Feedback for Contact Dermatitis – Shanelle Galuska

Risk factors for contact dermatitis include being fair skinned, having red hair, and working in “wet” professions, which I assume means working in professions that involve the workers using wet substances frequently. Allergic contact dermatitis is responsible for 10% of job related diseases. Lots of glove wearing and handwashing can also contribute to development of allergic contact dermatitis. Women are more likely to have allergic contact dermatitis. Further risk factors include having a history of eczema due to broken skin allowing for more substances to penetrate, resulting in immune responses. 

Allergic contact dermatitis (ACD), and irritation contact dermatitis (ICD) are two different afflictions. ICD has no immune system reaction, and ACD is a hypersensitivity four reaction. Hypersensitivity four reactions involve a sensitization phase and a response phase, as well as molecules (called haptens) which need support in producing an immune response. During the sensitization phase, haptens combine with skin proteins, get absorbed by antigen presenting cells, and the antigen presenting cells take a trip to the lymph nodes. In the lymph nodes, they show their hapten-protein complex (now functioning as an antigen), to naive T cells that activate memory T cells and T helper cells. This leads to a reaction the next time a person has contact with the same hapten. Now, when exposed, the T cells release a cocktail of inflammatory cytokines. These cytokines, mostly localized to the area of contact, and the path along lymph vessels, causing skin damage. This can look like rashes, blisters, itching, and redness. These symptoms can last for four days!

In diagnosis, ACD uses patch testing to determine what allergens are causing the reaction.

With irritation contact dermatitis, there is little immune response. The cells that are in contact with the allergen immediately release their cytokines and the inflammation starts with the first exposure. The irritated skin symptoms are also more localized to where the irritating factor touched the skin, rather than also going along the lines of lymph vessels. ICD also involves broken skin barriers, maybe by maceration from constant wetness, or adhesives, or alcohol based hand sanitizer.

ICD does not use patch tests for diagnosis. Removing the irritant is the only way to determine what is causing symptoms, due to said symptoms resolving. The nature of the reaction rash is different for each; ACD has ill-defined boundaries for the rash, while ICD has much clearer boundaries. Part of diagnosing comes from physically examining the rash. ICD symptoms also clear up faster than those of ACD. 

For ACD, immunosuppressants and corticosteroids and antihistamines are used to stop the reactions and heal the skin. With ICD, removal of the irritant is usually all that is needed.

I enjoyed listening to your podcast greatly. I found that you all had very engaging presenting voices, and were clear and concise in your speaking, pacing, and tone. I found the pathophysiology to be at the perfect level for our understanding, going into just the right amount of detail for our level which facilitated easy understanding. It felt very clear to me which cells are key players, what the cytokines are doing, and how the immune system responds. I also think Theo was a very memorable character, and that I will think of him moving forward as a nurse, if I notice rashes in my clients (or myself!) from things like excessive handwashing. I wonder how often nurses develop ICD from breaking in the skin, because this seems like something that would happen to healthcare professionals regularly?

I found that weaving Theo’s story in and along with the differing diagnoses, pathophysiologies, and treatments was confusing. I was unsure if Theo had ACD or ICD until I read through the script after listening to the podcast. Perhaps outlining Theo’s symptoms, the different symptoms of both ACD and ICD, and coming to a conclusion, would have facilitated my understanding better. When discussing the treatment options for ACD right after diagnosing Theo with ICD, might have been the leading cause of my confusion. I also feel as though there was more time spent on ACD, the diagnosis that Theo did not have. 

I think for Theo, it would be quite difficult to change his work life to accommodate this new diagnosis, and I query whether or not he will need to find a new job, and how these changes might affect him psychologically.

