Pediatric Contact Dermatitis Clinical Presentation
- Author: Nanette B Silverberg, MD; Chief Editor: Dirk M Elston, MD more...
When contact dermatitis is suspected, the history must include a detailed list of environmental exposures. Determine whether the patient has had any exposure to materials such as plants, paints, dyes, cleaning solutions, soaps, and protective gear such as eyewear and athletic gloves. Ask whether any new products or plants are present in the home or during recreational activities.
Query patients regarding hobbies that might be the source of an irritant or allergen. Determine whether the patient is applying any products or treatments to the involved area. If the lesions or symptoms appear to be primarily in exposed areas, determine how much sun exposure has occurred recently. Ask the patient if symptoms improve over weekends or vacations.
A detailed history may help determine whether the patient has irritant, allergic, or photo contact dermatitis or contact urticaria. The history should include the following questions:
What is the chief symptom? Irritant contact dermatitis, which is the most common form of contact dermatitis, usually causes mild pruritus or a burning sensation. Allergic contact dermatitis and contact urticaria are usually very pruritic. Pruritus is the main symptom in photoallergic reactions, whereas a burning sensation on affected (ie, sun-exposed) areas of the body is the primary symptom of phototoxic reactions.
When did the symptoms start? If a suspected substance is recognized, how long prior to the symptoms did the exposure occur? With irritant contact dermatitis, symptoms may occur within minutes of the exposure. Mild irritants require prolonged or repeated exposure before inflammation is noted, while strong irritants, such as strong acids and alkalis, can produce an immediate reaction similar to a thermal burn.
Allergic (type IV hypersensitivity) reactions usually take 6-24 hours to produce symptoms. Contact urticaria is usually rapid in onset. Because symptoms occur so rapidly following exposure, the etiology for contact urticaria is usually obvious. If the etiology is not apparent, an exposure history should include items commonly associated with this disorder (see Etiology).
Is this the first time this has occurred? When symptoms are episodic, an accurate diary of exposures occurring shortly prior to symptoms may help narrow the list of possible irritants or allergens.
Has the dermatitis been spreading? Allergic contact dermatitis frequently appears to spread over time. In fact, this represents delayed reactions to the allergens.
Several factors may produce the false impression that the dermatitis is spreading or is contagious. Heavily contaminated areas may break out first, followed by areas of lesser exposure. Thick skin may react much later than thin skin or may not react at all. Different sites may have come in contact with the allergen at different times. Gloves and other clothing contaminated with sap from poison ivy may expose the skin days, weeks, or months later.
The patient's age and the location and appearance of the dermatitis frequently lead the history in a particular direction. For example, if the dermatitis is perioral, the history might include exposure to the following:
Musical instruments played with a mouthpiece
Sports involving mouthpieces (eg, snorkeling, diving)
Products applied to treat the perioral symptoms
Sucking limes and lying in the sun
Eating foods such as mangos (specifically, exposure to the skin rind of the mango)
Occasionally, simply asking about some of these possible allergens may stimulate the patient or parent to recall an exposure they had forgotten.
Photo contact dermatitis usually occurs on sun-exposed areas (at some clothing-optional beaches or in tanning booths, sun-exposed areas may include most, if not all, of the skin surface). A detailed exposure history, including a detailed history of types and quantity of light exposure, is required. Determine whether the reaction occurred following exposure through window glass or on a cloudy day. This would suggest photo dermatitis related to ultraviolet A light.
Although the possible causes of contact dermatitis are virtually endless, identification of the probable type can help direct the search for a provoking agent. For a listing of the more common causes of contact dermatitis, see Etiology.
Many cases of contact dermatitis have a similar appearance regardless of the mechanism or cause of the inflammation. Other than distribution and severity, most cases of acute irritant contact dermatitis appear similar, and the clinical appearance does not suggest the etiologic agent. However, some distributions are highly suggestive of the etiologic agent. For example, pruritic dermatitis of the ear lobes or near the umbilicus almost always is the result of nickel allergy.
Inflammatory responses can be categorized into acute, subacute, and chronic phases.
In acute contact dermatitis, the skin is bright red and edematous. Clear fluid-filled vesicles or bullae may develop in these areas. As lesions break, they weep clear serum. Yellow crusts form as this serum dries. These may suggest that the area is infected. Although secondary infection can occur, it usually develops over several days and is usually more purulent than the yellow crusts. Most healthy patients do not require antibiotic therapy unless significant purulent drainage is noted or the healing of the wound is not progressing as expected.
