Atopic dermatitis and nutrition.

Atopic dermatitis, a common chronic and pruritic inflammatory skin disorder, can create significant disruptions in sleep and quality of life. Atopic dermatitis is especially common in infants and children; therefore, safe and natural therapeutic options have considerable appeal. Over the past several decades, there has been an increase in the prevalence of atopic dermatitis in industrialized nations. Also, there is variability in the prevalence of atopic dermatitis in the United States, both across and within states. Environmental factors including diet are believed to be associated with this increased risk. Dietary interventions continue to be an area of keen interest and have been studied extensively, albeit with variable results. Maternal dietary restrictions during pregnancy and lactation, hydrolyzed or partially hydrolyzed formulas, delaying the introduction of solid foods, and omega-3 or omega-6 fatty acids supplementation do not appear to have a beneficial effect on the treatment and prevention of atopic dermatitis. Exclusive breastfeeding for 3 to 4 months, a diet high in fruits and vegetables, and prebiotics might have a beneficial effect. Because environmental triggers, including dietary exposures, are thought to play a role in the pathogenesis of atopic dermatitis, we herein review the current literature on the role of dietary habits, vitamin and mineral supplementation, and probiotics on the treatment and prevention of atopic dermatitis.

Acne: Kids are not just little people.

Acne vulgaris is a common inflammatory disease of the pilosebaceous follicles that affects patients of all ages, from neonates to adults. We have compared and contrasted the clinical presentation of acne in neonates, infants, children, teenagers, and young adults and review the scenarios in which further systemic endocrine or hormonal tests are indicated. We also discuss age-dependent treatment considerations, including appropriate oral antimicrobial regimens and the proper dosing of isotretinoin in young children versus teenagers and adults.

Dermatologic conditions in internationally adopted children.

Over 200,000 children have been adopted into United States (US) families from abroad since the year 2000. Health care providers who care for children adopted internationally should be aware of the spectrum of illnesses seen in this population, and should be prepared to encounter potentially unusual situations. An appreciation for the unique pre-adoption exposures and vulnerabilities inherent in international adoption is critical for proper diagnosis and treatment of this heterogeneous group of children. It is important to consider the impact of potential early childhood stressors such as nutritional, sensory, and emotional deprivation, trauma and abuse, as well as prenatal exposures to drugs, alcohol, and infectious diseases. Providers must also take into account international variation in health care practices, including immunization, treatment, surgical, and hygiene standards. The differential diagnosis for cutaneous eruptions in children adopted internationally is broad and must encompass endemic systemic illnesses with skin manifestations, such as measles, tuberculosis, leprosy, and congenital syphilis, and primary dermatologic diseases such as scabies and bacterial and fungal infections. The importance of maintaining a broad differential and open mind when addressing the dermatologic needs of these children cannot be overemphasized.

Atopic dermatitis and nutrition.

Atopic dermatitis, a chronic disease with no cure, currently affects almost one-fifth of the population of industrialized nations. Treatment can be challenging for physicians and patients alike. Children are commonly affected, making it even more difficult to find safe therapeutic options, especially in severe disease. Interest in diet and nutrition has increased during the last few years. Nutritional interventions are both intriguing and accessible for many patients. Given the recent expansion of the field of nutrition in the realm of medicine and in popular culture, it is important for the dermatologist to be knowledgeable about the risks and benefits of nutritional interventions. This contribution reviews the current literature on the role of nutrition in atopic dermatitis, from dietary restriction to dietary supplementation, from traditional interventions such as vitamins and minerals to the emerging fields of probiotics and essential fatty acids, and from the prenatal period through infancy and adulthood.

A multiple-domain framework of clinical, economic, and patient-reported outcomes for evaluating benefits of intervention in atopic dermatitis.

Atopic dermatitis (AD) increases health care utilization, affects patient quality of life, places a burden on caregivers, decreases patient/parent productivity, and adds to health care costs. Few studies have examined the effect of specific treatment modalities across a variety of AD-related outcomes. This prospective, multicenter, open-label longitudinal study of adult and pediatric patients with moderate to severe AD was conducted to evaluate the effect of a specific therapeutic intervention on AD-related outcomes over a period of 6 months. Surveys collected physician clinical assessments and patient- and caregiver-reported data across the following domains: clinical outcome, health care utilization/costs, quality of life, physical appearance, productivity/absenteeism, and medication compliance. This study is intended to help guide future research efforts on the net costs and benefits of different interventions across a diverse set of domains and in larger populations.

The economics of topical immunomodulators for the treatment of atopic dermatitis.

