1010 Commentaries

References 1 Guilland JC, Favier A, Potier de Courcy G et al. [Hyperhomocysteinemia: an independent risk factor or a simple marker of vascular disease? 2. Epidemiological data]. Pathol Biol (Paris) 2003; 51:111–21 (in French). 2 Laddha NC, Dwivedi M, Mansuri MS et al. Vitiligo: interplay between oxidative stress and immune system. Exp Dermatol 2013; 22:245–50. 3 Chen JX, Shi Q, Wang XW et al. Genetic polymorphisms in the methylenetetrahydrofolate reductase (MTHFR) gene and risk of vitiligo in Han Chinese populations: a genotype–phenotype correlation study. Br J Dermatol 2014; 170: 1092–99. 4 Wang X, Cui L, Joseph J et al. Homocysteine induces cardiomyocyte dysfunction and apoptosis through p38 MAPK-mediated increase in oxidant stress. J Mol Cell Cardiol 2012; 52:753–60. 5 Weiss N, Zhang YY, Heydrick S et al. Overexpression of cellular glutathione peroxidise rescues homocyst(e)ine-induced endothelial dysfunction. Proc Natl Acad Sci USA 2001; 98:12503–8. 6 Laddha NC, Dwivedi M, Gani AR et al. Involvement of superoxide dismutase isoenzymes and their genetic variants in progression of and higher susceptibility to vitiligo. Free Radic Biol Med 2013; 65:1110–25. 7 Shaker OG, El-Tahlawi SM. Is there a relationship between homocysteine and vitiligo? A pilot study Br J Dermatol 2008; 159:720–4. 8 Karadag AS, Tutal E, Ertugrul DT et al. Serum holotranscobalamine, vitamin B12, folic acid and homocysteine levels in patients with vitiligo. Clin Exp Dermatol 2012; 37:62–4. 9 Yasar A, Gunduz K, Onur E et al. Serum homocysteine, vitamin B12, folic acid levels and methylenetetrahydrofolate reductase (MTHFR) gene polymorphism in vitiligo. Dis Markers 2012; 33:85–9. 10 Castro R, Rivera I, Ravasco P et al. 5,10-Methylenetetrahydrofolate reductase (MTHFR) 677C>T and 1298A>C mutations are associated with DNA hypomethylation. J Med Genet 2004; 41:454–8.

Occupational allergic contact dermatitis: the big challenge DOI: 10.1111/bjd.13018 ORIGINAL ARTICLE, p 1100 Occupational skin diseases impose a significant burden on affected individuals and society.1 Average incidence rates of occupational contact dermatitis across Europe were reported to be around 05–19 cases per 1000 full-time workers per year.2 Focusing on occupational allergic contact dermatitis, occupationally acquired contact allergies [odds ratio (OR) 385; 95% confidence interval (CI) 157–944; P = 0003] as well as multisensitization (OR 222; 95% CI 113–433) were reported to be the most important predictors for a poor prognosis and persistent eczema in affected patients. Age, sex and nonoccupationally acquired allergic contact dermatitis did not play a relevant role.3 Due to limited information on contact allergies in many occupational skin disease registers a follow-up of patients even with recognized occupational allergies is often difficult. In this issue of the BJD, Clemmensen et al.4 focus on this important topic. Their study adds relevant and reliable inforBritish Journal of Dermatology (2014) 170, pp1008–1014

mation on the impact of different occupational sensitizations on prognosis and quality of life (QoL) in affected workers. Analysis was based on data from the Danish National Board of Industrial Injuries (DNBII). DNBII registry data include detailed information on sociodemographic characteristics, diagnoses, co-diagnoses, age at onset, atopy, contact allergies and relevance of sensitizations, localization of eczema, occupations, exposures, degree of disability and compensations based on medical specialists certificates or patients’ files from dermatology departments.5 Based on these data, Clemmensen et al.4 had the opportunity to follow up a very well-characterized cohort of 199 Danish patients with recognized occupational dermatitis suffering from clinically relevant sensitizations to rubber chemicals, latex or epoxy resins to investigate the course of eczema/urticaria, job status and skin-related QoL 2 years after recognition.4 The study was questionnaire based. A considerable response rate of 75% was achieved. The authors report the highest frequencies of persistent disease and the lowest QoL in workers with sensitizations to latex proteins followed by rubber chemical sensitizations. The highest rates of eczema clearance and the lowest impairment in QoL were seen in epoxy resin-sensitized workers. They speculate that dissemination of allergens – nonubiquitous vs. ubiquitous – might be responsible for clearance or persistence of disease. However, this was significant only for latexinduced contact urticaria compared with epoxy resin contact allergy. Between rubber chemical and epoxy resin sensitizations no significant difference in prognosis was seen. However, a significant positive association between job change and improvement of skin condition was found. The high overall frequency of persistent disease in 89% of the patients 2 years after recognition is alarming. These data confirm published results on the poor prognosis of occupational contact dermatitis with considerable rates of persistent disease even after decades.6 Prevention strategies based on nationwide legal regulations have been successful concerning reduction of contact allergies to chromate in the building trades and glyceryl monothioglycolate sensitizations in hairdressers as well as contact urticaria to latex proteins in the healthcare sector.7–9 These successful interventions should guide future prevention strategies. In Denmark, as in other European countries, rubber chemicals and epoxy resins are allergens frequently causing occupational allergic contact dermatitis.4,7,10,11 Both allergens are high-priority candidates for future legal regulations. Conflicts of interest None declared. Department of Dermatology, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstr. 74, 01307 Dresden, Germany E-mail: [email protected]

