Psoriasiform Dermatitis and Idiopathic Erythroderma - The Derms on Drugs Clear Up Some Murky Topics

[music] [music] Welcome to Derms on Drugs. A video podcast brought to you by Scholars and Medicine. Derms on Drugs is where cutting edge dirt meets. Maybe mediocre comedy is leaning towards not very good. I'm Matt Zyres and each week I'm joined by my residency buddies Laura Ferris and Tim Patton to use our 60 years of combined experience to discuss, debate and dissect the hottest topics in dermatology. It is everything you need to know to be on the cutting edge of dermatology and it will be the most fun you've ever had while actually learning something useful. Now this week we are super excited. We've got sort of dermatitis, unspecified type direction. We are going to be taking with our special guest Dr. Amber Atwater who is a member of the North American Context from Titus Group and previously the residency director at Duke. But first we are going to go ahead and get into our first article and I'm going to kick it over to Dr. Ferris. All right, thanks Matt. So the paper that I picked was published in Nature Scientific Reports, targeted dual biologic therapy for a Rithriderma of unknown etiology guided by hyperameter peripheral blood immunofenotype things. That's a lot of this is corn mined at all, but it's Sean Quattro's group. Okay, so you know, I thought this was really interesting because we all encounter these patients through a Rithridermic. You're not sure what they have. You biopsy. You can't really tell. You try a biologic. They get better or worse. They not the tracks they cyclists born. So for one patient, this group they created an immunofenotyping platform. And what they did was they basically did. Man, I think it is special. I think it's special when I do a peer review to try and get a biological proof for somebody. Let alone create an immunoflow cytometry trying to figure the shit out. Man, exactly. So yes, so they looked at PVMC. They compared them to a Rithridermic patients who had sezary or PRP and a lot of science in this, but basically what they found was that he had this unique signature of making both IL-13 and IL-17. He basically had two gamma delta T cell clones that were doing this. And you know, sequence the genome did whole genome sequencing, found mutations related to IL-4-13 and 17. And you know, also found that the, you know, abnormals and granulocytes specifically increased MRG PRX2, which will mean more to people like you who love itch unless people like me who do not like itch that much. Now, wait a minute, I got another question here. First, you use the word clone. Does that mean that this guy had like a gamma delta T cell malignancy? Or these non malignancy? It's just like, it's a, it's a, it's a, it's clone. So they were, you know, restricted by the T cell. This wasn't like a malignant population. It was just an expanded population. That's the way I read it because that was kind of my first thought too. So, basically, if you find this person, they make too much IL-17, they make too much, you know, IL-13, what are you going to do? You're going to treat him with something with two drugs, dupexin and cosentics. And basically, the guy had to be on like Q2 week dupexin and Q3 week cosentics. But he cleared. They got rid of this gamma, this population of pathogenic T cells. And so, you know, I thought this was interesting because like this is personalized medicine to the max, right? Like you said, I feel like, wow, I did a peer to peer. You know, and this reminds me of those patients who are like, I want to know the root cause. And you're like, you're not going to tell, we're not going to tell you the root cause. Well, I'm going to make one up for them. It may or may not be accurate, but I'm going to make something up. Right. But dang it. If Quattra did not go make us all look bad by actually finding the root cause for this patient and getting them on two different drugs. So it's kind of cool though, because if you look at the basic immunofenotyping, it's like draw down some cells, stimulate them and then look at the cytokines that they're being made by flow cytometry, something that patent doesn't know a whole lot about. But, you know, but it's something it's a test that you could that you could actually kind of do. If you think about, you know, how we do gene profiling on things. But it would you would have to do because you wouldn't know that these were like if you did just regular flow cytometry, you would get that these were gamadelt the T cells, but you wouldn't know that they were like. Clonal, you know, aisle 13 producers or aisle 17 producers or whatever can you tell that basically get all the all the the pbmcs they stimulated them and then they ran them through a flow cytometer and looked at like is there a population that's