3/16/2021 DISCLOSURES • I have no disclosures • Off-label use of medications will be clearly labeled SUMMER IS NEAR AND SKIN ISSUES ARE HERE TANDY S. REPASS, MD 1 2 CLINICAL IMAGES CLINICAL IMAGES • DermNet New Zealand • www.dermnetnz.org • Unmodified images • https://creativecommons.org/licenses/by-nc-nd/3.0/nz/legalcode • Bolognia 3rd Edition • Edwards L. Genital Dermatology Atlas. Philadelphia: Lippincott Williams & Wilkins; 2004. 3 4 OBJECTIVES OBJECTIVES • Explore evidence-based practices related to • Explore evidence-based practices related to management of contact dermatitis, insect and management of contact dermatitis, insect and animal bites, and insect stings. animal bites, and insect stings. • Formulate effective strategies for managing • Formulate effective strategies for managing sunburns, burns, abrasions, abscesses, and fungal sunburns, burns, abrasions, abscesses, and fungal infections. infections. • Analyze management strategies for lacerations • Analyze management strategies for lacerations (suturing, Dermabond, medications, and follow-up). (suturing, Dermabond, medications, and follow-up). 5 6 1 3/16/2021 MANAGEMENT MANAGEMENT • Contact dermatitis • Contact dermatitis • Insect and animal bites • Insect and animal bites • Insect stings • Insect stings 7 8 CONTACT DERMATITIS CONTACT DERMATITIS • Irritant vs. allergic contact dermatitis • Irritant vs. allergic contact dermatitis • Allergic contact dermatitis • Allergic contact dermatitis • Poison ivy (urushiol) • Poison ivy (urushiol) • Nickel (chronic vs. acute) • Nickel (chronic vs. acute) • Balsam of Peru • Balsam of Peru • Neomycin • Neomycin • Formaldehyde • Formaldehyde • Special types of allergic contact dermatitis • Special types of allergic contact dermatitis • Photoallergic contact dermatitis • Photoallergic contact dermatitis • Airborne allergic contact dermatitis • Airborne allergic contact dermatitis • Stasis dermatitis • Stasis dermatitis • Hand dermatitis • Hand dermatitis • Management • Management 9 10 IRRITANT VS. ALLERGIC CONTACT IRRITANT CONTACT DERMATITIS DERMATITIS • Irritant contact dermatitis • Hand dermatitis • Non-immune-modulated • Note finger web spaces • Skin injury, direct cytotoxic effects, or cutaneous • Often from occupational exposures inflammation from contact with an irritant • Chemical irritants (solvents and cutting fluids) account for most cases • Allergic contact dermatitis • Type IV, T-cell mediated, delayed hypersensitivity response • Occurs with re-exposure • Common examples: Poison ivy, nickel, and fragrances Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55. 11 12 2 3/16/2021 IRRITANT CONTACT DERMATITIS CONTACT DERMATITIS • Lip licker’s dermatitis • Irritant diaper dermatitis • Allergic contact dermatitis • Irritant contact dermatitis • Wipes, lidocaine, male condoms, • Over-washing • Excessive lip licking spermicide, soap Edwards. Genital Dermatology Atlas. 2004 13 14 ALLERGIC CONTACT DERMATITIS CONTACT DERMATITIS • Eyelid dermatitis • Lip dermatitis • Irritant vs. allergic contact dermatitis • Allergic contact dermatitis • Poison ivy (urushiol) • Nickel (chronic vs. acute) • Balsam of Peru • Neomycin • Formaldehyde • Special types of allergic contact dermatitis • Photoallergic contact dermatitis • Airborne allergic contact dermatitis • Stasis dermatitis • Hand dermatitis • Management 15 16 URUSHIOL POISON IVY DERMATITIS • Sap of rhus plants • Wash off immediately before it is absorbed • Poison ivy, oak, and sumac • 50% can be removed at 10 minutes, 25% at 15 • Plants brush across skin minutes, and 10% at 30 minutes causing linear streaks of • After 30 minutes, sufficient penetration of urushiol erythema and vesicles has occurred • Lack of definitive preventative therapy besides avoidance Kim Y, Flamm A, ElSohly MA, Kaplan DH, Hage RJ Jr, Hamann CP, Usatine RP, Riojas M. Diagnosis and management of contact Kim Y, Flamm A, ElSohly MA, Kaplan DH, Hage RJ Jr, Hamann CP, Marks JG Jr. Poison Ivy, Oak, and Sumac Dermatitis: What is Marks JG Jr. Poison Ivy, Oak, and Sumac Dermatitis: What is dermatitis. Am Fam Physician 2010;82(3):249-55. Known and What is New? Dermatitis 2019;30(3): 183-190. Known and What is New? Dermatitis 2019;30(3): 183-190. 17 18 3 3/16/2021 NICKEL DERMATITIS NICKEL DERMATITIS • Component of many metals • White gold, German silver, gold plating, solder, stainless steel • Hairdressers using nickel- containing scissors • Crochet hooks Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55. Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55. 