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Ammonium persulfate (APS), an oxidizing agent used in hair products, manufacturing, and pool/spa water, can cause skin reactions, including allergic contact dermatitis.To characterize positive patch test reactions to APS (2.5% petrolatum).Retrospective analysis of patients tested to the North American Contact Dermatitis Group screening series from 2015 to 2018.Of 10,526 patients, 193 (1.8%) had positive patch test reactions to APS. Compared with APS-negative patients, APS-positive patients were significantly more likely to be male (43.2% vs 28.0%; P .0001); have primary hand dermatitis (30.2% vs 22.0%; P = .0064), scattered generalized dermatitis (25.5% vs 17.9%; P = .0064), or trunk dermatitis (8.9% vs 4.9%; P = .0123); and have dermatitis that is occupationally related (22.2% vs 10.9%; P .0001). More than half of the APS-positive reactions were currently relevant (57.0%); 19 (9.8%) were related to occupation, especially hairdressers (68.4%). Swimming pools/spas (23.3%) and hair care products (19.2%) were the most common sources of APS.Immediate reactions and follow-up testing were not captured.The proportion of patients positive to APS was 1.8%. APS positivity was significantly associated with male sex and hand dermatitis. Swimming pool/spa chemicals were important sources of APS exposure.

Background Alopecia areata (AA) is characterized by the loss of hair, often in well-demarcated areas. While the pathogenesis of AA is not entirely understood, it is known that CD8 T cell-mediated destruction of the hair follicle occurs. There are no curative therapies for AA, although several therapies have been utilized with variable results. Oral tofacitinib, a JAK inhibitor, has been demonstrated to be efficacious and well tolerated in the treatment of adult AA. However, few studies have examined the clinical efficacy and tolerability of oral tofacitinib in the treatment of pediatric AA. Objective To summarize the clinical outcomes of pediatric patients with AA treated with oral tofacitinib at the University of Colorado Hospital Dermatology Clinic. Methods This is a retrospective case series conducted at the University of Colorado Hospital Dermatology Clinic. We included patients with a diagnosis of AA who were 18 years old or younger at the initiation of tofacitinib therapy. Demographics, treatment response, and adverse events were collected from electronic medical records. Results Eleven patients (seven females, four males) with AA presented to the University of Colorado Hospital Dermatology Clinic who were between the ages of 8 and 18 years. Eight patients (72.7%) experienced hair regrowth with oral tofacitinib, while three patients (27.3%) experienced minimal to no hair regrowth. There were no serious adverse events recorded in the study population during the observed treatment period. Conclusions Oral tofacitinib was clinically effective in the majority our of patients and well tolerated.

Background Little is known about the relationship between psoriasis and allergic contact dermatitis (ACD). Objective To examine the associations with ACD, related clinical characteristics, and common positive and clinically relevant allergens of patients with a final diagnosis of psoriasis who were referred for patch testing. Methods Retrospective analysis of 38,723 patients from the North American Contact Dermatitis Group. Results Patients with a final diagnosis of psoriasis had lower proportions of ACD than those without psoriasis (32.7% vs 57.8%). In multivariable logistic regression models, psoriasis was inversely associated with female sex, black or Asian race, history of atopic dermatitis and hay fever. Patients with a final diagnosis of psoriasis were less likely to have one or more positive allergic patch test reactions or to have a current clinically relevant patch test reaction to the majority of the most commonly positive and/or relevant allergens. The most clinically relevant allergens included nickel sulfate, methylisothiazolinone, and fragrance mix I. Conclusion Approximately one-third of patients who were referred for patch testing with a final diagnosis of psoriasis were also diagnosed with ACD. In select patients with suspected psoriasis who also have a clinical presentation suggestive of ACD, patch testing may be helpful. This article is protected by copyright. All rights reserved.

