Faculty Bibliography

Contact dermatitis accounts for 95% of occupational skin disorders. Irritant contact dermatitis (ICD) is often caused by cumulative exposure to weak irritants, accounting for 80% of all cases of contact dermatitis. ICD can co-exist with atopic dermatitis (AD) and allergic contact dermatitis (ACD). Patients with AD and ACD may have a lower inflammatory threshold for developing ICD. Therefore, it needs to be distinguished from lesions of AD and ACD. ICD Patients report stinging and burning in excess of pruritus. Pruritus is classically reported by patients with AD and ACD. ICD lesions are typically well-demarcated unlike AD and ACD. ICD is diagnosed by exclusion. Patients undergo testing to rule out type I and type IV hypersensitivity. Negative results suggest a diagnosis of ICD. Management consists of irritant identification and avoidance with regular emollient use. Although ICD is more common in certain occupations, genetics and environment play significant roles in its development.

Rationale: Mandatory influenza vaccination for all hospital employees is increasingly common, and was a policy at NYU Langone Health System (NYC, Winthrop, Lutheran) in 2017. Employees applying for exemption based on prior allergic reaction underwent evaluation by an allergist. We assessed the success of mandating the vaccine and whether allergic evaluation increased vaccination rates. Method(s): Prior reaction history, skin testing, and outcomes of evaluation were reviewed from charts. Primary outcomes were total vaccination rate and outcomes of those that applied for exemption. Result(s): A total of 39,146 of 39,558 employees (98.9%) received vaccination without evaluation. Of 39,558 employees, 419 (0.01%) applied for exemption; 73 sought exemption based on prior allergic reaction. Exemption was granted to 303 employees for other reasons. Egg-free vaccine was administered to 38/73 (52%) who reported egg allergy. The remaining 35 underwent allergy evaluation; 15 were granted exemption while 20 (57%) were vaccinated. At Winthrop, 46 employees applied for medical exemption due to allergy; 45 (97%) were ultimately vaccinated. Eight employees with reported vaccine allergy were evaluated. Four received the vaccine without testing, while four were skin tested. One patient developed a generalized rash with skin testing and was granted exemption. The other three successfully received influenza vaccine via graded challenge. Institution-wide, 99.04% (39,182 of 39,558) of employees received the vaccine. Conclusion(s): Mandating flu vaccination is by itself an effective method to ensure compliance (98.9%). Allergy evaluation increased the vaccination rate in those applying for an exemption due to allergy, with only 15/73 (20%) granted exemption.

BACKGROUND:Atopic dermatitis (AD) is associated with skin lesions, multiple symptoms, and effect of quality of life, all of which factor into disease severity. Self-reported global AD severity may be a valid severity assessment for epidemiologic research. OBJECTIVE:To validate self-reported global AD severity in a representative cohort of adults with AD. METHODS:Preliminary probing-cognitive interviews were performed (n = 8). Next, a cross-sectional US population-based survey study of adults with AD was performed. AD was diagnosed using an adap/tation of the UK Working Party criteria (n = 602). AD severity was assessed using self-reported global AD severity (mild, moderate, severe), Patient-Oriented Scoring AD (PO-SCORAD), Patient-Oriented Eczema Measure (POEM), Numeric Rating Scale (NRS)-itch, NRS-sleep, NRS-pain, and Hospital Anxiety and Depression Scale (HADS). RESULTS:Self-reported global AD severity had good content validity. Self-reported global AD severity had strong correlations with PO-SCORAD (Spearman correlation ρ = 0.61) and objective PO-SCORAD (ρ = 0.61); moderate correlations with POEM (ρ = 0.54), NRS-itch (ρ = 0.44), NRS-pain (ρ = 0.46), and HADS (ρ = 0.41); and weak correlation with NRS-sleep (ρ = .32) (P < .001 for all). Consistent and significant correlations were observed in stratified analyses by age, sex, race/ethnicity, and level of education. There were stepwise increases of PO-SCORAD, NRS-itch, NRS-sleep, NRS-pain, POEM, and HADS with increasing self-reported global AD severity (Kruskal-Wallis test, P < .01). There was weak-moderate concordance between self-reported AD severity and established severity strata for PO-SCORAD (ρ = 0.44), NRS-itch (ρ = 0.30), and POEM (ρ = 0.43). Rather, self-reported global AD severity was best predicted by a combination of PO-SCORAD, POEM, NRS-itch, NRS-pain, and HADS. No differential item reporting was found by age, sex, or race/ethnicity. CONCLUSION/CONCLUSIONS:Self-reported AD severity simultaneously assesses multiple AD constructs and appears to be sufficiently valid for assessing AD severity in clinical and epidemiologic studies.

