Management of Contact Dermatitis

Issued by: Date of Issue Date of Expiry

British Journal of Dermatology 2009 Not updated

Citation Link to full text

Bourke, J., I. Coulson, and J. English. Guidelines for http://www.guideline.gov/content.aspx?id=158
the management of contact dermatitis: an 81
update. British Journal of Dermatology 160.5 (2009):
946-954.
Summary of Critical Appraisal:
This update aims to provide evidence based guidelines for the definitions of contact dermatitis and their
relevance, diagnosis, and treatment of patients with this condition. This is prepared by dermatologists in
behalf of the British Association of Dermatologists Therapy Guidelines and Audit Subcommittee.

No clinical algorithm in the diagnosis of contact dermatitis was provided in this guideline. Evidence were
appraised and rated accordingly.

It should also be noted that the health system in the UK is organized differently from the Philippines.
Some recommendations in terms of medical services may not be widely available in our setting. A
formal cost analysis is not included in the guideline. Some diagnostic and treatment options were not
given grades and levels of evidence but were nevertheless included. Users are cautioned in interpreting
the data as this reflects the best data available at the time the report was prepared. Furthermore, future
studies may require alteration of conclusions or recommendations in the guidelines.

PDS has reviewed this summary and added additional information for clarity and update. These
information are referenced in the footnotes.

Strength of recommendations
A There is good evidence to support the use of the procedure

B There is fair evidence to support the use of the procedure

C There is poor evidence to support the use of the procedure

D There is fair evidence to support the rejection of the use of the procedure

E There is good evidence to support the rejection of the use of the procedure
Quality of Evidence
I Evidence obtained from at least one properly designed, randomized controlled trial

II-i Evidence obtained from well-designed controlled trials without randomization

II-ii Evidence obtained from well-designed cohort or case-control analytic studies, preferably
from more than one centre or research group
II-iii Evidence obtained from multiple time series with or without the intervention. Dramatic
results in uncontrolled experiments (such as the results of the introduction of penicillin
treatment in the 1940s) could also be regarded as this type of evidence
III Opinions of respected authorities based on clinical experience, descriptive studies or reports
of expert committees
IV Evidence inadequate owing to problems of methodology (e.g., sample size, or length or
comprehensiveness of follow-up or conflicts of evidence)

Summary of Recommendations
Definitions

Contact dermatitis Skin condition created by a reaction to an externally applied substance1

Subjective irritancy idiosyncratic stinging and smarting reactions occurring within minutes
of contact, usually on the face, in the absence of visible changes.
Cosmetic or sunscreen constituents are common precipitants.
Acute irritant contact often the result of a single overwhelming exposure or a few brief
dermatitis exposures to strong irritants or caustic agents
Chronic (cumulative) occurs following repetitive exposure to weaker irritants which may be
irritant contact dermatitis either "wet," such as detergents, organic solvents, soaps, weak acids
and alkalis, or "dry," such as low humidity air, heat, powders and dusts
Allergic contact dermatitis involves sensitization of the immune system to a specific allergen or
allergens with resulting dermatitis or exacerbation of pre-existing
dermatitis
Phototoxic, photoallergic some allergens are also photoallergens. It is not always easy to
and photoaggravated distinguish between photoallergic and phototoxic reactions
contact dermatitis
Systemic contact seen after the systemic administration of a substance, usually a drug, to
dermatitis which topical sensitization has previously occurred

1
American Academy of Dermatology Basic Curriculum on Contact Dermatitis
(http://www.aad.org/education/basic-dermatology-curriculum/suggested-order-of-modules/four-week-
rotation/week-3/contact-dermatitis)
 Recommendation Strength of Level of
recommendation evidence
WHO SHOULD BE INVESTIGATED

 Patch testing is an essential investigation when contact A II-ii

allergy is suspected in patients with persistent eczematous
eruptions
 Formal training in patch test reading and interpretation, A II-i
testing with additional series and prick testing in the
investigation of patients with contact dermatitis are
important. B II-ii
 Approximate annual workload for a contact dermatitis
investigation clinic has been suggested to be one individual
investigated per 700 of the population served, i.e., 100
patients patch tested for every 70,000 of the catchment
population per year.

