Contact dermatitis Revised: July 31, 2013

Copyright Elsevier BV. All rights reserved.

Key points

Contact dermatitis ranks among the most common reasons for patient visits to a dermatologist

There are two main types of contact dermatitis: irritant contact dermatitis, which accounts for

approximately 80% of cases, and allergic contact dermatitis, which accounts for approximately 20%

of cases

Irritant contact dermatitis is a non–immune-mediated reaction caused by direct injury to the skin

following exposure to an irritant chemical or physical agent (eg, alkalis in soaps and solvents),

whereas allergic contact dermatitis is a type IV delayed hypersensitivity reaction that only affects

patients who have been previously sensitized to an allergen (eg, nickel, poison ivy oleoresin,

bacitracin, neomycin)

The diagnosis is established on the basis of a history of exposure, compatible clinical features, and

the results of patch testing

Treatment of both types of contact dermatitis begins with avoidance of the offending substance(s)

and use of emollients and soap substitutes to help repair the skin barrier

Oral antihistamines (H1-blockers) are useful for the treatment of pruritus

Moderate contact dermatitis responds to treatment with topical corticosteroids used in the lowest

concentration and potency that produce a beneficial effect

Severe allergic contact dermatitis may require treatment with systemic corticosteroids or other

immunosuppressive agents, although evidence supporting their use is limited

Although extremely uncommon, immediate contact reactions to high-molecular-weight antigens (eg,

natural rubber latex) or even more uncommon to chemicals (eg, bacitracin) can produce an

immunoglobulin E–mediated Type I immediate hypersensitivity reaction resulting in contact urticaria

, angioedema , and possibly anaphylactic shock . Early administration of epinephrine is the mainstay of

treatment, along with supportive care and strict avoidance of the inciting agent

Chemical burns, a form of acute irritant contact dermatitis, require rapid and copious

irrigation. Each specific chemical agent that is responsible needs to be appropriately investigated,

and treatment is based on the chemical that is responsible. Severe cases need to be immediately

transferred to an emergency department for more specific treatment

Treatment

Summary approach

The goals of treatment of contact dermatitis are to reduce morbidity, prevent complications, allow

patients with occupational contact dermatitis to return to work, and provide education regarding

avoidance of additional episodes

Treatment of contact dermatitis depends on the type, extent, and location of skin lesions. Although

allergic contact dermatitis is considered to be a chronic condition, most patients report resolution of

symptoms within days to months once the allergen has been removed. Additionally, some patients

may not exhibit symptoms with every exposure to the allergen; for example, patients with gold

allergy often tolerate gold dental crowns without any mucosal or systemic reactions

Patients who have been exposed to hydrofluoric acid should be transferred to the emergency room

immediately. Diluted hydrofluoric acid solutions penetrate the skin deeply before dissociating,

thereby producing delayed injury (solutions of less than 7% may take several hours to produce

symptoms), resulting in deeper penetration and, consequently, a more severe burn. Hypocalcemia is

a direct result of hydrofluoric acid exposure

Emergency treatment may be required for other chemical burns depending on the specific chemical

cause, site, and extent of the burn and whether systemic symptoms are present

Patients with severe allergic reactions associated with type I IgE-mediated allergy prick testing may

require treatment with epinephrine and resuscitation

Advanced Cardiovascular Life Support trained individuals should be available in any prick testing

center

Allergen and irritant avoidance:

Eliminate further exposure to the agent through simple lifestyle changes ; this is the most efficacious

treatment option

Allergen avoidance lists and allergen alternatives are available from published sources on the

Internet, in appropriate texts, and through the American Contact Dermatitis Society Web site

Reduction of skin dryness:

Many cases of localized mild contact dermatitis respond well to cool compresses (soaked with clean

water or isotonic sodium chloride solution) applied for 5 to 10 minutes followed by air drying