activated and making aisle 17 or yes, interferon gamma no aisle 13. Yes, so that's it's actually like not the most complicated to do all this like do you have a clonal population blah blah blah you'd have to do that, but this is actually a way it could sort of see what's going on in the, you know, in the peripheral blood and actually target a patient actually target a patient's very specific pathology. Pat and what would you so normal a rithroid or a patient so meaning they didn't have preceding psoriasis they didn't have preceding a topic dermatitis they don't have islands of sparing or anything you know the good nice head to toe progression just your call you. You know, consulted you go see them. But four months ago this rash starting out horrible what would you do what he's trying to ask you what would you do yeah so right that's why this paper was a huge waste of time and money you you say that this guy is a rithroidermic a topic because you can find some sponge on the biopsy that gets them on the dupe. And then you give him reform last to take care of the 17 part there I just saved you seven million dollars. I put this wasn't seven million dollars. Oh, do you know how much flow cytometers costs it is a pretty penny but not not serious. I'm using him because no, no, no, the paper with the PhD I said to Tim we were reviewing a paper in journal club. I said do you even know how to do flow cytometry and then of course I found out that like he spent three years working in this like sophisticated flow cytometry lab before she saw she saw this poor little D.O. In the Durham program thought I was an idiot and now she knows me and she knows I'm an idiot. I did I did flow cytometry for like four years so no, no, I mean this is this is great right it's just woods an amazing amount of work. But don't you think you'd have an easier time so what would I do with an arithmetomic patient. You know like method tracks a cyclosporne if you're going with broad anti inflammatory treatments. I mean I love dupexen for so much a lot of these biopsies are sponge Durham non specific if it's not definitely PRP or psoriasis. So so I think dupe dupexen makes a lot of sense for these people I can't say that alone didn't do it prednisone didn't do it. Yeah, he mirrored and do it like no I get it. But like it's not unreasonable that you would say this is a this is just really bad a topic coming to throw do be out of right given right or give them a whole bunch of I mean that's right I would be interested to see where the jacks are is there a I was wondering that because they always show those pictures of the jacks connected to these receptors and you know aisle 17 binds this receptor and it activates this jack combination. Like a perfect jack inhibitor that would have hit your your aisle 13 and your aisle 17 together or just more broad jack inhibitor. I think like a broad jack. Most money talking about. Yeah, tofoceted give him to a number something. But that brought it's actually primarily a jack three inhibitor I would actually think no ruxil it is a one two and upa. Rhinvoca is a one two and then delgocit nibb which is a new one coming from Leo is a one two three tick. But that's topical. And that's probably your best broad spectrum e jack. Yeah, that would have been interesting. All right, let's so good. So sticking with that same theme of Greg was talking about somebody who's got both aisle 13 and aisle 17. So we're talking about somebody who's got pathophysiologically incite a kind of both a topic to my title. So we're next going to jump in a first minute introduce our guest for the week who is the author of the next paper that we're talking about and we're the. going to go into the deep dive. So Dr. Amber Atwater has been a friend of mine for a long time, a fellow member of the North American contact dermatitis group. We've known each other for a good 10, 15 years. We were both program directors at the same time, Meadow, Iowa State University, Amber at Duke University. She then left Duke for a little while went to work in industry with Lily on Libertismab and now is back taking care of patients again in North of Virginia. And a little trouble getting permission to bring her on since she's a former dukey. But since it's a former dukey, it was okay. I think if she was still at Duke, I might have had some trouble getting Dr. Ferris to let her on. But Amber, great to have you here. Thank you. So let's get right into this paper. So I couldn't. So the question that I as a contact dermatitis a topic dermatitis rash person get all the time is, well, what do you do with sore assiform dermatitis? What do you do with sore assiform dermatitis? And there's no articles about this. And so this study, right? So final clinical diagnosis in cases of histopathologic sore assiform dermatitis, retrospective