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Allergic Contact Dermatitis (Skin Allergies)

(continued)

Treatment continued...

Diet: Some chemicals tested by the TRUE test may be present in the diet. Individuals with severe dermatitis, particularly if it is a disabling vesicular dermatitis of the hands, may be treated with diets low in minerals and chemicals to which the individual is allergic. A low-nickel diet is the most common, but published diets are available that are low in chromate, cobalt, or balsam of Peru. These diets may be attempted for the occasional allergic patient with severe chronic vesicular dermatitis.

Activity: Individuals with severe acute ACD may be incapacitated temporarily and unable to work. Most individuals with ACD may require light duties or restrictions of duties. They should avoid further contact with the chemicals to which they are allergic or chemicals that cross-react with these materials. Patients also should minimize exposure to irritant chemicals, particularly if the dermatitis is active or recently resolved. They should use mild cleansing agents on the skin, such as Aquanil, Cetaphil cleanser, or Oilatum-AD, and should apply bland protective emollients, such as SBR Lipocream, Cetaphil cream or Neutrogena hand cream, to help minimize relapse of ACD or development of irritant contact dermatitis of ceramide cream (eg, Impruv).
 

Medication

The goal of pharmacotherapy is to reduce morbidity and to prevent complications. Topical glucocorticosteroids are the mainstay of therapy. When choosing a topical glucocorticosteroid, match the potency to the location of the dermatitis and the vehicle to the morphology (ointment for dry scaling lesions; lotion or cream for weeping areas of dermatitis).

For severe acute ACD (eg, rhus dermatitis, erythroderma), systemic glucocorticosteroids or other immunosuppressive medications may be needed.

In some cases, ACD may prove persistent despite avoidance of the allergen. In some of these cases (eg, nickel), ingestion of minute amounts of the allergen is believed to drive the process, and chelation therapy with disulfiram can be beneficial. In other instances, the cause of persistence remains enigmatic; many allergens penetrate through rubber gloves. PUVA can be helpful in these cases.

For details of some of these therapies, which are by no means all inclusive, see the drug tables below.
 

Drug Category: Topical immunomodulators - These agents modify immune processes that promote inflammation.

Drug Name
 
Pimecrolimus (Elidel cream) - Indicated for eczema and atopic dermatitis. First nonsteroid cream approved in the United States for mild-to-moderate atopic dermatitis. Derived from ascomycin, a natural substance produced by fungus Streptomyces hygroscopicus var. ascomyceticus. Selectively inhibits production and release of inflammatory cytokines from activated T cells by binding to cytosolic immunophilin receptor macrophilin-12. Resulting complex inhibits phosphatase calcineurin, thus blocking T-cell activation and cytokine release.
Cutaneous atrophy was not observed in clinical trials, a potential advantage over topical corticosteroids.
Adult DoseApply topically to affected areas bid
Pediatric Dose<2 years: Not established
>2 years: Administer as in adults
ContraindicationsDocumented hypersensitivity
InteractionsNone reported
PregnancyC - Safety for use during pregnancy has not been established.
PrecautionsPotential exacerbation of existing infection at site of application; may cause burning and irritation
Drug Name
 
Tacrolimus (Protopic 1%) -- Reduces itching and inflammation by suppressing release of cytokines from T cells. Also inhibits transcription for genes that encode IL-3, IL-4, IL-5, GM-CSF, and TNF-alpha, all of which are involved in the early stages of T-cell activation. Additionally, may inhibit release of preformed mediators from skin mast cells and basophils and may down-regulate expression of FCeRI on Langerhans cells. Can be used in patients as young as 2 y. More expensive than topical corticosteroids. Available as ointment in concentrations of 0.03 and 0.1%.
Adult DoseApply thin layer to affected skin areas bid and rub in gently and completely; continue treatment for 1 wk after clearing of signs and symptoms
Pediatric Dose<2 years: Not established
2-15 years: Apply 0.03% ointment bid to affected area(s)
>15 years: Administer as adults
ContraindicationsDocumented hypersensitivity
InteractionsNone reported
PregnancyC - Safety for use during pregnancy has not been established.
PrecautionsPatients may experience burning sensation during first few days of application; skin can become photosensitive and patients should be cautioned about exposure to direct or artificial sunlight and to use sunscreen; safety and efficacy in infected atopic dermatitis not known; application under occlusion, which may promote systemic exposure, has not been evaluated (do not use with occlusive dressings); absorption following topical applications is minimal (relative to systemic administration), but tacrolimus is excreted in human milk and, thus, a decision should be made whether to discontinue nursing or to discontinue drug, taking into account importance of drug to mother (potential for serious adverse reactions in nursing infants from tacrolimus should also be a concern)

WebMD Medical Reference from eMedicineHealth

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