What is the treatment for contact dermatitis?

Treatment of Contact Dermatitis

The most effective treatment for contact dermatitis requires identifying and completely avoiding the causative agent, applying topical corticosteroids for inflammation, and using moisturizers to repair the skin barrier. 1

Initial Management Approach

Identify and Avoid the Trigger

• Obtain a detailed history including initial symptom location, spread pattern, relationship to specific products or activities, and occupational/recreational exposures 1
• Pattern and morphology alone are unreliable for distinguishing between irritant, allergic, or endogenous dermatitis 1
• If the causative agent can be completely avoided, the dermatitis will clear 2

First-Line Topical Treatment

For mild to moderate cases:

• Apply mid-to-high potency topical corticosteroids such as triamcinolone 0.1% or betamethasone valerate 0.1% 1, 3
• Use soap substitutes and gentle cleansers instead of harsh soaps 1
• Apply moisturizers immediately after washing hands to repair skin barrier 1

For severe or persistent cases:

• Escalate to very high potency topical corticosteroids such as clobetasol propionate 0.05% for 2 weeks 1
• This achieves clear or almost clear skin in 67.2% of patients with severe dermatitis compared to 22.3% with vehicle 1
• Adverse events are low, with only 0.8% withdrawals in treatment groups versus 11.3% in vehicle groups 1

Moisturizer Application Technique

• Use moisturizers packaged in tubes rather than jars to prevent contamination 1
• Apply two fingertip units of moisturizer to hands after each washing 1
• "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 1

Systemic Treatment for Extensive Disease

When allergic contact dermatitis involves greater than 20% body surface area:

• Systemic steroid therapy is required and offers relief within 12-24 hours 3
• For severe rhus (poison ivy) dermatitis, taper oral prednisone over 2-3 weeks to prevent rebound dermatitis 3
• Rapid discontinuation of steroids can cause rebound dermatitis 3

Diagnostic Testing for Persistent Cases

Patch testing is essential when:

• The diagnosis remains unclear after initial treatment 1
• Dermatitis persists despite avoidance measures 1
• Test to at least an extended standard series of allergens 1

Critical testing precautions:

• Do not apply potent topical steroids to the back within 2 days of patch testing (causes false negatives) 1
• Avoid oral corticosteroids or immunosuppressants during testing; if unavoidable, keep prednisolone ≤10 mg daily 1

Protective Measures

Hand Protection

• Use rubber or PVC gloves with cotton liners for household tasks 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 may create false security 1
• After-work creams have demonstrated benefit in reducing irritant contact dermatitis incidence 1

Special Considerations for Facial Contact Dermatitis

The face requires particular caution:

• Facial skin is more prone to atrophic changes from corticosteroids than other body areas 1
• Overuse of topical corticosteroids on the face can lead to skin thinning, telangiectasia, and perioral dermatitis 2
• The face is particularly sensitive to cosmetics, sunscreens, and fragrances 2
• For severe facial cases not responding to topical corticosteroids, consider topical tacrolimus as an alternative 2

Second-Line Therapies for Refractory Cases

When first-line treatments fail:

• Topical tacrolimus 0.1% is effective and avoids corticosteroid allergy risk 1
• Phototherapy (PUVA) is an established second-line treatment supported by prospective clinical trials 1
• Systemic immunosuppressants such as azathioprine or ciclosporin for severe or recalcitrant cases 1
• Alitretinoin for severe chronic hand eczema 1

Critical Pitfalls to Avoid

Do not:

• Wash hands with dish detergent or other known irritants 1
• Use very hot or very cold water for hand washing 1
• Use disinfectant wipes to clean hands 1
• Apply products containing topical antibiotics without indication 1
• Apply prolonged occlusion without underlying moisturizer application 1
• Use topical corticosteroids for rosacea or perioral dermatitis 1

Occupational Contact Dermatitis

Workplace considerations:

• Workplace assessment may be necessary to identify all potential hazards 1
• Prognosis for occupational contact dermatitis is poor: only 25% achieve complete healing, 50% have periodic symptoms, and 25% have permanent symptoms 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

Monitoring for Adverse Effects

For patients using potent topical corticosteroids over large surface areas:

• Evaluate periodically for HPA axis suppression using urinary free cortisol and ACTH stimulation tests 4
• Clobetasol propionate can suppress the HPA axis at doses as low as 2g per day 4
• Recovery of HPA axis function is generally prompt and complete upon discontinuation 4
• Pediatric patients absorb proportionally larger amounts and are more susceptible to systemic toxicity 4