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Contact Dermatitis, Allergic: Treatment & Medication
Updated: Jul 31, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
The cause of allergic contact dermatitis (ACD) must be identified; otherwise, the patient is at increased risk for chronic or recurrent dermatitis. The Contact Allergan Replacement Database of the American Contact Dermatitis Society allows the physician to create a list of products free of allergens to which the patient is allergic.
- Symptomatic treatment
- 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.
- Sedating oral antihistamines may help diminish pruritus.
- Patients should avoid using topical antihistamines, including topical doxepin,16 because of the apparently high risk of iatrogenic allergic contact dermatitis to these agents.
- 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.
- Acute severe allergic contact dermatitis, such as acute severe allergic contact dermatitis to 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 corticosteroids. The systemic corticosteroids must be administered for 2 weeks, because shorter courses are notorious for allowing poison ivy dermatitis to relapse. Long-acting triamcinolone acetonide (Kenalog) 40-60 mg may be used in place of oral prednisone in these cases.
- 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.17 Pimecrolimus (Elidel cream) is a topical treatment often helpful for allergic contact dermatitis of the face. Tacrolimus (Protopic 0.1% ointment) appears to be the most helpful TIM for allergic contact dermatitis of the hands.
- Psoralen plus UV-A: Individuals with chronic allergic contact dermatitis that is not controlled well by topical corticosteroids may benefit from psoralen plus UV-A (PUVA) treatments.
- Immunosuppressive agents: Rarely, chronic immunosuppressive agents, such as azathioprine (Imuran)18 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.
Consultations
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. Acute dermatitis that resolves with short-term treatment does not require further evaluation. 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.
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.
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. They 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 of ceramide cream (eg, Impruv).
Medication
The goal of pharmacotherapy is to reduce morbidity and to prevent complications. Topical glucocorticosteroids are the mainstay of therapy. Topical calcineurin inhibitors (immunomodulators) may be preferred for persistent facial particularly periocular dermatitis. When choosing a topical glucocorticosteroid, match the potency to the location of the dermatitis and the vehicle to the morphology (ointment for dry scaling lesions; lotion or cream for weeping areas of dermatitis).
For severe acute allergic contact dermatitis (eg, rhus dermatitis, erythroderma), systemic glucocorticosteroids or other immunosuppressive medications (eg, azathioprine) may be occasionally needed for widespread and severe chronic dermatitis, particularly to airborne allergens such as feverfew (Parthenium hysterophores).
In some cases, allergic contact dermatitis may prove persistent despite avoidance of the allergen. In some of these cases (eg, nickel), ingestion of minute amounts of the allergen is believed to drive the process, and chelation therapy with disulfiram can be beneficial. In other instances, the cause of persistence remains enigmatic; many allergens penetrate through rubber gloves. PUVA can be helpful in these cases.
Oral antihistamines may help diminish pruritus caused by allergic contact dermatitis.
For details of some of these therapies, which are by no means all inclusive, see the drug tables below.
Topical immunomodulators
These agents modify immune processes that promote inflammation.
Pimecrolimus (Elidel cream)
Indicated for eczema and atopic dermatitis. First nonsteroid cream approved in the United States for mild-to-moderate atopic dermatitis. Derived from ascomycin, a natural substance produced by fungus Streptomyces hygroscopicus var ascomyceticus. Selectively inhibits production and release of inflammatory cytokines from activated T cells by binding to cytosolic immunophilin receptor macrophilin-12. Resulting complex inhibits phosphatase calcineurin, thus blocking T-cell activation and cytokine release.
Cutaneous atrophy was not observed in clinical trials, a potential advantage over topical corticosteroids.
Adult
Apply topically to affected areas bid
Pediatric
<2 years: Not established
>2 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Potential exacerbation of existing infection at site of application; may cause burning and irritation; product insert revised and contains boxed warning stating long-term safety of calcineurin inhibitors has not been established; although causal relationship has not been established, rare cases of malignancy (eg, skin and lymphoma) have been reported
Tacrolimus (Protopic 1%)
Reduces itching and inflammation by suppressing release of cytokines from T cells. Also inhibits transcription for genes that encode IL-3, IL-4, IL-5, GM-CSF, and TNF-alpha, all of which are involved in the early stages of T-cell activation. Additionally, may inhibit release of preformed mediators from skin mast cells and basophils and may down-regulate expression of FCeRI on Langerhans cells. Can be used in patients as young as 2 y. More expensive than topical corticosteroids. Available as ointment in concentrations of 0.03 and 0.1%.
