What is the recommended treatment for a patient with 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 (such as triamcinolone 0.1% or clobetasol 0.05% twice daily) and aggressive emollient therapy. 1

Immediate First-Line Management

Allergen/Irritant Identification and Avoidance

• 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
• Obtain a detailed history including initial location of symptoms, spread pattern, relationship to specific products or activities, and occupational/recreational exposures 1
• For persistent cases (>2 weeks despite treatment), refer for patch testing with an extended standard series of allergens to identify specific causative agents 1, 2
• Pattern and morphology alone are unreliable in distinguishing between irritant, allergic, or endogenous dermatitis, making patch testing essential when diagnosis remains uncertain 1

Topical Corticosteroid Therapy

For localized disease:

• Apply mid-potency topical corticosteroid (triamcinolone 0.1%) twice daily for 1-2 weeks for mild-to-moderate cases 3, 4
• For more severe localized disease, escalate to high-potency corticosteroid (clobetasol 0.05%) twice daily for up to 2 weeks, which achieves clear or almost clear skin in 67.2% of severe cases 2
• Do not use high-potency topical steroids on the face, groin, axillae, or genital regions due to increased absorption and risk of skin atrophy 3

For extensive disease (>20% body surface area):

• Systemic corticosteroid therapy is often required and offers relief within 12-24 hours 4
• For severe rhus dermatitis, taper oral prednisone over 2-3 weeks to prevent rebound dermatitis from rapid discontinuation 4

Important distinction for irritant vs. allergic contact dermatitis:

• Topical steroids are the primary treatment for allergic contact dermatitis and should be applied promptly 3
• For irritant contact dermatitis, use topical steroids only after conservative measures fail, as prolonged use may damage the skin barrier 1, 3

Aggressive Emollient Therapy

• Apply moisturizers liberally and frequently—use two fingertip units to hands after each washing 1, 2
• Use moisturizers packaged in tubes rather than jars to prevent contamination 1
• Implement the "soak and smear" technique: soak affected area in plain water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks 1, 2, 3
• For trunk involvement, apply approximately 100g of moisturizer per 2 weeks 1

Protective Measures

Glove Selection and Use

• For household tasks, use rubber or PVC gloves with cotton liners 1
• For latex allergy, use accelerator-free neoprene or nitrile gloves 1
• In occupational settings, select gloves based on specific chemical exposures and check Material Safety Data Sheets for permeation times—no glove is completely impermeable 1
• Remove gloves regularly to prevent sweat accumulation, which can aggravate dermatitis 1
• Apply moisturizer before wearing gloves 1

Barrier Creams

• 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 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 2 weeks:

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, 2, 3
• Tacrolimus 0.1% is particularly useful for facial or thin-skinned areas where steroid atrophy is a concern 2
• Pimecrolimus 1% is FDA-approved for atopic dermatitis in patients 2 years and older, with 35% achieving clear or almost clear skin at 6 weeks 5
• Important safety consideration: The long-term safety is not fully established; use only on areas with active dermatitis, not continuously for prolonged periods 5

Phototherapy

• PUVA (psoralen plus UVA) is an established second-line treatment for chronic hand eczema resistant to topical steroids, supported by prospective clinical trials 1, 2

Systemic Immunosuppressants

• For severe chronic hand eczema, alitretinoin is specifically recommended (strong recommendation) 1
• Consider azathioprine or ciclosporin for steroid-resistant chronic contact dermatitis 1, 2
• Methotrexate and mycophenolate mofetil are additional options for refractory cases 1, 6

Special Considerations

Post-Surgical Contact Dermatitis

• Immediately discontinue all topical antibiotics, especially neomycin and bacitracin 2
• Switch to plain white petrolatum for wound care 2
• Apply mid-to-high potency topical corticosteroid (triamcinolone 0.1%) two to three times daily 2

Occupational Contact Dermatitis

• Arrange workplace visits to identify hidden allergens, assess procedures causing accidental exposure, and review Material Safety Data Sheets 1
• Implement comprehensive educational programs, which demonstrate improvements in established hand dermatitis and prevention of new cases 1
• Prognosis is poor: only 25% 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

Monitoring for Complications

• Monitor for signs of topical steroid allergy—paradoxically, worsening dermatitis despite treatment warrants patch testing to corticosteroid allergens 1, 3
• Watch for skin atrophy, telangiectasia, perioral dermatitis, and red face syndrome with prolonged facial corticosteroid use 1
• Patients who develop lymphadenopathy should have etiology investigated; discontinue treatment if no clear etiology or if acute infectious mononucleosis is present 1

Critical Pitfalls to Avoid

• Do not wash hands with dish detergent or other known irritants 1
• Avoid very hot or very cold water for hand washing 1
• Do not use disinfectant wipes to clean hands 1
• Avoid products containing topical antibiotics without indication 1
• Do not apply prolonged occlusion without underlying moisturizer application 1
• Do not recommend exclusion diets—no good-quality studies support their use in contact dermatitis management 1

When to Reassess and Escalate

• Reassess patients after 2 weeks of appropriate topical corticosteroid treatment 2, 3
• If no improvement after 2 weeks, perform patch testing to identify clinically relevant allergens 1, 3, 4
• For persistent dermatitis despite high-potency steroids and allergen avoidance, refer for dermatology consultation and consider second-line systemic therapies 1, 2