What is the recommended treatment approach for inpatient management of severe poison ivy (Toxicodendron dermatitis) reactions?

Inpatient Management of Severe Poison Ivy Dermatitis

Systemic corticosteroids for at least 14 days are the cornerstone of inpatient treatment for severe poison ivy dermatitis, with longer courses (15 days) showing better outcomes in reducing the need for additional medications. 1, 2

Assessment of Severity

• Severe presentation indicators:
  • Widespread vesicles and bullae on erythematous bases
  • Facial, genital, or extensive involvement (>30% body surface area)
  • Signs of secondary infection
  • Systemic symptoms (fever, malaise)
  • Significant functional impairment

Treatment Algorithm

First-Line Treatment

1. Systemic Corticosteroids:

   • Prednisone 40mg daily for 5 days, followed by a taper:
     • 30mg daily for 2 days
     • 20mg daily for 2 days
     • 10mg daily for 2 days
     • 5mg daily for 4 days
   • Total duration: 15 days 2
   • Rationale: Longer courses (≥14 days) significantly reduce the need for additional medications (NNT=3) 2

2. Topical Management:

   • High-potency topical corticosteroids twice daily to affected areas 3
   • Cool compresses applied several times daily to reduce inflammation and pruritus
   • Calamine lotion for weeping lesions

For Secondary Infection

• Obtain bacterial cultures if infection is suspected 3
• Initiate appropriate antibiotics based on sensitivity for at least 14 days 3
• Consider bleach baths or topical sodium hypochlorite solutions

Symptomatic Relief

• Oral antihistamines for pruritus and sleep disturbance
• Oatmeal baths for widespread involvement
• Lidocaine 5% cream or patches for pain relief on particularly painful areas 3

Monitoring and Follow-up

• Reassess after 2 weeks of treatment
• If reactions worsen or do not improve, consider:
  • Extending systemic corticosteroid treatment
  • Adding immunomodulators for very severe cases 4
  • Re-examining to confirm diagnosis if no response after 6 weeks 4

Important Clinical Considerations

• Common pitfall: Prescribing short-duration corticosteroids (less than 14 days) is associated with increased risk of return visits and healthcare utilization 1
• Caution: Avoid topical corticosteroids on the face, especially around eyes; instead, use topical calcineurin inhibitors for facial involvement 4
• Patient education: Provide information on poison ivy identification to prevent future exposures 5

Special Considerations

• For facial involvement: Consider topical calcineurin inhibitors like tacrolimus 0.1% ointment or pimecrolimus 1% cream instead of topical corticosteroids to avoid skin atrophy 4
• For eyelid involvement: Urgent ophthalmology referral within 1 week if severe eyelid involvement or visual changes 4

This treatment approach addresses both the acute inflammatory response and symptom management while minimizing the risk of rebound symptoms or return visits, which have been documented with shorter treatment courses.