Detailed Notes on Contact Dermatitis: Allergic, Irritant, and Diaper

Contact Dermatitis

Contact Dermatitis: Allergic, Irritant, & Diaper

• Dr. Hanson, Dermatologist. Rash Decisions Made Here.
• Kaelen Dunican, PharmD. Office hours: virtually any time!

Allergic & Irritant Contact Dermatitis: OTC Drug Table

• Antipruritics
  • Generic: Camphor, menthol, plus moisturizers (petrolatum)
  • Brand: Sarna Anti-Itch Lotion
  • Pharmacologic category: Counterirritants
  • Dosing frequency: Apply 3-4 times per day
• Local anesthetics
  • Generic: Benzocaine, Benzyl Alcohol, Dibucaine, Pramoxine. Lidocaine, Phenol
  • Dosing frequency: Apply 3-4 times per day
• Astringents
  • Generic: Aluminum acetate (Burow’s Solution)
  • Brand: Domeboro
  • Astringent Soak for 15-30 minutes 2-4 times a day or use as a compress 4-6 times per day
• Astringent/protectant
  • Generic: Calamine
  • Dosing frequency: Apply 2-4 times per day
• Combination
  • Generic: Benzyl Alcohol 10%, Camphor 0.50%, Menthol 0.25%
  • Brand: Ivy Dry
  • Pharmacologic category: Astringent/ anesthetic, analgesic
  • Dosing frequency: Apply TID
• See “Atopic Dermatitis and Xerosis” lecture for: topical steroids (Rx &OTC), cleansers, baths, moisturizers, and antihistamines (Rx & OTC)

Objectives

• Given a case, design an appropriate, patient-specific treatment plan for managing contact dermatitis (allergic, irritant, and diaper).
• Describe and recognize the typical presentation of each type of dermatitis (allergic, irritant, and diaper).
• Differentiate between atopic (AD), allergic (ACD), and irritant (ICD) contact dermatitis.
• List the pharmacologic category, brand/generic name, and dosing frequency of medication used to treat contact dermatitis including ICD, ACD, and diaper dermatitis (see “drug tables”).
• Identify exclusions to self care of contact dermatitis (including allergic, irritant and diaper).
• Identify the most appropriate and alternate medication options based on patient-specific parameters (ex: location of the condition, patient/provider-specific requests, precautions/contraindications for use, cost of medication).
• Utilize the “fingertip method” to determine the days' supply of a prescription for a cream or an ointment.
• Differentiate between topical dosage forms and determine the most appropriate option (cream or ointment) based upon the patient case.
• List nonpharmacologic strategies for ACD, ICD, and diaper dermatitis.
• Describe prevention strategies for each condition.
• Discuss counseling points for medications for contact dermatitis.
• Describe appropriate application/administration of medication.
• List treatment expectations – onset and duration of action, dosing, and common side effects.

Contact Dermatitis

• Skin disorder characterized by inflammation, redness, and often vesicle and pustule formation.
• Symptoms: pruritus, burning, and stinging

Irritant Contact Dermatitis (ICD)

• Inflammatory skin reaction caused by exposure to an irritant.

Allergic Contact Dermatitis (ACD)

• An immunologic skin reaction elicited by an antigen-formed response in response to contact with an allergic substance.

Irritant Contact Dermatitis (ICD)

• May take minutes to hours to appear.
• Chemical irritants are more likely to produce immediate and severe inflammatory reaction.
• Mild irritants (detergents and solvents) may only cause reaction after repeated exposure.
• Cause:
  • Severe (immediate reaction): chemical, alkalis, & acids,
  • Mild (repeated exposure): solvents, soaps, detergents.
• Direct tissue damage.

Allergic Contact Dermatitis (ACD)

• May take days to appear.
• Cause:
  • Plants: Poison ivy, sumac, or oak, primrose, tulips
  • Nickel
  • Bacitracin, benzocaine, neomycin
  • Latex
  • Lanolin
• Immune reaction.

