What is the best course of treatment for a 19-year-old male patient with a recurrent rash, previously treated with prednisone and triamcinolone, with a normal serum Immunoglobulin E (IgE) level, now being started on Vistaril (hydroxyzine) and hydrocortisone 1%?

From the Guidelines

I strongly recommend treating this 19-year-old male's recurrent rash with a combination of systemic corticosteroids and very potent topical steroids, as suggested by the British Association of Dermatologists' guidelines for the management of bullous pemphigoid 1. The patient's history of previous treatments with prednisone and triamcinolone, which provided only temporary relief, suggests that a more comprehensive approach is needed. Given the patient's serum IgE level is within normal limits (57.5), this rash may not be an atopic or allergic condition, and therefore, treatment should focus on reducing inflammation and preventing further skin damage. Some key points to consider in the treatment plan include:

• Using systemic corticosteroids at a dose of 0.5–1.0 mg kg-1 daily, with a weaning dose once control is achieved, as recommended for moderate-to-severe disease 1
• Applying very potent topical steroids to lesional skin, which has been shown to be effective in localized or mild disease 1
• Considering the addition of anti-inflammatory antibiotics, such as doxycycline or minocycline, if the patient does not respond to systemic corticosteroids and topical steroids alone 1 The patient should be closely monitored for any side effects and advised to maintain good skin hygiene and avoid potential irritants. It is essential to note that the treatment plan may need to be adjusted based on the patient's response and any underlying comorbidities, and therefore, regular follow-up appointments are crucial to ensure the best possible outcome.

From the FDA Drug Label

PRECAUTIONS THE POTENTIATING ACTION OF HYDROXYZINE MUST BE CONSIDERED WHEN THE DRUG IS USED IN CONJUNCTION WITH CENTRAL NERVOUS SYSTEM DEPRESSANTS Patients should be advised against the simultaneous use of other CNS depressant drugs, and cautioned that the effect of alcohol may be increased QT Prolongation/Torsade de Pointes (TdP) Cases of QT prolongation and Torsade de Pointes have been reported during post-marketing use of hydroxyzine. Acute Generalized Exanthematous Pustulosis (AGEP) Hydroxyzine may rarely cause acute generalized exanthematous pustulosis (AGEP), a serious skin reaction characterized by fever and numerous small, superficial, non-follicular, sterile pustules, arising within large areas of edematous erythema Inform patients about the signs of AGEP, and discontinue hydroxyzine at the first appearance of a skin rash, worsening of pre-existing skin reactions which hydroxyzine may be used to treat, or any other sign of hypersensitivity.

The patient is being started on Vistaril 50 mg for 7 days, then Vistaril 25 mg for 7 days, and hydrocortisone 1%.

• The patient should be warned of the possibility of drowsiness and cautioned against driving a car or operating dangerous machinery while taking Vistaril.
• The patient should be advised against the simultaneous use of other CNS depressant drugs.
• The patient should be cautioned that the effect of alcohol may be increased.
• The patient should be informed about the signs of AGEP and hydroxyzine should be discontinued at the first appearance of a skin rash or any other sign of hypersensitivity 2.
• Hydrocortisone 1% is being used as a topical treatment, and its drug label does not provide information on its use in conjunction with Vistaril 3.

From the Research

Patient Treatment

The patient is being treated with Vistaril 50 mg for 7 days, then Vistaril 25 mg for 7 days, and hydrocortisone 1% for a persistent rash.

• The patient's serum IgE level is 57.5, which may indicate an allergic reaction.
• The patient has been previously treated with prednisone and triamcinolone, which are corticosteroids used to reduce inflammation and suppress the immune system 4, 5.
• Hydrocortisone 1% is a topical corticosteroid that can be used to treat inflammatory skin conditions such as psoriasis and atopic dermatitis 6.

Corticosteroid Treatment

Corticosteroids are commonly used to treat various medical conditions, including allergic reactions and inflammatory skin conditions.

• Systemic corticosteroids, such as prednisone, can be used to reduce inflammation and suppress the immune system 4, 5.
• Topical corticosteroids, such as hydrocortisone 1%, can be used to treat inflammatory skin conditions such as psoriasis and atopic dermatitis 6.
• The potency and duration of corticosteroid treatment can vary depending on the condition being treated and the patient's response to treatment 6, 5.

Pruritus Treatment

The patient's persistent rash may be causing pruritus (itching), which can be treated with various medications and therapies.

• Cutaneous pruritus can be classified into two categories: localized and generalized, and can be caused by various underlying conditions, including systemic diseases and neuropathic disorders 7.
• Treatment approaches for cutaneous pruritus include device-based physical therapies, such as phototherapy, and medications that act on the itch-perception processing pathway 7.
• Vistaril (hydroxyzine) is an antihistamine that can be used to treat itching and allergic reactions, and may be effective in reducing pruritus in this patient 7.