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Contact dermatitis

This year, we have witnessed an increase in the incidence of dermatitis mainly due to the COVID19 pandemic. The discomfort, pimples or redness that appear as a consequence of the daily use of face masks and gloves is clinically known as contact dermatitis. Even though we know it is not the most severe consequence of the COVID19 pandemic, it is very frequent and uncomfortable. In today’s post we will explain what it is, how it appears and how to care it.

Contact dermatitis is defined as an inflammatory skin condition induced first by the exposure to a chemical, physical or environmental non infectious agent (1, 2). There are many kinds of contact dermatitis. The two main types are: irritant contact dermatitis and allergic contact dermatitis. The first one rises locally as a consequence of a continued exposure to an irritant agent. What does irritant agent mean? It isany physical or chemical element able to cause cell perturbation when it is applied on the skin at enough concentration and for a certain period of time (1). Allergic contact dermatitis could have a genetic background and it is based on the generation of an immune response to a determined non-infectious agent that could be detected previously. We post here a table that will help you to distinguish both kinds of contact dermatitis.

Table 1: Features for the distinction of allergic and irritant contact dermatitis (3):

Feature Irritant Allergic
Location Mainly hands Surface of the skin exposed
Symptoms Burning, pruritus, pain Pruritus
Apearance Dryness and cracking of the skin Vesicles and bullae
Borders Less marked edges Distinct borders

A study carried out in five European countries estimated that contact dermatitis affects about 8.2% of the population. People suffering this skin condition manifest that, many times, it affects their daily life: in their personal relationships, when they practice sport or even on their jobs. In fact, there are many jobs, such as hairdressers, florists, sanitary personal, etc. in which contact dermatitis is considered a work-related illness, since it can be caused by the equipment needed to carry out the profession  their job (4).

How does contact dermatitis occur?

Most of the human pathogens generate signals called pathogen-associated molecular patterns that are able to activate an immune response that starts with inflammation. In allergic dermatitis, irritant agents can interact similarly with our cells leading to an immune response based on reactive oxygen species, activation of proinflammatory signals and immune cells synthesis. Summarizing, irritant agents such as pollution particles, cosmetics, fabrics… which are present in our daily life, … can cause in sensitive people a reaction similar to the one occurring when a pathogen infects us (1).

In irritant contact dermatitis there is no agent recognition by the immune system. Instead it reacts to an irritation produced on the skin. When an external agent significantly hurts the skin it leads to a relatively rapid inflammatory response characterized by the appearance of an eczema. When damage is not that aggressive but it is repetitive, it overburdens reparative mechanisms and subtoxic contact dermatitis occurs. Despite the differences in the origin of immune reaction in contact dermatitis, the actual inflammatory process in the tissue is relatively uniform (2).

The typical clinical manifestations of contact dermatitis can range from slight scaling, redness, or edema to an eczematous condition. Features and severity of lesions are influenced by a variety of factors both endogenous and exogenous. On the one hand, endogenous factors comprise: skin hypersensitivity, individual sensitivity to an external agent, atopy conditions, age, ethnical factors, sensitivity towards UV radiation, etc. On the other hand, exogenous factors could be: part of contact with the body, body temperature, pH, period of contact, climatic conditions…(2).

This wide variety of symptoms and factors has enabled the creation of an irritant contact dermatitis classification based on morphology and temporally aspects (1).

Table 2: Types of irritant contact dermatitis (1).

Types of irritant contact dermatitis. (ICD) Agent Clinical course Signs and symptoms
Acute ICD Strong irritant (usually single agent) Acute onset after exposure. Usually (not always) quick recovery Erythema, edema, vesicles, bullae, Exudation. Burning, pain, stinging, pruritus
Delayed acute ICD Distinctive delayed/acute irritants Onset delayed- 12–24 h or longer after exposure Similar to acute ICD except for delayed onset
Irritant reaction Mild irritants like water, soap, and detergents Usually acute onset, multiple exposures Usually (not always) recovery with withdrawal redness, scaling, chapping, pustules, or erosions
Subjective (sensory) irritation Distinctive agents inducing sensory irritation Symptoms occur quickly following exposure Stinging, tingling, burning or itching
Non-erythematous (suberythematous) irritation Mild irritants like water, soap, and detergents Early stage of skin irritation No clinical signs
Chronic (cumulative) ICD Several weak irritants (chemical and physical agents) Slowly developing (weeks to years) Mild erythema, xerosis, hyperkeratosis, fissuring.
Traumatic ICD Traumatic factors (physical or chemical) Slowly developing after preceding trauma Similar to chronic ICD
Frictional dermatitis Low-grade frictional force Slowly developing Erythema, scaling hyperkeratosis, and fissuring in areas of friction
Asteatotic irritant eczema Low humidity, low temperatures Slowly developing Xerosis, ichthyosiform scaling, and superficial fissuring, especially on the lower legs
Acneiform ICD Metal, tars, oils, greases, metalworking fluids and chlorinated agents Slowly developing (weeks to months) Open and closed comedones, cysts, pustules
Airborne ICD Irritants released into the air (dusts, fibers, fumes, vapors) Variable, usually acute onset Dermatitis predominates in exposed areas, although it may affect protected skin due to contaminated clothing