Delayed hypersensitivity reaction:

• Develops after the person has been exposed and previously sensitized to that allergen (doesn’t usually occur with first contact).
• After previously sensitized, the rash will typically appear within 24-48 hours after exposure.

Poison Ivy: Fact or Fiction…

• Poison ivy is transmitted via weeping vesicles. (FALSE)
• It is essential to differentiate poison oak from poison ivy in order to adequately manage these types of contact dermatitis. (FALSE)
• Pets can spread poison ivy. (TRUE)
• Urushiol oil can remain on garden tools for over a year. (TRUE)

Allergic Contact Dermatitis: Poison Ivy

• Occurs at the area of contact.
• Typically a linear presentation, but the oil is often spread when scratching.
• Lesion: papules, small vesicles
• Skin: red, inflamed, and swollen
• Oozing vesicles may form crust
• Prolonged itching may result in lichenification.
• Symptoms (itching, burning, stinging) begin within a few hours up to 24-48 hours after contact.
• Rash does NOT spread but may appear to do so because urushiol is absorbed at different rates.

Exclusions to Self-Care

• P&P: Prevent and Protect. STAT = Immediately, SOON = not defined in transcript.

Exclusions to Self-Care

Non-Pharmacologic Treatment with Referral

Nonprescription Medicine Treatment with Referral

Topical hydrocortisone

• Strengths available OTC? - not defined in the transcript.
• Role in contact dermatitis is to reduce itch and inflammation.
• Dosage form:
  • Cream is preferred during the acute phase when still weeping (ointment may trap bacteria and lead to a secondary infection).
  • Spray may be preferred because no touch required (propellant may be an irritant for some).
  • Gel may have alcohol = drying effect.
  • May use ointment once dries out and gets more lichenified
• Apply BID (up to 4 times daily) for up to 7 days for self-treatment of ACD. BID for steroids-weak cream preferred caring.

Astringents

• Role in contact dermatitis: to dry out the ooze, also helps with inflammation.
• Apply up to 6 times per day until the area dries out.
• Calamine may cake up (also works as a protectant).

Aluminum acetate

• Primary role is to “dry” also has a mild antipruritic effect.
• Will also help to soften/remove any crusting.
• Package contains powder packets – prepare by adding to 1 pint of cool water (1:40 dilution).
• Soak for 15 minutes 3-4 times per day or use as a wet compress for 20-30 minutes 4-6 times per day.

Aluminum acetate - Directions

Mix one, two, or three packets in 16 oz of water to obtain the following modified Burow's Solution:

• Do not strain or filter the solution.
• Can be used as a compress, wet dressing, or a soak.
• For use as a compress or wet dressing:
  • Soak a clean, soft cloth in the solution.
  • Apply cloth loosely to affected area for 15 to 30 minutes.
  • Repeat as needed or as directed by a doctor.
  • Discard solution after each use.
• For use as a soak:
  • Soak the affected area for 15 to 30 minutes as needed, or as directed by a doctor.
  • Repeat 3 times a day or as directed by a doctor.
  • Discard solution after each use.

Antipruritics & antihistamines

• Oatmeal bath:
  • Role in contact dermatitis: helps with the itch, leaves a protectant film.
  • Use only AFTER removing all oil from the skin.
• Antihistamines:
  • Role of topical antihistamines: not routinely recommended.
  • Role of oral antihistamines: sedating effect may be helpful.
  • Which generation? - Not specified in transcript.

Anesthetics

• Anesthetics: benzocaine, benzyl alcohol, dibucaine, pramoxine, lidocaine, phenol.
• Role in contact dermatitis: questionable role because sensitizing but may help with itch.
• Avoid use on open lesions and tender, inflamed tissues, may cause local burning and irritation.
• ADR’s: Many can cause allergic contact dermatitis
• Pramoxine and benzyl alcohol = less cross-reactivity and less incidence of ADRs.

