Dermatologic Allergy

John C. Hall
Contact dermatitis, industrial dermatoses, atopic eczema, and drug eruptions are included
in this chapter because of their obvious allergenic factors. (However, some cases of contact
dermatitis and industrial dermatitis are caused by irritants.) Nummular eczema is also included
because it resembles some forms of atopic eczema and may even be a variant of atopic eczema.
Contact Dermatitis
Contact dermatitis (Figures 9-1, 9-2, 9-3, and 9-4), or dermatitis venenata, is a very
common inflammation of the skin caused by the exposure of the skin either to primary irritant
substances, such as soaps, or to allergenic substances, such as poison ivy resin. Industrial
dermatoses are considered at the end of this section.
Presentation
Primary Lesions
Any of the stages, from mild redness, edema, or vesicles to large bullae with a marked
amount of oozing, are seen. This is usually limited to the site where the contactant touched the
skin, but can flare beyond the site when the inflammation is severe. With poison ivy, oak, and
sumac, a black stain on skin or clothing is rarely seen.
Secondary Lesions
Crusting from secondary bacterial infection, excoriations, and lichenification occurs. A
generalized eruption can occur in a symmetrical distribution in a widespread distribution when
the local site is severely affected. This is called an Id or autoeczemtous eruption. It commonly
causes vesicles on the palms, soles, and sides of the fingers and toes. It is very pruritic.
Distribution and Causes
Any agent can affect any area of the body. However, certain agents commonly affect certain skin
areas.

Face and Neck (Figure 9-5): Cosmetics, soaps, insect sprays, ragweed, perfumes or hair
sprays (sides of neck), fingernail polish (eyelids), hat bands (forehead), mouthwashes,
toothpaste, or lipstick (perioral), nickel metal (under earrings), necklaces and collars
(neck), industrial oil (facial chloracne).

Hands and Forearms: Soaps, hand lotions, wrist bands, industrial chemicals, poison ivy,
and a multitude of other agents. Irritation from soap often begins under rings as does
allergic reactions from nickel (common) or gold (rare). Latex from gloves can cause a
contact dermatitis and contact urticaria. It can be associated with life-threatening
anaphylaxis and is becoming an increasing danger because of increased use of latex
gloves and latex contraceptives.

Axillae: Deodorants, dress shields, detergents, bleaching agents, fabric softener, antistatic
agents, and dry cleaning solutions.

Trunk: Clothing (new, not previously cleaned), rubber or metal attached to, or in, clothing
(central abdomen under metal clasp), and transdermal drug patches.

Anogenital region: Douches, dusting powder, contraceptives, colored toilet paper, topical
hemorrhoid preparations, poison ivy, or topicals for treatment of pruritus ani, candida,
and fungal infections.

Feet: Shoes, foot powders, topical agents for athlete's foot infection.

Generalized eruption: Volatile airborne chemicals (paint, spray, ragweed), medicaments

locally applied to large areas, bath powder, or clothing.

Course
Duration can be very short (days) to very chronic (weeks, months, and even years). As a
general rule, successive recurrences become more chronic (e.g., seasonal
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ragweed dermatitis can become a year-round dermatitis). An established hypersensitivity reaction
is seldom lost. Also, certain people are more susceptible to allergic and irritant contact dermatitis
than others. This is particularly true in patients who already have inflamed skin such as irritants
in patients with eczema. A very careful seasonal history of the onset, in chronic cases, may lead
to discovery of an unsuspected causative agent, such as ragweed.

Familial incidence of contact dermatitis is not evident. The eczematous reaction (e.g., the blister
fluid of poison ivy) contains no allergen that can cause the dermatitis in another person or in
other areas on the same person. However, if the poison ivy oil or other allergen remains on the
clothes of the affected person, contact of the allergen with a susceptible person could cause a
dermatitis. The hair or fur of animals, and utensils used in hunting or gardening can also transfer
to allergenic resine of poison ivy.
Laboratory Findings
Patch tests (see Chap. 2) are of value in eliciting the cause in a problem case. Careful
interpretation is required.
Differential Diagnosis
A contact reaction must be considered and ruled in or out in any case of eczematous or oozing
dermatitis on any body area.
Treatment
Two of the most common contact dermatoses seen in the physician's office are poison ivy (or
poison oak or sumac) dermatitis and hand dermatitis. The treatments for these two conditions are
discussed separately.
Treatment of Contact Dermatitis Owing to Poison Ivy
Case Example

A patient comes to the office with a linear, vesicular dermatitis of the feet, hands, and face. He
states that he spent the weekend fishing and that the rash broke out the next day. The itching is
rather severe but not enough to keep him awake at night. He had poison ivy 5 years ago.
SAUER'S NOTES

In obtaining a history, question the patient carefully about home, over-the-counter, other
physicians', and well-meaning friends' remedies. Contact dermatitis on top of a contact
dermatitis is quite common.

When you are unable to find the cause of a generalized contact dermatitis, determine the
site of the initial eruption and think of the agents that touch the area.

First Visit

There are several mistaken notions about poison ivy dermatitis. Assure the patient that he
cannot give the dermatitis to his family or spread it on himself from the blister fluid.

Suggest that the clothes worn while fishing be washed in warm soapy water to remove
the allergenic resin.

Prescribe Burow's solution wet packs.

Sig: Add one packet of powder (Domeboro) to 1 quart of cool water. Apply sheeting or
toweling, wet with the solution, to the blistered areas for 20 minutes twice a day. The wet
packs need not be removed during the 20-minute period. (For a more widespread case of
poison ivy dermatitis, take cool baths with half box of Aveeno [colloidal oatmeal] or
soluble starch to the tub, which gives considerable relief from the itching.)

