Improving Outcomes

Poison Ivy- Short vs long course of steroids?

When I was a teenager, two friends & I worked for the Parks & Recreation Department in our town. We did things like manage the softball & baseball fields, water town greens, cut grass, etc. Both of my friends, every summer, managed to get some ugly cases of poison ivy. I always remember one of them requiring “the long course” of steroids because “it always came back with only a few days of prednisone.”

This has always sort of stuck with me since I started practicing. Poison Ivy & the like are generally the only time I will write for a steroid taper. I recently reviewed the evidence, and low and behold, found this:

This study compared long taper vs short term fixed dosing for patients greater than 14 years old with “severe” cases of poison ivy defined as having a clear exposure, a rash consistent with poison ivy, PLUS one of the following: 1) rash >20% of body surface area 2) rash on hands, feet, face, or genitals, or 3) involvement of two or more body areas. 27 patients were allocated to the short treatment arm (5 days of 40mg prednisone), and 28 patients allocated to a long taper (30mg x 2 days, 20mg x 2 days, 10mg x 2 days, 5mg x 4 days). One patient in the short treatment arm discontinued treatment due to weight gain, while 3 in the long term taper were lost to follow up and 2 discontinued treatment due to improvement of rash.

While not statistically significant, the mean time to improvement favored the long taper (2.93 days vs 4.42 days), as did mean time to resolution (11.7 days vs 14.63 days), and rate of side effects (3 vs 0). The rate of seeking additional medication to use was statistically significant, favoring long taper treatment with 5 patients using additional meds, vs 15 patients in the short course treatment arm (22.7% vs 55.6%). In the short course, these additional medications ranged from an additional oral steroid prescription in 11 cases (vs 2 additional steroid prescriptions for the long course), as well as calamine lotion, antihistamines, topical hydrocortisone, and other OTC lotions. The NNT with longer tapers to avoid having to take additional medications– 3.

My thoughts: If you’re going to get poison ivy, isn’t it usually on your hands or involve more than 2 body areas? Based on their definition of “severe,” the authors essentially recommend to give oral steroids to the majority of patients with poison ivy who present to the ED. While this seems odd on first glance, then again, almost half of the patients in the short course of steroids bounced back and required an additional oral steroid prescription, so the authors are probably on to something. The numbers are small, but compelling enough that unless patients really put up a fight about having steroids, I would just give them a tapered dose. If they are adamant about only having as short a course as possible, giving them two prescriptions with the second being the taper would seem reasonable.

Oh, and if you’re looking for preventative therapy, Tecnu has the most efficacy (70% protection after exposure), with Goop and Dial being the most cost effective ($0.07 per ounce for both vs $1.25 for Tecnu, with protection after exposure rates of 62% and 56% respectively), though results were not statistically significant from each other, but were statistically significant above placebo.

Happy & Safe Fourth.

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