AUTHOR AND EDITOR INFORMATION

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INTRODUCTION

Section 2 of 11  

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Background

Irritant contact dermatitis (ICD) is inflammation of the skin typically manifested by erythema, mild edema, and scaling. ICD is a nonspecific response of the skin to direct chemical damage that releases mediators of inflammation predominately from epidermal cells. A corrosive agent causes the immediate death of epidermal cells as manifested by chemical burns and cutaneous ulcers.

ICD remains understudied compared to allergic contact dermatitis. Most articles on contact dermatitis concern allergic contact dermatitis (see Contact Dermatitis, Allergic). This largely reflects the fact that with patch testing, a specific hypersensitivity and a probable cause of dermatitis can be identified in most cases of allergic contact dermatitis. No diagnostic test exists for ICD. The diagnosis rests on the exclusion of other cutaneous diseases (especially allergic contact dermatitis) and on the clinical appearance of dermatitis at a site sufficiently exposed to a known cutaneous irritant.

In the consumer world, the term hypoallergenic is used widely, although no Food and Drug Administration–approved definition of hypoallergenic exists. A necessity exists for hypoirritating cleansers, cosmetics, moisturizers, and protectants; however, no standard method exists to identify products that are of great use to individuals with susceptible skin (eg, atopic dermatitis, facial skin of individuals with rosacea).

The hands are the most important sites of ICD. Most occupational skin disorders are ICD resulting from repeated workplace exposure of the hands to soaps, cleansers, and solvents.

Pathophysiology

ICD is the clinical result of sufficient inflammation arising from the release of proinflammatory cytokines from skin cells (principally keratinocytes), usually in response to chemical stimuli. Different clinical forms may arise. The 3 main pathophysiological changes are skin barrier disruption, epidermal cellular changes, and cytokine release.

A wide range of chemicals with sufficient concentration or duration of exposures are capable of acting as cutaneous irritants. Common cutaneous irritants include detergent and water. Most cases of homemaker's eczema are ICD resulting from repeated skin exposure to low-grade cutaneous irritants, particularly soaps, water, and detergents.

Cumulative ICD from repeated mild skin irritation from soap and water is common. For example, hand-washing frequency of more than 35 times per shift was associated strongly with occupational hand dermatitis in intensive care unit workers (odds ratio = 4.13).

Solvents are another major cause of cutaneous irritation because they remove essential fats and oils from the skin, which increases transepidermal water loss and renders the skin susceptible to the increased direct toxic effects of other previously well-tolerated cutaneous exposures.

Microtrauma also may produce skin irritation. A common example is fiberglass, which may produce pruritus with minimal visible inflammation in susceptible individuals. Many plant leaves and stems bear small spicules and barbs that produce direct skin trauma.

Physical irritants (eg, friction, abrasive grains, occlusion) and detergents such as sodium lauryl sulfate (SLS) in combination produce more ICD in combination than singly.

Skin irritation predisposes the skin to develop sensitization to topical agents. Skin irritation by both nonallergenic and allergenic compounds induces Langerhans cell migration and maturation.¹ An exacerbation of ICD may reflect development of allergic contact dermatitis to topical creams, medications, or rubber gloves.

The pathogenesis of ICD involves resident epidermal cells, dermal fibroblasts, endothelial cells, and various leukocytes interacting with each other under the control of a network of cytokines and lipid mediators. Keratinocytes play an important role in the initiation and perpetuation of skin inflammatory reactions through the release of and responses to cytokines. Resting keratinocytes produce some cytokines constitutively.

A variety of environmental stimuli (eg, ultraviolet light, chemical agents) can induce epidermal keratinocytes to release inflammatory cytokines (interleukin 1, tumor necrosis factor a), chemotactic cytokines (interleukin 8, interleukin 10), growth promoting cytokines (interleukin 6, interleukin 7, interleukin 15, granulocyte-macrophage colony-stimulating factor, transforming growth factor a), and cytokines regulating humoral versus cellular immunity (interleukin 10, interleukin 12, interleukin 18). Intercellular adhesion molecule 1 promotes the infiltration of leukocytes into the epidermis in cutaneous inflammatory reactions, including ICD.