Background Prolonged wear of facial protective equipment can lead to occupational dermatoses. Objective To identify important causes of occupational dermatoses from facial protective equipment. Methods A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed using PubMed and Embase databases. Articles were included if they reported occupational dermatoses caused by surgical/procedure masks or N95 respirators, or both. Results We identified 344 articles, and 16 were suitable for inclusion in this review. Selected articles focused on facial occupational dermatoses in health care workers. Allergic contact dermatitis to the elastic straps, glue, and formaldehyde released from the mask fabric was reported. Irritant contact dermatitis was common on the cheeks and nasal bridge due to pressure and friction. Irritant dermatitis was associated with personal history of atopic dermatitis and prolonged mask wear (>6 hours). Acneiform eruption was reported due to prolonged wear and occlusion. Contact urticaria was rare. Limitations Only publications listed in PubMed or Embase were included. Most publications were case reports and retrospective studies. Conclusion This systematic review from members of the American Contact Dermatitis Society highlights cases of occupational dermatitis to facial protective equipment, including potential offending allergens. This work may help in the diagnosis and treatment of health care workers with facial occupational dermatitis.

Background: Dermatology residency programs are considerably varied in regard to their resident research requirements and resources. The authors examined the availability of 12 key resident research-related criteria in 30 ACGME dermatology residency programs in the United States. Objective: To assess the degree to which dermatology residency programs require and support their new physician graduates in scholarly research. Methods: This cross-sectional study employed a 12-item survey administered online that was informed and created by literature search, expert feedback, and a thorough review and revision process. The primary purpose of the study was to examine the differences in programs’ policies and structure around resident research. Results: Thirty out of 114 PDs (26%) responded to the survey. We found that while most programs had publication and QI project requirements for residents, the majority did not have required research rotations, research electives, or a formal mentorship program. Thus, in spite of a growing need for new physician–scientists coupled with the various benefits associated with conducting research during residency training, considerable hurdles dissuade new physician graduates from pursuing careers in clinical research. Conclusions: Our survey findings supply timely, objective data on dermatology resident research requirements across the country. Medical schools, residency programs, and the ACGME/ AMA may all find our results valuable in further enhancing, evolving, and systematizing dermatology residency policies and provisions.

Background The coronavirus infectious disease 2019 pandemic has resulted in health care workers donning personal protective equipment (PPE) for extended periods. Objectives The aims of the study were to review facial PPE (surgical masks and N95 respirators) ingredients, to identify facial PPE resterilization techniques, and to recommend strategies for prevention and management of facial PPE-related dermatoses. Methods Twenty-one facial PPE (11 N95 respirators, 10 surgical masks) were reviewed. Resterilization techniques were identified. Personal protective equipment-induced occupational dermatoses and management strategies were explored. Results Polypropylene is the most common chemical identified in facial PPE. Most masks contain aluminum at the nosepiece. Two surgical masks released nickel. Facial PPE dermatoses include irritant contact dermatitis, allergic contact dermatitis, acne, and contact urticaria. Strategies for prevention and management of facial PPE occupational dermatoses are discussed. Conclusions There are increasing reports of occupational dermatoses associated with facial PPE. This review discusses the components of facial PPE, mask resterilization methods, and strategies for prevention and management of facial PPE dermatoses.

In the second article in this continuing medical education series, we review the treatment of leprosy, its immunologic reactions, and important concepts, including disease relapse and drug resistance. A fundamental understanding of the treatment options and management of neuropathic sequelae are essential to reduce disease burden and improve patients' quality of life.

Lanolin is an important cause of allergic contact dermatitis.The aims of this study were to describe the epidemiology of lanolin allergy and to assess trends in patch test reactions to lanolin over time.This study used a retrospective analysis of patients patch tested with lanolin alcohol 30% or Amerchol L-101 50% in petrolatum by the North American Contact Dermatitis Group between 2001 and 2018 (n = 43,691).Overall, 1431 (3.3%) had a positive reaction, and 1238 (2.8%) were currently relevant. Prevalence of lanolin allergy was 4.63% between 2011 and 2018 (P0.0001). Most lanolin-allergic patients had + (52%) reactions; 18%, and 6% had ++ and +++ reactions, respectively. Common primary anatomic sites of dermatitis were the hands (20.7%), scattered/generalized distribution (19.6%), and face (17.0%). Allergic reactions to lanolin were more common in children (4.5%) than in adults (3.2%, P = 0.0018). Compared with nonallergic patients, lanolin-allergic patients were more likely to have history of eczema or hay fever, male sex, older than 40 years, or Black race (P0.05). Common lanolin sources were personal care products and drugs/medications. Only 2.24% of the positive reactions were linked to occupation.Lanolin sensitivity was common. Reactions were often clinically relevant and linked to personal care products and medications.

