Prevalence of allergic contact dermatitis in children with and without atopic dermatitis: A multicenter retrospective case-control study.

BACKGROUND: As both allergic contact dermatitis and atopic dermatitis (AD) have similar clinical presentations and are characterized by spongiotic dermatitis on skin biopsy, many children with AD are not referred for patch testing and allergic contact dermatitis is underdiagnosed. OBJECTIVE: To provide updated prevalence data of common contact allergens in children with and without AD. METHODS: This is a retrospective case-control study using the Pediatric Allergic Contact Dermatitis Registry from 2018 to 2022. RESULTS: A total of 912 children were included (615 with AD and 297 without AD). Children with AD were more likely to have a longer history of dermatitis (4.1 vs 1.6 years, P < .0001), have seen more providers (2.3 vs 2.1, P = .003), have greater than 1 positive patch test (PPT) result (P = .005), have a greater number of PPT results overall (2.3 vs 1.9, P = .012), and have a more generalized distribution of dermatitis (P = .001). PPT to bacitracin (P = .030), carba mix (P = .025), and cocamidopropyl betaine (P = .0007) were significantly increased in children with AD compared to those without AD. LIMITATIONS: Technical variation between providers and potential for misclassification, selection, and recall biases. CONCLUSION: Children with AD are significantly more likely to have PPT reactions and should be referred for evaluation of allergic contact dermatitis and obtain patch testing.

Contact dermatitis: An important consideration in leg ulcers.

The prevalence of chronic wounds is increasing with the aging population, with 1% to 2% of the worldwide population experiencing leg ulcers and positive patch tests reported in up to 75% of this population. With the introduction of modern dressings and compression therapies, clinicians should be cognizant of the potential risk of contact dermatitis in patients with leg ulcers. Contact dermatitis (both allergic and irritant) to wound products may present as maceration, pain, and overall impaired wound healing. Herein, we review the literature on contact dermatitis to wound-care products.

Epidemics of Dermatitis.

Allergic contact dermatitis (ACD) remains a globally prevalent disease for both children and adults. The silent ACD epidemic continues to be fueled by the introduction of novel allergens in industrial and household products and the continued presence of known allergens. In 1997, Allan Dillarstone noted a sinusoidal pattern to epidemics when allergenic preservatives were replaced by alternative chemicals within the market, which then similarly increased in allergenicity. A call for public health vigilance and prevention initiatives is needed to intervene in the ACD epidemic.

Patch Test Clinic Start-up: From Basics to Pearls.

Allergic contact dermatitis is a prevalent burdensome condition affecting millions of Americans. Patch testing, the criterion-standard allergic contact dermatitis diagnostic tool, is underused by US dermatologists. Incorporating patch testing into modern dermatology practices is achievable with utilization of accurate resources and sustainable support. This review focuses on the basics of patch testing and provides practical pearls to assist novice providers in establishing a contact dermatitis specialty practice.

Contact dermatitis and atopic dermatitis: two tales, an interwoven story.

Atopic dermatitis is a multifactorial disease that can concomitantly occur with irritant or allergic contact dermatitis. The colloquial use of atopic dermatitis and eczema interchangeably has created confusion among patients and providers alike. Atopic skin is a complex entity that involves a defective barrier and biome, an aberrant immune response, and abnormal neural activation, while eczema is a generalized term denoting a particular appearance common to multiple diagnoses including atopic dermatitis and contact dermatitis. The conventional paradigm that simplifies atopic dermatitis and allergic contact dermatitis into distinct Th2 and Th1 processes, respectively, fails to acknowledge potential immunologic intersection points and contributes to impaired disease management. This article will review the complex interplay of atopic dermatitis and contact dermatitis and discuss treatment strategies for recalcitrant cases.

A 4-year retrospective assessment of postoperative complications in immunosuppressed patients following Mohs micrographic surgery.

