • Lesions
  • Swelling
  • Redness
  • Formation of papules (including distribution)
  • Crusting
  • Oozing
  • Scaling
  • Fissuring

You may also experience feelings of:

  • Itchiness
  • Tenderness
  • Burning
  • Stinging

Your Medical History

Prior episodes of contact dermatitis may signify that you have sensitive skin, and are prone to future episodes.

Goals of Treatment

Some forms of dermatitis clear up within a few days or weeks with over-the-counter creams and ointments such as calamine lotion, anti-itch creams, topical cortisone, and oatmeal-bath solutions to help relieve symptoms. Others require persistent, diligent treatment to keep symptoms under control and may require prescription topical corticosteroids, or antibiotics (if a secondary infection has developed from scratching). In severe cases, your doctor may prescribe a corticosteroid taken orally. The only cure for contact dermatitis is to completely avoid the allergen that causes the symptoms.

Treatment should help relieve itching, inflammation, and other discomforts, return skin to its normal appearance, and if possible, prevent recurrence

Treatment Overview

Removing and avoiding the offending agent is the most important consideration.

Many therapies are available for the different forms of dermatitis. Proper therapy is assigned according to the form of dermatitis you suffer from as well as your response to the prescribed therapy. Treatments may include topical soaks with cool tap water, or saline (one teaspoon of salt to one pint of water), lukewarm water baths, oatmeal baths (such as Aveeno), and for chronic dermatitis, emollients (such as petroleum jelly or Eucerin cream).

For specific types of dermatitis, symptoms can be relieved by:

  • Contact dermatitis: treated by removing or avoiding the allergen. It is important to wash the area with mild soap and rinse well with water. Corticosteroid creams or ointments usually relieve itching. Cool, therapeutic baths containing colloidal oatmeal may reduce itching.
  • Atopic dermatitis: an inflammatory process. Corticosteroid creams or ointments may decrease inflammation and relieve itching. Attention to skin dryness is an important aspect of treatment. Bathing every other day will help you avoid irritants found in soap, water, and towels. Apply lubricating ointments after bathing. Antihistamines may help control itching by sedation (best at bedtime). Severe atopic dermatitis may be treated with prescription corticosteroid tablets.
  • Chronic dermatitis of the hands and feet: treated by avoiding the irritant. Corticosteroid creams are used for inflammation and itching. If a fungus is causing the symptoms, an antifungal drug would be appropriate.
  • Seborrheic dermatitis: adults can use a shampoo containing pyrithione zinc, selenium sulfide, salicylic acid and sulfur, or tar. A weak corticosteroid cream is recommended for short-term use on the face. Ketoconazole cream may also be used. Children who have a thick, scaly scalp rash can have mineral oil rubbed gently into the scalp at bedtime. Shampoo daily until the rash is gone. Infants with seborrheic dermatitis (cradle cap) should have their scalps washed with mild baby shampoo. Hydrocortisone cream can then be rubbed into the scalp.
  • Generalized exfoliative dermatitis: treated by first eliminating any drug or chemical that may be irritating the skin. Fluid and protein loss through damaged skin can be profound, so this illness is often treated in the hospital with antibiotics, IV fluids, and nutritional supplements. You may be swathed in heated blankets to prevent a drop in body temperature. Cool baths and applications of petroleum jelly help protect the damaged skin.
  • Nummular dermatitis: treated with oral antibiotics, barrier creams, corticosteroid creams and injections, and ultraviolet light therapy. No single treatment is effective for everyone.
  • Diaper rash: treated with frequent diaper changes, petroleum jelly, zinc oxide, or Eucerin creams. Use soft cloths and water for cleansing rather than diaper wipes. Avoid plastic pants. Also, allowing your baby to go without a diaper for a while during the day can be helpful.

Drugs most commonly prescribed

The drugs of choice for treating each form of dermatitis are specific to the dermatitis itself as well as your response to the medication. In general, they include moisturizers, steroids, and anti-allergen medications such as:

  • Calamine lotion, oatmeal lotions, menthol lotions (such as Sarna)
  • Corticosteroids like fluocinonide (applied topically) and prednisone (taken systemically)
  • Antibiotics like erythromycin (if secondary infection is suspected)
  • Antihistamines like diphenhydramine (Benadryl) or hydroxyzine
  • A "shake lotion" consisting of zinc oxide, talc, and 0.5% phenol and 0.25% methanol

Surgery

Surgery is never needed. In extreme cases of stasis dermatitis, vein stripping or skin grafts may be necessary.

Appropriate Healthcare Setting

Outpatient management is almost always sufficient.

Healthcare Professionals Who May Be Involved in Treatment

  • Family practice physicians
  • Internists
  • Dermatologists
  • Pediatricians (for children)

Activity and Diet Recommendations

There are no restrictions for contact dermatitis except to avoid the allergen and activities that may make the condition worse.

Those with outbreaks of atopic dermatitis should avoid any activity which causes sweating or overheating. What's more, avoid those activities which cause stress, which can exacerbate the outbreak.

Some foods cause allergic reactions more frequently than others do, such as milk and other dairy products, eggs, shellfish, wheat, soy, peanuts, tomatoes, and citrus fruits.

Monitoring the Condition

Depending on the recommended treatment as well as the form of dermatitis, constant monitoring is recommended for all forms as many can recur. Proper education about what causes your particular form of dermatitis is a must to prevent future outbreaks or occurrences.

