Mark H. Lowitt, Md

Mark H. Lowitt, MD Clinical Associate Professor of Dermatology University of Maryland School of Medicine Private Practice, Greater Baltimore Medical Center

Contact Dermatitis Cases Clinical Features of Allergic Contact Dermatitis Mechanisms of Allergic Contact Dermatitis Patch Testing

Case 1 51 y/o F Phlebotomist Itchy and painful fingers and hands, worsening over years Not seasonal What’s the diagnosis? What’s the cause?

Case 2 Same photo

73 y/o F Severe eyelid pain and itch worsening over weeks What’s the diagnosis? What’s the cause?

Case 3 40 y/o M Auto mechanic for 20 years Similar eruption on feet What’s the diagnosis? What’s the cause?

Erythema Edema Vesiculation Scaling Lichenification Well defined edges

and Straight lines

Pruritus History: The more you treat, the worse it gets

What’s new in contact dermatitis? What makes a good contact allergen? Low molecular weight Lipophilic Able 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

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-21pivalate, Budesonide Dyes: P-phenylenediamine, Disperse blue Rubber products: Mercaptobenzathiazole, Carba mix, thiuram mix, mixed dialkyl thiourea Other: Benzocaine, Colophony, ethyl acrylate

Hand Dermatitis Allergic Contact Dermatitis Irritant Contact Dermatitis Dyshidrotic Eczema Palmar psoriasis Tinea Manum Mycosis fungoides

Hand Dermatitis Patch test positive for Quaternium-15 Common preservative

Chronic Hand Dermatitis Major Occupational Health Problem 40% of all Occupational Health Claims are from skin 90% of these are Dermatitis 65% are Irritant Contact 35% are Allergic Contact 

THEREFORE, 12% OF ALL WORKMAN’S COMP CLAIMS ARE DUE TO ALLERGIC CONTACT DERMATITIS

Allergic Contact Dermatitis of the Hands 22,035 patients patch tested between 1994 and 2004 6953 had hand involvement 959 with a solitary dx of ACD Quaternium-15 17% Formaldehyde

13% Nickel 12% Fragrance Mix 11% Thiuram Mix 10%

Eyelid Dermatitis Differential Diagnosis Contact dermatitis Atopic dermatitis Dermatomyositis Atopic dermatitis

Dermatomyositis (heliotrope rash)

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 nickel

in gold alloys

Eyelid Dermatitis Most common causes of eyelid allergic contact dermatitis: Gold

22% Fragrance mix 19% Balsam of Peru 17% Nickel 16% Neomycin 9%

Treatment with topical

cortisones initially help, but then the condition worsens

Tinea manum (dermatophyte infection)

Patch test positive for Budesonide Cross reacts with triamcinolone, fluocinonide, fluocinolone,

desonide, budesonide

Corticosteroids were the American Contact Dermatitis

Society 2005 “Allergen of the Year”

Corticosteroid allergy Class A

Hydrocortisone and tixocortol type

Cortisone, hydrocortisone, methylprednisolone, prednisolone

Class B

Triamcinolone acetate type

Triamcinolone, halcinonide, flucinonide, fluocinolone, desonde,

budesonide, amcinonide

Class C

Bethamethasone type

Betamethasone, dexamethasone, flucortolone

Class D

butyrate

Hydrocortisone-17-butyrate and clobetasol 17-

Patient education – CARD Database

Allergic Contact Dermatitis: Review Have 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

Allergic Contact Dermatitis: Review Patch testing can help to identify the allergen Hand dermatitis most often caused by quaternium-15 Eyelid dermatitis most often caused by gold In pts not getting better, consider contact dermatitis to

topical steroids

www.contactderm.org

American Contact Dermatitis Society (ACDS)

www.dormer.com

Dormer Labs (Canada) patch test materials

www.allergEAZE.com

patch test materials