Contact dermatitis

Contact dermatitis: Signs and symptoms

When to seek immediate medical care

A few people develop a severe allergic reaction known as anaphylaxis (an-uh-fuh-lax-sis). Symptoms occur within seconds or minutes. A person may have:

• Difficulty breathing due to swelling in the throat
• Swollen face and/or eyes
• Confusion

In short, the entire body reacts. If you have any of these symptoms, you need immediate medical care.

Allergic contact dermatitis

This skin condition occurs when you have an allergic reaction to something that comes in contact with your skin.

Signs and symptoms rarely appear on contact. It may take a few hours for your skin to react. If this is your first time that your skin has an allergic reaction to that substance, weeks may pass before you notice anything.

When signs and symptoms appear, you may have:

• Itchy skin (often intense)
• Rash (skin red, swollen, and hot)
• Excessively dry skin
• Burning 
• Stinging
• Hives (round welts on the skin that itch intensely)
• Fluid-filled blisters
• Oozing blisters that leave crusts and scales

If exposure to the allergen continues, your skin may:

• Flake and crack
• Become scaly
• Darken, thicken, and feel leathery

Irritant contact dermatitis

Many substances can irritate our skin. Soap, shampoo, food, and water are mild irritants. With lots of exposure, these can cause irritant contact dermatitis. Getting a strong irritant like battery acid or fiberglass on your skin just once also can cause irritant contact dermatitis.

The signs and symptoms differ for mild and strong irritants. 

Mild irritant: The signs and symptoms develop over time. You’ll gradually notice:

• Dry, chapped skin. 
• With repeat exposure, patches of itchy, red, swollen, and scaly skin develop. By this time, each time something that can irritate the skin touches the affected skin, you may feel stinging and burning right away.
• If exposure continues, the skin may crack, get scaly, and become excessive dry. 
• Sores and blisters may develop and erupt, causing crusts and scales.

Strong irritant: On contact or within a few hours, the skin can:

• Burn, sting, and/or itch
• Become inflamed (red and swollen) 
• Develop fluid-filled blisters 

When you have irritant contact dermatitis, many things can irritate your skin. You may feel pain on contact. With repeat exposure, the condition worsens.

Reduced quality of life

This skin condition often affects a person’s quality of life. The rash can make many daily activities painful, especially when the rash forms on the hands. The rash can cause:

• Missed work days
• Inability to enjoy leisure activities
• Loss of sleep

Images used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides.

References:
Kadyk DL, McCarter K. “Quality of life in patients with allergic contact dermatitis.” J Am Acad Dermatol. 2003;49:1037-48.
Lewin Group (prepared for the Society for Investigative Dermatology and the American Academy of Dermatology Association). “The Burden of Skin Diseases.” 2005. p. 37-40.
Wentworth AB, Yiannias JA, et at. “Trends in patch testing,” J Am Acad Dermatol. 2014;70:269-75.

Contact dermatitis: Who gets and causes

Who gets contact dermatitis?

Anyone can develop contact dermatitis. People working in certain professions have a higher risk. In fact, this is so common that your doctor may tell you that you have occupational dermatitis.

People who are more likely to get occupational dermatitis include:

• Nurses (and other health care workers)
• Beauticians
• Bartenders 
• Chefs (and others who work with food)
• Florists (and others who work with plants)
• Construction workers
• Janitors
• Mechanics
• Plumbers

Nurses and beauticians often develop dry, cracked skin on their palms and fingers. Wearing latex gloves frequently throughout the day causes some people to develop an allergy to latex. A common sign of this allergy is itchy, inflamed hands. 

You also have a greater risk of developing contact dermatitis if you have (or had) one of these medical conditions:

• Asthma
• Hay fever
• Atopic dermatitis (often called eczema)

Your environment also plays a role. Extreme heat or cold, high humidity, and very dry air make the skin more vulnerable.

What causes contact dermatitis?

A person develops contact dermatitis when something that touches the skin does one of the following:

• Irritates the skin 
• Causes an allergic reaction

When the skin is irritated, a person develops irritant contact dermatitis. Anyone can develop this type of contact dermatitis. It happens when something damages the outer layers of skin.

