What is the treatment for acute contact dermatitis?

Treatment of Acute Contact Dermatitis

For acute contact dermatitis, immediately identify and remove the causative agent, then apply mid- to high-potency topical corticosteroids (such as clobetasol 0.05% or triamcinolone 0.1%) twice daily for up to 2 weeks, combined with aggressive moisturization to repair the skin barrier. 1, 2

Immediate Management Algorithm

Step 1: Remove the Offending Agent

• Complete avoidance of the causative irritant or allergen is non-negotiable and determines treatment success 3
• For occupational exposures, request Material Safety Data Sheets (MSDS) to identify specific chemicals involved 3
• Consider a workplace visit to identify hidden sources of exposure and assess contamination risks 3

Step 2: Apply Topical Corticosteroids

• Use mid- to high-potency topical corticosteroids as the cornerstone of acute treatment 1, 2
• For localized acute lesions, apply clobetasol 0.05% or triamcinolone 0.1% twice daily 2
• Apply a thin layer to affected areas and rub in gently and completely 4
• Limit treatment to 2 consecutive weeks maximum, using no more than 50 grams per week 4
• Discontinue therapy when control is achieved; if no improvement occurs within 2 weeks, reassess the diagnosis 4

Step 3: Aggressive Moisturization

• Apply moisturizers immediately after washing hands to repair the skin barrier 1
• Use moisturizers packaged in tubes rather than jars to prevent contamination 5, 1
• Apply two fingertip units of moisturizer to hands after each washing 1
• For severe cases, use the "soak and smear" technique: soak hands in plain water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks 5

Step 4: Consider Systemic Therapy for Extensive Involvement

• If allergic contact dermatitis involves more than 20% of body surface area, systemic corticosteroid therapy is often required 2
• Systemic steroids provide relief within 12-24 hours 2
• For severe cases (such as poison ivy dermatitis), taper oral prednisone over 2-3 weeks to prevent rebound dermatitis 2

Distinguishing Irritant vs. Allergic Contact Dermatitis

Clinical Features (Note: Pattern and morphology are unreliable for distinguishing types) 1

• Acute phase: characterized by erythema and vesiculation 5
• Chronic phase: characterized by dryness, lichenification, and fissuring 5
• Clinical features alone cannot reliably distinguish irritant from allergic contact dermatitis, particularly on hands and face 1

Irritant Contact Dermatitis Specifics

• Results from single overwhelming exposure or repetitive exposure to weaker irritants (detergents, solvents, soaps) 5
• Identify and avoid irritants; use soap substitutes and gentle cleansers 1
• Apply topical corticosteroids if conservative measures fail, but consider potential steroid-induced damage to skin barrier with prolonged use 5, 1

Allergic Contact Dermatitis Specifics

• Involves T-cell-mediated delayed hypersensitivity reaction requiring prior sensitization 5
• Carries worse prognosis than irritant dermatitis unless allergen is identified and avoided 3
• Patch testing is the gold standard for identifying specific allergens (70-80% sensitivity and specificity) 3

Protective Measures During Treatment

Hand Protection

• Use appropriate gloves based on specific chemical exposures, checking MSDS for permeation times 3
• Remove gloves regularly to prevent sweat accumulation, which aggravates dermatitis 1
• Apply moisturizer before wearing gloves 5
• For household tasks, use rubber or PVC gloves with cotton liners 1

Glove Selection for Allergic Contact Dermatitis

• For glove-related allergic contact dermatitis, use accelerator-free gloves such as rubber-free neoprene or nitrile gloves 5
• Consider cotton glove liners or loose plastic gloves 5
• Latex, vinyl, and nitrile gloves are resistant to breakdown from ethanol or isopropyl alcohol 5

Critical Pitfalls to Avoid

Common Errors That Worsen Outcomes

• Washing hands with dish detergent or other known irritants 5
• Using very hot or very cold water for hand washing 5
• Using disinfectant wipes to clean hands 5
• Applying products containing topical antibiotics (neomycin, bacitracin) without indication 5
• Prolonged occlusion without underlying moisturizer application 5
• Over-reliance on barrier creams, which have questionable value and may create false security 1, 3

Steroid-Related Precautions

• Do not use clobetasol propionate on face, groin, or axillae 4
• Do not use with occlusive dressings 4
• Monitor for HPA axis suppression when treating large surface areas or using for extended periods 4
• Pediatric patients are more susceptible to systemic toxicity due to larger skin surface-to-body mass ratios 4

When to Escalate Care

Indications for Dermatology Referral

• Recalcitrant hand dermatitis not responding to initial treatment 5, 1
• Need for patch testing to identify specific allergens 1
• Consideration of advanced therapies including phototherapy, systemic immunosuppressants, or occupational modification 5, 1

Advanced Treatment Options for Refractory Cases

• For steroid-resistant chronic hand dermatitis, consider PUVA (psoralen plus UVA), azathioprine, or ciclosporin 1
• Topical tacrolimus may be considered where topical steroids are unsuitable or ineffective 5
• For severe chronic hand eczema, alitretinoin should be offered 5

Prognosis Considerations

• For occupational contact dermatitis, prognosis is often poor: only 25% achieve complete healing, 50% have periodic symptoms, and 25% have permanent symptoms 1, 3
• Changing occupation does not improve prognosis in 40% of cases 1
• If complete allergen avoidance is achieved in allergic contact dermatitis, the dermatitis will clear 3