eMedicine Specialties > Pediatrics: General Medicine > Dermatology

Contact Dermatitis: Treatment & Medication

Author: Mark A Crowe, MD, Assistant Clinical Instructor, Department of Medicine, Division of Dermatology, University of Washington School of Medicine
Contributor Information and Disclosures

Updated: Aug 6, 2009

Treatment

Medical Care

Once the correct diagnosis has been established, many patients improve with adequate hygiene and avoidance of the contactant. Depending on the degree of involvement, duration, and presence or absence of secondary infection, each of the following therapies may be considered. The American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology have established a practice parameter for the management of contact dermatitis.8

  • Removal of the contactant: In acute irritant dermatitis, the first goal must be to prevent further damage by removal of the irritant. Immediately rinse the site of both acid and alkali burns with large quantities of water. Acid burns can be treated with weak alkali solutions, such as sodium bicarbonate or soap solutions. Following irrigation, alkalis (eg, soaps, detergents, bleaches, ammonia preparations, lye, drain pipe cleaners, toilet bowl and oven cleansers) may be buffered by rinsing the skin with a weak acid solution, such as vinegar or lemon juice. Alkalis cause tissue destruction by dissolving keratin. Oral and topical steroid therapies are of no benefit in irritant contact dermatitis. Thoroughly wash skin exposed to significant allergens, such as poison ivy, and remove and wash contaminated clothing. Patients may be able to minimize or eliminate allergic contact dermatitis if the skin is adequately washed as soon as possible following exposure.
  • Topical nonsteroidal therapy
    • Many cases of localized mild contact dermatitis respond well to cool compresses and adequate wound care. Cool wet soaks applied for 5-10 minutes followed by air-drying may significantly reduce serous drainage from the site. Clean water, isotonic sodium chloride solution, and Burow solution can all be used with good success. Application of topical calamine is usually of minimal benefit.
    • Gently clear the loose crusts from the affected sites and apply a thin coat of Vaseline ointment or antibacterial ointment. Most episodes of contact dermatitis do not require antibiotic therapy if treated promptly and if adequate wound care can be provided. Secondary infection usually takes at least 2-3 days to develop. Initial yellow crusts are simply dried serum from ruptured bullous lesions. If a significant degree of purulent material is present, a wound culture may be performed and oral antibiotics may be of benefit. Adequate coverage for staphylococci and streptococci can usually be achieved with a 5- to 10-day course of erythromycin, dicloxacillin, or a cephalosporin.
  • Steroids
    • Low-strength topical steroids, such as hydrocortisone, may be effective in decreasing inflammation and symptoms associated with very mild contact dermatitis in infants, but they are useless as therapy for significant areas of allergic contact dermatitis. Potent topical steroids, such as clobetasol propionate (Temovate) or betamethasone dipropionate (Diprolene) applied twice daily for 1-2 weeks, are effective for treating small areas of moderate allergic contact dermatitis.
    • Systemic steroids are the mainstay of therapy in acute episodes of severe extensive allergic contact dermatitis. Without therapy, an episode of rhus dermatitis may be expected to persist as long as 3-4 weeks. Early adequate use of prednisone can significantly shorten this course. The duration of prednisone therapy is generally 7-10 days, but severe episodes of allergic contact dermatitis may recur when therapy is stopped; thus, an additional few days of systemic therapy may be required. In otherwise healthy individuals, a tapering dose of prednisone is not required for short courses of systemic therapy (7-10 d). In adolescents and adults, an alternative to oral therapy is a single intramuscular (IM) dose of 4 mg (1 mL) of betamethasone sodium phosphate (Celestone) mixed with 40-60 mg of triamcinolone (Kenalog). This provides rapid onset and prolonged action over 2-4 weeks.
  • Antihistamines: Severe pruritus may respond to antihistamines, such as hydroxyzine (Atarax) or diphenhydramine (Benadryl).

Consultations

  • A primary care provider can treat most cases of contact dermatitis on an outpatient basis.
  • Deep chemical burns, extensive bullous reactions, or pulmonary symptoms related to inhaled agents may require admission and consultation as appropriate.
  • Refer the patients who have recurrent episodes of dermatitis with unclear etiology to a dermatologist.

Activity

  • Warm weather, hot showers, and activities vigorous enough to cause perspiration increase pruritus.

Medication

Therapy depends on the etiology and severity of contact dermatitis. In acute contact dermatitis, contaminated clothing must be removed and the contactant rinsed from the skin with large quantities of water. Mild-to-moderate acute allergic contact dermatitis responds to topical care with astringents in a wet compress, topical corticosteroids, and systemic antipruritics. Acute severe allergic contact dermatitis with marked edema and bullae should receive the same treatment but may also require the addition of systemic corticosteroids.

Acute irritant contact dermatitis from acids or alkalis should be treated with vigorous irrigation with water to remove the irritant and then should be treated as a thermal burn. Treatment of chronic contact dermatitis requires identification and removal of the contactant. Chronic allergic contact dermatitis should be treated with mid-potency topical corticosteroids and general skin care with emollients. Chronic irritant dermatitis is extremely common. Irritant dermatitis of the hands secondary to soaps or volatile solutions are exceedingly common in adolescents and adults.

