Dermatologists are often consulted for the care of patients with suspected contact dermatitis. In the simpler cases, the physician can seek a through history and physical exam and pose relevant questions to the patient. Patients can then self-experiment with suspected allergens and reach some understanding. Yet this formula doesn’t always work. Often, if inflammation persists despite avoidance and appropriate topical therapy, the care of dermatologists specialized in contact dermatoses may be in order. The dermatologists who are attracted in this area are most often interested in inflammatory skin disease. Contact dermatitis specialists often liken their work to medical detective work. An investigative spirit with a mindset of perseverance and patience is required in this field of trial and error testing. Training The main skill important for a dermatologist specializing in contact dermatitis is the ability to read and interpret patch tests. A patch test is conducted by placing several contact allergens on an adhesive strip. This strip is then placed on the patient’s skin, usually the back, for 48 hours. Then, for interpretation of the test, the patient is asked to return to clinic again within 72 to 96 hours after the initial patch was placed. The necessary training can be obtained by first completing a general dermatology residency. Yet not all of these residency programs will give an exposure to patch testing. Supplemental training can be gained in one of two ways. 1. The first involves a more informal route. There is no established fellowship in contact dermatitis per se. The American Contact Dermatitis Society (ACDS) has a mentoring program. In this program, participants can work for 2 to 4 weeks with people who routinely do patch testing. If you’re seeking a practice well-versed in patch testing, seek individuals who are officers or board members of the ACDS. Additionally, interested dermatologists can attend courses in contact dermatitis offered by the ACDS and American Academy of Dermatology (AAD). 2. The other option involves seeking more formal training. In this pathway the physician becomes trained in occupational and environmental medicine in addition to a dermatology residency. These residencies are usually 2 years, and the first year is spent completing a Masters in Public Health. The next year is the practicum year where the individual completes rotations in industry, the government and the hospitals. A more global view is gained by following this approach. Staffing a contact dermatitis unit As for personnel, usually one nurse is all that is necessary. For example, one physician applied patch tests on Mondays and removed them on Wednesdays. The final read could then be completed on Friday or the following Monday. With this routine, the nurse does not have to be solely used for the contact dermatitis unit in a 40-hour work week. These individuals are usually trained on the job, and the learning curve is usually quick and steep. The most important trait in a nurse involved with patch testing is organizational skills. This attribute becomes key because the order in which contact allergens are applied is critical. For instance, one physician mentioned that if one allergen is forgotten, the whole frame of the test is shifted, and the results can’t be correctly interpreted. Clinic Operations The first decision in setting up a clinic is location. The physician needs to consider the opportunity that a location provides to meet the critical mass to sustain a contact dermatitis enterprise. Furthermore, a specialist in contact dermatoses is dependent on the referrals from dermatologists, allergists and other primary care specialists. It is important to maintain good relationships with these groups in order to reach critical mass as well. There are various supplies needed for a contact dermatitis clinic. The thin-layer rapid use epicutaneous test (T.R.U.E. test) has 23 allergens and one control. This standard test strip is approved by the Food and Drug Administration and is good for screening. Other standard strips are available as well and these are categorized by source. Examples include the TROLAB Herbal Patch Test Allergens from Europe and the North American Contact Dermatitis Group Tray, which has a total of 50 antigens. Some examples include cosmetic, textile and boil & coolant standard strips. Additionally, the North American standard series is also available and has 65 allergens. Many times, an individual’s susceptibilities are not clarified using these standard strips and other allergens, which number in the hundreds, must be used. These allergens must be obtained from abroad. Special tape strips must be used for these allergens since they don’t come prepared like standard strips. Finn chambers or IQ chambers are examples of tape strips available. Individual allergens can be purchased for $25 to $40 per vial but can be used many times before expiration in 1 to 2 years. On average, a patient with a suspected contact dermatitis is tested with 65 to 110 allergens. Reimbursement Issues The physician bills on a per test or per unit