Should I Use Topical Steroid Again for Soap
Diagnosis and Management of Contact Dermatitis
Am Fam Dr.. 2010 Aug 1;82(iii):249-255.
Patient data: See related handout on contact dermatitis, written by the authors of this article.
Article Sections
- Abstruse
- Epidemiology
- Pathophysiology
- Clinical Presentation
- Diagnosis
- Management
- References
Contact dermatitis is a mutual inflammatory peel condition characterized by erythematous and pruritic skin lesions that occur after contact with a foreign substance. There are two forms of contact dermatitis: irritant and allergic. Irritant contact dermatitis is caused by the non–immune-modulated irritation of the pare by a substance, leading to skin changes. Allergic contact dermatitis is a delayed hypersensitivity reaction in which a foreign substance comes into contact with the skin; skin changes occur after reexposure to the substance. The nearly common substances that cause contact dermatitis include poison ivy, nickel, and fragrances. Contact dermatitis usually leads to erythema and scaling with visible borders. Itching and discomfort may as well occur. Acute cases may involve a dramatic flare with erythema, vesicles, and bullae; chronic cases may involve lichen with cracks and fissures. When a possible causative substance is known, the outset footstep in confirming the diagnosis is determining whether the problem resolves with avoidance of the substance. Localized acute allergic contact dermatitis lesions are successfully treated with mid- or high-potency topical steroids, such equally triamcinolone 0.1% or clobetasol 0.05%. If allergic contact dermatitis involves an extensive area of pare (greater than 20 per centum), systemic steroid therapy is ofttimes required and offers relief within 12 to 24 hours. In patients with severe rhus dermatitis, oral prednisone should be tapered over two to three weeks considering rapid discontinuation of steroids tin crusade rebound dermatitis. If treatment fails and the diagnosis or specific allergen remains unknown, patch testing should be performed.
Contact dermatitis is a mutual inflammatory pare condition characterized past erythematous and pruritic peel lesions after contact with a foreign substance. The condition can exist categorized as irritant or allergic. Irritant contact dermatitis is acquired by non–immune-modulated irritation of the skin by a substance, leading to pare changes.1 Allergic contact dermatitis is a delayed hypersensitivity reaction in which a strange substance comes into contact with the skin; skin changes occur with reexposure.
SORT: Central RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| In patients with contact dermatitis, the priority is to identify and avoid the causative substance. | C | 3 |
| Localized acute allergic contact dermatitis lesions are successfully treated with mid- or high-potency topical steroids, such as triamcinolone 0.1% (Kenalog, Aristocort) or clobetasol 0.05% (Temovate). | C | 4 |
| On areas with thinner peel (e.grand., flexural surfaces, eyelids, face up, anogenital region), lower-potency steroids, such as desonide ointment (Desowen), can be helpful and minimize the hazard of peel atrophy. | C | 4 |
| If allergic contact dermatitis involves extensive areas of the skin (greater than 20 percent), systemic steroid therapy is often required and offers relief within 12 to 24 hours. | C | 4 |
Epidemiology
- Abstract
- Epidemiology
- Pathophysiology
- Clinical Presentation
- Diagnosis
- Direction
- References
Data from the National Health Interview Survey (north = 30,074) showed a 12-month prevalence for occupational contact dermatitis of i,700 per 100,000 workers.two Co-ordinate to another study, the industries with the highest rates of contact dermatitis are natural resources and mining, manufacturing, and health services.3
Occupational skin diseases rank second only to traumatic injuries as the most common types of occupational disease. Chemic irritants, such as solvents and cutting fluids used in machining, account for well-nigh cases of irritant contact dermatitis. Ane study showed that easily were primarily afflicted in 64 pct of workers with allergic contact dermatitis and 80 percentage of those with the irritant form.4
Pathophysiology
- Abstract
- Epidemiology
- Pathophysiology
- Clinical Presentation
- Diagnosis
- Management
- References
Irritant contact dermatitis is caused by skin injury, direct cytotoxic furnishings, or cutaneous inflammation from contact with an irritant. Symptoms may occur immediately and may persist if the irritant is unrecognized.
