By Cohen, Philip R; Schulze, Keith E; Totz, Robert; Nelson, Bruce R
The “Clinical Snapshot” series provides a concise examination of a clinical presentation including history, treatment, patient education, and nursing measures. Using the format here, you are invited to submit your “Clinical Snapshot” to Dermatology Nursing.
History: A 49-year-old white man had a squamous cell carcinoma of his nose excised using the Mohs micrographie surgical technique. The post-surgical defect was repaired with a full-thickness skin graft taken from his right preauricular area. Prior to bandaging, Mastisol liquid adhesive was applied to both sites.
Description of Skin Lesions: Within 36 hours pruritic erythematous edematous plaques with minute vesicles appeared on the patient’s face where the adhesive had been applied: the right preauricular cheek (see Figure 1), the nose, and the bilateral paranasal and malar regions (see Figure 2).
Etiology: Allergic contact dermatitis is a cell-mediated type IV delayed hypersensitivity reaction. It occurs when a specific antigen penetrates the epidermis of the skin, combines with a protein mediator, travels to the dermis, and sensitizes the patient’s T lymphocytes. The allergic reaction occurs following each subsequent exposure of the skin to the allergen.
Location: The cutaneous lesions appear at the skin sites that have come in contact with the antigen to which the patient is allergic.
Hallmark of the Disease: Clear fluid-filled vesicles or bullae on pruritic, erythematous, and edematous skin, which subsequently become exudative and weeping after the lesions rupture, characterize the presentation of an acute allergic contact dermatitis. Subacute and chronic clinical forms of the dermatitis can also occur; the former often appears as papules with less edema whereas the latter typically develops as lichenified plaques with scaling and fissures.
Figure 1.
Pruritic red edematous plaques with minute vesicles on the preauricular area.
Figure 2.
The erythematous and itching dermatitis includes not only the area of the skin graft on the patient’s nose, but also the bilateral adjacent paranasal and malar regions.
Treatment: The initial management requires removal and avoidance of the offending agent. Topical measures include wet soaks (such as Burow’s solution) if the affected area is weeping, and corticosteroid application in either a cream, ointment, gel, or foam base. Oral antihistamines may be helpful to alleviate pruritus. Also, systemic corticosteroid therapy may be necessary if the dermatitis is severe, generalized, or both.
Normal Course: The lesions resolve within 1 to 3 weeks after exposure to the associated allergen has been stopped and topical (with or without systemic) treatment has been started.
Patient Education: Avoiding contact with the dermatitis-inducing material is essential. In addition, prevention of subsequent cutaneous exposure to the allergen is important. For some patients, patch testing to the components of the dermatitis-causing agent may be helpful to identify the specific allergen(s). Alternatively, if the etiologic agent of the dermatitis is unknown, patch testing to several common allergens may be useful to determine the specific allergen(s).
Nursing Measures: This patient’s dermatitis persisted after topical treatment with a mid-potency corticosteroid (fluticasone propionate [Cutivate] 0.05%) cream was initiated. A 6-day tapering course of a systemic corticosteroid (methylprednisolone, starting at 24 mg and decreasing by 4 mg each consecutive day) was started. Subsequently, the patient promptly improved over the next few days. The patient was instructed to avoid future use of the Mastisol liquid adhesive and the potential allergens which it contains: gum mastic and styrax liquid. Avoidance, or patch testing prior to die use, of other topical adhesives was also recommended.
Philip R. Cohen, MD, is a Mohs Micrographic Surgery Fellow, Dermatologie Surgery Center of Houston, and Clinical Associate Professor of Dermatology, Department of Dermatology, University of Texas-Houston Medical School, Houston, TX.
Keith E. Schulze, MD, is Co-Director, Dermatologie Surgery Center of Houston, Houston, TX.
Robert Totz, MD, is in Private Practice, Houston, TX.
Bruce R. Nelson, MD, is Director, Dermatologie Surgery Center of Houston, Houston, TX.
Copyright Anthony J. Jannetti, Inc. Feb 2006
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