basis. The billing document should contain the general ICD-9 of 692 with modifiers depending on the etiology as follows: 692.0 detergents, 692.1 oils and grease, 692.2 solvents, 692.3 drugs and medicines, 692.4 chemical products, 692.5 food, 692.6 plants, 692.7 solar, 692.8 other specified, and 692.9 not otherwise specified. The CPT code for a patch or application test is 95044, which has a reimbursement between $10 to $20 for each allergen. The number of tests applied should be specified. An issue in this area is that insurance companies sometimes place limits on the number of patch tests they will reimburse per visit. There is no clinical basis for this limit, and if the physician appeals, the insurance company will respect medical judgment. From the patient’s perspective, numerous visits for patch test applications are cumbersome and unpleasant as there are limits on bathing. It is most convenient and cost-effective to simply place all allergens in one visit. Resources Books Marks, JG, et al. Contact & Occupational Dermatology. St. Louis Mosby, 2002 Rietschel, RL, et al. Fisher’s Contact Dermatitis. Philadelphia: Lippincott Williams & Wilkins, 2001 Web sites American Contact Dermatitis Society: www.contactderm.org American Academy of Dermatology: www.aad.org Mr. Venkat and Dr. Feldman are with the Center for Dermatology Research, which is funded by a grant from Galderma. They’re both in the Department of Dermatology at Wake Forest University School of Medicine in Winston-Salem, NC. Dr. Cohen is with the Occupational and Environmental Dermatology Program, in the Department of Dermatology at the New York University School of Medicine in New York, NY.
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Spotlight on: Contact Dermatitis
Dermatologists are often consulted for the care of patients with suspected contact dermatitis. In the simpler cases, the physician can seek a through history and physical exam and pose relevant questions to the patient. Patients can then self-experiment with suspected allergens and reach some understanding. Yet this formula doesn’t always work. Often, if inflammation persists despite avoidance and appropriate topical therapy, the care of dermatologists specialized in contact dermatoses may be in order. The dermatologists who are attracted in this area are most often interested in inflammatory skin disease. Contact dermatitis specialists often liken their work to medical detective work. An investigative spirit with a mindset of perseverance and patience is required in this field of trial and error testing. Training The main skill important for a dermatologist specializing in contact dermatitis is the ability to read and interpret patch tests. A patch test is conducted by placing several contact allergens on an adhesive strip. This strip is then placed on the patient’s skin, usually the back, for 48 hours. Then, for interpretation of the test, the patient is asked to return to clinic again within 72 to 96 hours after the initial patch was placed. The necessary training can be obtained by first completing a general dermatology residency. Yet not all of these residency programs will give an exposure to patch testing. Supplemental training can be gained in one of two ways. 1. The first involves a more informal route. There is no established fellowship in contact dermatitis per se. The American Contact Dermatitis Society (ACDS) has a mentoring program. In this program, participants can work for 2 to 4 weeks with people who routinely do patch testing. If you’re seeking a practice well-versed in patch testing, seek individuals who are officers or board members of the ACDS. Additionally, interested dermatologists can attend courses in contact dermatitis offered by the ACDS and American Academy of Dermatology (AAD). 2. The other option involves seeking more formal training. In this pathway the physician becomes trained in occupational and environmental medicine in addition to a dermatology residency. These residencies are usually 2 years, and the first year is spent completing a Masters in Public Health. The next year is the practicum year where the individual completes rotations in industry, the government and the hospitals. A more global view is gained by following this approach. Staffing a contact dermatitis unit As for personnel, usually one nurse is all that is necessary. For example, one physician applied patch tests on Mondays and removed them on Wednesdays. The final read could then be completed on Friday or the following Monday. With this routine, the nurse does not have to be solely used for the contact dermatitis unit in a 40-hour work week. These individuals are usually trained on the job, and the learning curve is usually quick and steep. The most important trait in a nurse involved with patch testing is organizational skills. This attribute becomes key because the order in which contact allergens are applied is critical. For instance, one physician mentioned that if one allergen is forgotten, the whole frame of the test is shifted, and the results can’t be correctly interpreted. Clinic Operations The