Periorbital dermatitis (periocular eczema)

A 45-year-old woman is seen in the allergy clinic with a complaint of red, itchy, scaly rash around the eyes for 5 months. No eye itching but she has occasional sneezing and a history of allergic rhinitis.

Examination is positive for dry skin and macular rash around both eyes, below the orbits.

What is the most likely diagnosis?

Periorbital dermatitis. Differential diagnosis includes atopic dermatitis, contact dermatitis, nonspecific dermatitis.

What would you suggest?

TRUE patch test for contact dermatitis.

If negative, then a skin test with airborne allergens could be considered.

For mild exacerbations, use topical hydrocortisone 1% for up to 1-3 weeks or Elidel. Use topical moisturizer such as Eucerin for dry areas.

Summary

Periorbital dermatitis is common and frequently difficult to treat. Patients with periorbital dermatitis often suffer severely because their disease is in such a visible location.

Predominant causes of periorbital dermatitis are:

- allergic contact dermatitis, 32-44%
- atopic eczema, 14-25%
- airborne contact dermatitis, 2-10%
- irritant contact dermatitis, 8-9%
- less frequent causes for secondary eczematous periocular skin lesions were periorbital rosacea, allergic conjunctivitis or psoriasis vulgaris

Risk factors include female gender, atopic skin diathesis and age of 40 years and older.

Common causes of periorbital allergic contact dermatitis are leave-on cosmetic products (face cream, eye shadow) and eye drops with the typical allergens being fragrances, preservatives and drugs.

Exact identification of relevant contact allergens and allergen elimination are essential for successful treatment.

Calcineurin inhibitors are the first-line therapy for facial atopic eczema.



Contact Dermatitis - Approach to Treatment (click to enlarge the image).

References

Periorbital dermatitis: causes, differential diagnoses and therapy. J Dtsch Dermatol Ges. 2010 Mar;8(3):159-66. doi: 10.1111/j.1610-0387.2009.07216.x. Epub 2009 Sep 14.
http://www.ncbi.nlm.nih.gov/pubmed/19751221
http://www.feingold.org/Research/PDFstudies/Feser2010.pdf

Clothing Dermatitis or Textile Dermatitis

A 50-year-old woman is seen in the allergy clinic for rash.

For the last year, she reported a rash (fine bumps) when wearing "permanent press" clothing in high temperature environment. She works in a warehouse. The rash is less pronounced in lower temps. No rash with cotton clothing. She has to wear protective clothes at to work as part of the work rules. The rash is sometimes itchy but does not last longer than a day. No hives, angioedema or systemic symptoms. She thinks the rash is caused by polyesther.

What is the most likely diagnosis?

Clothing Dermatitis. Differential diagnosis includes miliaria rubra (heat rash), or contact dermatitis.

Polyesther is not a common cause of contact dermatitis. In fact, it is so uncommon for polyesther to cause allergy that is used as a negative control in the TRUE patch test (the test base is made of polyesther). Patients who report polyesther allergy are typically allergic to the dyes used to color the material.

What happened?

The most likely diagnosis is miliaria rubra (heat rash).

Regarding dermatitis, see instructions below. For mild exacerbations, use topical hydrocortisone 1% for up to 1-3 weeks. For more severe exacerbations, I recommended topical triamcinolone 0.1% for up to 1-2 weeks.

TRUE patch was ordered to rule out contact dermatitis.

Any patient information handouts?

Yes, see the Educational Handout for Patients with Textile Finish/Formaldehyde Resin Allergic Contact Dermatitis by University Hospitals Health System University Hospitals of Cleveland.

For Textile Finish/Formaldehyde Resin Allergic Dermatitis, it is recommended:

1. WEAR clothes with labels that say:

- 100% silk

- 100% linen (if it wrinkles easily)

- 100% polyester

- 100% acrylic

- 100% nylon

- spandex

- flannel (if soft)

- denim (jeans)

- wool (may cause irritation)

2. DO NOT WEAR clothes with labels that say:

- Permanent press

- Wrinkle resistant

- Color-fast

- Stain-resistant

- "Blends" (including rayon, polyester-cotton)

- corduroy or shrink-proof wool

3. It may be helpful to remember this:

-Soft, easily wrinkled fabrics = SAFE

-Heavy, stiff fabrics = UNSAFE

4. Things that cause rubbing, pressure or sweating could cause your condition to flare. So, loose fitting clothes are helpful and you may be able to tolerate more kinds of fabrics in cooler temperatures than you can in higher temperatures (in the summer).

