What is the management for contact dermatitis?

Management of Contact Dermatitis

Immediate First-Line Treatment

The cornerstone of contact dermatitis management is complete avoidance of the causative irritant or allergen combined with emollients and topical corticosteroids for active inflammation. 1, 2

Identify and Eliminate the Trigger

• Replace all soaps and detergents with emollient substitutes for hand washing and bathing 2
• Common irritants to avoid include water itself (excessive contact), detergents, organic solvents, and in occupational settings: oils, coolants, alkalis, acids, and solvents 2, 3
• For occupational cases, conduct a workplace visit to identify hidden irritants not apparent from history alone—this is critical as many exposures are missed without direct observation 2, 3

Emollient Therapy (Essential for All Cases)

• Apply emollients immediately after every hand wash using two fingertip units per application 2
• Use tube packaging rather than jars to prevent bacterial contamination 2, 3
• "Soak and smear" technique for severe hand involvement: soak hands in plain water for 20 minutes, then immediately apply moisturizer to still-damp skin every night for up to 2 weeks 2

Topical Corticosteroid Protocol

• For body and hands: Apply mid- to high-potency topical corticosteroid (such as triamcinolone 0.1% or clobetasol 0.05%) twice daily for acute flares 3, 4
• For facial lesions: Use only low-potency steroids to minimize risk of skin atrophy 3
• Long-term intermittent use of mometasone furoate has Level I evidence for chronic hand eczema (Strength of recommendation B) 1
• Topical tacrolimus has demonstrated effectiveness in nickel-induced allergic contact dermatitis 1

Systemic Corticosteroids for Extensive Disease

• When allergic contact dermatitis involves >20% body surface area, systemic steroid therapy is required and provides relief within 12-24 hours 4
• For severe rhus (poison ivy) dermatitis: Taper oral prednisone over 2-3 weeks—rapid discontinuation causes rebound dermatitis 4

Protective Measures

• Use rubber or polyvinyl chloride gloves with cotton liners for household tasks, but remove regularly to prevent sweat accumulation that worsens dermatitis 3
• For occupational exposures, match glove type to specific chemical exposure by checking Material Safety Data Sheets for appropriate selection and permeation times 3

Diagnostic Workup for Persistent Cases

• Patients with persistent eczematous eruptions should undergo patch testing (Quality of evidence II.ii, Strength of recommendation A) 1
• Patch test to at least an extended standard series of allergens 1
• Trained personnel should perform day 2 and day 4 readings 1

Second-Line Treatments for Refractory Disease

For steroid-resistant chronic hand dermatitis, second-line options include: 1, 3

• Psoralen plus UVA (PUVA)
• Azathioprine
• Ciclosporin

These treatments have Level I evidence with Strength of recommendation A 1

Critical Pitfalls to Avoid

• Do not use topical corticosteroids for rosacea or perioral dermatitis—these conditions worsen with steroid application 1
• Avoid occlusive dressings with potent topical steroids as they increase systemic absorption and HPA axis suppression 5
• If treatment fails after 7 days, re-evaluate the diagnosis and consider dermatology referral 3

Prognosis Counseling

• The prognosis for occupational contact dermatitis is poor: only 25% of patients completely recover within 10 years 2, 3
• 50% have periodic symptoms and 25% have permanent symptoms 2
• Changing jobs does not guarantee improvement—40% of those who changed occupations showed no improvement 2