Patch Test Practice Patterns of Members of the American Contact Dermatitis Society.

BACKGROUND: Patch testing is the criterion standard for diagnosis and management of allergic contact dermatitis. Limitations on the number of allergens tested can negatively impact patient care. OBJECTIVE: This study reports clinical practice patterns of American Contact Dermatitis Society (ACDS) members. METHODS: In October and November 2018, the US-based members of the ACDS received an electronic survey regarding their procedures and experiences with patch testing. We evaluated the type of practice, number of patients tested, type of screening and supplemental series, number of allergens tested, and billing and reimbursement concerns. RESULTS: There were 149 respondents; 62% use ACDS Core 80, 70% "sometimes" or "always" test with supplemental series, and 70% "sometimes" or "always" test patient products. Participants estimated that supplemental series identify relevant allergens 35% of the time. Approximately 66% most commonly test more than 81 allergens per patient, and 78% expressed concerns regarding fair reimbursement. CONCLUSIONS: Most ACDS members routinely test more than 81 allergens per patient. Barriers to fair payment for beyond a fixed number of patches at any one visit may impede the diagnosis of allergic contact dermatitis, prolong suffering, and worsen outcomes.

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.

Survey of Patch Test Business Models in the United States by the American Contact Dermatitis Society.

BACKGROUND: Allergic contact dermatitis (ACD) remains a significant burden of disease in the United States. Patch testing is the criterion standard for diagnosing ACD, but its use may be limited by reimbursement challenges. OBJECTIVE: This study aimed to assess the current rate of patch test utilization among dermatologists in academic, group, or private practice settings to understand different patch testing business models that address these reimbursement challenges. METHODS: All members of the American Contact Dermatitis Society received an online survey regarding their experiences with patch testing and reimbursement. RESULTS: A "yes" response was received from 28% of survey participants to the question, "Are you or have you been less inclined to administer patch tests or see patients needing patch tests due to challenges with receiving compensation for patch testing?" The most commonly reported barriers include inadequate insurance reimbursement and lack of departmental support. CONCLUSIONS: Compensation challenges to patch testing limit patient access to appropriate diagnosis and management of ACD. This can be addressed through a variety of innovative business models, including raising patch testing caps, negotiating relative value unit compensation, using a fixed salary model with directorship support from the hospital, and raising the percentages of collection reimbursement for physicians.

Cost of illness from occupational hand eczema in Germany.

BACKGROUND: There is little knowledge about the costs of occupational hand eczema. OBJECTIVES: To estimate the societal costs of patients with occupational hand eczema in Germany. METHODS: Resource use during the past year, disease severity and quality of life [Dermatology Life Quality Index (DLQI)] were gathered for patients with occupational hand eczema before they entered a special rehabilitation programme. Costs were calculated from the societal perspective. The analysis focused on all patients and the severity groups no signs/mild (group A) and moderate to severe (group B). RESULTS: One hundred and fifty-one patients were analysed, with a mean age of 44.9~years and a mean DLQI score of 10.9; 64.9% were male. Sickness absence was recorded for 62.9% of all patients (76.4~days on average in the last 12~months). Annual societal costs were €8799 per patient. Indirect costs represented 70% of total costs. Quality of life (DLQI) was statistically different across both severity groups (group A, 7.9; group B, 12.9), but direct treatment costs were not (€2705 versus €2610, respectively). There was a trend towards higher indirect costs in patients in severity group B (group A, €5120; group B, €6796). CONCLUSION: The annual societal costs of patients with occupational hand eczema in this study are high, and similar to those for severe psoriasis and atopic dermatitis.

Evaluating lotion transfer from products to skin using the behind-the-knee test.

BACKGROUND/PURPOSE: Adding lotions or emollients to the surface of a variety of paper products confers a number of benefits to the skin of consumers. A modification of the 'behind-the-knee (BTK)' test model was used as a means of measuring the effectiveness of lotion transfer to the skin. METHODS: Two series of feminine protection pads were prepared: (1) identically constructed pads differing only in the amount of lotion applied to the surface and (2) pads of various compositions to compare the influence of other product characteristics. For the first series, pads were applied for 3 h using the BTK protocol, and lotion transfer was evaluated. For the second series of products, two sample pads were applied consecutively for 3 h each, and lotion transfer was evaluated a both time points (e.g., 3 and 6 h). In addition, a clinical in-use study was used to evaluate lotion transfer for the second product series. RESULTS: In the BTK model using pads of identical composition, lotion transfer was a function of the amount of lotion placed on the pad. However, results from the second product series indicated that when pads were prepared using different absorbant materials (supreabsorbent gelling material, or AGM and cellulose), pads with the AGM core transferred lotion more effectively than pads with a cellulose core. Other product characteristics, i.e., pad thickness and lotion configuration, did not detectibly influence lotion transfer. The results of an in-use clinical study conducted on the second series of test products were directionally similar to those from the BTK, but statistical significance was not reached. CONCLUSIONS: An adaptation of the BTK test method provides an effective means of evaluating the transfer of lotion formulations from feminine protection pads at a fraction of the cost of clinical in-use studies.

