Faculty Bibliography

Rationale: Carrying a penicillin allergy label is associated with increased healthcare costs and adverse events. De-labeling a penicillin allergy can optimize antimicrobial stewardship and improve patient care.
Method(s): We performed an IRB-approved retrospective study of patients over 11 years-old, who were de-labeled of penicillin allergy (negative skin testing and aminopenicillin oral challenge) in our clinic between May 2019 and May 2022. Patients had their penicillin allergy removed from our electronic medical record (EMR) and were given a wallet card denoting results. A letter with fax confirmation of receipt was sent to both primary care physician and pharmacy. EMR review and phone interviews with patients and pharmacies were subsequently conducted to determine penicillin allergy status and antibiotic prescribing patterns.
Result(s): A total of 78 charts were reviewed: 68 underwent phone interviews, 9 were lost to follow up, and 1 was deceased. From these charts, 77 (99%) remained de-labeled in our EMR, whereas 24 (31%) had an active penicillin allergy listed in their pharmacy. Out of 68 patients interviewed, 66 (97%) recalled a negative penicillin allergy result, 30 (44%) took penicillins since de-labeling, 31 (46%) were not prescribed penicillins, 4 (6%) avoided penicillins, while 3 (4%) reported unknown antibiotic use.
Conclusion(s): This study demonstrates that our pencillin de-labeling protocol is effective in maintaining a non-allergic status and allowing for subsequent penicillin administration. However, the discrepancy in allergy records between our EMR and patients' pharmacies exemplifies the need to identify barriers in universally de-labeling patients.
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OBJECTIVE:The objective of this article is to provide an overview and describe typically encountered skin contact allergens implicated in allergic contact dermatitis (ACD). DATA SOURCES/METHODS:Published literature obtained through textbooks, online PubMed, and Google Scholar database searches, author photography, and adapted figures were used. STUDY SELECTIONS/METHODS:Studies on the evaluation of ACD and specific skin contact allergens were selected, with a focus on original research articles and clinical reviews. RESULTS:Major classifications of common contact allergens include the following: (1) fragrances, (2) preservatives, (3) excipients, (4) rubber chemicals, (5) textile dyes, (6) topical medications, and (6) metals and other biomedical device components. The dermatitis distribution can aid in identifying the suspected contact allergen culprit. Certain contact allergens have features that are important to consider in the patch testing (PT) interpretation; these include possible irritant reactions, false-negative reactions or missed detection, and delayed reactions. Fragrances, preservatives, and excipients are culprits in personal products and facial or neck dermatitis. Patch testing with fragrances, preservatives, and patient-supplied products requires careful interpretation. Hand or foot dermatitis may be attributed to rubber chemicals or textile dyes. The management of topical corticosteroid contact allergy is guided on the basis of structural group classifications. Metal sensitization has been associated with dermatitis or biomedical device complications. CONCLUSION/CONCLUSIONS:Each skin contact allergen has unique characteristics with regard to the dermatitis clinical presentation and potential PT nuances. These features are critical to recognize in the evaluation of ACD and PT interpretation and clinical relevance, leading to an accurate diagnosis.

PURPOSE OF REVIEW:COVID-19 (coronavirus viral disease 2019), due to the novel SARS-CoV-2, may present with different types of cutaneous manifestations of varying pathophysiology. During the ongoing pandemic, publications reporting dermatologic findings in COVID-19 continue to emerge. RECENT FINDINGS:Cutaneous vasculopathy and microthrombus-related changes including acral and sacral lesions, retiform purpura, livedo reticularis, and cutaneous vasculitis are notable findings in adult patients. Other exanthems include urticaria or angioedema, morbilliform/maculopapular exanthems, erythema multiforme, and vesicular eruptions. Increased recognition of these findings, especially those consistent with cutaneous microthrombi or vasculitis, is of particular importance. Additionally, occupational dermatologic disease related to extended personal protective equipment (PPE) use, such as skin damage and irritant or allergic contact dermatitis (ACD), represents another emerging problem amidst the pandemic. In this review, we highlight the various cutaneous manifestations associated with COVID-19 in adult patients and occupational dermatitis in health care workers (HCWs) caring for this patient population.