cross-section analysis of a southeastern United States population, 2004 to 2017. So a 13 year period. And I guess when I first saw this study, I was like, I can't believe somebody actually did this because basically you guys took everybody who had a biopsy that showed sore assiform dermatitis over many year period at Duke. And then literally somebody went through each of their charts to see what the heck happened with them and what was the eventual final diagnosis. Is that is that about right for what you guys did? Yes. And the reason we did it, Matt, is because when things bother me that there's no data on them that I can't find any information on, that's when it becomes a project, right? So this is how this became a project. It had been bothering me for about 10 years. And I finally had a fellow Jordan Ward who's the first author on this paper. And I said, this is what we're going to do. We're going to look at this. And kind of the right way to analyze the data came to us, right? And so we could do it and we did it. But it's because it bothered me. And I think that's how some of the best projects come up. One of the first questions I got to ask you bit. So well, first let's just get to the results. So the results, my main takeaway, right? So if you get, if you're out there in practice to see somebody you're looking at, I don't know, I can't really tell. This doesn't look like class again, anything that's biopsies, who will be get comes back. Sorry, assiform epidermal hyperplasia with minimal to moderate spongiosis and a paraphrase of lymphocytic infiltrate with a few eosinophils, psoriasis, or dermatitis. And then you're still like, I don't know, okay, great. No help at all. Thanks. Right. But so what eventually happened to them was about a third of them ended up having psoriasis, about a third of them ended up having dermatitis of some sort. And then about a third of them had whatever, right? Anything from like annoyed dermatitis to final diagnosis of psoriasis, or dermatitis to CTCL pairs, psoriasis, whatever. And then the dermatitis patients got split into, so you guys did a nice breakout. Half of them had just quote chronic dermatitis, which I can't wait to talk more about what the hell chronic dermatitis means, right? And then you had, you know, 13% of the metal or chocontact dermatitis, 13% had a topidermatitis, some had quote other dermatitis. So, but about, you know, chronic dermatitis, any topidermatitis, probably the top two. And then the body area involvement was interesting and useful as well. So the main takeaway was if you had it on your scalp, you probably have psoriasis. If you have it on your face, you probably have dermatitis of some sort. If you've got it in your endogenital area, we're probably never going to figure out what the heck you've got. And other than that, we don't know, none of it's particularly helpful. Is that a reasonable, so a third to third to third, a third surizes, third atopic dermat, third, whatever. And then distribution didn't help a whole lot. Is that, is that your takeaway? Yeah. And it's really interesting because this analysis to kind of find if there were any locations that were associated with a diagnosis was the idea of Adam Briss. So I want to give him credit there. We were going through our 700th version of this paper. And he said, wouldn't it be, it'd be cool if we did this extra analysis. And I think that's a really important part of the paper now that that really makes it shine a little bit more. So I'm glad we did it. Now I got to ask why isn't this in a better journal? Right. So it's in the archives of dermatological research. This is for, but for practicing dermatologists, this is like as uber useful as anything could ever get. If there's ever been an article that to me should have been in the, like, did you guys send it to Chad? And they were just like, ah, you guys are in a drug company, you're not advertising. So to hell with your article, like what happened? Why is this not in Chad? And why is it in archives of dermatological research? Well, you know that this project was 2004 to 2017. We started the project in 2019. And honestly, it was done in 2020, 2021. And at that time, we submitted to six journals. Six, six, all of them except for one. Just flat out, denied it. And the one that didn't deny it tortured me with revisions and then denied it. And so we almost gave up. But interestingly, the paper is a little different than there's a lot more data. And I had analyzed it a little bit differently. And honestly, I learned when I was working with Pharma, how to write a succinct paper that people care about. And I changed my paper. Not a lot, but a little. I changed it and I shortened it. And I cut out some extra data. We had a whole table on what drugs patients were taking. We took a lot out and I took some of the