INTRODUCTION
Irritant dermatitis includes several inflammatory reactions, which follow non-immunological damage to the skin. This may be the result of an a/c toxic insult to the skin, or due to the result of repeated and cumulative damage from both physical and chemical agents. Irritant dermatitis is also called as the irritant contact dermatitis (ICD).Irritant dermatitis is not a uniform entity of disease each irritant exerts its particular noxious effects on the skin36
Dermatitis is a term used to denote a polymorphic pattern of inflammation of skin characterized by erythema, edema, vesiculation, oozing, crusting, papules scaling and lichenification.

Contact dermatitis includes:
1) Irritant contact dermatitis
2) Allergic contact dermatitis
3) Phototoxic, photoallergic and light aggravated contact dermatitis
4) Immediate type contact dermatitis

Irritant contact dermatitis is due to non-immunologocial damage to skin.
Allergic contact dermatitis leads to type IV hypersensitivity and cell mediated immune damage to skin. Here the offending agent is a hapten and it combines with skin protein to become antigenic.
Photo dermatitis involves immunological and non-immunological damage to skin due to exposure to sun.
Immediate type contact dermatitis also leads to both immunological and non-immunological damage to skin.

Irritant contact dermatitis due to soap detergents commonly affects housewives and cleaners who immerse their hands in water and detergent. It is presumably due to the combination of asteatosis, exposure to mild irritants such as soap and mild trauma. e.g. wringing out dishcloths.
ICD is one of the greatest health problems. This problem is on the increase as the new brands of soaps and detergents marketed are having many additives like perfumes, antibacterial, antimicrobials coloring agents etc which act as sensitizers. Hygienic measurements like avoidance of soaps and detergents is not wholly possible for many owing to the cultural and socio economic conditions. Modern school medication offers sudden relief for all the symptoms but there is resurgence of the symptoms on discontinuing the meditation and when the patient is again, exposed to soaps and detergents. Many patients are not able to continue modern medicines because of their disastrous side effects and also due to economic reasons. Homoeopathic medicines becomes their only hope and aid, as the cure affected is rapid, gentle and permanent without any deleterious effect.

Homoeopathy has for its foundation, solid concrete facts united by great natural principles. The practical demonstration of Homoeopathy is committed to its personal representatives whose ability, acquired technical proficiency and logical consistency can bring to the system a scientific stand and success. Master Hahnemann through years of closest observation and careful experimentation has constructed this system on the basic principles of similia similibus curenter, minimum dose and single remedy. The structure is further raised on the fundamental principles, which are consistent with the universal laws and the framework is being furnished by years of study and experiments by the younger generations of homoeopaths. A humble effort in this regard is made on attempting to study the efficacy of homoeopathic medicines in the management of irritant contact dermatitis due to soap and detergents with the help of experienced hands in homoeopathy.

It is not ICD as such, which is the object of our consideration, but the man affected with ICD. The man is affected in the internals and it is the manifestation of internals, which present as ICD. It should be given due thought that, all people exposed to the noxious effects of soaps and detergents are not having the disease manifestation. Why is some people peculiarly disposed to have this disease? What brought forth the disease manifestation? What is behind the cell disturbance or life perversion in the affected part?

Hahnemann through his diligent study and 12 years of accurate observation and experimentation came to the fact that the ostensible disease manifestation was a mere fragment of a much more deep seated primitive evil, which he called miasm. Thus miasms were discovered to be the unknown primitive malady, which caused all ailments and symptoms. Understanding miasm involves understanding sum total of all the sufferings of the patient, which in turn involves a comprehensive study of the etiology, symptamatology, pathology and life situation of the patient. So in the succeeding pages, the subject matter is dealt with, due stress on etiology, symptamatology, pathology, diagnostic criteria’s and miasmatic interpretation.

AIMS OF THE STUDY
To ascertain the effectiveness of homoeopathic medicines in the management of irritant contact dermatitis due to soap and detergents. There are many effective homoeopathic medicines for this malady but until now nobody has undertaken a scientific study in this manner based on statistical data.

In addition to this special attention is given to
1) Trace out the prominent miasm behind the malady.
2) Relation of irritant contact dermatitis to the socio-economic status of the patient.
3) Whether medicinal management is effective, if so to what extent.
4) Are there cases beyond the scope of homoeopathic treatment?

