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LIVE BLOG: Practical Contact Dermatitis For The Busy w/ Matthew Zirwas, MD

When it comes to practical contact dermatitis treatment, Dr. Matthew Zirwas has all the (incredible) answers.  Prescribing a diet of Jalepenos, or, say, a cup of powdered milk added to laundry detergent has never seemed more practical.  In his lighthearted lecture, Dr. Zirwas runs through various types of contact dermatitis with simple with profound ways to treat them.  We’ll cover Eyelids, Lips, Perianal, Hands, and Feet.

 

How to Present Positive Patch Test Results

When presenting positive patch results, be sure to avoid information overload.  When too much information is presented the patient will retain and act on nothing that is said.  Be sure to tell them only about the relevant allergies.  If they tested positive to hair dye, but have never once dyed their hair, you can leave that one out.  The more you tell them, the less they’re likely to retain.  Give them the main and relevant allergens.

 

How to Help Patients Avoid their Allergens

Explain any handouts that you provide.  Verbal information is much better absorbed than written information, but combination of both is best.  Explain what a positive test means and give them info on the allergen.  It is much easier to tell them what products they should USE rather than list all the products they should AVOID.

 

EYELIDS

-Allergic Contant Derm.

-Irritant Contant Derm.

 

Empiric Management for Suspected Eyelid ACD

+ California Baby Supersensitive Shampoo and Body Wash for shampoo and hand soap

+ California Baby Super Sensitive Conditioner

+ Wash face with gentle cleanser AFTER rinsing out shampoo and conditioner

+ Low potency ointments

+ Low-allergenicity moisturizer and cleanser for face and hands

+ No nail cosmetics except Revlon Nail Enamels (don’t have common nail allergens in them)

 

Side Note: Do you know what the worst nail polish is? 

Answer: OPI

It is *full* of nail allergens  

 

LIPS

Main DDx:

+ Irritant derm/cosmetic addiction

+ Lip licking

 

Side Note:

Don’t ask the patient: “Do you lick your lips?” They often don’t realize that they do. Just watch them during their visit and you’ll know the answer to your question.

+ Most ACD violates the vermilion border

 

Common Cause:

+Medicated Lip Balms and Tooth Paste are the big two 

 

TOOTH PASTE ALLERGY

+ Noticeable irritation on lower lip and one side: tooth paste runs down your lip, sits in the corner of your mouth

+ Only dermatitis if you cannot see the vermilion border

 

What to do with ACD of the lips?

Laura Mercier Satin Lip Color: better than Burt’s Bees

 

Empiric Management

+ Use petroleum jelly

+ Avoid vaseline lip therapy advanced formula

+ Active ingredients white petrolatum USP (100%)

+ Toothpaste option: Tom’s of Maine Orange Toothpaste

 

PERIANAL

Main DDx:

+ Psoriasis

+ Irritant Derm.

+ Idiopathic anal pruritus

 

ASK: “What kind of toilet paper are you using?”

Stool is an irritant.  Moist toilet paper helps but be aware that it’s an irritant.

+ Moist toilet paper: 7th Gen Free and Clear Wipes- no allergens

+ Topical therapy: low to medium potency topical steroid, tacrolimus or pimecrolimus (this will cause burning, so let patients know that the burn means that it’s working!)

+ Diet: Eat hot peppers, jalepenos (this will cause release of substance P.  After a few days of hot peppers, the body will run out of substance P and the irritation may subside.  This is the same for other forms of dermatitis) 

 

FEET

Main DDx: 

If dorsal: sweat, socks 

If plantar:

Keratoderma

Hyperkeratotic foot eczema

Tinea

Psoriasis

Culprits:

Sweat and Socks (Allergic to glue in shoes?  Leather in shoes?  Sample a piece 

of their shoe for fungus)

 

Empiric Management of Suspected Foot ACD

+ Address hyperhidrosis if possible

Dorsal Foot

+ Stop wearing all shoes: buy new shoes and wear only the new shoes.  Re-introduce new shoes later, one at a time

+ ACD likely due to retained allergens in multiple pairs

+ Use only desoximetasone ointment

+ smooth sock liners

Plantar Foot

+ Pre-place all insoles with cork or felt 

 

 

HANDS

 

What are the culprits?

+ Gloves

+ Hand soaps: (especially in public restrooms: they are full of anti-bacterial and fragrance)

+ Moisturizers

+ OTC/Rx Topicals

+ Hair Styling Products

+ Dietary Nickel

 

Side Note:

What is the best thing to tell an OR nurse with horrible hand dermatitis who has a positive patch test reaction to a rubber accelerator?

Answer: Wear sterile neoprene gloves

 

Empiric Management of Suspected ACD of the Hands

+ Low allergenicity soap, moisturizer

+ Desoximetasone Ointment

+ Avoid/Consider hair products

+ Gloves

– N-DEX free nitrile

– Micro-touch nitraFree

– Any vinyl gloves

 

Side Note: Which fabric is most likely to cause contact dermatitis?

Answer: Cotton

 

TEXTILE DYE ALLERGY

+ Acute, intermittent, more dermal

+ Wear only 100% Cotton

+ Textile Resins

+ Chronic, constant, more epidermal

+ Add 1 cup of non-fat powdered milk to laundry!

 

HOT TUB ALLERGY

Wide Spread Dermatitis? Probably because of a Hot Tub.

 

Allergy to Shock Treatment:

+ Chlorine kills germs, yes, but skin oils and cells accumulates. Everyone adds Shock Treatment to their hot tub.

Rash is commonly found on inner arms and backs of the calves often which matches the hot tub posture: arms propped on the side of the tub, or feet dipping inside

 

[Image by gmundo]

 

 

 

 




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