Allergic contact dermatitisMANAGEMENT

DERMATOLOGY PRESENTATIONS · 12 SECTIONS

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513 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Allergic contact dermatitis Bullous Pemphigoid Cutaneous Abscess Eczema Herpeticum Erysipelas Erythema multiforme Henoch-Schönlein purpura Herpes Zoster (Shingles)Herpetic Whitlow Paronychia Pediculosis (Lice)Pemphigus Vulgaris Pilonidal Abscess Pressure injury Psoriasis (acute flare)Psoriasis Flare Staphylococcal Scalded Skin Syndrome Stevens-Johnson Syndrome (SJS)Toxic Epidermal Necrolysis (TEN)Urticaria (acute)Warfarin-induced Skin Necrosis

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp67

Immediate threats and escalation

›Stabilization priorities

›Airway compromise concern

›Periorbital edema with inability to open eyes

›Lip or tongue swelling with voice change

›Stridor

›If airway concern, immediate resuscitation bay

›Anaphylaxis alternate diagnosis

›Hypotension

›Bronchospasm

›Generalized urticaria within minutes to 2 hours

›If suspected, manage as anaphylaxis

›Severe cutaneous adverse reaction alternate diagnosis

›Mucosal involvement

›Skin pain out of proportion

›Widespread dusky or targetoid lesions

›Epidermal detachment or positive Nikolsky sign

›If suspected SJS/TEN, immediate specialty consultation and admission

›Necrotizing soft tissue infection alternate diagnosis

›Rapid progression

›Severe pain

›Bullae with systemic toxicity

›If suspected, immediate surgical consult

›Sepsis concern

›Fever with tachycardia and hypotension

›Altered mental status

›If suspected, sepsis pathway

Focused bedside differentiation

›Pattern recognition

›Allergic contact dermatitis typical pattern

›Well-demarcated erythema in exposure distribution

›Papules and vesicles

›Serous weeping and crusting

›Pruritus predominant

›Irritant contact dermatitis pattern

›Burning or stinging predominant

›Dryness and fissuring

›Immediate onset after exposure

›Cellulitis pattern

›Unilateral warmth and tenderness

›Poorly demarcated erythema

›Lymphangitic streaking

›Dermatitis herpetiformis alternate diagnosis

›Grouped excoriated papules on extensor surfaces

›Symmetric distribution

›Scabies alternate diagnosis

›Burrows

›Interdigital involvement

›Household contacts with itch

Initial management targets

›Early control strategy

›Allergen identification and avoidance

›Remove suspected product and wash exposed skin

›Avoid re-exposure until diagnosis clarified

›Symptom control

›Pruritus reduction to prevent excoriation

›Skin barrier restoration

›Complication prevention

›Secondary infection risk reduction

›Ocular involvement screening

PEARLS

›Key practical points

›Delayed onset 12 to 72 hours after exposure supports type IV hypersensitivity

›Linear streaks with vesicles suggest urushiol exposure

›Hands and face are common sites due to frequent exposures

›Recurrent dermatitis in same location suggests repeated allergen contact

PITFALLS

›Common errors

›Assuming antibiotics needed for erythematous pruritic plaques without warmth or tenderness

›Using topical antihistamines or topical antibiotics that can worsen allergic dermatitis

