HPI: This 27 yo woman, whose wedding is August 4th, 2012, presented on July 19th with a one day history of a facial eruption. She has a history of rhus allergy and had been at the beach collecting leaves for an architecture project a couple of days before the onset of symptoms. At the time, she was wearing a bathing suit and a wrap-around towel. The rash first appeared on her face and left lower abdomen. She has a history of acne vulgaris which is quiescent now. She was on prednisone 20 and 10 mg a day for a week, ~ 10 days before this episode.
O/E: July 19th: Marked erythema and induration on left forehead, cheek, chin. Vesicles and small bullae scattered in the area; A few erythematous streaky patches lsft hip. Over the next few days, in spite of treatment the process progressed to involve abdomen, neck and fingers. On July 23, there are new erythematous-bullous areas on the left lower abdomen and hip. (see photos).
Clinical Photos: See below
Therapy:
July 19th: Prednisone 20 mg b.i.d. (her weight is 54 kg). Cool tap water compresses. Hydroxizine 20 - 30 mg hs.
July 21: Because of progression of dermatitis, prednisone increased to 50 mg per day in divided doses. Dome Boro compresses 3 x per day, Silvadene cream because of some erosions at site of bullae. Prednisone is causing her to feel anxious and panicky. Lunesta 1 - 2 mg added for sleep.
July 23: I am surprised that new lesions continue to develop in spite of an adequate dose of prednisone (see photos). Have added a "soak and smear" protocol for body lesions and desoximetasone cream bid for dermatitis on body and once daily for face.
Diagnosis: Severe Allergic Phyto-Contact Dermatitis secondary to rhus. We saw this at onset and in spite of a reasonable dose of prednisone and cool compresses it has progressed. Steroid dose was limited because of CNS symptoms and initially I was reluctant to use topical steroids due to her history of acne; but have just started desoximetasone cream on 7/23. The timeline is important as she is getting married in 12 days. It is odd that this has progressed after what is usually an adequate dose of prednisone, and I am worried that increasing the prednisone may cause more anxiety and insomnia. Most likely this is a severe anamnestic response to urushiol and she may indeed need a higher dose of prednisone or she may not be absorbing it.
Questions:
1) How would you handle the facial erythema?
2) Topical corticosteroids as well as oral steroids can exacerbate acne. Should we add a moderate to strong topical corticosteroid for a few days to suppress erythema?
3) She is anxious and has insomnia secondary to prednisone already. I feel prednisoen is the key to improvement, but am reluctant to push the dose. Your thoughts?
4) Is there a role for topical tacrolimus?
Your suggestions re: diagnosis and management will be appreciated.
Photos:
July 19
July 20
July 21
July 22
July 23
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| New lesions 4 d p start prednisone July 24 Real Improvement Noted Today  7/30 Pretty Much Better  |
What about using cyclosporine as steroid sparing and fast action required.
ReplyDeleteI also agree that topical Tacrolimus or pimecrolimus may be used on face, with fucicort skin cream.
I think we have to be cautious before adding prednisolone further. Prednisolone would have worked at this dose if it is mainly an eczematous process. If you look at the lesions, it is mainly on the left cheek with edema, erythema and blisters formation. The left eye appeared edematous too.
ReplyDeleteConsider superimposed bacterial infection. I would reduce the dose of predisolone instead. Culture and add an oral antibiotic which cover staph. Cephalosporin such as cefuroxime would be useful. Use a mild topical steroids for the face such as desonide cream/ointment.
I am not sure whether we should also consider secondary herpetic infection as well. But I would watch closely for any signs of it and start antiviral if necessary.
Comments by Dr. Obaidat and Dr. Foont are very thoughtful. What would be the difference be between prednisolone and prednisone? I agree with adding an antibiotic with staph coverage. However, I would push the prednisone dose to a minimum of 1 mg/kg, maybe up to 1.5 mg/kg....or the cyclosporine is a great idea.
ReplyDeletefrom JAM: Interesting that the erythema is so confluent on her face...could she have a phytophoto reaction? I assume she is not taking any photosensitizing meds or supplements...Is she staying totally out of the sun?
ReplyDeleteI agree with starting topical steroids in addition to oral especially since she is anxious from the prednisone (and the impending wedding!). Might try an ointment-based steroid like triamcinolone 0.1% BID for her face given how weepy it still looks - might sting less than a cream and could have a more potent effect. My peds Derm mentors have taught me that petrolatum is not comedogenic and I think they're right - so I don't think a vaseline-based ointment will cause acne (though as you said the steroids may). As soon as she starts to turn the corner I do think it's a good idea to consider switching her to tacrolimus for her face, but I'd keep her on 30-40mg daily of PO prednisone until the wedding so she doesn't rebound. We always treat with PO pred for at least 3 weeks in this scenario.
DJE added from a doc who wishes to be anonymous: "Cyclosporine is very fast and effective in suppressing T cell mediated immune responses, and as a short term treatment rather safe, too. Perhaps 5 mg/kg BW? After careful discussion with her, of course
ReplyDeletefrom Brenda Dintiman:
ReplyDeleteI like the neoral )cyclosporine) idea
Rxderm docs have repeatedly shown how they completely turn off contact derm within one to two doses.
She would have done better with IM kenalog also
They also show that this had less side effects and less agitation.
I like the idea if elidel or metro cream.
Is she putting anything else irritating on her face.
Is she on doxycycline for the acne and flushing?
Acute photophytodermatitis usually presents like a surge and I think this patient has passed the top of it (on 21th July, perhaps).
ReplyDeleteIn general, I rather to use 2 shots of triamcinolone for such cases (at days 1 and 21)and believe that side effects are considerably lower in comparison with prednisolone.
It is a good thought to be always cautious about the possibility of drug-induced/aggravated reactions in such cases.
Regarding topical therapies, I doubt if topical calcineurin inhibitors have any effects on this. I prefer a simple soothing emollient.
Her photo on July 24th showed great improvement which confirms that we are in the right direction. Patient is a young lady and I don't expect her to have any hepatic disease which could make differece in using prednisone and prednisolone. I think 50mg per daily is quite reasonable for her condition based upon the weight. An aveeno soak (100% colloidal solution) for 20mins 3-4 times daily with steroid treatment could also relieve the discomfort on the skin lesions. As soon as she turns around the corner, we can change to morning dose only. I agree viral and bacterial cx would be helpful for secondary inf. Hopefully she will keep making good progress. I'll keep her in my thoughts.
ReplyDeletefrom Fran Storrs, Portland, OR: Oh my goodness!!! poor thing. We use prednisone in single AM not bid doses as it is easier to control. With her, would probably have started at 50 mg q-AM. If pretty big would use 60 mg.
ReplyDeleteI would add a potent steroid cream (betamethasone is strong enough) to her face and follow with wet compresses left in place all day. The wet stratum corneum will absorb the steroid much better. Silvadene a very good idea too. The steroid cream will vasoconstrict her and the wet compresses will dry her out as well as increase percutaneous absorption. Stop wet compresses as soon as improvement occurs.
Incredible! She has improved so much with the treatment. We don't see poison ivy dermatitis here and it's really cool to learn that the contact dermatitis can be so severe. Was she treated with wet compress, topical triamcinolone ointment bd and oral prednisolone 40mg daily? It has worked very fast.
ReplyDelete