One of the teaching and learning strategies that I found supported my learning were the elements used in the video. I really enjoyed all the visuals that you used! I found the video elements that were used were dynamic and engaging. The strange, amorphous blobs that wiggled around while the narrators spoke kept my attention from wandering. I also appreciated that every time Theo was mentioned, his “avatar” appeared on the screen. This really cemented him to me as a person, and made me think of what this diagnosis would mean to him. I am assuming that as a make-up artist, he values art, and his chosen avatar reflected that. I liked the creativity in using graphics for the symptoms. I do not think it would be easy to show what a release of cytokines would look like in a graphic and dynamic way, and I think the creativity in using a confetti-type animation was cleverly delivered. There was also an animation of an explosion to represent the immune reaction which represented hypersensitivity reactions well, in my opinion. Seeing the symptoms like the rashes, the fluid filled blisters (also known as vesiculations), and the papules, will make it much harder to forget going forward in my own practice, as opposed to just hearing about them. Also, having a Canadian nickel represent nickel as a common irritant, will reinforce my memory of potential causes of contact dermatitis. With diverse learning needs, using a variety of learning strategies is helpful and I appreciate the effort put in to making it more accessible and more engaging to those who appreciate visuals!

I would recommend organizing the differences between allergic contact dermatitis and irritant contact dermatitis more sequentially. Arranging it in different way, perhaps going through risk factors, symptoms, pathophysiology, diagnosis, and treatment for allergic contact dermatitis, then going through it again for irritant contact dermatitis? Then afterwards we could come to a formed conclusion about Theo’s diagnosis, and it would be supported in our well divided, well compared knowledge. 

Then, I would dive further into what this diagnosis means for Theo. The psychosocial impact of reacting to the cosmetics he works with is probably going to pose some significant challenges for him. I wonder if the allergy safe cosmetic products are readily available, high enough quality, if they are affordable, and if they are available in as wide a range as non-allergy safe cosmetic products. What are the chances that he would require to change professions altogether? How could we support him through this transition? I wonder if using emollients and diphenhydramine would be enough to heal his skin, especially in a “wet profession”. I would also make it abundantly clear that the immunosuppressants and corticosteroids are not necessary treatment for irritant contact dermatitis, which is what I assume, based on the fact that irritant contact dermatitis does not activate the immune system at large. Some elaboration on sargassum would add to the organization of this podcast, I think. Is sargassum appropriate for irritant contact dermatitis, or allergic contact dermatitis, or both? I do think that including complementary and alternative therapies or medicines is an interesting addition, and it would have been nice if time allowed for more time spent on this.

My biggest takeaway from this podcast was to take skin irritation more seriously. I will consider allergic contact dermatitis and irritant contact dermatitis for any clients I have who are having skin problems. Knowing that contact dermatitis accounts for 10% of workplace related illnesses, I know that this may be a common issue that my clients will face. If my client works with common irritants such as nickel or adhesives, or works in a profession with a lot of hand washing, I will consider the differences between allergic contact dermatitis and irritation contact dermatitis. If my clients have any other risk factors, such as red hair, lighter toned skin, preexisting skin conditions, and biological female sex, it will raise red flags in my mind when they are experiencing skin irritation, and I will consider if they are experiencing contact dermatitis. Some of the things I will watch for include erythema, papules, fluid filled bubbles, and itching as cardinal signs of contact dermatitis. 

I will also take note of the differences in the presentation of disease for both allergic contact dermatitis and irritation contact dermatitis. With ACD, I will watch for less defined borders for the rashes, and rashes that spread along lymph vessels. I know that the dendritic cells travel to the lymph nodes to present the hapten-protein complex to memory and helper T cells which cause reactions along the way. I will pay attention to how long the rash has persisted, and I know that with ACD, the rash can persist up to four days. 

I will remember what to expect with diagnosis for both conditions. For allergic contact dermatitis, they will use patch testing to determine what is causing the reaction.

For irritant contact dermatitis, I know they will remove irritating factors and focus on healing the skin and restoring skin integrity, and finding ways to reduce or eliminate contact with the known irritants.

I will be able to anticipate treatments for ACD, such as using antihistamines, corticosteroids, and if needed, immunosuppressants such as methotrexate. I will also keep an open mind to complementary and alternative therapies that a client may wish to try, such as sargassum. 

Thank you for providing me such a clear and easy to follow explanation of a prevalent condition, so that I can take what I have learned into my future career.