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

Treatment of Contact Dermatitis

Immediate First-Line Management

For allergic contact dermatitis, apply mid- to high-potency topical corticosteroids such as triamcinolone 0.1% or clobetasol 0.05% twice daily to localized areas, while for irritant contact dermatitis, prioritize allergen/irritant avoidance and aggressive moisturization first, reserving topical steroids only if conservative measures fail. 1, 2

The critical distinction here is that allergic contact dermatitis responds promptly to topical steroids and should be treated immediately, whereas irritant contact dermatitis may paradoxically worsen with steroids due to skin barrier damage. 1, 3

Treatment Algorithm by Type and Severity

Localized Allergic Contact Dermatitis (≤20% body surface area)

• Apply mid-potency topical corticosteroid (triamcinolone 0.1%) twice daily for 1-2 weeks for mild-moderate disease 1, 4
• Escalate to high-potency corticosteroid (clobetasol 0.05%) twice daily for severe or refractory cases 1, 4
• Very high potency steroids achieve clear or almost clear skin in 67.2% of patients with severe dermatitis within 2 weeks 2
• Critical caveat: Never use high-potency steroids on face, groin, axillae, or genitals due to increased absorption and atrophy risk 1

Widespread Allergic Contact Dermatitis (>20% body surface area)

• Initiate systemic corticosteroids (oral prednisone) for extensive involvement, providing relief within 12-24 hours 4
• Essential pitfall to avoid: For severe rhus (poison ivy) dermatitis, taper prednisone over 2-3 weeks—rapid discontinuation causes rebound dermatitis 4

Irritant Contact Dermatitis

• First-line approach: Complete avoidance of irritants, replace all soaps with emollients, and apply moisturizers immediately after every hand washing 1, 2
• Use 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, 2
• Apply two fingertip units of moisturizer to hands after each washing 2
• Only consider topical corticosteroids if conservative measures fail after 2 weeks, as steroids may damage the already compromised skin barrier 1, 2
• One study found topical corticosteroids ineffective for surfactant-induced irritant dermatitis compared to vehicle alone 3

Essential Adjunctive Measures (Apply to All Cases)

Allergen/Irritant Identification and Avoidance

• The cornerstone of treatment is complete avoidance of the causative agent—without this, all other treatments will fail 2, 5
• If dermatitis persists despite 2 weeks of appropriate topical steroid therapy, perform patch testing with an extended standard series of allergens 1, 2
• Pattern and morphology alone are unreliable for distinguishing irritant from allergic dermatitis, making patch testing essential for persistent cases 2, 6
• For occupational cases, arrange workplace visits to identify hidden allergens and assess accidental exposure routes 6, 2

Barrier Restoration

• Replace all soaps and detergents with emollients immediately—these are universal irritants that perpetuate inflammation even if not the primary cause 2, 6
• Use soap substitutes devoid of allergenic surfactants, preservatives, fragrances, or dyes 1
• Apply moisturizers packaged in tubes rather than jars to prevent contamination 2
• Lipid-rich moisturizers both prevent and treat irritant contact dermatitis 7

Protective Measures

• Select gloves based on specific chemical exposures—no glove is completely impermeable, and "impervious" gloves have finite permeation times 6, 2
• For general household tasks, use rubber or PVC gloves with cotton liners 2
• Remove gloves regularly to prevent sweat accumulation, which aggravates dermatitis 6, 2
• Important: Barrier creams alone have questionable value and should not be over-promoted, as they create false security and reduce implementation of appropriate preventive measures 6, 2
• After-work creams (applied after exposure) demonstrate benefit in reducing irritant contact dermatitis incidence and should be readily available in workplaces 6, 2

Steroid-Sparing Alternatives for Sensitive Areas

For facial and intertriginous areas where prolonged steroid use risks atrophy, telangiectasia, and perioral dermatitis:

• Consider topical calcineurin inhibitors: tacrolimus 0.1% or pimecrolimus 1, 2
• Tacrolimus 0.1% is effective for contact dermatitis and appropriate for prolonged use (≥4 weeks) on sensitive areas 1, 2
• Use these agents when topical steroids are contraindicated, have caused adverse effects, or for chronic facial dermatitis 1, 2

Second-Line Therapies for Refractory Cases

If no improvement after 2 weeks of appropriate topical therapy with confirmed allergen avoidance:

Phototherapy

• PUVA (psoralen plus UVA) is an established second-line treatment for chronic hand eczema resistant to topical steroids, supported by prospective clinical trials 6, 2

Systemic Immunosuppressants

• Consider azathioprine, cyclosporin, methotrexate, or mycophenolate mofetil for steroid-resistant chronic contact dermatitis 6, 2
• For severe chronic hand eczema specifically: Offer alitretinoin (strong recommendation) 2, 6

Critical Monitoring and Pitfalls

Watch for Treatment Failure Indicators

• Monitor for signs of topical steroid allergy—paradoxically, dermatitis may worsen despite treatment 1
• A small subset of patients develop allergic contact dermatitis to topical corticosteroids themselves, requiring patch testing to corticosteroid allergens 2
• Monitor for skin atrophy, striae, or secondary infection during treatment 1

Common Mistakes to Avoid

• 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 excessive occlusion without underlying moisturizer application 2
• Do not apply potent topical steroids to the back within 2 days of patch testing—this causes false negatives 2

Prognosis and Long-Term Management

The long-term prognosis for occupational contact dermatitis is often poor: only 25% achieve complete healing over 10 years, 50% have intermittent symptoms, and 25% have permanent symptoms. 6, 2 Changing occupation does not improve prognosis in 40% of cases. 6, 2 This underscores the critical importance of early identification and complete allergen avoidance for the best chance of resolution. 2

For milder cases with easily avoidable triggers, prognosis is favorable if the patient can completely avoid the causative agent. 6