Bark Lynn Lew

An inverse relationship between ceramide synthesis and clinical severity in patients with psoriasis.

Ceramides play major roles in maintaining the epidermal barrier. It has been sus-pected that the depletion of ceramides, associated with disrupted barrier function in the epidermis, leads to the clinical manifestation of dryness and inflammation seen in patients with psoriasis. The aim of the present study was to determine the relation-ship between the level of ceramide synthesis in the epidermis and the clinical severity in patients with psoriasis. Samples from lesional and unlesional epidermis obtained from psoriasis patients were incubated with [14C]serine, an initiator of ceramide syn-thesis. otal ceramide was fractionated using high performance thin layer chromato-graphy, and the radioactivity was measured. The clinical severity of psoriasis was graded according to the psoriasis area and severity index scoring system. The level of ceramide synthesis in the lesional epidermis of patients was significantly lower than that in the unlesional epidermis and bore a negative correlation with the clinical severity of psoriasis. The present results suggest that the decreased level of ceramide synthesis in the epidermis contributes to the clinical severity of psoriasis.

Consensus Guidelines for the Treatment of Atopic Dermatitis in Korea (Part II): Systemic Treatment

Background Since the treatment guidelines for atopic dermatitis (AD) were issued by the Korean Atopic Dermatitis Association (KADA) work group in 2006, there have been further advances in the systemic treatment of AD. Objective We aimed to establish updated evidence- and experience-based systemic treatment guidelines for Korean AD. Methods We compiled a database of references from relevant systematic reviews and guidelines regarding the systemic management of AD, including antihistamines, antimicrobials, systemic immunomodulators, allergen-specific immunotherapy, phototherapy, adjunctive treatment, and complementary and alternative medicines. Evidence for each statement was graded and classified based on the strength of the recommendation. Thirty-nine council members of KADA participated in the three rounds of votes and expert consensus recommendations were established. Results The use of antihistamines is recommended to relieve pruritus and to prevent exacerbation due to scratching in AD patients. Infection should be controlled as needed and long-term medication should be avoided. For moderate to severe AD patients, concomitant active treatments with systemic immunomodulators are indicated. Cyclosporine is the first choice among systemic immunomodulators and others should be considered as second-line alternatives. Allergen-specific immunotherapy could be effective in AD patients with aeroallergen hypersensitivity. Phototherapy can be useful for moderate to severe AD patients and narrow-band ultraviolet B is the most effective option. Complementary and alternative medicines cannot be recommended for treating AD. Conclusion We expect these recommendations to be a reference guide for physicians and AD patients in choosing the appropriate treatment to improve quality of life and decrease unnecessary social medical costs.

Consensus Guidelines for the Treatment of Atopic Dermatitis in Korea (Part I): General Management and Topical Treatment

Background Since the treatment guidelines for atopic dermatitis (AD) were released by the Korean Atopic Dermatitis Association (KADA) work group in 2006, there have been several advances in AD management. Objective We aimed to establish updated evidence- and experience-based treatment guidelines for Korean AD. Methods We collected a database of references from relevant systematic AD reviews and guidelines regarding general AD management such as bathing and skin care, avoidance of exacerbating factors, education and psychosocial support, and the use of moisturizers and topical anti-inflammatory and antipruritic drugs. Evidence for each statement was graded and the strength of the recommendation for each statement classified. Thirty-nine KADA council members participated in three rounds of voting to establish an expert consensus of recommendations. Results Basic AD treatment includes proper bathing and skin care, avoidance of exacerbating factors, proper education and psychosocial support, and use of moisturizers. The regular use of moisturizer has a steroid-sparing effect and reduces relapse episodes. The short- and long-term use of topical corticosteroids and calcineurin inhibitors improves AD symptoms and should be encouraged to use in an active and proactive treatment. Wet-wrap therapy can be used for rapid recovery of acute exacerbation. Topical antipruritic drugs cannot be recommended for the treatment of AD. Conclusion This report provides up-to-date evidence- and experience-based treatment guidelines for AD regarding general management and topical treatment. In addition, the average agreement scores obtained by a panel of experts based on the Korean healthcare system and patient adherence are presented.

