Irritant contact dermatitis

Published on 19/03/2015 by admin

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Irritant contact dermatitis

Nathaniel K. Wilkin

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

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(Courtesy of Kalman Watsky, MD. From Bolognia, J.L., Jorizzo, J.L., Schaffer, J.V. (Eds.), Dermatology, third ed. pp. 249–259. © Elsevier.)

Irritant contact dermatitis (ICD) is the most common form of contact dermatitis and is defined as the reaction to an exogenous substance – the irritant – that damages the epidermis through physical or chemical mechanisms, triggering an innate immunological response only. Clinical manifestations of ICD vary in presentation and severity according to multiple factors: pre-existing status of the skin (atopy, barrier disruption, etc.), the nature and number of irritants (corrosives or caustic), the duration and frequency of contact, and the conditions of exposure (moisture, occlusion, temperature). Acute ICD is usually attributable to a single irritant. Chronic ICD usually results from exposure to multiple irritants, often in association with endogenous factors such as atopy or stress. Chronic cumulative ICD usually involves the hands.

ICD is common, often has a poor prognosis, has a significant economic impact on society, and seriously degrades the quality of life of affected individuals beyond the ability to work.

Management strategy

The first step in any management strategy is prevention. Patients should be educated about proper skin care and protection, including: hand washing, the use of moisturizers and barrier creams, avoidance of common irritants, and the use of protective clothing such as gloves and aprons when handling potentially irritating substances.

Dermatologists can encourage primary prevention by counseling patients at higher risk because of endogenous factors (e.g., atopy) or exogenous factors (e.g., frequent occupational exposures, such as in hairdressing). Secondary prevention includes measures that enable patients to remain employed without interfering with the resolution of the ICD. Chronic hand dermatitis is a common presentation of ICD, and patient education can be facilitated with a handout on lifestyle management principles directed at hand washing and moisturizing, occlusive moisturizing therapy at night, special protective modalities (such as type of glove to exclude specific irritants), and specific agents to avoid.

Azathioprine, cyclosporine, oral retinoids, psoralen and UVA (PUVA), Grenz ray therapy, and superficial radiotherapy may be justified for short-term control in patients who are compliant with moisturizing, use of protective modalities (gloves), and application of topical corticosteroids, and still have a severe disruption of their quality of life due to active ICD. Because the goal of these second- and third-line therapies is to reduce the severity such that first-line therapies may become sufficient, patient selection is critical.

Specific investigations

First-line therapies

image Physical skin protection C
image Emollients C
image Barrier creams C
image Topical corticosteroids C
image Topical calcineurin inhibitors C

Double-blind, randomized trial of scheduled use of a novel barrier cream and an oil-containing lotion for protecting the hands of health care workers.

McCormick RD, Buchman TL, Maki DG. Am J Infect Control 2000; 28: 302–10.

The scheduled use of petrolatum oil-containing lotion or a barrier cream was associated with a marked improvement (69% and 52%, respectively) in chronic hand irritant dermatitis.

It is debatable whether the distinction between ‘skin care’ and ‘skin protection’ is real. Side effects in using emollients and barrier creams are irritation and sensitization to their ingredients. A useful procedure is to include patch tests of those emollients and barrier creams anticipated to be used by the patient in the initial comprehensive patch testing evaluation of the chronic contact dermatitis.

Second-line therapies

image Cyclosporine C
image UVB therapy C
image PUVA therapy C
image Bexarotene gel C

Novel treatment of chronic severe hand dermatitis with bexarotene gel.

Hanifin JM, Stevens V, Sheth P, Breneman D. Br J Dermatol 2004; 150: 545–53.

A phase I–II open-label randomized clinical study of bexarotene gel, alone and in combination with a low- and a mid-potency steroid, was conducted in 55 patients with chronic severe hand dermatitis at two academic clinics. Patients using bexarotene gel monotherapy reached a 79% response rate for at least 50% clinical improvement and a 39% response rate for at least 90% clearance of hand dermatitis. Adverse events possibly related to treatment in all patients were stinging or burning (15%), flare of dermatitis (16%), and irritation (29%). Bexarotene gel appears to be safe, tolerated by most patients, with useful therapeutic activity in chronic severe hand dermatitis.

Comparison of cyclosporine and topical betamethasone 17,21-dipropionate in the treatment of severe chronic hand eczema.

Granlund H, Erkko P, Eriksson E, Reitamo S. Acta Derm Venereol 1996; 76: 371–6.

Low-dose oral cyclosporine at 3 mg/kg daily was compared with topical 0.05% betamethasone dipropionate in a randomized, double-blind study of 41 patients with chronic hand dermatitis and an inadequate response to treatment with topical halogenated corticosteroids for at least 3 to 4 weeks, and/or PUVA and avoidance of relevant contact allergens. Both treatment groups had similar improvement and similar relapse rates after successful treatment. Adverse events were slightly more common in patients treated with cyclosporine.

Low-dose cyclosporine may be a useful alternative treatment, although very high-potency topical corticosteroids can be effective in patients who do not have an adequate response to other mid- to high-potency topical corticosteroids.

Third-line therapies

image Superficial radiotherapy A
image Oral alitretinoin A

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