Significantly increased numbers of dividing keratinocytes are present 48 and 96 hours after exposure to the anionic emulsifying agent SLS (used in medicated shampoos, skin cleansers, acne treatments, and toothpastes and as an experimental irritant). At sites of previous ICD chronic skin reactivity to SLS, hyperreactivity developed even after the 10th week postinduction compared with normal sites.

All irritants provoke a similar pattern of cellular infiltration in the dermis; the densities of most of the cell types rise in proportion to the intensity of inflammation. Within the epidermis, marked differences exist in the patterns of cellular infiltration among different irritants.

Frequency

United States

ICD is common in occupations that involve repeated hand washing or repeated exposure of the skin to water, food materials, and other irritants. High-risk occupations include cleaning, hospital care, food preparation, and hairdressing. The prevalence of occupational hand dermatitis was found to be 55.6% in 2 intensive care units and was 69.7% in the most highly exposed workers (those reporting a frequency of hand washing >35 times per shift). Hand-washing frequency of more than 35 times per shift was associated strongly with occupational hand dermatitis.²

International

In Denmark, cleaners comprise the greatest number of affected workers, but culinary workers have the highest incidence. A higher proportion of prolonged sick leave is seen among those in food-related occupations compared with those in wet occupations.³ The incidence rates of ICD and allergic contact dermatitis in Germany were 4.5 patients per 10,000 workers for ICD, compared with 4.1 patients per 10,000 workers for allergic contact dermatitis. The highest ICD annual incidence rates were found in hairdressers (46.9 cases per 10,000 workers per year), bakers (23.5 cases per 10,000 workers per year), and pastry cooks (16.9 cases per 10,000 workers per year.⁴

Mortality/Morbidity

Hydrofluoric acid is a potent cutaneous irritant used in low-technology and high-technology industries and at home in rust removal. Exposure to this strong inorganic acid may produce death from hypocalcemia if as little as 1% of the skin's surface area is exposed sufficiently to this toxic agent and if complications are not managed optimally (see Hydrofluoric Acid Burns).

Sex

ICD is significantly more common in women than in men. The high frequency of hand eczema in women in comparison with men is caused by environmental factors, not genetic factors. Occupational ICD affects women almost twice as often as men in contrast to other occupational diseases that predominantly affect men. Women are exposed more highly to cutaneous irritants from their disproportionately greater role in housecleaning and the care of small children at home. In addition, women predominantly perform many occupations at high risk for ICD (eg, hairdressing, nursing).

Age

ICD may occur at any age. Many cases of diaper dermatitis are ICD resulting from direct skin irritants present in urine and, especially, feces. Older persons have drier and thinner skin that does not tolerate soaps and solvents as well as younger individuals. Occupational hand eczema (OHE) often is associated with persistent dermatitis and prolonged sick leave with substantially greater severity among those with occupational ICD and atopic dermatitis (AD) and age above 50 years.

CLINICAL

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History

A detailed history is required because the diagnosis of ICD rests on the history of exposure of the affected body site to the cutaneous irritant. Patch testing also is used in severe or persistent cases to exclude allergic contact dermatitis as a component of the individual's cutaneous manifestations.