Awareness, Knowledge, and Vaccine Acceptability of Herpes Zoster in Korea: A Multicenter Survey of 607 Patients

Background Herpes zoster (HZ) infection can significantly impair the quality of life of the affected individuals, and its treatment imposes a considerable cost burden on the health-care system and on society at large. However, there is little information on the perception of this disease and the acceptability of vaccines in Korea. Objective The aim of this study is to determine the awareness of HZ and its vaccine, and to identify factors associated with the acceptability of the HZ vaccine among outpatients of dermatology clinics. Methods A questionnaire-based survey was conducted on 607 outpatients who visited the dermatologic clinics. Results The responses of the patients revealed a high awareness of HZ (85.4%) but a relatively low knowledge about HZ and its vaccine (42.3%). The HZ vaccination rate among patients aged ≥50 years was 9%. A history of HZ infection, being older, and greater knowledge about HZ and its vaccine were associated with a higher HZ vaccine acceptability. Of those who had not been vaccinated, 58.3% were interested in receiving the vaccine. The most frequent reason for this interest was severe sequelae, followed by knowing someone who has HZ and recommendation from a doctor. High cost was the most common reason for unwillingness to receive the vaccination. Conclusion Despite a high awareness of HZ, vaccine acceptability was extremely low among this study cohort. Vaccination acceptability would be improved by encouraging doctors to educate elderly patients about the disease and the availability of vaccination, and by the provision of insurance coverage for HZ vaccination.

Minor Salivary Gland Sialolithiasis of the Upper Lip

Dear Editor: n nSialolithiasis is a common disease of the salivary glands. Most calculi occur in the major salivary glands such as the submandibular glands (80% to 92%) and parotid glands (16% to 19%), while minor salivary glands are rarely affected (2%)1. Minor salivary gland sialolithiasis is characterized by a small, solitary submucosal nodule, which is hard and in some cases can be movable in the surrounding tissue2. Since it is rare and its clinical features are not always typical, clinical misdiagnosis is possible3. Most otolaryngologists and dentists are relatively familiar with sialolithiasis, but many dermatologists are not. In order to heighten the awareness of this disease and to facilitate diagnosis, we report a case of minor salivary gland sialolithiasis that was initially misdiagnosed clinically. n nA 56-year-old man presented with a six-year history of an asymptomatic solitary submucosal nodule on the upper lip. He reported no history of trauma to the lip. Physical examination revealed a small (0.4×0.4 cm), firm, movable, well-defined submucosal nodule on the inner side of the upper lip (Fig. 1). We presumed the lesion was a mucocele and performed excisional biopsy. Histopathologic examination revealed heterogeneous lamellated calculi within the lumen of a dilated minor salivary duct. The calculi had a relatively homogenous core with alternating basophilic and eosinophilic bands at the periphery (Fig. 2A). The excretory ductal epithelium had undergone squamous metaplasia (Fig. 2B). These pathological features were consistent with the diagnosis of minor salivary gland sialolithiasis3,4. n n n nFig. 1 n nA 0.4×0.4 cm sized, firm, mobile, asymptomatic nodule on the inner side of the upper lip. n n n n n nFig. 2 n n(A) Heterogeneous lamellated calculi were found within the lumen of a dilated minor salivary duct (H&E, ×40). (B) Squamous metaplasia of the excretory ductal epithelium and exfoliated epithelium were observed in the minor salivary glands ... n n n nA sialolith of the minor salivary glands is commonly described as a solitary, firm, asymptomatic, mobile nodule. It is most likely to develop near the upper lip and buccal mucosa that are susceptible to masticatory trauma4. Its clinical characteristics can resemble those of other lesions, resulting in frequent misdiagnosis. Anneroth et al. observed the correct diagnosis was made in only 20% of patients2. The differential diagnosis includes mucocele, foreign body, benign salivary neoplasm, and calcinosis cutis. A mucocele is clinically similar to minor salivary gland sialolithiasis. However, it can be readily diagnosed because of its cyst-like appearance lined by granulation tissues. A foreign body is difficult to diagnose unless imaged by radiography. It can only be confirmed after excision and microscopic examination. A benign minor salivary neoplasm tends to be an indolent, painless, firm, nodule, and the most frequent location is the same as minor salivary gland sialolithiasis. Microscopic examination is required to determine the exact histologic nature of the tumor. Several case reports have described calcinosis cutis of the lip, and this condition is difficult to differentiate from minor salivary gland sialolithiasis5. However, it reveals relatively homogeneous calcium deposits surrounded by epithelial-like cells, rather than heterogeneous lamellated calculi. n nSialolithiasis of the minor salivary glands is frequently misdiagnosed, mostly because its frequency, signs, and symptoms are relatively unknown, especially to dermatologists. We should be aware of this disease and consider it as a possible diagnosis when swelling of the oral mucosal tissues is observed in a patient.

