Roles & Responsibilities of the Advanced Nurse Practitioners

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Chapter 11:

Contact Dermatitis

Definition: alteration in skin reactivity caused by exposure to an external agent

Causes: combination of genetic and environmental factors

Irritant contact dermatitis (ICD): alteration in skin reactivity caused by exposure to any agent that has a toxic effect on the skin

Allergic contact dermatitis (ACD): alteration in skin reactivity caused by exposure to an antigen that causes an immunologic response

Irritant Contact Dermatitis (ICD)

Not an allergic response; result of damage to the water–protein–lipid matrix of the outer layer of the skin

Appears as erythematous, scaly eruption resulting from friction, exposure to a chemical, or thermal injury

Severity depends on condition of the skin, concentration and toxicity of irritant, and length of exposure

Allergic Contact Dermatitis (ACD)

An immunologically mediated response to an allergen (antigen) occurs.

Initial sensitization phase: the host is immunized to the allergen.

Secondary immune response: T cells are key mediators of the reaction and release cytokines, chemokines, and cytotoxins.

Stimulation of local blood vessels, recruitment of immune cells, and subsequent amplification of the sensitization response occurs.

Allergic Contact Dermatitis (cont.)

Within 5 to 7 days after sensitization, there is visual evidence of the response. On subsequent exposures, however, dermatitis may develop within 6 to 18 hours.

Hypersensitivity can occur after one exposure or after years of repeated exposures. Contact dermatitis may spread extensively beyond the area of contact.

Atopic dermatitis (eczema) is a form of allergic dermatitis characterized as a pruritic, chronic inflammatory condition.

Conditions Occurring in Atopic Dermatitis (Eczema)

High concentrations of serum immunoglobulin (Ig) E

Decreased numbers of immunoregulatory T cells

Defective antibody-dependent cellular cytotoxicity

Decreased cell-mediated immunity

Pathogenesis of Atopic Dermatitis

Genetic factors

Adaptive and innate immune response genes

Skin barrier defects

Deficiency in filaggrin (FLG)

May cause increased transepidermal water loss, infection, and inflammation associated with the exposure of cutaneous immune cells to allergens

Immune dysregulation

Question

A clinician examines a patient who manifests with a rash and classifies it as allergic contact dermatitis. What patient data most likely led to the diagnosis?

The reaction appears only on the area exposed to the irritant.

The patient was exposed to chemicals in the workplace.

The rash developed 6 hours after working in the garden and spread to other areas of the body.

The rash is a chronic inflammatory condition.

Answer

C. The rash developed 6 hours after working in the garden and spread to other areas of the body.

Rationale: Irritant contact dermatitis and allergic contact dermatitis appear as linear streaks of papules, vesicles, and blisters that are very pruritic. In irritant contact dermatitis, the lesions are found only in the area of exposure to the irritant (such as a chemical). In allergic contact dermatitis, the lesions are usually more diffuse, and they may present over an underlying area of edema. Atopic dermatitis (eczema), a form of allergic dermatitis is characterized as a pruritic, chronic inflammatory condition.

Lesions Occurring in Atopic Dermatitis

Papules

Erythema

Excoriations

Lichenification

Treatment for Dermatitis

Prevention is the most effective treatment; patient must be aware of triggers and avoid them.

Mild symptoms are treated with cool compresses; baths with colloidal oatmeal; compresses of Burow solution.

If these fail or dermatitis is more extensive, drug therapy is initiated.

Consideration for Initiating Drug Therapy for Dermatitis

Delivery of the drug to the skin

Protection/barrier function

Cosmetic acceptability

Choosing Drug Therapy for Dermatitis

Ointment and gels offer the best delivery and protection barrier; creams are less greasy but less effective.

Solutions are alcohol-based liquids and are useful for treating the scalp because they do not coat the hair.

Lipid-rich moisturizers both prevent and treat ICD.

Barrier creams containing dimethicone or perfluoropolyethers, cotton liners, and softened fabrics help to prevent ICD.

Choosing Drug Therapy for Dermatitis

Goals of Drug Therapy for Dermatitis

Restoration of a normal epidermal barrier

Treatment of inflammation of the skin

Control of itching

Mainstays of Therapy for Dermatitis

Topical corticosteroids

Topical immunosuppressives

Systemic corticosteroids

Antihistamines

Topical Corticosteroids

Safer than systemic steroidal therapy

Effective for smaller outbreaks

Reduce inflammation and buildup of scale

Least potent topical corticosteroid should be used for the shortest possible time

Should be avoided if there are additional bacterial, viral, or fungal skin infections

Not recommended for prophylaxis

Question

A patient presents with mild, localized dermatitis. What is the first line of therapy recommended for this patient?