DIAGNOSTIC TESTS

I. Patch Testing
 Mainstay of diagnosis in allergic contact dermatitis. It A II-ii
has a sensitivity and specificity of 70-80%.
 Reproduces allergic contact dermatitis in an individual
sensitized to a particular allergen.
 Standard Method vs. Preprepared tests

Standard Method
Individual allergens are placed in Finn aluminium chambers
(most commonly used application system) or IQ
polyethylene chambers2. Allergens applied onto the skin
(most commonly the back) are in standardized
concentrations in an appropriate vehicle and under
occlusion.

Preprepared tests
o i.e., TRUE test and Epiquick test I
o Preprepared tests are significantly more reliable
than operator-prepared tests.
 Larger chambers may give more reproducible tests, but
may only apply to some allergens; can be used to obtain II-ii
a more definite positive reaction when a smaller
chamber has previously given a doubtful one.

2
Doumit J and Pratt M. Comparative study of IQ-ultra and Finn Chambers test methodologies in detecting 10
common standard allergens that cause allergic contact dermatitis. J Cutan Med Surg. 2012 Jan-Feb; 16(1): 18-22.
A. Timing of Patch Test Readings A II-ii
 The optimum timing of readings is day 2 and 4. An
additional reading at day 6 or 7 will pick up a ~10% more
positives that were negative at days 2 and 4.

B. Relevance of Positive Reactions

1. Current relevance – patient has been exposed to
allergen during the current episode of dermatitis and
improves when exposure ceases
2. Past relevance – past episode of dermatitis from
exposure to allergen
3. Relevance not known – not sure of exposure is current
or old
4. Cross reaction – positive test is due to cross-reaction
with another allergen
5. Exposed – history of exposure but not resulting to
dermatitis from that exposure, or no history of exposure
but with definite positive allergic patch test

C. Patch Test Series

1. A screening series will pick up approximately 80% of
allergens; series will vary from country to country
and should be revised on a regular basis.
2. Patient’s own cosmetics, toiletries and medicaments
should be tested at non-irritant concentrations.
o Undiluted or “as is” for leave on products and
dilutions for wash-off products
o Strong irritants such as powdered detergents
should not be patch tested
o Occupational products should be tested at non-
irritant concentrations.
o Most useful reference source for documented
test concentrations and vehicles for chemicals,
groups of chemicals and products is De Groot
AC. Patch Testing. Test concentrations and
vehicles for 3700 chemicals, 2nd ed. Amsterdam:
Elsevier, 1994.

D. Photopatch Testing
 Application of photoallergen series and any suspected
materials in duplicate on either side of the upper back.
 One side is irradiated with 5 J cm-2 of UVA after an
interval of 1-2 days and readings are taken in parallel
after another 2 days.
 It is recommended that allergens be subjected to 5 J cm-2
UVA and a reading after 2 days; incidence of A II-ii
photoallergy in suspected cases was low at <5% but
 further readings at 3 and 4 days increased the detection
rate.
 Irradiation of the test site may be done after 1-2 days
after allergen application; the 2 day interval was found
to be favourable.

E. Open Patch Testing

1. Open Patch Test
 commonly used where potential irritants or
sensitizers are being assessed
 useful in the investigation of contact urticaria and
protein contact dermatitis
 performed on the forearm (or upper outer arm or
scapular areas)
 site is assessed at regular intervals for the first 30 to
60 minutes and a later reading is carried out after 3
to 4 days

2. Repeated open application test (ROAT)

 involves application of the product onto the forearm
twice daily for up to a week, stopping if a reaction
develops
 useful in the assessment of cosmetics, where
irritancy or combination effects may interfere with
standard patch testing

F. Preparation of Patient
A. Factors altering the accuracy of patch testing
 characteristics of individual allergens
 method of patch testing
I
 irritant-reaction causing allergens being
misclassified as positive reactions
B. Patient characteristics
 skin on the back is free of dermatitis
 skin disease elsewhere is well controlled to avoid
II-iii
“angry back syndrome” with numerous false
positives
 risk in false negative results when potent topical
II-iii
steroids are applied to the back up to 2 days
prior to the test or
 when oral corticosteroids/ immunosuppressant
drugs are being taken, a daily dose of no higher
than 10 mg prednisolone, suppression of
positive patch test is unlikely
 UV radiation may also interfere with results but
the amount required to do so and the relevant
interval between exposure and patch testing are
 poorly quantified