Possible Complications

  • Repeated contact over time with the allergen causing your outbreaks could result in repeated outbreaks even when you've had no recent contact with the allergen
  • Secondary bacterial infection due to scratching

Considerations for Children and Adolescents

Children with very severe atopic dermatitis should not be vaccinated against smallpox. Such vaccinations can cause eczema herpeticum, a serious illness that requires hospitalization.

Atopic dermatitis is generally a disease of childhood. By the time they reach puberty, 90% of children with the disease are no longer affected. Take special care that children's fingernails are clipped short and their hands are kept clean. Scratching with dirty fingernails can cause serious secondary infections.

Considerations for Older People

Older people are more susceptible to contact dermatitis due to the lack of skin moisture associated with age.


Diet

Many studies show that dermatitis often results from food sensitivities. For example, Dutch researchers placed children and adults with severe dermatitis on an elimination diet, which involves cutting out specific foods and then reintroducing them to see what happens. The majority of the subjects improved after this diet pinpointed problem foods. The foods most likely to cause allergic reactions were eggs, milk, peanuts, fish, wheat, and soybeans. [1]

Supplements

  • Fish oil contains the omega-3 fatty acids found in cold-water fish. Dermatitis is caused by inflammatory compounds called prostaglandins, which these acids neutralize. Good cold-water fish to add to your diet include salmon, mackerel, and herring.
  • Evening primrose oil also contain omega-3 fatty acids. A British study showed that compared with a placebo treatment, evening primrose oil provided significant relief of dermatitis. [2] Its use is considered controversial by many medical experts.

Herbs

  • Chamomile has anti-inflammatory action. Commission E, the German expert panel that judges the safety and effectiveness of medicinal herbs for Germany's counterpart of the Food and Drug Administration, endorses chamomile compresses for dermatitis and other inflammatory skin conditions.
  • Chinese herbs: Some evidence suggests they help relieve dermatitis. British researchers gave a Chinese herb formula to 10 people with eczema. Two months later, their skin was significantly clearer. [3] Consult a practitioner of Chinese herbalism for specific advice. Before using Chinese herbs, keep in mind these important warnings: Chinese herbs vary greatly, are often unmarked, can contain arsenic, and should not be given to children. Beware: the formulations you buy are not monitored for quality control or approved ingredients by the U.S. Food and Drug Administration (FDA).

Relaxation

Stress may contribute to dermatitis. Incorporate a stress-management regimen into your life that includes relaxing therapies such as meditation, biofeedback, yoga, or deep breathing.

Hydrotherapy

An oatmeal bath helps relieve itching. Grind oatmeal fine in a coffee grinder and add a handful or two to a warm bath. Or use Aveeno powder, which is also fine-ground oatmeal.


1 De Maat-Bleeker, F., et al. "Food Allergy in Adults with Atopic Dermatitis," Highlights in Food Allergy 32:157, 1996.

2 Morse, P.F., et al. "Meta-Analysis of Placebo-Controlled Studies of the Efficacy of Epogram in Treatment of Atopic eczema," British Journal of Dermatology 121:75, 1989.

3 Xu, X.J., et al. "Modulation by Chinese Herbal Therapy of Immune Mechanisms in the Skin of Patients with Atopic Eczema," British Journal of Dermatology 136:54, 1997.


Preventing Dermatitis

  • Identify and avoid any allergens that irritate your skin.
  • Wear cotton-lined gloves when working with irritating chemicals such as hair dyes, gardening products, or hobby paints, to prevent you from coming into contact with these potential allergens.
  • Wash new clothes before wearing them.
  • Avoid stress.

Self-Care Measures

  • Try not to scratch. It aggravates the inflammation and can cause a secondary bacterial infection.
  • Showering dries skin. Take quick showers, avoiding overly hot water, and apply moisturizing lotion immediately afterwards and throughout the day when you feel itchy.
  • Use mild soap.
  • Avoid skin irritants, which include harsh soaps, detergents, solvents, fragrances, fumes, paints, and any fabrics to which you are sensitive.
  • Treat your allergies-- they often play a role in dermatitis.
  • Alcohol dries skin. Don't use personal-care products that contain it.
  • A dry environment contributes to dermatitis. Install a humidifier to help add moisture to the air.
  • Wash new clothes before wearing them to remove potential irritants.

  • Websites & Organizations

    American Academy of Dermatology
    P.O. Box 4014
    Schaumburg, IL 60168
    Phone: 708-330-0230

    American Dermatologic Society of Allergy and Immunology
    Mayo Clinic
    Rochester, MN 55905
    Phone: 507-284-2555

    Canadian Dermatology Association
    Suite 521
    774 Echo Drive
    Ottawa, ON K1S 5N8
    Phone: 800-267-3376 or 613-730-6262
    Fax: 613-730-1116
    Email: cda.albagli@rcpsc.edu

    Dermatology Foundation
    1653 Maple Avenue
    Evanston, IL 60201
    Phone: 312-328-2256

    Health World Online

    National Jewish Medical and Research Center
    1400 Jackson St.
    Denver, CO 80206
    Phone: 303-388-4461 or 800-222-LUNG (5864)

    Society for Investigative Dermatology
    Suite 340
    820 West Superior Avenue
    Cleveland, OH 44113-1800
    Phone: 216-579-9300
    Fax: 216-579-9333
    Email: SID@SIDNET.org

    Society for Pediatric Dermatology
    5422 North Bernard
    Chicago, IL 60625
    Phone: 773-583-9780
    Fax: 773-583-9765

    Women's Dermatologic Society
    930 North Meacham Road
    Schaumberg, IL 60173
    Phone: 847-330-9830
    Fax: 847-330-1090
    Email: kward@aad.org

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