Management of

Contact Dermatitis

Philippine Dermatological Society

Rm. 1015 South Tower, Cathedral Heights Building Complex
St. Luke’s Medical Center
E. Rodriguez Avenue, Quezon City, Philippines 1102
Tel No.: (632) 723-0101 loc 2015
Telefax No.: 727-7309
E-mail: pds_org@pldtdsl.net, pds_org@yahoo.com
Website: www.pds.org.ph

Contact Dermatitis
Cataract

CPM 18TH ED DIVIDERS 1.31.2017.i15 15 02/07/2017 2:10:36 PM

 Contact Dermatitis

Philippine Dermatological Society

Rm. 1015 South Tower, Cathedral Heights Building Complex
St. Luke’s Medical Center
E. Rodriguez Avenue, Quezon City, Philippines 1102
Tel No.: (632) 723-0101 loc 2015
Telefax No.: 727-7309
E-mail: pds_org@pldtdsl.net, pds_org@yahoo.com
Website: www.pds.org.ph

Officers and Directors (2017-2018)

President Ma. Angela M. Lavadia, MD

Vice-President Ma. Purita Paz-Lao, MD
Secretary Cecilia R. Rosete, MD
Treasurer Maria Jasmin J. Jamora, MD

Immediate Past President Daisy K. Ismael, MD

Directors Bernadette B. Arcilla, MD

Blossom T. Chan, MD
Francisco D. Rivera IV, MD
Krisinda C. Dim-Jamora, MD
Julie W. Pabico, MD
Ma. Lourdes H. Palmero, MD
Arnold C. Yu, MD

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 Contact Dermatitis
Management of Contact Dermatitis
Summary of Critical Appraisal:
This update aims to provide evidence based guidelines
for the definitions of contact dermatitis and their rele­
vance, diagnosis, and treatment of patients with this
condition. This is prepared by dermatologists in behalf
of the British Association of Dermatologists Therapy
Guidelines and Audit Subcommittee.
No clinical algorithm in the diagnosis of contact dermatitis
was provided in this guideline. Evidence were appraised
and rated accordingly.
It should also be noted that the health system in the
UK is organized differently from the Philippines. Some
recommendations in terms of medical services may not
be widely available in our setting. A formal cost analysis
is not included in the guideline. Some diagnostic and
treatment options were not given grades and levels of
evidence but were nevertheless included. Users are
cautioned in interpreting the data as this reflects the
best data available at the time the report was prepared.
Furthermore, future studies may require alteration of
conclusions or recommendations in the guidelines.
PDS has reviewed this summary and added additional
information for clarity and update. These information are
referenced in the footnotes.
Strength of recommendations
There is good evidence to support the use of the
A procedure
There is fair evidence to support the use of the
B procedure
There is poor evidence to support the use of the
C procedure
There is fair evidence to support the rejection of
D the use of the procedure
There is good evidence to support the rejection
E of the use of the procedure
Quality of Evidence
I Evidence obtained from at least one properly
designed, randomized controlled trial
II-i Evidence obtained from well-designed controlled
trials without randomization
II-ii Evidence obtained from well-designed cohort
or case-control analytic studies, preferably from
more than one centre or research group
II-iii Evidence obtained from multiple time series with
or without the intervention. Dramatic results in un-
controlled experiments (such as the results of the
introduction of penicillin treatment in the 1940s)
could also be regarded as this type of evidence
III Opinions of respected authorities based on clinical
experience, descriptive studies or reports of expert
committees
IV Evidence inadequate owing to problems of metho­
dology (e.g., sample size, or length or compre-
hensiveness of follow-up or conflicts of evidence)
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08 CPM 18th ed Contact Dermatiti78 78
Summary of Recommendations
Definitions
Contact Skin condition created by a reaction
dermatitis to an externally applied substance1
Subjective idiosyncratic stinging and smarting
irritancy reactions occurring within minutes
of contact, usually on the face, in
the absence of visible changes.
Cosmetic or sunscreen constituents
are common precipitants.
Acute often the result of a single over-
irritant whelming exposure or a few brief
contact exposures to strong irritants or caustic
dermatitis agents
Chronic occurs following repetitive exposure
(cumulative) to weaker irritants which may be either
irritant “wet,” such as detergents, organic
contact solvents, soaps, weak acids and
dermatitis alkalis, or “dry,” such as low humidity
air, heat, powders and dusts
Allergic involves sensitization of the immune
contact system to a specific allergen or
dermatitis allergens with resulting dermatitis or
exacerbation of pre-existing dermati-
tis
Phototoxic, some allergens are also photo aller-
photoallergic gens. It is not always easy to dis-
and photo- tinguish between photoallergic and
aggravated phototoxic reactions
contact
dermatitis
Systemic seen after the systemic administra-
contact tion of a substance, usually a drug, to
dermatitis which topical sensitization has pre-
viously occurred
Strength Level
Recommendation of recom- of
mendation evidence
WHO SHOULD BE
INVESTIGATED
• Patch testing is an essen- A II-ii
tial investigation when
contact allergy is suspected
in patients with persistent
eczematous eruptions
• Formal training in patch A II-ii
test reading and interpreta-
tion, testing with additional
series and prick testing in
the investigation of patients
with contact dermatitis are
important.
1
American Academy of Dermatology Basic Curriculum on Contact Dermatitis
(http://www.aad.org/education/basic-dermatology-curriculum/suggested-
order-of-modules/four-week-rotation/week-3/contact-dermatitis)
02/06/2017 1:50:33 PM
 Contact Dermatitis

