Severe Contact Dermatitis with Secondary Ulceration in Healthcare Worker

Case at a Glance

A 28-year-old Asian female dental hygienist presented with progressive ulcerating skin lesions on her neck and arms over a 10-day period, complicating her pre-existing atopic dermatitis. The condition developed following exposure to adhesive materials and was exacerbated by occupational requirements.

Patient's Story

The patient, a dental hygienist working in Arizona's hot climate, had a lifelong history of intermittent atopic dermatitis. She reported chronic scratching behaviors that occasionally led to bleeding but had never experienced ulcerative lesions. On day 1, she noticed a small erosion the size of a pencil eraser on her jawline after scratching, which caused stinging pain. Her work environment exposed her to aerosols and required patient contact, making wound protection necessary but challenging.

Initial Assessment

Physical examination revealed multiple ulcerating lesions on the neck and right arm, with surrounding erythema and inflammation. The patient was afebrile with stable vital signs. Current medications included cetirizine, diphenhydramine, oral contraceptives, topical clobetasol, and mupirocin ointment. She had previously used hydrocortisone and triple antibiotic ointment. The lesions were confined to areas above the ribcage and elbow, sparing the face.

The Diagnostic Journey

The progression was documented over 10 days: Initial small erosion was treated with adhesive patches, which caused further skin stripping. A hydrocolloid patch application resulted in severe contact dermatitis reaction. Telemedicine consultation led to mupirocin prescription with recommendation to leave uncovered, which was impractical due to occupational exposure risks. Urgent care visit on day 8-9 resulted in intramuscular corticosteroid injection and clobetasol prescription, but symptoms paradoxically worsened with increased inflammation and new skin breakdown.

Final Diagnosis

Severe allergic contact dermatitis with secondary bacterial colonization, superimposed on atopic dermatitis. The condition was complicated by adhesive allergies and occupational exposure requirements.

Treatment Plan

Topical clobetasol ointment 0.05% twice daily, mupirocin ointment for secondary infection prevention, hypoallergenic self-adhesive bandages for occupational protection, and barrier creams. Oral diphenhydramine 25mg 2-3 times daily for symptom control. Recommendation for silicone-based adhesive-sensitive bandages to prevent further allergic reactions. Dermatology referral for specialized management and possible patch testing.

Outcome and Follow-up

Patient was advised that emergency department evaluation was not necessary as lesions showed no signs of systemic infection. Dermatology consultation was scheduled for definitive diagnosis and long-term management plan. Occupational modifications were discussed, including potential medical leave if healing required extended periods without protective covering. Patient counseled on proper wound care and adhesive avoidance strategies.