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.

Comparison of Nickel Sulfate 2.5% and Nickel Sulfate 5% for Detecting Nickel Contact Allergy.

BACKGROUND: Nickel is among the most common contact allergens found on patch testing worldwide and, because of its ubiquitous nature in our environment, often has important implications for allergen avoidance strategies. In both North America and Europe, nickel positivity is found in approximately 20% of patients who undergo patch testing. Whereas in North America, nickel sulfate is typically tested at a concentration of 2.5%, in Europe, it is tested at a 5% concentration. OBJECTIVE: The primary objective was to assess the differences in patch test positivity to nickel sulfate 2.5% and 5%. METHODS: We investigated 205 consecutive patients between September 2017 and February 2018 who were tested to nickel sulfate at concentrations of both 2.5% and 5%. RESULTS: Among the 205 patients tested, 33% were positive (+, ++, or +++) to at least 1 concentration of nickel sulfate, 20% were positive to nickel sulfate 2.5%, and 31% were positive to nickel sulfate 5% (χ1(N = 205) = 16.1, P = 0.0001). Patients were 6.5 times more likely to have a positive reaction to nickel sulfate 5% than 2.5% (odds ratio 95% confidence interval, 2.3-25.6). CONCLUSIONS: Given our findings, we propose an additional evaluation of nickel sulfate 5% as a standard allergen for patch testing in North America.

Insights on methotrexate in psoriatic disease.

The folic acid analogue methotrexate is used as an anti-neoplastic agent and treatment for inflammatory disorders including psoriasis, dermatomyositis, lupus erythematous, sarcoidosis, and systemic sclerosis. Despite the introduction of newer biologic agents, methotrexate remains a first-line systemic therapy for many patients with disorders of chronic inflammation. Here we briefly describe the current clinical evidence for methotrexate use in psoriatic disease, our current understanding of methotrexate's anti-inflammatory properties, and the future role of methotrexate in the treatment of immune mediated disorders.

CCL20 and IL22 Messenger RNA Expression After Adalimumab vs Methotrexate Treatment of Psoriasis: A Randomized Clinical Trial.

IMPORTANCE: Methotrexate is a first-line systemic agent for treating of psoriasis, although its onset of effects is slower and overall it is less effective than tumor necrosis factor blockers. OBJECTIVE: To differentiate the response of psoriatic disease to adalimumab and methotrexate sodium. DESIGN, SETTING, AND PARTICIPANTS: Single-center, randomized, assessor-blind, 2-arm clinical trial of 30 patients from the outpatient dermatology center of Tufts Medical Center, enrolled from August 18, 2009, to October 11, 2011. Patients aged 18 to 85 years with chronic plaque-type psoriasis, a minimum Physician Global Assessment score of 3 (higher scores indicate more severe disease), and a psoriatic plaque of at least 2 cm were randomized in a 1:1 fashion to receive subcutaneous adalimumab or oral methotrexate. Skin biopsy specimens obtained at baseline and weeks 1, 2, 4, and 16 were given a histologic grade by blinded assessors to evaluate treatment response. Analyses were conducted from April 16, 2013, to January 5, 2015. INTERVENTIONS: A 16-week course of subcutaneous adalimumab (40 mg every 2 weeks after a loading dose) or low-dosage oral methotrexate sodium (7.5-25 mg/wk). MAIN OUTCOMES AND MEASURES: Changes in genomic, immunohistochemical, and messenger RNA (mRNA) profiles. RESULTS: Methotrexate responders experienced significant downregulation of helper T-cell-related (T(H)1, T(H)17, and T(H)22) mRNA expression compared with methotrexate nonresponders. Comparisons among adalimumab-treated patients were limited by the number of nonresponders (n = 1). Between adalimumab and methotrexate responders, we found no significant differences in gene expression at any study point or in the expression of T-cell-related mRNA at week 16. Adalimumab responders demonstrated early downregulation of chemokine (C-C motif) ligand 20 (CCL20) mRNA (mean [SE] at week 2, -1.83 [0.52], P < .001; week 16, -3.55 [0.54], P < .001) compared with late downregulation for methotrexate responders (week 2, 0.02 [0.51], P = .96; week 16, -2.96 [0.51], P < .001). Similar differences were observed with interleukin 22 (IL22) mRNA showing early downregulation for adalimumab responders (week 2, -3.17 [1.00], P < .001; week 16, -3.58 [1.00], P < .001) compared with late downregulation for methotrexate responders (week 2, -0.44 [0.68], P = .64; week 16, -5.14 [0.68], P < .001). Analysis of variance findings for key mRNA and immunohistochemical marker expression over the study course were significant only for CCL20 (P = .03) and IL22 (P = .006) mRNA comparing adalimumab and methotrexate responders. CONCLUSIONS AND RELEVANCE: Methotrexate is an immunomodulator with effects on helper T-cell signaling in psoriasis. Similar genomic and immunohistochemical response signatures and levels of mRNA downregulation at study completion among adalimumab and methotrexate responders suggest a disease-driven instead of therapeutic-driven pathway regulation. Adalimumab and methotrexate responses are differentiated by patterns of normalization of CCL20 and IL22 mRNA expression and may explain the varied onset and degree of clinical responses by each treatment. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00932113.