Emollients and barrier creams and ointments may be helpful in patients with localized, mild contact

dermatitis

Use of soap substitutes will diminish drying of the skin during washing and is particularly helpful in

patients with contact dermatitis on the hands. Mild liquid soaps or bar soaps, which contain fewer

preservatives than liquid forms, are preferred

Washing with cold or lukewarm water is preferred over hot water. The use of emollients immediately

after washing is imperative

Treatment of the inflammatory process:

Low-potency topical corticosteroids , such as hydrocortisone , may be effective in decreasing symptoms

and inflammation associated with mild contact dermatitis but are not effective for larger areas of

allergic contact dermatitis

More potent topical corticosteroids, such as clobetasol or betamethasone dipropionate , are effective in

treating small areas of moderate allergic contact dermatitis

Rarely, oral corticosteroids such as prednisone may be used in patients with severe, extensive allergic

contact dermatitis

Topical calcineurin inhibitors ( tacrolimus or pimecrolimus ) may be an option in patients with chronic

dermatitis who develop adverse effects from topical corticosteroids, patients with chronic eyelid

dermatoses, and patients whose dermatitis is unresponsive to corticosteroids. Clinical trials have

shown both medications to be effective in patients with nickel allergic contact dermatitis, although

both are associated with an increased risk of immunosuppression and cancer

Chronic or severe contact dermatitis:

In patients with very severe contact dermatitis, treatment with immunosuppressive agents, such as

prednisone or cyclosporine , can provide rapid relief

Ultraviolet light therapy has been shown to be effective in preventing occupation-related hand contact

dermatitis and treating longstanding contact dermatitis, but continued treatment is needed to

maintain results

Treatment of pruritus:

Oral antihistamines , such as hydroxyzine , may be effective in patients with severe pruritus and may

improve sleep

Treatment of poison oak and poison ivy:

The skin should be washed with soap within 10 minutes of exposure, which can be effective in

preventing the onset of dermatitis

Everything that may have come into contact with the offending plants, including clothing, shoes,

tools, and pets, should be washed thoroughly

Calamine lotion and colloidal oatmeal baths may help with pruritus

Corticosteroid treatment should be reserved for more severe cases

Quaternium-18 bentonite 5% lotion applied to the skin 1 hour before patch testing with urushiol in

patients allergic to poison ivy and poison oak resulted in absent or significantly reduced reactions to

urushiol compared to control subjects. This is commercially available and may be used

preventatively

Treatment of chemical burns, a form of acute irritant contact dermatitis:

Rapid and copious irrigation, with a combination of soap and water for insoluble agents, is the initial

step in management

o Hydrofluoric acid, which is used mainly in industrial settings, is one of the strongest inorganic acids.

Diluted solutions penetrate the skin deeply before dissociating, thereby producing delayed injury

(solutions of less than 7% may take several hours to produce symptoms), resulting in deeper

penetration and, consequently, a more severe burn. Patients exposed to hydrofluoric acid require

immediate transportation to the emergency department, as systemic complications, such as

decalcification of bone, cardiac arrhythmias, and permanent damage to nerve conduction, can occur

o Exposure to strong alkalis, such as calcium oxide (found in wet cement), sodium hydroxide,

potassium hydroxide, calcium hydroxide, sodium silicate, potassium cyanide, and trisodium

phosphate, requires urgent attention. Strong alkali burns generally are more severe and more painful

than strong acid burns, with the exception of hydrofluoric acid burns

Medications

Topical corticosteroids

Indications

Treatment of symptoms and inflammation associated with small areas of mild contact dermatitis

(hydrocortisone)

Treatment of small areas of moderate allergic contact dermatitis (clobetasol, betamethasone

dipropionate)

Dose information

Hydrocortisone (1.0-2.5%):

A small amount applied to the affected area(s) two to three times a day initially, reducing the dose as

lesions remit

Clobetasol (0.05%):

In adults: a small amount applied to the affected area(s) twice daily for up to 2 weeks, not to exceed