Contact dermatitis and workforce economics.

The roots of education in patch testing begin with Jadassohn and have been passed down through generations of dermatologists through didactic teachings and mentoring. Currently, we are faced with workforce economics tipping the balance of dermatology toward cosmetic and surgical practices. This imbalance is easily found in the subspecialty of contact dermatitis, where the current demand for patch test services is on the rise and the number of new dermatology-based patch test providers cannot keep up with the current demand. Steps are being made to remedy this discrepancy through societies and fellowships, yet the question remains: were the steps in time and were they big enough?

Lessons from atopy patch testing in atopic dermatitis.

The exposure of atopic eczema (AE) patients to their relevant protein allergens (eg, from house dust mite, cat dander, grass pollen, or food allergens) can trigger an exacerbation or maintain the disease. Diagnostic procedures are needed to specify allergen avoidance recommendations for the individual patient. Skin prick tests and specific serum IgE tests might be helpful in pointing out potential trigger factors, but relevance needs to be confirmed (eg, with food provocation tests). The atopy patch test (APT) involves the epicutaneous application of intact protein allergens in a diagnostic patch test setting with an evaluation of the induced eczematous skin lesions after 24 to 72 hours. The APT targets the cellular component of AE and helps round out the AE test spectrum. As a number of apparently minor test modifications greatly influence the sensitivity, specificity, and reproducibility of the APT, the European Task Force on Atopic Dermatitis (ETFAD) has developed a standardized APT technique. It consists of purified allergen preparations in petrolatum, applied in 12-mm diameter Finn chambers mounted on Scanpor tape to non-irritated, non-abraded, or tape-stripped skin of the upper back. The APT is read at 48 and 72 hours according to the test criteria and reading key of the ETFAD for appearance of erythema, and number and distribution pattern of the papules. In contrast with skin prick tests, the APT might even detect a relevant sensitization in the absence of specific IgE. Many studies have been undertaken to objectify the sensitivity and specificity of the APT to show its diagnostic use in clinical practice.

Patch testing by additional series of allergens: results of further experiences.

BACKGROUND: Patch testing with additional series (AS) of allergens may be a useful tool in diagnosing allergic contact dermatitis (ACD). OBJECTIVE: Aim of the study was to verify the usefulness, to check the reliability in clinical practice and to evaluate the economic costs of AS previously built up. METHODS: A total of 281 patients with suspicious ACD underwent patch test with the standard series (SS) and with one or more AS (51 among 71 built up). RESULTS: A total of 170 patients (60.5%) showed positive reactions to SS; 116 (41.3%) to AS. Among 582 nonstandard allergens used, 113 (19.4%) elicited 1 or more positive reactions: out of 10,916 patch tests carried out, 260 (2.4%) positive reactions were observed. The correlation between SS and AS indicated that 8.2% patients resulted SS-/AS+, 27.7% SS+/AS-, 32.7% SS+/AS+, 31.3% SS-/AS-. The most frequently used AS showed the following percentages of patients with 1 or more positive reactions: clothes 41.4%, building industry 51.8%, hairdressers 77.3%, textile industry 42.1%, shoes 36.8%. Positive reactions to the most frequently used nonstandard allergens resulted: propylene glycol 0.4%, cobalt chloride 12.6%, phenylmercuric nitrate 2.2%, p-aminophenol 4.5%. The approximate economic cost of patch testing with AS has been evaluated in 1.3 euro per single patch test. CONCLUSION: The cost of patch testing AS is not irrelevant, but it can be compensated by the advantages deriving from the increase of data concerning ACD etiology. A reduction in the number of allergens included in single AS should be performed. Cobalt chloride, taking into account the high percentage of positive reactions observed and its presence in a large number of AS, could be (re)introduced in the standard series.

Commercial availability of a house dust mite patch test.

