Treatment of Allergic Dermatitis
Topical corticosteroids are the first-line treatment for allergic dermatitis, followed by topical calcineurin inhibitors, with systemic treatments reserved for severe or refractory cases. 1, 2
Diagnosis and Assessment
When evaluating allergic dermatitis, consider:
- Pattern and morphology of the dermatitis (particularly on hands and face)
- Personal or family history of atopy
- Initial symptoms location and spread
- Relationship to specific products, activities, or occupational exposures
- Exposure to potential irritants or allergens
Remember that clinical features alone are unreliable in distinguishing allergic contact from irritant and endogenous dermatitis, particularly with hand and facial dermatitis 1.
First-Line Treatment
Topical Corticosteroids
- Use mid- to high-potency topical steroids for localized acute allergic contact dermatitis 3
- Apply a thin layer to affected areas twice daily
- Match potency to severity and location:
- Low potency for face, genitals, and intertriginous areas
- Medium to high potency for trunk and extremities
- Ultra-high potency for thick, lichenified areas
Emollients and Skin Care
- Apply emollients liberally and frequently
- Replace soaps and detergents with soap substitutes 1
- Maintain good skin barrier function with regular moisturizing
Second-Line Treatment
Topical Calcineurin Inhibitors
- Pimecrolimus 1% cream or tacrolimus 0.03%/0.1% ointment
- Particularly useful for sensitive areas (face, neck, intertriginous areas)
- Apply twice daily to affected areas 4, 5
- Can be used in conjunction with topical corticosteroids 5
Allergen Avoidance
- Patch testing should be offered for patients with chronic or persistent dermatitis 1
- Identify and avoid specific allergens when possible
- Consider workplace assessment for occupational dermatitis 1
Treatment for Moderate-to-Severe or Refractory Cases
Systemic Corticosteroids
- For extensive allergic contact dermatitis (>20% body surface area) 3
- Oral prednisone tapered over 2-3 weeks to prevent rebound dermatitis
- Provides relief within 12-24 hours
Phototherapy
- Consider for moderate to severe cases not responding to topical treatments 6, 5
- Safe and effective when first-line treatments are inadequate
Advanced Systemic Therapies
For severe chronic cases:
- Dupilumab for atopic dermatitis 2, 7
- Cyclosporine as first-line systemic immunosuppressant 7
- Methotrexate or azathioprine as second-line options 1, 7
Special Considerations
Occupational Contact Dermatitis
- Prognosis is often poor - only 25% completely heal over a 10-year period 1
- Workplace modifications and protective equipment are essential
- Consider appropriate gloves based on specific allergen/irritant exposure 1
Secondary Infections
- Treat secondary skin infections with appropriate antistaphylococcal antibiotics 5
- Consider bleach baths for recurrent infections 6
Common Pitfalls to Avoid
Misdiagnosis: Clinical features alone are unreliable in distinguishing allergic contact from irritant and endogenous dermatitis. Consider patch testing for persistent cases 1.
Inadequate treatment duration: Topical treatments should be continued until complete clearance, then gradually tapered to prevent rebound.
Neglecting barrier repair: Emollients are crucial even when not the primary cause of dermatitis 1.
Prolonged use of high-potency steroids: Can lead to skin atrophy, telangiectasia, and tachyphylaxis, especially on sensitive areas.
Overlooking occupational factors: Workplace assessment may be necessary to identify hidden allergens or irritants 1.
By following this treatment approach, most cases of allergic dermatitis can be effectively managed, improving patients' quality of life and preventing chronic disease.