50 g/week

Betamethasone dipropionate (0.05%):

In adults: a small amount applied to the affected area(s) three times a day initially, reducing the dose

as lesions remit

Major contraindications

Fungal infection (hydrocortisone)

Hypersensitivity to corticosteroids

Idiopathic thrombocytopenic purpura (betamethasone dipropionate)

Comments

There are varying strengths of topical corticosteroids. Class I topical steroids are the most potent (for

example, clobetasol 0.05%). Class VI are the least potent (for example, hydrocortisone 1.0%)

Effective in reducing inflammation and pruritus

May cause thinning of the skin (atrophy), striae, and telangiectasias

Systemic absorption can cause reversible hypothalamic-pituitary-adrenal (HPA) axis suppression,

manifestations of Cushing syndrome, hyperglycemia, glucosuria, and glaucoma; children are more

susceptible to HPA axis suppression and Cushing syndrome than mature patients because of a larger

skin surface area–to–body weight ratio. Such adverse effects are unlikely with low-potency

corticosteroids but may occur with use of moderate- to high-potency corticosteroids, even at low

doses. Conditions that augment systemic absorption include use of more potent corticosteroids,

application over large surface areas, prolonged use, and the addition of occlusive dressings

If no improvement is seen in 2 weeks, the diagnosis should be reassessed

The risk of contact sensitization to corticosteroids is considerably higher than generally believed;

allergic contact dermatitis from corticosteroids should be considered in patients who fail to respond

appropriately to treatment and can be confirmed with patch testing

Oral corticosteroids

Indications

Treatment of severe local contact dermatitis, lesions that are progressing, or contact dermatitis

affecting large areas of the skin, or involving the face causing severe swelling of the eyelids with

impaired vision

Dose information

Prednisone

Adult:

A 2-week course, starting with 60 mg/d orally for 4 days, followed by 50 mg/d for 2 days, and then

gradually reducing by 10 mg every 2 days before ceasing therapy. This regimen generally should not

be repeated more than once every 3 to 4 months and requires consultation with a dermatologist

A treatment taper for 2 to 3 weeks may be required in patients with extensive dermatitis due to

poison ivy or poison oak

Pediatric:

0.05 to 1.0 mg/kg/d orally daily for 7 to 14 days, tapering as in the adult dose regimen

Major contraindication

Fungal infection

Uncontrolled diabetes

Uncontrolled hypertension

Comments

Only used to treat the worst cases of contact dermatitis

Considered beneficial in patients with severe contact dermatitis, such as widespread dermatitis due

to poison ivy or poison oak, resulting in a reduction in symptoms and more rapid clearing of skin

lesions; also a strong and rapid treatment for severe, blistering acute contact dermatitis due to other

substances

The dose must be individualized according to the disease and the response

Higher doses may be required before, during, and after unusual stress, such as surgery or trauma

The dose should be gradually reduced before ceasing therapy; treatment should not be discontinued

abruptly

Long-term use (usually more than 3 weeks) or use of doses greater than physiologic amounts (7.5

mg) may lead to clinically relevant suppression of the pituitary-adrenal axis, suppression of linear

growth (possibly irreversible) in pediatric patients, or Cushing syndrome

Topical calcineurin inhibitors

Indications

Treatment of contact dermatitis in patients who cannot use corticosteroids or whose dermatitis is

unresponsive to them

This is an off-label indication

Dose information

Safety and efficacy in patients under age 2 have not been established

Tacrolimus

Adult:

A small amount of 0.03% or 0.1% ointment applied to the affected area(s) twice daily, continuing for

1 week after symptoms have cleared

In pediatric patients aged 2 years and older: a small amount of 0.03% ointment applied to the

affected area(s) twice daily, continuing for 1 week after symptoms have cleared

Pimecrolimus

Adult:

