What is the appropriate pharmacologic treatment for a 6-year-old child with a nickel-induced contact dermatitis rash on the bilateral posterior legs?

From the Guidelines

The most appropriate pharmacologic treatment for a 6-year-old child with nickel-induced contact dermatitis on the bilateral posterior legs is triamcinolone acetonide 0.1% ointment twice daily for 7-10 days, as it is a medium-potency corticosteroid effective in reducing inflammation and promoting healing 1.

Treatment Overview

The treatment of nickel-induced contact dermatitis involves a combination of avoiding the allergen, applying topical corticosteroids, and in some cases, using oral antihistamines to manage symptoms. Given the child's age and the location of the rash, a topical corticosteroid is the most appropriate first-line treatment.

Topical Corticosteroids

• Triamcinolone acetonide 0.1% ointment is a medium-potency corticosteroid that can be applied thinly to the affected areas twice daily for 7-10 days. This duration and potency are typically sufficient for managing contact dermatitis in children without causing significant side effects 1.
• For more severe cases, a short course of a higher-potency steroid like fluocinonide 0.05% cream may be considered for 3-5 days before transitioning to a lower-potency preparation.

Additional Measures

• Identifying and removing the nickel source is crucial in managing nickel-induced contact dermatitis. In this case, switching the child to an alternate chair without nickel-plated screws is essential.
• Applying a barrier cream containing dimethicone after the rash resolves can help prevent recurrence if nickel contact cannot be completely avoided.
• Oral antihistamines like cetirizine (5 mg once daily) or diphenhydramine (12.5 mg every 6 hours as needed) can be used to manage itching, although the child in this scenario denies pruritus.

Considerations

• The choice of treatment should always prioritize minimizing potential side effects while effectively managing the condition.
• Given the child's symptoms and the absence of pruritus, the focus should be on reducing inflammation and promoting healing with topical corticosteroids.

From the FDA Drug Label

Pediatric patients may demonstrate greater susceptibility to topical corticosteroid-induced HPA axis suppression and Cushing's syndrome than mature patients because of a larger skin surface area to body weight ratio Administration of topical corticosteroids to children should be limited to the least amount compatible with an effective therapeutic regimen.

The appropriate pharmacologic treatment for a 6-year-old child with a nickel-induced contact dermatitis rash on the bilateral posterior legs is hydrocortisone 1% cream twice daily for 7 days 2.

• This option is chosen due to the need for a mild topical corticosteroid in pediatric patients to minimize the risk of HPA axis suppression and other systemic effects.
• The treatment duration and frequency should be limited to the least amount necessary to achieve an effective therapeutic response.

From the Research

Nickel-Induced Contact Dermatitis Treatment

The patient's condition is consistent with nickel-induced contact dermatitis, given the recent exposure to nickel-plated screws and the presence of coin-shaped lesions with scaling and surrounding erythema.

• The lesions are described as sore, but not pruritic, which is consistent with contact dermatitis.
• The patient has not responded to daily application of an over-the-counter moisturizer, indicating the need for a more targeted treatment approach.

Pharmacologic Treatment Options

Considering the patient's condition and the need for a pharmacologic treatment, the following options are available:

• Topical corticosteroids, such as triamcinolone acetonide or hydrocortisone, are commonly used to treat contact dermatitis.
• The study by 3 suggests that local application of triamcinolone acetonide can suppress patch test reactions to nickel sulfate, indicating its potential efficacy in treating nickel-induced contact dermatitis.

Recommended Treatment

Based on the available evidence, the recommended treatment for the patient is:

• Triamcinolone acetonide 0.5% ointment twice daily for 7-21 days, depending on the severity of the condition and the patient's response to treatment.
• This treatment option is supported by the study by 4, which found no significant difference in efficacy between triamcinolone acetonide cream and ointment in treating atopic dermatitis, suggesting that the ointment formulation may be effective in treating contact dermatitis as well.

Additional Considerations

• It is essential to advise the patient's parents to switch the child to an alternate chair to avoid further exposure to nickel.
• The patient should be monitored for any signs of improvement or worsening of the condition, and the treatment plan should be adjusted accordingly.
• Further studies, such as 5 and 6, provide additional information on the effects of triamcinolone acetonide, but are not directly relevant to the treatment of nickel-induced contact dermatitis.
• The study by 7 discusses the use of triamcinolone acetonide in treating hypertrophic scars, which is not relevant to the patient's condition.