Eui Hyun Oh

Epidemiology and cardiovascular comorbidities in patients with psoriasis: A Korean nationwide population-based cohort study

There is a lack of nationwide studies examining the epidemiology and comorbidities of psoriasis vulgaris (PsV) and psoriatic arthritis (PsA) in Asian populations. The purpose of this study is to determine the demographics of psoriasis in Korea along with the incidence of cerebro‐cardiovascular (CV) comorbidities and to compare these risks between populations with PsA and with PsV. This cohort study identified 15 484 patients with psoriasis among 855 003 subjects in the Korean National Health Insurance Database from 2002 through 2010. The cases were further classified into PsA and PsV. We used hazard ratios (HR) and 95% confidence intervals (CI) from the univariate and age–sex adjusted logistic regression model to assess the risk of comorbidities in patients with PsA and PsV. The annual prevalence of psoriasis increased from 313.2 to 453.5/100 000 people from 2002 through 2010; however, the overall incidence rate for psoriasis slightly decreased (252.7–212.6/100 000 population). Of psoriatic patients, 10.8% had PsA, and after adjusting for age and sex, PsA patients had a significantly higher risk of dyslipidemia than PsV patients (adjusted HR, 1.185; 95% CI, 1.049–1.338). When stratified by age group, subjects aged 20–39 years had a higher risk of stroke and many CV risk factors. In conclusion, the prevalence of psoriasis, while within the range of previous reports, tended to increase over time. Patients with PsA had higher burdens of specific comorbid diseases than those with PsV, especially at a comparatively early age.

Treatment of disseminated superficial actinic porokeratosis with oral alitretinoin

Disseminated superficial actinic porokeratosis (DSAP), the most common type of porokeratosis, usually presents as large numbers of lesions on sun-exposed skin. Although several treatment options including corticosteroids, keratolytics, 5-fluorouracil, imiquimod, vitamin D3 analogues, cryotherapy, curettage, laser therapy and dermabrasion may be considered, there is no evidence-based standard treatment.1-2 Patient 1 was a 26-year-old female who presented with a 2-year history of progressive scaly macules on both upper and lower extremities. This article is protected by copyright. All rights reserved.

Clinical experience of cyclosporin treatment in patients with psoriasis and psoriatic arthritis

Dear Editor, There have been few well-designed studies comparing the clinical features and efficacy of cyclosporin (CS) in subjects with psoriasis (PsO) and psoriatic arthritis (PsA). This study aimed to investigate differences between patients with PsO and PsA in clinical characteristics and treatment response to CS. We conducted a 12-week, prospective, observational study. Patients who were diagnosed with moderate to severe PsO or with PsA were enrolled. All patients took CS (3–5 mg/kg/day), which could be tapered by 1–1.5 mg/kg according to treatment response. Clinical outcomes were based on the Psoriasis Area and Severity Index (PASI) and the modified Nail Psoriasis Severity Index (mNAPSI). To evaluate arthropathy, we assessed swollen joint count (SJC), tender joint count and psoriatic arthritis response criteria (PsARC). The study was approved by the institutional review board of Hanyang University Hospital. Among 100 patients, 18% had PsA. The PsA group included a higher proportion of female patients than the PsO group. The prevalence of nail psoriasis and the mean mNAPSI were higher in PsA patients than PsO patients. Also, PsA patients had a higher frequency of erythrocyte sedimentation rate (ESR) elevation than PsO patients. After 12 weeks of treatment with CS, both psoriatic skin lesions and arthritic symptoms improved in terms of PASI, mNAPSI, SJC and PsARC; however, the differences in the PASI and mNAPSI reduction values between the two groups were not statistically significant (Table 1). The 18% PsA prevalence that we found in this study is similar to that found in previous studies. Our report supports preceding studies that found more frequent and severe nail involvement and a higher frequency of ESR elevation in PsA patients compared with PsO patients. Interestingly, the proportion of female patients was higher in the PsA group than in the PsO group. Of patients with PsA, the reduction of PASI, mNAPSI and SJC was significant, and 44.4% of the patients showed a PsARC response. A previous report revealed that the effectiveness of CS in PsA patients with peripheral involvement was comparable with that of methotrexate therapy. The relatively high response rate among our patients may be because our PsA subjects were mostly in the early stages of arthritis without prominent bony abnormalities. Previous studies reported that CS was more effective for delaying onset of erosion in patients with early rheumatoid arthritis than conventional antirheumatic therapy, and similar results may be obtained for patients with PsA. Although in current treatment recommendations for PsA CS was withdrawn from the peripheral arthritis domain, the results of this study suggest that CS

