Approach
After an allergen or irritant is identified, the main goals of treatment are avoidance of future exposure, skin protection, and resolution of existing dermatitis.[22]
Allergic contact dermatitis (ACD)
Severity is dependent on the distribution of ACD, the amount of distress it causes the patient, and examination findings. Mild ACD is characterized with slight erythema or scaling, moderate ACD by induration, and severe ACD by presence of bullae/vesicles.
The main treatments for ACD are topical corticosteroids, topical calcineurin inhibitors (pimecrolimus and tacrolimus), or topical phosphodiesterase 4 (PDE4) inhibitors (e.g., crisaborole). All are approved for the treatment of atopic dermatitis, but not ACD.
The vehicle of the topical treatment is important. The effectiveness of topical therapies may be related to their emollient properties, as they have high lipid content. In general, ointments are more effective than creams due to their high lipid content. Scalp dermatitis is best treated with a liquid or gel while hand dermatitis is best treated with an ointment.
Topical corticosteroids are first-line treatment.[22] The potency of the topical corticosteroid used for treatment is determined by the severity and location of the dermatitis.
High- to mid-potency corticosteroids can be used on thicker-skinned areas such as the torso, scalp, palms, and soles.
Low-potency corticosteroids or topical calcineurin inhibitors should be used on areas with thinner skin, such as skin folds, neck, and face, to avoid skin atrophy, telangiectasia, hypopigmentation, and striae.
Choice of topical corticosteroid may differ between adults and children. For example, an infant with severe dermatitis on the face may require desonide, while an adult with mild dermatitis on the face may require hydrocortisone.
Topical calcineurin inhibitors or PDE4 inhibitors can be used as second-line therapy for mild to moderate ACD, when other prescription topical treatments fail or are not indicated. Topical calcineurin inhibitors are useful in thin-skinned areas, where use of an equivalent-potency topical corticosteroid may lead to skin atrophy, telangiectasia, hypopigmentation, and striae. Pimecrolimus and tacrolimus are effective in nickel-induced ACD, but pimecrolimus cream was not effective for the treatment of Toxicodendron oleoresin ACD.[36][37][38]
Severe ACD may require treatment with oral corticosteroids. For example, Toxicodendron species oleoresin may be present in the skin for up to 3 weeks after contact, and symptoms may be severe. In severe cases, a 3-week tapering dose of oral corticosteroids can be started within a few days of exposure. Shorter courses may suffice if there is a delay between symptom onset and treatment. If oral corticosteroids are contraindicated or topical and oral corticosteroids fail, phototherapy can be used. Prevention of occupational poison ivy, oak, or sumac dermatitis is a major concern for outdoor workers.[39]
Phototherapy with UV-B and psoralen plus ultraviolet-A (PUVA) are effective in ACD and irritant contact dermatitis (ICD). PUVA is effective in hand dermatitis.[5] Phototherapy should be avoided if phototoxic or photoallergic dermatitis is expected.
The immunosuppressants cyclosporine, mycophenolate, and azathioprine may be used to treat refractory cases of contact dermatitis when oral corticosteroids are contraindicated and phototherapy is not available or is ineffective.[40]
Irritant contact dermatitis (ICD)
After an irritant is determined, the main goals of treatment are avoidance of future exposure and resolution of existing dermatitis. ICD is treated by washing off the irritant as soon as possible and postexposure treatment with thick barrier protecting emollients.[41]
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Moisturizers without fragrance, antibacterials, or urea are preferred as these substances often cause sensitization. In one study, 45.3% of patients with fragrance contact allergy succeeded in finding some scented products that they could tolerate (e.g., by use of ingredient labeling), but a significant proportion had continued skin problems.[42] Cream or ointments are preferable over lotions or gels.
Topical corticosteroids are also commonly used for ICD, because treatment is often initiated before ICD and ACD differentiation, but very few studies have been performed to evaluate the effectiveness of topical corticosteroids for treatment of ICD, and the results of these studies are conflicting.[43] However, topical corticosteroids can be used if moisturizers are not effective. As with ACD, the potency of the topical corticosteroid used for treatment is determined by the severity and location of the dermatitis.
Management following resolution of the acute episode
The mainstay of management is avoidance of exposure to the allergen or irritant. If elimination or substitution is impractical, then the next most effective way of preventing skin disease is to design and operate processes to avoid contact in the first place.[44]
Quaternium-18-bentonite lotion (Organoclay) is used for the prevention of allergic contact dermatitis from Toxicodendron species oleoresin. Recommend application 15 minutes before anticipated exposure. One clinical trial suggested that the application of topical quaternium-18 bentonite lotion 15 minutes prior to contact with poison ivy can prevent or reduce the severity of dermatitis.[45] Washing with dish soap and scrubbing in one direction within 2 hours of contact can reduce oleoresin absorption and decrease the severity of dermatitis.[46]
Dimethicone-containing barrier cream is used for the prevention of ICD.[47] Recommend application prior to anticipated exposure.
Apply white soft paraffin to areas affected by ICD or areas that may come into contact with an irritant or allergen for the prevention and treatment of all types of contact dermatitis.
The use of occlusive gloves can potentiate ICD, and very few gloves are protective against all external agents. Cotton glove liners may improve protection when worn under occlusive gloves.[22][41]
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