The presence and impact of biofilm-producing staphylococci in atopic dermatitis.

IMPORTANCE: Atopic dermatitis (AD) is thought to be a double-hit phenomenon with an unknown environmental component and a genetic abnormality likely centered on the filaggrin gene. Biologically, the presence of Staphylococcus aureus in AD was reported more than 2 decades ago, but the relationship to AD has been elusive. OBJECTIVE: To explore the bacteria that produce the biofilms in the lesions of AD and the response of the innate immune system to these biofilm occlusions of the sweat ducts by specifically evaluating Toll-like receptor 2. DESIGN, SETTING, AND PARTICIPANTS: University hospital dermatologic clinic study involving the environmental component related to the characterization, correlation, and impact of staphylococci and their biofilms in AD. We processed routine skin swabs from lesional and nonlesional skin from 40 patients with AD and performed scrapings and biopsies. We also obtained 20 samples from controls (10 inflamed skin samples and 10 normal skin samples). EXPOSURES: Gram staining, bright-field microscopy, hematoxylin and eosin, periodic acid-Schiff, Congo red, and light microscopy. MAIN OUTCOMES AND MEASURES: Association of staphylococcal biofilms with AD pathogenesis. RESULTS: All AD-affected samples contained multidrug-resistant staphylococci, with S aureus (42.0%) and Staphylococcus epidermidis (20.0%) as the predominant species. All isolates were positive for extracellular polysaccharide and biofilm (85.0% strong biofilm producers and 15.0% moderately to weakly positive). Polymerase chain reaction revealed the biofilm-mediating icaD (93.0%) and aap (12.5%) genes in the isolates (some contained both). We also examined tissues for microbial identification, extracellular biomass formation, biofilm formation, and staphylococcal biofilm in skin tissues. Occlusion of sweat ducts with periodic acid-Schiff-positive and Congo red-positive material was noted on microscopic tissue examination. Toll-like receptor 2 was shown to be activated in AD lesional skin (immediately proximal to the sweat ducts), which likely led to the initiation of proteinase-activated receptor 2-mediated pruritus and MyD88-mediated spongiosis. CONCLUSIONS AND RELEVANCE: Biofilm formation by AD-associated staphylococci almost certainly plays a major role in the occlusion of sweat ducts and leads to inflammation and pruritus. We believe the environmental hit in AD relates to staphylococci and their biofilms, which occlude sweat ducts.

Readability of Patient-oriented Online Dermatology Resources.

BACKGROUND: Supplemental educational reading material is of no value to patients if it is not read and comprehended. OBJECTIVE: Using standardized research tools, online patient education materials were comparatively assessed for readability and length in words to identify the strengths and weaknesses of widely utilized sources. METHODS: Three sources of patient-education material on the internet (WebMD.com, Wikipedia.org, and MedicineOnline.com) were compared with materials produced by the American Academy of Dermatology for readability utilizing Flesch-Kincaid Grade Level and Flesch Reading Ease Scale. Automated word counts were used to determine the length of each educational piece. RESULTS: The information presented in American Academy of Dermatology electronic pamphlets on the internet is significantly harder to comprehend than MedicineOnline.com, but easier than Wikipedia.org. The latter site proved significantly harder to comprehend than all other sources. The American Academy of Dermatology electronic pamphlets and MedicineOnline.com materials were the most concise, averaging 1,200 words or less, although this was not a statistically significant difference in length compared to other online patient-education resources. No single source of online patient-education material demonstrates optimal features with regard to each of these parameters. LIMITATIONS: Only 15 topic areas in the four most commonly accessed sources of patient information were analyzed in this study. CONCLUSION: No single source of commonly used internet patient-education material demonstrates optimal features with regard to readability, length, and presence of photographic illustrations. These educational materials should target a length of 1,200 words, be illustrated with clinical images, and readability should correspond with the national average reading level.

The electronic medical record in dermatology.

Governmental incentives to stimulate the "meaningful use" of electronic medical records and future disincentives for Medicaid and Medicare provide an impetus for dermatologists to consider adding this technology to their clinical practice. Dermatologists should carefully weigh the pros and cons of establishing an electronic medical record system before incorporating this expensive technology. This article reviews available scientific and economic data required for dermatologists to help make an informed choice.