What is the treatment for chronic dermatitis?

Treatment of Chronic Dermatitis

First-Line Topical Therapy

Begin treatment with mid-to-high potency topical corticosteroids applied twice daily for 2-4 weeks combined with aggressive emollient therapy—this is the cornerstone of chronic dermatitis management regardless of subtype. 1, 2

Topical Corticosteroid Selection and Application

• For moderate chronic dermatitis, initiate triamcinolone 0.1% or betamethasone valerate 0.1% applied twice daily to affected areas 3, 4
• For severe or refractory cases, escalate to clobetasol propionate 0.05% twice daily for up to 2 weeks maximum, which achieves clear or almost clear skin in 67.2% of severe cases 3, 4
• Apply corticosteroids to clean, slightly damp skin for optimal absorption, then wait 15-30 minutes before applying emollients 4
• Critical safety consideration: Use no more than 100g of moderately potent corticosteroids per month, with mandatory periods each year employing alternative treatments to prevent skin atrophy 1

Essential Emollient Therapy (Non-Negotiable)

• Apply emollients liberally at least twice daily—these are not optional adjuncts but essential components that restore barrier function 1, 4
• Use two fingertip units to hands after each washing if hands are affected 3, 2
• Consider 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 3, 2
• Oil-in-water creams or ointments are preferred over alcohol-containing lotions 4

Maintenance Therapy After Initial Control

After achieving control (typically 2-4 weeks), transition to proactive maintenance therapy rather than stopping treatment abruptly—this is critical to prevent relapse. 1, 4

• Apply medium-potency topical corticosteroids twice weekly (weekend therapy) to previously affected areas for 16-20 weeks 4
• This approach reduces relapse risk by 3.5-fold compared to stopping steroids entirely, with 87.1% remaining flare-free versus 65.8% with emollient alone 4
• Continue daily emollient use indefinitely during maintenance phase 4
• The twice-weekly maintenance approach shows only 1% incidence of skin thinning in trials up to 52 weeks 4

Allergen Identification and Avoidance

Refer for patch testing with an extended standard series if dermatitis persists beyond 2 weeks despite appropriate topical corticosteroid treatment—clinical features alone cannot reliably distinguish between irritant, allergic, or endogenous dermatitis. 1, 3, 2

• Pattern and morphology of dermatitis, especially on hands and face, is unreliable for distinguishing subtypes 1, 2
• Include testing for corticosteroid allergy if dermatitis worsens with treatment 3
• Complete allergen avoidance after identification offers the best chance for resolution 3, 2

Protective Measures

• Replace all soaps and detergents with emollients immediately, even if not the identified cause, as these are universal irritants that perpetuate inflammation 1, 2
• Use rubber or PVC gloves with cotton liners for household tasks, removing regularly to prevent sweat accumulation 1, 2
• Do not over-rely on barrier creams alone—they have questionable clinical value and may create false security 1, 2

Second-Line Therapies for Refractory Cases

Consider topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) as second-line therapy when topical corticosteroids are unsuitable, ineffective, or when chronic facial dermatitis raises concerns about steroid-induced skin damage. 1, 2, 5

• 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 prescription treatments 5
• Tacrolimus 0.1% ointment applied twice daily is particularly useful for facial or thin-skinned areas where steroid atrophy is a concern 3, 2
• These agents avoid the risk of corticosteroid-induced skin atrophy with long-term use 2, 6

Phototherapy

Phototherapy is a second-line treatment after failure of optimized topical therapy (emollients, topical steroids, and topical calcineurin inhibitors). 1

• Narrowband UVB is the preferred initial phototherapy modality, administered 3-5 times weekly 1
• Initial dose should be 50% of minimal erythema dose (MED), increasing by 10% of initial MED for treatments 1-20 1
• PUVA (psoralen plus UVA) is an established alternative for chronic hand dermatitis and chronic actinic dermatitis resistant to topical steroids 1, 2
• Phototherapy can be used as maintenance therapy in patients with chronic disease, though maintenance frequency varies tremendously between individuals 1

Systemic Immunomodulatory Therapy

Reserve systemic therapy for moderate to severe disease unresponsive to optimized topical management and phototherapy. 1, 4

For Acute Exacerbations

• Oral prednisolone for short-term control of severe flares 7, 8

For Chronic Management

• Azathioprine is effective for chronic actinic dermatitis and chronic hand dermatitis requiring systemic treatment beyond a few weeks 1, 7, 8, 9
• Cyclosporine for severe refractory cases, though requires careful monitoring for toxicity 1, 7, 9
• Mycophenolate mofetil as an alternative systemic immunomodulator 1, 7
• Methotrexate for persistent contact dermatitis 1

Critical Pitfalls to Avoid

• Undertreatment is a common error: Use appropriate potency and adequate duration based on severity rather than defaulting to weak steroids 4
• Failure to implement maintenance therapy leads to rapid relapse—do not stop corticosteroids abruptly after clearing 4
• Neglecting emollients significantly compromises outcomes—these are essential, not optional 1, 4
• Prolonged use of high-potency steroids on facial or thin skin risks atrophy, telangiectasia, and perioral dermatitis 2
• Unsupervised repeat prescriptions of topical corticosteroids without regular clinical review 1

Prognosis and Long-Term Outlook

The long-term prognosis for chronic dermatitis, particularly occupational contact dermatitis, is often poor despite treatment. 1, 3, 2

• Only 25% of patients achieve complete healing over 10 years 1, 3, 2
• 50% will have intermittent symptoms and 25% will have permanent symptoms 1, 3, 2
• Changing occupation does not improve prognosis in 40% of cases 1, 2
• Early identification and complete avoidance of allergens offers the best chance for resolution 3, 2
• For chronic actinic dermatitis, photoprotection and allergen avoidance may lead to spontaneous resolution in 50% of patients over 15 years 7