Faculty Bibliography

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.

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.

BACKGROUND:Little is known about the predictors of healthcare utilization among US adults with atopic dermatitis (AD). OBJECTIVES/OBJECTIVE:To determine the proportion and predictors of utilization in outpatient, urgent care, emergency department (ED) and hospital settings in US adults with AD. METHODS:A cross-sectional, population-based study of 3,495 adults was performed. AD was determined using modified United Kingdom Working Party (UKWP) Criteria. AD severity was assessed using Patient-Oriented Eczema Measure (POEM), Patient-Oriented Scoring AD (PO-SCORAD) and Numeric rating scale (NRS)-itch. Weighted frequency and prevalence (95% confidence intervals [CI]) of utilization were determined. RESULTS:Overall, 10.42% (95% CI: 8.55-12.28%; weighted frequency: 25,844,871) reported a diagnosis of AD or eczema, 7.39% (5.81-8.97%; 18,324,869) met UKWP criteria, and 3.56% (2.40-4.72%; 8,830,095) met both. 31.8% (2,711,690) had a severe score for POEM, PO-SCORAD and/or NRS-itch, with 4.0% (337,586) having severe scores for all three. Outpatient utilization for AD was low for mild disease (29.3-34.7%) and increased by severity (moderate: 36.2-49.8%; severe: 50.6-86.6%). Timeliness of appointments, expenses and insurance coverage were also predictors of outpatient utilization. Severe POEM, PO-SCORAD and/or NRS-itch were associated with being uninsured, not having full prescription coverage, AD prescriptions being denied by insurers, and costs of AD medications being problematic. One in 10 adults with AD had ≥1 urgent care, ED or hospital visit in the past year. Urgent care or ED visits were significantly more common among blacks and Hispanics, lower household income, lower education level, and AD prescriptions being denied by their insurance company. CONCLUSION/CONCLUSIONS:Adults with AD had low rates of outpatient and high rates of urgent care, ED and hospital visits. The major predictor of outpatient utilization for AD care was AD severity. Racial/ethnic, socio-economic and/or healthcare disparities reduce outpatient utilization and increase urgent, ED and hospital utilization.

Few studies examine the experience of AD in adults and AD-treating physicians. Our objective was to compare the perspectives on AD among adults with, and AD-treating physicians. A cross-sectional sample of 602 adults who met AD UK Working Party criteria. Severity was assessed using POEM. A national sample of AD-treating physicians in outpatient settings wwere surveyed (N=401). Based on POEM score, 40% patients had moderate/severe AD (MSAD). Itch was reported as the most bothersome symptom for patients (57.5%) and AD-treating physicians. 15% of MSAD patients reported daily sleep disturbance, compared to 7% of physicians who reported that their MSAD patients experience this everyday. 41.4% of MSAD patients reported an average pain level of 7 or greater during the past week compared to 14.0% of physicians who rated their patient's pain. With respect to treatment experience, 29.6% of MSAD patients felt both physician and patient were equally in charge of treatment decisions vs 60.9% of physicians. 67.7% of physicians think their patients are very/somewhat satisfied with treatment vs 72.2% of patients with MSAD. Among those who reported treatment dissatisfaction, the primary reason was that these do not appear to work. Lastly, 1/3 of patients reported not being well informed about the cause of AD, similar to physicians who reported 34.0% of patients were not well informed. Recognition of itch burden, need for improved therapies, and disease education were similar between patients and physicians. Differences were observed in perception of pain and treatment experience. Our findings can help inform strategies to improve the care of adults with AD.