Alkyl glucosides are nonionic surfactants that are increasingly used in personal care products.To characterize positive patch test reactions to decyl glucoside (5% petrolatum, tested 2009-2018) and lauryl glucoside (3% petrolatum, tested 2017-2018).Retrospective analysis of patients tested by the North American Contact Dermatitis Group.Of 24,097 patients patch tested to decyl and/or lauryl glucoside, 470 (2.0%) had positive reactions. Compared with glucoside-negative patients, glucoside-positive patients had higher odds of occupational skin disease (13.4% vs 10.1%; P = .0207), history of hay fever (38.5% vs 31.6%; P = .0014), atopic dermatitis (39.0% vs 28.6%; P .0001), and/or asthma (21.8% vs 16.5%; P = .0023). Most glucoside reactions (83.9%) were currently relevant. The most common source was personal care products (63.0%), especially hair products (16.5%) and skin cleansers (15.2%). Of 4933 patients tested to decyl and lauryl glucoside, 134 (2.7%) were positive to 1 or both; 43.4% (43 of 99) of decyl-positive patients were also positive to lauryl glucoside and 55.1% (43/78) of lauryl glucoside patients were also positive to decyl glucoside.The cohort predominantly reflects a referral population, and follow-up after testing was not captured.Glucoside positivity occurred in 2.0% of the tested patients. Reactions were often clinically relevant and linked to personal care products. Cross-reactivity was40%.

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

Social media provides a readily accessible means to promote user-generated content, broaden interpersonal connections, and encourage social collaboration. In this paper, we will review the use of popular social media platforms within dermatology along with the potential benefits and harms of these platforms when used by dermatology providers and their patients. Social media has also found a place in medicine and presents new opportunities and challenges for health care professionals. In dermatology specifically, social media has become a platform for patient education, public outreach, and professional development and networking. Although there are many risks associated with social media use in dermatology, there is also opportunity to promote public health, patient education, and professional interactions.

BACKGROUND: Many patients with chronic skin diseases lack regular access to dermatologists in the United States and suffer poor clinical outcomes. INTRODUCTION: We performed a 12-month randomized controlled trial to evaluate the impact of an online, collaborative connected health (CCH) model for psoriasis management on access to specialty care. MATERIALS AND METHODS: The 300 enrolled patients were randomized to online or in-person care. We compared distance traveled as well as transportation and in-office waiting time between the two groups and obtained patient and provider perspectives on CCH. RESULTS: At baseline, no differences existed between the groups in difficulties obtaining specialty care. Over 12 months, the mean (standard deviation [SD]) distance traveled to and from appointments was 174.8 (±577.4) km/person for the in-person group and 2.2 (±14.2) km/person for the online group (p = 0.0003). The mean (SD) time spent on transportation and in-office waiting for in-person appointments was 4.0 (±4.5) h/person for the in-person group and 0.1 (±0.4) h/person for the online group (p = 0.0001). Patients found CCH to be safe, accessible, equitable, efficient, effective, and patient-centered. Providers found CCH to be useful for providing psoriasis care. DISCUSSION: The CCH model resulted in significantly less distance traveled as well as transportation and in-office waiting time compared to in-person care. Both patients and providers were highly satisfied with CCH. CONCLUSIONS: The CCH model resulted in increased access to specialty care and enabled patient-centered, safe, and effective management of psoriasis patients.

