What is the recommended treatment for a patient with irritant contact dermatitis?

Treatment of Irritant Contact Dermatitis

The cornerstone of treating irritant contact dermatitis is immediate and complete avoidance of all irritants, replacement of all soaps and detergents with emollients, aggressive moisturization applied immediately after washing, and mid-to-high potency topical corticosteroids if conservative measures fail within 7-10 days. 1

Immediate First-Line Management

Irritant Avoidance and Substitution

• Eliminate all soaps, detergents, and cleansers immediately—these are universal irritants that perpetuate inflammation even if they are not the primary cause. 1
• Replace with fragrance-free, dye-free emollients or soap substitutes for all washing activities. 1, 2
• Avoid washing with dish detergent, very hot or very cold water, and disinfectant wipes. 1
• Stop using products containing topical antibiotics, as these commonly cause sensitization without clear benefit. 1, 2

Aggressive Moisturization Protocol

• Apply moisturizers immediately after every hand washing—this is critical for barrier repair. 1, 2
• Use the "soak and smear" technique for intensive treatment: soak affected area in plain water for 20 minutes, then immediately apply moisturizer to damp skin nightly for up to 2 weeks. 1, 3
• Use tube-packaged moisturizers rather than jars to prevent contamination. 1, 2
• Apply two fingertip units of moisturizer to hands after each washing. 1
• For trunk areas, use approximately 100g per 2 weeks. 1

Topical Corticosteroid Therapy

When Conservative Measures Fail

• If irritant avoidance and moisturization fail after 7-10 days, escalate to mid-to-high potency topical corticosteroids. 1, 2
• For body sites (hands, trunk, extremities): use triamcinolone 0.1% or betamethasone valerate 0.1% initially. 1, 4
• For facial dermatitis: use only low-potency steroids (hydrocortisone 1%) due to high risk of steroid-induced atrophy, telangiectasia, and perioral dermatitis from increased percutaneous absorption. 1, 2

Severe or Persistent Cases

• For severe dermatitis that fails mid-potency steroids, escalate to very high potency topical corticosteroids such as clobetasol propionate 0.05% for 2 weeks. 1, 3
• This achieves clear or almost clear skin in 67.2% of patients with severe dermatitis within 2 weeks, compared to 22.3% with vehicle. 1, 3
• Adverse events are low, with only 0.8% withdrawals in treatment groups versus 11.3% in vehicle groups. 1
• Critical caveat: Prolonged topical corticosteroid use damages the skin barrier—limit high-potency steroids to 2 weeks and avoid chronic use. 1, 2

Protective Measures for Hand Dermatitis

Glove Selection and Use

• Use rubber or PVC gloves with cotton liners for household tasks. 1
• Remove gloves regularly to prevent sweat accumulation, which aggravates dermatitis. 1
• Apply moisturizer before wearing gloves. 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

Barrier Creams: Limited Value

• 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 to Escalate

• Consider second-line therapies if dermatitis persists after 2 weeks of high-potency topical steroids and complete irritant avoidance. 1, 3

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, 3
• Topical tacrolimus avoids the risk of skin atrophy and is particularly important for facial and intertriginous areas like the axilla. 1, 3

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

Systemic Therapies for Severe Chronic Cases

• For steroid-resistant chronic contact dermatitis, consider azathioprine or ciclosporin, both supported by prospective clinical trials. 1
• For severe chronic hand eczema specifically, offer alitretinoin (strong recommendation). 1

Distinguishing Irritant from Allergic Contact Dermatitis

Clinical Features Are Unreliable

• Pattern and morphology of dermatitis, especially on hands and face, is unreliable in distinguishing between irritant, allergic, or endogenous dermatitis. 1
• Irritant contact dermatitis results from single overwhelming exposure or repetitive exposure to weaker irritants such as detergents, solvents, or soaps. 1, 5

When to Pursue Patch Testing

• Refer for patch testing to at least an extended standard series of allergens if dermatitis persists beyond 4 weeks despite treatment or if the causative agent remains unknown. 1, 3
• Do not apply potent topical steroids to the back within 2 days of patch testing, as this causes false negatives. 1
• Avoid oral corticosteroids or immunosuppressants during patch testing; if unavoidable, keep prednisolone ≤10 mg daily. 1

Occupational Irritant Contact Dermatitis

Workplace Assessment

• Arrange workplace visits to identify hidden irritants, assess procedures causing accidental exposure, and review Material Safety Data Sheets. 1
• Implement comprehensive educational programs for occupational contact dermatitis, which demonstrate improvements in established hand dermatitis and prevention of new cases. 1

Poor 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 despite treatment. 1, 3
• Changing occupation does not improve prognosis in 40% of cases. 1
• Early identification and complete avoidance of irritants offers the best chance for resolution. 1, 3

Common Pitfalls to Avoid

• Failing to identify and completely remove the causative irritant prevents healing—this is the most common error. 2
• Continuing to use soaps and detergents instead of replacing them with emollients perpetuates inflammation. 1
• Prolonged occlusion without underlying moisturizer application worsens dermatitis. 1
• Using very hot or very cold water for hand washing increases irritation. 1
• Applying topical antibiotics without clear indication introduces unnecessary sensitization risk. 1, 2
• Over-promoting barrier creams creates false security and reduces implementation of proper protective measures. 1