Background information
- Occupation: Florist (Wear gloves)
- Rash on two fingers
Possible Presentation
- Contact dermatitis causes the skin to become itchy, blistered, dry and cracked.
- Lighter skin can become red, and darker skin can become dark brown, purple or grey.
- Symptoms can affect any part of the body but most commonly the hands and face.
ODIPARA
- Could you please tell me more about it?
- When did it start?
- If one hand (ask what about on the other side?)
- Where did it start?
- Is it spreading?
- Does it happen suddenly or gradually?
- Is it continuous or comes and goes?
- Is there anything that makes it worse?
- Is there anything that makes it better?
Differential Diagnosis
- Irritant Contact dermatitis - Exposure to strong irritants (such as strong acids or alkalis), stinging, burning, dryness, tightness, and chapping, protective area (gloves) will be clear,
- Allergic contact dermatitis - Clinical reactions usually develop 24–72 hours, itching, blistering, weeping, oedema
- Urticaria – pruritic, raised skin lesions, pale to pink erythematous
- Eczema - itchiness, skin dryness, Acute eczema - varies in appearance, from poorly demarcated redness to fluid in the skin (vesicles), scaling, or crusting of the skin. Chronic eczema - thickened (lichenified) skin resulting from repeated scratching.
- Psoriasis — less itchy, well-circumscribed, reddish, flat-topped plaques with silvery scales; typically symmetrical, triggered by stress, medications, infection, trauma, smoking, obesity
Past Hx, MAFTOSA/DESA
- Does it ever happen to you before?
- Do you have underlying medical condition?
- Are you taking any medication?
- Do you have allergy to certain medication or food?
- Does anyone in your family has any medical condition that I should be aware of?
- What you do for living?
- What do you eat on daily basis?
- Do you smoke?
- Do you drink alcohol?
Examination and Investigation
- Vital Sign
- Physical Examination
- Skin examination
- Skin patch test (refer to allergic clinic)
Diagnosis
- Contact dermatitis is an itchy rash caused by direct contact with a substance or an allergic
reaction to it.
Management
- If causative agent has been identified: Advise the person that avoidance of the stimulus is the most important element of treatment and prevention of recurrent episodes of contact dermatitis. 8–12 weeks of avoidance may be needed before clinical improvement is seen.
- Use emollient and soap substitutes to maintain skin hydration and improve barrier repair.
- an ointment for very dry skin
- a cream or lotion for less-dry skin
- an emollient to use instead of soap
- an emollient to use on your face and hands, and a different one to use on your body
- If complete avoidance of the stimulus is not possible, advise the person:
- Rinsing with water or washing with soap or, preferably, a soap substitute as soon as possible after contact, use gloves
- Topical steroids may be required to control symptoms — choice of topical corticosteroid depends on the specific clinical situation including the age of the person and severity, location, and extent of dermatitis.
- Safety netting – Not feeling better, does not respond to medication, infection, functional impairment
- Leafleft
NICE CKS Guidelines
- Contact dermatitis is an inflammatory skin condition affecting the epidermis and dermis, that occurs as a result of exposure to an external irritant or allergen.
- Allergic contact dermatitis is a type IV (delayed) hypersensitivity reaction that occurs after sensitization and subsequent re-exposure to a specific allergen or allergens.
- Common allergens include personal care products (such as cosmetics, skin care products, nail varnish, fragrances, and hair dye), metals (such as nickel), topical medications (including antibiotics and corticosteroids), and certain plants (such as sunflower and primula).
- Irritant contact dermatitis is a non-immunological inflammatory reaction caused by the direct physical or toxic effects of an irritating substance on the skin — prior sensitisation is not required.
- Common irritants include repeated exposure to water (‘wet work’), detergents, cleaning agents, acids and alkalis, and certain plants such as ranunculus.
- Anatomical distribution may aid diagnosis, for example, dermatitis in the webs of fingers is suggestive of irritant contact dermatitis.
- Investigations such as patch testing may be required to identify the cause of contact dermatitis.
- Differential diagnoses include other causes of dermatitis (atopic or seborrhoeic); skin infection (cellulitis, impetigo, and fungal infections); and other skin conditions such as urticaria, psoriasis, and lupus erythematosus.
- Treatment of acute contact dermatitis involves:
- Avoiding contact with the stimulus.
- Liberal application of an emollient.
- Consideration of topical corticosteroids (depending on the clinical situation).
- Appropriate treatment of secondary skin infection, if present.
- Referral to dermatology should be considered for:
- Contact dermatitis associated with occupation — employers have a legal duty to report a case of occupational skin disease to the Health and Safety Executive and assess health risks at work and prevent (or if this is not reasonably practicable) adequately control exposure to hazards.
- Severe, chronic, or recurrent dermatitis, especially of the hands and face.
- Previously stable dermatitis that has become difficult to control in primary care.
- Contact dermatitis which appears atypical or is not responding to measures in primary care.