CYCLOSPORIN USED TO TREAT ALLERGIC CONTACT DERMATITIS ------------------------------------------------------------ Saw a guy Friday with extensive poison ivy contact derm on the face, left arm and penis - and a bad history of peptic ulcer disease, so prednisone was not a good idea. Gave him cyclosporine 200 mg bid over the weekend and he had improved greatly when I saw him Monday. In a few days he'll cut back to 100 mg bid, the stop the CyA in a couple of weeks. Got great before and after photos. I'd prefer CyA too if I had bad poison ivy, even though I've got no Hx of ulcers. My big fear is avascular necrosis of bone (not common, but I if happened to me it would be a disaster.) KC Smith MD FRCPC ----------------- Had a lady with a lot of poison ivy on the arms and legs do well with CyA 200 mg bid for a week then 100 mg bid for another week. She's read the prodnisone handout and the CyA handout, and she's glad she got CyA (for her, cost is no object). KC Smith MD FRCPC ----------------- Who is paying for all the CyA? In the states I'd estimate the cost of drug at about $150 to $200. That's a lot for a questionably documented toxicity of steroids. Mark Ling, M.D., Ph.D. ---------------------- CyA isn't exactly non-toxic. Nephrotoxicity, hepatic toxicity, hypertension, systemic immunosuppression that can result in opportunistic infection, etc. I think I'll stick with topical steroids. Rick Sharpe ----------- Drug plans pay for it, or I have some that patients give me if they don't need it and I pass it along to those who need it. We've had some bad lawsuits about avascular necrosis (AVN) here in Canada (luckily none against me) and we're spooked. AVN can happen even after a few weeks of prednisone, and is more common above 30 mg / day, in the obese, alcoholics, the very active (who put more stress on their joints), and in those with Raynaud's. AVN is thought to result from obstruction of blood flow out of the bone in the joint, because the amount of fat in the bone increases and with nowhere to go it compresses the vessels, and perhaps there is also an element of vasospasm. After hearing about the possible effects of prednisone patients who can afford it often opt for a short course of CyA. Its cheaper than a total hip! See the premier issue (came out last month) of The Canadian Journal of Dermatology and Dermatologic Surgery (edited by Dr. Dan Sauder) for an excellent review of corticosteroid complications by Dr. Robert Lester. KC Smith MD FRCPC ----------------- We all agree that CyA can certainly be a problem if used for long periods of time - but for a couple of weeks it is remarkably devoid of problems, and is a lot better tolerated and (in my view) safer than 50 mg / day of prednisone. In my experience topical corticosteroids (even under occlusion) are just not adequate for a bad poison ivy. If YOU had a nasty poison ivy would you: - suffer for 3 weeks - use Temovate, and still suffer for 3 weeks - take prednisone 50 mg / day for 10 days, then 25 mg day for 10 days and accept the risk of AVN (which for a derm who has to be up seeing patients all day and operating would be a disaster), and the risks of psychological disturbance and GI problems while taking prednisone. - take CyA 200 mg bid for 10 days, then 100 mg bid for 10 days, see your skin clear up in 2-4 days, and feel fine (but have your drug plan be out a couple of hundred bucks)? Give me a short course of CyA any day in preference to a short course of prednisone (God forbid that I should get a shot of Kenalog 40 - no way to control absorption kinetics, and no way to reverse it if severe psych effects). KC Smith MD FRCPC ----------------- Let me clarify that I don't automatically reject CyA for rhus dermatitis as outrageous from a medical standpoint, rather that for now in the US healthcare environment it seems unlikely to catch on as a common approach. While I also agree fully with Rick Sharpe that CyA is not a non-toxic drug, I am also aware that systemic steroids can be highly toxic, and that topical steroids sometimes just don't do the job for bad cases. It would be neat to see a trial someday which compares the two regimens, although since the major toxicity you mention, AVN, takes decades to develop in some cases I guess it will never be definitively answered. BTW, regarding the AVN issue, I have never to date been impressed with the data supporting the association of AVN with short courses of steroids, but I'm always willing to learn. Mark Ling, M.D., Ph.D. ---------------------- I agree with the risk of AVN..I don't believe it has been described with topical steroids. Rick Sharpe ----------- Would someone please post the frequency of AVN after a short course of systemic steroids? It was my impression that this is an unusual if not rare complication with short courses less than 3 weeks. Also, does the specific type of corticosteroid make any difference in the incidence statistics? Walter H. Wood, M.D. --------------------