Almost any chemical, including water, can damage the skin with enough contact. Toxic substances like fiberglass and turpentine quickly damage the skin. Many people develop irritant contact dermatitis when they work with hair dyes, solvents, oils, paints, varnishes, foods, or metalworking fluids.

An allergic reaction causes allergic contact dermatitis. People develop allergic reactions to many substances. Some of the most common causes of allergic contact dermatitis are:

• Poison ivy
• Nickel (used in cell phones, jewelry, eyeglass frames, zippers, belt buckles)
• Nail cosmetics: Nail polish, adhesives
• Fragrances
• Latex
• Cement

Many people touch a substance for years before an allergy develops.

Sometimes a trigger is needed for an allergic reaction to occur. Allergic contact dermatitis may only occur when the skin:

• Sweats
• Has ultraviolet rays (sun, tanning bed) hit it

More than 3,600 substances can cause allergic contact dermatitis. These substances include preservatives in cosmetics, antibiotics applied to the skin, animal dander, dyes in clothing and shoes, and rubber.

With thousands of causes, successfully treating this skin condition can take a bit of detective work. Dermatologists frequently treat this condition. In fact, this is one of the most common reasons to see a dermatologist.

Images 1,3,4,5,7,8,9, and 10 used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides

References:
American Academy of Dermatology 

• “Contact dermatitis.” Medical Student Core Curriculum. Last update July 2011.
• “Musicians at risk for common skin condition.” News release issued March 16, 2012. 

Cohen DE et al. “Contact and Occupational Dermatology.” Presented as a course at: The 63rd Annual Meeting of the American Academy of Dermatology. February 2005; New Orleans.
Kadyk DL, McCarter K. “Quality of life in patients with allergic contact dermatitis.” J Am Acad Dermatol. 2003;49:1037-48.
The Lewin Group (prepared for the Society for Investigative Dermatology and the American Academy of Dermatology Association). “The Burden of Skin Diseases.” 2005. p. 37-40.
Kockentiet B, Adams BB. “Contact dermatitis in athletes.” J Am Acad Dermatol. 2007;56:1048-55.
Saary J, Qureshi R. “A systematic review of contact dermatitis treatment and prevention.” J Am Acad Dermatol. 2005;53:845-55.
Zug KA et al. “Contact and Occupational Dermatitis.” Presented as a symposium at: The 64th Annual Meeting of the American Academy of Dermatology. March 2006; San Francisco.

Contact dermatitis: Diagnosis and treatment

How dermatologists diagnose contact dermatitis

To diagnose this common skin condition, dermatologists:

• Examine your skin, paying close attention to the rash.
• Ask about current and past health issues.
• Ask questions to help them determine what is causing the rash.

Finding the cause can require a bit of detective work. Your dermatologist may ask you questions about your work, free time, pets, and skin care products. Be sure to tell your dermatologist about all cosmetics you use. If you or a close family member uses a skin lightener, be sure to mention this, too.

If your dermatologist suspects that you have an allergy, patch testing may be recommended. This offers patients a safe and effective way to find out if your skin has developed an allergic reaction to anything.

What happens during patch testing?

If patch testing is recommended, the following will happen:

1. Patches containing small amounts of substances to which you may be allergic will be applied to your skin, usually on your back.
2. You keep the substances on your skin for a specific amount of time, usually 2 days. 
3. You return to your doctor’s office so that the doctor can check your skin for reactions. 
4. You may need to keep some patches on your skin for a longer time and see your doctor again in a few days.

To find out if the allergen is causing your rash, you will need to avoid that substance. For example, if the test shows that you have a nickel allergy, you may need to:

• Stop wearing jewelry and clothing (zippers, fasteners) that contains nickel.
• Cover your cell phone with a case to avoid touching the metal.
• Get a pair of eyeglasses made without nickel. 

If your skin clears when you avoid the allergen, it is likely the cause of your rash.

How dermatologist treat contact dermatitis

Treatment is the same for both types of contact dermatitis.

Avoid what is causing your rash. If avoiding the cause will be difficult, ask your dermatologist for help. 

For example, if you are allergic to latex but must wear exam gloves, your dermatologist can recommend another type of glove that you can wear. If you must work outdoors where poison ivy grows, your dermatologist can recommend a protective barrier cream and clothing that can help.

