Allergic contact dermatitis

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doi:doi: 10.12788/jfp.0678

Dx Across the Skin Color Spectrum

Allergic contact dermatitis

J Fam Pract. 2023 October;72(8):350-352,355 | doi: 10.12788/jfp.0678

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References

1. Mowad CM, Anderson B, Scheinman P, et al. Allergic contact dermatitis: patient diagnosis and evaluation. J Am Acad Dermatol. 2016;74:1029-1040. doi: 10.1016/j.jaad.2015.02.1139

2. Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician. 2010;82:249-255.

3. Bertoli MJ, Schwartz RA, Janniger CK. Autoeczematization: a strange id reaction of the skin. Cutis. 2021;108:163-166. doi: 10.12788/cutis.0342

4. Johansen JD, Bonefeld CM, Schwensen JFB, et al. Novel insights into contact dermatitis. J Allergy Clin Immunol. 2022;149:1162-1171. doi: 10.1016/j.jaci.2022.02.002

5. Karagounis TK, Cohen DE. Occupational hand dermatitis. Curr Allergy Asthma Rep. 2023;23:201-212. doi: 10.1007/s11882-023- 01070-5

6. Cvetkovski RS, Rothman KJ, Olsen J, et al. Relation between diagnoses on severity, sick leave and loss of job among patients with occupational hand eczema. Br J Dermatol. 2005;152:93-98. doi: 10.1111/j.1365-2133.2005.06415.x

7. Owen JL, Vakharia PP, Silverberg JI. The role and diagnosis of allergic contact dermatitis in patients with atopic dermatitis. Am J Clin Dermatol. 2018;19:293-302. doi: 10.1007/s40257-017-0340-7

8. Brites GS, Ferreira I, Sebastião AI, et al. Allergic contact dermatitis: from pathophysiology to development of new preventive strategies. Pharmacol Res. 2020;162:105282. doi: 10.1016/ j.phrs.2020.105282

9. Nielsen NH, Menne T. The relationship between IgE‐mediatedand cell‐mediated hypersensitivities in an unselected Danish population: the Glostrup Allergy Study, Denmark. Br J Dermatol. 1996;134:669-672. doi: 10.1111/j.1365-2133.1996.tb06967.x

10. Alinaghi F, Bennike NH, Egeberg A, et al. Prevalence of contact allergy in the general population: a systematic review and meta‐analysis. Contact Dermatitis. 2019;80:77-85. doi: 10.1111/cod.13119

11. DeLeo VA, Alexis A, Warshaw EM, et al. The association of race/ ethnicity and patch test results: North American Contact Dermatitis Group, 1998-2006. Dermatitis. 2016;27:288-292. doi: 10.1097/ DER.0000000000000220

12. Warshaw EM, Schlarbaum JP, Silverberg JI, et al. Contact dermatitis to personal care products is increasing (but different!) in males and females: North American Contact Dermatitis Group data, 1996-2016. J Am Acad Dermatol. 2021;85:1446-1455. doi: 10.1016/j jaad.2020.10.003

13. Dickel H, Taylor JS, Evey P, et al. Comparison of patch test results with a standard series among white and black racial groups. Am J Contact Dermatol. 2001;12:77-82. doi: 10.1053/ajcd.2001.20110

14. DeLeo VA, Taylor SC, Belsito DV, et al. The effect of race and ethnicity on patch test results. J Am Acad Dermatol. 2002;46(2 suppl):S107-S112. doi: 10.1067/mjd.2002.120792

15. Scott I, Atwater AR, Reeder M. Update on contact dermatitis and patch testing in patients with skin of color. Cutis. 2021;108:10-12. doi: 10.12788/cutis.0292

16. Tamazian S, Oboite M, Treat JR. Patch testing in skin of color: a brief report. Pediatr Dermatol. 2021;38:952-953. doi: 10.1111/ pde.14578

17. Litchman G, Nair PA, Atwater AR, et al. Contact dermatitis. Stat- Pearls [Internet]. Updated February 9, 2023. Accessed September 25, 2023. www.ncbi.nlm.nih.gov/books/NBK459230/

18. Alexis AF, Callender VD, Baldwin HE, et al. Global epidemiology and clinical spectrum of rosacea, highlighting skin of color: review and clinical practice experience. J Am Acad Dermatol. 2019;80:1722-1729. doi: 10.1016/j.jaad.2018.08.049

19. Rodriguez-Homs LG, Liu B, Green CL, et al. Duration of dermatitis before patch test appointment is associated with distance to clinic and county poverty rate. Dermatitis. 2020;31:259-264. doi: 10.1097/DER.0000000000000581

20. Foschi CM, Tam I, Schalock PC, et al. Patch testing results in skin of color: a retrospective review from the Massachusetts General Hospital contact dermatitis clinic. J Am Acad Dermatol. 2022;87:452-454. doi: 10.1016/j.jaad.2021.09.022

21. Qian MF, Li S, Honari G, et al. Sociodemographic disparities in patch testing for commercially insured patients with dermatitis: a retrospective analysis of administrative claims data. J Am Acad Dermatol. 2022;87:1411-1413. doi: 10.1016/j.jaad.2022.08.041

22. Young K, Collis RW, Sheinbein D, et al. Retrospective review of pediatric patch testing results in skin of color. J Am Acad Dermatol. 2023;88:953-954. doi: 10.1016/j.jaad.2022.11.031

23. Kadyk DL, Hall S, Belsito DV. Quality of life of patients with allergic contact dermatitis: an exploratory analysis by gender, ethnicity, age, and occupation. Dermatitis. 2004;15:117-124.

Ethnicity and cultural practices influence epidemiologic patterns of ACD. Darker hair dyes used in Black patients¹⁴ and deeply pigmented PPD dye found in henna tattoos used in Indian and Black patients¹⁵ may lead to increased sensitization to PPD. ACD due to formaldehyde is more common in White patients, possibly due to more frequent use of formaldehyde-containing moisturizers, shampoos, and creams.¹⁵

Key clinical features in people with darker skin tones

In patients with SOC, the clinical features of ACD vary, posing a diagnostic challenge. Hyperpigmentation, lichenification, and induration are more likely to be seen than the papules, vesicles, and erythematous dermatitis often described in lighter skin tones or acute ACD. Erythema can be difficult to assess on darker skin and may appear violaceous or very faint pink.16

Worth noting

A high index of suspicion is necessary when interpreting patch tests in patients with SOC, as patch test kits use a reading plate with graduated intensities of erythema, papulation, and vesicular reactions to determine the likelihood of ACD. The potential contact allergens are placed on the skin on Day 1 and covered. Then, on Day 3 the allergens are removed. The skin is clinically evaluated using visual assessment and skin palpation. The reactions are graded as negative, irritant reaction, equivocal, weak positive, strong positive, or extreme reaction at around Days 3 and 5 to capture both early and delayed reactions.¹⁷ A patch test may be positive even if obvious signs of erythema are not appreciated as expected.

ACD is more common in women, with nickel being the most frequently identified allergen.

Adjusting the lighting in the examination room, including side lighting, or using a blue background can be helpful in identifying erythema in darker skin tones.^15,16,18 Palpation of the skin also is useful, as even slight texture changes and induration are indicators of a possible skin reaction to the test allergen.¹⁵

Health disparity highlight

Clinical photographs of ACD and patch test results in patients with SOC are not commonplace in the literature. Positive patch test results in patients with darker skin tones vary from those of patients with lighter skin tones, and if the clinician reading the patch test result is not familiar with the findings in darker skin tones, the diagnosis may be delayed or missed.¹⁵

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