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Quality of life in patients with allergic contact dermatitis
Quality of life in patients with allergic contact dermatitis Deana L. Kadyk, MD, Kevin McCarter, PhD, Fritz Achen, BA, and Donald V. Belsito, MD, MBA Kansas City, Kansas Background: Allergic contact dermatitis (ACD), a common dermatological disorder, often results in ongoing disease and disability. However, relatively little has been published quantifying the quality of life (QoL) of patients with ACD. Objectives: This study was conducted to investigate the impact of ACD on QoL and explore prognostic factors that influence outcomes. Methods: A total of 428 subjects with ACD were, at varying times after diagnosis, mailed a QoL questionnaire modified from Skindex-16 to include an additional 5 items pertaining to occupational impact. The QoL scores were correlated with subject demographics, disease characteristics, and management techniques to ascertain factors that impact QoL in subjects with ACD. Results: The response rate was 35%, with 149 subjects returning the postal survey. Responders reported being bothered most by itching, skin irritation, and persistence of the condition. Of the four scales included in the QoL questionnaire, the emotions scale had the worst composite QoL score, followed by symptoms, functioning, and occupational impact. Patients with ACD of the face were significantly more bothered by the appearance of their skin. Hand involvement and occupationally related ACD were associated with worse QoL scores within the occupational impact and functioning scales. Subjects that had changed jobs because of ACD had more severe QoL impairment than any other group analyzed, with significantly worse scores on 17 of the 21 QoL items. A history of atopic eczema seemed to impart improved outcomes on patients with ACD, and these subjects were less worried about being fired from their jobs. Subjects diagnosed by patch testing more than 36 months after disease onset seemed to have worse QoL scores than those diagnosed earlier in the natural history of the disease. Patients diagnosed by patch testing within the last 6 months had the worst QoL scores, while the best outcomes were reported in subjects patch tested 6 to 12 months ago. A slight decline in QoL was observed 12 months after patch testing, but scores did not diminish back to the level seen immediately after diagnosis. Conclusions: ACD has an appreciable effect on QoL, especially when it affects the hands, the face, or is occupationally related. Of the four scales included in our study, the emotions scale suffered the greatest effect. Emotional impact is therefore an important measure of QoL in ACD patients. Outcomes in patients with ACD were improved by early diagnosis and subjects enjoyed their best QoL at 6 to 12 months after patch testing. However, individuals who elected to change jobs because of their skin condition reported significantly worse QoL than those who retained their current positions. (J Am Acad Dermatol 2003;49: 1037-48.)
M
any skin disorders have a significant impact on quality of life (QoL).1 Dermatological diseases invoke strong negative emo-
From the Division of Dermatology, University of Kansas Medical Center. Funding source: None. Conflict of interest: None identified. Accepted for publication May 5, 2003. Reprints not available from authors. Correspondence to: Donald Vincent Belsito, MD, MBA, Division of Dermatology, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, Kansas 66160-1719. E-mail: dbelsito@ kumc.edu. Copyright © 2003 by the American Academy of Dermatology, Inc. 0190-9622/2003/$30.00 ⫹ 0 doi:10.1016/S0190-9622(03)02112-1
tions, troublesome symptoms, and impaired functioning in social and professional arenas. In addition to thermoregulation, physical protection, and sensory perception, the skin is responsible for presentation. Flawed presentation often results in reduced esteem by self and others.2 The intensity of the effect of skin disease on individual patients is widely variable, and not well correlated with clinical assessment of severity.3 The degree to which QoL is affected may depend on several factors, including the patient’s demographic characteristics, the natural history and location of the skin disorder, and the duration of time before diagnosis. In the last fifteen years, there has been increasing interest in the accurate measurement of out1037
1038 Kadyk et al
comes in dermatology patients. As a result, several dermatology-specific QoL instruments have been developed.4-7 Allergic contact dermatitis (ACD), a common disorder caused by exposure to a contact allergen, is characterized, acutely, by erythematous macules and papules, edema, vesicles, or bullae, and chronically, by lichenification or scaling.8 Recent research shows that ACD could be responsible for as much as 50 to 60% of occupational contact dermatitis (OCD) and, therefore, may have an estimated economic impact of $3 billion each year.9-11 The annual cost of non-occupational ACD is difficult to measure, although a recent report suggests that ACD caused by an allergen contacted outside of the workplace is three times more common than occupationally related ACD.11 A review of the literature indicates that contact dermatitis often results in ongoing disease and disability, especially when occupationally related.12-16 However, relatively little has been published concerning outcomes in patients with ACD as an entity distinct from irritant contact dermatitis (ICD). Anderson and Rajagopalan developed and used the Dermatology-Specific Quality of Life (DSQL) instrument to show the beneficial impact of patch testing in patients suspected of ACD.5,17,18 More recently, a modified version of the Dermatology Life Quality Index (DLQI) was used to assess QoL outcomes in a patch test clinic population.12 As one of twelve participants in the North American Contact Dermatitis Group (NACDG), the University of Kansas Medical Center is a referral center for ACD and specializes in the use of patch testing for diagnosis. The objective of this study was to administer a standardized, dermatological QoL survey to patients with ACD in order to (1) investigate the impact of ACD on QoL, and (2) explore prognostic factors that influence outcomes.
METHODS The University of Kansas Medical Center, a NACDG test center, performs patch testing using standardized screening procedures and allergen trays.19 Between July 1994 and June 2002, patch tests were conducted on 993 patients seen in dermatology clinics at the Medical Center. Demographic, occupational, and medical information was collected prior to testing using a standardized NACDG questionnaire. Patients were patch tested using the NACDG standard screening tray and other suspected allergens, which were chosen based on history and physical examination. Patch testing was accom¨ y, Tuplished with Finn Chambers (Epitest Ltd., O usula, Finland) adhered to the upper back using
J AM ACAD DERMATOL DECEMBER 2003
Scanpor tape (Norgeplaster Aksjeselskap, Vennesia, Norway). The allergens were removed after 48 hours. Reaction sites were examined at the time of removal and 96 hours after placement of the patches. The severity of the patch test reaction was scored from 1 to 6. Grades of 1, 2 and 3 indicated a positive allergic reaction; a grade of 4 indicated a questionable reaction; and grades of 5 or 6 indicated irritant or negative reactions, respectively. The relevance of the allergen to the patient was also rated from 1 to 6. For relevance, grades of 1, 2 or 3 indicated definite, probable or possible relevance, while a grade of 4 indicated past relevance. All demographic and patch test data was entered into a Microsoft Access (Microsoft Corp., Seattle, Wash.) database for evaluation. The 428 patients diagnosed with a relevant ACD by patch testing between July 1994 and June 2002 were identified from the computerized database. Each patient was mailed a questionnaire that was modified from the Skindex-16, a dermatological QoL instrument that has undergone reliability and validity testing.4 The self-directed survey included the original 16 items, categorized into three scales: symptoms, emotions and functioning. A fourth scale was added to measure occupational impact (Table I). Each of the 21 QoL items measured the degree to which the respondent was bothered by their dermatitis in the last month, scaled from 0 (never bothered) to 100 (always bothered). Surveys completed by inconsistent responders were handled by eliminating from the analysis any scale that was missing more than 25% of the responses. The questionnaire also asked about the duration of the skin condition prior to patch testing, the number of doctor visits made concerning the disorder, the treatment methods used, and whether it was necessary to change jobs because of the dermatitis. The data to be analyzed was extracted from the Access database as Microsoft Excel files (Microsoft Corp, Seattle, Wash). The records were imported into the SAS Software System (v 8.01), which was used to conduct all statistical analyses (SAS Institute Inc, Cary, NC). A 5% significance level was used for all tests. Comparisons of QoL scores were performed utilizing a variety of procedures. t-Tests were used for making unadjusted comparisons of QoL scores when only two comparison groups were involved. t-Tests using Satterthwaite-adjusted degrees of freedom and the Wilcoxon rank sum test were employed in those situations where heteroscedasticity was determined to exist. Analysis of variance (ANOVA) was utilized for making unadjusted com-
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Table I. Skindex-16* plus 5 questions measuring occupational impact† During the past month, how often have you been bothered by:
Symptoms 1) Your skin condition itching 2) Your skin condition burning or stinging 3) Your skin condition hurting 4) Your skin condition being irritated Emotions 5) The persistence/reoccurrence of your skin condition 6) Worry about your skin condition 7) The appearance of your skin condition 8) Frustration about your skin condition 9) Embarrassment about your skin condition 10) Being annoyed about your skin condition 11) Feeling depressed about your skin condition Functioning 12) The effects of your skin condition on your interactions with others 13) The effects of your skin condition on your desire to be with people 14) Your skin condition making it hard to show affection 15) The effects of your skin condition on your daily activities 16) Your skin condition making it hard to work or do what you enjoy Occupational Impact 17) Concerns that you may need to leave your job because of your skin condition 18) Fear for your financial future because of your skin condition 19) Concerns that your interactions with co-workers will be difficult because of your skin condition 20) Difficulty with using your hands at work because of your skin condition 21) Fear of being fired from your job because of your skin condition *Skindex16©MMChren, 1997. † Occupational questions courtesy of Dr. Kathryn Zug, Hanover, NH.
parisons of QoL scores when more than two groups were involved. The Kruskal-Wallace test, a nonparametric alternative to ANOVA, was used when ANOVA was deemed inappropriate due to the presence of heteroscedasticity. Hartley’s F-max test was employed to check for heteroscedasticity when more than two groups were involved. Analysis of covariance (ANCOVA) was used for making adjusted comparisons of QoL scores. When comparing more than two groups, multiplicity that resulted from making several comparisons became a problem. In all analyses involving more than two groups, Fisher’s least significant difference (LSD) procedure was undertaken to determine when pairwise comparisons could be made.
Using this procedure, preplanned comparisons of interest were investigated only if the overall F-test was significant. If the overall F-test was not significant, pairwise comparisons were not made. This procedure maintained the experiment-wise Type I error rate at the desired level for each group of comparisons.20 Regression was utilized to identify trends in the QoL scores. Comparisons of group proportions, as well as tests of independence between patient groups and categorical variables of interest, were performed using chi-square analyses. In those situations where the expected cell frequencies were low, rendering the chi-square test inappropriate, Fisher’s exact test was performed instead. Odds ratios were estimated using logistic regression. Generalized linear models were used to perform multivariate analysis while reducing the model if possible.
