Best practices, new perspectives and the perfect emollient: optimizing the management of contact dermatitis.

Contact dermatitis (CD) is caused by environmental agents, irritants, and allergens that penetrate the epidermis and lead to inflammation. An intact skin barrier prevents penetration and is important in maintaining healthy skin. Classical diagnosis of CD is made using the patch test, and traditional treatment strategies for CD promote skin barrier integrity and resolve the inflammatory component of the condition. This can be achieved by using emollient-based therapy, which is most important for skin barrier repair, and in addition to topical glucocorticosteroids, which are used in severe cases of CD and are most effective in reducing inflammation. Preventative measures, such as irritant and allergen avoidance in the workplace, also play a pivotal role in effective CD management. Moreover, CD management necessitates a holistic approach that incorporates prevention, barrier repair, and inflammatory resolution to ensure optimized efficacy. It is also important to consider potential barriers to optimal management when evaluating individuals with CD, such as limited patient education or poor access to care. Finally, key literature and our own clinical practice experience have highlighted the value of patient preference, as well as safety, efficacy and simplicity, in building the perfect emollient.

Proposed ICDRG Classification of the Clinical Presentation of Contact Allergy.

The International Contact Dermatitis Research Group proposes a classification for the clinical presentation of contact allergy. The classification is based primarily on the mode of clinical presentation. The categories are direct exposure/contact dermatitis, mimicking or exacerbation of preexisting eczema, multifactorial dermatitis including allergic contact dermatitis, by proxy, mimicking angioedema, airborne contact dermatitis, photo-induced contact dermatitis, systemic contact dermatitis, noneczematous contact dermatitis, contact urticaria, protein contact dermatitis, respiratory/mucosal symptoms, oral contact dermatitis, erythroderma/exfoliative dermatitis, minor forms of presentation, and extracutaneous manifestations.

Environmental airborne contact dermatoses.

This chapter is complementary to Chapter 4 published in the same series. Airborne contact dermatitis (ABCD) is considered a prototype in the field of environmental dermatology. It is often underestimated in most textbooks of general dermatology, despite its frequent occurrence in daily life. ABCD may be irritant, allergic, phototoxic, or photoallergic. Airborne contact urticaria is another example. A particular clinical aspect is the "head and neck dermatitis", which occurs in atopic adult patients. Occupational ABCD represents a most difficult issue in terms of diagnostic procedures. It is obvious that non-occupational ABCD cases involve similar problems, usually easier to solve, and our comments refer to both conditions. Two examples of potentially airborne skin infections (e.g., anthrax and Ebola virus hemorrhagic fever) are also described because they are closely related to the same problematics. A new example of airborne irritant contact dermatitis, not reported so far, is linked with the use of continuous airway pressure in the treatment of obstructive sleep apnea.

Allergic contact dermatitis: clinical aspects.

The best way to be acquainted with the various facets of clinical lesions of allergic contact dermatitis (ACD) is to refer to the concept of the ACD syndrome. Obtaining differential diagnosis between irritant contact dermatitis and ACD based on clinical grounds is difficult. Moreover, hand eczema and photoalleregic contact dermatitis deserve special attention. The patch test remains the "gold standard" diagnostic tool, but many other very useful complementary tests have been developed in recent years.

A comparison of the irritant and allergenic properties of antiseptics.

Over recent years, interest in the use of antiseptics has been reinforced as these molecules are not concerned by the problem of bacterial resistance. Whereas the in vitro efficacy of antiseptics has been well-studied, much less is known regarding their irritant and allergenic properties. This review provides an update on the comparative irritant and allergenic properties of commonly-used antiseptics in medicine nowadays. All antiseptics have irritant properties, especially when they are misused. Povidone-iodine has an excellent profile in terms of allergenicity. Allergic contact dermatitis is uncommon but is often misdiagnosed by practitioners, who confuse allergy and irritation. Chlorhexidine has been incriminated in some cases of allergic contact dermatitis; it is considered a relatively weak allergen, although it may rarely cause immunological contact urticaria and even life-threatening anaphylaxis. Octenidine is considered a safe and efficient antiseptic when used for superficial skin infections, however, aseptic tissue necrosis and chronic inflammation have been reported following irrigation of penetrating hand wounds. Polihexanide is an uncommon contact allergen as regards irritant and/or allergic contact dermatitis but cases of anaphylaxis have been reported. Considering the data available comparing the irritant and allergenic properties of major antiseptics currently in use, it should be acknowledged that all antiseptics may induce cutaneous side-effects. The present article reviews the most recent safety data that can guide consumers' choice.