Adult
Apply thin layer to affected skin areas bid and rub in gently and completely; continue treatment for 1 wk after clearing of signs and symptoms
Pediatric
<2 years: Not established
2-15 years: Apply 0.03% ointment bid to affected area(s)
>15 years: Administer as adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use with occlusive dressings; may be associated with an increased risk of folliculitis in adults; may cause local burning sensation, stinging, soreness, or pruritus (typically improve as lesions heal); for external use only; minimize exposure to natural or artificial sunlight (eg, tanning beds or UVA/B treatment); be sure skin is completely dry before application; product insert revised and contains boxed warning stating long-term safety of calcineurin inhibitors has not been established; although causal relationship has not been established, rare cases of malignancy (eg, skin and lymphoma) have been reported; only 0.03% ointment indicated for use in children aged 2-15 y
Corticosteroids
Have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.
Clobetasol (Temovate)
Class I superpotent topical steroid; suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction.
Use 0.05% cream or ointment.
Adult
Apply bid for up to 2 wk; not to exceed 50 g/wk
Pediatric
Not established
None reported
Documented hypersensitivity; viral or fungal skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May suppress adrenal function in widespread or prolonged therapy; superpotent topical steroid and, in general, should not be applied to face or intertriginous areas except under care and close supervision of experienced dermatologist; skin atrophy, striae, or other problems may result from inappropriate use
Hydrocortisone (Valerate, Westcort)
Adrenocorticosteroid derivative suitable for application to skin or external mucous membranes. Has mineralocorticoid and glucocorticoid effects resulting in anti-inflammatory activity.
Use 0.2% cream or ointment.
Adult
Apply sparingly to affected areas bid
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; viral, fungal, and bacterial skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged use, applying over large surface areas, application of potent steroids, and occlusive dressings may increase systemic absorption of corticosteroids and may cause Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria; ointment is more potent than cream and, in general, more caution should be exercised; should not be applied to face or intertriginous areas except under care and close supervision of experienced dermatologist; skin atrophy, striae, or other problems may result from inappropriate use
Prednisone (Deltasone, Meticorten, Orasone)
Immunosuppressant for treatment of autoimmune disorders; may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Stabilizes lysosomal membranes and also suppresses lymphocytes and antibody production.
Adult
40-60 mg/d PO qd or divided bid/qid; taper over 2-3 wk, as symptoms resolve; 0.5-2 mg/kg/d; taper as condition improves; single morning dose is safer for long-term use, but divided doses have more anti-inflammatory effect
Pediatric
4-5 mg/m2/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid; taper over 2-3 wk, as symptoms resolve
Ketoconazole, erythromycin, clarithromycin, estrogens, and birth control pills increase levels; aminoglutethimide, phenytoin, phenobarbital, rifampin, cholestyramine, and ephedrine decrease levels
May increase levels of potassium-depleting diuretics (potentiates potassium loss and digitalis toxicity) and cyclosporine; May decrease levels of isoniazid, insulin (resistance is induced), and salicylates; monitor anticoagulant therapy and theophylline levels
Absolute: Systemic fungal infection; herpes simplex keratitis; hypersensitivity (usually with corticotropin, occasionally with IV preparations)
Relative: hypertension, active tuberculosis, congestive heart failure, prior psychosis, positive IPPD test result, glaucoma, severe depression, diabetes, active peptic ulcer disease, cataracts, osteoporosis, recent bowel anastomosis, pregnancy
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use; use lower dose in hypothyroidism, liver disease, and obesity (decrease cortisol-binding globulin and increase free fraction of steroid); pregnancy, hyperthyroidism, and concurrent estrogen therapy may increase cortisol-binding globulin
Triamcinolone (Aristocort, Amcort, Aristospan Intra-articular)
For inflammatory dermatosis responsive to steroids; decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Intramuscular injection may be used for widespread skin disorder or intralesional injections may be used for localized skin disorder.
