Contact Dermatitis Nursing Care Management

Jim is a janitor at a public hospital. While cleaning the ward, one of his cleaning substances spilled on his hands. He was not wearing his safety gloves. He just washed his hands off and shrugged off the incident. A few days later, he noticed that the affected area is very itchy and red. A few days more, the affected area turned into skin lesions. He brought his problem into the outpatient department, and the physician diagnosed him with contact dermatitis.

Description


Skin sensitivity in contact dermatitis may develop after a brief or prolonged periods of exposure.

  • Contact dermatitis, a type IV delayed hypersensitivity reaction, is an acute or chronic skin inflammation that results from direct skin contact with chemicals or allergens.
  • Often sharply demarcated inflammation and irritation of the skin caused by contact to substances by which the skin is sensitive.

Classification


There are four basic types: allergic, irritant, phototoxic, and photoallergic.

  • Allergic dermatitis. Allergic dermatitis results from direct contact with substances called allergens.
  • Irritant contact dermatitis. Irritant contact dermatitis develops when your skin comes into contact with an irritating substance.
  • Phototoxic contact dermatitis. Phototoxic contact dermatitis is a sunburn-like skin disorder resulting from direct tissue damage following the ultraviolet light-induced activation of a phototoxic agent.
  • Photoallergic contact dermatitis. Photoallergic contact dermatitis is a delayed-type hypersensitivity cutaneous reaction in response to a photoantigen applies to the skin in subjects previously sensitized to the same substance.

Types


Other types of dermatitis

  • Contact dermatitis. Caused by an allergen or an irritating substance. Irritant contact dermatitis accounts for 80% of all cases of contact dermatitis.
  • Atopic dermatitis. Very common worldwide and increasing in prevalence. It affects males and females equally and accounts for 10%–20% of all referrals to dermatologists. Individuals who live in urban areas with low humidity are more prone to develop this type of dermatitis.
  • Dermatitis herpetiformis. Appears as a result of a gastrointestinal condition, known as celiac disease.
  • Seborrheic dermatitis. More common in infants and in individuals between 30 and 70 years old. It appears to affect primarily men and it occurs in 85% of people suffering from AIDS.
  • Nummular dermatitis. A less common type of dermatitis, with no known cause and which tends to appear more frequently in middle-age people.
  • Stasis dermatitis. An inflammation on the lower legs which is caused by buildups of blood and fluid and it is more likely to occur in people with varicose.
  • Perioral dermatitis. Somewhat similar to rosacea; it appears more often in women between 20 and 60 years old.
  • Infective dermatitis. Dermatitis secondary to a skin infection

Pathophysiology


The pathophysiology of contact dermatitis involves pathogens that irritate the skin.

  • Binding. The hapten (small hydrophobic molecules)-protein complex enters the stratum corneum and binds to epidermal antigen-presenting Langerhans cells.
  • Deception. These cells process the antigen and travel to regional lymph nodes where they present the antigen to naive CD4 T cells.
  • Proliferation. These T cells then proliferate into memory and effector T cells, which elicit contact dermatitis within 48 to 96 hours of reexposure to the allergen.

Statistics and Incidences


Contact dermatitis incidences are widespread around the world.

  • 80% of cases are caused by excessive exposure to or additive effects of irritants.
  • The most common type of dermatitis is irritant contact dermatitis, which accounts for about 80% of all cases of contact dermatitis.
  • In occupational irritant contact dermatitis, the incidence of confirmed cases is 5 per 100,000 workers.

Causes


If there is a history of suffering from allergic conditions, then the skin must be sensitive and is more likely to develop contact dermatitis.

  • Water. You may be surprised, but water can aggravate contact dermatitis, through frequent hand washing and prolonged contact with water.
  • Soaps. All kinds of soaps, detergents, shampoos and other cleaning agents have harmful substances that could possibly irritate the skin.
  • Solvents. Solvents such as turpentine, kerosene, fuel, and thinners are strong substances that are harmful to the sensitive skin.
  • Extremes of temperature. There are people who are really sensitive even when exposed to extremes of temperature and could cause contact dermatitis.

Clinical Manifestations


Usually, there are no systemic symptoms unless the eruption is widespread.