first decision in setting up a clinic is location. The physician needs to consider the opportunity that a location provides to meet the critical mass to sustain a contact dermatitis enterprise. Furthermore, a specialist in contact dermatoses is dependent on the referrals from dermatologists, allergists and other primary care specialists. It is important to maintain good relationships with these groups in order to reach critical mass as well. There are various supplies needed for a contact dermatitis clinic. The thin-layer rapid use epicutaneous test (T.R.U.E. test) has 23 allergens and one control. This standard test strip is approved by the Food and Drug Administration and is good for screening. Other standard strips are available as well and these are categorized by source. Examples include the TROLAB Herbal Patch Test Allergens from Europe and the North American Contact Dermatitis Group Tray, which has a total of 50 antigens. Some examples include cosmetic, textile and boil & coolant standard strips. Additionally, the North American standard series is also available and has 65 allergens. Many times, an individual’s susceptibilities are not clarified using these standard strips and other allergens, which number in the hundreds, must be used. These allergens must be obtained from abroad. Special tape strips must be used for these allergens since they don’t come prepared like standard strips. Finn chambers or IQ chambers are examples of tape strips available. Individual allergens can be purchased for $25 to $40 per vial but can be used many times before expiration in 1 to 2 years. On average, a patient with a suspected contact dermatitis is tested with 65 to 110 allergens. Reimbursement Issues The physician bills on a per test or per unit basis. The billing document should contain the general ICD-9 of 692 with modifiers depending on the etiology as follows: 692.0 detergents, 692.1 oils and grease, 692.2 solvents, 692.3 drugs and medicines, 692.4 chemical products, 692.5 food, 692.6 plants, 692.7 solar, 692.8 other specified, and 692.9 not otherwise specified. The CPT code for a patch or application test is 95044, which has a reimbursement between $10 to $20 for each allergen. The number of tests applied should be specified. An issue in this area is that insurance companies sometimes place limits on the number of patch tests they will reimburse per visit. There is no clinical basis for this limit, and if the physician appeals, the insurance company will respect medical judgment. From the patient’s perspective, numerous visits for patch test applications are cumbersome and unpleasant as there are limits on bathing. It is most convenient and cost-effective to simply place all allergens in one visit. Resources Books Marks, JG, et al. Contact & Occupational Dermatology. St. Louis Mosby, 2002 Rietschel, RL, et al. Fisher’s Contact Dermatitis. Philadelphia: Lippincott Williams & Wilkins, 2001 Web sites American Contact Dermatitis Society: www.contactderm.org American Academy of Dermatology: www.aad.org Mr. Venkat and Dr. Feldman are with the Center for Dermatology Research, which is funded by a grant from Galderma. They’re both in the Department of Dermatology at Wake Forest University School of Medicine in Winston-Salem, NC. Dr. Cohen is with the Occupational and Environmental Dermatology Program, in the Department of Dermatology at the New York University School of Medicine in New York, NY.
Dermatologists are often consulted for the care of patients with suspected contact dermatitis. In the simpler cases, the physician can seek a through history and physical exam and pose relevant questions to the patient. Patients can then self-experiment with suspected allergens and reach some understanding. Yet this formula doesn’t always work. Often, if inflammation persists despite avoidance and appropriate topical therapy, the care of dermatologists specialized in contact dermatoses may be in order. The dermatologists who are attracted in this area are most often interested in inflammatory skin disease. Contact dermatitis specialists often liken their work to medical detective work. An investigative spirit with a mindset of perseverance and patience is required in this field of trial and error testing. Training The main skill important for a dermatologist specializing in contact dermatitis is the ability to read and interpret patch tests. A patch test is conducted by placing several contact allergens on an adhesive strip. This strip is then placed on the patient’s skin, usually the back, for 48 hours. Then, for interpretation of the test, the patient is asked to return to clinic again within 72 to 96 hours after the initial patch was placed. The necessary training can be obtained by first completing a general dermatology residency. Yet not all of these residency programs will give an exposure to patch testing. Supplemental training can be gained in one of two ways. 1. The first involves a more informal route. There is no established fellowship in contact dermatitis per se. The American Contact Dermatitis Society (ACDS) has a mentoring program. In this program, participants can work for 2 to 4 weeks with people who routinely do patch testing. If you’re seeking a practice well-versed in patch testing, seek individuals who are officers or board members of the ACDS. Additionally, interested dermatologists can attend courses in contact dermatitis offered by the ACDS and American Academy of Dermatology (AAD). 