• Approximate annual work- B II-ii A. Timing of Patch Test

load for a contact dermatitis Readings A II-ii
investigation clinic has been • The optimum timing of
suggested to be one indivi- readings is day 2 and
dual investigated per 700 4. An additional reading
of the population served, at day 6 or 7 will pick up
i.e., 100 patients patch a ~10% more positives
tested for every 70,000 of that were negative at
the catchment population days 2 and 4.
per year.
B. Relevance of Positive
Reactions
DIAGNOSTIC TESTS 1. Current relevance –
patient has been
exposed to allergen
I. Patch Testing
during the current epi-
• Mainstay of diagnosis in A II-ii
sode of dermatitis and
allergic contact dermatitis.
improves when expo-
It has a sensitivity and
sure ceases
specificity of 70-80%.
2. Past relevance – past
• Reproduces allergic
episode of dermatitis
contact dermatitis in an
from exposure to
individual sensitized to a
allergen
particular allergen.
3. Relevance not known –
• Standard Method vs.
not sure of exposure is
Preprepared tests
current or old

4. Cross reaction – posi-
Standard Method
tive test is due to cross-
Individual allergens are
reaction with another
placed in Finn aluminium
allergen
chambers (most commonly
5. Exposed – history of
used application system) or
exposure but not
IQ polyethylene chambers2.
resulting to dermatitis
Allergens applied onto the
from that exposure, or
skin (most commonly the
no history of exposure
back) are in standardized
but with definite positive
concentrations in an appro-
allergic patch test
priate vehicle and under
occlusion.
C. Patch Test Series
1. A screening series will
Preprepared tests
pick up approximately
o i.e., TRUE test and I
80% of allergens; series
Epiquick test
will vary from country to
o Preprepared tests are
country and should be
significantly more
revised on a regular
reliable than operator-
basis.
prepared tests.
2. Patient’s own cosmetics,
• Larger chambers may II-ii
toiletries and medica-
give more reproducible
ments should be tested
tests, but may only apply
at non-irritant concen-
to some allergens; can be
trations.
used to obtain a more
o Undiluted or “as is”
definite positive reaction
for leave on products
when a smaller chamber
and dilutions for
has previously given a
wash-off products
doubtful one.
o Strong irritants such
as powdered deter-
gents should not be
2
Doumit J and Pratt M. Comparative study of IQ-ultra and Finn Chambers patch tested
test methodologies in detecting 10 common standard allergens that cause o Occupational products
allergic contact dermatitis. J Cutan Med Surg. 2012 Jan-Feb; 16(1): 18-
22.
should be tested at

