Management of acute food allergic reactions by general practitioners

BACKGROUND

Food is one of the leading causes of anaphylaxis. In the Netherlands, patients visit a general practitioner (GP) as often as an emergency department (ED) in case of an acute food allergic reaction. So far, the management of food allergic reactions by GPs has not been investigated. Therefore, we explored the management of acute food allergic reactions by GPs regarding specific treatment, observation period, prescription of emergency medication to treat new episodes, diet advices and referral to a specialist.

METHODS

A questionnaire containing three hypothetical cases (two anaphylactic and one mild case) with questions about their management was sent to 571 GPs.

RESULTS

Overall, treatment choice was dependent on the severity of the reaction (mild vs. anaphylaxis, P < .001). However, epinephrine was used for treatment of anaphylaxis with mainly respiratory symptoms in only 27% and for anaphylaxis with mainly cardiovascular symptoms in 73%. At discharge, the percentages for prescription of self-injectable epinephrine were 53% and 77%, respectively. A short observation period of <2 hours was advised by 42% of general practitioners in case of anaphylaxis.

CONCLUSIONS

Treatment of food induced anaphylaxis by GPs appears to be suboptimal: a considerable number of patients would not be treated with epinephrine for the acute reaction (especially anaphylactic cases with respiratory symptoms), the observation period chosen by GPs was often too short and self-injectable epinephrine was not always prescribed at discharge to treat possible new episodes. Education programs are needed to increase the awareness of GPs to recognize and treat anaphylactic reactions.

Brand placement and consumer choice: an in-store experiment

An in-store experiment was performed to investigate the effects of shelf placement (high, middle, low) on consumers' purchases of potato chips. Placement of potato chips on the middle shelf was associated with the highest percentage of purchases. The results confirm the importance of item placement as a factor in consumers' buying behavior.

Acquired cutis laxa in childhood Sweet's syndrome

In Sweet's syndrome, the essential features are the characteristic morphology of the lesions, their histologic appearance, the dramatic response to corticosteroids and the absence of scarring. We report an 8-month-old infant in whom Sweet's syndrome was diagnosed and who developed acquired cutis laxa in the skin lesions.

High prevalence of esophageal involvement in lichen planus: a study using magnification chromoendoscopy

BACKGROUND AND STUDY AIMS

The first cases of squamous cell carcinoma in esophageal lichen planus were recently described. We performed a study to establish the prevalence of endoscopic and histopathologic abnormalities consistent with lichen planus and (pre-) malignancy in a cohort of patients with lichen planus.

PATIENTS AND METHODS

A total of 24 patients with lichen planus were prospectively studied using high-magnification chromoendoscopy. Focal esophageal abnormalities were mapped, classified, and biopsied. Biopsies were also taken from normal-appearing esophageal mucosa at three levels (proximal, middle, and distal). The presence of a lymphohistiocytic interface inflammatory infiltrate and Civatte bodies (i. e. apoptotic basal keratinocytes) at histopathologic examination was considered diagnostic for esophageal lichen planus. Symptoms were assessed using validated questionnaires.

RESULTS

A total of 38 focal abnormalities were biopsied. These consisted of: layers of mucosa peeling off, hyperemic lesions, papular lesions, submucosal plaques/papules, a flat polypoid lesion, and segments of cylindrical epithelium. No endoscopic signs of dysplasia were present. Esophagitis consistent with gastroesophageal reflux disease was noted in 12 / 24 patients. Histopathology showed chronic inflammation of the esophageal mucosa in the majority (18 / 24) of patients. In 50 % (12 / 24), the diagnosis of esophageal lichen planus was made. Dysplasia was not present. There were no differences in symptoms between patients with and without esophageal lichen planus.

CONCLUSIONS

At screening endoscopy a high prevalence (50 %) of esophageal lichen planus was found in patients with orocutaneous lichen planus. No dysplasia was found.

[The practice guideline 'Acne' (second revision) from the Dutch College of General Practitioners; a response from the perspective of dermatology]

The second revised practice guideline 'Acne' from the Dutch College of General Practitioners contains adequate and scientifically well-supported recommendations for the management of patients with acne. There are some concerns about the initial treatment steps in these guidelines which only allow very slow progress to systemic therapy. This might, in some cases, lead to inadequate treatment of patients with more severe acne.

