Page 18 - Journal of Special Operations Medicine - Summer 2015

Oral Steroids for Dermatitis

Andrew D. Fisher, MPAS, APA-C;
Jesse Clarke, EMT-B; Timothy K. Williams, BS

ABSTRACT

Contact/allergic dermatitis is frequently treated inap- care provider with a complaint of erythematous macu-
propriately with lower-than-recommended doses or lopapular rash across his entire posterior thorax and
inadequate duration of treatment with oral and intra- axillary fold. The patient complains that the rash is ex-
muscular glucocorticoids. This article highlights a case tremely pruritic and the areas affected have a constant
of dermatitis in a Ranger Assessment and Selection burning sensation. He first noticed the rash about 3
Program student who was improperly treated over 2 weeks before his visit to the BAS. The rash began with
weeks with oral steroids after being bit by Cimex lectu- a group of 12 to 18 small papules localized to the pa-
larius, commonly known as bed bugs. The article also tient’s right scapula region and has since spread across
highlights the pitfalls of improper oral steroid dosing his entire posterior thorax and axillary folds bilaterally.
and provides reasoning for longer-duration oral steroid The patient denied recent contact with known infectious
treatment. disease or recent travel but endorses contact with a new
domesticated pet dog that correlates with the onset of
Keywords: dermatitis; steroids; bed bugs; military; Cimex his symptoms. The patient’s past medical, surgical, and
lectularius family histories were noncontributory. He also denied
any recent viral infections or immunizations. The pa-
tient’s medical records indicate that all immunization
were up to date. The patient was seen at two other clin-
Introduction
ics, neither of which provided him a definitive diagnosis;
Insect infestations in the US military have been a problem both treated him symptomatically with oral steroids and
since World War I. Presenting symptoms for bed bug antihistamines. The patient states he has short-term re-
1
(Cimex lectularius) bites can include pain and itching, lief (1 to 2 days) but denies any significant benefit from
and at times, are psychologically bothersome. In the previous medications prescribed by the clinics.
2-4
1950s, there was a considerable reduction in bedbug oc-
currences in the United States. Whether from globaliza- Examination of the patient’s skin reveals an asymmetri-
2
tion, increased world travel, or resistance to insecticides, cally distributed erythematous maculopapular rash with
within the past 15 years, there has been a resurgence several papules varying in size from 0.1cm to 1cm. The
of bedbug infestations. 2,5,6 Bed bug bites cause a vari- patient has many excoriated papules that have hemor-
ety of dermatologic conditions ranging from purpuric, rhagic crust without purulence. The erythematous mac-
vesicular, and bullous lesions, to pruritic erythematous ulopapular rash is distributed across the patient’s entire
maculopapular lesions, and to a contact/allergic derma- posterior thorax, axillary folds bilaterally, and on the
titis. Dermatitis is one of the most common medical patient’s right side near the pectoral region. No rash
3,4
complaints within the military. It is not uncommon to appears on any portions superior to the superior por-
1,6
treat contact/allergic dermatitis secondary to bed bug in- tion of the shoulders bilaterally, any portion of the arms
festations with oral and/or parenteral glucocorticoids. distal to the patient’s elbows bilaterally, or any portion
7
While, the literature does not recommend the use of ste- inferior to the patient’s waistline. Diagnostic laboratory
roids for these types of reactions, if it is used, it should evaluation with complete blood count revealed an el-
be a long tapering dose. 2,4,8 Here, we will highlight the evated white blood cell count, which could have been
improper treatment of contact/allergic dermatitis due to explained by the oral steroid use. Additionally, 5mm
improper administration of oral and parenteral steroids. punch biopsy specimens were obtained at four symp-
tomatic locations. The rest of the findings on physical
examination, which included head, eyes, ears, nose, and
Case Report
throat; and his respiratory, cardiovascular, gastrointesti-
A 21-year-old active duty Servicemember initially pres- nal, neurologic, and musculoskeletal systems, were nor-
ents to the Battalion Aid Station (BAS) and his primary mal or unremarkable.

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