What is the first line treatment for contact dermatitis?

First-Line Treatment for Contact Dermatitis

The first-line treatment for contact dermatitis is complete avoidance of the causative allergen or irritant combined with mid-to-high potency topical corticosteroids (such as triamcinolone 0.1% or clobetasol 0.05%) and aggressive emollient therapy to restore the skin barrier. 1

Immediate Management Strategy

Allergen/Irritant Identification and Avoidance

• Avoidance is the absolute cornerstone of management and must be implemented immediately 2
• Replace all soaps and detergents with emollients, as these are irritants that compound dermatitis even when not the primary cause 2, 1
• For persistent or unclear cases, refer for patch testing to identify specific allergens using at least an extended standard series 1
• Pattern and morphology alone are unreliable for distinguishing irritant from allergic contact dermatitis, making patch testing essential for definitive diagnosis 1

Topical Corticosteroid Therapy

• Apply mid-to-high potency topical corticosteroids as the cornerstone of acute treatment 1, 3
• For localized acute lesions, use triamcinolone 0.1% or clobetasol 0.05% 3
• Very high potency topical corticosteroids achieve clear or almost clear skin in 67.2% of patients with severe dermatitis over 2 weeks 1
• Adverse events with very high potency steroids are low (0.8% withdrawal rate) over 2-week treatment periods 1

Important caveat: One study found corticosteroids ineffective for surfactant-induced irritant dermatitis 4, but this contradicts the broader guideline consensus. The British Association of Dermatologists and American Academy of Dermatology both strongly support topical corticosteroids as first-line therapy 2, 1, and this should guide clinical practice.

Emollient and Barrier Restoration

• Apply moisturizers liberally and frequently to restore skin barrier function 1
• Use the "soak and smear" technique: soak affected area in plain water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks 1
• Apply two fingertip units of moisturizer to hands after each washing 1
• Use moisturizers packaged in tubes rather than jars to prevent contamination 1

Systemic Therapy for Extensive Disease

• If allergic contact dermatitis involves >20% body surface area, systemic corticosteroids are required 3
• Oral prednisone provides relief within 12-24 hours 3
• For severe rhus (poison ivy) dermatitis, taper oral prednisone over 2-3 weeks to prevent rebound dermatitis from rapid discontinuation 3

Protective Measures

Glove Selection and Use

• Use appropriate gloves based on specific chemical exposures, checking Material Safety Data Sheets for permeation times 2
• For household tasks, use rubber or PVC gloves with cotton liners 1
• Remove gloves regularly to prevent sweat accumulation, which aggravates dermatitis 1
• Apply moisturizer before wearing gloves 1
• For glove-related allergic contact dermatitis, use accelerator-free gloves such as neoprene or nitrile 1

Barrier Creams

• Barrier creams alone have questionable value and should not be over-promoted, as they create false security 2, 1
• After-work creams have demonstrated benefit in reducing irritant contact dermatitis incidence 1

Critical Pitfalls to Avoid

• Never wash hands with dish detergent or other known irritants 1
• Avoid very hot or very cold water for hand washing 1
• Do not use disinfectant wipes to clean hands 1
• Avoid products containing topical antibiotics without clear indication 1
• Do not apply prolonged occlusion without underlying moisturizer application 1
• Do not apply potent topical steroids to the back within 2 days of planned patch testing, as this causes false negatives 1

Second-Line Therapies for Refractory Cases

When first-line treatment fails despite proper allergen avoidance:

• Consider topical tacrolimus 0.1% where topical steroids are unsuitable or ineffective 1
• Topical tacrolimus is effective for contact dermatitis and avoids risk of corticosteroid allergy 1
• Phototherapy (PUVA) is an established second-line treatment for chronic contact dermatitis 2, 1
• For severe chronic hand eczema, offer alitretinoin 1
• Systemic immunosuppressants such as methotrexate, mycophenolate mofetil, azathioprine, or ciclosporin may be considered 2, 1

Prognosis Considerations

• Prognosis for occupational contact dermatitis is often poor: only 25% achieve complete healing, 50% have intermittent symptoms, and 25% have permanent symptoms 2, 1
• Changing occupation does not improve prognosis in 40% of cases 1
• Early identification and complete avoidance of allergens offers the best chance for resolution 1