3/9/2016

IrritantContactDermatitisClinicalPresentation:History,PhysicalExamination,Complications

IrritantContactDermatitisClinicalPresentation
Author:DanielJHogan,MDChiefEditor:WilliamDJames,MDmore...
Updated:Apr16,2014

History
Adetailedhistoryisrequiredbecausethediagnosisofirritantcontactdermatitis
restsonthehistoryofexposureoftheaffectedbodysitetothecutaneousirritant.
Patchtestingalsoisusedinsevereorpersistentcasestoexcludeallergiccontact
dermatitisasacomponentoftheindividual'scutaneousmanifestations.
Onsetofsymptomsoccurswithinminutestohoursofexposureinsimpleacute
irritantcontactdermatitis.Acutedelayedirritantcontactdermatitisischaracteristic
ofcertainirritants,suchasbenzalkoniumchloride(eg,zephiran,apreservativeand
disinfectant),whichelicitsadeferred(824hafterexposure)inflammatoryreaction.
[14]

Theonsetofsignsandsymptomsmaybedelayedbyweeksincumulativeirritant
contactdermatitis.Cumulativeirritantcontactdermatitisisaconsequenceof
multipleincidentsofsubthresholddamagetotheskin,withthetimebetween
exposuresbeingtooshortforafullresolutionofskinbarrierfunction.Patientswith
sensitiveskin(ie,atopicindividuals)haveadecreasedirritantthresholdora
prolongedrestorationtime,makingthemmorevulnerabletoclinicalirritantcontact
dermatitis.
Cumulativeirritantcontactdermatitistypicallyoccurswithexposuretoweakirritants
ratherthanstrongones.Often,theexposure(eg,water)isnotonlyatworkbutalso
athome.
Thesepatientsreportbothitchingandpaincausedbyfissuringofthehyperkeratotic
skin(chapping).Pain,burning,stinging,ordiscomfortexceedingpruritusoccurearly
intheclinicalcourse.
Lessimportantsubjectivecriteriaforirritantcontactdermatitisincludetheonsetof
dermatitiswithin2weeksofexposure,andreportsofmanyothercoworkersor
familymembersaffected.

Occupationalhistory
Irritantcontactdermatitisisamajoroccupationaldiseaseskindisorderscomprise
upto40%ofoccupationalillnesses.Thephysicianneedstotakeanoccupational
historyfromadultswithsuspectirritantcontactdermatitis.
Occupationalirritantcontactdermatitistypicallyaffectsworkerswhoarenewtoa
job,whoareconstitutionallymoresusceptibletoirritantcontactdermatitis,orwho
havenotlearnedtoprotecttheirskinfromcutaneousirritants.Individualswith
historyofatopicdermatitis(especiallyofthehands)aremoresusceptibletoirritant
contactdermatitis,particularlyofthehands.
Mostaffectedworkershaveadegreeofpermanentinjurythatislowerthanthatof
otheroccupationaldiseaseshowever,thecompensationpaywashigherforskin
diseasesthanfordiseasesoftherespiratorysystemormusculoskeletaldisorders,
accordingtoastudyinDenmark.

PhysicalExamination
RietschelandFowlerproposedthefollowingasprimarydiagnosticcriteriaforirritant
contactdermatitis[15]:
Macularerythema,hyperkeratosis,orfissuringpredominatingover
vesiculation
Glazed,parched,orscaldedappearanceoftheepidermis
Healingprocessbeginningpromptlyonwithdrawalofexposuretothe
offendingagent
Negativeresultsonpatchtestingthatincludesallpossibleallergens
Minorobjectivecriteriaforirritantcontactdermatitisincludethefollowing:
Sharpcircumscriptionofthedermatitis
Evidenceofgravitationalinfluencesuchasadrippingeffect
Lowertendencyforthedermatitistospreadthanincasesofallergiccontact
dermatitis
Morphologicchangessuggestingsmalldifferencesinconcentrationor
contacttimeproducinglargedifferencesinskindamage
Individualsmaydevelopahabitofcontinuingtorubasiteinitiallyaffectedbyirritant
contactdermatitisandmaydevelopsecondaryneurodermatitisorlichensimplex
chronicus(lichenification).Thismaybeacceptedasasequelaofanoccupational
injury.

Complications
Skinlesionsmaybecomecolonizedsecondarilyand/orinfected,particularlyby
Staphylococcusaureus.Secondaryneurodermatitis(lichensimplexchronicus)may
developinindividualswithirritantcontactdermatitis,particularlyinthosewith
workplaceexposuresorunderpsychologicalstress.

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Postinflammatoryhyperpigmentationorhypopigmentationmayoccurinareas
affectedbyirritantcontactdermatitisorpersistafterresolutionofirritantcontact
dermatitisinindividualswithmorepigmentedskin.
Scarringmayoccuraftercorrosiveagentexposure,excoriation,orartifact,causing
ulceration.
Irritantcontactdermatitisincreasestheriskofsensitizationtotopicalmedications.
DifferentialDiagnoses

ContributorInformationandDisclosures
Author
DanielJHogan,MDClinicalProfessorofInternalMedicine(Dermatology),NovaSoutheasternUniversity
CollegeofOsteopathicMedicineInvestigator,HillTopResearch,FloridaResearchCenter
DanielJHogan,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanAcademyof
Dermatology,AmericanContactDermatitisSociety,CanadianDermatologyAssociation
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
MichaelJWells,MD,FAADAssociateProfessor,DepartmentofDermatology,TexasTechUniversityHealth
SciencesCenter,PaulLFosterSchoolofMedicine
MichaelJWells,MD,FAADisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
AcademyofDermatology,AmericanMedicalAssociation,TexasMedicalAssociation
Disclosure:Nothingtodisclose.
PaulKrusinski,MDDirectorofDermatology,FletcherAllenHealthCareProfessor,DepartmentofInternal
Medicine,UniversityofVermontCollegeofMedicine
PaulKrusinski,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology,
AmericanCollegeofPhysicians,SocietyforInvestigativeDermatology
Disclosure:Nothingtodisclose.
ChiefEditor
WilliamDJames,MDPaulRGrossProfessorofDermatology,ViceChairman,ResidencyProgramDirector,
DepartmentofDermatology,UniversityofPennsylvaniaSchoolofMedicine
WilliamDJames,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology,
SocietyforInvestigativeDermatology
Disclosure:Nothingtodisclose.

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