Allergic Contact Dermatitis (Skin Allergies)
Medical Care: The cause of ACD must be identified; otherwise, the patient is at increased risk for chronic or recurrent dermatitis. The Contact Allergan Replacement Database of the American Contact Dermatitis Society allows the physician to create a list of products free of allergens to which the patient is allergic.
- Symptomatic treatment
- Cool compresses with saline or aluminum acetate solution are helpful for acute vesicular dermatitis (eg, poison ivy).
- Some individuals with widespread vesicular dermatitis may obtain relief from lukewarm oatmeal baths.
- Sedating oral antihistamines may help diminish pruritus.
- Patients should avoid using topical antihistamines, including topical doxepin, because of the apparently high risk of iatrogenic ACD to these agents.
- Topical corticosteroids are the mainstay of treatment, with the strength of the topical corticosteroid appropriate to the body site. For severe ACD of the hands, 3-week courses of class I topical corticosteroids are required, while class 6 or class 7 topical corticosteroids typically are used for ACD of intertriginous areas.
- Acute severe ACD, such as acute severe ACD to poison ivy, often needs to be treated with a 2-week course of systemic corticosteroids. Most adults require an initial dose of 40-60 mg. The oral corticosteroid is tapered over a 2-week period, but a complicated tapering regimen probably is not necessary given the short duration of systemic corticosteroids. The systemic corticosteroids must be administered for 2 weeks, because shorter courses are notorious for allowing poison ivy dermatitis to relapse. Long-acting triamcinolone acetonide (Kenalog) 40-60 mg may be used in place of oral prednisone in these cases.
- Topical immunomodulators: Topical immunomodulators (TIMs) are approved for atopic dermatitis and are prescribed for cases of ACD when they offer safety advantages over topical corticosteroids. TIMs do not cause cutaneous atrophy or glaucoma or cataracts when applied near the eye. Pimecrolimus (Elidel cream) is a topical treatment often helpful for ACD of the face. Tacrolimus (Protopic 0.1% ointment) appears to be the most helpful TIM for ACD of the hands.
- Psoralen plus UV-A: Individuals with chronic ACD that is not controlled well by topical corticosteroids may benefit from psoralen plus UV-A (PUVA) treatments.
- Immunosuppressive agents: Rarely, chronic immunosuppressive agents, such as azathioprine (Imuran) or cyclosporine (Neoral), are used in recalcitrant cases of severe chronic widespread ACD or severe hand dermatitis that prevents the individual from working or performing daily activities. Biologicals active on T cells may be helpful in the future.
- Disulfiram: Occasionally, an individual who is highly allergic to nickel with severe vesicular hand dermatitis benefits from treatment with disulfiram (Antabuse). The chelating effect of disulfiram is helpful in reducing the body's nickel burden. Alcohol ingestion may produce severe adverse reactions in patients taking disulfiram.
Consultations: Many primary care physicians treat individuals with typical poison ivy dermatitis who respond well to a 2-week treatment course using topical or systemic corticosteroids and subsequently avoid poison ivy and related plants. Acute dermatitis that resolves with short-term treatment does not require further evaluation. Individuals with chronic dermatitis, particularly if it possibly is related to work, require detailed history and patch testing to standard screening sets and additional allergens as indicated by history, occupation, hobbies, and results on initial patch testing.