Allergic contact dermatitis

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Allergic contact dermatitis
Blausen 0014 AllergicDermatitis.png
Illustration of allergic contact dermatitis
Specialty Dermatology, immunology

Allergic contact dermatitis (ACD) is a form of contact dermatitis that is the manifestation of an allergic response caused by contact with a substance; the other type being irritant contact dermatitis (ICD).

Contents

Although less common than ICD, ACD is accepted to be the most prevalent form of immunotoxicity found in humans. [1] By its allergic nature, this form of contact dermatitis is a hypersensitive reaction that is atypical within the population. The mechanisms by which these reactions occur are complex, with many levels of fine control. Their immunology centres on the interaction of immunoregulatory cytokines and discrete subpopulations of T lymphocytes.

Signs and symptoms

The symptoms of allergic contact dermatitis are very similar to the ones caused by irritant contact dermatitis, which makes the first even harder to diagnose. The first sign of allergic contact dermatitis is the presence of the rash or skin lesion at the site of exposure. [2] Depending on the type of allergen causing it, the rash can ooze, drain or crust and it can become raw, scaled or thickened. Also, it is possible that the skin lesion does not take the form of a rash but it may include papules, blisters, vesicles or even a simple red area. The main difference between the rash caused by allergic contact dermatitis and the one caused by irritant contact dermatitis is that the latter tends to be confined to the area where the trigger touched the skin, whereas in allergic contact dermatitis the rash is more likely to be more widespread on the skin. [3] [ failed verification ] Another characteristic of the allergic contact dermatitis rash is that it usually appears after a day or two after exposure to the allergen, unlike irritant contact dermatitis that appears immediately after the contact with the trigger.

Other symptoms may include itching, skin redness or inflammation, localized swelling and the area may become more tender or warmer. If left untreated, the skin may darken and become leathery and cracked. [4] Pain can also be present. Dermatitis can occur anywhere on the skin, but is most common on the hands (22% of people), scattered across the body (18%), or on the face (17%). [5]

The rash and other symptoms typically occur 24 to 48 hours after the exposure; in some cases, the rash may persist for weeks. [2] Once an individual has developed a skin reaction to a certain substance it is most likely that they will have it for the rest of their life, and the symptoms will reappear when in contact with the allergen.

Cause

Common allergens implicated include the following:

Mechanism

Allergic contact dermatitis (ACD) arises as a result of two essential stages: an induction phase, which primes and sensitizes the immune system for an allergic response, and an elicitation phase, in which this response is triggered. [1] During the induction phase, exposure to the allergic substance (allergen) leads to its processing and presentation by immune cells, priming the immune system for a response. In the elicitation phase, subsequent contact with the same allergen, T cells directly recognize the allergen resulting in an immune response at the contact site. The allergic reaction, being mediated directly by T-cells, is classified as a Type IV hypersensitivity reaction. This classification differs from the more prevalent Type I hypersensitivity (e.g., hay fever), where allergens bind to antibodies, that subsequently trigger mast cells.

In contact allergies, the molecules responsible (allergens) are typically small and cannot be directly recognized by the immune system. These allergens can trigger a reaction only after they undergo a process called haptenization. During haptenization, the allergens bind to larger molecules (carrier proteins) naturally present in the skin. This complex of allergen and carrier protein is what the immune system detects as foreign, leading to an allergic response.

The conjugate formed is then recognized as a foreign body by the Langerhans cells (LCs) (and in some cases other Dendritic cells (DCs)), which then internalize the protein; transport it via the lymphatic system to the regional lymph nodes; and present the antigen to T-lymphocytes. This process is controlled by cytokines and chemokines – with tumor necrosis factor alpha (TNF-α) and certain members of the interleukin family (1, 13 and 18) – and their action serves either to promote or to inhibit the mobilization and migration of these LCs. [1] As the LCs are transported to the lymph nodes, they become differentiated and transform into DCs, which are immunostimulatory in nature.

Once within the lymph glands, the differentiated DCs present the allergenic epitope associated with the allergen to T lymphocytes. These T cells then divide and differentiate, clonally multiplying so that if the allergen is experienced again by the individual, these T cells will respond more quickly and more aggressively.

