What is the treatment for contact dermatitis?

Treatment of Contact Dermatitis

The primary treatment for contact dermatitis includes allergen/irritant identification and avoidance, along with topical corticosteroids as first-line therapy for established dermatitis, followed by topical calcineurin inhibitors when needed. 1

Types of Contact Dermatitis

Contact dermatitis can be classified into two main types:

1. Irritant contact dermatitis: Caused by direct chemical damage from substances like acids, alkalis, detergents, or solvents 1
2. Allergic contact dermatitis: Occurs in susceptible individuals with allergic reactions to specific antigens (metals, chemicals, plastics, etc.) 1

Treatment Algorithm

Step 1: Identification and Avoidance

• Identify and completely avoid the suspected irritant or allergen 1, 2
• For occupational exposures, consider workplace modifications or protective measures 1
• For nickel sensitivity, consider low-nickel diets in selected patients 1

Step 2: Skin Barrier Restoration

• Emollients and soap substitutes should be used regularly 1
• After-work creams are beneficial in occupational settings 1
• Avoid harsh cleansers that can further damage the skin barrier 1

Step 3: Topical Anti-inflammatory Treatment

• First-line: Topical corticosteroids

  • For localized acute allergic contact dermatitis: Mid- to high-potency topical steroids (e.g., triamcinolone 0.1% or clobetasol 0.05%) 3
  • For chronic hand eczema: Intermittent use of mometasone furoate has proven efficacy 1

• Second-line: Topical calcineurin inhibitors

  • Tacrolimus 0.1% ointment or pimecrolimus 1% cream are effective alternatives, particularly for facial or intertriginous areas 1
  • Shown to be effective in nickel-induced allergic contact dermatitis models 1

Step 4: Systemic Treatment (for extensive or resistant cases)

• Systemic corticosteroids: For extensive involvement (>20% body surface area) 3

  • Oral prednisone with 2-3 week taper to prevent rebound dermatitis 3

• Second-line systemic treatments for steroid-resistant chronic dermatitis:

  • Phototherapy (PUVA)
  • Immunosuppressants: azathioprine, methotrexate, mycophenolate mofetil
  • Ciclosporin
  • Alitretinoin (for chronic hand dermatitis) 1

Special Considerations

For Infected Dermatitis

• Consider topical corticosteroid/antibiotic combinations 1

For Occupational Contact Dermatitis

• Educational programs can help improve outcomes 1
• Soap substitutes and after-work creams should be readily available in the workplace 1
• Caution with barrier creams: They have questionable value and may create a false sense of security 1

When Avoidance Is Not Possible

• More aggressive treatment with systemic agents may be required 4
• Consider integrated care programs with multidisciplinary teams for work-related dermatitis 1

Prognosis

The prognosis for contact dermatitis depends on the ability to avoid the causative agent. Unfortunately, occupational contact dermatitis often has a poor long-term prognosis, with studies showing that 55% of patients still had dermatitis after 2 years from diagnosis 1.

Common Pitfalls to Avoid

• Misdiagnosis: Contact dermatitis can mimic many skin conditions including atopic dermatitis, lichen planus, and psoriasis 2
• Inadequate patch testing: Persistent eczematous eruptions should be patch tested to identify specific allergens 1
• Premature discontinuation of steroids: Rapid discontinuation can cause rebound dermatitis, especially in severe cases 3
• Over-reliance on barrier creams: These have questionable protective value against irritants 1
• Neglecting skin barrier repair: Focusing only on anti-inflammatory treatment without addressing barrier function can lead to persistent symptoms 1

By following this structured approach to the management of contact dermatitis, clinicians can effectively address both the underlying cause and symptoms of the condition, leading to improved outcomes and quality of life for patients.