BACKGROUND: Many patients undergoing Mohs micrographic surgery for basal and squamous cell carcinomas are immunocompromised, yet postoperative complications associated with different types of immunosuppression are largely unstudied. OBJECTIVE: To determine the incidence and nature of postoperative complications in immunosuppressed patients undergoing Mohs micrographic surgery. METHODS: A retrospective cross-sectional chart review of patient characteristics, clinical characteristics, and complications. RESULTS: Univariable analysis showed that compared with immunocompetence, immunosuppression was associated with 9.6 times the odds of postoperative complication (P = .003), with solid organ transplant recipients having 8.824 times higher odds (P = .006) and immunosuppressive therapy use displaying 5.775 times higher odds (P = .021). Surgical site infection (2.5%) and dehiscence (0.51%) were more prevalent among immunosuppressed patients, with an overall complication rate of 5.4% in the immunosuppressed population. Multivariable analysis of the association between immunosuppression and postoperative complication closely trended toward, but did not meet, significance (P = .056). LIMITATIONS: This was a single-center, retrospective study. Other limitations include lack of non-solid organ transplants, limited medication-related data on nontransplant patients, and exclusion of cases involving patients with double transplants or multiple sources of immunosuppression. CONCLUSIONS: Immunosuppression overall, particularly owing to solid organ transplant and immunosuppressive therapy use, places patients at higher risk for postoperative complications, including surgical site infection and wound dehiscence following MMS.

Contact Dermatitis in Atopic Dermatitis Children-Past, Present, and Future.

Allergic contact dermatitis (ACD) used to be considered a rarity in children, but recently has been estimated to effect 4.4 million children in the USA alone, with a notable rise in investigative research in the field of pediatric ACD. Researchers have shown that patch testing is safe and effective in afflicted children and that those with atopic dermatitis (AD) have similar sensitization rates, although they have a higher sensitization to certain allergens, thought to be related to the inflammatory (IL-4) milieu. Patch testing assessment guidelines in children include five key considerations: if a patient's dermatitis worsens, changes distribution, fails to improve with topical therapy, or immediately rebounds after removal of topical treatments; if a patient has a particular distribution of dermatitis; if a working patient has hand eczema that fails to improve with therapy; if the patient has AD that started in adolescence or adulthood with definitely no history of childhood eczema; and importantly, if a patient has severe or widespread atopic dermatitis that will require immunosuppressive systemic medication.

A Retrospective Analysis of Complication Rates in Mohs Micrographic Surgery Patients With Clinically Large Tumors and Tumors With Aggressive Subclinical Extension.

BACKGROUND: Clinically large cutaneous tumors and those with aggressive subclinical extension (ASE) often require wider margins and increased operative time during Mohs micrographic surgery (MMS). Our goal is to improve dermatologic surgeons' counseling information on complication risks for aggressive tumors. OBJECTIVE: To examine the incidence of postoperative complications in MMS patients, with a focus on differences between aggressive and non-aggressive tumors. METHODS AND MATERIALS: We performed a retrospective cross-sectional chart review of 4151 MMS cases at the University of California, San Diego. A postoperative complication was defined as an adverse event directly related to MMS reported within 6 weeks of the procedure. RESULTS: Clinically, large tumors had 50 times the odds of postoperative complication as compared to all other tumors (P less than 0.001). ASE was not found to be significantly associated with higher rates of postoperative complications when controlled for other factors. CONCLUSION: Clinically, large tumors may be at higher risk for complications following MMS due to their increased size and need for repair with methods other than linear closures. Tumors with ASE were not found to be at higher risk for postoperative complications. J Drugs Dermatol. 2018;17(5):511-515.

A Retrospective Assessment of Postoperative Bleeding Complications in Anticoagulated Patients Following Mohs Micrographic Surgery.