A small amount of 1% cream applied to the affected areas(s) twice daily for as long as symptoms

persist

Major contraindications

Hypersensitivity to polyoxyethylated castor oil (tacrolimus)

Hypersensitivity to tacrolimus or pimecrolimus

Comments

Effectively decreases symptoms and reduces skin lesions, but should only be used as a last resort

when other treatments have failed; evidence for pimecrolimus is lacking

Should only be used for short periods of time

Associated with an increased risk of varicella zoster virus infection, herpes simplex virus infections,

or eczema herpeticum, especially in immunocompromised patients, and potentially may increase the

risk of cancer (see the U.S. Food and Drug Administration public health advisory )

Topical administration is safer than systemic administration and has not been shown to have adverse

effects on the immune system

May cause photosensitivity; should not be administered with other photosensitizing drugs (eg, some

antibiotics, thiazide diuretics), and patients should be instructed to use a sunscreen

Pimecrolimus may cause short-term facial flushing after ingestion of alcohol

Evidence

A double-blind, randomized, controlled trial (RCT) comparing topical 0.1% tacrolimus ointment

versus placebo (vehicle) in 19 volunteers and 10 patients with nickel-induced allergic contact

dermatitis found that tacrolimus was significantly more effective than placebo in ameliorating the

nickel reaction. [1] Level of evidence: 2

A double-blind RCT in 28 female volunteers found that topical 0.1% tacrolimus ointment reversed

nickel-induced contact dermatitis significantly better than petrolatum control and to a similar extent

as 0.1% mometasone furoate ointment. [2] Level of evidence: 2

A prospective RCT in patients allergic to nickel showed that 0.1% tacrolimus ointment is well

tolerated and effective in treating nickel-induced allergic contact dermatitis. [3] Level of evidence: 2

A randomized, prospective study compared tacrolimus 0.1% ointment to mometasone ointment for

the treatment of allergic contact dermatitis of the hands. The treatments were determined to be

equivalent. [4] Level of evidence: 2

References

Cyclosporine

Indication

Cyclosporine is used to treat severe contact dermatitis

This is an off-label indication

Dose information

Safety and efficacy in children under age 2 have not been established

In patients aged 2 years and older:

5 mg/kg/d orally, typically for a short course (ie, 6-8 weeks), although there are reports describing

long-term therapy in adults and multiple short courses (12-week cycles with at least 7 days between

each course of therapy) and continuous therapy (for 1 year) in children

Major contraindications

Hypertension

Neoplastic disease

Ocular infection

Polyoxyethylated castor oil hypersensitivity

Prior photochemotherapy

Radiation therapy

Renal disease

Renal failure

Renal impairment

Comments

Usefulness is limited by adverse effects and rapid relapse of symptoms following discontinuation of

therapy

Oral antihistamines

Indication

Treatment of pruritus

Dose information

Should not be used in neonates and premature infants

Hydroxyzine :

Adult: 25 mg orally three to four times daily as needed

Pediatric: 2 mg/kg/d orally in equally divided doses every 6 to 8 hours as needed

Major contraindications

Hypersensitivity to hydroxyzine

Pregnancy

Comments

Provide relief from pruritus

Use of sedating antihistamines in children under age 2 is not recommended

Associated with a risk of sedation, glaucoma, falls, and urinary obstruction

Evidence

A multicenter RCT in 188 patients aged 12 years and older with symptomatic chronic idiopathic

urticaria found that treatment with hydroxyzine or cetirizine resulted in a significant improvement

in urticarial symptoms, including pruritus, compared to placebo. [5] Level of evidence: 2

References

Non-drug treatments

Lifestyle changes

Description

Avoidance of further contact with the causative irritant or allergen, as well as cross-reacting agents

Moisturizing; cleansing using mild, unscented bar soaps or soap substitutes; and protecting the skin

(eg, wearing gloves in cold weather; use of adequate protection, such as vinyl gloves, when working

with irritating substances)

