What is the treatment for contact dermatitis?

Treatment of Contact Dermatitis

The primary treatment for contact dermatitis is identification and avoidance of the causative agent, followed by topical corticosteroids for symptomatic relief, with systemic treatments reserved for severe or widespread cases. 1

Types of Contact Dermatitis

Contact dermatitis can be classified into two main types:

1. Irritant Contact Dermatitis (ICD) - More common, caused by direct skin damage from irritating substances
2. Allergic Contact Dermatitis (ACD) - Immune-mediated response requiring prior sensitization

First-Line Treatment Approach

1. Identification and Avoidance

• Identify and avoid the causative agent (allergen or irritant)
• Workplace assessment may be necessary to identify sources of exposure 2
• For occupational cases, substitution of products or protective measures are essential

2. Topical Treatments

• Topical corticosteroids: First-line treatment for established contact dermatitis 2

  • Mid to high-potency steroids for localized acute lesions (e.g., triamcinolone 0.1%, clobetasol 0.05%) 3
  • Apply twice daily for 1-2 weeks
  • Caution: Avoid prolonged use of superpotent corticosteroids (>2 weeks) due to risk of HPA axis suppression 4

• Emollients and soap substitutes:

  • Use regularly to maintain skin barrier function
  • Evidence supports their use in reducing incidence and prevalence of contact dermatitis 2
  • Apply after washing and throughout the day

• Topical calcineurin inhibitors:

  • Tacrolimus 0.1% ointment as second-line therapy 1
  • Particularly useful for steroid-induced cases or when steroids are contraindicated
  • Apply twice daily for up to 4 weeks

3. Protection Strategies

• Gloves: Appropriate for hand protection

  • For household tasks: rubber or PVC gloves with cotton liners
  • For occupational exposure: specific gloves based on chemical exposure
  • Remove regularly to prevent sweating which may worsen dermatitis 2

• Barrier creams:

  • Limited value in protecting against irritants 2
  • Should not be overpromoted as they may create false sense of security

• After-work creams:

  • Beneficial in reducing incidence of irritant contact dermatitis
  • Should be made readily available in workplaces 2

Systemic Treatments for Severe Cases

For severe or widespread contact dermatitis (>20% body surface area):

1. Oral corticosteroids:

   • Prednisone 0.5-1 mg/kg/day for 1-2 weeks with 4-6 week taper 1, 3
   • Provides relief within 12-24 hours
   • For severe rhus dermatitis (poison ivy), taper over 2-3 weeks to prevent rebound 3

2. Oral antibiotics:

   • Tetracycline (500 mg twice daily) for 4-6 weeks for adults
   • Doxycycline (100 mg once or twice daily) as an alternative
   • For children under 8 years: erythromycin (30-50 mg/kg/day divided into 3-4 doses) 1

3. Second-line treatments:

   • For steroid-resistant chronic hand dermatitis:
     • PUVA (psoralen plus UVA)
     • Azathioprine
     • Ciclosporin
   • These treatments have supporting evidence from prospective clinical trials 2

Special Considerations

Pediatric Patients

• Children may absorb proportionally larger amounts of topical corticosteroids
• More susceptible to systemic toxicity due to larger skin surface to body mass ratio 5
• Avoid tetracyclines in children under 8 years due to risk of dental staining 1

Occupational Contact Dermatitis

• Poor long-term prognosis: only 25% completely heal after 10 years 2
• Changing occupation does not necessarily improve prognosis
• Healthcare workers and cleaning staff have higher rates (up to 30% prevalence) 1

Nickel Allergies

• Low-nickel diets may benefit some nickel-sensitive patients 2

Monitoring and Follow-up

• For patients using potent topical steroids over large areas, monitor for HPA axis suppression
• If treatment fails and specific allergen remains unknown, patch testing should be performed 3
• Regular follow-up to assess treatment response and adjust therapy as needed

Common Pitfalls to Avoid

1. Overuse of topical corticosteroids - Can lead to skin atrophy, telangiectasia, and HPA axis suppression
2. Inadequate allergen identification - Failure to identify and avoid the causative agent will lead to treatment failure
3. Misdiagnosis - Consider other conditions like psoriasis or fungal infections if not responding to treatment
4. Reliance on barrier creams alone - Not sufficient without proper avoidance and protection measures
5. Premature discontinuation of oral steroids - Can lead to rebound dermatitis, especially in severe cases

By following this structured approach to treatment, most cases of contact dermatitis can be effectively managed, though occupational cases may have a more challenging long-term prognosis.