• Primary subjective symptoms include the following:
• • History of sufficient exposure to a cutaneous irritant is noted.
  • Onset of symptoms occurs within minutes to hours of exposure in simple acute ICD. Acute delayed ICD is characteristic of certain irritants, such as benzalkonium chloride (eg, zephiran, a preservative and disinfectant), which elicits a retarded (8-24 h after exposure) inflammatory reaction.
  • The onset of signs and symptoms may be delayed by weeks in cumulative ICD. Cumulative ICD is a consequence of multiple incidents of subthreshold damage to the skin, with the time between exposures being too short for a resolution of skin barrier function. Patients with sensitive skin (ie, atopic individuals) have a decreased irritant threshold or a prolonged restoration time, making them more vulnerable to clinical ICD. Cumulative ICD is not dependent on exposure to a potent irritant, but exposure to weak irritants, which prompt the reaction. Often, the exposure (ie, water) is not only at work but also at home. These patients report both itching and pain caused by fissuring of the hyperkeratotic skin (chapping).
  • Pain, burning, stinging, or discomfort exceeding pruritus early in the clinical course occur.
• Less important subjective criteria include the following:
• • Onset of dermatitis within 2 weeks of exposure
  • Reports of many other coworkers or family members affected
• Occupational ICD typically affects workers who are new to a job, who are constitutionally more susceptible to ICD, or who have not learned to protect their skin from cutaneous irritants.
• Verified history of many other coworkers affected by similar contact dermatitis indicates ICD because most allergens do not sensitize more than a few percent of exposed individuals. Exceptions are potent contact sensitizers, such as the contact allergen in poison ivy, or experimental sensitizers such as diphencyprone or dinitrochlorobenzene (DNCB).
• Individuals with history of atopic dermatitis (especially of the hands) are more susceptible to ICD, particularly of the hands.
• Other causes of contact dermatitis (particularly allergic contact dermatitis) must be excluded by history and/or patch testing to the relevant allergens.

Physical

• Rietschel and Fowler⁵ proposed the primary diagnostic criteria for ICD as follows:
• • Macular erythema, hyperkeratosis, or fissuring predominating over vesiculation
  • Glazed, parched, or scalded appearance of the epidermis
  • Healing process beginning promptly on withdrawal of exposure to the offending agent
  • Patch testing negative and includes all possible allergens
• Minor objective criteria include the following:
• • Sharp circumscription of the dermatitis
  • Evidence of gravitational influence such as a dripping effect
  • Lower tendency for the dermatitis to spread than in cases of allergic contact dermatitis
  • Morphologic changes suggesting small differences in concentration or contact time producing large differences in skin damage
• Individuals may develop a habit of continuing to rub a site initially affected by ICD and may develop secondary neurodermatitis or lichen simplex chronicus (lichenification), which may be accepted as a sequela of an occupational injury.

Causes

Almost any material may be a cutaneous irritant with sufficient exposure in time and/or concentration.

