Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Poison Ivy/Poison Oak Dermatitis
An acute, intensely pruritic vesicular dermatitis characterized by a linear eruption.
I. Etiology
A. Rhus toxins produced by poison ivy and poison oak
B. The eruption is a delayed hypersensitivity reaction to urushiol, the oil in the sap, which is present in the poison ivy and poison oak plants and is released with trauma to the leaves.
C. Dried leaves, stems, and roots and burning vines may release particles, affecting sensitive individuals.
II. Incidence
A. These are the most common contact dermatoses seen in physicians’ offices.
B. Most frequently occurs in the summer but can occur at any time of year
C. Poison ivy is the most prevalent because it grows in all the contiguous states.
III. Communicability
A. Poison ivy or poison oak dermatitis cannot be transmitted to another person. However, if the oil from the plant is on the skin of the affected person, a susceptible person could contract it in that manner.
B. Contact can also occur when a person touches an object that has come in contact with the sap or inhales airborne products, such as from a burning plant.
IV. Subjective data
A. Rash
1. Vesicular
2. Intensely itchy
3. Continues to occur over a period of several days
B. History
1. Playing in the woods; skating on bogs, ponds; camping; fishing; other outdoor activities
2. Weeding, burning brush
3. Previous episode of poison ivy or oak dermatitis
V. Objective data
A. Classic eruption is a vesicular, linear rash, but linear and nonlinear erythematous papules are found as well.
B. Face may be erythematous and edematous.
C. Inspect entire body; rash may be found anywhere on body.
D. Rash commonly found on genitals
1. From exposure to the plant when voiding in the woods
2. From failure to wash hands prior to using bathroom
E. Check for secondary infection or ulceration from scratching.
VI. Diagnosis
A. Diagnosis is generally made by characteristic, intensely pruritic, vesicular rash in a linear distribution.
B. Differential diagnosis
1. Scabies
2. Contact dermatitis from primary irritants: By distribution of rash and history
3. Psoriasis: Dry patches with silvery scales
4. Eczema: By distribution of rash and history
VII. Plan
A. Mild
1. Domeboro soaks
a. Dissolve one packet in 1 pint of cool water.
b. Apply for 20 minutes bid to tid
2. Benadryl: 12.5 to 25 mg tid to qid or
3. Chlor-Trimeton
a. 2 to 5 years: 1 mg every 4 to 6 hours (maximum 4 mg in 24 hours)
b. 6 to 12 years: 2 mg every 4 to 6 hours (maximum 12 mg in 24 hours)
c. Over 12 years: 4 mg every 4 to 6 hours
4. Calamine lotion: Use as needed.
5. 1% hydrocortisone cream qid for inflammation
6. Aveeno oatmeal baths
B. Extensive
1. As above
2. Prednisone: 1 to 2 mg/kg/d in 3 divided doses for 5 days
C. Secondary infection
1. For small area: Bacitracin ointment qid
2. For extensive involvement: Treat as for impetigo with Bactroban or systemic antibiotics.
VIII. Education
A. Rash may appear within hours if very sensitive or a lot of contact with the plant.
1. Rash may occur later on the arms, legs, and trunk than on the face because the skin is thicker, and it takes longer for the urushiol to penetrate.
2. The eruption of the rash also depends on the amount of toxin reaching the skin (i.e., on areas of greater exposure, rash appears sooner).
B. Rash continues to appear over several days on areas where contact was minimal.
C. Domeboro soaks should be used as long as there are blisters and oozing.
D. Use of antihistamine will help break the “itch-scratch” cycle.
E. Vesicular fluid does not spread infection. Child cannot spread it to other parts of the body or give it to anyone else.
F. If contact with poison ivy or poison oak is suspected, immediate scrubbing of areas suspected to have contact may help prevent, or at least modify, the course.
G. Clothing should be washed in hot, soapy water after exposure to remove allergenic resin.
H. Rash may last for 2 weeks.
I. Poison ivy cannot be contracted from an animal per se, but if the urushiol is adherent to an animal’s fur, a person may get it from contact with the animal fur.
J. Barrier creams, such as Hydropel and Stokogard, may decrease incidence if used prior to anticipated exposure.
K. Sensitivity tends to wane with age.
IX. Follow-up
A. Mild: Generally none necessary
B. Extensive: Telephone follow-up after 4 days, prior to discontinuing prednisone
C. Secondary infection: Return to office if suspected.
X. Consultation/referral
A. Extensive dermatitis in a child younger than 2 years
B. Severe reactions (for consideration of desensitization)