The first step to curb the consequences of contact dermatitis is to suppress the exposure to the causing agent. When this is not possible, it is needed to minimize the surface of contact with irritant agents. Cool compresses or colloidal oatmeal baths can alleviate the symptoms of acute contact dermatitis and help dry and calm acute, oozing lesions. Generally, treatments recommended consist of topic treatments based on moisturizing creams or ointments that contain natural calming ingredients. When damage persists or it is very acute, doctors usually recommend topical steroids during a concrete period of time (3).

As we anticipated previously, there has been an increase in the incidence of contact dermatitis this year due to the continuous use of face masks and gloves and to the recommendation of washing hands frequently with hydroalcoholic solutions. In a study performed in Wuhan in February (5), a 74.5% of the asked people (n=280) manifested having adverse reactions on in the skin during the pandemic. The most common reaction was skin dryness or scaling followed by erythema and skin maceration, whereas the most common affected areas were the hands, nasal bridge and cheeks, which are the body sites frequently washed or in direct contact with masks, gloves and glasses. The authors of this work observed that this kind of reactions were more frequent in women than in men and in people that wore full body personal protective equipment for more than 6 hours.

Other studies have showed similar results in other populations (6-8), including Spain(9). Besides, many people asked expressed a deterioration of their previous cutaneous conditions such as acne or rosacea (7, 10).

What can we do to avoid this reaction?

It is essential to keep our skin well moisturized. If washes and desinfection are more frequent, moisturizing should also be.

In order to minimize the dehydrating effects of hydroalcoholic gels, we can use solutions without glycerin. Besides, it is preferable to use moisturizing creams that do not contain perfumes so we avoid an overexposure of our skin to irritant agents.

We all have seen pictures of sanitary workers with face marks caused by personal protection equipments. Some of these marks are due to the pressure they put on the skin, others appear as a consequence of the friction that occurs with the normal movements and others arise when we scratch ourselves. Whatever the origin is, many people end up developing contact dermatitis that can range from hematomas to wounds and pimples. This kind of mechanical dermatitis can be avoided with the use of dressings at pressure points on the face and ears or silicone gels in the equipments to ensure a less aggressive skin contact and minimize the rubbing (10).

REFERENCES

  1. Ale IS, Maibach HI. Irritant contact dermatitis. Rev Environ Health. 2014;29(3):195-206.
  2. Brasch J, Becker D, Aberer W, et al. Contact dermatitis. J Dtsch Dermatol Ges. 2007;5(10):943-951.
  3. Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician. 2010;82(3):249-255.
  4. Rashid RS, Shim TN. Contact dermatitis. BMJ. 2016;353:i3299. Published 2016 Jun 30.
  5. Lin P, Zhu S, Huang Y, et al. Adverse skin reactions among healthcare workers during the coronavirus disease 2019 outbreak: a survey in Wuhan and its surrounding regions [published online ahead of print, 2020 Apr 7]. Br J Dermatol. 2020;10.1111/bjd.19089.
  6. Bothra A, Das S, Singh M, Pawar M, Maheswari A. Retroauricular dermatitis with vehement use of ear loop face masks during COVID-19 pandemic [published online ahead of print, 2020 Jun 3]. J Eur Acad Dermatol Venereol. 2020;10.1111/jdv.16692.
  7. Lan J, Song Z, Miao X, et al. Skin damage among health care workers managing coronavirus disease-2019. J Am Acad Dermatol. 2020;82(5):1215-1216.
  8. Xie Z, Yang YX, Zhang H. Mask-induced contact dermatitis in handling COVID-19 outbreak [published online ahead of print, 2020 May 10]. Contact Dermatitis. 2020;10.1111/cod.13599.
  9. Navarro-Triviño FJ, Ruiz-Villaverde R. Therapeutic approach to skin reactions caused by personal protective equipment (PPE) during COVID-19 pandemic: An experience from a tertiary hospital in Granada, Spain [published online ahead of print, 2020 Jun 15]. Dermatol Ther. 2020;e13838.
  10. Balato A, Ayala F, Bruze M, et al. European Task Force on Contact Dermatitis statement on coronavirus disease-19 (COVID-19) outbreak and the risk of adverse cutaneous reactions [published online ahead of print, 2020 Apr 30]. J Eur Acad Dermatol Venereol. 2020;10.1111/jdv.16557.
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