• Identify the stimulus.
• Inform the person about the likely course of the dermatitis and provide advice about avoiding the identified irritant or allergen.
• Treat contact dermatitis with:
• Frequent application of emollients.
• A topical corticosteroid for inflamed areas (use a potency suitable for the severity and location of dermatitis).
• Consider treatment with an oral corticosteroid if the dermatitis is extensive and causing distress.
• Treat infected contact dermatitis with an oral antibiotic.
• Refer to a dermatologist if:
• The person has chronic, recurring, or unrelenting eczematous or lichenified dermatitis despite appropriate avoidance measures.
• There is a suspicion of contact dermatitis but no clear history of relevant exposure.
• Recalcitrant or chronic contact dermatitis does not respond to corticosteroid therapy.

• If possible, identify the stimulus by taking a detailed history and examination, including:
• Occupational, recreational, and medical history, including family history of atopic dermatitis.
• The anatomical distribution of the rash.
• The amount of contact with the irritant or allergen.
• History of exposure to irritants, for example wet work or friction.
• Duration of contact.
• Time from contact to first presentation.
• Evolution of symptoms, for example one episode or recurrent episodes; does the skin clear completely between episodes?
• Establish whether the pattern of distribution of the dermatitis suggests contact with a particular allergen or irritant.
• Consider referral to a recognized centre for patch testing to exclude allergic dermatitis.
• Assess for any indication of secondary infection, for example rapid worsening of dermatitis, tenderness, increased erythema, heat, or discharge.

• The anatomical distribution of the rash may help in the identification of the likely irritant or allergen.
• Head:
• Hair dyes and shampoos.
• Facial cosmetics (especially those applied to the thin skin of eyelids and cheeks).
• Toiletries.
• Metal from piercings.
• Topical antibiotics (eyes and ears).
• Airborne allergens, such as from compositae.
• Neck:
• Cosmetics, including nail varnish.
• Toiletries.
• Fragrances.
• Jewellery.
• Musical instruments, such as violins.
• Hands:
• Jewellery.
• Foods.
• Fragrances and preservatives in cosmetics, liquid soaps, and hand lotions.
• Musical instruments.
• Gloves.
• Feet:
• Leather dyes.
• Glues.
• Rubber components in shoes.

[Mark and Slavin, 2006]

• Identification and subsequent avoidance of the stimulus is an important part of management. The recommendations for the method of identifying the irritant or allergen is based on current literature [Bourke et al, 2001; Beck and Wilkinson, 2004; Wilkinson and Beck, 2004; Beltrani et al, 2006; Mark and Slavin, 2006].

• Advise the person to avoid contact with the stimulus.
• Apply an emollient first-line to cool the skin and restore the skin barrier.
• Treat localized acute dermatitis with a topical corticosteroid.
• Prescribe a potency appropriate to the severity and location of the dermatitis.
• Consider a systemic corticosteroid if there is significant impairment of function, such as in eczema on the hands.
• Consider treating extensive acute dermatitis (greater than 20% of total skin surface involved) with a systemic corticosteroid.
• Recommend frequent, liberal use of an emollient to maintain skin hydration and improve barrier repair.
• CKS does not recommend the use of antihistamines for relieving pruritus associated with acute contact dermatitis.

• Further information on preventing work-related skin problems can be found on the Health and Safety Executive website at www.hse.gov.uk/skin/employ/prevention.htm.

Irritant/allergen avoidance

• Identifying and eliminating exposure to potential stimuli is the most important step in the treatment of contact dermatitis. This recommendation is supported by expert opinion from one UK guideline [Bourke et al, 2001], one US guideline [Beltrani et al, 2006], and the current literature [Beck and Wilkinson, 2004; Wilkinson and Beck, 2004; Mark and Slavin, 2006].

Cold compresses

• The use of cool, moist compresses or wet dressings is recommended by several experts in the current medical literature [Beck and Wilkinson, 2004; Beltrani et al, 2006; Jacob and Castanedo-Tardan, 2007].
• CKS expert reviewers advised against the use of cold compresses because soaking the skin can make dermatitis worse.
• CKS found no good-quality evidence to support or refute the use of cool, moist compresses.

Topical corticosteroids

• Topical corticosteroids are recommended by experts for the management of both allergic and irritant contact dermatitis [Beck and Wilkinson, 2004; Wilkinson and Beck, 2004; Beltrani et al, 2006].
• Good evidence from several small studies indicates that very potent or moderately potent topical corticosteroids are effective at improving acute allergic contact dermatitis.
• The efficacy of topical corticosteroids in irritant contact dermatitis has been questioned in recent studies. However, because it is often difficult to distinguish clinically between allergic and contact dermatitis, topical corticosteroids are recommended for the treatment of irritant contact dermatitis.

Systemic corticosteroids

• Systemic corticosteroid treatment is recommended by experts for widespread contact dermatitis (usually allergic) [Beltrani et al, 2006; Jacob and Castanedo-Tardan, 2007].

Emollients

• The recommendation for the use of emollients in treating contact dermatitis is based on evidence from several small studies [Saary et al, 2005] and is supported by expert opinion [Jacob and Castanedo-Tardan, 2007].

Antihistamines

• Antihistamines are generally considered ineffective for the management of pruritus associated with contact dermatitis [Beltrani et al, 2006].