RESULTS The overall response rate to the postal survey was 35%, with 149 subjects returning the questionnaire. The demographic differences between the responders and nonresponders are summarized in Table II. A comparison between the two groups revealed that the respondents were more likely to be over 40 years old, female, and white. There were no significant dissimilarities between the responders and nonresponders with respect to occupational versus nonoccupational ACD, hand involvement, facial involvement, or history of atopic eczema. The scores for the QoL questions are summarized in Table III. Each item was scaled from 0 (never bothered) to 100 (always bothered). Therefore, a higher score indicated a more impaired QoL. In general, patients with ACD reported being bothered most by itching, skin irritation, and the persistence or recurrence of the disease. They were more frustrated and annoyed by the condition than embarrassed or depressed. When the items within each of the four scales were averaged for all subjects, the emotions scale had the worst composite QoL score, followed by symptoms, functioning, and occupational impact. In order to explore prognostic factors that influence outcomes in patients with ACD, the QoL scores of patients with specific characteristics were analyzed. Of the 149 respondents, 17% had facial dermatitis. Table IV summarizes the QoL scores of subjects with and without facial involvement. A comparison between the two groups revealed that subjects with ACD of the face had a significantly worse QoL score on the item asking about the appearance of their skin. In addition, patients with involvement of the face felt a higher degree of an-
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Table II. Demographic characteristics of responders versus nonresponders All patients
All patients Age (y) ⬎19 20–39 40–59 60–79 80⫹ Sex Male Female Ethnicity Asiatic Black Caucasian Hispanic Other Ethnicity Caucasian Non-Caucasian Occupationally related No Unsure Yes Body site Face Hand Atopic eczema Average age (y)
Nonresponders
Responders
No.
%
No.
%
No.
%
P value
428
100
279
65.19
149
34.81
—
16 66 194 134 18
3.74 15.42 45.33 31.31 4.21
11 54 120 83 11
3.94 19.35 43.01 29.75 3.94
5 12 74 51 7
3.36 8.05 49.66 34.23 4.70
.0433*
152 276
35.51 64.49
111 168
39.78 60.22
41 108
27.52 72.48
.0115*
5 48 361 9 5
1.17 11.21 84.35 2.10 1.17
2 39 228 5 5
0.72 13.98 81.72 1.79 1.79
3 9 133 4 0
2.01 6.04 89.26 2.68 0.00
.0321*
361 67
84.35 15.65
228 51
81.72 18.28
133 16
89.26 10.74
.0408*
296 18 114
69.16 4.21 26.64
192 11 76
68.82 3.94 27.24
104 7 38
69.80 4.70 25.50
.8802*
65 146 51
15.19 34.11 11.92
39 98 29
13.98 35.13 10.39
26 48 22
17.45 32.21 14.77
.3405 .5451 .1836
All patients
Nonresponders
Responders
P value
53.01 ⫾ 16.62
51.66 ⫾ 17.37
55.55 ⫾ 14.84
.0154
*P values for age, sex, ethnicity, and occupational relatedness result from chi-square testing across the subgroups.
noyance that trended toward significance. However, they had significantly better QoL scores than those without facial disease on two questions: fear of being fired, and difficulty using their hands at work. It is important to note that only 15% of responders with facial ACD also had involvement of the hands, compared to 36% of responders without disease of the face. Therefore, the data showed that the odds of hand involvement are 3 times greater for those without facial involvement (Table V). Thirty-two percent of responders were diagnosed with ACD of the hands. The effect of hand involvement on QoL scores is cataloged in Table VI. Subjects with hand dermatitis had significantly worse QoL scores on all items within the Occupational Impact Scale. Within the functioning scale, these subjects reported that it was significantly harder to work or do what they enjoy and three other items trended toward significance. There were no statistically significant differences between those with and
without hand involvement in the Symptoms or Emotions Scales. Occupationally related ACD was diagnosed in 27% of the respondents. The QoL scores of subjects with and without occupational ACD are summarized in Table VII. Like ACD of the hands, the QoL scores for subjects with occupationally related disease were significantly worse within the Occupational Impact and Functioning Scales. Of importance, 76% of respondents with occupational ACD also had involvement of the hands, compared to 14% of respondents with nonoccupational ACD. Analysis of the data revealed that the odds of hand involvement are 19 times greater for those with work-related ACD than for those with non-work-related ACD (Table V). A multivariate analysis was used to incorporate both hand involvement and occupational relatedness as predictors of the QoL questions that were found to be significant in the work-related analysis. Occupationally related
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Table III. QoL scores for all subjects scaled from 0 (never bothered) to 100 (always bothered) No.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Survey item
Symptoms Scale Itching Burning/stinging Hurting Irritated Emotions Scale Persistence/reoccurrence Worry Appearance Frustration Embarrassment Annoyed Depressed Functioning Scale Interactions with others Desire to be with people Show affection Daily activities Work/what you enjoy Occupational Scale May need to leave job Financial future Interactions with co-workers Difficulty using hands Fear of being fired
No.
Mean
SD
146 147 146 147 147 144 146 148 148 148 148 147 147 146 147 148 149 149 149 146 149 147 149 149 148
31.01 38.12 24.79 20.76 40.04 36.02 41.68 35.17 34.84 43.70 29.30 42.31 24.27 20.78 19.07 18.50 15.81 24.64 25.19 13.32 15.12 13.84 12.32 16.91 7.90
30.17 33.06 32.37 33.68 33.85 33.39 36.06 39.23 36.58 40.48 37.35 38.24 33.94 29.83 31.92 31.54 29.43 33.73 35.00 25.75 31.56 29.59 27.34 31.87 23.69
SD, Standard deviation.
Table IV. Impact of face involvement on QoL scores Face not involved
Face involved
No.
%
No.
%
123
82.55
26
17.45
Face not involved
Symptoms Scale Emotions Scale Appearance Annoyed Functioning Scale Occupational Scale Difficulty using hands Fear of being fired
Face involved
Mean
SD
Mean
SD
P value
30.48 34.52 31.63 39.92 22.15 14.53 19.53 9.09
30.51 33.02 35.40 37.47 30.27 27.08 33.97 25.72
33.57 43.24 50.68 54.00 14.17 7.48 4.50 2.04
28.92 34.88 38.87 40.59 27.23 17.26 13.80 5.64
.6431 .2365 .0171 .0936 .2244 .1024 .0004 .0070
ACD, but not hand involvement, was found to be a predictor for the responses to questions 16 to 18 and 21. Conversely, hand ACD was a predictor for questions 19 and 20, while occupational dermatitis was not. Thirteen percent of the responders reported that they had changed jobs because of ACD. These nineteen subjects had more severe QoL impairment than any other group analyzed. The data revealed that
changing jobs was associated with significantly worse QoL scores on 17 of the 21 survey items (Table VIII). All of the items within the Symptoms Scale, Functioning Scale, and Occupational Impact Scale had significantly poorer scores. Within the Emotions Scale, subjects who changed jobs reported significantly greater embarrassment and depressive feelings, as well as being bothered more by their appearance. The remaining four items in the emo-
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Table V. Association between hand involvement and other prognostic factors Hand Involved
All Responders
Face involvement No 123 Yes 26 Occupationally related No 104* Yes 38* History of atopic eczema No 127 Yes 22 Duration of time before patch testing ⬍1 mo 5† 1 to 2.9 mo 13† 3 to 5.9 mo 11† 6 to 11.9 mo 19† 12 to 35.9 mo 40† ⬎36 mo 56† Duration of time since patch testing ⬍6 mo 7 6 to 11.9 mo 15 12 to 35.9 mo 62 ⬎36 mo 65
No.
%
P value
OR
44 4
35.77 15.38
.0330
3.0630
15 29
14.42 76.32
⬍.0001
19.1170
41 7
32.28 31.82
.9656
-
0 6 5 5 8 24
0.00 46.15 45.45 26.32 20.00 42.86
.0377
-
3 5 18 22
42.86 33.33 29.03 33.85
.8670
-
OR, Odds ratio. *Seven responders were not sure if ACD was occupationally related and were not included in the analysis. † The analysis includes the 144 responders that reported the duration of their symptoms before patch testing.
Table VI. Impact of hand involvement on QoL scores Hand not involved
Hand involved
No.
%
No.
%
101
67.79
48
32.21
Hand not involved
Symptoms Scale Emotions Scale Functioning Scale Interactions with others Desire to be with people Show affection Daily activities Work/what you enjoy Occupational Scale May need to leave job Financial future Interactions with coworkers Difficulty using hands Fear of being fired
Hand involved
Mean
SD
Mean
SD
P value
31.37 36.08 18.14 16.67 17.52 13.57 21.64 21.30 8.24 9.44 9.60 8.27 9.42 4.35
30.14 33.37 28.78 31.50 31.99 27.87 32.34 32.56 19.76 24.77 26.28 23.29 24.64 17.68
30.26 35.94 26.37 24.17 20.54 20.52 30.96 33.40 23.69 27.08 22.58 20.83 32.67 15.29
30.56 33.78 31.55 32.56 30.80 32.26 36.01 38.72 32.82 40.18 34.11 33.01 39.15 31.85
.8366 .9810 .1197 .1849 .5871 .1790 .1155 .0483 .0038 .0067 .0228 .0205 .0003 .0300
tions scale also had worse QoL scores for subjects who had changed jobs because of their skin condition, but not to a significant degree. Fifteen percent of responders had a history of atopic eczema. The data indicated that subjects with
atopic dermatitis enjoyed a better QoL across all four scales than those subjects without atopic eczema, although not to a significant degree (data not shown). One QoL item yielded a significantly different score between the two groups. Subjects with a
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Table VII. QoL scores for occupationally related ACD versus nonoccupational ACD Nonoccupational ACD
Occupationally related ACD
No.*
%*
No.*
%*
104
73.24
38
26.76
Nonoccupational ACD
Symptoms Scale Emotions Scale Functioning Scale Interactions with others Desire to be with people Show affection Daily activities Work/what you enjoy Occupational Scale May need to leave job Financial future Interactions with coworkers Difficulty using hands Fear of being fired
Occupationally related ACD
Mean
SD
Mean
SD
P value
29.56 34.08 16.26 15.22 15.72 12.21 19.26 18.76 7.438 7.39 8.01 7.87 9.95 3.89
29.01 32.25 26.48 29.58 29.99 26.20 29.14 30.68 20.45 22.62 24.45 22.99 24.19 17.34
28.39 33.87 26.72 23.29 20.78 19.37 32.50 35.58 23.54 32.05 25.03 18.00 28.11 14.50
29.37 33.80 31.89 32.54 31.30 30.12 39.08 39.13 29.05 40.88 34.11 29.30 38.93 29.04
.8352 .9731 .0536 .1645 .3848 .1687 .0623 .0083 .0028 .0010 .0068 .0329 .0098 .0396
*Seven responders were not sure if ACD was occupationally related and were not included in the analysis.