White et al. have suggested that there appears to be a threshold to the mechanisms of allergic sensitization by ACD-associated allergens (1986). [15] This is thought to be linked to the level at which the toxin induces the up-regulation of the required mandatory cytokines and chemokines. It has also been proposed that the vehicle in which the allergen reaches the skin could take some responsibility in the sensitization of the epidermis by both assisting the percutaneous penetration and causing some form of trauma and mobilization of cytokines itself.

Memory response

Once an individual is sensitized to an allergen, future contacts with the allergen can trigger a reaction, commonly known as a memory response, in the original site of sensitization. So for example if a person has an allergic contact dermatitis on the eyelids, say from use of makeup, touching the contact allergen with the fingers can trigger an allergic reaction on the eyelids.[ citation needed ]

This is due to local skin memory T-cells, which remain in the original sensitization site. In a similar fashion, cytotoxic T lymphocytes patrol an area of skin and play an important role in controlling both the reactivation of viruses (such as the "cold sore" virus) and in limiting its replication when reactivated. [16] Memory response, or "Retest Reactivity", usually takes 2 to 3 days after coming in contact with the allergen, and can persist for 2 to 4 weeks.

Diagnosis

Diagnosing allergic contact dermatitis is primarily based on physical exam and medical history. In some cases doctors can establish an accurate diagnosis based on the symptoms that the patient experiences and on the rash's appearance. In the case of a single episode of allergic contact dermatitis, this is all that is necessary. Chronic and/or intermittent rashes which are not readily explained by history and physical exam often will benefit from further testing.

Patch test Epikutanni-test.jpg
Patch test

A patch test (contact delayed hypersensitivity allergy test) [17] is a commonly used examination to determine the exact cause of an allergic contact dermatitis. According to the American Academy of Allergy, Asthma, and Immunology, "patch testing is the gold standard for contact allergen identification". [2]

The patch test consists of applying small quantities of potential allergens to small patches and which are then placed on the skin. [18] After two days, they are removed and if a skin reaction occurred to one of the substances applied, a raised bump will be noticeable underneath the patch. The tests are again read at 72 or 96 hours after application.

Patch testing is used for patients who have chronic, recurring contact dermatitis. [2] Other tests that may be used to diagnose contact dermatitis and rule out other potential causes of the symptoms include a skin biopsy and culture of the skin lesion.

Treatment

The clinical expression of the dermatitis can be mitigated by avoidance of the allergen. Through compliance with avoidance measures, the immune system can become less stimulated. The key to avoidance is proper evaluation and detection of the inciting allergen. However, once the immune system registers the allergen, the recognition is usually permanent.

The first step in treating the condition is appropriate recognition of the clinical problem, followed by identification of the culprit chemical and the source of that chemical. Corticosteroid creams should be used carefully and according to the prescribed directions because when overused over longer periods of time they can cause thinning of the skin. Also, in some instances such as poison ivy dermatitis calamine lotion and cool oatmeal baths may relieve itching. [19]

Unlike the more common Type I allergies (e.g. hay fever), contact allergies are not mediated by histamine, making the use of normal allergy medication (antihistamine) medication ineffective and other drugs have to be used to treat the allergic reaction.

Usually, severe cases are treated with systemic corticosteroids which may be tapered gradually, with various dosing schedules ranging from a total of 12 – 20 days to prevent the recurrence of the rash (while the chemical allergen is still in the skin, up to 3 weeks, as well as a topical corticosteroid. [2] Tacrolimus ointment or pimecrolimus cream can also be used additionally to the corticosteroid creams or instead of these. Oral antihistamines such as diphenhydramine or hydroxyzine may also be used in more severe cases to relieve the intense itching via sedation. [20] Topical antihistamines are not advised as there might be a second skin reaction (treatment associated contact dermatitis) from the lotion itself.

The other symptoms caused by allergic contact dermatitis may be eased with cool compresses to stop the itching. It is vital for treatment success that the trigger be identified and avoided. The discomfort caused by the symptoms may be relieved by wearing smooth-textured cotton clothing to avoid frictional skin irritation or by avoiding soaps with perfumes and dyes. Commonly, the symptoms may resolve without treatment in 2 to 4 weeks but specific medication may hasten the healing as long as the trigger is avoided. Also, the condition might become chronic if the allergen is not detected and avoided.

