Medical Care: The cause of ACD must be identified;
otherwise, the patient is at increased risk for chronic or recurrent
dermatitis. The Contact Allergan Replacement Database of the American Contact
Dermatitis Society allows the physician to create a list of products free of
allergens to which the patient is allergic.
- Symptomatic treatment
- Cool compresses with saline or aluminum acetate solution are helpful for
acute vesicular dermatitis (eg, poison ivy).
- Some individuals with widespread vesicular dermatitis may obtain relief
from lukewarm oatmeal baths.
- Sedating oral antihistamines may help diminish pruritus.
- Patients should avoid using topical antihistamines, including topical
doxepin, because of the apparently high risk of iatrogenic ACD to these
- Topical corticosteroids are the mainstay of treatment, with the strength of
the topical corticosteroid appropriate to the body site. For severe ACD of the
hands, 3-week courses of class I topical corticosteroids are required, while
class 6 or class 7 topical corticosteroids typically are used for ACD of
- Acute severe ACD, such as acute severe ACD to poison ivy, often needs to be
treated with a 2-week course of systemic corticosteroids. Most adults require
an initial dose of 40-60 mg. The oral corticosteroid is tapered over a 2-week
period, but a complicated tapering regimen probably is not necessary given the
short duration of systemic corticosteroids. The systemic corticosteroids must
be administered for 2 weeks, because shorter courses are notorious for allowing
poison ivy dermatitis to relapse. Long-acting triamcinolone acetonide (Kenalog)
40-60 mg may be used in place of oral prednisone in these cases.
- Topical immunomodulators: Topical immunomodulators (TIMs) are approved for
atopic dermatitis and are prescribed for cases of ACD when they offer safety
advantages over topical corticosteroids. TIMs do not cause cutaneous atrophy or
glaucoma or cataracts when applied near the eye. Pimecrolimus (Elidel cream) is
a topical treatment often helpful for ACD of the face. Tacrolimus (Protopic
0.1% ointment) appears to be the most helpful TIM for ACD of the hands.
- Psoralen plus UV-A: Individuals with chronic ACD that is not controlled
well by topical corticosteroids may benefit from psoralen plus UV-A (PUVA)
- Immunosuppressive agents: Rarely, chronic immunosuppressive agents, such as
azathioprine (Imuran) or cyclosporine (Neoral), are used in recalcitrant cases
of severe chronic widespread ACD or severe hand dermatitis that prevents the
individual from working or performing daily activities. Biologicals active on T
cells may be helpful in the future.
- Disulfiram: Occasionally, an individual who is highly allergic to nickel
with severe vesicular hand dermatitis benefits from treatment with disulfiram
(Antabuse). The chelating effect of disulfiram is helpful in reducing the
body's nickel burden. Alcohol ingestion may produce severe adverse reactions in
patients taking disulfiram.
Consultations: Many primary care physicians treat
individuals with typical poison ivy dermatitis who respond well to a 2-week
treatment course using topical or systemic corticosteroids and subsequently
avoid poison ivy and related plants. Acute dermatitis that resolves with
short-term treatment does not require further evaluation. Individuals with
chronic dermatitis, particularly if it possibly is related to work, require
detailed history and patch testing to standard screening sets and additional
allergens as indicated by history, occupation, hobbies, and results on initial