atlas-cover-3

Chapter 3. Allergic Contact Dermatitis

Definition

Allergic contact dermatitis is an inflammatory process induced by direct contact of the skin of a sensitized individual to an allergen. Within hours, red macules or patches develop that usually evolve rapidly, sometimes through an intermediate stage of urticarial papules or plaques, into vesicles that may become bullae. Because the lesions, i.e., macules, papules, vesicles, and bullae, are not in themselves specific, diagnosis clinically is made by virtue of distinctive distribution that reflects the manner in which a particular allergen was contacted.

Examples of common allergic contactants are Rhus toxicodendron (“poison ivy”), nickel, thiurames in rubber, parabens in ointments, and chemicals in fragrances, whereas agents commonly responsible for irritant contact dermatitis are acids, alkaloids, machine oils, organic solvents, and oxidants.

Adjunctive Diagnostic Test

The most effective method for diagnosis with surety of allergic contact dermatitis is the patch test. Red macules, papules, or tense vesicles that arise at a site where the suspected causative agent has been applied confirm the diagnosis of allergic contact dermatitis.

Course

Within hours after the skin of a sensitized person has come into contact with a particular allergen, red macules or patches develop that usually evolve rapidly, sometimes through an intermediate stage of urticarial papules or plaques, into vesicles that may become bullae. Sometimes, however, allergic contact dermatitis may present itself only as reddish papules or papulovesicles, but more often as tense vesicles as well. Episodically, depending on the patient’s degree of hypersensitivity, bullae may come into being. If the offending agent is removed, lesions of allergic contact dermatitis, no matter how widespread or severe, resolve, even without therapy, in a matter of weeks at most. If, however, the allergen continues to come into contact with the skin, the process may persist for years. In that latter situation, annoying pruritus leads to persistent rubbing, which causes lichen simplex chronicus to be imposed on the effects of longstanding allergic contact dermatitis.

The same general principles that apply to allergic contact dermatitis apply equally to irritant contact dermatitis, the earliest stage being red macules or patches that very soon are surmounted by vesicles or bullae, or both. In the case of irritant-induced blisters, however, the roof of the lesions often has a gray cast, a consequence of the epidermis having become necrotic secondary to the effects of the irritant. Although both allergic contact dermatitis and irritant contact dermatitis result from direct contact of the skin with an offending agent, the two mechanisms are completely different; allergic contact dermatitis results from immunologic mechanisms, whereas irritant contact dermatitis does not.

Integration: Unifying Concept

What has been written about clinical diagnosis of allergic contact dermatitis applies in principle to irritant contact dermatitis. Distribution, in addition to character of individual lesions, is decisive.

Irritant contact dermatitis is unrelated to hypersensitivity and is inducible in every human being by virtue of the intrinsically damaging character of an irritant, the earliest stage being red macules or patches that very soon are surmounted by vesicles, bullae, or both.

All of the morphologic expressions of allergic contact dermatitis and of irritant contact dermatitis are a consequence of a basic pathologic process, to wit, delayed hypersensitivity for the former and nonhypersensitivity, irritation, often with necrotizing effects, for the latter. In short, papules, vesicles, and bullae that develop in response to contact allergens and contact irritants are a reflection of an inflammatory process that involves the dermis and epidermis, the dermis first for allergic contact dermatitis in regard to where changes pathologic are witnessed initially and the epidermis first for irritant contact dermatitis. Conceptually, the epidermis is the first affected in allergic contact dermatitis, that being the site where a haptene forms without which the immunologic process could not commence. Spongiosis with little if any ballooning or necrosis is present in the case of allergic contact dermatitis, and ballooning accompanied by necrosis and little if any spongiosis is manifest that of irritant contact dermatitis.

Therapy

Click here for an up-to-date discussion of therapeutic management presented in Therapeutic Strategies in Dermatology.

Distribution

at003g01.jpg

Fig. 3-1

The patient’s face and neck are affected by erythema, edema, vesicles, and yellow crusts.


at003g02.jpg

Fig. 3-2

Edema, erythema, papules, pustules, and crusts. The bridge of the nose and paranasal folds have been spared.


at003g03.jpg

Fig. 3-3

Erythematous patches, papules, and plaques distributed in symmetrical fashion.


at003g04.jpg

Fig. 3-4

The upper eyelids show edema, erythema, and scales.


at003g05.jpg

Fig. 3-5

Lichenification and hyperpigmentation of eyelids. The allergic contactant was sulfa in eye drops.


at003g06.jpg

Fig. 3-6

Perioral region displaying erythematous papules and plaques, crusts, scales, and fissures.