Identification of the allergen can be aided by the site of the dermatitis. Allergic dermatitis of the hands is often due to contact with preservatives, fragrances, metals, rubber, or topical antibiotics. [5] Dermatitis at the front of the face is often due to gold (from jewelry and foundation), make-up, moisturizers, wrinkle creams, and topical medication. [5] Along the eyelids as well as the sides of the head and neck, dermatitis is often caused by shampoo and conditioner dripping down from the hair. [5] Inflammation on one side of the face often suggests transfer of an allergen from the hands or from the face of a partner. [5]

Epidemiology

Allergic contact dermatitis is common, affecting up to 20% of all people. [5] People sensitive to one allergen are at an increased risk of being sensitive to others. [5] Family members of those with allergic contact dermatitis are at higher risk of developing it themselves. [5] Women are at higher risk of developing allergic contact dermatitis than men. [5]

Related Research Articles

<span class="mw-page-title-main">Allergy</span> Immune system response to a substance that most people tolerate well

Allergies, also known as allergic diseases, are various conditions caused by hypersensitivity of the immune system to typically harmless substances in the environment. These diseases include hay fever, food allergies, atopic dermatitis, allergic asthma, and anaphylaxis. Symptoms may include red eyes, an itchy rash, sneezing, coughing, a runny nose, shortness of breath, or swelling. Note that food intolerances and food poisoning are separate conditions.

An allergen is a type of antigen that produces an abnormally vigorous immune response in which the immune system fights off a perceived threat that would otherwise be harmless to the body. Such reactions are called allergies.

<span class="mw-page-title-main">Food allergy</span> Hypersensitivity reaction to a food

A food allergy is an abnormal immune response to food. The symptoms of the allergic reaction may range from mild to severe. They may include itchiness, swelling of the tongue, vomiting, diarrhea, hives, trouble breathing, or low blood pressure. This typically occurs within minutes to several hours of exposure. When the symptoms are severe, it is known as anaphylaxis. A food intolerance and food poisoning are separate conditions, not due to an immune response.

<span class="mw-page-title-main">Contact dermatitis</span> Human disease

Contact dermatitis is a type of acute or chronic inflammation of the skin caused by exposure to chemical or physical agents. Symptoms of contact dermatitis can include itchy or dry skin, a red rash, bumps, blisters, or swelling. These rashes are not contagious or life-threatening, but can be very uncomfortable.

<span class="mw-page-title-main">Photodermatitis</span> Skin condition

Photodermatitis, sometimes referred to as sun poisoning or photoallergy, is a form of allergic contact dermatitis in which the allergen must be activated by light to sensitize the allergic response, and to cause a rash or other systemic effects on subsequent exposure. The second and subsequent exposures produce photoallergic skin conditions which are often eczematous. It is distinct from sunburn.

<span class="mw-page-title-main">Allergic conjunctivitis</span> Medical condition

Allergic conjunctivitis (AC) is inflammation of the conjunctiva due to allergy. Although allergens differ among patients, the most common cause is hay fever. Symptoms consist of redness, edema (swelling) of the conjunctiva, itching, and increased lacrimation. If this is combined with rhinitis, the condition is termed allergic rhinoconjunctivitis (ARC).

<span class="mw-page-title-main">Urushiol-induced contact dermatitis</span> Medical condition

Urushiol-induced contact dermatitis is a type of allergic contact dermatitis caused by the oil urushiol found in various plants, most notably sumac family species of the genus Toxicodendron: poison ivy, poison oak, poison sumac, and the Chinese lacquer tree. The name is derived from the Japanese word for the sap of the Chinese lacquer tree, urushi. Other plants in the sumac family also contain urushiol, as do unrelated plants such as Ginkgo biloba.

<span class="mw-page-title-main">Patch test</span> Medical test to determine substances causing allergic reactions

A patch test is a diagnostic method used to determine which specific substances cause allergic inflammation of a patient's skin.

<span class="mw-page-title-main">Balsam of Peru</span> Type of tree balsam

Balsam of Peru or Peru balsam, also known and marketed by many other names, is a balsam derived from a tree known as Myroxylon balsamum var. pereirae; it is found in El Salvador, where it is an endemic species.

