What is the first line treatment for an elderly individual with repeat contact dermatitis on the face due to picking?

Treatment for Elderly Patients with Repeat Contact Dermatitis on Face Due to Picking

First-line treatment for elderly patients with repeat contact dermatitis on the face due to picking should include emollients and topical steroids for at least 2 weeks to exclude asteatotic eczema, along with addressing the underlying picking behavior. 1

Initial Management Approach

• Apply moisturizers with high lipid content immediately after cleansing to maintain skin barrier function 1
• Use a low to medium potency topical corticosteroid such as hydrocortisone or clobetasone butyrate to affected areas for inflammation control 1, 2
• Apply topical steroids no more than 3-4 times daily to affected areas 2
• Use gentle cleansing with mild soap substitutes and lukewarm water, followed by patting dry rather than rubbing 3, 4
• Identify and eliminate potential irritants or allergens that may be exacerbating the condition 3, 5

Addressing the Picking Behavior

• Consider cognitive behavioral techniques such as relaxation therapy or self-hypnosis to address the picking behavior 1
• Evaluate for underlying psychological factors that may contribute to skin picking 1
• Consider referral to a clinical psychologist for management of compulsive picking behaviors 1

Medication Considerations for Elderly Patients

• Avoid sedative antihistamines as they are not recommended in elderly patients with pruritus 1
• Consider non-sedative antihistamines (H1 antagonists) such as fexofenadine 180 mg or loratadine 10 mg, or mildly sedative agents such as cetirizine 10 mg if pruritus is a significant symptom 1
• For persistent pruritus, consider gabapentin which may benefit elderly patients with pruritus 1

When to Consider Advanced Treatment

• If no response to initial treatment after 2 weeks, reassess the patient 1
• Consider referral to secondary care if there is diagnostic doubt or if primary care management does not relieve symptoms 1
• For recalcitrant cases, consider patch testing to identify specific allergens 3, 5
• Avoid systemic corticosteroids except in severe cases, and only for short-term use 1

Common Pitfalls to Avoid

• Do not use crotamiton cream as it is not effective for generalized pruritus 1
• Avoid topical capsaicin or calamine lotion which are not recommended for pruritus in elderly skin 1
• Do not use very hot water for cleansing as it can further damage the skin barrier 3, 4
• Avoid applying known allergens or irritants to the affected area 3, 5
• Be cautious of potential steroid-induced damage with prolonged use of topical corticosteroids 3, 6

Special Considerations for Facial Application

• Use lower potency topical steroids on the face to minimize risk of skin atrophy 2, 7
• Consider topical calcineurin inhibitors as steroid-sparing agents for facial dermatitis if available 7
• Apply moisturizers more frequently throughout the day to maintain skin hydration 3, 4

By following this treatment approach, most elderly patients with contact dermatitis due to face picking should experience improvement in their condition. Regular follow-up is essential to monitor response to treatment and adjust the management plan as needed.