CLINICAL MANIFESTATION

AND PATHOMECHANISM OF IRRITANT CONTACT

DERMATITIS AND ALLERGIC CONTACT DERMATITIS
by :
Qanitah binti Marzuki C014172224
Nur Farahin binti Shabuddin C014172215
Nurul Aifaa Nazihah binti Mohd Zin C014172165

Resident
dr. Irene Djuardi

Supervisor
Dr. Irma Helina, SpKK
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INTRODUCTION
 Contact dermatitis is an inflammatory skin reaction caused by direct
contact with the substance attached to the skin [1,2].
 It represents a significant burden on the health system, economy, and
patient quality of life [3].
 It is divided into two distinct disease [2]:
- Irritant contact dermatitis (ICD)
- Allergic contact dermatitis (ACD)

1. Chris T. Dermatitis Kontak. Dalam: Kapita Selekta Kedokteran. Essentials of Medicine, edisi ke-4. Jakarta, 2015: 330-33.
2. Menaldi SL SW, Bramono K, Indriatmi W. Dermatitis Kontak (Dermatitis Kontak Iritan, Alergi dan Autosensitasi). Dalam: Ilmu Penyakit Kulit dan Kelamin. 2016;7(2):
158-65
3. Gil S Weintraub, Isabellea NL, Christina NK. Review of Allergic Contact Dermatitis: Scratching the Surface. World J Dermatol. 2015; 4(2): 95-102
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EPIDEMIOLOGY

 ICD (80%) > ACD (20%) [4]

 Affect anybody with different ages,
races, and gender [5].
 Increase along with the increasing
number of products containing chemicals
used by the community [2].

2. Menaldi SL SW, Bramono K, Indriatmi W. Dermatitis Kontak (Dermatitis Kontak Iritan, Alergi dan Autosensitasi). Dalam: Ilmu Penyakit Kulit dan Kelamin.
2016;7(2): 158-65
4. Ali A, et al. Review of Dermatology. Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2017; 9780323296724, 68-71.
5. R.S. Siregar. Penyakit Kulit Alergi. Dalam: Atlas Berwarna Saripati Penyakit Kulit, edisi ke-2. Jakarta: EGC. 2015; 107-12
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ETIOLOGY
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ICD
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ACD
1. Metal 2. Medications

3. Cosmetics 4. Plant
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PATHOMECHANISM
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PATHOMECHANISM OF CONTACT DERMATITIS

• ICD is a non immunologic, multifactorial, direct tissue reaction

• T-cells activated by non immune, irritant, or innate mechanisms release
proinflammatory cytokines.
• ACD represents a classic cell mediated, delayed (type IV)
hypersensitivity reaction [2].
• Two main processes involved sensitization and elicitation [6].
• The induction of sensitivity is the primary event, which has to take
place before clinical expression of dermatitis can occur [7].

2. Menaldi SL SW, Bramono K, Indriatmi W. Dermatitis Kontak (Dermatitis Kontak Iritan, Alergi dan Autosensitasi). Dalam: Ilmu Penyakit Kulit dan Kelamin. 2016;7(2):
158-65

6. Tony B, et al. Contact Dermatitis: Irritant and Allergic. In: Rook’s Textbook of Dermatology, Vol 1. 8th ed. United Kingdom: Wiley-Blackwell. 2010; 1071-202.

7. Wolf K, et al. Irritant Contact Dermatitis and Allergic Contact Dermatitis. In: Fitzpatrick Dermatology in General Medicine. 8th ed. United States: MC Graw Hill.
2012; 152-164, 499-506.
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PATHOMECHANISM OF ICD PATHOMECHANISM OF ACD

8. Nikhil D, et. al. Mechanisms of Contact Sensitization Offer Insights into the Role of Barrier Defects Versus Intrinsic Immune Abnormalities as Drivers of Atopic
Dermatitis. J Invest Dermatol. 2013 October; 133(10): 2311–14.
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CLINICAL MANIFESTATION
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ICD

