What is the first line treatment for contact dermatitis?

First-Line Treatment for Contact Dermatitis

The first-line treatment for contact dermatitis is identifying and avoiding the causative agent, applying topical corticosteroids for inflammation, and using moisturizers to repair the skin barrier. 1

Initial Management Approach

• Identify and completely avoid the irritant or allergen that is causing the dermatitis 2, 1
• Replace soaps and detergents with emollients, as they can compound irritation even if they are not the primary cause of the dermatitis 2
• Apply moisturizers immediately after washing hands to repair the skin barrier 1
• Use topical corticosteroids when conservative measures fail to control inflammation 1, 3

Specific Treatment Based on Type

For Irritant Contact Dermatitis:

• Use gentle cleansers and soap substitutes to prevent further irritation 1
• Apply moisturizers packaged in tubes (rather than jars to prevent contamination) 1
• Apply two fingertip units of moisturizer to hands after washing 1
• Avoid washing hands with dish detergent or other known irritants 1

For Allergic Contact Dermatitis:

• Complete allergen avoidance is essential after identification through patch testing 1
• For localized acute allergic contact dermatitis, apply mid- or high-potency topical steroids (such as triamcinolone 0.1% or clobetasol 0.05%) 3
• For extensive allergic contact dermatitis (>20% body surface area), systemic steroid therapy may be required 3

Protective Measures

• Use appropriate gloves for hand dermatitis protection - rubber or PVC gloves with cotton liners for household tasks 1
• Remove gloves regularly and apply moisturizer before wearing gloves to prevent dermatitis 1
• Note that barrier creams alone have questionable protective value against irritants 2, 1
• After-work creams have shown benefit in reducing irritant contact dermatitis 2, 1

Treatment of Persistent Contact Dermatitis

• For dermatitis persisting despite allergen/irritant removal and skin protection, treatment follows management of atopic/endogenous dermatitis 2
• Studies support the efficacy of both topical steroids and topical tacrolimus in persistent contact dermatitis 2
• Second-line treatments for steroid-resistant cases include:
  • Phototherapy 2
  • Systemic immunomodulators (methotrexate, mycophenolate mofetil) 2
  • PUVA, ciclosporin, and alitretinoin (particularly useful for chronic hand dermatitis) 2
  • Azathioprine (useful in chronic actinic dermatitis) 2

Common Pitfalls and Caveats

• Prolonged glove use may impair stratum corneum barrier function, though the clinical relevance is unclear 2
• Barrier creams should not be over-promoted as they may give users a false sense of security 1
• The long-term prognosis for occupational contact dermatitis is often poor, with studies showing only 25% of patients completely healed over a 10-year period 2
• For severe rhus dermatitis (poison ivy), oral prednisone should be tapered over 2-3 weeks as rapid discontinuation can cause rebound dermatitis 3
• Exclusion diets (except possibly low-nickel diets in nickel-sensitive patients) have limited evidence supporting their use in contact dermatitis management 2, 1

Special Considerations

• For occupational dermatitis, workplace assessment may be necessary to identify all potential hazards 1
• Educational programs may help in secondary prevention and improve outcomes for chronic occupational contact dermatitis 2
• If treatment fails and the specific allergen remains unknown, patch testing should be performed 3