How to manage irritant contact dermatitis?

Management of Irritant Contact Dermatitis

The cornerstone of managing irritant contact dermatitis (ICD) is identifying and avoiding irritants, applying frequent moisturization, and using topical steroids for recalcitrant cases. 1, 2

First-Line Management

Identify and Avoid Irritants

• Common irritants include:
  • Soaps and detergents
  • Frequent hand washing
  • Very hot or cold water
  • Disinfectant wipes
  • Bleach and other cleaning products 1
• Switch to less-irritating products when possible
• Use dispersible creams as soap substitutes to avoid removing natural skin lipids 2

Moisturization (Essential)

• Apply fragrance-free, hypoallergenic moisturizers multiple times daily 2
  • Look for products containing petrolatum or mineral oil
  • Keep pocket-sized moisturizers for frequent reapplication 1
• Apply moisturizer immediately after washing hands while skin is still damp 1
• For severe cases, try "soak and smear" technique:
  • Soak hands in plain water for 20 minutes
  • Immediately apply moisturizer to damp skin
  • Continue nightly for up to 2 weeks 1

Protective Measures

• For nighttime treatment:
  • Apply moisturizer followed by cotton or loose plastic gloves to create an occlusive barrier 1
• For occupational exposure:
  • Use appropriate gloves based on specific irritants
  • Apply water-based moisturizer before wearing gloves (oil-based moisturizers can break down latex/rubber) 1
  • Consider cotton glove liners under protective gloves 1

Second-Line Management

Topical Steroids

• Consider topical steroids if conservative measures fail 1, 2
• Apply mid-potency corticosteroid (e.g., triamcinolone 0.1%) twice daily as a thin film to affected areas 2, 3
• Limit use to 2 weeks to avoid skin atrophy 2
• For adults and children over 2 years, hydrocortisone can be applied to affected areas no more than 3-4 times daily 4
• Be cautious with topical steroids as they may potentially damage the skin barrier 1

Occlusive Dressing Technique (for recalcitrant cases)

• Apply a thin coating of triamcinolone cream to the lesion
• Cover with pliable nonporous film and seal edges
• Can use 12-hour occlusion (evening to morning)
• Apply additional cream without occlusion during the day
• Discontinue if infection develops 3

Management of Extensive or Severe ICD

Systemic Therapy

• For extensive involvement (>20% body surface area), consider systemic steroids 5
• Provides relief within 12-24 hours
• May require phototherapy or other systemic therapy for recalcitrant cases 1
• Consider occupational modification if necessary 1

When to Refer

• Recalcitrant hand dermatitis should prompt dermatology consultation 1
• Refer if there is:
  • Failure to respond to appropriate first-line treatment
  • Uncertainty about diagnosis 2

Special Considerations

Secondary Infection

• Monitor for signs of infection
• Consider topical antimicrobials for suspected secondary infection 2
• Take bacterial swabs if infection is suspected
• Use oral antibiotics if signs of systemic infection are present 2

Monitoring and Follow-up

• Watch for signs of topical steroid side effects (skin atrophy, telangiectasia) 2
• For those on systemic steroids, monitor for signs of HPA axis suppression 2

Common Pitfalls to Avoid

• Overlooking continued exposure to irritants
• Inadequate moisturization
• Overuse of topical steroids
• Missing secondary infection
• Misdiagnosis (ICD can co-exist with atopic dermatitis and allergic contact dermatitis) 6
• Using greasy creams that may occlude follicles 2

Remember that ICD patients typically report stinging and burning more than pruritus, and lesions are usually well-demarcated, which helps distinguish it from allergic contact dermatitis 6.