feedback that we had received around one. And I submitted it to one other journal who denied it, which was a journal I had denied it the first time. I think that might just be a vendetta against me personally, but that's a whole another story. And then I asked one of my friends, Jonathan Silverberg is a friend of mine and I said to him, can you please look at this paper because I cannot get it published. And I don't know why. So he read it and he's like the paper is fine. Submit it to one of these two journals. And I did and they got accepted. So I have a whole storyline there, right? Like getting advice from others, making revisions when you need, there's so much to it. But it was hilarious when Matt emailed me a couple of weeks ago and was like, what's the deal with this paper? And I'm like, this is the paper I could never get published. Right? Because it is just so you like for it is the most common question I get is what do you do a story, ask the form of derby and there's nothing about it in the literature, nothing. So all right, I've been kind of monopolizing, which I usually do. And so I'm going to I'm going to see Pat and what do you what do you got? I had a quite not specifically about this the journal article, but you and Matt, you know, you've published a lot on patch testing. So I did patch testing for like a second. And one of the things that I just felt that people did other dermatologists was they get a patient with dermatitis and they're just like just you might be allergic to something. We'll do a biopsy. There's some spungiosis with eos and oh, that's got to be an allergy. And so all these people getting sent to me and it's like you go through their history and they have a family history of asthma and things like that. They they weren't counseled at all on, you know, maybe trying sensitive things like that. Don't you think that patch testing is like way overdone? Like there are things that can be done before those patients are even referred to you. That's just not done or do you think the referrals are appropriate for the most part? Honestly, I think referrals are usually appropriate. I mean, in my experience. So I was at a large academic center where I had everything basically in the state sent to me, right? Except sometimes they got sent to UNC, but usually to me, I do, Clara. Those people are still have their rashes. They don't, their, their fairances needs another year to get them all cleaned up. But now I mean, a private practice in northern Virginia and I'm getting referrals and it's still kind of appropriate. Now, there are many situations where people have been patch tested and they're actually not counseled to avoid their allergens. And they come to me and I'm like, let's try this first. You've already been patch tested. Let's avoid your allergen. But I often think it's appropriate and sometimes it's, you know, wrongdiagnosis.com. And that's appropriate too because I can actually help the patient, right? Like I can actually move them towards improving and that's actually the only thing the patient cares about, right? Is is is is is clearing their skin? So I usually I think they're okay. So Amber, if you were, I have a question for about the, do you think it's just because like when you're a patch tester, you become like a dermatitis aficionado expert, right? Like I'm wondering if the benefit is truly all the patch testing or if it's more like the, the more thoughtful approach to that patient. Like what do you think about that? For sure, for sure because not everybody has an algae. Right. There's a bunch of of people that either we don't test because it's not appropriate or we do test and they don't have an allergy or we do test and they have an allergy and they don't get better. But I personally feel it's still my responsibility to help them. And there are all sorts of tricks up my sleeve and I'm sure up my sleeve as well that we can do it to help those patients. So it's not always allergy but there's lots of other, it's it's multifactorial, right? So we do all those things. Would you really not patch this? Like that blows me away. I mean, it's almost like these patients have been waiting and they have their stack of papers. Would you actually tell somebody like, we're not patch testing you, like blah, blah, blah, whatever. It's not the rule. It's the exception. But I've had acne sent to me for patch testing. I'm not the patch test them. Yeah, sorry about that. I got that. I was. I was. I was. I was. I was. But what was this? D.H. Bulls, Pempagoid. I mean, all of these things have been sent to me for patch testing. And then do a biopsy or hold up. We're going to do this first. And then we don't patch test those patients. So. Ember the patch testing. So first of all, we ask a very direct specific question. So you were, let's, let's say you