Atopic Dermatitis

NEW ORLEANS - Food allergy continues to be misdiagnosed, in part because of clinician reliance on patch tests and food avoidance tests rather than on overt clinical signs of food allergy, according to Dr. Jon Hanifin.

Also, clinicians are often responsive to parents insistence that their children have food allergies. About 75% of what parents suspect to be food allergies are really just food intolerance, Dr. Hanifin, of Oregon Health and Science University in Portland, said at the annual meeting of the American Academy of Dermatology.

Food allergies typically have a rapid-onset reaction, usually consisting of urticaria, swelling, and respiratory or gastrointestinal symptoms, he said. The most common food allergens are egg, milk, peanut, soy, wheat, and fish.

In 2010, the National Institute of Allergy and Infectious Diseases issued new guidelines for the diagnosis and treatment of food allergies. The result of evaluations by a 25-member expert panel, which included three dermatologists, the guidelines were based on a systematic review of the available evidence from the Rand Corp. (JAMA 2010;303:1848-56).

The report concluded that food allergies affect at least 1%-2% – but fewer than 10% – of the United States population, and that most testing is not sufficient to diagnose the condition. Furthermore, food allergy has been misdiagnosed as a result of inadequate diagnostic criteria and the limited sensitivity and specificity of IgE testing.

In the guidelines, food allergy is now defined as an adverse health effect arising from a specific immune response that occurs upon exposure to a given food, said Dr. Hanifin.

Despite the publication of those guidelines, the nature of food allergies continues to be misunderstood, and clinicians continue to struggle to diagnose food allergies, he said. The costs of these misunderstandings include unnecessary visits to physicians and alternative practitioners, expensive test panels, and the expense of special foods. Some children even end up with impaired nutrition or poor growth as a result of dietary changes that were made in the belief that they would alleviate the allergy.

Dr. Hanifin reported no conflicts relevant to this talk.

NEW ORLEANS - Food allergy continues to be misdiagnosed, in part because of clinician reliance on patch tests and food avoidance tests rather than on overt clinical signs of food allergy, according to Dr. Jon Hanifin.

Also, clinicians are often responsive to parents insistence that their children have food allergies. About 75% of what parents suspect to be food allergies are really just food intolerance, Dr. Hanifin, of Oregon Health and Science University in Portland, said at the annual meeting of the American Academy of Dermatology.

Food allergies typically have a rapid-onset reaction, usually consisting of urticaria, swelling, and respiratory or gastrointestinal symptoms, he said. The most common food allergens are egg, milk, peanut, soy, wheat, and fish.

In 2010, the National Institute of Allergy and Infectious Diseases issued new guidelines for the diagnosis and treatment of food allergies. The result of evaluations by a 25-member expert panel, which included three dermatologists, the guidelines were based on a systematic review of the available evidence from the Rand Corp. (JAMA 2010;303:1848-56).

The report concluded that food allergies affect at least 1%-2% – but fewer than 10% – of the United States population, and that most testing is not sufficient to diagnose the condition. Furthermore, food allergy has been misdiagnosed as a result of inadequate diagnostic criteria and the limited sensitivity and specificity of IgE testing.

In the guidelines, food allergy is now defined as an adverse health effect arising from a specific immune response that occurs upon exposure to a given food, said Dr. Hanifin.

Despite the publication of those guidelines, the nature of food allergies continues to be misunderstood, and clinicians continue to struggle to diagnose food allergies, he said. The costs of these misunderstandings include unnecessary visits to physicians and alternative practitioners, expensive test panels, and the expense of special foods. Some children even end up with impaired nutrition or poor growth as a result of dietary changes that were made in the belief that they would alleviate the allergy.

Dr. Hanifin reported no conflicts relevant to this talk.

NEW ORLEANS - Food allergy continues to be misdiagnosed, in part because of clinician reliance on patch tests and food avoidance tests rather than on overt clinical signs of food allergy, according to Dr. Jon Hanifin.

Also, clinicians are often responsive to parents insistence that their children have food allergies. About 75% of what parents suspect to be food allergies are really just food intolerance, Dr. Hanifin, of Oregon Health and Science University in Portland, said at the annual meeting of the American Academy of Dermatology.

Food allergies typically have a rapid-onset reaction, usually consisting of urticaria, swelling, and respiratory or gastrointestinal symptoms, he said. The most common food allergens are egg, milk, peanut, soy, wheat, and fish.

In 2010, the National Institute of Allergy and Infectious Diseases issued new guidelines for the diagnosis and treatment of food allergies. The result of evaluations by a 25-member expert panel, which included three dermatologists, the guidelines were based on a systematic review of the available evidence from the Rand Corp. (JAMA 2010;303:1848-56).

The report concluded that food allergies affect at least 1%-2% – but fewer than 10% – of the United States population, and that most testing is not sufficient to diagnose the condition. Furthermore, food allergy has been misdiagnosed as a result of inadequate diagnostic criteria and the limited sensitivity and specificity of IgE testing.

In the guidelines, food allergy is now defined as an adverse health effect arising from a specific immune response that occurs upon exposure to a given food, said Dr. Hanifin.

Despite the publication of those guidelines, the nature of food allergies continues to be misunderstood, and clinicians continue to struggle to diagnose food allergies, he said. The costs of these misunderstandings include unnecessary visits to physicians and alternative practitioners, expensive test panels, and the expense of special foods. Some children even end up with impaired nutrition or poor growth as a result of dietary changes that were made in the belief that they would alleviate the allergy.

Dr. Hanifin reported no conflicts relevant to this talk.

NEW ORLEANS - A novel, highly attenuated, nonreplicating smallpox vaccine showed excellent safety and immunogenicity in atopic dermatitis patients in a phase II clinical trial.

"These results strongly suggest that [it] may be suitable for vaccination of atopic dermatitis patients, who are excluded from vaccination with traditional smallpox vaccines," Dr. Maria Yadira Hurley said in presenting the study findings at the annual meeting of the American Academy of Dermatology.

Called Imvamune, the vaccine is derived from the parent strain Modified Vaccinia virus Ankara (MVA-BN), a highly attenuated pox virus that has lost the capacity to replicate in human cells, according to its maker, Bavarian Nordic A/S, a Denmark-based biotechnology company.

Based upon the highly favorable results of this and more than a dozen other clinical trials totalling in excess of 2,500 subjects, the U.S. government is already stockpiling the vaccine. The government considers smallpox a top-level biologic threat and has placed high priority on developing a vaccine for individuals who aren't supposed to receive the current vaccines, all of which are live-virus vaccines requiring viral replication in order to generate immunity, explained Dr. Hurley, a dermatologist at St. Louis University.

The government estimates 28 million doses of the new smallpox vaccine are needed just for patients with active atopic dermatitis or a history of the disease. Other potential recipients of the vaccine include individuals who are HIV positive or otherwise immunocompromised, as well as their household contacts.

The phase II trial in which Dr. Hurley served as principal investigator included 350 subjects aged 18-40 years with mild to moderate atopic dermatitis and 282 healthy controls, all of whom received two vaccinations 4 weeks apart.

The vaccine was well tolerated, with no cases of eczema vaccinatum, myocarditis, or pericarditis. Additionally, there was no indication that the new vaccine worsens atopic dermatitis.

The atopic dermatitis patients generated strong vaccinia-specific immune responses similar to those noted in healthy controls. Neutralizing responses were comparable to what is seen with the traditional smallpox vaccines in healthy individuals. Immune responses were greatest in both study arms 2 weeks after the second vaccination.

Smallpox is estimated to have killed 300-500 million people worldwide in the 20th century alone. Although naturally occurring variola virus has been eradicated, stored samples are known to exist in the United States and Russia, and undeclared samples may exist elsewhere. The DNA sequence of the variola virus was published in 1992, and it's possible today to recreate the virus using gene synthesis techniques. Vaccination is the only known means of protection, Dr. Hurley noted.

She declared having received a research grant from Bavarian Nordic and being on the speakers bureaus for Abbott Laboratories and Amgen.

NEW ORLEANS - A novel, highly attenuated, nonreplicating smallpox vaccine showed excellent safety and immunogenicity in atopic dermatitis patients in a phase II clinical trial.

"These results strongly suggest that [it] may be suitable for vaccination of atopic dermatitis patients, who are excluded from vaccination with traditional smallpox vaccines," Dr. Maria Yadira Hurley said in presenting the study findings at the annual meeting of the American Academy of Dermatology.

Called Imvamune, the vaccine is derived from the parent strain Modified Vaccinia virus Ankara (MVA-BN), a highly attenuated pox virus that has lost the capacity to replicate in human cells, according to its maker, Bavarian Nordic A/S, a Denmark-based biotechnology company.

Based upon the highly favorable results of this and more than a dozen other clinical trials totalling in excess of 2,500 subjects, the U.S. government is already stockpiling the vaccine. The government considers smallpox a top-level biologic threat and has placed high priority on developing a vaccine for individuals who aren't supposed to receive the current vaccines, all of which are live-virus vaccines requiring viral replication in order to generate immunity, explained Dr. Hurley, a dermatologist at St. Louis University.

The government estimates 28 million doses of the new smallpox vaccine are needed just for patients with active atopic dermatitis or a history of the disease. Other potential recipients of the vaccine include individuals who are HIV positive or otherwise immunocompromised, as well as their household contacts.

The phase II trial in which Dr. Hurley served as principal investigator included 350 subjects aged 18-40 years with mild to moderate atopic dermatitis and 282 healthy controls, all of whom received two vaccinations 4 weeks apart.

The vaccine was well tolerated, with no cases of eczema vaccinatum, myocarditis, or pericarditis. Additionally, there was no indication that the new vaccine worsens atopic dermatitis.

The atopic dermatitis patients generated strong vaccinia-specific immune responses similar to those noted in healthy controls. Neutralizing responses were comparable to what is seen with the traditional smallpox vaccines in healthy individuals. Immune responses were greatest in both study arms 2 weeks after the second vaccination.

Smallpox is estimated to have killed 300-500 million people worldwide in the 20th century alone. Although naturally occurring variola virus has been eradicated, stored samples are known to exist in the United States and Russia, and undeclared samples may exist elsewhere. The DNA sequence of the variola virus was published in 1992, and it's possible today to recreate the virus using gene synthesis techniques. Vaccination is the only known means of protection, Dr. Hurley noted.