5. Start by READING THE LABELS IN YOUR CLOSET. Put to one side all the clothes that are safe to wear. See 1 above. Wear only these clothes for one month.

6. If you need to buy new clothes, remember that clothing made in Japan may be the safest choice for imported textiles. Japan enforces the strictest standards for formaldehyde release from the textile finishes. Also, the companies that market in or out of Japan meet acceptable standards and are generally safe.

7. Clothing made by GAP, OLD NAVY, BANANA REPUBLIC, LIZ CLAIBORNE, EDDIE BAUER, CUDDL DUDS, and LEVI STRAUSSS is recommended. Also, products from VERMONT COUNTRY STORE and AVANTAL U.S. claim to use very low amounts of formaldehyde resins in finishing their textiles (amounts below the U.S. industry standard.

8. Do note that washing clothing will not significantly reduce the levels of formaldehyde resins in your clothing necessary for an allergic reaction. Use of dry cleaning fluids and spray starch are okay. Washing your family's clothes is okay if you do not develop fingertip dermatitis.

9. If exposure to formaldehyde resins in your clothes cannot be avoided, then you may consider wearing undergarments to protect your skin. Silk is an acceptable choice for an undergarment.

10. If you have been told that you are also allergic to formaldehyde preservatives, you also need to check your personal care products such as cosmetic creams, medication, nail products and shampoo. The Contact Allergen Replacement Database (CARD) printout provided by your doctor can be your shopping list for products that do not contain the allergens.

11. You may also come in contact with fabrics containing formaldehyde in other than clothes, such as bed sheets, upholstered furniture and craft fabrics. Use of knitting yarns and needlework floss is acceptable.

12. Keep in mind that you MUST AVOID FORMALDEHYDE RESINS AT ALL TIMES. Even exposure once a month would be enough to cause a rash to continue. "Dress clothes" only worn on weekends is enough to maintain your dermatitis.

13. Also, realize that since you have had an allergic reaction, now even low levels of formaldehyde may be enough to cause flares. Try to add only one new product per week. If you have a flare after a new product, STOP FOR 3 WEEKS until clear.

14. Remember this is a difficult process. Be patient and call with questions.

What are the panel allergens in the patch test?

Panel Allergens - T.R.U.E. TEST is used as a patch test for contact allergies to the common allergens shown below. For more information about where each allergen can be found and how to avoid it, check the manufacturer's website: http://www.truetest.com/panelallergens.aspx

Panel 1.2
Nickel sulfate
Wool alcohols
Neomycin sulfate
Potassium dichromate
Caine mix
Fragrance mix
Colophony
Paraben mix
Negative control
Balsam of Peru
Ethylenediamine dihydrochloride
Cobalt Dichloride

Panel 2.2
p-tert-Butylphenol formaldehyde resin
Epoxy resin
Carba mix
Black rubber mix
Cl+ Me- isothiazolinone (MCI/MI)
Quaternium-15
Methyldibromo glutaronitrile
p-Phenylenediamine
Formaldehyde
Mercapto mix
Thimerosal
Thiuram mix

Panel 3.2
Diazolidinyl urea
Quinoline mix
Tixocortol-21-pivalate
Gold sodium thiosulfate
Imidazolidinyl urea
Budesonide
Hydrocortizone-17-butyrate
Mercaptobenzothiazole
Bacitracin
Parthenolide
Disperse blue 106
2-Bromo-2-nitropropane-1,3-diol (Bronopol)

References:

Diagnosis and Treatment of Dermatitis Due to Formaldehyde Resins in Clothing - Medscape, 2004. http://buff.ly/1DTrISb
Contact Dermatitis | Symptoms and Treatment | ACAAI http://buff.ly/1tAFyWj
Clothing dermatitis - WA.org http://buff.ly/1tAFB49
Textile contact dermatitis. DermNet NZ http://buff.ly/1tAFCp0

Angioedema of the tongue secondary to glossitis due to toothpaste

Author: V. Dimov, M.D., Allergist/Immunologist, Cleveland Clinic
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at NSU

A 20-year-old male presented to the allergy clinic with a complaint of a swollen tongue one day after he used a toothpaste with cinnamon flavor. The toothpaste - Colgate Cinnamon - caused burning sensation in the mouth and he noted swelling of the tongue the next day. The swelling was present for 2 days. He had used the same toothpaste before but only for a few seconds before rinsing and spitting it out.

