Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

irritant contact dermatitis

1st line – moisturizer and/or topical corticosteroid + irritant avoidance

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ACUTE
|
irritant contact dermatitis
1st line – 

moisturizer and/or topical corticosteroid + irritant avoidance

After an irritant is determined, the main goals of treatment are avoidance of future exposure and resolution of existing dermatitis.

Irritant contact dermatitis (ICD) is treated by washing off the irritant as soon as possible and postexposure treatment with thick barrier protecting emollients.[41]​ 

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 allergic contact dermatitis 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. 

The potency of the topical corticosteroid used for treatment is determined by the severity and location of the dermatitis.[22]​ Low-potency corticosteroids include hydrocortisone and desonide and are generally used on the face. Medium-potency corticosteroids include betamethasone valerate and fluticasone propionate and are generally used on the torso. High-potency corticosteroids include betamethasone dipropionate and clobetasol and are generally used on palmoplantar skin.

Choice of topical corticosteroid depends on site and severity, and 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.

Primary options

hydrocortisone topical: (2.5%) children and adults: apply sparingly to the affected area(s) twice daily

OR

desonide topical: (0.05%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice daily

OR

betamethasone valerate topical: (0.1%) children and adults: apply sparingly to the affected area(s) twice daily

OR

fluticasone propionate topical: (0.005% or 0.05%) children ≥3 months of age and adults: apply sparingly to the affected area(s) once daily for up to 4 weeks

OR

betamethasone dipropionate topical: (0.05%) children ≥13 years of age and adults: apply sparingly to the affected area(s) once or twice daily

OR

clobetasol topical: (0.05%) children ≥12 years of age and adults: apply sparingly to the affected area(s) twice daily for up to 2 weeks, maximum 50 g/week

allergic contact dermatitis (ACD)

1st line – topical corticosteroid + allergen avoidance

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ACUTE
|
allergic contact dermatitis (ACD)
|
mild to moderate
1st line – 

topical corticosteroid + allergen avoidance

Severity is dependent on the distribution of ACD, the amount of distress it causes the patient, and exam findings. Mild ACD is characterized with slight erythema or scaling, moderate ACD by induration, and severe ACD by presence of bullae/vesicles.

After an allergen is determined, the main goals of treatment are avoidance of future exposure and resolution of existing dermatitis.

Topical corticosteroids are the main treatment for ACD.

Choice of vehicle (i.e., gel, solution, cream, ointment) depends on the clinical picture, patient preference, and location of dermatitis. Scalp dermatitis is best treated with a liquid or gel while hand dermatitis is best treated with an ointment. The vehicle may also affect corticosteroid potency; ointments tend to be more potent than their cream, gel, or solution equivalents.

Low-potency corticosteroids include hydrocortisone and desonide and are generally used on the face. Medium-potency corticosteroids include betamethasone valerate and fluticasone propionate and are generally used on the torso. High-potency corticosteroids include betamethasone dipropionate and clobetasol and are generally used on palmoplantar skin.

Choice of topical corticosteroid depends on site and severity, and 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.

Reassess patients for improvement after 1-2 weeks of treatment, to determine if a higher-potency corticosteroid is needed, or if the patient can be switched to a lower-potency corticosteroid or stop treatment, to avoid cutaneous adverse effects.

Patients can develop ACD to topical corticosteroids, especially with prolonged use. Consider this in patients whose dermatitis worsens with topical corticosteroid therapy.

Prevention of occupational poison ivy, oak, or sumac dermatitis is a major concern for outdoor workers.[39]

Primary options

hydrocortisone topical: (2.5%) children and adults: apply sparingly to the affected area(s) twice daily

OR

desonide topical: (0.05%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice daily

OR

betamethasone valerate topical: (0.1%) children and adults: apply sparingly to the affected area(s) twice daily

OR

fluticasone propionate topical: (0.005% or 0.05%) children ≥3 months of age and adults: apply sparingly to the affected area(s) once daily for up to 4 weeks

OR

betamethasone dipropionate topical: (0.05%) children ≥13 years of age and adults: apply sparingly to the affected area(s) once or twice daily

OR

clobetasol topical: (0.05%) children ≥12 years of age and adults: apply sparingly to the affected area(s) twice daily for up to 2 weeks, maximum 50 g/week

2nd line – topical calcineurin inhibitor or topical PDE4 inhibitor + allergen avoidance

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ACUTE
|
allergic contact dermatitis (ACD)
|
mild to moderate
2nd line – 

topical calcineurin inhibitor or topical PDE4 inhibitor + allergen avoidance

Topical calcineurin inhibitors (tacrolimus or pimecrolimus) or phosphodiesterase 4 (PDE4) inhibitors (e.g., crisaborole) 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]​​​​​​

Primary options

tacrolimus topical: (0.03%) children ≥2 years of age and adults: apply to the affected area(s) twice daily; (0.1%) children ≥15 years of age and adults: apply to the affected area(s) twice daily

OR

pimecrolimus topical: (1%) children ≥2 years of age and adults: apply to the affected area(s) twice daily

OR

crisaborole topical: (2%) children ≥3 months of age and adults: apply to the affected area(s) twice daily

3rd line – phototherapy + allergen avoidance

Back
ACUTE
|
allergic contact dermatitis (ACD)
|
mild to moderate
3rd line – 

phototherapy + allergen avoidance

Used for patients with contact dermatitis resistant to treatment with topical and oral corticosteroids; patients in whom topical corticosteroids are ineffective and oral corticosteroids are contraindicated; and patients who cannot avoid repeated exposure to the causative allergen or irritant.