were dermatologist who doesn't do patch testing. There's two or three month wait to get into the good patch tester in town. Maybe it's a 45 minute drive and I guess to take three days off work. Like so it's not trivial, right? To get somebody patch tested. How would you decide? Because right until 2017, like I was still like, you just get a patch tested because you get a patch that we just need to find out we don't, if we don't get a patch, it's we're never any good treatments. Now we've got great treatments, right? We've got dupey and grin vogue and ebbliss and adbree and tbinko and Nemo and whatever. So how do you decide who to just empirically be like? Well, let's try treating you for contact for a topic, Dermann. If that doesn't work, was it for patch testing versus first thing we're going to do is send you for patch testing, right? How do you, because that's a huge question. So for me, it depends on the story and the distribution, right? So if it's there, of course, our cases of contact, Dermann, that look like a topic, Dermann, right? Yeah, yeah. Classic a topic, Dermann. I'm going to treat classic a topic, Dermann first. But you know, there's certain body parts that are supposedly more consistent with allergy hands, being one of them. I know you guys recently talked about this last week or the week before. Eyelids is another one that that might be more likely allergy. So, so the answer is it depends, right? It depends on the story. If for me, if there's any chance that it's going to be allergy, I'll patch test. Because I do not want to put patients on a lifetime of any type of systemic medication if they don't need to be. Like that's really important to me to not do that, not just because of money, but because of that's really annoying to have to do that as a patient. Yeah. I have to delete it. That's actually, I wanted to say one thing about the paper, which I think is kind of funny. So, Sean has a 2025 version of kind of like my paper, right? My paper is like the pre-dupe version. So, so my data went to December 2017. Like, do be like, wasn't even really available then. And so there's this whole other version. I feel like if we re-did the analysis for 2017 at 2025, you might see something different, right? And so, I think it's really different drugs to treat their patients. Sometimes people choose the diagnosis based on the drug. What's one of the things that I thought was interesting from your paper was that it's about 30% of people were diagnosed with dermatitis, what all of a sudden done. About 12% of them were diagnosed with allergic contact dermatitis. So when you get about, you know, based on that group, sorely assiform dermatitis strongly went against allergic contact dermatitis, right? So about 4%. Which is 125, not none. But it was one in 25 people with a biopsy that showed sorely assiform dermatitis had a positive patch test and a finite diagnosis of contact germ. And that's another, so another thing I want to get into. So Peggy Wu, another friend of ours in the NACDG, just published an article looking at histopathologic features of ACD. And basically, so she looked at people at a biopsy and then a patch test. And on the biopsy predicted positive patch test. And the main takeaway was, yes, in a Phil's go against allergic contact dermatitis and spungiotic vesicles with langer hand cells in them go for it. Now the spungiotic vesicles with langer hand cells are rare anyways. But so EOS went against contact dermatitis and that was about it. And they weren't strongly against it. So the takeaway for me was another confirming that biopsies are pretty worthless in terms of determining the cause of dermatitis and what's like, you know, what you should do next. So for all four of us, right? So let's start, right? Because Pat and Ferris, you guys have had plenty of biopsies of, you know, oh, spung derm, EOS recommend patch testing might be a drug rash blah, blah, blah, blah. And I don't know if the derm path it pit would give, you know, recommendations are just, it's dermatitis period. What did you ever find biopsies helpful in spung derm patients? Pat and you go first. Just to prove that it was spung derm and, you know, not psoriasis or other, you know, I thought patient with DM recently that I thought really looked more spungiotic clinically. And it came back as a more like annoyed type of inflammation. So just to show that it's sponge, but I never, I mean, I think that's such an odd thing when patients come in because I had a couple patients, honestly, in the last month, they came in with spung derm with EOS and said, my doctor doesn't know what I'm allergic to. He thought maybe you could tell. And like I'm done patch testing. So it wasn't even a path tester for all it was just, what am I allergic to? Can you tell me this? And I'm like, I don't like, why do