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Contact dermatitis

Background

Overview

Definition
CD is an inflammatory intolerance response characterized by successive and coexistent erythema, blisters, exudation, papules, and flaking.
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Pathophysiology
CD is caused by allergens (triggered by environmental factors and genetic mutations, such as filaggrin mutation), irritants (chemical and physical agents, plants, photoxic agents, airborne irritants) or microbials, and intrinsic factors (autoimmune responses).
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Disease course
The contact of allergens and irritants lead to an autoimmune inflammatory response that results in CD, which causes clinical manifestations of erythema, blisters, skin edema, pustules, hemorrhage, crusts, scales, erosions, pruritus, pain, dryness of skin, scaly patches and plaques with lichenification and desquamation. Disease progression in chronic irritant CD may result in paronychia and chronic allergic CD in acute allergic CD with distant lesions.
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Prognosis and risk of recurrence
CD is not associated with increased mortality.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of contact dermatitis are prepared by our editorial team based on guidelines from the American College of Obstetricians and Gynecologists (ACOG 2020), the British Association of Dermatologists (BAD 2017), the American Academy of Allergy, Asthma & Immunology (AAAAI/ACAAI 2015), and the German Society of Dermatology (DDG/BVDD/DKG/DGAKI/AeDA/IVDK 2014). ...
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Screening and diagnosis

Clinical presentation
As per AeDA/BVDD/DDG/DGAKI/DKG/IVDK 2014 guidelines:
Recognize that allergic CD affects all age groups with a high prevalence and incidence rates.
E
Recognize that skin reactions to external contact agents can sometimes produce a clinical picture not suggestive of dermatitis at first glance.
E
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Diagnostic investigations

General principles
As per AeDA/BVDD/DDG/DGAKI/DKG/IVDK 2014 guidelines:
Elicit patient history, perform clinical examination, and obtain skin testing for the diagnosis of CD. Consider obtaining additional investigations if necessary.
E
Recognize that dermatitis is a final common pathway of different conditions affected by multiple variables. Use a differentiated approach for the diagnosis of CD, usually involving patch testing.
E

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  • Indications for evaluation

  • Evaluation for specific allergens (personal products/cosmetics)

  • Evaluation for specific allergens (occupational)

  • Evaluation for specific allergens (pollen)

  • Evaluation for systemic CD

  • Patch testing (indications)

  • Patch testing (technical considerations)

  • Patch testing (interpreting results)

  • Investigational tests

Medical management

General principles: as per AAAAI/ACAAI 2015 guidelines, offer appropriate adjunct medical treatment in addition to avoidance of exposure in patients with allergic CD.
B

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  • Corticosteroids

  • Topical tacrolimus

  • Retinoids

Nonpharmacologic interventions

Allergen and irritant avoidance
As per AAAAI/ACAAI 2015 guidelines:
Advise avoiding exposure to irritants and allergens to prevent CD.
B
Advise avoiding contact with the offending agent if the allergen or irritant has been identified, and inform about any cross-reactivity concerns.
B

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  • Skin care

Therapeutic procedures

Phototherapy: as per BAD 2017 guidelines, consider performing PUVA therapy in patients with chronic hand dermatitis.
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Perioperative care

Perioperative patch testing
As per AAAAI/ACAAI 2015 guidelines:
Consider obtaining preoperative patch testing for metal sensitization in patients with a significant history of metal allergy.
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Consider obtaining patch testing to the components of the joint implant in patients with joint replacement failure, after infection and biomechanical causes have been excluded.
C

Specific circumstances

Patients with vulvar CD: as per ACOG 2020 guidelines, counsel patients with vulvar CD regarding vulvar care and removal of vulvar irritants and allergens.
B
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Patient education

Patient education: as per BAD 2017 guidelines, consider providing education in patients with occupational CD.
C