What is the recommended treatment for dermatitis?

Treatment of Dermatitis

The recommended first-line treatment for dermatitis is topical corticosteroids, with potency selection based on severity, accompanied by emollients and soap substitutes for maintenance therapy. 1, 2

Diagnostic Considerations

• Determine the type of dermatitis (atopic, contact, irritant) through clinical presentation
• For persistent eczematous eruptions, patch testing should be considered to identify potential allergens 2
• For recurrent or treatment-resistant cases, consider referral to a dermatologist 1

First-Line Treatment

Topical Corticosteroids

• Potency selection based on severity and location:
  • High-potency: For acute flares
  • Medium-potency: For longer treatments
  • Low-potency: For mild cases and sensitive areas (face, genitals, skin folds)
  • Use for short periods (2-4 weeks) to avoid side effects like skin atrophy 1

Skin Care Regimen

• Emollients and moisturizers:
  • Apply liberally and frequently (3-8 times daily)
  • Use even when skin appears normal
  • Apply immediately after bathing to trap moisture 1
• Bathing recommendations:
  • Use soap substitutes/dispersible creams instead of soap
  • Consider adding bath oils 1
• After-work creams are beneficial in reducing irritant contact dermatitis (evidence level I, recommendation A) 2

Second-Line Treatments

Topical Calcineurin Inhibitors

• Pimecrolimus 1% cream:
  • Indicated for mild to moderate atopic dermatitis in patients ≥2 years old who have failed other topical treatments 3
  • Causes less skin thinning than corticosteroids, making it suitable for sensitive areas 4
• Tacrolimus:
  • Effective for patients ≥2 years old unresponsive to conventional therapies 1
  • 0.03% tacrolimus has shown greater efficacy than 1% hydrocortisone acetate in children with moderate to severe atopic dermatitis 5

Phototherapy

• Consider for moderate to severe cases unresponsive to topical treatments
• Oral PUVA has shown 81-86% improvement or clearance in hand and foot eczema 1

Treatment for Severe or Refractory Cases

Systemic Treatments

• Systemic corticosteroids:
  • Limited role in severe acute flares
  • Oral prednisone (1 mg/kg/day) with tapering over at least 4 weeks 1
  • Not recommended for maintenance treatment 1
• Biologics and immunomodulators for moderate-to-severe atopic dermatitis:
  • Dupilumab
  • JAK inhibitors (abrocitinib, baricitinib, upadacitinib)
  • Traditional immunomodulators (cyclosporine, methotrexate, azathioprine, mycophenolate mofetil) 1, 6

Infection Management

• Treat clinically evident infections with appropriate antibiotics
• Consider antiseptic washes with aqueous chlorhexidine 0.05% for erosive lesions
• Bleach baths with 0.005% sodium hypochlorite twice weekly can help prevent infections 1

Important Considerations and Pitfalls

1. Avoid prolonged use of high-potency corticosteroids, especially on the face, as they can cause skin atrophy, telangiectasias, and striae 1, 4

2. Barrier creams alone have questionable value in protecting against irritants and may give a false sense of security (evidence level I, recommendation E) 2

3. Oral antihistamines are not recommended for treating atopic dermatitis as they do not effectively reduce pruritus 7

4. Prognosis varies - studies show that only 25% of occupational contact dermatitis cases completely heal, with 50% having periodic symptoms and 25% permanent symptoms 2

5. Avoidance of triggers is crucial - prognosis for milder cases depends on the ability to avoid causative agents 2