The house dust mite long has been studied for its potential role in atopic dermatitis. Its part in the pathogenesis of asthma and allergic rhinitis has been studied and is accepted. Testing for the dust mite allergen in this arena is performed with radioallergosorbent tests (RASTs) and prick testing. For several reasons, including the lack of a standardized testing tool, the difficulty in removing dust from the environment and the lack of association of dust and skin disease by patients, the role of the house dust mite in the pathogenesis of atopic dermatitis and skin disease has been questioned. Chemotechnique Diagnostics (Malmo, Sweden) now provides a standardized dust mite allergen in petrolatum in 2 concentrations. Dermatophagoides mix is a 50:50 mix of Dermatophagoides pteronyssinus and D. farinae at concentrations of 20% and 30%. The availability of a standardized patch test allergen for the house dust mite provides a better tool to investigate the role of this allergen as a contactant.

An economic evaluation of patch testing in the diagnosis and management of allergic contact dermatitis.

BACKGROUND: A previous retrospective study indicated that patch testing is cost-effective and well accepted by patients. OBJECTIVE: The objective of this observational prospective study was to show the cost-effectiveness of patch testing in patients suspected of allergic contact dermatitis (ACD) and to determine the order in which different severity groups rank in terms of cost-effectiveness. METHODS: This observational study was conducted in 567 patients from 10 investigator sites over a period of 1 year. All patients with a suspicion of contact allergy who exhibited at least moderate disease activity were included in the study and were stratified according to disease severity and whether or not they were patch tested. In each severity category, the cost-effectiveness of patch testing was evaluated. Patients who were ruled out for contact allergy by the first 6 months after admission were excluded. A validated dermatology-specific quality of life instrument was administered to all the patients at entrance into the study and at 6 and 12 months after that. The cost-effectiveness analysis is shown using a decision analysis model. RESULTS: Patch testing was performed on 22% of patients with mild disease, 41% of patients with moderate disease, and 50% of patients with severe disease. As a result of changes made in their lifestyle, 66% in the patch-tested group and 51% in the non-patch-tested group reported 75% or more improvement in disease symptoms after 6 months. Early confirmation of diagnosis helped reduce the prediagnosis costs of treatment, which was mostly based on preliminary diagnosis. The greatest quality of life benefits from patch testing, relative to no patch testing, occurred in subjects with recurrent or chronic ACD. CONCLUSION: Patch testing is most cost-effective and reduces the cost of therapy in patients with severe ACD.

The use of decision-analytical modelling in economic evaluation of patch testing in allergic contact dermatitis.

OBJECTIVE: The objective of this observational prospective study was to demonstrate the cost effectiveness of patch testing in patients suspected of allergic contact dermatitis (ACD) and to determine the order in which different severity groups rank in terms of cost effectiveness. DESIGN AND SETTING: This observational study was conducted on 567 patients from 10 investigator sites in the US over a period of 1 year. All patients with a suspicion of contact allergy who exhibited at least moderate disease activity were included in the study and were stratified according to disease severity and whether or not they were patch tested. In each severity category, the cost effectiveness of patch testing was evaluated. Patients who were ruled out for contact allergy (without the use of patch test) by the first 6 months after admission were excluded. A validated dermatology-specific quality of life (DSQL) instrument was administered to all patients at the start of the study, and at 6 and 12 months thereafter. The cost-effectiveness analysis is demonstrated using a decision-analytical model. Costs included office visits and prescription costs without generic substitution. The cost of patch testing was not included due to the large variation in price among commercially available products. MAIN OUTCOME MEASURES AND RESULTS: Patch testing was performed on 22% of patients with mild disease, 41% of patients with moderate disease and 50% of those with severe disease. There was a significant difference between the patch-tested and non-patch-tested groups in terms of the time to obtain a confirmed diagnosis (medians = 8 and 175 days, respectively) and a significant difference in the ratio of patients who had a confirmed diagnosis (88 and 69%, respectively). As a result of changes made in their lifestyle, 66% of patients in the patch-tested group and 51% in the non-patch-tested group reported 75% or more improvement in their disease symptoms after 6 months. Early confirmation of diagnosis helped reduce the prediagnosis cost of treatment which was mostly based on preliminary diagnosis. The greatest quality-of-life (QOL) benefits from patch testing relative to nonpatch testing occurred in patients with recurrent/chronic ACD. CONCLUSIONS: Patch testing is most cost effective and reduces the cost of therapy in patients with severe ACD. Greater improvements in quality of life were seen in patients with recurrent/chronic ACD who were patch tested than patients who were not patch tested within the same group. Results were not sensitive to changes due to the addition of indirect costs or costs using generic substitution.

