3/9/2016

IrritantContactDermatitisTreatment&Management:ApproachConsiderations,EmergencyDepartmentCare,BarrierCreams

IrritantContactDermatitisTreatment&Management
Author:DanielJHogan,MDChiefEditor:WilliamDJames,MDmore...
Updated:Apr16,2014

ApproachConsiderations
Thedefinitivetreatmentofirritantcontactdermatitisistheidentificationand
removalofanypotentialcausalagents.Aninflammatoryreactionfromacute
delayedirritantcontactdermatitistoanagentsuchasbenzalkoniumchloride(eg,
zephiran)rarelyneedstreatmentandusuallyresolveswithcessationofexposure.
Furthersymptomatictherapydependsonthedegreeofinvolvementandthe
presenceorabsenceofsecondaryinfection.
Adviseindividualstouseceramidescreamsorblandemollientsafterwashinghands
withsoapandbeforesleep.Cleansersmayberankedbytheirirritancy. [18]
Recommendmildskincleansers(eg,Aquanil,Cetaphilcleanser,OilatumAD,
Neutrogenacleanser)inplaceofsoaponaffectedareas.Instructindividualsto
refrainfromtheuseofinappropriatesolvents(eg,gasoline)orabrasives(eg,
pumicestone)tocleansehandsthesedirectlydefatortraumatizetheskin.
AsummaryoftheDanishContactDermatitisGroupguidelineforhandeczema
includesadiagrammedsequenceofgeneraltreatmentprinciplesandnotesthat
moisturizingcreamshouldbegivenincombinationwithalltreatments.Ifhand
eczemadoesnotresolvewithin1month,theguidelinerecommendsphysicians
referthepatienttoadermatologistlongerdelaysareassociatedwithapoorer
prognosis. [19]
GotoAllergicContactDermatitis,PediatricContactDermatitis,andProteinContact
Dermatitisforcompleteinformationonthesetopics.

EmergencyDepartmentCare
Emergencydepartmenttreatmentmayincludethefollowing:
Topicalsoakswithcooltapwater,Burowsolution(1:40dilution),saline(1
tsp/pint)
Lukewarmwaterbaths(antipruritic)
Aveeno(oatmeal)lukewarmbaths
Emollients(eg,whitepetrolatum,Eucerin)maybebeneficialchroniccases.
Largevesiclesmaybenefitfromtherapeuticdrainage(butnotremovingthevesicle
tops). [1]Theselesionsshouldthenbecoveredwithantibioticdressingoradressing
soakedinBurowsolution.
Hospitaladmissionisrequiredonlyinseverecutaneousirritantcontactdermatitis,
ie,chemicalburnsfromhydrofluoricacidor,occasionally,fromfreshlymixed
Portlandcement.

BarrierCreams
Creamscontainingceramides(eg,Impruv,Cerave,CetaphilRESTORADERM)may
beparticularlyhelpfulinrestoringtheepidermalbarrierinpersonswithirritant
contactdermatitisandatopicdermatitis.Creamscontainingdimethicone(eg,
Cetaphilcream)canbehelpfulinrestoringtheepidermalbarrierinpersonswithwet
workrelatedirritantcontactdermatitis.