Ten-year retrospective clinicohistological study of cutaneous lupus erythematosus in Korea

An understanding of the differences in clinical manifestations and laboratory abnormalities between subtypes of cutaneous lupus erythematosus (CLE) is still lacking. The purpose of this study was to analyze demographic, clinical and histological features of CLE according to three main presentation subsets: acute (ACLE), subacute (SCLE) and chronic (CCLE). A 10‐year retrospective analysis was performed on data from patients who were diagnosed with CLE between March 2005 and September 2015 in a Korean tertiary referral dermatology clinic. We compared demographic data and clinical and histological findings between three different CLE groups. An overall sample of 220 patients with CLE consisted of 67 patients with ACLE, 25 patients with SCLE and 135 patients with CCLE. Patients with CCLE regardless of systemic lupus erythematosus (SLE) presence had lower prevalence of anemia, urinary abnormalities and elevated erythrocyte sedimentation rate. Furthermore, CCLE patients who only had skin lesions showed lower female predominance, lower extracutaneous manifestation, fewer laboratory and immunological abnormalities including low antinuclear antibody titers and the lowest positivity for C3, C4 and anti‐dsDNA, anti‐Ro, anti‐Sm and anti‐RNP antibodies, and more prominent perieccrine inflammation and dermal fibrosis in histological findings. Considering distinct cutaneous manifestations of LE, a comprehensive awareness of each CLE subtype is important for achieving a favorable prognosis through appropriate diagnosis and management. This study provides comparative clinical and histological profiles of patients with different CLE subtypes in Korea.

Alitretinoin treatment of lichen amyloidosis

Lichen amyloidosis (LA) is characterized by the deposition of amyloid that may respond to chronic scratching that may be secondary to atopic dermatitis, stasis dermatitis, or interface dermatitis. Despite the development of several therapeutic strategies, including topical steroids, oral antihistamines, cyclosporine, and retinoids, an effective treatment for LA has not been established. A 49‐year‐old woman who has been treated irregularly for atopic dermatitis for 7 years presented with localized brownish papules on the left forearm and right elbow. They developed 3 months prior and were becoming more prominent despite of treatment with cyclosporine, oral antihistamines, and topical steroids for 5 months prior to presentation. A skin biopsy revealed amyloid deposition in the dermal papillae and the patient was diagnosed with LA associated with atopic dermatitis. A 6‐month course of daily oral alitretinoin 30 mg produced marked improvement in the thickness and color of the hyperkeratotic papules without aggravation of the patients atopic dermatitis. Histologic evaluation showed clearance of amyloid deposition and almost normalization of the epidermal changes. Herein, we report a case of LA treated with alitretinoin and suggest that it could be a potential treatment option for LA, especially in patients with inflammatory skin diseases including atopic dermatitis.