Table VIII. Impact of changing jobs because of ACD on QoL scores No job change
Job change
No.
%
No.
%
130
87.25
19
12.75
No job change
Symptoms Scale Emotions Scale Functioning Scale Occupational Scale
Job change
Mean
SD
Mean
SD
P value
28.63 33.70 17.74 8.62
28.77 32.49 27.50 18.78
46.95 51.41 41.12 44.76
35.09 35.98 37.05 40.95
.0131 .0307 .0013 .0012
history of atopic dermatitis were significantly less worried about being fired from their job than those without that condition (P ⫽ .0034). There was no difference between those with a history of atopic eczema and those without a history of atopic eczema in terms of hand involvement. Both groups had 32% of respondents with involvement of the hands (Table V). An analysis was also undertaken to determine if an atopic history, defined as a history of allergic rhinitis, asthma, or atopic eczema, affected the QoL of patients with ACD. The QoL scores revealed no significant differences between atopic and nonatopic responders (data not shown). The data in Table IX summarize the impact of the duration of ACD prior to diagnosis on QoL scores. Within the Symptoms Scale, the subjects diagnosed by patch testing more than 36 months after disease
onset seemed to have worse QoL scores than those diagnosed earlier in the natural history of the condition. Although the trend was not statistically significant, the symptoms scores appeared to be directly proportional to the elapsed time between onset and diagnosis of ACD. Neither the Emotions nor the Functioning Scale revealed a significant relationship between QoL and duration of disease prior to patch testing. The duration of ACD prior to diagnosis appreciably affected one item within the Occupational Impact Scale. Although significant, the data did not trend in a predictable fashion. Subjects patch tested 1 to 3 months after disease onset reported the highest degree of difficulty using their hands at work, followed by those with ACD for greater than 36 months prior to diagnosis. Forty-six percent of respondents who were patch tested 1 to
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Table IX. Impact of duration of condition prior to diagnosis by patch testing on QoL scores < 1 mo No.*
5
3 to 5.9 mo
12 to 35.9 mo
6 to 11.9 mo
> 36 mo
%*
No.*
%*
No.*
%*
No.*
%*
No.*
%*
No.*
%*
3.47
13
9.02
11
7.64
19
13.19
40
27.78
56
38.89
< 1 mo
Symptoms Scale Emotions Scale Functioning Scale Occupational Scale May need to leave job Financial future Interactions with coworkers Difficulty using hands Fear of being fired
1 to 2.9 mo
1 to 2.9 mo
3 to 5.9 mo
6 to 11.9 mo
Mean
SD
Mean
SD
Mean
SD
Mean
17.11 20.38 12.64 1.84 6.70 3.67 1.70
29.11 31.57 19.17 5.53 16.12 11.00 5.38
23.38 31.60 23.68 23.86 28.23 21.85 15.38
27.18 34.14 29.73 34.87 42.14 33.63 30.00
27.68 29.91 24.34 13.02 18.18 13.64 12.09
34.19 37.50 41.05 30.53 40.45 32.33 27.89
28.72 31.23 20.02 10.73 18.47 10.53 11.42
3.30 10.44 35.92 45.54 12.09 27.89 1.70 5.38 17.92 37.54 9.09 30.15
SD
> 36 mo
12 to 35.9 mo Mean
SD
Mean
P value†
SD
32.36 33.17 29.39 35.02 31.50 32.89 37.99 31.23 41.22 34.57 28.54 17.33 27.35 23.55 31.67 22.52 5.73 13.96 19.05 30.02 35.58 4.20 13.99 19.64 35.11 28.94 5.13 18.73 20.84 34.83 28.86 7.48 21.61 17.30 31.61
8.79 19.58 4.42 15.65
9.60 24.68 23.84 36.48 1.68 10.59 12.15 28.21
.5335 .5029 .8527 .0649 .0981 .1162 .4439 .0239 .1559
*Analysis includes the 144 responders that answered this question. † Analysis as continuous variable yielded no P values ⬍ .05.
Table X. Impact of duration of time since patch testing on QoL scores <6 mo No.
7
6 to 11.9 mo %
No.
%
No.
%
No.
%
4.70
15
10.07
62
41.61
65
43.62
<6 mo
Symptoms Scale Emotions Scale Functioning Scale Occupational Scale †
>36 mo
12 to 35.9 mo
6 to 11.9 mo
>36 mo
12 to 35.9 mo
Mean
SD
Mean
SD
Mean
SD
Mean
SD
P value†
58.89 60.22 51.46 38.57
33.71 34.15 41.38 45.14
20.03 27.00 11.81 9.79
23.65 29.55 18.69 18.20
33.60 35.89 22.76 10.78
30.25 30.87 30.98 22.18
28.02 35.63 17.60 13.83
29.57 35.90 27.72 26.86
.0272 .1886 .0194 .0526
Analysis as continuous variable yielded no P values ⬍ .05.
3 months after disease onset had ACD of the hands. Forty-three percent of subjects diagnosed after more than 36 months of symptoms had hand involvement, as did 45% of those patch tested 3 to 6 months into their condition. There was a significantly lower incidence of hand involvement in those subjects patch tested less than 1 month or 6 to 36 months after disease onset (Table V). The time elapsed since patch testing had a significant impact of QoL scores in patients with ACD (Table X). All four of the scales revealed that subjects patch tested within the last 6 months had the worst QoL scores, while those diagnosed 6 to 12 months ago had the best scores. The scores worsened slightly after 12 months, although the QoL did not diminish back to the level seen immediately after diagnosis. Several survey items showed statistically
significant differences in scores depending on the duration of time since patch testing. The most recently diagnosed subjects reported significantly more hurting and skin irritation than subjects who had carried a patch test diagnosis for a longer time. In addition, newly diagnosed subjects reported more difficulty interacting with others, lessened desire to be with people, more problems showing affection, and adverse effects on daily activities. Within the Occupational Impact Scale, patients patch tested in the last 6 months expressed more fear for their financial future and more concern about difficult interactions with co-workers than subjects who had been cognizant of their diagnosis for a longer time. None of the items within the Emotions Scale were significantly affected by the duration of time since patch testing. There were
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no differences seen in the prevalence of hand involvement based on the time elapsed since patch testing (Table V).
DISCUSSION The purpose of this study was to determine the impact of ACD on QoL and explore patient, disease and management factors that influence outcomes. As expected, ACD was found to have an appreciable effect on QoL, as measured by the modified Skindex-16 questionnaire. It was difficult to compare these results with data in the literature for two reasons. First, there is relatively little published about QoL outcomes in patients with ACD. The vast majority of research regarding contact dermatitis includes patients with ICD as well. Second, the small amount of data available concerning outcomes in ACD was obtained using different dermatologyspecific QoL instruments. Each survey utilizes different questions and scoring to measure QoL, making comparison difficult. The overall response rate to the questionnaire was 35%. Utilization of mailed questionnaires should always raise concerns about nonresponse bias. In this study, the respondents were more likely to be over 40 years old, white, and female. Little has been published concerning nonresponse bias in the realm of dermatological research. However, a search of the general medical literature revealed that young men were more likely to be nonresponders than responders.21 Likewise, another study showed that women were more likely to return a mailed questionnaire.22 There was conflicting data regarding the impact of age upon response rate,22,23 and very little published concerning the effect of gender. When attempting to determine the impact that these demographic differences may have on the QoL data, the literature again yielded contradictory information. Several studies indicated that age and gender did not significantly affect the prognosis of contact dermatitis, while others reported that women and young persons were likely to feel more distress due to their skin disease.2,14 Once again, little has been published regarding the prognosis of contact dermatitis based on ethnicity. Although age, gender, and ethnicity differed between the responder and non-responder groups, there were no dissimilarities based on important patient and disease characteristics that have long been suspected of adversely affecting the QoL of patients with ACD. Responders were equally as likely as nonresponders to have occupationally related disease, involvement of the hands, involvement of the face, and a history of atopic eczema. The impact of confounders, such as age, gender, ethnic-
Kadyk et al 1045
ity, and occupation, on the QoL of the subjects in this study will be addressed in a subsequent report. Skindex-16 has been used to measure the QoL of patients with several dermatological conditions.4 Patients with a diagnosis of eczematous dermatitis in Chren’s study had worse QoL scores than our subjects with ACD. At first, the discrepancy seemed to indicate that ACD is associated with a less severe impact on QoL than some of the other conditions categorized as eczematous dermatitis. However, comparing Chren’s data to the QoL scores of our subjects patch tested within the last 6 months painted a different picture. These recently patch tested subjects, likely to be still suffering from the acute phase of the disease, reported a worse QoL than patients with eczematous dermatitis in Chren’s study. Therefore, ACD seems to be as disabling as other eczematous dermatitides in its active form. However, after diagnosis by patch testing, the disease remits if the allergen can be successfully avoided. Goh14 reported that ICD is often associated with a worse prognosis than ACD, possibly because of the difficulty of avoiding the multitude of irritants in the environment, especially soap and water. In a study of a patch test clinic population using the DLQI, Holness12 reported that the most common effect was pain or itching. The subjects also reported significant embarrassment, interference with work, and difficulties with sleep. Likewise, our subjects were bothered most by itching and skin irritation. However, within the Emotions Scale, our patients reported greater annoyance and frustration than embarrassment. Since the DLQI did not address frustration or annoyance and used a different method of scoring than Skindex-16, it was impossible to determine if the subjects in the two studies felt similar degrees of embarrassment. Of the four scales included in our study, the Emotions Scale suffered the greatest effect. Emotional impact is therefore an important measure of QoL in patients with ACD. Of the five items within the functioning scale, the question related to ACD making it hard to work yielded the worst QoL score. Holness’ results12 corresponded roughly to this data. Rajagopalan and Anderson24 used the DSQL to measure QoL in patients with suspected contact allergy. The results revealed that ACD had the most appreciable impact in the areas of physical symptoms, vitality, and self-perception. Likewise, our data showed that the worst QoL scores existed within the Symptoms and the Emotions scales. Patients with ACD of the face were significantly more bothered by their appearance than those without facial involvement. They also reported greater annoyance due to their skin condition, although not
1046 Kadyk et al
