Should oral prednisone (Pred) be extended in a patient with a skin rash that has not resolved after 5 days of treatment with oral prednisone and Zyrtec (cetirizine)?

From the Guidelines

I do not recommend extending the prednisone treatment without consulting a dermatologist, as the current treatment regimen may not be effectively targeting the underlying cause of the skin rash. The patient's skin rash not resolving after 5 days of oral prednisone and Zyrtec suggests that the current treatment approach may need to be reassessed 1. According to the guidelines for managing toxicities associated with immune checkpoint inhibitors, a rash covering more than 10% of the body surface area (BSA) with symptoms such as pruritus, burning, or tightness may require a non-urgent dermatology referral and consideration of topical corticosteroids or oral antihistamines 1. Some key considerations for the patient's treatment plan include:

• The use of oral antihistamines such as cetirizine or loratadine, which may be effective in managing symptoms such as pruritus and burning 1
• The application of topical corticosteroids, which can help reduce inflammation and alleviate symptoms 1
• The potential need for a same-day dermatology consult if the rash is severe, covering more than 30% of the BSA, or associated with systemic hypersensitivity 1
• The importance of ruling out systemic hypersensitivity and considering alternative treatment strategies, such as changing to a different antihistamine or prescribing topical steroids 1.

From the FDA Drug Label

If after a reasonable period of time there is a lack of satisfactory clinical response, PredniSONE should be discontinued and the patient transferred to other appropriate therapy IT SHOULD BE EMPHASIZED THAT DOSAGE REQUIREMENTS ARE VARIABLE AND MUST BE INDIVIDUALIZED ON THE BASIS OF THE DISEASE UNDER TREATMENT AND THE RESPONSE OF THE PATIENT

• The decision to extend prednisone treatment should be based on the individual patient's response to therapy.
• No specific guidance is provided in the drug label for the management of a skin rash that has not resolved after 5 days of treatment with oral prednisone and Zyrtec.
• Given the lack of direct information, it is uncertain whether to extend the prednisone treatment in this scenario 2.

From the Research

Skin Rash Treatment with Oral Prednisone and Zyrtec

• The provided studies do not directly address the question of extending oral prednisone treatment for a skin rash that has not resolved after 5 days of treatment with oral prednisone and Zyrtec 3, 4, 5, 6, 7.
• However, the studies discuss the use of topical corticosteroids for treating skin conditions such as eczema and atopic dermatitis, which may be relevant to skin rash treatment 3, 4, 5, 6, 7.
• Topical corticosteroids are classified by strength and potency, and their use can be associated with adverse effects such as skin thinning and impaired skin barrier function 4, 5, 6, 7.
• The studies suggest that potent and moderate topical corticosteroids are probably more effective than mild topical corticosteroids for treating eczema, but there is uncertain evidence to support the use of very potent topical corticosteroids 5.
• Intermittent use of topical corticosteroids for up to 5 years may result in little to no difference in risk of growth abnormalities, non-skin infections, and skin thinning 6.

Considerations for Treatment

• The decision to extend oral prednisone treatment should be based on the specific diagnosis and severity of the skin rash, as well as the patient's response to treatment 3, 4, 5, 6, 7.
• Topical corticosteroids may be considered as an alternative or adjunct treatment for skin rash, but their use should be guided by the severity and location of the rash, as well as the patient's individual needs and medical history 3, 4, 5, 6, 7.
• Further research is needed to determine the optimal treatment strategies for skin rash and to address the knowledge gaps in the use of topical corticosteroids for this condition 5, 6.