What are the treatment options for dermatitis?

Treatment for Dermatitis

For atopic dermatitis, apply topical corticosteroids as first-line therapy for active disease, combined with liberal daily use of emollients and soap-free cleansers for maintenance. 1, 2

Initial Management Approach

Maintenance Therapy (All Patients)

• Apply emollients liberally and frequently to restore and maintain the skin barrier, even when skin appears clear 1, 2
• Replace all soaps and detergents with soap-free cleansers or emollient substitutes 3, 4
• Bathe daily with lukewarm water and soap-free products, applying moisturizer immediately to damp skin within minutes of bathing 2
• Use at least 100g of moisturizer per 2 weeks for trunk areas; apply two fingertip units for adequate hand coverage 5

Active Disease Treatment

Topical Corticosteroids (First-Line)

• Select potency based on severity and anatomic location: use lower potency (hydrocortisone) for face, neck, and intertriginous areas; mid-to-high potency for trunk and extremities; very high potency (clobetasol 0.05%) for severe or refractory disease 1, 4, 5
• Apply twice daily to affected areas until lesions clear, typically 2-6 weeks 1, 6
• Very high potency steroids achieve clear or almost clear skin in 67% of severe cases within 2 weeks 5
• Critical pitfall: Avoid prolonged use on facial skin—this causes skin thinning, telangiectasia, perioral dermatitis, and increased systemic absorption 5

Topical Calcineurin Inhibitors (Steroid-Sparing Agents)

• Use tacrolimus 0.1% or pimecrolimus 1% for sensitive areas (face, neck, intertriginous sites) or as steroid-sparing maintenance therapy 1, 7, 2
• Apply twice daily to affected areas; particularly useful when chronic use raises concerns about steroid-induced skin damage 4, 5
• Expect local burning or stinging in approximately 50% of patients during first few days, which typically improves as dermatitis resolves 7
• Do not use in children under 2 years old or on infected skin 7

Contact Dermatitis Specific Management

The single most important step is identifying and completely avoiding the causative allergen or irritant. 3, 4, 5

Diagnostic Approach

• Refer for patch testing when dermatitis persists despite treatment or the cause remains unknown—pattern and morphology alone are unreliable for distinguishing irritant from allergic contact dermatitis 3, 4, 5
• Test to at least an extended standard series of allergens 5
• Consider workplace assessment if occupational exposure is suspected 4, 5

Treatment Algorithm

• Mild to moderate cases: Apply mid-potency topical corticosteroids twice daily + emollients and soap substitutes regularly 4
• Severe or extensive cases: Consider short-term systemic corticosteroids (though use cautiously) + patch testing to identify allergens 4
• Chronic or recurrent cases: Implement proactive therapy with twice-weekly topical corticosteroids or calcineurin inhibitors to previously affected areas 4

Protective Measures for Hand Dermatitis

• Avoid frequent hand washing, dish detergents, very hot/cold water, and disinfectant wipes 3
• Use rubber-free gloves (neoprene or nitrile) if latex allergy suspected; consider cotton liners under gloves 3, 5
• Apply moisturizer before wearing gloves and remove gloves regularly to prevent sweat accumulation 3, 5
• Barrier creams alone have questionable value and may create false security—do not rely on them as primary protection 4, 5

Advanced Therapies for Moderate-to-Severe or Refractory Disease

Systemic Therapies (Strong Recommendations)

For atopic dermatitis unresponsive to topical therapy, strongly consider:

• Dupilumab, tralokinumab, abrocitinib, baricitinib, or upadacitinib as first-line systemic agents 1
• These biologics and JAK inhibitors have the strongest evidence for efficacy and safety 1

Second-Line Systemic Options (Conditional Recommendations)

• Cyclosporine, methotrexate, azathioprine, or mycophenolate mofetil 1
• Conditionally recommend AGAINST systemic corticosteroids due to substantial risk of serious adverse events and rebound flares upon discontinuation 1
• If systemic corticosteroids are used, limit to short courses only as a bridge to other long-term therapies 1

Phototherapy

• PUVA or narrowband UVB phototherapy is effective for chronic, steroid-resistant dermatitis 1, 4
• Particularly useful for chronic hand eczema 4, 5

Contact Dermatitis Specific Advanced Options

• For severe chronic hand eczema: alitretinoin 4, 5
• Topical tacrolimus 0.1% for nickel-induced allergic contact dermatitis 5

Critical Pitfalls to Avoid

• Never use topical antibiotics routinely—they are common allergens themselves (neomycin, bacitracin) and are not indicated for uncomplicated dermatitis 3, 4
• Reserve systemic antibiotics only for clinically evident bacterial infection (purulent exudate, pustules) 1
• Oral antihistamines are not recommended—they do not reduce pruritus in atopic dermatitis 2
• Avoid applying gloves to wet hands after washing or sanitizing 3
• Do not apply potent topical steroids to the back within 2 days of patch testing—this causes false negatives 5

Special Considerations

Infection Management

• Treat eczema herpeticum immediately with systemic antivirals (acyclovir)—this is a dermatologic urgency 1
• Use systemic antistaphylococcal antibiotics only for frank bacterial infections with clinical signs (not for colonization alone) 1
• Obtain skin culture with antibiotic susceptibility for recurrent or non-responsive infections 1

Prognosis

• Occupational contact dermatitis has poor prognosis: only 25% achieve complete healing over 10 years, 50% have intermittent symptoms, and 25% have permanent symptoms 4, 5
• Changing occupation does not improve prognosis in 40% of cases 5
• Early identification and complete allergen avoidance offers the best chance for resolution 5