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Histopathology
Cellular changes seen in the skin vary according to the chemical nature and concentration of the irritant applied, duration of exposure, severity of ensuring response and time. Histological examinations reveal some degree of intercellular edema or spongiosis in epidermis. Spongiosis is usually less pronounced than seen in allergic contact dermatitis. Parakeratosis is observed widely.

The histology of c/c ICD is one of hyperkeratosis with areas of parakeratosis, moderate to marked epidermal hyperplasia (acanthosis) and elongation of the rete ridges.

Clinical feature
Acute irritant contact dermatitis is often the result of one single overwhelming exposure to an irritant or a series of brief physical or chemical contacts. This result in acute inflammation of the skin and is usually associated with an immediate sensitization of burning or stinging. The initial reaction is usually strictly limited to the site of application or contact, the concentration of the substances diffusing outside the area of contact almost immediately falls below the critical threshold necessary to provoke a reaction. The rapidity of acute irritant responses usually makes the cause obvious as the toxic reaction occurs within minutes. The duration of application necessary to provoke a reaction varies considerably and milder injuries may only induce a transient non – eczematous dermatitis or irritant reaction. Irritant effects may be considerably enhanced by occlusion (and care must always be taken to ensure that irritants also do not penetrate gloves or protective clothing).

Cumulative insult dermatitis develops as a result of a series of repeated and damaging insults to the skin. These insults include both chemical irritants and a variety of physical factors like friction, micro trauma, cold etc. Susceptibility to cumulative insult dermatitis will depend not only on the level of exposure but also on the site, age and individual predisposition, atopics and those with impaired resistance due to coexistent or recently healed eczema. The elderly, those with fair and dry skin, those with an atopic background (personal or family history of asthma, hay fever or eczema) are more vulnerable.38 Individuals with a history of eczema or dermatitis, those with active eczema or chronic skin ulceration and those with high baseline transepidermal water loss appear to be at an increased risk of developing an irritant contact dermatitis. Once the stratum corneum skin barrier has been breached, a great number of normally innocuous substances can perpetuate an irritant contact dermatitis. Scratching, rubbing and even topical treatment may on occasions become causes or persistence. Chronic irritant dermatitis may therefore be due to the summation of various adverse factors many of which would not in themselves be strong enough to cause irritant contact dermatitis but which taken together are enough to weaken the skin and lead to the development of cumulative irritant contact dermatitis. These minor irritants may also act as perpetuating factors once the dermatitis has become established.

Occupational dermatosis
Irritant contact dermatitis is one of the greatest public health problems. In the industry, most outbreaks of dermatitis is not due to allergy but due to the introduction of irritants into the work process or changes in the environment such as humidity or excessive drying. Irritant eczema accounts for the majority of industrial cases and work losses.39

ICD has a spectrum of disease, which ranges from a little dryness, reduces, or chapping irritant readily through various types of eczematous dermatitis. Cumulative irritant dermatitis most commonly affects thin, exposed skin. E.g. back of hands and webs of fingers. It often begins as a few localized patches of dry, slightly inflamed as chapped skin and the tendency to disseminate is normally less than with constitutional or contact allergic forms of eczema. It finds to be static and less pleomorphic than other forms of eczema.

Occupations with high incidence involves
1) Housework
2) Cleaning
3) Catering
4) Nursing
5) Hair dressing etc
Most workers however even those working in high risk occupations usually develop only minor degrees of dermatitis and constitutional factors are therefore probably important in those who develop more severe forms of dermatitis.

Clinical varieties
Ring eczema-An irritable patch of eczema begins under a ring and tends to spread in a typical manner to involve the adjacent side of the middle finger and the adjacent area of the palm. Transference of the ring to the other hand is often rapidly followed by the appearance of eczema at the new site. This type of eczema is probably due primarily to concentrations of soaps and detergents beneath rings, but micro trauma especially friction also plays a role.

