This is the protocol for contact dermatitis:Contact Dermatitis
Let’s break it down!
Contact Dermatitis is just a fancy way of saying that the skin becomes inflamed after it comes into “contact” with something that it doesn’t like. Sometimes it’s a localized allergic response to something like poison ivy, body washes, medications (allergic contact dermatitis), and other times its just irritation from things like fertilizers, pesticides, rubbing alcohol (irritant contact dermatitis). Although there are two different subtypes, they’re both pretty much treated the same way.
For the sake of understanding the vernacular of dermatology, “dermatitis” is interchangeable with the word Eczema. Eczema is just an inflammation of the skin and it comes in a variety of flavors (atopic dermatitis, nummular eczema, stasis dermatitis, dyshidrotic eczema, seborrheic dermatitis, etc.). Contact Dermatitis is just another one of those flavors.
The video below gives a decent summary of the topic:
It’s an inflammatory response, so you can expect it to look erythematic (red) and raised. However, it’s appearance can vary in many ways depending on what substance came in contact with the skin and how long it’s been wreaking havoc. Many cases will look like your standard hives reaction (like you see in the protocol above), but some plants like poison ivy, oak, or sumac can cause these fluid-filled sacs called vesicles (small sacs) and bulla (big sacs) to develop, like those found in this picture:
These sacs can eventually build up, rupture, ooze, and crust over…..leaving the skin vulnerable to secondary bacterial infections that’ll make things even worse. That’s why it’s important that we identify and treat this as promptly as we can.
Sometimes it can be difficult to differentiate contact dermatitis from other things like fungal infections, cellulitis, and insect bites….so here are a few extra pointers that might help you distinguish it from others and lock in your diagnosis:
- It’s localized
- Contact dermatitis, by definition, affects ONLY what the irritant or allergen comes into contact with. This means that it’s probably not going to appear all over your body unless you got naked and evenly cooked yourself on poison ivy for every square inch of your body. This typically differentiates contact dermatitis from viral rashes.
- It’s found on areas exposed to the environment
- You won’t typically find contact dermatitis on areas underneath your clothing unless the problem is the clothing itself or your detergent. The arms, legs, and neck are particularly susceptible. Rashes and red areas around the feet or groin are more likely to be fungal as opposed to contact dermatitis.
Removing the suspected agent is the MOST IMPORTANT thing you can do for contact dermatitis. You can throw as many medications as you want at it, but if the allergen or irritant is still making contact with the patient, then nothing is going to help.
A good thorough history from the patient should help determine the exact source, but if you can’t clearly identify the agent through questioning, taking a clean shower and putting on some fresh clothes should relieve whatever was causing it. However, keep in mind that certain laundry detergents and soaps can cause contact dermatitis
4. Topical cold wet compress AAA
May help with some of the pain and inflammation to the affected area after the initial exposure.
5. Topical Calamine lotion AAA
Calamine lotion is an over the counter medication that can be used to treat mild itchiness of the skin. Although certainly not curative treatment, calamine lotion is very safe for use by patients.
6. Topical 1% Hydrocortisone AAA qid until dermatitis resolves
Hydrocortisone is a topical steroid cream that can be very useful against inflammatory rashes such as contact dermatitis. Of the select treatments, hydrocortisone will likely contribute to the majority of symptomatic relief. If using calamine with this, be sure to alternate periodically.
7. Cover with dry dressing to help prevent spread to other parts of the body or clothing
Dry, sterile gauze around the affected site will help prevent the spread of the inflammation, as well as protect it from additional exposure to the irritant/allergen
After your topical agents are exhausted, PO and IM medications are going to be your next go to:
Diphenhydramine is an antihistamine, specifically targeting H1 receptors which are responsible for the hives and the pruritus (itchiness). There seems to be some debate as to whether or not diphenhydramine is really all that effective, but it typically won’t hurt the patient to try. Keep in mind though, the diphenhydramine is going to make the patient feel very sleepy….especially if you give it 4 times a day as the protocol advises. That’s why the protocol says “if tactically feasible“.
Now there is a way you may be able to avoid some of the sedative effects of PO Diphenhydramine. There is a diphenhydramine gel that you can apply topically to the area that’ll have the same antihistamine properties on the skin without giving your patient the feeling of being hit over the head with a rock. It doesn’t appear that its use has been well studied in the literature, but you’ll find a lot of patients online who swear by it. Very easy to find at your local pharmacy.
Steroids are big-time anti-inflammatories, which works really well for this particular condition. However, the important question here is at what point would you consider the contact dermatitis to be severe enough to warrant these? There’s no particularly great guidance for this. Some articles suggest that if the dermatitis is covering more than 25% of the patient’s body, then that would be considered severe. But some clinicians will give it regardless of whether or not it meets that criteria. If you’re curious, here’s are a few things that may lower the threshold for steroids:
- If you look at the affected area and say “Oh wow that looks really bad”
- If it’s in a sensitive area, such as the face, genitalia, etc. that’s causing the patient significant distress
- If the mission requires a speedy recovery ⏱
Now, out of the three steroids, which one should you use? You won’t be crucified for choosing either of the three, but for what it’s worth, it does seem as though Dexamethasone is becoming the more popular option….especially when it comes to dermatitis associated with poison ivy. But really, just do what you feel most comfortable with.
Most of the time, evacuation isn’t going to be required. The soldier should see clear skin within about 1-3 weeks, regardless of treatment. This is, of course, is assuming that the soldier can identify the allergen or irritant that’s causing the inflammation. Contact dermatitis takes a while to fully heal, but the treatment will help expedite the process and also provide relief from the pruritus and discomfort.
As stated, you’ll want to get a priority evacuation if they satisfy one of those criteria (severe, eye/mouth involvement, >50% BSA involved). But if they don’t satisfy either of those criteria and they’re still failing to get better despite all available treatment, you may want to transport anyway or reconsider your differentials.
Good luck out there!
- UpToDate: Management of allergic contact dermatitis
- MedlinePlus: Eczema
- National Eczema Association: Contact Dermatitis
- Advanced Tactical Paramedic Protocols Handbook. 10th ed., Breakaway Media LLC, 2016
- Stapczynski JS, Tintinalli JE. Tintinallis Emergency Medicine: a Comprehensive Study Guide, 8th Edition. New York: McGraw-Hill Education; 2016.