Approach Considerations
Topical corticosteroids are the mainstay of treatment, while a variety of symptomatic treatments can provide short-term relief of pruritus. However, the definitive treatment of allergic contact dermatitis is the identification and removal of any potential causal agents; otherwise, the patient is at increased risk for chronic or recurrent dermatitis. Online resources allow the physician to create a list of products free of allergens to which the patient is allergic.
Go to Irritant Contact Dermatitis, Pediatric Contact Dermatitis, and Protein Contact Dermatitis for complete information on these topics.
Symptomatic Treatment
Topical soaks with cool tap water, Burow solution (1:40 dilution), saline (1 tsp/pint) can be soothing. Cool compresses with saline or aluminum acetate solution are helpful for acute vesicular dermatitis (eg, poison ivy). Some individuals with widespread vesicular dermatitis may obtain relief from lukewarm oatmeal baths.
Large vesicles may rarely benefit from therapeutic drainage (but not removing the vesicle tops). [28] Puncturing or incising vesicles may introduce bacteria and lead to infection. These lesions should then be covered with dressing soaked in Burow solution.
Emollients (eg, white petrolatum, Eucerin) may be beneficial in chronic cases.
Sedating oral antihistamines may help diminish pruritus via a central effect. Patients should avoid using topical antihistamines, including topical doxepin, [29] because of the apparently high risk of iatrogenic allergic contact dermatitis to these agents; additionally, sedation can occur if large amounts of doxepin cream are applied.
Corticosteroids
Topical corticosteroids are the mainstay of treatment, with the strength of the topical corticosteroid appropriate to the body site. For severe allergic contact dermatitis of the hands, 3-week courses of class I topical corticosteroids are required, while class 6 or class 7 topical corticosteroids typically are used for allergic contact dermatitis of intertriginous areas or the face.
Acute severe allergic contact dermatitis, such as from poison ivy, often needs to be treated with a 2-week course of systemic corticosteroids. Most adults require an initial dose of 40-60 mg. The oral corticosteroid is tapered over a 2-week period, but a complicated tapering regimen probably is not necessary given the short duration of systemic corticosteroid use.
The systemic corticosteroids must be administered for 2 weeks, because shorter courses are notorious for allowing poison ivy dermatitis to relapse. Long-acting intramuscular triamcinolone acetonide (Kenalog) 40-60 mg may be used in place of oral prednisone.
Long-term use of systemic corticosteroids to treat allergic contact dermatitis may produce severe morbidity. Individuals with allergic contact dermatitis should not receive long-term systemic corticosteroids or immunosuppressives unless extensive patch testing and evaluation have failed to identify remedial causes of the severe dermatitis.
Long-term widespread use of potent topical corticosteroids may produce local skin atrophy and systemic adverse effects. In particular, use around the eyes may theoretically cause cataracts, glaucoma, corneal thinning/perforation, and loss of the eye.
Allergy to corticosteroid molecules without C16-methyl substitution in the D-ring (ie, groups A [eg, hydrocortisone, hydrocortisone-21-butyrate] and D2 [eg, hydrocortisone-17-butyrate] may be much more frequently observed than allergy to those corticosteroid molecules that are halogenated and have a methyl group at C16 (ie, groups D1 [eg, betamethasone dipropionate, clobetasol propionate, diflorasone diacetate, fluticasone propionate, mometasone furoate] and C [eg, desoximetasone, desoxymethasone]). [30] C16-methylated corticosteroids should be preferentially prescribed if topical corticosteroid treatment is indicated.
Topical Immunomodulators
Topical immunomodulators (TIMs) are approved for atopic dermatitis and are prescribed for cases of allergic contact dermatitis when they offer safety advantages over topical corticosteroids. TIMs do not cause cutaneous atrophy, glaucoma, or cataracts when applied near the eye.
Topical tacrolimus is an option in patients with allergic contact eyelid dermatitis not controlled by brief courses of class l or ll topical corticosteroids and allergen avoidance. [31] Pimecrolimus (Elidel cream) is a topical treatment that may be helpful for mild allergic contact dermatitis of the face. Tacrolimus (Protopic 0.1% ointment) is the most helpful TIM for allergic contact dermatitis of the hands. [32]
Phototherapy
Individuals with chronic allergic contact dermatitis that is not controlled well by topical corticosteroids may benefit from psoralen plus ultraviolet-A (PUVA) treatments. Psoralen is a photosensitizer that is ingested prior to light exposure. Narrow-band UVB phototherapy may be as effective. Light at 308 nm can also be delivered to limited chronic areas of dermatitis.