to a significant degree. Logic supported the fact that dermatitis of such a highly visible area of skin would adversely impact scores within the Emotions cale to the greatest degree. Two of the Occupational Impact items, difficulty using the hands at work and fear of being fired, had significantly better scores for responders with ACD of the face. The superior QoL scores may be explained by the fact that subjects with facial involvement were 3 times less likely to have ACD of the hands. Hand and occupational dermatitis significantly worsens the scores of these two QoL items. Several reports have indicated that contact dermatitis of the hands negatively affects the ability to work and pursue normal daily activities.1,2,12 The QoL data collected in our study for subjects with contact dermatitis of allergic etiology agreed with the literature. Hand involvement was associated with significant impairment within the Functioning and Occupational Impact scales. The vital role that healthy skin plays in protecting the hands during everyday tasks does not need to be explained, especially when discussing the wet-work performed around a household. In the workplace, hands are important for both functionality and presentation. In occupations that require direct interaction with the public, such as food service, childcare, and sales, even noncontagious lesions of the hands are often viewed with suspicion and distaste.2 Holness’ study12 revealed that involvement of the hand was the factor influencing the greatest number of QoL outcomes in a patch test clinic population. While analyzing our data to explore other characteristics that were suspected of worsening the prognosis of ACD, the associations between hand involvement and the other prognostic factors were calculated in order to ensure that the data was not being skewed by an unequal overlap. Occupational ACD is a common dermatological diagnosis and one that significantly impairs QoL.11-13,16 Holness reported that patients suspected of work related ACD had poorer outcomes in several areas, including physical symptoms, daily chores, leisure activities, work, relationships, sleep, and treatment of the condition.12 Another study showed that patients with occupational contact dermatitis had the most severe QoL impairment in the realms of symptoms and feelings.13 While it is true that our subjects with occupationally related ACD had the worst QoL scores in the symptoms and emotions scales, the scores were not significantly different from the subjects with nonoccupationally related disease. In contrast, subjects with work related disease had significantly worse outcomes in the Occupational Impact and Functioning Scales than pa-
J AM ACAD DERMATOL DECEMBER 2003
tients with non-work-related ACD. It was not surprising to find that QoL scores for subjects with occupational ACD mirrored scores recorded for subjects with hand involvement, because patients with occupational ACD were 19 times more likely to have ACD of the hands. However, a multivariate analysis including the two variables showed that only occupational ACD predicted the responses to questions 16 to 18 and 21, while only hand involvement predicted QoL items 19 and 20. Contradictory conclusions have been published concerning outcomes in patients who changed jobs because of contact dermatitis, and skin disease in general. Several reports indicated that a job change exerted a beneficial effect on QoL, while others concluded that changing jobs had equivocal value or no impact whatsoever.14-16 The responders in our study who changed jobs because of ACD suffered greater QoL impairment than any other group analyzed. It was difficult to determine whether the poor outcomes were a direct result of changing jobs, or whether analyzing outcomes based on job change introduced a selection bias toward subjects who had a more severe form of ACD to begin with. There are, however, valid reasons why changing jobs could result in worse QoL scores in patients with ACD. First, leaving a job does not guarantee a significant improvement in the dermatitis, and a preexisting dermatological condition is an obvious disability that may discourage an employer from hiring the worker.14,16 In addition, patients with occupational skin disease (OSD) who changed jobs were found to lose more time from work and, consequently, net a diminished income.15 A history of atopy has long been suspected of being associated with worse QoL scores in patients with contact dermatitis, but a search of the literature yielded conflicting reports.14 Subjects with a history of atopic eczema in our study did not suffer poorer outcomes; in fact, these patients enjoyed better QoL scores than subjects without a history of atopic eczema. Responders with a history of atopic eczema were significantly less afraid of being fired because of their skin condition. Atopic eczema classically afflicts patients at a young age and it is fair to speculate that these patients may develop and exhibit greater resiliency and coping skills in the face of skin disease. In addition, a history of atopic eczema may encourage patients to choose careers that are gentler to the skin, thereby avoiding wet-work and manual labor. However, differences in occupation based on history of atopic eczema were not analyzed for this report. Delay in the diagnosis and treatment of contact dermatitis has been linked to chronicity and poorer
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J AM ACAD DERMATOL VOLUME 49, NUMBER 6
prognosis.16 Patch testing is the accepted method of diagnosis for ACD, but is often performed only after months or years of active dermatitis. The data collected in this study revealed that 67% of patients diagnosed with ACD suffered with the disease for greater than 12 months prior to being referred for patch testing. The QoL scores within the symptoms scale worsened proportionally to the duration of the condition prior to patch testing, although not to a statistically significant degree. It is possible that the number of subjects in each time category was not large enough to identify this trend as significant. However, extrapolating the number of subjects necessary to render a data set significant after the data has been collected is a questionable usage of power analysis and was not undertaken in this study.25 Although there was no statistically significant trend revealed within the emotions and functioning scale, a striking difference in QoL scores was noted between the subjects patch tested less than 1 month after disease onset and those tested greater than 36 months after onset of symptoms. The QoL scores within the occupational impact scale showed significant differences between time categories, but did not trend predictably. However, the data made sense once hand involvement was taken into account. A disproportionately large percentage of subjects with hand involvement were found in the groups patch tested 1 to 3 months, 3 to 6 months, and greater than 36 months after disease onset. The disturbing aspect of the data was that subjects with hand involvement made up nearly half of the subjects who were patch tested greater than 36 months after disease onset. In order to be managed appropriately, patients with contact dermatitis of allergic etiology require identification of the responsible allergens. Therefore, the data underscore the need for practitioners to aggressively pursue patch testing in patients with dermatitis of the hands. Outcomes in patients with ACD were affected dramatically by the duration of time since patch testing. Subjects’ QoL improved significantly about 6 months after diagnosis by patch testing. The data indicated that identification of the responsible allergens by patch testing and education regarding how to avoid these allergens resulted in a sizeable improvement in patients’ QoL. The subjects in this study not only received extensive verbal and written information concerning the management of their condition at the time of diagnosis, they were also scheduled to return in 4 to 8 weeks to reemphasize the material. One report revealed that workers with contact dermatitis who could not correctly identify their diagnosis were twice as likely to still have active dermatitis, suffer from more severe skin dis-
ease, and report a worse QoL.26 In addition, it would be appropriate to inform patients that resolution of the condition occurs over months, not weeks, of allergen avoidance. Providing a suitable time frame will help to prevent patients from prematurely abandoning efforts of allergen avoidance. The QoL scores worsened slightly in subjects patch tested more than 12 months ago, but did not dwindle back to the level seen immediately postdiagnosis. Two scenarios could reasonably account for the decline in QoL observed after 1 year of successful management. First, the patients may have become less motivated to avoid allergens after the dermatitis had resolved. Second, because many allergens possess long and complex chemical names, it is reasonable to assume that patients may become confused about the etiology of their condition over time. The QoL of patients with ACD would likely benefit from annual follow-up appointments geared towards reeducation and evaluation of current allergen exposures. Limitations exist within this study. The response rate of 35% is lower than desired, but the sample size of 149 subjects is adequate to detect statistically significant differences between the QoL scores for the prognostic subcategories. Postal surveys traditionally have low response rates and a telephone follow-up is usually necessary to boost participation. The QoL scores were not adjusted for age, gender, ethnicity, or occupation. The impact of these confounders on the QoL scores of the study participants will be the subject of a subsequent report. The literature shows that QoL in dermatological conditions may not be well correlated with clinical assessment of severity. An objective measure of clinical severity would be an interesting element to add to future studies and would provide an opportunity to examine the correlation between the reported QoL and the patient’s clinical status.
CONCLUSION This was the first study to use the modified Skindex-16 to show that ACD has an appreciable effect on QoL. Of the four scales included in the survey, the Emotions Scale suffered the greatest overall effect. Comparing the QoL scores of patients with specific characteristics generated interesting observations. Facial involvement was associated with worse QoL scores in the realm of emotions. Hand and occupationally related ACD were associated with significant impairment within the Functioning and Occupational Impact Scales. A history of atopic eczema seemed to impart better QoL in patients with ACD. Individuals who elected to change jobs because of their skin condition reported significantly
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worse QoL than those who did not change jobs. QoL seemed to be improved by early diagnosis and subjects reported their best QoL at 6 to 12 months after patch testing. We thank Mary-Margaret Chren, MD, for allowing the use of Skindex-16 and for statistical advice. We also thank Kathryn Zug, MD, for formulating the five questions related to occupational impact.
REFERENCES 1. Ryan TJ. Disability in dermatology. Br J Hosp Med 1991;46:33-6. 2. Ginsburg IH. The psychosocial impact of skin disease. Dermatol Clin 1996;14:473-84. 3. Zachariae R, Zachariae H, Blomqvist K, Davidsson S, Molin L, Mork C, et al. Quality of life in 6497 Nordic patients with psoriasis. Br J Dermatol 2002;146:1006-16. 4. Chren MM, Lasek RJ, Sahay AP, Sands LP. Measurement properties of Skindex-16: a brief quality-of-life measure for patients with skin diseases. J Cutan Med Surg 2001;5:105-10. 5. Anderson RT, Rajagopalan R. Development and validation of a quality of life instrument for cutaneous diseases. J Am Acad of Dermatol 1997;37:41-50. 6. Morgan M, McCreedy R, Simpson J, Hay RJ. Dermatology quality of life scales: a measure of the impact of skin diseases. Br J Dermatol 1997;136:202-6. 7. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI): a simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210-6. 8. Belsito DV. A Sherlockian approach to contact dermatitis. Dermatol Clin 1999;17:705-13. 9. Burnett CA, Lushniak BD, McCarthy W, Kaufman J. Occupational dermatitis causing days away from work in US private industry, 1993. Am J Ind Med 1998;34:568-73. 10. Meyer JD, Chen Y, Holt DL, Beck MH, Cherry NM. Occupational contact dermatitis in the UK: a surveillance report from EPIDERM and OPRA. Occup Med 2000;50:265-73. 11. Kucenic MJ, Belsito DV. Occupational allergic contact dermatitis is more prevalent than irritant contact dermatitis: a five year study. J Am Acad Dermatol 2002;46:695-9.