1% Hydrocortisone lotion q.s. 60.0 (1% Hytone [available OTC] lotion, 1% HC

Pramosone lotion (contains the antipruritic antihistamine pramoxine, etc.)
Sig: Apply t.i.d. and prn itching to the affected areas.

Chlorpheniramine maleate tablets, 4 mg #60

Sig: 1 tablet t.i.d. (for relief of itching).
Comment: Warn patient about side effect of drowsiness. This drug is available over the
counter and is less expensive than if a prescription is written.

Use cortisone-type injection. Short- but rapid-acting corticosteroids are moderately

beneficial, such as betamethasone (Celestone Phosphate) (3 mg/mL in a dose of 1 to 2
mL subcutaneously), or dexamethasone (Decadron LA) (8 mg/mL) in a dose of 1 to 1.5
mL intramuscularly. Triamcinolone (Kenalog 20) to 40 mg IM can also be given.

Subsequent Visits

Continue the wet packs only as long as there are blisters and oozing. Extended use is too
drying for the skin.

After 3 or 4 days of use, the lotion may be too drying. Substitute fluorinated
corticosteroid emollient cream q.s. 60.0
Sig: Apply small amount locally t.i.d., or more often if itching is present.

SAUER'S NOTES

Most failures in the therapy for severe poison ivy or oak dermatitis result from the failure
to continue the oral corticosteroid for 1014 days or longer.

Medrol Dosepak therapy does not provide enough days of treatment for most cases of
poison ivy dermatitis.

Explain to the patient that it is common for new lesions, even blisters, to continue to pop
out during the entire duration of the eruption.

Severe Cases of Poison Ivy Dermatitis

An oral corticosteroid is indicated in severe cases of poison ivy dermatitis: prednisone, 10

mg #30
Sig: 5 tablets each morning for 2 days, 4 tablets each morning for 2 days, 3 tablets each
morning for 2 days, 2 tablets each morning for 2 days, and 1 tablet each morning for 2
days. Take with food in the morning.

The use of poison ivy vaccine orally or intramuscularly is contraindicated during an acute
episode. Desensitization may occur after a long course of oral ingestion of graduated doses of the
allergen, but pruritus ani, generalized pruritus, and urticaria probably make the treatment worse
than the disease. Desensitization does not occur after a short course of IM injections of the
vaccine, and this form of prophylactic therapy is worthless. Barrier creams may decrease
dermatitis if applied before exposure; examples include Hydropel and Ivy Block.
A window of up to 2 hours may exist where washing the skin with a surfactant (e.g., Dial soap)
and oil-removing compound (soap or Goop) or a chemical inactivator (Tecnu) may ameliorate or
prevent the contact dermatitis.
Treatment of Contact Dermatitis of the Hand Owing to Soap
Case Example
A young housewife states that she has had a breakout on her hands for 5 weeks. The dermatitis
developed about 4 weeks after the birth of her last child. She states that she had a similar
eruption after her previous two pregnancies. She has used a lot of local medication of her own,
and the rash is getting worse instead of better. The patient and her immediate family never had
any asthma, hay fever, or eczema.
Examination of the patient's hands reveals small vesicles on the sides of all of her fingers, with a
5-cm area of oozing and crusting around her left ring finger.
SAUER'S NOTES

Housewives' eczema cannot usually be cured with a corticosteroid salve alone

without observing the other protective measures.

After the dermatitis is clear, it is very important to advise the patient to treat the area for
at least another week to prevent a recurrence. I call this therapy plus.

First Visit

Assure the patient that the hand eczema is not contagious to her family.

Inform the patient that soap irritates the dermatitis and that it must be avoided as much as
possible. A homemaker will find this avoidance very difficult. One of the best remedies is
to wear protective gloves when extended soap-and-water contact is unavoidable. Rubber
gloves alone produce a considerable amount of irritating perspiration, but this is absorbed
when thin white cotton gloves are worn under the rubber gloves. Lined rubber gloves are
not as satisfactory because the lining eventually becomes dirty and soggy and cannot be
cleaned easily. Bluettes is an excellent protective glove.

For body cleanliness, a mild soap, such as Dove, can be used, or any of the following:
Cetaphil soapless cleanser, Basis soap, and Neutrogena soaps.

Tell the patient that these prophylactic measures must be adhered to for several weeks
after the eruption has apparently cleared or there will be a recurrence. Injured skin is
sensitive and needs to be pampered for an extended time.

Burow's solution soaks.

Sig: Add 1 packet of powder (Domeboro) to 1 quart of cool water. Soak hands for 15
minutes twice a day.

Fluorinated corticosteroid ointment (see Formulary in Chap. 5) 15.0

Sig: Apply sparingly, locally, q.i.d.

Resistant, Chronic Cases

To the corticosteroid ointment add, as indicated, sulfur (3% to 5%), coal tar solution (3%
to 10%), or an antipruritic agent such as menthol (0.25%) or camphor (2%).

Oral corticosteroid therapy. A short course of such therapy rapidly improves or cures a
chronic dermatitis.

Prevention of flares of contact dermatitis can be accomplished by frequent use of

emollient preparations. SBR
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Lipocream, Curel, Cetaphil Hand Cream and Neutrogena Norwegian Hand Cream are
examples. Bag Balm or Udder Cream are odiferous, less cosmetic choices.