No shortness of breath or systemic symptoms. No hives. No connection to any foods. No new medications. No family history of HAE.

What is the most likely diagnosis?

Angioedema of the tongue secondary to glossitis due to toothpaste containing cinnamal (flavouring of cinnamon).

The cause of the above reaction is either:

- Irritant contact reaction to the toothpaste, for example, cinnamal – flavouring derived from cinnamon
- allergic reaction to cinnamal – flavouring derived from cinnamon (Hexyl cinnamaldehyde).

Glossitis is inflammation of the tongue. Glossitis is often a symptom of other conditions, such as:

- Allergic reactions to oralcare products, foods, or medicine
- Dry mouth due to Sjogren syndrome
- Infection from bacteria, yeast or viruses (including oral herpes)
- Injury (such as from burns, rough teeth, or bad-fitting dentures
- Skin conditions that affect the mouth
- Irritants such as tobacco, alcohol, hot foods, spices, or other irritants

What management would you recommend?

Regarding angioedema of the tongue, avoidance is recommended of toothpastes that contain cinnamal – flavouring derived from cinnamon.

If there is another, unprovoked episode of angioedema, then the following workup may be indicated: CBCD, CMP, ESR, CRP, IgG, IgA, IgM, SPEP, thyroid function tests (TSH and T4), thyroid antibodies, Helicobacter pylori IgG, total IgE, ANA, RF, vitamin D level, and specific workup for angioedema including C4, C1 esterase inhibitor and CH50.

What is cinnamal?

Hexyl cinnamaldehyde (hexyl cinnamal) is a common additive in perfume and cosmetic industry as aroma substance. It is found naturally in the essential oil of chamomile. Hexyl cinnamaldehyde is an allergen and an irritant in concentrations higher than recommended.

Final diagnosis

Angioedema of the tongue secondary to glossitis due to toothpaste containing cinnamal (flavouring of cinnamon).

References

Glossitis: MedlinePlus Medical Encyclopedia http://buff.ly/1DgkwA5
Toothpaste Allergy Diagnosis and Management: JCAD | The Journal of Clinical and Aesthetic Dermatology http://buff.ly/1DgkSXg
Contact reactions to toothpaste and other oral hygiene products. DermNet NZ http://buff.ly/1BK6FQH

Published: 02/26/2009
Updated: 09/12/2014

Allergic reaction to dental braces

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at NSU

A 15-year-old girl is at the allergy clinic for evaluation of suspected allergic reaction to dental braces. Braces were placed by an orthodontist 2 months ago, and within a week, she started to feel oral itching and gagging. No history of nickel or latex allergy.

Physical Examination showed mild gingival erythema and dry lips.

What could be the cause of symptoms?

Delayed hypersensitivity to dental braces materials (nickel, cobalt, etc) is rare but described in the literature. Typically, patients have oral or perioral lesions.

What would you recommend?

Regarding the suspected delayed hypersensitivity to dental braces materials (nickel, cobalt, etc), the following is recommended:

- TRUE patch test
- ask the orthodontist to provide the materials of the braces to be added to the patch test

References

Cutaneous and oral eruption from oral exposure to nickel in dental braces. Schultz JC1, Connelly E, Glesne L, Warshaw EM. Dermatitis. 2004 Sep;15(3):154-7.
http://www.ncbi.nlm.nih.gov/pubmed/15724351

Full text from Medscape: http://www.medscape.com/viewarticle/496365_3

Nickel allergy and orthodontics, a review and report of two cases. British Dental Journal 204, 297 - 300 (2008).
http://www.nature.com/bdj/journal/v204/n6/full/bdj.2008.198.html

TRUE patch test info for nickel.
https://www.truetest.com/PatientPDF/Patient_Nickel.pdf

Published: 02-12-2014
Updated: 05-28-2014

Contact Dermatitis - patient information

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at NSU

When certain substances come into contact with your skin, they may cause a rash called contact dermatitis. There are 2 types of contact dermatitis - irritant and allergic.

