Marcella Aquino

The Role of Contact Dermatitis in Patients with Atopic Dermatitis

Because both atopic dermatitis (AD) and contact dermatitis (CD) are characterized by a similar morphologic appearance and similar distribution of skin involvement, the diagnosis of CD in AD has been difficult. Historically, it was thought that patients with AD were unable or less likely to develop CD due to various studies in which patients with AD stimulated with strong allergens failed to develop sensitization at rates similar to patients without AD. However, more recent evidence from the United States and Europe has shown that patients with AD have similar if not higher rates of positive patch test results to common contact allergens, including metals and fragrance, than those patients without AD. In this review, we highlight evidence for and against the role of contact allergy in patients with AD and seek to give clinically relevant management recommendations for the evaluation of CD in the patient with AD.

Systemic Contact Dermatitis and Allergy to Biomedical Devices

Systemic contact dermatitis (SCD) refers to a skin condition where an individual who is cutaneously sensitized to an allergen will subsequently react to that same allergen or a cross-reacting allergen via the systemic route. It occurs to allergens including metals, medications, and foods. There has been recent interest in metal allergy as it relates to the implantation of devices such as orthopedic, dental, cardiac, and gynecologic implants. This review will briefly address all causes of systemic contact dermatitis with a special and expanded focus on metal implant allergy. We present literature on SCD to various metal biomedical devices, patch testing for diagnosis of metal allergy pre and post implantation and treatment.

A multi-center, retrospective review of patch testing for contact dermatitis in allergy practices

BACKGROUND Studies assessing patch testing (PT) in allergy practices are limited. OBJECTIVES To determine whether PT results using a limited panel of allergens such as in the Thin-Layer Rapid-Use Epicutaneous Test (TT) as compared with an expanded panel, such as the addition of supplemental allergens (North American Contact Dermatitis [NACD] Panel, Dormer Cosmetics, hairdressing series, corticosteroid series, and personal products) will miss a significant number of positive PTs. To compare our PT results with published data from dermatology practices. METHODS This is a 5-year multicenter retrospective chart review of PT at 3 separate allergy practices. RESULTS Four hundred twenty-seven patients (mean age, 49.8 years) were patch tested. Eighty-two percent were female; 54% reported an atopic history. Of the standardized allergens, the 5 most common positives were nickel sulfate, fragrance mix I, p-phenylenediamine (PPD), thimerosal, and cobalt chloride. Two hundred eighteen (56.9%; 95% CI = 51.9-61.8%) patients were positive to at least 1 TT allergen. Ninety-eight (25.6%; 95% CI = 21.5-30.2%) patients were positive to both a TT and a supplemental allergen. Forty-eight (12.5%; 95% CI = 9.6-16.2%) patients were negative to a TT allergen but positive to a supplemental allergen. CONCLUSION Positive allergens would have been missed in 12.5% of patients when evaluating with TT allergens alone, whereas 25.6% would be partially evaluated. Patch test performance characteristics for these allergy practices appear to parallel that seen for dermatology. The TT remains an adequate screening tool in an allergy practice, but a more comprehensive panel may be needed to fully evaluate contact dermatitis.

Current Strategies in Treating Severe Contact Dermatitis in Pediatric Patients

Allergic contact dermatitis in children is underdiagnosed and undertreated, and its incidence is increasing. Appropriate history taking and the suspicion for allergic contact dermatitis is essential, and patch testing remains the gold standard in diagnosis. Avoidance of the offending allergen, once identified, is the first goal of treatment. Medical therapies include topical corticosteroid and topical immunomodulators. In severe cases, oral corticosteroids or immunomodulators are utilized, although prospective randomized trials for the treatment of this disease in children are lacking. A PubMed literature search was performed to identify publications on allergic contact dermatitis in the pediatric population with the keywords: dermatitis, children, allergic contact dermatitis, pediatrics, contact hypersensitivity, contact allergy, treatment, and management. This review will address the major principles behind the diagnosis and management of this disease in the pediatric population, and highlight useful strategies that may result in improved treatment of this condition.

Anaphylaxis in the community setting: determining risk factors for admission

BACKGROUND Although the identification and management of anaphylaxis in an emergency department setting has been well studied, our understanding of the risk factors for admission in a community-based hospital is lacking. OBJECTIVE To determine the demographics and the predictors of hospitalization, in patients presenting with anaphylaxis to a community-based emergency department (ED). METHODS We performed a five-year retrospective chart review of all patients seen in the ED of Winthrop University Hospital, a community-based institution, with an International Classification of Diseases, 9(th)Edition code related to anaphylaxis. RESULTS Fifty-eight visits met inclusion criteria, of which 34% resulted in hospital admission (95% CI: 22-48%). Univariate predictors for admission included (1) the involvement of 2, 3, and 4 organ systems (26%, 55%, and 75%, respectively; P < .02); (2) gastrointestinal symptoms vs no symptoms (59% vs 24%, P < .02); (3) non-sting (ingested and other allergens) vs insect sting allergen (50% vs 12.5%, P < .005); and (4) a history of an ED visit for anaphylaxis vs none (67% vs 30%, P < .05). Multivariate analysis (logistic regression) confirmed non-sting allergens (p < 0.02) and number of organ systems involved (P < .05) as independent predictors of hospitalization. CONCLUSION In our study population, the involvement of multiple organ systems, particularly gastrointestinal involvement, a history of ED visits for anaphylaxis, and involvement of ingested or other allergens (non-sting) demonstrated higher admission rates.

Clinical evaluation and treatment of chronic urticaria.

