What is the role of steroids in treating poison ivy?

Role of Steroids in Treating Poison Ivy

Over-the-counter topical steroids have uncertain usefulness for treating poison ivy reactions, while systemic corticosteroids are effective for moderate to severe cases requiring a 14-21 day course to prevent symptom rebound. 1, 2

Initial Management

• Immediate washing with soap and water or commercial decontamination products is most effective, removing up to 100% of poison ivy oils if done immediately, decreasing to 50% at 10 minutes and only 10% at 30 minutes 1, 2
• Washing with commercial hand cleaners or dishwashing soap and water can reduce local symptoms by 55-70% even when used 2 hours after exposure 1

Topical Steroid Therapy

• Over-the-counter topical steroids have uncertain efficacy for poison ivy reactions according to the American Heart Association guidelines 1
• Low-potency corticosteroids (0.2% hydrocortisone lotion, 1.0% hydrocortisone ointment, 2.5% hydrocortisone ointment/cream) have not been shown to improve symptoms in controlled trials 1
• High-potency topical corticosteroids may be effective when combined with systemic treatment but require prescription strength 1, 2
• Topical corticosteroids work through anti-inflammatory, antipruritic, and vasoconstrictive actions 3

Systemic Steroid Therapy

• For moderate to severe poison ivy reactions, systemic corticosteroids at 0.5-1 mg/kg/day are recommended 2, 4
• Despite recommendations for at least 14 days of treatment, many providers prescribe shorter courses, which is associated with increased return visits 4
• A 14-21 day tapering course is optimal to prevent symptom rebound, as shorter durations (1-13 days) are associated with 30% higher odds of return healthcare visits 4
• Systemic absorption of topical corticosteroids can occur, especially with occlusive dressings, potentially affecting the hypothalamic-pituitary-adrenal axis 3

Supportive Measures

• Cool compresses can provide symptomatic relief for local symptoms 1, 2
• Oatmeal baths may be considered for relief of local symptoms 1, 2
• Oral antihistamines have uncertain usefulness for local symptoms but may help with sleep at night 1

Treatment Algorithm Based on Severity

1. Mild localized reactions:

   • Immediate washing with soap and water 1
   • Cool compresses and oatmeal baths for symptomatic relief 1
   • Prescription-strength topical steroids may be beneficial 2, 5

2. Moderate to severe reactions (extensive rash, facial/genital involvement):

   • Systemic corticosteroids (prednisone 0.5-1 mg/kg/day) 2, 6
   • Treatment duration of 14-21 days with gradual tapering 4
   • Consider adding high-potency topical steroids to affected areas 2

3. Severe reactions with systemic symptoms:

   • Immediate medical attention 7
   • Higher-dose systemic corticosteroids with appropriate tapering 6, 4

Common Pitfalls to Avoid

• Relying solely on over-the-counter topical steroids, which have uncertain efficacy 1, 2
• Prescribing too short a course of systemic steroids (less than 14 days), leading to symptom rebound and return visits 4
• Delaying washing after exposure, significantly reducing the effectiveness of decontamination 1, 2
• Using oral antihistamines as primary treatment for itching, which has limited supporting evidence 1