  • Itching. Once the patient is exposed to an irritating substance, severe itching would occur.
  • Erythema. The skin turns red as a result of the irritation.
  • Skin lesions. Vesicles are a common manifestation of contact dermatitis.
  • Weeping. Weeping refers to the oozing of the contents of the vesicles, which can be pus or a watery substance.
  • Crusting. The vesicles start to form a crust as it slowly becomes dry.
  • Drying. The skin finally becomes dry and peels off.

Complications


Contact dermatitis could lead to the following complications:

  • Chronic itchy, scaly skin. A skin condition called neurodermatitis starts with a patch of itchy skin, which, when scratched habitually, may result in a thick,leathery, and discolored skin.
  • Infection. If a rash is scratched habitually, it may turn into an open wound wherein bacteria could enter and cause infection.

Assessment and Diagnostic Findings


The location of the skin eruption and the history of exposure aid in determining the condition.

  • Patch test. Patch test on the skin with suspected offending agents may clarify the diagnosis.
  • Thin-layer Rapid Use Epicutaneous (TRUE) test. The patch test most commonly used is the TRUE test.

Medical Management


The most important step in the medical management of dermatitis is to recognize the causative factor so that it could be avoided.

  • Avoiding the irritant. The key is to identify the substance that causes the rash so that it could be avoided.
  • Phototherapy. There are patients that need light therapy to calm their immune system, and the method is called phototherapy.
  • Medicated baths. Medicated baths are prescribed for larger areas of dermatitis.

Pharmacologic Therapy

Drug therapy for contact dermatitis usually consists of lotion, creams, and oral medications.

  • Hydrocortisone, a corticosteroid, may be prescribed to combat inflammation in a localized area.
  • Antihistamines. Prescription antihistamines may be given if non-prescription strength is inadequate.
  • Barrier cream. These products can provide a protective layer for the skin.
  • Antibiotics. Topical or oral antibiotics may be used to treat secondary infection.

Nursing Management


Nursing management of a patient with contact dermatitis involves the following:

Nursing Assessment

Skin assessment should be the focus in a patient with contact dermatitis.

  • Skin characteristics. Assess skin, noting color, moisture, texture, and temperature.
  • Lesions. Note erythema, edema, tenderness, presence of erosions, excoriations, fissures, and thickening.
  • Appearance. Assess the patient’s perception of and behavior related to changed appearance.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnoses are:

Nursing Care Planning & Goals

Main Article: 4 Dermatitis Nursing Care Plans

The major goals for the patient are:

  • Patient maintains optimal skin integrity within limits of the disease, as evidenced by intact skin.
  • Patient verbalizes feeling about lesions and continues daily activities and interactions.
  • Patient remains free of secondary infection.
  • Patient reports increased comfort level and skin remains intact.

Nursing Interventions

Nursing interventions appropriate for the patient include:

  • Skin care. Encourage the patient to bathe in warm water using a mild soap, then air dry the skin and gently pat to dry.
  • Topical application. Usual application of topical steroid creams and ointments is twice a day, spread thinly and sparingly.
  • Phototherapy preparation. Prepare the patient for phototherapy, because this method uses ultraviolet A or B light waves to promote healing of the skin.
  • Acknowledge patient’s feelings. Allow patient to verbalize feelings regarding their skin condition.
  • Proper hygiene. Encourage the patient to keep the skin clean, dry, and well lubricated to reduce skin trauma and risk for infection.

Evaluation

Expected patient outcomes include:

  • Patient maintained optimal skin integrity within limits of the disease, as evidenced by intact skin.
  • Patient verbalized feeling about lesions and continues daily activities and interactions.
  • Patient remained free of secondary infection.
  • Patient reported increased comfort level and skin remains intact.

Discharge and Home Care Guidelines

To help reduce itching and soothe inflamed skin, the following should be followed:

  • Avoid the irritant. Avoid allowing the reaction-causing substance to touch the skin
  • Anti-itch creams. Apply anti-itch creams or calamine lotion to the affected area.
  • Cold application. Moisten soft cloths and hold them against the rash to soothe the skin for 15 to 30 minutes.
  • Avoid fragrance-containing substances. Choose soaps, powders, and other personal products that are fragrance-free, as it could irritate the affected area.

Documentation Guidelines

The focus of documentation include:

  • Characteristics of lesions or condition.
  • Causative and contributing factors.
  • Impact of condition on personal image and lifestyle.
  • Observations, presence of maladaptive behaviors, emotional changes, level of independence.
  • Support system available.
  • Recent or current antibiotic therapy.
  • Signs and symptoms of infectious process.
  • Plan of care.
  • Teaching plan.
  • Responses to interventions, teaching, and actions performed.
  • Attainment or progress toward desired outcomes.
  • Modifications to plan of care.