Dry palmar eczema – Palmar skin becomes dry and criss crossed with superficial cracks and with damaged horny layer and is unable to respond with its normal pliability to hand and finger movement. These cracks often stand out white against an erythematous background. In addition to the palmar involvement there may be dryness and chapping of the skin over the dorsa of the knuckle joints.

Acrodermatitis continua - Deep vesicles and pustules with moderate inflammation , affecting the acral portion of the fingers . It is recurrent and persistant with atrophy of the skin , nails and digitis .Trauma and chemical irritants are the precipitating and perpetuating factors 40.

Dishydrotic eczema – It involves multiple intensly pruritic small papules and vesicles occurring in the thenar eminence , hypothenar eminence and the sides of the fingers .37

Fingertip eczema-It involves the palmar surface of the tips of some or all the fingers. The skin is dry, cracked and sometimes breaks into painful tissures. Usually it remains localized. It may occasionally extend down the palmar surfaces of the fingers and merge with palmar eczema. Two patterns may be distinguished. The first and most common one involves most or all of the fingers, more predominantly those of the master hand and particularly the thumb and forefinger.

Diagnostic criteria 50
A detailed history is required because the diagnosis of ICD rests on the history of exposure of the affected body site to the cutaneous irritant.
Primary subjective symptoms include the following
1) History of sufficient exposure to a cutaneous irritant.
2) Onset of symptoms occurs within minutes to hours of exposure in simple acute ICD. The onset of signs and symptoms may be delayed by weeks in cumulative ICD.
3) Pain, burning, stinging or discomfort exceeding prurities early in the clinical course occur.

Less important subjective criteria include the following
- Onset of dermatitis within 2 weeks of exposure.
- Reports of many other coworkers of family members affected.
- Individuals with history of atopic dermatitis (especially of the hands) are more susceptible to ICD particularly of the hands.

1. Rietschel proposed the primary diagnostic criteria for ICD as follows.
o Macular erythema, hyperkeratosis or tissuring predominantly over vesiculation.
o Glazed, parched or scaled appearance of the epidermis.
o Healing process beginning promptly on withdrawal of exposure to the offending agent.

Minor objective criteria
o Sharp circumscription of the dermatitis.
o Lower tendency for the dermatitis to spread than the cases of allergic contact dermatitis.
o Morphologic changes suggesting small differences in concentration or contact time producing large difference in skin damage.
Other criteria include the following
o ICD may be manifested by vesicles particularly on the hand.
o Reports of many other coworkers or family members affected.
Activity: Activities of early living with work may be reduced by severe ICD.

Diagnosis of ICD – soap
By their clinical pattern
Sites of lesion are palm, fingertips, webs of fingers.
Signs includes erythema, dry chapped skin, cracking vesiculation
Symptoms are burning, stinging, itching, associated with loss of pliability of skin and reduced movement of fingers.
-Glazed, parched and scaled appearance of the epidermis.
1) History of exposure
2) A bacterial culture can be obtained in cases complicated by secondary bacterial infection
3) Patch test-Patch testing can be performed to diagnose contact allergies but no patch test exists that can prove a cutaneous irritant is responsible for a particular case of ICD.
4) Skin biopsy can help to exclude other disorders such as tinea, psoriasis or cutaneous T cell lymphoma. But skin biopsy of skin lesions of palms and soles has several potential pitfalls. The strateum corneum and epidermis are particularly thick on palms and soles. This makes the histological diagnosis more difficult and increases the possibility that the biopsy specimen lacks sufficient dermis for optimal diagnosis. An overly deep skin biopsy of the thinner area can cut the motor nerve, which is the recusant branch of the median nerve. A deep biopsy may also leave a chronic painful scar.
So the diagnosis of contact dermatitis due to soap rests mainly on the clinical presentation and history of exposure.

Differential diagnosis of irritant contact dermatitis
1. Psoriasis – Psoriasis is a chronic inflammatory skin disorder characterized by erythematous , sharply demarcated papules and rounded plaques , covered by silvery micaceous scales . Psoriasis of the palms is frequently mistaken for hyperkeratotic eczema. In psoriasis scales will be adherent, thick pearly white and more abundant. Lesions will be symmetrically distributed and there will be nail changes like nail pitting.