Atopic dermatitis is a common, chronic, relapsing inflammatory skin disease frequently affecting infants and children. The worldwide prevalence of atopic dermatitis is estimated to be 5--20% of the paediatric population. First-line therapy has generally consisted of dry skin care, avoidance of triggers, application of topical corticosteroids, and administration of antihistamines and oral antibacterials. Topical corticosteroids improve the lesions of atopic dermatitis; however, concern on the part of physicians and patients regarding adverse effects has led to reluctance to utilise topical corticosteroids early and especially for prolonged periods. Topical immunomodulators (TIMs), including tacrolimus ointment and pimecrolimus cream, were recently introduced for the treatment of atopic dermatitis. Clinical data show that TIMs are effective in atopic dermatitis, yet do not cause the significant adverse effects associated with topical corticosteroids. Questions remain regarding the place of TIMs as a treatment for atopic dermatitis and how to use them most effectively, from both therapeutic and pharmacoeconomic standpoints. Specifically, two major issues remain unresolved: (i) how TIMs measure up to other therapies, especially topical corticosteroids; and (ii) how members of the TIM drug class compare against each other. Previous research has established that atopic dermatitis has a significant impact on quality of life (QOL) and carries a substantial economic burden. Some studies have also measured the utility of various atopic dermatitis disease states. While there is a need for further research, early economic studies provide evidence that TIMs positively affect the QOL of patients and families. In certain patients, TIMs may be cost effective and have an acceptable incremental cost utility compared with topical corticosteroids.Making cost-effectiveness comparisons between tacrolimus and pimecrolimus is challenging because there are limited head-to-head comparative data. Given currently available efficacy data, the results of one study suggest that tacrolimus may be more cost effective than pimecrolimus in paediatric patients with moderate atopic dermatitis. The full economic and QOL benefits of both agents are yet to be completely understood. The studies reviewed herein are the first to delineate the pharmacoeconomic benefits of TIMs in atopic dermatitis, and lay the foundation for future analyses. TIMs represent an exciting advance in the treatment of atopic dermatitis. Additional research will help determine the proper place of TIMs among the current array of therapeutic options for atopic dermatitis.

Melanoma screening behavior among primary care physicians.

The incidence of malignant melanoma is rising concomitantly with dramatic changes in our healthcare system. Primary care physicians (PCPs) are responsible for an increasing number of skin-related healthcare visits. Therefore, PCPs must be on the forefront of early detection of suspicious pigmented lesions. Understanding the PCPs' screening and referral patterns for pigmented lesions is the first step in ensuring that atypical pigmented lesions will be properly evaluated within the confines of the present healthcare system. To develop a better understanding of how PCPs (internists, family practitioners, and pediatricians) manage pigmented lesions in their practice, we mailed a 28-question survey to 999 PCPs in Connecticut. Fewer than half of the 248 respondents indicated they "often" performed full skin examinations. However, when suspicious lesions were found, most PCPs referred patients to a dermatologist for a biopsy of the lesion. PCPs did not feel pressure from managed care companies to limit these referrals. However, many PCPs did not feel highly confident in their ability to recognize melanoma and thought their training was not adequate to prepare them to diagnose and manage pigmented lesions. Family practitioners were more likely than internists and pediatricians to manage suspicious pigmented lesions and to perform a biopsy on their own. Family practitioners also were more confident in performing these tasks and were more likely to think their training in these areas was adequate. Very few PCPs reported sending their biopsy specimens to a dermatopathology laboratory. In fact, many PCPs seemed unaware of who interpreted the histopathology. PCPs do not emphasize full skin examinations in their practice and seem unaware of the advantages inherent in using dermatopathologists in the histopathologic interpretation of pigmented lesions. Furthermore, lack of confidence on the part of PCPs, as well as their concern about adequate training in the management of pigmented lesions, suggest there is need for improvement in the education of primary care residents and physicians.

Validation of expert opinion in identifying comorbidities associated with atopic dermatitis/eczema.

BACKGROUND: The use of expert opinion is widespread in economic studies of healthcare utilisation; however, few studies have attempted to assess the validity of assumptions derived from such sources. OBJECTIVE: To examine the use of such expert opinion in determining comorbidities associated with atopic dermatitis/eczema (AD/E), which were assessed as part of a recent third-party payer cost-of-illness study. DESIGN: To identify the disease-related comorbidities that would represent costs associated with AD/E, physicians on an expert panel were asked individually and then collectively to group all International Classification of Diseases, 9(th) Edition-Clinical Modification (ICD-9-CM) diagnosis codes as 'most likely', 'possibly' or 'definitely not' related to the costs of identifying and treating patients with AD/E. Claims representing $US464 million in payer reimbursements from nearly 125 000 patients with AD/E were identified within two separate claims databases (1997 values). Over 850 ICD-9-CM diagnosis codes were identified in the first-listed position from these claims. For each group of 'most likely', 'possibly' and 'definitely not' related diagnosis codes, prevalence rates were compared within AD/E and non-AD/E populations from the two historical payer claims databases. Adjusted and non-adjusted odds ratios were calculated by comparing prevalence rates between AD/E and non-AD/E patients in the same payer population. RESULTS: The mean prevalence rate of any diagnosis code in the AD/E population was 0.65 +/- 1.82% (SD) with a mean odds ratio of 1.81 +/- 0.96. Comorbidities considered by the expert panel 'most likely' to be associated with AD/E had higher prevalence rates (3.28 +/- 3.63%) and odds ratios (2.14 +/- 1.14). Comorbidities considered to be 'possibly' related to AD/E had prevalence rates and odds ratios of 3.01 +/- 5.06% and 1.84 +/- 0.82, respectively. Comorbidities considered to be 'definitely not' related to AD/E had the lowest prevalence rates (0.45 +/- 1.09%) and odds ratios (1.80 +/- 0.97). CONCLUSIONS: Comparing the result of consensus panels with actual claims histories validated the use of expert opinion in determining comorbidities associated with AD/E. Expert opinion yielded valid results in terms of identifying comorbidities that manifested frequently and disproportionately in the AD/E population. Limited statistical measurements of comorbidities would have been less specific than expert opinion. Future cost-of-illness studies should consider alternative data sources and methodologies to enhance the validity and importance of expert opinion and to corroborate their findings.