A. BAUER

© 2014 British Association of Dermatologists

Commentaries

References 1 Augustin M. Pharmacoeconomics of occupational diseases. In: Kanerva’s Occupational Dermatology (Rustemeyer T, Elsner P, John SM, Maibach HI, eds), 2nd edn, vol. I. Berlin: Springer, 2012; 16–26. 2 Diepgen TL. Occupational skin-disease data in Europe. Int Arch Occup Environ Health 2003; 76:331–8. 3 Macan J, Rimac D, Kezic S, Varnai VM. Occupational and nonoccupational allergic contact dermatitis: a follow-up study. Dermatology 2013; 227:321–9. 4 Clemmensen KBC, Carøe TK, Thomsen SF et al. Two-year followup survey of patients with allergic contact dermatitis from an occupational cohort. Is the prognosis dependent on the omnipresence of the allergen? Br J Dermatol 2014; 170:1100–105. 5 Carøe TK, Ebbehøj N, Agner T. A survey of exposures related to recognized occupational contact dermatitis in Denmark in 2010. Contact Dermatitis 2014; 70:56–62. 6 Meding B, Lanetto R, Lindahl G et al. Occupational skin disease in Sweden – a 12 year follow-up. Contact Dermatitis 2005; 53:308–13. 7 Geier J, Krautheim A, Uter W et al. Occupational contact allergy in the building trade in Germany: influence of preventive measures and changing exposure. Int Arch Occup Environ Health 2011; 84: 403–11. 8 Uter W, Geier J, Lessmann H, Schnuch A. Is contact allergy to glyceryl monothioglycolate still a problem in Germany? Contact Dermatitis 2006; 55:54–6. 9 Allmers H, Schmengler J, John SM. Decreasing incidence of occupational contact urticaria caused by natural rubber latex allergy in German health care workers. J Allergy Clin Immunol 2004; 114: 347–51. 10 Bauer A. Contact dermatitis in the cleaning industry. Curr Opin Allergy Clin Immunol 2013; 13:521–4. 11 Geier J, Lessmann H, Mahler V et al. Occupational contact allergy caused by rubber gloves – nothing has changed. Contact Dermatitis 2012; 67:149–56.

‘Putting in the graft’ to optimize outcomes in nasal alar reconstruction DOI: 10.1111/bjd.12892 ORIGINAL ARTICLE, p 1106 The nose is the commonest site within the head and neck region for the occurrence of skin cancer;1 within its aesthetic subunits, the nasal ala is the most frequent site for the occurrence of basal cell carcinoma.2 As a consequence, the reconstruction of alar defects is frequently encountered by surgical specialists involved in skin cancer management. The stakes are high when reconstructing the ala: the free margin of its inferior rim is readily displaced, the alar crease superiorly is readily effaced, and its marked convex contour readily depressed. Furthermore, its prominent centrofacial location means that any subtle alteration in its form often results in an unforgiving asymmetry compared with its contralateral counterpart, which is therefore readily apparent to the

© 2014 British Association of Dermatologists

1011

observer. Beyond its aesthetic importance, the nasal ala and the associated nasal valve has an important functional role in maintaining patency of the nasal vestibule to enable unimpeded airflow, which should not be compromised during its repair. By virtue of its tissue-sparing properties Mohs micrographic surgery enables the creation of shallow surgical defects. The nasal ala is a site at which such shallow defects may heal very well by secondary intention.3 Patient preference, proximity to the alar rim and depth of the surgical defect, however, may preclude this as an option. Although skin grafting of alar defects is a well-established technique, an acknowledgement by reconstructive surgeons that a local flap repair enables optimal restoration of volume, contour and tissue match has led to the propagation of numerous single- and two-stage flap repairs for such defects. All flap repairs, however, create further incision lines either on the cheek, nose or forehead and commonly necessitate an increase in the size and depth of shallow surgical defects to enable replacement of the entire alar subunit to optimize results. In this issue of BJD, Tan et al.4 present the largest (retrospective) series to date of full-thickness skin grafting (FTSG) for the repair of Mohs surgical defects of the ala. The authors elegantly describe their experience of 186 cases using FTSG for a variety of alar defects. Although FTSG is (quite rightly) viewed as a simple and reproducible reconstructive technique, there are many nuances when repairing the ala by which the surgeon may optimize aesthetic and functional outcomes. Indeed, this Journal alone has had three recent publications discussing ways of maximizing the adherence of skin grafts to the tricky convex shape of the ala.5–7 Similar ‘pearls’ are well highlighted by Tan et al. in their article. Although previous studies have confirmed what is seen in clinical practice – that the careful choice of a donor site to optimize FTSG ‘tissue match’ results in better surgical outcomes8 – this is a matter of individual surgical preference and experience. No two patients or their surgical defects are identical. Creating ‘algorithms’ for surgical reconstruction is thus invariably difficult but may serve as a useful guide when approaching challenging regions of the face such as the nasal ala or lips. The fact that in their paper, the authors have utilized 11 different FTSG donor sites bears testimony to the fact that they have not adopted a ‘one size fits all approach’ (which inevitably leads to suboptimal results in some patients), but tailored the chosen reconstructive approach according to the characteristics of the nasal skin, the size of the defect and the optimal donor site in each individual patient. With the selected use of postoperative dermabrasion and intralesional steroids, they also show that good to excellent results can be achieved. Their article also challenges the perceived surgical dogma regarding the use of FTSG in alar reconstruction in that they demonstrate that optimal outcomes may be achieved without the need to replace the entire cosmetic subunit of the ala. This approach has the benefit of enabling the use of several potential donor sites. British Journal of Dermatology (2014) 170, pp1008–1014

Occupational allergic contact dermatitis: the big challenge.

Occupational allergic contact dermatitis: the big challenge. - PDF Download Free
50KB Sizes 0 Downloads 4 Views