• Advise people that preventing further episodes of contact dermatitis relies on avoidance of the causative stimulus.
• If complete avoidance is not possible, advise the person on the use of measures aimed at preventing or minimizing contact with affected areas of skin, for example:
• Rinsing with water or washing with soap or, preferably, a soap substitute as soon as possible after contact (overuse of skin-cleaning agents can aggravate contact dermatitis).
• Substituting products that contain identified allergens or irritants with other products that do not contain them.
• Reducing the duration and frequency of contact with an irritant.
• Using protective clothing. Most irritant contact dermatitis involves the hands, and protective gloves are the mainstay of protection:
• For handling potential irritants, cotton-lined rubber or plastic gloves are usually sufficient.
• Certain chemicals may demand more heavy-duty protective materials which are not subject to chemical degradation.
• For dry work, fabric gloves that 'breathe' (e.g. cotton) should be used.
• Gloves should be removed frequently, as sweating may aggravate existing dermatitis.
• Consider appropriate use of a barrier cream. Barrier creams may help to prevent irritant contact dermatitis, but their use as sole protection against contact with allergens or irritants is not recommended.
• Advise the use of emollient soap substitutes:
• Emollient soap substitutes are useful to avoid the drying effects of soaps and should be considered for all people with dermatitis.
• They are particularly useful for people who are required to wash or wet their hands frequently.
• Recommend frequent application of emollients:
• Where irritant contact dermatitis is caused by cumulative exposure to an irritant, such as at work, emollients should be applied regularly during and after work to prevent dermatitis.

There is little good-quality evidence on the prevention of contact dermatitis. These recommendations are largely based on common sense, supported by expert opinion from the current literature [Beck and Wilkinson, 2004; Wilkinson and Beck, 2004; Beltrani et al, 2006] and UK guidelines for the management of contact dermatitis [Bourke et al, 2001].

Measures for minimizing exposure

• Barrier creams: although some evidence indicates that barrier creams reduce irritant contact dermatitis under experimental conditions, their use in clinical situations is often disappointing. This is, at least in part, because how they are applied influences their effectiveness [Jacob and Castanedo-Tardan, 2007].
• Soap substitutes and after-work creams: some evidence shows benefit of the use of soap substitutes [Lauharanta et al, 1991] and after-work creams [Halkier-Sorensen, 1996] in reducing the incidence and prevalence of contact dermatitis.

Application of emollients/moisturizers

• Frequent application of emollients will help prevent dryness and chapping of the skin and is a widely accepted method of preventing subsequent recurrence of dermatitis, although there is little evidence to support it [Wilkinson and Beck, 2004].

• If measures to avoid the stimulus do not resolve the dermatitis:
• Reassess the diagnosis.
• Reassess the identity of possible allergens and irritants.
• Refer to a recognized centre for patch testing if not already done.
• Exclude ongoing exposure to irritants or allergens:
• Check compliance with avoidance measures.
• If compliance is good, step up avoidance measures where possible.
• Consider using a more potent topical corticosteroid if response to initial treatment is poor.
• Consider a contact allergy from topical medication (including allergy to topical corticosteroids) if dermatitis fails to respond or deteriorates with use:
• Confirm the suspicion by applying the product on skin that is unaffected by dermatitis and observing for a reaction.
• If allergy from a topical medication is suspected, refer for patch testing to try and identify which topical medication(s) the person is sensitized to.
• Refer to a dermatologist if:
• The person has chronic, recurring, or unrelenting eczematous or lichenified dermatitis despite avoidance measures and appropriate-strength topical corticosteroid treatment.
• There is a suspicion of contact dermatitis but no clear history of relevant exposure.
• Recalcitrant or chronic contact dermatitis does not respond to first-line corticosteroid therapy.

• Second-line treatment in secondary care might include phototherapy, such as psoralen and ultraviolet A or B, or steroid-sparing immunosuppressant therapy.

[Jacob and Castanedo-Tardan, 2007]

• CKS found no guidelines regarding the management of persistent contact dermatitis. These recommendations are pragmatic measures to confirm correct identification of the irritant or allergen and to ensure that the irritant or allergen is being avoided.
• The recommendation for testing for allergy to topical corticosteroids is based on expert opinion [English, 2000].
• The recommendation for referral criteria is based on a UK guideline [Bourke et al, 2001] and expert opinion [Beltrani and Beltrani, 1997; Mark and Slavin, 2006]:
• People with chronic, recurring, or unrelenting eczematous or lichenified dermatitis may benefit from second-line treatment.
• If contact dermatitis is suspected but there is no obvious exposure, patch testing may be indicated.
• Expert opinion indicates that desensitization protocols (allergy vaccination) have no role in managing allergic contact dermatitis [Beltrani and Beltrani, 1997].

• Suspect secondary infection if clinical signs of infection are present, for example rapid worsening of dermatitis with marked erythema, discharge, or increased pain. The person will often feel unwell or feverish:
• The typical appearance of impetigo (crusted lesions that may be yellow) may be difficult to distinguish from dermatitis.
• It is common practice to have a low threshold of diagnosing infection when dermatitis is severe or unexpectedly deteriorates.
• For visibly infected dermatitis, swab the skin and start oral antibiotics:
• Flucloxacillin or clarithromycin (if the person is allergic to penicillin) is recommended first-line.
• If visible infection fails to respond to a first-line antibiotic, microbiological investigations to ascertain sensitivities may be useful.

• The recommendation to use oral flucloxacillin or clarithromycin is in line with the national guidance on the management of impetigo [HPA and Association of Medical Microbiologists, 2008].
• CKS found no randomized controlled trial evidence to support the use of antibiotics when there is no visible sign of infection.