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Toxicodendron Poisoning Treatment & Management

  • Author: Steven L Stephanides, MD; Chief Editor: Asim Tarabar, MD  more...
 
Updated: Apr 12, 2016
 

Prehospital Care

Preventive measures for toxicodendron dermatitis includes using barriers. Classic preventive 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 gloves. 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.

The initial treatment of toxicodendron dermatitis is to wash the affected area as soon as possible after exposure. 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 three categories:

  • Decontamination
  • Topical/symptomatic treatment
  • 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.[8] 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.

Zanfel, a soap mixture of ethoxylate and sodium lauroyl sarcosinate surfactants, is a product claimed 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.[9]

A number of herbally based folk remedies (eg, jewelweed[10] ) have been proposed over the years and are receiving some new attention, although none can be particularly endorsed at this time.[11] A study by Abrams Motz and colleagues confirmed that jewelweed mash is effective for preventing development of dermatitis after poison ivy contact, but is less effective than soap.[12] These researchers subsequently confirmed that saponins in jewelweed are responsible for this effect.[13]

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 (up to 3 wks). A study by Curtis and Lewis in 49 patients with severe poison ivy dermatitis found that patients who received a 5-day burst followed by a 10-day taper were significantly less likely to utilize other medications, compared with patients who received a burst regimen only (22.7% vs. 55.6%, P = 0.02). The longer regimen consisted of 5 days of 40 mg oral prednisone daily followed by a  taper of 30 mg daily for 2 days, 20 mg daily for 2 days, 10 mg daily for 2 days, and 5 mg daily for 4 days.[14]

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, 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, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and 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.

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.

Additional Contributors

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

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

Disclosure: Nothing to disclose.

Acknowledgements

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.

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

  2. Leclercq RM. [Severe contact-allergy dermatitis due to poison ivy--a plant that is rarely encountered in The Netherlands; a family history]. Ned Tijdschr Geneeskd. 2005 Jul 23. 149(30):1697-700. [Medline].

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

  4. Rader RK, Mu R, Shi H, Stoecker WV, Hinton KA. Dermoscopy of black-spot poison ivy. Dermatol Online J. 2012 Oct 15. 18(10):8. [Medline]. [Full Text].

  5. Botanical dermatology: allergic contact dermatitis. Electronic Textbook of Dermatology. Available at http://telemedicine.org/botanica/bot6.htm. Accessed: April 11, 2016.

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

  7. Tadjimukhamedov FK, Huang G, Ouyang Z, Cooks RG. Rapid detection of urushiol allergens of Toxicodendron genus using leaf spray mass spectrometry. Analyst. 2012 Mar 7. 137(5):1082-4. [Medline].

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

  9. Davila A, Laurora M, Fulton J, Jacoby J, Reed J, Heller M. 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. Abrams Motz V, Bowers CP, Mull Young L, Kinder DH. The effectiveness of jewelweed, Impatiens capensis, the related cultivar I. balsamina and the component, lawsone in preventing post poison ivy exposure contact dermatitis. J Ethnopharmacol. 2012 Aug 30. 143(1):314-8. [Medline].

  11. Canavan D, Yarnell E. Successful treatment of poison oak dermatitis treated with Grindelia spp. (Gumweed). J Altern Complement Med. Aug 2005. 11(4):709-11. [Medline].

  12. Abrams Motz V, Bowers CP, Mull Young L, Kinder DH. The effectiveness of jewelweed, Impatiens capensis, the related cultivar I. balsamina and the component, lawsone in preventing post poison ivy exposure contact dermatitis. J Ethnopharmacol. 2012 Aug 30. 143 (1):314-8. [Medline].

  13. Motz VA, Bowers CP, Kneubehl AR, Lendrum EC, Young LM, Kinder DH. Efficacy of the saponin component of Impatiens capensis Meerb.in preventing urushiol-induced contact dermatitis. J Ethnopharmacol. 2015 Mar 13. 162:163-7. [Medline].

  14. Curtis G, Lewis AC. Treatment of severe poison ivy: a randomized, controlled trial of long versus short course oral prednisone. J Clin Med Res. 2014 Dec. 6 (6):429-34. [Medline]. [Full Text].

  15. [Guideline] Contact dermatitis: a practice parameter. Ann Allergy Asthma Immunol. 2006 Sep. 97(3 Suppl 2):S1-38. [Medline].

  16. Shofner JD, Kimball AB. Plant-induced dermatitis. Auerbach PS, Ed. Wilderness Medicine. 6th ed. Philadelphia PA: Elsevier Mosby; 2012. 1232-50.

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  19. Tanner TL. Rhus (Toxicodendron) dermatitis. Prim Care. 2000 Jun. 27(2):493-502. [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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