What is the first line treatment for a patient with contact dermatitis?

First-Line Treatment of Contact Dermatitis

The first-line treatment for contact dermatitis consists of complete avoidance of the causative agent, mid-to-high potency topical corticosteroids (such as triamcinolone 0.1% or clobetasol 0.05%), and aggressive emollient therapy with immediate replacement of all soaps and detergents with soap substitutes. 1

Immediate Management Steps

Allergen/Irritant Avoidance

• Identify and completely avoid the causative substance—this is the cornerstone of treatment and offers the best chance for resolution. 1, 2
• Replace all soaps and detergents with emollients immediately, as these are universal irritants that perpetuate inflammation even if they are not the primary cause. 1
• For occupational exposures, arrange workplace visits to identify hidden allergens and assess procedures causing accidental exposure. 1

Topical Corticosteroid Therapy

• Apply mid-to-high potency topical corticosteroids as the primary anti-inflammatory treatment: 1, 2
  • For localized acute contact dermatitis: triamcinolone 0.1% two to three times daily 3, 2
  • For more severe cases: clobetasol propionate 0.05% twice daily for up to 2 weeks, which achieves clear or almost clear skin in 67.2% of severe cases 3
• For extensive involvement (>20% body surface area), systemic corticosteroids are often required and provide relief within 12-24 hours. 2
• In severe cases like rhus (poison ivy) dermatitis, taper oral prednisone over 2-3 weeks to prevent rebound dermatitis from rapid discontinuation. 2

Aggressive Emollient Therapy

• Apply moisturizers liberally and frequently—use two fingertip units to hands after each washing if hands are affected. 1, 3
• Consider 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, 3
• Use moisturizers packaged in tubes rather than jars to prevent contamination. 1

Protective Measures During Treatment

• Select appropriate gloves based on specific exposures: 1
  • Rubber or PVC gloves with cotton liners for general household tasks 1
  • Neoprene or nitrile gloves for latex allergy 1
  • Check Material Safety Data Sheets for permeation times—no glove is completely impermeable 1
• Remove gloves regularly to prevent sweat accumulation, which aggravates dermatitis. 1
• Apply moisturizer before wearing gloves. 1

Critical Pitfalls to Avoid

• Do not wash with dish detergent, very hot or very cold water, or disinfectant wipes. 1
• Avoid products containing topical antibiotics (especially neomycin and bacitracin) without indication, as these are common allergens. 1, 3
• Do not over-rely on barrier creams alone—they have questionable value and may create false security, reducing implementation of appropriate preventive measures. 1
• 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. 1

When to Escalate or Refer

• If dermatitis persists beyond 2 weeks despite appropriate treatment, refer for patch testing with an extended standard series of allergens to identify specific causative agents. 1, 3
• Pattern and morphology alone are unreliable in distinguishing between irritant, allergic, or endogenous dermatitis, making patch testing essential for persistent cases. 1
• Reassess after 2 weeks of treatment—if worsening or no improvement occurs, escalate therapy. 1, 3

Second-Line Therapies for Refractory Cases

• 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
• PUVA (psoralen plus UVA) phototherapy is an established second-line treatment for chronic hand eczema resistant to topical steroids, supported by prospective clinical trials. 1
• For severe chronic hand eczema specifically, offer alitretinoin. 1
• For steroid-resistant chronic contact dermatitis, consider azathioprine, ciclosporin, methotrexate, or mycophenolate mofetil. 1

Prognosis Considerations

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