eMedicine Specialties > Pediatrics: General Medicine > Dermatology

Contact Dermatitis: Follow-up

Author: Mark A Crowe, MD, Assistant Clinical Instructor, Department of Medicine, Division of Dermatology, University of Washington School of Medicine
Contributor Information and Disclosures

Updated: Aug 6, 2009

Follow-up

Deterrence/Prevention

  • Prevention of contact dermatitis is better than cure. The most important part of the treatment is to identify and eliminate further exposure to the causative agent.
  • Urushiol is the oily resin in poison ivy, poison sumac, and poison oak, which causes an allergic reaction. Keep in mind this resin can remain active for years on virtually any surface. Thoroughly wash everything that might have brushed against the plants, including clothing, shoes, tools, camping equipment, and pets.
  • Wearing a long-sleeved shirt, pants, gloves, and boots when in an infested area and bathing as soon as possible after exposure are effective methods to limit rhus dermatitis.
  • The only places in the United States where poison ivy is not found are areas above 4000 ft elevation, Alaska, Hawaii, and some desert areas of California and Nevada. Poison ivy usually grows east of the Rocky Mountains and in Canada. Poison oak grows in the western United States, Canada, and Mexico (western poison oak), and in the southeastern states (eastern poison oaks). Poison sumac grows in the eastern states and southern Canada.
  • Learn to recognize poison ivy, poison sumac, and poison oak and have them removed from areas where children are likely to play. Several features of poison ivy, oak, and sumac are useful in identification. Poison ivy and oak may be shrubs or climbing vines. All species of poison ivy and oak have 3 leaflets per leaf, hence the reminder, "Leaves of 3, let them be." The leaf stalk has a groove where it attaches to the branch. Blooms and fruits arise in the angle between the leaf and the branch. Young leaves frequently are reddish in color, and the mature fruit is tan or cream colored. Poison sumac is a shrub or small tree usually 5-10 feet tall and grows in swampy areas or peat bogs. Poison sumac contains 7-13 paired leaflets in a row. The American Academy of Dermatology has handouts with color photographs available for purchase or viewing on their web site.
  • Poison ivy, poison sumac, and poison oak are most dangerous in the spring and summer when plenty of sap is present. The leaves, branches, and trunk may show black marks where they have been injured. The sap turns black after exposure to air.
  • Do not let pets run through wooded areas where poison ivy, poison sumac, and poison oak grow. They may carry urushiol on their fur, causing contact dermatitis in family members who come in contact with the animal. Urushiol can travel in smoke if it burns in a fire; do not burn plants that look like poison ivy, poison sumac, or poison oak.

Complications

  • 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.

Prognosis

  • The prognosis of contact dermatitis depends on the cause and the possibility of avoiding repeated or continued exposure to the causal allergen or irritant. Most contact dermatitis resolves without intervention in 4-6 weeks if further exposure is prevented. Obviously, long-term success in treatment is poor if the correct diagnosis and offending agent are not identified.
  • Numerous individual factors are also important in prognosis. Although an alert patient can reduce contact, some ubiquitous allergens, such as rubber or nickel, are quite impossible to totally avoid.
  • Some allergens probably are still unknown, and the significance of others may not be fully realized yet.
  • New sensitivities to topical medications or other substances may develop during the course of dermatitis. Sensitivity to rubber gloves may complicate dermatitis of the hands. Sensitivity to neomycin may complicate the course when applied to an infected dermatitis. During a long course of relapsing dermatitis, sensitivity to various allergens may accumulate, increasing the risk of recurrence.
  • Contact dermatitis of the hands is generally of mixed origin, caused by alternating or simultaneous exposure to allergens and irritants. Half of patients with hand dermatitis have had symptoms of dermatitis for more than 5 years. When followed up after 6-22 months, one quarter of the patients heal completely, half of the patients improve, and one quarter of the patients are unchanged or worse. No difference in prognosis between irritant and allergic dermatitis is observed.
  • Relapses or chronicity is due not only to reexposure to allergens and irritants, but also to other contributory mechanisms.
    • The barrier function of the skin is impaired for months or even years after an episode of dermatitis. Recovery can be prevented by exposure to irritants or allergens in concentrations that may be tolerated by normal skin.
    • Inappropriate treatment with irritants or allergens, such as overzealous use of cleansers and antiseptics, use of various popular or herbal remedies, or both, may prolong the course.
    • Secondary infection is common in chronic contact dermatitis, preventing normal recovery.