REVIEW OF LITERATURE
Irritant contact dermatitis is caused by direct chemical or physical damage to the skin. It is not a uniform entity of disease ,each irritant exerts its particular noxious effects on the skin and each occupation has its special risk of substance and mode of physical contact .Everyone is susceptible to the development of an irritant contact dermatitis if exposed to an irritant (toxic) agent is sufficient quantity. It occurs particularly where the stratum corneum is thinnest. Hence, it is often seen in the finger webs and back of the hands rather than the palms.

Examples of common irritants 50
* Wet work * Soluble coolants
* Solvents * Vegetable juices
* Detergents * Wet cement
With all of above the skin may hit at several target sites

There are two main types of irritant contact dermatitis acute and chronic. The acute form occurs after exposure to an agent or agents causes an early impairment in the function of the stratum corneum and an acute inflammatory reaction (Fig 1:1) .The chronic form follows repeated exposure to the same or different factors causing cumulative damage until an inflammatory reaction ensues that persists even after further exposure is stopped. Thus clinically apparent disease occurs only after a subliminal damaging effect has occurred. (Fig 1:2). Chronic irritant dermatitis is mostly due to the summation of various adverse factors. These factors are together known as the ‘loading factors’.(Fig1:3) . These include individual predisposition, atopics, impaired resistance, skin temperature, repair capacity, high baseline trans epidermal water loss, scratching, rubbing etc. Many of these are not strong enough to cause irritant dermatitis as such but when taken together they are enough to weaken the skin and develop irritant contact dermatitis. These minor irritants may also act as perpetuating factors once the dermatitis has become established .Repeated exposure to some of the milder irritants may in course of time produce a hardening effect . This process makes the skin more resistant to the irritant effect of the given substance.35

Anatomy – Microstructure of skin
The epidermis is a compound tissue consisting mainly of a continuously self-replacing stratified keratinized squamous epithelium. The chief cells of epidermis are the keratinocytes, there are other cells called melanocytes, Langerhan cells and lymphocytes. Sensory nerve endings are also sparsely present in the epidermis. Epidermis serves as an important barrier to the loss of water and other substances through the body surface and to their permeation from without. Experiments measuring diffusion of water from the exterior show that the entire stratum corneum provides an effective though not complete barrier. The water barrier is composed of intercellular glyco lipid sheets or lamelloe derived from the lamellar granules of the stratum granulosum.44

Development
Embryonic skin consists of a single layer of ectodermal cells overlying a mesenchyme. From this surface epidermis and its appendages and dermis are formed. Surface ectoderm gives rise to the keratinizing general surface epidermis and its appendages, the pilosebaceous units, sudoriferous glands and nails. Some of the ectodermal cells become the keratinocytes. Non-keratinocytic cells of the epidermis are immigrant cells of different developmental origin. The dermis is composed of irregular connective tissue. The connective tissue is developed from the mesenchyme.

Histology of normal skin
The cells produced by mitosis in the germinal layer adjacent to the dermis undergo maturational changes concerned with the production of keratin. The outer keratinised layer is shed continuously and is replaced by the progressive movement and maturation of cells from the germinal layer. The rate of mitosis in the germinal layer generally equals the rate of desquamation of keratin from the outer surface. This process of maturation of basal cells through to desquamation takes approximately 28 days in humans.

The phases of this dynamic process are represented in five morphological layers.
1) The stratum germinativum or stratum basale B: is the germinal layer of the epidermis. This layer is also sometimes referred to as stratum malpighii
2) The stratum spinosum or prickle cell layer S: So named for the prickly appearance of the cells at high magnification. This layer contains cells, which are in the process of growth and early keratin synthesis.
3) The stratum granulosum or granular layer G: is characterized by the presence of granules within the cells, which contribute to the process of keratinisation.
4) The stratum lucidum L: is only present in extremely thick skin and appears as a homogeneous layer between the stratum granulosum and the keratinised layer.
5) The stratum corneum or cornified layer C: consists of flattened, fused cell remnants composed mainly of fibrous protein keratin.

Histology of epidermis
The epidermis is a non vascular stratified epithelium of ectodermic origin the deeper layer five layers which consists is living, it consists of several strata of polyhedral cells resting on a single stratum of columnar (basal) cells. The superficial layer, the horny layer or stratum corneum, is dead, it consists of several strata of dry, flattened, scaly cells perpetually being rubbed away and are perpetually being replaced by cells of the germinative layer.
Irritant dermatitis due to detergents and soaps

SYNONYMS
House wife’s eczema, asteatotic hand eczema, wears and tears dermatitis and traumiterative dermatitis.

