Contact dermatitis: patient treatment

By Cristiano Antonino On Feb 15, 2023

Contact dermatitis, a type IV delayed hypersensitivity reaction, is an acute or chronic skin inflammation resulting from direct skin contact with chemicals or allergens

What is contact dermatitis?

Skin sensitivity in contact dermatitis can develop after short or prolonged exposure.

Contact dermatitis, a type IV delayed hypersensitivity reaction, is an acute or chronic skin inflammation resulting from direct skin contact with chemicals or allergens.

The inflammation and irritation of the skin is often clearly demarcated and caused by contact with substances to which the skin is sensitive.

There are four basic types: allergic, contact, phototoxic and photoallergic

Allergic dermatitis. Allergic dermatitis results from direct contact with substances called allergens.

Irritant contact dermatitis. Irritant contact dermatitis develops when the skin comes into contact with an irritant substance.

Phototoxic contact dermatitis. Phototoxic contact dermatitis is a skin disorder similar to sunburn that results from direct tissue damage following the activation of a phototoxic agent induced by ultraviolet light.

Photoallergic contact dermatitis. Photoallergic contact dermatitis is a delayed-type hypersensitivity skin reaction in response to a photoantigen applied to the skin in subjects previously sensitised to the same substance.

Other types of dermatitis

Contact dermatitis. Caused by an allergen or irritant substance. Irritant contact dermatitis accounts for 80% of all cases of contact dermatitis.
Atopic dermatitis. Very common worldwide and on the increase. It affects males and females equally and accounts for 10%-20% of all referrals to the dermatologist. Individuals living in urban areas with low humidity are more prone to develop this type of dermatitis.
Dermatitis herpetiformis. Appears as a consequence of a gastrointestinal condition known as celiac disease.
Seborrhoeic dermatitis. More common in infants and in individuals between the ages of 30 and 70. It seems to affect mostly men and occurs in 85% of people with AIDS.
Nummular dermatitis. A less common type of dermatitis, for which the cause is unknown and which tends to appear more frequently in middle-aged people.
Stasis dermatitis. This is an inflammation of the lower legs caused by accumulations of blood and fluid, occurring most often in people with varicose veins.
Perioral dermatitis. Somewhat similar to rosacea, it appears most often in women between the ages of 20 and 60.
Infectious dermatitis. Dermatitis secondary to a skin infection.

The pathophysiology of contact dermatitis involves pathogens that irritate the skin

Binding. The hapten complex (small hydrophobic molecules) – protein enters the stratum corneum and binds to Langerhans cells that present the antigen at epidermal level.
Deception. These cells process the antigen and head to regional lymph nodes where they present the antigen to naive CD4 T cells.
Proliferation. These T cells then proliferate into memory and effector T cells, which cause contact dermatitis within 48-96 hours of re-exposure to the allergen.

The incidence of contact dermatitis is widespread throughout the world

80% of cases are caused by excessive exposure or the additive effects of irritants.

The most common type of dermatitis is irritant contact dermatitis, which accounts for about 80% of all contact dermatitis cases.

In occupational irritant contact dermatitis, the incidence of confirmed cases is 5 per 100,000 workers.

Causes

If there is a history of allergic conditions, the skin must be sensitive and contact dermatitis is more likely to develop.

Water. It may surprise you, but water can aggravate contact dermatitis due to frequent hand washing and prolonged contact with water.

Soaps. All types of soaps, detergents, shampoos and other cleaning agents contain harmful substances that can irritate the skin.

Solvents. Solvents such as turpentine, paraffin, fuel and thinners are strong substances that are harmful to sensitive skin.

Temperature extremes. There are people who are very sensitive even when exposed to temperature extremes, which may cause contact dermatitis.

Clinical manifestations

There are usually no systemic symptoms unless the rash is widespread.

Itching. When the patient is exposed to an irritant, severe itching occurs.

Erythema. The skin becomes red due to irritation.

Skin lesions. Vesicles are a common manifestation of contact dermatitis.

Tearing. Weeping refers to the oozing of vesicle contents, which may be pus or a watery substance.

Scabs. Vesicles begin to form a crust that slowly dries out.

Drying. The skin becomes dry and peels off.

