Retrospective review of insurance coverage for patch testing.

BACKGROUND: There is a paucity of data on the burden of insurance limitations for patients undergoing patch testing. OBJECTIVE: To characterize the burden of insurance limitations and its impact on differences in management and execution of patch testing. METHODS: A retrospective chart review was performed on patients with a diagnosis of contact dermatitis (International Classification of Disease [ICD], Ninth Edition, code ICD 692) who received patch testing (Current Procedural Terminology code 95044) at the George Washington Medical Faculty Associates Dermatology Clinic between January 1, 2015 and June 30, 2017. Variables including allergen limitations were compared between government-sponsored insurance and private insurance providers (eg, Insurers A, B, C, and D). RESULTS: A total of 371 records were identified. Government-sponsored insurance patients encountered allergen limitations more frequently than private insurance patients (86.8% vs 14.2%, P < .0001). Insurer C and D patients were least likely to encounter allergen limitations (1.2% vs 0%, P < .0001) and were tested to the most allergens (mean = 146 vs 152, P < .0001). Insurer A patients had the least allergens tested among those privately insured. CONCLUSION: Considering modification of insurance policies to allow patch testing with a larger number of allergens without restrictions is needed, with the goal of improving quality of life of these patients while saving costs from chronic use of topical corticosteroids.

A systematic review of evidence-based treatments for prurigo nodularis.

Prurigo nodularis is a chronic dermatologic condition involving the development of multiple cutaneous nodules in the setting of intractable pruritus. Given emerging treatment options for this difficult-to-treat condition, a current review of therapeutics is needed. A systematic review was performed for clinical studies investigating prurigo nodularis treatment published from 1990 to present including ≥5 subjects. A total of 35 articles were assigned a level of evidence according to the Oxford Center for Evidence-based Medicine. All 5 studies investigating topical agents, including corticosteroids, calcineurin inhibitors, calcipotriol, and capsaicin, conveyed some beneficial effect with level of evidence 2b or higher. Six of 8 reports investigating photo- and photochemotherapy achieved levels of evidence 2b or greater and showed good partial response rates. Thalidomide was studied by 6 reports providing evidence of good symptom response, only 2 of which were rated level 2b or greater. Cyclosporine and methotrexate have demonstrated benefit in 4 combined studies, albeit with level 4 evidence. Pregabalin, amitriptyline, paroxetine, fluvoxamine, and neurokinin-1 receptor antagonists have demonstrated promising evidence in 5 level 2b studies. Higher-powered studies and additional randomized controlled trials are needed for the evaluation of safe and efficacious systemic treatment options for prurigo nodularis.

A Review of the Dermatologic Symptoms of Idiopathic Mast Cell Activation Syndrome

Since the first reported cases in 2007, idiopathic mast cell activation syndrome has been increasingly recognized. Understanding of the cutaneous manifestations of this condition is imperative for dermatologists given the substantial clinical heterogeneity in its presentation and high estimated prevalence. A review of PubMed® and SCOPUS® databases was performed in order to investigate the most common dermatologic manifestations of idiopathic mast cell activation syndrome. Evidence to date suggests that flushing, pruritus, and clotting dysfunction or bleeding disorder are the most frequently observed dermatologic symptoms in idiopathic mast cell activation syndrome, while dermatographism has been identified as a common finding in patients as well. Mast cell activation syndromes have also been linked to connective tissue disorders, including an Ehlers-Danlos Syndrome-like phenotype possibly mediated by matrix metalloproteinases and tryptase released by mast cells. Current literature regarding dermatologic manifestations of idiopathic mast cell activation syndrome is limited by the heterogeneity of studies including clinical descriptions, inconsistency of diagnostic criteria implemented, and a paucity of literature available. This work provides a guide for dermatologists to strengthen diagnostic acuity for idiopathic mast cell activation syndrome, therefore contributing toward a goal of helping patients to receive timely, effective, and targeted therapy. J Drugs Dermatol. 2019;18(2):162-168.

Complex Regional Pain Syndrome: What the Dermatologist Should Know.

