What is the treatment for allergic contact dermatitis?

Treatment of Allergic Contact Dermatitis

The cornerstone of treatment is complete identification and avoidance of the causative allergen, combined with mid-to-high potency topical corticosteroids for acute inflammation and aggressive emollient therapy to restore the skin barrier. 1, 2

Immediate Management Steps

Allergen Identification and Avoidance

• Refer for patch testing to at least an extended standard series of allergens if the causative agent is unknown, dermatitis persists despite treatment, has unusual distribution, or is recalcitrant 1, 2
• Pattern and morphology alone are unreliable for distinguishing irritant from allergic contact dermatitis, making patch testing essential 1
• Patch testing sensitivity ranges from 60-80%, and positive results only indicate sensitization—clinical relevance to active dermatitis must be demonstrated 2
• Do not apply potent topical steroids to the back within 2 days of patch testing as this causes false negatives 1
• Avoid oral corticosteroids or immunosuppressants during patch testing; if unavoidable, keep prednisolone ≤10 mg daily 1

First-Line Topical Therapy

• Apply mid-to-high potency topical corticosteroids such as triamcinolone 0.1% or clobetasol 0.05% to affected areas 3
• For localized acute cases, use these steroids 2-4 times daily 4
• Clobetasol propionate 0.05% achieves clear or almost clear skin in 67.2% of patients with severe dermatitis over 2 weeks, compared to 22.3% with vehicle 1
• Limit superpotent corticosteroids to 2 weeks maximum and treat only small areas at a time due to HPA axis suppression risk 5

Skin Barrier Restoration

• Replace all soaps and detergents with emollients as these are common irritants that perpetuate dermatitis 1
• Apply moisturizers packaged in tubes (not jars to prevent contamination) using two fingertip units to hands after each washing 1
• Use the "soak and smear" technique: soak affected areas in plain water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks 1
• Apply approximately 100g of moisturizer per 2 weeks for trunk area 1

Systemic Therapy for Extensive Disease

When to Use Systemic Corticosteroids

• If allergic contact dermatitis involves >20% body surface area, systemic steroid therapy is required and offers relief within 12-24 hours 3
• For severe cases, oral prednisone should be tapered over 2-3 weeks because rapid discontinuation causes rebound dermatitis 3
• Prednisone is indicated for severe or incapacitating allergic conditions including contact dermatitis 6

Protective Measures

Glove Selection and Use

• Use rubber or PVC gloves with cotton liners for household tasks, removing them regularly to prevent sweat accumulation which aggravates dermatitis 7, 1
• For glove-related allergic contact dermatitis, use accelerator-free gloves such as rubber-free neoprene or nitrile gloves 1, 2
• Apply moisturizer before wearing gloves 1, 2
• Check Material Safety Data Sheets (MSDS) to determine permeation time—no glove is completely impermeable 7
• Latex gloves are penetrated by methyl methacrylate in 1 minute; nitrile (5 min), butyl (15 min), and three-layer PVP gloves (20 min) offer better but finite protection 7

Barrier Creams

• Barrier creams alone have questionable value and should not be over-promoted as they create false security and may reduce implementation of appropriate preventive measures 1
• After-work creams have shown benefit in reducing irritant contact dermatitis and should be readily available in workplace settings 1

Second-Line Therapies for Refractory Cases

When First-Line Treatment Fails

• Consider topical tacrolimus 0.1% where topical steroids are unsuitable, ineffective, or when chronic facial dermatitis raises concerns about steroid-induced skin damage 1, 2
• Topical tacrolimus has shown effectiveness in nickel-induced allergic contact dermatitis and avoids risk of corticosteroid allergy 1
• Exercise extreme caution with topical corticosteroids on facial skin—prolonged use causes skin thinning, telangiectasia, perioral dermatitis, and red face syndrome due to increased percutaneous absorption 1

Advanced Systemic Therapies

• For steroid-resistant chronic hand dermatitis, consider PUVA (psoralen plus UVA), azathioprine, or ciclosporin, all supported by prospective clinical trials 1
• Alitretinoin should be offered for severe chronic hand eczema 1
• Currently, no systemic treatments are FDA-indicated specifically for widespread recalcitrant contact dermatitis, though off-label agents are used 8

Occupational Contact Dermatitis Considerations

Workplace Assessment

• Organize workplace visits in conjunction with on-site nursing/medical/safety personnel to identify hidden allergens, assess procedures causing accidental exposure, and help prevent unnecessary irritant exposure 7
• Request Material Safety Data Sheets for all materials to which workers are exposed 7
• Assess whether suitable substitutes are available for identified allergens/irritants 7
• Consider moving the patient to a different work area; changing occupation is usually the last resort but may be preferable if severe contact dermatitis is diagnosed early in training 7

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, 2
• Do not use disinfectant wipes to clean hands 1
• Avoid products containing topical antibiotics without indication as they can cause sensitization 1, 4
• Do not apply prolonged occlusion without underlying moisturizer application 1
• Allergic contact dermatitis to corticosteroids is diagnosed by observing failure to heal rather than clinical exacerbation—corroborate with appropriate diagnostic patch testing 5

Prognosis and Follow-Up

• Only 25% of patients with occupational contact dermatitis achieve complete healing over 10 years; 50% have intermittent symptoms and 25% have permanent symptoms 7, 1
• In 40% who changed occupation, overall prognosis was not improved 7
• Complete resolution is expected if the causative agent is identified and avoided early 2
• Early identification and complete avoidance of allergens offers the best chance for resolution 1