14_199_254* 05.11.2005 10:15 Uhr Seite 201 Chapter 14 General Aspects 14 Niels K. Veien Contents 14.1 Introduction . 201 14.4.2.1 Cement Ulcerations . 224 14.4.2.2 Pigmented Contact Dermatitis . 225 14.2 The Medical History of the Patient . 202 14.4.2.3 Caterpillar Dermatitis and Irritant Dermatitis 14.2.1 History of Hereditary Diseases . 202 from Plants and Animals . 225 14.2.2 General Medical History . 202 14.4.2.4 Head and Neck Dermatitis . 225 14.2.3 History of Previous Dermatitis . 203 14.4.2.5 Dermatitis from Transcutaneous Delivery 14.2.4 Time of Onset . 203 Systems . 225 14.2.5 History of Aggravating Factors . 204 14.4.2.6 Berloque Dermatitis . 226 14.2.6 Course of the Dermatitis . 205 14.4.2.7 Stomatitis due to Mercury or Gold Allergy . 226 14.2.7 Types of Symptoms . 205 14.5 Regional Contact Dermatitis . 226 14.3 Clinical Features of Eczematous Reactions . 206 14.5.1 Dermatitis of the Scalp . 226 14.3.1 Acute and Recurrent Dermatitis . 206 14.5.2 Dermatitis of the Face and Neck . 228 14.3.2 Chronic Dermatitis . 210 14.5.2.1 The Lips . 230 14.3.3 Nummular (Discoid) Eczema . 211 14.5.2.2 The Eyes and Eyelids . 230 14.3.4 Secondarily Infected Dermatitis . 211 14.5.2.3 The Ear . 231 14.3.5 Clinical Features of Contact Dermatitis 14.5.3 Dermatitis of the Trunk . 232 in Specific Groups of Persons . 212 14.5.3.1 The Axillary Region . 233 14.3.5.1 Gender . 212 14.5.3.2 The Anogenital Region . 233 14.3.5.2 Children . 212 14.5.3.3 Stoma Dermatitis . 235 14.3.5.3 Elderly Persons . 212 14.5.4 Dermatitis of the Legs . 236 14.3.5.4 Ethnicity . 213 14.5.5 Dermatitis of the Feet . 237 14.3.5.5 Atopy . 214 14.5.5.1 Recurrent, Pruritic, Vesicular, 14.4 Identifying the Cause of Contact Dermatitis Plantar Dermatitis . 238 from the Clinical Pattern . 214 14.5.5.2 Hyperkeratotic Plantar Eczema . 238 14.4.1 Clinical Patterns Indicating General Causes 14.5.6 Dermatitis of the Arms . 238 of Contact Dermatitis . 214 14.5.7 Contact Stomatitis . 239 14.4.1.1 Contact Pattern . 214 14.5.8 Dermatitis Caused by Items Within 14.4.1.2 Streaked Dermatitis in Exposed Areas . 217 the Body . 240 14.4.1.3 Airborne Contact Dermatitis . 218 14.6 Differential Diagnosis . 240 14.4.1.4 Mechanical Dermatitis . 218 14.4.1.5 Hyperkeratotic Eczema . 219 14.7 Case Reports . 244 14.4.1.6 Ring Dermatitis . 220 References . 247 14.4.1.7 Follicular Reactions . 220 14.4.1.8 Connubial and Consort Dermatitis . 221 14.4.1.9 Recurrent Vesicular Hand and/or Foot Dermatitis . 221 14.1 Introduction 14.4.1.10 Fingertip Eczema (Pulpitis) . 221 14.4.1.11 Eczema Nails . 222 A diagnosis of contact dermatitis requires the careful 14.4.1.12 Papular and Nodular Excoriated Lesions . 222 consideration of many variables, including patient 14.4.1.13 Contact Urticaria of the Hands and Lips . 223 history, physical examination, and various types of 14.4.1.14 Clinical Patterns of Systemically Induced Contact Dermatitis . 224 skin testing. A thorough knowledge of the clinical 14.4.2 Characteristic Clinical Patterns of Dermatitis features of the skin’s reactions to various contactants Associated with Specific Substances or Types is important in making a correct diagnosis of contact of Application . 224 dermatitis. 14_199_254* 05.11.2005 10:15 Uhr Seite 202 202 Niels K.Veien While an eczematous reaction is the most com- A family history of psoriasis is important as it may monly encountered adverse reaction to contactants, be difficult to distinguish psoriasis from contact der- other clinical manifestations may also be seen. These matitis and seborrheic dermatitis. This is particular- include erosions, ulcerations, urticaria, erythema ly true on the scalp, the face, the anogenital area, and multiforme, purpura, lichenoid eruptions, exan- the hands. Köbner reactions on the hands of psoria- thems, erythroderma, allergic contact granuloma, sis patients can mimic irritant or allergic contact der- lymphocytoma, sarcoidal reactions, toxic epidermal matitis [15]. Likewise, Köbner reactions on the hands necrolysis, pigmented contact dermatitis, and photo- may show a striking resemblance to hyperkeratotic sensitive reactions [1–3]. Generalized symptoms have hand eczema. Both psoriasis and hyperkeratotic also been described in association with contact sen- hand eczema can be aggravated by physical trauma sitivity, as documented by challenge experiments [4, from, for example, the handles of tools. 5], and contact urticaria may become anaphylactoid [6] and life-threatening [7]. The emphasis in this chapter will be on eczemas as 14.2.2 General Medical History a manifestation of contact dermatitis. Other clinical manifestations will be described in detail in Chap. 21 Malnutrition may cause eczematous lesions in, for – and hand eczema, in particular, in Chap. 19. example, alcohol dependency [16] or in patients with acrodermatitis enteropathica or metabolic disorders such as phenylketonuria. In order to make a diagno- 14.2 The Medical History of the Patient sis of systemically induced dermatitis it is necessary to take a complete history of drug intake. Cutaneous 14.2.1 History of Hereditary Diseases sensitization to a drug may give rise to symmetrical dermatitis when the same drug,or a chemically relat- The family and personal history of a patient with ed drug, is taken orally or injected [17] (see Chaps. 