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Contact Dermatitis
Contact Dermatitis is a common skin disorder in the United States.
It is estimated that the condition results in 5.7 million physician
visits a year. Specifically, in the field of occupational illnesses,
where skin diseases account for 30% of all diseases, contact dermatitis
represents 90% of these, totaling approximately 300,000 workers
a year.
Johns Hopkins Contact Dermatitis Clinical Center, directed by Dr.
Elizabeth Whitmore, provides
comprehensive evaluation for patients suspected of having contact
dermatitis, whether the source of the culprit allergen is encountered
in the home or workplace. The goal of initial consultation is to
determine the likelihood of contact dermatitis and whether comprehensive
evaluation with patch testing is indicated.
Based on this evaluation, including a review of exposures, patients
may be patch tested with appropriate allergens.
The series available for testing include:
• North American Contact Dermatitis Research Group Screening
Series of 65 allergens
• Cosmetic Series of 50 allergens
• Fragrance Series
• Corticosteroid Steroid Series
• Sunscreen Series
• Shoe Series
• Hairdressing Series
• Acrylate Series
• Plastics Series
• Oil and Cooling Fluid Series
• Bakery Series
• Plant Series
• Glue Series
The Contact Dermatitis Clinical Center is a consultative service
only, thus, after evaluation has been completed and patients are
appropriately educated about the source and prevention of their
contact dermatitis, they are referred back to their referring dermatologist
for ongoing dermatologic care.
Referring Physicians: To access the contact dermatitis referral
form - pdf file, click
here
*All patients requesting appointments with Dr. Whitmore must have
a request for consultation from their primary care physician or
dermatologist. Contact Tracey Estep 410-955-3397 to schedule an
appointment.
The Importance of Comprehensive Patch Testing
In a very succinct editorial by Dr. Andrew Scheman( Arch Dermatology
2004; 140:1529), Dr. Sheman explains why comprehensive patch testing
is vital in the evaluation of persons with dermatitis which is recalcitrant
to therapy:
• a study by Rietschel ( J Am Acad Dermatol 1989; 21: 885)
estimated that 16% of patients with dermatitis would benefit from
patch testing
• thus, a conservative estimate of 900,000 patients per year
in the US would benefit from patch testing
• it is estimated that “ the TRUE test fully identifies
the responsible allergens in less than 1 in 5 patients”, i.e.
less than 20% of patients tested
Common Asked Questions and Interesting Pearls
1. When Should a
Possible Diagnosis of Allergic Contact Dermatitis Be Entertained?
• Anytime a diagnosis of dermatitis is entertained, be it atopic
dermatitis, irritant contact dermatitis, nummular dermatitis, or
seborrheic dermatitis, allergic contact dermatitis should be considered
as an alternative primary diagnosis or secondary diagnosis.
• Anytime a patient is being treated topically for any skin
disease and secondary eczematous changes develop, allergic contact
dermatitis may be considered as a possible secondary diagnosis.
Even in very young patients?
YES!
• 85 healthy asymptomatic children (Denver, CO area) ages 6
months to 5 years were patch tested with the 24 panel allergen T.R.U.E.
TEST
• 20 (24.5%) reacted to one or more allergens
Bruckner et al. Does Sensitization to Contact Allergens Begin in
Infancy? Pediatrics 2000;105:1.e3.
2. Can’t the causative allergen be
identified deductively without patch testing?
Prior to testing, the causative allergen is correctly pinpointed
less than half of the time:
- nickel: 80%
- rubber, fragrance, rosin: 50%
- other allergens: 10-20%
Testing is beneficial.
It is essential for accuracy in diagnosis.
Accuracy in diagnosis solves problems and saves money.
Undiagnosed or misdiagnosed contact dermatitis is taxing mentally,
physically, and financially.
3. Among patients referred to patch testing
clinics, are atops more or less likely to have positives?
