Management of contact dermatitis

Dr Graham Johnston gives an overview of evidence-based recommendations for the management of contact dermatitis.

The British Association of Dermatologists (BAD) published evidence-based recommendations for the management of contact dermatitis in February 2017. The guidelines were the result of a detailed appraisal of all relevant literature up to February 2016. They focus on recent developments, aim to address important clinical questions, and offer recommendations for practical use in the clinic.

In addition to the guidelines, an updated patient information leaflet has been published which is available on the BAD website.1

The guidelines are predominantly aimed at hospital-based units, but a number of points are relevant for healthcare professionals practising dermatology in a wider context.

Taking the history

The importance of taking a detailed history, including the symptoms and the effect on quality of life are emphasised in the recommendations. Questions to ask the patient include:

  • Is there a personal history of atopic dermatitis in infancy or childhood?
  • Are there other atopic features, such as asthma and hayfever?
  • Is there a family history of atopy?
  • Where did the initial symptoms begin, and where did they spread to later?
  • Were symptoms related to the application of any particular product, especially cosmetics, personal-care products, topical medication, clothing, bandages or personal protection such as gloves?
  • Were symptoms related to any particular activity, such as hairdressing, holidays, home improvements, painting, decorating, recreation or sport?
  • Are symptoms related to work or specific activity within the workplace?
  • Do symptoms improve when environment changes, for example at weekends and during holidays, and recur on return to work?
  • Do symptoms get worse after sunlight exposure?

The history should identify any contact with primary skin irritants. Consider wet agents, (including water, the frequency of hand washing and which products have been used), as well as dry, desiccating products.

Many wash products contain harsh emulsifiers/surfactants which can cause significant damage to the skin barrier in predisposed individuals, such as those with atopic or endogenous dermatitis, after a short period of exposure. Ask patients to try to detail every wash product that has come into contact with the skin, including shampoos.

If a patient reports a link between their symptoms and their work, identify the products handled at work and examine health and safety data sheets where possible. Also determine personal protection practices such as the use of gloves or goggles.

Clinical assessment

The guidelines remind us that healthcare professionals should be offering patch testing to any patient with a chronic or persistent dermatitis, particularly if it is localised to one body site such as the hands, face or genitals. This is because clinical features alone are unreliable in distinguishing allergic contact from irritant and endogenous dermatitis, especially in cases of hand and facial dermatitis.

The guidelines also encourage more detailed clinical assessment using tools such as the Dermatology Life Quality Index (DLQI) and the Hand Eczema Severity Index (HECSI) , for both the initial assessment and the monitoring of treatment response in patients with contact dermatitis.

When offering a patch test, the guidelines recommend providing a patient information leaflet as part of the counselling process. This should include information on potential side-effects.

The use of additional series’ beyond the baseline series in a patch test improves its diagnostic accuracy. The so-called standard series is rarely enough. Patients’ own products should be tested because these can provide useful evidence of causation. Additional readings are recommended at day six or seven if the results are unexpectedly negative at day four. This can increase the diagnostic yield by 10%.

Prevention and treatment

There is evidence that skin care and skin protection creams, as well as patient education, are useful in preventing and treating occupational dermatitis.

Consider topical tacrolimus in patients with contact dermatitis where topical steroids are unsuitable or ineffective before moving on to psoralen and ultraviolet A (PUVA) treatment, particularly in chronic hand eczema.

There is good evidence that oral alitretinoin improves outcomes in patients with severe chronic hand eczema. This should be considered sooner rather than later because disabling chronic hand eczema represents a considerable loss to society in terms of sick days, and a burden on primary care resources.

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References

  1. BAD. Contact dermatitis. May 2017. www.bad.org.uk/for-the-public/patient-informationleaflets (accessed 13 September 2017).

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