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CHAPTER 17 BURNING AND STINGING SKIN
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CHAPTER 18 Contact Dermatitis (Type 4 Sensitive Skin)
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OVERVIEW OF CONTACT DERMATITIS
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Contact dermatitis is an umbrella expression for a group of dermatoses that are initiated by the pivotal event of the epidermis coming into contact with a triggering chemical For practical purposes, there are three main clinical forms: (1) irritant contact dermatitis (ICD); (2) contact urticaria (CU); and (3) allergic contact dermatitis (ACD) Approximately 80% of contact dermatitis cases are identified as ICD, because ICD represents a nonspecific inflammatory response to a chemical when the skin barrier function is impaired Wet work (immersing in detergents, water, or other activities that require frequent hand washing) predisposes an individual to these irritant-type reactions because of disruptions in skin barrier function (see 11) Irritancy can also occur after chronic exposure to an environment with low humidity,1 or chronic exposure to saliva (lip smacking), urine, or feces Another example of an inducible ICD is epidermal keratinocyte damage following a cosmetic peel (Fig 18-1) At the other end of the spectrum is CU, which accounts for approximately 05% of the contact dermatitides This type of reaction is IgE-mediated and represents an immediate-type hypersensitivity response Clinically, CU manifests classic wheals and flares (hives); with extreme cases the clinical symptoms may progress to severe respiratory compromise, anaphylaxis, and death A primary example is latex hypersensitivity The pathophysiology of ACD is remarkably different from the other types of contact dermatitis Like CU, ACD is an immunologic reaction; however, unlike CU, ACD is a consequence of lymphocyte activation (a T-cell mediated Type IV delayed-type hypersensitivity [DTH] reaction) To assist with the visualization of the sensitization process, it can be useful to consider the triggering of ACD as similar to serial vaccination, although scientifically it is important to note that they are different immunologic
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COSMETIC DERMATOLOGY: PRINCIPLES AND PRACTICE
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FIGURE 18-1 Glycolic acid is an irritant that can result in keratinolysis In this gure, pink tender plaques occurred on the cheeks 1 day after a 30% glycolic acid peel processes That is, with each subsequent dose of a chemical the ability to remember that chemical for future interactions becomes more likely For example, with the hepatitis B vaccine, three shots are required for establishing long-lasting and effective immunity, or memory of that chemical; conversely, a tetanus vaccine must be boosted to guarantee memory Like the tetanus, the more potent chemicals may only require a single dose, such as poison ivy In most cases of ACD, however, the shots are mini-doses that taken sequentially over a given period of time result in the individual being sensitized to that chemical routinely exposed These chemicals usually have a molecular weight less than 500 Da allowing them to penetrate the skin or mucous membranes and activate an immunologic cascade2,3 Subsequent to entry into the skin these chemicals are taken up by epidermal immunologic cells (Langerhans cells) and further processed for presentation to na ve T lymphocytes This process of chemical capture and presentation is known as the induction phase of sensitization With induction there is clonal expansion of memory T cells, each inheriting the capability to mount an immune response upon reexposure to the allergenic chemical Upon reexposure, or challenge, the elicitation phase of sensitization ensues, which involves a complex interplay between immune cells (ie, Langerhans, lymphocytes, and keratinocytes) Each cell releases its respective cytokine repertoire leading
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STEPS LEADING TO ALLERGIC CONTACT DERMATITIS
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The chemicals likely to elicit an ACD are generally small lipophilic compounds to which an individual is
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to the clinical picture of ACD It is important to note that while the initial sensitization process may take up to 21 days, subsequent reexposure of the sensitized individual may result in a rechallenge reaction within 48 to 120 hours2 For the most part, primary allergic contact type lesions present in the distribution of allergen epidermal contact, which ultimately provides a very important diagnostic clue as to the identity of the culprit chemical allergen There is a notable exception to this rule, however the recall reaction In the recall reaction, sites of previous sensitization may be remotely activated when contact with the chemical is initiated at a distant site The confounding factors of delay and recall pose a unique challenge in the diagnosis of ACD For example, one might not suspect the sensitizing role of the hair dye paraphenylenediamine when a patient develops a subsequent reaction to an ester-based topical anesthetic (both are para-aminobenzoic acid derivatives)4 (Fig 18-2)
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CHAPTER 18 CONTACT DERMATITIS (TYPE 4 SENSITIVE SKIN)
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