• 410 patients patch tested; 46% (189) “definitely”
atopic; 44% (180) with no Hx of atopy
• Among 198 patients with relevant positives, 52% (103) were
definite atops and 41% (79) were nonatops
• This difference was not statistically significant, therefore
suggesting that atops are at least as likely as nonatops to have
ACD
Klas PA, Corey G, Storrs FJ, Chan SC, Hanifin JM. Allergic and irritant
patch test reactions in atopic disease. Contact Dermatitis. 1996;34:121.
4. What’s worse: a temporary Henna tattoo
or a pierced navel? (i.e.,“choosing your battles”)
• Most Henna tattoos contain p –phenylenediamine, the
key ingredient in almost all hair dyes in the US
• Theoretically, once sensitized, always allergic!
• Whereas coloring your hair in the teen years is “for
fun” (nonessential), it tends to be viewed by graying women
as essential
• PPD cross reactivity: p- phenylenediamine and other p-amino
compounds such as PABA ester containing sunscreens and benzocaine
may cross react with oral sulfonamide diuretics and hypoglycemic
medications, as well as saccharine.
The potential severity of p-phenylenediamine allergy due to Henna
tattoos and hair dye
is great
• 8 consecutive patient ages 12 to 15 years presenting with
hair dye reactions were evaluated
• 5 were hospitalized, 1 in the ICU (due to severe face and
neck edema)
• 6 reported a prior reaction to a temporary black tattoo 1
to 6 years earlier
• All showed positive patch tests to p-phenylenediamine and
related dyes
Sosted et al. Severe allergic hair dye reactions in 8 children.
Contact Dermatitis. 2006;54:87.
5. Back to the piercing battle…
Do I have a medical reason to tell my daughter
that she can’t have herself pierced until a year or more after
she has had her braces applied?
YES, Indeed!!!
• In a study of 1501 8th graders, the incidence of ACD to nickel
was associated with ear piercing and those girls who had braces
applied > 1 year prior to piercing had a lesser prevalence of
nickel allergy [1 in 48 (2%) vs 31 in 138(23%)]
• Also, of clinical relevance, nickel allergy was significantly
associated with hand eczema
Motrz et al. Nickel sensitization in association with ear piercing,
use of dental braces and hand eczema. Acta Derm Venereol 2002;82:359.
6. And can I tell my daughter that taking
away her cell phone is medically indicated?
• Yes, now that she has been sensitized to nickel through piercing,
she and you will become more aware of where nickel is found.
• You can share with your daughter a report of 2 patients with
dermatitis, localized to right chin in one and left cheek in the
other who were found to be allergic to nickel on patch testing and
who had resolution of facial dermatitis with avoidance of “phone
contact”.
Pazzaglia et al. Contact dermatitis in mobile phones. Contact Dermatitis
2000;42:362.
7. Dietary Ingestion of Contact Allergens
May Be the Unidentified Trigger…
In persons with allergic contact dermatitis to nickel, Balsam of
Peru, or fragrance, exacerbation of contact dermatitis and systemic
allergic contact dermatitis may occur with dietary ingestion of
these allergens. Consider recommending a trial of a low nickel or
low balsam diet (J Am Acad Dermatol 2001; 44:616; 2001; 45:377).
In honor of Dr. Alexander Fisher who always had a pertinent quote
or comment...
• The International Nickel Company, in its brochure, “The
Romance of Nickel”, states, “Nickel is with you and does
things for you from the time you get up in the morning until you
go to sleep at night.”
• yes…it may be in buttons, snaps, earrings and other
jewelry, zippers, safety pins, metal toys, magnets, eyeglass frames,
ID tags, watch bands, bracelets, doorknobs, keys, and… cell
phones
For further information and to book appointments, please contact:
S.
Elizabeth Whitmore, MD, ScM, MA
Call Tracey for referrals: (410) 955.3397
Fax: (410) 614-0635
To access the contact dermatitis referral form - pdf file, click
here
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