›Under-treating severe poison ivy with inadequate systemic steroid duration

›Missing periocular involvement requiring ophthalmology input for eyelid disease

02History/hx58

Exposure and timeline

›Exposure history

›New products

›Soaps and shampoos

›Cosmetics and sunscreen

›Fragrances and essential oils

›Topical medications

›Occupational and hobby exposures

›Gloves and rubber accelerators

›Metals and tools

›Hair dyes and salon chemicals

›Cement and epoxy resins

›Plant exposures

›Poison ivy, oak, sumac

›Gardening and yardwork

›Adhesives and medical devices

›Tapes and dressings

›Continuous glucose monitor adhesives

›Wound care products

›Clothing and detergents

›New detergent or fabric softener

›Formaldehyde resins in textiles

›Timeline features

›Onset relative to exposure

›12 to 72 hours after exposure

›Worsening with repeated contact

›Evolution

›Vesiculation to crusting

›Persistent pruritus

›Prior episodes

›Similar rash with same product

›Seasonal recurrence with outdoor activities

Symptoms and severity

›Symptom profile

›Pruritus severity

›Sleep disruption

›Interference with school or work

›Pain or burning

›Prominent pain suggests infection or severe drug eruption

›Systemic symptoms

›Fever

›Malaise

›Respiratory symptoms

›Mucosal symptoms

›Oral ulcers

›Conjunctival irritation

Risk factors and comorbidities

›Predisposing factors

›Atopic dermatitis history

›Increased barrier disruption risk

›Chronic hand wet work

›Irritant dermatitis overlap

›Immunosuppression

›Higher infection risk

›Medication reactions

›Recent new systemic medication

Relevant coding

›Coding anchors

›ICD-10 L23.9 allergic contact dermatitis, unspecified cause

›ICD-10 L23.7 allergic contact dermatitis due to plants, except food

›ICD-10 L23.0 allergic contact dermatitis due to metals

›SNOMED CT allergic contact dermatitis concept mapping for problem list

03Physical Exam/exam43

Distribution and morphology

›Morphology assessment

›Acute findings

›Erythematous papules

›Vesicles and bullae

›Serous weeping

›Subacute findings

›Crusting

›Scale

›Excoriations

›Chronic findings

›Lichenification

›Fissures

›Hyperpigmentation

›Distribution clues

›Sharply demarcated borders matching contact area

›Wrist under watchband

›Earlobes with earrings

›Abdomen under belt buckle

›Linear streaks

›Plant resin exposure

›Eyelid dermatitis

›Airborne allergens or transfer from hands

›Hand dermatitis pattern

›Glove or occupational exposure

Severity and complications

›Severity markers

›Body surface area estimate

›Palmar method

›Face and genital involvement

›Edema severity

›Periorbital swelling

›Functional impairment

›Hand use limitation

›Infection assessment

›Honey-colored crusting

›Impetigo concern

›Purulence

›Abscess concern

›Warmth and tenderness out of proportion to pruritus

›Cellulitis concern

PITFALLS

›Exam traps

›Bilateral symmetric erythema misread as cellulitis

›Vesicles misattributed to herpes without dermatomal pain

›Facial swelling assumed allergic contact dermatitis when angioedema features present

