Immunomodulation in dermatology: lessons learned in the treatment of psoriasis.

With the widespread recognition that T-cells are the key mediators of psoriasis, current treatment strategies have focused on reducing the population of these cells or modulating their activity through the use of immunosuppressive treatments such as methotrexate, cyclosporine, and psoralens plus ultraviolet A radiation. Now, a greater understanding of the immunologic basis of psoriasis based on scientific advances are enabling the development of rationally designed, biologic agents that selectively target specific elements in the immune system that are directly involved in the pathophysiology of psoriasis. This review discusses several basic strategies for biologic therapies for psoriasis and concludes that the allergist/immunologist is eminently qualified to treat this immune skin disorder.

The allergy and immunology specialist: what is the role in the treatment of skin disease?

The practice of medicine transcends our neat borders of demarcation between the myriad of medical specialties and medical disciplines. There are no two specialties in which this clinical interface is more blurred than the clinical interface between allergy and dermatology. With a background in both dermatology and allergy, I address where the specialty of allergy/ immunology is heading, as we navigate the coastal waters separating my two primary disciplines. I also discuss the tools traditionally used only in dermatology, which are now being used increasing by a vanguard of allergists to aid in the diagnosis and treatment of allergic skin disease.

Toxic mold: phantom risk vs science.

OBJECTIVE: To review the available literature on the subject of fungi (molds) and their potential impact on health and to segregate information that has scientific validity from information that is yet unproved and controversial. DATA SOURCES: This review represents a synthesis of the available literature in this area with the authors' collective experience with many patients presenting with complaints of mold-related illness. STUDY SELECTION: Pertinent scientific investigation on toxic mold issues and previously published reviews on this and related subjects that met the educational objectives were critically reviewed. RESULTS: Indoor mold growth is variable, and its discovery in a building does not necessarily mean occupants have been exposed. Human response to fungal antigens may induce IgE or IgG antibodies that connote prior exposure but not necessarily a symptomatic state. Mold-related disease has been discussed in the framework of noncontroversial and controversial disorders. CONCLUSIONS: When mold-related symptoms occur, they are likely the result of transient irritation, allergy, or infection. Building-related illness due to mycotoxicosis has never been proved in the medical literature. Prompt remediation of water-damaged material and infrastructure repair should be the primary response to fungal contamination in buildings.

Patch testing for allergic contact dermatitis in the allergist office.

The identification of allergens responsible for allergic contact dermatitis (ACD) is key to the management of this disease. The patch test (PT) is the only safe, objective, scientific, and practical method for the diagnosis of ACD. There is no single PT panel that will screen all the relevant allergens in a patient's environment. It is generally thought that 20 to 30 allergens in routine screening tests can identify 50% to 70% of clinically relevant ACD. However, the usefulness of patch testing is enhanced with the number of allergens tested. Although the PT might be simple to apply, it might be difficult to read, interpret, and correlate to the patient's symptoms. A familiarity with the patient's environment, the process of the industry in that environment, and the uses of various chemicals in the industry is needed in most cases.

Differential diagnosis of angioedema.

Angioedema without an associated urticarial syndrome evokes a completely different differential diagnosis from urticaria. This review of the literature discusses hereditary angioedema as prototype of angioedema without urticaria. The review then establishes a differential diagnosis for angioedema, which includes allergic contact dermatitis, connective tissue disease, endocrine associations, parasitic disease, tumor masses, and miscellaneous causes for angioedema. Angioedema without urticaria is a distinct syndrome differing from chronic urticaria. The astute clinician should be familiar with the spectrum of disorders ranging from a functional or quantitative deficiency in C1-esterase inhibitor to a panoply of cutaneous and internal medical disorders. Angioedema without urticaria is a symptom in which there are many different disease mechanisms producing subcutaneous swelling recognizable as angioedema.

Urticaria and angioedema.

Urticaria and angioedema evoke a completely different differential diagnosis from angioedema without an associated urticarial syndrome. This review of the literature is to give the reader a global insight into the spectrum of urticaria and angioedema, focusing on differential diagnosis and pathogenic mechanisms. It will define the role of the mast cell, explore a possible autoimmune basis for urticaria, and examine the purported role of food allergy in chronic urticaria. Last, the work-up and treatment will be discussed. Urticaria and angioedema are frustrating problems for both physicians and their patients; however, the problem can best be approached by considering urticaria as a symptom rather than a specific disease. The physical examination and medical history remain the two most important pieces of information.

Pruritic dermatoses: overview of etiology and therapy.

This review begins with a brief survey of the neurophysiology and neuroanatomy of pruritus, and goes on to describe the etiology of the major allergic and nonallergic pruritic disorders. The etiology of pruritus often suggests the appropriate treatment. For example, urticaria, which is primarily mediated by histamine, is amenable to treatment with H1 antihistamines. Second-generation, nonsedating antihistamines appear to be more effective than sedating antihistamines, perhaps because of better compliance. Other systemic pharmacologic options may be useful in nonhistamine-mediated disorders, for example, immunomodulators for inflammation-induced pruritus or opiate antagonists for atopic dermatitis. Nonpharmacologic measures, such as proper skin care, and physical modalities, such as phototherapy or acupuncture, may also be helpful.