Irritant contact dermatitis

Irritant contact dermatitis is often more painful than itchy, and is caused by a substance damaging the part of your skin it comes into contact with. The longer your skin is in contact with the substance, or the stronger the substance is, the more severe your reaction will be. These reactions appear most often on the hands and are frequently work-related due to use of soap, other detergensts, etc.

Allergic contact dermatitis

Allergic contact dermatitis is best known by the itchy, red, blistered reaction experienced after you touch poison ivy. This allergic reaction is caused by a chemical in the plant called urushiol. You can have a reaction from touching other items the plant has come into contact with. However, once your skin has been washed, you cannot get another reaction from touching the rash or blisters. Allergic contact dermatitis reactions can happen 24 to 48 hours after contact. Once a reaction starts, it takes 14 to 28 days to go away, even with treatment.

Nickel, perfumes, dyes, rubber (latex) products and cosmetics also frequently cause allergic contact dermatitis.

Some ingredients in medications applied to the skin can cause a reaction, most commonly neomycin, an ingredient in antibiotic creams.

Treatment

For irritant contact dermatitis, you should avoid the substance causing the reaction. You should also avoid spilling chemicals on your skin. Gloves can sometimes be helpful. Since these reactions are non-allergic, avoiding the substance will relieve your symptoms and prevent lasting damage to your skin.

Treatment for allergic contact dermatitis depends on the severity of symptoms. Cold soaks and compresses can offer relief for the acute, early, itchy blistered stage of your rash. You may also be prescribed topical corticosteroid creams, such as hydrocortisone 1% (available over the counter). To prevent the reaction from returning, avoid contact with the offending substance.

If you and your allergist cannot determine the substance that caused the reaction from your history and examination, your allergist may conduct a series of patch tests to help identify it. The patch test is applied to the back and it is left there for 48 to 72 hours (2 to 3 days). After that period, the allergist will remove the patch test from your back and determine what you are allergic to.

References

Allergic Skin Conditions. AAAAI.

Published: 11/28/2011
Updated: 02/08/2012

Contact Dermatitis

Editor: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago

Information For Patients

Contact dermatitis
Patch Testing Procedure - step-by-step photos
Hives (urticaria) and angioedema
Eczema or atopic dermatitis
Allergy Testing
Skin Allergy Quiz by AAAAI

Information For Doctors

Contact Dermatitis: Teaching Cases

How to Diagnose Contact Dermatitis?
Irritant contact dermatitis
Irritant contact dermatitis to acne medication that contains benzoyl peroxide

Other Forms of Dermatitis

Atopic dermatitis
An "Allergic Rash" Which Turned Out to be Seborrheic Dermatitis
It's not a drug reaction but a fungal infection in an immunosuppressed patient (tinea corporis)
Correct diagnosis is keratosis pilaris rather than an "allergic rash"
How to Diagnose Latex Allergy
Tattoo Allergy. NEJM Images in Clinical Medicine.
Common Rashes Not to Miss: Slideshow. Medscape.
Contact Dermatitis - Evaluation and Diagnosis
Why Can't Contact Dermatitis Be Diagnosed by Blood Test?

Related blog posts from AllergyNotes

Published: 07/12/2008
Updated: 09/15/2012

Textile Dermatitis and Contact Dermatitis

Author: V. Dimov, M.D., Allergist/Immunologist, Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist, Assistant Professor at NSU

A 53-year-old female is in the clinic for evaluation of her complaints of feeling of skin "burning", discomfort and mild erythema with different clothes. These symptoms mostly affect the lower part of the body but also occasionally the upper extremities. They started approximately 6 years ago after she used a hair dye with quaternary ammonium. An allergist at the time performed contact allergy testing with T.R.U.E. Test and, as per patient, this test was positive for cobalt, nickel and quaternary ammonium. It has been a struggle for her to avoid the use of products with quaternary ammonium, also known as benzalkonium chloride, which is widely used as a disinfectant. She is able to tolerate pure cotton clothes, but she has difficulty finding those in the stores.