Broadband UV-B (BUVB) and psoralen plus ultraviolet-A (PUVA) are effective in the treatment of contact dermatitis. They may cause phototoxic reactions, especially with PUVA. PUVA is effective in hand dermatitis.[5]

Dosing is based on the specific light source and patient skin type.

1st line – topical corticosteroid + allergen avoidance

Back
ACUTE
|
allergic contact dermatitis (ACD)
|
severe
1st line – 

topical corticosteroid + allergen avoidance

Severity is dependent on the distribution of ACD, the amount of distress it causes the patient, and exam findings. Mild ACD is characterized with slight erythema or scaling, moderate ACD by induration, and severe ACD by presence of bullae/vesicles.

After an allergen is determined, the main goals of treatment are avoidance of future exposure and resolution of existing dermatitis.

Topical corticosteroids are the main treatment for ACD.

Choice of vehicle (i.e., gel, solution, cream, ointment) depends on the clinical picture, patient preference, and location of dermatitis. Scalp dermatitis is best treated with a liquid or gel while hand dermatitis is best treated with an ointment. The vehicle may also affect corticosteroid potency; ointments tend to be more potent than their cream, gel, or solution equivalents.

Low-potency corticosteroids include hydrocortisone and desonide and are generally used on the face. Medium-potency corticosteroids include betamethasone valerate and fluticasone propionate and are generally used on the torso. High-potency corticosteroids include betamethasone dipropionate and clobetasol and are generally used on palmoplantar skin.

Choice of topical corticosteroid depends on site and severity, and 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.

Reassess patients for improvement after 1-2 weeks of treatment, to determine if a higher-potency corticosteroid is needed, or if the patient can be switched to a lower-potency corticosteroid or stop treatment, to avoid cutaneous adverse effects.

Patients can develop ACD to topical corticosteroids, especially with prolonged use. Consider this in patients whose dermatitis worsens with topical corticosteroid therapy.

Primary options

hydrocortisone topical: (2.5%) children and adults: apply sparingly to the affected area(s) twice daily

OR

desonide topical: (0.05%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice daily

OR

betamethasone valerate topical: (0.1%) children and adults: apply sparingly to the affected area(s) twice daily

OR

fluticasone propionate topical: (0.005% or 0.05%) children ≥3 months of age and adults: apply sparingly to the affected area(s) once daily for up to 4 weeks

OR

betamethasone dipropionate topical: (0.05%) children ≥13 years of age and adults: apply sparingly to the affected area(s) once or twice daily

OR

clobetasol topical: (0.05%) children ≥12 years of age and adults: apply sparingly to the affected area(s) twice daily for up to 2 weeks, maximum 50 g/week

2nd line – oral corticosteroid + allergen avoidance

Back
ACUTE
|
allergic contact dermatitis (ACD)
|
severe
2nd line – 

oral corticosteroid + allergen avoidance

Used in severe ACD or ACD due to Toxicodendron species (poison ivy).

Prednisone is the oral corticosteroid of choice. Requires hydroxylation in the liver for conversion to active form, so reduced efficacy may be seen in patients with liver disease.

Taper dose over a 2- to 3-week course.

Primary options

prednisone: children and adults: 0.5 to 1 mg/kg/day orally

3rd line – phototherapy + allergen avoidance

Back
ACUTE
|
allergic contact dermatitis (ACD)
|
severe
3rd line – 

phototherapy + allergen avoidance

Used for patients with contact dermatitis resistant to treatment with topical and oral corticosteroids; patients in whom topical corticosteroids are ineffective and oral corticosteroids are contraindicated; and patients who cannot avoid repeated exposure to the causative allergen or irritant.

Broadband UV-B (BUVB) and psoralen plus ultraviolet-A (PUVA) are effective in the treatment of contact dermatitis. They may cause phototoxic reactions, especially with PUVA. PUVA is effective in hand dermatitis.[5]

Dosing is based on the specific light source and patient skin type.

4th line – systemic immunosuppressant + allergen avoidance

Back
ACUTE
|
allergic contact dermatitis (ACD)
|
severe
4th line – 

systemic immunosuppressant + allergen avoidance

Cyclosporine, mycophenolate, and azathioprine can be used for the treatment of refractory contact dermatitis when oral corticosteroids are contraindicated and phototherapy is not available or is ineffective.[40]

If possible, continued allergen avoidance is advised.

Primary options

azathioprine: children and adults: consult specialist for guidance on dose

OR

cyclosporine modified: children and adults: consult specialist for guidance on dose

OR

mycophenolate mofetil: children and adults: consult specialist for guidance on dose

ONGOING

contact dermatitis

1st line – allergen/irritant avoidance ± prophylactic skin protectants

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ONGOING
|
contact dermatitis
1st line – 

allergen/irritant avoidance ± prophylactic skin protectants

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 also reduce oleoresin absorption and decrease the severity of dermatitis.[46] 

Dimethicone-containing barrier cream is used for the prevention of irritant contact dermatitis (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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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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