Eyelid dermatitis.

Cosmetic alteration of a patient's orbital skin is a common reason for professional consultation. This review presents the differential diagnosis and recommended evaluation of inflamed eyelids. To better understand the diseases, each is individually addressed clinically, pathogenetically, and therapeutically. It is critical to recognize the lesions correctly and to have full knowledge of the putative clinical disease process. An algorithm for an appropriate work-up for each disease is offered. With this background, a successful therapeutic response can be anticipated.

The clinical spectrum of atopic dermatitis.

Updating our clinical concept of atopic dermatitis (AD) evolves from the better understanding of all the immunologic aberrations expressed by the polygenic combinations and permutations associated with the atopic diathesis. Recognizing the immunopathologic features of AD readily underscores that AD without "atopy" is an oxymoron. Appreciating "pruritus" as the impetus to scratch, which isomorphically gives rise to the "eczema," shifts the goal of management from suppressing inflammation to avoiding the triggers of pruritus. Recognizing the full spectrum of dermatologic findings in AD endorses the preferred label as a dermatitis, rather than the inferred restrictive label, atopic eczema. As our knowledge of immunology evolves, our criteria for the diagnosis and management of the atopic diathesis are sure to change.

Managing atopic dermatitis.

"Itchy" rashes occurring in patients (usually an infant or child) with a personal and/or family history of itching, sneezing, and/or wheezing should be considered part of the spectrum of skin problems labeled "atopic dermatitis" (AD). Multiple factors influence AD, and effective management requires that none be overlooked. The complicated nature of treatment means parents and family members require repeated reinforcement and education, particularly in avoiding "triggers of itch;" and use of medications. When all the aspects of AD are adequately addressed, more than 90% of patients with AD can be effectively managed.

Allergic dermatoses.

Defining "allergy" and elucidating the immunopathology of what is too often described as allergic rashes is the objective of this article. The differentiation of inflammatory reactions, which at times is indistinguishable from the immunologic dermatoses is outlined. A rationale plan for management, with indications warranting referral to "the specialist" are suggested.

Contact dermatitis.

LEARNING OBJECTIVES: Reading this article will reinforce the reader's knowledge of the definition, pathophysiology, differential diagnosis, evaluation, and management of the most common of all the "eczemas," contact dermatitis, which can have an allergic and/or an irritant pathogenesis. DATA SOURCES: Relevant articles and current texts on contact dermatitis were referenced and reviewed. The personal experiences of the authors in an Environmental Medicine Clinic, their private practices, and their teaching of residents and other physicians were evaluated. A MEDLINE database using subject keywords was searched from 1986 to date. STUDY SELECTION: Book chapters, pertinent articles, data source abstracts, guidelines for the management of contact dermatitis set by the American Academy of Dermatology, and the American Contact Dermatitis Society were critiqued. RESULTS: The recent elucidation of the pathoimmunology of contact dermatitis is concisely reviewed, highlighting its clinical implications. The protean clinical presentations of contact dermatitis, both "allergic" and "irritant" type are cited. The signs and symptoms warranting the search for a contactant are outlined. The most likely regional contactants are listed, but the need to reference a more complete textbook is often required. That patch testing is the gold standard to identify an allergenic agent causing allergic contact dermatitis is stressed. While the "who" and "when" to patch test is amply described, a cookbook "how" to patch test has been omitted in order to emphasize the importance of "hands on" experience for such testing. The advantages and limitations of the commercially available standard patch tests (Hermal, and T.R.U.E.) are described, plus the sources for "nonstandard" patch tests is made available. Therapeutic modalities, topical and systemic, for management of the uncomfortable patient are outlined. CONCLUSION: The physician who manages a patient with an "eczematous" rash must be aware of the complete differential diagnosis of that clinical presentation. Suspicion that a "contactant" is the cause must have high priority, especially when the rash is persistent, and fails to respond to "appropriate" therapy. The value of a skin biopsy is limited to confirming its eczematous (spongiotic) nature and ruling out other diseases. Appreciating the paradox of patch testing, namely the deceptive simplicity of application versus the required expertise for interpretation and recognition of clinical significance, is the key to the proper management of the patient with contact dermatitis.

Urticaria and angioedema.

This article discusses the allergist's or dermatologist's rational pathophysiologic approach to urticaria and angioedema. Every recognized cause is outlined and identified for preventing acute urticaria. Appreciating chronic urticaria as a "twitchy mast cell" syndrome is emphasized. The "art of pharmacologic" gymnastics is presented for the safest and most effective management of patients with urticaria.

Managing the patient with hives.

Urticaria, or hives, is a usually transient reaction involving the upper dermis. Understanding the causes and treatments of urticaria will help the dermatology nurse manage the patient with hives.

Creating an indoor environmental problem from a nonproblem: a need for cautious evaluation of antibodies against hapten-protein complexes.

An epidemic of illness in three schools in New York State occurred in early 1983. An epidemiological review of the problem led to the conclusion that some of the symptoms could have been explained by irritant reactions to boiler exhaust gases but that a major factor was likely public concern about environmental contamination and heightened awareness of common minor symptoms and of exacerbations of chronic illnesses. Diphenylmethane diisocyanate (MDI) from polyurethane insulation had previously been suspected as a potential cause. An earlier investigation had found low levels of anti MDI-human serum albumin in a small number of subjects who did not have typical symptoms of identified MDI or other hypersensitivity syndromes. Similar antibodies were found in two of nine unaffected children in Chicago, who served as a comparison group. The identification of these antibodies, however, was inappropriately used to support the idea of a school contaminated with MDI in spite of the absence of detectable MDI in the environment. The availability of highly sensitive immunoassays should not be inappropriately used to accelerate the fear of environmental toxins when there is no clinical correlation.