Once you have established the differential diagnosis (including tinea pedis, lichen simplex chronicus, atopic dermatitis, urticaria and others) and strongly suspect contact dermatitis, you may proceed with treatment. Exploring The Various Treatment Options Obviously, the first key is for the patient to avoid exposure to the suspected causative agent throughout the treatment program and afterward. Wet dressings and cold compresses help to dry oozing secretions, soften scales and crusts, and cleanse purulent wounds. Cold compresses are also beneficial in relieving burning, itching and paresthesia caused by irritant contact dermatitis through the cooling and drying effect of the solution. In cases in which the contact dermatitis primarily involves the foot, one may immerse the area in a foot bath of cold to warm water mixed with aluminum acetate (Burrow’s solution), diluted 1:10, for 15 to 20 minutes. Topical steroids are the mainstay of treatment for contact dermatitis. There are five types of topical corticosteroid formulations: ointments, gels, creams, lotions and solutions. Ointments are the most efficacious but creams have greater cosmetic appeal. Lotions, gels and solutions are preferred for hair-bearing areas of the body. Topical corticosteroid preparations vary greatly in potency and are categorized into seven groups with group I being superpotent and group VII having the lowest potency. Examples of commonly used steroids include clobetasol propionate (Temovate cream 0.05%) from group I, triamcinolone acetonide (Kenalog cream 0.01%) from group IV (medium potency) and hydrocortisone (Hytone cream 1%) from group VII. Be sure to remind patients that they should not apply medium-potency and superpotent topical corticosteroids to the face or body folds for longer than two weeks. One may use systemic corticosteroids to treat more severe forms of contact dermatitis as long as there are no obvious contraindications. In most cases of contact dermatitis involving the lower extremities, a relatively short course of oral therapy of not more than two weeks is recommended. You may recommend systemic antihistamines to reduce itching but let patients know they have an undesirable sedative effect. One should also consider nonsedating antihistamines such as fexofenadine (Allegra) and loratidine (Claritin) as they minimize drug interactions. The chronic form of contact dermatitis can also be managed by avoiding the contact allergen or establishing a barrier. For example, when it comes to contact dermatitis secondary to rubber materials in footgear, you may apply a topical corticosteroid cream to the foot, proceed to apply talcum powder and have the patient wear a heavy white sock. Have the patient change the sock frequently during the day to prevent dampness which brings out the rubber material within the shoe. Secondary control of perspiration via activated charcoal insoles will also help reduce hyperhidrosis and bromhidrosis, and reduce the amount of inflammatory response to a contact irritant on the feet. Dr. Caselli is an Adjunct Professor in the Department of Orthopedic Sciences at the New York College of Podiatric Medicine. He is also a Staff Podiatrist at the VA Hudson Valley Health Care System.
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