Faculty Bibliography

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.

Contact dermatitis (CD) is a common skin condition caused by contact with an exogenous agent that elicits an inflammatory response. While history and physical exam can be helpful in distinguishing between irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD), the gold standard for diagnosing ACD is patch testing. While the actual patch test (PT) procedure and application is relatively straightforward, the decisions involving which allergens to use, interpretation of results, determination of relevant allergens and subsequent patient management requires more skill and expertise. Often, the distribution of the presenting dermatitis can provide insight into the potential causative allergens and should be taken into account when selecting PT allergens. Commercially available PT panels and personal care products can be used for patch testing. Determining the clinical relevance of PT results is a critical component of the PT procedure. Patients must be educated on avoidance of relevant allergens and given guidance on alternative products available for use. Special populations, including children with ACD, occupational contact dermatitis (OCD), and patients with biomedical devices have unique allergen considerations and PT panels should be directed as such to address all potential allergens.

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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Allergic contact dermatitis is common, resulting in considerable morbidity. Diagnosis is based on a thorough history, physical examination, and patch testing. Several commercially available panels of patch testing are currently used. Allergens are found in a wide variety of daily products, occupational exposures, and foods. The mainstay of treatment is avoidance of the allergen, and databases like Contact Allergen Management Program and Contact Allergen Replacement Database help patients to select products that do not contain allergens to which they are sensitized. Topical corticosteroids can be used to treat exacerbations, but should be avoided in long-term treatment.

BACKGROUND:Structured patient-reported outcomes of AD severity are not standardized in clinical practice. We sought to determine the construct validity, internal consistency, cross-cultural validity, floor or ceiling effects of multiple AD severity assessments. METHODS:A cross-sectional, population-based study of 2893 adults, including 602 adults that met a modified UK Diagnostic Criteria for AD. AD severity was assessed using self-reported global AD severity, Patient-Oriented Eczema Measure (POEM), Patient-Oriented Scoring AD (PO-SCORAD) and its objective and subjective components, and numerical rating scale (NRS)-itch. QOL was assessed using short-form (SF-)12 mental and physical health scores, SF-6D health utility scores, Dermatology Life Quality Index (DLQI). Hospital Anxiety and Depression Scale (HADS) was assessed. RESULTS:PO-SCORAD, PO-SCORAD objective and subjective sub-scores, NRS-itch and POEM all had moderate to strong correlations with each other, and DLQI, fair to moderate correlations with HADS-A and HADS-D, and inverse correlations with SF-12 MCS and SF-6D (Pearson correlations, P<0.0001). All scores showed good criterion validity as judged by analysis of variance and receiver operator characteristics. PO-SCORAD, PO-SCORAD objective sub-scores and POEM had similarly good internal consistency (Cronbach's alpha=0.84, 0.82 and 0.86); PO-SCORAD subjective sub-score was less internally consistent (alpha=0.57). All scores showed potentially poor cross-cultural validity as demonstrated by uniform and non-uniform differential item functioning by age, sex and/or race/ethnicity for multiple items. There were floor effects for POEM, but not for the other assessments CONCLUSIONS: PO-SCORAD, PO-SCORAD objective and subjective sub-scores, NRS-itch and POEM appear to be valid for assessing AD severity in clinical practice.

OBJECTIVE:Characterize the frequency, intensity, characteristics and associations of pain from AD. METHODS:A cross-sectional, US population internet survey-based study of 602 adults with AD from the AD in America study was performed (modified UK Working Party Criteria). RESULTS:Overall, 365 (61%) reported pain from AD, with 199 (33%) experiencing pain at least once per week and 30 (5%) with pain daily. Among those with AD pain, 22% reported worst pain intensity ≥7. Frequency and intensity of AD pain were associated with PO-SCORAD, PO-SCORAD-itch and -sleep, and POEM (P≤0.004 for all). Among those experiencing AD pain, 179 (48%) reported pain occurring only after frequent scratching, 156 (42%) reported intermittent pain and 27 (11%) reported constant pain throughout the day. AD pain was most commonly associated with open areas caused by scratching (27%) and fissures in the skin (27%), followed by inflamed red skin (25%), with only a minority reporting pain mostly caused by burning from creams or ointments (10%). Mild AD was associated with more pain from scratching, whereas severe AD was associated with more constant pain and pain from inflamed skin. CONCLUSION/CONCLUSIONS:Pain is a distinct symptom in AD, with heterogeneous frequency, characteristics, intensity and QOL impact. Pain was related to scratching, fissures, and/or inflamed red skin, and least from burning from topical medications. Skin pain should be assessed in AD patients and monitoring treatment response.

Quality of life (QOL) assessments are not standardized in atopic dermatitis (AD). We sought to determine the validity of Short-Form 12 (SF-12), a generic QOL assessment, in AD and compare its measurement properties with Dermatology Life Quality Index (DLQI). A cross-sectional, population-based study of 3495 adults was performed, including 602 that met a modified UK Working Party Criteria for AD. SF-12 mental component score (MCS) and SF-6D had a strong correlation with each other, and moderate inverse correlations with Patient-Oriented Eczema Measure, Patient Oriented-Scoring AD (PO-SCORAD), PO-SCORAD-itch, PO-SCORAD-sleep, and numerical rating scale of pain (Pearson correlations, P<0.0001 for all). MCS and SF-6D showed good discriminant validity as judged by analysis of variance and receiver operator curves (ROC). SF-12 physical component score (PCS) had weak correlations with AD severity assessments and poor discriminant validity. DLQI had better convergent and discriminant validity than SF-12. SF-12 and DLQI showed good internal consistency (Cronbach's alpha: 0.89 and 0.94). Differential item functioning was found for items in SF-12 and DLQI. There were floor effects for DLQI, but not SF-12 MCS, PCS and SF-6D. Severity thresholds were selected. In conclusion, SF-12 MCS and SF-6D showed good validity in AD, but inferior construct validity than DLQI.