She declared having received a research grant from Bavarian Nordic and being on the speakers bureaus for Abbott Laboratories and Amgen.

NEW ORLEANS - A novel, highly attenuated, nonreplicating smallpox vaccine showed excellent safety and immunogenicity in atopic dermatitis patients in a phase II clinical trial.

"These results strongly suggest that [it] may be suitable for vaccination of atopic dermatitis patients, who are excluded from vaccination with traditional smallpox vaccines," Dr. Maria Yadira Hurley said in presenting the study findings at the annual meeting of the American Academy of Dermatology.

Called Imvamune, the vaccine is derived from the parent strain Modified Vaccinia virus Ankara (MVA-BN), a highly attenuated pox virus that has lost the capacity to replicate in human cells, according to its maker, Bavarian Nordic A/S, a Denmark-based biotechnology company.

Based upon the highly favorable results of this and more than a dozen other clinical trials totalling in excess of 2,500 subjects, the U.S. government is already stockpiling the vaccine. The government considers smallpox a top-level biologic threat and has placed high priority on developing a vaccine for individuals who aren't supposed to receive the current vaccines, all of which are live-virus vaccines requiring viral replication in order to generate immunity, explained Dr. Hurley, a dermatologist at St. Louis University.

The government estimates 28 million doses of the new smallpox vaccine are needed just for patients with active atopic dermatitis or a history of the disease. Other potential recipients of the vaccine include individuals who are HIV positive or otherwise immunocompromised, as well as their household contacts.

The phase II trial in which Dr. Hurley served as principal investigator included 350 subjects aged 18-40 years with mild to moderate atopic dermatitis and 282 healthy controls, all of whom received two vaccinations 4 weeks apart.

The vaccine was well tolerated, with no cases of eczema vaccinatum, myocarditis, or pericarditis. Additionally, there was no indication that the new vaccine worsens atopic dermatitis.

The atopic dermatitis patients generated strong vaccinia-specific immune responses similar to those noted in healthy controls. Neutralizing responses were comparable to what is seen with the traditional smallpox vaccines in healthy individuals. Immune responses were greatest in both study arms 2 weeks after the second vaccination.

Smallpox is estimated to have killed 300-500 million people worldwide in the 20th century alone. Although naturally occurring variola virus has been eradicated, stored samples are known to exist in the United States and Russia, and undeclared samples may exist elsewhere. The DNA sequence of the variola virus was published in 1992, and it's possible today to recreate the virus using gene synthesis techniques. Vaccination is the only known means of protection, Dr. Hurley noted.

She declared having received a research grant from Bavarian Nordic and being on the speakers bureaus for Abbott Laboratories and Amgen.

NEW ORLEANS – Topical immunomodulators did not increase overall risk for lymphoma in a large retrospective study of patients with atopic dermatitis.

Researchers identified 760 cases of lymphoma in a claims database of 625,915 atopic patients. They assessed risk of lymphoma associated with pimecrolimus cream 1%, tacrolimus ointment 0.1% or 0.3%, and topical corticosteroid treatment, compared with patients not treated with the agents. They also looked at a group of 3,040 atopic dermatitis patients to control for age and gender in each lymphoma case.

"This study found no increased risk of overall lymphoma in atopic dermatitis patients treated with topical corticosteroids or topical calcineurin inhibitors," said Dr. Alejandro Arana, a researcher in Zaragoza, Spain, at the annual meeting of the American Academy of Dermatology.

Compared with lymphoma risk in the control group of atopic dermatitis patients who did not use any of the agents in the study (odds ratio, 1), risk was lower with pimecrolimus (OR, 0.76) and topical corticosteroids (OR, 0.90). In contrast, risk was increased for patients treated with tacrolimus (OR, 1.24).

"The lower risk of lymphoma appears to be reassuring," said session moderator Dr. Jan Izakovic, a dermatologist at the University of Miami.

Because of specific concerns about elevated risk for lymphoma associated with topical immunomodulators in children and adolescents, Dr. Arana and his associates separately assessed the 186 atopic patients with lymphoma and 741 atopic controls younger than 20 years.

"The results were similar," said Dr. Arana.

In the younger population 186 atopic patients with lymphoma and 741 atopic controls all risks for lymphoma were lower: with pimecrolimus (OR, 0.64); topical corticosteroids (OR, 0.72); and tacrolimus (OR, 0.96).

"Among those younger than 20, we feel very reassured," Dr. Arana said. "We didn’t find any risk."

All atopic dermatitis and lymphoma cases were identified using ICD-9 codes in the PharMetrics Integrated Database between July 1995 and March 2009. Mean age was 38 years, and 43% of patients were male.

The researchers also looked at subtypes of lymphoma. Of the 760 cases, 106 were Hodgkin's lymphoma. The 200 cases of non-Hodgkin's lymphoma included 118 T-cell lymphomas, 30 B-cell lymphomas, and 52 indeterminate types. The remaining 454 cases (60%) were not classified by subtype, a potential limitation of the study.

"We also looked at exposure to immunomodulators and risk of T-cell lymphoma, the subtype we are most concerned about," Dr. Arana said.

Dr. Arana and his associates assessed this risk in patients of all ages. Compared with a reference group of 45 cases with T-cell lymphoma and 228 controls not exposed to any of the medications (OR, 1.0), risk was lower with pimecrolimus (OR, 0.85); slightly increased with corticosteroids (OR, 1.16); and greater with tacrolimus (OR, 4.95).

"We should be very, very careful with these results," Dr. Arana said. The results are only suggestive, he added, because of the small number of cases of T-cell lymphoma, and the researchers' inability to determine lymphoma subtype in a majority of cases. In addition, cases with more severe atopic dermatitis could have confounded the results.

Nevertheless, the study size was sufficient to precisely estimate the association between overall lymphoma risk and use of topical calcineurin inhibitors, Dr. Arana said.

The researchers also looked at overall risk of lymphoma in all patients by dose. For example, they looked at pimecrolimus doses less than 0.3 g; 0.3 g to less than 0.6 g; 0.6 g to less than 1.0 g; and 1.0 g or greater. They also looked at tacrolimus doses of less than 0.03 g; 0.03 g to less than 0.06 g; 0.06 g to less than 0.10 g; and 0.10 g or greater.

"We didn't see any dose response for any corticosteroids or pimecrolimus, and a slightly increased risk for tacrolimus of 0.10 g or greater, with an odds ratio of 2.08," Dr. Arana said.

The study was funded through an unrestricted grant from Novartis. Dr. Arana had no relevant disclosures, but said two of the study coauthors are Novartis employees.

NEW ORLEANS – Topical immunomodulators did not increase overall risk for lymphoma in a large retrospective study of patients with atopic dermatitis.

Researchers identified 760 cases of lymphoma in a claims database of 625,915 atopic patients. They assessed risk of lymphoma associated with pimecrolimus cream 1%, tacrolimus ointment 0.1% or 0.3%, and topical corticosteroid treatment, compared with patients not treated with the agents. They also looked at a group of 3,040 atopic dermatitis patients to control for age and gender in each lymphoma case.

"This study found no increased risk of overall lymphoma in atopic dermatitis patients treated with topical corticosteroids or topical calcineurin inhibitors," said Dr. Alejandro Arana, a researcher in Zaragoza, Spain, at the annual meeting of the American Academy of Dermatology.

Compared with lymphoma risk in the control group of atopic dermatitis patients who did not use any of the agents in the study (odds ratio, 1), risk was lower with pimecrolimus (OR, 0.76) and topical corticosteroids (OR, 0.90). In contrast, risk was increased for patients treated with tacrolimus (OR, 1.24).

"The lower risk of lymphoma appears to be reassuring," said session moderator Dr. Jan Izakovic, a dermatologist at the University of Miami.

Because of specific concerns about elevated risk for lymphoma associated with topical immunomodulators in children and adolescents, Dr. Arana and his associates separately assessed the 186 atopic patients with lymphoma and 741 atopic controls younger than 20 years.

"The results were similar," said Dr. Arana.

In the younger population 186 atopic patients with lymphoma and 741 atopic controls all risks for lymphoma were lower: with pimecrolimus (OR, 0.64); topical corticosteroids (OR, 0.72); and tacrolimus (OR, 0.96).

"Among those younger than 20, we feel very reassured," Dr. Arana said. "We didn’t find any risk."

All atopic dermatitis and lymphoma cases were identified using ICD-9 codes in the PharMetrics Integrated Database between July 1995 and March 2009. Mean age was 38 years, and 43% of patients were male.

The researchers also looked at subtypes of lymphoma. Of the 760 cases, 106 were Hodgkin's lymphoma. The 200 cases of non-Hodgkin's lymphoma included 118 T-cell lymphomas, 30 B-cell lymphomas, and 52 indeterminate types. The remaining 454 cases (60%) were not classified by subtype, a potential limitation of the study.

"We also looked at exposure to immunomodulators and risk of T-cell lymphoma, the subtype we are most concerned about," Dr. Arana said.

Dr. Arana and his associates assessed this risk in patients of all ages. Compared with a reference group of 45 cases with T-cell lymphoma and 228 controls not exposed to any of the medications (OR, 1.0), risk was lower with pimecrolimus (OR, 0.85); slightly increased with corticosteroids (OR, 1.16); and greater with tacrolimus (OR, 4.95).

"We should be very, very careful with these results," Dr. Arana said. The results are only suggestive, he added, because of the small number of cases of T-cell lymphoma, and the researchers' inability to determine lymphoma subtype in a majority of cases. In addition, cases with more severe atopic dermatitis could have confounded the results.

Nevertheless, the study size was sufficient to precisely estimate the association between overall lymphoma risk and use of topical calcineurin inhibitors, Dr. Arana said.

The researchers also looked at overall risk of lymphoma in all patients by dose. For example, they looked at pimecrolimus doses less than 0.3 g; 0.3 g to less than 0.6 g; 0.6 g to less than 1.0 g; and 1.0 g or greater. They also looked at tacrolimus doses of less than 0.03 g; 0.03 g to less than 0.06 g; 0.06 g to less than 0.10 g; and 0.10 g or greater.

"We didn't see any dose response for any corticosteroids or pimecrolimus, and a slightly increased risk for tacrolimus of 0.10 g or greater, with an odds ratio of 2.08," Dr. Arana said.

The study was funded through an unrestricted grant from Novartis. Dr. Arana had no relevant disclosures, but said two of the study coauthors are Novartis employees.

