What is the best treatment for mild cellulitis (inflammation of the skin and subcutaneous tissues) on the hand caused by a bandage in an elderly patient, considering the use of topical steroids such as hydrocortisone (corticosteroid)?

Treatment of Bandage-Related Irritant Contact Dermatitis on the Hand in an Elderly Patient

Do not use topical steroids for this condition—this is irritant contact dermatitis (ICD) from bandage occlusion, not cellulitis, and requires removal of the irritant, moisturization, and barrier repair rather than anti-inflammatory treatment. 1

Critical Diagnostic Distinction

The clinical scenario describes inflammation caused by a bandage, which represents irritant contact dermatitis (ICD) rather than true cellulitis:

• Cellulitis presents with acute onset of warmth, swelling, tenderness, and spreading erythema caused by bacterial infection of the deep dermis and subcutaneous tissue 2
• Bandage-related ICD occurs from occlusion, moisture accumulation, and mechanical irritation under adhesive dressings 1
• Occluding fingers or hands with adhesive bandages is specifically identified as a risk factor for inducing or worsening hand dermatitis 1

Primary Management Algorithm

Step 1: Remove the Offending Agent

• Immediately discontinue the bandage that is causing the irritation 1
• Avoid re-application of adhesive bandages impregnated with potential allergens like bacitracin or benzalkonium chloride 1

Step 2: Restore Skin Barrier Function

• Apply moisturizer immediately after washing hands and throughout the day, carrying it for frequent reapplication 1
• Use the "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
• At night, apply moisturizer followed by cotton or loose plastic gloves (clear disposable food gloves) to create an occlusive barrier for enhanced healing 1

Step 3: Consider Topical Steroid Only If Conservative Measures Fail

• For ICD, topical steroids should only be considered if conservative measures fail, as they can potentially cause steroid-induced damage to the already compromised skin barrier 1
• If a topical steroid is deemed necessary after barrier repair attempts, use it judiciously and for a limited duration 1

When Topical Steroids Are Contraindicated

Topical corticosteroids are specifically contraindicated if there is any concern for actual infection:

• The potent anti-inflammatory actions of corticosteroids increase susceptibility to bacterial and fungal infections 3
• Children and elderly patients may be more vulnerable to systemic effects due to proportionately greater percutaneous absorption 3
• If true cellulitis is present (warmth, tenderness, spreading erythema, systemic symptoms), antibiotic therapy is required, not topical steroids 4, 5

If True Cellulitis Is Present

Should clinical reassessment reveal actual bacterial cellulitis rather than ICD:

• First-line treatment is oral beta-lactam antibiotics such as cephalexin 500 mg four times daily or dicloxacillin 250-500 mg every 6 hours for 5 days 4, 5
• Beta-lactam monotherapy is successful in 96% of typical cellulitis cases 4
• MRSA coverage is not routinely needed for typical nonpurulent cellulitis 4, 5
• Elevation of the affected hand promotes drainage and hastens improvement 4

Common Pitfalls to Avoid

• Do not reflexively prescribe topical steroids for all red, inflamed skin—distinguish between infection (requiring antibiotics) and irritation (requiring barrier repair) 1, 3
• Do not continue occlusive bandaging without addressing the underlying irritant dermatitis 1
• Do not use topical antibiotics like neomycin or bacitracin, as these are common allergens that can worsen the condition 1
• Do not ignore predisposing factors such as frequent hand washing with irritants, which can perpetuate the dermatitis 1