Contact dermatitis is a non-infectious inflammatory skin disease
caused by an offending substance localized at the site of contact.
The prevalence and incidence are increasing throughout the world,
especially in Europe and North America. There are two main groups
irritant contact dermatitis and allergic contact dermatitis with
the former being more frequent. However, more than 4,000 contact
allergens are known to cause allergic contact dermatitis in
populations, of which nickel is the most common. Allergic contact
dermatitis is a delayed IV type hypersensitivity resulting from
cutaneous contact with a specific allergen. In pathogenesis, there
is a significant difference between irritant and allergic
dermatitis. Irritant contact dermatitis is a nonimmunologic,
nonspecific inflammatory reaction to a wide range of chemical,
physical or mechanical hazardous causes involving the innate immune
system without prior sensitization. On the other hand, in a delayed
type of hypersensitivity, concomitant activation of both the innate
and adaptive immune systems is required. Recent studies disclose
the role of TH17 in the pathogenesis of allergic contact
dermatitis. Despite a distinct pathogenesis of both irritant and
allergic contact dermatitis, there is no absolute visual
distinction between both types of contact dermatitis. In general,
irritant contact dermatitis tends to be milder than its allergic
counterpart. Patch testing is a standardized diagnostic procedure
used to confirm the causative allergen. The most common technique
is an occlusive patch test, but in exceptional circumstances a
modification of the patch test such as a photopatch test, open
test, repeated open application test (ROAT), strip patch test or
atopic patch test is used. Irritant contact dermatitis does not
possess special testing. The diagnosis is therefore established by
exclusion of negative test results in patch testing. Patch test may
also be performed in infants and children, whereby the indications
and testing technique are the same as in adults. In the management
of contact dermatitis, the keystone is to cease causal exposure,
meaning avoiding contact with the offending substance. In topical
therapy, the choice of active substance is important, but a
suitable vehicle disposes transportation to the site of
inflammation. Selection of the vehicle depends on the clinical
appearance and course of disease. The choice of an unsuitable
vehicle may result in the drop-out of topical therapy. Topical
corticosteroids are the mainstay therapy. Calcineurin inhibitors
are employed in dermatology as an alternative therapy to topical
corticosteroids with a better safety profile. Systemic treatments
are used in severe cases and may provide temporary remission, but
are not always suitable for prolonged use due to adverse effects.
Alitretinoin is used to treat severe and refractory chronic hand
dermatitis. After clinical clearance of contact dermatitis, the
skin barrier requires restoration therapy provided by a
moisturizing agent, which should be used for a prolonged period.
The application of a moisturizing agent promotes epidermal barrier
healing, prolongs the time to flare and reduces the number of
flares. Most frequently, absolute avoidance of the triggering
offending contact is very difficult, or even impossible. Therefore,
protective measures to prevent renewed skin contact are indicated.
Any type of symptomatic treatment cannot substitute this approach.
General
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