Acute ICD
 Sign : Burning, stinging, smarting in
seconds
 Late type Acute : within 1-2 minutes.
 Efflorescence : erythema ,vesicle &
blisters necrosis

7. Wolf K, et al. Irritant Contact Dermatitis and Allergic Contact Dermatitis. In: Fitzpatrick Dermatology in General Medicine. 8th ed. United States: MC Graw Hill.
2012; 152-164, 499-506.
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ICD

Chronic ICD
Sign : Stinging, burning, itching
Efflorescence : dryness, fissures,

& erythema lichenification

7. Wolf K, et al. Irritant Contact Dermatitis and Allergic Contact Dermatitis. In: Fitzpatrick Dermatology in General Medicine. 8th ed. United States: MC Graw Hill.
2012; 152-164, 499-506.
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MISCELLANEOUS OF ICD

Hand dermatitis Pustulose and acneiform Cheilitis

6. Tony B, et al. Contact Dermatitis: Irritant and Allergic. In: Rook’s Textbook of Dermatology, Vol 1. 8th ed. United Kingdom: Wiley-Blackwell. 2010; 1071-202.
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MISCELLANEOUS OF ICD

Perianal dermatitis Air borne ICD

6. Tony B, et al. Contact Dermatitis: Irritant and Allergic. In: Rook’s Textbook of Dermatology, Vol 1. 8th ed. United Kingdom: Wiley-Blackwell. 2010; 1071-202.
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ACD

 The duration of ACD varies, resolving in around 1 to 2 weeks

• Worsen as long as the allergen continues in contact.
• Acute = Erythema -> papules -> vesicles erosions -> crusts -> scaling
• Chronic = Papules -> scaling -> lichenification -> excoriations

SYMPTOMS
• Intense pruritus, stinging and pain.

9. Jean L. Bolognia, et al. Contact Dermatitis. In: Dermatology, 4th ed. 2018: 242-57.
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ACD
ARRANGEMENT
 Initially confined to the area of contact with the allergen, then later
spreading beyond.
 Often linear, with artificial patterns.

DISTRIBUTION
 Isolated, localized (e.g., shoe dermatitis) or generalized (e.g., plant
dermatitis).

9. Jean L. Bolognia, et al. Contact Dermatitis. In: Dermatology, 4th ed. 2018: 242-57.
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ACD

• Location : lips
• Efflorescence : bright erythema,
microvesiculation, papules.
• Diagnose : acute allergic contact
dermatitis

7. Wolf K, et al. Irritant Contact Dermatitis and Allergic Contact Dermatitis. In: Fitzpatrick Dermatology in General Medicine. 8th ed. United States: MC Graw Hill.
2012; 152-164, 499-506.
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ACD

• Location : foot
• Efflorescence : erythematous papules
and papulovesicles
• Diagnose : acute allergic contact
dermatitis

9. Jean L. Bolognia, et al. Contact Dermatitis. In: Dermatology, 4th ed. 2018: 242-57.
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ACD

• Location : foot
• Efflorescence : scaling
• Diagnose : chronic allergy contact
dermatitis

9. Jean L. Bolognia, et al. Contact Dermatitis. In: Dermatology, 4th ed. 2018: 242-57.
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ACD

• Location : foot
• Efflorescence : Pebbled and lichenified
plaques with both hypopigmentation and
hyperpigmentation.
• Diagnose : chronic allergy contact
dermatitis

9. Jean L. Bolognia, et al. Contact Dermatitis. In: Dermatology, 4th ed. 2018: 242-57.
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DIAGNOSIS
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ICD
1. History taking
• History of allergy, causatic chemicals, occupational

2. Physical examination = type of irritants (acute/chronic)

3. Diagnostic tools
 Acute : epidermal cell necrosis, neutrophils, vesicles
 Chronic : acanthosis, hyperkeratosis, lymphocytic infiltrate