Noninfectious granulomatous dermatitides: a review of 8 disorders (Part 1 of 3).

In this review we focus on 2 of the noninfectious granulomatous dermatitides, granuloma annulare and interstitial granulomatous dermatitis (the remaining 6 will be discussed in Parts 2 and 3), with an overview of their clinical and histological presentations, differential diagnoses, and treatment options. The disorders we discuss are polymorphic in their clinical and histopathological presentations, follow chronic or undulating disease courses, and are typically recalcitrant to therapeutic interventions. Although the clinical history may be helpful, careful and thorough histopathological examination is required. Established treatment algorithms for these disorders are lacking, and no randomized, placebo-controlled studies have been published. Future investigations should focus on the evaluation of larger cohorts, not only to establish treatment recommendations in randomized, placebo-controlled trials, but also to reach a greater understanding of disease pathogenesis and clinical-pathological presentation.

Congenital subungual melanocytic nevus with a pseudo-Hutchinson sign.

We describe a 29-year-old woman with congenital melanonychia striata and compound nevus of the right first digit. There was extension of the hyperpigmentation onto the proximal nail fold, even beyond the borders established by the band of melanonychia striata. A dermal plaque with irregular borders and variegated pigmentation was also present over the distal digit extending from the pigmented region of the hyponychium. A limited number of biopsy proven congenital subungual melanocytic nevi have been reported in the literature. Interestingly, we found that the majority of these cases present with longitudinal melanonychia in association with periungual hyperpigmentation, constituting a pseudo-Hutchinson sign. Currently studies evaluating the diagnostic test characteristics of Hutchinson sign are lacking. While Hutchinson sign is traditionally considered a worrisome feature it is certainly not pathognomonic and a malignant cause should not be assumed without thorough assessment.

Prevalence of the metabolic syndrome in children with psoriatic disease.

Adults with psoriasis have a greater risk of developing metabolic syndrome (MetS) and cardiovascular disease (CVD), but few studies have investigated the prevalence of MetS and other risk factors for CVD in children with psoriasis. In an assessor-blinded study, 20 children ages 9-17 years with a current or previously documented history of psoriasis involving 5% or more of their body surface area or psoriatic arthritis were compared with a cohort of age- and sex-matched controls with benign nevi, warts, or acne. MetS, our primary endpoint, was defined by the presence of abnormal values in at least three of the following measures: triglycerides, high-density lipoprotein cholesterol (HDL-C), fasting blood glucose (FBG), waist circumference, and blood pressure. Secondary endpoints included high-sensitivity C-reactive protein (hs-CRP), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C). Thirty percent (6/20) of children with psoriasis met the criteria for MetS, compared with 5% (1/20) of the control group (p < 0.05). Subjects with psoriasis had higher mean FBG (91.1 mg/dL) than the control group (82.9 mg/dL) (p = 0.01). There were no statistically significant differences in the other four components of MetS, BMI, BMI percentile, hs-CRP, TC, or LDL-C. The results of this trial demonstrate that children with psoriasis have higher rates of MetS than age- and sex-matched controls. It may therefore be important to evaluate children with psoriasis for components of MetS to prevent future CVD morbidity and mortality.