at003g07a.jpg

Fig. 3-7 A

Periocular, erythematous papules. The cause was rubber in goggles.


at003g07b.jpg

Fig. 3-7 B

Periocular, erythematous papules. The cause was rubber in goggles.


at003g08.jpg

Fig. 3-8

Ear with edema, erythema, crusts, and scales.


at003g09.jpg

Fig. 3-9

Erosion on an earlobe and plaques on the neck and face.


at003g10.jpg

Fig. 3-10

Face, neck, and dorsa of hands and wrists with edema, erythema, scales, and erosions.


at003g11.jpg

Fig. 3-11

Dorsa of hands with tense vesicles and a bulla.


at003g12.jpg

Fig. 3-12

Nipple and areola altered by a scaly plaque.


at003g13.jpg

Fig. 3-13

Scales, erosions, and discrete and confluent erythematous papules. The cause was nickel in the belt buckle.


Configuration

at003g14.jpg

Fig. 3-14

A rectangular zone of erythema is artificial indicating external cause, a plaster containing an herb.


at003g15.jpg

Fig. 3-15

A line of erythematous papules and vesicles of Rhus dermatitis.


at003g16.jpg

Fig. 3-16

A line of erythematous macules, papules, and scales induced by sensitivity to nickel in a bracelet.


at003g17.jpg

Fig. 3-17

Arciform lesion of the hard palate secondary to a sensitizer in a prosthesis.


Individual Lesions

at003g18.jpg

Fig. 3-18

Marked edema, diffuse erythema, papules, and vesicles.


at003g19.jpg

Fig. 3-19

Closely-set papules and papulovesicles around an ulcer that had been treated by neomycin.


at003g20.jpg

Fig. 3-20

Diffuse erythema, papules, vesicles, and a bulla.


at003g21.jpg

Fig. 3-21

Clusters of vesicles and scattered bullae on a red base.


at003g22.jpg

Fig. 3-22

Vesicles and bullae on a base of erythema.


at003g23.jpg

Fig. 3-23

Skin-colored and pink papules, and hemorrhagic vesicles and bullae.


at003g24.jpg

Fig. 3-24

Extensive edema of the entire face, including eyelids, cheeks, lips, and ear, with oozing and scale-crusts.


at003g25.jpg

Fig. 3-25

Erythematous macules and urticarial papules and plaques called forth by a sensitizer in a hair dye.


at003g26.jpg

Fig. 3-26

Clusters of pustules on an erythematous base consequent to an allergen in a hair dye.


at003g27.jpg

Fig. 3-27

Scale-crusts, erosions, and fissures in an edematous face.


at003g28.jpg

Fig. 3-28

Scale-crusts and fissures, as well as erythematous urticarial papules and plaques.


at003g29.jpg

Fig. 3-29

Scales and erosions on an erythematous base secondary to an allergen in fingernail polish.


at003g30.jpg

Fig. 3-30

Erythematous papules, some excoriated, and others lichenified secondary to vigorous rubbing.


at003g31.jpg

Fig. 3-31

Keratoses, crusts, and fissures of a markedly edematous hand.


at003g32.jpg

Fig. 3-32

Diffuse erythema, keratoses, scales, and erosions.


at003g33.jpg

Fig. 3-33

Slightly erythematous papules, some of them lichenified, verrucous keratoses, scales, and erosions.


at003g34.jpg

Fig. 3-34

Papules and vesicles.


at003g35.jpg

Fig. 3-35

Vesicles, crusts, and extensive periorbital edema.


at003g36.jpg

Fig. 3-36

Tense vesicles on an edematous right hand and red papuleson the left one.


at003g37.jpg

Fig. 3-37

Papules and vesicles on edematous lips.


at003g38.jpg

Fig. 3-38

Papules and papulovesicles at the site of a ring.


at003g39.jpg

Fig. 3-39

Scales, crusts, lichenification, and fissures secondary to rubber in gloves.


New! Additional Images

at003eg001.jpg

Fig. 3-40

Allergic contact dermatitis: Papules have become confluent to form a plaque on which is situated vesicles and bullae.


at003eg002.jpg

Fig. 3-41

Allergic contact dermatitis: Papules, papulovesicles, and vesicles in linear array consequent to the effects of Rhus toxicodendron.


at003eg003.jpg

Fig. 3-42

Allergic contact dermatitis: Papules and plaques, the latter resulting from confluence of papules.


at003eg004.jpg

Fig. 3-43

Irritant contact dermatitis: This example of irritant contact dermatitis resembles a burn, to which it is analogous.