Wound-Related Allergic/Irritant Contact Dermatitis
JUNE 2016CLINICALMAe xtraNAGEMENTWound-Related Allergic/IrritantContact DermatitisC M E1 AMA PRACategory 1 CreditTMANCC2.5 Contact HoursAfsaneh Alavi, MD & Assistant Professor & Department of Medicine (Dermatology), University of Toronto & Toronto,Ontario, CanadaR. Gary Sibbald, BSc, MD, DSc (Hons), MEd, FRCPC (Med)(Derm), FAAD, MAPWCA & Professor & Medicine and PublicHealth & Director & International Interprofessional Wound Care Course (IIWCC) & Masters of Science Community Health(Prevention and Wound Care) & Dalla Lana Faculty of Public Health & University of Toronto & Toronto, Ontario, Canada &Clinical Editor & Advances in Skin & Wound CareBarry Ladizinski, MD, MPH, MBA & Dermatology Resident & Division of Dermatology & John H. Stroger, Jr. Hospital ofCook County & Chicago, IllinoisAmi Saraiya, MD & Research Fellow & Department of Dermatology, Tufts University & Boston, MassachusettsKachiu C. Lee, MD & Assistant Professor & Department of Dermatology, Brown University & Providence, Rhode IslandSandy Skotnicki-Grant, MD & Assistant Professor & Department of Dermatology, University of Toronto & Toronto, Ontario, CanadaHoward Maibach, MD & Professor & Department of Dermatology, University of California, San Francisco School of MedicineAll authors, staff, and planners, including spouses/partners (if any), in any position to control the content of this CME activity have disclosed that they have no financial relationships with, orfinancial interests in, any commercial companies pertaining to this educational activity. This article has been reviewed and all potential or actual conflicts have been resolved.To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least 14 of the 19 questions correctly.This continuing educational activity will expire for physicians on June 30, 2017, and for nurses on June 30, 2018.All tests are now online only; take the test at http://cme.lww.com for physicians and www.nursingcenter.com for nurses. Complete CE/CME information is on the last page of this article.PURPOSE:To provide information from a literature review about the prevention, recognition, and treatment for contact dermatitis.TARGET AUDIENCE:This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.ADVANCES IN SKIN & WOUND CARE & VOL. 29 NO. 6278Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.WWW.WOUNDCAREJOURNAL.COM
OBJECTIVES:After participating in this educational activity, the participant should be better able to:1. Identify signs and symptoms of and diagnostic measures for contact dermatitis.2. Identify causes and risks for contact dermatitis.3. Select appropriate treatment for contact dermatitis and its prevention.leg ulcers have 1 or more positive patch test reactions, with mostof the identified allergens relating to previous exposure or ahistory of contact dermatitis.1 The allergic sensitization typicallyresults from long-term exposure to allergens under occlusionfrom dressings and compression wraps combined with theimpaired barrier function of the ulcerated skin.There are many sources of allergens, from topical dermatological preparations to wound care products designed as wraps(Figure 1) or modern occlusive dressings with autolytic debridement and anti-inflammatory, antimicrobial, or moisture-balancingproperties. Clinically, wound-associated contact dermatitis presentswith localized itching, pain, and discrete or diffuse periwounddermatitis of varying severity that may delay healing or worsen thewound base and margin despite appropriate treatment (Figure 2).Early recognition of allergic contact dermatitis (ACD) and removal of the suspected allergen are critical to minimize patientsuffering, curtail topical suspected allergen overuse, and optimizethe healing environment.ABSTRACTOBJECTIVE: Contact dermatitis to wound care products is acommon, often neglected problem. A review was conducted toidentify articles relevant to contact dermatitis.METHODS: A PubMed English-language literature review wasconducted for appropriate articles published between January2000 and December 2015.RESULTS: Contact dermatitis is both irritant (80% of cases) orallergic (20% of cases). Frequent use of potential contactallergens and impaired barrier function of the skin can lead torising sensitization in patients with chronic wounds. Commonknown allergens to avoid in wound care patients includefragrances, colophony, lanolin, and topical antibiotics.CONCLUSIONS: Clinicians should be cognizant of the allergens inwound care products and the potential for sensitization. Allmedical devices, including wound dressings, adhesives, andbandages, should be labeled with their complete ingredients, andmanufacturers should be encouraged to remove commonallergens from wound care products, including topical creams,ointments, and dressings.KEYWORDS: allergic contact dermatitis, irritant contactdermatitis, wound careMETHODSA PubMed English-language literature review was conducted toidentify relevant articles published between January 2000 andDecember 2015. The search terms included ‘‘wound care,’’ ‘‘irritant contact dermatitis,’’ and ‘‘allergic contact dermatitis.’’ Thecommonly reported wound product–related irritant and allergeningredients were identified and summarized. These allergens weresubsequently used as search terms for additional PubMed literaturesearches. References were also reviewed and evaluated for relevance.ADV SKIN WOUND CARE 2016;29:278-86.INTRODUCTIONContact dermatitis can be divided into irritant and allergic subtypes. Irritant contact dermatitis (ICD) can occur on initial exposure and is a result of excessive moisture or irritation on the skinsurface. This form of contact dermatitis is often red and scalywith poorly defined borders. If moisture is associated, the hydration of keratin leads to a white macerated surface, especially ifocclusive or moisture balance dressings are applied locally.The allergic form of contact dermatitis occurs after an initialsensitizing exposure is associated with reexposure of the responsible allergen. Allergic contact dermatitis is often more acute withbright red erythema in the pattern of skin contact with the responsible allergen. Acute contact dermatitis presents with smallblisters (vesicles that are fluid-filled 1 cm) or larger bullae (blisters 1 cm). Allergic contact dermatitis is common in patients withchronic ulcers because of allergenic properties of frequentlyutilized wound care products.1 Up to 80% of patients with venousWWW.WOUNDCAREJOURNAL.COMREVIEW OF THE CURRENT LITERATURETreatment of minor wounds includes local application of creams,ointments, dressings, and wraps. Multiple potential allergens inthese products may result in sensitization (Table 1). A directrelationship between ulcer duration and number of multiplepositive allergen sensitivities has been documented.2 A changein the most common allergens has occurred since the authors’previous work1 (Table 2).A prospective multicenter study of 423 patients with chronic legulcers (CLUs) demonstrated that Myroxylon pereirae (balsam ofPeru) (41%), fragrance mix (26.5%), antiseptics (26.5%), andtopical corticosteroids (8%) were the most common allergens.2The North American Contact Dermatitis Group identified that1.5% to 9.1% of patch-tested patients older than 20 years are279ADVANCES IN SKIN & WOUND CARE & JUNE 2016Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
& Topical healing ointment composed of petrolatum (41%),mineral oil, caresin (a white wax extracted from ozokerite, alsocalled earth wax), lanolin alcohol, panthenol, glycerin, and bisabolol& Topical emulsion8 with ingredients that include liquid paraffin,ethylene glycol monostearate, propylene glycol (PG), paraffinwax, methylparaben, propylparaben, and fragrance.The results did not identify induction ACD with the testedproducts. The topical emulsion caused the most irritation, andthe topical healing ointment caused the least. The topical tripleantibiotic combination ointment and the topical healing ointmenthad similar irritation potential on normal skin; however, on tapestripped ‘‘wounded’’ skin, the topical triple antibiotic combinationointment with polymyxin B sulfate/bacitracin/neomycinappeared to cause the most irritation of the 3 topical preparationsin the study.8 Allergic contact dermatitis may not have occurredbecause of the relatively short duration of the study comparedwith the longer duration of potential allergen application tochronic wounds.A 2007 study9 of 30 disease-free participants compared transepidermal water loss and irritancy from 6 common wound caredressing products applied to the same area of skin, 6 times over a14-day period. The dressings with lower irritancy in this studywere soft silicone-faced polyurethane foam dressing, polyurethanefoam self-adhesive island dressing, soft hydrophilic polyurethane foam dressing, polyurethane foam dressing, hydrocolloid semipermeable polyurethane dressing, and hydrocolloidsemipermeable