Immunosuppressive Agents
Rarely, chronic immunosuppressive agents, such as azathioprine (Imuran), [33] mycophenolate (CellCept), or cyclosporine (Neoral), are used in recalcitrant cases of severe chronic widespread allergic contact dermatitis or severe hand dermatitis that prevents the individual from working or performing daily activities. Biologicals active on T cells may be helpful in the future.
Disulfiram
Occasionally, an individual who is highly allergic to nickel with severe vesicular hand dermatitis benefits from treatment with disulfiram (Antabuse). The chelating effect of disulfiram is helpful in reducing the body's nickel burden. Alcohol ingestion may produce severe adverse reactions in patients taking disulfiram.
Diet
Some chemicals tested by the TRUE test may be present in the diet. Individuals with severe dermatitis, particularly if it is a disabling vesicular dermatitis of the hands, may be treated with diets low in minerals and chemicals to which the individual is allergic. A low-nickel diet is the most common, but published diets are available that are low in chromate, cobalt, or balsam of Peru. These diets may be attempted for the occasional allergic patient with severe chronic vesicular dermatitis.
Hospital Admission
Inpatient care rarely is required for allergic contact dermatitis (ACD) unless the dermatitis is so severe that patients cannot care for themselves. Examples may include severe allergic contact dermatitis with marked eyelid swelling that impairs vision or severe allergic contact dermatitis of the penis, which may impede urination. If patients develop chronic severe allergic reactions to their home or workplace, they may require a temporary change of environment until the cause of the dermatitis is identified.
Activity
Individuals with severe acute allergic contact dermatitis may be incapacitated temporarily and unable to work. Most individuals with allergic contact dermatitis may require light duties or restrictions of duties. They should avoid further contact with the chemicals to which they are allergic or chemicals that cross-react with these materials. Patients also should minimize exposure to irritant chemicals, particularly if the dermatitis is active or recently resolved.
Prevention
To prevent recurrence of allergic contact dermatitis, instruct patients thoroughly concerning allergen(s) and the types of products likely to contain allergen(s). For many patients with allergic reactions to fragrances, preservatives, vehicles, and medicaments, reading cosmetic labels and package inserts of topical/systemic medicaments may be sufficient to avoid allergens.
For patients allergic to nickel, the dimethylgloxime test can alert them the presence of the metal. For many other patients with allergic reactions to chemicals that are unlikely to be labeled on consumer products (eg, rubber accelerators), suitable allergen alternatives (eg, gloves specifically known to be accelerator free) must be provided by the practitioner.
Many cases of allergic contact dermatitis, especially of the hands, occur in the occupational setting. Proper worker education and hygiene may prevent allergic reactions. For example, glutaraldehyde is a known sensitizer with widespread use as a cold sterilizing agent in medicine and dentistry. [34] Needless cases of allergic contact dermatitis to this biocide occur because of the lack of proper education regarding the appropriate use of gloves and other barriers to cutaneous contact.
Advise patients to avoid identified chemicals to which they are allergic to minimize the risk of relapse, the risk of chronic contact dermatitis, and the risk of adverse effects from chronic use of nonspecific suppressive treatments (eg, topical and systemic corticosteroids, cyclosporine).
Patients should use mild cleansing agents on the skin, such as Aquanil, Cetaphil cleanser, or Oilatum-AD, and should apply bland protective emollients, such as SBR Lipocream, Cetaphil cream or Neutrogena hand cream, to help minimize relapse of allergic contact dermatitis or development of irritant contact dermatitis. Creams containing ceramides (eg, Impruv, Cerave) can help restore the epidermal barrier in persons with irritant contact dermatitis and atopic dermatitis.
Consultations
Acute dermatitis that resolves with short-term treatment does not require further evaluation or specialist consultation. For example, many primary care physicians treat individuals with typical poison ivy dermatitis who respond well to a 2-week treatment course using topical or systemic corticosteroids and subsequently avoid poison ivy and related plants.
Individuals with chronic dermatitis, particularly if it possibly is related to work, require detailed history and patch testing to standard screening sets and additional allergens as indicated by history, occupation, hobbies, and results on initial patch testing.
Long-Term Monitoring
Individuals may develop new allergies. A patient who experiences a relapse or a worsening of allergic contact dermatitis may require further history and, possibly, further patch testing.
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Chronic stasis dermatitis with allergic contact dermatitis to quaternium-15, a preservative in moisturizer. Allergic contact dermatitis produces areas of erythema in areas of atrophie blanche and varicose veins.
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Erythema multiformelike reaction that developed acutely following hair dying.
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Allergic contact dermatitis to nickel in a necklace.
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Severe allergic contact dermatitis resulting from preservatives in sunscreen. Patch testing was negative to the active ingredients in the sunscreen.
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Onycholysis developing from allergic contact dermatitis to formaldehyde used to harden nails.
