The utility of the TRUE test in a private practice setting

BACKGROUND

Studies suggest that the Thin-Layer Rapid-Use Epicutaneous Test (TRUE Test) may be inadequate to completely diagnose a significant number of patients with allergic contact dermatitis (ACD).

OBJECTIVE

To study the usefulness of the TRUE Test as a triage tool in a private practice setting.

METHODS

A retrospective chart review of patients who were patch-tested with the TRUE Test between July 1, 2000, and June 30, 2004, in four private dermatology practices was conducted.

RESULTS

Of the 183 patients evaluated, 50.8% had at least one positive reaction, 31.7% had a diagnosis of ACD, and 24.0% were suspected to have ACD from other allergens. Of the patients with positive reactions, 62.4% were determined to have reactions that were of present relevance.

CONCLUSIONS

The TRUE Test allows patients with dermatitis to be triaged systematically in a private practice setting. It is important to supplement patch testing with the patients' personal products, especially in cases of facial or periorbital dermatitis, and to be aware of potential false negatives, particularly with fragrance and rubber additives.

An experiment using neutron activation analysis and a rare earth element to mark cotton plants and two insects that feed on them

Studies on insect dispersal and other behaviors can benefit from using markers that will not alter flight and fitness. Rare earth elements, such as samarium (Sm), have been used as ingested markers of some insects and detected using neutron activation analysis (NAA). In this study, samarium nitrate hexahydrate was mixed into artificial diet for boll weevils, Anthonomus grandis grandis Boheman (Coleoptera: Curculionidae), at different dosages and in water used to irrigate cotton, Gossypium hirsutum L. Samarium was detected in adult boll weevils fed on the samarium-labeled diet, but not after 5 or 10 days of being switched to non-labeled diet, even if the insects were given labeled diet for as long as 7 consecutive days. Introduced in irrigation water, 1% samarium (m/m) was detectable in cotton squares and leaf tissue. However, boll weevil adults fed samarium-labeled squares did not retain detectable levels of samarium, nor did boll weevil adults reared to adulthood from samarium-labeled squares. Fourth instar beet armyworms, Spodoptera exigua (Hübner) (Noctuidae: Lepidoptera), fed on samarium-labeled cotton leaves obtained enough samarium for NAA detection, but adult moths reared from them did not have detectable amounts of samarium. Although samarium can be useful as a marker when insects are presented with a continuous pulse of the label, elements that are assimilated by the insect would be more useful if a continuous infusion of the marker cannot be provided.

Subcutaneous fat in normal and diseased states: 2. Anatomy and physiology of white and brown adipose tissue

White and brown adipose tissues, both present to some degree in all mammals, represent counter actors in energy metabolism. One of the primary functions of white adipocytes is to store excess energy as lipid, which is then mobilized to other tissues in response to metabolic needs that arise in times of food shortage. White adipocyte physiology can be grouped into 3 main categories with potentially overlapping mechanisms: lipid metabolism, glucose metabolism, and endocrine functions. Brown adipocytes, on the other hand, use accumulated lipid from food primarily as a source for chemical energy that can then be released from the cell in the form of heat. Recently, new discoveries about the significance of brown fat have sparked interest in this organ as a potential tool in the fight against obesity in adult humans. A basic overview of the anatomy and physiology of adipose tissue, with particular emphasis on the differences between white and brown fat, is presented.

Dermatologic toxicity of chemotherapeutic agents

Due to its high metabolic rate, skin represents one of the major target organs of chemotherapy-associated toxicity. Reactions range from common, nonspecific exanthematous eruptions to rare but distinctive cutaneous lesions that may not become apparent until a drug transitions from clinical trials to widespread oncologic use. The challenge of the physician is to recognize reaction patterns that reflect a drug reaction, identify a likely causative drug, and determine whether the reaction is a dose-limiting toxicity. This review will focus on the cutaneous side effects of the newer classes of chemotherapy drugs, including targeted monoclonal antibody therapy and small molecule inhibitors.