Background: Subcutaneous allergen immunotherapy (SCIT) is a very effective treatment modality; however, it can be associated with both local and systemic reactions (SR). Identifying patient factors that predict SR remains paramount. Objective: Our aim was to identify the rate of SRs to SCIT as well as identify patient risk factors associated with the development of SRs. Methods: We conducted an institutional review board approved 10-year retrospective chart review of 459 patients who received SCIT in our clinic. The patients were placed into cohorts according to age, which included pediatric (5-18 years), adult (19-64 years), and senior (>65 years) patients. Results: An SR (N = 177) was identified in 24.8% of the patients (n = 114). The incidence of SR per injection was 0.2% (177 SRs of 74,183 total injections). SRs were identified as class 1 (n = 152), class 2 (n = 21), class 3 (n = 2), and class 4 (n = 2) according to the 2010 World Allergy Organization's SR grading system. There were no observed differences in the number of SRs with respect to age group. Female patients were more likely to have an SR (p = 0.02) overall as well as more than one reaction (p = 0.002). Other risk factors included the following: a patient-reported history of food allergy (p = 0.05), drug allergy (p = 0.005), or positive skin test result to cat and/or dog (p = 0.01). In addition, patients who were receiving SCIT to cat and/or dog (p = 0.004) or to dust mite (p = 0.03) were more likely to have an SR. Conclusion: In our patient population, the majority of SRs to SCIT occurred in female patients, patients with a history of drug or food allergies, and those who were receiving pet or dust-mite SCIT.

BACKGROUND:The relationship between atopic dermatitis (AD), anxiety and depression in the U.S. adult population is not well established. OBJECTIVES/OBJECTIVE:To determine the relationship of AD and its severity with symptoms and diagnosis of anxiety and depression in U.S. adults. METHODS:A cross-sectional, population-based study of 2893 adults was performed. AD was determined using modified U.K. Diagnostic Criteria. RESULTS:Adults with AD vs. those without AD had higher mean Hospital Anxiety and Depression Scale anxiety (HADS-A) (7·7 vs. 5·6) and depression (HADS-D) (6·0 vs. 4·3) scores and higher prevalences of abnormal (≥ 11) HADS-A (28·6% vs. 15·5%) and HADS-D (13·5% vs. 9·0%) scores. In multivariable linear and logistic regression models controlling for sociodemographics, AD was associated with significantly higher mean HADS-A and HADS-D scores (7·7 and 6·0) and higher odds of abnormal HADS-A [odds ratio (OR) 2·19, 95% confidence interval (CI) 1·65-2·91] and HADS-D scores (OR 1·50, 95% CI 1·04-2·17) (P ≤ 0·03 for all). Mean and abnormal HADS-A and HADS-D scores were increased in moderate and severe/very severe self-reported global AD severity, Patient-Oriented Eczema Measure (POEM), Patient-Oriented Scoring AD (PO-SCORAD), PO-SCORAD itch and sleep (P < 0·0001 for all). All respondents with severe PO-SCORAD, POEM and PO-SCORAD itch had borderline or abnormal HADS-A and HADS-D scores. Adults with AD vs. those without AD had higher prevalence of self-reported healthcare-diagnosed anxiety or depression in the past year (40·0% vs. 17·5%). Many adults with AD who had borderline and/or abnormal HADS-A or HADS-D scores reported no diagnosis of anxiety or depression. CONCLUSIONS:AD is associated with significantly increased anxiety and depression, which may go undiagnosed.

BACKGROUND:The distribution of atopic dermatitis (AD) lesions and its impact on quality of life (QOL) is not well-established in the US adult population. OBJECTIVE:To elucidate the distribution of AD lesions and its impact on QOL in US adults with AD. METHODS:A cross-sectional, population-based study of 602 adults was performed. AD was determined using modified UK Diagnostic Criteria, and its lesional distribution was assessed. QOL was assessed using Dermatology Life Quality Index (DLQI). Latent class analysis (LCA) was used to determine distinct phenotypes of AD lesional distribution. Multivariable logistic regression was used to determine the relationship between DLQI and distinct phenotypes. RESULTS:The most common sites of skin lesions were reported to be the popliteal fossae, lower legs, dorsal feet and antecubital fossae. Most persons reported partial (19.0%) or complete (63.0%) symmetry of lesions on the extremities. Lesions on the trunk were significantly more common in blacks and Hispanics. Age ≥60 years was associated with significantly lower proportions of active lesions on the face and scalp, and significantly higher proportion of lesions on the buttocks or genitals. LCA identified 5 classes of lesional distribution: 1. lower probabilities of lesions affecting any sites; 2. Higher probability of lesions involving the anterior and posterior neck and trunk; 3. lesions involving the antecubital fossae and upper extremities; 4. lesions involving the arms, posterior hands, genitals and buttocks, and to a lesser extent face, palms and legs; 5. lesions affecting all sites. Class-2 (multivariable logistic regression; adjusted odds ratio [95% confidence interval]: 7.19 [3.21-16.07], class-3 (7.11 [3.20-15.80]), class-4 (6.90 [3.07-15.50]) and class-5 (7.92 [3.54-17.71]) were all significantly associated with higher DLQI scores compared to class 1. CONCLUSION/CONCLUSIONS:AD is associated with heterogeneous distribution of AD lesions, and distinct phenotypes that are associated with QOL impact.