What is the most likely diagnosis and initial management for a 54‑year‑old white male with alcohol use disorder who developed an erythematous, painful rash after extensive application of isopropyl alcohol to his skin?

Irritant Contact Dermatitis from Isopropyl Alcohol

This patient has irritant contact dermatitis caused by extensive topical application of isopropyl alcohol (rubbing alcohol), and management consists of immediate cessation of alcohol application, gentle cleansing with lukewarm water, application of emollients or low-potency topical corticosteroids, and patient education about avoiding skin irritants.

Diagnosis

The clinical presentation is consistent with irritant contact dermatitis rather than allergic contact dermatitis, based on the following:

• Alcohols cause skin irritation primarily through direct toxic effects on the stratum corneum, causing denaturation of proteins, changes in intercellular lipids, decreased corneocyte cohesion, and decreased water-binding capacity 1
• Isopropanol is typically more irritating than ethanol, and extensive body application dramatically increases the risk of irritant dermatitis 1
• True allergic contact dermatitis to alcohols is extremely rare—surveillance data from large hospitals using alcohol-based products for over 10 years identified essentially no documented allergic reactions 1
• The immediate temporal relationship between application and symptoms, combined with extensive use over the entire body, strongly suggests irritant rather than allergic etiology 1

Immediate Management

Discontinue the Offending Agent

• Stop all topical alcohol application immediately 1
• Remove any residual alcohol from the skin with gentle cleansing using lukewarm (not hot) water 1

Skin Barrier Restoration

• Apply alcohol-free moisturizing creams or ointments twice daily, preferably containing urea (5%-10%) to restore skin barrier function 1
• Avoid hot water for bathing or showering, as this exacerbates skin barrier disruption 1

Anti-inflammatory Treatment

• Apply low-potency topical corticosteroids (e.g., hydrocortisone 2.5% or alclometasone 0.05% twice daily) to affected areas 1
• For more severe or widespread involvement, consider moderate-potency topical corticosteroids 1

Patient Education and Prevention

Avoid Skin Irritants

• Counsel the patient to avoid all skin irritants, including over-the-counter anti-acne medications, solvents, and disinfectants 1
• Emphasize that frequent washing with hot water worsens skin barrier damage 1
• Explain that alcohol-based products, while generally safe for brief hand hygiene use, cause significant irritation with extensive body application 1

Address Underlying Alcohol Use Disorder

• Given the patient's history of alcoholism and unusual behavior (applying rubbing alcohol to entire body), assess for:
  • Nutritional deficiencies that can cause cutaneous manifestations in chronic alcohol users 2, 3
  • Psychiatric comorbidities or altered judgment related to alcohol use disorder 4
  • Risk of systemic isopropanol toxicity from transdermal absorption, particularly if large quantities were used repeatedly 5

Important Clinical Caveats

Rule Out Systemic Toxicity

• Although uncommon, transdermal absorption of isopropanol can cause systemic toxicity, especially with extensive application over large body surface areas 5
• Monitor for signs of isopropanol toxicity: altered mental status, hypoglycemia, elevated osmolar gap, or acetone odor on breath 5
• If systemic symptoms are present, check serum osmolality, osmolar gap, and consider isopropanol/acetone levels 5

Distinguish from Other Alcohol-Related Dermatoses

• This presentation differs from other cutaneous manifestations of chronic alcoholism (urticaria, flushing, porphyria cutanea tarda, psoriasis) which are systemic rather than contact-related 4, 2
• Some alcohol-related rashes in chronic users may represent nutritional deficiencies and require vitamin supplementation rather than just topical therapy 2, 3

When to Suspect Allergic Rather Than Irritant Dermatitis

• True alcohol allergy would require strict avoidance of all ethanol-containing products and prescription of epinephrine auto-injector 6
• However, this diagnosis requires formal allergist evaluation and patch testing, as it remains extremely rare 1, 6
• The extensive application and immediate irritant response in this case make irritant contact dermatitis far more likely 1

Expected Course

• Irritant contact dermatitis from alcohols typically improves within days to weeks with cessation of exposure and appropriate supportive care 1
• Regular use of emollients and hand-care products can prevent recurrence and improve skin barrier function 1
• Long-term skin health depends on avoiding repeated exposure to the irritant and addressing any underlying alcohol use disorder 3