contact dermatitis

Guidelines for the Management of Contact Dermatitis: An Update: Intervention and Treatment

J. Bourke,¹ I. Coulson* and J. English †
http://www.medscape.com/viewarticle/703348_6

Intervention and Treatment of Irritant Contact Dermatitis

The management of irritant contact dermatitis principally involves the protection of the skin from irritants. The most common irritants are soaps and detergents, although water itself is also an irritant. In occupational settings other irritants such as oils and coolants, alkalis, acids and solvents may be important. The principles of management involve avoidance, protection and substitution, as follows.

Avoidance. In general, this is self-evident. However, a visit to the workplace may be necessary to identify all potential skin hazards.

Protection. Most irritant contact dermatitis involves the hands. Gloves are therefore the mainstay of protection. For general purposes and household tasks, rubber or polyvinyl chloride household gloves, possibly with a cotton liner or worn over cotton gloves, should suffice. It is important to take off the gloves on a regular basis as sweating may aggravate existing dermatitis. There is also some evidence that occlusion by gloves may impair the stratum corneum barrier function[45] (Quality of evidence I). In an occupational setting, the type of glove used will depend upon the nature of the chemicals involved. Health and safety information for handling the chemical should stipulate which gloves ought to be used[46] (Appendix 5). Exposure time is an important factor in determining the most appropriate glove as so-called 'impervious' gloves have a finite permeation time for any particular substance; a glove may be protective for a few minutes but not for prolonged contact, e.g. NRL gloves and methacrylate bone cement.

Substitution. It may be possible to substitute nonirritating agents. The most common example of this is the use of a soap substitute. Correct recycling of oils in heavy industry and reduction of, or changing, the biocide additives may help.

Allergic Contact Dermatitis
Detection and avoidance of the allergen is often easier said than done. Again, a site visit may be necessary to identify the source of allergen contact and methods of avoidance. It may be necessary to contact manufacturers of products to determine if the allergen is present. It may also be necessary to contact a number of manufacturers to identify suitable substitutes.

Visiting the Workplace
Visiting the workplace has an important place in the management of contact dermatitis. Apart from identifying potential allergens and irritants, it may be essential in the effective treatment and prevention of contact dermatitis (Quality of evidence III) (Strength of recommendation B). More information about the indications for visiting a patient's workplace and how to go about it are given elsewhere.[47]

Barrier Creams and After-work Creams?
Barrier creams by themselves are of questionable value in protecting against contact with irritants[48,49] (Quality of evidence I) (Strength of recommendation E). Their use should not be overpromoted as this may confer on workers a false sense of security and encourage them to be complacent in implementing the appropriate preventive measures.

After-work creams appear to confer some degree of protection against developing irritant contact dermatitis. There are controlled clinical trials showing benefit in the use of soap substitutes[50] and after-work creams[51] in reducing the incidence and prevalence of contact dermatitis (Quality of evidence I) (Strength of recommendation A). They should be encouraged and made readily available in the workplace.

Topical Corticosteroids
Topical corticosteroids, soap substitutes and emollients are widely accepted as the treatment of established contact dermatitis. There is one study demonstrating a marginal benefit of the use of a combined topical corticosteroid/antibiotic combination[52] in infected or potentially infected eczema (Quality of evidence IV) (Strength of recommendation C). There is an open prospective randomized trial demonstrating the long-term intermittent use of mometasone furoate in chronic hand eczema[53] (Quality of evidence I) (Strength of recommendation B).

Topical tacrolimus has been shown to be effective in a nickel model of allergic contact dermatitis.[54]

Second-line Treatments
Second-line treatments such as psoralen plus UVA, azathioprine and ciclosporin are used for steroid-resistant chronic hand dermatitis. There are several prospective clinical trials to support these treatments[55-57] (Quality of evidence I) (Strength of recommendation A). A randomized controlled trial of Grenz rays for chronic hand dermatitis showed a significantly better response with this therapy compared with use of topical corticosteroids[58] (Quality of evidence I) (Strength of recommendation B). Oral retinoids have been used in the treatment of chronic hand eczema with a recently published trial of alitretinoin showing promise[59] (Quality of evidence I) (Strength of recommendation B).

Nickel Elimination Diets
There is some evidence[60,61] to support the benefit of low nickel diets in some nickel-sensitive patients (Quality of evidence IV) (Strength of recommendation C).