12. Holness DL. Results of a quality of life questionnaire in a patch test clinic population. Contact Dermatitis 2001;44:80-4. 13. Hutchings CV, Shum KW, Gawkrodger DJ. Occupational contact dermatitis has an appreciable impact on quality of life. Contact Dermatitis 2001;45:17-20. 14. Goh CL. Prognosis of contact dermatitis following secondary preventive measures. Curr Probl Dermatol 1996;25:154-62. 15. Holness DL, Nethercott JR. Work outcome in workers with occupational skin disease. Am J Ind Med 1995;27:807-15. 16. Cooley JE, Nethercott JR. Prognosis of occupational skin disease. Occup Med 1994;9:19-24. 17. Rajagopalan R, Anderson R. Impact of patch testing on dermatology-specific quality of life in patients with allergic contact dermatitis. Am J Contact Dermatitis 1997;8:215-221. 18. Rajagopalan R, Anderson R, Sarma S, Kallal J, Retchin C, Jones J, et al. An economic evaluation of patch testing in the diagnosis and management of allergic contact dermatitis. Am J Contact Dermatitis 1998;9:149-154. 19. Storrs FJ, Rosenthal LE, Adam RM, Clendenning W, Emmett EA, Fisher AA, et al. Prevalence and relevance of allergic reactions in patients patch tested in North America: 1984 to 1985. J Am Acad Dermatol 1989;20:1938-45. 20. Milliken GA, Johnson DE. Analysis of messy data, volume I: designed experiments. London: Chapman & Hall; 1992. 21. Kotaniemi JT, Hassi J, Kataja M, Jonsson E, Laitinen LA, Sovijarvi AR, et al. Does non-responder bias have a significant effect of the results in a postal questionnaire study? Eur J Epidemiol 2001;17:809-17. 22. Kreiger N, Nishri ED. The effect of non-response on estimation of relative risk in a case-control study. Ann Epidemiol 1997;7:194-9. 23. Ronmark E, Lundqvist A, Lundback B, Nystrom L. Non-responders to a postal questionnaire on respiratory symptoms and diseases. Eur J Epidemiol 1999;15:293-9. 24. Rajagopalan R, Anderson R. The profile of a patient with contact dermatitis and a suspicion of contact allergy (history, physical characteristics, and dermatology-specific quality of life). Am J Contact Dermat 1997;8:26-31. 25. Hoenig J, Heisey D. The abuse of power: the pervasive fallacy of power calculations for data analysis. Am Stat 2001;55:19-24. 26. Holness DL, Nethercott JR. Is a worker’s understanding of their diagnosis an important determinant of outcome in occupational contact dermatitis? Contact Dermatitis 1991;25:296-301.
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M
any skin disorders have a significant impact on quality of life (QoL).1 Dermatological diseases invoke strong negative emo-
From the Division of Dermatology, University of Kansas Medical Center. Funding source: None. Conflict of interest: None identified. Accepted for publication May 5, 2003. Reprints not available from authors. Correspondence to: Donald Vincent Belsito, MD, MBA, Division of Dermatology, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, Kansas 66160-1719. E-mail: dbelsito@ kumc.edu. Copyright © 2003 by the American Academy of Dermatology, Inc. 0190-9622/2003/$30.00 ⫹ 0 doi:10.1016/S0190-9622(03)02112-1
tions, troublesome symptoms, and impaired functioning in social and professional arenas. In addition to thermoregulation, physical protection, and sensory perception, the skin is responsible for presentation. Flawed presentation often results in reduced esteem by self and others.2 The intensity of the effect of skin disease on individual patients is widely variable, and not well correlated with clinical assessment of severity.3 The degree to which QoL is affected may depend on several factors, including the patient’s demographic characteristics, the natural history and location of the skin disorder, and the duration of time before diagnosis. In the last fifteen years, there has been increasing interest in the accurate measurement of out1037
1038 Kadyk et al
comes in dermatology patients. As a result, several dermatology-specific QoL instruments have been developed.4-7 Allergic contact dermatitis (ACD), a common disorder caused by exposure to a contact allergen, is characterized, acutely, by erythematous macules and papules, edema, vesicles, or bullae, and chronically, by lichenification or scaling.8 Recent research shows that ACD could be responsible for as much as 50 to 60% of occupational contact dermatitis (OCD) and, therefore, may have an estimated economic impact of $3 billion each year.9-11 The annual cost of non-occupational ACD is difficult to measure, although a recent report suggests that ACD caused by an allergen contacted outside of the workplace is three times more common than occupationally related ACD.11 A review of the literature indicates that contact dermatitis often results in ongoing disease and disability, especially when occupationally related.12-16 However, relatively little has been published concerning outcomes in patients with ACD as an entity distinct from irritant contact dermatitis (ICD). Anderson and Rajagopalan developed and used the Dermatology-Specific Quality of Life (DSQL) instrument to show the beneficial impact of patch testing in patients suspected of ACD.5,17,18 More recently, a modified version of the Dermatology Life Quality Index (DLQI) was used to assess QoL outcomes in a patch test clinic population.12 As one of twelve participants in the North American Contact Dermatitis Group (NACDG), the University of Kansas Medical Center is a referral center for ACD and specializes in the use of patch testing for diagnosis. The objective of this study was to administer a standardized, dermatological QoL survey to patients with ACD in order to (1) investigate the impact of ACD on QoL, and (2) explore prognostic factors that influence outcomes.
METHODS The University of Kansas Medical Center, a NACDG test center, performs patch testing using standardized screening procedures and allergen trays.19 Between July 1994 and June 2002, patch tests were conducted on 993 patients seen in dermatology clinics at the Medical Center. Demographic, occupational, and medical information was collected prior to testing using a standardized NACDG questionnaire. Patients were patch tested using the NACDG standard screening tray and other suspected allergens, which were chosen based on history and physical examination. Patch testing was accom¨ y, Tuplished with Finn Chambers (Epitest Ltd., O usula, Finland) adhered to the upper back using
J AM ACAD DERMATOL DECEMBER 2003
Scanpor tape (Norgeplaster Aksjeselskap, Vennesia, Norway). The allergens were removed after 48 hours. Reaction sites were examined at the time of removal and 96 hours after placement of the patches. The severity of the patch test reaction was scored from 1 to 6. Grades of 1, 2 and 3 indicated a positive allergic reaction; a grade of 4 indicated a questionable reaction; and grades of 5 or 6 indicated irritant or negative reactions, respectively. The relevance of the allergen to the patient was also rated from 1 to 6. For relevance, grades of 1, 2 or 3 indicated definite, probable or possible relevance, while a grade of 4 indicated past relevance. All demographic and patch test data was entered into a Microsoft Access (Microsoft Corp., Seattle, Wash.) database for evaluation. The 428 patients diagnosed with a relevant ACD by patch testing between July 1994 and June 2002 were identified from the computerized database. Each patient was mailed a questionnaire that was modified from the Skindex-16, a dermatological QoL instrument that has undergone reliability and validity testing.4 The self-directed survey included the original 16 items, categorized into three scales: symptoms, emotions and functioning. A fourth scale was added to measure occupational impact (Table I). Each of the 21 QoL items measured the degree to which the respondent was bothered by their dermatitis in the last month, scaled from 0 (never bothered) to 100 (always bothered). Surveys completed by inconsistent responders were handled by eliminating from the analysis any scale that was missing more than 25% of the responses. The questionnaire also asked about the duration of the skin condition prior to patch testing, the number of doctor visits made concerning the disorder, the treatment methods used, and whether it was necessary to change jobs because of the dermatitis. The data to be analyzed was extracted from the Access database as Microsoft Excel files (Microsoft Corp, Seattle, Wash). The records were imported into the SAS Software System (v 8.01), which was used to conduct all statistical analyses (SAS Institute Inc, Cary, NC). A 5% significance level was used for all tests. Comparisons of QoL scores were performed utilizing a variety of procedures. t-Tests were used for making unadjusted comparisons of QoL scores when only two comparison groups were involved. t-Tests using Satterthwaite-adjusted degrees of freedom and the Wilcoxon rank sum test were employed in those situations where heteroscedasticity was determined to exist. Analysis of variance (ANOVA) was utilized for making unadjusted com-
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Table I. Skindex-16* plus 5 questions measuring occupational impact† During the past month, how often have you been bothered by:
Symptoms 1) Your skin condition itching 2) Your skin condition burning or stinging 3) Your skin condition hurting 4) Your skin condition being irritated Emotions 5) The persistence/reoccurrence of your skin condition 6) Worry about your skin condition 7) The appearance of your skin condition 8) Frustration about your skin condition 9) Embarrassment about your skin condition 10) Being annoyed about your skin condition 11) Feeling depressed about your skin condition Functioning 12) The effects of your skin condition on your interactions with others 13) The effects of your skin condition on your desire to be with people 14) Your skin condition making it hard to show affection 15) The effects of your skin condition on your daily activities 16) Your skin condition making it hard to work or do what you enjoy Occupational Impact 17) Concerns that you may need to leave your job because of your skin condition 18) Fear for your financial future because of your skin condition 19) Concerns that your interactions with co-workers will be difficult because of your skin condition 20) Difficulty with using your hands at work because of your skin condition 21) Fear of being fired from your job because of your skin condition *Skindex16©MMChren, 1997. † Occupational questions courtesy of Dr. Kathryn Zug, Hanover, NH.
parisons of QoL scores when more than two groups were involved. The Kruskal-Wallace test, a nonparametric alternative to ANOVA, was used when ANOVA was deemed inappropriate due to the presence of heteroscedasticity. Hartley’s F-max test was employed to check for heteroscedasticity when more than two groups were involved. Analysis of covariance (ANCOVA) was used for making adjusted comparisons of QoL scores. When comparing more than two groups, multiplicity that resulted from making several comparisons became a problem. In all analyses involving more than two groups, Fisher’s least significant difference (LSD) procedure was undertaken to determine when pairwise comparisons could be made.
Using this procedure, preplanned comparisons of interest were investigated only if the overall F-test was significant. If the overall F-test was not significant, pairwise comparisons were not made. This procedure maintained the experiment-wise Type I error rate at the desired level for each group of comparisons.20 Regression was utilized to identify trends in the QoL scores. Comparisons of group proportions, as well as tests of independence between patient groups and categorical variables of interest, were performed using chi-square analyses. In those situations where the expected cell frequencies were low, rendering the chi-square test inappropriate, Fisher’s exact test was performed instead. Odds ratios were estimated using logistic regression. Generalized linear models were used to perform multivariate analysis while reducing the model if possible.