• Dry air: Dry air renders the skin more susceptible to cutaneous irritants. Sufficiently dry air alone may provoke ICD. Most cases of winter itch are a result of dry skin from the drier air found during sustained periods of cold weather.
• Temperature variation: An increase in temperature (up to 43ºC from 20ºC) increases the cutaneous effect of an irritant.⁶
• Water: Continual exposure to water may produce maceration or repeated evaporation of water from the skin may produce cutaneous irritation by desiccation of the skin. Even distilled water experimentally provokes increased CD11c⁺ cells and neutrophils in the epidermis.
• Solvents: Many individuals are exposed to solvents, particularly at work. Solvents such as alcohol or xylene remove lipids from the skin, producing direct ICD and rendering the skin more susceptible to other cutaneous irritants, such as soap and water.
• Alcohol: ICD from alcohol most often is cumulative. Manual workers may wash their hands inappropriately with solvents to remove oil, grease, paints, or other materials; thus, they develop ICD. Inappropriate skin cleansing is a primary cause of ICD in the workplace. Washing facilities and methods must be inspected when investigating the workplace for 1 or more cases of occupational ICD. The irritating agents include aromatic, aliphatic, and chlorinated solvents, as well as solvents such as turpentine, alcohol, esters, and ketones. Some organic solvents produce an immediate erythematous reaction on the skin and remove lipids from the stratum corneum.
• Metalworking fluids: Neat oils most commonly produce folliculitis and acne. They may cause ICD (as well as allergic dermatitis). Water-based metalworking fluids often cause ICD in exposed workers; surfactants in these fluids are the main culprit.
• Cumulative ICD: This is common in many occupations that often are termed wet work. Health care workers wash their hands 20-40 times a day, producing cumulative ICD. Similar exposures occur among individuals who wash hair repeatedly or in cleaners or kitchen workers. Multiple skin irritants may be additive or synergistic in their effects. Alcohol-based hand-cleansing gels cause less skin irritation than hand washing and therefore are preferred for hand hygiene from the dermatological point of view. An alcohol-based hand-cleansing gel may even decrease, rather than increase, skin irritation after a hand wash, owing to a mechanical partial elimination of the detergent.⁷
• Microtrauma: Many plant leaves and stems bear small spicules and barbs that produce direct skin trauma.
• Fiberglass: Fiberglass produces direct damage to the skin, usually manifested by pruritus that may result in excoriation and secondary skin damage. Cutaneous irritation primarily is caused by fiberglass with diameters exceeding 4.5 µm. Controversy surrounds whether individuals with dermatographism are more susceptible to fiberglass dermatitis. Most workers with ICD resulting from fiberglass develop hardening, in which they tolerate further cutaneous exposure to fiberglass.
• Mechanical trauma: Pressure produces callus formation. Pounding produces petechia or ecchymosis. Sudden trauma or friction produces blistering in the epidermis. Repeated rubbing or scratching produces lichenification. Sweating and friction appear to be the main cause of dermatitis that appears under soccer shin guards in children.⁸
• Rubber gloves: Some rubber gloves may provoke direct cutaneous irritation. Many workers complain of irritation from the powder in rubber gloves. Remember that gloves compromised by a hole may allow an irritant to enter; occlusion dramatically increases skin damage from the irritant. Occlusion accentuates the effects, good or bad, of topical agents. Kerosene may produce skin changes similar to that of toxic epidermal necrolysis following occluded cutaneous exposure. Excessive amounts of ethylene oxide in surgical sheets also may produce similar changes.
• Sodium lauryl sulfate: This chemical is found in some topical medications, particularly acne medications, and also is a classic experimental cutaneous irritant.
• Hydrofluoric acid: A hydrofluoric acid burn is a medical emergency. Remember that onset of clinical manifestations may be delayed after the acute exposure (crucial to diagnosis). Unfortunately, hydrofluoric acid burns are most frequent on the digits where the pain is most severe and management is most difficult (see Hydrofluoric Acid Burns).
• Alkalis: Skin surfaces normally have an acidic pH and alkalis (eg, many soaps) produce more irritation than many acids. The "acid mantle" of the stratum corneum seems to be important for both permeability barrier formation and cutaneous antimicrobial defense. Use of skin cleansing agents, especially synthetic detergents with a pH of approximately 5.5 rather than alkaline pH, may help prevent skin disease.⁹

DIFFERENTIALS

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WORKUP

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Lab Studies

• A bacterial culture can be obtained in cases complicated by secondary bacterial infection.
• A KOH examination may be performed and samples for mycology may be obtained to exclude superficial tinea infections or candidal infections, depending on site and morphology of lesions.
• Findings of significantly elevated serum immunoglobulin E occasionally are useful to substantiate an atopic diathesis in the absence of a personal or family history of atopy.

Procedures

• Patch testing can be performed to diagnose contact allergies, but no patch test exists that proves that a cutaneous irritant is responsible for a particular case of ICD. Diagnosis rests on exclusion of allergic contact dermatitis and history of sufficient exposure to a cutaneous irritant.
• Skin biopsy can help exclude other disorders, such as tinea, psoriasis, or cutaneous T-cell lymphoma. All clinical cases of dermatitis are similar histologically. Skin biopsy of skin lesions of the palms and soles has several potential pitfalls. The stratum corneum and epidermis are particularly thick on the palms and soles. This makes the histologic diagnosis of psoriasis more difficult and increases the possibility that the biopsy specimen lacks sufficient dermis for optimal diagnosis. An overly deep skin biopsy of the thenar area can cut the motor nerve, which is the recurrent branch of the median nerve. A biopsy from the sole may leave a chronic painful scar on which the patient must walk. A saucerized shave biopsy is usually the most suitable method.

Histologic Findings

The histopathology of acute experimental ICD has been studied to a greater extent than chronic ICD, which is the primary clinical complaint.

