Severe Contact Dermatitis with Secondary Bacterial Infection Concerns

Case at a Glance

A 28-year-old male landscaper presented with severe contact dermatitis following occupational exposure to Toxicodendron diversilobum (poison oak) during yard maintenance work. Despite initial corticosteroid treatment, the patient developed worsening symptoms with blistering, inflammation, and progressive spread of lesions.

Patient's Story

The patient, a landscaping professional with known sensitive skin, performed extensive yard work over two consecutive days (July 7-8) while wearing inadequate protective clothing. He was unknowingly exposed to poison oak for approximately 2+ hours daily. Initial symptoms appeared 24 hours post-exposure with erythematous, pruritic lesions on bilateral lower extremities. The patient sought medical attention when lesions began vesiculating and spreading to facial and cervical regions.

Initial Assessment

Physical examination revealed extensive vesiculobullous eruption predominantly affecting the right thigh and knee, with secondary involvement of the left popliteal region. Additional lesions were noted on face and neck. Patient appeared uncomfortable but hemodynamically stable. Vital signs within normal limits. Weight: 130 lbs, consistent with lean body habitus.

The Diagnostic Journey

Clinical presentation and exposure history were consistent with severe allergic contact dermatitis secondary to urushiol exposure. Initial treatment included intramuscular corticosteroid injection and oral prednisone 20mg daily, along with topical triamcinolone acetonide 0.1% cream. Despite treatment initiation, patient reported progressive worsening with increased blistering, inflammation, and concerning bruising around affected areas over subsequent 48 hours.

Final Diagnosis

Severe allergic contact dermatitis (poison oak exposure) with potential secondary bacterial superinfection. Differential considerations include cellulitis or impetigo secondary to compromised skin barrier and possible self-inoculation from scratching.

Treatment Plan

Continue systemic corticosteroid therapy with possible dose adjustment. Initiate empirical antibiotic therapy if signs of secondary bacterial infection develop (increased warmth, purulent discharge, lymphangitis, or systemic symptoms). Recommend cool compresses, topical barrier protection, and strict avoidance of further allergen exposure. Patient counseled on proper protective equipment for future occupational activities.

Outcome and Follow-up

Patient advised to return for urgent evaluation if experiencing fever, spreading erythema beyond current borders, purulent discharge, or red streaking. Close dermatologic follow-up scheduled within 48-72 hours to assess treatment response and monitor for complications. Long-term prognosis excellent with appropriate management, though patient at risk for future severe reactions given demonstrated sensitivity.