Past medical history

Her past medical history is remarkable for the above-referenced symptoms of contact dermatitis/textile dermatitis, as well as anxiety and panic attacks.

Drug allergies include Bactrim with rash and also possiblle allergic reactions with Augmentin, Levaquin and amoxicillin, and pruritus but no rash with Motrin and Cipro.

Her current medications include Ativan b.i.d.

Her family history and social history are unremarkable.

The physical examination is normal.

Procedures: CBC, differential and CMP were ordered.

What is the most likely diagnosis?

This is a patient with a history of contact dermatitis with positive T.R.U.E. Test to cobalt, nickel and quaternary ammonium, which is also know as benzalkonium chloride, with a suspected diagnosis of textile dermatitis. Interestingly, she does not actually have a skin rash. It is mostly manifested by burning sensation and pruritus with some mild erythema. However, the presence of rash is important for the conclusive diagnosis of dermatitis. In any case, textile dermatitis can be caused by irritant reactions to textile fibers or contact allergy to textile dyes and finishing chemicals. It is important to be aware that dispersed dyes can also cause a reaction in sensitive patients.

What would you suggest in terms of diagnostic tests?

We recommended that she has CBC with differential count and CMP for basic screening for other causes of the sensation of skin "burning" and pruritus. Also, we advised her to take loratadine 10 mg p.o. daily, and to use "All Clear" detergent without any perfumes to wash her clothing. She will request the T.R.U.E. Test results from her previous allergist. There is currently no evidence of environmental sensitization to trees, gasses, mold and no evidence of symptoms for allergic rhinitis, conjunctivitis, asthma or food allergy and we decided to postpone skin prick testing to environmental allergens and food allergens at this time because it is not likely that IgE mediated allergy plays a role in this clinical setting. After we review the T.R.U.E. Test results, it may be reasonable to refer her to a dermatologist who can perform an expanded T.R.U.E. test for more contact allergens (50 or 74 rather than the initial 25 allergens included in T.R.U.E.) to see if any other allergens play a role. It is recommended to avoid the triggering substances or textiles that cause irritation in this patient.

The patch test for contact dermatitis is expensive. The cost is $30 per potential allergen, and a 20-allergen TRUE test would cost around $160-600. The CPT code is 95044, it is paid only contact dermatitis is listed as ICD-9 code for the visit (source: http://www.aaaai.org/ask-the-expert/coding-for-the-Atopy-Patch-Test.aspx). A typical charge is in the range of $160 (professional fee of $40, facility fee $120).

Related reading

Thin-Layer Rapid-Use Epicutaneous Test (patch test) misses allergens in 12.5% of patients with contact dermatitis http://goo.gl/nqUsn

Published: 07/12/2010
Updated: 02/12/2012

Irritant contact dermatitis

Author: V. Dimov, M.D., Fellow, Creighton University Division of Allergy & Immunology
Reviewer: S. Randhawa, M.D., Fellow, LSU (Shreveport) Department of Allergy & Immunology

A 27-year-old female is self-referred to our clinic for evaluation of skin rash, maculopapular and pruritic which affects both hands, forearms, and the lower portion of her neck. She has had the rash for four months.

She works as a manual laborer at a parcel courier service, moving boxes. Apart from the rash, she does not report any other symptoms. The skin rash started 4 months ago. She is not on any medications and does not have any significant past medical history.

She wants to have "skin prick testing done for allergies."

Physical examination

The physical examination is positive for maculopapular rash and xerosis affecting both hands, forearms, and the lower portion of the neck.

What is the most likely diagnosis?

This is a patient with contact dermatitis which is most likely of irritant etiology. It is likely that her hands are in contact with the irritant substance and then she gets lesions wherever she scratches her skin with the contaminated hands, mostly on the forearms and lower portion of the neck.

What treatment would you suggest?

We prescribed prednisone 40 mg po daily for 5 days and hydrocortisone 1% ointment daily for 7 days and also we advised her to use skin moisturizers twice a day.

What did we learn from this case?

The occurrence of a rash on the neck and forearms does not mean that the rash originated there. Often, in the case of irritant allergic dermatitis, the irritant substance on the person's fingers and nails can cause a rash wherever they touch their skin or scratch.