Abstract Chronic urticaria is a common disease characterized by recurrent pruritic wheals with surrounding erythema for > 6 weeks. It is associated with a significant health care burden and affects patient quality of life. The etiology of chronic urticaria is often difficult to elucidate; however, known etiologies include autoimmune urticaria, physical urticarias (eg, cold, cholinergic, and delayed pressure urticaria), and idiopathic urticaria. The etiology is unknown in many patients, leading to a diagnosis of chronic idiopathic urticaria. The diagnosis of chronic idiopathic urticaria can be challenging for the primary care physician because of the diseases chronic symptoms. Diagnosis requires a detailed patient history and comprehensive physical examination, with additional testing tailored to the patients history. Effective treatments include antihistamines, leukotriene receptor antagonists in combination with antihistamines, and oral immunomodulatory drugs, including corticosteroids, cyclosporine, dapsone, hydroxychloroquine, and sulfasalazine. Newer experimental therapies include intravenous immunoglobulin and omalizumab. This article reviews the pathophysiology, diagnosis, and treatment of chronic urticaria.

Educational and process improvements after a simulation-based anaphylaxis simulation workshop

Anaphylaxis is frequently underdiagnosed and mismanaged in the inpatient and outpatient setting.1 Even when anaphylaxis is recognized early, epinephrine administration is often delayed or not given at all.2 Epinephrine is the first-line medication for anaphylaxis, and delayed administration is a risk factor for fatal anaphylactic reactions.3 Therefore, it is important that health care professionals are educated appropriately in anaphylaxis management. Studies have demonstrated that hands-on practice offered by case simulations is more effective than standard classroom instruction for emergency situational training.4e6 Simulations allow health care professionals to practice crises management and teamwork skills to increase confidence in life-threatening emergencies, such as anaphylaxis.5 Direct observation during simulations also helps to uncover technical errors.7 Because of undertreated anaphylactic reactions in our institution, we were motivated to identify knowledge gaps and educate health care professionals on anaphylaxis recognition and management through a simulation with a wireless patient simulator. The primary outcome was to determine whether participants recognized and treated anaphylaxis appropriately. Workshop participants (n 1⁄4 72) included nurses, midlevel health care professionals (nurse practitioners, physician assistants), and physicians in the Division of Hematology and Oncology, Winthrop University Hospital, Mineola, NY. This population was targeted because they administer chemotherapy through an induction of tolerance protocol in chemotherapy-hypersensitive patients and are likely to have encountered or will encounter anaphylactic reactions. The simulation involved SimMan3G (SM) (Laerdal Medical Corporation, Wappingers Falls, New York), a wireless patient simulator that developed wheezing, urticaria, and hypotension while receiving the seventh dose of carboplatin. A scenario algorithm was implemented whereby SM’s clinical condition deteriorated as the case progressed without epinephrine administration (ie, lightheadedness, decreased blood pressure [BP], decreased oxygen saturation [SpO2]). The workshop also included an anaphylaxis PowerPoint presentation. Participants were divided into 14 groups. Their recognition and treatment of anaphylaxis were assessed by an allergy fellow and attending physician, who used a checklist of specific medications and interventions (Table 1). Participants were also assessed on teamwork skills (ie, defined roles, effective communication). Before the simulation, 90% of participants reported confidence in epinephrine administration during anaphylaxis. However, only 48% reported using epinephrine in prior anaphylactic reactions at work. During the simulation, 6 of 14 groups (43%) did not administer epinephrine as the first-line medication, despite recognizing that SM was having an anaphylactic reaction. In these groups, epinephrine was administered when SM was hypotensive (mean BP, 70/40 mm Hg), hypoxic (mean SpO2, 79% on oxygen) and minimally responsive. Antihistamines and corticosteroids were given before epinephrine. Three groups used the autoinjectable epinephrine (AIE) pen incorrectly (upside down, injected in arm vs lateral thigh). One group used the wrong concentration of epinephrine (1:10,000 vs 1:1,000). All 14 groups correctly stopped the infusion as the first step on recognizing that SM was having an anaphylactic reaction.

Author response. Anaphylaxis in the community setting: determining risk factors for admission--the role of asthma.

To the Editor: We read with interest the recent article by Steele et al on anaphylaxis in a community setting.1 The authors identified predictors of hospitalization in patients with anaphylaxis who presented to the emergency department of their community hospital. Steele and colleagues are to be commended for addressing the paucity of literature on predictors of anaphylaxis hospital admissions. The authors cited our study of hospitalizations for anaphylaxis in Florida.2 They state in their discussion that our study, “.found a history of asthma to be predictive of hospitalization for anaphylaxis.”1 We thank the authors for acknowledging our work. However, our study was not designed to identify predictors of hospitalization. In our paper we studied only inpatients (n1⁄4 464 adults and children) who were discharged in 2001. We did not access data from emergency departments throughout Florida. Asthma is mentioned briefly in the results section of our paper.2 We reported a prevalence of asthma of 6.5% (30/464) among the adult and pediatric patients hospitalized with an anaphylaxis code. Nine of those 30 patients with asthma had a principal discharge diagnosis of anaphylaxis triggered by food. According to federal surveillance data for Florida (obtained by telephone interviews) for the year 2001, the prevalence of adults who have ever been told they have asthma was 9.9%, whereas the prevalence of adults who have been told they currently have asthma was 5.8%.3 Equivalent data for children are not readily available to us. For this letter we reanalyzed our Florida anaphylaxis hospital inpatient discharge database and excluded the records of patients under the age of 18 years to compare the prevalence of asthma in our adult patients hospitalized for anaphylaxis with the general population estimates from the federal surveillance system. Of the 415 adults in our study, 23 had International Classification of Diseases, 9th Revision-Clinical