RESULTS The overall response rate to the postal survey was 35%, with 149 subjects returning the questionnaire. The demographic differences between the responders and nonresponders are summarized in Table II. A comparison between the two groups revealed that the respondents were more likely to be over 40 years old, female, and white. There were no significant dissimilarities between the responders and nonresponders with respect to occupational versus nonoccupational ACD, hand involvement, facial involvement, or history of atopic eczema. The scores for the QoL questions are summarized in Table III. Each item was scaled from 0 (never bothered) to 100 (always bothered). Therefore, a higher score indicated a more impaired QoL. In general, patients with ACD reported being bothered most by itching, skin irritation, and the persistence or recurrence of the disease. They were more frustrated and annoyed by the condition than embarrassed or depressed. When the items within each of the four scales were averaged for all subjects, the emotions scale had the worst composite QoL score, followed by symptoms, functioning, and occupational impact. In order to explore prognostic factors that influence outcomes in patients with ACD, the QoL scores of patients with specific characteristics were analyzed. Of the 149 respondents, 17% had facial dermatitis. Table IV summarizes the QoL scores of subjects with and without facial involvement. A comparison between the two groups revealed that subjects with ACD of the face had a significantly worse QoL score on the item asking about the appearance of their skin. In addition, patients with involvement of the face felt a higher degree of an-
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Table II. Demographic characteristics of responders versus nonresponders All patients
All patients Age (y) ⬎19 20–39 40–59 60–79 80⫹ Sex Male Female Ethnicity Asiatic Black Caucasian Hispanic Other Ethnicity Caucasian Non-Caucasian Occupationally related No Unsure Yes Body site Face Hand Atopic eczema Average age (y)
Nonresponders
Responders
No.
%
No.
%
No.
%
P value
428
100
279
65.19
149
34.81
—
16 66 194 134 18
3.74 15.42 45.33 31.31 4.21
11 54 120 83 11
3.94 19.35 43.01 29.75 3.94
5 12 74 51 7
3.36 8.05 49.66 34.23 4.70
.0433*
152 276
35.51 64.49
111 168
39.78 60.22
41 108
27.52 72.48
.0115*
5 48 361 9 5
1.17 11.21 84.35 2.10 1.17
2 39 228 5 5
0.72 13.98 81.72 1.79 1.79
3 9 133 4 0
2.01 6.04 89.26 2.68 0.00
.0321*
361 67
84.35 15.65
228 51
81.72 18.28
133 16
89.26 10.74
.0408*
296 18 114
69.16 4.21 26.64
192 11 76
68.82 3.94 27.24
104 7 38
69.80 4.70 25.50
.8802*
65 146 51
15.19 34.11 11.92
39 98 29
13.98 35.13 10.39
26 48 22
17.45 32.21 14.77
.3405 .5451 .1836
All patients
Nonresponders
Responders
P value
53.01 ⫾ 16.62
51.66 ⫾ 17.37
55.55 ⫾ 14.84
.0154
*P values for age, sex, ethnicity, and occupational relatedness result from chi-square testing across the subgroups.
noyance that trended toward significance. However, they had significantly better QoL scores than those without facial disease on two questions: fear of being fired, and difficulty using their hands at work. It is important to note that only 15% of responders with facial ACD also had involvement of the hands, compared to 36% of responders without disease of the face. Therefore, the data showed that the odds of hand involvement are 3 times greater for those without facial involvement (Table V). Thirty-two percent of responders were diagnosed with ACD of the hands. The effect of hand involvement on QoL scores is cataloged in Table VI. Subjects with hand dermatitis had significantly worse QoL scores on all items within the Occupational Impact Scale. Within the functioning scale, these subjects reported that it was significantly harder to work or do what they enjoy and three other items trended toward significance. There were no statistically significant differences between those with and
without hand involvement in the Symptoms or Emotions Scales. Occupationally related ACD was diagnosed in 27% of the respondents. The QoL scores of subjects with and without occupational ACD are summarized in Table VII. Like ACD of the hands, the QoL scores for subjects with occupationally related disease were significantly worse within the Occupational Impact and Functioning Scales. Of importance, 76% of respondents with occupational ACD also had involvement of the hands, compared to 14% of respondents with nonoccupational ACD. Analysis of the data revealed that the odds of hand involvement are 19 times greater for those with work-related ACD than for those with non-work-related ACD (Table V). A multivariate analysis was used to incorporate both hand involvement and occupational relatedness as predictors of the QoL questions that were found to be significant in the work-related analysis. Occupationally related
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Table III. QoL scores for all subjects scaled from 0 (never bothered) to 100 (always bothered) No.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Survey item
Symptoms Scale Itching Burning/stinging Hurting Irritated Emotions Scale Persistence/reoccurrence Worry Appearance Frustration Embarrassment Annoyed Depressed Functioning Scale Interactions with others Desire to be with people Show affection Daily activities Work/what you enjoy Occupational Scale May need to leave job Financial future Interactions with co-workers Difficulty using hands Fear of being fired
No.
Mean
SD
146 147 146 147 147 144 146 148 148 148 148 147 147 146 147 148 149 149 149 146 149 147 149 149 148
31.01 38.12 24.79 20.76 40.04 36.02 41.68 35.17 34.84 43.70 29.30 42.31 24.27 20.78 19.07 18.50 15.81 24.64 25.19 13.32 15.12 13.84 12.32 16.91 7.90
30.17 33.06 32.37 33.68 33.85 33.39 36.06 39.23 36.58 40.48 37.35 38.24 33.94 29.83 31.92 31.54 29.43 33.73 35.00 25.75 31.56 29.59 27.34 31.87 23.69
SD, Standard deviation.
Table IV. Impact of face involvement on QoL scores Face not involved
Face involved
No.
%
No.
%
123
82.55
26
17.45
Face not involved
Symptoms Scale Emotions Scale Appearance Annoyed Functioning Scale Occupational Scale Difficulty using hands Fear of being fired
Face involved
Mean
SD
Mean
SD
P value
30.48 34.52 31.63 39.92 22.15 14.53 19.53 9.09
30.51 33.02 35.40 37.47 30.27 27.08 33.97 25.72
33.57 43.24 50.68 54.00 14.17 7.48 4.50 2.04
28.92 34.88 38.87 40.59 27.23 17.26 13.80 5.64
.6431 .2365 .0171 .0936 .2244 .1024 .0004 .0070
ACD, but not hand involvement, was found to be a predictor for the responses to questions 16 to 18 and 21. Conversely, hand ACD was a predictor for questions 19 and 20, while occupational dermatitis was not. Thirteen percent of the responders reported that they had changed jobs because of ACD. These nineteen subjects had more severe QoL impairment than any other group analyzed. The data revealed that
changing jobs was associated with significantly worse QoL scores on 17 of the 21 survey items (Table VIII). All of the items within the Symptoms Scale, Functioning Scale, and Occupational Impact Scale had significantly poorer scores. Within the Emotions Scale, subjects who changed jobs reported significantly greater embarrassment and depressive feelings, as well as being bothered more by their appearance. The remaining four items in the emo-
1042 Kadyk et al
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Table V. Association between hand involvement and other prognostic factors Hand Involved
All Responders
Face involvement No 123 Yes 26 Occupationally related No 104* Yes 38* History of atopic eczema No 127 Yes 22 Duration of time before patch testing ⬍1 mo 5† 1 to 2.9 mo 13† 3 to 5.9 mo 11† 6 to 11.9 mo 19† 12 to 35.9 mo 40† ⬎36 mo 56† Duration of time since patch testing ⬍6 mo 7 6 to 11.9 mo 15 12 to 35.9 mo 62 ⬎36 mo 65
No.
%
P value
OR
44 4
35.77 15.38
.0330
3.0630
15 29
14.42 76.32
⬍.0001
19.1170
41 7
32.28 31.82
.9656
-
0 6 5 5 8 24
0.00 46.15 45.45 26.32 20.00 42.86
.0377
-
3 5 18 22
42.86 33.33 29.03 33.85
.8670
-
OR, Odds ratio. *Seven responders were not sure if ACD was occupationally related and were not included in the analysis. † The analysis includes the 144 responders that reported the duration of their symptoms before patch testing.
Table VI. Impact of hand involvement on QoL scores Hand not involved
Hand involved
No.
%
No.
%
101
67.79
48
32.21
Hand not involved
Symptoms Scale Emotions Scale Functioning Scale Interactions with others Desire to be with people Show affection Daily activities Work/what you enjoy Occupational Scale May need to leave job Financial future Interactions with coworkers Difficulty using hands Fear of being fired
Hand involved
Mean
SD
Mean
SD
P value
31.37 36.08 18.14 16.67 17.52 13.57 21.64 21.30 8.24 9.44 9.60 8.27 9.42 4.35
30.14 33.37 28.78 31.50 31.99 27.87 32.34 32.56 19.76 24.77 26.28 23.29 24.64 17.68
30.26 35.94 26.37 24.17 20.54 20.52 30.96 33.40 23.69 27.08 22.58 20.83 32.67 15.29
30.56 33.78 31.55 32.56 30.80 32.26 36.01 38.72 32.82 40.18 34.11 33.01 39.15 31.85
.8366 .9810 .1197 .1849 .5871 .1790 .1155 .0483 .0038 .0067 .0228 .0205 .0003 .0300
tions scale also had worse QoL scores for subjects who had changed jobs because of their skin condition, but not to a significant degree. Fifteen percent of responders had a history of atopic eczema. The data indicated that subjects with
atopic dermatitis enjoyed a better QoL across all four scales than those subjects without atopic eczema, although not to a significant degree (data not shown). One QoL item yielded a significantly different score between the two groups. Subjects with a
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Table VII. QoL scores for occupationally related ACD versus nonoccupational ACD Nonoccupational ACD
Occupationally related ACD
No.*
%*
No.*
%*
104
73.24
38
26.76
Nonoccupational ACD
Symptoms Scale Emotions Scale Functioning Scale Interactions with others Desire to be with people Show affection Daily activities Work/what you enjoy Occupational Scale May need to leave job Financial future Interactions with coworkers Difficulty using hands Fear of being fired
Occupationally related ACD
Mean
SD
Mean
SD
P value
29.56 34.08 16.26 15.22 15.72 12.21 19.26 18.76 7.438 7.39 8.01 7.87 9.95 3.89
29.01 32.25 26.48 29.58 29.99 26.20 29.14 30.68 20.45 22.62 24.45 22.99 24.19 17.34
28.39 33.87 26.72 23.29 20.78 19.37 32.50 35.58 23.54 32.05 25.03 18.00 28.11 14.50
29.37 33.80 31.89 32.54 31.30 30.12 39.08 39.13 29.05 40.88 34.11 29.30 38.93 29.04
.8352 .9731 .0536 .1645 .3848 .1687 .0623 .0083 .0028 .0010 .0068 .0329 .0098 .0396
*Seven responders were not sure if ACD was occupationally related and were not included in the analysis.
Table VIII. Impact of changing jobs because of ACD on QoL scores No job change
Job change
No.
%
No.