2. The other option involves seeking more formal training. In this pathway the physician becomes trained in occupational and environmental medicine in addition to a dermatology residency. These residencies are usually 2 years, and the first year is spent completing a Masters in Public Health. The next year is the practicum year where the individual completes rotations in industry, the government and the hospitals. A more global view is gained by following this approach. Staffing a contact dermatitis unit As for personnel, usually one nurse is all that is necessary. For example, one physician applied patch tests on Mondays and removed them on Wednesdays. The final read could then be completed on Friday or the following Monday. With this routine, the nurse does not have to be solely used for the contact dermatitis unit in a 40-hour work week. These individuals are usually trained on the job, and the learning curve is usually quick and steep. The most important trait in a nurse involved with patch testing is organizational skills. This attribute becomes key because the order in which contact allergens are applied is critical. For instance, one physician mentioned that if one allergen is forgotten, the whole frame of the test is shifted, and the results can’t be correctly interpreted. Clinic Operations The first decision in setting up a clinic is location. The physician needs to consider the opportunity that a location provides to meet the critical mass to sustain a contact dermatitis enterprise. Furthermore, a specialist in contact dermatoses is dependent on the referrals from dermatologists, allergists and other primary care specialists. It is important to maintain good relationships with these groups in order to reach critical mass as well. There are various supplies needed for a contact dermatitis clinic. The thin-layer rapid use epicutaneous test (T.R.U.E. test) has 23 allergens and one control. This standard test strip is approved by the Food and Drug Administration and is good for screening. Other standard strips are available as well and these are categorized by source. Examples include the TROLAB Herbal Patch Test Allergens from Europe and the North American Contact Dermatitis Group Tray, which has a total of 50 antigens. Some examples include cosmetic, textile and boil & coolant standard strips. Additionally, the North American standard series is also available and has 65 allergens. Many times, an individual’s susceptibilities are not clarified using these standard strips and other allergens, which number in the hundreds, must be used. These allergens must be obtained from abroad. Special tape strips must be used for these allergens since they don’t come prepared like standard strips. Finn chambers or IQ chambers are examples of tape strips available. Individual allergens can be purchased for $25 to $40 per vial but can be used many times before expiration in 1 to 2 years. On average, a patient with a suspected contact dermatitis is tested with 65 to 110 allergens. Reimbursement Issues The physician bills on a per test or per unit basis. The billing document should contain the general ICD-9 of 692 with modifiers depending on the etiology as follows: 692.0 detergents, 692.1 oils and grease, 692.2 solvents, 692.3 drugs and medicines, 692.4 chemical products, 692.5 food, 692.6 plants, 692.7 solar, 692.8 other specified, and 692.9 not otherwise specified. The CPT code for a patch or application test is 95044, which has a reimbursement between $10 to $20 for each allergen. The number of tests applied should be specified. An issue in this area is that insurance companies sometimes place limits on the number of patch tests they will reimburse per visit. There is no clinical basis for this limit, and if the physician appeals, the insurance company will respect medical judgment. From the patient’s perspective, numerous visits for patch test applications are cumbersome and unpleasant as there are limits on bathing. It is most convenient and cost-effective to simply place all allergens in one visit. Resources Books Marks, JG, et al. Contact & Occupational Dermatology. St. Louis Mosby, 2002 Rietschel, RL, et al. Fisher’s Contact Dermatitis. Philadelphia: Lippincott Williams & Wilkins, 2001 Web sites American Contact Dermatitis Society: www.contactderm.org American Academy of Dermatology: www.aad.org Mr. Venkat and Dr. Feldman are with the Center for Dermatology Research, which is funded by a grant from Galderma. They’re both in the Department of Dermatology at Wake Forest University School of Medicine in Winston-Salem, NC. Dr. Cohen is with the Occupational and Environmental Dermatology Program, in the Department of Dermatology at the New York University School of Medicine in New York, NY.