[Skin eruptions as an adverse reaction to epidermal growth-factor receptor inhibitors]

Inhibition of the epidermal growth-factor receptor (EGFR) is a new strategy in the treatment of solid malignancies. Two men, aged 65 and 59 years, with a metastasized renal carcinoma and a 51-year-old man with a metastasized melanoma developed an acneiform eruption during EGFR inhibition. The second and third patient also developed paronychia. Treatment in all patients consisted of antiseptics and topical antibiotics; the first and third patient also received an oral antibiotic. Withdrawal of the EGFR inhibitor because of progression of the disease led to complete recovery of the cutaneous lesions in the first and the third patient; both died after several months. In the second patient, the side effects reached an acceptable level during continued EGFR therapy. EGFR inhibition is usually accompanied by cutaneous side effects. An acneiform eruption is seen in up to 90% of all treated patients. Other side effects include dry skin, and nail and hair changes. The pathogenesis of these side effects is related to inhibition of EGFR signalling pathways in the skin, but is not yet fully understood. The treatment of EGFR inhibitor-mediated cutaneous toxicity is based mainly on clinical experience.

Home ultraviolet B phototherapy for psoriasis: discrepancy between literature, guidelines, general opinions and actual use. Results of a literature review, a web search, and a questionnaire among dermatologists

BACKGROUND

Home ultraviolet B (UVB) phototherapy is a debated treatment. It is currently being prescribed for patients with psoriasis, although literature on the subject is scarce. Despite the apparent contradiction between clinical practice and literature, no systematic study of either has been conducted.

OBJECTIVES

To assess and compare the available publications and guidelines about home UVB phototherapy for psoriasis with the actual opinions and use of this therapy.

METHODS

The literature and guidelines were searched using databases, search engines and e-mail. A postal survey of 343 Dutch dermatologists and 142 dermatologists from 32 other countries was carried out; 255 and 102 dermatologists respectively responded. Outcome measures were the reported advantages, drawbacks and prescription rates of home UVB phototherapy.

RESULTS

Fourteen publications (nonrandomized) and six guidelines concerning home UVB phototherapy for psoriasis were identified. Most were reticent about the use of this treatment. Publications describing nonclinical research (7/14) reported most of the drawbacks mentioned (24/31). Home UVB phototherapy was prescribed to 5% (median) of all patients with psoriasis in The Netherlands who required UVB. However, 28% (68/244) of the Dutch dermatologists prescribed home UVB in 20 to 100% of their cases. Dermatologists from other countries reported that 0-10% of UVB treatments were offered at home. For both Dutch and other dermatologists, the most important reasons for prescribing home UVB concerned time and travel distance (80%, i.e. 163 of 205 and 75%, i.e. 33 of 44). Therapy-related drawbacks (such as poor service and equipment) were the objections mentioned most often (55%, i.e. 103 of 186 and 63%, i.e. 57 of 91). Concerns about the medicolegal liability of home UVB were rarely expressed by individual respondents, but frequently mentioned in the various reports.

CONCLUSIONS

A discrepancy exists between the actual use of home UVB phototherapy and the general opinions found in publications. The treatment is prescribed for a considerable number of patients despite the fact that literature and guidelines advise caution. Personal and nonevidence-based opinions on this therapy are widespread while randomized clinical studies have thus far not been conducted.

[Body dysmorphic disorder in 3-8% of patients in outpatient dermatology and plastic surgery clinics]

OBJECTIVE

To determine the 6-month prevalence of body dysmorphic disorder (BDD) in outpatient clinics of dermatology and plastic surgery in a university medical centre.

DESIGN

Questionnaire study.

METHOD

In the period January 2004-June 2004, the self-reported Body dysmorphic disorder questionnaire was completed by 530 and 475 new patients in the outpatient clinics of dermatology and plastic surgery, respectively. The dermatologist or plastic surgeon assessed the severity of the defect. To meet the DSM-IV criteria for BDD, the patient must have been preoccupied with treatment of all or part of their appearance, experienced obvious suffering or restriction of function with minimal or no defect present (defect score 1 or 2).

RESULTS

In the outpatient clinics ofdermatology and plastic surgery 8.5% (95% CI: 6.1-10.9) and 3.2% (95% CI: 1.7-4.7) of patients screened positive for BDD, respectively.

