1

INTRODUCTION


Irritant contact dermatitis is a non allergic inflammatory reaction of the skin
to external agents including chemical, physical or biologic agent that are capable
of irritating the skin, acutely or chronically. Acute irritant contact dermatitis often
the result of a single overwhelming exposure or a few brief exposures to strong
irritants or caustic agents, where as chronic irritant contact dermatitis also known
as cumulative irritant contact dermatitis occurs following repetitive exposure to
weaker irritants which may be either wet, such as detergents, organic solvents,
soaps, weak acids and alkalis, or dry, such as low humidity air, heat, powders and
dusts.
1,2,3

The prevalence of dermatitis in the general community are few but the point
prevalence of dermatitis in the U.K. is estimated at about 20%. Irritant contact
dermatitis is more common than allergic dermatitis; allergic dermatitis usually
carries a worse prognosis than irritant dermatitis unless the allergen is identified
and avoided. Irritant dermatitis makes up about 80% of contact dermatitis. The
other 20% is allergic. This disease is significantly more common in women than
in men. The high frequency in women in comparison with men is caused by
environmental factors, not genetic factors. Irritant contact dermatitis may occur at
any age.
3,5
There are several factors that have been identified as being involved in the
cutaneous irritation. These can be divided into endogenous and exogenous factors.
Endogenous (host) factor include: genetic, gender, age, ethnicity, skin site and
history of atopy. Exogenous factor include: irritant and environmental. Almost
any material act as irritants that produce a nonspecific inflammatory reaction of
the skin, if the exposure is sufficiently prolonged and/or the concentration of the
substance sufficiently high. Environmental factors may enhance the effect of other
irritants.
2,5
The concentration and the type of the toxic agent, the duration of
exposure, and the condition of the skin at the time of exprosure produces the
variation of the severity of the dermatitis from person to person, or from time to
time in the same person.
1,2,4


2

Pathogenesis mechanisms of irritant contact dermatitis depend on the phase
of the disease, acutely or chronically. Acute reaction involve direct cytotoxic
damage to keratinocytes, where as crhonic irritant contact dermatitis result from
repeated exposures solvent and surfactants that cause slow damage to cell
membranes, disrupting the skin barrier and leading to protein denaturation and
cellular toxicity.
1
The diagnosis of irritant contact dermatitis often made by excluding other
causes for dermatitis. A detailed inquiry, including history of exposure to irritant
substances, occupational, hobbies, and past medical histories, and meticulous
clinical examination are important for making correct diagnosis.

Patch testing is
often essential to help distinguish allergic contact dermatitis from irritant contact
dermatitis. Negative patch tests may suggest a diagnosis of irritant contact
dermatitis by exclusion of allergic contact dermatitis. It is important to perform
comprehensive patch testing with the appropriate substances and concentrations to
prevent incorrect conclusions.
1
The management of irritant contact dermatitis principally is protection the skin
from irritants. The principles of management involve irritant avoidance, using
personal protective equipment and substitution to less irritating substances. Care
should be taken for several months after the dermatitis has healed, as the skin
remains vulnerable to flares of dermatitis for a prolonged period.
1,3
Treatment for irritant contact dermatitis is identitify and remove the
etiologic agent. Once dermatitis develops, using topical treatment such as
corticosteroids may be helpful because of their anti inflammatory effect. Acute
irritant contact dermatitis has good prognosis if the causative irritant can be
identified and eliminated. The prognosis for chronic irritant dermatitis is guarded
and may be worse than that of allergic contact dermatitis. An atopic background,
lack of knowledge about the disease, a delayed diagnosis and treatment are factors
that lead to a worse prognosis.
1






3

CASE REPORT


Identity of Patient
Name : Ms. Y
Sex : Female
Age : 39 years old
Registration Number : 695605
Address : Desa Lampakuk, Kecamatan Kuta Cot Glie, Aceh Besar
Hospitalized : November 13
th
, 2013
Examination day : November 13
th
, 2013

Anamnesis
Chief Complaint
Present of swelling, redness patches, burning and painful sensation on the face
and hand since 4 days ago.

Present illness history
Patient came to hospital complaint about the appearance of swelling, redness
patches, burning and painful sensation on the face and hand since 4 days ago. At
first, patient found redness at her face until neck and her hand followed by
burning and painful sensation after using a facial soap, called collagen. And then,
after about 9 hours patient found her face swelling. As the time goes by, the
swelling at her face turn to become less, but burning and painful sensation still
came up. This is the first time for the patient using the soap. Patient got the facial
soap from her sister who use it everyday. Unlike her, her younger sister has no
skin problem after using the soap.

Past illness history
Patient has never have this kind of disease before.

Family disease history
None of her family had this kind of disease.



4

Medicine history
Patient did not take any medication before going to hospital.

Status of Dermatologist
1. Location : At facialis and volar manus region dextra et sinistra
Dermatologic status : Erithematous patch with diffuse border, irregular edge,
plakat, multiple, bilateral distribution

Figure 2.1 Erythematous patch at face


Figure 2.2 Erythematous patch at hand






5

Differential Diagnosis
1. Irritant contact dermatitis due to cosmetic (facial soap)
2. Allergic contact dermatitis
3. Photodermatitis
4. Erisepelas
5. Urticaria contact

Resume
A 39 years old woman presence of swelling, redness patches, burning and painful
sensation on the face and hand since 4 days ago. At first, patient found redness at
her face until neck and her hand followed by burning and painful sensation after
using a facial soap, called collagen. And then, after about 9 hours patient found
her face swelling. As the time goes by, the swelling at her face turn to become less,
but burning and painful sensation still came up. This is the first time for the
patient using the soap. Patient got the facial soap from her younger sister who use
it everyday. Unlike her, her sister has no skin problem after using the soap. On
dermatological status was found erithematous patch with diffuse and regular edge
at her face and erithematous patch at both her hand.

