What are the next steps for managing contact dermatitis that is not improving?

Management of Contact Dermatitis Not Improving

For contact dermatitis that fails to improve with initial treatment, you must immediately pursue patch testing to identify specific allergens while escalating to stronger topical corticosteroids or second-line systemic therapies. 1

Critical First Step: Identify Why Treatment Is Failing

Patch testing is essential for any persistent contact dermatitis to distinguish between allergic contact dermatitis (ACD) and irritant contact dermatitis (ICD), as management differs significantly. 1

• Patients with recalcitrant hand dermatitis should seek dermatology consultation and be evaluated for patch testing to identify clinically relevant allergens. 1
• If the diagnosis or specific allergen remains unknown after treatment failure, patch testing must be performed. 2
• Consider workplace visits for occupational cases to identify hidden irritants and allergen sources that may not be apparent from history alone. 1

Escalate Topical Therapy

If conservative measures fail, apply mid- to high-potency topical corticosteroids (such as triamcinolone 0.1% or clobetasol 0.05%) twice daily to affected areas. 3, 2

• For body and hands, use mid- to high-potency steroids; for facial lesions, use only low-potency steroids to minimize risk of skin atrophy. 3, 4
• Be cautious with prolonged topical steroid use as it can cause steroid-induced damage to the skin barrier, particularly in ICD. 1, 5
• If dermatitis involves greater than 20% body surface area, systemic steroid therapy is often required and offers relief within 12-24 hours. 2
• For severe cases, oral prednisone should be tapered over 2-3 weeks (not shorter) because rapid discontinuation causes rebound dermatitis. 2

Optimize Skin Protection and Barrier Repair

Replace all soaps and detergents with emollients immediately, as these are irritants that compound the situation even if they are not the primary cause. 1

• Apply moisturizers immediately after washing to repair the skin barrier, using tube packaging rather than jars to prevent contamination. 3
• For hand dermatitis, implement "soak and smear": soak hands in plain water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks. 1
• Use rubber or polyvinyl chloride gloves with cotton liners for household tasks, but remove them regularly to prevent occlusion that worsens dermatitis. 1, 3
• For occupational exposures, check Material Safety Data Sheets (MSDS) to select appropriate gloves with adequate permeation times for specific chemicals. 1, 3

Common Pitfall: Inadequate Allergen Avoidance

Complete avoidance of identified allergens is mandatory - partial avoidance will result in persistent dermatitis. 1

• Contact manufacturers to determine if allergens are present in products and identify suitable substitutes. 1
• For glove-related ACD, switch to accelerator-free gloves such as rubber-free neoprene or nitrile gloves. 1
• Apply moisturizer before wearing gloves to create a protective barrier. 1
• Consider cotton glove liners under work gloves to reduce direct contact and occlusion. 1

Second-Line Therapies for Refractory Cases

When topical steroids fail, consider topical tacrolimus, phototherapy, or systemic immunosuppressants. 1

• Topical tacrolimus has been shown effective in allergic contact dermatitis models. 1
• Psoralen plus UVA (PUVA) has demonstrated efficacy in chronic hand dermatitis with strong evidence. 1
• Systemic immunosuppressants including methotrexate, mycophenolate mofetil, azathioprine, and ciclosporin are supported by prospective clinical trials for steroid-resistant chronic hand dermatitis. 1
• Alitretinoin has been demonstrated useful specifically for chronic hand dermatitis. 1

Check for Complicating Factors

If dermatological infections are present, institute appropriate antifungal or antibacterial agents - the corticosteroid should be discontinued until infection is adequately controlled. 5, 4

• Combined topical corticosteroid/antibiotic combinations show marginal benefit in infected or potentially infected eczema. 1
• Avoid topical antibiotics like neomycin and bacitracin in contact dermatitis patients, as these are common allergens that can worsen the condition. 1

Critical Warning About Prognosis

The long-term prognosis for occupational contact dermatitis is often very poor - only 25% of patients completely heal over 10 years, and changing occupation does not guarantee improvement in 40% of cases. 1

• 55% of patients still have dermatitis after 2 years from diagnosis. 1
• Early aggressive intervention is essential to prevent chronicity and permanent symptoms. 1
• Re-evaluate if symptoms persist beyond 7 days despite treatment and strongly consider dermatology referral. 3