Irritant Contact Dermatitis Treatment & Management
- Author: Daniel J Hogan, MD; Chief Editor: William D James, MD more...
The definitive treatment of irritant contact dermatitis is the identification and removal of any potential causal agents. An inflammatory reaction from acute delayed irritant contact dermatitis to an agent such as benzalkonium chloride (eg, zephiran) rarely needs treatment and usually resolves with cessation of exposure. Further symptomatic therapy depends on the degree of involvement and the presence or absence of secondary infection.
Advise individuals to use ceramides creams or bland emollients after washing hands with soap and before sleep. Cleansers may be ranked by their irritancy. Recommend mild skin cleansers (eg, Aquanil, Cetaphil cleanser, Oilatum AD, Neutrogena cleanser) in place of soap on affected areas. Instruct individuals to refrain from the use of inappropriate solvents (eg, gasoline) or abrasives (eg, pumice stone) to cleanse hands; these directly defat or traumatize the skin.
A summary of the Danish Contact Dermatitis Group guideline for hand eczema includes a diagrammed sequence of general treatment principles and notes that moisturizing cream should be given in combination with all treatments. If hand eczema does not resolve within 1 month, the guideline recommends physicians refer the patient to a dermatologist; longer delays are associated with a poorer prognosis.
Emergency Department Care
Emergency department treatment may include the following:
Topical soaks with cool tap water, Burow solution (1:40 dilution), saline (1 tsp/pint)
Lukewarm water baths (antipruritic)
Aveeno (oatmeal) lukewarm baths
Emollients (eg, white petrolatum, Eucerin) may be beneficial chronic cases.
Large vesicles may benefit from therapeutic drainage (but not removing the vesicle tops). These lesions should then be covered with antibiotic dressing or a dressing soaked in Burow solution.
Hospital admission is required only in severe cutaneous irritant contact dermatitis, ie, chemical burns from hydrofluoric acid or, occasionally, from freshly mixed Portland cement.
Creams containing ceramides (eg, Impruv, Cerave, Cetaphil RESTORADERM) may be particularly helpful in restoring the epidermal barrier in persons with irritant contact dermatitis and atopic dermatitis. Creams containing dimethicone (eg, Cetaphil cream) can be helpful in restoring the epidermal barrier in persons with wet work–related irritant contact dermatitis.
Most soaps and detergents are alkaline and induce an increase in cutaneous pH, which affects the physiologic protective acid mantle of the skin by decreasing the fat content. Disruption of stratum corneum and changes in pH are key elements in the induction of irritant contact dermatitis and pruritus by soaps. These conditions are exacerbated in the winter months in patients with dry, sensitive skin.
Syndets, with a pH approximately 5.5, do not modify skin pH. Most bar soaps and liquid detergents available on the market are a mixture of soap and syndet. A study found that Dove and Cetaphil had a lower irritant effect than the other soaps tested. Interestingly, no significant correlation was made between the price of the products and their irritation potential.
Irritant contact dermatitis is a frequent problem in health care workers, due to frequent hand washing. The best antimicrobial efficacy can be achieved with ethanol (60-85%), isopropanol (60-80%), and N -propanol (60-80%). The antimicrobial efficacy of chlorhexidine (2-4%) and triclosan (1-2%) is both lower and slower and carries a potential risk of bacterial resistance.
The use of alcohol-based hand rubs containing various emollients instead of irritating soaps and detergents is one strategy to reduce skin damage, dryness, and irritation in health care workers. Irritant contact dermatitis occurs most frequently with preparations containing 4% chlorhexidine gluconate, less frequently with nonantimicrobial soaps and preparations containing lower concentrations of chlorhexidine gluconate, and least frequently with well-formulated alcohol-based hand rubs containing emollients and other skin conditioners.
Steroids and Immunomodulators
Topical corticosteroids and immunomodulators are of unproven use in treating irritant contact dermatitis. Corticosteroids were found ineffective in treating the surfactant-induced irritant dermatitis when compared with the vehicle and with the untreated control. However, topical steroids may be helpful for superimposed eczematous features.
Potential complications center on the use of steroids, particularly around the eye. The avoidance of long-term steroid use is essential, because such use may cause cataracts, glaucoma, corneal thinning/perforation, and loss of the eye, as well as other problems.
Topical tacrolimus is an irritant that may produce further stinging and irritation in persons with irritant contact dermatitis.
Multidisciplinary consultations may be required when many workers become affected with irritant contact dermatitis in a workplace. Identifying and remediating the causes of widespread irritant contact dermatitis interfering with workplace productivity and worker quality of life is important.
Any patient with hydrofluoric acid burn should be evaluated as a medical emergency by a physician experienced in the management of hydrofluoric exposures and burns. Consider regional intravenous infusion of calcium gluconate as a therapeutic option in hydrofluoric acid burns to forearm, hand, or digits when topical therapy fails.
Watkins SA, Maibach HI. The hardening phenomenon in irritant contact dermatitis: an interpretative update. Contact Dermatitis. 2009 Mar. 60(3):123-30. [Medline].