you think, you know, like that, that's what my doctor said. I'm allergic to something based on my biopsy. I never did that. Oh, the, no, I think that's passing the buck. I would say, um, I, I think like looking at your paper, Amber, about eight percent of those patients end up having CTCL. So when do I biopsy, when I want to make sure it's not something bad, right? So particularly we can go back and forth about does Dupy increase your risk of CTCL. But like if there's a question, I think a biopsy to rule out CTCL, um, if that's on your differential, maybe makes sense. And I guess maybe one of the questions. And also maybe you had very thoughtful, um, pathologists because Rami Al Rohel was your dermatopathologist who now works at UNC. So I do think there maybe it was partly because you had a really good time. You could have thoughtful, but yeah. So I guess one question like maybe to wrap up the paper and discussion is like, is there a pearl for people like, you know what? This was really more suggestive of CTCL. Or if you see this, you know, maybe a biopsy is more helpful because the, these are the patients other than the typical like it's on non-sonic, exposed skin, things like that. Well, Matt mentioned psoriasis scalp, um, each of it during a ton of his face and the association for CTCL actually was scattered generalized. So like whole body, which is like all the patients that used to come and do it for patch shusting. Um, but to that point, these people with whole body dermatitis for 15 years, we always should think about CTCL anyways, right? But that's the main marker for CTCL. And I also in the paper mentioned, you know, um, let me get this number right. In North Carolina, I believe is 35% black or African American. And in our study, we had a higher percentage of patients who are black or African American with CTCL and phoma. So thinking about a psoriasis from dermate and black and African American patients that might be even a stronger marker for CTCL. Hmm. Great. Interesting. All right. Amber, I got one last question for you that might be a, might be a five minute or do you believe? Yeah. And I like that. I just realized I like that I'm using the term believe in. Do you believe in the diagnosis of dermatitis unspecified? And let me, let me further characterize that by saying in the AAD's data, derm set, that is the most common inflammatory dermatosis is dermatitis unspecified. Like literally we diagnose that more than anything else. Do you think it's a real diagnosis? So it's not a real diagnosis. It is a diagnosis that we are forced to choose from ICD 10, I guess it is. And many, many of my patients have that diagnosis. And it does not mean I think that's the diagnosis. That means that's what I've chosen is essentially the equivalent to chronic dermatitis. So why not? So when you look at the AAD 2014 criteria, it should chronic spungiotic spares the groin and acylla. That's a topic dermatitis if it's not contact derms, CTCL, blah, blah, blah. According to those, you can interpret those criteria to say every single person who's ever been diagnosed with derma-specified or chronic dermatitis has a topic dermatitis. You read my paper, right? I said that chronic dermatitis might be this AD spectrum disorder, which is essentially AD. And so I, like, I would say that like my 2017 version of me would say unspecified dermatitis, the now corrupt pharma version of me, that is, I do believe in this AD spectrum disorder, right? This version of me believes that this is more leading to our day topic dermatitis. And I'm probably more likely to call it that maybe not on day one. Like, when somebody walks in with a phyto-politis, I'm like, I don't know unspecified dermatitis, right? But when I've had time to work it up, this more chronic dermatitis picture, I am much more likely to call that AD. How about dermatitis at this point? All right, patent DU use dermatitis unspecified chronic dermatitis dermatitis NOS. Do you use any of those or other than as a placeholder to? Yeah, placeholder, right? Because you want to put, right? I believe in the atopic dermatitis spectrum, you want to get them on Dupy. And so you need to call them atopic dermatitis because they'll be like, "Ah, you never gave them that diagnosis." So it's a placeholder. Okay. Ferris D, do you ever use it as a, because right, the patient I'm always thinking about is the 50-year-old with dermatitis on their upper back, you know, extensor arms, anterior thighs, had it for 18 months, had nothing as a child. Their mom is still alive and no, never had a rash as a kid. It's never been flexural. They have no atopic homoarbititis, no family history. They've been patch tested. They didn't get better. Or even, you know, they didn't even have patch tested, but they're using, you know, dove sensitive skin bar and, you know, a