Abstract
Dressings, adhesives, and topical medicaments used to cover wounds or stomas can irritate the skin or cause an allergic reaction, leading to contact dermatitis. This resource provides information on how to identify and manage irritant and allergic contact dermatitis types.
Contact dermatitis is a common problem for children and youth with complex health conditions who require frequent wound care or dressing changes. Contact dermatitis can be divided into 2 categories: irritant contact dermatitis, which accounts for approximately 80% of wound care-related dermatitis, and allergic contact dermatitis, which accounts for 20% of cases1.
Keywords: Allergic contact dermatitis (ACD), barrier protection, contact dermatitis (CD), irritant contact dermatitis (ICD), medical adhesive-related skin injury, medical adhesives, neomycin sensitization, patch testing, prevention, skin ulceration, tape allergy, topical antibiotics, topical corticosteroids, wound care, wound-related allergic/irritant contact dermatitis
Key Points
Irritant vs. allergic dermatitis
Dermatitis related to wound care is more likely to be irritant than allergic; however, skin ulceration and chronic exposure to many chemical components increase the risk of allergenic sensitization in individuals with complex conditions.
Avoid topical antibiotics
Topical antibiotics (neomycin, bacitracin, polysporin) should be avoided in most chronic wounds due to a high prevalence of sensitization. Alternative antiseptic agents include mupirocin, ionized silver, iodine, PHMB (a chlorhexidine derivative), or a combination of methylene blue and crystal violet1.
Patch testing
If there is any clinical concern for allergic contact dermatitis, patch testing may be a useful diagnostic tool. Early patch testing is cost-effective and can help prevent additional sensitization2.
Importance of early recognition
Early recognition and treatment of contact dermatitis, including removal of contact irritants and allergens, are important as contact dermatitis can delay healing. Important strategies to prevent irritant contact dermatitis and ACD are discussed under “Prevention.”
Pre-treatment for sensitive individuals
If adhesives tend to cause a reaction, pre-treatment with topical steroids or non-steroidals may be considered if a bandage/dressing is required.
Diagnosis
Common Wound-Related Causes of Contact Dermatitis
Wound-Related Causes of Irritant Contact Dermatitis (ICD)
Common causes of ICD include incontinence or peristomal fluid, medical adhesives (the sticky part of bandages), soaps/detergents, elastic bandages, antiseptics such as iodine that have not been adequately removed after a medical procedure or cleansing, and propylene glycol in hydrogel dressings1.
Wound-Related Causes of Allergic Contact Dermatitis (ACD)
For children with medical complexity, the combination of long-term exposure, ulcerated and injured skin, and allergens being applied under occlusion from dressings and compression wraps increases the risk of allergic sensitization. In children, the most common relevant allergens include nickel, hydroperoxides of linalool, methylisothiazolinone/methylchloroisothiazolinone, cobalt, and fragrance mix3. Additional, not uncommon causes of ACD, include neomycin, bacitracin, lanolin, colophony, and rubber accelerators4.
Topical corticosteroids (TCS) are also a potential cause of ACD, which is complicated by the fact that they are also the mainstay of treatment. If contact dermatitis worsens or fails to improve with TCS, patch testing may be considered. TCS classification is nuanced and allergenicity across different groups is poorly understood; repeat open application testing (aka “use test”) is recommended in the setting of potential steroid allergy. Additionally, other steroid-sparing topicals can be used if TCS is discovered with patch testing (see table)1.
Latex-associated allergy is an immediate type I hypersensivity rash and commonly causes immediate rash, including hives (urticaria), erythema, and swelling. Systemic symptoms may also occur. It is not a cause of allergic contact dermatitis.
Of note, based on skin patch testing, patient-reported allergies to medical adhesive bandages are more often irritant contact dermatitis rather than true allergy 5.