2. Tinea – It appears as unilateral hand dermatitis. Tinea is a dermatophyte infection caused by the members of the species trichophyton, Microsporum and Epidermophyton .Tinea is often chronic and is characterized by variable erythema , oedema , scaling , purities and occasionally vesiculation . It can be detected by mycological examination. Unilateral scaling of the palm should always suggest a possible infection with Trichophyton and a discoid plague clue to T verrucosum.

3. Lichen planus – Lichen olanus is an papulosquamous disorder of unknown etiology .The lesions are pruritic , polygonal , flat topped violaceous papules is a pattern of It is characterized histologically by acanthosis and hyperkeratosis and clinically by thickened appearance of the skin. Scating, crusting fissuring and lichenification occurs. Lichenification is the cutaneous response to repeated rubbing or scratching.

4. Pompholyx – is characterized by sudden onset of crops of clear vesicles, which appear deep seated. Itching may be severe preceding the eruption of vesicles. There is no erythema, but a sensation of heat and prickling of the palms may precede attacks.

5. Nummular eczema: Nummular eczema is characterized by coin like lesions of small oedematous papules that become crusty and scaly . In this the plagues of papulovesicles tend to occur symmetrically on the limbs.

6. Allergic contact dermatitis
In allergic contact dermatitis exposure to an allergen is followed by an allergic reaction characterized by erythema , vesiculaton and severe pruritis . If exposure is chronic the skin becomes thickened and scaly .
Allergic contact dermatitis is very similar to ICD in its manifestations. Allergic contact dermatitis is due to delayed or cell mediated immunity. On exposure to allergen an immune response occurs whereas in ICD a non immune response is seen. In Allergic contact dermatitis patch test is +ve while in ICD patch test is negative. In ACD tiny quantities may be sufficient to cause allergy while in ICD certain minimum exposure is necessary.

Complications
o ICD increases the risk of sensitization to topical medications
o Skin lesion becomes colonized secondarily or infected particularly by staphylococcus aurees.
o Secondary neuro dermatitis (licken simplex chronicus) may develop in individuals with ICD, particularly in those with workplace exposure or under psychological stress.
o Post inflammatory hyper pigmentation or hypo pigmentation may occur in areas affected by ICD or persist after resolution of ICD in individuals with more pigmented skin.

Prognosis
The medical prognosis depends on the possibility of avoiding repeated and continuous exposure to the irritant. . To assess prognosis, in a study of 408 patients, who were followed up, one-quarter were unchanged or worse. Repeated exposure to some of the mild irritants may in time produce a hardening effect. This process makes the skin more resistant to the irritant effects of the given substance. Prognosis is good for non-atopic individuals

Relapses: Relapses or chronicity are due not only to re-exposure to allergens and irritants but also to other contributory mechanisms.
1) The barrier function of skin is impaired for months or even years after an attack of dermatitis. Recovery is prevented by exposure to irritants in concentrations, which might well be tolerated by normal skin.
2) Inappropriate treatment, overzealous use of cleansers may prolong the course of dermatitis.
3) Secondary infection leads to relapses.
4) Stress is common in c/c dermatitis and may be both a consequence of eczema and a trigger.
5) A number of constitutional factor predispose to chronicity.
6) There appears to be an inherent tendency in almost any eczema to become continuous to chronic.

Specific tests: - No specific tests are necessary and it is easy to recognize irritant contact dermatitis. There are no specific tests that can reliably show what the effect of an irritant will be in each individual case. Patch test are done for allergic contact dermatitis and are not diagnostic to ICD. Almost all of the soaps, detergents and shampoo’s are irritants under patch test occlusion and probably leads to false negative responses.34

Management
Contact dermatitis can only be properly managed once it has been diagnosed and any relevant constitutional factors identified. All local and exciting elements should be removed as soon as possible 41. Patients should avoid irritants for several months after complete healing.

