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recommend topical treatment alone for mild cases of 4. Heukelbach J, Hengge UR. Bed bugs, leeches and hookworm
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for moderate to severe cases. The systemic treatments 7. Goddard J, deShazo R. Bed bugs (Cimex lectularius) and clini-
20
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listed by the American Dermatological Association in- 8. Habif TP. Habif’s clinical dermatology: a color guide to diag-
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10. Heymann WR. Bed bugs: a new morning for the nighttime
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11. Amodt ZT. Identification and management of bed bug infes-
Few studies exist that define best practices for oral ste- tation in austere environments. J Spec Oper Med. 2013;13:
roids with allergic dermatologic conditions. Some of the 6–11.
more-cited publications report on exposure to Toxiden- 12. Alsaad KO, Ghazarian D. My approach to superficial inflam-
dron (poison ivy, sumac, oak), and even those do not matory dermatoses. J Clin Pathol. 2005;58:1233–1241.
provide consensus for the provider on when the condi- 13. Peroni A, Chiara-Colato C, Schena D, Girolomoni G. Urti-
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Based on the literature and cited publications, it is 14. Leverkus M, Jochim RC, Schad S, et al. Bullous allergic hy-
recommended that the use of oral glucocorticoids for persensitivity to bed bug bites mediated by IgE against sali-
dermatitis-related illnesses should be reserved for only vary nitrophorin. J Invest Dermatol. 2006;126:91–96.
severe cases (greater than 20% body surface area) and 15. Epstein WL, Epstein JH. Plant-induced deramtitis. In: Auer-
bach PS, ed. Wilderness medicine. 4th ed. St Louis, MO:
should be prescribed in a tapering dose to be taken over Mosby; 2001.
15 to 21 days. It is the opinion of the authors that the 16. Usatine RP, Riojas M. Diagnosis and management of contact
liberal use of oral and IM glucocorticoids for contact/ dermatitis. AFP. 2010;82:249–255.
allergic dermatitis is unwarranted in most cases and these 17. Saladin KS, Sullivan S, Gan C. The endocrine system. In: Sala-
patients should be treated with topical glucocorticoids din KS, ed. Anatomy & physiology: the unity of form and
function. 7 ed. New York, NY: McGraw-Hill Higher Educa-
and/or an antihistamine. In the case of the 21-year-old tion; 2014:630–661.
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bites, we concluded that there was a high probability adrenal axis in neuroendocrine responses to stress. Dialogues
that the patient had developed rebound dermatitis due Clin Neurosci. 2006;8:383–395.
to the improper administration of oral glucocorticoids 19. Lloyd M. Philip Showalter Hench. Rheumatology. 2002;41:
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administered at the previous two clinics the patient at- 20. Contact dermatitis: basic dermatology curriculum. American
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21. Curtis G, Lewis AC. Treatment of severe poison ivy: a ran-
domized, controlled trial of long versus short course oral
Acknowledgments prednisone. J Clin Med Res. 2014;6:429–434.
22. Buttaravoli P, Leffler SM. Toxicodendron (Rhus) allergic con-
The authors would like to thank Todd Kielman, PA-C, tact dermatitis. 2012:740–745.
MAJ Chris Cordova, PA-C, LTC Mike Szczepanski,
MD, and Paula Barton Mann, BS, PharmD, RPh, JD,
CHC, CHPC, for reviewing the manuscript and for their
valuable comments. MAJ Fisher is the regimental physician assistant for the
75th Ranger Regiment, Fort Benning, Georgia. E-mail:
andrew.d.fisher@soc.mil.
Disclosures
The authors have nothing to disclose. SPC Clarke is a medic assigned to the 75th Ranger Regi-
ment Pre-Special Operations Combat Medic Program, Fort
Benning, Georgia.
References
Mr Williams is a recent graduate of Columbus State Univer-
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3. Delaunay P, Blanc V, Del Giudice P, et al. Bedbugs and infec-
tious diseases. Clin Infect Dis. 2011;52:200–210.

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