What is the treatment plan for a 62-year-old male prisoner with a rash and nonspecific skin eruption, currently being managed with reduced Vistaril (hydroxyzine) to 25 mg every evening (QPM) and hydrocortisone cream?

From the Guidelines

For a 62-year-old male prisoner with a nonspecific skin rash (R21), I recommend reducing Vistaril (hydroxyzine) to 25 mg at bedtime for one more week while continuing hydrocortisone cream application for 15 more days, as this approach is consistent with the management of grade 1 dermatologic toxicities, which involve macules/papules covering <10% BSA with or without symptoms, as outlined in the study by 1. This approach is based on the most recent and highest quality study, which provides guidance on the prevention and management of dermatological toxicities related to anticancer agents, and is applicable to this patient's situation. The dosage reduction of Vistaril minimizes potential side effects like sedation and dry mouth, which can be particularly bothersome in older patients. The two-week follow-up timing is appropriate to evaluate whether the rash has resolved or if further treatment modifications are needed, as suggested by the study 1, which recommends reassessing after 2 weeks. Key considerations in this management plan include:

• Gradually tapering the antihistamine to minimize side effects
• Maintaining topical steroid therapy to address inflammation
• Scheduling a follow-up appointment to assess treatment response
• Encouraging the patient to report any worsening of symptoms before the follow-up appointment. It is essential to note that the patient's symptoms and treatment response should be closely monitored, and adjustments made as necessary to ensure the best possible outcome in terms of morbidity, mortality, and quality of life, as emphasized by the study 1.

From the FDA Drug Label

THE POTENTIATING ACTION OF HYDROXYZINE MUST BE CONSIDERED WHEN THE DRUG IS USED IN CONJUNCTION WITH CENTRAL NERVOUS SYSTEM DEPRESSANTS 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 experiencing a rash and other nonspecific skin eruption, and the plan is to reduce the Vistaril dose to 25 mg QPM for one more week and continue with hydrocortisone cream for 15 more days.

• The rash could be a sign of AGEP, a serious skin reaction associated with hydroxyzine.
• Given the presence of a skin rash, it is recommended to discontinue hydroxyzine or exercise caution and monitor the patient closely for signs of worsening skin reaction or other hypersensitivity reactions 2.
• Dose reduction may not be sufficient, and alternative therapy should be considered if signs or symptoms suggest AGEP.

From the Research

Treatment Approach

The decision to reduce Vistaril to 25 mg QPM for one more week and continue with hydrocortisone cream for 15 more days is a treatment approach for the patient's rash and nonspecific skin eruption.

• The use of hydrocortisone cream is a common treatment for inflammatory skin conditions, as discussed in 3.
• Topical corticosteroids, such as hydrocortisone cream, are classified by strength and the risk of adverse effects, and their use should be tailored to the individual needs of the patient 3.

Topical Medications

The treatment plan involves the use of topical medications, which offer great advantages in treating skin diseases, including limited exposure to the drug and minimized systemic effects 4.

• Topical antifungal-corticosteroid combination therapy can be effective in treating superficial mycoses, particularly when an inflammatory component is present 5.
• However, the use of combination antifungal/corticosteroid topicals may be more expensive and less effective than single-agent antifungals, as noted in 6.

Follow-up

The plan to follow up with the patient in two weeks is a reasonable approach to monitor the effectiveness of the treatment and adjust as needed.

• The treatment of superficial fungal infections should be tailored to the individual needs of the patient, taking into account factors such as the type, location, and surface area of the infection, patient age, degree of inflammation, and underlying comorbidities 5.