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Mark H. Lowitt, MD

Clinical Associate Professor of DermatologyUniversity of Maryland School of Medicine

Private Practice, Greater Baltimore Medical Center

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Contact Dermatitis

Cases

Clinical Features of Allergic Contact Dermatitis

Mechanisms of Allergic Contact Dermatitis

Patch Testing

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Case 151 y/o F

Phlebotomist

Itchy and painful fingersand hands, worsening over

years

Not seasonal

Whats the diagnosis?

Whats the cause?

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Case 2Same photo 73 y/o F

Severe eyelid pain and

itch worsening over weeks

Whats the diagnosis?

Whats the cause?

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Case 340 y/o M

Auto mechanic for 20

yearsSimilar eruption on feet

Whats the diagnosis?

Whats the cause?

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Erythema

Edema

Vesiculation

Scaling

Lichenification

Well defined edges and Straight lines

PruritusHistory: The more you treat, the worse it gets

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Whats new in contact dermatitis?What makes a good contact allergen?

Low molecular weight

LipophilicAble to form covalent bonds with nucleophilic residues on

amino acid side chains

Sensitizing potential may be related to chemical reactivity

toward a few specific amino acids involve in sensitization Esp. cysteine residues

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North American Tray

Metals: Nickel, Gold, Cobalt, Copper

Fragrances: Fragrance mix, Balsam of Peru,

Isoeugenol, Lyral

Preservatives: Quaternium-15, Paraben mix,Formaldehyde, Kathon CG, Propylene glycol, Thimerosol

Medications: Neomycin, Bacitracin, Tixocortol-21-

pivalate, Budesonide

Dyes: P-phenylenediamine, Disperse blueRubber products: Mercaptobenzathiazole, Carba mix,

thiuram mix, mixed dialkyl thiourea

Other: Benzocaine, Colophony, ethyl acrylate

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Hand Dermatitis

Allergic Contact Dermatitis

Irritant Contact DermatitisDyshidrotic Eczema

Palmar psoriasis

Tinea Manum

Mycosis fungoides

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Hand DermatitisPatch test positive for Quaternium-15

Common preservative

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Chronic Hand DermatitisMajor Occupational Health Problem

40% of all Occupational Health Claims are from skin

90% of these are Dermatitis65% are Irritant Contact

35% are Allergic Contact THEREFORE, 12% OF ALL WORKMANS COMP CLAIMS

ARE DUE TO ALLERGIC CONTACT DERMATITIS

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Allergic Contact Dermatitis of the Hands22,035 patients patch tested between 1994 and 2004

6953 had hand involvement

959 with a solitary dx of ACDQuaternium-15 17%

Formaldehyde 13%

Nickel 12%

Fragrance Mix 11%

Thiuram Mix 10%

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Eyelid DermatitisDifferential Diagnosis

Contact dermatitis

Atopic dermatitisDermatomyositis

Atopic dermatitis

Dermatomyositis (heliotrope rash)

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Patch testing:

Positive for Gold sodiumthiosulfate

May be 10% of positive patch tests

More common in women

8% of gold + pts have eyelid dermatitis

Clinical picture can be confusing due to presence of nickelin gold alloys

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Eyelid DermatitisMost common causes of eyelid allergic contact dermatitis:

Gold 22%Fragrance mix 19%

Balsam of Peru 17%

Nickel 16%

Neomycin 9%

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Treatment with topical

cortisones initially help,

but then the condition

worsens

Tinea manum

(dermatophyte infection)

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Patch test positive for BudesonideCross reacts with triamcinolone, fluocinonide, fluocinolone,

desonide, budesonide

Corticosteroids were the American Contact Dermatitis

Society 2005 Allergen of the Year

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Corticosteroid allergyClass A Hydrocortisone and tixocortol type

Cortisone, hydrocortisone, methylprednisolone, prednisolone

Class B Triamcinolone acetate typeTriamcinolone, halcinonide, flucinonide, fluocinolone, desonde,

budesonide, amcinonide

Class C Bethamethasone type

Betamethasone, dexamethasone, flucortolone

Class D Hydrocortisone-17-butyrate and clobetasol 17-

butyrate

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Patient education CARD Database

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Allergic Contact Dermatitis: ReviewHave a high index of suspicion for ACD

Angulated lesions with straight edges and unusual shape

A refractory dermatitis

However, keep your mind open: not all dermatitis is

allergic

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Allergic Contact Dermatitis: ReviewPatch testing can help to identify the allergen

Hand dermatitis most often caused by quaternium-15

Eyelid dermatitis most often caused by goldIn pts not getting better, consider contact dermatitis to

topical steroids

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www.contactderm.org American Contact Dermatitis

Society (ACDS)

www.dormer.com Dormer Labs (Canada)

patch test materials

www.allergEAZE.com patch test materials

http://www.contactderm.org/http://www.dormer.com/http://www.allergeaze.com/http://www.allergeaze.com/http://www.dormer.com/http://www.contactderm.org/