This 12-month, pragmatic, randomized controlled equivalency trial evaluated whether an online, collaborative connected-health model results in equivalent improvements in quality of life compared with in-person care for psoriasis. Overall, 296 adults with physician-diagnosed psoriasis from ambulatory clinics were randomly assigned to either online or in-person care; all were analyzed for outcomes. In the online group, patients and primary care providers sought dermatologists' care directly and asynchronously online. The in-person group sought care face to face. Interventions did not allow blinding of participants; investigators were blinded during analysis. Across 12 months, for the online group, the mean ± standard deviation decline in Skindex-16 from baseline across follow-up visits was 9.02 ± 20.67 compared with 10.55 ± 23.50 for the in-person group. The difference in Skindex-16 between the two groups was -0.83 (95% confidence interval = -5.18 to 3.51), and this was within the equivalence margin (±7.0). For the online group, the mean ± standard deviation decline in Dermatology Life Quality Index was 1.64 ± 4.34 compared with 1.18 ± 4.77 for the in-person group. The difference in Dermatology Life Quality Index between the two groups was -0.45 (95% confidence interval = -1.29 to 0.38) and was within the equivalence margin (±2.5). In conclusion, the online model was as effective as in-person care in improving quality of life among psoriasis patients. This study was funded by the Patient-Centered Outcomes Research Institute and is registered on clinicaltrials.gov (NCT02358135).

Surfactants, many of which are used as detergents, can be found in many common household items, such as shampoos, conditioners, soaps, and cosmetics. One should recognize the multitude of surfactants that are used in today's products to identify any potential allergic contact dermatitis (ACD) or irritant contact dermatitis (ICD). Given their abundance in everyday products, it is understandable that many cases of occupational contact dermatitis that arise can be attributed to surfactants. The products most connected with ACD are cocamidopropyl betaine, oleamidopropyl dimethylamine, decyl glucoside, 3-dimethylaminopropylamine, amidoamine, and cocamide diethanolamine. Similarly, the most common surfactant-related causes of ICD are sodium lauryl sulfate and benzalkonium chloride. It is important for dermatologists to identify the causes and differentiate between the two, to adjust treatments and products accordingly. Here, the most frequently used surfactants, as well as their correlation between ACD and ICD, will be reviewed.

BACKGROUND/OBJECTIVES Topical medications may lead to allergic contact dermatitis. This study characterized positive patch test reactions associated with medications in patients evaluated by the North American Contact Dermatitis Group (NACDG). METHODS This study is a retrospective analysis of the NACDG data (2001-2018). Patients with at least 1 positive patch test reaction associated with a medication source were included. Allergens, reaction characteristics, clinical relevance, and source details were tabulated. RESULTS Of 43,722 patients, 6374 (14.6%) had positive allergic patch test reactions associated with 1 or more topical medication sources. Patients with versus without allergic reactions to medications were more likely to be older than 40 years (P < 0.0001) and/or have primary sites of dermatitis on the legs, anal/genital region, or trunk (P < 0.0001). There were 8787 reactions to NACDG allergens; the most common were neomycin (29.4%), bacitracin (29.1%), propylene glycol 100% (10.6%), tixocortol-17-pivalate (10.0%), lidocaine (7.9%), budesonide (4.9%), and dibucaine (4.4%). Propylene glycol 100% was the most common inactive ingredient (10.6%). Current relevance was present in 61.0%. A total of 6.5% of the individuals with medication allergy would have had 1 or more positive patch test reactions missed if only tested to the NACDG screening series. CONCLUSIONS Positive patch test reactions associated with topical medications were common (14.6%), and most were clinically relevant. Patients with topical medication allergy were twice as likely to have anal/genital involvement. Active ingredients, especially neomycin, bacitracin, and tixocortol-17-pivalate, were frequent culprits.

