Daniel J. Hogan

The prognosis of contact dermatitis

This article reviews the prognosis of contact dermatitis, particularly of occupational contact dermatitis. Most studies document a poor prognosis for occupational and nonoccupational contact dermatitis. The prognoses of occupational and nonoccupational contact dermatitis, irritant contact dermatitis, and allergic contact dermatitis are similar. Only a minority of studies on the prognosis of occupational contact dermatitis have found that a job change by the affected worker leads to clearing of the dermatitis. Dermatologic and nondermatologic factors associated with a poor prognosis are discussed.

Adverse dermatologic reactions to transdermal drug delivery systems.

Transdermal drug delivery systems are marketed in the United States for four different drugs, and others are in various stages of development. Cutaneous side effects occur frequently with these systems and sometimes necessitate discontinuation of therapy. This article will review these adverse reactions.

Long-term Efficacy of Topical Fluorouracil Cream, 5%, for Treating Actinic Keratosis: A Randomized Clinical Trial

IMPORTANCE Topical fluorouracil was demonstrated to be effective in reducing the number of actinic keratoses (AKs) for up to 6 months, but no randomized trials studied its long-term efficacy. OBJECTIVE To evaluate the long-term efficacy of a single course of fluorouracil cream, 5%, for AK treatment. DESIGN, SETTING, AND PARTICIPANTS The Veterans Affairs Keratinocyte Carcinoma Chemoprevention (VAKCC) trial was a randomized, double-blinded, placebo-controlled trial with patients from dermatology clinics at 12 VA medical centers recruited from 2009 to 2011 and followed up until 2013. Our study population comprised 932 veterans with 2 or more keratinocyte carcinomas in the 5 years prior to enrollment. The mean follow-up duration was 2.6 years in both treatment and control groups. INTERVENTIONS Participants applied either topical fluorouracil cream, 5% (n = 468), or vehicle control cream (n = 464) to the face and ears twice daily for up to 4 weeks. MAIN OUTCOMES AND MEASURES This study reports on AK counts and treatments, which were secondary outcomes of the VAKCC trial. Actinic keratoses on the face and ears were counted by study dermatologists at enrollment and at study visits every 6 months. The number of spot treatments for AKs on the face and ears at semiannual study visits and in between study visits was recorded. RESULTS The number of AKs on the face and ears per participant was not different between the fluorouracil and control groups at randomization (11.1 vs 10.6, P > .10). After randomization, the fluorouracil group had fewer AKs compared with the control group at 6 months (3.0 vs 8.1, P < .001) and for the overall study duration (P < .001). The fluorouracil group also had higher complete AK clearance rates (38% vs 17% at 6 months) and fewer spot treatments at 6-month intervals, at study visits, and in between study visits during the trial (P < .01 for all). The fluorouracil group took longer to require the first spot AK treatment (6.2 months) compared with the control group (6.0 months) (hazard ratio, 0.69; 95% CI, 0.60-0.79). The number of hypertrophic AKs was not different between the 2 groups overall (P = .60), although there were fewer hypertrophic AKs in the fluorouracil group at 6 months (0.23 vs 0.41) (P = .05). CONCLUSIONS AND RELEVANCE Our results indicate that a single course of fluorouracil cream, 5%, effectively reduces AK counts and the need for spot treatments for longer than 2 years. TRIAL REGISTRATION clinicaltrials.gov Identifier:NCT00847912.

Cost, utilization, and patterns of medication use associated with chronic idiopathic urticaria

BACKGROUND The literature on chronic idiopathic urticaria (CIU) lacks large-scale population-based studies. OBJECTIVE To characterize an insured population with CIU, including their demographic characteristics and comorbidities. METHODS We conducted a cross-sectional analysis using insurance claims. We included patients with 1 outpatient claim with an International Classification of Diseases, 9(th)Edition, Clinical Modification (ICD-9-CM) code for idiopathic, other specified, or unspecified urticaria (ICD-9-CM 708.1, 708.8, or 708.9) and either (1) another of these claims 6 or more weeks later; (2) a claim for angioedema (ICD-9-CM 995.1) 6 or more weeks from the urticaria diagnosis; or (3) overlapping claims for 2 prescription medications commonly used for CIU. RESULTS We identified 6,019 patients who had claims consistent with CIU. The mean age was 36 years. Fifty-six percent of patients had primary care physicians as their usual source of care, 14% had allergists, and 5% had dermatologists. Allergic rhinitis was diagnosed in 48%, asthma in 21%, other allergy in 19%, and atopic dermatitis in 8%. Sixty-seven percent of patients used prescription antihistamines, 54% used oral corticosteroids (OCSs), 24% used montelukast, and 9% used oral doxepin. Antihistamine users received a mean of 152 days of prescription antihistamines, OCS users 30 days of OCSs, montelukast users 190 days of montelukast, and oral doxepin users 94 days of doxepin. CONCLUSIONS Primary care physicians managed most patients with CIU. Antihistamines were the most common treatment for CIU, although OCSs were frequently prescribed. Thirty days of OCS supply among users may represent multiple steroid bursts each year. Given the known risks of OCSs, identifying other CIU treatments with more favorable safety profiles may be beneficial.

Rhodococcus infection of the skin with lymphadenitis in a nonimmunocompromised girl

A 7-year-old girl had a 4 X 3 X 3 cm nodule on the left wrist with axillary lymphadenopathy. Acid-fast bacilli were seen on a smear from a biopsy specimen of this granulomatous skin lesion. A Rhodococcus species grew on culture. Skin infections caused by Rhodococcus may be more common than the few prior case reports suggest.

