Faculty Bibliography

BACKGROUND:Allergic contact dermatitis (ACD) remains a significant burden of disease in the United States. Patch testing is the criterion standard for diagnosing ACD, but its use may be limited by reimbursement challenges. OBJECTIVE:This study aimed to assess the current rate of patch test utilization among dermatologists in academic, group, or private practice settings to understand different patch testing business models that address these reimbursement challenges. METHODS:All members of the American Contact Dermatitis Society received an online survey regarding their experiences with patch testing and reimbursement. RESULTS:A "yes" response was received from 28% of survey participants to the question, "Are you or have you been less inclined to administer patch tests or see patients needing patch tests due to challenges with receiving compensation for patch testing?" The most commonly reported barriers include inadequate insurance reimbursement and lack of departmental support. CONCLUSIONS:Compensation challenges to patch testing limit patient access to appropriate diagnosis and management of ACD. This can be addressed through a variety of innovative business models, including raising patch testing caps, negotiating relative value unit compensation, using a fixed salary model with directorship support from the hospital, and raising the percentages of collection reimbursement for physicians.

BACKGROUND: Little is known about the epidemiology of allergic contact dermatitis (ACD) in US children. More widespread diagnostic confirmation through epicutaneous patch testing is needed. OBJECTIVE: The aim was to quantify patch test results from providers evaluating US children. METHODS: The study is a retrospective analysis of deidentified patch test results of children aged 18 years or younger, entered by participating providers in the Pediatric Contact Dermatitis Registry, during the first year of data collection (2015-2016). RESULTS: One thousand one hundred forty-two cases from 34 US states, entered by 84 providers, were analyzed. Sixty-five percent of cases had one or more positive patch test (PPT), with 48% of cases having 1 or more relevant positive patch test (RPPT). The most common PPT allergens were nickel (22%), fragrance mix I (11%), cobalt (9.1%), balsam of Peru (8.4%), neomycin (7.2%), propylene glycol (6.8%), cocamidopropyl betaine (6.4%), bacitracin (6.2%), formaldehyde (5.7%), and gold (5.7%). CONCLUSIONS: This US database provides multidisciplinary information on pediatric ACD, rates of PPT, and relevant RPPT reactions, validating the high rates of pediatric ACD previously reported in the literature. The registry database is the largest comprehensive collection of US-only pediatric patch test cases on which future research can be built. Continued collaboration between patients, health care providers, manufacturers, and policy makers is needed to decrease the most common allergens in pediatric consumer products.

Alopecia areata (AA) is a complication of biologic therapy with several anti-tumor necrosis factor (TNF) inhibitors and efalizumab for the treatment of various autoimmune diseases. We report the case of a 51-year-old woman who developed AA universalis while undergoing treatment with daclizumab, an immunosuppressive biologic therapy, administered for treatment of inflammatory ocular disease. Although immunomodulatory agents that function by interfering with T helper cell stimulation are expected to impede autoimmune-related processes, we believe that daclizumab may be causally related to the development of AA.

A 53-year-old woman presented with a six-month history of non-pruritic, erythematous papules and papular-plaques that were localized to the anterior and lateral aspects of the neck. A biopsy specimen showed elastolysis and granuloma formation, which were consistent with a diagnosis of annular elastolytic giant-cell granuloma. This is one of the few reported cases of this entity that consists predominantly of papular lesions rather than annular plaques.

Chemical leukoderma is defined as an acquired, hypopigmented dermatosis that results from repeated cutaneous application of an agent that destroys epidermal melanocytes in genetically susceptible patients. Chemical leukoderma may develop both at the site of contact with the chemical as well as remotely from the exposure. Avoidance of the causative agent may lead to spontaneous repigmentation, but treatments commonly used in vitiligo, such as narrow-band ultraviolet B phototherapy, PUVA photchemotherapy, or topical immunosuppressants, often are necessary. We present a case of chemical leukoderma secondary to pyrethroid insecticides that has progressed despite avoidance of the agent for over ten years.

Clinical differentiation of dermatophyte infection from dystrophic changes due to psoriasis may be challenging. Typically, potassium hydroxide (KOH) preparations, fungal culture, and occasionally, nail unit biopsy specimens are utilized to help differentiate between the two. These tests are often time-consuming and may yield false-negative results. Increasing regulation of the office laboratory has caused some physicians to forgo this testing, which was previously routine. We investigated the utility of routine histologic examination of nail clippings in differentiating onychomycosis from psoriatic onychodystrophy. Twenty-three distal nail clipping specimens (twelve specimens from patients with onychodystrophy of unknown cause and eleven control specimens from nails with known cause) were evaluated by routine histology and periodic acid-Schiff (PAS) staining. Of the dystrophic cases, four were demonstrated to be onychomycosis by the presence of hyphae on histologic evaluation and by culture, whereas only three of these cases yielded positive results on KOH examination. Eight cases of onychodystrophy were due to psoriasis. Yeast forms were detected on one case of psoriatic onychodystrophy that demonstrated yeast growth on culture. In our study, routine histologic examination with PAS staining was equal to culture and superior to KOH preparation in leading to the correct diagnosis of dermatophyte infection. In addition, the diagnosis of psoriasis of the nail plate was detected accurately by routine histologic examination. Routine histologic examination with PAS staining is a rapid, simple, and reliable test in the evaluation of onychodystrophy

We report a case of vitiligo that occurred during the second month of interferon alpha 2a therapy for chronic active hepatitis C. The patient received the interferon for four months