Changes

January 2024 — reviewed. A literature search was conducted in January 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to recommendations have been made.

Update

Goals

To support primary healthcare professionals to:

• Make a diagnosis of contact dermatitis and identify precipitating allergens and irritants, where possible.
• Prescribe appropriate topical medication.
• Advise self-care measures for the management and prevention of contact dermatitis.
• Refer to secondary care for further assessment and management where appropriate.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

NICE quality standards

What is it?

• Contact dermatitis is an inflammatory skin condition affecting the epidermis and dermis, which occurs as a result of exposure to an external irritant or allergen:
  • Allergic contact dermatitis is a type IV (delayed) hypersensitivity reaction that occurs after sensitization and subsequent re-exposure to a specific allergen or allergens.
  • Irritant contact dermatitis is a non-immunological inflammatory reaction caused by the direct physical or toxic effects of an irritating substance on the skin — prior sensitisation is not required.
    • Acute irritant contact dermatitis typically occurs following a single overwhelming exposure or a few brief exposures to strong irritants.
    • Cumulative or chronic irritant contact dermatitis occurs following repeated exposure to weaker irritants such as detergents, soaps, dust or low humidity air.
  • Allergic and irritant contact dermatitis may co-exist.

[White, 2016; Wilkinson, 2016; Fonacier, 2018; Dickel, 2022; PCDS, 2022; BMJ Best Practice, 2023; HSE, 2023]

What are the common allergens and irritants?

• Common allergens include:
  • Personal care products such as cosmetics, skincare products, nail varnish, fragrances, sunscreen, and hair dye.
  • Metals such as nickel and cobalt (often found in jewellery) and chromate (in cement) – nickel is the most common allergen.
  • Topical medications including anti-infective agents and topical corticosteroids.
  • Rubber additives (often found in footwear).
  • Plants – those in the Compositae group (chrysanthemum and sunflowers), daffodils, tulips, and primula are the most common.
• Common irritants include:
  • Water, in particular repeated or prolonged contact, such as with wet working conditions. 
  • Sweating under occlusion.
  • Detergents, soaps, and cleaning agents.
  • Solvents and abrasives.
  • Machine and cutting oils.
  • Acids and alkalis (including cement).
  • Reducing agents and oxidizing agents (including sodium hypochlorite).
  • Powders, dust, and soil (such as exotic woods and cement).
  • Certain plants such as ranunculus, spurge, Boraginaceae and mustards.
• Dermatitis caused by nappy contact is the most common irritant contact dermatitis in the first year of life.
• UK data from 2020–2022 shows an increased proportion of occupational cases relating to soaps and cleaners, wet work, personal protective equipment, and bleaches and sterilisers, likely reflecting contemporaneous COVID guidance. 

[Fonacier, 2015; White, 2016; Wilkinson, 2016; BAD, 2017; Brar, 2021; Dickel, 2022; PCDS, 2022; BMJ Best Practice, 2023; HSE, 2023]

How common is it?

• The worldwide prevalence of contact dermatitis has been estimated at approximately 20% of the general population, with 80% of these cases being irritant contact dermatitis and 20% being allergic contact dermatitis [Nassau, 2020; BMJ Best Practice, 2023].
• A large cross-sectional study (n=12,377) of contact dermatitis in five European countries (Sweden, the Netherlands, Germany, Italy, and Portugal) [Diepgen, 2015] found that:
  • Of 3119 participants who were patch tested, 27% [95% CI 25.5–28.5] had positive reactions to at least one contact allergen.
  • There was a significantly higher prevalence in women than in men.
  • Nickel had the highest age-standardized prevalence (14.5%, 95% CI 13.2–15.8).
  • Risk of contact allergy was not higher in people with atopic dermatitis (prevalence 7.6%, 95% CI 6.7–8.6; odds ratio 1.0, 95% CI 0.7–1.4).
• Contact dermatitis accounts for 4–7% of dermatological consultations in secondary care.
  • Irritant contact dermatitis is more common than allergic contact dermatitis — up to 80% of contact dermatitis is irritant.
  • About two-thirds of all cases of contact dermatitis involve the hands.
  • Contact dermatitis tends to be most common in young females — this is thought to be due to environmental exposure to substances in jewellery (such as nickel) and cosmetics.
• Contact dermatitis in children occurs at an unknown prevalence.
  
