What is the best course of treatment for a 54-year-old female with persistent contact dermatitis due to poison ivy?

From the Guidelines

I strongly recommend treating this patient's persistent poison ivy rash with a prescription-strength topical corticosteroid, such as triamcinolone 0.1% cream, applied twice daily for 7-10 days, as the current over-the-counter treatments have been ineffective. The patient's rash has persisted for over two weeks, suggesting a moderate to severe reaction to urushiol, the oil in poison ivy that causes contact dermatitis 1. According to the 2024 American Heart Association and American Red Cross guidelines for first aid, washing with soap and water can remove up to 100% of poison ivy oils if done immediately after contact, but this is not applicable in this case as the exposure occurred 2 and a half weeks ago 1.

The patient should also be advised to take cool baths with colloidal oatmeal, avoid scratching to prevent secondary infection, and wear loose-fitting clothing over affected areas. Cool compresses and oatmeal baths may be considered for relief of local symptoms from exposure to poison ivy, oak, or sumac 1. If there are signs of infection (increased pain, swelling, warmth, or discharge), an antibiotic may be needed. The patient should be advised that even with appropriate treatment, poison ivy rash can take 2-3 weeks to fully resolve, and she should return if symptoms worsen or if she develops fever, extensive swelling, or difficulty breathing, which could indicate a more serious reaction requiring immediate attention.

Some key points to consider in the management of this patient's condition include:

• The usefulness of over-the-counter topical steroids to alleviate local symptoms from poison ivy, oak, or sumac is uncertain 1
• The patient's symptoms have not improved with over-the-counter medications, suggesting the need for prescription-strength treatment
• The importance of preventing secondary infection and providing symptomatic relief to improve the patient's quality of life.

From the FDA Drug Label

Apply triamcinolone acetonide cream USP, 0. 1% as appropriate, to the affected area two to three times daily. Rub in gently. The patient's rash is consistent with poison ivy and has not improved with over-the-counter medications.

• Treatment: Apply triamcinolone acetonide cream USP, 0. 1% to the affected area two to three times daily.
• Administration: Rub in gently. 2

From the Research

Patient Presentation

• A 54-year-old female presents with a rash on her back, consistent with poison ivy, which erupted 2 days after being at camp 2 and a half weeks ago.
• The patient has tried over-the-counter medications with no improvement and reports the rash continues to be pruritic and red.
• She denies any other associated symptoms.

Diagnosis and Management

• According to 3, contact dermatitis is a common inflammatory skin condition characterized by erythematous and pruritic skin lesions that occur after contact with a foreign substance.
• The study suggests that localized acute allergic contact dermatitis lesions are successfully treated with mid- or high-potency topical steroids, such as triamcinolone 0.1% or clobetasol 0.05%.
• If the allergic contact dermatitis involves an extensive area of skin (greater than 20 percent), systemic steroid therapy is often required and offers relief within 12 to 24 hours.

Treatment Options

• Topical corticosteroids are an essential tool for treating inflammatory skin conditions such as psoriasis and atopic dermatitis, as stated in 4.
• The study recommends that patients are informed that treatment should not exceed prescribed quantities, and continuing treatment should be under careful medical supervision.
• According to 5, patients should be advised to apply sufficient medication to achieve a satisfactory clinical response, and clear 'fingertip unit' instructions should be provided.

Poison Ivy Dermatitis Treatment

• A retrospective claims-based analysis 6 found that shorter duration oral corticosteroids and initial treatment for poison ivy dermatitis at the ED compared to primary care clinicians places patients at an increased risk for return visits with healthcare clinicians.
• The study suggests that emergency clinicians should consider treatment of two to three weeks when providing systemic steroid coverage when there are no limiting contraindications.

Systemic Contact Dermatitis

• A case report 7 describes a patient who had an allergic contact dermatitis to topical corticosteroids and developed a disseminated exanthema after oral treatment with prednisolone.
• The study highlights the importance of identifying a safe corticosteroid for patients with systemic contact dermatitis and suggests that patch and intradermal tests may be used for this purpose.