Cost-effectiveness analysis of tacrolimus ointment versus high-potency topical corticosteroids in adults with moderate to severe atopic dermatitis.

BACKGROUND: Few cost-effectiveness analyses have been conducted on topical therapies for atopic dermatitis. OBJECTIVE: We sought to compare cost-effectiveness of high-potency topical corticosteroids (HPTCs) and tacrolimus ointment for the treatment of moderate to severe atopic dermatitis for patients who are not responsive to or not well controlled with mid-potency topical corticosteroids. METHODS: A Markov model represented the cyclic nature of atopic dermatitis. Clinical outcomes were derived from published literature. "Efficacy" was defined as disease-controlled days on which patients experienced a greater than 75% improvement in their disease. Resource use and changes in management were on the basis of opinions of a physician panel; secondary treatment was an oral antibiotic with topical corticosteroids. Sensitivity analyses were conducted for all variables. RESULTS: The model was sensitive to duration of continuous treatment with HPTCs. HPTCs, when limited to 2-week treatment cycles, were associated with the highest total costs ($1682 per year) and the least efficacy (185 disease-controlled days). HPTCs in 4-week treatment intervals and tacrolimus ointment were similar in total costs and efficacy ($1317 vs $1323 for 194 vs 190 disease-controlled days, respectively). Although primary drug costs were higher for patients treated with tacrolimus ointment, patients treated with regimens of HPTCs incurred higher secondary drug costs. CONCLUSION: In the base case analyses, tacrolimus ointment was more cost-effective than HPTCs administered in 2-week treatment cycles, and similar in cost-effectiveness to 4-week cycles of HPTCs.

Cost of atopic dermatitis and eczema in the United States.

BACKGROUND: Atopic dermatitis/eczema (AD/E) is a common disease. Few studies have attempted to quantify the cost to third-party payers. OBJECTIVE: Our purpose was to identify the annual cost of medical services and prescription drugs for the treatment of AD/E to private insurance and Medicaid payers in the United States. METHODS: We used a retrospective study design employing claims data from 1997 and 1998 from a private insurer and a state Medicaid program to analyze costs incurred. Beneficiaries were considered to have AD/E if they had at least one claim in 1997 with a primary or secondary listing of 1 of 3 diagnosis codes: 691.8, other atopic dermatitis and related conditions; 692.9, contact dermatitis and other eczema when no cause is specified; or 373.3, noninfectious dermatoses of eyelid. Patients who did not meet the diagnosis criteria served as a control group in each payer for comparisons of expenditures with the AD/E group. RESULTS: Disease prevalence was 2.4% (private insurer) to 2.6% (Medicaid) of all eligible beneficiaries, and 3.5% to 4.1% of patients submitted at least one health care claim during the study period. Medicaid-insured patients used outpatient hospital visits and hospitalizations at a greater rate than did privately insured patients; neither used emergency departments extensively. The third-party payer cost of illness for AD/E ranged from $0.9 billion to $3.8 billion when projected across the total number of persons younger than 65 years insured by private insurers and Medicaid in the United States. More than one fourth of all health care costs for patients with AD/E may be attributed to AD/E and co-morbid conditions. CONCLUSIONS: Annual costs of AD/E are similar to those of other diseases such as emphysema, psoriasis, and epilepsy. Patients incur significant costs associated with AD/E and co-morbid conditions.

Henoch-Schönlein Purpura Presenting as a Rash and Proteinuria in a 59-Year-Old Woman.

Henoch-Schönlein purpura is a disease of unknown etiology. it is predominantly seen in children, although adults are also affected, and comprises a rash, arthritis, abdominal pain, and renal dysfunction. there is no effective treatment, although the syndrome is self-limiting and generally subsides without sequelae. The authors present a case of Henoch-Schönlein purpura in a 59-year-old woman who presented with a rash of six months' duration and a high level of urinary protein.