What is the treatment for a patient with contact dermatitis?

Treatment of Contact Dermatitis

The cornerstone of contact dermatitis treatment is complete allergen or irritant avoidance combined with mid-to-high potency topical corticosteroids and aggressive emollient therapy, with patch testing essential for any persistent or chronic dermatitis to identify the causative agent. 1

Immediate First-Line Management

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 This applies to both irritant and allergic contact dermatitis and should be done before any other intervention.

Topical Corticosteroids

• Apply mid-to-high potency topical corticosteroids (such as triamcinolone 0.1% or betamethasone valerate 0.1%) twice daily to affected areas for acute treatment. 1, 2
• For severe or refractory cases on the trunk or extremities, 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. 1, 2
• Exercise extreme caution with facial application—prolonged use causes skin thinning, telangiectasia, perioral dermatitis, and red face syndrome due to increased percutaneous absorption. 1

Moisturization Protocol

• Apply moisturizers liberally using products packaged in tubes rather than jars to prevent contamination. 1, 3
• Use two fingertip units of moisturizer to hands after each washing. 1
• For intensive treatment, employ the "soak and smear" technique: soak hands in plain water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks. 1, 3
• Recommended amount is 100g per 2 weeks for trunk area. 1

Diagnostic Approach: Patch Testing

Patch testing is the gold-standard investigation and should be performed for any chronic or persistent dermatitis, as clinical features alone are unreliable in distinguishing between irritant, allergic, or endogenous dermatitis, particularly on hands and face. 4, 1, 3

When to Patch Test

• Any patient with chronic or persistent dermatitis 4
• Atopic/endogenous dermatitis previously well-controlled that becomes difficult to control with the same topical treatments 4
• When the causative agent remains unknown despite treatment 1

Patch Testing Timing Considerations

• Defer for 6 weeks after natural and artificial UV exposure 4
• Defer for 3 months after finishing systemic agents 4
• Defer for 6 months after finishing biological agents 4
• Do not apply potent topical steroids to the back within 2 days of patch testing as this causes false negatives 1
• If oral corticosteroids or immunosuppressants cannot be stopped, keep prednisolone ≤10 mg daily 1

What to Test

• Test to at least an extended standard series of allergens, not just a basic panel 1
• Common allergens include nickel (14.5%), fragrances (37%), cobalt (22%), hydroxyisohexyl cyclohexene carboxaldehyde (14%), and p-phenylenediamine (1%) 4
• Include corticosteroid allergens in testing, as a small subset of patients develop allergic contact dermatitis to topical corticosteroids themselves 1

Allergen and Irritant Avoidance

Critical Irritants to Eliminate

• Avoid washing hands with dish detergent or other known irritants 1
• Avoid very hot or very cold water for hand washing 1
• Avoid disinfectant wipes to clean hands 1
• Avoid products containing topical antibiotics without indication 1
• Avoid excessive occlusion without underlying moisturizer application 1

Occupational Considerations

• Arrange workplace visits to identify hidden allergens, assess procedures causing accidental exposure, and review Material Safety Data Sheets. 1
• This is critical because only 25% of patients with occupational contact dermatitis achieve complete healing over 10 years, 50% have intermittent symptoms, and 25% have permanent symptoms. 1
• Changing occupation does not improve prognosis in 40% of cases. 1

Protective Measures

Glove Selection

• 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 gloves such as rubber-free neoprene or nitrile gloves. 1, 3
• Remove gloves regularly to prevent sweat accumulation, which can aggravate dermatitis. 1
• Apply moisturizer before wearing gloves. 1, 3

Barrier Creams: A Critical Caveat

• 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
• However, after-work creams have demonstrated benefit in reducing irritant contact dermatitis incidence and should be readily available in workplace settings. 1

Second-Line Therapies for Refractory Cases

When first-line treatment fails after 6 weeks or symptoms persist despite allergen avoidance:

Topical Calcineurin Inhibitors

• Consider topical tacrolimus 0.1% or pimecrolimus 1% where topical steroids are unsuitable, ineffective, or when chronic facial dermatitis raises concerns about steroid-induced skin damage. 1, 3
• Topical tacrolimus has demonstrated effectiveness in allergic contact dermatitis models. 1
• Pimecrolimus 1% cream is FDA-approved for atopic dermatitis in patients 2 years and older, with 35% of patients achieving clear or almost clear skin at 6 weeks. 5

Phototherapy

• PUVA (psoralen plus UVA) therapy is an established second-line treatment for chronic hand eczema resistant to topical steroids, supported by prospective clinical trials. 1, 3

Systemic Therapies

• Consider methotrexate, mycophenolate mofetil, azathioprine, or ciclosporin for steroid-resistant chronic contact dermatitis. 1
• Alitretinoin is specifically recommended for severe chronic hand eczema (strong recommendation). 1, 3

Systemic Corticosteroids

• If allergic contact dermatitis involves greater than 20% body surface area, systemic steroid therapy is often required and offers relief within 12 to 24 hours. 2
• In patients with severe rhus dermatitis, oral prednisone should be tapered over 2-3 weeks because rapid discontinuation causes rebound dermatitis. 2

Patient Education and Long-Term Management

• Implement comprehensive educational programs for occupational contact dermatitis, which demonstrate improvements in established hand dermatitis and prevention of new cases. 1
• Use clinical assessment tools (Dermatology Life Quality Index, Hand Eczema Severity Index) for initial assessment and monitoring treatment response. 1
• Do not recommend exclusion diets—no good-quality studies support their use in contact dermatitis management. 1
• Provide written information on patch testing, including potential side-effects, and obtain informed consent. 1

Critical Pitfalls to Avoid

• Failing to identify and remove the causative agent (allergen or irritant), which prevents healing 3
• Continuing use of topical steroids long-term in irritant contact dermatitis, which can damage the skin barrier 3
• Not considering patch testing in chronic or persistent dermatitis cases 3
• Over-promoting barrier creams as they may give false sense of security 1
• Using potent topical steroids on facial skin for prolonged periods due to increased percutaneous absorption and risk of steroid-induced damage 1

Special Considerations

Infections During Treatment

• Before commencing treatment, bacterial or viral infections at treatment sites should be resolved. 5
• Treatment with topical calcineurin inhibitors may be independently associated with increased risk of varicella zoster virus infection, herpes simplex virus infection, or eczema herpeticum. 5
• In cases where skin papillomas (warts) worsen or do not respond to conventional therapy, discontinue topical calcineurin inhibitors until complete resolution. 5

Lymphadenopathy

• Patients who develop lymphadenopathy should have the etiology investigated. 5
• In the absence of clear etiology or in the presence of acute infectious mononucleosis, discontinue topical calcineurin inhibitors. 5