Contact Dermatitis: Treatments and Patient Approaches

Jeff Yu, MD, is a board-certified dermatologist located at Massachusetts General Hospital in Boston, MA. He is also a specialist in allergic contact dermatitis, and occupational dermatitis in adults and children. His other clinical interests include eczema, genodermatoses, and pediatric dermatology across the whole spectrum. He is an active member in American Contact Dermatitis Society, Society of Pediatric Dermatology, Pediatric Dermatology Research Alliance, and the American Academy of Dermatology. In this video Dr Yu shares how to implement new treatments and approaches for patients with contact dermatitis prior to his presentation at AAD Summer Meeting.

Transcript:

Dr Yu: There are several steps to even getting to the answer for a diagnoses of contact derm. The first thing is someone shows up with a rash. Sometimes, contact dermatitis can, like you said, clinically can look like a lot of different things.

One of the most common things that contact dermatitis is confused with is something called atopic dermatitis, which is certainly better recognized. There's a lot of research going into atopic dermatitis.

It is also a very prevalent condition as well. For example, in children, atopic dermatitis affects about 20% of the overall pediatric population. Not a lot of pediatric dermatologists or pediatricians are really thinking contact dermatitis when they see something that clinically looks like eczema to them.

They're just saying, "Oh, this is most likely just atopic dermatitis, and we'll treat it that way." Most of the time, they're going to be correct. There are certainly about a 5th to a 4th of those kids that have atopic dermatitis, that you are going to miss the fact that they also have some sort of a contact allergy contributing to this picture when they show up with this eczema-looking rash.

The first thing is just failing to recognize it. The second thing is the lack of dermatologists who are really experts in the area of contact dermatitis. I currently live in the Boston area. Here, we probably have over 200 dermatologists just within a few miles of one another.

It's a very dermatology-heavy metropolitan area. However, in the entire city, there's probably 4 of us that really do patch testing and are really experts in contact dermatitis. The density of contact dermatologists is certainly not nearly as high as that of your dermatologist, dermatopathologist, most surgeons, eg.

There's certainly more of them than there are of us. I can imagine in areas, eg, that are more rural. I was just talking to someone the other day who lives out in eastern Washington. 

She is responsible for the entire are of eastern Washington, Wyoming, Idaho. All those places out there that really don't have anybody else that is doing patch testing. Even if you were an astute dermatologist thinking about it, who you're going to send to, to see if you can figure out what they are allergic to?

Once you figure out what they're allergic to, the next challenge comes in interpreting the results. Like most tests, you really have to interpret it correctly for the patient. For example, someone shows up with a rash, and they're allergic to 3 different things. 

It may be 1 of them is really the culprit and the other 2 are just either bystanders. Or there's something that they're allergic to in the past that may not be relevant. 

A good contact dermatologist is really able to dissect that out and say, "Oh, you're most likely allergic to this. Therefore, if you avoid this, hopefully things will get better," without upending their entire lives by having them avoid 20 different things that may not be relevant.

Contact dermatitis and the diagnoses of contact dermatitis still has a long way to go. The way that we diagnose contact dermatitis is through a method called patch testing. A lot of people confuse patch testing with what's called prick testing, which is what the allergists tend to do.

In prick testing, they're really looking for environmental and food allergens, things like pollen, cat, dust, dander, grass pollen, and things like that. In patch testing, we do it a little bit differently. We're really looking for identifying culprit allergens that you are coming in contact with.

Eg, like you've said, the shampoo. Or it could be metal jewelry. Or it could be the leather that you're wearing as a jacket when you go motorcycle riding, eg, with the leather in your upholstery. Things like that are what we're really looking for, things that your skin is coming in contact with.

Usually, when we do patch testing, we're probably looking at somewhere between 80 to almost up to 200 different allergens, depending on the patient, depending on what we're looking for, depending on their occupation.

There are different factors that go into what we choose to test to. Of course, with testing to that many allergens, there is a good possibility that we're going to find 1, 2, sometimes even 10 different things that may or may not be positive.

I always preface the test by telling patients that this test is highly sensitive. What that means is that we're going to pick up things that you may be allergic to. Just not all of them are going to be specific to you.

Eg, if you were a 40-year-old woman coming in with a rash that's predominantly on your face and you're allergic to, say, nickel, which is a very common metal that's found in things like jewelry. You can tell me that all your jewelry is made out of gold.

When you were 14 years old, you had a pair of earrings made from Claire's, eg. They were made out of custom jewelry. They were made out of nickel, and you had a reaction on your earlobe. 

That's probably why you're testing positive to nickel, as opposed to you actually coming in contact with nickel on your face, causing the current rash that you have right now. The history needs to be taken into account.

There are exceptions to that as well, because people could certainly consume nickel. Sometimes they can get a rash to that. Or you could be using nickel things like eyelash curlers on your face that could be contributing to the rash.

A lot of times, that's where the questioning really comes in. You have to ask questions like, are you using eyelash curlers? Do you eat a lot of nickel-heavy foods? Things like that, that will help play into how relevant I think a potential allergen is.

I always tell people, here are 10 things that I found that you are allergic to. Not all of them are going to be relevant. At this point in time, I probably don't know which 1 of these 10 things are relevant to you.

In the interest of everybody—my interest is to get you better. Your interest is to get better as well. We start off by being very strict. We say, you're going to avoid all of these things.

When people avoid all of these things, we have this really neat application that's available to us called the Contact Allergen Management Program. This is a database of products that has been vetted by experts and contact dermatitis that we know what the ingredients are. 

By knowing what the ingredients are, this really cool computer program that's also available as an app on your phone is going to be able to sort through your allergens and say, "You cannot use these 300 things, but these 50 products or these 50 shampoos are going to be OK for you to use."

I give every patient access to that program with a unique access code that they can then sort through and say, based on my contact allergens, I can use X-shampoo, Y-conditioner, this particular body wash. I can use this hand cream, this facial moisturizer, things like that.

I have them all be very strict and stick to this regimen for about the next 2 to 3 months until they clear up. After that, we meet again. We start to say, what do you think was causing it? What have you used so far? How are you doing? Have you started to add your original products back in?

I hate for patients to throw away thousands of dollar’s worth of cosmetics and shampoos without me really knowing, is that what's doing it? Have them hold on to everything and slowly add things back in every two weeks or so, and see if their rash clears up.

If everything is going well, chances are that was not the culprit allergen. Maybe it was something else.