Antimicrobial peptides: effectors of innate immunity in the skin

The ability of the cutaneous barrier to help defend the body against pathogens relies on both acquired and innate immune responses. Recently, a large body of research has suggested that a critical component of the innate immune response in the skin is 3 antimicrobial peptides: the cathelicidins, defensins, and dermcidins. These 3 classes of peptides have been shown to act as antimicrobials by directly inhibiting pathogen growth as well as potentiating other branches of the innate, humoral, and cell-mediated immune system. Here, we review the antimicrobial peptides with an emphasis on their role in the cutaneous immune response. We present an overview of defensin, cathelicidin, and dermcidin physiology, elucidating their various functions. In addition, we delve into the role of these peptides in specific dermatologic conditions including wound healing, atopy, and microbial infection. Finally, we discuss the future of antimicrobial peptide research including therapeutic options.

Soak and Smear

BACKGROUND

Atopic dermatitis, nummular eczema, chronic hand dermatitis, palmar plantar psoriasis, and xerotic eczema are common inflammatory skin conditions. They may be refractory to conventional topical and even systemic treatment. Little evidence is available that demonstrates the benefits of aggressive topical treatment of patients with these disorders.

OBJECTIVE

To describe a simple, inexpensive, effective topical treatment with an accompanying patient educational sheet.

DESIGN

A retrospective study of 28 patients referred to a tertiary care center for refractory chronic pruritic eruptions. Intervention with a plain water 20-minute soak followed by smearing of mid-strength to high-strength corticosteroid ointment led to clearing or dramatic improvement.

RESULTS

Objective and symptomatic improvement was obtained from aggressive topical treatment. It was well accepted in this group of referral patients.

CONCLUSIONS

Hydration for 20 minutes before bedtime followed by ointment application to wet skin and alteration of cleansing habits is an effective method for caring for several common skin conditions. Prospective studies are needed to further validate these findings.

Patients' attitudes toward resident participation in dermatology outpatient clinics

The attitudes of patients toward resident participation in a university-based dermatology outpatient clinic were evaluated. Of 206 patients asked to participate, 191 patients completed the self-administered questionnaire (92.7%). The overwhelming majority of patients (99.5%) were satisfied (81.8% "very satisfied" and 17.7% "satisfied") with the resident's participation in their care. Many more patients expressed a willingness to allow residents to take histories (93.6%), perform physical examinations (87.2%), and counsel on preventive measures (74.5%), than to allow surgical excisions of skin cancers (19.7%), perform skin biopsies (43.6%), or prescribe medications (44.7%). Of respondents to the questionnaire, 83.2% self-reported an understanding of the difference between "resident" and "attending" physicians. However, only 31.3% (95% confidence interval 24.5-38.1) were able to broadly categorize the amount of training completed by dermatology residents. Dermatology resident participation in outpatient clinics is essential to quality dermatologic education. Consistent with the results of prior studies in other medical disciplines, our study demonstrated an overwhelming patient satisfaction with the participation of dermatology residents in their care.

Subcutaneous fat in normal and diseased states

In recent years, our understanding of adipose tissue physiology and function has undergone an enormous transformation. Once considered a passive storage receptacle with a fixed number of cells and limited purpose, adipose tissue is now recognized as a complicated organ with important endocrine and metabolic functions. It is now known that both increased and decreased adipose tissue mass, as seen in obesity, anorexia, and lipodystrophy, have profound effects on multiple body systems, including immune, reproductive, and hematopoietic. The study of adipose tissue, therefore, is important not only for those who treat obesity, lipoatrophy, and their associated metabolic and endocrine derangements, but also for those dermatologists who specialize in the medical and surgical treatment of disorders within the body's largest adipose tissue subdivision, the subcutaneous fat. This introductory article is the first in a series about adipose tissue in normal and diseased states.

Rosacea: I. Etiology, pathogenesis, and subtype classification

Rosacea is one of the most common conditions dermatologists treat. Rosacea is most often characterized by transient or persistent central facial erythema, visible blood vessels, and often papules and pustules. Based on patterns of physical findings, rosacea can be classified into 4 broad subtypes: erythematotelangiectatic, papulopustular, phymatous, and ocular. The cause of rosacea remains somewhat of a mystery. Several hypotheses have been documented in the literature and include potential roles for vascular abnormalities, dermal matrix degeneration, environmental factors, and microorganisms such as Demodex folliculorum and Helicobacter pylori. This article reviews the current literature on rosacea with emphasis placed on the new classification system and the main pathogenic theories. Learning objective At the conclusion of this learning activity, participants should be acquainted with rosacea's defining characteristics, the new subtype classification system, and the main theories on pathogenesis.