Historical perspective on the use of visual grading scales in evaluating skin irritation and sensitization.

Visual assessment of skin reactions has long been used to evaluate the safety of chemicals and preparations that contact the skin, and to meet regulatory requirements. This article reviews the history of visual grading scales, and the results of investigations into the reliability of the method. Some examples are provided to illustrate the diverse array of protocols that use visual scoring to evaluate skin irritation. Furthermore, as bioengineering methods are developed that can quantitate certain aspects of skin irritant and sensitization reactions, it is important to consider whether such measures should supplement or replace visual assessment. Examples of investigations comparing the outcomes of studies that use visual scoring and those that use bioengineering methods are discussed. These examples provide little evidence that bioengineering measures provide an improvement in overall quality in comparison with current testing methods that rely on visual assessment. In addition, such measuring techniques can add considerably to the complexity of testing protocols. When benefits and cost are weighed in the balance, the visual assessment scales popularized by Draize and others remain an effective, practical method of evaluation.

Skin tolerability associated with transdermal drug delivery systems: an overview.

As transdermal patches become more widely prescribed, it is important that clinicians understand: (a) the common causes of skin reactions with these medications; (b) how to minimize these reactions; and (c) how to manage the signs and symptoms. Here we review published data for skin reactions with patch medications approved within the past decade. Overall, the most common application site signs and symptoms appear to be localized redness (erythema) or itching, sometimes accompanied by swelling (edema). Typically, these are mild to moderate in severity, transient in nature, and occur in 20% to 50% of patients. Most are localized to the area of application, and resolve spontaneously within several days following patch removal. Discontinuations due to these types of event are infrequent, ranging from 1.7% to 6.8% in the 6-month trials reviewed here. Based on expert opinion, the majority of these skin reactions would be a form of irritant contact dermatitis, with infrequent cases of allergic contact dermatitis. These types of reactions usually cause minimal pain or discomfort to the patient, and are unlikely to be of medical concern. Signs and symptoms of irritant contact dermatitis may be minimized by rotation of the application site, careful removal of the patch, and appropriate use of moisturizers and topical corticosteroids. In conclusion, the potential advantages of transdermal patches usually outweigh any additional skin issues; however, further research into treatment and management strategies is required.

Congenital erosive and vesicular dermatosis with reticulated scarring in a newborn: an innovative treatment using a silicone dressing.

Congenital erosive and vesicular dermatosis healing with reticulated supple scarring is a rare entity presenting in the newborn with crusted erosions and vesicles that heal relatively rapidly, forming unique reticulated scars. We report the case of a premature baby 31 weeks old. Diagnosis was confirmed by skin biopsies, and the clinical improvement was excellent, with complete healing observed within 7 weeks. This report highlights clinical and histopathologic features, and a new successful treatment approach using a silicone dressing.

[Diagnosis and treatment strategies in case of suspicion of contact dermatitis]. / Stratégie diagnostique et thérapeutique devant une suspicion d'eczéma de contact.

Contact dermatitis may be either irritant, allergic or both. The differential diagnosis is based on information from the patient, nature and concentration of chemicals involved and clinical examination. In case of suspicion of allergic contact dermatitis, the search for the responsible allergen(s) is built on patch testing. Positive patch test results, the current and/or past relevance of which has to be assessed, are confirmative. Additional tests, such as the repeated open application test, are sometimes recommended. Treatment which is symptomatic, is mainly based upon corticosteroids, either local or systemic; efficacy is rather limited. By any means, it cannot be substituted to the eviction of allergens. Primary and secondary prevention are linked with the complete eviction of allergens, but this caveat can be attenuated in some circumstances.

The management of dry skin with topical emollients--recent perspectives.