%
130
87.25
19
12.75
No job change
Symptoms Scale Emotions Scale Functioning Scale Occupational Scale
Job change
Mean
SD
Mean
SD
P value
28.63 33.70 17.74 8.62
28.77 32.49 27.50 18.78
46.95 51.41 41.12 44.76
35.09 35.98 37.05 40.95
.0131 .0307 .0013 .0012
history of atopic dermatitis were significantly less worried about being fired from their job than those without that condition (P ⫽ .0034). There was no difference between those with a history of atopic eczema and those without a history of atopic eczema in terms of hand involvement. Both groups had 32% of respondents with involvement of the hands (Table V). An analysis was also undertaken to determine if an atopic history, defined as a history of allergic rhinitis, asthma, or atopic eczema, affected the QoL of patients with ACD. The QoL scores revealed no significant differences between atopic and nonatopic responders (data not shown). The data in Table IX summarize the impact of the duration of ACD prior to diagnosis on QoL scores. Within the Symptoms Scale, the subjects diagnosed by patch testing more than 36 months after disease
onset seemed to have worse QoL scores than those diagnosed earlier in the natural history of the condition. Although the trend was not statistically significant, the symptoms scores appeared to be directly proportional to the elapsed time between onset and diagnosis of ACD. Neither the Emotions nor the Functioning Scale revealed a significant relationship between QoL and duration of disease prior to patch testing. The duration of ACD prior to diagnosis appreciably affected one item within the Occupational Impact Scale. Although significant, the data did not trend in a predictable fashion. Subjects patch tested 1 to 3 months after disease onset reported the highest degree of difficulty using their hands at work, followed by those with ACD for greater than 36 months prior to diagnosis. Forty-six percent of respondents who were patch tested 1 to
1044 Kadyk et al
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Table IX. Impact of duration of condition prior to diagnosis by patch testing on QoL scores < 1 mo No.*
5
3 to 5.9 mo
12 to 35.9 mo
6 to 11.9 mo
> 36 mo
%*
No.*
%*
No.*
%*
No.*
%*
No.*
%*
No.*
%*
3.47
13
9.02
11
7.64
19
13.19
40
27.78
56
38.89
< 1 mo
Symptoms Scale Emotions Scale Functioning Scale Occupational Scale May need to leave job Financial future Interactions with coworkers Difficulty using hands Fear of being fired
1 to 2.9 mo
1 to 2.9 mo
3 to 5.9 mo
6 to 11.9 mo
Mean
SD
Mean
SD
Mean
SD
Mean
17.11 20.38 12.64 1.84 6.70 3.67 1.70
29.11 31.57 19.17 5.53 16.12 11.00 5.38
23.38 31.60 23.68 23.86 28.23 21.85 15.38
27.18 34.14 29.73 34.87 42.14 33.63 30.00
27.68 29.91 24.34 13.02 18.18 13.64 12.09
34.19 37.50 41.05 30.53 40.45 32.33 27.89
28.72 31.23 20.02 10.73 18.47 10.53 11.42
3.30 10.44 35.92 45.54 12.09 27.89 1.70 5.38 17.92 37.54 9.09 30.15
SD
> 36 mo
12 to 35.9 mo Mean
SD
Mean
P value†
SD
32.36 33.17 29.39 35.02 31.50 32.89 37.99 31.23 41.22 34.57 28.54 17.33 27.35 23.55 31.67 22.52 5.73 13.96 19.05 30.02 35.58 4.20 13.99 19.64 35.11 28.94 5.13 18.73 20.84 34.83 28.86 7.48 21.61 17.30 31.61
8.79 19.58 4.42 15.65
9.60 24.68 23.84 36.48 1.68 10.59 12.15 28.21
.5335 .5029 .8527 .0649 .0981 .1162 .4439 .0239 .1559
*Analysis includes the 144 responders that answered this question. † Analysis as continuous variable yielded no P values ⬍ .05.
Table X. Impact of duration of time since patch testing on QoL scores <6 mo No.
7
6 to 11.9 mo %
No.
%
No.
%
No.
%
4.70
15
10.07
62
41.61
65
43.62
<6 mo
Symptoms Scale Emotions Scale Functioning Scale Occupational Scale †
>36 mo
12 to 35.9 mo
6 to 11.9 mo
>36 mo
12 to 35.9 mo
Mean
SD
Mean
SD
Mean
SD
Mean
SD
P value†
58.89 60.22 51.46 38.57
33.71 34.15 41.38 45.14
20.03 27.00 11.81 9.79
23.65 29.55 18.69 18.20
33.60 35.89 22.76 10.78
30.25 30.87 30.98 22.18
28.02 35.63 17.60 13.83
29.57 35.90 27.72 26.86
.0272 .1886 .0194 .0526
Analysis as continuous variable yielded no P values ⬍ .05.
3 months after disease onset had ACD of the hands. Forty-three percent of subjects diagnosed after more than 36 months of symptoms had hand involvement, as did 45% of those patch tested 3 to 6 months into their condition. There was a significantly lower incidence of hand involvement in those subjects patch tested less than 1 month or 6 to 36 months after disease onset (Table V). The time elapsed since patch testing had a significant impact of QoL scores in patients with ACD (Table X). All four of the scales revealed that subjects patch tested within the last 6 months had the worst QoL scores, while those diagnosed 6 to 12 months ago had the best scores. The scores worsened slightly after 12 months, although the QoL did not diminish back to the level seen immediately after diagnosis. Several survey items showed statistically
significant differences in scores depending on the duration of time since patch testing. The most recently diagnosed subjects reported significantly more hurting and skin irritation than subjects who had carried a patch test diagnosis for a longer time. In addition, newly diagnosed subjects reported more difficulty interacting with others, lessened desire to be with people, more problems showing affection, and adverse effects on daily activities. Within the Occupational Impact Scale, patients patch tested in the last 6 months expressed more fear for their financial future and more concern about difficult interactions with co-workers than subjects who had been cognizant of their diagnosis for a longer time. None of the items within the Emotions Scale were significantly affected by the duration of time since patch testing. There were
J AM ACAD DERMATOL VOLUME 49, NUMBER 6
no differences seen in the prevalence of hand involvement based on the time elapsed since patch testing (Table V).
DISCUSSION The purpose of this study was to determine the impact of ACD on QoL and explore patient, disease and management factors that influence outcomes. As expected, ACD was found to have an appreciable effect on QoL, as measured by the modified Skindex-16 questionnaire. It was difficult to compare these results with data in the literature for two reasons. First, there is relatively little published about QoL outcomes in patients with ACD. The vast majority of research regarding contact dermatitis includes patients with ICD as well. Second, the small amount of data available concerning outcomes in ACD was obtained using different dermatologyspecific QoL instruments. Each survey utilizes different questions and scoring to measure QoL, making comparison difficult. The overall response rate to the questionnaire was 35%. Utilization of mailed questionnaires should always raise concerns about nonresponse bias. In this study, the respondents were more likely to be over 40 years old, white, and female. Little has been published concerning nonresponse bias in the realm of dermatological research. However, a search of the general medical literature revealed that young men were more likely to be nonresponders than responders.21 Likewise, another study showed that women were more likely to return a mailed questionnaire.22 There was conflicting data regarding the impact of age upon response rate,22,23 and very little published concerning the effect of gender. When attempting to determine the impact that these demographic differences may have on the QoL data, the literature again yielded contradictory information. Several studies indicated that age and gender did not significantly affect the prognosis of contact dermatitis, while others reported that women and young persons were likely to feel more distress due to their skin disease.2,14 Once again, little has been published regarding the prognosis of contact dermatitis based on ethnicity. Although age, gender, and ethnicity differed between the responder and non-responder groups, there were no dissimilarities based on important patient and disease characteristics that have long been suspected of adversely affecting the QoL of patients with ACD. Responders were equally as likely as nonresponders to have occupationally related disease, involvement of the hands, involvement of the face, and a history of atopic eczema. The impact of confounders, such as age, gender, ethnic-
Kadyk et al 1045
ity, and occupation, on the QoL of the subjects in this study will be addressed in a subsequent report. Skindex-16 has been used to measure the QoL of patients with several dermatological conditions.4 Patients with a diagnosis of eczematous dermatitis in Chren’s study had worse QoL scores than our subjects with ACD. At first, the discrepancy seemed to indicate that ACD is associated with a less severe impact on QoL than some of the other conditions categorized as eczematous dermatitis. However, comparing Chren’s data to the QoL scores of our subjects patch tested within the last 6 months painted a different picture. These recently patch tested subjects, likely to be still suffering from the acute phase of the disease, reported a worse QoL than patients with eczematous dermatitis in Chren’s study. Therefore, ACD seems to be as disabling as other eczematous dermatitides in its active form. However, after diagnosis by patch testing, the disease remits if the allergen can be successfully avoided. Goh14 reported that ICD is often associated with a worse prognosis than ACD, possibly because of the difficulty of avoiding the multitude of irritants in the environment, especially soap and water. In a study of a patch test clinic population using the DLQI, Holness12 reported that the most common effect was pain or itching. The subjects also reported significant embarrassment, interference with work, and difficulties with sleep. Likewise, our subjects were bothered most by itching and skin irritation. However, within the Emotions Scale, our patients reported greater annoyance and frustration than embarrassment. Since the DLQI did not address frustration or annoyance and used a different method of scoring than Skindex-16, it was impossible to determine if the subjects in the two studies felt similar degrees of embarrassment. Of the four scales included in our study, the Emotions Scale suffered the greatest effect. Emotional impact is therefore an important measure of QoL in patients with ACD. Of the five items within the functioning scale, the question related to ACD making it hard to work yielded the worst QoL score. Holness’ results12 corresponded roughly to this data. Rajagopalan and Anderson24 used the DSQL to measure QoL in patients with suspected contact allergy. The results revealed that ACD had the most appreciable impact in the areas of physical symptoms, vitality, and self-perception. Likewise, our data showed that the worst QoL scores existed within the Symptoms and the Emotions scales. Patients with ACD of the face were significantly more bothered by their appearance than those without facial involvement. They also reported greater annoyance due to their skin condition, although not
1046 Kadyk et al
to a significant degree. Logic supported the fact that dermatitis of such a highly visible area of skin would adversely impact scores within the Emotions cale to the greatest degree. Two of the Occupational Impact items, difficulty using the hands at work and fear of being fired, had significantly better scores for responders with ACD of the face. The superior QoL scores may be explained by the fact that subjects with facial involvement were 3 times less likely to have ACD of the hands. Hand and occupational dermatitis significantly worsens the scores of these two QoL items. Several reports have indicated that contact dermatitis of the hands negatively affects the ability to work and pursue normal daily activities.1,2,12 The QoL data collected in our study for subjects with contact dermatitis of allergic etiology agreed with the literature. Hand involvement was associated with significant impairment within the Functioning and Occupational Impact scales. The vital role that healthy skin plays in protecting the hands during everyday tasks does not need to be explained, especially when discussing the wet-work performed around a household. In the workplace, hands are important for both functionality and presentation. In occupations that require direct interaction with the public, such as food service, childcare, and sales, even noncontagious lesions of the hands are often viewed with suspicion and distaste.2 Holness’ study12 revealed that involvement of the hand was the factor influencing the greatest number of QoL outcomes in a patch test clinic population. While analyzing our data to explore other characteristics that were suspected of worsening the prognosis of ACD, the associations between hand involvement and the other prognostic factors were calculated in order to ensure that the data was not being skewed by an unequal overlap. Occupational ACD is a common dermatological diagnosis and one that significantly impairs QoL.11-13,16 Holness reported that patients suspected of work related ACD had poorer outcomes in several areas, including physical symptoms, daily chores, leisure activities, work, relationships, sleep, and treatment of the condition.12 Another study showed that patients with occupational contact dermatitis had the most severe QoL impairment in the realms of symptoms and feelings.13 While it is true that our subjects with occupationally related ACD had the worst QoL scores in the symptoms and emotions scales, the scores were not significantly different from the subjects with nonoccupationally related disease. In contrast, subjects with work related disease had significantly worse outcomes in the Occupational Impact and Functioning Scales than pa-
