Hematogenic contact dermatitis L23.8

Author: Prof. Dr. med. Peter Altmeyer

Last updated on: 18.04.2024

Synonym(s)

hematogenic contact allergic eczema; hematogenic contact dermatitis; Hematogenic contact dermatitis; systemically induced contact dermatitis; Systemic contact dermatitis

Definition
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Contact allergic eczema characterized by great clinical diversity, triggered hematogenously (from within), in which sensitization and triggering or only triggering occurs through systemic allergen intake. The responsible allergen can be absorbed via the skin, orally, inhaled or systemically. Possible allergens include metals such as nickel, chromium, cobalt, gold, drugs, fungal antigens and food allergens. It is not uncommon for a consecutive, generalized (exanthematic) dermatitic reaction to occur.

Special forms are various forms of dyshidrotic hand and foot eczema (see below eczema, dyshidrotic) and Baboon syndrome ("baboon syndrome").

Occurrence/Epidemiology
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No reliable data is available on incidences or prevalences. A larger number of publications are available on the contact allergens nickel (see nickel allergy below) and Peru balsam. In most cases, proof of type IV sensitization (see allergy below) by the contact allergen in question (see allergen below) is a prerequisite for diagnosis.

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Clinical features
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Diverse exanthematic clinical picture that develops a few hours to days after allergen intake. The exanthema is usually clearly itchy, initially small spots, initially follicular, macular or papular, later also plaque-like, and the classic initial focus, as in contact allergic eczema, is usually absent. A special form is the Baboon syndrome, a frequently drug-induced contact eczema, which is localised on the inguinal and gluteal sides (baboon syndrome). Erythema exsudativum multiforme-like exanthema is found after antiphlogistic external agents (e.g. diclophenac-containing external agents). Symmetrical dyshidrotic eczema can also be induced hematogenically.

Laboratory
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Restricted general condition, fever, increased inflammatory parameters (e.g. CRP and ESR), lymphadenopathy and eosinophilia may be observed concomitantly.

Histology
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The histological picture is not diagnosis specific and shows a follicular but also non follicular spongiotic dermatitis of different acuteity. This cannot be distinguished from other clinical pictures with spongiotic dermatitis. Usually a slightly widened epidermis with orthohyperkeratosis is found. Frequent loss of the basket plexus structure. Focal epidermotropia with spongiosis. Edema of varying severity in the papillary dermis. Bulky, perivascularly oriented, but also diffuse, predominantly lymphocytic infiltrate is present.

Diagnosis
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Anamnesis, clinic, evidence of triggers and a systemic late type reaction. Allergen detection must be carried out by means of an epicutaneous test. It should be critically noted that epicutaneous testing can lead to "false negative results". Thus, various authors call for a positive oral provocation test for diagnosis. The provocation test should be preceded by a 6-8 week allergen avoidance phase. The oral provocation test is performed with the following test substances: Peru balsam (1.0 g); nickel (2.0-5.0 g) chromium (2.0-3.0 mg); cobalt (1.0 mg).

Differential diagnosis
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Clinical differential diagnoses:

A distinction must be made between disseminated allergic contact dermatitis (see below eczema, contact dermatitis, allergic), in which the allergen is introduced from the outside, but the contact reaction is not sharply demarcated from the healthy skin, but instead affects the non-contacted surrounding skin with "disseminated" eczema papules (for differential diagnosis see below eczema, contact dermatitis, toxic).
Dyshidrotic allergic contact dermatitis: Following local allergen contact, a vesicular or bullous dermatitis develops on the palms of the hands and soles of the feet with clear, intraepidermal vesicles or blisters.
Seborrhoeic eczema: mainly localized on the trunk, here in seborrhoeic zones (sweat grooves in the sternal region, along the spine, shoulder girdle) but also centrofacially. Chronic, mostly figured, slightly itchy, scaling of varying intensity, mostly localized, sharply defined, red or red-brown patches, papules or plaques.

Histological differential diagnoses:

The histologic picture is not diagnosis-specific. Therefore, all clinical pictures with spongiotic dermatitis should be considered in the differential diagnosis.

External therapy
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Refatting topical steroids. S.u. Eczema.

Internal therapy
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Short-term glucocorticoids (e.g. prednisolone) in dosages of 100-150 mg/day i.v. or p.o. antihistamines such as dimetine maleate (Fenistil 2 times/day 1 amp. i.v.).

Prophylaxis
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After the therapy of the acute skin symptoms a consequent avoidance of allergens should follow (familiarize the patient with the corresponding diet plans; diet consultants are recommended).

Literature
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Erdmann SM et al (2010) Hematogenous contact dermatitis caused by food. Allergo J 19: 264-271
Meier H et al. (1999) Occupationally-induced contact dermatitis and bronchial asthma in an unusual delayed reaction to hydroxychloroquine. Dermatologist 50: 665-669
Menne T et al (1984) Hematogenous contact dermatitis after oral administration of neomycin. Dermatologist 35: 319-320