[New advances in contact allergology]. / Nouvelles avancées en allergologie de contact.

In October 1996, dermatologists commemorated the centenary of the Patch test that Jadassohn had developed in 1896 at Breslau. A great amount of scientific information came to light in the following years due to progress in immunology applied to dermatology. To consider the most important recent advances in the field of contact allergic dermatitis, it is necessary to recognise the role of adhesion molecules specific for antigen presenting dendritic cells, also keratinocytes as antigen presenting cells, the importance of CD8 cells, IL10, IL12 and IL1 and their role in modulation of the contact allergy reaction. The chemistry of haptens should lead to a decision as to whether a new molecule is allergic or not, as well as the different possibilities of bonding to form sensitizing complexes. Epidemiology and the present development of epicutaneous tests are at the centre of studies that are mentioned in this general review.

Impact of patch testing on dermatology-specific quality of life in patients with allergic contact dermatitis.

BACKGROUND: A dermatology-specific quality-of-life instrument has been created and validated for its sensitivity, reproducibility, content, and construct validity. This instrument was used in an observational prospective study that evaluated the cost-effectiveness of patch testing in patients with contact dermatitis and suspicion of allergic component. OBJECTIVE: This multicenter, prospective, observational study was designed to study the various direct and indirect costs associated with diagnosis and treatment of suspected allergic contact dermatitis and the benefits of diagnosis with and without patch testing. The costs and benefits of various methods of diagnosis are evaluated to determine if patch testing is more cost-effective as a diagnostic method. One of the outcomes evaluated was the quality of life of the participants in the study and the impact of patch testing on this cohort. METHODS: A total of 567 subjects were enrolled to obtain evaluable data from at least 500 subjects from ten study centers; the investigators were chosen so as to obtain a mix of stratified degrees of usage of patch testing. Data were collected on demographics, physical characteristics, history of disease, visits to physicians, and, to evaluate costs, the use of resources such as drugs, nondrug substances, and services; other outcome data collected were on physician evaluation of improvement, confirmation of diagnosis, physician opinion of the disease management, and patient evaluation of dermatology-specific quality of life (DSQL), and pertinent economic factors. Only 6-month and 12-month follow-up visits were mandatorily scheduled according to the protocol; however, participants and providers were free to arrange additional visits as deemed necessary for health care. RESULTS: This report focuses on the evaluations at the 6-month follow-up. There are completely evaluable data on pharmacoeconomics and DSQL for 431 patients. About 43% were patch tested, and the rest were diagnosed using the information from history and physical examinations. There was significantly better improvement in each of the DSQL domains in patch tested subjects compared with non-patch-tested subjects. In addition, patients treated in "low" use clinics had lower quality of life at 6-month follow-up than those treated in "high" use clinics. CONCLUSION: Patch testing helps to diagnose the etiology of contact dermatitis early and treat the disease before it becomes chronic, thus reducing resources used and improving patient quality of life considerably.

Practical issues in conducting pharmacoeconomic studies.

Many difficulties are inherent to pharmacoeconomic studies. Because these studies are observational, there are many factors that cannot be controlled; for example, there are many variations across the country in the practice of any particular therapy. Therefore, designing a case report form that will match the source documents from various investigator sites is not easy. Issues arise in every activity such as choice of investigator site, data collection, data analysis, and interpretation of the results. These issues will be discussed, and an example of a pharmacoeconomic study conducted to evaluate the cost-effectiveness of patch testing in patients diagnosed with allergic contact dermatitis will be presented.

A retrospective evaluation of patch testing in patients diagnosed with allergic contact dermatitis.

One reason given by clinicians for not using patch testing in patients with dermatitis is that it may not improve the treatment outcome. The main objectives of this retrospective study were to determine the frequency of use of patch testing as an aid to the diagnosis of allergic contact dermatitis (ACD), to determine the ACD-related costs before and after diagnosis of the disease, and to determine the benefit of the diagnosis of ACD, with or without patch testing, to the patient's treatment outcome. This study will also provide definite direction for a prospective outcome study. Medical records of 270 patients with ACD were utilized retrospectively to study the benefit of patch testing. Patch testing was performed on 56 percent of these patients. Patch testing was found to bring about a larger decrease in the disease severity index and percentage disease activity from prediagnosis to postdiagnosis than diagnosis without patch testing. In the group of patients with a prediagnosis disease duration of two months to one year, the postdiagnosis duration was considerably less for those patch tested and treated than those that were treated without patch testing. Patch testing was found to be the most cost-effective in patients with a disease duration of two months to one year.