NEW ORLEANS – Topical immunomodulators did not increase overall risk for lymphoma in a large retrospective study of patients with atopic dermatitis.

Researchers identified 760 cases of lymphoma in a claims database of 625,915 atopic patients. They assessed risk of lymphoma associated with pimecrolimus cream 1%, tacrolimus ointment 0.1% or 0.3%, and topical corticosteroid treatment, compared with patients not treated with the agents. They also looked at a group of 3,040 atopic dermatitis patients to control for age and gender in each lymphoma case.

"This study found no increased risk of overall lymphoma in atopic dermatitis patients treated with topical corticosteroids or topical calcineurin inhibitors," said Dr. Alejandro Arana, a researcher in Zaragoza, Spain, at the annual meeting of the American Academy of Dermatology.

Compared with lymphoma risk in the control group of atopic dermatitis patients who did not use any of the agents in the study (odds ratio, 1), risk was lower with pimecrolimus (OR, 0.76) and topical corticosteroids (OR, 0.90). In contrast, risk was increased for patients treated with tacrolimus (OR, 1.24).

"The lower risk of lymphoma appears to be reassuring," said session moderator Dr. Jan Izakovic, a dermatologist at the University of Miami.

Because of specific concerns about elevated risk for lymphoma associated with topical immunomodulators in children and adolescents, Dr. Arana and his associates separately assessed the 186 atopic patients with lymphoma and 741 atopic controls younger than 20 years.

"The results were similar," said Dr. Arana.

In the younger population 186 atopic patients with lymphoma and 741 atopic controls all risks for lymphoma were lower: with pimecrolimus (OR, 0.64); topical corticosteroids (OR, 0.72); and tacrolimus (OR, 0.96).

"Among those younger than 20, we feel very reassured," Dr. Arana said. "We didn’t find any risk."

All atopic dermatitis and lymphoma cases were identified using ICD-9 codes in the PharMetrics Integrated Database between July 1995 and March 2009. Mean age was 38 years, and 43% of patients were male.

The researchers also looked at subtypes of lymphoma. Of the 760 cases, 106 were Hodgkin's lymphoma. The 200 cases of non-Hodgkin's lymphoma included 118 T-cell lymphomas, 30 B-cell lymphomas, and 52 indeterminate types. The remaining 454 cases (60%) were not classified by subtype, a potential limitation of the study.

"We also looked at exposure to immunomodulators and risk of T-cell lymphoma, the subtype we are most concerned about," Dr. Arana said.

Dr. Arana and his associates assessed this risk in patients of all ages. Compared with a reference group of 45 cases with T-cell lymphoma and 228 controls not exposed to any of the medications (OR, 1.0), risk was lower with pimecrolimus (OR, 0.85); slightly increased with corticosteroids (OR, 1.16); and greater with tacrolimus (OR, 4.95).

"We should be very, very careful with these results," Dr. Arana said. The results are only suggestive, he added, because of the small number of cases of T-cell lymphoma, and the researchers' inability to determine lymphoma subtype in a majority of cases. In addition, cases with more severe atopic dermatitis could have confounded the results.

Nevertheless, the study size was sufficient to precisely estimate the association between overall lymphoma risk and use of topical calcineurin inhibitors, Dr. Arana said.

The researchers also looked at overall risk of lymphoma in all patients by dose. For example, they looked at pimecrolimus doses less than 0.3 g; 0.3 g to less than 0.6 g; 0.6 g to less than 1.0 g; and 1.0 g or greater. They also looked at tacrolimus doses of less than 0.03 g; 0.03 g to less than 0.06 g; 0.06 g to less than 0.10 g; and 0.10 g or greater.

"We didn't see any dose response for any corticosteroids or pimecrolimus, and a slightly increased risk for tacrolimus of 0.10 g or greater, with an odds ratio of 2.08," Dr. Arana said.

The study was funded through an unrestricted grant from Novartis. Dr. Arana had no relevant disclosures, but said two of the study coauthors are Novartis employees.

NEW ORLEANS – Dimethyl fumarate – a volatile substance included in shipments of furniture, clothing, and shoes to inhibit growth of mold – earned the distinction as the American Contact Dermatitis Society's 2011 Allergen of the Year.

"We had a difficult decision," Dr. Donald V. Belsito said. "But we decided to go with dimethyl fumarate. It caused an epidemic in Europe starting in 2007."

The substance is now being regulated in Europe, "although apparently some stuff is still sneaking through," Dr. Belsito said. "To date, I know of no cases in the U.S., although Dr. Melanie Pratt has had a few cases in Ontario."

Dimethyl fumarate "produces an extremely severe dermatitis," said Dr. Belsito, a dermatologist in private practice in Shawnee, Kan.

The unlikely story behind identification of this preservative and fungicide demonstrates the benefits of international collaboration, he noted.

First noted by dermatologists in Finland, cases of the severe dermatitis began to appear in Sweden and the U.K. The severe rash, seen predominantly on the backs of the legs, buttocks, and back, was an etiologic mystery. Through extensive sleuth work, Finnish dermatologists determined a common link – each person recently purchased furniture from a particular Chinese manufacturer.

It then became commonly called "sofa dermatitis." A contact allergy to the upholstery fabric was initially suspected. However, no common chemical or fabric was identified among the different pieces of furniture purchased by affected patients.

Dr. Magnus Bruze, an occupational and environmental dermatologist at Malmo University in Sweden, and other investigators took apart the furniture, patch tested 40 affected patients to various components, and eventually identified the culprit: dimethyl fumarate. The allergen was enclosed in packets similar in appearance to silicone packets often labeled "Warning: Do Not Eat."

Dimethyl fumarate is so volatile it can vaporize within 6 weeks. The vapors cause the dermatitis – sometimes spread out and sometimes patchy – after permeating the sofas, clothing, and shoe products during shipment.

Particularly concerning is very low exposure levels to dimethyl fumarate can trigger a reaction, concentrations well below those of common contact dermatitis allergens.

In an unprecedented move, Dr. Belsito revealed the leading contender, at least for now, for the 2012 Allergen of the Year: acrylates and methacrylates. Acrylates and methacrylates are polymers and adhesives. Methacrylate, for example, is used as bone cement for prosthetic devices placed during orthopedic surgery. The ACDS is soliciting feedback from members about naming this class of compounds at their next Allergen of the Year.

Neomcyin was the 2010 Allergen of the Year. Dr. Belsito described neomycin reactions as "common, not readily recognized, and problematic." Neomycin was chosen because of its widespread use as an over-the-counter antibiotic product; its high propensity for cross-reaction with other agents in the aminoglycoside class, including gentamicin, kanamycin, and tobramycin; and because neomycin is included as a preservative in some vaccines. Because a neomycin allergy is not a type 1 IgE-mediated, a reaction results in eczema, not anaphylaxis and death.

Gold was the 2001 Allergen of the Year, and reactions to gold are common and clinically problematic. Bacitracin (2003) and glucocorticosteroids (2005) are other allergens that are both common and clinically relevant. In contrast, thimerosal (2002) is a common but nonrelevant allergen because it has been removed from most products in the United States. A reaction to mixed dialkyl thioureas (2009), used in production of rubber products, is relatively uncommon but important when it occurs.

Dr. Belsito said that he had no relevant disclosures.

NEW ORLEANS – Dimethyl fumarate – a volatile substance included in shipments of furniture, clothing, and shoes to inhibit growth of mold – earned the distinction as the American Contact Dermatitis Society's 2011 Allergen of the Year.

"We had a difficult decision," Dr. Donald V. Belsito said. "But we decided to go with dimethyl fumarate. It caused an epidemic in Europe starting in 2007."

The substance is now being regulated in Europe, "although apparently some stuff is still sneaking through," Dr. Belsito said. "To date, I know of no cases in the U.S., although Dr. Melanie Pratt has had a few cases in Ontario."

Dimethyl fumarate "produces an extremely severe dermatitis," said Dr. Belsito, a dermatologist in private practice in Shawnee, Kan.

The unlikely story behind identification of this preservative and fungicide demonstrates the benefits of international collaboration, he noted.

First noted by dermatologists in Finland, cases of the severe dermatitis began to appear in Sweden and the U.K. The severe rash, seen predominantly on the backs of the legs, buttocks, and back, was an etiologic mystery. Through extensive sleuth work, Finnish dermatologists determined a common link – each person recently purchased furniture from a particular Chinese manufacturer.

It then became commonly called "sofa dermatitis." A contact allergy to the upholstery fabric was initially suspected. However, no common chemical or fabric was identified among the different pieces of furniture purchased by affected patients.

Dr. Magnus Bruze, an occupational and environmental dermatologist at Malmo University in Sweden, and other investigators took apart the furniture, patch tested 40 affected patients to various components, and eventually identified the culprit: dimethyl fumarate. The allergen was enclosed in packets similar in appearance to silicone packets often labeled "Warning: Do Not Eat."

Dimethyl fumarate is so volatile it can vaporize within 6 weeks. The vapors cause the dermatitis – sometimes spread out and sometimes patchy – after permeating the sofas, clothing, and shoe products during shipment.

Particularly concerning is very low exposure levels to dimethyl fumarate can trigger a reaction, concentrations well below those of common contact dermatitis allergens.

In an unprecedented move, Dr. Belsito revealed the leading contender, at least for now, for the 2012 Allergen of the Year: acrylates and methacrylates. Acrylates and methacrylates are polymers and adhesives. Methacrylate, for example, is used as bone cement for prosthetic devices placed during orthopedic surgery. The ACDS is soliciting feedback from members about naming this class of compounds at their next Allergen of the Year.

Neomcyin was the 2010 Allergen of the Year. Dr. Belsito described neomycin reactions as "common, not readily recognized, and problematic." Neomycin was chosen because of its widespread use as an over-the-counter antibiotic product; its high propensity for cross-reaction with other agents in the aminoglycoside class, including gentamicin, kanamycin, and tobramycin; and because neomycin is included as a preservative in some vaccines. Because a neomycin allergy is not a type 1 IgE-mediated, a reaction results in eczema, not anaphylaxis and death.

Gold was the 2001 Allergen of the Year, and reactions to gold are common and clinically problematic. Bacitracin (2003) and glucocorticosteroids (2005) are other allergens that are both common and clinically relevant. In contrast, thimerosal (2002) is a common but nonrelevant allergen because it has been removed from most products in the United States. A reaction to mixed dialkyl thioureas (2009), used in production of rubber products, is relatively uncommon but important when it occurs.

