What is the best treatment for contact dermatitis?

Treatment of Contact Dermatitis

The best treatment for contact dermatitis is complete identification and avoidance of the causative allergen or irritant, combined with mid-to-high potency topical corticosteroids (such as triamcinolone 0.1% or clobetasol 0.05%) applied twice daily, and immediate replacement of all soaps and detergents with emollients. 1, 2

Initial Management Algorithm

Step 1: Immediate Allergen/Irritant Avoidance and Skin Protection

• Replace all soaps and detergents with emollients immediately, even if they are not the primary cause, as these compounds are irritants that perpetuate dermatitis 3, 1
• Apply moisturizers immediately after every hand washing using 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 1, 2
• Use tube packaging rather than jars to prevent contamination 1, 2
• Apply two fingertip units of moisturizer to hands after each washing 2

Step 2: Topical Corticosteroid Therapy

• For body and hands: Apply mid-to-high potency topical corticosteroids (triamcinolone 0.1% or clobetasol 0.05%) twice daily 1, 4
• For facial lesions: Use only low-potency steroids to minimize risk of skin atrophy, telangiectasia, and perioral dermatitis 1, 2
• Be cautious with prolonged topical steroid use as it can cause steroid-induced damage to the skin barrier, particularly in irritant contact dermatitis 1
• For extensive involvement (>20% body surface area): Consider systemic corticosteroids with relief expected within 12-24 hours 4
• For severe cases: Taper oral prednisone over 2-3 weeks to prevent rebound dermatitis 4

Step 3: Identify Specific Allergens Through Patch Testing

• Refer for patch testing to at least an extended standard series of allergens for any persistent contact dermatitis, as pattern and morphology alone are unreliable in distinguishing between irritant, allergic, or endogenous dermatitis 3, 1, 2
• Patch testing is the gold standard for identifying specific allergens and is essential when the diagnosis remains uncertain 5, 2
• Do not apply potent topical steroids to the back within 2 days of patch testing, as this causes false negatives 2
• Avoid oral corticosteroids or immunosuppressants during patch testing; if unavoidable, keep prednisolone ≤10 mg daily 2

Protective Measures for Hand Dermatitis

Glove Selection Based on Exposure

• For household tasks: Use rubber or polyvinylchloride gloves with cotton lining 3, 2
• For glove-related allergic contact dermatitis: Switch to accelerator-free gloves such as rubber-free neoprene or nitrile gloves 1, 2
• For occupational settings: Select gloves based on specific chemical exposures and consider permeation time, as "impervious" gloves have finite protection duration 2
• Remove gloves regularly to prevent sweat accumulation, which aggravates dermatitis 2
• Apply moisturizer before wearing gloves 2

Barrier Cream Limitations

• Barrier creams alone have questionable value in protecting against irritants and may create false security, reducing implementation of appropriate preventive measures 3, 2
• After-work creams have shown benefit in reducing irritant contact dermatitis incidence and should be readily available in workplace settings 2

Second-Line Therapies for Refractory Cases

When topical steroids fail despite allergen avoidance, escalate treatment systematically:

Topical Immunomodulators

• Topical tacrolimus 0.1% is effective for contact dermatitis where topical steroids are unsuitable, ineffective, or when chronic facial dermatitis raises concerns about steroid-induced skin damage 3, 1, 2
• Pimecrolimus 1% cream is FDA-approved as second-line therapy for mild to moderate atopic dermatitis in patients 2 years and older who have failed other topical treatments, though it is indicated for atopic dermatitis rather than contact dermatitis specifically 6

Phototherapy

• Psoralen plus UVA (PUVA) has demonstrated efficacy in chronic hand dermatitis with strong evidence from prospective clinical trials 3, 1, 2
• PUVA is an established second-line treatment for chronic contact dermatitis resistant to topical steroids 2

Systemic Immunosuppressants

• For severe refractory cases: Consider methotrexate, mycophenolate mofetil, ciclosporin, or azathioprine 3, 2
• Alitretinoin should be offered for severe chronic hand eczema 2

Critical Pitfalls to Avoid

• Never wash hands with dish detergent or other known irritants 2
• Avoid very hot or very cold water for hand washing 2
• Do not use disinfectant wipes to clean hands 2
• Avoid products containing topical antibiotics without indication 2
• Do not apply prolonged occlusion without underlying moisturizer application 2
• Do not over-promote barrier creams as they may give false sense of security 3, 2
• Exercise extreme caution with topical corticosteroids on facial skin—prolonged use causes skin thinning, telangiectasia, perioral dermatitis, and red face syndrome due to increased percutaneous absorption 2

Special Considerations for Occupational Contact Dermatitis

• Consider workplace visits to identify hidden irritants and allergen sources that may not be apparent from history alone 1, 2
• Workplace assessment is necessary to identify all potential hazards and assess procedures that may cause accidental exposure 2
• The long-term prognosis for occupational contact dermatitis is often very poor: only 25% of patients achieve complete healing over 10 years, 50% have intermittent symptoms, and 25% have permanent symptoms 3, 1, 2
• Changing occupation does not improve prognosis in 40% of cases 3, 2
• Educational programs may help in secondary prevention, though compliance with skin-protection programs is often poor 3

Prognosis and Long-Term Management

• Complete avoidance of identified allergens is mandatory—partial avoidance will result in persistent dermatitis 1
• Contact manufacturers to determine if allergens are present in products and identify suitable substitutes 1
• 55% of patients still have dermatitis after 2 years from diagnosis 3, 1
• Early aggressive intervention is essential to prevent chronicity and permanent symptoms 1
• The prognosis for milder cases depends upon the ease of avoidance 3