Contact Dermatitis: Clinical Presentation and Management

Pathophysiologic Types

Irritant contact dermatitis results from direct chemical damage to the skin without immune system involvement, causing inflammation through release of mediators from damaged epidermal cells, affecting all individuals in a dose-dependent manner, and is caused by acids, alkalis, soaps, detergents, and prolonged water exposure, according to the American Academy of Otolaryngology-Head and Neck Surgery 1
Allergic contact dermatitis occurs only in susceptible individuals through a delayed hypersensitivity (Type IV) reaction requiring prior sensitization to specific antigens, such as nickel, neomycin, fragrances, metals, cosmetics, and topical medications, with a maculopapular and often eczematous eruption on exposed areas, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 1

Topical calcineurin inhibitors, such as tacrolimus 0.1% ointment or pimecrolimus 1% cream, are recommended for facial/intertriginous areas to avoid steroid atrophy, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 1
Liberal emollient application to restore barrier function is essential, as stated by the British Journal of Dermatology 2
Replacement of soaps/detergents with emollients is recommended, according to the British Journal of Dermatology 2

Avoid topical antibiotics routinely, as they increase resistance and sensitization risk, such as neomycin sensitizing 5-15% of patients, as warned by the American Academy of Otolaryngology-Head and Neck Surgery 1
Do not overlook allergen identification, as only 25% of occupational contact dermatitis cases achieve complete healing, with 50% having intermittent symptoms at 10 years, as reported by the British Journal of Dermatology 2

The British Journal of Dermatology describes contact dermatitis lesions as having an inflammatory eczematous pattern with erythema, vesiculation, and pruritus in the acute phase, and dryness, lichenification, and fissures with visible borders in the chronic phase 3
Vesiculation is a characteristic feature that can progress to blister formation 3
Lichenification occurs with skin thickening due to chronic scratching 3
Marked dryness with scaling is present 3
Fissures are especially common in areas of flexion or movement 3

In airborn allergen contact dermatitis, the face, neck, arms, legs, and "V" area of the chest are more severely affected 4
Hand contact dermatitis can be clinically indistinguishable from atopic or irritant dermatitis, requiring patch tests for differentiation 3

Clinical characteristics alone are unreliable for distinguishing contact dermatitis from irritant or endogenous dermatitis, particularly on the hands and face 3
The British Journal of Dermatology recommends considering patch tests for chronic or persistent dermatitis 3
Unusual distribution of lesions suggesting contact with a specific allergen should be sought 5

Immediate hypersensitivity reactions (Type I) can occur, such as contact urticaria, especially with latex 6