Beltrani V S, Beltrani V P
Department of Dermatology, College of Physicians & Surgeons, Columbia University, New York, New York, USA.
Ann Allergy Asthma Immunol. 1997 Feb;78(2):160-73; quiz 174-6. doi: 10.1016/S1081-1206(10)63383-2.
Reading this article will reinforce the reader's knowledge of the definition, pathophysiology, differential diagnosis, evaluation, and management of the most common of all the "eczemas," contact dermatitis, which can have an allergic and/or an irritant pathogenesis.
Relevant articles and current texts on contact dermatitis were referenced and reviewed. The personal experiences of the authors in an Environmental Medicine Clinic, their private practices, and their teaching of residents and other physicians were evaluated. A MEDLINE database using subject keywords was searched from 1986 to date.
Book chapters, pertinent articles, data source abstracts, guidelines for the management of contact dermatitis set by the American Academy of Dermatology, and the American Contact Dermatitis Society were critiqued.
The recent elucidation of the pathoimmunology of contact dermatitis is concisely reviewed, highlighting its clinical implications. The protean clinical presentations of contact dermatitis, both "allergic" and "irritant" type are cited. The signs and symptoms warranting the search for a contactant are outlined. The most likely regional contactants are listed, but the need to reference a more complete textbook is often required. That patch testing is the gold standard to identify an allergenic agent causing allergic contact dermatitis is stressed. While the "who" and "when" to patch test is amply described, a cookbook "how" to patch test has been omitted in order to emphasize the importance of "hands on" experience for such testing. The advantages and limitations of the commercially available standard patch tests (Hermal, and T.R.U.E.) are described, plus the sources for "nonstandard" patch tests is made available. Therapeutic modalities, topical and systemic, for management of the uncomfortable patient are outlined.
The physician who manages a patient with an "eczematous" rash must be aware of the complete differential diagnosis of that clinical presentation. Suspicion that a "contactant" is the cause must have high priority, especially when the rash is persistent, and fails to respond to "appropriate" therapy. The value of a skin biopsy is limited to confirming its eczematous (spongiotic) nature and ruling out other diseases. Appreciating the paradox of patch testing, namely the deceptive simplicity of application versus the required expertise for interpretation and recognition of clinical significance, is the key to the proper management of the patient with contact dermatitis.
阅读本文将强化读者对最常见的“湿疹”即接触性皮炎的定义、病理生理学、鉴别诊断、评估及管理的认识，接触性皮炎可有过敏性和/或刺激性发病机制。
参考并回顾了有关接触性皮炎的相关文章和现行文献。评估了作者在环境医学诊所的个人经验、他们的私人执业经历以及他们对住院医师和其他医生的教学经验。使用主题关键词对1986年至今的MEDLINE数据库进行了检索。
对书籍章节、相关文章、数据源摘要、美国皮肤病学会和美国接触性皮炎协会制定的接触性皮炎管理指南进行了批判性分析。
简要回顾了接触性皮炎病理免疫学的最新阐释，突出了其临床意义。列举了接触性皮炎“过敏性”和“刺激性”类型的多种临床表现。概述了需要寻找接触源的体征和症状。列出了最可能的局部接触源，但通常需要参考更完整的教科书。强调斑贴试验是识别引起过敏性接触性皮炎的变应原的金标准。虽然对“谁”和“何时”进行斑贴试验有充分描述，但为强调此类试验“实践”经验的重要性，省略了按部就班的“如何”进行斑贴试验的内容。描述了市售标准斑贴试验（赫尔曼氏和TRUE）的优缺点，还提供了“非标准”斑贴试验的来源。概述了用于治疗不适患者的局部和全身治疗方法。
处理有“湿疹样”皮疹患者的医生必须了解该临床表现的完整鉴别诊断。怀疑“接触源”是病因时必须高度重视，尤其是当皮疹持续存在且对“适当”治疗无反应时。皮肤活检的价值仅限于确认其湿疹（海绵状）性质并排除其他疾病。认识到斑贴试验的矛盾之处，即应用看似简单但解读和识别临床意义需要专业知识，是正确处理接触性皮炎患者的关键。