BACKGROUND: A significant number of patients undergoing Mohs micrographic surgery (MMS) for skin cancer are treated with oral anticoagulants. The incidence of postoperative complications associated with new classes of oral anticoagulants remains largely unknown. OBJECTIVE: To determine the incidence of postoperative complications in patients undergoing MMS on both traditional oral anticoagulants and new novel oral anticoagulants. MATERIALS AND METHODS: A single-center retrospective chart review was performed for all patients treated with oral anticoagulants who underwent MMS between July 1, 2012 and June 30, 2015 at University of California, San Diego. RESULTS: The data from this study demonstrated that patients treated with a novel oral anticoagulant at the time of MMS had a statistically significant greater risk for developing postoperative hemorrhagic complications compared to patients treated with traditional oral anticoagulants. CONCLUSION: Dermatologic surgeons should manage both traditional oral anticoagulants and novel oral anticoagulants in a similar manner. Future studies are warranted.

Contact dermatitis considerations in atopic dermatitis.

Complex immunologic pathways, influenced by both genetic and environment triggers, contribute to the development of atopic dermatitis and allergic contact dermatitis. Suppressing mechanisms between the Th1-driven allergic contact dermatitis and the Th2-driven atopic dermatitis conditions were thought to reduce the simultaneous expression of both; however, recent evidence indicates that pediatric patients with atopic dermatitis are likely to develop clinically relevant positive patch tests and more likely to react to specific allergens, such as lanolin. We review the potential role of skin barrier defects, such as filaggrin mutations and impaired barrier function, including aberrancies in epidermal pH buffering capabilities, which may promote bacterial biofilms and create an environment favoring sensitization.

Practice Patterns of Dermatologists in the Pediatric Contact Dermatitis Registry.

BACKGROUND/OBJECTIVES: U.S. adults and children are equally likely to have allergic contact dermatitis. Historically the narrow geographic location of data-reporting providers has quantitatively and qualitatively limited the pediatric contact dermatitis data. The Pediatric Contact Dermatitis Registry was used to evaluate self-identified pediatric patch test providers within the United States with regard to demographic characteristics, geographic location, and practice patterns. METHODS: A wide range of U.S. providers were invited to join the registry by completing a secure online 11-question registration survey. RESULTS: There were 252 respondents from 50 states and the District of Columbia; 28.6% were pediatric dermatologists and members of the Society for Pediatric Dermatology (SPD), and 38% were members of the American Contact Dermatitis Society. The cumulative range of pediatric patch-test evaluations performed each year was 1,726 to 4,613 children. SPD members had a significantly greater likelihood of performing a commercially available patch test (odds ratio 7.14 [95% confidence interval 5.11, 9.97], p < .001) than those who were not SPD members. SPD members also had significantly lower odds of performing North American Contact Dermatitis Group standard tests than nonmembers. CONCLUSIONS: The frequency of patch test evaluations in children is significantly underreported. This study provides insight into the practice patterns of various providers who are patch testing children and makes recommendations for evidence-based modifications regarding these practices. Limitations of the study include survey responder selection bias and small sample size.

Pediatric Contact Dermatitis Registry Data on Contact Allergy in Children With Atopic Dermatitis.

Importance: Atopic dermatitis (AD) and allergic contact dermatitis (ACD) have a dynamic relationship not yet fully understood. Investigation has been limited thus far by a paucity of data on the overlap of these disorders in pediatric patients. Objective: To use data from the Pediatric Contact Dermatitis Registry to elucidate the associations and sensitizations among patients with concomitant AD and ACD. Design, Setting, and Participants: This retrospective case review examined 1142 patch test cases of children younger than 18 years, who were registered between January 1, 2015, and December 31, 2015, by 84 health care providers (physicians, nurse practitioners, physician assistants) from across the United States. Data were gathered electronically from multidisciplinary providers within outpatient clinics throughout the United States on pediatric patients (ages 0-18 years). Exposures: All participants were patch-tested to assess sensitizations to various allergens; history of AD was noted by the patch-testing providers. Main Outcomes and Measures: Primary outcomes were sensitization rates to various patch-tested allergens. Results: A total of 1142 patients were evaluated: 189 boys (34.2%) and 363 girls (65.8%) in the AD group and 198 boys (36.1%) and 350 girls (63.9%) in the non-AD group (data on gender identification were missing for 17 patients). Compared with those without AD, patch-tested patients with AD were 1.3 years younger (10.5 vs 11.8 years; P < .001) and had longer history of dermatitis (3.5 vs 1.8 years; P < .001). Patch-tested patients designated as Asian or African American were more likely to have concurrent AD (odds ratio [OR], 1.92; 95% CI, 1.20-3.10; P = .008; and OR, 4.09; 95% CI, 2.70-6.20; P <.001, respectively). Patients with AD with generalized distribution were the most likely to be patch tested (OR, 4.68; 95% CI, 3.50-6.30; P < .001). Patients with AD had different reaction profiles than those without AD, with increased frequency of reactions to cocamidopropyl betaine, wool alcohol, lanolin, tixocortol pivalate, and parthenolide. Patients with AD were also noted to have lower frequency of reaction to methylisothiazolinone, cobalt, and potassium dichromate. Conclusions and Relevance: Children with AD showed significant reaction patterns to allergens notable for their use in skin care preparations. This study adds to the current understanding of AD in ACD, and the continued need to investigate the interplay between these disease processes to optimize care for pediatric patients with these conditions.