Cellular changes seen in the skin vary according to the chemical nature and concentration of the irritant applied, duration of exposure, severity of ensuing response, and time of sampling for acute ICD. Many primary irritants cause overt necrosis if applied in a sufficiently high concentration for sufficient time.

Most histologic examinations of ICD reveal some degree of intercellular edema or spongiosis in the epidermis. Spongiosis usually is less pronounced than that seen in allergic contact dermatitis reactions.

Parakeratosis also is observed widely in ICD reactions.

The histology of chronic ICD is one of hyperkeratosis with areas of parakeratosis, moderate-to-marked epidermal hyperplasia (acanthosis), and elongation of the rete ridges.

TREATMENT

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Medical Care

Acute ICD reactions to potent irritants (eg, acids, alkaline solutions) are comparable to a chemical burn and can be graded like thermal burns (ie, first-, second-, or third-degree burns). With appropriate symptomatic management, the prognosis for this type of ICD is usually good, and, unless the dermis is damaged, no permanent scarring should occur. See Burns, Chemical for more information.

An inflammatory reaction from acute delayed ICD to an agent such as benzalkonium chloride (eg, zephiran) rarely needs treatment and usually resolves with cessation of exposure.

• Topical corticosteroids and immunomodulators are of unproven use in treating ICD. Corticosteroids were found ineffective in treating the surfactant-induced irritant dermatitis when compared with the vehicle and with the untreated control. Topical tacrolimus is an irritant that may produce further stinging and irritation in persons with ICD.
• Creams containing ceramides (eg, Impruv, Cerave) may be particularly helpful in restoring the epidermal barrier in persons with ICD and AD.
• Creams containing dimethicone (eg, Cetaphil cream) can be helpful in restoring the epidermal barrier in persons with work-related ICD.
• Most soaps and detergents are alkaline and induce an increase in cutaneous pH, which affects the physiologic protective acid mantle of the skin by decreasing the fat content. Disruption of stratum corneum and changes in pH are key elements in the induction of ICD and pruritus by soaps. These conditions are exacerbated in the winter months in patients with dry, sensitive skin.
• A new generation of cleansers (synthetic detergents, or syndets) has emerged. Syndets with a pH approximately 5.5 seem to be especially relevant because they do not modify skin pH. Most bar soaps and liquid detergents available on the market are a mixture of soap and syndet. A study found that Dove and Cetaphil had a lower irritant effect than the other soaps tested. Interestingly, no significant correlation was made between the price of the products and their irritation potential.
• ICD is a frequent problem in health care workers, due to frequent hand washing. The best antimicrobial efficacy can be achieved with ethanol (60-85%), isopropanol (60-80%), and N-propanol (60-80%). The antimicrobial efficacy of chlorhexidine (2-4%) and triclosan (1-2%) is both lower and slower and carries a risk of bacterial resistance. The use of alcohol-based hand rubs containing various emollients instead of irritating soaps and detergents is one strategy to reduce skin damage, dryness, and irritation in health care workers. ICD occurs most frequently with preparations containing 4% chlorhexidine gluconate, less frequent with nonantimicrobial soaps and preparations containing lower concentrations of chlorhexidine gluconate, and least frequent with well-formulated alcohol-based hand rubs containing emollients and other skin conditioners.

Consultations

• Multidisciplinary consultations may be required when many workers become affected with ICD in a workplace. Identifying and remediating the causes of widespread ICD interfering with workplace productivity and worker quality of life is important.
• Any patient with hydrofluoric acid burn should be evaluated as a medical emergency by a physician experienced in the management of hydrofluoric exposures and burns (see Hydrofluoric Acid Burns). Consider regional intravenous infusion of calcium gluconate as a therapeutic option in hydrofluoric acid burns to forearm, hand, or digits when topical therapy fails.

Activity

Activities of daily living and work may be reduced by severe ICD.

MEDICATION

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Use of bland emollients, avoidance of irritation, and use of bland barrier creams such as those containing dimethicone are the mainstays of treatment for ICD. A number of agents commonly found in therapeutic products for the skin (eg, propylene glycol, lactic acid, urea, salicylic acid) may produce further skin inflammation and may need to be avoided in these individuals. Topical corticosteroids play a limited role in the treatment of ICD. They do not address the process directly, but they may be helpful for superimposed eczematous features.