Adult
40-60 mg IM, may repeat in 4-6 wk
3-10 mg/mL intralesional
Pediatric
<6 years: Not established
6-12 years: 0.03-0.2 mg/kg IM
>12 years: Administer as in adults
Coadministration with barbiturates, phenytoin, and rifampin decreases effects of triamcinolone
Documented hypersensitivity; fungal, viral, and bacterial skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Multiple complications (eg, severe infections, hyperglycemia, edema, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression) may occur; abrupt discontinuation of glucocorticoids may cause adrenal crisis; SC injection may cause skin atrophy that may be slow to recover
Antihistamines
Act by competitive inhibition of histamine at the H1 receptor. May control itching by blocking effects of endogenously released histamine. Have no effect in treating allergic contact dermatitis beyond possibly decreasing pruritus via sedating effects.
Hydroxyzine (Atarax, Vistaril)
Antagonizes H1 receptors in periphery. May suppress histamine activity in subcortical region of CNS.
Adult
10-25 mg PO tid/qid; 25-100 mg PO qd/qid
Pediatric
0.7 mg/kg PO tid; 0.6 mg/kg/dose PO q6h
CNS depression may increase with alcohol or other CNS depressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Associated with clinical exacerbations of porphyria (may not be safe for patients with porphyria); ECG abnormalities (alterations in T waves) may occur; may cause drowsiness
Tricyclic antidepressants
Used in contact dermatitis for its sedative and antihistaminic properties. May consider oral doxepin (10-25 mg at night in adults if other oral antihistamines are not helpful). Maximum dose is 75 mg/d PO for dermatoses. This is achieved by increasing the initial dosage gradually. Topical doxepin should be avoided because of the risk of iatrogenic allergic contact dermatitis.16
Doxepin (Adapin, Sinequan)
Inhibits histamine and acetylcholine activity and has proven useful in the treatment of allergic dermatologic disorders.
Adult
10-25 mg/d PO hs or divided bid/tid
Pediatric
<12 years: Not recommended
>12 years: 10-25 mg/d PO hs or bid/tid
Decreases antihypertensive effects of clonidine but increases effects of sympathomimetics and benzodiazepines; effects of tricyclic antidepressants increase with phenytoin, carbamazepine, and barbiturates; plasma levels of doxepin and tricyclic antidepressants are increased significantly by drugs that inhibit liver's cytochrome-P450 system; discontinue MAOIs at least 2 wk prior to initiating therapy
Documented hypersensitivity; urinary retention; acute recovery phase following myocardial infarction; glaucoma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism, and patients receiving thyroid replacement
Chelation agents
Although marketed as a treatment for alcoholism, disulfiram chelates nickel, which then is excreted in the urine. Lowering systemic levels of nickel has been reported to benefit individuals with pompholyx and demonstrated hypersensitivity to the metal. Consider this therapy only for severe disabling dyshidrosis refractory to all other treatment in a patient proven allergic to nickel who does not drink alcohol and who consents to regular blood tests to identify liver toxicity from the medication.
Disulfiram (Antabuse)
Thiuram derivative that interferes with aldehyde dehydrogenase. For patients highly allergic to nickel with severe vesicular hand dermatitis. The chelating effect of disulfiram is helpful in reducing the body's nickel burden in the individual allergic to nickel. Do not administer if patient has ingested alcohol within last 12 h.
Adult
Initial: 500 mg PO qd
Maintenance: 125-500 mg PO qd
Pediatric
Not established
Increases effects of diazepam and chlordiazepoxide; metronidazole, isoniazid, and phenytoin may increase toxicity of disulfiram; coadministration with warfarin may increase PT time
Documented hypersensitivity; severe myocardial disease and coronary occlusion
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypothyroidism, diabetes, hepatic cirrhosis or insufficiency, and seizure disorders
More on Contact Dermatitis, Allergic |
| Overview: Contact Dermatitis, Allergic |
| Differential Diagnoses & Workup: Contact Dermatitis, Allergic |
 Treatment & Medication: Contact Dermatitis, Allergic |
| Follow-up: Contact Dermatitis, Allergic |
| Multimedia: Contact Dermatitis, Allergic |
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Further Reading
Keywords
contact dermatitis, allergic contact dermatitis, ACD, allergic dermatitis, skin allergy, contact hypersensitivity