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 Contact Dermatitis

non-irritant concen- the first 30 to 60

trations. minutes and a later
o Most useful reference reading is carried out
source for documen- after 3 to 4 days
ted test concentra- 2. Repeated open appli-
tions and vehicles for cation test (ROAT)
chemicals, groups of • involves application
chemicals and pro- of the product onto
ducts is De Groot AC. the forearm twice
Patch Testing. Test daily for up to a week,
concentrations and stopping if a reaction
vehicles for 3700 develops
chemicals, 2nd ed. • useful in the assess-
Amsterdam: Elsevier, ment of cosmetics,
1994. where irritancy or
combination effects
D. Photopatch Testing may interfere with
• Application of photo- standard patch
allergen series and any testing
suspected materials in
duplicate on either side F. Preparation of Patient
of the upper back. A. Factors altering the
• One side is irradiated accuracy of patch
with 5 J cm-2 of UVA testing
after an interval of 1-2 • characteristics of
days and readings are individual allergens
taken in parallel after • method of patch
another 2 days. testing
• It is recommended that A II-ii • irritant-reaction I
allergens be subjected causing allergens
to 5 J cm-2 UVA and a being misclassified
reading after 2 days; as positive reactions
incidence of photo-
allergy in suspected B. Patient characteristics
cases was low at <5% • skin on the back is
but further readings at free of dermatitis
3 and 4 days increased • skin disease else- II-iii
the detection rate. where is well-control-
• Irradiation of the test led to avoid “angry
site may be done after back syndrome” with
1-2 days after allergen numerous false-
application; the 2 day positives
interval was found to • risk in false-negative II-iii
be favourable. results when potent
topical steroids are
E. Open Patch Testing applied to the back
1. Open Patch Test up to 2 days prior to
• commonly used the test or
where potential irri- • when oral corticoste-
tants or sensitizers roids/immunosup-
are being assessed pressant drugs are
• useful in the investi- being taken, a daily
gation of contact urti- dose of no higher
caria and protein than 10 mg predniso-
contact dermatitis lone, suppression of
• performed on the positive patch test is
forearm (or upper unlikely
outer arm or scapu- • UV radiation may
lar areas) also interfere with
• site is assessed at results but the amount
regular intervals for required to do so and

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 Contact Dermatitis

the relevant interval

INTERVENTION AND
between exposure
TREATMENT
and patch testing are I. IRRITANT CONTACT
poorly quantified DERMATITIS
• management involves
II.
Testing for Type I Hyper- the protection of the skin
sensitivity for Natural from irritants
Rubber Latex (NRL) • most common irritants
Allergy are soaps and deter-
• May complicate allergic, gents, although water it-
irritant or atopic hand self is also an irritant
• Irritants such as oils and
dermatitis and may be
coolants, alkalis, acids
seen in combination
and solvents may be
with delayed (type IV)
important in the occupa-
hypersensitivity to NRL tional setting
or rubber additives.
• Prick test A. Avoidance
o involves an intrader- • self-evident; visit to
mal puncture and a the workplace may
drop of extract be necessary to
o A positive control test identify all potential
(histamine) is done skin hazards
so as not to give a
false-negative react- B. Protection
ion from oral antihis- • Most irritant contact
tamine ingestion dermatitis involves
o A negative control the hands
prick (saline) is done • Gloves are the main-
to check if the patient stay of protection
• Type of gloves used
is dermographic
depends on the
o A positive reaction is
nature of the chemi-
an urticarial wheal,
cals involved in an
apparent after 15-45 occupational setting
minutes • Exposure time is
• The use test important in deter-
o Involves application mining the most
of a glove soaked in appropriate glove as
water or saline for 20 it may be protective
minutes (for NRL for a few minutes but
hypersensitivity) not for prolonged
• The prick test is gene- A II-iii contact
rally favoured over the
use test because of Tips
reports of anaphylaxis o rubber or polyvinyl
following the latter chloride household
• Radioallergosorbent gloves, possibly
test (RAST) for NRL with a cotton liner
hypersensitivity is or worn over
cotton gloves, may
preferred by other
be used for gene-
clinicians when ade-
ral purposes and
quate facilities or training
household tasks
to deal with anaphylaxis o take off the gloves
are inadequate. on a regular basis
• Skin prick or use tests as sweating may
are also useful when aggravate existing
investigating protein dermatitis
contact dermatitis in
occupations at risk Caution: occlusion by gloves I
such as chefs or vete- may impair the stratum cor-
rinarians neum barrier function