Drug Category: Corticosteroids, topical

Immunosuppressives with anti-inflammatory properties that modify the body's immune response to diverse stimuli. Other actions include vasoconstriction and antiproliferation. Have limited use in the treatment of ICD.

FOLLOW-UP

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Further Inpatient Care

• Inpatient care is required only in severe cutaneous ICD, ie, chemical burns from hydrofluoric acid or, occasionally, from freshly mixed Portland cement.

Further Outpatient Care

• Individuals with ICD frequently are seen, particularly from the workplace. Identifying and minimizing exposure to cutaneous irritants at home and work is crucial.
• Advise individuals to use bland emollients after washing hands with soap and before sleep. Recommend mild skin cleansers (eg, Aquanil, Cetaphil cleanser, Oilatum AD, Neutrogena cleanser) in place of soap on affected areas.
• Instruct individuals to refrain from the use of inappropriate solvents (eg, gasoline) or abrasives (eg, pumice stone) to cleanse hands; these directly defat or traumatize the skin.

Complications

• ICD increases the risk of sensitization to topical medications.
• Skin lesions may become colonized secondarily and/or infected, particularly by Staphylococcus aureus.
• Secondary neurodermatitis (lichen simplex chronicus) may develop in individuals with ICD, particularly in those with workplace exposures or under psychologic stress.
• Postinflammatory hyperpigmentation or hypopigmentation may occur in areas affected by ICD or persist after resolution of ICD in individuals with more pigmented skin.
• Scarring may occur after corrosive agent exposure, excoriation, or artifact, causing ulceration.

Prognosis

• Prognosis is good for nonatopic individuals in whom ICD is diagnosed and managed promptly.
• Individuals with atopic dermatitis remain highly susceptible to ICD and may find that the tasks of many common occupations (eg, nursing, hairdressing) produce too much direct skin inflammation to continue with these careers.
• Hardening is specific to the irritant inducing the hardening phenomenon and does not occur in all persons chronically exposed to an irritant. An induction of an increase in the stratum corneum lipid ceramide 1 may play a key role as a protection mechanism against irritation by repeated application of SLS.

Patient Education

• Remind individuals that they must continue to avoid cutaneous irritants; they will redevelop or aggravate dermatitis if they continue to have the same skin care exposures that resulted in ICD. The possibility of secondary or complicating allergic contact dermatitis always must be borne in mind.
• For excellent patient education resources, visit eMedicine's Skin, Hair, and Nails Center. Also, see eMedicine's patient education article Contact Dermatitis.

MISCELLANEOUS

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Medical/Legal Pitfalls

• ICD is a major occupational disease. The physician needs to take an occupational history from adults with suspect ICD.
• Secondary lichen simplex chronicus contributes to chronicity and is compensable according to American Medical Association guidelines for impairment rating.

Special Concerns

• Presence of ICD facilitates the development of allergic contact dermatitis (many cutaneous allergens also are irritants). Cutaneous irritation sets the stage for cutaneous sensitization to agents applied to the area of cutaneous inflammation.
• Most affected workers have a degree of permanent injury that is lower than that of other occupational diseases; however, the compensation pay was higher for skin diseases than for diseases of the respiratory system or musculoskeletal disorders, according to a study in Denmark.
• ICD is the most common occupational skin disorder; skin disorders comprise up to 40% of occupational illnesses.

MULTIMEDIA

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Media file 1:  Chronic irritant contact dermatitis of the hands in an older worker; the condition resulted in early retirement.
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Media type:  Photo

REFERENCES

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26. Rietschel RL, Nethercott JR, Emmett EA, Maibach HI, Storrs FJ, Larsen WG, et al. Methylchloroisothiazolinone-methylisothiazolinone reactions in patients screened for vehicle and preservative hypersensitivity. J Am Acad Dermatol. May 1990;22(5 Pt 1):734-8. [Medline].
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Article Last Updated: Nov 30, 2007