low-allergenicity moisturizer. Do you, you know, are you in the same bucket as the rest of us? Yeah, we should just call all these people atopic dermat. Or do you, do you think that it's a different thing? It's a good question. I guess I like to think of it as atopic derm spectrum knowing it's different than typical, like, you know, early onset. I like the spectrum and I may like it more because then it helps me treat it, but I like it. So I say, let's go with it. Okay, fair. All right, so that is going to conclude our deep dive for the day. So now it's time for us, as I've been getting feedback from my friends and colleagues all over the country, it turns out that everyone's favorite part of the show is Pat and trivia. Which he was like, how did you trivia on the show? I was like, what are, what is this supposed to be smart? I know what I know what the people want. They love trivia. Trivia nights at bars. It's all it's, it's the thing. Okay, all right. All right. So Pat, we, you know, we went over the rules with Dr. Atwater before we started, but just to remind our listeners, we're going to let Dr. Pat and finish the question. And then once he finishes the question, we can start blurting out answers. It remake. All right, Ferris is undefeated so far. I have yet to win a week, but this week I'm feeling good, feeling good. Well, yeah, because the, the category here is allergens of the year. All right. All right. I'm ready. Okay, it's, it's, well, what are in the early 1930s, several women developed significant ocular toxicity, including congenitival edema, corneal ulceration, corneum macrosis after using lash lower an eyebrow and eyelash cosmetic that was promoted to give women fuller darker lashes and eyebrows. The tragic outcomes described above occurred because of a sleep severe allergic reaction to what allergen from aldehyde paraphernaline dimine. It's paraphernaline dimine. No. Yeah. Do you know why I gave it away with the darker? No, I thought it was the, from aldehyde preservative. No, so yeah, no paraphernaline dimine. So it was put one, one woman died. I mean, she, she got eyelid ulceration and she wound up with an infection and she died a sepsis. It was one of the catalysts for the passing of the Food Drug and Cosmetic Act in 1938. That gave the FDA the authority to regulate cosmetics. So it's pretty soon we're not going to have an FDA. So it doesn't matter. But yeah, that, that was kind of what like FDA is, if do I understand this right? FDA banned paraphernaline dimine for use on the skin directly, right? You can't do that in cosmetics or am I misunderstanding that rule? So the reason I knew it was PPD was I've done several class action. I've been in an expert witness in several class action lawsuits about using PPD for beer to die because right whenever you're dying your beard, you die much more frequently. And you're putting it on your face and it turns out your scalp is a relatively immunoprivileged site. So the stem cells and your follicles do a lot of protecting from allergic contact dermatitis. Susan Netteros taught me that. And it's why you can be a allergic to the preservative in your shampoo, but you don't get a rash on your scalp. You only get a rash on your face. Well, beer dies, the, the reactions that men get in the permanent scarring and the permanent dispigmentation and, and that the companies that make the beer dies put the, the exact same warnings that you put on hair dye. And the argument is putting it on your face is totally different from putting it on your scalp. And that becomes part of the argument is you're not even allowed to put it on your skin, but on your well, we're telling them to put it on their beard and the blah, blah, but that's the, so I would say that's one of my takeaways. If I was always like, when I got asked to be an expert witness for that, I was like, fuck yeah, because the like I was always like, I can't believe they're allowed to sell beer die. Like that seemed crazy to me. And yeah, so they're very, it's a very altruistic motivation. We're really shut up. That's right. I didn't get paid, except for my $8,000 hourly fee. Let's, let's move on here. All right. Number two, Bassitracin was the allergen of the year in 2003. Bassitracin was isolated from a bacteria, cultured from a compound fracture of a young girl. What was the species of bacteria that produced Bassitracin in that case? Bacteritis. No, that's a good guess because of the name. The girl's name, you told me this is a resident patent. The girl's name was Tracy. That was her last name. That was, and I feel like it was the name of the bacteria was like something subtilis. That's pretty amazing, man. It had to be a basilis subtilis. That's it. That goes the amber. She got it. It was the basilis subtilis. Yeah, the name of the young girl with the compound