Fluhr JW, Akengin A, Bornkessel A, Fuchs S, Praessler J, Norgauer J, et al. Additive impairment of the barrier function by mechanical irritation, occlusion and sodium lauryl sulphate in vivo. Br J Dermatol. 2005 Jul. 153(1):125-31. [Medline].
Jacobs JJ, Lehé CL, Hasegawa H, Elliott GR, Das PK. Skin irritants and contact sensitizers induce Langerhans cell migration and maturation at irritant concentration. Exp Dermatol. 2006 Jun. 15(6):432-40. [Medline].
Heinemann C, Paschold C, Fluhr J, Wigger-Alberti W, Schliemann-Willers S, Farwanah H, et al. Induction of a hardening phenomenon by repeated application of SLS: analysis of lipid changes in the stratum corneum. Acta Derm Venereol. 2005. 85(4):290-5. [Medline].
de Jongh CM, Khrenova L, Verberk MM, Calkoen F, van Dijk FJ, Voss H, et al. Loss-of-function polymorphisms in the filaggrin gene are associated with an increased susceptibility to chronic irritant contact dermatitis: a case-control study. Br J Dermatol. 2008 Sep. 159(3):621-7. [Medline].
Kartono F, Maibach HI. Irritants in combination with a synergistic or additive effect on the skin response: an overview of tandem irritation studies. Contact Dermatitis. 2006 Jun. 54(6):303-12. [Medline].
Löffler H, Kampf G, Schmermund D, Maibach HI. How irritant is alcohol?. Br J Dermatol. 2007 Jul. 157(1):74-81. [Medline].
Weston WL, Morelli JG. Dermatitis under soccer shin guards: allergy or contact irritant reaction?. Pediatr Dermatol. 2006 Jan-Feb. 23(1):19-20. [Medline].
Schmid-Wendtner MH, Korting HC. The pH of the skin surface and its impact on the barrier function. Skin Pharmacol Physiol. 2006. 19(6):296-302. [Medline].
Forrester BG, Roth VS. Hand dermatitis in intensive care units. J Occup Environ Med. 1998 Oct. 40(10):881-5. [Medline].
Cvetkovski RS, Rothman KJ, Olsen J, Mathiesen B, Iversen L, Johansen JD, et al. Relation between diagnoses on severity, sick leave and loss of job among patients with occupational hand eczema. Br J Dermatol. 2005 Jan. 152(1):93-8. [Medline].
Dickel H, Kuss O, Schmidt A, Kretz J, Diepgen TL. Importance of irritant contact dermatitis in occupational skin disease. Am J Clin Dermatol. 2002. 3(4):283-9. [Medline].
Mangion SM, Beulke SH, Braitberg G. Hydrofluoric acid burn from a household rust remover. Med J Aust. 2001 Sep 3. 175(5):270-1. [Medline].
Basketter DA, Marriott M, Gilmour NJ, White IR. Strong irritants masquerading as skin allergens: the case of benzalkonium chloride. Contact Dermatitis. 2004 Apr. 50(4):213-7. [Medline].
Rietschel RL, Fowler JF Jr. Fisher's Contact Dermatitis. 4th ed. Baltimore, Md: Lippincott Williams & Wilkins; 1995.
Bernstein IL, Li JT, Bernstein DI, et al. Allergy diagnostic testing: an updated practice parameter. Part 1. National Guideline Clearinghouse. Mar 2008. [Full Text].
Bernstein IL, Li JT, Bernstein DI, et al. Allergy diagnostic testing: an updated practice parameter. Part 2. National Guideline Clearinghouse. Mar 2008. [Full Text].
Lakshmi C, Srinivas CR, Anand CV, Mathew AC. Irritancy ranking of 31 cleansers in the Indian market in a 24-h patch test. Int J Cosmet Sci. 2008 Aug. 30(4):277-83. [Medline].
Menne T, Johansen JD, Sommerlund M, Veien NK. Hand eczema guidelines based on the Danish guidelines for the diagnosis and treatment of hand eczema. Contact Dermatitis. 2011 Jul. 65(1):3-12. [Medline].
Levin C, Zhai H, Bashir S, Chew AL, Anigbogu A, Stern R, et al. Efficacy of corticosteroids in acute experimental irritant contact dermatitis?. Skin Res Technol. 2001 Nov. 7(4):214-8. [Medline].
Fuchs M, Schliemann-Willers S, Heinemann C, Elsner P. Tacrolimus enhances irritation in a 5-day human irritancy in vivo model. Contact Dermatitis. 2002 May. 46(5):290-4. [Medline].
Draelos ZD. New treatments for restoring impaired epidermal barrier permeability: skin barrier repair creams. Clin Dermatol. 2012 May-Jun. 30(3):345-8. [Medline].
Miller DW, Koch SB, Yentzer BA, Clark AR, O'Neill JR, Fountain J, et al. An over-the-counter moisturizer is as clinically effective as, and more cost-effective than, prescription barrier creams in the treatment of children with mild-to-moderate atopic dermatitis: a randomized, controlled trial. J Drugs Dermatol. 2011 May. 10(5):531-7. [Medline].
Slotosch CM, Kampf G, Löffler H. Effects of disinfectants and detergents on skin irritation. Contact Dermatitis. 2007 Oct. 57(4):235-41. [Medline].