What are the treatment guidelines for a patient with contact dermatitis?

Contact Dermatitis Treatment Guidelines

First-Line Treatment: Avoidance and Topical Therapy

The cornerstone of contact dermatitis treatment is complete avoidance of the causative allergen or irritant combined with mid-to-high potency topical corticosteroids and aggressive emollient therapy. 1, 2

Immediate Management Steps

• 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, 2
• Apply mid-to-high potency topical corticosteroids (such as triamcinolone 0.1% or clobetasol 0.05%) to affected areas 3-4 times daily 3, 4
• Use moisturizers packaged in tubes rather than jars to prevent contamination, applying two fingertip units to hands after each washing 2
• For trunk areas, apply approximately 100g of moisturizer per 2 weeks to restore skin barrier function 2

"Soak and Smear" Technique for Severe Cases

• Soak affected areas in plain water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks 2
• This technique maximizes moisturizer penetration and barrier repair 2

Diagnostic Workup: Identifying the Culprit

Obtain patch testing with an extended baseline series of allergens for any persistent or chronic dermatitis, as clinical features alone cannot reliably distinguish between irritant, allergic, or endogenous dermatitis, particularly on hands and face. 1, 2

Key History Elements to Elicit

• Initial location of symptoms and spread pattern 2
• Relationship to specific products or activities 2
• Occupational and recreational exposures 2
• Timing of symptom onset relative to new product use 2

Critical Patch Testing Precautions

• Do not apply potent topical steroids to the back within 2 days of patch testing, as this causes false negatives 2
• Avoid oral corticosteroids or immunosuppressants during patch testing; if unavoidable, keep prednisolone ≤10 mg daily 2
• Obtain written informed consent and provide information on potential side effects 2

Protective Measures and Substitution

Glove Selection Based on Exposure

• Select gloves based on specific chemical exposures and check Material Safety Data Sheets for permeation times—no glove is completely impermeable 1, 2
• For general household tasks, use rubber or PVC gloves with cotton liners 1, 2
• For latex allergy, use accelerator-free neoprene or nitrile gloves 2
• Remove gloves regularly to prevent sweat accumulation, which aggravates dermatitis 2
• Apply moisturizer before wearing gloves 2

Material Substitution Examples

• Use thiuram-free gloves for rubber chemical allergy 1
• Change biocides in industrial coolant oils for occupational exposures 1
• Use isothiazolinone-free creams/cleansers for preservative allergy 1
• Use fragrance-free detergents and avoid metal belt buckles if nickel-sensitive 2

Critical Pitfall: Barrier Creams

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, 2 However, after-work creams (applied after exposure) have demonstrated benefit in reducing irritant contact dermatitis incidence 1, 2

Escalation for Refractory Cases

When to Escalate Topical Therapy

For persistent contact dermatitis that has failed mid-potency steroids, escalate to very high potency topical corticosteroids, such as clobetasol propionate 0.05%, for 2 weeks. 2

• Very high potency topical corticosteroids achieve clear or almost clear skin in 67.2% of patients with severe dermatitis, compared to 22.3% with vehicle, over a 2-week period 2
• Adverse events are low, with fewer withdrawals in treatment groups (0.8%) compared to vehicle groups (11.3%) 2

Facial-Specific Precautions

Exercise extreme caution with topical corticosteroids on facial skin—prolonged use causes skin thinning, telangiectasia, perioral dermatitis, and red face syndrome, due to increased percutaneous absorption. 2, 5

• For chronic facial dermatitis, consider topical tacrolimus 0.1% as an alternative to avoid steroid-induced atrophy 2, 5
• Topical tacrolimus has demonstrated effectiveness in allergic contact dermatitis models 1, 2

Second-Line Therapies for Steroid-Resistant Disease

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

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, 2

Systemic Immunosuppressants

• Consider methotrexate, mycophenolate mofetil, azathioprine, or ciclosporin for steroid-resistant chronic contact dermatitis 1, 2
• For severe chronic hand eczema specifically, offer alitretinoin (strong recommendation) 1, 2

Systemic Corticosteroids for Extensive Disease

• If allergic contact dermatitis involves an extensive area of skin (greater than 20%), systemic steroid therapy is often required and offers relief within 12-24 hours 4
• In patients with severe rhus dermatitis, oral prednisone should be tapered over 2-3 weeks because rapid discontinuation causes rebound dermatitis 4

Occupational Contact Dermatitis: Special Considerations

Workplace Assessment

• Arrange workplace visits to identify hidden allergens, assess procedures causing accidental exposure, and review Material Safety Data Sheets 1, 2
• Workplace visits are essential for identifying potential allergens and irritants and are critical for effective treatment and prevention 2

Educational Programs

• Implement comprehensive educational programs for occupational contact dermatitis, which demonstrate improvements in established hand dermatitis and prevention of new cases 1, 2
• Compliance with skin-protection programs is often poor, requiring ongoing reinforcement 1

Sobering Prognosis

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, 2
• Early identification and complete avoidance of allergens offers the best chance for resolution 2

What to Avoid: Common Pitfalls

Products and Practices to Eliminate

• Do not wash hands with dish detergent or other known irritants 2
• Avoid very hot or very cold water for hand washing 2
• Do not use disinfectant wipes to clean hands 2
• Avoid products containing topical antibiotics without clear indication 2
• Do not apply prolonged occlusion without underlying moisturizer application 2

Ineffective Interventions

• Do not recommend exclusion diets—no good-quality studies support their use in contact dermatitis management 1, 2

Monitoring and Assessment Tools

• Use clinical assessment tools (Dermatology Life Quality Index, Hand Eczema Severity Index) for initial assessment and monitoring treatment response 2
• Reassess at 7 days; if symptoms persist or worsen, refer for patch testing and dermatology consultation 3