Subacute contact dermatitis is less edematous and erythematous. Little or no drainage of serum is present. Superficial papules and excoriations are common.
Chronic contact dermatitis is characterized by scaling, fissuring, and lichenification with minimal edema. Mild erythema and excoriations are common. Pediatric patients of color may develop lichenified lesions, lichenoid papules, and/or postinflammatory hyperpigmentation more often than their white counterparts.
Patients with severe allergies may experience anaphylaxis. Anaphylaxis occurs most commonly in patients who are extremely sensitive to latex and is less common in patients sensitive to exposure to other antigens. Consequently, equipment and gloves should be latex-free during clinical examinations and surgical procedures of patients with whose history suggests extreme sensitivity to latex.
The clinical appearance of the dermatitis may suggest the type of contact dermatitis. This may help to narrow the list of possible causes.
Irritant contact dermatitis
Rash is often localized to the site of exposure. The most common site is the hands.
Severity depends on the irritant, concentration, dwell time, site, and condition of the skin. Thick dry skin is the most resistant to the effects of irritants. Maceration makes skin more vulnerable to irritants. Xerosis can predispose to irritant dermatitis.
Allergic contact dermatitis
In allergic contact dermatitis, skin involvement may extend beyond the borders of the region exposed to the allergen. Edema is generally much more pronounced with allergic contact dermatitis than with irritant contact dermatitis, and vesiculation is more common.
Clues to the allergen suggested by the distribution of the dermatitis include the following:
Scalp and ears - Shampoo, hair spray, hair dyes, earrings, eyeglasses, ear plugs, headphones, telephones, bathing caps, ear drops (Cerumenex)
Eyelids - Nail polish (transferred by rubbing), cosmetics, contact lens solution, sport goggles, fragrances, metals, neomycin, oleamidopropyl dimethylamine, tosylamide formaldehyde resin, benzalkonium chloride, other preservatives
Face - Airborne allergens (eg, poison ivy from burning leaves, ragweed), cosmetics, sunscreens, nose clips, perfumes
Lips - Lip balms, lipstick, toothpaste, mouthwash, bubble gum (ie, rosin, cinnamates), nickel in musical instrument mouthpiece, rubber in snorkeling mouthpiece, cane reed in a clarinet, food (eg, mango skin)
Neck - Necklaces, perfumes, aftershave lotion (men or women from contact with someone wearing aftershave), rubber or leather straps
Trunk - Topical medication, sunscreens, poison ivy, clothing, undergarments (eg, spandex bras, elastic waistbands), metal belt buckles, dive suits
Axilla - Deodorant (axillary vault), clothing (axillary folds)
Hands - Soaps and detergents, foods, poison ivy, solvents and oils, cement, metals, topical medications, gloves, athletic tape, rubber additives, innumerable occupational exposures
Wrists - Same as hands; watch, watchband, bracelets
Genitals - Poison ivy (transferred by hand), rubber condoms, nickel (allergy from a bed-wetting alarm was confused with herpes genitalis and child abuse), feminine hygiene products. One study noted that toilet seat dermatitis is more common than previously recognized and should be considered in children who present with dermatitis that involves the buttocks and posterior thighs.  Diaper wipes, diapers, and toilet paper may also be sources of buttock allergic contactants.
Anal region - Hemorrhoid preparations (eg, benzocaine, Nupercaine)
Lower legs - Topical medication (eg, benzocaine, lanolin, neomycin, paraben), dye in socks, latex/rubber in socks
Feet - Rubber, leather, glues, dyes, or nickel snaps in shoes and sandals; topical medications; swim fins; athletic tape
Photo contact dermatitis
Phototoxic photo contact dermatitis is essentially a severe sunburn or an allergic reaction to the sun, with a primary symptom of burning. In photoallergic photo contact dermatitis, manifestations on sun-exposed areas of the body range from sunburns to eczematous dermatitis or hyperpigmentation. Occasionally, aerosolized contactants may produce a similar clinical appearance.
Contact urticaria appears as hives or wheals or edematous pale or pink plaques. (See the image below.)
Contact reactions to pharmacologically active agent
Typical triple response (ie, erythema, flare, and wheal formation) is noted in seconds. Pruritus may last several hours.
Secondary bacterial infections are uncommon in the acute stages of contact dermatitis. They may occur several days after damage to the skin and should be treated with systemic antibiotics.
Generalized eruptions secondary to autosensitization may occur in association with severe localized allergic contact dermatitis.
Pulmonary symptoms may occur following inhalation of irritants or potent allergens.
Scar formation may result from deep chemical burns or significant secondary infection.
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