Allergic contact dermatitis is acquired past a type IV, T cell–mediated, delayed hypersensitivity reaction in which a strange substance comes into contact with the skin and is linked to skin poly peptide, forming an antigen complex that leads to sensitization. Upon reexposure of the epidermis to the antigen, the sensitized T cells initiate an inflammatory cascade, causing the skin changes associated with allergic contact dermatitis.1
Mutual substances that cause contact dermatitis include poison ivy, nickel, and fragrances.4 Patch testing data take shown that out of 3,700 known contact allergens, nickel acquired contact dermatitis in 14.3 percent of patients, fragrance mix in fourteen pct, neomycin in 11.6 pct, balsam of Peru in x.4 percent, and thimerosal in 10.4 per centum.5
Nickel is a component of many different types of metals, including white gilded, German silver, nickel and gold plating, solder, and stainless steel.half-dozen Unilateral nickel-induced facial dermatitis elicited by jail cell phone use has been reported.7 Hairdressers have been diagnosed with allergy-related mitt eczema from prolonged skin contact with nickel-containing pair of scissors and crochet hooks.8
Of the approximately 2,500 fragrance ingredients currently used in perfumes, at least 100 are known contact allergens.nine In addition to perfumes, these fragrances are used in cosmetics, shampoos and other hair products, soaps, moisturizers, and deodorants. Fragrance mix produces a patch testing reaction in most 10 percent of patients with eczema; 1.seven to 4.ane percent of the general population is sensitized to fragrance mix.9 Allergic contact dermatitis caused by fragrance occurs predominantly in women with facial or hand eczema.ix
Balsam of Republic of peru is used in many personal products and cosmetics as a fragrance or equally a fragrance masker in products labeled "unscented." Balsam is besides found in many foods and beverages, including spices, ketchup, chili sauce, barbecue sauce, citrus products, colas, beers, wines, bakery items, candy, water ice cream, chocolate, and tomatoes.10 Studies prove that balsam-restricted diets improve systemic contact dermatitis in patients with contact allergy to balsam of Republic of peru.ten
Neomycin is a common over-the-counter topical antibiotic. Because of the antibacterial and antifungal backdrop of organomercurials, thimerosal has been used as a topical disinfectant and preservative in medical preparations.11
Clinical Presentation
- Abstruse
- Epidemiology
- Pathophysiology
- Clinical Presentation
- Diagnosis
- Direction
- References
The clinical presentation of contact dermatitis varies based on the causative allergen or irritant and the affected area of peel. Table 1 summarizes the features that aid distinguish between irritant and allergic contact dermatitis.1
Table 1.
Features to Assistance Distinguish Between Irritant and Allergic Contact Dermatitis
| Feature | Irritant | Allergic |
|---|---|---|
| Location | Usually the hands | Usually exposed areas of skin, often the easily |
| Symptoms | Burning, pruritus, pain | Pruritus is the dominant symptom |
| Surface advent | Dry and fissured skin | Vesicles and bullae |
| Lesion borders | Less distinct borders | Distinct angles, lines, and borders |
Contact dermatitis usually manifests as erythema and scaling with relatively well-demarcated, visible borders. The hands, face, and neck are usually involved, although any expanse can be affected. Irritant contact dermatitis may occur on the lips with excessive lip licking and in the diaper region (irritant diaper dermatitis). Some manifestations of contact dermatitis can be both allergic and irritant. The patient may describe itching and discomfort, but some patients seek medical care based on the advent of the rash. Acute cases may involve a dramatic flare with erythema, vesicles, and bullae; chronic cases may involve lichen with cracks and fissures. Patient history is crucial in making the diagnosis, and the causative substance must be determined to resolve the dermatitis and prevent further damage.
A common cause of allergic contact dermatitis is exposure to urushiol, a substance in the sap of rhus plants (e.g., poisonous substance ivy, oak, sumac). Rhus plants often brush beyond the skin causing linear streaks of erythema and vesicles (Figure 1). Rhus dermatitis may as well cover large areas of the torso, including the face and genitals, leading to astringent discomfort and distress. More lxx percent of persons who are exposed to urushiol tin become sensitized.12
Figure 1.
A linear pattern of allergic contact dermatitis from poisonous substance ivy.
Allergic contact dermatitis caused by metals in jewelry frequently can be diagnosed with observation of the rash. Less expensive jewelry, and metal belt buckles and pant closures containing nickel ordinarily cause allergic contact dermatitis (Figure 2). Cheap kits that use dimethylglyoxime to test metals for nickel are widely available to consumers online.
Figure 2.
Common causes of allergic contact dermatitis from nickel exposure. Reaction to metallic in (A) belly-push button ring, (B) earring, (C) belt buckle, (D) pant closure. Note the scaling and erythema typical of this reaction.
