What is the treatment for contact dermatitis?

Treatment for Contact Dermatitis

The most effective treatment for contact dermatitis is complete avoidance of the causative agent combined with mid-to-high potency topical corticosteroids and aggressive emollient therapy. 1

Immediate First-Line Management

Replace All Cleansers and Initiate Barrier Repair

• Immediately substitute all soaps and detergents with emollients, even before identifying the specific trigger, as these are universal irritants that perpetuate inflammation regardless of the underlying cause 1
• Apply moisturizers packaged in tubes (not jars) to prevent contamination, using two fingertip units to hands after each washing 1
• Use 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

Topical Corticosteroid Application

• Apply mid-to-high potency topical corticosteroids (such as triamcinolone 0.1% or betamethasone valerate 0.1%) twice daily to affected areas 1, 3
• For persistent dermatitis failing initial treatment, escalate to very high potency corticosteroids (clobetasol propionate 0.05%) for 2 weeks, which achieves clear or almost clear skin in 67.2% of patients with severe dermatitis 1
• Exercise extreme caution on facial skin—use the least potent preparation required and stop for short periods when possible, as prolonged facial use causes irreversible skin thinning, telangiectasia, and perioral dermatitis due to increased percutaneous absorption 2, 4

Systemic Steroids for Extensive Disease

• If allergic contact dermatitis involves greater than 20% body surface area, systemic steroid therapy is required and offers relief within 12-24 hours 3
• For severe cases (such as poison ivy), taper oral prednisone over 2-3 weeks—rapid discontinuation causes rebound dermatitis 3

Identify and Avoid the Causative Agent

Critical History Elements

• Document initial location of symptoms, spread pattern, relationship to specific products or activities, and occupational/recreational exposures 1
• Pattern and morphology alone are unreliable in distinguishing between irritant versus allergic contact dermatitis, particularly on hands and face 1, 4

Patch Testing Indications

• Refer for patch testing to at least an extended standard series of allergens for any persistent or chronic dermatitis where the causative agent remains unknown 1, 4
• Do not apply potent topical steroids to the back within 2 days of patch testing (causes false negatives), and keep prednisolone ≤10 mg daily if systemic steroids are unavoidable during testing 1
• Include testing for corticosteroid allergy itself, as a small subset of patients develop allergic contact dermatitis to the topical steroids used for treatment 1

Complete Allergen Avoidance

• Once identified through patch testing, ensure complete avoidance of the allergen—this is the only definitive treatment and will lead to resolution if successfully implemented 4
• For occupational cases, arrange workplace visits to identify hidden allergens, assess procedures causing accidental exposure, and review Material Safety Data Sheets 1

Protective Measures

Glove Selection and Use

• Use rubber or PVC gloves with cotton liners for household tasks, removing them regularly to prevent sweat accumulation that aggravates dermatitis 1
• For occupational settings, select gloves based on specific chemical exposures and check Material Safety Data Sheets for permeation times—no glove is completely impermeable 1
• Apply moisturizer before wearing gloves to enhance barrier protection 1

Barrier Cream Limitations

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

Second-Line Therapies for Refractory Cases

Topical Calcineurin Inhibitors

• Consider topical tacrolimus 0.1% where topical steroids are unsuitable, ineffective, or when chronic facial dermatitis raises concerns about steroid-induced skin damage 1, 2, 4
• Tacrolimus is effective for contact dermatitis and avoids the risk of corticosteroid allergy and skin atrophy 2, 4

Phototherapy and Systemic Agents

• PUVA (psoralen plus UVA) is an established second-line treatment for chronic hand eczema resistant to topical steroids, supported by prospective clinical trials 1
• For severe chronic hand eczema specifically, offer alitretinoin (strong recommendation) 1
• Consider systemic immunosuppressants like azathioprine or ciclosporin for steroid-resistant chronic cases 1, 4

Critical Pitfalls to Avoid

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

Prognosis and Long-Term Outlook

• With early identification and complete allergen avoidance, resolution is achievable 2
• However, 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
• Comprehensive educational programs for occupational contact dermatitis demonstrate improvements in established hand dermatitis and prevention of new cases 1