Dr. Belsito said that he had no relevant disclosures.

NEW ORLEANS – Dimethyl fumarate – a volatile substance included in shipments of furniture, clothing, and shoes to inhibit growth of mold – earned the distinction as the American Contact Dermatitis Society's 2011 Allergen of the Year.

"We had a difficult decision," Dr. Donald V. Belsito said. "But we decided to go with dimethyl fumarate. It caused an epidemic in Europe starting in 2007."

The substance is now being regulated in Europe, "although apparently some stuff is still sneaking through," Dr. Belsito said. "To date, I know of no cases in the U.S., although Dr. Melanie Pratt has had a few cases in Ontario."

Dimethyl fumarate "produces an extremely severe dermatitis," said Dr. Belsito, a dermatologist in private practice in Shawnee, Kan.

The unlikely story behind identification of this preservative and fungicide demonstrates the benefits of international collaboration, he noted.

First noted by dermatologists in Finland, cases of the severe dermatitis began to appear in Sweden and the U.K. The severe rash, seen predominantly on the backs of the legs, buttocks, and back, was an etiologic mystery. Through extensive sleuth work, Finnish dermatologists determined a common link – each person recently purchased furniture from a particular Chinese manufacturer.

It then became commonly called "sofa dermatitis." A contact allergy to the upholstery fabric was initially suspected. However, no common chemical or fabric was identified among the different pieces of furniture purchased by affected patients.

Dr. Magnus Bruze, an occupational and environmental dermatologist at Malmo University in Sweden, and other investigators took apart the furniture, patch tested 40 affected patients to various components, and eventually identified the culprit: dimethyl fumarate. The allergen was enclosed in packets similar in appearance to silicone packets often labeled "Warning: Do Not Eat."

Dimethyl fumarate is so volatile it can vaporize within 6 weeks. The vapors cause the dermatitis – sometimes spread out and sometimes patchy – after permeating the sofas, clothing, and shoe products during shipment.

Particularly concerning is very low exposure levels to dimethyl fumarate can trigger a reaction, concentrations well below those of common contact dermatitis allergens.

In an unprecedented move, Dr. Belsito revealed the leading contender, at least for now, for the 2012 Allergen of the Year: acrylates and methacrylates. Acrylates and methacrylates are polymers and adhesives. Methacrylate, for example, is used as bone cement for prosthetic devices placed during orthopedic surgery. The ACDS is soliciting feedback from members about naming this class of compounds at their next Allergen of the Year.

Neomcyin was the 2010 Allergen of the Year. Dr. Belsito described neomycin reactions as "common, not readily recognized, and problematic." Neomycin was chosen because of its widespread use as an over-the-counter antibiotic product; its high propensity for cross-reaction with other agents in the aminoglycoside class, including gentamicin, kanamycin, and tobramycin; and because neomycin is included as a preservative in some vaccines. Because a neomycin allergy is not a type 1 IgE-mediated, a reaction results in eczema, not anaphylaxis and death.

Gold was the 2001 Allergen of the Year, and reactions to gold are common and clinically problematic. Bacitracin (2003) and glucocorticosteroids (2005) are other allergens that are both common and clinically relevant. In contrast, thimerosal (2002) is a common but nonrelevant allergen because it has been removed from most products in the United States. A reaction to mixed dialkyl thioureas (2009), used in production of rubber products, is relatively uncommon but important when it occurs.

Dr. Belsito said that he had no relevant disclosures.

LAS VEGAS – Immunosuppressive drug therapy is not an absolute contraindication for allergy patch testing, according to Dr. Joseph F. Fowler Jr.

A recent report on 11 patients who underwent patch testing while on a variety of systemic immunosuppressive drugs suggested patch testing may be more successful than many clinicians think, Dr. Fowler said. Speaking at the seminar sponsored by Skin Disease Education Foundation (SDEF), he fleshed out the findings with advice from his own experience in patch testing patients on immunosuppressives.

The retrospective chart review included patients on prednisone, cyclosporine, mycophenolate mofetil, or infliximab (Dermatitis 2009;20:265-70).

All but one of the patients who were taking 10 mg/day of prednisone had positive patch test reactions, said Dr. Fowler of the University of Louisville (Ky.) and president of the North American Contact Dermatitis Group.

"In the past, we had thought that about 10 mg/day was the maximum" prednisone dose that could still allow successful patch testing, but this belief was based on extrapolations of animal studies and case reports, with no hard data, he said. "I have personally seen patients who are on higher doses of prednisone produce good positive reactions."

Ideally, though, it’s best to patch test when patients are off prednisone, or on doses of 10 mg/day or less, he added. "If you could get them on every-other-day prednisone dosing, that would be even better."

For an untreated patient with fairly bad dermatitis, especially on the back, Dr. Fowler may treat for 5-7 days with a corticosteroid, perhaps prednisone 40-60 mg/day with no taper, and then stop the corticosteroid for 2-3 days before patch testing. "That’s one way you can get a person clear enough to patch test them if they’re already broken out," he said.

If the patient already is on chronic corticosteroid therapy, he tries to reduce the dose to 10 mg/day or less for several weeks before patch testing.

Dr. Fowler was surprised patients in the report who were being treated with cyclosporine 200 or 300 mg/day all had positive reactions to patch testing. "Generally, we expect cyclosporine to reduce the likelihood of positive reactions because of its broad immunosuppressant effect," he said. "These folks were on relatively low doses, so maybe that was a factor." In his own experience, Dr. Fowler said he has rarely seen positive reactions to patch testing in patients on cyclosporine, "so I think that’s problematic," he added.

One patient on mycophenolate (CellCept) 2 g/day had a negative result when patch tested but then stopped the drug and had a positive reaction on repeat patch testing. "That would suggest that the CellCept suppressed reactions," Dr. Fowler said. He advised not patch testing patients who are on CellCept, cyclosporine, tacrolimus, or azathioprine if at all possible.

One patient on infliximab (Remicade) whose last infusion occurred 3 weeks before patch testing developed multiple positive reactions. "That mirrors what I’ve been perceiving in clinical practice," he said.

Use of methotrexate or tumor necrosis factor–alpha inhibitors such as Remicade or etanercept (Enbrel) should not prevent patch testing. "I’ve had no problem patch testing people on methotrexate," Dr. Fowler said.

The report did not include antihistamines, which also are not a barrier to patch testing. "Other docs, allergists especially, tell patients they can’t take antihistamines when they’re being patch tested," he explained. "They may not be able to take antihistamines and get a good scratch test result, but remember in patch testing you’re looking at a T cell–mediated process. Antihistamines have essentially no effect on that."

Dr. Fowler has been a consultant, speaker, or researcher for Coria, Galderma, Graceway, Hyland, Johnson & Johnson, Quinnova, Ranbaxy, Shire, Stiefel, Triax, UCB, Medicis, Novartis, Abbott, Taro, Allerderm, Allergan, Amgen, Astellas, Centocor, Dermik, Dow, Genentech, Taisho, and 3M.

SDEF and this news organization are owned by Elsevier.

LAS VEGAS – Immunosuppressive drug therapy is not an absolute contraindication for allergy patch testing, according to Dr. Joseph F. Fowler Jr.

A recent report on 11 patients who underwent patch testing while on a variety of systemic immunosuppressive drugs suggested patch testing may be more successful than many clinicians think, Dr. Fowler said. Speaking at the seminar sponsored by Skin Disease Education Foundation (SDEF), he fleshed out the findings with advice from his own experience in patch testing patients on immunosuppressives.

The retrospective chart review included patients on prednisone, cyclosporine, mycophenolate mofetil, or infliximab (Dermatitis 2009;20:265-70).

All but one of the patients who were taking 10 mg/day of prednisone had positive patch test reactions, said Dr. Fowler of the University of Louisville (Ky.) and president of the North American Contact Dermatitis Group.

"In the past, we had thought that about 10 mg/day was the maximum" prednisone dose that could still allow successful patch testing, but this belief was based on extrapolations of animal studies and case reports, with no hard data, he said. "I have personally seen patients who are on higher doses of prednisone produce good positive reactions."

Ideally, though, it’s best to patch test when patients are off prednisone, or on doses of 10 mg/day or less, he added. "If you could get them on every-other-day prednisone dosing, that would be even better."

For an untreated patient with fairly bad dermatitis, especially on the back, Dr. Fowler may treat for 5-7 days with a corticosteroid, perhaps prednisone 40-60 mg/day with no taper, and then stop the corticosteroid for 2-3 days before patch testing. "That’s one way you can get a person clear enough to patch test them if they’re already broken out," he said.

If the patient already is on chronic corticosteroid therapy, he tries to reduce the dose to 10 mg/day or less for several weeks before patch testing.

Dr. Fowler was surprised patients in the report who were being treated with cyclosporine 200 or 300 mg/day all had positive reactions to patch testing. "Generally, we expect cyclosporine to reduce the likelihood of positive reactions because of its broad immunosuppressant effect," he said. "These folks were on relatively low doses, so maybe that was a factor." In his own experience, Dr. Fowler said he has rarely seen positive reactions to patch testing in patients on cyclosporine, "so I think that’s problematic," he added.

One patient on mycophenolate (CellCept) 2 g/day had a negative result when patch tested but then stopped the drug and had a positive reaction on repeat patch testing. "That would suggest that the CellCept suppressed reactions," Dr. Fowler said. He advised not patch testing patients who are on CellCept, cyclosporine, tacrolimus, or azathioprine if at all possible.

One patient on infliximab (Remicade) whose last infusion occurred 3 weeks before patch testing developed multiple positive reactions. "That mirrors what I’ve been perceiving in clinical practice," he said.

Use of methotrexate or tumor necrosis factor–alpha inhibitors such as Remicade or etanercept (Enbrel) should not prevent patch testing. "I’ve had no problem patch testing people on methotrexate," Dr. Fowler said.

The report did not include antihistamines, which also are not a barrier to patch testing. "Other docs, allergists especially, tell patients they can’t take antihistamines when they’re being patch tested," he explained. "They may not be able to take antihistamines and get a good scratch test result, but remember in patch testing you’re looking at a T cell–mediated process. Antihistamines have essentially no effect on that."

