Toxicodendron Poisoning Treatment & Management

  • Author: Steven L Stephanides, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Apr 19, 2011
 

Prehospital Care

The initial treatment of toxicodendron dermatitis includes using barriers to prevent exposure and washing the affected area as soon as possible after exposure.

  • Barriers: Classic preventative strategies include wearing long sleeves, long pants, and gloves. Vinyl gloves are preferred because they will not absorb the urushiol as readily as leather or fabric glove. Rubber gloves can be permeable to urushiol. A number of commercially available creams are marketed to prevent penetration of urushiol into the skin. The published data on these remedies are limited and conflicting. Although some protective effect is suggested, the degree of protection and the cost-to-benefit ratio are unclear.
  • Washing: Washing exposed areas with copious amounts of water within 20 minutes of exposure has been shown to reduce reactivity. The efficacy of washing appears to decrease over time.
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Emergency Department Care

Treatment can be considered in the following 3 categories: decontamination, topical/symptomatic treatment, and immunomodulation.

Decontamination

Immediate decontamination: Urushiol penetrates the skin and binds to membrane lipids within 10-20 minutes of contact. If the toxin can be removed before this occurs, reaction can be avoided.

Although multiple products are marketed for skin decontamination, they are only slightly more efficacious than soap and water. Copious water is recommended because soaps can spread the urushiol oil around the skin.

It is important to instruct patients to clean their clothes and any other objects that might have been in contact with the oils.

Topical or symptomatic care

Topical preparations for symptomatic relief are the standard care for poison ivy exposure. Domeboro, calamine, oatmeal baths, and Burow solution all have been recommended. To prevent ground oatmeal from caking in pipes, it can be placed in a tied sock before being dropped in the bathtub.

In recent years, a new product (ie, Zanfel) claiming to bind the urushiol resin for a number of days after exposure has been aggressively marketed. Limited data on this product show a mild benefit of up to 6 days after experimental exposure.

A number of herbally based folk remedies have been proposed over the years and are receiving some new attention, although none can be particularly endorsed at this time.[4]

Oral antihistamines can be of some benefit for the relief of pruritus, especially in severe cases with urticarial lesions accompanying the bullae.

Low-dose steroids and topical antihistamines have not been shown to have any beneficial effect.

Oral analgesics occasionally are required for very severe cases, especially as an aid to sleep.

Immunomodulation

Systemic steroids are the standard for severe toxicodendron dermatitis. These generally are given orally, although some authors prefer high-potency steroid creams (fluocinonide or clobetasol propionate applied topically twice a day for a week and then once a day for a week) if started early in the course. Orally, various bursts of prednisone or methylprednisolone are used. These medications should be tapered off for at least 10-14 days.

Early withdrawal of steroid therapy can lead to a recrudescence of the lesions. Therefore, avoid premade dose packs, and emphasize to the patient the importance of finishing his or her course of medication.

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Contributor Information and Disclosures
Author

Steven L Stephanides, MD  Attending Physician, Department of Emergency Medicine, Eisenhower Medical Center

Steven L Stephanides, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Chris Moore, PhD, MD  Medical Director, Department of Emergency Medicine, Virginia Mason Medical Center

Chris Moore, PhD, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT  Associate Clinical Professor; Medical and Managing Director, South Texas Poison Center, Department of Surgery/Emergency Medicine and Toxicology, University of Texas Health Science Center at San Antonio

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Clinical Toxicologists, American College of Emergency Physicians, American College of Medical Toxicology, American College of Occupational and Environmental Medicine, Society for Academic Emergency Medicine, and Texas Medical Association

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Michael Hodgman, MD  Assistant Clinical Professor of Medicine, Department of Emergency Medicine, Bassett Healthcare

Michael Hodgman, MD is a member of the following medical societies: American College of Medical Toxicology, American College of Physicians, Medical Society of the State of New York, and Wilderness Medical Society

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

References

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  2. Gach JE, Tucker W, Hill VA. Three cases of severe Rhus dermatitis in an English primary school. J Eur Acad Dermatol Venereol. Feb 2006;20(2):212-3. [Medline].

  3. Thoo CH, Freeman S. Hypersensitivity reaction to the ingestion of mango flesh. Australas J Dermatol. May 2008;49(2):116-9. [Medline].

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  6. Botanical dermatology: allergic contact dermatitis. Electronic Textbook of Dermatology. Available at http://telemedicine.org/botanica/bot6.htm. Accessed June 16, 2007.

  7. Cardinali C, Francalanci S, Giomi B, et al. Contact dermatitis from Rhus toxicodendron in a homeopathic remedy. J Am Acad Dermatol. Jan 2004;50(1):150-1. [Medline].

  8. Chapel TA, Chapel J. Toxicodendron dermatitis. In: Emergency Medicine - A Comprehensive Study Guide. 4th ed. 1996:1111-1113.

  9. Davila A, Laurora M, Fulton J. A New Topical Agent, Zanfel, Ameliorates Urushiol-Induced Toxicodendron Allergic Contact Dermatitis. Ann Emerg Med. 2003;42(4 supp 1):Abstract no 364; s98.

  10. Epstein WL. The poison ivy picker of Pennypack Park: the continuing saga of poison ivy. J Invest Dermatol. Mar 1987;88(3 Suppl):7s-11s. [Medline].

  11. Epstein WL. Topical prevention of poison ivy/oak dermatitis. Arch Dermatol. Apr 1989;125(4):499-501. [Medline].

  12. Epstein WL, Epstein JH. Plant-induced dermatitis. In: Auerbach PS, ed. Wilderness Medicine. 4th ed. Mosby; 2001:1088-1107.

  13. Oh SH, Haw CR, Lee MH. Clinical and immunologic features of systemic contact dermatitis from ingestion of Rhus (Toxicodendron). Contact Dermatitis. May 2003;48(5):251-4. [Medline].

  14. Orchard SM, Fellman JH, Storrs FJ. Topical substances which prevent poison ivy allergic contact dermatitis. Acta Derm Venereol Suppl (Stockh). 1987;134:103-6. [Medline].

  15. Sasseville D. Clinical patterns of phytodermatitis. Dermatol Clin. Jul 2009;27(3):299-308, vi. [Medline].

  16. Stibich AS, Yagan M, Sharma V, Herndon B, Montgomery C. Cost-effective post-exposure prevention of poison ivy dermatitis. Int J Dermatol. Jul 2000;39(7):515-8. [Medline].

  17. Tanner TL. Rhus (Toxicodendron) dermatitis. Prim Care. Jun 2000;27(2):493-502. [Medline].

  18. Williford PM, Sheretz EF. Poison ivy dermatitis. Nuances in treatment. Arch Fam Med. Feb 1994;3(2):184-8. [Medline].

  19. Wooldridge WE. Acute allergic contact dermatitis. How to manage severe cases. Postgrad Med. Mar 1990;87(4):221-4. [Medline].

 
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Forearm approximately 10 days after exposure to poison ivy in a garden. Note vesicles and linear areas of the rash.
 
 
 
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