J AM ACAD DERMATOL DECEMBER 2003
tients with non-work-related ACD. It was not surprising to find that QoL scores for subjects with occupational ACD mirrored scores recorded for subjects with hand involvement, because patients with occupational ACD were 19 times more likely to have ACD of the hands. However, a multivariate analysis including the two variables showed that only occupational ACD predicted the responses to questions 16 to 18 and 21, while only hand involvement predicted QoL items 19 and 20. Contradictory conclusions have been published concerning outcomes in patients who changed jobs because of contact dermatitis, and skin disease in general. Several reports indicated that a job change exerted a beneficial effect on QoL, while others concluded that changing jobs had equivocal value or no impact whatsoever.14-16 The responders in our study who changed jobs because of ACD suffered greater QoL impairment than any other group analyzed. It was difficult to determine whether the poor outcomes were a direct result of changing jobs, or whether analyzing outcomes based on job change introduced a selection bias toward subjects who had a more severe form of ACD to begin with. There are, however, valid reasons why changing jobs could result in worse QoL scores in patients with ACD. First, leaving a job does not guarantee a significant improvement in the dermatitis, and a preexisting dermatological condition is an obvious disability that may discourage an employer from hiring the worker.14,16 In addition, patients with occupational skin disease (OSD) who changed jobs were found to lose more time from work and, consequently, net a diminished income.15 A history of atopy has long been suspected of being associated with worse QoL scores in patients with contact dermatitis, but a search of the literature yielded conflicting reports.14 Subjects with a history of atopic eczema in our study did not suffer poorer outcomes; in fact, these patients enjoyed better QoL scores than subjects without a history of atopic eczema. Responders with a history of atopic eczema were significantly less afraid of being fired because of their skin condition. Atopic eczema classically afflicts patients at a young age and it is fair to speculate that these patients may develop and exhibit greater resiliency and coping skills in the face of skin disease. In addition, a history of atopic eczema may encourage patients to choose careers that are gentler to the skin, thereby avoiding wet-work and manual labor. However, differences in occupation based on history of atopic eczema were not analyzed for this report. Delay in the diagnosis and treatment of contact dermatitis has been linked to chronicity and poorer
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prognosis.16 Patch testing is the accepted method of diagnosis for ACD, but is often performed only after months or years of active dermatitis. The data collected in this study revealed that 67% of patients diagnosed with ACD suffered with the disease for greater than 12 months prior to being referred for patch testing. The QoL scores within the symptoms scale worsened proportionally to the duration of the condition prior to patch testing, although not to a statistically significant degree. It is possible that the number of subjects in each time category was not large enough to identify this trend as significant. However, extrapolating the number of subjects necessary to render a data set significant after the data has been collected is a questionable usage of power analysis and was not undertaken in this study.25 Although there was no statistically significant trend revealed within the emotions and functioning scale, a striking difference in QoL scores was noted between the subjects patch tested less than 1 month after disease onset and those tested greater than 36 months after onset of symptoms. The QoL scores within the occupational impact scale showed significant differences between time categories, but did not trend predictably. However, the data made sense once hand involvement was taken into account. A disproportionately large percentage of subjects with hand involvement were found in the groups patch tested 1 to 3 months, 3 to 6 months, and greater than 36 months after disease onset. The disturbing aspect of the data was that subjects with hand involvement made up nearly half of the subjects who were patch tested greater than 36 months after disease onset. In order to be managed appropriately, patients with contact dermatitis of allergic etiology require identification of the responsible allergens. Therefore, the data underscore the need for practitioners to aggressively pursue patch testing in patients with dermatitis of the hands. Outcomes in patients with ACD were affected dramatically by the duration of time since patch testing. Subjects’ QoL improved significantly about 6 months after diagnosis by patch testing. The data indicated that identification of the responsible allergens by patch testing and education regarding how to avoid these allergens resulted in a sizeable improvement in patients’ QoL. The subjects in this study not only received extensive verbal and written information concerning the management of their condition at the time of diagnosis, they were also scheduled to return in 4 to 8 weeks to reemphasize the material. One report revealed that workers with contact dermatitis who could not correctly identify their diagnosis were twice as likely to still have active dermatitis, suffer from more severe skin dis-
ease, and report a worse QoL.26 In addition, it would be appropriate to inform patients that resolution of the condition occurs over months, not weeks, of allergen avoidance. Providing a suitable time frame will help to prevent patients from prematurely abandoning efforts of allergen avoidance. The QoL scores worsened slightly in subjects patch tested more than 12 months ago, but did not dwindle back to the level seen immediately postdiagnosis. Two scenarios could reasonably account for the decline in QoL observed after 1 year of successful management. First, the patients may have become less motivated to avoid allergens after the dermatitis had resolved. Second, because many allergens possess long and complex chemical names, it is reasonable to assume that patients may become confused about the etiology of their condition over time. The QoL of patients with ACD would likely benefit from annual follow-up appointments geared towards reeducation and evaluation of current allergen exposures. Limitations exist within this study. The response rate of 35% is lower than desired, but the sample size of 149 subjects is adequate to detect statistically significant differences between the QoL scores for the prognostic subcategories. Postal surveys traditionally have low response rates and a telephone follow-up is usually necessary to boost participation. The QoL scores were not adjusted for age, gender, ethnicity, or occupation. The impact of these confounders on the QoL scores of the study participants will be the subject of a subsequent report. The literature shows that QoL in dermatological conditions may not be well correlated with clinical assessment of severity. An objective measure of clinical severity would be an interesting element to add to future studies and would provide an opportunity to examine the correlation between the reported QoL and the patient’s clinical status.
CONCLUSION This was the first study to use the modified Skindex-16 to show that ACD has an appreciable effect on QoL. Of the four scales included in the survey, the Emotions Scale suffered the greatest overall effect. Comparing the QoL scores of patients with specific characteristics generated interesting observations. Facial involvement was associated with worse QoL scores in the realm of emotions. Hand and occupationally related ACD were associated with significant impairment within the Functioning and Occupational Impact Scales. A history of atopic eczema seemed to impart better QoL in patients with ACD. Individuals who elected to change jobs because of their skin condition reported significantly
1048 Kadyk et al
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worse QoL than those who did not change jobs. QoL seemed to be improved by early diagnosis and subjects reported their best QoL at 6 to 12 months after patch testing. We thank Mary-Margaret Chren, MD, for allowing the use of Skindex-16 and for statistical advice. We also thank Kathryn Zug, MD, for formulating the five questions related to occupational impact.
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12. Holness DL. Results of a quality of life questionnaire in a patch test clinic population. Contact Dermatitis 2001;44:80-4. 13. Hutchings CV, Shum KW, Gawkrodger DJ. Occupational contact dermatitis has an appreciable impact on quality of life. Contact Dermatitis 2001;45:17-20. 14. Goh CL. Prognosis of contact dermatitis following secondary preventive measures. Curr Probl Dermatol 1996;25:154-62. 15. Holness DL, Nethercott JR. Work outcome in workers with occupational skin disease. Am J Ind Med 1995;27:807-15. 16. Cooley JE, Nethercott JR. Prognosis of occupational skin disease. Occup Med 1994;9:19-24. 17. Rajagopalan R, Anderson R. Impact of patch testing on dermatology-specific quality of life in patients with allergic contact dermatitis. Am J Contact Dermatitis 1997;8:215-221. 18. Rajagopalan R, Anderson R, Sarma S, Kallal J, Retchin C, Jones J, et al. An economic evaluation of patch testing in the diagnosis and management of allergic contact dermatitis. Am J Contact Dermatitis 1998;9:149-154. 19. Storrs FJ, Rosenthal LE, Adam RM, Clendenning W, Emmett EA, Fisher AA, et al. Prevalence and relevance of allergic reactions in patients patch tested in North America: 1984 to 1985. J Am Acad Dermatol 1989;20:1938-45. 20. Milliken GA, Johnson DE. Analysis of messy data, volume I: designed experiments. London: Chapman & Hall; 1992. 21. Kotaniemi JT, Hassi J, Kataja M, Jonsson E, Laitinen LA, Sovijarvi AR, et al. Does non-responder bias have a significant effect of the results in a postal questionnaire study? Eur J Epidemiol 2001;17:809-17. 22. Kreiger N, Nishri ED. The effect of non-response on estimation of relative risk in a case-control study. Ann Epidemiol 1997;7:194-9. 23. Ronmark E, Lundqvist A, Lundback B, Nystrom L. Non-responders to a postal questionnaire on respiratory symptoms and diseases. Eur J Epidemiol 1999;15:293-9. 24. Rajagopalan R, Anderson R. The profile of a patient with contact dermatitis and a suspicion of contact allergy (history, physical characteristics, and dermatology-specific quality of life). Am J Contact Dermat 1997;8:26-31. 25. Hoenig J, Heisey D. The abuse of power: the pervasive fallacy of power calculations for data analysis. Am Stat 2001;55:19-24. 26. Holness DL, Nethercott JR. Is a worker’s understanding of their diagnosis an important determinant of outcome in occupational contact dermatitis? Contact Dermatitis 1991;25:296-301.
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