Diagnosis
Irritant contact dermatitis due to cosmetic (facial soap)

Management
Systemic
1. Kortikosteroid : Metilprednisolon tab 8 mg, 2 x 1, 3 until 5 days
2. Antihystamine : Cetirizin tab 10 mg, 1 x 1, 3 days

Topical
1. Thyamphenicol 2% + Desoxymethason 0,25% oint applic at face and hand
three times a day.







6

Education
Avoid irritant that potential effect to induce skin problem. If contact does occur,
wash with water as soon as possible and come to hospital to take medication if
needed.

Prognosis
Quo ad Vitam : dubia ad bonam
Quo ad Functionam : dubia ad bonam
Quo ad Sanactionam : dubia ad bonam

Follow up (November 19
th
2013)
Five days after first visit to hospital and take medication, the skin condition of the
lesion area both face and hand start to turn in normal condition again. There is no
present of swelling at face and the redness patches became less, only appear
around nose and chin.

Location : At perinasal et mental region
Dermatologic status : Erithematous patch with diffuse border, irregular adge,
plakat, multiple, regional distribution


Figure 2.3 Erythematous patch at perinasal and mental



7


Location : At volar manus dekstra et sinistra region
Dermatologist status : Present of scale and the underlying skin is not red anymore


Figure 2.4 Present of scale at hand


















8

DISCUSSION

Irritant contact dermatitis is an acute or chronic inflammatory reactions to
substances that contact with the skin such as chemical or other physical agents
that are capable of irritating the skin.
1
One of irritant substance is lactic acid that
cause erythema and whealing at the affected site of the skin.
2
The collagen soap
that patient used containe lactic acid that play a role in irritating patients skin.
This patient complain some skin problem including swelling, redness, burning and
painful sensation after using a facial soap called collagen that potentially contain
irritant substances. The type of clinical feature in this case is acute irritant contact
dermatitis. Acute irritant contact dermatitis usually result from a single exposure
to a strong irritant or caustic chemical such as alkalis and acids. Burning, itching
or stinging sensation may occur immediately after the exposure to the irritant.
Erythema, edema and vesiculation may present in the patient.
1
in this case the
patient presence of swelling, redness patches, burning and painful sensation on the
skin face and the hand.
Irritant contact dermatitis may occur at any age. In this case, patient
suffering the disease at 39 years old. Older persons have drier and thinner skin
that does not tolerate soaps and solvents as well as younger individuals, so they
are more susceptible to have skin problems.
The diagnosis of irritant contact dermatitis often made by excluding other
causes for dermatitis. A detailed inquiry, including history of exposure to irritant
substances, occupational, hobbies, and past medical histories, and meticulous
clinical examination are important for making correct diagnosis. Rietschel has
proposed criteria with subjective and objective features, each with mayor and
minor findings for the diagnostic of irritant contact dermatitis. Mayor subjective
criteria are 1). onset of symptoms within minute to hours of exposure 2). pain,
burning, stinging or discomfort exceeding itching early in the clinical course.
Mayor objective criteria are 1). Macular erythema, hyperkeratosis, or fissuring
predominating over vesiculation 2). Glazed, parched, or scalded appearance of the
epidermis 3). Healing process begin promptly on with drawal of exposure to the
offending agent 4). Patch testing is negative. Minor subjective criteria are 1).


9

Onset of the dermatitis within 2 weeks of exposure 2). Many people in th
environment affected similarly. Minor objective criteria are 1). Sharp
circumspection of the dermatitis 2). Evidence of gravitational influence, such as
dripping effect 3). Lack of tendency of the dermatitis to spread 4). Morphologic
changes suggesting small concentration differences or contact time produce large
difference in skin damage. The more features identified, the stronger the case for
irritant contact dermatitis.
1
In this case, patient has two mayor subjective criteria
include: onset within minute and patient feel pain, burning and discomfort
sensation, and two mayor objective criteria include: erithematous patch and
healing process begin promptly on with drawal of exposure to the offeding agent.
In this case, patch testing did not perform because of limited equipments and the
difficulty of controlling patient. Normally, patch testing is needed to help
distinguish allergic contact dermatitis from irritant contact dermatitis. Negative
result may suggest a diagnosis of irritant contact dermatitis by exclusion of
allergic contact dermatitis. It is important to perform comprehensive patch testing
with the appropriate substances and concentrations to prevent incorrect
conclusions.
1
In the acute stage of irritant contact dermatitis, topical corticosteroids are
indicated. If there is deep tissue destruction or signs of bacterial infection,
systemic corticosteroids and antimicrobial agents should be administered.
2
In this
case, the patient got corticosteroid, antihystamin, and antimicrobial topical for her
medication.s












10




REFERENCE

1. Goldsmith L, Katz S, Gilchrest B, Paller A, Leffel D, Wolff K. Fitzpatricks
Dermatology in General Medicine. Eighth Edition. 2008. McGraw-Hill:
New York. P.395-400

2. Frosch PJ, John SM. Clinical Aspects of Irritant Contact Dermatitis. 2006.
Available at http://www.springer.com/978-3-540-24471-4 (November 16
th
,
2013).

3. Bourke J, Coulson I, English J. 2008. Guidelines for The Management of
Contact Dermatitis: An Update. British Journal of Dermatology. St Johns
Institue of Dermatology, Kings College: London.

4. James WD, Berger TG, Elston DM. Andrews Disease of The Skin Clinical
Dermatology. Eleventh Edition. 2011. Saunders Elsevier : USA. P.88-91

5. Health and Safety Authority. Guidelines on Occupational Dermatitis. 2009.
The Metropolitan Building, James Joyce Street, Dublin.