Allergic contact dermatitis from topical products (e.yard., medicines, cosmetics, adhesive tape) oft produces reactions with well-demarcated borders (Figures 3 and four 13). Dermatitis of the paw has variable presentations, from balmy irritant dermatitis to a more severe allergic contact dermatitis (Figure 5). Dermatitis of the human foot is more than common on the dorsal surfaces rather than on the soles (Figure 6).
Figure three.
Allergic contact dermatitis caused by neomycin (A) on the leg in the pattern of a large nonstick pad used to comprehend the antibody ointment and (B) under the eyes.
Figure 4.
Acute allergic contact dermatitis caused by (A) topical herbal medicine for a sprained talocrural joint (severe reaction), (B) fragrance in deodorant, and (C) adhesive tape used later abdominal hysterectomy.
Reprinted with permission from Halstater B, Usatine RP. Contact dermatitis. In: Milgrom EC, Usatine RP, Tan RA, Spector SL. Practical Allergy. Philadelphia, Pa.: Elsevier; 2004.
Figure 5.
Contact dermatitis of the manus. (A) Irritant contact dermatitis in a wellness intendance worker. (B) Allergic contact dermatitis in a custodial engineer.
Effigy six.
Allergic contact dermatitis from new shoes. Note the typical distribution on the back of the anxiety.
Diagnosis
- Abstract
- Epidemiology
- Pathophysiology
- Clinical Presentation
- Diagnosis
- Management
- References
The diagnosis of contact dermatitis is well-nigh often made with history and concrete examination findings. Table 2 summarizes the differential diagnosis of contact dermatitis.
Table 2.
Differential Diagnosis of Contact Dermatitis
| Atmospheric condition | Distinguishing features | Method for diagnosis | Treatment principles |
|---|---|---|---|
| Atopic dermatitis | More than widespread than contact dermatitis and follows a certain distribution involving flexor surfaces | History and clinical appearance, skin biopsy when uncertain | Topical steroids and emollients |
| Dyshidrotic eczema | Occurs on the hands and feet with clear, deep-seated vesicles resembling tapioca; erythema; and scaling | History and clinical appearance, skin biopsy when uncertain | Topical steroids and emollients |
| Inverse psoriasis | Well-demarcated erythema in intertriginous areas | History and clinical appearance, pare biopsy when uncertain | Topical steroids and topical calcineurin inhibitors |
| Latex allergy | Erythema, pruritus, and possibly a systemic reaction | History and clinical advent, allergy testing when uncertain | Abstention of latex |
| Palmoplantar psoriasis | Plaques and pustules on the palms and soles | History and clinical appearance, skin biopsy when uncertain | Strong topical steroids and oral retinoids |
| Scabies | Burrows and typical distribution on hands, feet, waist, axilla, or groin | History and clinical appearance, skin scraping when uncertain | Overnight therapy with permethrin (Elimite) |
| Tinea pedis | Usually occurs between toes, on the soles, and on the sides of the feet; whereas contact dermatitis is more common on the dorsum of the foot | History and clinical appearance, potassium hydroxide testing when uncertain | Topical and/or oral antifungal medications |
Irritant and allergic contact dermatitis may be complicated past bacterial superinfection, and bacterial culture should be considered with the presence of exudate, weeping, and crusting. A potassium hydroxide (KOH) preparation is useful if tinea or Candida infection is suspected, because these fungal infections tin accept erythema and scaling similar to contact dermatitis. If the KOH preparation has negative results but a fungal etiology is still suspected, a fungal culture should be sent for laboratory testing. Dermoscopy and microscopy can be used to wait for scabies and mites.
When a possible causative substance is known, the first step in confirming the diagnosis is observing whether the problem resolves with avoidance of the substance. If avoidance and empiric treatment do not resolve the dermatitis or the allergen remains unknown, patch testing may be indicated. In one report, patch testing had a sensitivity and specificity of betwixt lxx and eighty percent.14 However, it is expensive and time-consuming, and prohibits the patient from showering (a "sponge bath" technique may be used). Patch testing should not be confused with other types of allergy testing. Skin prick and radioallergosorbent tests are used for the diagnosis of type I hypersensitivity, such as respiratory, latex, and nutrient allergies, just non for contact dermatitis.
The patient may be referred to a dermatologist with feel in patch testing, or patch test kits and individual allergens can exist purchased for testing in the physician's office. One kit is the Truthful (Sparse-layer Rapid Use Epicutaneous) Test, which consists of three panels with 29 antigens commonly involved in allergic contact dermatitis (Table three15 and Figure vii). Although the True Test is expensive, reimbursement compensates for the price of the test.
Table 3.