dressing. Also, soft silicone-faced polyurethane foam dressings, polyurethane foam self-adhesive islanddressings, and soft hydrophilic polyurethane foam dressingshad low mean transepidermal water loss values closer to thatof normal skin. Based on this study, those 3 foam dressings mayFigure 1.ALLERGIC CONTACT DERMATITIS: A WELL-DEMARCATEDERYTHEMATOUS PLAQUE DUE TO CONTACT DERMATITISTO DRESSINGallergic to bacitracin, and 7.2% to 13.1% of patch-tested patientsolder than 20 years have allergic sensitization to neomycin.3–5In a recent study on 354 patients with CLUs, the percentageof positive patch test to modern wound-related materials wasreported as high as 59.6%.6 The number of positive patch testwas correlated with the duration of ulcerative disease andindependent of ulcer etiology (venous, arterial, or mixedarteriovenous).6 The top 5 common allergens in 5 studiesfrom 2009 to 2015 include balsam of Peru, lanolin, amerchol,fragrance mix, and benzocaine (Table 2).Prolonged topical antibiotic use, impaired skin barrier, andocclusion for extended periods increase the risk of developingallergic contact dermatitis (ACD) from topical antibiotics.4 Topical antibiotics often require only 1 mutation to induce resistanceto bacteria, and they do not provide the wound bed preparationcomponents of moisture balance provided by some antisepticdressings containing silver (calcium alginate, foam, hydrofibers,gel), iodine (cadexomer), chlorhexidine derivatives (PHMB[polyhexamethylene biguanide] foam), or methylene blue/crystalviolet foam. Allergic contact dermatitis is more common inpatients with chronic venous insufficiency, chronic otitis externa,postoperative or posttraumatic wounds, chronic eczematousconditions (eg, atopic dermatitis, nummular eczema, stasiseczema), and in certain occupations (nurses, farmers, veterinarysurgeons, and pharmaceutical workers who handle antibiotics)involving skin contact with topical or systemic antibiotics.4A 2011 double-blind randomized study investigated the allergyand irritancy potential of 5 topical wound care products7:& Topical triple antibiotic combination ointment: bacitracin; ointments with neomycin, polymyxin B sulfate, and bacitracin zinc;and combination product of polymyxin B/bacitracin ointmentADVANCES IN SKIN & WOUND CARE & VOL. 29 NO. 6Figure 2.ALLERGIC CONTACT DERMATITIS: DIFFUSE ALLERGICREACTION TO ZINC OXIDE IN COMPRESSION WRAP280Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.WWW.WOUNDCAREJOURNAL.COM
Table 1.CONTACT DERMATITIS TO WOUND PRODUCTS AND RELEVANT PRODUCTSEvidence/CommentProducts Containing AllergenBacitracin: 1.5%–9.1% patients 20 y old3–5are allergicPolysporin ointment preparations but the creamformulations have gramicidin with both productshaving polymyxinNeomycin: 7.2%–13.1% patients 20 y old3–5are allergicNeomycin products or products with the tripleantibiotic formulations often have neomycinNeomycin was associated with greaterlocal wound irritation compared with10products in combination with polymyxinNeomycin cross-reacts with framycetin and maycross-reacts with other aminoglycosideantibioticsVgentamicin, amikacin, tobramycinPreservatives:Propylene glycol (PG)Formaldehyde-releasingpreservatives includingquaternium 15Parabens are ubiquitous in topicalformulations and seldom cause irritationor very rarely a specific allergenHydrogels may contain PG, as well as benzoylperoxide, or sodium alginateFragrances:balsam of PeruVcancross-react with fragrancesStage 1–2 pressure ulcers treated withtrypsin/balsam of Peru/castor oilcombination productSome combination ointments have balsam of PeruTopical antibiotics:BacitracinNeomycinFragrance is present in most topical skin care productsUnscented products may have a masking hylcellulose30Sensitization with certain hydrocolloidsand positive patch test to colophony11,28,29in 4%applied to the skin for 48 hours with fixed erythema on thecovered skin when the dressing is removed. Colophony may alsocross-react to cloves and cinnamon leaf (eugenol/isoeugenol),balsam of Peru, citrus fruit peel, and Tiger Balm (a popular overthe-counter Chinese medicine herbal formulation). Tiger Balmcontains variable amounts of menthol, camphor, dementholizedmint oil, cajuput or eucalyptus oil, and clove bud oil.The concept of wound bed preparation dates back to ancienttimes when wounds were cleansed and covered by oils andtopical products. Over the past decade, some wound careproducts have moved from passive to active treatment in orderto