Susan Nedorost

A variant of nephrogenic fibrosing dermopathy with osteoclast-like giant cells: a syndrome of dysregulated matrix remodeling?

Nephrogenic fibrosing dermopathy (NFD) is a disorder characterized by dramatic thickening and hardening of skin in the extremities and trunk, which occurs in individuals on dialysis for renal disease. The pathophysiology is unknown. Increased transforming growth factor‐β (TGF‐β) and collagen deposition have been reported in a small group of patients studied by Jimenez et al. 1 We report two patients with NFD and osteoclast‐like giant cells in the fibrotic dermis; one patient also had dystrophic cutaneous calcification. These findings have been seen in a small percentage of NFD patients (estimated 2–5%) and may represent a variant of the disease. The hypothesis of altered matrix dysregulation due to altered TGF‐β, metalloproteinases, and activation of osteoclasts as an explanation for this variant is proposed.

American contact dermatitis society core allergen series.

Evidence for the effectiveness of patch testing and the need for an expanded series that provides experience and evidence-based suggestions for an extended patch testing series are examined in this review. Many of those testing with shorter allergen series are interested in expanding the spectrum of patch testing. The American Contact Dermatitis Society (ACDS) Core Allergen Series Group has arranged a group of suggested allergen groups that can be logically scaled up or down depending on the needs of the patch tester and the community being tested. This is not an ACDS 80 Standard. We suggest a core group of allergens similar to the TRUE Test (SmartPractice, Phoenix, Ariz) with subsequent trays providing a greater breadth of coverage in a logical fashion, with more likely allergens being higher in the tray. For more extensive testing, specialty trays (ie, cosmetics, metals, plant, etc) are recommended.

Patterns of Clinical Management of Atopic Dermatitis in Infants and Toddlers: A Survey of Three Physician Specialties in the United States

OBJECTIVEnTo describe atopic dermatitis (AD) management patterns in children ≤36 months old as reported by pediatricians, dermatologists, and allergists in the US.nnnSTUDY DESIGNnA nationally-representative survey was administered to pediatricians (n = 101), dermatologists (n = 26), and allergists (n = 26). Main outcomes included referrals to health care professionals, suggested/ordered laboratory tests, management approach (dietary, pharmacologic, or combination of both) by age, AD location, and severity.nnnRESULTSnSignificant differences were observed in referrals to healthcare professionals (P < .001). Pediatricians more frequently referred to dermatologists than allergists in mild (52.4% vs 32.0%) and moderate/severe (60.6% vs 38.1%) cases. Dermatologists referred to allergists less frequently for mild (9.1%) than moderate/severe (40.7%) AD cases. Pediatricians (59%), allergists (61.5%), and dermatologists (26.9%) reported treating at least some of their patients with AD with dietary management (infant formula change) alone (with or without emollients). Soy-based formulas were often used. For mild AD, the most commonly reported first-line pharmacologic treatments included topical emollients, topical corticosteroids, and barrier repair topical therapy/medical devices. Over 80% of physicians used a dietary and pharmacologic combination approach. Dermatologists were most likely to manage AD symptoms with a pharmacologic-only approach. AD lesion location influenced pharmacologic treatment in >80% of physicians.nnnCONCLUSIONSnSignificant and distinct differences in AD treatment approach exist among physicians surveyed. Most pediatricians and allergists use formula change as a management strategy in some patients, whereas dermatologists favor a pharmacologic approach. This diversity may result from inadequate evidence for a standard approach. Consistent methods for managing AD are needed.

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.

A Pragmatic Approach to Patch Testing Atopic Dermatitis Patients: Clinical Recommendations Based on Expert Consensus Opinion

Allergic contact dermatitis (ACD) may complicate the clinical course of atopic dermatitis (AD), and patch testing remains the criterion standard for diagnosing ACD. To date, there have been no guidelines or consensus recommendations on when and how to patch test individuals with AD. Failure to patch test when appropriate may result in overlooking an important and potentially curable complicating comorbidity. In this article, we present consensus recommendations regarding when to perform patch testing in the AD patient, best practices, and common pitfalls. Patch testing should be considered in AD patients with dermatitis that fails to improve with topical therapy; with atypical/changing distribution of dermatitis, or pattern suggestive of ACD; with therapy-resistant hand eczema in the working population; with adult- or adolescent-onset AD; and/or before initiating systemic immunosuppressants for the treatment of dermatitis. A suggested patch testing algorithm for AD patients is provided.

