Cutaneous Manifestation of Toxic Exposures

Cutaneous Manifestations of Toxic
Exposures
Dr Errol Williamson Moderator: Dr Hutson

THE SKIN
Largest organ of the body
It functions as a barrier protecting the body against external stimuli:

• Thermoregulation
• Body fluid and electrolyte balance
• Synthesis of Vitamin D
• Immune system function
• Sensory function
PRESENTATION TITLE 2
Layers of the Skin
Epidermis Dermis Subcutaneous tissue
Comprises of squamous Comprises of fibrous Loose connective tissue
epithelium: connective tissue with elastic
Adipose tissue
• Langerhans cells and reticular fibres
• Melanocytes • Sweat glands

• Sebaceous glands
• Markel cells
• Hair follicles
• Blood vessels
• Lymphatic vessels
Introduction
Cutaneous toxicity can be classified according to the mechanism of onset into
the following:
(1) contact dermatitis 6) hair disturbance

(2) Photosensitivity (7) nail disturbance
(3) contact urticaria (8) Drug rash
(4) Chemical-induced acne (9) tumor-induced
(5) pigmentary disturbance (10) Others
Contact Dermatitis
Contact Dermatitis
Contact dermatitis is skin inflammation occurring as a result of
direct contact of the skin with a substance.
It can be classified into the following:

• Irritant contact dermatitis
• Allergic contact dermatitis
• Chemical burns
Irritant contact dermatitis
Irritant dermatitis is an inflammatory change caused by direct
irritation of the skin
Usually happen within the same day or the following day.
Contact allergic dermatitis
Contact Allergic Dermatitis: This refers to skin inflammation upon
re-exposure to a drug/agent that had been previously administered
Chemical burns
Chemical burns are an injury caused by a chemical substance that
is extremely corrosive or irritating (e.g., strong acid or strong
alkali).
It often involving itching and/or ulceration due to local coagulative
necrosis.
Photosensitive
Dermatitis
Photosensitive Dermatitis
Photosensitive dermatitis (photosensitivity) is a general term that refers
to skin inflammation caused by the combined effect of a drug and light.
It occurs in the sun-exposed areas of the body.
It can be classified into two types, either with or without involvement of

an immunological mechanism
Some examples of photosensitizing drugs are phenothiazine, tetracyclines,

sulfonamides, chlorpromazine, nalidixic
PRESENTATIONacid,
TITLE and fluorocoumarins 12
Reaction to doxycycline Reaction to chlorpromazine
Phototoxic dermatitis
A condition caused by a drug that is sensitive to light (ultraviolet light)
following sun exposure.
This generally occurs without the involvement of an immune mechanism.
Signs of phototoxicity are sunburn-like reactions, especially in non-

pigmented areas.
Photoallergic dermatitis
Skin inflammation upon re-exposure to a previously administered drug
that absorbed ultraviolet light.
Once there is exposure to light(UV), there is the absorption of photon

energy; this interaction causes the transformation of a protein in the
body. This, in turn, acts as an antigen.
Once sensitized following re-exposure the immune system
Some examples of photosensitizing drugs are phenothiazine,
tetracyclines, sulfonamides, chlorpromazine, nalidixic acid, etc
Contact Urticaria
Contact Urticaria
Contact urticaria is acute redness or rash that occurs within several
minutes to one hour following exposure to a drug.
It is a transient wheal and flare reaction that occurs within 10 to 60 minutes
at the site of contact of the offending agent and completely resolves within
24 hours.
Contact Urticaria
It can be caused by a direct effect of the drug on vascular walls, indirectly
via histamine release from mast cells or by an IgE-mediated immediate
(type I) allergic reaction with the involvement of an immune mechanism.
For immune contact urticaria, known conditions include systemic reactions

to penicillin or food, as well as urticaria due to natural rubber products
(e.g.latex allergy)
Chemical Induced
Acne
Chemical Induced Acne
Chemical-induced acne is a disease of hair follicles caused by a chemical
substance and is characterized by keratin plugs in hair follicles due to
excessive proliferation of keratinocytes in hair follicles (comedo), sebum
retention and inflammation.
Eg including: exposure of the skin to cutting oils, as well as chloracne,
induced by dioxins
Clinically, the lesions are located around the eyes, ears, back, and genitalia;
and other symptoms include hyperpigmentation, conjunctivitis, and ocular
discharge.
Pigmentary
Disturbance
Pigmentary Disturbance
Altered pigmentation is a condition that sometimes follows skin
inflammation and is characterized histopathologically by an increase or
decrease in the number of melanocytes as well as melanin production.
Hyperpigmentation
A condition occurring in association with increased melanin production
due to activation of melanocytes, hemosiderin deposition due to
haemorrhage, or deposition of the drug itself
Drugs that can cause hyperpigmentation include:

Cyclophosphamide, minocycline, busulfan,
long term high dose ACTH
Hypopigmentation
A condition occurring in association with loss of melanin or
selective damage to melanocytes or by inhibition of melanin
synthesis.
Drugs that cause hypopigmentation include:

Hydroquinone, phenols, catechols
Hair Disturbance
Hair Disturbance
Many drugs induce hair disorders, such as hair loss, stimulated hair
growth, or, more rarely, changes in the hair shape and color [27].
Hair loss (hypotrichosis or alopecia)
Alopecia
A condition due to drugs with an androgenic effect acting on hair
follicles to shorten the hair cycle, or drugs with an antimitotic
effect inducing atrophy of hair follicles and prolongation of the
resting phase of the hair cycle
E.g. Anticancer drugs , irradiation
Hypertrichosis
A condition due to prolongation of the anagen phase of hair follicles
induced by certain immunosuppressants, antihypertensives (minoxidil),
or drugs for benign prostatic hyperplasia (finasteride)
Hypertrichosis is observed as an increase

in the length, thickness, and number of
eyelashes
Nail Disturbance
Nail Disturbance
A condition arising from damage to the nail matrix cells due to
drugs with an antimitotic effect or deposition of the drugs
themselves.
Drug Rash
Drug Rash
Drug rash (cutaneous reaction) is the most common adverse drug reaction
reported to occur with antibiotics.
The most serious forms of drug rash are toxic epidermal necrolysis (TEN)
and Stevens-Johnson syndrome
The use of various drugs, including penicillin derivative or cephem

derivative antibiotics, antipyretic analgesics (particularly NSAIDs),
allopurinol, amine antiepileptic drugs (phenytoin and carbamazepine), etc
Skin
carcinogenesis
Treatment of psoriasis by photochemotherapy (PUVA)
with oral methoxsalen in conjunction with UVA
radiation, is associated with an increased risk of
irregular pigmented skin lesions, squamous cell
carcinoma, and malignant melanoma
Others
• Acne formation due to anti-inflammatory analgesics
• Drug-induced skin atrophy
• Skin ulcer due to peripheral circulatory insufficiency
• Drug-induced granulomatous reaction
Summary
• Cutaneous toxicity of drugs or chemical substances may appear in various forms.
• Chemicals can be absorbed through skin and into the blood stream causing toxic effects
both cutaneous and systemically
• Some individuals may be particularly sensitive to a compound or a plant; others may

experience little or no effects from contact.
Summary
• Determining the cause of dermatitis may be easy or it may be difficult.
• The best way to prevent cutaneous toxicity is the appropriate and correct use of
protective clothing, and the use of safe handling and application procedures.
REFERENCES
• Yoshizawa K, Yuki M, Tsubura A. Drug-Induced Cutaneous Toxicity [Internet]. Toxicology -

New Aspects to This Scientific Conundrum. InTech; 2016. Available from:
http://dx.doi.org/10.5772/64473
• DermNet online
• Google Images
Thank you

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Cutaneous Manifestations of Toxic

Dr Errol Williamson Moderator: Dr Hutson

It functions as a barrier protecting the body against external stimuli:

• Melanocytes • Sweat glands

(1) contact dermatitis 6) hair disturbance

It can be classified into the following:

Usually happen within the same day or the following day.

It occurs in the sun-exposed areas of the body.

It can be classified into two types, either with or without involvement of

Some examples of photosensitizing drugs are phenothiazine, tetracyclines,

Signs of phototoxicity are sunburn-like reactions, especially in non-

Once there is exposure to light(UV), there is the absorption of photon

Once sensitized following re-exposure the immune system

For immune contact urticaria, known conditions include systemic reactions

Drugs that can cause hyperpigmentation include:

Drugs that cause hypopigmentation include:

E.g. Anticancer drugs , irradiation

Hypertrichosis is observed as an increase

The use of various drugs, including penicillin derivative or cephem

• Cutaneous toxicity of drugs or chemical substances may appear in various forms.

• Some individuals may be particularly sensitive to a compound or a plant; others may

• Determining the cause of dermatitis may be easy or it may be difficult.

• Yoshizawa K, Yuki M, Tsubura A. Drug-Induced Cutaneous Toxicity [Internet]. Toxicology -

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