<span class="mw-page-title-main">Lotion</span> Skin treatment preparation

Lotion is a low-viscosity topical preparation intended for application to the skin. By contrast, creams and gels have higher viscosity, typically due to lower water content. Lotions are applied to external skin with bare hands, a brush, a clean cloth, or cotton wool.

MELISA is a blood test that detects type IV hypersensitivity to metals, chemicals, environmental toxins and molds. Type IV hypersensitivity reactions, particularly to nickel, are well established and may affect 20% of the population.

Eyelid dermatitis is commonly related to atopic dermatitis or allergic contact dermatitis. Volatile substances, tosylamide, epoxy hardeners, insect sprays, and lemon peel oil may be implicated, with many cases of eyelid contact dermatitis being caused by substances transferred by the hands to the eyelids.

Id reactions are types of acute dermatitis developing after days or weeks at skin locations distant from the initial inflammatory or infectious site. They can be localised or generalised. This is also known as an 'autoeczematous response' and there must be an identifiable initial inflammatory or infectious skin problem which leads to the generalised eczema. Often intensely itchy, the red papules and pustules can also be associated with blisters and scales and are always remote from the primary lesion. It is most commonly a blistering rash with itchy vesicles on the sides of fingers and feet as a reaction to fungal infection on the feet, athlete's foot. Stasis dermatitis, allergic contact dermatitis, acute irritant contact eczema and infective dermatitis have been documented as possible triggers, but the exact cause and mechanism is not fully understood. Several other types of id reactions exist including erythema nodosum, erythema multiforme, Sweet's syndrome and urticaria.

Dogs are susceptible to allergies much like their human companions. Most allergies occur in dogs over 6 months old. A dog that is repeatedly exposed to a particular allergen becomes sensitized to it, and the immune system overreacts to a subsequent exposure, most commonly manifesting in the form of skin irritation. Some of the signs are redness, itching, hair loss, and recurring skin infections from the irritation. Skin irritation may be generalized or localized. The dog may be more prone to scratching and licking at the irritated site, further exacerbating the problem.

Perfume intolerance or perfume allergy is a condition wherein people exhibit sensitivity or allergic reactions to ingredients in some perfumes and some other fragrances. It is a form of multiple chemical sensitivity, a more general phenomenon for this diagnosis.

Allergy testing can help confirm or rule out allergies and consequently reduce adverse reactions and limit unnecessary avoidance and medications.

<span class="mw-page-title-main">Nickel allergy</span> Medical condition

Nickel allergy is any of several allergic conditions provoked by exposure to the chemical element nickel. Nickel allergy often takes the form of nickel allergic contact dermatitis (Ni-ACD), a form of allergic contact dermatitis (ACD). Ni-ACD typically causes a rash that is red and itchy and that may be bumpy or scaly. The main treatment for it is avoiding contact with nickel-releasing metals, such as inexpensive jewelry. Another form of nickel allergy is a systemic form: systemic nickel allergy syndrome (SNAS) can mimic some of the symptoms of irritable bowel syndrome (IBS) and also has a dermatologic component.

<span class="mw-page-title-main">Allergies in children</span> Medical condition

Allergies in children, an incidence which has increased over the last fifty years, are overreactions of the immune system often caused by foreign substances or genetics that may present themselves in different ways. There are multiple forms of testing, prevention, management, and treatment available if an allergy is present in a child. In some cases, it is possible for children to outgrow their allergies.

<span class="mw-page-title-main">Lip licker's dermatitis</span> Medical condition

Lip licker's dermatitis is a type of skin inflammation around the lips due to damage by saliva from repetitive lip licking and is classified as a subtype of irritant contact cheilitis. The resulting scaling, redness, chapping, and crusting makes a well-defined ring around the lips. The rash may extend as far as the tongue can reach and usually does not occur at the corners of the mouth. It commonly occurs during winter months but some people can have it year-round if lip licking is a chronic habit.

<span class="mw-page-title-main">Metal allergy</span> Medical condition

Metal allergies inflame the skin after it has been in contact with metal. They are a form of allergic contact dermatitis. They are becoming more common, as of 2021, except in areas with regulatory countermeasures.