BACKGROUND:Atopic dermatitis (AD) has been associated with multiple comorbid extracutaneous and systemic disorders. The relation between AD severity and disease comorbidities is complex and not fully understood. OBJECTIVE:To determine the complex relation between AD severity and comorbidities. METHODS:A cross-sectional US population-based study of 8,217 adults who were participants in a nationally representative internet health panel was performed using a structured questionnaire. A diagnosis of AD was determined using modified United Kingdom Working Party Criteria for AD (n = 602). AD severity was assessed using Patient-Oriented Scoring AD, Patient-Oriented Eczema Measure, Dermatology Life Quality Index, and self-reported global AD severity. Logistic regression and structural equation models were used to explore associations of AD with self-reported allergic, cardiometabolic, anxiety and depression, and autoimmune disease. RESULTS:In multivariable regression models controlling for sociodemographics, AD was associated with higher odds of asthma (adjusted odds ratio [OR] 2.09, 95% confidence interval [CI] 1.71-2.55), hay fever (OR 4.31, 95% CI 3.27-5.69), food allergy (OR 2.07, 95% CI 1.54-2.77), anxiety and depression (OR 2.34, 95% CI 1.91-2.87), autoimmune disease (OR 3.05, 95% CI 2.31-4.03), obesity (OR 1.37, 95% CI 1.13-1.67), diabetes (OR 1.52, 95% CI 1.16-1.99), high blood pressure (OR 1.46, 95% CI 1.18-1.80), and heart disease (OR 1.94, 95% CI 1.40-2.70) compared with controls (P < .01 for all). All these associations were significant in mild and/or moderate disease, with even stronger effects in severe AD. Results of structural equation models showed direct effects of moderate to severe AD on food allergy, anxiety and depression, and diabetes, direct and indirect effects on obesity, and indirect effects on high blood pressure and heart disease. CONCLUSION/CONCLUSIONS:There is a strong relation of AD severity to allergic, autoimmune, and cardiovascular comorbidities.

BACKGROUND:Patient-Oriented Eczema Measure (POEM) is the preferred patient-reported outcome (PRO) for assessing symptoms of atopic dermatitis (AD). Dermatology Life Quality Index (DLQI) is commonly used to assess the burden of skin disease. Previous severity strata were developed for POEM and DLQI in clinical cohorts, which may be biased toward more severe disease. Severity strata were not previously examined in population-based cohorts. Patient-Oriented Scoring AD (PO-SCORAD) is another commonly used PRO for assessing AD symptoms; however, severity strata are not established. OBJECTIVE:We sought to confirm previously developed strata for POEM and DLQI, and to develop strata for the PO-SCORAD in a population-based cohort of adults with AD. METHODS:A cross-sectional, population-based study of 8,217 adults was performed using a structured questionnaire. A diagnosis of AD was determined using modified UK Diagnostic Criteria for AD (n = 602). AD severity was assessed using self-reported global AD severity (anchoring question), POEM, PO-SCORAD, and DLQI. Strata were selected using an anchoring approach based on patient-reported disease severity. RESULTS:We confirmed the existing strata for DLQI (mild = 0-5, moderate = 6-10, severe = 11-30) (kappa = 0.446). However, the preferred strata for POEM was mild = 0-7, moderate = 8-19, and severe = 20-28 (kappa = 0.409) and PO-SCORAD was mild = 1-27, moderate = 28-56, severe = 57-104 (kappa = 0.444). CONCLUSION/CONCLUSIONS:Existing strata for DLQI performed well in a population-based cohort of adult AD. The optimal severity strata for the POEM in our AD population varies slightly from those previously published for AD. This may suggest that different strata may be optimal in different study settings and cohorts. Finally, we proposed new strata for PO-SCORAD in adult AD.