Indications

Treatment and prevention of recurrence of contact dermatitis

Comments

Most effective measure to prevent allergic contact dermatitis

Patients should be educated about the effectiveness of these simple measures

A low-nickel diet has been shown to be helpful in patients with nickel-induced contact dermatitis or

dyshidrotic hand eczema

Emollients

Description

Lipid-rich moisturizers, such as lanolin and paraffin

Indications

Prevention and treatment of irritant contact dermatitis

Comments

A simple and effective intervention to moisturize and protect the skin

Decreases transepidermal water loss

Barrier creams and ointments

Description

Barrier creams containing dimethicone or zinc oxide and ointments containing perfluoropolyethers

(eg, petroleum jelly, petrolatum-based ointments)

Indication

Prevention of irritant contact dermatitis

Comments

Reduce transepidermal water loss and increase skin lubrication

A simple but effective method to prevent skin irritation

Coverage must thick to provide sufficient barrier protection

There is evidence that barrier creams containing quaternium-18 bentonite can prevent allergic

contact dermatitis caused by poison oak and poison ivy

There is evidence that barrier creams containing the chelating agent diethylenetriaminepentaacetic

acid (DTPA) may prevent metal-related allergic contact dermatitis

Evidence

A double-blind RCT comparing a barrier cream versus its moisturizing vehicle in a total of 50

hospital nurses with mild skin irritation found that clinical skin status improved and stratum

corneum hydration increased significantly in both groups, leading the investigators to conclude that

there were no significant differences in efficacy between the barrier cream and the emollient vehicle.

[6] Level of evidence: 2

A single-blind, multicenter RCT evaluated the efficacy and safety of 5% quaternium-18 bentonite

lotion for prevention of experimentally induced poison ivy and poison oak allergic contact dermatitis

in 211 volunteers with known sensitivity to poison ivy and poison oak. Significantly reduced reactions

to urushiol were observed at patch test sites that were pretreated with quaternium-18 bentonite

lotion compared to untreated (control) sites, leading the investigators to conclude that quaternium-

18 bentonite lotion is effective in preventing or reducing allergic contact dermatitis from poison ivy

or poison oak. [7] Level of evidence: 2

A double-blind RCT evaluating a barrier cream containing DTPA (a chelator) in patients with metal-

induced allergic contact dermatitis found that those who were exposed to allergens on sites

pretreated with DTPA cream had negative patch test results. [8] Level of evidence: 2

References

Soap substitutes

Description

Use of gentle cleansers instead of soap when bathing

Indication

Management of patients with dermatitis

Comments

Decrease drying of skin by increasing lubrication

A simple but effective way to aid in treatment of dermatitis

Ultraviolet light therapy

Description

Supervised delivery of short-wave ultraviolet B light (narrow bandvsbroadband UVB therapy)

Indications

Treatment of occupation-related contact dermatitis on the hands

Treatment of longstanding contact dermatitis

Complications

Skin cancer

Sunburn and skin damage

Cataracts

Worsening of other skin diseases

Increased photoaging

Comments

Continued therapy is needed to maintain results

Time-intensive

Special circumstances

Topical and systemic corticosteroids should be used cautiously in infants and children, as high-

potency topical corticosteroids may be absorbed systemically, and systemic corticosteroids may stunt

growth, among other adverse effects.

Comorbidities

In patients in whom secondary bacterial infection in areas of skin erosion or breakdown is suspected,

appropriate cultures and antibiotics should be considered

Some patients with chronic dermatitis can develop allergies to medications, particularly topical

corticosteroids and neomycin

Patients with leg ulcers, venous insufficiency, and lower leg edema are particularly prone to contact

dermatitis of the lower legs resulting from altered sensitivity to certain chemicals. Topical

medications containing wool alcohols, fragrance, parabens, and neomycin should not be used in

these patients

Patient satisfaction/lifestyle priorities

Antihistamines with sedating effects are not recommended in patients whose occupation requires

them to operate heavy machinery, fly a plane, or drive a vehicle.