19 20 ALLERGIC CONTACT DERMATITIS: NICKEL DERMATITIS: CHRONIC ACUTE Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55. Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55. 21 22 BALSAM OF PERU NEOMYCIN • In personal care products and cosmetics • Over-the-counter • Fragrance topical antibiotic • Fragrance masker in products labeled “unscented” • Balsam of Peru diet • Vesicles • Avoid: Spices, ketchup, chili sauce, barbecue sauce, citrus products, colas, beers, wines, bakery items, candy, ice cream, chocolate, and tomatoes • Geometric • Improve systemic contact dermatitis in patients with contact allergy • Important to distinguish from infection Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55. 23 24 4 3/16/2021 NEOMYCIN FORMALDEHYDE SENSITIVITY • Diffuse truncal rash • Permanent press/wrinkle-resistant fabrics release formaldehyde • Formaldehyde in the clothing could be contributing Mowad CM, Anderson B, Scheinman P, Pootongkam S, Nedorost S, Brod B. Allergic contact dermatitis: Patient management and education. J Am Acad Dermtol. 2016;24(6): 1043-54. Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55. 25 26 SPECIAL TYPES OF ALLERGIC CONTACT CONTACT DERMATITIS DERMATITIS • Irritant vs. allergic contact dermatitis • Photoallergic contact dermatitis • Allergic contact dermatitis • Airborne contact dermatitis • Poison ivy (urushiol) • Stasis dermatitis • Nickel (chronic vs. acute) • Balsam of Peru • Hand dermatitis • Neomycin • Formaldehyde • Special types of allergic contact dermatitis • Photoallergic contact dermatitis • Airborne allergic contact dermatitis • Stasis dermatitis • Hand dermatitis • Management 27 28 PHOTOALLERGIC CONTACT AIRBORNE CONTACT DERMATITIS DERMATITIS • Sun-exposed areas • Sparing behind the ear, under • Allergic contact dermatitis the chin, and under clothing • Irritant contact dermatitis • Areas on the skin with maximal exposure to sunlight • Most common causative • Type IV hypersensitivity agent is plants • Requires chemical exposed to Bolognia. Dermatology. 3rd ed. 2012. UV radiation • Photopatch testing Chrysanthemum allergy • Sunscreens (most frequently) Mowad CM, Anderson B, Scheinman P, Pootongkam S, Nedorost S, Brod B. Allergic contact dermatitis: Patient management and education. J Am Acad Dermtol. 2016;24(6): 1043-54. 29 30 5 3/16/2021 STASIS DERMATITIS CHRONIC HAND ECZEMA • Irritant contact dermatitis • Avoid latex gloves • Wound secretions • Wear nonlatex gloves • Allergic contact dermatitis when working with from various topicals solvents, soaps, and • Topical antibiotics detergents • Lanolin derivatives • Use cotton liners under • Fragrances gloves • Preservatives • Contact sensitization leads to secondary dissemination • Note the eruption on the arms • Id Reaction Bolognia. Dermatology. 3rd ed. 2012. Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55. 31 32 CHRONIC HAND ECZEMA CONTACT DERMATITIS • Patch testing positive to • Irritant vs. allergic contact dermatitis potassium dichromate • Allergic contact dermatitis and a piece of his glove • Poison ivy (urushiol) • Nickel (chronic vs. acute) • Balsam of Peru • Neomycin • Formaldehyde • Special types of allergic contact dermatitis • Photoallergic contact dermatitis • Airborne allergic contact dermatitis • Stasis dermatitis • Hand dermatitis • Management Bolognia. Dermatology. 3rd ed. 2012. 33 34 MANAGEMENT CONTACT DERMATITIS: MANAGEMENT • Education • Identify and avoid causative • Self-management substance • Education • Topical treatment • Self-management • Dimethylglyoxime test (nickel • Systemic treatment spot test) for nickel allergy • Widely available online • Patch testing/TRUE Test • Pink color change indicates presence of nickel • Example: Nickel Dermatitis • Cover metal tabs on jeans with iron-on patches or coats of clear nail polish Bolognia. Dermatology. 3rd ed. 2012. 35 36 6 3/16/2021 EDUCATION SELF-MANAGEMENT • Education on reading labels • Advise on how to test a new skin care product • “Fragrance-free” • Repeat Open Application Test • “Sensitive skin” • Apply a small amount of product to the volar aspect of the • “Dermatologist-tested” forearm twice a day for 1-2 weeks • “For baby” • If any eczematous reaction occurs they should avoid the • These products can still contain fragrance product • If ingredients are not used ”solely to impart an odor to a product” it is legal for a “fragrance-free” product to contain a fragrance Mowad CM, Anderson B, Scheinman P, Pootongkam S, Nedorost S, Brod B. Allergic contact dermatitis: Patient management and education. J Am Acad Dermtol. 2016;24(6): 1043-54. Rashid RS, Shim TN. Contact dermatitis. BMJ