Oral corticosteroids for poison ivy dermatitis

Michael McKee and colleagues have performed a valuable service by documenting the finding that osteonecrosis of the femoral head may result from a short course of a moderate dose of corticosteroids in relatively young men.1 However, I question their inference in a subsequent letter to the editor that oral corticosteroids are not an appropriate treatment for poison ivy.2

Poison ivy dermatitis, although self- limiting, may persist for 2 months or more. Intensely pruritic blisters and dermatitis may cover more than 50% of the body surface and involve areas that cause particular discomfort or embarrassment such as the genitals, face, hands and feet. If untreated, poison ivy dermatitis can result in prolonged absence from work and many sleepless nights. Mild to moderate cases can be treated with local therapy, but the only effective treatment for severe cases is systemic corticosteroids. Use of a potentially toxic therapy such as oral corticosteroids may in fact be more appropriate for a self-limiting condition than for a chronic condition that may recur after the therapy is discontinued.

It would be helpful if the incidence of avascular necrosis resulting from corticosteroid therapy could be more precisely defined. Do the authors have any suggestions why avascular necrosis does not seem to develop in women or men outside of the 20–41-year age range following short-term corticosteroid therapy? Are a significant majority of the authors' patients men who are 20–41 years old? Does alcoholism increase the risk of osteonecrosis with short-term corticosteroid therapy? One of their 3 patients who had poison ivy dermatitis was also an alcoholic and did not develop pain from osteonecrosis until 23 months after his oral corticosteroid therapy.1

I continue to prescribe oral corticosteroids for patients with severe progressive poison ivy dermatitis. I continue to warn them of the potential side effects, including the risk of avascular necrosis. Any further information to precisely define the risk would be of great service to my patients.