Consultation for treatment

Consultation with a dermatologist should be considered in patients with severe contact dermatitis or

whose dermatitis does not respond to multiple treatment regimens

If treatment failure is related to inability to identify the causal allergen, the patient should be

referred to a specialist for patch testing

Follow-up

Plan for review:

If the patient's dermatitis responds well to treatment and there are no complications, no follow-up is

required, unless medications are being used that necessitate monitoring for adverse effects (eg, high-

potency corticosteroids)

If the patient's dermatitis does not respond to treatment or worsens, re-evaluation and

implementation of a different treatment regimen is necessary. Consultation with a specialist should

be considered if the alternative treatment regimen fails

If the patient is showing signs of adverse effects to the medication prescribed, the treatment plan

should be altered

Secondary prevention:

The most effective method of preventing recurrences of contact dermatitis is to avoid exposure to the

causative irritant or allergen. In the case of allergic contact dermatitis, measures to prevent the

elicitation phase are important. Patch testing is a useful diagnostic tool, and determination of the

relevance of positive reactions is important. Identifying sources of allergens and irritants can be

particularly challenging in some cases. The Contact Allergy Management Program (CAMP) is a resource

available to members of the American Contact Dermatitis Society that can be used to help patients

identify products that are free of specific allergens and cross-reacting substances

Some forms of allergic contact dermatitis can be prevented using topical treatments, such as topical

skin protectant and quaternium-18 bentonite to prevent urushiol-induced (poison ivy and poison

oak) allergic contact dermatitis

Protective clothing, such as gloves, gauntlets, and aprons, is also an important adjunct in preventing

contact dermatitis, although it is important to verify that gloves may be worn safely and are not at

risk of getting caught in machinery

Use of the nickel spot (dimethylglyoxime) test to identify sources of nickel exposure is an effective

means of prevention in patients with nickel allergy

Prognosis:

The prognosis in patients with contact dermatitis depends on the cause and the ability of the patient

to avoid repeated exposure to the causative irritant or allergen

Most cases of contact dermatitis will resolve in 4 to 6 weeks if further exposure to the causative agent

is prevented

The prognosis is worse in patients in whom the causative agent cannot be identified, and recurrence

is more likely

New sensitivities to topical medications may develop during the course of the dermatitis

Occult exposures may produce chronic or recurrent contact dermatitis. Some ubiquitous allergens,

such as rubber or nickel, are almost impossible to avoid completely

Chromate dermatitis has been associated with chronic occupational dermatitis

After significant contact dermatitis, the barrier function of the skin can be impaired for months to

years. Exposure to irritants or allergens at a lower concentration than would be required to elicit a

response in normal skin can hamper recovery or result in recurrence

During a long course of dermatitis that relapses, sensitivity to various allergens may accumulate,

which increases the risk of recurrence

Sources of allergen alternatives are available

Complications:

Irritant contact dermatitis increases the risk of sensitization to topical medications

Although uncommon during the acute stages of contact dermatitis, secondary bacterial infections,

particularlyStaphylococcus aureusinfection, can occur and should be treated with systemic

antibiotics

Postinflammatory hyper- or hypopigmentation may occur in areas affected by contact dermatitis

Secondary neurodermatitis may develop in patients with irritant contact dermatitis, particularly

those with occupational dermatitis and those under psychologic stress

Scar formation may result from deep chemical burns or significant secondary infection

Rarely, erythema multiforme has been reported following allergic contact dermatitis resulting from

exposure to poison ivy, tropical woods, nickel, and hair dye

Implant failure due to metal-induced allergic contact dermatitis is controversial

In-stent restenosis has been associated with metal allergy in some reports, but further study is

needed, as some trials have not shown a correlation between positive patch test results and in-stent

restenosis

Patient education

Patients with contact dermatitis should be educated about the importance of avoiding exposure to

causative irritants or allergens. They should also be informed that taking simple precautions, such as

wearing long pants and long-sleeved shirts in areas where there is poison ivy or wearing vinyl gloves

to protect against exposure to water or chemicals, may prevent recurrence of the condition.

