What is the recommended treatment for contact dermatitis?

Treatment of Contact Dermatitis

The cornerstone of contact dermatitis treatment is identification and complete avoidance of the causative allergen or irritant, combined with topical corticosteroids, soap substitutes, and regular emollients for established disease. 1

First-Line Treatment Approach

Allergen/Irritant Identification and Avoidance

• Patients with persistent eczematous eruptions should undergo patch testing to identify specific allergens, as this is essential for effective management 1
• Detection and avoidance of the allergen is the primary therapeutic intervention, though this often requires workplace visits to identify sources and implement effective avoidance strategies 1
• For occupational cases, visiting the workplace is essential for identifying potential allergens and irritants and is critical for effective treatment and prevention 1
• When the causative substance is known, confirm the diagnosis by determining whether the problem resolves with complete avoidance 2

Hand Hygiene and Skin Protection

• Use lukewarm or cool water for hand washing (avoid hot water which damages the skin barrier), and pat hands dry gently rather than rubbing 3
• Choose soaps/synthetic detergents without allergenic surfactants, preservatives, fragrances, or dyes, preferably with added moisturizers 3
• For hand sanitizers, use alcohol-based products with at least 60% alcohol and added moisturizers, but do not wash hands with soap immediately before or after using alcohol-based products 3

Moisturization Strategy

• Apply moisturizer immediately after every hand washing using two fingertip units for adequate hand coverage 3
• Choose moisturizers in tubes rather than jars to prevent contamination, and consider pocket-sized versions for frequent reapplication 3
• For severe dryness, use the "soak and smear" technique: soak hands in plain water for 20 minutes followed by immediate moisturizer application to damp skin nightly for up to 2 weeks 3, 4

Topical Corticosteroid Therapy

Standard Application

• Topical corticosteroids, soap substitutes, and emollients are widely accepted as the treatment of established contact dermatitis 1
• Apply a thin layer of topical corticosteroid to affected areas and rub in gently, typically twice daily 4
• For localized acute allergic contact dermatitis, use mid- or high-potency topical steroids such as triamcinolone 0.1% or clobetasol 0.05% 2

Escalation for Severe Cases

• For severe or recalcitrant cases, consider a short course (up to 2 weeks) of very potent topical steroid like clobetasol propionate 0.05% 4
• Long-term intermittent use of mometasone furoate has demonstrated efficacy in chronic hand eczema 1
• Avoid occlusive dressings with high-potency steroids and remain alert for signs of topical steroid allergy (worsening dermatitis despite treatment) 4

Important Caveat About Irritant Contact Dermatitis

• Be cautious with prolonged topical steroid use in irritant contact dermatitis, as steroids may cause additional damage to the already compromised skin barrier 3
• One study found topical corticosteroids ineffective for surfactant-induced irritant dermatitis, suggesting their benefit may be limited in pure irritant reactions 5

Systemic Corticosteroid Therapy

When to Use Systemic Steroids

• If allergic contact dermatitis involves an extensive area of skin (greater than 20% body surface area), systemic steroid therapy is often required and offers relief within 12 to 24 hours 2

Dosing and Duration

• For severe rhus (poison ivy) dermatitis, oral prednisone should be tapered over 2 to 3 weeks, as rapid discontinuation can cause rebound dermatitis 2
• Adequate duration is critical—short courses are insufficient for severe allergic contact dermatitis 2

Second-Line Treatments for Refractory Disease

When to Consider Advanced Therapy

• Consider advanced treatment when hand dermatitis does not improve after 6 weeks of first-line treatment 3
• Evaluate for possible allergic contact dermatitis through patch testing if not already done 4
• Check for secondary bacterial infection and treat if present 4

Treatment Options

• Second-line treatments such as psoralen plus UVA (PUVA), azathioprine, and cyclosporine are used for steroid-resistant chronic hand dermatitis, with several prospective clinical trials supporting these treatments 1
• Topical tacrolimus has shown effectiveness in nickel-induced allergic contact dermatitis models 1
• Phototherapy is an established option for recalcitrant cases 3, 4

Special Considerations and Common Pitfalls

Barrier Creams

• Barrier creams by themselves are of questionable value in protecting against contact with irritants and should not be overpromoted, as this may give workers a false sense of security 1
• However, after-work creams (soap substitutes and moisturizers) do confer protection against developing irritant contact dermatitis and should be encouraged and made readily available in the workplace 1

Occupational Modifications

• For healthcare workers, use water-based moisturizers under gloves, as oil-based moisturizers can break down latex and rubber 3
• For glove-related allergic contact dermatitis, use accelerator-free gloves (rubber-free neoprene or nitrile), and consider cotton glove liners 3
• Latex, vinyl, and nitrile gloves are resistant to breakdown from ethanol or isopropyl alcohol 3

Pitfalls to Avoid

• Do not apply gloves when hands are still wet from hand washing or sanitizer 3
• Avoid washing hands with dish detergent or other known irritants 3
• Do not use superglue to seal inflammatory or healing fissures 3
• Avoid increased duration of glove occlusion without underlying moisturizer 3

Prognosis and Long-Term Management

• The long-term prognosis for occupational contact dermatitis is often poor: only 25% of patients completely heal, with half having periodic symptoms and one quarter having permanent symptoms 1
• In 40% of patients who changed occupations, the overall prognosis was not improved, highlighting the importance of early intervention 1
• For milder cases, prognosis depends on ease of avoidance—if the patient can completely avoid the causative agent, dermatitis will clear 1

When to Refer to Dermatology

• Refer for suspected allergic contact dermatitis requiring patch testing 3
• Refer for recalcitrant hand dermatitis not responding to initial treatments after 6 weeks 3
• Refer when there is a change in baseline hand dermatitis pattern 3
• If treatment fails and the diagnosis or specific allergen remains unknown, patch testing should be performed 2