One example is a patient who complains of rash affecting the eyelids which is actually caused by the nail polish applied to the fingernails. Many of these patients have lengthy evaluations for periorbital rashs while the correct diagnosis is irritant contacts dermatitis of the hands with a secondary spread to the periorbital area.

Published: 02/23/2010
Updated: 02/23/2010

Irritant contact dermatitis to acne medication that contains benzoyl peroxide

Author: V. Dimov, M.D., Fellow, Creighton University Division of Allergy & Immunology
Reviewer: S. Randhawa, M.D., Fellow, LSU (Shreveport) Department of Allergy & Immunology

A 25-year-old Caucasian female developed worsening symptoms of facial dermatitis during the last 3 months. She started using over-the-counter hydrocortisone cream yesterday and her symptoms are better now. This is the third episode of similar complaints in the last 3 months. She reports long term use of the acne cream Proactiv, which contains benzyl peroxide, and she also uses Eucerin lotion on her face.

Medications

Her medications include Allegra (fexofenadine), Flonase (fluticasone nasal) and levothyroxine. Proactiv and Eucerin.

Past medical history

She has a long history of allergic rhinitis and conjunctivitis.

Physical examination

The physical examination is positive for facial erythema with some eyelid eczema.

What is the most likely diagnosis?

Facial dermatitis related to Proactiv, containing benzoyl peroxide. The etiology of the dermatitis is either irritant or allergic contact dermatitis to benzoyl

peroxide. Considering that she had two prior episodes that resolved and the rash is not worsening now, the most likely explanation for her condition is irritant contact dermatitis to benzoyl peroxide.

What treatment would you suggest?

The patient was advised to use hydrocortisone at the lowest of concentration of 1%, daily, on the face, for a week. She had to stop using Proactiv immediately. She could still use Eucerin daily.

Final diagnosis

Irritant contact dermatitis to acne medication that contains benzoyl peroxide.

Benzoyl peroxide (BP) is shown to be a weak allergen. In a study of 25 guinea pigs, only 5 were sensitized in the TINA test. BP is a skin irritant. However, only 11 of 155 acne patients had clinical signs of intolerance, which settled despite continued use in 10 cases.

References

Purpuric contact dermatitis to benzoyl peroxide. van Joost T, van Ulsen J, Vuzevski VD, Naafs B, Tank B. J Am Acad Dermatol. 1990 Feb;22(2 Pt 2):359-61.

Allergic contact angioedema to benzoyl peroxide. Minciullo PL, Patafi M, Giannetto L, Ferlazzo B, Trombetta D, Saija A, Gangemi S. J Clin Pharm Ther. 2006 Aug;31(4):385-7.

Allergic and irritant potential of benzoyl peroxide. Haustein UF, Tegetmeyer L, Ziegler V. Contact Dermatitis. 1985 Oct;13(4):252-7.

Contact dermatitis due to benzoyl peroxide. Morelli R, Lanzarini M, Vincenzi C, Reggiani M. Contact Dermatitis. 1989 Mar;20(3):238-9.

Related YouTube videos





Published: 01/30/2010
Updated: 01/30/2010

How to Diagnose Contact Dermatitis?

Author: V. Dimov, M.D., Allergist/Immunologist, Assistant Professor, University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist; Jeffrey R. Stokes, M.D., Associate Professor of Medicine, Creighton University Division of Allergy & Immunology

A 54-year-old female is referred by her dermatologist for an allergy evaluation for suspected contact dermatitis. She complains of "eczema" consisting of patches affecting both palms for the last 2 years. The rash barely responded to steroid cream and resolved completely after direct steroid injections. The lesions recurred several months later.

Past medical history (PMH)

Negative PMH.

Medications

None.

Physical examination

Stable vital signs (VSS). The patient has a red scaly patch affecting the palmar surface of the right hand, 4 x 5 cm in size. A red patch affecting the palmar surface of the left hand, 2 x 1 cm in size (after steroid injections a month ago).

What is the most likely diagnosis?

Contact dermatitis.

The patient reports that she plays golf and the lesions are in the distribution of the area where the golf pole comes in contact with the skin. She does not play golf during the winter however but the lesions persist year-round.