Online information for patients

American Academy of Allergy, Asthma, and Immunology:

o Allergic Skin Conditions: Tips to Remember

o Scratching the Surface on Skin Allergies

o Skin Allergy

o Two Cents about Nickel

American Academy of Dermatology:

o Poison Ivy, Oak, and Sumac

o Types of Eczema: Contact Dermatitis

Centers for Disease Control and Prevention: Skin Exposures and Effects in the Workplace

Mayo Clinic:

o Contact Dermatitis

o Poison Ivy Rash

Resources

Summary of evidence

Evidence

Topical calcineurin inhibitors:

A double-blind RCT comparing topical 0.1% tacrolimus ointment versus placebo (vehicle) in 19

volunteers and 10 patients with nickel-induced allergic contact dermatitis found that tacrolimus was

significantly more effective than placebo in ameliorating the nickel reaction. [1] Level of evidence: 2

A double-blind RCT in 28 female volunteers found that topical 0.1% tacrolimus ointment reversed

nickel-induced contact dermatitis significantly better than petrolatum control and to a similar extent

as 0.1% mometasone furoate ointment. [2] Level of evidence: 2

A prospective RCT in patients allergic to nickel showed that 0.1% tacrolimus ointment is well

tolerated and effective in treating nickel-induced allergic contact dermatitis. [3] Level of evidence: 2

A randomized, prospective study compared tacrolimus 0.1% ointment to mometasone ointment for

the treatment of allergic contact dermatitis of the hands. The treatments were determined to be

equivalent. [4] Level of evidence: 2

Oral antihistamines:

A multicenter RCT in 188 patients aged 12 years and older with symptomatic chronic idiopathic

urticaria found that treatment with hydroxyzine or cetirizine resulted in a significant improvement

in urticarial symptoms, including pruritus, compared to placebo. [5] Level of evidence: 2

Barrier creams and ointments:

A double-blind RCT comparing a barrier cream versus its moisturizing vehicle in a total of 50

hospital nurses with mild skin irritation found that clinical skin status improved and stratum

corneum hydration increased significantly in both groups, leading the investigators to conclude that

there were no significant differences in efficacy between the barrier cream and the emollient vehicle.

[6] Level of evidence: 2

A single-blind, multicenter RCT evaluated the efficacy and safety of 5% quaternium-18 bentonite

lotion for prevention of experimentally induced poison ivy and poison oak allergic contact dermatitis

in 211 volunteers with known sensitivity to poison ivy and poison oak. Significantly reduced reactions

to urushiol were observed at patch test sites that were pretreated with quaternium-18 bentonite

lotion compared to untreated (control) sites, leading the investigators to conclude that quaternium-

18 bentonite lotion is effective in preventing or reducing allergic contact dermatitis from poison ivy

or poison oak. [7] Level of evidence: 2

A double-blind RCT evaluating a barrier cream containing DTPA (a chelator) in patients with metal-

induced allergic contact dermatitis found that those who were exposed to allergens on sites

pretreated with DTPA cream had negative patch test results. [8] Level of evidence: 2

References

References

Evidence references

1. 1. Saripalli YV, Gadzia JE, Belsito DV. Tacrolimus ointment 0.1% in the treatment of nickel-induced

allergic contact dermatitis. J Am Acad Dermatol. 2003;49:477-82

View In Article | CrossRef

2. 2. Alomar A, Puig L, Gallardo CM, Valenzuela N. Topical tacrolimus 0.1% ointment (protopic)

reverses nickel contact dermatitis elicited by allergen challenge to a similar degree to mometasone

furoate 0.1% with greater suppression of late erythema. Contact Dermatitis. 2003;49:185-8