Treat the rash. Once you can avoid the cause, your rash should clear. To relieve your symptoms, a dermatologist may recommend the following:

• Mild reaction: Antihistamine pills, moisturizer, and a corticosteroid that you can apply to your skin. Most patients apply the medicine twice a day for 1 week and once a day for 1 to 2 weeks.
  
  Oatmeal baths can relieve discomfort.
   
• Severe reaction: If you have a lot of swelling, your face swells, or the rash covers much of your body, you may need a strong medication. Your dermatologist may prescribe prednisone. It is important to take this medication exactly as directed to avoid another flare.
  
  Wet dressings can help soothe skin that has lots of oozing and crusting. If your dermatologist recommends wet dressings, you’ll receive instructions to help you make these at home. 

If you have an infection, your dermatologist may prescribe an antibiotic. 

Some patients need light therapy to calm their immune system. Your dermatologist may refer to this as phototherapy. 

If you avoid what caused the rash, your skin will clear. Most people see clear skin within 1 to 3 weeks.

Clearing may take longer if poison ivy, poison oak, or poison sumac caused your rash. The first time you have an allergic reaction to one of these plants, the rash may linger for 6 weeks. If you get another rash, your skin should clear within 10 to 21 days.

Once your skin clears, you must continue to avoid what caused your rash. 

If your rash does not clear, you should tell your dermatologist. You may need extra help.

Systemic contact dermatitis

Some people develop a rash even when they avoid touching the allergen. A rash can appear when the substance to which you have an allergy gets inside your body. The medical term for this condition is systemic contact dermatitis. 

The allergen can get inside your body in different ways. You could:

• Eat food that contains the allergen
• Inhale or inject a medicine that contains the allergen
• Use birth control (IUD or spermicide) that contains the allergen

While rare, some people develop a rash because the fillings in their mouth contain mercury. They could only get rid of the rash when a dentist replaced their fillings with fillings that did not contain mercury.

Trying to find everything that contains the allergen can be a challenge. Your dermatologist may be able to help you create a list of things you need to avoid. The list often varies from region to region.

Outcome for patients with contact dermatitis

By avoiding what caused the rash, most people can avoid flare-ups. 

If you work with substances that caused the rash, you can still avoid a rash. Your dermatologist can recommend ways to work and products to use. More than 80% of people diagnosed with occupational dermatitis successfully manage the condition and recover without any problems.

Image used with permission of Journal of the American Academy of Dermatology: 2010; 62:1064-5. 

References:
American Academy of Dermatology. ”Contact dermatitis.” Medical Student Core Curriculum. Last update July 2011.
Hamann CR, Boonchai W. “Spectrometric analysis of mercury content in 549 skin-lightening products: is mercury toxicity a hidden global health hazard?” J Am Acad Dermatol. 2014;70:281-7.
Katta R, Schlichte M. “Diet and dermatitis: Food triggers.” J Clin Aesthet Dermatol. March 2014;30-36.
Nguyen JC, Chesnut G, et al. “Allergic contact dermatitis caused by lanolin (wool) alcohol contained in an emollient in three postsurgical patients.” J Am Acad Dermatol. 2010;62:1064-5.
Saary J, Qureshi R. “A systematic review of contact dermatitis treatment and prevention.” J Am Acad Dermatol. 2005;53:845-55.
Salam TN, Fowler JF. “Balsam-related systemic contact dermatitis.” J Am Acad Dermatol. 2001;45:377-81.
Warshaw EM, Buchholz HJ et al. “Allergic patch test reactions associated with cosmetics: retrospective analysis of cross-sectional data from the North American Contact Dermatitis Group, 2001-2004.” J Am Acad Dermatol. 2009 Jan;60:23-38
Wentworth AB, Yiannias JA, et at. “Trends in patch testing,” J Am Acad Dermatol. 2014;70:269-75.

Contact dermatitis: Tips for managing

Sometimes you can get rid of a rash yourself. These dermatologists’ tips can help you find the cause.

Once you know what’s causing your rash, avoiding it often clears the rash.

To help you find the cause, follow these steps: 

1. Ask yourself the questions on this page (below) that are relevant. 
2. If you answered yes to a question, stop using/wearing what you think caused the rash. 
3. If the rash begins to clear, you may have found the culprit. If the rash worsens or remains for 2 weeks, make an appointment to see a dermatologist. You’ll need help to get rid of the rash.

