From the Guidelines
If a rash is not responding to prednisone, consider switching to or adding alternative treatments such as azathioprine, methotrexate, or dapsone, as recommended by the British Association of Dermatologists' guidelines for the management of bullous pemphigoid 2012 1. When a rash does not respond to prednisone, it is essential to reassess the diagnosis and consider alternative treatments. The British Association of Dermatologists' guidelines for the management of bullous pemphigoid 2012 provide recommendations for treatment choices, including the use of systemic corticosteroids, very potent topical steroids, and anti-inflammatory antibiotics 1.
Key Considerations
- The severity of the disease and patient comorbidities should be taken into consideration when choosing a treatment.
- Topical steroids may be used as an adjunct to any other treatment or used as a monotherapy, either locally applied to lesions or all over the skin.
- Anti-inflammatory antibiotics have a smaller evidence base for efficacy but are widely used and may be a safer treatment for patients with comorbidities.
- For disease of any severity not responding to existing treatment, consider switching to or adding alternative treatments such as azathioprine, methotrexate, or dapsone 1.
Treatment Options
- Azathioprine 1–2.5 mg kg-1 daily (strength of recommendation D) 1
- Methotrexate 5–15 mg weekly (strength of recommendation D) 1
- Dapsone 50–200 mg daily (strength of recommendation D) 1 It is crucial to consult with a dermatologist for proper evaluation and alternative treatment, as the specific treatment depends on the exact type of rash, which requires professional diagnosis 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Possible Causes of Rash Not Responding to Prednisone
- Hypersensitivity reactions to corticosteroids, including immediate and non-immediate reactions, can occur in some patients 2
- Allergic contact dermatitis (ACD) is a common non-immediate hypersensitivity reaction, usually following topical corticosteroid application 2
- Acute generalized exanthematous pustulosis (AGEP) is a rare cutaneous eruption that can be provoked by systemic prednisolone 3
- Delayed systemic allergic reactions to corticosteroids can occur, with variable clinical presentations and evaluation methods 4
Evaluation and Management
- A detailed evaluation is required to confirm the presence of a true hypersensitivity reaction to the suspected drug and choose the safest alternative 2
- Patch and intradermal tests with standardized allergens can be useful in supporting the clinical diagnosis of generalized delayed systemic reactions to corticosteroids 4
- Steroid-sparing agents, such as azathioprine, can be used in the treatment of recalcitrant itch or urticarial dermatitis 5
- Alternative immunosuppressant drugs, such as methotrexate or mycophenolate mofetil, can be considered in patients who are intolerant of or unresponsive to azathioprine 6