View In Article | CrossRef

3. 3. Belsito D, Wilson DC, Warshaw E, et al. A prospective randomized clinical trial of 0.1% tacrolimus

ointment in a model of chronic allergic contact dermatitis. J Am Acad Dermatol. 2006;55:40-6

View In Article | CrossRef

4. 4. Katsarou A, Makris M, Papagiannaki K, Lagogianni E, Tagka A, Kalogeromitros D. Tacrolimus

0.1% vs mometasone furoate topical treatment in allergic contact hand eczema: a prospective

randomized clinical study. Eur J Dermatol. 2012;22:192-6

View In Article | CrossRef

5. 5. Breneman DL. Cetirizine versus hydroxyzine and placebo in chronic idiopathic urticaria. Ann

Pharmacother. 1996;30:1075-9

View In Article

6. 6. Berndt U, Wigger-Alberti W, Gabard B, Elsner P. Efficacy of a barrier cream and its vehicle as

protective measures against occupational irritant contact dermatitis. Contact Dermatitis.

2000;42:77-80

View In Article

7. 7. Marks JG Jr, Fowler JF Jr, Sheretz EF, Rietschel RL. Prevention of poison ivy and poison oak

allergic contact dermatitis by quaternium-18 bentonite. J Am Acad Dermatol. 1995;33:212-6

View In Article

8. 8. Wöhrl S, Kriechbaumer N, Hemmer W, et al. A cream containing the chelator DTPA

(diethylenetriaminepenta-acetic acid) can prevent contact allergic reactions to metals. Contact

Dermatitis. 2001;44:224-8

View In Article

Guidelines

The American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and

Immunology have produced the following:

Beltrani VS, Bernstein IL, Cohen DE, Fonacier L. Contact dermatitis: a practice parameter . Ann Allergy

Asthma Immunol. 2006;97(Suppl 2):S1-38

The American Academy of Allergy, Asthma, and Immunology has produced the following:

Bernstein IL, Li JT, Bernstein DI, et al. Allergy diagnostic testing: an updated practice parameter . Ann

Allergy Asthma Immunol. 2008;100(Suppl 3):S1-148

The British Association of Dermatologists has produced the following:

Bourke J, Coulson I, English J; British Association of Dermatologists Therapy Guidelines and Audit

Subcommittee. Guidelines for the management of contact dermatitis: an update . Br J Dermatol.

2009;160:946-54

The British Occupational Health Research Foundation has produced the following:

Occupational contact dermatitis and urticaria: a guide for general practitioners and practice nurses . London:

British Occupational Health Research Foundation; 2010

Further reading

Mark BJ, Slavin RG. Allergic contact dermatitis. Med Clin North Am. 2006;90:169-85

Kockentiet B, Adams BB. Contact dermatitis in athletes. J Am Acad Dermatol. 2007;56:1048-55

Reines HD, Seifert PC. Patient safety: latex allergy. Surg Clin North Am. 2005;85:1329-40

Honari G, Ellis SG, Wilkoff BL, Aronica MA, Svensson LG, Taylor JS. Hypersensitivity reactions

associated with endovascular devices. Contact Dermatitis. 2008;59:7-22

Behrens V, Seligman P, Cameron L, Mathias CG, Fine L. The prevalence of back pain, hand

discomfort, and dermatitis in the US working population. Am J Public Health. 1994;84:1780-5

Thyssen JP, Menné T. Metal allergy—a review on exposures, penetration, genetics, prevalence, and

clinical implications. Chem Res Toxicol. 2010;23:309-18

Bauer A, Kelterer D, Bartsch R, et al. Prevention of hand dermatitis in bakers' apprentices: different

efficacy of skin protection measures and UVB hardening. Int Arch Occup Environ Health.

2002;75:491-9

Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician.

2010;82:249-55

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