Oral Prednisone Dosing for Severe Contact Dermatitis
For severe contact dermatitis affecting more than 20-30% of body surface area, start oral prednisone at 0.5-1 mg/kg/day and taper over a minimum of 2-3 weeks to prevent rebound dermatitis. 1, 2
Initial Dosing Strategy
- Start prednisone at 0.5-1 mg/kg/day for extensive or severe contact dermatitis, particularly when affecting more than 20-30% of body surface area 1, 3
- Administer as a single morning dose prior to 9 am to minimize adrenal suppression, as this aligns with the body's natural cortisol peak between 2-8 am 4
- Take with food or milk to reduce gastric irritation 4
- Consider antacids between meals when using large doses to prevent peptic ulcers 4
Critical Duration and Tapering Protocol
The most common and dangerous pitfall is prescribing courses shorter than 2 weeks, which leads to severe rebound dermatitis. 1, 2, 5
- Minimum treatment duration: 2-3 weeks with gradual taper 1, 2, 3
- For severe rhus (poison ivy) dermatitis specifically, taper over 2-3 weeks to prevent rebound 3
- Begin tapering only after achieving disease control, using small dose decrements at appropriate intervals 1
- Never abruptly discontinue therapy—gradual withdrawal is essential regardless of treatment duration to prevent adrenal suppression 2, 4
When to Use Systemic vs. Topical Therapy
Systemic steroids are indicated when:
Topical steroids remain first-line for:
Expected Clinical Response
- Relief typically occurs within 12-24 hours of starting systemic steroids for extensive allergic contact dermatitis 3
- Monitor for satisfactory response over a reasonable period; if inadequate, discontinue prednisone and consider alternative therapy 4
Short-Term Adverse Effects to Monitor
- Hypertension, glucose intolerance, gastritis, and weight gain 1, 2, 7
- Consider dietary salt restriction 4
- Monitor blood pressure and glucose, particularly in patients with pre-existing conditions 1
Long-Term Risks (if therapy extends beyond intended duration)
- Decreased bone density, adrenal suppression, and emotional lability 1, 2, 7
- Avoid long-term or chronic intermittent use of systemic corticosteroids for any dermatologic condition 2, 7
Special Populations
Patients with History of Skin Conditions
- Rule out other etiologies (infection, other drug reactions, systemic disease) before attributing symptoms to contact dermatitis 6
- Consider dermatology referral if autoimmune skin disease is suspected or if treatment fails 6
- Rare cases of systemic contact dermatitis from oral corticosteroids themselves have been reported in patients with topical corticosteroid allergy 8
Pregnant Patients
- Avoid all antihistamines if possible, especially during first trimester 1, 7
- Weigh risks vs. benefits of systemic steroids carefully in pregnancy 1
Children
- Generally should not receive systemic steroids for dermatitis unless required to manage comorbid conditions 1, 2, 7
Adjunctive Measures
- Identify and eliminate the causative allergen or irritant—this is essential for preventing recurrence 1, 3
- Apply emollients regularly to maintain skin hydration 1
- Consider oral antihistamines (cetirizine 10 mg daily, hydroxyzine 10-25 mg QID) for pruritus control 6, 1
- If diagnosis or specific allergen remains unknown after treatment failure, perform patch testing 3
Dosage Adjustments
- Dosage requirements are highly variable and must be individualized based on disease severity and patient response 4
- Adjust dosing for changes in clinical status, disease exacerbations, or exposure to stressful situations 4
- If long-term therapy becomes necessary (which should be avoided), consider alternate-day therapy to minimize HPA axis suppression 4, 9