Table 1: Common Components Related to Dressings and Ointments That May Cause Dermatitis
| Category | Allergens | Common Sources | Clinical Tips |
| Rubber Accelerators | Tetramethylthiuram disulfide, mercaptobenzothiazole, diphenylguanidine, zinc dibutyldithiocarbamate. Carba mix and thiuram mix are common screening agents | Adhesive tapes and dressings, compression garments, rubber gloves (including latex-free), compression bandages | Use of an “accelerator-free” glove, vinyl gloves, or cotton undergloves/liners is a potential avoidance practice. |
| Acrylates | Methyl methyacrylate,ethyl acrylate, 2-hydroxyethyl methacrylate (HEMA), isobornyl acrylate (IBOA) | Adhesive tapes and dressings, continuous glucose monitoring systems (CGMs) and insulin pumps, ostomy adhesives | Many bandages/adhesives are proprietary and presence of acrylates is unknown. Usage of non-stick bandages (such as Telfa) with paper tape may be considered. In the setting of ostomy and CGMS, patch testing may be especially helpful to identify alternatives. Usage of a barrier cream, including a nasal spray or topical non-steroid, may be considered. |
| Cyanoacrylates | 2-octyl-cyanoacrylate (Dermabond), ethyl cyanoacrylate (Super Glue) | Adhesive tapes and dressings, post-surgical glue, glucose sensors and insulin pumps, ostomy adhesives | See above. Cyanoacrylates do not cross-react with acrylates, although allergenicity to both types of allergens may occur. Dermabond should not be used in these cyanoacrylate-allergic patients. |
| Lanolin | Amerchol, lanolin, wool fat, wool grease, wool alcohol | Aquaphor, dressings, moisturizers, and some topical medications | Allergenicity is more common in patients with eczema or chronic wound care needs. Consider using plain petrolatum jelly (Vaseline) instead of Aquaphor or other compounds. |
| Topical Corticosteroids | Clobetasol, triamcinolone, hydrocortisone, desonide, betamethasone, mometasone, etc | Topical corticosteroids (prescription and over the counter), hemorrhoid ointment, anti-itch creams | Consider TCS allergy in patients who fail to improve with TCS. If ACD to TCS, recommend a use test as well as transition to topical calcineurin inhibitors, JAK inhibitors, or PDE4 inhibitors. |
| Balsam of Peru | Myroxylon pereirae. Constituents include cinnamic acid, benzyl benzoate, benzoic acid, and vanillin | Moisturizers, topical medicaments, tincture of benzoin, calamine lotion | In the setting of Balsam of Peru allergy, avoidance of all fragrance ingredients is recommended. Many products are labeled as “unscented” or “fragrance-free” and may contain fragrance ingredients. |
| Topical Antibiotics | Neomycin, bacitracin, polysporin | Topical antibiotics, antibiotic-impregnated dressings | In addition to topical creams and ointments, avoidance of eye and ear drops containing these ingredients is recommended. Systemic (PO, IM, IV) usage of related antibiotics may also cause a rash. |
| Colophonium | Colophony, pentalyn rosin, abitol, abietic acid | Hydrocolloid bandages (e.g., DuoDERM), other dhesive tapes and dressings, continuous glucose monitoring systems (CGMs) and insulin pumps, ostomy adhesives | Sensitization to hydrocolloid dressings is observed in 11% to 52% of patients with chronic wounds6. Non-stick bandages, as above, may be beneficial in allergic patients. |
Differentiating Irritant from Allergic Contact Dermatitis
Irritant contact dermatitis is mediated by the innate immune system and is a non-specific inflammatory response to injury from friction, chemicals (acids, alkalis, detergents, or solvents), or environmental factors (e.g., prolonged water contact). Irritant contact dermatitis does not require prior exposure and can be induced in anyone exposed to a sufficiently high chemical concentration. Irritant contact dermatitis may be acute (from a harsh acid or alkali), occurring in minutes to hours, or chronic (e.g., chronic wet-work and handwashing), developing over days to weeks4.
Allergic contact dermatitis is a delayed immunologic response (cell-mediated type IV hypersensitivity) that requires prior exposure to a specific allergen, though one can have many years of exposure before developing clinical hypersensitivity4. Following sensitization, it may occur from several hours to up to 1 week after exposure. It is particularly common in the setting of long-term exposure to allergens under occlusion from dressings and compression wraps, combined with the impaired barrier function of the ulcerated skin1. Once an allergy is established, it persists for the rest of an individual’s life.
Presentations
The symptoms of contact dermatitis may include redness, itching, bumps (papules), swelling, blisters (vesicles), and pain in the area of exposure.
Irritant contact dermatitis is the most common type of contact dermatitis. It leaves skin red, dry, and rough, and it may look like a burn in the area of contact. With acute ICD, blisters (vesicles and bullae) may occur. Chronic ICD looks more like standard eczema. Typically, it is confined to the area where the irritant was present, though if caused by wound exudate, it may follow a gravitational path1. It tends to present with pain, burning, and often itching.
Allergic contact dermatitis may appear similar to irritant contact dermatitis, though occasionally, more robust cases of ACD may display blisters (vesicles). It is characteristically very well-demarcated, corresponding to the exposure. The rash, as noted above, may occur hours to days after a preceding exposure. It is characteristically extremely pruritic.
Differential Diagnosis
Distinguishing between ICD and ACD can be difficult. History, distribution, and exposures are often most helpful in reaching a diagnosis. Ultimately, there are no tests for ICD, and negative patch testing may be required to effectively rule out ACD and make the diagnosis. Comprehensive patch testing is recommended to be completed with a board-certified dermatologist or.