Reflex sympathetic dystrophy is a subtype of complex regional pain syndrome, a condition characterized by persistent post-injury extremity pain. Temperature and sweating changes, edema, mobility changes, and a variety of hair, nail, and skin sequelae have been described. Only 23 articles published since 1990 describe dermatologic changes in CRPS. Given this paucity of literature, we present a case to further elucidate cutaneous manifestations of CRPS. Our patient is a 52-year-old Caucasian woman with a 19-year history of reflex sympathetic dystrophy who has presented with several dermatologic complaints. She was first referred to the clinic due to episodic, mildly tender, clustered, non-blanching, and non-palpable petechiae on the legs bilaterally, which was histologically consistent with leukocytoclastic vasculitis. No systemic involvement was identified and symptoms resolved with topical steroids. The patient was also noted to have severe ten toenail dystrophy without any evidence of onychomycosis based on multiple cultures and PAS staining of clipped nails. Avulsion of the great toenail was performed to provide symptomatic relief. Incidentally, the patient was found to have lower extremity and facial hypotrichosis on physical exam. Further, she required increased lidocaine administration in addition to pre and post-procedure lidocaine and prilocaine 5% emulsion cream for various office procedures, suggestive of lidocaine insensitivity. This case captures previously described cutaneous manifestations of CRPS such as vasculitis, nail dystrophy, extremity hypotrichosis, and telangiectasia, along with newly described potential manifestations about which dermatologists should be aware, including facial hypotrichosis and lidocaine insensitivity. J Drugs Dermatol. 2018;17(5):532-536.

Postoperative symptoms of psychosis after deep brain stimulation in patients with Parkinson's disease.

OBJECT: Cases of postoperative psychosis in Parkinson's disease patients receiving deep brain stimulation (DBS) treatment have previously been published. However, the magnitude of symptom incidence and the clinical risk factors are currently unknown. This retrospective study sheds light on these issues by investigating psychosis in a group of 128 Parkinson's disease patients who received DBS implants. METHODS: A retrospective chart review was performed to obtain surgery dates, follow-up clinic visit dates, and associated stimulation parameter settings (contacts in use and the polarity of each along with stimulation voltage, frequency, and pulse width) for each patient. Unified Parkinson's Disease Rating Scale II Thought Disorder scores, used as a clinical assessment tool to evaluate the presence of psychosis at each visit, were also collected. The data were compiled into a database and analyzed. RESULTS: The lifetime incidence of psychosis in this cohort of patients was 28.1%. The data suggest that risk of psychosis remains fairly constant throughout the first 5 years after implantation of a DBS system and that patients older at the time of receiving the first DBS implant are not only more likely to develop psychosis, but also to develop symptoms sooner than their younger counterparts. Further analysis provides evidence that psychosis is largely independent of the clinically used electrode contact and of stimulation parameters prior to psychosis onset. CONCLUSIONS: Although symptoms of psychosis are widely seen in patients with Parkinson's disease in the years following stimulator placement, results of the present suggest that most psychoses occurring postoperatively are likely independent of implantation and stimulation settings.

Psychological Therapies in Management of Psoriatic Skin Disease: A Systematic Review.

BACKGROUND: Psoriasis is a chronic, immune-mediated skin disease shown to have a multifaceted relationship with psychological factors. Because these factors have been shown to both worsen and result from psoriasis, an increasing number of studies have sought to investigate the efficacy of various psychological interventions in psoriasis management. METHODS: A systematic review of PubMed® and Scopus® databases was performed for studies investigating psychological interventions in psoriasis management published from 1 January 1990 through 4 November 2018. Primary articles published in English and conveying physical treatment outcomes were included, whereas articles not describing clinical outcomes were excluded. Studies supporting intervention efficacy were graded with a level of evidence according to the Scottish Intercollegiate Guidelines Network levels of evidence. RESULTS: A total of 28 reports studying 27 unique sets of patients receiving psychological therapies in psoriasis management were identified, including three case reports and series and 24 clinical trials, investigating 1522 patients in total. Cognitive behavioral therapy and its variants, biofeedback, meditation and mindfulness-based therapies, hypnosis, music resonance therapy, motivational interviewing, emotional disclosure, and educational and multidisciplinary approaches have been studied in the treatment of psoriasis. Although 16 randomized controlled trials were included in this review, literature is limited by heterogeneity of methodology, analyses, and outcomes. Only 4 of 27 studies (three of which investigated cognitive behavioral therapy) were rated a level of evidence of 1+ or greater. Studies, overall, have sample sizes often < 50 patients, lack follow-up past 12 months, and have attrition rates > 20%. CONCLUSIONS: Based on assigned levels of evidence, the most promising methods of psychological intervention in psoriasis include cognitive behavioral therapy, mindfulness-based therapies, motivational interviewing, and educational and interdisciplinary interventions. Further study is needed to determine the efficacy, practicality, and economic feasibility of these treatment options for patients with psoriasis.