Dr. Fowler has been a consultant, speaker, or researcher for Coria, Galderma, Graceway, Hyland, Johnson & Johnson, Quinnova, Ranbaxy, Shire, Stiefel, Triax, UCB, Medicis, Novartis, Abbott, Taro, Allerderm, Allergan, Amgen, Astellas, Centocor, Dermik, Dow, Genentech, Taisho, and 3M.

SDEF and this news organization are owned by Elsevier.

LAS VEGAS – Immunosuppressive drug therapy is not an absolute contraindication for allergy patch testing, according to Dr. Joseph F. Fowler Jr.

A recent report on 11 patients who underwent patch testing while on a variety of systemic immunosuppressive drugs suggested patch testing may be more successful than many clinicians think, Dr. Fowler said. Speaking at the seminar sponsored by Skin Disease Education Foundation (SDEF), he fleshed out the findings with advice from his own experience in patch testing patients on immunosuppressives.

The retrospective chart review included patients on prednisone, cyclosporine, mycophenolate mofetil, or infliximab (Dermatitis 2009;20:265-70).

All but one of the patients who were taking 10 mg/day of prednisone had positive patch test reactions, said Dr. Fowler of the University of Louisville (Ky.) and president of the North American Contact Dermatitis Group.

"In the past, we had thought that about 10 mg/day was the maximum" prednisone dose that could still allow successful patch testing, but this belief was based on extrapolations of animal studies and case reports, with no hard data, he said. "I have personally seen patients who are on higher doses of prednisone produce good positive reactions."

Ideally, though, it’s best to patch test when patients are off prednisone, or on doses of 10 mg/day or less, he added. "If you could get them on every-other-day prednisone dosing, that would be even better."

For an untreated patient with fairly bad dermatitis, especially on the back, Dr. Fowler may treat for 5-7 days with a corticosteroid, perhaps prednisone 40-60 mg/day with no taper, and then stop the corticosteroid for 2-3 days before patch testing. "That’s one way you can get a person clear enough to patch test them if they’re already broken out," he said.

If the patient already is on chronic corticosteroid therapy, he tries to reduce the dose to 10 mg/day or less for several weeks before patch testing.

Dr. Fowler was surprised patients in the report who were being treated with cyclosporine 200 or 300 mg/day all had positive reactions to patch testing. "Generally, we expect cyclosporine to reduce the likelihood of positive reactions because of its broad immunosuppressant effect," he said. "These folks were on relatively low doses, so maybe that was a factor." In his own experience, Dr. Fowler said he has rarely seen positive reactions to patch testing in patients on cyclosporine, "so I think that’s problematic," he added.

One patient on mycophenolate (CellCept) 2 g/day had a negative result when patch tested but then stopped the drug and had a positive reaction on repeat patch testing. "That would suggest that the CellCept suppressed reactions," Dr. Fowler said. He advised not patch testing patients who are on CellCept, cyclosporine, tacrolimus, or azathioprine if at all possible.

One patient on infliximab (Remicade) whose last infusion occurred 3 weeks before patch testing developed multiple positive reactions. "That mirrors what I’ve been perceiving in clinical practice," he said.

Use of methotrexate or tumor necrosis factor–alpha inhibitors such as Remicade or etanercept (Enbrel) should not prevent patch testing. "I’ve had no problem patch testing people on methotrexate," Dr. Fowler said.

The report did not include antihistamines, which also are not a barrier to patch testing. "Other docs, allergists especially, tell patients they can’t take antihistamines when they’re being patch tested," he explained. "They may not be able to take antihistamines and get a good scratch test result, but remember in patch testing you’re looking at a T cell–mediated process. Antihistamines have essentially no effect on that."

Dr. Fowler has been a consultant, speaker, or researcher for Coria, Galderma, Graceway, Hyland, Johnson & Johnson, Quinnova, Ranbaxy, Shire, Stiefel, Triax, UCB, Medicis, Novartis, Abbott, Taro, Allerderm, Allergan, Amgen, Astellas, Centocor, Dermik, Dow, Genentech, Taisho, and 3M.

SDEF and this news organization are owned by Elsevier.

After 2 years of deliberations, evidence review, and public comments, the National Institute of Allergy and Infectious Diseases released a first-of-its-kind guideline for physicians on the diagnosis and management of food allergy in the United States.

While the document, which was released on Dec. 6 by the NIAID, is not specifically targeted at dermatologists, it is imperative that we become familiar with these guidelines to help improve the care of our patients with atopic dermatitis. The Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-sponsored Expert Panel is available for free at that the agency Web site, and has been published in The Journal of Allergy and Clinical Immunology (2010;126:1105-18).

The evidence is clear that clinically relevant food allergies are more common in patients with moderate to severe atopic dermatitis. Therefore, as dermatologists, we must recognize that we are taking care of patients who are at an increased risk for significant food allergies. In fact, data show that as many as 30%-40% of patients with moderate to severe atopic dermatitis may also have a food allergy.

It is especially important to keep this in mind when seeing pediatric patients. Children are particularly at risk for food allergies, including anaphylaxis. The food allergies that are most common in children with atopic dermatitis are milk, egg, peanut, wheat, and soy.

The NIAID guidelines panel concluded that in children under age 5 years with moderate to severe atopic dermatitis whose condition is persistent despite optimized management with topical therapy, or where there is a reasonable history of an immediate allergic reaction after ingesting a specific food, physicians should consider having the child tested for food allergies.

Skin prick and serum IgE tests are reasonable options for allergy testing. Physicians should steer clear of other testing methods, which the NIAID guidelines show are not supported by evidence. However, even skin prick and serum IgE tests have their limitations. These tests are considered overly sensitive and in testing a large population, many individuals will have positive tests but will not have clinically notable allergic responses when challenged with the food.

These false positives can create a great deal of confusion, and patients and their families need to be counseled that a positive test doesn't necessarily mean that they are allergic. There is a real risk that people will have their children avoid foods that could have a significant impact on their growth and development.

At Rady Children's Hospital, we have seen two children in the last 6 months who had significant malnutrition because their families were avoiding broad sets of foods because of concerns that foods might be contributing to severe eczema.

Another important take-home message from the new guidelines is that food allergen avoidance is rarely useful in treating atopic dermatitis. However, if someone with atopic dermatitis has a clinically significant food allergy, which might include hives, gastrointestinal effects, or angioedema, for instance, avoidance is a reasonable strategy.

Even when a food allergy is not the trigger for a dermatologic condition, it is important for dermatologists to ask patients about possible allergic reactions related to food. Since our atopic dermatitis patients are at increased risk for food allergies, our time with them can be an opportunity to prescribe intramuscular epinephrine as a treatment for potential, acute, life-threatening food allergies. EpiPens and EpiPen juniors are appropriate for individuals at almost any age and can be life saving.

The guidelines provide important information on non-IgE allergies to food such as allergic contact dermatitis and the rare systemic contact dermatitis, as well as IgE-mediated contact urticaria. These are all conditions that dermatologists should be aware of as other manifestations of food allergy.

Dermatologists can have confidence that these guidelines are thoughtful and evidence-based and were developed with significant input from the dermatology community, including participation by the American Academy of Dermatology, the Society for Investigative Dermatology, and the Society for Pediatric Dermatology.

Dermatologists continue to be the experts in the diagnosis and management of atopic dermatitis and can help to determine optimal disease care for our patients. We have a responsibility to be aware of the new food allergy guidelines and specifically the recommendations related to consideration of food allergy in children with seemingly intractable atopic disease.

Dr. Eichenfield is chief of pediatric and adolescent dermatology and professor of pediatrics and medicine (dermatology) at Rady Children’s Hospital and University of California, San Diego, and served as a member of the expert panel that developed the NIAID food allergy guidelines. Dr. Eichenfield has received funding and grants from a variety of not-for-profit foundations, as well as Astellas, Ferndale, Johnson and Johnson, Novartis, Sinclair, Stiefel, and Therapeutics Inc.

After 2 years of deliberations, evidence review, and public comments, the National Institute of Allergy and Infectious Diseases released a first-of-its-kind guideline for physicians on the diagnosis and management of food allergy in the United States.

While the document, which was released on Dec. 6 by the NIAID, is not specifically targeted at dermatologists, it is imperative that we become familiar with these guidelines to help improve the care of our patients with atopic dermatitis. The Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-sponsored Expert Panel is available for free at that the agency Web site, and has been published in The Journal of Allergy and Clinical Immunology (2010;126:1105-18).

The evidence is clear that clinically relevant food allergies are more common in patients with moderate to severe atopic dermatitis. Therefore, as dermatologists, we must recognize that we are taking care of patients who are at an increased risk for significant food allergies. In fact, data show that as many as 30%-40% of patients with moderate to severe atopic dermatitis may also have a food allergy.

It is especially important to keep this in mind when seeing pediatric patients. Children are particularly at risk for food allergies, including anaphylaxis. The food allergies that are most common in children with atopic dermatitis are milk, egg, peanut, wheat, and soy.

The NIAID guidelines panel concluded that in children under age 5 years with moderate to severe atopic dermatitis whose condition is persistent despite optimized management with topical therapy, or where there is a reasonable history of an immediate allergic reaction after ingesting a specific food, physicians should consider having the child tested for food allergies.

Skin prick and serum IgE tests are reasonable options for allergy testing. Physicians should steer clear of other testing methods, which the NIAID guidelines show are not supported by evidence. However, even skin prick and serum IgE tests have their limitations. These tests are considered overly sensitive and in testing a large population, many individuals will have positive tests but will not have clinically notable allergic responses when challenged with the food.

These false positives can create a great deal of confusion, and patients and their families need to be counseled that a positive test doesn't necessarily mean that they are allergic. There is a real risk that people will have their children avoid foods that could have a significant impact on their growth and development.

At Rady Children's Hospital, we have seen two children in the last 6 months who had significant malnutrition because their families were avoiding broad sets of foods because of concerns that foods might be contributing to severe eczema.

Another important take-home message from the new guidelines is that food allergen avoidance is rarely useful in treating atopic dermatitis. However, if someone with atopic dermatitis has a clinically significant food allergy, which might include hives, gastrointestinal effects, or angioedema, for instance, avoidance is a reasonable strategy.

Even when a food allergy is not the trigger for a dermatologic condition, it is important for dermatologists to ask patients about possible allergic reactions related to food. Since our atopic dermatitis patients are at increased risk for food allergies, our time with them can be an opportunity to prescribe intramuscular epinephrine as a treatment for potential, acute, life-threatening food allergies. EpiPens and EpiPen juniors are appropriate for individuals at almost any age and can be life saving.

