Alison Ehrlich

Contact Dermatitis in the United States: Epidemiology, Economic Impact, and Workplace Prevention

Contact dermatitis in the United States poses a significant public health concern. This article provides a definition of contact dermatitis and its associated risk factors. The authors discuss the epidemiology of occupational contact dermatitis including its incidence and prevalence, and describe how estimates are calculated in the United States. The burden of disease on the individual, and its economic impact and cost to society, are also elucidated. A review of preventive measures to help reduce contact dermatitis in the workplace and an additional section on patch testing concludes the article.

Applications of the Excimer Laser: A Review.

BACKGROUND The 308-nm excimer laser has been approved by the Food and Drug Administration for the treatment of psoriasis and vitiligo. Its ability to treat localized areas has led to many studies determining its potential in the treatment of focal diseases with inflammation or hypopigmentation. OBJECTIVE To review the different applications of the 308-nm excimer laser for treating dermatologic conditions. METHODS AND MATERIALS An extensive literature review was conducted by searching PubMed, MEDLINE, and ClinicalKey to find articles pertaining to dermatologic conditions treated with the 308-nm excimer laser. Articles published that contributed to new applications of the excimer laser were included, as well as initial studies utilizing the excimer laser. RESULTS The outcomes and results were compiled for different dermatologic conditions treated with the excimer laser. CONCLUSION The 308-nm excimer laser has a wide range of uses for focal inflammatory and hypopigmented conditions. Treatment is generally well tolerated, with few adverse reactions. Larger studies and studies evaluating the long-term effects of the 308-nm excimer laser are needed.

Trends in dermatology practices and the implications for the workforce

Background: The American Academy of Dermatology (AAD) practice profile surveys have been conducted for more than a decade to gauge trends in our workforce supply and demand. Objective: To update the trends and current workforce issues for the field of dermatology. Methods: The AAD Practice Profile Survey is sent by both e‐mail and postal mail to a random sample of practicing dermatologists who are AAD members. Results: Shifts are noted in the primary practice setting; fewer dermatologists are in solo practice and more are in group practices than in previous years. Teledermatology use trended upward from 7% to 11% between 2012 and 2014. The implementation of electronic health records increased from 51% in 2011 to 70% in 2014. Limitations: There is potential for response bias and inaccurate self‐reporting. Survey responses collected may not be representative of all geographic areas. Conclusion: The demand for dermatology services remains strong. Shifts in the practice setting may be related to increases in overhead costs that are partially associated with the implementation of technology‐based medical records. Integration of electronic health records and utilization of telemedicine are increasing.

Patch Testing for Evaluation of Hypersensitivity to Implanted Metal Devices: A Perspective From the American Contact Dermatitis Society.

The American Contact Dermatitis Society recognizes the interest in the evaluation and management of metal hypersensitivity reactions. Given the paucity of robust evidence with which to guide our practices, we provide reasonable evidence and expert opinion–based guidelines for clinicians with regard to metal hypersensitivity reaction testing and patient management. Routine preoperative evaluation in individuals with no history of adverse cutaneous reactions to metals or history of previous implant-related adverse events is not necessary. Patients with a clear self-reported history of metal reactions should be evaluated by patch testing before device implant. Patch testing is only 1 element in the assessment of causation in those with postimplantation morbidity. Metal exposure from the implanted device can cause sensitization, but a positive metal test does not prove symptom causality. The decision to replace an implanted device must include an assessment of all clinical factors and a thorough risk-benefit analysis by the treating physician(s) and patient.

Shoe allergic contact dermatitis

Foot dermatitis is a widespread condition, affecting men and women of all ages. Because of the location, this condition may present as a debilitating problem to those who have it. Allergic contact dermatitis involving the feet is frequently due to shoes or socks. The allergens that cause shoe dermatitis can be found in any constituent of footwear, including rubber, adhesives, leather, dyes, metals, and medicaments. The goal of treatment is to identify and minimize contact with the offending allergen(s). The lack of product information released from shoe manufacturers and the continually changing trends in footwear present a challenge in treating this condition. The aim of this study is to review the current literature on allergic contact shoe dermatitis; clinical presentation, allergens, patch testing, and management will be discussed. PubMed and MEDLINE databases were used for the search, with a focus on literature updates from the last 15 years.

Fragrance series testing in eyelid dermatitis.

BackgroundAllergic contact dermatitis is considered one of the most common causes of eyelid dermatitis. In addition to metals and topical antibiotics, fragrances have emerged as a leading source of contact allergy for individuals with this condition. ObjectivesThe objective of this study was to determine the added benefit of including a fragrance tray when patch testing patients presenting with eyelid dermatitis. MethodsDuring a 4.5-year period, all patients with suspected allergic contact dermatitis involving the eyelids were patch tested with both standard and fragrance trays. ResultsOne hundred consecutive patients with eyelid dermatitis were patch tested. Of these patients, 42 (42%) tested positive for 1 or more allergens within the fragrance series. Of these patients, 15 (36%) had no fragrance markers detected on the standard series, and these allergens would therefore have been missed had fragrance series testing not been performed. Overall, fragrance markers within the standard series detected 73.2% (41/56) of cases of fragrance allergy. ConclusionsOur results suggest that there may be a significant benefit to fragrance series testing in patients with eyelid dermatitis. Fragrance tray inclusion in this population may identify additional cases of fragrance allergy that are missed by the standard series.

