What are the next treatment options for a 46-year-old patient with a severe rash, elevated Immunoglobulin E (IgE) levels, and allergies to egg white and dust mites, who has not responded to hydrocortisone (hydrocortisone) and Fucidin (fusidic acid), and has experienced recurrent symptoms after two 7-day courses of oral prednisolone (prednisolone)?

Treatment Options for Severe Allergic Rash with High IgE Levels

For a 46-year-old patient with widespread rash, elevated IgE (2700), and known egg white and dust mite allergies who has failed topical treatments and experiences recurrence after oral prednisolone courses, referral to a dermatologist and consideration of immunomodulatory therapy such as cyclosporine is strongly recommended.

Assessment of Current Situation

The patient presents with:

• Widespread rash affecting the entire body
• Very high IgE level (2700)
• Known allergies to egg white and dust mites
• Failed treatments:
  • Topical hydrocortisone and fusidic acid
  • Oral antihistamines (ongoing)
  • Two 7-day courses of oral prednisolone (temporary relief with recurrence)

Treatment Algorithm

Step 1: Rule Out Steroid Allergy

• Consider the possibility of hypersensitivity to corticosteroids, which occurs in approximately 0.3-0.5% of patients 1
• Signs of steroid allergy include worsening of rash after steroid administration or development of new symptoms
• If suspected, patch testing with different corticosteroids may be needed

Step 2: Immediate Management

1. Optimize antihistamine therapy:

   • Increase to higher doses of non-sedating antihistamines (up to 4× standard dose)
   • Consider combination of H1 and H2 blockers
   • Add sedating antihistamines at night for better symptom control 2

2. Consider longer course of systemic steroids:

   • Extend prednisolone treatment to 3-4 weeks with slower tapering
   • Initial dose of 0.5-1 mg/kg/day (based on severity) 2, 3
   • Taper gradually over at least 4 weeks rather than abruptly 3

Step 3: Second-Line Therapy (If Step 2 Fails)

• Refer to dermatologist for specialist evaluation and management 2
• Consider immunomodulatory therapy:
  • Cyclosporine: Effective in about two-thirds of patients with severe autoimmune urticaria at 4 mg/kg daily for up to 2 months 2
  • Treatment duration of 16 weeks shows better outcomes than 8 weeks 2

Step 4: Additional Therapeutic Options

• Phototherapy: Consider narrow-band UVB (312 nm) treatment 2
• Other immunosuppressants if cyclosporine fails:
  • Tacrolimus
  • Mycophenolate mofetil
  • Methotrexate (anecdotal evidence) 2

Allergen Management

• Implement dust mite avoidance measures despite limited evidence of effectiveness 2
• Consider dietary manipulation if history strongly suggests food allergy 2
• Allergen immunotherapy may be beneficial for atopic dermatitis with aeroallergen sensitivity 2

Important Considerations and Pitfalls

Diagnostic Pitfalls

• Misdiagnosis: Ensure the condition is not being misdiagnosed as simple atopic dermatitis when it could be:
  • Chronic urticaria with angioedema
  • Drug-induced eruption
  • Contact dermatitis
  • Underlying systemic disease with cutaneous manifestations

Treatment Pitfalls

1. Steroid dependence: Avoid long-term systemic corticosteroids as maintenance therapy 2
2. Inadequate antihistamine dosing: Many physicians underdose antihistamines
3. Overlooking allergic triggers: Dust mite allergy should be addressed through environmental control
4. Delayed specialist referral: Don't persist with ineffective treatments before seeking specialist input

Follow-up

• Reassess every 2-4 weeks during active treatment
• Monitor for side effects of immunosuppressive medications
• Consider maintenance therapy once control is achieved

Remember that a short course of oral prednisone induced remission in nearly 50% of patients with chronic urticaria, and a second course induced remission in a further 9% of patients 4. However, when these measures fail, immunomodulatory therapy becomes necessary.