Advice to patients
To speed healing, and prevent dermatitis from returning, you must now take great care of your hands and allow your skin to heal and recover its natural resilience/strength (This may take many months).49

1. Washing hands: Use lukewarm water and soap substitute. If soap is used, find a soap with no fragrance tar or sulphur, use it sparingly, rinse thoroughly then dry thoroughly (especially webs and wrist).
2. Avoid contact with detergents and other cleaning agents. Always dilute them according to manufacture’s instructions. Keep outside of containers clean or you will contaminate your hands with the product.
3. Use plastic gloves and wear gloves in winter.
4. Rings should not be worn during wet work even when your hands are better. Never wash hands with soap when wearing rings. Keep the inside of rings clean (brush under running water).
5. When washing use running water and a pot brush rather than a cloth.
6. If gloves are worn, use plastic rather than rubbers preferably use cotton lined glove. This allows the sweat to be absorbed rather than being rubbed into the dermatitis. Gloves should not be worn for long periods (max 20 min). If water enters a glove remove immediately. Have several pairs of plastic and cotton gloves. Wash them regularly. Plastic gloves should be quite dry inside before use – French chalk, talc helps.
7. Washing, machines and dishwaters are a great help, but avoid contact with detergent powder – use a measure with a handle.
8. Water softeners are helpful but too expensive. Try adding water softeners, to dish water, washing water, baths etc. as less soap /detergent is required.
9. Polythene occlusion and occlusive bandages are the best way to control the eczematous process .42

Homoeopathic concept in ICD
We know that it is the patient, the sick man that is to be treated and not the disease, because the so called disease is not really the disease , but only an expression of it. If we can treat the sick man and bring him back to health, that is to say, if we can make him perform the normal functions and processes of life, the above so called disease will automatically disappear. Because, having been enabled to perform the normal functions and processes of life, the man will no longer be sick to develop abnormalities in any direction. To treat a sick man one ought to know what caused the man to be sick.
The reason for the cause of disease used to baffle the minds of medical men for long. The entity that was behind the names of numerous forms and varieties of disease was beyond comprehension. It was the genius of Hahnemann who settled the enquiry into the cause of disease by his famous discovery of miasm as the producer of all disease of manifestation. An understanding of miasm, its classification, the manifestation and its mode of treatment are essential for the proper understanding of disease and ways to its cure.

A simple form of ICD comes under the Hahnemann classification of inappropriately called chronic diseases.
§77 Those diseases are inappropriately named chronic, which persons incur who expose themselves continually to avoidable noxious influences,.. . These states of ill-health, which persons bring upon themselves, disappear spontaneously, provided no chronic miasm lurks in the body, under an improved mode of living, and they cannot be called chronic diseases.

Cumulative chronic irritant contact dermatitis comes under the Hahnemannian classification of true natural chronic diseases due to chronic miasm. In §72 he defines chronic disease as disease “…. with small, often imperceptible beginnings, dynamically derange the living organism, each in its won peculiar manner, and cause it gradually to deviate from healthy condition, in such a way that the automatic life energy called vital force, whose office is it to preserve the health, only opposes to them at the commencement and during their progress makes imperfect, unsuitable useless resistance, but is unable to extinguish them, but must helplessly suffer (them to spread and) itself to be ever more and more abnormally deranged, until at length the organism is destroyed.
As the main symptoms of this disease are localized on the external part of the body, it takes the form of local malady of dynamic origin.
§ 201 ”It is evident that man’s vital force when encumbered with chronic disease which it is unable to overcome by its own powers, adapts the plan of developing a local malady on some external part. Solely for this object, that by making and keeping in a diseased state this part which is not indispensable in human life, it may thereby silence the internal disease which other wise threatens to destroy the vital organs,…… The local affection, however is never anything else than a part of the general disease, but a part of it increased all in one direction by the organic vital force and transferred to a less dangerous (external) part of the body, in order to allay the internal ailment”31……

