Clinical Features

In acute allergic contact dermatitis, erythema with papules, vesicles, and/or bullae is present. It is intensely pruritic and excoriations are noted. Chronic allergic contact dermatitis has less prominent vesiculation and more scale, lichenification, and fissuring. Distribution is the most helpful clue to aid in diagnosis. When the hands or feet are involved in allergic contact dermatitis, the eruption tends to be present on the dorsal surfaces sparing the palms, soles, and web spaces. The thick stratum corneum of the palms and soles prevents penetration of potential allergens. Furthermore, distribution with linear streaks suggests a plant allergy such as rhus hypersensitivity (Fig, 2.3.9.-5..:$). Sharp demarcation of footwear indicates a reaction to a component of the patient's shoes ( Fig.; ,239-56). An eruption also present behind the earlobes, around the neck or at the site of a pant snap suggests a possible nickel allergy.

FIG. 239-5. Allergic contact dermatitis. A. Allergic contact dermatitis from exposure to poison ivy. Erythema, vesiculation and bullae are present on the fingers and the dorsal surfaces of the hands. Note the linear streak across the right hand. This finding is a diagnostic clue for rhus contact dermatitis (poison ivy). B. Allergic contact dermatitis to the straps of sandals. Erythema, scale and excoriations are noted in a symmetric patterned distribution matching to this patient's footwear.

Irritant dermatitis resulting from a strong irritant like an acid or alkali initially begins as immediate burning in the exposed area. Vesiculation and bullae formation with surrounding erythema follow. In severe reactions, necrosis and ulceration may even be present. These eruptions often occur as a result of accidental exposure. Irritant dermatitis from weaker irritants presents as erythema, scale, and fissuring. Vesiculation is less prominent, and often is not present. Irritant contact dermatitis is a common problem in occupations that require frequent handwashing or water exposure, such as health care workers, bartenders, and housewives.

Dyshidrosis initially begins as very small, deep-seated, pruritic vesicles on the lateral aspects and the volar surfaces of the palms and soles. The dorsal surface of the distal phalanges may also become involved. A key feature separating this disorder from other dermatitides is the lack of erythema at the onset. Over time, the vesicles may form pustules or desquamate to leave small collarettes of scales. In chronic cases, erythema and scales become more prominent and may be difficult to distinguish from other forms of hand and foot dermatitis.

Atopic dermatitis of the hands and feet often presents as erythematous, pruritic scaly patches with prominent involvement of the dorsal surfaces as well as the palms and soles. Chronic atopic dermatitis will also have hyperpigmentation and lichenification and fissuring. Oftentimes, other areas of the body are involved. Common areas of involvement include the antecubital and popliteal fossae, the posterior neck, and the wrists and ankles.

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