BACKGROUND There is limited measurement and reporting of quality of life (QoL) outcomes for patients with contact dermatitis (CD). OBJECTIVE The purpose of this study is to develop a standardized Contact Dermatitis Quality of Life index (CDQL) for adult patients. METHODS A list of 81 topics was compiled from a review of QoL measures used previously in CD research. A total of 2 rounds of web-based Delphi surveys were sent to physicians who registered to attend the 2018 American Contact Dermatitis Society meeting, asking that they rank the relevance of topics for measuring QoL in CD using a 4-point scale. Items met consensus for inclusion if at least 78% of respondents ranked them as relevant or very relevant, and their median score was ≥3.25. RESULTS Of the 210 physicians contacted, 34 physicians completed the initial survey and 17 completed the follow-up survey. A total of 22 topics met consensus for inclusion in the CDQL, addressing symptoms, emotions, functions of daily living, social and physical functions, work/school functions, and treatment. CONCLUSIONS This study was limited by the following factors: few open-ended questions in the initial survey, a lack of direct patient feedback, and long survey length, which likely contributed to lower survey participation. The CDQL is a comprehensive, CD-specific QoL measure developed on the basis of expert consensus via a modified Delphi process to be used by physicians and other health care professionals who care for adult patients with contact dermatitis.

Little is known about the relationship between psoriasis and allergic contact dermatitis (ACD).To examine the associations with ACD, related clinical characteristics, and common positive and clinically relevant allergens of patients with a final diagnosis of psoriasis who were referred for patch testing.Retrospective analysis of 38 723 patients from the North American Contact Dermatitis Group.Patients with a final diagnosis of psoriasis had lower proportions of ACD than those without psoriasis (32.7% vs 57.8%). In multivariable logistic regression models, psoriasis was inversely associated with female sex, Black or Asian race, and history of atopic dermatitis and hay fever. Patients with a final diagnosis of psoriasis were less likely to have one or more positive allergic patch-test reactions or to have a current clinically relevant patch-test reaction to the majority of the most commonly positive and/or relevant allergens. The most clinically relevant allergens included nickel sulfate, methylisothiazolinone, and fragrance mix I.Approximately one-third of patients who were referred for patch testing with a final diagnosis of psoriasis were also diagnosed with ACD. In select patients with suspected psoriasis who also have a clinical presentation suggestive of ACD, patch testing may be helpful.

BACKGROUND An increasing number of studies have investigated the adverse effect profile of oral cannabinoids; however, few studies have provided sufficient data on the tolerability of topical cannabinoids in human participants. AIM To assess the tolerability profile of several commercial topical formulations containing cannabidiol (CBD) and palmitoylethanolamide (PEA) on the skin of healthy human participants. METHODS Three human clinical trials and one in vitro study were conducted. The potential for skin irritation, sensitization and phototoxicity of several products, were assessed via patch testing on healthy human skin. The products assessed included two formulations containing CBD and PEA, one containing hemp seed oil and four concentrations of CBD alone. Ocular toxicity was tested using a traditional hen's egg chorioallantoic membrane model with three CBD, PEA and hemp seed oil formulations. RESULTS There was no irritation or sensitization of the products evident via patch testing on healthy participants. Additionally, mild phototoxicity of a hemp seed oil product was found at the 48-h time point compared with the negative control. The in vitro experiment demonstrated comparable effects of cannabinoid products with historically nonirritating products. CONCLUSION These specific formulations of CBD- and PEA-containing products are nonirritating and nonsensitizing in healthy adults, and further encourage similar research assessing their long-term safety and efficacy in human participants with dermatological diseases. There are some limitations to the study: (i) external validity may be limited as formulations from a single manufacturer were used for this study, while vast heterogeneity exists across unregulated, commercial CBD products on the market; and (ii) products were assessed only on normal, nondiseased human skin, and therefore extrapolation to those with dermatological diseases cannot be assumed.

Background An updated understanding of allergic contact dermatitis is needed, particularly in children. Objectives To compare positive and clinically relevant reactions in children versus adults referred for patch testing. Methods Retrospective analysis of 1871 children and 41,699 adults from the North American Contact Dermatitis Group (NACDG) from 2001-2018. Results Both final diagnosis of allergic contact dermatitis (55.2% versus 57.3%; chi square, P = .0716) and prevalence of ≥ 1 currently relevant reaction to a NACDG screening allergen (49.2% vs 52.2%; P = .1178) were similar between children and adults. Currently in children, the most common relevant allergens were nickel sulfate (17.3%), hydroperoxides of linalool (7.8%), methylisothiazolinone (7.7%), cobalt chloride (7.0%), and fragrance mix I (4.9%). Approximately a fifth of children had a positive reaction to a non-NACDG allergen. Conclusion Over half of children referred for patch testing were diagnosed with allergic contact dermatitis. The most common relevant allergens in children were nickel sulfate, cobalt chloride, and hydroperoxides of linalool. Twenty percent of children had at least 1 positive reaction to allergens/substances not on the NACDG screening series, underscoring the need for comprehensive testing.