DEFINITION
Is a chronic inflammatory reaction of the skin, to a series of repetitive and damaging insults which include both chemical irritants and harmful physical factors such as friction, micro trauma, low humidity, heat, cold, solvents, degreasing agents such as soap and detergent and desiccant effects of water. Irritant contact dermatitis due to soap clinically manifests as a spectrum of disease ranging from a little dryness, redness or chapping (irritant reactions) through various types of eczematous dermatitis. It mostly affects thin exposed skin, mostly on the back of hands, webs of fingers etc. Housewife’s dermatitis remains confined to hands.

EPIDEMIOLOGY
Irritant contact dermatitis accounts for 4-7 % of all dermatological consultations. It accounts for almost all reported cases of occupational diseases. Hand eczema affects more than 2% of all the populations. Over 20% of females will suffer from hand eczema at some stage of their life.

INCIDENCE AND PREVALENCE
The disease exits in all countries, it is more prevalent in some places than in others. Prevalence varies from country to country. Measures like wearing proctective gloves are found to reduce the incidence of irritant contact dermatitis.

SEASONAL CHANGE
Chapping of skin during winter predispose to irritant contact dermatitis and increases its incidence. Other factor, which increases the incidence of irritant contact dermatitis, includes technical factors like concentration of irritant, vehicle, exposure time etc.
AGE
Age has little influence on capacity for sensitization. Occupational sensitization may occur only after decades of contact with a senitizer. Sensitivities may also fade with time but this is probably due more to lack of exposure rather than age per se. The inflammatory response is however diminished in elderly patients. Young, adults are more likely to have irritant dermatitis.
SEX
As name suggests irritant dermatitis due to soap is more common in females so it is also called housewife’s dermatitis .HORMONES
Pregnancy may either improve or flare up contact dermatitis. Irritant dermatitis may flare up premenustrually. No systemic studies on the capacity for sensitization as related to menstrual period have yet been performed.

CONSTITUTIONAL AND GENETIC FACTORS
Development of ICD presupposes an individual susceptibility. In humans susceptibility does not follow mendelian inheritance.
It is found that atopics have an increased risk of developing irritant hand eczema.

INTERACTION OF CONSTITUTIONAL, CUMULATIVE AND ALLERGIC FACTORS
In many cases of hand dermatitis, constitutional irritant and allergic factors will co-exit. A hand eczema that starts as contact dermatitis may continue as an apparently constitutional, post insult form of eczema. Associated detergents may promote sensitization and lower the threshold for the elicitation of allergic contact dermatitis. It is however, often very difficult to verify a suspicion of allergic sensitivity to an ingredient in soap or detergent unless all ingredients in soap or detergents are tested separately and at appropriate concentrations. Allergic factors may play a part in the persistence and reactivations of some cases of irritant or constitutional hand eczema.
In case of soaps and detergents, soap and detergent part acts as the irritant but the antimicrobials, the antibacterials, formaldehyde, perfumes etc. added during the manufacture acts as the sensitizers. Further if the patient uses rubber gloves it adds to the sensitivity .

ENVIRONMENTAL FACTOR
Low ambient humidity is the single most important factor as far as the water content of the stratum corneum is concerned. Although the effect of temperature and humidity are to some degree interrelated , cold alone will reduce the water content and plasticity of stratum corneum and lead to cracking of the corneum (horny layer).

Low temperature and humidity reduces the water content of stratum corneum and leads to cracking of stratum corneum. Simultaneous exposure to these factors may maintain a dermatosis or cause transition from a simple chapping to a more eczematous dermatitis.
Occlusion promotes percutaneous absorption and may facilitate skin irritation and enhance the effect of irritants to which an individual has previously been exposed. Increasing the water content of stratum corneum by occlusion can enhance percutaneous absorption of certain substances many times. It is of practical importance that rubber and plastic gloves, waterproof adhesives and the natural folds of skin provide such occlusion. Soft paraffin by itself has an occlusive effect.