II. Testing for Type I Hypersensitivity for Natural Rubber Latex

(NRL) Allergy
 May complicate allergic, irritant or atopic hand
dermatitis and may be seen in combination with delayed
(type IV) hypersensitivity to NRL or rubber additives.
 Prick test
o involves an intradermal puncture and a drop of
extract
o A positive control test (histamine) is done so as
not to give a false negative reaction from oral
antihistamine ingestion
o A negative control prick (saline) is done to check
if the patient is dermographic
o A positive reaction is an urticarial wheal,
apparent after 15-45 minutes
 The use test
o Involves application of a glove soaked in water
or saline for 20 minutes (for NRL
hypersensitivity)
 The prick test is generally favoured over the use test A II-iii
because of reports of anaphylaxis following the latter
 Radioallergosorbent test (RAST) for NRL hypersensitivity
is preferred by other clinicians when adequate facilities
or training to deal with anaphylaxis are inadequate.
 Skin prick or use tests are also useful when investigating
protein contact dermatitis in occupations at risk such as
chefs or veterinarians
INTERVENTION AND TREATMENT
I. IRRITANT CONTACT DERMATITIS
 management involves the protection of the skin from
irritants
 most common irritants are soaps and detergents, although
water itself is also an irritant
 Irritants such as oils and coolants, alkalis, acids and solvents
may be important in the occupational setting

A. Avoidance
 self-evident; visit to the workplace may be necessary to
identify all potential skin hazards

B. Protection
 Most irritant contact dermatitis involves the hands
 Gloves are the mainstay of protection
 Type of gloves used depends on the nature of the
chemicals involved in an occupational setting
  Exposure time is important in determining the most
appropriate glove as it may be protective for a few
minutes but not for prolonged contact

Tips
o rubber or polyvinyl chloride household gloves,
possibly with a cotton liner or worn over cotton
gloves, may be used for general purposes and
household tasks
o take off the gloves on a regular basis as sweating
may aggravate existing dermatitis

Caution: occlusion by gloves may impair the stratum corneum barrier

function I

C. Substitution
 Substitute with non-irritating agents (as in soap
substitutes)
 Correct recycling of oils in heavy industry and reduction
of, or changing, the biocide additives may help.

II. ALLERGIC CONTACT DERMATITIS

A. Workplace Visit
 identifies potential allergens and irritants B III
 may be essential in the effective treatment and
prevention of contact dermatitis

B. Barrier and After-Work Creams

 Barrier creams by themselves are of questionable value E I
in protecting against contact with irritants. This should
not overpromoted as it may give a false sense of security
and be complacent in implementing appropriate
preventive measures.
 There is benefit in the use of soap substitutes and after- A I
work creams in reducing the incidence and prevalence of
contact dermatitis.

C. Topical Corticosteroids
 Steroid Potency
o Regular use of Class 1, 2 or 3 steroids on thin skin
will lead to steroid atrophy (thinning and easy
bruising/purpura) and also hypopigmentation in
darker skin types.
o For the face: Class 6, 7 steroids (least potent or
 mild) can safely be used intermittently during
flares if topical steroids are to be used on the
eyelid for a period of more than one month, refer
to an ophthalmologist for monitoring of
intraocular pressure and the development of
cataracts1.
 There is marginal benefit in the use of a combined C IV
topical corticosteroid/antibiotic combination in infected
or potentially infected eczema.

D. Second-Line Treatments
 Psoralen plus UVA, azathioprine and cyclosporin are A I
used for steroid-resistant chronic hand dermatitis.
 Grenz rays for chronic hand dermatitis showed a B I
significantly better response compared with use of
topical corticosteroids.
 Oral retinoids (Alitretinoin) have been used in the B I
treatment of chronic hand eczema.

E. Nickel Elimination Diets

C IV
 There is some benefit of low nickel diets in some nickel-
sensitive patients.
Prognosis
 long-term prognosis for occupational contact dermatitis
is often very poor
 Over a 10 year period, a quarter of cases completely
healed, a quarter had permanent symptoms and half had
periodic symptoms; No resolution in 40% even after
changing occupations (Swedish study)
II-ii
 55% of patients still had dermatitis after 2 years from
diagnosis (Australian study)
 Milder cases can resolve depending on the ease of
avoidance.