Rash beneath jewelry, shoes, or clothing

If a rash develops where jewelry, shoes, gloves or other clothing, a zipper, a buckle, or a fastener touches your skin:

• Stop wearing the item for a few days. 

If the rash begins to clear when you stop wearing the item, you may have an allergy to a metal, dye, or fabric finisher.

Some people develop an allergy to jewelry that they’ve worn for years. The cause is often nickel, a metal found in many pieces of jewelry. A wedding ring can cause this problem. In fact, this rash is so common that it has a name, wedding-ring dermatitis. 

If this happens, ask your dermatologist for tips to prevent getting a rash from your wedding ring.

Rash on face

It can be a challenge to find the cause of this rash, but you can start by answering the following questions:

• Have you recently tried a new makeup, eye cream, or fragrance?
  Some people are allergic to ingredients in these products.
• Do you use an eyelash curler or tweezers? 
  These items often contain nickel, which is a common cause of allergic contact dermatitis. Brief direct contact with an eyelash curler or tweezers can cause an allergic skin reaction.
• Do you rub your eyes?
  If you find yourself rubbing your eyes, try to stop. Indirect contact with an allergen can cause a rash on your face. Even nickel used in a doorknob or keys can end up on your face when you rub your eyes. 
• Do you wear nail polish or artificial nails?
  These products can cause a rash when you touch your face. Even when you don’t develop a rash on your hands, the skin on your face can react. 
• Has a fragrance touched your skin?
  Directly applying a fragrance can cause a rash. You can also get a rash from indirect contact. Touching a a towel or pillow that has a fragrance on it could cause a rash.

Rash on side of face, neck, hairline, or chest

You can often find the cause of a rash in one of these areas by asking yourself these questions:

• Do you hold your cell phone against your face?
  A rash that appears on one side of the face may indicate that you have an allergy to nickel or chromium. Some cell phones contain one of these metals. You also could have an allergy to something in the case you use for your cell phone. 
• Have you recently switched shampoo or conditioner?
  If you are allergic to an ingredient in a shampoo or conditioner, a rash can appear where the product runs down your body when you rinse. 
• Have you recently used a hair dye or perm solution?
  These can cause a rash. 

Rash after hiking or being in a wooded area

If you were in a wooded area, you may have touched poison ivy, poison oak, or poison sumac without knowing it. Poison ivy is one of the most common causes of allergic contact dermatitis.

Rash from musical instrument

Metals in musical instruments, such as nickel, cobalt, palladium, silver, and gold, can cause a rash. So too can cane reeds and exotic woods. Stains, glues, and varnishes also cause contact dermatitis.

Dermatologists recommend the following to people who get a rash from playing a musical instrument:

1. Stop playing the instrument while your skin heals. 
2. See a dermatologist. You may need medication to treat the rash. Patch testing also can be very helpful. This medical test helps to find allergens. It is important to know if you have an allergy to something in the instrument that you play.
3. Once the cause is found, your dermatologist can help you make some changes so that you can play again.

When to see a dermatologist

You’ll want to make an appointment If you have a rash that:

• Is severe (raw skin, blisters, oozing, or intense itch).
• Does not clear in a few weeks.
• Comes and goes.
• Is caused by something in your workplace.

Sometimes we can find one cause but miss others. For example, many people develop an allergy to nickel. This metal is so common that it may be in your wedding ring and dozens of products that you regularly use.

A dermatologist can help you find out if you have any allergies. If you have an allergy, your dermatologist can create a plan to help you avoid things that cause your rash.

Many dermatologists use databases that can tell them what products you should avoid if you have an allergy and what products you can use. This alone could save you lots of time and money.

References:
American Academy of Dermatology:

• “Contact dermatitis.” Medical Student Core Curriculum. Last update July 2011.
• “Musicians at risk for common skin condition.” News release issued March 16, 2012. 
• “Saving face: Dermatologists helping patients identify source of facial allergic contact dermatitis.” News release issued August 1, 2013.

Ehrlich A. “Fragrance Allergy.” Presented as a focus session at: The American Academy of Dermatology’s ACADEMY ’06 Summer Meeting. July 2006; San Diego.
Saary J, Qureshi R. “A systematic review of contact dermatitis treatment and prevention.” J Am Acad Dermatol. 2005;53:845-55.

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