Alkaline solutions have a deleterious action on the horny layer and promote percutaneous absorption. Cross-links in the Keratin are broken and water can penetrate into the fibrils and cause the swelling of horny layer. If reducing substances are present the damages is still greater. Irritants damage the stratum corneum directly or indirectly by damaging the basal layer of epidermis or otherwise by inducing abnormal keratinization. Damage in either form will lead to increased skin permeability.
Percutaneous absorption is also facilitated by inflammatory changes in the epidermis. Thus an irritant contact dermatitis can promote penetration of allergens and conversely an allergic contact dermatitis the penetration of irritants.
Thus it could be seen that an irritants like detergents and soaps will produce cell damage if applied for sufficient time in sufficient concentrations. Immunological process are not involved and dermatitis occurs without prior sensitization. Irritants penetrate skin and alter skin cells. Dermatitis arises when the repair capacity of skin is exhausted and when the penetration of chemicals excites and inflammatory response. The detergents causes damage by gradually exhausting the horny layer, denaturing the keratin, removing stratum corneum lipids and altering the water holding capacity of skin. This eventually leads to damage to the cells of the epidermis.

Pathophysiology
Irritant contact dermatitis includes several inflammatory reaction patterns, which follow non-immunological (usually chemical) damage to the skin. This may be the result of an acute toxic insult to the skin or due to repeated and cumulative damage both physical and chemical. Detergents and soap may cause both conventional irritant and non-immunological reaction pattern, which vary from individual to individual depending upon the application site, nature of chemical applied and the degree of damage to the skin.

The skin provides the first and most important line of defense against exogenous noxious agents and this is one of its primary physiological functions. This defense is however, far from perfect as many substances penetrate readily into and through the epidermis even when it is intact. The surface film is the first line of defense. It is composed of sebum emulsified with sweat and break down products from the horny layer. The buffer capacity of the surface film varies considerably from one body region to another, but in reality it has negligible influence on percutaneous absorption and on the barrier function of skin. The barrier function of the skin mostly resides in the stratum corneum. Damage to or a reduction in strateum corneum is therefore normally followed by an increase in the percutaneous absorption and in trans epidermal water loss. (The strateum corneum, having a predominantly lipid intercellular composition is more susceptible to lipid soluble irritants). The main barrier to water transport through the skin is attributed to these lipids and when the lipids of the strateum corneum are removed by solvents, water transport rates through the skin will increase.

The flexibility and cohesion of the horny layer depend mostly on its water content. The cell walls of the keratin layer constitute a lipid containing, semi-permeable membrane that encloses the water soluble substances as in an envelope. If the water holding substances are reduced, the water content of the stratum corneum decreases and superficial cracks develop. This collection of in situ water holding substances is referred to as natural moisturing factor. The principle components include sodium pyrrolidone, carboxylic acid, sodium calcium lactate, amino acids, urea and a sugar protein complex. These substances bind three – four times their own weight of water. Following the removal of cell wall lipids by exposure to a solvent, subsequent immersion in water for 2 minutes will remove as many of the water-soluble substances from the keratin layer as a 2-hour immersion in water.
A detergent effects the combined removal of both lipids and water holding substances and thus predisposes to chapping. Washing with a slush of ice and acetone has a three – fold effect of removing both lipids and water holding substances

Most cases of housewife’s eczema are ICD resulting from repeated skin exposure to low-grade cutaneous irritants, particularly soaps, water and detergents. It is the cumulative ICD from repeated mild skin irritation from soap and water. For e.g. hand washing frequency of more than 35 times per day was associated strongly with occupational hand dermatitis in intensive care worker’s .

The pathogenesis of ICD involves resident epidermal cells, dermal fibroblasts, endothelial cells and various leukocytes interacting with each other under the control of a network of cytokines and lipid mediators. Keratinocytes play an important role in the irritation and perpetuation of skin inflammatory reactions through the release of and response to cytokines. Resting keratinocytes produce some cytokines constitutively. Irritants can induce epidermal keratinocytes to release inflammatory cytokines (interleukin 1, TNKα), chemotactic cytokines (IL8, IL10), growth promoting cytokines (IL - 6, IL – 7, IL – 15 granuloyte – macrophage colony stimulating factor, transforming growth factor α) and cytokines regulating humoral versus cellular immunity (IL – 10, IL – 12, IL – 18). Intercellular adhesion molecules 1 promote the infiltration of leukocytes into the epidermis causing a cutaneous inflammatory reaction.
Significantly increased number of dividing keratinocytes is present 48 and 96 hours after exposure to an ionic emulsifying agent like soaps and detergents.
Soap if kept in contact with skin for a long time causes irritant dermatitis . No immunological mechanism take part in this reaction.43

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