Contact dermatitis can lead to the following complications:

Chronic itching and scaly skin. A skin condition called neurodermatitis starts with an itchy patch of skin that, if scratched habitually, can result in thick, leathery, discoloured skin.

Infection. If a rash is scratched habitually, it can turn into an open wound where bacteria can enter and cause an infection.

Assessment and diagnostic results

The location of the rash and exposure history help determine the condition.

Patch test. Patch testing of the skin with suspected agents can clarify the diagnosis.

Rapid thin layer epicutaneous test (TRUE). The most commonly used patch test is the TRUE test.

Medical management

The most important step in the medical management of dermatitis is to recognise the causative factor so that it can be avoided.

Avoiding the irritant. The key is to identify the substance causing the rash so that it can be avoided.

Phototherapy. There are patients who need light therapy to calm the immune system, and the method is called phototherapy.

Medicated baths. Medicated baths are prescribed for larger areas of dermatitis.

Drug therapy

Drug therapy for contact dermatitis usually consists of lotions, creams and oral medications.

Hydrocortisone, a corticosteroid, may be prescribed to combat inflammation in a localised area.

Antihistamines. Prescription antihistamines may be administered if the potency of non-prescription drugs is inadequate.

Barrier cream. These products can provide a protective layer to the skin.

Antibiotics. Topical or oral antibiotics may be used to treat secondary infection.

Nursing management

The nursing management of a patient with contact dermatitis involves the following:

Nursing assessment

Skin assessment should be the main focus of a patient with contact dermatitis.

Skin characteristics. Assess the skin, noting colour, moisture, texture and temperature.

Lesions. Note erythema, oedema, tenderness, presence of erosions, excoriations, fissures and thickening.

Appearance. Assess the patient’s perception and behaviour in relation to changes in appearance.

Nursing diagnosis

Based on the assessment data, the main nursing diagnoses are:

skin integrity impairment related to contact with irritants or allergens.
Disturbance of body image related to visible skin lesions.
Risk of infection related to skin abrasions and breaks.
Risk of impairment of skin integrity related to frequent scratching and dry skin.

Nursing care planning and objectives

Main article: 4 Nursing care plans for dermatitis

The main goals for the patient are:

The patient maintains optimal skin integrity within the limits of the disease, as evidenced by intact skin.
The patient verbalises his/her feelings about the lesions and continues daily activities and interactions.
The patient remains free of secondary infections.
The patient reports an increase in comfort level and the skin remains intact.

Nursing interventions

Appropriate nursing interventions for the patient include:

Skin care. Encourage the patient to bathe in warm water with a mild soap, then air-dry the skin and gently pat it dry.
Topical application. The usual application of topical steroid creams and ointments is twice daily, spread thinly and sparingly.
Preparation for phototherapy. Prepare the patient for phototherapy, because this method uses ultraviolet A or B light waves to promote skin healing.
Acknowledge the patient’s feelings. Allow the patient to verbally express his or her feelings about the skin condition.
Proper hygiene. Encourage the patient to keep the skin clean, dry and well lubricated to reduce skin trauma and the risk of infection.

Assessment

Patient’s expected outcomes include:

The patient maintained optimal skin integrity within the limits of the disease, as evidenced by intact skin.
The patient verbalised his feelings about the lesions and continued daily activities and interactions.
The patient remained free of secondary infections.
The patient reported increased comfort level and that the skin remained intact.

Discharge and home care guidelines

To reduce itching and soothe inflamed skin, the following guidelines should be followed:

Avoid the irritant. Avoid letting the substance causing the reaction come into contact with the skin.
Anti-itch creams. Apply anti-itch creams or calamine lotions to the affected area.
Cold application. Moisten soft cloths and hold them against the rash to soothe the skin for 15-30 minutes.
Avoid substances containing perfume. Choose perfume-free soaps, powders and other personal products as they may irritate the affected area.

Documentation guidelines

Documentation should focus on

Characteristics of the injury or condition.
Causal and contributing factors.
Impact of the condition on personal image and lifestyle.
Observations, presence of maladaptive behaviour, emotional changes, level of independence.
Available support system.
Recent or ongoing antibiotic therapy.
Signs and symptoms of the infectious process.
Treatment plan.
Teaching plan.
Responses to interventions, teaching and actions performed.
Achievement or progress towards desired outcomes.
Changes to the treatment plan.