What is the recommended treatment for allergic dermatitis?

Treatment of Allergic Dermatitis

The first-line treatment for allergic dermatitis includes identification and avoidance of allergens, regular use of moisturizers, and application of topical corticosteroids for flare-ups. 1

Diagnosis and Classification

Allergic dermatitis can be classified into two main types:

• Allergic Contact Dermatitis (ACD): A delayed hypersensitivity reaction where a foreign substance contacts the skin and causes a reaction after reexposure 2
• Atopic Dermatitis (AD): A chronic, relapsing inflammatory skin condition often associated with a personal or family history of allergic conditions 1

Treatment Algorithm

Step 1: Identify and Avoid Triggers

• For allergic contact dermatitis, allergens should be identified and avoided 1
• Patch testing should be considered for patients with persistent/recalcitrant disease or history consistent with allergic contact dermatitis 1
• Common allergens include nickel, fragrances, preservatives, and topical antibiotics 1

Step 2: Skin Care and Barrier Repair

• Moisturizers: Apply immediately after bathing to lock in moisture 1

  • Choose products free of allergenic surfactants, preservatives, fragrances, or dyes 1
  • Use moisturizers in tubes rather than jars to prevent contamination 1

• Bathing practices:

  • Use soap-free cleansers that are gentle on the skin 1
  • Avoid very hot or very cold water for washing 1
  • Pat dry gently rather than rubbing 1

Step 3: Pharmacological Treatment for Flares

Topical Corticosteroids (First-line)

• Apply to affected areas during flare-ups, not more than 3-4 times daily 3
• Choose potency based on location:
  • For face, neck, and skin folds: Use lower potency corticosteroids to avoid skin atrophy 1
  • For body: Mid to high-potency corticosteroids like triamcinolone 0.1% or clobetasol 0.05% 2
• For maintenance after clearing: Apply 1-2 times per week to previously affected areas to prevent flares 1

Topical Calcineurin Inhibitors (Alternative or Adjunctive)

• Pimecrolimus cream 1% or tacrolimus ointment 0.03%/0.1% 1, 4
• Particularly useful for sensitive areas like the face where potent corticosteroids may cause atrophy 4
• Can be used 2-3 times per week for maintenance therapy after clearing 1

Step 4: Management of Severe or Refractory Cases

• For extensive involvement (>20% body surface area): Consider systemic corticosteroids 2
• For recalcitrant cases: Consider referral for:
  • Stronger topical steroids 1
  • Phototherapy (not recommended for children under 12) 1, 4
  • Systemic therapies such as cyclosporin, azathioprine, or methotrexate 1
  • Newer biologics like dupilumab for severe atopic dermatitis 1, 4

Special Considerations

Hand Dermatitis

• Apply moisturizer after washing hands and before wearing gloves 1
• For occupational hand dermatitis, consider workplace modifications 1
• "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

Eyelid Dermatitis

• Common causes include eye drops (54.2%), creams/lotions (24.6%), and cosmetics (13.1%) 5
• Identify and eliminate causative agents 5
• Use mild topical corticosteroids specifically formulated for sensitive areas 5

Common Pitfalls to Avoid

• Overuse of topical corticosteroids: Can lead to skin atrophy, especially on face and skin folds 1
• Long-term use of topical antibiotics: Increases risk of resistance and skin sensitization 1
• Topical antihistamines: Not recommended due to risk of contact dermatitis 1
• Food elimination diets: Not recommended unless there is a true IgE-mediated allergy confirmed by testing 1
• Complementary therapies: Insufficient evidence for Chinese herbal therapy, massage therapy, and supplements like evening primrose oil, fish oil, or vitamins 1

Monitoring and Follow-up

• Assess response to treatment within 1-2 weeks 2
• If no improvement, consider:
  • Reevaluation of diagnosis 1
  • Patch testing if not already performed 1
  • Referral to dermatology for recalcitrant cases 1

By following this structured approach to treating allergic dermatitis, focusing on allergen identification and avoidance, proper skin care, and appropriate use of anti-inflammatory medications, most patients will experience significant improvement in their condition and quality of life.