Can allergic contact dermatitis flare while on oral steroids?

Can Allergic Contact Dermatitis Flare While on Oral Steroids?

Yes, allergic contact dermatitis (ACD) can flare while on oral steroids, particularly when there is continued exposure to the causative allergen or when the oral steroid dose is insufficient to control the immune response. 1

Mechanisms and Considerations

• Oral corticosteroids are generally effective for controlling allergic contact dermatitis through their immunosuppressive and anti-inflammatory properties, but they may not completely prevent flares if the allergen exposure continues 1

• Systemic steroids are typically reserved for severe or widespread cases of allergic contact dermatitis, but they are not considered a first-line or maintenance therapy due to their potential adverse effects 1, 2

• For recalcitrant cases of allergic contact dermatitis, a stronger topical steroid, phototherapy, systemic therapy, or occupational/environmental modification may be necessary 1

Factors That May Contribute to Flares Despite Oral Steroid Use

• Continued allergen exposure: If the causative allergen is not identified and avoided, ACD can persist or flare even while on oral steroids 1

• Insufficient dosing: If the oral steroid dose is too low or the duration too short, it may not adequately suppress the allergic reaction 2

• Steroid tapering: Rapid discontinuation of oral steroids can cause rebound dermatitis, particularly in severe cases 2

• Steroid allergy: Although rare (0.3% incidence), patients can develop allergic reactions to the corticosteroids themselves, which can manifest as worsening dermatitis 3, 4

• Cross-reactivity: Patients allergic to one corticosteroid may react to others due to structural similarities 3, 4

Management Recommendations

For Acute Flares While on Oral Steroids

• Reassess for continued allergen exposure and ensure complete avoidance of identified triggers 1

• Consider patch testing if the causative allergen remains unknown or if multiple allergens are suspected 1

• For severe widespread ACD (>20% body surface area) not responding to current oral steroid dose, adjustment of the dose may be necessary 2

• When discontinuing oral steroids for severe ACD, taper over 2-3 weeks to prevent rebound flares 2

For Recalcitrant Cases

• Consider alternative systemic therapies such as cyclosporine, methotrexate, or azathioprine for cases that fail to respond to oral steroids 5

• Evaluate for possible steroid allergy if dermatitis worsens with steroid therapy 3, 6

• For hand ACD specifically, consider:

  • Using accelerator-free gloves if rubber allergy is present 1
  • Applying moisturizers after washing and before wearing gloves 1
  • Using cotton glove liners or loose plastic gloves as barriers 1

Special Considerations

• Steroid allergy: If steroid allergy is suspected (worsening with steroid therapy), diagnostic testing may include skin testing, patch testing, or oral challenge 6, 4

• Medication interactions: Some medications may need to be discontinued before accurate patch testing can be performed, including oral steroids which can suppress test results 1

• Rebound phenomenon: Patients on long-term topical or systemic steroids may develop dependence, making withdrawal difficult and potentially causing flares that mimic allergic reactions 3

• Underlying skin conditions: Pre-existing atopic dermatitis or other skin conditions can complicate the presentation and management of ACD 1

Remember that the primary approach to managing allergic contact dermatitis is identifying and avoiding the causative allergen, with medications like oral steroids serving as temporary measures to control symptoms rather than definitive treatment 1.