  • One review found that patch testing was positive in 27–95% of referred children [Admani, 2014].
  • In North America the most common allergens reported in children are nickel, neomycin, cobalt, fragrance, and balsam of Peru.
• Occupational contact dermatitis is common.
  • Between 13–34% of all occupational diseases are skin diseases — of these 90–95% are contact dermatitis.
  • Data from the UK National Occupational Health Surveillance Scheme (EPIDERM) 1996–2022 showed that around 53% of cases of occupational contact dermatitis were allergic and 60% were irritant (there was a small proportion of cases with allergic and irritant components) [HSE, 2023].
    • Contact with soaps and cleaning products and working with wet hands (“wet work”) were the most commonly recorded causes.
  • Analysis of EPIDERM data from 2010–2019 showed that the highest rates of occupational dermatitis (per 100,00 workers per year) were reported in [HSE, 2023]:
    • Beauticians (75.4).
    • Cooks (68.0).
    • Florists (56.1).
    • Hairdressers and barbers (50.9).
    • Metal working machine operatives (46.4).
    • Dental practitioners (32.9).

[Adisesh, 2013; Fonacier, 2015; Rashid, 2016; Wilkinson, 2016; Alfonso, 2017; BAD, 2017; HSE, 2023]

What is the prognosis?

• The prognosis of contact dermatitis is variable and depends on the causative agent and the feasibility of avoiding exposure.
  • In some cases where causative agents are easy to identify and avoid, contact dermatitis may resolve within a few weeks.
  • However, in cases where allergens are ubiquitous in the environment and are difficult to avoid completely contact dermatitis may be recurrent or persistent.
    • Sensitivity to some allergens (for example, epoxy resin, chromate, primin, and paraphenylenediamine [commonly used in permanent hair dyes]) may persist even after allergens are avoided.
  • Allergic contact dermatitis has a worse prognosis than irritant contact dermatitis unless the allergen can be accurately identified and avoided.
• Poor prognosis is associated with:
  • Continuation of exposure – knowingly or unknowingly.
  • Certain causative allergens such as chromium, epoxy resin, and the Compositae family of flowering plants — these appear to trigger chronic dermatitis, even after avoidance.
  • Severe dermatitis at presentation.
  • Delay in diagnosis.

[Fonacier, 2015; Johansen, 2015; White, 2016; Wilkinson, 2016; BAD, 2017; Dickel, 2022; BMJ Best Practice, 2023]

What are the complications?

• Complications of contact dermatitis include:
  • Reduced quality of life — functional impairment, discomfort, and loss of sleep due to chronic contact dermatitis may impact employment and personal and social relationships.
  • Lowered self-esteem.
  • Secondary skin infections such as impetigo or cellulitis.
  • Post-inflammatory hypo- or hyper-pigmentation.

[Pigatto, 2015; Wilkinson, 2016; Bauer, 2018; Fonacier, 2018; BMJ Best Practice, 2023]

What are the clinical features of contact dermatitis?

• Atopic/endogenous dermatitis, allergic contact dermatitis and irritant contact dermatitis are not easily distinguished clinically and aetiology may be mixed.
• Contact dermatitis can present as acute or chronic:
  • Acute contact dermatitis typically presents with erythema and vesiculation — dryness, scaling, and bullae may also be present.
  • Chronic contact dermatitis typically presents with dryness, lichenification (thickening of the skin), and fissuring.
• In irritant contact dermatitis:
  • Exposure to strong irritants (such as strong acids or alkalis) can cause immediate reactions whereas mild irritants usually require prolonged or repeated exposure before a reaction becomes apparent.
  • Symptoms and signs vary and may include stinging, smarting, burning, dryness, tightness, and chapping — vesicles are less commonly seen than in allergic contact dermatitis.
  • Skin changes are usually restricted to the area in contact with the irritant — protected areas (for example, under gloves) typically remain clear.
  • Anatomical distribution may aid diagnosis, for example, dermatitis in the webs of fingers/underneath a ring in someone repeatedly exposed to water or detergents is suggestive of irritant contact dermatitis.
  • Avoidance of the causative agent usually leads to resolution of symptoms within a few days.
• In allergic contact dermatitis:
  • Clinical reactions usually develop 24–72 hours (or longer in some cases) after re-exposure to an allergen in a sensitized person.
  • The dominant symptom is usually itching.
  • In acute and severe cases blistering, weeping, and/or oedema may develop.
  • Dermatitis may affect areas not directly in contact with the allergen, for example, due to transfer of nail varnish from the fingertips to the eyelids.
  • Resolution can take many days, with or without treatment.

How should I assess a person with suspected contact dermatitis?