Biosimilars: potential implications for clinicians

With the expiration of patent protection for several biologics looming, the production of highly similar therapeutic agents has begun to emerge on the pharmaceutical market. These alternative drugs are referred to as biosimilars. Many anticipate that the introduction of these agents will result in a reduction in health care costs, which may create a more affordable biopharmaceutical market and also improve patient access. In contrast to generics, which are exact copies of their original products, biosimilars are not identical to their reference products. Due to concern about the safety and efficacy of biosimilars, separate regulatory approval pathways have been developed and implemented by several countries, including the US and Europe. Europe has led the way in acceptance of biosimilars into mainstream clinical practice. Biosimilars are not generic products and require extensive clinical and nonclinical bioequivalence studies before receiving marketing approval. Not only is there a lengthy developmental process, but also they will likely be required to have postmarketing surveillance and ongoing safety monitoring to keep track of issues that may arise, such as immunogenicity. Although US Food and Drug Administration approved the first biosimilar product in March 2015, physicians remain unfamiliar about their indications.

Lacosamide-induced rash

Cutaneous eruptions and hypersensitivity represent frequently reported side effects of anti-seizure medications. However, these side-effects have rarely been previously reported for lacosamide, a newer-generation anti-seizure medication with a novel mechanism of action. Here, we report a case of diffuse skin eruption in a patient with history of epilepsy soon after initiation of lacosamide. The rash resolved after discontinuation of lacosamide and use of antihistamines and steroids. We also review the information on drug hypersensitivity syndrome.

Environmental Factors Associated with Disease Flare in Juvenile and Adult Dermatomyositis.

Objective The aim was to assess environmental factors associated with disease flare in juvenile and adult dermatomyositis (DM). Methods An online survey of DM patients from the USA and Canada examined smoking, sun exposure, infections, medications, vaccines, stressful life events and physical activity during the 6 months before flares, or in the past 6 months in patients without flares. Differences were evaluated by χ 2 and Fishers exact tests, and significant univariable results were examined in multivariable logistic regression. Residential locations before flare were correlated with the National Weather Service UV index. Results Of 210 participants (164 juvenile and 46 adult DM), 134 (63.8%) experienced a disease flare within 2 years of the survey. Subjects more often reported disease flare after sun exposure [odds ratio (OR) = 2.0, P = 0.03], although use of photoprotective measures did not differ between those with and without flare. Urinary tract infections (OR = 16.4, P = 0.005) and gastroenteritis (OR = 3.2, P = 0.04) were more frequent in the preceding 6 months in those who flared. Subjects who flared recently used NSAIDS (OR = 3.0, P = 0.0003), blood pressure medicines (OR = 3.5, P = 0.049) or medication for depression or mood changes (OR = 12.9, P = 0.015). Moving to a new house (OR = 10.3, P = 0.053) was more common in those who flared. Only sun exposure (OR = 2.2) and NSAIDs (OR = 1.9) were significant factors in multivariable analysis. Conclusion Certain classes of environmental agents that have been associated with the initiation of DM, including sun exposure and medications, may also play a role in disease flares.

Sesquiterpene lactone-related allergic contact dermatitis after exposure to tulip poplar wood and bark.

Sesquiterpene lactones (SLs) are naturally occurring plant compounds that are capable of inducing allergic contact dermatitis (ACD). More than 1000 SL structures have been identified, mostly within the Compositae family of plants, which includes ragweed, feverfew, pyrethrum, chrysanthemum, tansy, and chamomile, among many others. A 59-year-old man was referred to our clinic with a chief complaint of a rash on his eyelids that had manifested 4 times in the last 9 months. The patient stated that the dermatitis first appeared after he began removing bark from trees to make walking sticks from tulip poplar, oak, mulberry, and maple wood. He had previously been prescribed a topical steroid cream, which was only slightly helpful in ameliorating his symptoms, and he reported that the rash would promptly recur after stripping trees. On physical examination, there were erythematous, lichenified plaques with mild scaling on his bilateral upper and lower eyelids, sparing the nasal bridge and extending to the zygomatic prominence on each side. The patient underwent patch testing with an expanded North American standard tray (Chemotechnique Diagnostics, Malmö, Sweden) and samples of tree bark and wood chips. The tested tree components included the following: pine wood, ironwood wood, mulberry bark and wood, holly bark and wood, oak bark and wood, poplar bark and wood, and maple bark and wood. In addition, the polyurethane that he used to seal his walking sticks was tested. At the 96-hour reading, the patient had positive reactions to SL mix (+3), poplar wood (+1), poplar bark (+3), maple wood (+1), and maple bark (+1). Five control patients all tested negative to the same poplar and maple tree components. The patient’s dermatitis resolved with avoidance of poplar and maple wood. Quinones are well-known wood sensitizers that are present in a wide variety of species, including cocobolo, teak, primrose, mahogany, and Brazilian rosewood. Terpenes, phenols, and resins are other components within wood that have also been found to cause ACD. We concluded that our patient likely reacted to SLs (a specific type of terpene joined to a lactone ring) within tulip poplar bark and wood, as supported by his patch-test results and resolution of his dermatitis with avoidance of this wood type. In addition, the SL mix used for testing consisted of equimolar amounts of alantolactone, dehydrocostus lactone, and costunolide, the latter being known to be a component of tulip poplar bark along with several other SLs. Although we are not aware of any SLs that have been isolated from maple wood, several studies have found related compounds such as sesquiterpenes within the leaves of certain maple species. It is therefore possible that the positive reactions to maple wood and bark seen in our patient may have represented SL-induced cross-sensitization to similarly structured terpene compounds. Tulip poplar (Liriodendron tulipifera) is native to eastern North America, where it may grow to heights of 50 m and is known for its numerous pale green to yellow flowers. Other trees known to contain SLs include Magnolia species (within the same Magnoliaceae family as tulip poplar) and bay laurel trees (Laurus nobilis, native to the Mediterranean region). Finally, Frullania species, or liverworts, are a group of nonvascular plants that grow on bark and rocks worldwide and that have caused occupational ACD due to the presence of SLs (Fig. 1).