What type of allergy is contact dermatitis?

Type IV, delayed hypersensitivity according to ACID classification.

This is a mnemonic for Gell and Goombs classification of hypersensitivity reactions: ACID

Anaphylaxis, angioedema, asthma, type I
Cytotoxic, antibody-mediated, type II, e.g AIHA, ITP, Graves'
Immune complex disease (CIC), type III, e.g. GN, serum sickness
Delayed, cell-mediated, type IV, e.g. contact dermatitis

The etiology of contact dermatitis is either allergic contact dermatitis (20% of cases) or irritant contact dermatitis (80% of cases).

The skin reaction to poison ivy or poison oak is a classic example of allergic contact dermatitis.

How do you test for contact dermatitis?

The most established test for contact dermatitis is skin patch testing. The patient is advised to take a shower the day before the test. Two patches are placed on the back. The patient should not take a bath of the whole body until test is read 48-72 hours later.

The patient should remove the patch at home before driving to the clinic. This time period of 30-60 minutes allows the surrounding nonspecific erythema (from the patch) itself to subside. The test area should be examined again 72-96 hours later to detect any delayed skin reaction.

A commercially available kit is the thin layer rapid use epicutaneous test (T.R.U.E. Test). The T.R.U.E. test manufacture website provides useful patient information handouts on avoidance of specific contact allergens.

The patch test for contact dermatitis is expensive. The cost is $30 per potential allergen, and a 20-allergen TRUE test would cost around $160-600. The CPT code is 95044, it is paid only contact dermatitis is listed as ICD-9 code for the visit (source: http://www.aaaai.org/ask-the-expert/coding-for-the-Atopy-Patch-Test.aspx). A typical charge is in the range of $160 (professional fee of $40, facility fee $120).

People can develop contact allergic dermatitis to topical steroids, a 20-allergen T.R.U.E. test does not include steroids, the 50-test includes 3.

A patient would need a hyperadhesive tape to hold the 50-allergen T.R.U.E. test on the back for diagnosis of contact dermatitis, otherwise it peels off.

Related Reading

Guidelines for the Management of Contact Dermatitis: an Update. J. Bourke; I. Coulson; J. English. The British Journal of Dermatology, Medscape, 06/02/2009.
Allergic skin diseases. Luz S. Fonacier, MD, Stephen C. Dreskin, MD, PhD, Donald Y.M. Leung, MD, PhD. The Journal of Allergy and Clinical Immunology, Volume 125, Issue 2, Supplement 2 , Pages S138-S149, February 2010 (PDF).
Cell phone contact dermatitis due to nickel allergy. ConsultantLive.
Cellphone contact dermatitis with nickel allergy. CMAJ • January 1, 2008; 178 (1).

In people with nickel allergies, cellphones can cause an allergic reaction. NYTimes, 2010.
Contact Dermatitis: A Learning Module by AAMC http://bit.ly/A1dnc
Least-Welcome Sign of Summer - Poison Ivy - WSJ, 2010, http://goo.gl/pM6E

Patch testing to metal implants. AAAAI - Ask the Expert, 2011.

Post-Traumatic Basal Cell Carcinoma Associated With Patch Testing - with strongly positive reaction to gold. Actas Dermo-Sifiliográficas (English Edition), 2009.
Harry Potter star Daniel Radcliffe was allergic to wizard' glasses - the frames contained nickel http://goo.gl/FRRNd
Thin-Layer Rapid-Use Epicutaneous Test (patch test) misses allergens in 12.5% of patients with contact dermatitis http://goo.gl/nqUsn

Video Lectures

Contact Dermatitis. Paul Dowling, MD. Conferences Online For Allergy. Children's Mercy Hospitals & Clinics, July 11, 2008.

Questions

FIT Corner Questions. Chapter 87 of the 6th edition of Middleton’s Allergy Principles and Practice, edited by N. Franklin Adkinson, et al. January 31, 2007. Chapter 87: Contact Dermatitis.
Review Questions: Pediatric Allergy: Principles & Practices, Donald Y.M. Leung, et al., Chapter 55: Contact Dermatitis http://bit.ly/3l7fT

Published: 07/12/2008
Updated: 03/08/2012