What is the first line treatment for contact dermatitis?

First-Line Treatment for Contact Dermatitis

The first-line treatment for contact dermatitis is complete identification and avoidance of the causative allergen or irritant, combined with replacement of all soaps and detergents with emollients, and application of mid- to high-potency topical corticosteroids (such as triamcinolone 0.1% or clobetasol 0.05%) to inflamed areas. 1, 2, 3

Immediate Management Steps

1. Allergen/Irritant Identification and Avoidance

• Avoidance is the absolute cornerstone of management - partial avoidance will result in persistent dermatitis 1, 4
• Take a detailed history focusing on:
  • Initial symptom location and spread pattern 1
  • Relationship to specific products (cosmetics, personal care products, topical medications, clothing, gloves) 1
  • Occupational exposures and whether symptoms improve on weekends/holidays 1
  • All wash products and frequency of hand washing 1
• Pattern and morphology alone are unreliable for distinguishing irritant from allergic contact dermatitis - history is critical 1, 2

2. Replace All Soaps with Emollients

• Immediately substitute all soaps and detergents with emollients, even if they are not the primary cause, as they are irritants that compound the situation 1, 2, 4
• Apply moisturizers immediately after washing hands to repair the skin barrier 2
• 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 2, 4
• Use moisturizers packaged in tubes rather than jars to prevent contamination 2

3. Topical Corticosteroids

• For localized acute allergic contact dermatitis: Apply mid- to high-potency topical corticosteroids such as triamcinolone 0.1% or clobetasol 0.05% twice daily 5, 2, 3
• For facial dermatitis: Use only low-potency steroids (such as hydrocortisone 1%) to minimize risk of skin atrophy, telangiectasia, and perioral dermatitis 5, 2
• For extensive involvement (>20% body surface area): Systemic corticosteroids may be required, offering relief within 12-24 hours 3
• For severe rhus (poison ivy) dermatitis, taper oral prednisone over 2-3 weeks to prevent rebound dermatitis 3

Protective Measures

Glove Selection and Use

• Use appropriate gloves based on specific exposures: rubber or PVC gloves with cotton liners for household tasks 1, 2
• Check Material Safety Data Sheets (MSDS) to determine permeation time for the glove being used - no glove is completely impermeable 1
• Remove gloves regularly to prevent sweat accumulation, which aggravates dermatitis 2
• Apply moisturizer before wearing gloves 2
• For latex allergy, use accelerator-free gloves such as neoprene or nitrile 2, 4

Barrier Creams

• Do not over-rely on barrier creams alone - they have questionable value in protecting against irritants and may create false security 1, 2
• After-work creams have shown benefit in reducing irritant contact dermatitis and should be readily available in workplace settings 2

When to Escalate Care

Patch Testing Indications

• Patch testing is the gold-standard investigation when allergic contact dermatitis is suspected 1, 2
• Refer for patch testing if:
  • Dermatitis persists despite initial treatment 2, 4
  • The causative agent remains unknown 2, 4
  • Occupational dermatitis is suspected 1
• Test to at least an extended standard series of allergens 2
• Avoid potent topical steroids to the back within 2 days of patch testing (causes false negatives) 2
• Keep oral prednisolone ≤10 mg daily if immunosuppression cannot be stopped 2

Second-Line Therapies for Refractory Cases

• Consider topical tacrolimus 0.1% where topical steroids are unsuitable or ineffective 2, 4
• For severe chronic hand eczema, alitretinoin may be offered 2
• Phototherapy (PUVA) is an established second-line treatment for chronic contact dermatitis resistant to topical steroids 2, 4
• For steroid-resistant cases, consider azathioprine or ciclosporin (supported by prospective clinical trials) 2

Critical Pitfalls to Avoid

• Do not continue using irritants or allergens - this prevents healing 5
• Avoid washing hands with dish detergent or other known irritants 2
• Do not use very hot or very cold water for hand washing 2
• Avoid disinfectant wipes to clean hands 2
• Do not apply products containing topical antibiotics without indication 2
• Beware of prolonged topical steroid use - it can cause steroid-induced damage to the skin barrier, particularly in irritant contact dermatitis 2, 4
• Do not ignore occupational exposures that might be transferred to other body areas via hands 5

Prognosis Considerations

• The prognosis depends on ease of allergen/irritant avoidance 5
• For occupational contact dermatitis, prognosis is often very poor: only 25% of patients achieve complete healing over 10 years, 50% have intermittent symptoms, and 25% have permanent symptoms 1, 4
• Changing occupation does not improve prognosis in 40% of cases 1, 2
• 55% of patients still have dermatitis after 2 years from diagnosis 4
• Early identification and complete avoidance of allergens offers the best chance for resolution 2