From the Guidelines
For a patient with persistent poison ivy rash despite 10 days of oral steroids, the next treatment step should be a referral to a dermatologist for evaluation and possible alternative therapies. The dermatologist may prescribe a longer course of oral steroids at a higher dose or with a more gradual taper, as premature discontinuation can lead to rebound inflammation, as suggested by the management of grade 2 rash in patients treated with immune checkpoint inhibitor therapy 1. They might also consider adding a potent topical steroid like clobetasol 0.05% cream applied twice daily to affected areas. For severe cases, other options include intramuscular steroid injections (such as triamcinolone 40-60mg) or oral immunosuppressants like cyclosporine in extreme cases. The persistent rash suggests either an unusually severe allergic reaction to urushiol (the oil in poison ivy), secondary infection, or possibly misdiagnosis of another condition like contact dermatitis from a different allergen.
While awaiting the dermatology appointment, the patient should continue to avoid scratching, apply cool compresses, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1, use calamine lotion for itch relief, and take oral antihistamines like hydroxyzine 25mg three times daily or cetirizine 10mg daily to help manage symptoms. The usefulness of over-the-counter topical steroids and antihistamines is uncertain, but they may be considered for relief of local symptoms from exposure to poison ivy, oak, or sumac 1.
Key considerations in managing this patient include:
- Avoiding further exposure to poison ivy, oak, or sumac
- Using topical emollients and mild-moderate potency topical corticosteroids for rash covering < 10% BSA, as recommended for grade 1 rash 1
- Considering holding or discontinuing oral steroids and monitoring weekly for improvement if skin toxicity is not improved after 4 weeks, as recommended for grade 2 rash 1
- Initiating oral prednisone or equivalent at dosing 0.5-1 mg/kg, tapering over at least 4 weeks, for rash covering > 30% BSA with moderate or severe symptoms, as recommended for grade 3 rash 1.
From the Research
Next Treatment Steps for Ongoing Poison Ivy Rash
- The patient has been on 10 days of oral steroids for poison ivy rash and it is continuing, indicating a need for alternative or additional treatment options.
- Considering the patient's ongoing symptoms, the following options may be considered:
- Topical corticosteroids, as discussed in 2, which can be effective in treating inflammatory skin conditions.
- Other topical anti-inflammatory agents, such as calcineurin inhibitors, as mentioned in 3.
- Adjunctive treatment options, including wet wrap therapy, anti-histamines, and vitamin D supplementation, as discussed in 3.
- It is essential to note that oral corticosteroids, as prescribed to the patient, are commonly used for atopic dermatitis, as seen in 4, but may not be the most effective long-term option due to their side effect profile.
- The clinical pharmacology of corticosteroids, as explained in 5, highlights the importance of dosing strategies to minimize the risk of hypothalamic-pituitary-adrenal axis suppression and other adverse effects.
- Given the patient's ongoing symptoms, a re-evaluation of the treatment plan and consideration of alternative options, such as those mentioned above, may be necessary to effectively manage the poison ivy rash.