Patients should be educated about the cause of the dermatitis and instructed in methods of skin protection and care with emollients.

Wet compresses with an astringent

These agents are used to reduce pain, pruritus, and serous drainage in acute weeping contact dermatitis.


Aluminum acetate (Burow solution, Domeboro)

Moist compresses are soothing, have a mild antipruritic effect, reduce serous drainage, and gently debride the wound. Effective in the early stages of acute contact dermatitis when serous drainage is most severe.

Adult

Dissolve aluminum acetate tab in water to obtain a 1:40 solution; apply as a compress for 20-30 min 4-6 times/d; rewet dressings with solution during application to maintain moisture

Pediatric

Administer as in adults

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

For external use only; compresses should be kept moist at all times; wet-to-dry compresses are painful and destroy fragile tissues

Emollients

These agents may be used an adjunct treatment to moisturize dry skin in subacute and chronic contact dermatitis.


Eucerin, Lubriderm, Moisturel, Vaseline Intensive Care

Numerous emollients are available as creams, ointments, or lotions. Use ointments on dry or cracked skin and creams on inflamed or weeping lesions. Most patients prefer creams. These may be helpful in subacute and chronic contact dermatitis because they help add moisture to skin, minimize moisture loss, or both.

Adult

Apply to affected area prn

Pediatric

Administer as in adults

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

Hydrating skin with soaks in plain water before application may make products more effective

Antihistamines

These agents may be used as adjunctive therapy to relieve pruritus. They are used to treat minor allergic reactions and anaphylaxis and may be used to pretreat patients with prior documentation of minor allergic reactions. These agents may control itching by blocking effects of endogenously released histamine.


Hydroxyzine HCl (Atarax, Vistaril)

Antagonizes H1 receptors in periphery. May suppress histamine activity in subcortical region of CNS. Available in 10 mg/5 mL and as 10-mg and 25-mg tab.

Adult

25-50 mg PO tid/qid prn

Pediatric

0.5-1.5 mg/kg/dose PO q6-8h prn

CNS depression may increase with alcohol or other CNS depressants

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 produce drowsiness; use caution while driving or performing other tasks requiring alertness or physical dexterity; paradoxically, some younger children develop hyperactivity; use caution with epilepsy or porphyria; ECG abnormalities (alterations in T waves) may occur


Diphenhydramine (Benadryl)

Used for symptomatic relief of allergic symptoms caused by released histamine.

Adult

25-50 mg cap PO q6h prn

Pediatric

1-1.5 mg/kg/dose PO q6-8h prn

Potentiates effect of CNS depressants; because of alcohol content, do not administer syr dosage form to patient taking medications that can cause disulfiramlike reactions

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 exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction

Topical corticosteroids

These agents decrease the inflammatory reaction associated with allergic contact dermatitis.


Triamcinolone acetate (Aristocort, Kenalog)

Use ointments on dry or cracked skin and creams on inflamed or weeping lesions. Most patients prefer creams. A moderate-potency topical corticosteroid, it is available in both ointment (0.1%) and cream (0.1% or 0.5%).
Decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.

Adult

Apply sparingly tid initially; reduce as lesions remit

Pediatric

Administer as in adults

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

Prolonged use may cause skin atrophy or corticosteroid acne; avoid use on face and intertriginous areas; limit use to 3 wk; systemic absorption of topical corticosteroids may cause Cushing syndrome, reversible hypothalamic-pituitary-adrenal (HPA) axis suppression, hyperglycemia, and glycosuria


Hydrocortisone (Cortaid, Dermacort, Westcort)

Lower-potency topical steroids useful on the face and intertriginous areas.

Adult

Apply sparingly tid initially; reduce as lesions remit

Pediatric

Administer as in adults

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

Low-potency topical corticosteroids are extremely safe; atrophy or significant adrenal suppression is rare with prolonged use

Superpotent topical corticosteroids

Low- or moderate-strength topical corticosteroids are useless as therapy for moderate-to-severe allergic contact dermatitis. Superpotent topical corticosteroids, such as clobetasol propionate (Temovate) or betamethasone dipropionate (Diprolene), applied 2-3 times daily for 1-2 weeks may be effective in small areas of acute allergic contact dermatitis or in lichenified areas of chronic contact dermatitis.


Clobetasol propionate (Temovate)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.

Adult

Apply sparingly tid initially; reduce as lesions remit

Pediatric

Children: Not established
Adolescents: Administer as in adults

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 may cause skin atrophy or corticosteroid acne; avoid use on face and intertriginous areas; limit use to 3 wk and to older children and adults; systemic absorption of topical corticosteroids may cause Cushing syndrome, reversible HPA axis suppression, hyperglycemia, and glycosuria


Betamethasone dipropionate (Alphatrex, Diprolene, Maxivate, Luxiq)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.

