Initial Treatment for Spongiotic Dermatitis
The initial treatment for spongiotic dermatitis is topical corticosteroids of appropriate potency, which serve as the mainstay of therapy and should be selected based on the location and severity of involvement. 1
Treatment Algorithm by Location and Severity
For Non-Facial, Non-Intertriginous Areas in Adults
- Start with moderate to high potency topical corticosteroids (class 2-5) for up to 4 weeks maximum 1
- Apply no more than twice daily; many newer formulations require only once-daily application 1
- Use the least potent preparation required to control the dermatitis to minimize adverse effects 1
For Facial, Intertriginous Areas, and Children
- Use lower potency corticosteroids to avoid skin atrophy and other adverse effects 1
- These sensitive areas require particular caution due to increased systemic absorption 2, 3
- Consider topical tacrolimus as an alternative where topical steroids are unsuitable or ineffective 1
Essential Adjunctive Measures
Emollients and Barrier Protection
- Emollient therapy is an essential component that should not be neglected 1
- Identify and avoid irritants and allergens 1
- Recommend cotton clothing rather than irritant materials like wool 1
Management of Pruritus
- Consider sedating antihistamines for short-term use during severe pruritus relapses 1
- Non-sedating antihistamines have little value in this context 1
Addressing Secondary Infection
- If bacterial infection is present, add appropriate antibiotics 1
- For herpes simplex infection, initiate oral acyclovir early in the course 1
- Failure to address secondary infection can result in treatment resistance 1
Critical Precautions and Monitoring
Avoiding Common Pitfalls
- Undertreatment due to steroid phobia is common and leads to prolonged disease and patient suffering 1
- Explain the benefits and risks of topical corticosteroids to address patient concerns 1, 2
- Overuse of potent steroids on sensitive areas can cause skin atrophy, HPA axis suppression, and other adverse effects 2, 3
Monitoring and Follow-up
- Assess response after 2-4 weeks 1
- Consider referral to a dermatologist if no improvement occurs 1
- Prolonged use without periodic assessment may lead to tachyphylaxis and adverse effects 1
- Do not exceed 100g of a moderate potency preparation per month 4
- Plan annual periods where alternative treatment is employed 4
Patient Education Requirements
- Demonstrate proper application of topical preparations and provide written information 1
- Instruct patients this medication is for external use only and to avoid eye contact 2, 3
- Advise patients not to bandage or occlude treated areas unless specifically directed 2, 3
- Parents should avoid tight-fitting diapers or plastic pants in the diaper area, as these constitute occlusive dressings 2, 3
Options for Chronic or Recalcitrant Cases
- Consider vitamin D analogues (calcipotriene, calcitriol) for chronic cases 1
- Consider combination therapy with topical corticosteroids and vitamin D analogues for enhanced efficacy 1
- For chronic hand and foot involvement, PUVA therapy may be considered 1
- Oral alitretinoin is an option for severe chronic hand eczema 1