CONCLUSION

A high prevalence of BDD was found in the outpatient clinics ofdermatology and plastic surgery. Because dermatologists and plastic surgeons do not often recognise BDD, a simple screening tool is needed.

[Increased consultations and numbers of sexually transmitted diseases at the STD clinic of Utrecht, 1994-2002]

OBJECTIVE

To determine trends in numbers of visitors and their demographic characteristics, reasons for visit, number of STDs and high-risk groups.

DESIGN

Secondary analysis of registration data.

METHOD

Data of every client that visited the STD clinic in Utrecht, the Netherlands, were aggregated from 1994 to 2002 in order to analyse trends.

RESULTS

The number of visitors as well as the number of STDs rose strongly over the period investigated. The age of the visitors decreased. In 1994 17% of the visitors was born outside the Netherlands, in 2002 6%. The majority of the clients (56%) visited the STD clinic to get themselves tested preventively and 27% came because of symptoms. Visitors with symptoms or who were warned by others had a three-fold increased risk of having an STD. Other risk groups were: homosexual men, visitors born outside the Netherlands and visitors who have had an STD before. Groups with an increased risk of having a Chlamydia trachomatis infection were: visitors aged under 34 years old and visitors born in Morocco, Surinam and the Antilles. The number of Chlamydia infections rose sharply among homosexual male visitors.

CONCLUSION

The increase in the number of visitors and of STD requires an increase in STD prevention, aimed at high-risk groups. More research is needed into the limited help-seeking behaviour of immigrants and more attention needs to be paid to Chlamydia trachomatis infections among homosexual men.

[Nephrogenic fibrosing dermopathy]

A 58-year-old man with renal insufficiency, who was being treated by haemodialysis, developed progressive skin lesions. He had thickening and hardening of the skin at the extremities and swelling of the toes and fingers with flexion contractures. His face was not affected. Laboratory evaluation was unremarkable and a skin biopsy [table: see text] showed an increase of collagen and mucin, without an inflammatory infiltrate. These clinical features resemble a recently reported new disorder: nephrogenic fibrosing dermopathy. This disorder manifests as scleromyxedema-like cutaneous skin lesions without associated paraproteinemia, occurring in the setting of renal disease. The histopathologic features of nephrogenic fibrosing dermopathy, i.e. thickened collagen and mucin deposition, are unique. The incidence, prevalence and cause of the disease are unknown and there is currently no effective treatment. The Centers for Disease Control and Prevention (CDC) in the USA are calling on physicians who have encountered patients suffering from this type of lesions to contact the CDC for an intended control study.

Photosensitivity in patients with lupus erythematosus: a clinical and photobiological study of 100 patients using a prolonged phototest protocol

BACKGROUND

There is a clear relationship between ultraviolet (UV) radiation (UVR) and the clinical manifestations of patients with lupus erythematosus (LE). Cutaneous lesions are induced or exacerbated by exposure to UVR. Of patients with LE, 24-83% are reported to be photosensitive to UVR. LE tumidus appears to be the most photosensitive subtype of LE, followed by subacute cutaneous LE (SCLE). In general, the history of patients with LE correlates poorly with the presence or absence of photosensitivity, due to a delayed time interval between UV exposure and exacerbation of skin lesions. Phototesting using artificial UVR and visible light is a reliable way of diagnosing photosensitivity.

OBJECTIVES

To investigate the photoreactivity of patients with various subtypes of LE using an individualized phototest protocol. The results of phototests were correlated with the history of photosensitivity, the subtype of LE, the presence of autoantibodies and the use of anti-inflammatory medication by these patients.

METHODS

Phototesting with UVA, UVB and visible light was performed in 100 patients with LE. The diagnosis of LE was established both on clinical examination and skin histology. Serological studies were also performed in all patients. The phototests were performed on large skin areas of the forearm or trunk; the first dose was twice the minimal erythema dose and the dosage was increased according to the individual reactions of the patients at the test sites. Follow-up of skin reactions at the test sites was performed for up to 2 months. Histological examination of the photoprovoked skin lesions was carried out in 57 patients.