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 Contact Dermatitis

C. Substitution steroids are to be

• Substitute with non- used on the eyelid
irritating agents (as in for a period of
soap substitutes) more than one
• Correct recycling of month, refer to
oils in heavy industry an ophthalmolo-
and reduction of, or gist for monitoring
changing, the biocide of intraocular pres-
additives may help. sure and the deve-
lopment of cata-
racts1.
II. ALLERGIC CONTACT • There is marginal C IV
DERMATITIS benefit in the use of
A. Workplace Visit a combined topical
• identifies potential B III corticosteroid/anti-
allergens and irritants biotic combination in
• may be essential in infected or potentially
the effective treatment infected eczema.
and prevention of
contact dermatitis D. Second-Line
Treatments
B. Barrier and After- • Psoralen plus UVA, A I
Work Creams azathioprine and
• Barrier creams by E I cyclosporin are used
themselves are of for steroid-resistant
questionable value in chronic hand derma-
protecting against titis.
contact with irritants. • Grenz rays for chro- B I
This should not over- nic hand dermatitis
promoted as it may showed a signifi-
give a false sense of cantly better res-
security and be com- ponse compared with
placent in implement- use of topical corti-
ing appropriate pre- costeroids.
ventive measures. • Oral retinoids (Alitre- B I
• There is benefit in the A I tinoin) have been
use of soap substi- used in the treatment
tutes and after-work of chronic hand
creams in reducing eczema.
the incidence and
prevalence of contact E. Nickel Elimination
dermatitis. Diets
• There is some benefit C IV
C. Topical Corticosteroids of low nickel diets in
• Steroid Potency some nickel-sensitive
o Regular use of patients.
Class 1, 2 or 3
steroids on thin
skin will lead to Prognosis
steroidatrophy • long-term prognosis
(thinning and easy for occupational
bruising/purpura) contact dermatitis is
and also hypo- often very poor
pigmentation in • Over a 10 year
darker skin types. period, a quarter of
o For the face: Class cases completely
6, 7 steroids (least healed, a quarter had
potent or mild) can and half had periodic
safely be used in- symptoms; No reso-
termittently during lution in 40% even
flares if topical after changing occu-

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 Contact Dermatitis

pations (Swedish
study) II-ii
• 55% of patients still
had dermatitis
after 2 years from
diagnosis (Australian
study)
• Milder cases can
resolve depending
on the ease of
avoidance.

Citation:
Bourke, J., I. Coulson, and J. English. Guidelines for the
management of contact dermatitis: an update. British
Journal of Dermatology 160.5 (2009): 946-954.

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 Contact Dermatitis

Index of Drugs Referred to in the Guideline

This index lists the products of interest and/or their therapeutic classifications related to the guideline. This index
is not part of the guideline. For the doctor's convenience, brands available in the PPD references are listed under
each of the classes. For drug information, refer to the PPD references, namely: PPD, PPD App, Better Pharmacy
and TheFilipinoDoctor.com.

Emollients
Atopiclair Cream/Lotion
Calmoseptine Ointment
Ceradan
Ceraklin
Cetaphil Daily Advance
Ultra Hydrating Lotion
Cetaphil Moisturising Lotion
Cetaphil Restoraderm
Ellgy H2O ARR Lotion
Elovera
Nutraplus
Physiogel AI Cream
Physiogel Cream/Physiogel
Lotion

Topical Corticosteroids

Betamethasone
Betacrem
Betnovate
Diprosone
Clobetasol
Clobex
Clonate
Dermacare
Dermovate
Glevate
Desonide
Desowen Cream/
Desowen Lotion
Fluticasone
Cutivate
Halobetasol
Halovate
Hydrocortisone
Cortizan
Eczacort
Methylprednisolone
Advantan Cream/Ointment
Mometasone
Allerta Dermatec
Elica
Elocon
Lomeane
Mezo
Momate
Momecort

Azathioprine
Imuran

Ciclosporin
Arpimune
Sandimmun Neoral

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