Dry skin (xerosis) is a common symptom of a number of chronic skin diseases, such as atopic dermatitis, but can also be caused by environmental factors, such as cold weather and frequent showering. The condition can cause unsightliness of the skin, discomfort, itching, and can have a negative impact on patients' quality of life. This article will cover recent developments in the understanding of xerosis and its management with emollients. The stratum corneum consists of corneocytes and lipid-enriched intercellular bilayers. These are both produced from keratinocytes in a process called epidermal differentiation. Disturbed epidermal differentiation, resulting in the impairment of stratum corneum intercellular lipid bilayers and natural moisturizing factor, is the root cause of xerosis. The constituent ingredients of emollients should, therefore, address the different factors that contribute to dry skin and, most importantly, attempt to restore epidermal differentiation. The use of lipids, physiological lipids, humectants and antipruritics will help to restore the lipid lamellae, improve skin hydration, skin elasticity and prevent itching. The ideal emollient will include these ingredients plus an agent to support epidermal differentiation. Selecting the correct emollient product and using it regularly are vital factors in the management of xerosis.

Allergic contact dermatitis from povidone-iodine: a re-evaluation study.

500 consecutive patients were patch tested with a 10% povidone-iodine (PVP-I) solution, diluted 10 times in water. Readings were made at 2 and 4 days. 14 of the 500 (2.8%) showed a positive test to PVP-I. The 14 positive patients to PVP-I were subjected to a repeated open application test (ROAT) with a PVP-I solution, as is; 2 of the 14 were recorded as positive. It was concluded that only 2 of the 500 patients had true allergic contact dermatitis from PVP-I (0.4%). This study emphasizes the need for more complete investigation, when testing with some allergens, when they share both irritant and allergenic properties, such as PVP-I. The approach is important to rule out false-positive patch test reactions and to assess true clinical relevance.

High nickel release from 1- and 2-euro coins: are there practical implications?

PURPOSE: To determine the release of nickel from 1- and 2-euro coins and the ability to produce allergic contact dermatitis from the application of coins to the palmar skin of nickel-sensitized individuals. METHODS: Three experiments were conducted. Experiments 1 and 2 checked the release of nickel from 1- and 2-euro coins by using the dimethylglyoxime test. In experiment 3, the elicitation of positive reactions was checked by applying coins to the palmar skin for 48 h under occlusion in nickel-sensitized and non-sensitized individuals. RESULTS: The dimethylglyoxime test for release of nickel was positive in all cases. Positive patch test reactions to euro coins applied to the palmar skin of nickel-sensitized individuals were observed at 48 and 96 h. CONCLUSION: The results show that positive patch test reactions to euro coins can be obtained from nickel-sensitized individuals after 48 h of application to the palmar skin under occlusion. These results do not contradict other experiments in which repeated handling of coins was unable to provoke fingertip allergic contact dermatitis. A dose-response relationship is a credible explanation to support such potential discrepancies.

Drug-induced eosinophilia and multisystemic failure with positive patch-test reaction to spironolactone: DRESS syndrome.

We report the case of a 58-year-old man who suffered from a generalized and intolerable itching one month after starting treatment with colchicine, amiodarone, perindopril, allopurinol and spironolactone. From the start of treatment he had progressively developed erythroderma, fever, anorexia and prostration, oedema of both hands and face, hypereosinophilia (42%; 5810 eosinophils/mm3), hepatic failure (including cholestatic jaundice, cytolysis, coagulation abnormalities and hypoproteinaemia), exocrine pancreatic failure (with severe steatorrhoea), renal failure, metabolic acidosis, aggravation of pre-existing cardiac insufficiency and oedema of the lower extremities. All medications were stopped and the condition improved slowly until complete remission was reached 4 months later. Patch-testing was performed, including the various drugs. All the tests (including components of the vehicles) were negative, except for spironolactone, which gave a strong positive reaction. Ten controls in healthy volunteers were negative. The diagnosis of drug rash with eosinophilia and systemic symptoms (DRESS) induced by spironolactone was made. This is the first report of DRESS due to spironolactone.

[Occupational dermatitis: irritation or allergy?]. / Dermatoses professionnelles: irritation ou allergie?

Occupational dermatitis is a very frequent subject of consultation, as much in general practice as in dermatology. The most frequently found pathologies are linked to environmental factors. In these cases, irritant dermatitis and allergic contact dermatitis represent the majority of the cutaneous problems. Rigorous history taking associated with an attentive examination and a few investigations, essentially consisting of skin testing, form an incontestable tripod. The therapeutic approach, as much preventative as curative, can only be envisaged after having made a precise diagnosis, of which the conclusions should be pertinent and adapted to each patient presenting in consultation. In occupational disease, the distinction between irritant dermatitis and allergic contact dermatitis is primordial.