RESULTS

Of the 100 patients included (81 women and 19 men; mean age 41 years, range 17-79), 46 had chronic discoid LE, 30 SCLE and 24 systemic LE. An abnormal reaction to UVR and visible light was found in 93% of our patients with LE. No clinical or histological evidence at the phototest sites of polymorphic light eruption was found. There was no correlation between photosensitivity and LE subtype, presence of autoantibodies or medical history. Concomitant use of anti-inflammatory medication seemed to exert only minimal influence on the results of phototesting.

CONCLUSIONS

When using an extended phototesting protocol, almost all patients with LE in this study showed clinical and histological evidence of aberrant photosensitivity. Therefore, patients with LE should receive thorough advice and instruction on photoprotective measures, regardless of their history, LE subtype or presence of autoantibodies.

Is granuloma annulare related to intermediate uveitis with retinal vasculitis?

AIM

To report on eight patients with severe idiopathic intermediate uveitis (IU) and granuloma annulare (GA), a self limiting cutaneous condition of unknown aetiology.

METHODS

Retrospective case series. Clinical ophthalmic and dermatological data were studied and fluorescein angiography and skin biopsies were reviewed.

RESULTS

All patients with idiopathic IU had similar ocular features (eight with vitritis, seven with retinal vasculitis) and developed complications such as cystoid macular oedema (n=5), cataract (n=4), and glaucoma (n=3). Systemic diseases were not found, but a localised type of GA was observed in all.

CONCLUSION

Seven out of eight patients with IU and GA developed severe retinal vasculitis. Further studies are needed for a better understanding of this association, a common pathogenesis, and its eventual clinical consequences.

Psychosocial impact of acne vulgaris. evaluation of the relation between a change in clinical acne severity and psychosocial state

BACKGROUND

Although knowledge concerning the impact of acne vulgaris on quality of life has increased in recent years, relatively few studies have assessed the effect of a change in clinical severity on psychosocial state.

OBJECTIVE

Assessment of the effect of a change in clinical acne severity on psychosocial state.

METHODS

This was investigated by means of questionnaires and clinical assessments by acne patients and dermatologists. Fifty females with mild to moderate facial acne were seen before and after a 9-month treatment with oral contraceptives.

RESULTS

The results showed a great variability in psychosocial impairment between individuals. After 9 months, a significant reduction in clinical severity was seen overall which did not relate to the significant improvements in self-esteem, stability of self-esteem and acceptance of appearance.

CONCLUSION

Perceived psychosocial impairment is individually based, is greater in women who subjectively overrate their acne and does not relate to clinical improvement.

The incidence of erythroderma: a survey among all dermatologists in The Netherlands

BACKGROUND

Erythroderma is a rare skin disorder, and studies on its incidence and causes are lacking. The annual incidence has been estimated to be 1 to 2 patients per 100,000 inhabitants.

OBJECTIVE

We investigated the incidence and cause of erythroderma in an unselected population and evaluated the referral pattern of erythrodermic patients by nonacademic dermatologists.

METHODS

A survey was performed among all nonacademic dermatologists in The Netherlands, using a mailed questionnaire. Questions dealt with the number of patients diagnosed with erythroderma in the year 1997, the cause of the erythroderma, and whether these patients were referred to a university hospital. A questionnaire was also sent to all university hospitals.

RESULTS

Seventy-eight percent of the nonacademic dermatologists answered the questionnaire, and all 8 university hospitals responded. In the year 1997, 141 patients were diagnosed with erythroderma in The Netherlands. The annual incidence of erythroderma based on these figures is 0.9 patients per 100,000 inhabitants. Compared with the university hospitals, erythroderma was more often diagnosed as an exacerbation of preexisting dermatoses (61% vs 51%; P =.37) and less often as idiopathic (14% vs 31%; P =.04) among the nonacademic dermatologists. Cutaneous T-cell lymphoma was rarely the cause, occurring in only 1% of patients diagnosed by the nonacademic dermatologists but in 6% of patients at the university hospitals. Overall, only 37% of nonacademic dermatologists referred patients with erythroderma to a university hospital.

CONCLUSIONS

The incidence of erythroderma in The Netherlands is slightly lower than the earlier estimate in the literature. Moreover, the cause of erythroderma is different among patients diagnosed in an academic and a nonacademic setting. The majority of dermatologists in The Netherlands treat patients with erythroderma themselves and do not refer these patients to university hospitals.