Topical tacrolimus: a review of its uses in dermatology

Tacrolimus is one of the newer immunosuppressants that act by inhibiting T-cell activation and cytokine release. It is approved for the treatment of atopic dermatitis, and its safety and efficacy have been extensively studied in large-scale randomized controlled trials and open-label studies worldwide involving over 12,000 patients and up to 3 years of follow-up. Since its introduction, anecdotal reports and case series have found topical tacrolimus also to be effective and well tolerated in patients with a variety of other skin disorders, including other types of eczema, papulosquamous disorders, disorders of cornification, rosacea, other inflammatory skin conditions, vesiculobullous diseases, vitiligo, connective-tissue diseases, graft-versus-host disease, and follicular disorders. This paper reviews the currently available evidence on the use of topical tacrolimus for these conditions, as well as its safety profile and cost-effectiveness. Tacrolimus does appear to offer a safe and efficacious alternative that minimizes the need for topical glucocorticoids and does not cause skin atrophy. However, the risk of systemic absorption is increased with generalized disruption of the skin barrier. Further large-scale studies are needed to clarify the efficacy of topical tacrolimus in a variety of conditions for which anecdotal reports of success exist, especially in regard to different racial groups and in comparison to (as well as in combination with) other existing therapies. Long-term safety data should continue to be monitored and reported.

Neoprene

Neoprene is a synthetic rubber with many common uses, including use in shoe insoles and adhesives, orthopedic braces, and gloves. Many cases of type IV hypersensitivity from neoprene contact have been reported. Thioureas, the most commonly used vulcanization accelerators in the manufacture of neoprene, are responsible for the majority of these cases. However, thioureas are not included in the TRUE Test whereas the North American Contact Dermatitis Group standard tray contains only mixed dialkyl thioureas. Since most data indicate that many cases will be missed when only mixed dialkyl thioureas are used for screening, a more complete thiourea panel should be used when neoprene hypersensitivity is suspected.

Rosacea: II. Therapy

Despite an incomplete understanding of the pathogenesis of rosacea, therapeutic modalities continue to expand. The principal subtypes of rosacea include erythematotelangiectatic rosacea, papulopustular rosacea, phymatous rosacea, and ocular rosacea. These phenotypic expressions are probably caused by divergent pathogenic factors and consequently respond to different therapeutic regimens. A subtype-directed approach to therapy is discussed in part II of this review. We provide an overview of the available topical, oral, laser, and light therapies in the context of these cutaneous subtypes, review the evidence that supports their use, and outline their therapeutic approach. Suggestions for future areas of study also are provided. Learning objective At the completion of this learning activity, participants should be familiar with the subtype-directed approach to therapy for rosacea including available topical, oral, laser, and light therapies.

Use of aromatherapy products and increased risk of hand dermatitis in massage therapists

OBJECTIVES

To determine the 12-month prevalence of hand dermatitis among massage therapists, to investigate a potential association between hand dermatitis and the use of aromatherapy products, and to study potential associations with other known risk factors for hand dermatitis.

DESIGN

Mailed survey.

SETTING

Philadelphia, Pa.

PARTICIPANTS

Members of a national massage therapy organization who live in the greater Philadelphia region.

MAIN OUTCOME MEASURES

Self-reported and symptom-based prevalences of hand dermatitis.

RESULTS

The number of respondents was 350 (57%). The 12-month prevalence of hand dermatitis in subjects was 15% by self-reported criteria and 23% by a symptom-based method. In multivariate analysis, statistically significant independent risk factors for self-reported hand dermatitis included use of aromatherapy products in massage oils, lotions, or creams (odds ratio, 3.27; 95% confidence interval, 1.53-7.02; P =.002) and history of atopic dermatitis (odds ratio, 8.06; 95% confidence interval, 3.39-19.17; P<.001).

CONCLUSIONS

The prevalence of hand dermatitis in massage therapists is high. Significant independent risk factors include use of aromatherapy products in massage oils, creams, or lotions and history of atopic dermatitis.

From road rash to top allergen in a flash: bacitracin

BACKGROUND

Bacitracin is an antibiotic that is produced by Bacillus subtilis, which is used in several types of consumer products, including cosmetics and ophthalmic and cutaneous ointments.