TRUE Exam Allergen Panels: Patch Examination for Contact Dermatitis
| Panel one.1 |
| i. Nickel sulfate |
| 2. Wool alcohols |
| three. Neomycin |
| 4. Potassium dichromate |
| 5. Caine mix |
| half-dozen. Fragrance mix |
| 7. Colophony |
| 8. Paraben mix |
| 9. Negative control |
| x. Balsam of Peru |
| xi. Ethylenediamine dihydrochloride |
| 12. Cobalt dichloride |
| Panel two.i |
| xiii. p-tert-butylphenol formaldehyde resin |
| 14. Epoxy resin |
| 15. Carba mix |
| 16. Black rubber mix |
| 17. Methylchloroisothiazolinone/methylisothiazolinone |
| 18. Quaternium-15 |
| 19. Mercaptobenzothiazole |
| 20. p-Phenylenediamine |
| 21. Formaldehyde |
| 22. Mercapto mix |
| 23. Thimerosal |
| 24. Thiuram mix |
| Panel 3.1 |
| 25. Diazolidinyl urea |
| 26. Imidazolidinyl urea |
| 27. Budesonide (Rhinocort) |
| 28. Tixocortol-21-pivalate |
| 29. Quinoline mix |
Effigy vii.
(A) Allergic contact dermatitis from a chemical in hair dye. (B) Patch testing in the same patient. The positive True Exam outcome for No. xx (p-Phenylenediamine), an ingredient in pilus dye, was crucial in identifying the patient'southward allergy. See Table iii for names of each allergen in the panels.
In a recent meta-analysis, the almost prevalent allergens detected using the TRUE Test were nickel (14.7 percent of patients), thimerosal (5.0 pct), cobalt (four.viii pct), fragrance mix (3.four per centum), and balsam of Peru (three.0 percent).five The True Test may miss some important antigens, nevertheless. If the suspected allergen is not included in the TRUE Test, the patient may be referred to a subspecialist who offers customized patch testing. Personal products, such every bit cosmetics and lotions, can be diluted for specialized patch testing.
Direction
- Abstruse
- Epidemiology
- Pathophysiology
- Clinical Presentation
- Diagnosis
- Direction
- References
In patients with contact dermatitis, the priority is to identify and avert the causative substance.3 Cool compresses can soothe the symptoms of acute contact dermatitis, and calamine balm and colloidal oatmeal baths may help dry and soothe astute, oozing lesions.4
Localized acute allergic contact dermatitis lesions are successfully treated with mid- or loftier-authorization topical steroids, such equally triamcinolone 0.1% (Kenalog, Aristocort) or clobetasol 0.05% (Temovate).4 On areas with thinner skin (e.g., flexural surfaces, eyelids, face, anogenital region), lower-say-so steroids, such equally desonide ointment (Desowen), can be helpful and minimize the gamble of skin atrophy.4 At that place are bereft information to support the employ of topical steroids for irritant contact dermatitis. All the same, because it is difficult to clinically distinguish between allergic and irritant contact dermatitis, these agents are often used successfully for the irritant form.
If allergic contact dermatitis involves an extensive expanse of skin (greater than 20 percent), systemic steroid therapy is often required and offers relief within 12 to 24 hours.4 5 to seven days of prednisone, 0.v to i mg per kg daily, is recommended. If the patient is comfortable after this initial therapy, the dose may exist reduced by 50 percent for the next 5 to seven days. The rate of reduction of the steroid dosage depends on factors such as the severity and duration of allergic contact dermatitis, and how effectively the allergen can be avoided.4 In severe rhus dermatitis, oral prednisone should be tapered over two to three weeks considering rapid discontinuation of steroids can crusade rebound dermatitis. A steroid dose pack has bereft dosing and duration and should non be prescribed. There is no show to support the use of long-acting injectable steroids in the treatment of contact dermatitis.
In patients with nickel-induced contact dermatitis, it is helpful to cover the metal tab of jeans with an iron-on patch (most effective) or a few coats of clear nail smoothen. Clear nail polish can likewise be used on belt buckles, but may need to be reapplied oftentimes.