References

  1. 1 2 3 Kimber I, Basketter DA, Gerberick GF, Dearman RJ (2002). "Allergic contact dermatitis". Int. Immunopharmacol. 2 (2–3): 201–11. doi:10.1016/S1567-5769(01)00173-4. PMID   11811925.
  2. 1 2 3 4 5 "Contact dermatitis". Medline Plus. U.S. National Library of Medicine. Archived from the original on 15 June 2010. Retrieved 8 April 2022.
  3. ↑ Cole GW. Shiel Jr WC (ed.). "Contact Dermatitis Symptoms". eMedicineHealth.com. WebMD, Inc. Retrieved 2010-06-16.
  4. ↑ "Allergic Contact Dermatitis". The American Osteopathic College of Dermatology. Archived from the original on 28 June 2010. Retrieved 2010-06-16.
  5. 1 2 3 4 5 6 7 8 9 Nassau S, Fonacier L (January 2020). "Allergic Contact Dermatitis". Med Clin North Am. 104 (1): 61–76. doi:10.1016/j.mcna.2019.08.012. PMID   31757238. S2CID   208234562.
  6. 1 2 Ngan V (2002). "Balsam of Peru contact allergy". Dermnetnz.org. Retrieved March 5, 2014.
  7. ↑ Schmalz G, Bindslev DA (2008). Biocompatibility of Dental Materials. Springer. ISBN   978-3-540-77782-3 . Retrieved March 5, 2014.
  8. ↑ Habif TP (2009). Clinical Dermatology. Elsevier Health Sciences. ISBN   978-0-323-08037-8 . Retrieved March 6, 2014.
  9. ↑ Ngan V (2002). "Allergy to fragrance mix". DermNetNZ.
  10. ↑ "Nickel Allergic Contact Dermatitis". dermatitisacademy.com.
  11. ↑ Kamerud KL, Hobbie KA, Anderson KA (2013). "Stainless steel leaches nickel and chromium into foods during cooking". Journal of Agricultural and Food Chemistry. 61 (39): 9495–501. doi:10.1021/jf402400v. PMC   4284091 . PMID   23984718.
  12. ↑ Jacob SE, Goldenberg A, Pelletier JL, Fonacier LS, Usatine R, Silverberg N (2015), "Nickel allergy and Our Children's Health: A Review of Indexed Cases and a View of Future Prevention", Pediatric Dermatology, 32 (6): 779–85, doi:10.1111/pde.12639, PMID   26212605, S2CID   23566200
  13. ↑ Jacob SE, ed. (February 2015). "Nickel-Directed US Health Policy". The Dermatologist.
  14. ↑ Veverka KK, Hall MR, Yiannias JA, Drage LA, El-Azhary RA, Killian JM, et al. (2018). "Trends in Patch Testing With the Mayo Clinic Standard Series, 2011-2015". Dermatitis. 29 (6): 310–315. doi:10.1097/DER.0000000000000411. PMID   30422883. S2CID   53303401.
  15. ↑ White SI, Friedmann PS, Moss C, Simpson JM (1986). "The effect of altering area of application and dose per unit area on sensitization by DNCB". Br. J. Dermatol. 115 (6): 663–8. doi:10.1111/j.1365-2133.1986.tb06646.x. PMID   3801307. S2CID   21476276.
  16. ↑ Iwasaki A (2009). "Local advantage: skin DCs prime, skin memory T cells protect". Nature Immunology. 10 (5): 451–453. doi:10.1038/ni0509-451. PMC   3662044 . PMID   19381136.
  17. ↑ "Contact dermatitis". The Mayo Clinic. Archived from the original on 19 June 2010. Retrieved 2010-06-16.
  18. ↑ "Tests and diagnosis". The Mayo Clinic. Archived from the original on 19 June 2010. Retrieved 2010-06-16.
  19. ↑ Cole GW. Shiel Jr WC (ed.). "Self-Care at Home". eMedicineHealth.com. WebMD, Inc. Archived from the original on 15 June 2010. Retrieved 2010-06-16.
  20. ↑ Prok L. "Patient Education: Poison Ivy". UpToDate. Retrieved 22 July 2020.
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