Therapy for Contact Dermatitis

Topical preperations can relieve the symptoms of both allergic and irritant contact dermatitis.

Contact dermatitis is a dermatologic condition that causes acute inflammation of the skin as a result of an exposure to irritants or allergens. ¹ Upon this exposure, the skin may become inflamed and swollen. Patients with contact dermatitis may present with inflammation, burning, pruritus, and erythema, as well as formation of vesicles and pustules. ^1-3 Both the severity and symptoms associated with contact dermatitis vary from patient to patient and are dependent upon the cause and extent of exposure to the allergen or irritant. ^1,2

Many patients with contact dermatitis will elect to use nonprescription topical products to obtain symptomatic relief. Pharmacists can provide patients with pertinent information to make informed decisions and assist them in the proper selection of available products. Products marketed for contact dermatitis may contain a combination of ingredients in various dosage forms, including creams, ointments, gels, lotions, and sprays. Topical hydrocortisone, oral antihistamines, and other antipruritic agents are often employed to manage various types of dermatitis. ^1,2 Patients can also use astringent products (ie, aluminum acetate, zinc oxide, zinc acetate) to promote drying of moist, wet, oozing lesions, as well as to serve as a protective covering for inflamed skin. ² Calamine and colloidal oatmeal baths are also helpful in providing relief from itching. ²

Types of Contact Dermatitis

The 2 primary types of contact dermatitis are irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD). ^1,2 ICD is the most prevalent form of contact dermatitis, and is the result of an inflammatory reaction of the skin due to exposure to an irritant such as chemicals, soaps, detergents, or household cleaning products; the reaction typically resembles a burn. ^1,2 ICD is prevalent in those individuals who work in an environment that requires frequent and repeated use of hand washing or hand hygiene products, food handling, exposure to chemicals, or glove use. ² The majority of ICD cases occur on exposed or unprotected areas of the skin, such as the face and dorsal areas of the

hands and forearms. ^2,3

ACD is characterized as an inflammatory reaction of the skin due to an exposure to an allergen, such as poison ivy, poison oak, or poison sumac. ^1-4 Metal allergy, especially to nickel salts, which are found in jewelry, clothing, and cell phones, is also a common cause of ACD. ³ Other possible causes of ACD include exposure to products containing latex, cosmetics, fragrances, and some skin care products. ^2,3 The signs and symptoms of ACD may include localized pruritus, rash, pain, and the formation of blisters.^2,3 The skin may appear red and swollen. ^2,3

Differentiating ACD from ICD can be difficult, especially if the cause of the irritation is unknown. ACD is typically confined to the contact area, however, whereas ICD may appear more widespread on the skin. ^2-5 In general, a red rash typically occurs immediately in ICD cases, whereas sometimes a rash may not appear for 24 to 48 hours after exposure to an allergen with ACD. ^2,3,5,6

Finding Relief

The goals of treating contact dermatitis include removing and avoiding the offending irritant when possible, and providing the patient with relief from the inflammation and itching. ² Avoiding the offending irritant is often considered the hallmark of treating ICD. ² Patients should also be advised to incorporate preventive measures to avoid irritants by using protective clothing or gloves to reduce exposure. ²

For the treatment of ICD, regardless of severity, the area of initial exposure should be washed with a sufficient amount of tepid water and cleansed with a mild or hypoallergenic soap. ² The use of colloidal oatmeal baths may also be helpful in providing relief from itching. The use of emollients, moisturizers, and barrier creams, especially those that contain dimethicone, is recommended in the treatment and prevention of ICD, because these products assist in repairing the epidermal barrier. ²

Patients may also take an oral antihistamine when appropriate and without contraindications if they experience severe itching. ^2-6 Topical corticosteroids are typically not considered optimal therapy for ICD because their efficacy is not clear. ² The use of topical “canine” type anesthetics should also be avoided because of the potential of causing an ACD reaction. ²

Treatment of ACD depends upon the severity of the symptoms from the antigenic reaction. ² The use of topical OTC products may be useful in providing symptomatic relief. Topical hydrocortisone, for example, may be applied to localized rashes that exhibit itching and are erythematic. Hydrocortisone may reduce inflammation, relieve itching, and dry up weeping lesions, if present. ²

Hydrocortisone cream is considered the most effective form of topical therapy for treating the symptoms of mild-tomoderate ACD that does not involve edema and extensive areas of the skin. ^2-6 A small amount should be applied to affected areas up to 4 times a day, and bandages and dressings should not be used when topical hydrocortisone is applied. ² Hydrocortisone in ointment form should not be applied to open lesions and its use is not recommended in ACD. ²

Patients may also utilize astringent or cool compresses and baths to dry oozing vesicles. If large areas of nonweeping lesions are present, calamine lotion and colloidal oatmeal may be used. ² Cold or tepid soapless showers may be beneficial in temporarily relieving itching. ^2-6

Counseling Points

Prior to recommending any product for contact dermatitis (Table), it is imperative for pharmacists to determine if selftreatment is appropriate. Patients should always be advised to seek further medical evaluation when warranted. Patients who should be referred for medical evaluation include those who exhibit signs of a skin infection or who are younger than 2 years; those who have dermatitis involving more than 20% of the body, numerous bullae, edema around the eyes, eyelids, or mucous membranes, or swelling of the body or extremities; or those who experience failure of self-management after 7 days. ²

During counseling, patients should be instructed on the proper use and duration of the selected product as well as possible adverse effects. Patients electing to use topical antihistamine products should be reminded that these agents can cause sensitivity reactions and should not be applied to large areas of the skin. They should not be used concurrently with other antihistamine-containing products, including oral dosage forms, because increased serum concentrations may occur. ² It is also important to remind patients that topical antihistamines should not be applied to broken, blistered, or oozing skin, and should not be used for more than 7 days unless directed. ²

In addition, external analgesics, such as phenol, menthol, and camphor, which are available in many dermatologic products, may provide antipruritic and anesthetic relief, but should not be used on open lesions and inflamed skin because they may cause local irritation and burning. ² Pharmacists can also make recommendations regarding the use of colloidal oatmeal bath products to soothe affected areas.

Pharmacists should remind patients to immediately contact their primary health care provider if there are no signs of improvement after self-treatment or if symptoms worsen. Typically, both irritant and allergic contact dermatitis will be resolves in 7 to 21 days with or without medical treatment by the patient’s immune system. ³ PT

References

1. Contact dermatitis and latex allergy. Centers for Disease Control website. www.cdc.gov/oralhealth/infectioncontrol/faq/latex.htm. Accessed December 29, 2011.

2. Plake K, Darbishire P. Contact dermatitis. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 17th ed. Washington, DC: American Pharmacists Association; 2012:645-659.

3. Contact dermatitis. Medline Plus website. www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001872/. Accessed December 30, 2011.

4. Hogan D. Allergic contact dermatitis. Medscape website. http://emedicine.medscape.com/article/1049216-overview. Accessed December 30, 2011.

5. Contact dermatitis. American Academy of Dermatology website. www.skincarephysicians.com/eczemanet/contact_dermatitis.html. Accessed December 29, 2011.

6. Contact dermatitis. Asthma and Allergy Foundation of America website. www.aafa.org/display.cfm?id=9&sub=23&cont=329. Accessed December 29, 2011.

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.