HLA typing in polymorphous light eruption

Human leukocyte antigen typing of 41 white patients with polymorphous light eruption (limited concept) showed no significant differences when compared with the typing of 51 white control subjects. We previously found that actinic prurigo, an idiopathic photodermatosis particularly associated with Amerindians, has a positive association with antigens A24 and Cw4 and a negative association with A3. We suggest, on the basis of both laboratory and clinical findings, that polymorphous light eruption (limited concept) and actinic prurigo are two different and distinct diseases.

Histopathology of actinic prurigo.

Actinic prurigo (AP) is an idiopathic familial photodermatosis seen in American Indians. We report on 17 patients: 16 had dermatitis and one had actinic cheilitis. Ten patients had acute dermatitis and six had chronic dermatitis. The histologies of acute AP and polymorphous light eruption (PLE: limited concept) are eczematous and indistinguishable. Both show spongiosis, superficial (and sometimes deep) perivascular lymphocytic infiltrates, and papillary dermal edema. Both also show vacuolar degeneration of the basal layer. In contrast, the chronic lichenified AP lesions are associated with marked hyper-keratosis, acanthosis, elongation of the rete ridges, and tissue repair. The large lymphoid germinal centers in the lamina propria are the main features of the lip histology. Seven biopsies were positive in the basal membrane zone on direct immunofluorescent testing, four were negative, and one was inconclusive. IgM was present in six and C3 in two. These immunofluorescent results are probably not significant. Immunofluorescent testing of the lip was negative. Although it is not possible to distinguish acute AP from PLE histologically, it is possible to differentiate the two conditions when chronic AP changes are present.

Chemoprevention of basal and squamous cell carcinoma with a single course of fluorouracil, 5%, cream: A randomized clinical trial

Importance Keratinocyte carcinoma (ie, cutaneous basal and squamous cell carcinoma) is the most common cancer in the United States. Objective To determine whether topical fluorouracil could prevent surgically treated keratinocyte carcinoma. Design, Setting, and Participants The Veterans Affairs Keratinocyte Carcinoma Chemoprevention Trial was a randomized, double-blind, placebo-controlled trial of topical fluorouracil for chemoprevention of keratinocyte carcinoma. Participants were recruited from May 2009 to September 2011 from 12 Veterans Affairs medical centers and followed until June 30, 2013. Participants were veterans (n = 932) with a history of at least 2 keratinocyte carcinomas in the past 5 years; almost all were white males and the median age was 70 years. Interventions Application of fluorouracil, 5%, (n = 468) or vehicle control cream (n = 464) to the face and ears twice daily for 2 to 4 weeks upon randomization. Main Outcomes and Measures Surgically treated keratinocyte, basal cell, and squamous cell carcinoma risk on the face and ears in the first year after enrollment; and time to first surgically treated keratinocyte, basal cell, and squamous cell carcinoma. The a priori hypothesis was that fluorouracil would be effective in preventing these cancers. Results Of 932 participants (916 men [98%]; 926 white [99%]; median age, 70 years), 299 developed a basal cell carcinoma end point (95 in year 1) and 108 developed a squamous cell carcinoma end point (25 in year 1) over 4 years (median follow-up, 2.8 years). Over the entire study, there was no difference between treatment groups in time to first keratinocyte, basal cell, or squamous cell carcinoma. During the first year, however, 5 participants (1%) in the fluorouracil group developed a squamous cell carcinoma vs 20 (4%) in the control group, a 75% (95% CI, 35%-91%) risk reduction (P = .002). The 11% reduction in basal cell carcinoma risk during year 1 (45 [10%] in the fluorouracil group vs 50 [11%] in the control group) was not statistically significant (95% CI, 39% reduction to 31% increase), nor was there a significant effect on keratinocyte carcinoma risk. However, a reduction in keratinocyte carcinomas treated with Mohs surgery was observed. Conclusions and Relevance A conventional course of fluorouracil to the face and ears substantially reduces surgery for squamous cell carcinoma for 1 year without significantly affecting the corresponding risk for basal cell carcinoma. Trial Registration clinicaltrials.gov Identifier: NCT00847912

Impact of Regulation on Contact Dermatitis

Contact dermatitis is a serious public health and dermatologic concern. The prevalence of contact dermatitis in the United States was estimated to be 13.6 per 1000 population according to the National Health and Nutritional Examination Survey using physical examinations by dermatologists of a selected sample of Americans. The American Medical Care Survey estimated that for all American physicians dermatitis is the second most common dermatologic diagnosis proffered. It is essential that government, industry, and dermatologists work together to enhance regulatory methods to control and prevent contact allergy epidemics. Increased knowledge and awareness of occupational skin diseases by dermatologists and other health care professionals will assist in achieving national public health goals. This article reviews governmental regulations-some helpful for patients and workers and some not helpful for dermatologists in their quest to assist patients with contact dermatitis.

Law of unintended consequences

(PubMed) when using CD34 and CTN or spindle cell proliferation (in place of CTN) still does not reveal these articles. We purposely avoided the remark that we were the first to describe CD34 CTN, but discuss that CD34 is not a recognized marker of CTN. Certainly CTN encompasses many hamartomas that are likely not all included in our article. Because the search engines rely on MeSH (medical subject headings) terms that index articles, we would argue that there is no foolproof way of reviewing literature that guarantees that all articles of the subject are seen by the reviewer (especially if some or many of the articles are not indexed or indexed in a way that reveals themselves with a search such as this). Again, we appreciate Dr Fraitag’s inclusion of the rare medallion-like dermal dendrocyte hamartoma as a cutaneous CD34-positive nonvascular fibrotic tumor, which is likely a poorly recognized variant of CTN.