What is the recommended management for contact dermatitis?

Management of Contact Dermatitis

The cornerstone of contact dermatitis management is complete avoidance of the offending agent combined with topical corticosteroids, soap substitutes, and emollients for established disease. 1

First-Line Treatment Approach

Immediate Actions

• Identify and completely avoid the causative agent—this is the single most important intervention and will lead to resolution if successfully implemented 1, 2
• Take a detailed history focusing on initial symptom location, spread pattern, timing of onset, and relationship to specific products, occupational exposures, or activities 2
• Note that clinical appearance alone cannot reliably distinguish irritant from allergic contact dermatitis 2

Topical Therapy for Established Dermatitis

• Apply mid- to high-potency topical corticosteroids such as triamcinolone 0.1% or clobetasol 0.05% twice daily to affected areas 3
• For localized acute allergic contact dermatitis, mid- or high-potency topical steroids achieve clear or almost clear skin in 35% of patients within 6 weeks 3
• Use soap substitutes instead of harsh soaps and apply emollients immediately after washing to restore barrier function 1, 2
• Apply moisturizers liberally and frequently—use two fingertip units to hands after each washing if hands are affected 4
• Consider the "soak and smear" technique: soak affected area in plain water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks 4

Systemic Therapy for Extensive Disease

• For extensive involvement (>20% body surface area), prescribe oral prednisone tapered over 2-3 weeks 3
• Systemic steroids provide relief within 12-24 hours for severe cases 3
• Critical caveat: Rapid discontinuation of steroids causes rebound dermatitis—always taper over 2-3 weeks, particularly in severe rhus (poison ivy) dermatitis 3

Facial Contact Dermatitis: Special Considerations

Exercise extreme caution with topical corticosteroids on facial skin—the face has increased percutaneous absorption, making it highly susceptible to steroid-induced atrophy, telangiectasia, and perioral dermatitis 2

Facial-Specific Management

• Use only low-potency corticosteroids on the face for short durations 2
• Avoid very hot or very cold water for facial washing 2
• Do not use disinfectant wipes on facial skin 2
• Use moisturizers packaged in tubes rather than jars to prevent contamination 2
• Common facial triggers include cosmetics, sunscreens, and fragrances 2

Second-Line Treatments for Refractory Cases

For steroid-resistant chronic contact dermatitis, escalate to phototherapy (PUVA), azathioprine, or ciclosporin—these have Level I evidence supporting their use 1, 4

Alternative Topical Agents

• Consider topical tacrolimus 0.1% ointment twice daily as an alternative to prolonged corticosteroid use, particularly for facial or thin-skinned areas where steroid atrophy is a concern 1, 2, 4
• Topical tacrolimus has demonstrated effectiveness in nickel-induced allergic contact dermatitis models and avoids the atrophy risk of steroids 1
• Pimecrolimus cream 1% is FDA-approved for atopic dermatitis and may be considered, though specific contact dermatitis trials were not included in this review 5

Systemic Immunosuppression

• Azathioprine, ciclosporin, or phototherapy (PUVA) are supported by prospective clinical trials for chronic hand dermatitis 1, 4

Diagnostic Workup for Persistent Cases

Perform patch testing with an extended standard series of allergens if dermatitis persists despite appropriate treatment and avoidance measures 1, 2, 4, 3

Patch Testing Protocol

• Patch test to at least an extended standard series of allergens 1
• Testing should be prescribed and interpreted by someone trained in contact dermatitis investigation, with readings at day 2 and day 4 1
• Critical precautions during patch testing:
  • Do not apply potent topical steroids to the back within 2 days of testing (causes false negatives) 2
  • Avoid oral corticosteroids or immunosuppressants; if unavoidable, keep prednisolone ≤10 mg daily 2
• Consider testing for corticosteroid allergy if dermatitis worsens with treatment 4

Prevention Strategies

Workplace and Occupational Dermatitis

• After-work creams (applied after exposure) reduce the incidence and prevalence of contact dermatitis with Level I evidence 1, 2
• Soap substitutes should be encouraged and made readily available in the workplace 1
• Barrier creams applied before exposure have questionable value and should not be overpromoted—they may create false security and reduce compliance with proper protective measures 1, 2
• Workplace visits may be essential for identifying allergens and implementing effective prevention strategies 1

Specific Allergen Avoidance

• For nickel-sensitive patients with persistent dermatitis, consider low-nickel diets (Level IV evidence) 1
• Diethylenetriamine pentaacetic acid (chelator) cream prevents nickel, chrome, and copper dermatitis 6
• Topical skin protectant and quaternium 18 bentonite prevent rhus (poison ivy) dermatitis 6
• Barrier creams containing dimethicone or perfluoropolyethers, cotton liners, and softened fabrics prevent irritant contact dermatitis 6

Post-Surgical Contact Dermatitis

Immediately discontinue all topical antibiotics (especially neomycin and bacitracin) and switch to plain white petrolatum for wound care 4

• Apply mid-to-high potency topical corticosteroid such as triamcinolone 0.1% two to three times daily 4
• For severe or extensive involvement (>20% BSA), escalate to clobetasol propionate 0.05% twice daily for up to 2 weeks—this achieves clear or almost clear skin in 67.2% of severe cases 4
• Refer for patch testing if dermatitis persists beyond 2 weeks despite appropriate treatment 4

Common Pitfalls to Avoid

• Do not use combined topical corticosteroid/antibiotic combinations routinely—they show only marginal benefit in infected eczema and increase sensitization risk 1
• Avoid products containing topical antibiotics without clear indication 2
• Do not use harsh detergents, fragranced products, or known irritants 2
• Beware of corticosteroid inefficacy in acute irritant contact dermatitis—one study found corticosteroids ineffective for surfactant-induced irritant dermatitis compared to vehicle 7

Prognosis and Long-Term Outcomes

The long-term prognosis for contact dermatitis is often poor unless the causative agent is completely avoided 1, 2, 4

• Only 25% of patients with occupational contact dermatitis achieve complete healing over 10 years 1, 4
• 50% have periodic symptoms and 25% have permanent symptoms despite intervention 1
• Changing occupation does not improve prognosis in 40% of cases 1
• Allergic contact dermatitis carries a worse prognosis than irritant contact dermatitis unless the specific allergen is identified and avoided 2
• For milder cases with successful allergen avoidance, dermatitis will clear 1, 2