INTRODUCTION

Irritant contact dermatitis is a non allergic inflammatory reaction of the skin to external agents including chemical, physical or biologic agent that are capable of irritating the skin, acutely or chronically. Acute irritant contact dermatitis often the result of a single overwhelming exposure or a few brief exposures to strong irritants or caustic agents, where as chronic irritant contact dermatitis also known as cumulative irritant contact dermatitis occurs following repetitive exposure to weaker irritants which may be either wet, such as detergents, organic solvents, soaps, weak acids and alkalis, or dry, such as low humidity air, heat, powders and dusts.1,2,3 The prevalence of dermatitis in the general community are few but the point prevalence of dermatitis in the U.K. is estimated at about 20%. Irritant contact dermatitis is more common than allergic dermatitis; allergic dermatitis usually carries a worse prognosis than irritant dermatitis unless the allergen is identified and avoided. Irritant dermatitis makes up about 80% of contact dermatitis. The other 20% is allergic. This disease is significantly more common in women than in men. The high frequency in women in comparison with men is caused by environmental factors, not genetic factors. Irritant contact dermatitis may occur at any age.3,5 There are several factors that have been identified as being involved in the cutaneous irritation. These can be divided into endogenous and exogenous factors. Endogenous (host) factor include: genetic, gender, age, ethnicity, skin site and history of atopy. Exogenous factor include: irritant and environmental. Almost any material act as irritants that produce a nonspecific inflammatory reaction of the skin, if the exposure is sufficiently prolonged and/or the concentration of the substance sufficiently high. Environmental factors may enhance the effect of other irritants.2,5 The concentration and the type of the toxic agent, the duration of exposure, and the condition of the skin at the time of exprosure produces the variation of the severity of the dermatitis from person to person, or from time to time in the same person.1,2,4

Pathogenesis mechanisms of irritant contact dermatitis depend on the phase of the disease, acutely or chronically. Acute reaction involve direct cytotoxic damage to keratinocytes, where as crhonic irritant contact dermatitis result from repeated exposures solvent and surfactants that cause slow damage to cell membranes, disrupting the skin barrier and leading to protein denaturation and cellular toxicity.1 The diagnosis of irritant contact dermatitis often made by excluding other causes for dermatitis. A detailed inquiry, including history of exposure to irritant substances, occupational, hobbies, and past medical histories, and meticulous clinical examination are important for making correct diagnosis. Patch testing is often essential to help distinguish allergic contact dermatitis from irritant contact dermatitis. Negative patch tests may suggest a diagnosis of irritant contact dermatitis by exclusion of allergic contact dermatitis. It is important to perform comprehensive patch testing with the appropriate substances and concentrations to prevent incorrect conclusions.1 The management of irritant contact dermatitis principally is protection the skin from irritants. The principles of management involve irritant avoidance, using personal protective equipment and substitution to less irritating substances. Care should be taken for several months after the dermatitis has healed, as the skin remains vulnerable to flares of dermatitis for a prolonged period.1,3 Treatment for irritant contact dermatitis is identitify and remove the etiologic agent. Once dermatitis develops, using topical treatment such as corticosteroids may be helpful because of their anti inflammatory effect. Acute irritant contact dermatitis has good prognosis if the causative irritant can be identified and eliminated. The prognosis for chronic irritant dermatitis is guarded and may be worse than that of allergic contact dermatitis. An atopic background, lack of knowledge about the disease, a delayed diagnosis and treatment are factors that lead to a worse prognosis.1

CASE REPORT

Identity of Patient Name Sex Age : Ms. Y : Female : 39 years old

Registration Number : 695605 Address Hospitalized Examination day Anamnesis Chief Complaint Present of swelling, redness patches, burning and painful sensation on the face and hand since 4 days ago. Present illness history Patient came to hospital complaint about the appearance of swelling, redness patches, burning and painful sensation on the face and hand since 4 days ago. At first, patient found redness at her face until neck and her hand followed by burning and painful sensation after using a facial soap, called collagen. And then, after about 9 hours patient found her face swelling. As the time goes by, the swelling at her face turn to become less, but burning and painful sensation still came up. This is the first time for the patient using the soap. Patient got the facial soap from her sister who use it everyday. Unlike her, her younger sister has no skin problem after using the soap. Past illness history Patient has never have this kind of disease before. Family disease history None of her family had this kind of disease. : Desa Lampakuk, Kecamatan Kuta Cot Glie, Aceh Besar : November 13th, 2013 : November 13th, 2013

Medicine history Patient did not take any medication before going to hospital.

Status of Dermatologist 1. Location : At facialis and volar manus region dextra et sinistra

Dermatologic status : Erithematous patch with diffuse border, irregular edge, plakat, multiple, bilateral distribution

Figure 2.1 Erythematous patch at face

Figure 2.2 Erythematous patch at hand

Differential Diagnosis 1. Irritant contact dermatitis due to cosmetic (facial soap) 2. Allergic contact dermatitis 3. Photodermatitis 4. Erisepelas 5. Urticaria contact Resume A 39 years old woman presence of swelling, redness patches, burning and painful sensation on the face and hand since 4 days ago. At first, patient found redness at her face until neck and her hand followed by burning and painful sensation after using a facial soap, called collagen. And then, after about 9 hours patient found her face swelling. As the time goes by, the swelling at her face turn to become less, but burning and painful sensation still came up. This is the first time for the patient using the soap. Patient got the facial soap from her younger sister who use it everyday. Unlike her, her sister has no skin problem after using the soap. On dermatological status was found erithematous patch with diffuse and regular edge at her face and erithematous patch at both her hand.