04Differential Diagnosis/ddx44

Dangerous and time-sensitive

›Must-not-miss conditions

›Anaphylaxis

›ICD-10 T78.2

›Stevens-Johnson syndrome and toxic epidermal necrolysis

›ICD-10 L51.1

›ICD-10 L51.2

›Necrotizing fasciitis

›ICD-10 M72.6

›Orbital cellulitis

›ICD-10 H05.012

Common mimics

›Dermatitis and inflammatory

›Irritant contact dermatitis

›ICD-10 L24.9

›Atopic dermatitis flare

›ICD-10 L20.9

›Seborrheic dermatitis

›ICD-10 L21.9

›Psoriasis

›ICD-10 L40.9

›Urticaria

›ICD-10 L50.9

›Infectious

›Cellulitis

›ICD-10 L03.90

›Impetigo

›ICD-10 L01.00

›Tinea corporis

›ICD-10 B35.4

›Scabies

›ICD-10 B86

›Herpes zoster

›ICD-10 B02.9

Differentiating clinical clues

›Key discriminators

›Contact dermatitis

›Pruritus predominant

›Exposure distribution

›Delayed onset hours to days

›Urticaria

›Transient wheals less than 24 hours per lesion

›Tinea

›Annular plaque with peripheral scale

›Cellulitis

›Tenderness and warmth

›Systemic symptoms more likely

05Laboratory Tests/lt19

Routine testing

›Limited role of labs

›No routine labs for uncomplicated allergic contact dermatitis

›Diagnosis primarily clinical with exposure correlation

›If systemic symptoms, targeted labs based on alternate diagnosis

›Fever evaluation pathway

Infection or complication workup

›Secondary bacterial infection evaluation

›Wound culture

›Purulent drainage

›Failure of initial topical therapy with suspected infection

›Complete blood count for systemic toxicity concern

›Leukocytosis interpretation with clinical context

›C-reactive protein for severe infection concern

›Non-specific elevation limitation

Allergy evaluation adjuncts

›Allergy testing labs

›Total IgE

›Not diagnostic for allergic contact dermatitis

›Eosinophil count

›Non-specific

›More relevant for drug reactions and atopy

06Diagnostic Tests/dt44

Scoring Systems

›Severity and tracking tools

›Body surface area estimate

›Palmar method

›Face, hands, genital involvement as high-impact sites

›Physician Global Assessment style severity

›Mild localized erythema and pruritus

›Moderate vesiculation or multiple sites

›Severe widespread or facial edema

›Patient-reported itch scale

›0 to 10 numeric rating for treatment response tracking

MRI

›MRI role

›Not indicated for allergic contact dermatitis

›No benefit for primary diagnosis

›If concern for orbital cellulitis complications, MRI orbit as alternative to CT

›Specialty-guided choice

›CT role

›Not indicated for allergic contact dermatitis

›No imaging for primary diagnosis

›If concern for orbital cellulitis, CT orbit and sinuses

›Proptosis

›Ophthalmoplegia

›Decreased visual acuity

Ultrasound

›Ultrasound role

›Not indicated for allergic contact dermatitis

›No sonographic diagnostic target

›If focal fluctuance, point-of-care ultrasound for abscess evaluation

›Fluid collection

›Guidance for drainage decision

Patch testing and dermatologic diagnostics

›Confirmatory and etiologic testing

›Patch testing

›Persistent or recurrent dermatitis despite avoidance

›Occupational dermatitis

›Facial or eyelid dermatitis with unclear trigger

›Referral to dermatology or contact dermatitis specialist

›Skin biopsy

›Atypical presentation

›Concern for psoriasis, cutaneous T-cell lymphoma, drug eruption

›Spongiotic dermatitis pattern supportive but non-specific

›KOH preparation

›Annular lesions

›Tinea mimic concern

›Scabies scraping or dermoscopy

›Burrows

›Household outbreak

07Disposition/dispo26

Level of care

›Admission and escalation criteria

›Suspected SJS/TEN

›Immediate admission

›Burn unit or ICU based on institutional pathway

›Orbital cellulitis concern

›Admission and IV antibiotics pathway

›Extensive dermatitis with inability to maintain hydration or oral intake

›Consider admission

›Severe secondary infection with systemic toxicity

›Admission and sepsis pathway

›Outpatient management criteria

›No systemic toxicity

›Afebrile

›Hemodynamically stable

›Localized or moderate disease with reliable follow-up

›Safe discharge with topical therapy plan