16 contact dermatitis should be taken in detail, especial- and 35). Drug intake can also play a significant role in ly with regard to atopy. Patients who have suffered a number of photodermatoses. from severe atopic dermatitis in childhood are likely Obesity is an important factor in the development to experience irritant contact dermatitis later in life, of intertriginous dermatoses and mechanical contact particularly on the hands [8].A history of contact ur- dermatitis due to friction; the latter may be seen, for ticaria, in particular on the lips and hands, due to un- example, on the inner surfaces of the thighs of obese cooked food items is common among atopics [8]. children. Contact urticaria due to animal dander may aggra- Psychiatric disorders can lead to contact der- vate atopic dermatitis of the arms and the periorbital matitis caused by the compulsive clutching of keys 14 area. It can be useful to note the results of prick tests containing nickel (Fig. 1) or mechanical dermatitis carried out; for example, in previous attempts to dis- caused by the compulsive rubbing of the skin (Fig. 2). cover the cause of respiratory allergy.A positive prick test to house dust mites,animal dander or pollen may correlate with the results of an atopic patch test and Core Message may be relevant as an aggravating factor in atopic dermatitis [9, 10]. í Both family and medical history are impor- Patients with recurrent vesicular hand eczema are tant when making a diagnosis of contact often atopic [11], and Schwanitz [12] coined the term dermatitis. Rashes seen in metabolic dis- “das atopische Palmoplantareksem”after a study of eases and in obese persons may mimic the literature and having seen 58 patients with recur- contact dermatitis. Contact urticaria and rent vesicular hand eczema. Edman, however [13], irritant contact dermatitis are common in found no statistical correlation between atopy and persons with current or previous atopic this type of hand dermatitis. Details concerning the dermatitis. relationship between atopy and contact sensitization are given in Sect. 14.3.5.5 Atopy. It is unusual for a patient to have a family history of contact dermatitis. Although hereditary factors were seen to have some significance among twins with nickel allergy,these were found to be less impor- tant than environmental factors [14]. 14_199_254* 05.11.2005 10:15 Uhr Seite 203 General Aspects Chapter 14 203 Fig. 1. Allergic contact dermatitis in a nickel-sensitive psychi- atric patient who clutched nickel-containing keys all day contact with the same haptens if an otherwise unex- plained eruption of contact dermatitis occurs. A his- tory of axillary intolerance to spray deodorants is a good indication of fragrance allergy [18]. Further de- tails on the relationship between the history of nick- el allergy and atopy are given in Sect. 14.3.5.5 Atopy. A history of previous dermatitis near leg ulcers should lead to a suspicion of topical medicaments as the cause of current or possible future eruptions of dermatitis in this area or elsewhere.A history of der- matitis where adhesive tape has been applied should lead the physician to search for possible colophony sensitivity. It should be mentioned, however, that most modern adhesive tapes contain no colophony, as the adhesive substance is now usually an acrylate. 14.2.4 Time of Onset For long-standing contact dermatitis, the exact time of onset is usually ill-defined and is not useful in es- tablishing the final diagnosis. The cause of contact dermatitis with recent abrupt onset may be estab- Fig. 2. Factitious dermatitis from compulsory rubbing of the lished by taking a careful history of contactants dur- skin of the fingers. Note the sharp delineation from normal ing the days immediately preceding the onset of der- skin matitis. The history should include occupational ex- posures and exposures during leisure time and while working in the home or doing hobbies, as well as any 14.2.3 History of Previous Dermatitis changes in clothing or cosmetics, including soaps and detergents. Topical remedies used for the treat- A firm history of previous allergic contact dermatitis ment of the dermatitis, both prescription and over- from, for example, nickel, fragrances or topical me- the-counter products, should be recorded, as well as dicaments would be reason to suspect inadvertent any recent changes in systemic drug therapy.