promote healing. The use of topical preparations in the formof ointments, creams, and dressings is determined by the underlying wound characteristics. These externally applied topicalpreparations (potential irritant contacts and allergens), as wellas wound fluids (potential contact allergens), have the potential tocause contact dermatitis of the periwound skin.Symptoms of itching and burning often accompany contactdermatitis and can cause considerable discomfort. In routinepractice, products containing common allergens should beavoided. The integrity of periwound skin is an important concept of wound care. Early diagnosis of contact dermatitis isalso be better tolerated for wound care applications wherepatients are susceptible to ICD.9Colophony or resin is extracted from conifer trees, usuallypine species. Its manufactured use includes adhesives in hydrocolloid dressings along with violin and baseball resin, soldering flux, chewing gum, and printing/paper processing.Colophonium derivative is an adhesive adjunct used as tackifying agent (adhesive) in some hydrocolloid dressings, and thisingredient is often responsible for allergic sensitization to hydrocolloid dressings that contain this ingredient. Sensitizationto hydrocolloid dressings is observed in 11% to 52% of patientswith chronic wounds.10,11 The reported allergen may be listedas pentalyn H, which is the derivative of colophony (the pentaerythritol ester of the hydrogenated resin), originally believed tobe a purified resin that would not act as an allergen, and otherester gum resins.12,13 Patients with hydrocolloid dressing allergymay also show cross sensitization to unmodified colophony, butunfortunately, patients with sensitization to pentaerythritol esterof the hydrogenated resin may have a negative patch test tocolophony.6,14 Pentaerythritol ester of the hydrogenated resin isnot commercially available for patch testing and should be testedwith a small piece (1 cm2) of the suspected hydrocolloid dressingWWW.WOUNDCAREJOURNAL.COM11Some hydrocolloids contain a derivative ofcolophony that is the most common allergen inhydrocolloids, but patch test to colophony maybe negative (test to the hydrocolloid product).281ADVANCES IN SKIN & WOUND CARE & JUNE 2016Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
Table 2.COMPARISON OF 10 TOP ALLERGENS IN LEG ULCERS 2009–2015Reich-Schupke et al31(2010), Germany(N 95)Beliauskiene et al7(2011), Lithuania(N 94)Valois et al,6(2015), France(N 354)Renner et al14(2013),Germany (N 70)81010Barbaud et al2(2009) France(N 423)Myroxylonpereirae resin(balsam of Peru)810Lanolin alcoholV6187Amerchol L1016V5V8Fragrance mix IVV9V9BenzocaineV10V5VVColophoniumV9VV5Fragrance mix Iand II7VV6VFragrance mix IIV3V9VVBenzalkoniumchlorideVV6V6Thiuram mixVVV73Top 10 allergens in each study, given a score of 10 (most common allergen) to 1 (least common allergen).to PG on uncompromised skin appears to be quite low but islikely higher in persons with leg ulcers. As previously mentioned,controlled gel hydrocolloids contain a purified derivative ofcolophony called the pentaerythritol tetranitrate ester of hydrogenated rosin. This is an adhesive in some hydrocolloid dressingsthat commonly cross-reacts with colophony.13 In the study bySaap et al,17 only 17% (1/6) of patients with a positive patch testresult to the control gel hydrocolloid and 25% (1/4) of patients witha positive patch test result to thin polyurethane hydrocolloid werealso allergic to colophony. In a 2008 case series, 100 patients withleg ulcers were patch tested, and 46% had at least 1 positive patchtest with the most common sensitizers identified as fragrance,lanolin, antibacterial agents, and rubber allergens.1Wound hydrogels are common irritant/allergens in woundproducts, mainly due to ICD because 70% to 90% of hydrogelsare water with a backbone to allow them to adhere to woundscalled tack. The backbone of some hydrogel dressings is PG,which is generally a more common irritant than a common allergen. In studies on patients with chronic wounds, the rate of sensitization to hydrogels was common, ranging from 9% to 23%.10,14critical to optimize local wound and skin care. Patients withchronic wounds may develop a sensitization to even weak allergens in wound care materials. Possible causes are intrinsicgenetic predisposition, lipophilic galenic formulations (the compounding of medicines for optimum absorption), and the useof occlusive dressings combined with disrupted skin barriers.15The