What is the treatment for contact dermatitis?

Treatment of Contact Dermatitis

The cornerstone of contact dermatitis treatment is complete avoidance of the causative allergen or irritant combined with mid-to-high potency topical corticosteroids and aggressive emollient therapy. 1, 2

Immediate Management Steps

Allergen/Irritant Identification and Avoidance

• Obtain patch testing with an extended baseline series of allergens for any persistent or chronic dermatitis, as clinical features alone cannot reliably distinguish between irritant, allergic, or endogenous dermatitis, particularly on hands and face. 1, 2
• Take a detailed history documenting initial symptom location, spread pattern, relationship to specific products or activities, and occupational/recreational exposures. 2
• Replace all soaps and detergents with emollients immediately, even if they are not the identified cause, as these are universal irritants that perpetuate inflammation. 1
• For occupational cases, arrange workplace visits to identify hidden allergens, assess procedures causing accidental exposure, and review Material Safety Data Sheets. 1

First-Line Topical Therapy

• Apply mid-to-high potency topical corticosteroids (triamcinolone 0.1% or clobetasol 0.05%) twice daily to affected areas. 3
• For localized acute allergic contact dermatitis, mid-to-high potency topical steroids achieve resolution in most cases. 3
• For severe persistent dermatitis failing initial treatment, escalate to very high potency topical corticosteroids (clobetasol propionate 0.05%) for 2 weeks, which achieves clear or almost clear skin in 67.2% of patients versus 22.3% with vehicle. 2
• Exercise extreme caution with facial application—use the least potent preparation required and implement steroid-free periods to prevent irreversible skin thinning, telangiectasia, and perioral dermatitis. 2, 4

Aggressive Moisturization Protocol

• Apply moisturizers packaged in tubes (not jars) to prevent contamination, using two fingertip units to hands after each washing. 2, 4
• Implement 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. 2, 4
• Prescribe approximately 100g of moisturizer per 2 weeks for trunk areas; adjust proportionally for other body regions. 2

Systemic Therapy for Extensive Disease

• For allergic contact dermatitis involving >20% body surface area, initiate oral prednisone with a 2-3 week taper to prevent rebound dermatitis from rapid discontinuation. 3
• Systemic steroids provide relief within 12-24 hours for extensive acute allergic contact dermatitis. 3

Protective Measures

Glove Selection and Use

• Select gloves based on specific chemical exposures and check Material Safety Data Sheets for permeation times—no glove is completely impermeable. 1
• For general household tasks, use rubber or PVC gloves with cotton liners. 1
• For latex allergy, use accelerator-free neoprene or nitrile gloves. 2
• Remove gloves regularly to prevent sweat accumulation, which aggravates dermatitis. 2
• Apply moisturizer before wearing gloves to enhance barrier protection. 2

Barrier Creams

• Do not over-rely on barrier creams alone—they have questionable clinical value in workplace settings and may create false security, reducing implementation of appropriate preventive measures. 1, 2
• After-work creams demonstrate benefit in reducing irritant contact dermatitis incidence and should be readily available. 2

Second-Line Therapies for Refractory Cases

When dermatitis persists despite allergen avoidance and high-potency topical steroids:

Topical Immunomodulators

• Consider topical tacrolimus 0.1% where topical steroids are unsuitable, ineffective, or when chronic facial dermatitis raises concerns about steroid-induced damage. 1, 2
• Topical tacrolimus is effective for nickel-induced allergic contact dermatitis and avoids corticosteroid allergy risk. 1, 2

Phototherapy

• Consider PUVA (psoralen plus UVA) therapy for chronic hand eczema resistant to topical steroids, supported by prospective clinical trials. 1, 2

Systemic Immunosuppressants

• For severe recalcitrant cases, consider methotrexate, mycophenolate mofetil, azathioprine, or ciclosporin. 1, 2
• Offer alitretinoin specifically for severe chronic hand eczema (strong recommendation). 1

Patient Education

• Implement comprehensive educational programs for occupational contact dermatitis, which demonstrate improvements in established hand dermatitis and prevention of new cases. 1
• Provide written information on patch testing, including potential side-effects, and obtain informed consent. 1
• Educate on proper substitution of materials—use thiuram-free gloves, change biocides in industrial coolant oils, and use isothiazolinone-free products when these allergens are identified. 1

Critical Pitfalls to Avoid

• Never wash with dish detergent, very hot or very cold water, or disinfectant wipes. 2, 4
• Avoid products containing topical antibiotics without clear indication—these are common sensitizers. 2, 4
• 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
• Do not recommend exclusion diets—no good-quality studies support their use in contact dermatitis management. 1

Prognosis and Follow-Up

• The long-term prognosis for occupational contact dermatitis is poor: only 25% achieve complete healing over 10 years, 50% have intermittent symptoms, and 25% have permanent symptoms. 1, 2
• Changing occupation does not improve prognosis in 40% of cases. 1
• Early identification and complete allergen avoidance offer the best chance for resolution. 2
• Use clinical assessment tools (Dermatology Life Quality Index, Hand Eczema Severity Index) for initial assessment and monitoring treatment response. 1