Contact Dermatitis Nursing Care Management and Study Guide

Contact dermatitis is a type IV delayed hypersensitivity reaction, an acute or chronic skin inflammation from direct skin contact with chemicals or allergens. Sensitivity can develop after brief or prolonged exposure, and the result is sharply demarcated inflammation and irritation where the skin met the offending substance. The work is simple in concept and hard in practice: find the trigger and get it off the skin.

Classification

Four basic types: allergic (direct contact with allergens), irritant (contact with an irritating substance), phototoxic (a sunburn-like disorder from UV-light activation of a phototoxic agent), and photoallergic (a delayed-type hypersensitivity reaction to a photo antigen in a previously sensitized patient).

Other dermatitis types worth knowing. Contact dermatitis comes from an allergen or irritant, and irritant contact dermatitis accounts for 80% of all cases. Atopic dermatitis is common and rising worldwide, affects males and females equally, makes up 10% to 20% of dermatology referrals, and is more likely in low-humidity urban areas. Dermatitis herpetiformis stems from celiac disease. Seborrheic dermatitis is more common in infants and in people 30 to 70 years old, hits men more, and occurs in 85% of people with AIDS. Nummular dermatitis is less common, has no known cause, and favors middle age. Stasis dermatitis inflames the lower legs from blood and fluid buildup, more often in people with varicose veins. Perioral dermatitis resembles rosacea and appears more often in women 20 to 60 years old. Infective dermatitis is dermatitis secondary to a skin infection.

Pathophysiology

A hapten (small hydrophobic molecule) binds protein, enters the stratum corneum, and attaches to epidermal antigen-presenting Langerhans cells. Those cells process the antigen and travel to regional lymph nodes, where they present it to naive CD4 T cells. The T cells proliferate into memory and effector cells that elicit contact dermatitis within 48 to 96 hours of reexposure to the allergen.

Statistics and Incidences

Excessive exposure to or additive effects of irritants cause 80% of cases, and irritant contact dermatitis is the most common type at about 80% of all contact dermatitis. In occupational irritant contact dermatitis, confirmed cases run 5 per 100,000 workers.

Causes

A history of allergic conditions means more sensitive skin and a higher chance of contact dermatitis. Common triggers: water (frequent hand washing and prolonged contact), soaps, detergents, shampoos and other cleaning agents, solvents such as turpentine, kerosene, fuel, and thinners, and extremes of temperature.

Clinical Manifestations

There are usually no systemic symptoms unless the eruption is widespread. After exposure, expect severe itching, erythema as the skin reddens, vesicular skin lesions, weeping as the vesicles ooze pus or watery fluid, crusting as they dry, and finally drying and peeling.

Complications

Neurodermatitis: a patch of itchy skin that, scratched habitually, thickens into leathery, discolored skin. Infection: habitual scratching opens the skin and lets bacteria in.

Assessment and Diagnostic Findings

Location of the eruption plus exposure history points to the diagnosis. Patch testing with suspected agents can confirm it, and the most common patch test is the Thin-layer Rapid Use Epicutaneous (TRUE) test.

Medical Management

Identify the causative agent so it can be avoided; that is the most important step. Some patients need phototherapy (light therapy) to calm the immune response, and medicated baths are prescribed for larger areas.

Pharmacologic therapy runs to lotions, creams, and oral drugs. Hydrocortisone, a corticosteroid, fights localized inflammation. Prescription antihistamines are added when over-the-counter strength is inadequate. Barrier creams provide a protective layer. Topical or oral antibiotics treat secondary infection.

Nursing Management

Assessment. Focus on the skin: note color, moisture, texture, and temperature; document erythema, edema, tenderness, erosions, excoriations, fissures, and thickening; and assess how the patient perceives and reacts to the changed appearance.

Diagnosis. Major nursing diagnoses: impaired skin integrity related to contact with irritants or allergens, disturbed body image related to visible lesions, risk for infection related to excoriations and skin breaks, and risk for impaired skin integrity related to frequent scratching and dry skin.

Planning and goals: maintain optimal skin integrity within the limits of the disease (intact skin), verbalize feelings about the lesions while continuing daily activities and interactions, stay free of secondary infection, and report increased comfort.

Interventions. Have the patient bathe in warm water with a mild soap, then air dry and gently pat. Apply topical steroid creams and ointments thinly and sparingly, usually twice a day. Prepare the patient for phototherapy, which uses ultraviolet A or B light to promote healing. Let the patient verbalize feelings about the skin condition. Keep skin clean, dry, and well lubricated to cut trauma and infection risk.

Evaluation. The patient maintains intact skin within the limits of the disease, verbalizes feelings about the lesions while staying active, remains free of secondary infection, and reports increased comfort.

Discharge and Home Care Guidelines

To reduce itching and soothe inflamed skin: keep the reaction-causing substance off the skin, apply anti-itch creams or calamine lotion, hold moist soft cloths against the rash for 15 to 30 minutes, and choose fragrance-free soaps, powders, and personal products.

Documentation Guidelines

Document the characteristics of lesions, causative and contributing factors, the impact on self-image and lifestyle, observations of maladaptive behaviors and emotional changes, level of independence, support system, recent or current antibiotic therapy, signs of infection, the plan of care, the teaching plan, responses to interventions and teaching, progress toward outcomes, and any modifications to the plan.