Pediatric Contact Dermatitis Treatment & Management

Once the correct diagnosis has been established, many patients improve with adequate hygiene and avoidance of the contactant. Further therapy depends on the degree of involvement, duration, and presence or absence of secondary infection.

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. ^[31]

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 midpotency 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 is 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.

Investigators have found that most people could be immunized against poison ivy through prescription pills; however, this procedure can take months to achieve a reasonable degree of hyposensitization and must be continued over a long period. Immunization can cause uncomfortable side effects and should only be considered for individuals, such as firefighters, who must live or work in areas where they come into constant contact with poison ivy.

In systemic contact dermatitis, contact urticaria, and any time when systemic symptoms are noted, caution is required. In acute severe cases, emergency care can be required. Comanagement with an allergist when type I allergy is suspected in addition to type IV, as well as in cases that are severe, may benefit the patient.

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. ^[32]

Go to Irritant Contact Dermatitis, Allergic Contact Dermatitis, and Protein Contact Dermatitis for complete information on these topics.

The definitive treatment of both irritant contact dermatitis and allergic contact dermatitis is the identification and removal of any potential causal agents. Emergency department treatment may include the following:

• Topical soaks with cool tap water, Burow solution (1:40 dilution), or saline (1 tsp/pint)

• Lukewarm water baths (antipruritic)

• Oatmeal baths

Emollients (eg, white petrolatum, Eucerin) may be beneficial chronic cases.

Large vesicles may benefit from therapeutic drainage (but not removing the vesicle tops). ^[1] These lesions should then be covered with dressing soaked in Burow solution.

In acute irritant dermatitis, the first goal must be to prevent further damage by removal of the irritant. Remove clothing and accessories that the contactant touched. 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. If believed to be a poison, poison control can be consulted in the United States through the website http://poisonhelp.hrsa.gov/what-can-you-do/ or by calling 800-222-1222.

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.

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 petroleum jelly (Vaseline) 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.

In long-lasting contact dermatitis cases, topical tacrolimus can be used long-term to control symptomatology.

Low-strength topical steroids, such as hydrocortisone, may be effective in decreasing inflammation and symptoms associated with very mild contact dermatitis in infants. However, 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. Usage of a midpotency agent is often more appropriate in children for milder disease. In the setting of proven allergic contact dermatitis due to topical corticosteroids, the choice of product must be modified to avoid the allergen and known cross-reactive agents.

Topical steroid therapy is of no benefit in irritant 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 the setting of proven allergic contact dermatitis due to topical corticosteroids, the choice of product must be modified to avoid the allergen and known cross-reactive agents.

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.

Severe pruritus may respond to antihistamines. Popular choices include hydroxyzine (Atarax) or diphenhydramine (Benadryl).

Warm weather, hot showers, and activities vigorous enough to cause perspiration increase pruritus. Individuals with severe acute allergic contact dermatitis may be incapacitated temporarily

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 patients who have recurrent episodes of dermatitis with unclear etiology to a dermatologist.

When procedures involving metal rods are needed (eg, the Nuss procedure), prescreening for nickel and other metal allergies is needed to identify children requiring alternative alloys.

Dietary modifications are controversial, particularly in children. However, food preservatives have been identified as a source of allergic contact dermatitis and high-nickel diets can worsen some patients, Therefore, judicious food avoidance based on documented allergens and relevant reduction in symptoms with withdrawal can aid some children. Avoidance diets are known to trigger malnutrition in some children. Comanagement with a nutritionist may benefit children on avoidance diets.

Prevention of contact dermatitis is better than cure. The most important part of the treatment is to identify and eliminate further exposure to the causative agent.

Urushiol is the oily resin in poison ivy, poison sumac, and poison oak, which causes an allergic reaction. Keep in mind this resin can remain active for years on virtually any surface. Thoroughly wash everything that might have brushed against the plants, including clothing, shoes, tools, camping equipment, and pets.

Wearing a long-sleeved shirt, pants, gloves, and boots when in an infested area and bathing as soon as possible after exposure are effective methods to limit rhus dermatitis.

The only places in the United States where poison ivy is not found are areas above 4000 ft elevation, Alaska, Hawaii, and some desert areas of California and Nevada. Poison ivy usually grows east of the Rocky Mountains and in Canada. Poison oak grows in the western United States, Canada, and Mexico (western poison oak), and in the southeastern states (eastern poison oaks). Poison sumac grows in the eastern states and southern Canada.

Patients should learn to recognize poison ivy, poison sumac, and poison oak and have them removed from areas where children are likely to play. Several features of poison ivy, oak, and sumac are useful in identification.

Poison ivy and oak may be shrubs or climbing vines. All species of poison ivy and oak have 3 leaflets per leaf, hence the reminder, "Leaves of 3, let them be." The leaf stalk has a groove where it attaches to the branch. Blooms and fruits arise in the angle between the leaf and the branch. Young leaves frequently are reddish in color, and the mature fruit is tan or cream colored.

Poison sumac is a shrub or small tree usually 5-10 feet tall and grows in swampy areas or peat bogs. Poison sumac contains 7-13 paired leaflets in a row. The American Academy of Dermatology has handouts with color photographs available for purchase or viewing on their web site.

Poison ivy, poison sumac, and poison oak are most dangerous in the spring and summer when sap is plentiful. The leaves, branches, and trunk may show black marks where they have been injured, as the sap turns black after exposure to air.

Do not let pets run through wooded areas where poison ivy, poison sumac, and poison oak grow. After contacting these plants, pets may carry urushiol on their fur, causing contact dermatitis in family members who come in contact with the animal. Urushiol can travel in smoke if it burns in a fire; do not burn plants that look like poison ivy, poison sumac, or poison oak.

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 claylike 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.

Allergic contact dermatitis profiles can change with age, and repeat testing every 5 years may benefit children with more severe and recalcitrant dermatitis, or new flares in an unusual distribution.