Can oral steroids be used to treat contact dermatitis?

Oral Steroids for Contact Dermatitis

Oral steroids should be used for contact dermatitis only when it involves an extensive area of skin (greater than 20% body surface area) or when topical treatments have failed. 1 For most cases of contact dermatitis, topical corticosteroids remain the first-line treatment.

Treatment Algorithm for Contact Dermatitis

First-Line Treatment

• Topical corticosteroids are the mainstay of treatment for localized contact dermatitis 2, 3
  • Use low to medium potency steroids for facial dermatitis 3
  • Use mid- or high-potency topical steroids for localized acute allergic contact dermatitis on the body 1
  • Apply once or twice daily until significant improvement 3

Second-Line Treatment (When to Consider Oral Steroids)

Oral steroids are indicated when:

1. Contact dermatitis involves >20% of body surface area 1
2. Topical treatments have failed
3. Severe inflammation is present

Oral Steroid Regimen

• When using oral prednisone for severe contact dermatitis (such as rhus dermatitis), taper over 2-3 weeks 1, 4
• A longer taper (10-21 days) is recommended to prevent rebound dermatitis 4
• Oral steroids typically provide relief within 12-24 hours 1

Important Considerations

Benefits of Oral Steroids

• Rapid relief (within 12-24 hours) for extensive or severe cases 1
• More effective than topical treatments for widespread disease

Risks and Precautions

• Potential for rebound dermatitis if discontinued too quickly 1, 4
• Systemic side effects including:
  • Suppression of the pituitary-adrenal axis 2
  • Potential growth interference in children 2
• Rare possibility of allergic reactions to corticosteroids themselves 5

Adjunctive Treatments

• Antihistamines: Sedating antihistamines can be helpful for severe pruritus during flares 2, 3
  • Non-sedating antihistamines have little value in contact dermatitis 2
  • Antihistamines work primarily through their sedative properties 2
• Emollients and soap substitutes should be used regularly 3
• Antibiotics if secondary bacterial infection is present 2, 3

Special Situations

Contact Dermatitis on the Face

• Use low to medium potency topical corticosteroids only 3
• Avoid high-potency steroids on the face due to increased risk of:
  • Skin atrophy
  • Perioral dermatitis
  • Rosacea 3
• Consider topical calcineurin inhibitors as steroid-sparing alternatives 3

When Treatment Fails

• If no improvement after 2 weeks of appropriate treatment, consider:
  • Patch testing to identify specific allergens 2, 3
  • Alternative diagnoses
  • Referral to a dermatologist 3

Common Pitfalls to Avoid

1. Using oral steroids as first-line treatment for limited contact dermatitis
2. Stopping oral steroids abruptly, which can cause rebound dermatitis 1, 4
3. Using high-potency steroids on the face or intertriginous areas 3
4. Prolonged use of systemic corticosteroids without exploring other treatment options 6
5. Failure to identify and remove the causative agent, which is the most important step in management 2

Remember that the cornerstone of contact dermatitis management is identification and avoidance of the causative agent, with appropriate anti-inflammatory treatment to control symptoms while the skin heals.