What is the treatment approach for allergic contact dermatitis vs irritant dermatitis?

Treatment Approach for Allergic Contact Dermatitis vs Irritant Dermatitis

The primary treatment difference between allergic contact dermatitis (ACD) and irritant contact dermatitis (ICD) is that ACD requires allergen identification through patch testing and complete allergen avoidance, while ICD focuses on irritant avoidance and barrier restoration. 1

Diagnosis and Differentiation

• Patch testing is the gold standard for diagnosing ACD and should be performed when allergic contact dermatitis is suspected, as clinical features alone are unreliable in distinguishing between ACD and ICD 1
• A detailed history should include exposure to potential irritants or allergens, relationship to specific activities or products, and improvement during weekends/holidays 1
• Clinical presentation alone cannot reliably differentiate between ACD and ICD, particularly with hand and facial dermatitis 1

Treatment for Allergic Contact Dermatitis (ACD)

• For ACD, allergen identification and complete avoidance is the cornerstone of treatment 1
• Individuals with suspected ACD should be patch tested to evaluate for clinically relevant causal allergens 1
• For acute flares, apply a topical steroid to mitigate symptoms (mid to high-potency for localized areas) 1, 2
• For extensive ACD (>20% body surface area), systemic steroids may be necessary, with prednisone tapered over 2-3 weeks to prevent rebound dermatitis 2
• For recalcitrant cases, consider stronger topical steroids, phototherapy (especially PUVA for chronic hand eczema), systemic therapy, or occupational modification 1
• For glove-related ACD, use accelerator-free gloves such as rubber-free neoprene or nitrile gloves 1

Treatment for Irritant Contact Dermatitis (ICD)

• For ICD, identify and avoid irritants while focusing on skin barrier restoration through moisturization 1
• Common irritants to avoid include frequent hand washing, dish detergents, hot water, disinfectant wipes, and bleach 1
• Use barrier creams and humectants, though their effectiveness is comparable to regular moisturizers 1
• Switch to less-irritating products (soaps/detergents without allergenic surfactants, preservatives, fragrances, or dyes) 1
• Topical steroids can be considered if conservative measures fail, but use cautiously as they may damage the skin barrier further 1
• For severe cases, consider phototherapy, systemic therapy, or occupational modification 1

Moisturization Strategy for Both Conditions

• Apply moisturizer after hand washing and before wearing gloves 1
• Use moisturizers in tubes rather than jars to prevent contamination 1
• For intensive treatment, use the "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
• For nighttime treatment, apply moisturizer followed by cotton or loose plastic gloves to create an occlusive barrier 1

Advanced Therapies for Recalcitrant Cases

• Consider alitretinoin for severe chronic hand eczema 1
• Topical tacrolimus may be beneficial where topical steroids are unsuitable or ineffective 1
• PUVA therapy is recommended for chronic hand eczema 1
• For cases where allergen/irritant avoidance is impossible (occupational exposure, medical devices), systemic immunosuppressive therapies may be necessary 3

Common Pitfalls to Avoid

• Failing to identify and remove the causative agent (allergen or irritant), which prevents healing 1
• Continuing use of topical steroids long-term in ICD, which can damage the skin barrier 1
• Not considering patch testing in chronic or persistent dermatitis cases 1
• Misdiagnosing ACD as ICD or endogenous dermatitis, leading to inappropriate treatment 1, 4
• Occluding hands with adhesives or wraps without underlying moisturizer application 1