2. Menaldi SL SW, Bramono K, Indriatmi W. Dermatitis Kontak (Dermatitis Kontak Iritan, Alergi dan Autosensitasi). Dalam: Ilmu Penyakit Kulit dan Kelamin.
2016;7(2): 158-65
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ACD
1. History taking
• History of allergy, occupational, hobby, drugs consumed, cosmetic used

2. Physical examination = type of allergy (acute/chronic)

3. Diagnostic tools
 Acute : spongiosis, lymphocyte, histiocytes and eosinophils
 Chronic : acanthosis, papilomatosis, hyperkeratosis, lymphocyte

2. Menaldi SL SW, Bramono K, Indriatmi W. Dermatitis Kontak (Dermatitis Kontak Iritan, Alergi dan Autosensitasi). Dalam: Ilmu Penyakit Kulit dan Kelamin.
2016;7(2): 158-65
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Patch test

Placement of allergens to the patient’s back utilizing Sites of specific patch tests labelled for future reference
allergEAZE chambers. following removal of the chambers.

9. Jean L. Bolognia, et al. Contact Dermatitis. In: Dermatology, 4th ed. 2018: 242-57.
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PATCH TEST REACTION

A = +/− to + reaction. G = Pustular irritant reactionat the site of the

B, C = + reaction. application of a metalworking fluid.
D = ++ reaction. H = Three different patch test reactions : +/−
E = +++ reaction. to quaternium-15, + to formaldehyde, and ++ to
F = erythematous papules at the edge of nickel
the Finn chamber application site

9. Jean L. Bolognia, et al. Contact Dermatitis. In: Dermatology, 4th ed. 2018: 242-57.
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9. Jean L. Bolognia, et al. Contact Dermatitis. In: Dermatology, 4th ed. 2018: 242-57.
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DIFFERENTIAL DIAGNOSIS
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Diagnose ICD ACD

Causes Irritant substance Hyperreactivity Type IV

Risk Factor Occupational History of atopic disease

 Sharply-marginated  ill-defined border

 Clear erythema  Unclear erythema

Diagnostic tools Patch test : negative Patch test : positive

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Diagnose Atopic Eczema Palmoplantar Pustulosis

Causes Genetic, psychology, hygiene Autoimmune & Genetic

Risk Factor History of atopic disease, Hereditary
<2 years old

 Typical distribution  Pustules crust

 Scaling, erythem  Unclear border of erythema

Diagnostic tools Bacterial/ Virus Culture Histopathology

CBC: Ig E 
Histopathology
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TREATMENT
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ICD

PREVENTION
• Wearing protective clothing
• If contact occur, wash with water.
No hand sanitizers!
• Barrier creams
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ICD
TOPICAL
 Steroid

SYSTEMIC
• Corticosteroid, azathioprin,
cyclosporine
• PUVA
• Antibiotics
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ACD
 Avoidance
 Use protective equipment
 Allergen identification and educate the patient.
 Use of hydrating emollients and soap
substitutes.
 For acute weeping forms of ACD, wet
dressings with saline, aluminium acetate or
silver nitrate may be of benefit.

3. Gil S Weintraub, Isabellea NL, Christina NK. Review of Allergic Contact Dermatitis: Scratching the Surface. World J Dermatol. 2015; 4(2): 95-102
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ACD
• Topical corticosteroid is first-line treatment for ACD.
• In acute, severe, localized ACD a potent topical corticosteroid should
be used.
• In more chronic or widespread contact allergies the potency may need
to be reduced.
• Long-term use in certain sites (face, genitals and flexures) mild topical
corticosteroids are indicated.

6. Tony B, et al. Contact Dermatitis: Irritant and Allergic. In: Rook’s Textbook of Dermatology, Vol 1. 8th ed. United Kingdom: Wiley-Blackwell. 2010; 1071-202.
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CONCLUSION
 Contact dermatitis include ICD and ACD.
 Mechanism of ICD is a non imunologic, multifactorial and direct tissue
reaction while ACD is a type IV cell-mediated hypersensitivity
reaction.
 Contact dermatitis manifestation depends on the cause and how
sensitive the skin to the substance.
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THANK YOU