Follow-up

›Timelines

›Primary care follow-up in 3 to 7 days for symptom check

›Dermatology follow-up for recurrent or unclear triggers

›Patch testing referral if persistent beyond 2 to 4 weeks

Return precautions triggers

›Escalation triggers

›Rapid spread over hours

›Fever or chills

›Increasing pain or warmth

›Facial swelling affecting vision

›Mucosal lesions

08Treatment/t99

Allergen avoidance and decontamination

›Exposure control

›Immediate steps for suspected recent exposure

›Soap and water wash within minutes to hours when feasible

›Remove contaminated clothing and wash separately

›Urushiol exposure measures

›Clean under fingernails

›Clean tools and pet fur if exposure suspected

›Avoid sensitizing topical agents

›Topical neomycin avoidance

›Topical diphenhydramine avoidance

Skin barrier and non-pharmacologic care

›Supportive care

›Cool compresses

›10 to 15 minutes

›Several times daily as needed

›Wet dressings for weeping dermatitis

›Normal saline or water

›Follow with topical corticosteroid and emollient

›Emollients

›Petrolatum-based ointment

›Fragrance-free thick creams

›Irritant avoidance

›Hot showers avoidance

›Harsh soaps avoidance

Topical anti-inflammatory therapy

›Topical corticosteroids

›Selection by site and severity

›Face and intertriginous areas

›Hydrocortisone 1% to 2.5% topical

›Duration 5 to 7 days then reassess

›Trunk and extremities moderate severity

›Triamcinolone 0.1% topical

›Frequency twice daily

›Duration 7 to 14 days then taper frequency

›Hands and thick plaques

›Clobetasol 0.05% topical

›Frequency twice daily

›Duration up to 14 days

›Avoid face and groin

›Application technique

›Fingertip unit dosing education

›Ointment preferred for dry lichenified lesions

›Cream or lotion for weeping areas

›Adverse effects counseling

›Skin atrophy risk with prolonged high potency use

›Perioral dermatitis risk with facial steroids

›Topical calcineurin inhibitors

›Tacrolimus 0.03% topical for pediatrics

›Frequency twice daily

›Eyelid and face steroid-sparing option

›Tacrolimus 0.1% topical for adults

›Frequency twice daily

›Pimecrolimus 1% topical

›Frequency twice daily

Systemic therapy

›Indications for systemic corticosteroids

›Extensive involvement

›Greater than 20% body surface area

›Severe facial or genital involvement

›Significant edema impairing function

›Severe urushiol dermatitis with progressive vesiculation

›Prednisone oral regimen

›Initiate 0.5 to 1 mg/kg/day

›Typical adult range 40 to 60 mg daily

›Duration to prevent rebound for poison ivy

›Total course 14 to 21 days

›Taper approach

›Maintain initial dose 5 to 7 days

›Taper by 10 mg every 2 to 3 days as tolerated

›Contraindications and precautions

›Uncontrolled diabetes

›Active infection

›Peptic ulcer disease risk

›Psychiatric history risk

›Alternative systemic options

›Intramuscular triamcinolone

›Consider when adherence to taper uncertain

›Avoid if infection concern

›Antipruritic symptom control

›Cetirizine 10 mg oral daily

›Non-sedating daytime option

›Loratadine 10 mg oral daily

›Non-sedating daytime option

›Hydroxyzine 10 to 25 mg oral at bedtime

›Sedation risk

›Avoid in high fall risk

Secondary infection management

›Bacterial superinfection treatment

›Topical mupirocin 2% for localized impetigo

›Frequency three times daily

›Duration 5 days

›Oral antibiotics for cellulitis features

›Guided by local antibiogram and risk factors

›Avoid antibiotics when dermatitis without infection signs

Evidence and guideline framing

›Evidence summary

›High potency topical corticosteroids reduce inflammation in localized allergic contact dermatitis

›Class I recommendation based on broad dermatology consensus

›Systemic corticosteroids for severe urushiol dermatitis require 14 to 21 day course to reduce rebound risk

›Class IIa recommendation based on clinical experience and observational evidence

›Patch testing for recurrent or occupational dermatitis improves allergen identification and avoidance success