Rx Options

• Prescription options for severe poison ivy (see exclusion table) or if causes bacterial infection.
  • Large BSA
  • Face involvement
  • Genital involvement
• Prescription options:
  • Topical Steroids
  • Oral Steroids (prednisone, methylprednisolone)
  • Antihistamines (hydroxyzine HCL or hydroxyzine pamoate)
  • Antibiotics if evidence of a secondary infection

Preventing poison ivy

• Prior to exposure:

  • Bentoquatam – provides a barrier
  • IvyBlock / generics

• After exposure:

  • Wash the area within 10 minutes (up to 30 minutes) or flush with lots of water
  • Tecnu Outdoor Skin Cleanser
    • Apply AFTER exposure and rubbed into the affected area for a minimum of 2 minutes
    • Use ASAP but may be used up to 8 hours after exposure
    • No water necessary for initial cleansing but should be wiped or washed off later
    • Advantage over soap and water?

• Zanafel

  • $$$ (as of 6/2021=$30-$40)
  • Measure 1&½” into palm, wet both hands and rub into a paste then rub onto area for up to 3 minutes until no sign of itching then rinse. Repeat if itching returns.

• Dial Ultra dishwashing soap and Goop grease remover have also shown evidence of efficacy in removing the oil end.

Prevention and protection

• Avoid exposure
• Wear protective clothing
• Wash affected area ASAP: Shower is preferred over bath
• Wash anything that may have been exposed to oil including:
  • Tools / equipment
  • Clothing
  • Pets
• Avoid washing with alcohol to prevent further spread

Non-pharmacologic Recommendations

• Education on prevention strategies
• Non-pharm – relief of itching
  • Cut fingernails/ use brush to remove oil
  • Shower
  • Temperature – cool water may be more soothing
  • Use mild soap
  • Once oil is removed can take bath: Cold - Cool - Lukewarm/tepid - Warm - Hot

Practice case: “How did I get poison ivy again!”

• DA is a 28-year-old man seeking a recommendation for poison ivy. Upon inspection, the linear lesion appears red with oozing vesicles with some crusting; DA complains that the lesions are not only itchy, they are painful and burn. DA is frustrated because he had a terrible case of poison ivy last year so he used a weed killer to get rid of all the poison ivy in his yard. But somehow, when he started doing yard work again this year (yesterday), he got it again!

UPON FURTHER QUESTIONING… patient states the itching is most problematic, he wants a cream he can apply to help control the itching.

Which is the MOST appropriate recommendation?
A. Aveeno B. Calamine C. Cortizone D. Domeboro E. Sarna - not specified in transcript.

• Patient wants a bath he can soak in to soothe the irritation - not specified in transcript.
• Patient wants a product that will dry the ooze- not specified in transcript.
• Patient wants a product that will cool the burning sensation- not specified in transcript.

*Agent (brand, generic, route of administration & frequency) - Treatment expectations - Key counseling points - When to follow up: - not specified in transcript.

Irritant Contact Dermatitis (ICD)

Typical patient:

• Wash their hands frequently, handle food, and/or have repeated contact with skin irritants (chemicals)
• More common from occupational settings (common examples: hairstylist, restaurant workers, and custodial staff).
  Release of pro- inflammatory cytokines that produce inflammation & skin changes - Stimulation of epidermal cells - Disruption of skin barrier

Clinical Presentation

• Occurs at the site of contact – hands, forearms
• After exposure to irritant skin becomes inflamed, swells, and turns erythematous
• Symptoms include itching, stinging, and burning
• Skin appears dry or macerated, painful, cracked, and inflamed
• Lesions: bullae, pustules, or coalescing vesicles confined to the site of contact; lesions may crust within days
• If chronically exposed skin will remain inflamed and may develop fissures and scales and become hyper or hypopigmented may lead to lichenification

Treatment and prevention of ICD

Treatment:

• First remove offending agent – wash with lots of water and use a mild cleanser like Cetaphil
• Keep moisturized and protected – petrolatum
• Oatmeal may be helpful to soothe and relieve itch
• Avoid:
  • Hydrocortisone is unlikely to be helpful
  • Topical anesthetics and topical antihistamines may cause further irritation
    Prevention
• Wear protective gloves/ clothing
• Application of barrier creams

Name that Drug!

