What is the best treatment for a 38-year-old male with worsening contact dermatitis unresponsive to Triamcinolone (triamcinolone)?

From the Guidelines

The patient's treatment plan should include patch testing to confirm the diagnosis of allergic contact dermatitis, in addition to the prescribed Prednisone and Clobetasol, as the patient's history and physical exam suggest a possible allergic contact dermatitis, which is a common condition in patients with atopic dermatitis 1. The patient is a 38-year-old male with a worsening rash on his right forearm that began as a hook-shaped lesion 10 days ago and has now spread across the entire forearm, along with dry skin on his right hand. The treatment plan includes Prednisone 40 mg daily for 5 days and Clobetasol cream applied twice daily for 14 days.

• The oral corticosteroid (Prednisone) will help reduce inflammation systemically,
• while the topical high-potency steroid (Clobetasol) will target the affected area directly. The allergy panels and IgE testing will help identify potential triggers for the dermatitis. However, patch testing is essential to confirm the diagnosis of allergic contact dermatitis, as it can identify specific allergens that may be causing the patient's symptoms 1. The patient should be advised to:
• avoid potential irritants,
• use mild soap,
• apply moisturizer regularly,
• and return for follow-up if symptoms persist after completing the medication course. Potential side effects of prednisone include mood changes, increased appetite, and elevated blood sugar, while clobetasol may cause skin thinning with prolonged use. It is also important to note that the patient's history of contact dermatitis and previous positive response to prednisone support the use of these medications, but patch testing will help to determine the underlying cause of the patient's symptoms and guide further treatment 1.

From the FDA Drug Label

Clobetasol propionate is a highly potent topical corticosteroid that has been shown to suppress the HPA axis at doses as low as 2 g (of ointment) per day. Systemic absorption of topical corticosteroids has resulted in reversible HPA axis suppression, manifestations of Cushing's syndrome, hyperglycemia, and glucosuria in some patients. Conditions that augment systemic absorption include the application of the more potent corticosteroids, use over large surface areas, prolonged use, and the addition of occlusive dressings Patients receiving a large dose of a potent topical steroid applied to a large surface area should be evaluated periodically for evidence of HPA axis suppression by using the urinary free cortisol and ACTH stimulation tests.

The patient is being prescribed Clobetasol BID for 14 days for a rash on the right forearm.

• The FDA drug label recommends evaluating patients for HPA axis suppression when using a large dose of a potent topical steroid applied to a large surface area.
• The patient's treatment area is the whole right forearm, which can be considered a large surface area.
• The patient is also being prescribed Prednisone 40 mg for 5 days, which may increase the risk of HPA axis suppression.
• It is recommended to monitor the patient for signs of HPA axis suppression and consider using the urinary free cortisol and ACTH stimulation tests to evaluate the patient's HPA axis function 2.

From the Research

Patient Treatment

The patient is being treated for contact dermatitis with a prescription of Prednisone 40 mg for 5 days and Clobetasol BID for 14 days.

• The use of Clobetasol propionate, as mentioned in the study 3, is a common treatment for various skin diseases, including atopic dermatitis and psoriasis, due to its anti-inflammatory, immunosuppressive, and antimitotic effects.
• However, as noted in the study 4, hypersensitivity reactions to corticosteroids, including Clobetasol, can occur, and patients should be closely monitored for any adverse reactions.
• The patient's history of responding well to Prednisone in the past, as well as the current prescription, is consistent with the study 5, which recommends Prednisone 40 mg for 5 days in the treatment of severe COPD exacerbations.

Laboratory Tests

The patient will undergo several laboratory tests, including:

• Food panel
• Outdoor panel
• Sheep epithelium
• IgE, SERUM
• These tests may help identify any potential allergens or underlying conditions contributing to the patient's symptoms, as discussed in the study 4, which highlights the importance of evaluating patients for hypersensitivity reactions to corticosteroids.

Corticosteroid Effects

The use of corticosteroids, such as Prednisone, can have various effects on the body, including:

• Decreased serum immunoglobulins, as noted in the study 6, which found that Prednisone decreased mean serum IgG and IgE levels in atopic asthmatic patients.
• Skin blanching, as evaluated in the study 7, which used a Chroma Meter to determine the skin blanching effect of topically applied steroids in animals.
• Potential adverse effects, such as new or worsening hyperglycemia or hypertension, as reported in the study 5, which found that systemic corticosteroids were not prescribed in accordance with evidence-based recommendations, resulting in a greater incidence of adverse effects and readmissions.