Differential Diagnoses for Contact Dermatitis
| Condition | Description | Treatment |
| Cellulitis | Erythema, edema, warmth, tenderness to palpation, and poorly defined borders. Systemic symptoms such as fevers, chills, and leukocytosis may be present. | Antibiotics |
| Atopic Dermatitis | Often more widespread, often following flexor surfaces in childhood, typically bilateral; often pruritic, chronic, and possibly lichenified | TCS, topical non-steroidals, emollients, biologics (such as dupilumab), phototherapy |
| Stasis Dermatitis | Most common on the lower extremities, bilateral, poorly defined erythema with or without hyperpigmentation, drainage, and desquamation | TCS, compression stockings, elevation |
| Urticaria | Pruritic wheal (“hive”) that resolves within 24 hours, often transient and dynamic on exam; urticaria is most commonly idiopathic or secondary to viral illnesses or medications. Contact urticaria may develop from a contact allergen (often within 60 minutes). | Antihistamines (often at high doses). Supportive care. Review of medication lists, avoidance of potential contactants. |
Treatment and Management
If a reaction occurs to a medical dressing, it is important to remove the dressing and gently wash the underlying skin with soap and water to remove any residue. Adhesive removers can be helpful as well if the material is quite adherent. Families sometimes improvise with homemade adhesive removers that often include a small amount of oil, such as coconut oil, mixed with baking soda and a bit of water.
Gentle emollients (rich moisturizers without many additives) can soothe and protect the area. Over-the-counter medications, such as anti-itch creams and hydrocortisone, can help with mild itching, but more severe reactions should be evaluated medically and may require stronger topical steroids or specialized wound dressings.
Patch testing with a dermatologist or allergist may help determine the nature and cause of the reaction. Once the offending agent is identified, it is best to avoid using that material again. Practitioners who perform patch testing often use the Contact Allergen Management Program (CAMP) to identify alternative personal care products that patients may use when an allergen is identified. CAMP is available to members of the American Contact Dermatitis Society. Often, dressing and adhesive allergies require barrier protection with other tolerated non-stick bandages. Many dressings/bandages are proprietary. Be sure to list any relevant allergies on the child’s allergy list and include the type and severity of reaction.
Prevention
If adhesives tend to cause a reaction, alternatives include paper tapes, hypoallergenic tapes, and self-adhering gauze. Sensitive individuals may benefit from protecting the healthy underlying skin with a barrier film or coating (such as Cavilon). You can also try cotton tubular gauze under bandages to avoid direct skin exposure. Pre-treatment with topical steroids or non-steroidals may be considered if a bandage/dressing is required.
If wound exudate is the cause of ICD, the surrounding skin can be protected with products like zinc paste, petrolatum, or a windowed hydrocolloid dressing. Of course, these can also later cause ACD, so it is important to be vigilant for skin changes over time.
When applying occlusive dressings, be sure the skin is completely dry after using chlorhexidine or an antiseptic wash7.
Referrals
- Consider referral to a wound care specialist for diagnostic clarification and treatment plan as needed.
- Consider referral to a dermatologist or allergist who performs patch testing.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
References
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2. Freise J, Kohaus S, Korber A, et al. Contact sensitization in patients with chronic wounds: results of a prospective investigation. J Eur Acad Dermatol Venereol JEADV. 2008;22(10):1203-1207. doi:10.1111/j.1468-3083.2008.02775.x
3. Silverberg JI, Hou A, Warshaw EM, et al. Age-related differences in patch testing results among children: Analysis of North American Contact Dermatitis Group Data, 2001-2018. J Am Acad Dermatol. 2022;86(4):818-826. doi:10.1016/j.jaad.2021.07.030
4. James W, Elston D, Treat J, Rosenbach M. Andrews’ Diseases of the Skin. In: Contact Dermatitis and Drug Eruptions. 13th ed. Elsevier; 2019:92-139.
5. Widman TJ, Oostman H, Storrs FJ. Allergic contact dermatitis from medical adhesive bandages in patients who report having a reaction to medical bandages. Dermat Contact Atopic Occup Drug. 2008;19(1):32-37.
6. Renner R, Simon JC, Seikowksi K, Treudler R. Contact allergy to modern wound dressings: a persistent but neglected problem. J Eur Acad Dermatol Venereol JEADV. 2011;25(6):739-741. doi:10.1111/j.1468-3083.2010.03760.x
7. Zitelli BJ, Chalifoux TM. Dermatology for the Anesthesiologist. In: Smith’s Anesthesia for Infants and Children. Ninth. Elsevier; 2017:1220-1234.e1,. https://doi.org/10.1016/B978-0-323-34125-7.00053-X.
