What is the treatment for plant contact dermatitis in pediatric (peds) patients?

Treatment of Plant Contact Dermatitis in Pediatric Patients

For plant contact dermatitis in children, initiate treatment with low to medium potency topical corticosteroids as first-line therapy, with the specific potency and duration determined by the location and severity of the rash.

Initial Management Approach

Immediate Decontamination

• Remove the child from plant exposure and thoroughly wash affected skin areas with soap and water to remove plant residues, oils, or irritants 1, 2
• This step is critical for both irritant and allergic contact dermatitis to prevent further allergen penetration 2

First-Line Topical Corticosteroid Therapy

For trunk and extremities:

• Use low to medium potency topical corticosteroids as the primary treatment 3
• Apply once to twice daily for 1-2 weeks depending on response 3
• In children ages 0-6 years, use lower potency formulations due to increased risk of hypothalamic-pituitary-adrenal (HPA) axis suppression given their high body surface area-to-volume ratio 3

For facial and genital involvement:

• Tacrolimus 0.1% ointment is the preferred agent for sensitive areas (face, genitals, intertriginous areas) 3
• This avoids the risk of skin atrophy from corticosteroids in these high-risk locations 3
• Pimecrolimus cream 1% is an alternative for facial involvement 3

Potency Selection Algorithm

• Mild dermatitis (minimal erythema, no vesiculation): Low potency corticosteroids (hydrocortisone 1-2.5%) 3
• Moderate dermatitis (erythema, edema, some vesicles): Medium potency corticosteroids 3
• Severe dermatitis (extensive vesiculation, weeping): High potency corticosteroids for short-term use (≤2 weeks), then taper to lower potency 3

Critical Safety Considerations

Corticosteroid Precautions

• Never use ultra-high-potency corticosteroids on the face, neck, or skin folds due to high risk of skin atrophy 3
• Limit high-potency corticosteroid use to ≤2 weeks to prevent HPA suppression, especially in young children 3
• Provide caregivers with specific instructions on amount to apply and avoid abrupt discontinuation to prevent rebound flares 3
• Supply limited quantities and follow closely for overuse 3

Wet-Wrap Therapy for Severe Cases

• For moderate to severe plant contact dermatitis with extensive involvement, consider wet-wrap therapy with topical corticosteroids for 3-7 days (maximum 14 days) 3
• This enhances corticosteroid penetration and provides a barrier against scratching 3
• This should be considered before escalating to systemic therapy 3

Adjunctive Treatments

Emollients

• Apply emollients liberally and frequently to restore skin barrier function 3
• Can be used simultaneously with topical corticosteroids or at different times of day 3
• Regular emollient use has steroid-sparing effects 3

Oral Antihistamines

• Use as adjunctive therapy for pruritus control 3
• Particularly helpful at bedtime to reduce nocturnal scratching 3

Avoid Topical Antihistamines

• Do not use topical antihistamines as they increase the risk of contact sensitization 3

What NOT to Do

Systemic Corticosteroids

• Avoid routine use of oral corticosteroids in pediatric plant contact dermatitis 3
• If absolutely necessary for severe acute cases, limit to <7 days due to high risk of rebound flares upon discontinuation 3
• Long-term oral corticosteroid use is contraindicated due to well-known adverse effects 3

Topical Antibiotics

• Do not use topical antibiotics routinely as they increase resistance and sensitization risk 3
• Reserve for cases with clear evidence of secondary bacterial infection 3

Clinical Pearls

Distinguishing Plant Dermatitis Types

• Irritant contact dermatitis: Immediate onset, confined to contact area, no prior sensitization required 1, 2
• Allergic contact dermatitis: Delayed onset (24-48 hours), may extend beyond contact area, requires prior sensitization 2, 4
• Phytophotodermatitis: Requires both plant contact AND sun exposure, results in hyperpigmentation 2

Duration of Treatment

• Most plant contact dermatitis resolves within 1-2 weeks with appropriate topical therapy 3, 4
• Linear streaking patterns suggest direct plant contact and support the diagnosis 4

Prevention of Recurrence

• Identify and remove or avoid the offending plant 4
• Common culprits include poison ivy (Toxicodendron species), Virginia creeper, and various garden plants 1, 4, 5