The guidelines provide important information on non-IgE allergies to food such as allergic contact dermatitis and the rare systemic contact dermatitis, as well as IgE-mediated contact urticaria. These are all conditions that dermatologists should be aware of as other manifestations of food allergy.

Dermatologists can have confidence that these guidelines are thoughtful and evidence-based and were developed with significant input from the dermatology community, including participation by the American Academy of Dermatology, the Society for Investigative Dermatology, and the Society for Pediatric Dermatology.

Dermatologists continue to be the experts in the diagnosis and management of atopic dermatitis and can help to determine optimal disease care for our patients. We have a responsibility to be aware of the new food allergy guidelines and specifically the recommendations related to consideration of food allergy in children with seemingly intractable atopic disease.

Dr. Eichenfield is chief of pediatric and adolescent dermatology and professor of pediatrics and medicine (dermatology) at Rady Children’s Hospital and University of California, San Diego, and served as a member of the expert panel that developed the NIAID food allergy guidelines. Dr. Eichenfield has received funding and grants from a variety of not-for-profit foundations, as well as Astellas, Ferndale, Johnson and Johnson, Novartis, Sinclair, Stiefel, and Therapeutics Inc.

After 2 years of deliberations, evidence review, and public comments, the National Institute of Allergy and Infectious Diseases released a first-of-its-kind guideline for physicians on the diagnosis and management of food allergy in the United States.

While the document, which was released on Dec. 6 by the NIAID, is not specifically targeted at dermatologists, it is imperative that we become familiar with these guidelines to help improve the care of our patients with atopic dermatitis. The Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-sponsored Expert Panel is available for free at that the agency Web site, and has been published in The Journal of Allergy and Clinical Immunology (2010;126:1105-18).

The evidence is clear that clinically relevant food allergies are more common in patients with moderate to severe atopic dermatitis. Therefore, as dermatologists, we must recognize that we are taking care of patients who are at an increased risk for significant food allergies. In fact, data show that as many as 30%-40% of patients with moderate to severe atopic dermatitis may also have a food allergy.

It is especially important to keep this in mind when seeing pediatric patients. Children are particularly at risk for food allergies, including anaphylaxis. The food allergies that are most common in children with atopic dermatitis are milk, egg, peanut, wheat, and soy.

The NIAID guidelines panel concluded that in children under age 5 years with moderate to severe atopic dermatitis whose condition is persistent despite optimized management with topical therapy, or where there is a reasonable history of an immediate allergic reaction after ingesting a specific food, physicians should consider having the child tested for food allergies.

Skin prick and serum IgE tests are reasonable options for allergy testing. Physicians should steer clear of other testing methods, which the NIAID guidelines show are not supported by evidence. However, even skin prick and serum IgE tests have their limitations. These tests are considered overly sensitive and in testing a large population, many individuals will have positive tests but will not have clinically notable allergic responses when challenged with the food.

These false positives can create a great deal of confusion, and patients and their families need to be counseled that a positive test doesn't necessarily mean that they are allergic. There is a real risk that people will have their children avoid foods that could have a significant impact on their growth and development.

At Rady Children's Hospital, we have seen two children in the last 6 months who had significant malnutrition because their families were avoiding broad sets of foods because of concerns that foods might be contributing to severe eczema.

Another important take-home message from the new guidelines is that food allergen avoidance is rarely useful in treating atopic dermatitis. However, if someone with atopic dermatitis has a clinically significant food allergy, which might include hives, gastrointestinal effects, or angioedema, for instance, avoidance is a reasonable strategy.

Even when a food allergy is not the trigger for a dermatologic condition, it is important for dermatologists to ask patients about possible allergic reactions related to food. Since our atopic dermatitis patients are at increased risk for food allergies, our time with them can be an opportunity to prescribe intramuscular epinephrine as a treatment for potential, acute, life-threatening food allergies. EpiPens and EpiPen juniors are appropriate for individuals at almost any age and can be life saving.

The guidelines provide important information on non-IgE allergies to food such as allergic contact dermatitis and the rare systemic contact dermatitis, as well as IgE-mediated contact urticaria. These are all conditions that dermatologists should be aware of as other manifestations of food allergy.

Dermatologists can have confidence that these guidelines are thoughtful and evidence-based and were developed with significant input from the dermatology community, including participation by the American Academy of Dermatology, the Society for Investigative Dermatology, and the Society for Pediatric Dermatology.

Dermatologists continue to be the experts in the diagnosis and management of atopic dermatitis and can help to determine optimal disease care for our patients. We have a responsibility to be aware of the new food allergy guidelines and specifically the recommendations related to consideration of food allergy in children with seemingly intractable atopic disease.

Dr. Eichenfield is chief of pediatric and adolescent dermatology and professor of pediatrics and medicine (dermatology) at Rady Children’s Hospital and University of California, San Diego, and served as a member of the expert panel that developed the NIAID food allergy guidelines. Dr. Eichenfield has received funding and grants from a variety of not-for-profit foundations, as well as Astellas, Ferndale, Johnson and Johnson, Novartis, Sinclair, Stiefel, and Therapeutics Inc.

GOTHENBURG, SWEDEN - Compliance with topical dermatologic therapies is worse than most physicians realize, according to a new study presented at the annual congress of the European Academy for Dermatology and Venereology.

Through a series of Danish studies utilizing the nation’s comprehensive electronic medical and pharmacy records system, investigators concluded that more than one in three new prescriptions for creams and ointments for dermatologic diseases is never picked up. And for those who actually do fill their prescriptions, treatment adherence just goes downhill from there.

"I would say that even an optimistic estimate would be that only one in five patients truly follows the treatment advice and takes their treatment at home. It's really an alarming figure. The typical result is that the patient comes in complaining, 'It didn't work, doctor,' and now they expect another prescription," Dr. Jørgen Serup said.

"Creams and ointments are truly messy, greasy, cumbersome, and patients can only treat a limited number of lesions on a limited area, and only on certain anatomic sites. These are serious limitations. This is a lot more difficult than just taking a pill," added Dr. Serup, professor of dermatology at Copenhagen University. "Maybe the creams and ointments are really obsolete because they are so difficult to use in clinical practice. Maybe we should be using much more systemic therapy."

He and his colleagues examined all new prescriptions for previously untried medications issued for dermatologic outpatients at Copenhagen University Hospital every 15th day during 2006. Thirty-one percent of the 322 eligible patients exhibited what Dr. Serup termed "primary nonadherence," meaning they never collected their medication. Patients with psoriasis were the biggest offenders; they failed to pick up their medications 44% of the time. This was also the case for 31% of atopic dermatitis patients, 12% being treated for skin infections, and 9% of acne patients.

Thirty-five percent of prescriptions for topical preparations remained behind the pharmacy counter. Prescriptions for systemic agents fared much better; only 14% went unredeemed (J. Am. Acad. Dermatol. 2008;59:27-33).

In another study, the Danish dermatologists visited the homes of 17 first-time dermatologic outpatients who had been given prescriptions for previously untried topical medications. Upon weighing the patients' drug containers, the investigators found only 1 of the 17 patients used the directed dosage. Two patients never picked up their prescriptions, 13 used too little drug, and 1 patient used too much (J. Am. Acad. Dermatol. 2008;59:975-80).

Inadequate application of topical agents is another problem. In a joint study conducted with Swedish dermatologists, the Danish investigators found that highly motivated volunteers applied a fluorescent test cream to only 69% of the skin surface as directed. Areas prone to neglect included the upper breast, axilla and surrounding skin, posterior trunk, legs, and soles of the feet (Br. J. Dermatol. 2007;156:974-8).

Yet another form of treatment noncompliance results from patients’ failure to show up for scheduled appointments. Dr. Serup and coworkers recently reviewed 3,592 patient appointments at the university hospital’s outpatient dermatology clinic and found that 13% of patients didn’t keep their appointments. Patients failed to show for about 10% of all appointments because of forgetfulness or a variety of excuses; this was most common in patients under age 30. The rest of the no-shows were caused by booking mistakes by the clinic staff.

Poor physician-patient communication plays a role in noncompliance as well, as underscored in a study in which Dr. Serup’s colleagues taped and studied 57 dermatologic consultations with 17 dermatology patients, all of whom received new prescriptions for topical agents. At follow-up 2 weeks later, only 41% of patients were familiar with their diagnosis, 71% understood the recommended number of treatment applications per day, and 35% knew the planned duration of treatment. Just 12% of patients understood the proper quantity of the topical agent to be applied; their ignorance on this score was understandable, since dermatologists covered that key issue in only 18% of the recorded clinic visits. Moreover, dermatologists provided a clear explanation of the diagnosis in only 65% of cases (J. Dermatolog. Treat. 2009;20:190-3).

On a more optimistic note, Dr. Serup believes mobile phones and other modern tools can be better utilized to boost compliance among dermatology patients, especially the younger ones, who tend to have the lowest compliance rates. The literature shows that text message reminders and email consultations are effective in this regard, at least within general medicine. A system recently developed in Sweden allows patients to install software on their mobile phone so they can monitor their disease and phone their physician for data transfer and to communicate about therapy. Dr. Serup has utilized this technology to follow the course of treatment in patients with atopic dermatitis.

"It is exactly the language of the [younger generation] to have the information displayed on a mobile phone screen. This can't be used in the elderly, though," he said.

He declared having no relevant financial interests.

GOTHENBURG, SWEDEN - Compliance with topical dermatologic therapies is worse than most physicians realize, according to a new study presented at the annual congress of the European Academy for Dermatology and Venereology.

Through a series of Danish studies utilizing the nation’s comprehensive electronic medical and pharmacy records system, investigators concluded that more than one in three new prescriptions for creams and ointments for dermatologic diseases is never picked up. And for those who actually do fill their prescriptions, treatment adherence just goes downhill from there.

"I would say that even an optimistic estimate would be that only one in five patients truly follows the treatment advice and takes their treatment at home. It's really an alarming figure. The typical result is that the patient comes in complaining, 'It didn't work, doctor,' and now they expect another prescription," Dr. Jørgen Serup said.

"Creams and ointments are truly messy, greasy, cumbersome, and patients can only treat a limited number of lesions on a limited area, and only on certain anatomic sites. These are serious limitations. This is a lot more difficult than just taking a pill," added Dr. Serup, professor of dermatology at Copenhagen University. "Maybe the creams and ointments are really obsolete because they are so difficult to use in clinical practice. Maybe we should be using much more systemic therapy."