Patient Education

  • Patch testing can be extremely important in diagnosing the cause of allergic contact dermatitis; however, patients forget more than 40% of identified allergens. Provide a printed list of sources of allergic contact to the patient. Discuss sources of allergic contact with the same or cross-reacting allergens.
  • Discuss prognosis. Acute allergic contact dermatitis may take several weeks to completely resolve. Recurrences are common unless the contactant is identified and avoided.
  • Provide instructions for reduction of further contact, identification of sources of contactant, barrier protection, good skin care, and hygiene.
  • Allergy does not disappear when the dermatitis clears. Risk of relapses usually persists throughout life.
  • Following significant episodes of dermatitis, the area of involved skin may be especially sensitive to recurrences for several months.
  • Allergic contact dermatitis may be prolonged by subsequent contact with weak irritants. Conversely, patients with irritant dermatitis may develop an undetected secondary allergy to an ingredient of creams or rubber gloves being used to treat the initial dermatitis.
  • Secondary infection is common in subacute or chronic contact dermatitis. If the contact dermatitis is resistant to appropriate therapy or suddenly worsens for no particular reason, secondary bacterial infection should be considered.
  • Urushiol, the allergen in poison ivy, can remain active for months. Exposed clothing, shoes, tools, camping equipment, and pets must be washed thoroughly.
  • If rhus dermatitis is a problem, patients must learn to recognize the plants and have them removed from areas where children are likely to play. The American Academy of Dermatology has handouts with color photographs available for purchase or viewing on their web site.
  • Wearing a long-sleeved shirt, pants, gloves, and boots when in areas infested with poison ivy and bathing as soon as possible after exposure are effective methods for reducing rhus dermatitis.
  • For excellent patient education resources, visit eMedicine’s Skin, Hair, and Nails Center. Also, see eMedicine’s patient education articles Contact Dermatitis and Eczema.

Miscellaneous

Medicolegal Pitfalls

  • Potential sources for exposure to specific allergens and irritants are often extensive. Extensively counsel patients with documented contact dermatitis on possible sources of future exposure. If possible, provide a written list of potential sources. Although listing every potential source of exposure is impossible, provide the patient with the name of the contactant and related chemical compounds. Failure to do so may result in the patient experiencing unnecessary exposure and dermatitis. In cases of extreme sensitivity, exposure may produce severe or fatal reactions.
  • 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.
  • Inadvertent exposure to latex in a patient with severe latex allergy may result in adverse outcomes and litigation. Equipment and gloves should be latex-free during clinical examinations and surgical procedures of patients with extreme sensitivity to latex. Failure to obtain a history suggestive of recognized or unrecognized latex allergy may result in adverse outcomes and litigation.
  • Anaphylaxis may occur shortly after application of antigens used in patch testing. This finding is particularly true when testing for latex allergy but may occur with exposure to other antigens.
  • Monitor patients for anaphylactic reactions to antigens used in patch testing. Appropriate resuscitation must be available should anaphylaxis occur during the early stages of patch testing.

Special Concerns

  • Occupational contact dermatitis is a major problem.9 Patients may need assistance with positively identifying irritants or allergens in the work place. Once identified, the patient's environment must be appropriately adjusted. Patients may need assistance with documentation for worker's compensation claims.
  • Although some studies suggest an increased incidence of allergic contact dermatitis exists in atopic patients, most recent studies suggest incidence of allergic contact dermatitis in atopic patients is similar to that of patients experiencing other conditions, such as seborrheic dermatitis. Some evidence suggests that atopic patients may be less easily sensitized than other groups. Patients with severe atopic dermatitis, in fact, may have a diminished capacity for dinitrochlorobenzene (DNCB) sensitization. Atopic patients are also more susceptible to irritant patch test reactions, especially when testing with metals. This may lead to false-positive results from routine patch testing. In a study of 101 sets of twins, no correlation was found between positive patch test results and atopy.
  • Investigators have found that most people could be immunized against poison ivy through prescription pills; however, this procedure can take months to achieve a reasonable degree of hyposensitization and must be continued over a long period. Immunization can cause uncomfortable side effects and should only be considered for individuals, such as firefighters, who must live or work in areas where they come into constant contact with poison ivy.
 


More on Contact Dermatitis

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Differential Diagnoses & Workup: Contact Dermatitis
Treatment & Medication: Contact Dermatitis
Follow-up: Contact Dermatitis
Multimedia: Contact Dermatitis
References
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Further Reading

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Keywords

contact dermatitis, allergic contact dermatitis, ACD, dermatitis venenata, contact eczema, rhus dermatitis, poison ivy, poison oak, poison sumac, irritant contact dermatitis, ICD, primary irritant dermatitis, photo contact dermatitis, photoallergic contact dermatitis, phototoxic contact dermatitis, berloque dermatitis, contact urticaria, hives, whelps, eczematous dermatitis, acute caustic burn, cold urticaria, cholinergic urticaria, dermatographism, pressure urticaria, aquagenic pruritus, aquagenic urticaria, solar urticaria, heat urticaria, papular urticaria, exercise-induced urticaria, latex allergy, sunburn, nickel allergy, hyperpigmentation, folliculitis, melanoderma, Umbelliferae family

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Contributor Information and Disclosures

Author

Mark A Crowe, MD, Assistant Clinical Instructor, Department of Medicine, Division of Dermatology, University of Washington School of Medicine
Mark A Crowe, MD is a member of the following medical societies: American Academy of Dermatology and North American Clinical Dermatologic Society
Disclosure: Nothing to disclose.

Medical Editor

Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center
Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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