Some patients may be allergic to preservatives used in the base of steroid creams. Steroid ointment is recommended because it allows the medication to maintain contact with the pare longer and there is little hazard of an allergic reaction (allergic reaction to the steroid itself is rare). Likewise, soaking the affected areas earlier applying the steroid is thought to help better penetration and increase its effectiveness.xvi
Although antihistamines are generally not effective for pruritus associated with allergic contact dermatitis, they are commonly used. Sedation from more than soporific antihistamines (e.g., diphenhydramine [Benadryl], hydroxyzine [Vistaril]) may offer some degree of relief.4 Emollients, moisturizers, or bulwark creams may be instituted every bit secondary prevention strategies to help avoid continued exposure.4 To foreclose irritant contact dermatitis of the hands, persons should avoid latex gloves; wear nonlatex gloves when working with potentially irritating substances, such as solvents, soaps, and detergents; use cotton wool liners under the gloves for comfort and absorption of sweat; and keep hands clean, dry out, and well moisturized when possible.
To see the total commodity, log in or purchase access.
REFERENCES
show all references
1. Usatine RP. Contact dermatitis. In: Usatine RP, Smith M, Mayeaux EJ Jr, et al., eds. Color Atlas of Family unit Medicine. New York, NY: McGraw-Hill; 2009. ...
2. Behrens Five, Seligman P, Cameron 50, Mathias CG, Fine L. The prevalence of back pain, manus discomfort, and dermatitis in the United states of america working population. Am J Public Health. 1994;84(11):1780–1785.
3. U.S. Department of Labor. Workplace injuries and illnesses in 2008. http://www.bls.gov/news.release/pdf/osh.pdf. Accessed April 19, 2010.
4. American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology. Contact dermatitis: a practice parameter [published correction appears in Ann Allergy Asthma Immunol. 2006;97(6):819]. Ann Allergy Asthma Immunol. 2006;97(iii suppl 2):S1–S38.
5. Krob HA, Fleischer AB Jr, D'Agostino R Jr, Haverstock CL, Feldman Due south. Prevalence and relevance of contact dermatitis allergens: a meta-analysis of 15 years of published T.R.U.E. test data. J Am Acad Dermatol. 2004;51(iii):349–353.
6. Garner LA. Contact dermatitis to metals. Dermatol Ther. 2004;17(4):321–327.
7. Moennich JN, Zirwas M, Jacob SE. Nickel-induced facial dermatitis: adolescents beware of the cell phone. Cutis. 2009;84(iv):199–200.
8. Thyssen JP, Milting K, Bregnhøj A, Søsted H, Duus Johansen J, Menné T. Nickel allergy in patch-tested female person hairdressers and cess of nickel release from hairdressers' scissors and crochet hooks. Contact Dermatitis. 2009;61(v):281–286.
9. Johansen JD. Fragrance contact allergy: a clinical review. Am J Clin Dermatol. 2003;four(11):789–798.
10. Srivastava D, Cohen DE. Identification of the constituents of balsam of Republic of peru in tomatoes. Dermatitis. 2009;xx(2):99–105.
11. Risher JF, Murray HE, Prince GR. Organic mercury compounds: human exposure and its relevance to public wellness. Toxicol Ind Health. 2002;xviii(3):109–160.
12. Wolff K, Johnson RA, eds. Fitzpatrick'south Color Atlas and Synopsis of Clinical Dermatology. 6th ed. New York, NY: McGraw-Loma; 2009:xxx.
xiii. Halstater B, Usatine RP. Contact dermatitis. In:Milgrom EC, Usatine RP, Tan RA, Spector SL. Practical Allergy. Philadelphia, Pa.: Elsevier; 2004.
14. Bourke J, Coulson I, English language J; British Association of Dermatologists Therapy Guidelines and Audit Subcommittee. . Guidelines for the management of contact dermatitis: an update. Br J Dermatol. 2009;160(5):946–954.
xv. T.R.U.Eastward. Test Patch Test System, manufactured for SmartPractice by Mekos Laboratories. http://world wide web.truetest.com/panelallergens.aspx. Accessed April 15, 2010.
16. Gutman AB, Kligman AM, Sciacca J, James WD. Soak and smear: a standard technique revisited. Curvation Dermatol. 2005;141(12):1556–1559.
Copyright © 2010 by the American University of Family unit Physicians.
This content is owned by the AAFP. A person viewing it online may brand i printout of the textile and may use that printout only for his or her personal, non-commercial reference. This material may non otherwise be downloaded, copied, printed, stored, transmitted or reproduced in whatsoever medium, whether now known or afterwards invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.
MOST Contempo Issue
Mar 2022
Access the latest issue of American Family unit Doctor
Read the Result
Electronic mail Alerts
Don't miss a single issue. Sign up for the free AFP electronic mail table of contents.
Sign Up Now
Source: https://www.aafp.org/afp/2010/0801/p249.html
Post a Comment for "Should I Use Topical Steroid Again for Soap"