Cool compresses of Burow solution and colloidal oatmeal baths

Barrier cream containing dimethicone or perfluoropolyethers

Treatment with an intermediate- or high-potency topical corticosteroid

Treatment with systemic steroids

Answer

A. Cool compresses of Burow solution and colloidal oatmeal baths

Rationale: If the symptoms are mild, compresses of Burow solution and baths with colloidal oatmeal may offer relief from pruritus. If these treatments fail or if the dermatitis is more extensive, drug therapy is initiated. If the dermatitis is mild and localized, topical steroids are prescribed. If the dermatitis is widespread or resistant to treatment with topical steroidal preparations, oral corticosteroids may be used.

Topical Corticosteroid Therapy

Dosage: initiate treatment with an intermediate- or high-potency topical corticosteroid.

Short-term therapy with more potent topical corticosteroids is preferred to longer-term therapy.

Low-potency corticosteroids should be used in the facial and intertriginous.

Maximum recommended length of treatment with topical corticosteroids is 2 weeks for adults and 1 week for children.

Actions of Systemic Corticosteroids

Inhibit cytokine and mediator release

Attenuate mucus secretion

Upregulate beta-adrenergic receptors

Inhibit IgE synthesis

Decrease microvascular permeability

Suppress the influx of inflammatory cells and the inflammatory process

Dosing Systemic Corticosteroids

Tapering dose schedule is recommended:

Starting dose of 1 mg/kg is decreased by 5 mg every 2 days for 2 to 3 weeks.

The entire dose of steroids can be taken at the same time in the morning to minimize sleep disturbances.

Taking the corticosteroids for less than 2 weeks may cause rebound dermatitis, especially with poison ivy.

If dermatitis flares up during the tapering, the dosage can be increased and tapered again.

Topical Immunosuppressives

Act on T cells by suppressing cytokine transcription.

Used in patients with moderate to severe atopic dermatitis who cannot tolerate topical steroids or are not responsive to other treatments, or where there is a concern for topical steroid–induced atrophy.

Tacrolimus and pimecrolimus are the preparations currently available and are applied twice a day until the lesions clear and then for an additional 7 days.

Antihistamines

Used to relieve pruritus associated with contact dermatitis.

Best time to use them is before bed since side effect is drowsiness.

Selecting the Most Appropriate Agent

First-line therapy: a topical corticosteroid preparation with low to intermediate potency applied twice a day

Second-line therapy: a more potent topical corticosteroid or topical immunosuppressants

Third-line therapy: systemic corticosteroids for treating widespread dermatitis; given on a tapered-dose schedule (1 mg/kg, with the dose decreased every 2 days for at least 2 weeks and up to 3 weeks)

Question

For which patient would topical immunosuppressives be prescribed as a second-line therapy?

A patient with poison ivy

A baby with diaper dermatitis

A patient with irritant contact dermatitis

A patient with severe atopic dermatitis

Answer

D. A patient with severe atopic dermatitis

Rationale: Topical immunosuppressives act on T cells by suppressing cytokine transcription. These agents are used in patients with moderate to severe atopic dermatitis who cannot tolerate topical steroids or are not responsive to other treatments, or where there is a concern for topical steroid–induced atrophy.

Special Populations

Pediatric

Topical corticosteroids should be used for only 7 days in children younger than age 6 and at the lowest potency.

Geriatric

Topical corticosteroids can cause atrophy of the skin in elderly people.

Patient Education

Teaching to avoid causative substance

Using mild soaps without perform

Demonstrating how to apply topical preparations and occlusive dressing

Hydrating the skin before applying medication

Hydrating with bland emollients

Taking daily soaking baths for 10 to 20 minutes and using moisturizer afterward

Complementary and Alternative Medicine

Vitamin A 50,000 international units daily

Vitamin E 400 international units daily

Zinc 50 mg daily, to be decreased as the condition clears

EPA 540 mg and DHA 360 mg daily or flaxseed oil 10 g daily

Evening primrose oil 3,000 mg daily

Summary

According to the American Academy of Dermatology, contact dermatitis is a common problem and results in approximately 5.7 million visits to health care providers each year.

In conjunction with drug therapy, monitoring patient response to therapy and providing patient education are key interventions for the treatment of dermatitis.