Cleansers
MostsoapsanddetergentsarealkalineandinduceanincreaseincutaneouspH,
whichaffectsthephysiologicprotectiveacidmantleoftheskinbydecreasingthefat
content.DisruptionofstratumcorneumandchangesinpHarekeyelementsinthe
inductionofirritantcontactdermatitisandpruritusbysoaps.Theseconditionsare
exacerbatedinthewintermonthsinpatientswithdry,sensitiveskin.
Syndets,withapHapproximately5.5,donotmodifyskinpH.Mostbarsoapsand
liquiddetergentsavailableonthemarketareamixtureofsoapandsyndet.Astudy
foundthatDoveandCetaphilhadalowerirritanteffectthantheothersoapstested.
Interestingly,nosignificantcorrelationwasmadebetweenthepriceoftheproducts
andtheirirritationpotential.
Irritantcontactdermatitisisafrequentprobleminhealthcareworkers,dueto
frequenthandwashing.Thebestantimicrobialefficacycanbeachievedwith
ethanol(6085%),isopropanol(6080%),andNpropanol(6080%).The
antimicrobialefficacyofchlorhexidine(24%)andtriclosan(12%)isbothlowerand
slowerandcarriesapotentialriskofbacterialresistance.
Theuseofalcoholbasedhandrubscontainingvariousemollientsinsteadof
irritatingsoapsanddetergentsisonestrategytoreduceskindamage,dryness,and
irritationinhealthcareworkers.Irritantcontactdermatitisoccursmostfrequently
withpreparationscontaining4%chlorhexidinegluconate,lessfrequentlywith
nonantimicrobialsoapsandpreparationscontaininglowerconcentrationsof
chlorhexidinegluconate,andleastfrequentlywithwellformulatedalcoholbased
handrubscontainingemollientsandotherskinconditioners.

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IrritantContactDermatitisTreatment&Management:ApproachConsiderations,EmergencyDepartmentCare,BarrierCreams

SteroidsandImmunomodulators
Topicalcorticosteroidsandimmunomodulatorsareofunprovenuseintreating
irritantcontactdermatitis.Corticosteroidswerefoundineffectiveintreatingthe
surfactantinducedirritantdermatitiswhencomparedwiththevehicleandwiththe
untreatedcontrol. [20]However,topicalsteroidsmaybehelpfulforsuperimposed
eczematousfeatures.
Potentialcomplicationscenterontheuseofsteroids,particularlyaroundtheeye.
Theavoidanceoflongtermsteroiduseisessential,becausesuchusemaycause
cataracts,glaucoma,cornealthinning/perforation,andlossoftheeye,aswellas
otherproblems.
Topicaltacrolimusisanirritantthatmayproducefurtherstingingandirritationin
personswithirritantcontactdermatitis. [21]

Consultations
Multidisciplinaryconsultationsmayberequiredwhenmanyworkersbecome
affectedwithirritantcontactdermatitisinaworkplace.Identifyingandremediating
thecausesofwidespreadirritantcontactdermatitisinterferingwithworkplace
productivityandworkerqualityoflifeisimportant.
Anypatientwithhydrofluoricacidburnshouldbeevaluatedasamedicalemergency
byaphysicianexperiencedinthemanagementofhydrofluoricexposuresandburns.
Considerregionalintravenousinfusionofcalciumgluconateasatherapeuticoption
inhydrofluoricacidburnstoforearm,hand,ordigitswhentopicaltherapyfails.
Medication

ContributorInformationandDisclosures
Author
DanielJHogan,MDClinicalProfessorofInternalMedicine(Dermatology),NovaSoutheasternUniversity
CollegeofOsteopathicMedicineInvestigator,HillTopResearch,FloridaResearchCenter
DanielJHogan,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanAcademyof
Dermatology,AmericanContactDermatitisSociety,CanadianDermatologyAssociation
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
MichaelJWells,MD,FAADAssociateProfessor,DepartmentofDermatology,TexasTechUniversityHealth
SciencesCenter,PaulLFosterSchoolofMedicine
MichaelJWells,MD,FAADisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
AcademyofDermatology,AmericanMedicalAssociation,TexasMedicalAssociation
Disclosure:Nothingtodisclose.
PaulKrusinski,MDDirectorofDermatology,FletcherAllenHealthCareProfessor,DepartmentofInternal
Medicine,UniversityofVermontCollegeofMedicine
PaulKrusinski,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology,
AmericanCollegeofPhysicians,SocietyforInvestigativeDermatology
Disclosure:Nothingtodisclose.
ChiefEditor
WilliamDJames,MDPaulRGrossProfessorofDermatology,ViceChairman,ResidencyProgramDirector,
DepartmentofDermatology,UniversityofPennsylvaniaSchoolofMedicine
WilliamDJames,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology,
SocietyforInvestigativeDermatology
Disclosure:Nothingtodisclose.

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