He and his colleagues examined all new prescriptions for previously untried medications issued for dermatologic outpatients at Copenhagen University Hospital every 15th day during 2006. Thirty-one percent of the 322 eligible patients exhibited what Dr. Serup termed "primary nonadherence," meaning they never collected their medication. Patients with psoriasis were the biggest offenders; they failed to pick up their medications 44% of the time. This was also the case for 31% of atopic dermatitis patients, 12% being treated for skin infections, and 9% of acne patients.

Thirty-five percent of prescriptions for topical preparations remained behind the pharmacy counter. Prescriptions for systemic agents fared much better; only 14% went unredeemed (J. Am. Acad. Dermatol. 2008;59:27-33).

In another study, the Danish dermatologists visited the homes of 17 first-time dermatologic outpatients who had been given prescriptions for previously untried topical medications. Upon weighing the patients' drug containers, the investigators found only 1 of the 17 patients used the directed dosage. Two patients never picked up their prescriptions, 13 used too little drug, and 1 patient used too much (J. Am. Acad. Dermatol. 2008;59:975-80).

Inadequate application of topical agents is another problem. In a joint study conducted with Swedish dermatologists, the Danish investigators found that highly motivated volunteers applied a fluorescent test cream to only 69% of the skin surface as directed. Areas prone to neglect included the upper breast, axilla and surrounding skin, posterior trunk, legs, and soles of the feet (Br. J. Dermatol. 2007;156:974-8).

Yet another form of treatment noncompliance results from patients’ failure to show up for scheduled appointments. Dr. Serup and coworkers recently reviewed 3,592 patient appointments at the university hospital’s outpatient dermatology clinic and found that 13% of patients didn’t keep their appointments. Patients failed to show for about 10% of all appointments because of forgetfulness or a variety of excuses; this was most common in patients under age 30. The rest of the no-shows were caused by booking mistakes by the clinic staff.

Poor physician-patient communication plays a role in noncompliance as well, as underscored in a study in which Dr. Serup’s colleagues taped and studied 57 dermatologic consultations with 17 dermatology patients, all of whom received new prescriptions for topical agents. At follow-up 2 weeks later, only 41% of patients were familiar with their diagnosis, 71% understood the recommended number of treatment applications per day, and 35% knew the planned duration of treatment. Just 12% of patients understood the proper quantity of the topical agent to be applied; their ignorance on this score was understandable, since dermatologists covered that key issue in only 18% of the recorded clinic visits. Moreover, dermatologists provided a clear explanation of the diagnosis in only 65% of cases (J. Dermatolog. Treat. 2009;20:190-3).

On a more optimistic note, Dr. Serup believes mobile phones and other modern tools can be better utilized to boost compliance among dermatology patients, especially the younger ones, who tend to have the lowest compliance rates. The literature shows that text message reminders and email consultations are effective in this regard, at least within general medicine. A system recently developed in Sweden allows patients to install software on their mobile phone so they can monitor their disease and phone their physician for data transfer and to communicate about therapy. Dr. Serup has utilized this technology to follow the course of treatment in patients with atopic dermatitis.

"It is exactly the language of the [younger generation] to have the information displayed on a mobile phone screen. This can't be used in the elderly, though," he said.

He declared having no relevant financial interests.

GOTHENBURG, SWEDEN - Compliance with topical dermatologic therapies is worse than most physicians realize, according to a new study presented at the annual congress of the European Academy for Dermatology and Venereology.

Through a series of Danish studies utilizing the nation’s comprehensive electronic medical and pharmacy records system, investigators concluded that more than one in three new prescriptions for creams and ointments for dermatologic diseases is never picked up. And for those who actually do fill their prescriptions, treatment adherence just goes downhill from there.

"I would say that even an optimistic estimate would be that only one in five patients truly follows the treatment advice and takes their treatment at home. It's really an alarming figure. The typical result is that the patient comes in complaining, 'It didn't work, doctor,' and now they expect another prescription," Dr. Jørgen Serup said.

"Creams and ointments are truly messy, greasy, cumbersome, and patients can only treat a limited number of lesions on a limited area, and only on certain anatomic sites. These are serious limitations. This is a lot more difficult than just taking a pill," added Dr. Serup, professor of dermatology at Copenhagen University. "Maybe the creams and ointments are really obsolete because they are so difficult to use in clinical practice. Maybe we should be using much more systemic therapy."

He and his colleagues examined all new prescriptions for previously untried medications issued for dermatologic outpatients at Copenhagen University Hospital every 15th day during 2006. Thirty-one percent of the 322 eligible patients exhibited what Dr. Serup termed "primary nonadherence," meaning they never collected their medication. Patients with psoriasis were the biggest offenders; they failed to pick up their medications 44% of the time. This was also the case for 31% of atopic dermatitis patients, 12% being treated for skin infections, and 9% of acne patients.

Thirty-five percent of prescriptions for topical preparations remained behind the pharmacy counter. Prescriptions for systemic agents fared much better; only 14% went unredeemed (J. Am. Acad. Dermatol. 2008;59:27-33).

In another study, the Danish dermatologists visited the homes of 17 first-time dermatologic outpatients who had been given prescriptions for previously untried topical medications. Upon weighing the patients' drug containers, the investigators found only 1 of the 17 patients used the directed dosage. Two patients never picked up their prescriptions, 13 used too little drug, and 1 patient used too much (J. Am. Acad. Dermatol. 2008;59:975-80).

Inadequate application of topical agents is another problem. In a joint study conducted with Swedish dermatologists, the Danish investigators found that highly motivated volunteers applied a fluorescent test cream to only 69% of the skin surface as directed. Areas prone to neglect included the upper breast, axilla and surrounding skin, posterior trunk, legs, and soles of the feet (Br. J. Dermatol. 2007;156:974-8).

Yet another form of treatment noncompliance results from patients’ failure to show up for scheduled appointments. Dr. Serup and coworkers recently reviewed 3,592 patient appointments at the university hospital’s outpatient dermatology clinic and found that 13% of patients didn’t keep their appointments. Patients failed to show for about 10% of all appointments because of forgetfulness or a variety of excuses; this was most common in patients under age 30. The rest of the no-shows were caused by booking mistakes by the clinic staff.

Poor physician-patient communication plays a role in noncompliance as well, as underscored in a study in which Dr. Serup’s colleagues taped and studied 57 dermatologic consultations with 17 dermatology patients, all of whom received new prescriptions for topical agents. At follow-up 2 weeks later, only 41% of patients were familiar with their diagnosis, 71% understood the recommended number of treatment applications per day, and 35% knew the planned duration of treatment. Just 12% of patients understood the proper quantity of the topical agent to be applied; their ignorance on this score was understandable, since dermatologists covered that key issue in only 18% of the recorded clinic visits. Moreover, dermatologists provided a clear explanation of the diagnosis in only 65% of cases (J. Dermatolog. Treat. 2009;20:190-3).

On a more optimistic note, Dr. Serup believes mobile phones and other modern tools can be better utilized to boost compliance among dermatology patients, especially the younger ones, who tend to have the lowest compliance rates. The literature shows that text message reminders and email consultations are effective in this regard, at least within general medicine. A system recently developed in Sweden allows patients to install software on their mobile phone so they can monitor their disease and phone their physician for data transfer and to communicate about therapy. Dr. Serup has utilized this technology to follow the course of treatment in patients with atopic dermatitis.

"It is exactly the language of the [younger generation] to have the information displayed on a mobile phone screen. This can't be used in the elderly, though," he said.

He declared having no relevant financial interests.

LAS VEGAS - Improved understanding of itching and best practices in management of the condition may lead to U.S. medical centers specializing in treating pruritus.

A recent gathering of experts convened by the National Institutes of Health (NIH) may be the first step in this direction, Dr. Timothy G. Berger said at a dermatology seminar sponsored by Skin Disease Education Foundation.

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) pulled together 50 physicians on Oct. 29, 2010, to discuss the topic of pruritus. One of a series of roundtable discussions held by NIAMS, this was the first to focus on itching. A summary of the meeting and a list of attendees will be posted on the NIAMS website by the end of 2010, NIAMS media liaison Trish Reynolds said in an interview.

“These things are usually followed by calls for proposals,” said Dr. Berger of the University of California, San Francisco (UCSF), who did not attend the roundtable discussion. “The NIH is moving to a model of having major itch referral centers at several sites.”

Patients with itch would be referred to a center where their tissue samples and data could be stored and analyzed while they get expert treatment. “There will be direct translational benefits” from this approach, he predicted.

These centers would be patterned after two models – referral centers for pain, and European itch centers. The U.S. itch centers might first appear at UCSF; Washington University, St. Louis; and Harvard University, Boston, he said.

“In Europe, every patient with itch goes to a medical center for itch, is seen in a standard way, and has a defined database established about that patient. They now have tens of thousands of itch patients of various types logged into this database,” and data it provides are helping to build greater understanding of the problem of itching, Dr. Berger said.

One of the key insights into itching in recent years has been the understanding that chronic itch is like chronic pain. Chronic itch is thought to begin peripherally but then trigger anatomic changes in the CNS that make treatment much more difficult. “This suggests that we will have agents that will act both peripherally and centrally” to ease itching, he said. “We’re now at the verge of being able to do something about itching.”

Chronic itching should be treated aggressively because once central sensitization occurs, it is very, very hard to manage, he advised. Chronic itching has a huge impact on quality of life, earning the same scores by patients as the reduced quality of life reported by patients with chronic renal failure on dialysis.

Once itch is chronic, the threshold for sensation of itch is reduced. “Even if you make their rash better, they still itch,” he said. Itch intensity increases with chronicity, producing more itch from the same rash. Even when the skin is clear, patients may have short bursts of spontaneous itch. In atopic dermatitis and perhaps some other forms of itchy lesions, patients may scratch themselves raw because inflammatory mediators of pain are perceived as itch.

“This whole system is miswired” in chronic itch, Dr. Berger said.

Perceived itch is a delicate interaction between the skin, nerves, and immune system, and treatments may target or more of these pathways. The most common medication for chronic itch is second-generation antihistamines, in higher doses than used for the approved indication of allergic rhinitis. “These substances also block other inflammatory mediators that may be important for itch, so they may have benefit beyond what we know,” Dr. Berger said.

