What is the first line treatment for dermatitis?

First-Line Treatment for Dermatitis

The first-line treatment for dermatitis is topical corticosteroids of appropriate potency for the affected area, combined with liberal use of emollients and gentle skin care practices. 1, 2

Types of Dermatitis and Initial Treatment Approach

Atopic Dermatitis

1. Topical Corticosteroids

   • Medium-potency for most body areas (apply once daily for 2-4 weeks) 1
   • Low-potency (hydrocortisone 0.1-2.5%) for face, neck, and intertriginous areas 1
   • For severe cases: High-potency may be needed for short periods on thickened areas 3

2. Emollients/Moisturizers

   • Apply liberally and frequently, especially after bathing 1
   • Use fragrance-free, hypoallergenic formulations 1
   • Continue daily even when skin appears normal 1

3. Bathing Practices

   • Use gentle, soap-free cleansers 1, 2
   • Avoid hot water and harsh soaps 1
   • Apply moisturizers immediately after bathing to lock in moisture 1

Contact Dermatitis

1. Allergen/Irritant Avoidance

   • Identify and eliminate triggering substances 3, 4
   • For occupational contact dermatitis, workplace evaluation may be necessary 3

2. Topical Corticosteroids

   • Mid- to high-potency for localized acute allergic contact dermatitis 4
   • For extensive involvement (>20% body surface), systemic steroids may be required 4

3. After-work Creams

   • Shown to provide protection against developing irritant contact dermatitis 3
   • Should be made readily available in workplaces 3

Second-Line and Alternative Treatments

Topical Calcineurin Inhibitors (TCIs)

• Effective steroid-sparing agents for sensitive areas like face and neck 1, 3
• Pimecrolimus 1% cream: Apply twice daily to affected areas 1
• Tacrolimus: Particularly effective for facial dermatitis 1, 5
• Note: May cause burning sensation initially; counsel patients about black box warning 3

Proactive Maintenance Therapy

• Twice-weekly application of TCS or TCI to previously affected areas helps prevent relapse 1
• "Weekend therapy" approach for maintenance 1

Wet Wrap Therapy

• Consider for moderate cases that don't respond adequately to initial treatment 1
• Particularly useful for acute flares 3

Special Considerations

For Severe or Refractory Cases

• Consider referral to dermatologist if no improvement after 2 weeks 1
• Systemic options may include:
  • Phototherapy for moderate to severe cases 3, 6
  • Immunosuppressants (cyclosporine, azathioprine, methotrexate) 3, 6
  • Newer biologics like dupilumab for severe cases 1, 6

Secondary Infections

• Assess for signs of bacterial or viral superinfection 1
• For eczema herpeticum (HSV infection): Prompt treatment with systemic antivirals is essential 1
• For bacterial superinfection: Consider appropriate antibiotics 2

Common Pitfalls to Avoid

1. Undertreatment

   • Using too low potency corticosteroid for the affected area 3
   • "Steroid phobia" leading to inadequate application 3

2. Inappropriate Treatment

   • Using potent topical corticosteroids on face for prolonged periods 1
   • Long-term application of topical antibiotics (risk of resistance) 1
   • Using topical antihistamines (risk of contact dermatitis) 1

3. Failure to Address Underlying Causes

   • Not identifying and avoiding triggers 1
   • Neglecting to treat predisposing factors before therapy 3

Treatment Algorithm

1. Assess severity and location

   • Mild to moderate: Topical corticosteroids + emollients
   • Severe or widespread: Consider systemic therapy or specialist referral

2. Select appropriate topical corticosteroid potency

   • Face/intertriginous areas: Low potency (hydrocortisone 0.1-2.5%)
   • Body: Medium potency
   • Thick/lichenified areas: High potency (short-term)

3. Implement skin care regimen

   • Daily gentle bathing with soap-free cleansers
   • Immediate application of emollients after bathing
   • Avoidance of known triggers and irritants

4. Reassess after 2 weeks

   • If improving: Continue treatment until clear, then consider maintenance therapy
   • If not improving: Consider alternative diagnosis, treatment adjustment, or referral

Remember that adherence to treatment is crucial for success. Educate patients about proper application techniques and address any concerns about topical corticosteroid use to improve compliance.