What is the first line treatment for contact dermatitis?

First-Line Treatment for Contact Dermatitis

The first-line treatment for contact dermatitis is topical corticosteroids, along with allergen/irritant identification and avoidance. 1

Types of Contact Dermatitis

• Contact dermatitis can be divided into two main types: allergic contact dermatitis (ACD) and irritant contact dermatitis (ICD) 1, 2
• Allergic contact dermatitis involves sensitization of the immune system to specific allergens 1
• Irritant contact dermatitis occurs from direct skin damage by irritating substances without immune sensitization 1

Treatment Algorithm

Step 1: Identify and Avoid Triggers

• Identify potential allergens or irritants through a detailed history of exposures 1
• Perform patch testing for persistent cases to confirm specific allergens 1
• Complete avoidance of identified allergens/irritants is the cornerstone of management 1
• For occupational exposures, workplace modifications or protective equipment may be necessary 1

Step 2: First-Line Pharmacological Treatment

• Topical corticosteroids are the mainstay of treatment for established contact dermatitis 1
  • For localized lesions: mid- to high-potency topical steroids (e.g., triamcinolone 0.1%, mometasone furoate) 1, 3
  • For hand dermatitis: evidence supports long-term intermittent use of mometasone furoate 1
• Moisturizers and emollients should be used concurrently to repair skin barrier 1
  • Apply after washing hands and before wearing gloves 1
  • Use at least two fingertip units of moisturizer for hands after washing 1

Step 3: Supportive Measures

• Replace soaps and detergents with gentle emollients for washing 1
• For hand dermatitis: "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
• Consider cotton glove liners or loose plastic gloves for protection 1

Step 4: For Severe or Refractory Cases

• For extensive involvement (>20% body surface area): short course of systemic corticosteroids 3
• For chronic, recalcitrant cases: consider second-line treatments 1
  • Topical calcineurin inhibitors (tacrolimus) 1
  • Phototherapy (PUVA) 1
  • Systemic immunomodulators (azathioprine, ciclosporin, methotrexate) 1
  • Alitretinoin for chronic hand dermatitis 1

Special Considerations

For Irritant Contact Dermatitis

• Focus on skin barrier repair with moisturizers 1
• Topical steroids may be considered if conservative measures fail 1
• Be cautious with prolonged steroid use as it can potentially damage the skin barrier 1

For Allergic Contact Dermatitis

• Allergen identification through patch testing is crucial 1
• Topical steroids are more consistently effective for ACD than for ICD 4
• Provide patient education on allergen avoidance 1

Common Pitfalls and Caveats

• Barrier creams alone have questionable value in preventing irritant contact dermatitis and may give a false sense of security 1
• Oil-based moisturizers can break down latex and rubber gloves; water-based moisturizers are safe under all gloves 1
• Prolonged glove use without moisturizers can impair skin barrier function 1
• Prognosis for occupational contact dermatitis is often poor, with only 25% of patients completely healing over a 10-year period 1
• For recalcitrant cases, dermatology consultation is recommended for patch testing and advanced treatment options 1