In the treatment of local maladies Hahnemann says
§205 The homoeopathic physician never treats one of these primary symptoms of chronic miasms, nor get one of their secondary affections that result from their further development by local remedies (neither by those external agents that act dynamically, nor yet by those that act mechanically) but he cures ……. Only the great miasm on which they depend, where upon its primary as also its secondary symptoms disappear spontaneously…..”.
As no external disease can arise, persist or grow without the participation of the living whole, the medicinal treatment must be directed against the whole by means of internal medicines. This can be affected by taking in conjunction, the external character of local affection and all the changes, sufferings and symptoms observable in the patient’s health to form a complete picture of the disease before searching among the medicines. The remedy corresponding to the totality of the symptoms is selected, which will be the true homeopathic medicines.

In ‘A dictionary of domestic medicine and homoeopathic treatment with a special section on disease of irritants,’ J.H.Clarke says
The skin is often the outlet for chronic delicacies to manifest themselves upon. In these cases care must be taken not to treat them as if they were merely local affections. Many persons who suffer from eczema notice that they are much better when the disease is out than when it is in and it must always be regarded as a misfortune when a skin disease disappears and some internal disease shows itself instead. The only proper treatment for all such affections is that which regards the constitution as a whole .25

J.H.Allen in his book ‘The Chronic miasm’ says ‘The skin is the mirror or the reflector of the internal stress, the internal dynamics, the internal working of this human machine. It has in the skin, its reflectors, its kaleidoscope its kinetoscopic views of its internal movements and multiple shadings of disease, its lights and its shadow that go to make up a picture, thrown upon the human canvas, the skin, showing much of perverted life action in the organism.3

Chronic miasm in ICD
Irritant dermatitis accrding to the theory of chronic miasms , is a condition of three great miasms - Psora , syphilis and sycosis . These three miams are seen in varying combinations. The miasm in the background is Psora, according to the progress of pathology we can find a syphilitic predominance .

Miasmatic expression
In indications of miasm by Dr. Harimohan Choudhary 5
Psora – The characteristic of psoric skin is intense itching and burning. Itching is more frequent and more unbearable late in the evening, before midnight, heat of bed and undressing. Psoric skin is generally dry, rough and unwashed with or without little pus and blood. Vesicles of the itch, patient rubs and scratches, better for a few moments immediately after which there is a long continued burning of the affected parts.
Syphilis – Eruptions with scales thick and heavy. An urge for destruction seems to run throughout the syphilitic miasm.
Sycosis – There is erythematous eczema. There is chronic inflammation with oedema. There is formation of cracks with oozing of sticky fluid.

J.H.Allen in his book ‘The Chronic miasm’ 3says the skin of psoric patient is dry, rough, dirty or unhealthy looking. The more you bathe it, the rougher it becomes as it cannot endure water. Pseudo Psora presents as eczemafissum and itching of the skin. There is very little suppuration in psoric skin diseases, they are apt to be dry, with scanty suppuration, scropurulent and occasionally bloody. There is no itching in syphilitic and very little soreness, itching is wholly a psoric symptom the vesicle is also a psoric lesion when found in non-syphilitic case. The scales and crusts of syphilis are always thick and heavy, while those of Psora are thin, light, fine and small and usually quite general over the affected part. Sycotic skin will be oily and greasy.

Eczema fissum – This is a chronic form found in patients of a tubercular taint. It is typically a manifestation of latent syphilis upon a psoric base. It is aggravated by cold, wet weather and working in water. It affects those parts where the epidermis is thickest, as on the hands and feet. The slightest irritation of the skin, such as handling of irritants, exposure to various kinds of weather the excessive use of water or soap etc. are prone to get this disease. The skin becomes dry, hard and thick. The fissures are sometimes superficial but may extend deeply into corneum with raw, tender and bleeding surfaces. The skin may remain dry or there may be oozing of a sticky honey – like secretion, and often bleeding from deeper fissure

Dr.Samuel Hahnemann in ‘The Chronic disease their peculiar nature and their homeopathic cure”1 says that eruptions, arising from time to time and passing away again, voluptuously itching, pustules especially on the fingers or other parts which after scratching burn belongs to internal Psora. Dryness of the skin of the whole body belongs to Psora.