Inflamed skin predisposes to sensitization to less potent allergens

BACKGROUNDnIrritant dermatitis, caused by genetic barrier dysfunction in atopic dermatitis or wet work in hand dermatitis, induces innate immune response that might predispose to allergic contact sensitization to less potent sensitizers.nnnOBJECTIVESnWe sought to determine if positive patch test results to less potent allergens are more prevalent in patients with a history of childhood flexural dermatitis or current wet work.nnnMETHODSnWe examined our database of patients presenting to a contact dermatitis clinic tested to potential contact allergens as indicated by their history. Allergens from our most recent standard were studied if they could be classified as weak, moderate, or strong sensitizers based on published data from the local lymph node assay. Patients were stratified by a history of childhood-onset flexural dermatitis as a proxy for atopic dermatitis and by occupation.nnnRESULTSnHistory of childhood-onset dermatitis predisposed to contact allergy to weak sensitizers and wet work to medium-potency sensitizers. Neither predisposed to contact allergy from strong sensitizers.nnnLIMITATIONSnAssociation cannot prove causation.nnnCONCLUSIONSnWe conclude that strong sensitizers do not require wet work or atopy to cause sensitization. Barrier defects associated with childhood eczema and wet work may promote sensitization to weak antigens.

Allergic contact dermatitis Patient diagnosis and evaluation

Allergic contact dermatitis resulting from exposure to a chemical or chemicals is a common diagnosis in the dermatologists office. We are exposed to hundreds of potential allergens daily. Patch testing is the criterion standard for diagnosing the causative allergens responsible for allergic contact dermatitis. Patch testing beyond standard trays is often needed to fully diagnose patients, but not all dermatology practices have access to this testing procedure or these allergens. In order to adequately evaluate patients, physicians must understand the pathophysiology of the disease process and be well versed in the proper evaluation of patients, indications for patch testing, proper testing procedure, and other diagnostic tools available and be aware of new and emerging allergens.

American Contact Dermatitis Society Core Allergen Series: 2017 Update

The American Contact Dermatitis Society Core Allergen Series was introduced in 2012. After 4 years of use, changes in our recommended allergens are necessary. For the updated series, we have reordered the first 4 panels to approximately mirror the current TRUE Test and removed parthenolide, triclosan, glutaraldehyde, and jasmine. Polymyxin B, lavender, sodium benzoate, ethylhexylglycerin, and benzoic acid are new additions to the American Contact Dermatitis Society series.

Effects of occlusion on the skin of atopic dermatitis patients

Background: Atopic dermatitis (AD) may be exacerbated by occlusion from items such as occlusive gloves or textiles, especially if the occlusion is removed suddenly, creating a steep humidity gradient. Most previous studies of occlusion have focused on normal skin. Occlusion has been shown to be beneficial in psoriatic skin, but many atopic patients complain of increased inflammation after occlusion. Objective: To evaluate the response of noninflamed AD skin to occlusion. Methods: Six patients with AD were patch‐tested with occlusive polyethylene wrap and sodium lauryl sulfate (SLS) in standard Finn Chambers taped to noninflamed skin of the back. Cytokine and chemokine messenger ribonucleic acid (mRNA) for interleukin‐8 (IL‐8), interleukin‐1 alpha (IL‐1&agr;), and interleukin‐1 receptor antagonist (IL‐1RA), as well as the 18S rRNA housekeeping gene, was obtained via tape‐stripping the skin and measured using quantitative real‐time polymerase chain reaction. We also measured transepidermal water loss after removal of occlusion. Results: Polyethylene occlusion alone with abrupt removal induced IL‐8 and IL‐1&agr; levels similar to or exceeding that of SLS. IL‐‐1RA was up‐regulated by SLS and occlusion, with SLS showing a stronger response. Conclusion: Removal of occlusion with polyethylene film up‐regulates the inflammatory cytokines IL‐8, IL‐1&agr;, and IL‐1RA in patients with AD. This may explain the worsening of AD with the use of occlusive gloves, athletic equipment, and fabrics.

Allergic contact dermatitis: Patient management and education

Allergic contact dermatitis is a common diagnosis resulting from exposure to a chemical or chemicals inxa0a patients personal care products, home, or work environment. Once patch testing has been performed, the education and management process begins. After the causative allergens have been identified, patient education is critical to the proper treatment and management of the patient. Thisxa0must occur if the dermatitis is to resolve. Detailed education is imperative, and several resources are highlighted. Photoallergic contact dermatitis and occupational contact dermatitis are other considerations a clinician must keep in mind.