What is the treatment for allergic contact dermatitis?

Treatment for Allergic Contact Dermatitis

The first-line treatment for allergic contact dermatitis involves allergen identification and avoidance, followed by application of topical corticosteroids to mitigate flares, with systemic steroids reserved for extensive cases involving >20% of body surface area. 1

Diagnosis and Identification

• Allergic contact dermatitis (ACD) is a delayed hypersensitivity reaction characterized by erythema, scaling, and pruritus with visible borders
• Distinguish from irritant contact dermatitis (ICD), which is more common but has a better prognosis
• Patch testing is essential for patients with:
  • Chronic or persistent dermatitis
  • Hand or facial dermatitis
  • Recalcitrant cases
  • Suspected allergic etiology 1

Treatment Algorithm

Step 1: Allergen Avoidance

• Identify and avoid triggering allergens
• For workplace-related dermatitis, investigate work practices and products 1
• Replace irritating soaps/detergents with gentle emollients 2

Step 2: Topical Therapy

• Acute mild-moderate ACD:

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

• For face, groin, or axillae:

  • Avoid clobetasol propionate in these areas 3
  • Consider topical calcineurin inhibitors (tacrolimus 0.1%) as steroid-sparing alternatives 2

Step 3: Systemic Therapy (for extensive or severe cases)

• Indications: ACD involving >20% body surface area or severe symptoms 4

• First-line systemic therapy: Oral prednisone 30-60 mg (or 1 mg/kg) daily

  • Taper over 2-3 weeks to prevent rebound dermatitis 4
  • Provides relief within 12-24 hours 4

• For recalcitrant cases:

  • Consider phototherapy, systemic immunosuppressants, or occupational modification 1
  • Note: No systemic treatments are FDA-approved specifically for widespread recalcitrant contact dermatitis 5

Supportive Measures

Skin Barrier Repair

• Apply moisturizers immediately after cleansing and frequently throughout the day 1
• Choose products free of allergenic surfactants, preservatives, fragrances, or dyes 1
• For nighttime use: Apply moisturizer followed by cotton or loose plastic gloves for occlusive effect 1

Hand Dermatitis Specific Measures

• For glove-related ACD, use accelerator-free gloves (rubber-free neoprene or nitrile) 1
• Consider cotton glove liners or loose plastic gloves 1
• "Soak and smear" technique: Soak hands in plain water for 20 minutes and immediately apply moisturizer to damp skin nightly for up to 2 weeks 1

Monitoring and Follow-up

• Reassess after 2 weeks of treatment to evaluate effectiveness 2
• For patients with recurrent or persistent symptoms, refer for patch testing 1
• Monitor for signs of topical steroid side effects (skin atrophy, telangiectasia) 3
• For those on systemic steroids, watch for signs of HPA axis suppression 3

Common Pitfalls to Avoid

• Misdiagnosis: Clinical features alone are unreliable in distinguishing allergic from irritant dermatitis 1
• Overuse of topical corticosteroids: Limit superpotent corticosteroids to 2 weeks and small areas 3
• Inadequate allergen identification: Failure to identify and avoid allergens leads to treatment failure 2
• Premature discontinuation of systemic steroids: Taper over 2-3 weeks to prevent rebound dermatitis 4
• Neglecting skin barrier repair: Regular use of emollients is essential for management 1