Localized Telogen Effluvium after Face Lift Surgery

Dear Editor: n nA 62-year-old woman presented at Kyung Hee University Hospital at Gangdong with a 2-month history of frontal and bitemporal shedding and thinning. Two months prior to visiting our clinic, she had undergone rhytidectomy at a local plastic surgery clinic. Her past medical history was not significant. There was no drug history, weight change, or chronic illness, and the patient denied any other trauma history. The physical examination revealed symmetric frontal and bitemporal thinning and decreased hair density (Fig. 1A, B). In a hair pull test, ≥10 hairs were easily pulled from around the suture line of the rhytidectomy; however, the hair pull test was negative in other parts of the scalp. On transverse sections of a 5-mm punch biopsy specimen, normal follicular density and increased numbers of telogen hair follicles were observed. Peribulbar inflammation, scarring, and hair shaft abnormality were not observed (Fig. 1C). On the basis of the clinical and histopathologic findings, she was diagnosed with telogen effluvium, which occurred after rhytidectomy. Without any treatment, the patient noted the natural recovery of hair shedding, and the regrowth of many hairs was observed around the affected areas 4 months after rhytidectomy (Fig. 2). n n n nFig. 1 n n(A, B) Hair thinning and a decreased hair density is observed symmetrically along the frontal and bitemporal incision lines

Acantholytic Anaplastic Extramammary Paget's Disease: A Case Report and Review of the Literature

Extramammary Pagets disease (EMPD) is an uncommon intraepithelial neoplasm that most commonly arises on the vulva and perianal region. Very few cases of EMPD revealing a histological Bowenoid appearance have been reported. This study describes scrotal EMPD presenting with histological features of Bowens disease in a 79-year-old man. He presented with a 5-year history of a pruritic erythematous plaque and a verrucous papule on the scrotum. The verrucous papule histopathologically showed Bowenoid features, and the erythematous plaque demonstrated acantholytic EMPD. Immunohistochemical findings revealed strong expression for carcinoembryonic antigen, Cam 5.2, epithelial membrane antigen, cytokeratin (CK) 7, and pancytokeratin (AE1/AE3) in both areas, but negative CK20 staining, supporting the overall diagnosis of primary acantholytic anaplastic EMPD. This is the first reported case of acantholytic anaplastic EMPD in the Korean literature.