BACKGROUND:The patient burden and quality of life (QOL) impact of atopic dermatitis (AD) in the United States population is not well established. OBJECTIVE:To elucidate the patient burden of AD in the US population. METHODS:A cross-sectional, population-based study of 602 adults was performed. Atopic dermatitis was determined using modified UK Diagnostic Criteria for AD. Its severity was assessed using self-reported global AD severity, Patient-Oriented Eczema Measure (POEM), Patient-Oriented Scoring AD (PO-SCORAD), PO-SCORAD-itch, and sleep. Quality of life was assessed using short-form (SF-)12 mental and physical health scores and Dermatology Life Quality Index (DLQI). RESULTS:Adults with AD reported higher proportions of having only fair/poor overall health (25.8% vs. 15.8%), being somewhat/very dissatisfied with life (16.7% vs 11.4%), lower weighted mean (standard deviation [SD]) SF-12 mental (45.9 [9.9] vs 50.9 [9.2]) and physical health subscores (53.0 [2.5] vs 53.5 [2.3]) and higher DLQI (4.9 [6.5] vs 1.1 [2.8]). In multivariable regression models adjusting for sociodemographics and multiple comorbid health disorders, significant stepwise decreases by AD severity (self-reported, POEM, PO-SCORAD) of overall health, life satisfaction, SF-12 mental health, and increases of DLQI scores were seen. The SF-12 physical health scores were only associated with moderate AD. Concurrently, severe PO-SCORAD, POEM, or PO-SCORAD-itch was associated with very low mean SF-12 mental health (34.7) and high DLQI scores (24.7). Atopic dermatitis commonly limited lifestyle (51.3%), led to avoidance of social interaction (39.1%), and impacted activities (43.3%). The most burdensome AD symptoms were itch (54.4%), excessive dryness/scaling (19.6%), and red/inflamed skin (7.2%). CONCLUSION/CONCLUSIONS:These data support the heavy burden that AD places on patients, particularly those with moderate and severe AD.

OBJECTIVE:To review of contact dermatitis (CD) and its key allergens and provide updates and recommendations for the practicing allergist. DATA SOURCES/METHODS:Through the use of various scientific search engines (eg, PubMed and MEDLINE), we reviewed literature on CD, patch tests (PTs), key allergens, occupational dermatitis, and treatment. STUDY SELECTIONS/METHODS:Studies on CD, important allergens, and PTs were considered. RESULTS:Contact-induced dermatitis may be due to allergic CD, irritant CD, systemic CD, contact urticaria, and protein CD. Key allergens include metals (nickel, gold), topical medicaments (topical corticosteroids), and cosmetics and personal care products (fragrances and preservatives such as methyl- and methylchloro-isothiazolinone). Present relevance of a positive PT result is the combination of definite, probable, and possible relevance and should be correlated with the patient's history and physical examination. Treatment of allergic CD includes identification of relevant allergens, patient education, avoidance, and provision of alternative products the patient can use. CONCLUSION/CONCLUSIONS:CD is a common inflammatory skin disease and should be suspected in patients presenting with acute, subacute, or chronic dermatitis. The gold standard for diagnosing allergic CD is a PT. This article provides practical recommendations for the diagnosis and management of CD commonly seen by the allergist in their practice.