Practice Quiz: Contact Dermatitis


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1. A 28 yr-old nurse has complaints of itching and a rash of both hands. Contact dermatitis is initially suspected. The diagnosis is confirmed if the rash appears:

A. Erythematous with raised papules.
B. Dry and scaly with flaking skin.
C. Inflamed with weeping and crusting lesions.
D. Excoriated with multiple fissures.

1. Answer: A. Erythematous with raised papules.

  • A: Contact dermatitis is caused by exposure to a physical or chemical allergen, such as cleaning products, skin care products, and latex gloves. Initial symptoms of itching, erythema, and raised papules occur at the site of the exposure and can begin within 1 hour of exposure.
  • B:  Allergic reactions tend to be red and not scaly or flaky.
  • C:  Weeping, crusting lesions are also uncommon unless the reaction is quite severe or has been present for a long time.
  • D: Excoriation is more common in skin disorders associated with a moist environment.

2. A 25-year-old female presents to you with a rash over her eyelids after using a new cosmetic brand. What is the BEST test to confirm the cause of the rash?

A. Indirect immunofluorescent antibody test.
B. Patch testing.
C. Prick skin testing.
D. Punch biopsy.

2. Answer: B. Patch testing. 

  • B: Patch testing on the skin with suspected offending agents may clarify the diagnosis of contact dermatitis.
  • A: Immunofluorescence (IF) or cell imaging techniques rely on the use of antibodies to label a specific target antigen with a fluorescent dye (also called fluorophores or fluorochromes) such as fluorescein isothiocyanate (FITC).
  • C: Skin prick testing or SPT demonstrates an allergic response to a specific allergen.
  • D: Punch biopsy is considered the primary technique to obtain diagnostic, full-thickness skin specimens.

3. A 30-year-old female is diagnosed with allergic contact dermatitis of the face, likely due to a nickel allergy from the frames of her glasses. What treatment would you recommend other than avoidance of nickel?

A. Clobetasol ointment.
B. Erythromycin gel.
C. Fluconazole gel.
D: Ketoconazole cream.

3. Answer: A. Clobetasol ointment.

  • A: Clobetasol cream is a topical corticosteroid. It works by decreasing certain immune responses, which reduces redness and itching of skin.
  • B: Erythromycin gel is a topical macrolide antibiotic that is thought to improve acne by slowing the growth of bacteria on the skin, which causes acne.
  • C: Fluconazole is a topical anti-fungal medication used to treat skin conditions such as ringworm or psoriasis.
  • D: Ketoconazole is used to treat skin infections such as athlete’s foot, jock itch, ringworm, and certain kinds of dandruff.

4. Contact dermatitis is a type of hypersensitivity: 

A. Type I.
B. Type II.
C. Type III.
D. Type IV.

4. Answer: D. Type IV.

  • D: Type IV hypersensitivity is a delayed hypersensitivity reaction that are inflammatory in nature initiated by mononuclear leukocytes.
  • A: Type I hypersensitivity is triggered by an innocuous foreign substance (like dust, pollen or animal dander) that would cause no problems in the majority of people.
  • B: Type II hypersensitivity is the process by which IgG or IgM binds to a cell to cause injury or death (Antibody Dependent Cytotoxicity).
  • C: Type III hypersensitivity is tissue damage created by immune complexes, which are aggregations of antigen and antibodies.

5. A light therapy used to calm the immune system is called:

A. Wood’s lamp examination.
B. Phototherapy.
C. Patch test.
D. Prick test.

5. Answer: B. Phototherapy.

  • B: There are patients that need light therapy to calm their immune system, and the method is called phototherapy.
  • A: A Wood’s lamp examination is a test that uses ultraviolet (UV) light to look at the skin closely.
  • C: A patch test is a method used to determine whether a specific substance causes allergic inflammation of a patient’s skin.
  • D:  Skin prick testing or SPT demonstrates an allergic response to a specific allergen.

See Also

Further Reading and External Resources

  1. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
  2. Medical-Surgical Nursing: Assessment and Management of Clinical Problems
  3. Medical-Surgical Nursing: Patient-Centered Collaborative Care
  4. Saunders Comprehensive Review for the NCLEX-RN Examination
  5. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing
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