Appropriate Testing of Isothiazolinones in Children.

BACKGROUND/OBJECTIVE: The isothiazolinones methylchloroisothiazolinone (MCI) and methylisothiazolinone (MI) are prevalent pediatric contact sensitizers. MI allergic contact dermatitis (ACD) is underreported in the literature. The objective of the current study was to use a database of provider-reported U.S. pediatric patch test cases to evaluate the positive patch test (PPT) prevalence rates of the combined preservative test substrate MCI/MI and of MI alone. METHODS: U.S. pediatric patch test providers in all 50 states who had joined the registry were invited to submit deidentified cases to the database. More than 1100 logged cases in the database were evaluated for PPTs to MCI/MI combination, MCI/MI and MI, and MI alone. RESULTS: Within 1 year of data collection, 96 cases with a PPT for MCI/MI, MCI/MI and MI, and MI alone were identified; 37 of these were positive to MCI/MI, with MI alone not tested or negative, and 39 were positive to MI only, with MCI/MI and MI tested. Fifteen (41%) of the MCI/MI cases were detected using an epicutaneous patch test alone and 22 cases (59%) using comprehensive patch testing. Only one case (3%) of MI alone sensitization was detected using T.R.U.E. plus a supplemental panel of tests; the remaining 38 cases (97%) were detected using comprehensive testing. Testing with only the combined MCI/MI preservative substrate may miss 51% of MI allergies. CONCLUSION: Appropriate testing of isothiazolinones is needed to clarify the true prevalence of sensitization to these allergens and the burden of pediatric ACD. Patch testing for MI alone in addition to MCI/MI combination is warranted in children with recalcitrant dermatitis.

Squamous Cell Carcinoma In Situ Upstaged to Invasive Squamous Cell Carcinoma: A 5-Year, Single Institution Retrospective Review.

BACKGROUND: Shave biopsy may not be able to accurately distinguish squamous cell carcinoma in situ (SCCIS) from invasive squamous cell carcinoma (SCC). Information on the incidence of biopsy-proven SCCIS upstaged to SCC after a more complete histologic examination is limited. OBJECTIVE: To determine the incidence and clinical risk factors associated with upstaging the biopsy diagnosis of SCCIS into invasive SCC based on findings during Mohs micrographic surgery (MMS). METHODS: All MMS cases of SCCIS performed between March 2007 and February 2012 were identified, MMS operative notes were examined, and invasive dermal components were confirmed by the MMS slide review. Upstaged SCCIS was defined as biopsy-diagnosed SCCIS subsequently found to be an invasive SCC during MMS. RESULTS: From 566 cases with the preoperative diagnosis of SCCIS, 92 (16.3%) cases were SCCIS upstaged to SCC. Location of ears, nose, lips, and eyelids, preoperative diameter >10 mm, and biopsy report mentioning a transected base were significant predictors of upstaged SCCIS. CONCLUSION: Considering the possibility that over 16% of SCCIS may be truly invasive SCC, biopsy-proven SCCIS should be treated adequately with margin-assessed treatment modalities such as surgical excision or Mohs surgery when indicated.