›Class I recommendation from specialty society practice standards

›ACEP Level C

›Antibiotics not indicated for uncomplicated dermatitis without infection signs

09Special Populations/sp37

Pregnancy

›Pregnancy considerations

›Diagnosis and testing

›Patch testing generally deferred unless essential

›Avoid new sensitizers in pregnancy skin care

›Topical therapy safety

›Low to medium potency topical corticosteroids preferred

›Avoid extensive high potency use

›Systemic corticosteroids

›Use lowest effective dose

›Shortest effective duration

›Obstetric consultation for prolonged courses

›Antihistamines

›Cetirizine and loratadine commonly used options

›Sedating agents with caution due to maternal drowsiness

Geriatric

›Geriatric considerations

›Skin fragility

›Increased steroid atrophy risk

›Prefer lower potency and shorter duration

›Medication safety

›Sedating antihistamines increase fall risk

›Polypharmacy interaction review

›Infection risk

›Lower threshold for evaluating superinfection

Pediatrics

›Pediatric considerations

›Weight-based systemic steroid dosing

›Prednisone 0.5 to 1 mg/kg/day

›Max dosing based on clinical judgment

›Topical potency selection

›Low potency for face and folds

›Medium potency for trunk and extremities

›Common pediatric allergens

›Nickel

›Fragrances

›Preservatives in wipes

›School and daycare implications

›Non-contagious counseling for contact dermatitis

›Scabies and impetigo exclusion rules if alternate diagnosis found

10Background/b33

Epidemiology

›Frequency and patterns

›Common clinical problem in primary care and emergency settings

›Hand and occupational dermatitis common presentations

›Common allergens

›Nickel

›Fragrance mix

›Preservatives

›Rubber accelerators

›Hair dye agents

›Topical antibiotics and anesthetics

›Plant dermatitis

›Urushiol as common cause of acute vesicular dermatitis in North America

Pathophysiology

›Mechanism

›Type IV delayed hypersensitivity reaction

›T-cell mediated response

›Sensitization phase after initial exposures

›Elicitation phase after re-exposure

›Timing

›Symptoms typically begin 12 to 72 hours after exposure

›Skin barrier disruption

›Increased penetration of allergens and irritants

Therapeutic Considerations

›Treatment rationale

›Allergen avoidance as definitive intervention

›Prevents ongoing immune activation

›Topical corticosteroids as first-line for localized disease

›Anti-inflammatory effect reduces erythema and vesiculation

›Systemic corticosteroids for severe widespread disease

›Prevents progression and reduces edema

›Adequate duration prevents rebound in urushiol dermatitis

›Calcineurin inhibitors for sensitive sites

›Steroid-sparing for eyelids and face

›Barrier repair with emollients

›Reduces recurrence and irritant overlap

11Patient Discharge Instructions/pdi29

Copy discharge instructions

›Discharge text

›Diagnosis is allergic contact dermatitis

›Avoid suspected trigger

›Stop the new product or exposure linked to the rash

›Do not restart until advised

›Skin care

›Gentle soap and lukewarm water

›Fragrance-free moisturizer at least twice daily

›Cool compresses for itch

›Medications

›Use topical steroid as prescribed

›Do not use high potency steroid on face, groin, or armpits unless instructed

›If taking prednisone, take in morning with food

›Complete the full course as prescribed to prevent rebound

›Itch control

›Cetirizine or loratadine daily if needed

›Sedating antihistamine only at bedtime if prescribed

›Return to emergency care now

›Trouble breathing

›Swelling of lips or tongue

›Severe eye swelling or vision change

›Fever

›Rapidly worsening redness with increasing pain or warmth

›Pus or spreading crusting

›Mouth sores or rash on eyes or genitals

›Follow-up

›See primary care in 3 to 7 days if not improving

›Dermatology referral if rash keeps coming back or trigger unclear

›Patch testing discussion for recurrent cases

12References/r14

Clinical guidelines and society resources

›Key references

›American Contact Dermatitis Society

›Patch testing standards and allergen series guidance

›American Academy of Dermatology clinical resources

›Contact dermatitis management principles

›National and regional poison ivy and urushiol dermatitis clinical summaries

›Systemic steroid course length to reduce rebound risk

Evidence-based sources

›Evidence base

›Review literature on allergic contact dermatitis pathophysiology and diagnosis

›Type IV hypersensitivity mechanism and timing

›Clinical reviews on topical corticosteroid potency selection by body site

›Adverse effect risk mitigation

›Studies and consensus statements supporting patch testing for recurrent dermatitis

›Improved identification and avoidance outcomes

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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