OBJECTIVE

To call attention to the rising allergic contact dermatitis associated with bacitracin.

RESULTS

Mass usage has resulted in an increasing number of clinically relevant allergic contact dermatitis reactions and near fatal anaphylaxis. The North American Contact Dermatitis Group has recorded its emergence as a leading allergen and continues to monitor the ever-growing allergic reaction rates.

CONCLUSION

The clinical impact, scientific evidence, and need for medical cost containment all advocate the discontinuation of routine usage of bacitracin in clean surgical wounds.

Comparison of Skin Biopsy Triage Decisions in 49 Patients With Pigmented Lesions and Skin Neoplasms

OBJECTIVE

To determine the relative efficacy of store-and-forward teledermatology vs face-to-face dermatology consultations in triage decisions about the need for a biopsy of neoplastic skin changes.

DESIGN

Prospective study of consecutive patients judged by an internist to require dermatologic consultation for a skin growth.

SETTING

Private primary care and dermatology practices and an academic dermatology practice.

PATIENTS

Patients requiring dermatology consultation for evaluation of skin growths. Patients were seen by a single primary care physician between July 10, 1998, and August 4, 2000.

INTERVENTION

Digital photographs of skin growths were obtained by the primary care physician and evaluated by a teledermatologist. The patient was then seen face-to-face by a dermatologist. A biopsy was performed if either dermatologist favored biopsy.

MAIN OUTCOME MEASURES

Decisions to perform a biopsy. Agreement between the dermatologists was assessed.

RESULTS

Of the 49 patients with evaluable photographs, the face-to-face dermatologist and teledermatologist recommended a biopsy for the same 26 patients, yielding a sensitivity of the teledermatologist of 1.00 (95% confidence interval [CI], 0.87-1.00) and a specificity of 1.00 (95% CI, 0.85-1.00). The agreement between the dermatologists (kappa) was 1.00 (95% CI, 0.72-1.00).

CONCLUSION

Store-and-forward teledermatology may provide an accurate and cost-effective method of determining whether skin growths in patients presenting to primary care physicians should undergo biopsy.

Large solitary café au lait spots: a report of 5 cases and review of the literature

The presence of multiple café au lait spots (CALSs) has been well described and associated with several neurocutaneous and genetic syndromes including, most commonly, neurofibromatosis. However, scant literature exists regarding the clinical significance of the large solitary CALS. We describe 5 patients with congenital large solitary CALSs without associated abnormalities. Our cases and review of the literature suggest that large solitary CALSs are uncommon benign lesions that most likely are not associated with any neurocutaneous syndromes or developmental anomalies.

Annular lichen planus: a case series of 20 patients

BACKGROUND

Annular lichen planus (ALP) is a long-recognized clinical variant of lichen planus, but is often considered uncommon in occurrence. The typical distribution and presentation of this variant have not been well described.

OBJECTIVE

We sought to better define the sites affected and clinical characteristics of the annular variant of lichen planus, along with the age and race of patients affected with this disorder.

METHODS

We conducted a retrospective review of 20 patients given a diagnosis of ALP during an 18-year period. The diagnosis was confirmed histologically in all but 3 cases of classic ALP that presented on the glans penis.

RESULTS

Patients ranged in age from 24 to 76 years. There were 18 men and 2 women; 15 were Caucasian and 5 were African American. Sites of involvement in order of decreasing frequency included: axilla (35%); penis (25%); extremities (25%); groin (including the inguinal creases and scrotum) (20%); back (15%); buttocks (10%); flanks (5%); neck (5%); and eyelids (5%). None of the patients had oral mucosal, vulval, scalp, or nail lesions. A total of 18 patients had purely annular lesions, whereas 2 of the 20 had a few purple polygonal papules in the vicinity of the annular forms. Some eruptions were macular, whereas the majority had a slightly raised edge with central clearing. In all, 6 patients had solitary lesions whereas only 4 had 10 or greater lesions. None exhibited a linear Koebnerized response or generalized lesions. Most patients were asymptomatic.

CONCLUSIONS

ALP commonly involves the male genitalia but also has a predilection for intertriginous areas such as the axilla and groin folds. Eruptions typically consist of a few lesions localized to one or a few sites. Distal aspects of the extremities, and less commonly the trunk, may also be involved. ALP is a subtype of lichen planus that may be more common than is reflected in the literature.