Treatment of Contact Dermatitis
For contact dermatitis, the first-line treatment is mid-potency topical corticosteroids such as triamcinolone 0.1% applied twice daily as a thin film to affected areas for up to 2 weeks, along with avoidance of the triggering substance and regular use of fragrance-free, hypoallergenic moisturizers. 1
Treatment Algorithm
Step 1: Identify and Remove the Causative Agent
- Determine whether the dermatitis is irritant or allergic
- Complete avoidance of suspected irritants or allergens is crucial
- For extensive cases, consider patch testing to identify specific allergens (defer testing for 6 weeks after UV exposure or 3 months after systemic agents) 1
Step 2: Topical Treatment
Topical Corticosteroids
- Apply mid-potency corticosteroid (triamcinolone 0.1%) twice daily as a thin film 1, 2
- Limit use to 2 weeks to avoid skin atrophy and other side effects 1, 3
- For facial or intertriginous areas, consider lower potency steroids to minimize adverse effects
- Monitor for signs of topical steroid side effects (skin atrophy, telangiectasia) 1
Skin Care and Barrier Repair
- Use dispersible cream as a soap substitute instead of regular soaps or detergents 1
- Apply fragrance-free, hypoallergenic moisturizers with petrolatum or mineral oil multiple times daily 1
- Pat dry gently rather than rubbing the skin 1
- Add emollient bath oils to short, lukewarm baths or showers 1
- Avoid greasy creams that may occlude follicles 1
Step 3: Systemic Treatment (for extensive cases)
- For dermatitis affecting >20% body surface area, consider systemic steroids 1, 2
- Systemic steroids provide relief within 12-24 hours 1, 2
- For severe cases (like rhus dermatitis), taper oral prednisone over 2-3 weeks to prevent rebound dermatitis 2
- Monitor for signs of HPA axis suppression in patients on systemic steroids 1, 3
Step 4: Management of Secondary Infection
- Consider topical antimicrobials (clindamycin 2% or erythromycin 1% cream) for suspected secondary infection 1
- Take bacterial swabs if infection is suspected 1
- For signs of systemic infection, use oral antibiotics (penicillinase-resistant penicillin or first-generation cephalosporin) 1
- For MRSA concerns, consider clindamycin, doxycycline, or SMX-TMP 1
- A 5-day course of antibiotics can be as effective as 10 days if clinical improvement occurs 1
Special Considerations
Pediatric Patients
- Children may absorb proportionally larger amounts of topical corticosteroids 3
- More susceptible to systemic toxicity and HPA axis suppression 3
- Limit application to the least amount compatible with effective treatment 3
- Monitor for growth retardation, delayed weight gain, and low plasma cortisol levels 3
Pregnant and Nursing Women
- Use topical corticosteroids during pregnancy only if the potential benefit justifies the potential risk 3
- Avoid extensive use in large amounts or for prolonged periods 3
- Exercise caution when administering to nursing women 3
Common Pitfalls to Avoid
- Overlooking continued exposure to irritants 1
- Inadequate moisturization 1
- Overuse of topical steroids leading to skin atrophy 1, 3
- Missing secondary infection 1
- Misdiagnosis of irritant dermatitis 1
- Using occlusive dressings with potent steroids, which increases systemic absorption 3
- Applying treatment near the eyes without proper precautions 1
Evidence Quality and Contradictions
While most guidelines recommend topical corticosteroids for contact dermatitis 1, 2, one experimental study found corticosteroids ineffective for surfactant-induced irritant dermatitis compared to vehicle alone 4. However, this contradictory finding should be interpreted cautiously as it used a specific irritant model and may not apply to all forms of contact dermatitis.
The American Academy of Dermatology and British Journal of Dermatology guidelines provide strong evidence supporting the use of topical corticosteroids, moisturizers, and allergen avoidance as the cornerstone of contact dermatitis management 1.