Faculty Bibliography

Atopic dermatitis (AD) is a common, chronic, relapsing, inflammatory skin disease that affects children and adults. Until recently, the only Food and Drug Administration-approved systemic treatment option for patients with moderate-to-severe AD was systemic steroids, which are not recommended by current guidelines and are commonly associated with disease rebound. Instead, clinicians choose from several off-label immunosuppressants, which can have serious adverse effects. A significant number of these patients go untreated. Research on the immunopathogenesis of AD has paved the way for new, targeted, systemic therapies for moderate-to-severe AD. In early 2017, the Food and Drug Administration approved dupilumab for adults with moderate-to-severe AD whose disease is not adequately controlled with topical therapies. Although the national guidelines can be very helpful to clinicians, the process for updating them does not allow for timely incorporation of novel therapies. A steering committee of AD experts, including dermatologists, allergists, and a patient advocacy group representative, developed recommendations on the basis of a literature review and expert opinion to help clinicians understand how new therapies fit into the current treatment paradigm and to provide practical recommendations for assessing AD severity, treatment response, and treatment failure.

BACKGROUND:There has been growing interest in the potential for adverse immunologic reactions to metals in biomedical devices and increasing referrals for the evaluation and management of metal hypersensitivity reactions reported in orthopedic, cardiac, gynecologic, and dental implant devices. However, there are few studies that give evidence-based recommendations on how to evaluate this issue in our practices. METHODS:We reviewed reasonable evidence and expert opinion on biomedical device hypersensitivity and published guidelines on pre- and postimplantation evaluation of delayed hypersensitivity reactions in patients suspected of possible metal hypersensitivity to biomedical devices. RESULTS:There is consensus that routine preimplantation evaluation in individuals with no history of adverse cutaneous reactions to metals or a history of implant-related adverse events is not necessary. However, patients with a history of metal hypersensitivity of a magnitude sufficient to cause concern for the patient or health care provider may benefit from evaluation by patch testing (PT) before device implantation. Patients after implantation and with chronic unexplained implant failure or with dermatitis may benefit from patch test evaluation after other causes, such as infection and biomechanical issues, are ruled out. However, a positive metal patch test result does not prove symptom causality, and the decision regarding implant revision can only be made after a thorough discussion among the patient, the allergist or dermatologist, and the orthopedic surgeon. CONCLUSION/CONCLUSIONS:Consensus guidelines for the evaluation of hypersensitivity to biomedical devices can be used by the practicing physician while awaiting for the results of further investigations.

Inhaled, intranasal, and cutaneous steroids are prescribed by physicians for a plethora of disease processes including asthma and rhinitis. While the high efficacy of this class of medication is well known, the wide range of adverse effects, both local and systemic, is not well elucidated. It is imperative to monitor total steroid burden in its varied forms as well as tracking for possible side effects that may be caused by a high cumulative dose of steroids. This review article highlights the adverse effects of different steroid modalities as well as suggests a monitoring tool to determine steroid totality and side effects.

Atopic dermatitis (AD) is a chronic inflammatory skin condition that requires a manifold approach to therapy. The goal of therapy is to restore the function of the epidermal barrier and to reduce skin inflammation. This can be achieved with skin moisturization and topical anti-inflammatory agents, such as topical corticosteroids and calcineurin inhibitors. Furthermore, proactive therapy with twice weekly use of both topical corticosteroids and calcineurin inhibitors in previously affected areas has been found to reduce the time to the next eczematous flare. Adjunctive treatment options include wet wrap therapy, anti-histamines, and vitamin D supplementation. Bacterial colonization, in particular Staphylococcus aureus, can contribute to eczematous flares and overt infection. Use of systemic antibiotics in infected lesions is warranted; however, empiric antibiotics use in uninfected lesions is controversial. Local antiseptic measures (i.e., bleach baths) and topical antimicrobial therapies can be considered in patients with high bacterial colonization. Difficult-to-treat AD is a complex clinical problem that may require re-evaluation of the initial diagnosis of AD, especially if the onset of disease occurs in adulthood. It may also necessitate evaluation for contact, food, and inhaled allergens that may exacerbate the underlying AD. There are a host of systemic therapies that have been successful in patients with difficult-to-treat AD, however, these agents are limited by their side effect profiles. Lastly, with further insight into the pathophysiology of AD, new biological agents have been investigated with promising results.

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.

Contact dermatitis is a common disease seen by allergists, dermatologists, and primary care physicians. The gold standard for diagnosing allergic contact dermatitis (ACD) is patch testing and is indicated in any patient with a chronic, pruritic, eczematous, or lichenified dermatitis if underlying or secondary ACD is suspected. Patients with acute generalized dermatitis who have extensive eczema on the back, are on immunosuppressant medications, and have applied topical corticosteroids, topical calcineurin inhibitors, or ultraviolet radiation to the patch test (PT) site may have suppressed PT reactions. The procedure of patch testing is not a difficult one to perform, but the interpretation of the PT needs some critical components, including having an appropriate level of suspicion for the diagnosis of ACD, testing the relevant allergens in their proper vehicle and concentration, and the necessary experience to properly interpret the results. Careful history and physical examination must be correlated with the result of the PT to establish clinical relevance. Once the PT is completed, allergens are identified, and relevance has been established, educating the patient about the avoidance of exposure is critical. The Joint Task Force of the American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma and Immunology has developed updated practice parameters for contact dermatitis and patch testing, and their recommendations will be discussed (Fonacier LF, Bernstein DI, Pacheco K, Holness DL. Contact dermatitis: a practice parameter update 2015. J Allergy Clin Immunol Pract 2015; 3(3S):S1-S40.).

Nickel is the leading cause of allergic contact dermatitis (ACD) from early childhood through adolescence. Studies have shown that skin piercings and other nickel-laden exposures can trigger the onset of nickel ACD in those who are susceptible. Nickel ACD causes a vast amount of cutaneous disease in children. Cases of nickel ACD in children have been reported in peer-reviewed literature from 28 states. Common items that contain inciting nickel include jewelry, coins, zippers, belts, tools, toys, chair studs, cases for cell phones and tablets, and dental appliances. The diagnosis of nickel ACD has been routinely confirmed by patch testing in children older than 6 months suspected of ACD from nickel. Unlike in Europe, there are no mandatory restrictions legislated for nickel exposure in the United States. Denmark has demonstrated that regulation of the nickel content in metals can lower the risk of ACD and the associated health care-related costs that arise from excess nickel exposure. To further awareness, this article reviews the prominent role of nickel in pediatric skin disease in the United States. It discusses the need for a campaign by caretakers to reduce nickel-related morbidity. Lastly, it promotes the model of European legislation as a successful intervention in the prevention of nickel ACD.