What are the management steps for a female patient of reproductive age with a history of skin rash or reaction using the Mirena (levonorgestrel) implant?

Management of Skin Rash with Mirena (Levonorgestrel-Releasing Intrauterine System)

Immediate Assessment

If a female patient of reproductive age develops a skin rash while using Mirena, immediately assess the severity and characteristics of the reaction to determine whether the device should be removed. 1, 2

Critical Exclusion Criteria Requiring Immediate Mirena Removal

• Acute urticaria (hives) with systemic symptoms such as pruritus, dizziness, or abdominal pain requires immediate device removal 2
• Severe cutaneous reactions including mucosal involvement, blistering, or skin exfoliation suggesting Stevens-Johnson syndrome or toxic epidermal necrolysis 3
• Fever greater than 39°C indicating severe hypersensitivity reaction 3
• Signs of DRESS syndrome including lymphadenopathy, hepatitis, or other organ involvement 3

Assess Body Surface Area and Severity

• Calculate the percentage of body surface area involved to grade the severity of the reaction 3
• Document the morphology of the rash (maculopapular, urticarial, seborrheic, etc.) 1, 2

Management Algorithm Based on Rash Severity

For Severe Reactions (Urticaria, Systemic Symptoms, or Extensive Involvement)

Remove the Mirena device immediately and permanently—do not attempt reinsertion. 2

• Administer oral corticosteroids (e.g., methylprednisolone 10 mg daily for 5 days) 2
• Prescribe oral antihistamines (e.g., desloratadine 5 mg daily for 5 days) for symptomatic relief 2
• Monitor for resolution, which typically occurs within days to weeks after device removal 2

For Mild to Moderate Localized Reactions (e.g., Seborrheic Dermatitis)

Consider device removal if the rash is clearly temporally related to Mirena insertion and causes significant patient distress. 1

• Apply topical corticosteroids (mild to moderate potency) to affected areas 3, 1
• Prescribe oral antihistamines for pruritus if needed 3
• If the device is removed, the rash should resolve completely with topical treatment within weeks 1

For Mild Rash Without Systemic Symptoms

• Counsel the patient that mild skin reactions can occur with levonorgestrel-containing devices 4, 5
• Initiate symptomatic treatment with topical emollients and antihistamines 3
• Monitor closely for progression with weekly follow-up if Grade 2 severity 3
• If the rash persists beyond 2 weeks despite treatment or worsens, remove the device 3, 1

Laboratory Workup

Obtain baseline studies to assess for systemic involvement:

• Complete blood count to evaluate for eosinophilia (DRESS syndrome) 3
• Comprehensive metabolic panel to assess liver and kidney function 3

Critical Pitfalls to Avoid

• Never rechallenge with Mirena if it has been confirmed as the causative agent of a hypersensitivity reaction 3, 6
• Do not use prophylactic corticosteroids or antihistamines when considering reinsertion, as this has not been proven effective and may mask early warning signs 7, 3
• Avoid sedating antihistamines in elderly patients or those at risk for falls 3
• Do not delay removal if systemic symptoms develop, as reactions can progress rapidly 2

Timeline for Resolution

• Most mild to moderate skin reactions begin improving within days of device removal 6
• Complete resolution typically occurs within 2-3 weeks after removal with appropriate topical treatment 1, 2
• New lesions may continue to appear in crops for up to 2-3 weeks after device removal 6

Follow-Up and Monitoring

• Schedule weekly follow-up until the rash improves to Grade 1 or resolves 3
• Refer urgently to dermatology if there is no response after 2 weeks of treatment, diagnostic uncertainty, or progression despite management 3
• Seek immediate consultation if fever develops, mucosal involvement appears, or systemic symptoms emerge 3

Alternative Contraception Counseling

After Mirena removal for skin reaction:

• Counsel on alternative contraceptive methods that do not contain levonorgestrel 7
• Consider copper IUD, barrier methods, or non-hormonal options 7
• If hormonal contraception is desired, consider methods with different progestins, though cross-reactivity is possible 4
• Ensure the patient has effective contraception in place before sexual activity resumes 7