Diagnosis Irritant contact dermatitis due to cosmetic (facial soap) Management Systemic 1. Kortikosteroid : Metilprednisolon tab 8 mg, 2 x 1, 3 until 5 days 2. Antihystamine : Cetirizin tab 10 mg, 1 x 1, 3 days Topical 1. Thyamphenicol 2% + Desoxymethason 0,25% oint applic at face and hand three times a day.

Education Avoid irritant that potential effect to induce skin problem. If contact does occur, wash with water as soon as possible and come to hospital to take medication if needed.

Prognosis Quo ad Vitam Quo ad Functionam : dubia ad bonam : dubia ad bonam

Quo ad Sanactionam : dubia ad bonam Follow up (November 19th 2013) Five days after first visit to hospital and take medication, the skin condition of the lesion area both face and hand start to turn in normal condition again. There is no present of swelling at face and the redness patches became less, only appear around nose and chin.

Location

: At perinasal et mental region

Dermatologic status : Erithematous patch with diffuse border, irregular adge, plakat, multiple, regional distribution

Figure 2.3 Erythematous patch at perinasal and mental

Location

: At volar manus dekstra et sinistra region

Dermatologist status : Present of scale and the underlying skin is not red anymore

Figure 2.4 Present of scale at hand

DISCUSSION
Irritant contact dermatitis is an acute or chronic inflammatory reactions to substances that contact with the skin such as chemical or other physical agents that are capable of irritating the skin.1 One of irritant substance is lactic acid that cause erythema and whealing at the affected site of the skin.2 The collagen soap that patient used containe lactic acid that play a role in irritating patients skin. This patient complain some skin problem including swelling, redness, burning and painful sensation after using a facial soap called collagen that potentially contain irritant substances. The type of clinical feature in this case is acute irritant contact dermatitis. Acute irritant contact dermatitis usually result from a single exposure to a strong irritant or caustic chemical such as alkalis and acids. Burning, itching or stinging sensation may occur immediately after the exposure to the irritant. Erythema, edema and vesiculation may present in the patient.1 in this case the patient presence of swelling, redness patches, burning and painful sensation on the skin face and the hand. Irritant contact dermatitis may occur at any age. In this case, patient suffering the disease at 39 years old. Older persons have drier and thinner skin that does not tolerate soaps and solvents as well as younger individuals, so they are more susceptible to have skin problems. The diagnosis of irritant contact dermatitis often made by excluding other causes for dermatitis. A detailed inquiry, including history of exposure to irritant substances, occupational, hobbies, and past medical histories, and meticulous clinical examination are important for making correct diagnosis. Rietschel has proposed criteria with subjective and objective features, each with mayor and minor findings for the diagnostic of irritant contact dermatitis. Mayor subjective criteria are 1). onset of symptoms within minute to hours of exposure 2). pain, burning, stinging or discomfort exceeding itching early in the clinical course. Mayor objective criteria are 1). Macular erythema, hyperkeratosis, or fissuring predominating over vesiculation 2). Glazed, parched, or scalded appearance of the epidermis 3). Healing process begin promptly on with drawal of exposure to the offending agent 4). Patch testing is negative. Minor subjective criteria are 1).

Onset of the dermatitis within 2 weeks of exposure 2). Many people in th environment affected similarly. Minor objective criteria are 1). Sharp circumspection of the dermatitis 2). Evidence of gravitational influence, such as dripping effect 3). Lack of tendency of the dermatitis to spread 4). Morphologic changes suggesting small concentration differences or contact time produce large difference in skin damage. The more features identified, the stronger the case for irritant contact dermatitis.1 In this case, patient has two mayor subjective criteria include: onset within minute and patient feel pain, burning and discomfort sensation, and two mayor objective criteria include: erithematous patch and healing process begin promptly on with drawal of exposure to the offeding agent. In this case, patch testing did not perform because of limited equipments and the difficulty of controlling patient. Normally, patch testing is needed to help distinguish allergic contact dermatitis from irritant contact dermatitis. Negative result may suggest a diagnosis of irritant contact dermatitis by exclusion of allergic contact dermatitis. It is important to perform comprehensive patch testing with the appropriate substances and concentrations to prevent incorrect conclusions.1 In the acute stage of irritant contact dermatitis, topical corticosteroids are indicated. If there is deep tissue destruction or signs of bacterial infection, systemic corticosteroids and antimicrobial agents should be administered.2 In this case, the patient got corticosteroid, antihystamin, and antimicrobial topical for her medication.s

REFERENCE
1. Goldsmith L, Katz S, Gilchrest B, Paller A, Leffel D, Wolff K. Fitzpatricks Dermatology in General Medicine. Eighth Edition. 2008. McGraw-Hill: New York. P.395-400 2. Frosch PJ, John SM. Clinical Aspects of Irritant Contact Dermatitis. 2006. Available at http://www.springer.com/978-3-540-24471-4 (November 16th, 2013). 3. Bourke J, Coulson I, English J. 2008. Guidelines for The Management of Contact Dermatitis: An Update. British Journal of Dermatology. St Johns Institue of Dermatology, Kings College: London. 4. James WD, Berger TG, Elston DM. Andrews Disease of The Skin Clinical Dermatology. Eleventh Edition. 2011. Saunders Elsevier : USA. P.88-91 5. Health and Safety Authority. Guidelines on Occupational Dermatitis. 2009. The Metropolitan Building, James Joyce Street, Dublin.

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