BACKGROUND:Severe asthma (SA) often requires subspecialist management and treatment with biologic therapies and/or maintenance systemic corticosteroids (mSCS). OBJECTIVE:To describe contemporary, real-world biologic and mSCS use among U.S., subspecialist-treated patients with SA. METHODS:CHRONICLE is an ongoing, noninterventional study of U.S. adults with SA treated by allergists/immunologists or pulmonologists. Eligible patients are receiving biologics and/or mSCS or are uncontrolled on high-dosage inhaled corticosteroids with additional controllers (HD ICS+). Biologic and mSCS use patterns and patient characteristics were summarized for patients enrolled between February 2018 and February 2019. RESULTS:Among protocol-eligible patients, 58% and 12% were receiving biologics and mSCS respectively, with 7% receiving both. Among 796 enrolled, most were female (67%), non-Hispanic white (71%), of suburban residence (50%), and had elevated body mass index (median 31). Respiratory and nonrespiratory comorbidities were highly prevalent. With biologics (n=557), 51% were anti-IgE and 48% were anti-IL5/IL-5Rα; from May 2018, 76% of initiations were anti-IL-5/IL-5Rα. In patients receiving mSCS, median prednisone-equivalent daily dose was 10 mg. Multivariate logistic regression demonstrated patients of hospital clinics, sites with fewer nonphysician staff, and with a recorded concurrent chronic obstructive pulmonary disease diagnosis were less likely to receive biologics and more likely to receive mSCS. CONCLUSION/CONCLUSIONS:In this real-world sample of U.S., subspecialist-treated patients with SA not controlled by HD ICS+, mSCS use was infrequent and biologic use was common, with similar prevalence of anti-IgE and anti-IL-5/IL-5Rα biologics. Treatment differences associated with patient and site characteristics should be investigated to ensure equitable access to biologics and minimize mSCS use.

Rationale: Cutaneous, inhaled, intranasal and systemic corticosteroids(CS) are commonly prescribed for the treatment of atopic dermatitis(AD), asthma, and allergic rhinitis. The cumulative burden of these steroids in individual patients are not routinely assessed by providers and can lead to adverse effects. We sought to use an EMR-tool to increase documentation of the total steroid burden(SB) in our patients with atopic dermatitis and asthma.
Method(s): A SB EMR-tool was used for 99 AD encounters and 64 asthma encounters over an 18-month period. Data collected included corticosteroid type, potency, frequency, side effects, interventions and counseling.
Result(s): There were 99 AD encounters assessed in 58 patients(53% female, mean age of 31). Of these 99 encounters using topical corticosteroids(TCS), 24 were using inhaled CS; 12 using intranasal CS and 8 using systemic CS. The most common side effects encountered while on TCS included: pigment changes(n=20), skin atrophy(n=11), easy bruising(n=7), telangiectasias(n=6), striae(n=6), rosacea(n=3), and hair growth(n=2). Twenty-eight encounters(28%) had an intervention: 10 decreased dose, 3 decreased potency and 15 discontinued TCS. 85 encounters(86%) documented patient counseling. There were 64 asthma encounters assessed in 49 patients(63% female, mean age of 56). Of these 64 encounters using inhaled CS, 27 were using intranasal CS and 18 using systemic CS. The most common side effects encountered while using inhaled CS included: candidiasis(n=6) and hoarseness(n=1). Four encounters(6.25%) had an intervention: 3 decreased dose, 1 discontinuation. 62 encounters(97%) documented patient counseling.
Conclusion(s): Using our EMR-tool facilitates the identification and tracking of total SB in patients, associated side effects and leads to meaningful intervention.
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