What is the best treatment approach for a patient presenting with contact dermatitis?

Contact Dermatitis Treatment

The best treatment approach for contact dermatitis is immediate identification and complete avoidance of the causative agent (allergen or irritant), combined with mid-to-high potency topical corticosteroids and aggressive emollient therapy, with patch testing performed for any chronic or persistent cases to identify specific allergens. 1, 2

Distinguish Between Irritant and Allergic Contact Dermatitis

Clinical features alone cannot reliably differentiate between irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD), particularly on hands and face. 3 You must obtain a detailed history focusing on:

• Occupational and recreational exposures to chemicals, detergents, solvents, cosmetics, personal-care products, topical medications, clothing, or gloves 3
• Temporal relationship: Do symptoms improve on weekends/holidays and worsen upon return to work? 3
• Initial location and spread pattern of the dermatitis 3
• Frequency of hand washing and wet work, as water itself is an irritant 3
• Personal or family history of atopy (childhood eczema, asthma, hay fever) 3

Patch testing is the gold-standard investigation and should be performed in any patient with chronic or persistent dermatitis, or when previously well-controlled dermatitis becomes refractory to treatment. 3, 4, 5

Treatment for Allergic Contact Dermatitis

For ACD, allergen identification through patch testing and complete avoidance is the cornerstone of treatment—without this, healing will not occur. 1, 2

Acute Management

• Apply mid-to-high potency topical corticosteroids such as triamcinolone 0.1% or clobetasol 0.05% to affected areas 1, 6
• For extensive involvement (>20% body surface area), use systemic corticosteroids: oral prednisone tapered over 2-3 weeks to prevent rebound dermatitis 6
• Apply emollients liberally (at least 100g per 2 weeks for trunk area) to restore skin barrier 2

Allergen Avoidance Strategy

• Replace all soaps and detergents with emollients immediately, even if not the identified allergen, as these perpetuate inflammation 2
• For nickel allergy: avoid metal belt buckles, jewelry, and consider low-nickel diet in severe cases 2
• For fragrance allergy: use fragrance-free detergents and personal care products 2
• For glove-related ACD: switch to accelerator-free gloves such as rubber-free neoprene or nitrile gloves 1

Refractory Cases

• Consider topical tacrolimus 0.1% where topical steroids are unsuitable, ineffective, or for chronic facial dermatitis to avoid steroid-induced skin damage 1, 2, 5
• PUVA phototherapy is an established second-line treatment for chronic hand eczema resistant to topical steroids 1, 2
• Alitretinoin is specifically recommended for severe chronic hand eczema 1, 5
• Systemic immunosuppressants (azathioprine, ciclosporin, methotrexate, mycophenolate mofetil) for steroid-resistant cases 2, 5

Treatment for Irritant Contact Dermatitis

For ICD, identify and avoid irritants while focusing on skin barrier restoration through aggressive moisturization. 1, 2

Irritant Avoidance

• Avoid common irritants: frequent hand washing, dish detergents, hot water, disinfectant wipes, bleach, and products containing topical antibiotics 1, 2
• Use soap substitutes and gentle cleansers instead of traditional soaps 2
• Limit water exposure and hand washing frequency 3

Barrier Restoration

• Apply moisturizers immediately after every hand washing (two fingertip units per application) 1, 2
• Use moisturizers packaged in tubes rather than jars to prevent contamination 1, 2
• "Soak and smear" technique for intensive treatment: soak hands in plain water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks 1, 2

Topical Corticosteroids

• Use topical corticosteroids cautiously if conservative measures fail, as prolonged use may further damage the skin barrier 1, 2
• For persistent cases, escalate to very high potency steroids (clobetasol propionate 0.05%) for 2 weeks, which achieves clear or almost clear skin in 67.2% of patients with severe dermatitis 2

Protective Measures

Select gloves based on specific chemical exposures—no glove is completely impermeable. 2

• For household tasks: rubber or PVC gloves with cotton liners 2
• For latex allergy: neoprene or nitrile gloves 2
• For occupational exposures: check Material Safety Data Sheets for permeation times and select appropriate gloves 2
• Remove gloves regularly to prevent sweat accumulation, which aggravates dermatitis 2
• Apply moisturizer before wearing gloves 1, 2

Barrier creams alone have questionable value and should not be over-promoted, as they may create false security and reduce implementation of appropriate preventive measures. 2 However, after-work creams have demonstrated benefit in reducing irritant contact dermatitis incidence. 2

Patch Testing Protocol

Patch testing should be performed for any chronic or persistent dermatitis, or when atopic dermatitis becomes difficult to control with previously effective treatments. 3

Timing Considerations

• Defer patch testing for 6 weeks after UV exposure (natural or artificial) 3
• Defer for 3 months after finishing systemic agents and 6 months after finishing biological agents to minimize false-negatives 3
• Do not apply potent topical steroids to the back within 2 days of patch testing 2
• Antihistamines do not need to be avoided unless testing for urticaria 3

Testing Approach

• Test to at least an extended standard series of allergens, not just a basic panel 2
• Common allergens include: nickel (14.5%), fragrances (37%), cobalt (22%), hydroxyisohexyl cyclohexene carboxaldehyde (14%), and p-phenylenediamine (1%) 3
• Bring suspected products for testing 3

Clinical Assessment Tools

Use standardized assessment tools for initial evaluation and monitoring treatment response. 3

• Dermatology Life Quality Index for generic quality of life assessment 3
• Hand Eczema Severity Index for objective scoring 3
• Investigators Global Assessment (measuring induration, scaling, fissuring) for chronic hyperkeratotic hand dermatitis, though not useful for pompholyx 3

Occupational Contact Dermatitis Considerations

Arrange workplace visits to identify hidden allergens, assess procedures causing accidental exposure, and review Material Safety Data Sheets. 2

The prognosis for occupational contact dermatitis is poor: only 25% achieve complete healing over 10 years, 50% have intermittent symptoms, and 25% have permanent symptoms. 2 Changing occupation does not improve prognosis in 40% of cases. 2

Comprehensive educational programs for occupational contact dermatitis demonstrate improvements in established hand dermatitis and prevention of new cases. 2

Critical Pitfalls to Avoid

• Failing to identify and remove the causative agent prevents healing regardless of treatment intensity 1, 2
• Not considering patch testing in chronic cases—clinical morphology is unreliable for diagnosis 3
• Prolonged use of topical steroids in ICD can further damage the skin barrier 1, 2
• Over-reliance on barrier creams creates false security without addressing the underlying problem 2
• Rapid discontinuation of systemic steroids in severe cases causes rebound dermatitis—taper over 2-3 weeks 6
• Occluding hands without underlying moisturizer application 1, 2
• Using very hot or very cold water for hand washing 1, 2
• Recommending exclusion diets—no good-quality studies support their use in contact dermatitis 2