From the Guidelines
For a small bumpy rash not responding to oral prednisone or Zyrtec, the next step should be to consider omalizumab as a second-line treatment, starting with a dose of 300 mg every 4 weeks, as recommended by the latest international urticaria guideline 1. This approach is based on the recent update of the international urticaria guideline, which streamlines the treatment algorithm into three steps: first-line treatment with antihistamines, second-line treatment with omalizumab, and third-line treatment with cyclosporine 1. Some key points to consider when using omalizumab include:
- Starting with a dose of 300 mg every 4 weeks, with the option to updose if necessary, by shortening the interval and/or increasing the dosage 1
- Allowing up to 6 months for patients to respond to omalizumab, with the maximum recommended dose being 600 mg every 14 days 1
- Monitoring patients closely for potential side effects, and considering cyclosporine as an alternative for patients who do not respond to higher than standard doses of omalizumab 1 It is also important to note that the treatment approach should be tailored to the individual patient's needs, using an "as much as needed and as little as possible" approach, and stepping up or stepping down treatment based on levels of disease control assessed with the UCT 1. In addition to considering omalizumab, it may also be helpful to:
- Try a different antihistamine, such as fexofenadine (Allegra) 180mg daily or diphenhydramine (Benadryl) 25-50mg every 6 hours as needed
- Use a topical corticosteroid, such as triamcinolone 0.1% cream, applied twice daily for 7-10 days to reduce inflammation
- Avoid potential irritants, including fragranced products, harsh soaps, and new detergents
- Keep a diary of potential triggers, such as foods, medications, or environmental exposures, and take photos of the rash to document any changes.
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
The patient's small bumpy rash has not resolved with oral prednisone or Zyrtec, indicating a lack of satisfactory clinical response. The next step would be to discontinue prednisone and consider alternative therapies. 2
From the Research
Next Steps for Treating a Small Bumpy Rash
- If the rash has not resolved with oral prednisone or Zyrtec, the next steps may involve:
- Topical treatments: High-potency topical steroids, such as clobetasol propionate 3, may be effective in treating the rash.
- Identifying the cause: Determining whether the problem resolves with avoidance of a suspected substance can help confirm the diagnosis of contact dermatitis 4.
- Patch testing: If the diagnosis or specific allergen remains unknown, patch testing should be performed to identify potential allergens 4.
- Alternative treatments: Other treatments, such as crisaborole or dupilumab, may be considered for atopic dermatitis, but may be cost-prohibitive 5, 6.
- Diagnostic tools: Hyperspectral imaging and genetic tests may be used to diagnose and manage allergic rashes, but more research is needed to demonstrate their effectiveness 7.
Considerations for Treatment
- The choice of treatment will depend on the severity and extent of the rash, as well as the patient's medical history and other factors.
- Topical corticosteroids, such as triamcinolone or clobetasol, may be effective for localized acute allergic contact dermatitis lesions 4.
- Systemic steroid therapy may be required for extensive areas of skin involvement (greater than 20 percent) 4.
- Maintenance therapy for atopic dermatitis may include liberal use of emollients, daily bathing with soap-free cleansers, and topical corticosteroids or calcineurin inhibitors 6.