Neuroleptic medications for itch include amitriptyline or other tricyclic antidepressants, gabapentin, pregabalin, duloxetine, or thalidomide for prurigo nodularis. “These act primarily on the neural axis,” he said.

Central-acting agents include paroxetine, amitriptyline, doxepin, or mirtazapine. In a large European cohort, 6-9 months of treatment with paroxetine reduced chronic itch by 75% in 70% of patients. “It’s now become one of our drugs to treat itch, and is the treatment of choice for itch in polycythemia vera,” he said.

Research has shown that patients with liver disease can develop itch caused by abnormalities in opiate metabolism, leading some clinicians to treat chronic itch with naltrexone, butorphanol or other agents that act on the opiate pathway.

Phototherapy also has been used to treat chronic itch, including narrow-band UVB, psoralen plus UVA, or broadband UVB for itch associated with renal disease. “Phototherapy probably has an immunomodulatory effect that can benefit itch,” Dr. Berger said.

Several European itch centers incorporate a biopsychosocial approach to managing itch. As with chronic pain, focusing on the itch through education and support from nurses helps reduce the itch and decrease feelings of helplessness or inability to cope. Patients miss less work and report more low-itch days and improved quality of life. “So, there’s a biopsychosocial aspect that probably will need to be addressed,” he said. Some U.S. centers have employed this approach in managing atopic dermatitis.

Dr. Berger has been a consultant for Prescription Solutions and received research funding from GlaxoSmithKline, Clinsys Clinical Research, Merz Pharmaceuticals, and Pharmanet, none of which is relevant to this topic, he said. All the medications for itching that he discussed are used off-label. SDEF and this news organization are owned by Elsevier.

LAS VEGAS - Improved understanding of itching and best practices in management of the condition may lead to U.S. medical centers specializing in treating pruritus.

A recent gathering of experts convened by the National Institutes of Health (NIH) may be the first step in this direction, Dr. Timothy G. Berger said at a dermatology seminar sponsored by Skin Disease Education Foundation.

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) pulled together 50 physicians on Oct. 29, 2010, to discuss the topic of pruritus. One of a series of roundtable discussions held by NIAMS, this was the first to focus on itching. A summary of the meeting and a list of attendees will be posted on the NIAMS website by the end of 2010, NIAMS media liaison Trish Reynolds said in an interview.

“These things are usually followed by calls for proposals,” said Dr. Berger of the University of California, San Francisco (UCSF), who did not attend the roundtable discussion. “The NIH is moving to a model of having major itch referral centers at several sites.”

Patients with itch would be referred to a center where their tissue samples and data could be stored and analyzed while they get expert treatment. “There will be direct translational benefits” from this approach, he predicted.

These centers would be patterned after two models – referral centers for pain, and European itch centers. The U.S. itch centers might first appear at UCSF; Washington University, St. Louis; and Harvard University, Boston, he said.

“In Europe, every patient with itch goes to a medical center for itch, is seen in a standard way, and has a defined database established about that patient. They now have tens of thousands of itch patients of various types logged into this database,” and data it provides are helping to build greater understanding of the problem of itching, Dr. Berger said.

One of the key insights into itching in recent years has been the understanding that chronic itch is like chronic pain. Chronic itch is thought to begin peripherally but then trigger anatomic changes in the CNS that make treatment much more difficult. “This suggests that we will have agents that will act both peripherally and centrally” to ease itching, he said. “We’re now at the verge of being able to do something about itching.”

Chronic itching should be treated aggressively because once central sensitization occurs, it is very, very hard to manage, he advised. Chronic itching has a huge impact on quality of life, earning the same scores by patients as the reduced quality of life reported by patients with chronic renal failure on dialysis.

Once itch is chronic, the threshold for sensation of itch is reduced. “Even if you make their rash better, they still itch,” he said. Itch intensity increases with chronicity, producing more itch from the same rash. Even when the skin is clear, patients may have short bursts of spontaneous itch. In atopic dermatitis and perhaps some other forms of itchy lesions, patients may scratch themselves raw because inflammatory mediators of pain are perceived as itch.

“This whole system is miswired” in chronic itch, Dr. Berger said.

Perceived itch is a delicate interaction between the skin, nerves, and immune system, and treatments may target or more of these pathways. The most common medication for chronic itch is second-generation antihistamines, in higher doses than used for the approved indication of allergic rhinitis. “These substances also block other inflammatory mediators that may be important for itch, so they may have benefit beyond what we know,” Dr. Berger said.

Neuroleptic medications for itch include amitriptyline or other tricyclic antidepressants, gabapentin, pregabalin, duloxetine, or thalidomide for prurigo nodularis. “These act primarily on the neural axis,” he said.

Central-acting agents include paroxetine, amitriptyline, doxepin, or mirtazapine. In a large European cohort, 6-9 months of treatment with paroxetine reduced chronic itch by 75% in 70% of patients. “It’s now become one of our drugs to treat itch, and is the treatment of choice for itch in polycythemia vera,” he said.

Research has shown that patients with liver disease can develop itch caused by abnormalities in opiate metabolism, leading some clinicians to treat chronic itch with naltrexone, butorphanol or other agents that act on the opiate pathway.

Phototherapy also has been used to treat chronic itch, including narrow-band UVB, psoralen plus UVA, or broadband UVB for itch associated with renal disease. “Phototherapy probably has an immunomodulatory effect that can benefit itch,” Dr. Berger said.

Several European itch centers incorporate a biopsychosocial approach to managing itch. As with chronic pain, focusing on the itch through education and support from nurses helps reduce the itch and decrease feelings of helplessness or inability to cope. Patients miss less work and report more low-itch days and improved quality of life. “So, there’s a biopsychosocial aspect that probably will need to be addressed,” he said. Some U.S. centers have employed this approach in managing atopic dermatitis.

Dr. Berger has been a consultant for Prescription Solutions and received research funding from GlaxoSmithKline, Clinsys Clinical Research, Merz Pharmaceuticals, and Pharmanet, none of which is relevant to this topic, he said. All the medications for itching that he discussed are used off-label. SDEF and this news organization are owned by Elsevier.

LAS VEGAS - Improved understanding of itching and best practices in management of the condition may lead to U.S. medical centers specializing in treating pruritus.

A recent gathering of experts convened by the National Institutes of Health (NIH) may be the first step in this direction, Dr. Timothy G. Berger said at a dermatology seminar sponsored by Skin Disease Education Foundation.

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) pulled together 50 physicians on Oct. 29, 2010, to discuss the topic of pruritus. One of a series of roundtable discussions held by NIAMS, this was the first to focus on itching. A summary of the meeting and a list of attendees will be posted on the NIAMS website by the end of 2010, NIAMS media liaison Trish Reynolds said in an interview.

“These things are usually followed by calls for proposals,” said Dr. Berger of the University of California, San Francisco (UCSF), who did not attend the roundtable discussion. “The NIH is moving to a model of having major itch referral centers at several sites.”

Patients with itch would be referred to a center where their tissue samples and data could be stored and analyzed while they get expert treatment. “There will be direct translational benefits” from this approach, he predicted.

These centers would be patterned after two models – referral centers for pain, and European itch centers. The U.S. itch centers might first appear at UCSF; Washington University, St. Louis; and Harvard University, Boston, he said.

“In Europe, every patient with itch goes to a medical center for itch, is seen in a standard way, and has a defined database established about that patient. They now have tens of thousands of itch patients of various types logged into this database,” and data it provides are helping to build greater understanding of the problem of itching, Dr. Berger said.

One of the key insights into itching in recent years has been the understanding that chronic itch is like chronic pain. Chronic itch is thought to begin peripherally but then trigger anatomic changes in the CNS that make treatment much more difficult. “This suggests that we will have agents that will act both peripherally and centrally” to ease itching, he said. “We’re now at the verge of being able to do something about itching.”

Chronic itching should be treated aggressively because once central sensitization occurs, it is very, very hard to manage, he advised. Chronic itching has a huge impact on quality of life, earning the same scores by patients as the reduced quality of life reported by patients with chronic renal failure on dialysis.

Once itch is chronic, the threshold for sensation of itch is reduced. “Even if you make their rash better, they still itch,” he said. Itch intensity increases with chronicity, producing more itch from the same rash. Even when the skin is clear, patients may have short bursts of spontaneous itch. In atopic dermatitis and perhaps some other forms of itchy lesions, patients may scratch themselves raw because inflammatory mediators of pain are perceived as itch.

“This whole system is miswired” in chronic itch, Dr. Berger said.

Perceived itch is a delicate interaction between the skin, nerves, and immune system, and treatments may target or more of these pathways. The most common medication for chronic itch is second-generation antihistamines, in higher doses than used for the approved indication of allergic rhinitis. “These substances also block other inflammatory mediators that may be important for itch, so they may have benefit beyond what we know,” Dr. Berger said.

Neuroleptic medications for itch include amitriptyline or other tricyclic antidepressants, gabapentin, pregabalin, duloxetine, or thalidomide for prurigo nodularis. “These act primarily on the neural axis,” he said.

Central-acting agents include paroxetine, amitriptyline, doxepin, or mirtazapine. In a large European cohort, 6-9 months of treatment with paroxetine reduced chronic itch by 75% in 70% of patients. “It’s now become one of our drugs to treat itch, and is the treatment of choice for itch in polycythemia vera,” he said.

Research has shown that patients with liver disease can develop itch caused by abnormalities in opiate metabolism, leading some clinicians to treat chronic itch with naltrexone, butorphanol or other agents that act on the opiate pathway.

Phototherapy also has been used to treat chronic itch, including narrow-band UVB, psoralen plus UVA, or broadband UVB for itch associated with renal disease. “Phototherapy probably has an immunomodulatory effect that can benefit itch,” Dr. Berger said.

Several European itch centers incorporate a biopsychosocial approach to managing itch. As with chronic pain, focusing on the itch through education and support from nurses helps reduce the itch and decrease feelings of helplessness or inability to cope. Patients miss less work and report more low-itch days and improved quality of life. “So, there’s a biopsychosocial aspect that probably will need to be addressed,” he said. Some U.S. centers have employed this approach in managing atopic dermatitis.

Dr. Berger has been a consultant for Prescription Solutions and received research funding from GlaxoSmithKline, Clinsys Clinical Research, Merz Pharmaceuticals, and Pharmanet, none of which is relevant to this topic, he said. All the medications for itching that he discussed are used off-label. SDEF and this news organization are owned by Elsevier.