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 mid-to-high potency topical corticosteroids for inflammation control, and using emollients liberally to repair the skin barrier. 1

Initial Management Approach

The cornerstone of treatment is three-pronged: allergen/irritant identification and avoidance, topical corticosteroid therapy, and aggressive moisturization. 1 This approach applies to both irritant and allergic contact dermatitis, though the specific interventions differ slightly.

Allergen and Irritant Identification

• Obtain a detailed history focusing on 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—patch testing is essential for persistent cases. 1
• Refer for patch testing to at least an extended standard series of allergens when dermatitis persists despite treatment or the causative agent remains unknown. 1
• Consider workplace visits if occupational exposure is suspected, as these are critical for identifying hidden allergens and assessing procedures causing accidental exposure. 1

Common pitfall: 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 testing; if unavoidable, keep prednisolone ≤10 mg daily. 1

Topical Corticosteroid Therapy

For Localized Acute Contact Dermatitis

• Apply mid-to-high potency topical corticosteroids such as triamcinolone 0.1% or betamethasone valerate 0.1% to affected areas. 1, 2
• For persistent dermatitis failing initial therapy, escalate to very high potency corticosteroids such as clobetasol propionate 0.05% for 2 weeks. 1
• Very high potency steroids achieve clear or almost clear skin in 67.2% of patients with severe dermatitis over 2 weeks, with low adverse event rates (0.8% withdrawals). 1

For Extensive Contact Dermatitis

• When allergic contact dermatitis involves >20% body surface area, systemic steroid therapy is required and provides relief within 12-24 hours. 2
• For severe rhus (poison ivy) dermatitis, taper oral prednisone over 2-3 weeks—rapid discontinuation causes rebound dermatitis. 2

Critical caveat: Exercise extreme caution with topical corticosteroids on facial skin, as prolonged use causes skin thinning, telangiectasia, perioral dermatitis, and red face syndrome due to increased percutaneous absorption. 1 Prolonged use on any site can cause steroid-induced damage to the skin barrier. 1

Important note: One experimental study found corticosteroids ineffective for surfactant-induced irritant dermatitis compared to vehicle, though this counterintuitive finding requires verification with other irritants. 3 However, clinical guidelines consistently support their use based on broader clinical experience. 1

Emollient and Moisturizer Therapy

• Replace all soaps and detergents with emollients as soap substitutes—these are common irritants that perpetuate dermatitis. 1
• Use moisturizers packaged in tubes rather than jars to prevent contamination. 1
• Apply two fingertip units of moisturizer to hands after each washing. 1
• Use the "soak and smear" technique for hands: soak in plain water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks. 1
• Apply moisturizers liberally—recommended amount is 100g per 2 weeks for trunk area. 1
• After-work creams have demonstrated benefit in reducing irritant contact dermatitis incidence and should be readily available in workplace settings. 1

Protective Measures

• Use appropriate gloves based on specific exposures: rubber or PVC gloves with cotton liners for household tasks. 1
• For latex allergy, use accelerator-free gloves such as rubber-free neoprene or nitrile gloves. 1
• In occupational settings, select gloves based on specific chemical exposures and consider permeation time—"impervious" gloves have finite protection duration. 1
• Remove gloves regularly to prevent sweat accumulation, which aggravates dermatitis. 1
• Apply moisturizer before wearing gloves. 1

Important caveat: Barrier creams alone have questionable value in protecting against irritants and should not be over-promoted, as they may create false security and reduce implementation of appropriate preventive measures. 1

Critical Avoidance Measures

• Do not 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 indication. 1
• Avoid prolonged occlusion without underlying moisturizer application. 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
• Topical tacrolimus has shown effectiveness in nickel-induced allergic contact dermatitis and avoids the risk of corticosteroid allergy. 1
• Offer alitretinoin for severe chronic hand eczema. 1
• Phototherapy (PUVA) is an established second-line treatment for chronic contact dermatitis resistant to topical steroids, supported by prospective clinical trials. 1
• For steroid-resistant chronic hand dermatitis, consider azathioprine or ciclosporin, both supported by prospective clinical trials. 1

Special Considerations for Facial Dermatitis

Facial dermatitis is the prototypical presentation of cosmetic contact dermatitis, with the eyelids frequently involved. 4 Common sources include shampoo, conditioner, facial cleansers, makeup remover, mascara, nail polish, acrylic nails, makeup sponges, eyelash curlers, and allergens transferred from hands. 4

• Lateral facial/neck dermatitis often represents a "rinse-off" pattern from shampoo and/or conditioner. 4
• Central facial dermatitis can be due to gold released from rings contaminating makeup foundation, or ingredients in moisturizers, wrinkle creams, topical medications, or makeup. 4
• Generalized facial dermatitis should trigger consideration of airborne contactants, facial cleansers, makeup foundation, and moisturizers/medications applied confluently. 4

Prognosis and Long-Term Outlook

• Prognosis for occupational contact dermatitis is often poor: only 25% of patients achieve complete healing, with 50% having periodic symptoms and 25% having 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
• Complete resolution is expected if the causative agent is identified and avoided; chronic cases develop if triggers are not identified or eliminated. 1

Common Allergens to Consider

The most common substances causing contact dermatitis include poison ivy, nickel, and fragrances. 2 Recent years have identified 10 new contact allergens, several relating to anti-aging products. 5 Frequent allergens causing considerable morbidity include methylisothiazolinone (preservative), fragrance allergens (especially terpenes), and acrylates found in medical devices for diabetes control. 5