In ‘Notes on the Miasm’ by Dr. Proceso Sanchez Ortega 4he says syphitics has cold and pale skin which is red, hot exconated and ulcerated. There will be erythema and discolouration of various kinds.
Sycotic will have pruruginous red spots, tubercles and nodosities along with warty excresences and condylomdas. The basic psoric condition is deficiency or lack, so it will be manifested as cold skin with great sensitivity to cold and dampness.

Dr. J.T.Kent in his lectures on the homoeopathic philosophy 24gives us some guidelines for the treatment of skin diseases. He says “If you are treating a vicious form of scaly eruption, dry hard horney scales, you will, under accurate prescribing, notice these scaly formations disappear but after the vital force has become strong enough, you need not be surprised to see vesicular eruptions develop, for the original so called disease had changed from its vicious squamous form to the milder vesicular form. The different eruptions change into varying forms but they are all from one cause and will come back in their successive stages under homoeopathic treatment”.

According to Dr.J.T.Kent it is the perverted thinking, which leads to Psora, and perverted action, which leads to syphilis and sycosis.

Dr.Subrata Kumar Banerjee in ‘Miasmatic Diagnosis’23 gives a comparison of dermatological symptoms.
Psoric skin: dirty dry, harsh skin, itching without pus or discharge, sensation of burning, scaly eruptions and tendency of recurring skin diseases. Cracks of hand and feet.
Syphilitic skin – All sorts of ulcers, boils which do not heat fast with discharge of fluid and pus, which is offensive and spreads. Skin is ulcerated with pus and blood. There is putridity and offensiveness of all discharge.
Tubercular skin – Skin disease is aggravated at night by touch, warmth of bed, after itching and amel. By cold.

Dr. H.A.Roberts in ‘The principles and art of cure by homoeopathy50 gives the indication of Psora as… “ skin is dry, rough, dirty or unhealthy. In all psoric conditions, itching is a persistent symptom. There is very little suppuration; there may be a few vesicles or a papular manifestiation. With a dry skin there is a decided tendency for fine thin scales.
In syphilis there are pustular eruption which suppurate. The most striking character of syphilitic eruption is that they do not itch. There is very little soreness. If these eruption progress to scaling and crusts, as they usually do they are very thick and occur in patches or circumscribed spots.
In sycosis skin tends towards overgrowth and extra deposits. All manifestations of unnaturally thickened skin belongs to this group.

Dr.Phllis Speight in ‘A Comparision of the Chronic Miasms Psora, Pseudo-Psora, Syphilis, Sycosis’22 gives the indication of
1) Psora – Skin is dry, rough, dirty or unhealthy looking has an unwashed appearance. Pruritis – Very little suppuration in psoric skin diseases – apt to be dry with scanty suppuration seropurulent and occasionally bloody. Eruptions often popular in form accompanied by intense itching. Usually color of skin unless an inflammatory process is present. Itchihng - Scales and crusts thin and light, fine and small and usually quite general over affected part.
2) Syphilis – Syphilis are arranged in circular groupings, ring or segments of circles. Copper coloured or raw ham color, brownish or very red at their base. No itching and very little soreness. Scales and crusts thick and heavy, patchy and in circumscribed spots.
3)Sycosis – Scales patchy and in circumscribed spots. Eczema – exfoliata.

Dr . R .Patel in his ‘Chronic miasms in homoeopathy and their cure with classification of their rubrics ( symptoms in Dr. Kent’s repertory ) 21 says
a)Extremities chapped hands , working in water – P
b) Extrimities chapped fingers -P
c) Extremities chapped fingers about the nails – P
d) Extremities chapped fingers tips –P
e) Extremities cracked skin hands – Latent Psora
f) Extremities cracked skin hands, itching – Psora
g) Extremities cracked skin hands , winter in - Psora

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