• This drug is a VERY HIGH potency topical steroid.
  • Clobetasol
• This drug is a LOW potency topical steroid.
  • Hydrocortisone
• This drug is used to DRY weeping poison ivy.
  • Domeboro
• This drug would be best for nocturnal pruritus.
  • Hydroxyzine
• This drug has a BBW for increased all cause mortality.
  • Pimecrolimus
• This drug is administered SubQ.
  • Dupixent

DIAPER DERMATITIS

NONPRESCRIPTION PRODUCTS

• Be familiar with these – no need to memorize all ingredients!

DIAPER DERMATITIS

• Diaper rash is a form of irritant contact dermatitis
• Patient: Infants and toddlers who wear diapers. Can also occur with older adults.
• Occurs where skin is in contact with the diaper: Perineum, buttocks, lower abdomen, and inner thighs
• Incidence has declined due to disposable diapers and improved diaper technology

moisture- Microbes More alkaline pH- Mechanical irritation- Proteolytic enzymes & bile salts from GI- Thinness of skin in diaper area ==WHAT CAUSES OF DIAPER RASH?

TYPICAL PRESENTATION

• Symptoms: Red, shiny, wet-looking
• Characteristics / onset: Can occur within an hour of urination / defecation
• Location: should be confined to diaper area but may be more in the front/back depending on positioning

AGGRAVATING & REMITTING FACTORS

• Aggravating:
  • Infrequent diaper changes
  • Type of diaper: Cloth diapers vs disposable
  • Wipes: some have irritating fragrances
  • Medication and food that affect motility or microbial flora (antibiotics)
• Remitting:
  • Keep as dry as possible
  • Wipes?
  • ↓friction
  • Breastfeeding

EXCLUSIONS TO SELF-CARE

EXCLUSIONS TO SELF-CARE

NONPRESCRIPTION MEDICINE TREATMENT WITH REFERRAL

ABCDE Mnemonic for Diaper Rash Treatment

• Air: Allow diaper area skin to air dry frequently; allow diaper-free time
• Barrier: Apply a barrier skin protectant liberally to the diaper area with each diaper change to prevent and treat diaper dermatitis
• Cleaning: Gently cleanse the diaper area with a soft cloth and warm water or with a baby wipe when stool is present
• Diaper: Change the diaper frequently (every 2 hours) and as soon as it is soiled, if possible. Use absorbent disposable diapers if possible.
• Education: Educate parents/caregivers about nonpharmacologic diaper hygiene practices and pharmacotherapy

TREATMENT & PREVENTION SKIN PROTECTANTS

Mechanism of action:

• Physical barrier between the skin and external irritants
• Serve as a lubricant in areas where skin-to-skin or skin-to-diaper friction could aggravate or predispose the area to the development of diaper dermatitis
• Absorb moisture or prevent moisture from coming into direct contact with skin
• Allow skin to heal
• Are effective to TREAT and PREVENT
• Apply with every diaper change – cannot be overused!

SKIN PROTECTANTS

• Allantoin
• Aluminum hydroxide
• Calamine
• Cocoa butter
• Cod liver oil (in combination)
• Colloidal oatmeal
• Dimethicone
• Glycerin
• Hard fat
• Kaolin
• Lanolin
• Mineral oil
• Petrolatum
• Topical cornstarch
• White petrolatum
• Talc
• Zinc carbonate
• Zinc oxide
  Diaper rash products can NOT contain: antimicrobials, topical analgesics, hydrocortisone, or antifungals

WHAT IS THE ROLE OF EACH INGREDIENT?

PRACTICE CASE: “MY BABY’S BOTTOM IS SO SENSITIVE!”

• LK is a 4-month-old boy with a red bottom. His mother states that if she doesn’t catch his dirty diaper “in time” his “bum gets all red.”

WHAT WOULD YOU RECOMMEND FOR LK’S DIAPER RASH?

• Agent (brand, generic & frequency)
• Treatment expectations
• Key counseling points
• When to follow up