The coronavirus infectious disease 2019 pandemic has resulted in health care workers donning personal protective equipment (PPE) for extended periods.The aims of the study were to review facial PPE (surgical masks and N95 respirators) ingredients, to identify facial PPE resterilization techniques, and to recommend strategies for prevention and management of facial PPE-related dermatoses.Twenty-one facial PPE (11 N95 respirators, 10 surgical masks) were reviewed. Resterilization techniques were identified. Personal protective equipment-induced occupational dermatoses and management strategies were explored.Polypropylene is the most common chemical identified in facial PPE. Most masks contain aluminum at the nosepiece. Two surgical masks released nickel. Facial PPE dermatoses include irritant contact dermatitis, allergic contact dermatitis, acne, and contact urticaria. Strategies for prevention and management of facial PPE occupational dermatoses are discussed.There are increasing reports of occupational dermatoses associated with facial PPE. This review discusses the components of facial PPE, mask resterilization methods, and strategies for prevention and management of facial PPE dermatoses.

The American Contact Dermatitis Society Core Allergen series was introduced in 2013 and updated in 2017. Changes in our recommended allergens are again necessary, taking into account data from the American Contact Dermatitis Society's Contact Allergen Management Program top 100 allergens from 2018. For the updated series, we removed methyldibromoglutaronitrile and added new haptens: Lyral, Limonene, Linalool, carmine, benzyl salicylate, disperse yellow 3, jasmine, peppermint, pramoxine, shellac, and lauryl polyglucose (glucosides). These additional allergens should increase the yield of relevant positive reactions for our patients.

Parkinson’s disease (PD) is a neurodegenerative disorder associated with multiple comorbidities, including seborrheic dermatitis (SD), which develops in more than half of PD patients. SD in patients with PD can be severe and frequently intractable by traditional topical therapy. Cannabinoids possess anti-inflammatory and neuromodulatory properties working within the intrinsic endocannabinoid system, the activation of which may alleviate the motor symptoms of PD. The effect of cannabinoids on SD is unknown. Here we explore the pathophysiological mechanisms and possible therapeutic role of oral cannabinoids in PD patients with SD, and review speculative mechanisms underlying the association of PD and SD. Current data supporting the use of cannabinoids in both PD and SD, as well as oral cannabinoid safety and tolerability, are presented. Cannabinoids may provide the possibility of simultaneous treatment of both SD and PD. Specific SD studies and additional safety data on oral cannabinoids are needed.

Allergic contact dermatitis is a delayed type IV hypersensitivity skin reaction to external stimuli. Patterns of dermatitis depend on allergen exposure and patch testing is the gold standard to identify causal agents. The American Contact Dermatitis Society identifies an "Allergen of the Year" in order to highlight facts about particular allergens, which may range from showing increasing prevalence of disease, to documenting low levels of relevant allergic reactions. This article reviews the allergens of the year from 2000 to 2020 with an emphasis on clinical relevance. Categories of allergens include adhesives, dyes, medications, metals, preservatives, rubber accelerators, surfactants, and other skin care product ingredients.

BACKGROUND Melanoma is a rare diagnosis in the pediatric population. Differences in incidence, presentation, and survival distinguish pediatric melanoma from adult melanoma. In order to improve our understanding of pediatric melanoma, our case series investigates differences in incidence, age of onset, and anatomic site between male and female pediatric melanoma patients in Colorado between 1988 and 2015. METHODS All data were gathered from the Colorado Central Cancer Registry. A request for de-identified data on pediatric melanoma patients between 1988 and 2015 was made by the University of Colorado Department of Dermatology. Chi-square tests were used to compare the differences reported in melanoma between sex, age-groups, and site of lesion. RESULTS A total of 256 cases of melanoma were reported in Colorado in patients