Approach Considerations
The definitive treatment of irritant contact dermatitis (ICD) 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 containing creams or bland emollients after washing hands with soap and before sleep. Cleansers may be ranked by their irritancy. [25] 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. [26]
Go to Allergic Contact Dermatitis, Pediatric Contact Dermatitis, and Protein Contact Dermatitis for complete information on these topics.
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). [4] 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.
Barrier Creams
Creams containing ceramides (eg, Impruv, Cerave, Cetaphil RESTORADERM) may be particularly helpful in restoring the epidermal barrier in persons with irritant contact dermatitis (ICD) 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.
Cleansers
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 (ICD) 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 healthcare workers, owing 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 healthcare 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 (ICD). Corticosteroids were found ineffective in treating the surfactant-induced irritant dermatitis when compared with the vehicle and with the untreated control. [27] However, topical steroids may be helpful for superimposed eczematous features.
Potential complications are associated with 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 can be used as an alternative to topical corticosteroids, but occasionally is an irritant that may produce further stinging and irritation in persons with irritant contact dermatitis. [28]
Consultations
Multidisciplinary consultations may be required when many workers become affected with irritant contact dermatitis (ICD) 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.
-
Chronic irritant contact dermatitis of the hands in an older worker; the condition resulted in early retirement.