Take a history, asking about:

• Clinical features such as itching, burning, stinging, erythema, scaling, or fissuring.
• Onset, location, and chronicity of rash.
  • Identify the initial site and any spread to other areas over time. Check if the rash is persistent or intermittent.
• Possible precipitating, aggravating, and relieving factors including:
  • Contact with potential allergens or irritants such as cosmetics, personal-care products, medication, jewellery, detergents, water, bandages, or substances and personal protective equipment (PPE) at work.
    • Substances causing allergic contact dermatitis may have been in use for some time.
    • If a potential allergen or irritant is identified, ask about the amount and duration of contact, and time between exposure and development of symptoms.
  • Occupations past and present.
    • Certain occupations (including those with frequent exposure to water and the use of detergents) may increase the risk of dermatitis.
    • Check if symptoms improve at weekends and during holidays, and recur on return to work.
  • Household and recreational activities such as cleaning, hobbies (for example, gardening, home improvement, and painting), and some sports.
• Past medical history including previous history of similar rashes or atopy.
• Family history of skin conditions or atopy.

Examine the person, checking for:

• Clinical features of contact dermatitis — the anatomical distribution may help in the identification of a likely irritant or allergen.
  • Hands and arms are a common site of contact dermatitis often due to repeated exposure to water or detergents.
  • Face — contact dermatitis of the face due to fragrances, hair dyes, skincare products, cosmetics, and nail varnish is common.
  • Eyelids — the eyelids may be directly affected by cosmetics or contaminated by the fingers (for example with nail varnish), airborne droplets (for example fragrance sprays), or volatile substances (for example epoxy resin).
  • Ears — many irritants and allergens including topical medications, earrings, or spectacle frames can cause contact dermatitis of the external ear.
  • Scalp — hair dyes are a common cause of contact dermatitis of the scalp.
  • Neck — nickel in jewellery or zips or airborne allergens (such as from plants) can cause contact dermatitis on the neck.
  • Axillae — contact dermatitis can be caused by irritation from sweating, occlusion, or use of antiperspirants.
  • Ano-genital area — topical medications (prescribed and over-the-counter) such as those used in the treatment of pruritus or haemorrhoids may contain allergens including fragrance, local anaesthetics, or balsam of Peru.
  • Lower legs — allergic contact dermatitis from topical treatments (such as antibiotics and creams) and dressings can occur in people with varicose eczema and ulcers.
  • Feet — leather, rubber, glues, and nickel in footwear, stockings, topical medications, antiseptics, and antiperspirants can cause contact allergy of the feet.
• Signs of secondary infection such as fever, increased erythema, heat, or discharge.

Investigations:

• The gold standard investigation for diagnosis of contact dermatitis is patch testing — if patch testing is indicated, refer to dermatology.

What else might it be?

• Other causes of dermatitis such as:
  • Atopic dermatitis. For more information, see the CKS topic on Eczema – atopic.
  • Seborrhoeic dermatitis. For more information, see the CKS topic on Seborrhoeic dermatitis.
• Skin infection including:
  • Fungal infections such as tinea corporis. For more information, see the CKS topics on Candida - skin, Fungal skin infection - body and groin, Fungal skin infection - foot, Fungal skin infection - scalp.
  • Bacterial infections such as cellulitis and impetigo. For more information, see the CKS topic on Cellulitis - acute.
  • Viral infections such as herpes simplex or varicella zoster. For more information, see the CKS topics on Chickenpox and Shingles.
  • Parasitic infections such as scabies. For more information, see the CKS topic on Scabies.
• Other skin conditions such as:
  • Urticaria. For more information, see the CKS topic on Urticaria.
  • Psoriasis. For more information, see the CKS topic on Psoriasis.
  • Lupus erythematosus.
  • Dermatomyositis.
  • Mycosis fungoides.
  • Fixed drug eruption.
  • Photosensitivity.
  • Lichen planus of the hands.
  • Basal cell carcinoma.
• Consider non-accidental injury in children. For more information, see the CKS topic on Child maltreatment - recognition and management.

Scenario: Management of contact dermatitis

From age 1 month onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of contact dermatitis.

Search dates

June 2018 - January 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCO MEDLINE (searched 28th June 2018). These terms were combined with search filters for systematic reviews and guidelines in EBSCO MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S3 S1 OR S2

S2 AB ( ((contact or occupational or industrial or irritant* or allerg*) N3 (dermatitis or dermatos* or eczema*)) ) OR TI ( ((contact or occupational or industrial or irritant* or allerg*) N3 (dermatitis or dermatos* or eczema*)) )

S1 (MH "Dermatitis, Contact+")  

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.