Topical tacrolimus for the treatment of atopic dermatitis with truncal lesion

Background Topical tacrolimus is an effective anti-inflammatory therapy for acute and chronic states of atopic dermatitis (AD) in both adults and children. Topical tacrolimus has particular use at sensitive areas such as the face, anogenitals, and skin folds of neck and extremities. However, many AD patients also experience aggravated symptoms on trunk. Objective The aim of this study was to investigate the efficacy and safety of topical tacrolimus for AD patients with truncal lesions. Methods AD patients with truncal lesions who were aged ≥2 years were recruited from 20 centres in Korea. They received treatment with topical tacrolimus ointment twice daily during 4 weeks. The primary end point was change of the local eczema area and severity index (EASI) of the trunk from baseline to day 28. The secondary end points were changes in the patient global assessment (PGA) score and itch visual analogue scale (VAS) score of the trunk between baseline and day 28. Results Two hundred and ninety-one patients were recruited, and 176 patients completed the full 4-week treatment course. By the end of the treatment, the mean local EASI of the trunk (2.2±4.71) was significantly decreased from that at baseline (4.71±4.03, p<0.001). PGA (1.71±1.15) and itch VAS score of the trunk (2.61±2.19) on day 28 were also profoundly decreased compared with the baseline (2.96±1.07 and 5.15±2.47, respectively). No serious adverse events were observed during the study period. Conclusion Topical tacrolimus is an effective and safe therapy for truncal lesions in AD patients.

Awareness of Atopic Dermatitis and Attitudes toward Different Types of Medical Institutions for Its Treatment among Adult Patients and the Parents of Pediatric Patients: A Survey of 500 Participants

Background Physicians can play a crucial role in the knowledge that patients have about a disease and its prognosis. Recently, patients with atopic dermatitis (AD) are increasingly turning from western medicine to oriental herbal medicine. However, their awareness of AD and attitude toward Western medicine and oriental herbal medicine clinics are scarcely reported. Objective The aim of this study was to determine the understanding of AD among patients and their parents and to identify their awareness of and attitude toward Western medicine and oriental herbal medicine as treatments for AD. Methods An online questionnaire was administered to 500 consenting respondents with AD (age, 16~49 years) and parents of children with AD (age, 0~15 years). Results The mean percentage of correct answers to questions about AD was 52.54%. A parental history of AD was independently associated with higher respondent’s knowledge about the disease and its treatment. The satisfaction with treatment outcomes was highest among patients treated at private clinic of dermatology specialists (49.4%), while lowest among those treated at oriental herbal medicine clinics (38.4%). Many participants were aware that oriental herbal medicine requires a longer treatment period for a cure and does not burden the skin, while steroid phobia was seen in most of participants. Conclusion Physicians need to educate AD patients and their parents about the disease and its treatment. Misconceptions for Western medicine and oriental herbal medicine among AD patients and parents should be corrected to improve their prognosis.

A Study about the Cause and Clinicopathologic Findings of Injection-Induced Dermatitis

Background Cases of dermatitis induced by the injection of certain drugs have been reported. Objective The aim of this study was to assess the cause and clinicopathologic findings of injection-induced dermatitis, and to reveal whether the reaction has any relation to the patients age, injection site, drug concentration, and time interval from the injection to the occurrence of the skin lesion. Methods In this study, we enrolled 10 patients who developed erythematous skin lesions after the injection of causative drugs. The lesions were compared to each other according to the injection site, time interval from the injection to the occurrence of the skin lesion, and clinical characteristics. We performed intradermal and patch tests in each patient with different concentrations of causative drugs. Results The most common causative drugs were diclofenac and vitamin K1. The eczematous type was the most frequent clinical type. The intradermal test showed more positive results than the patch test. The patch tests with diclofenac (as is, 2.5%, 5%, and 10%) and vitamin K1 (10%) were all negative in 10 patients. Furthermore, intradermal tests with diclofenac (as is) and vitamin K1 (0.1%, 1%, and 10%) were performed in 8 patients. Six patients had a positive reaction, consisting of erythema, induration, and vesiculation, after 1 and 2 days. Conclusion Our results showed that the most common causative agents were diclofenac and vitamin K1. Moreover, it seems that that intradermal test is more useful than the patch test in the diagnosis of injection-induced dermatitis.