clinical relevance of this observation requires further study.Venous stasis dermatitis is associated with decreased venousreturn, local pitting edema, exudation of red blood cells, inflammatory cytokines, and the dermal fibril deposition (fibrin cuff)often associated with recurrent or chronic ulcers.7 These changesinterfere with the cutaneous barrier function and lead to potential increased absorption of allergens.16 In a 2008 prospectivestudy of 45 patients with chronic wounds and sensitization towound dressings, the most common contact sensitizers identified were povidone-iodine, balsam of Peru, fragrance mix,colophony, and potassium dichromate.15 A 2004 prospectivestudy of 54 patients with CLUs who underwent patch testingdemonstrated a high incidence of positive patch test results;the most common allergens were balsam of Peru, fragrancemix, wood tar mix, PG, neomycin sulfate, benzalkonium chloride,carba mix, nickel sulfate, and control gel hydrocolloid.17 Propyleneglycol is primarily a vehicle in topical medications, cosmetics,and topical corticosteroids and may cause allergic dermatitisor ICD.18 Lessmann et al19 demonstrated that PG exhibitsvery low sensitization potential, and the risk of sensitizationADVANCES IN SKIN & WOUND CARE & VOL. 29 NO. 6IRRITANT CONTACT DERMATITISIrritant contact dermatitis involves direct physical or chemicaldamage to the skin. Because it is not a cell-mediated response,previous sensitization exposure is not necessary.16 Acuteirritant dermatitis has a rapid onset within 6 to 72 hours of282Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.WWW.WOUNDCAREJOURNAL.COM
exposure and is usually confined to the contact area.20 Chroniccumulative irritant dermatitis is also likely in patients withlongstanding lower-extremity ulcers, espec
of positive patch test to modern wound-related materials was reported as high as 59.6%.6 The number of positive patch test was correlated with the duration of ulcerative disease and independent of ulcer etiology (venous, arterial, or mixed arteriovenous).6 The top 5 common allergens in 5 studies from 2009 to 2015 include balsam of Peru, lanolin .
7865 Lt Gray Primer Sprayon Products Anesthetic Irritant Flammable Yes Paint 793/795 Dry Silver Paper 3m Center Toxic Irritant Nervous/Repro System Yes 900 Goldend Paste A.W. Chesterton Co. Irritant Unknown Unknown Yes 9065 (518)-3 Vermillion Gunther Wagner Pel,W Ingestion Irritant Ingestion Yes
Hay fever (allergic rhinitis) is a medical condition caused by allergy to substances breathed in the air. Most people with allergic rhinitis are allergic to house dust mites, pollen, pets, moulds, or a combination of these. Allergic rhinitis is sometimes called 'hay fever' when it occurs during the times of year when there are a lot of
board-certified wound care nurse from 8am–5pm Central Standard Time Monday–Friday. 1-888-701-SKIN (7546) » The NE1 Wound Assessment Tool This proprietary wound assessment tool is designed to dramatically increase accuracy, consistency and transparency in wound assessment. » WoundRounds Wound Management System This unique wound management
Sloughy Wound (Pale layer of dead or fibrinous tissue over all or part of the wound bed) Macerated Skin (Soft, pale/white, wet or soggy skin surrounding wound) Granulating Wound (Wound bed filled with highly vascular, fragile tissue) Determine if present dressing regime is Goal of Treatment Keep woundRemove non-vital tissue and management of
Wound edges open Not healing Wound with 25% avascular tissue (eschar and/or slough) OR Signs/symptoms of infection OR Clean but nongranulating wound bed OR Closed/hyperkeratotic wound edges OR Persistent failure to improve despite appro-priate comprehensive wound management Note. Data from WOCN (2009).
Triad was applied to the wound bed and periwound skin. Wound as presented on Day 2. Triad is applied to the wound bed. Wound as presented on Day 2. Triad is applied to wound bed and periwound skin. "After 1 application of Triad, wound was progressing and the patient was able to continue to use Triad at home for wound treatment."
Jasco Paint and Epoxy Remover d Irritant, Toxic Johnson Lemon Pledge c Flammable K2r Spot-lifter d Flammable, Irritant, Toxic Krylon Interior/ Exterior Paint d Flammable, Irritant, Toxic Liquid-Plumr d Corrosive, Toxic Mill Creek Castile Soap No c-W-d-P None Para Moth Balls c Not clear from front of label * That can be seen on the front of the .
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