Adult

Apply sparingly tid initially; reduce as lesions remit

Pediatric

Children: Not established
Adolescents: Administer as in adults

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 may cause skin atrophy or corticosteroid acne; avoid use on face and intertriginous areas; limit use to 3 wk and to older children and adults; systemic absorption of topical corticosteroids may cause Cushing syndrome, reversible HPA axis suppression, hyperglycemia, and glycosuria

Systemic corticosteroids

These agents are reserved for severe cases of allergic contact dermatitis with involvement of more than 20% of the total body surface area (TBSA), significant bullae, or significant facial involvement. They have anti-inflammatory (glucocorticoid) and salt-retaining (mineralocorticoid) properties. Glucocorticoids cause profound and varied metabolic effects and modify the body's immune response.


Prednisone (Deltasone)

Approximately 7-10 d of therapy is usually adequate and does not require a tapering dosage schedule. Lesions occasionally recur following a course of therapy, and an additional few days of therapy may be required.
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Adult

50-60 mg PO qd

Pediatric

1 mg/kg/d PO

Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity; significant viral, fungal, tubercular, or bacterial infections

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Patients are at risk of severe infections; abrupt discontinuation may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible


Prednisolone (Pedia-Pred, Delta-Cortef)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Adult

50-60 mg PO qd

Pediatric

1 mg/kg/d PO

Coadministration with estrogens may decrease prednisolone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity; viral, fungal, or tubercular skin lesions

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

Patients are at risk of severe infections; abrupt discontinuation may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible


Betamethasone sodium phosphate (Celestone) mixed with triamcinolone (Kenalog)

In adolescents and adults, an alternative to PO therapy is an IM dose of betamethasone sodium phosphate (Celestone) mixed with triamcinolone (Kenalog). This provides rapid onset and prolonged action over 2-4 wk.

Adult

4 mg (1 mL) single dose of betamethasone sodium phosphate (Celestone) mixed with 40-60 mg of triamcinolone (Kenalog) IM

Pediatric

Not recommended

May increase digitalis toxicity secondary to hypokalemia when used with digoxin; phenobarbital, phenytoin, and rifampin may also increase metabolism of glucocorticoids; monitor patients for hypokalemia when taking this medication concurrently with diuretics

Documented hypersensitivity; significant viral, fungal, tubercular, or bacterial infections; patients with diabetes mellitus, hypertension, psychiatric disorders, or disorders of the muscles or bones may require special monitoring

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

Severe infections; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use; some authors believe risk of these complications is less with IM therapy than with PO therapy

Barrier products

Barrier creams, such as zinc oxide or Desenex, are common effective agents to treat or prevent irritant diaper dermatitis. In the past, barrier creams or preexposure treatments offered little hope for protection from poison oak and ivy. However, new over-the-counter products, such as a lotion containing bentoquatam (IvyBlock), may offer some protection. Bentoquatam creates a clay-like barrier on the skin that protects against urushiol, the oily resin in poison ivy, oak, and sumac. Bentoquatam is not a replacement for accepted protective devices, such as gloves, boots, and clothing. When exposure cannot be avoided completely, barrier products may protect areas of exposed skin, such as the neck and face.


Zinc oxide paste, Desenex, Ivy block, Work shield, Chimyl skin shield

Provides relief of minor skin irritations and may provide barrier against future exposures to irritants and allergens.

Adult

Follow the directions on barrier creams intended to prevent exposure to urushiol resins

Pediatric

Diaper area: Apply after gentle cleansing and drying with each diaper change; follow directions on barrier creams intended to prevent exposure to urushiol resins

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

For external use only; do not apply to eyes

More on Contact Dermatitis

Overview: Contact Dermatitis
Differential Diagnoses & Workup: Contact Dermatitis
Treatment & Medication: Contact Dermatitis
Follow-up: Contact Dermatitis
Multimedia: Contact Dermatitis
References
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Further Reading

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Keywords

contact dermatitis, allergic contact dermatitis, ACD, dermatitis venenata, contact eczema, rhus dermatitis, poison ivy, poison oak, poison sumac, irritant contact dermatitis, ICD, primary irritant dermatitis, photo contact dermatitis, photoallergic contact dermatitis, phototoxic contact dermatitis, berloque dermatitis, contact urticaria, hives, whelps, eczematous dermatitis, acute caustic burn, cold urticaria, cholinergic urticaria, dermatographism, pressure urticaria, aquagenic pruritus, aquagenic urticaria, solar urticaria, heat urticaria, papular urticaria, exercise-induced urticaria, latex allergy, sunburn, nickel allergy, hyperpigmentation, folliculitis, melanoderma, Umbelliferae family

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Contributor Information and Disclosures

Author

Mark A Crowe, MD, Assistant Clinical Instructor, Department of Medicine, Division of Dermatology, University of Washington School of Medicine
Mark A Crowe, MD is a member of the following medical societies: American Academy of Dermatology and North American Clinical Dermatologic Society
Disclosure: Nothing to disclose.

Medical Editor

Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center
Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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