fracture, Margaret Tracy. She got hit by like an ice truck and she had this compound fracture. And they debrided it. And in the lab, the bacteriaologist said this, something's in here is like killing staff. And they isolated it. And there it was, Bassitracin. It's really cute. The sun was kind of bitter because Bassitracin made a lot of money and the mom never saw any of it. But he finally came around and he told the story of how he would put the Bassitracin on his daughters, scrapes, and cuts and said, this is grandma helping you out. It's like the healer cell of contact dermatitis. It is the healer's story. Yeah, exactly. All of the lessons in the allergen of the ear article from Bassitracin. Let's say that again. You read this in the allergen of the ear article for Bassitracin, this story? No, I like did a rabbit. No, it's not. Pat and spends. I don't get out much. I do not ever. That's, that's what I did for Valentine's. When you text Patten, if you don't get a response in eight seconds, you're like, what, are you okay, buddy? All right. Third and final. We got a tie going in. This is exciting. The allergen of the ear designation began in the year 2000 of the 25 allergens of the year. How many are elements? I thought you're going to say how many? Nine allergens. No. You only get one guess here. Sorry. Come on people. One. No. I could have asked it another way that might have been more obvious. Well, Nikol and Cobalt are elements, right? And they know about allergens of the year. So it has to be, it's not two, because Laura said two. That's the two I was thinking of. I said three. Is it four? What do you want to go with? Finally answer. The C. The tie or is that what are the winner? What are the other allergens of the year that are elements? Tia, Tia, isn't by Chromie Chromian three. I still think it's three. It's not. It's four. It's the it's the medals. It's the medals. What's the four gold gold gold vehicle, Cobalt, I'm, wait, I'm challenging. I'm challenging. I think gold was one of the non allergens of the year. That was it was 2001. I don't think you guys got that clever yet. 2019 was your only non allergen with the parabens. There was another one. They're what? They Marisa was a non allergen of the year too. Wait, can we hold on what was the allergen of the year this year? Author this was I thought it was lame one Recent one of the recent ones was so so so fights. Wow. So fights was last year. Who is the first author Matt? It's man. Did they announce it was Atlanta? We got it's me. I was the first author PTDS pair two lane diamond. That's right PTDS So for those for for our listeners PTDS is pair of tall you in diamond sulfate It is used in some PPD free hair dyes and particular Madison read is Based sort of around PTDS But the problem is if you're allergic to PPD There's a few there's a 50 50 change you either are or will become allergic to PTDS So unless you're patch testing to PTDS. You don't want to just say Switch over to Madison read because it's PPD free But my paper has a bunch of other alternatives other than Madison read so go read it everybody right now It just came out and it's in the journal you know, it's in the journal dermatitis. I would assume And again, I think I want to tell everybody so Amber was the president of the American contact dermatitis society The camp app they just read I think they probably started that it was like a five-year process of redoing the camp app And it is so good now. It is so I don't know how anybody practice contact Durham prior to having camp Just makes it so easy comparatively Well Amber was closest on that last question. So I'm giving it to her so that's that's an Amber Amber win for Amber Another loss for Matt look at Ferris looks like she's ready to die over there. She's So as a middle-aged woman having lots of hair dye allergens This is all bad news and I've lost so thanks a lot Amber Thank you so much Amber for joining us. Thank you This was great. I'm a Amber definitely. Thank you and have a great rest of the week and good luck And if you are a dermatologist in the northern Virginia area Dr. Atwater just recently kind of Started left industry and is now practicing again, and is I promise you the best patch tester you will ever be able to send a patient to Hands down Appreciate that all right, so thank you everybody for joining us for this week's episode really Appreciate it. I hope the deep dive into sorry assiform dermatitis and dermatitis unspecified was helpful If you got questions comments ideas for topics that we should do on the show shoot us an email at questions at Dermsundrugs.com I hope you learned a few things. I hope you laughed once or twice and mostly I hope you're planning to join us next week Until then I'm Matt Cyrus I'm Tim Patlin. I'm Laura Ferris and we are Derms on drugs (upbeat music)