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

Treatment of Contact Dermatitis

Complete avoidance of the causative allergen or irritant combined with mid-to-high potency topical corticosteroids and aggressive emollient therapy is the cornerstone of contact dermatitis treatment. 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 2, 1
• 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
• For occupational cases, arrange workplace visits to identify hidden allergens, assess procedures causing accidental exposure, and review Material Safety Data Sheets 2, 1

Topical Corticosteroid Therapy

• Apply mid-to-high potency topical corticosteroids such as triamcinolone 0.1% or clobetasol 0.05% twice daily to localized areas of allergic contact dermatitis 3, 4
• For irritant contact dermatitis, use topical steroids only after conservative measures fail, as they may damage the skin barrier 3
• Do not use high-potency topical steroids on the face, groin, axillae, or genital region due to increased absorption and risk of skin atrophy 3
• Maximum treatment duration is up to 12 weeks for high or medium potency topical steroids 3

Aggressive Moisturization

• Apply moisturizer immediately after hand washing, using two fingertip units for adequate hand coverage 1, 5
• 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, 3
• Choose moisturizers in tubes rather than jars to prevent contamination 1, 5
• Apply 100g per 2 weeks for trunk area coverage 1

Protective Measures

Glove Selection and Use

• Select gloves based on specific chemical exposures and check Material Safety Data Sheets for permeation times—no glove is completely impermeable 2, 1
• For general household tasks, use rubber or PVC gloves with cotton liners 2, 1
• For glove-related allergic contact dermatitis, use accelerator-free gloves such as rubber-free neoprene or nitrile 1, 5
• Remove gloves regularly to prevent sweat accumulation, which can aggravate dermatitis 1
• For healthcare workers, use water-based moisturizers under gloves, as oil-based moisturizers can break down latex and rubber 5

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 2, 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 Treatment

• If no improvement after 2 weeks of appropriate topical steroid therapy, perform patch testing to identify clinically relevant allergens 3
• Consider advanced treatment when hand dermatitis does not improve after 6 weeks of treatment 5

Topical Alternatives

• Consider topical tacrolimus 0.1% where topical steroids are unsuitable, ineffective, or when chronic facial dermatitis raises concerns about steroid-induced skin damage 2, 1, 3
• For facial and intertriginous areas, consider topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus) as steroid-sparing alternatives 3

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 2, 1

Systemic Therapies

• For severe chronic hand eczema specifically, offer alitretinoin (strong recommendation) 2, 1
• Consider methotrexate, mycophenolate mofetil, azathioprine, or ciclosporin for steroid-resistant chronic contact dermatitis 1
• For extensive disease requiring systemic steroids, initiate oral prednisone at 0.5-1 mg/kg/day and taper over 2-3 weeks minimum to prevent rebound dermatitis 3, 4
• For severe rhus dermatitis, oral prednisone should be tapered over at least 2-3 weeks because rapid discontinuation causes rebound dermatitis 4

Material Substitution Strategies

• 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 2, 1

Patient Education and Occupational Considerations

• Implement comprehensive educational programs for occupational contact dermatitis, which demonstrate improvements in established hand dermatitis and prevention of new cases 2, 1
• Compliance with skin-protection programs is often poor, requiring ongoing reinforcement 1
• Consider occupational modification for recalcitrant cases 5, 3

Critical Pitfalls to Avoid

• Avoid washing hands with dish detergent or other known irritants 1
• Do not use very hot or very cold water for hand washing 1
• Avoid disinfectant wipes for hand cleaning 1, 5
• Do not apply products containing topical antibiotics without indication 1
• Avoid prolonged occlusion without underlying moisturizer application 1
• Do not apply gloves when hands are still wet from hand washing or sanitizer 5
• Do not use superglue to glue inflammatory or healing fissures 5
• Monitor for signs of topical steroid allergy—paradoxically, worsening dermatitis despite treatment 3

What NOT to Recommend

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

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 2, 1
• Changing occupation does not improve prognosis in 40% of cases 2, 1
• Early identification and complete avoidance of allergens offers the best chance for resolution 1

When to Refer to Dermatology

• Refer for suspected allergic contact dermatitis requiring patch testing 5
• Refer for recalcitrant hand dermatitis not responding to initial treatments 5
• Refer when there is a change in baseline hand dermatitis 5
• Refer for consideration of phototherapy or systemic immunosuppressants 1, 3