Irritant contact dermatitis

Management Strategy

Correct diagnosis is essential in the management of ICD. A thorough evaluation will include patch testing to rule out allergic contact dermatitis (ACD), a family history (including history of atopy, psoriasis, or other skin conditions), and history of work, habits, hobbies, and exposures to determine the possible causative irritants. Irritant avoidance is key to treatment and prevention. Minimizing contact with the irritant and using protective equipment such as gloves and aprons are necessary, as is appropriate patient and employer education. However, even with avoidance and education, further treatment for ICD is often required. These treatments have not been rigorously evaluated in patients with ICD despite their widespread use; rather, the majority of the literature includes patients with chronic hand dermatitis (CHD), ACD, or atopic dermatitis.

Moisturizers, emollients, and barrier creams are used as first-line therapy. While the terms ‘moisturizer’ and ‘emollient’ are often used synonymously, moisturizers include humectants like lactic acid, urea, glycerin, or sorbic acid, which attract water to hydrate the stratum corneum. Moisturizers come in different consistencies (from light to heavy): lotions, creams (Vanicream, Eucerin, CeraVe cream, Cetaphil cream), or ointments (Aquaphor, Vaseline petroleum jelly, shea butter). Emollients (petrolatum, lanolin, mineral oil) work by slowing transepidermal water loss, and also hydrating the skin like moisturizers. Barrier creams, on the other hand, are designed to repair the skin barrier to allow for healing. Moisturizers, emollients, and barrier creams can be used liberally multiple times a day on the affected or exposed areas.

Topical corticosteroids can also be used to aid in the treatment of ICD if avoidance and moisturizing are not sufficient. For severe acute ICD or chronic ICD with skin thickening, a super high-potency steroid can be applied 1–2 times daily for the acute phase, with expeditious transition to medium-to-high potency steroids. ICD involving the face or flexural areas should be treated with a medium- or low-potency corticosteroid applied 1–2 times daily. Additionally, topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1% cream) can be used 1–2 times daily for refractory ICD when topical therapy is required for an extended period of time to avoid the atrophy that accompanies chronic topical corticosteroid use.

Second-line therapies for ICD include narrowband ultraviolet light (NB-UVB) or broadband UVB therapy . UV therapy can be administered 2–4 times per week from home with devices like the M Series unit from Daavlin or Handisol II from National Biological. Hand psoralen plus UVA (PUVA) photochemotherapy can be delivered using oral or topical psoralen administration. PUVA is considered inferior to UVB due to its phototoxic effects in overdose or if the topical solution is not applied evenly.

Dupilumab is a monoclonal antibody injection that acts as a dual inhibitor of IL-4 and IL-13 signaling. The recommended dose for an adult patient is 600 mg (two 300 mg injections), then 300 mg injections every other week. At the time of this publication, dupilumab is approved for moderate-to-severe atopic dermatitis, asthma, and nasal polyps; however, even in its early stages of testing, the medication is showing extremely promising results with CHD.

Finally, steroid-sparing immunosuppressants like methotrexate (10–25 mg/week) and ciclosporin (3–5 mg/kg/day), or acitretin (10–50 mg)/ alitretinoin (30 mg), can be used but are not recommended unless the ICD is refractory to all other conventional therapies.