Drug-induced bullous Sweet's syndrome by celecoxib

Dear Editor, Sweet’s syndrome (SS) is characterized by abrupt onset of fever and painful erythematous plaques with dermal neutrophil infiltration. This disorder rarely results from several drugs including granulocyte colony-stimulating factor, all-trans-retinoic acid and antibiotics. A 58-year-old woman presented with aggravation of preexisting brownish-to-erythematous plaques and bullae with tenderness distributed on the buttocks and lower extremities (Fig. 1a–c). She complained of fever (38.1°C) and burning sensation. She had a 2-year history of rheumatoid arthritis (RA) and had been treated with low-dose prednisone and methotrexate. She reported two episodes of similar cutaneous findings that had appeared 1 and 6 months prior. Six months prior, she had been treated with systemic antibiotics with suspicion of infection by a rheumatologist. One month prior, plastic surgeons had performed surgical debridement considering the possibility of necrotizing fasciitis. Despite these therapies, she showed a partial response. A few days after admission for severe joint pain, celecoxib was prescribed at a dose of 400 mg/day. One day later, she consulted the department of dermatology for skin problems with intractable pain. Laboratory

CD30-Positive Anaplastic Lymphoma Kinase-Negative Systemic Anaplastic Large-Cell Lymphoma in a 9-Year-Old Boy

Anaplastic large-cell lymphoma (ALCL) is a CD30-positive T-cell/null-cell lymphoma that is clinically classified into either primary cutaneous ALCL or systemic ALCL (S-ALCL) sub-types. Because 90% of childhood S-ALCL cases are anaplastic lymphoma kinase (ALK)-positive, there is a lack of data on ALK-negative S-ALCL cases among pediatric patients. Herein, we report a rare case of ALK-negative S-ALCL in a 9-year-old Korean boy who initially presented with itchy erythematous maculopapules and an erosive nodule on the trunk area. We emphasize the need of high index of suspicion of an underlying malignant disease in the presence of refractory eczematous lesions.

A 1064 nm Long-Pulsed Nd:YAG Laser for Treatment of Diverse Vascular Disorders

Results Five men and nine women were finally enrolled (mean age 45.4 ± 16.4 years) in this study. Thirteen of 14 patients (92.9%) had good or excellent PGA results. Ten of 14 patients were very satisfied or satisfied with the clinical results (71.4%), and all patients reported that immediate treatment discomfort was tolerable. Side effects were minimal; four patients (28.6%) reported erythema, vesicles, or hyperpigmentation which recovered without scarring.

Rare case of cutaneous involvement of Lennert lymphoma as an initial manifestation

Dear Editor, Lennert lymphoma (LL), classified as a “lymphoepithelioid cell variant of the peripheral T-cell lymphomas, unspecified” in the World Health Organization classification, is a rarely reported subtype of lymphoma first described by Lennert and Mestdagh in 1968. A 65-year-old man presented with generalized erythematous papules on the entire trunk and both upper extremities. He had been diagnosed with interstitial granulomatous dermatitis (IGD) for the same cutaneous manifestation 1 year prior (Fig. 1a,b) and treated with systemic steroid and dapsone showing little clinical improvement. He complained of fever, weight loss and poor appetite of 1 month in duration. On physical examination, multiple lymph nodes were enlarged on palpation, which was confirmed using computed tomography. Skin punch biopsy and gun biopsy of an enlarged lymph node were performed. A biopsy taken 1 year previously revealed perivascular lymphoid infiltration with granulomatous areas in the dermis (Fig. 1c). The granulomatous areas were surrounded by lymphoid cells without prominent atypia intermingled with clusters of epithelioid histiocytes (Fig. 1d). Rebiopsy of the papule on the back was performed during the most recent presentation, which revealed several granulomatous cellular infiltrations around blood vessels and skin appendages in the dermis. The infiltrations consisted of atypical small lymphoid cells admixed with epithelioid histiocytes. Immunohistochemical staining of the skin showed positivity for CD3, CD8 and CD68, and negativity for CD4 (Fig. 1e–h). Biopsy of the inguinal lymph node showed diffuse effacement of lymph node architecture and infiltrate composed of epithelioid cells and atypical lymphocytes, similar to the skin (Fig. 1i,j). Lymph node immunohistochemical findings were similar to those of the skin. Additional study for T-cell receptor gene rearrangement revealed monoclonality in a skin specimen. We concluded that our patient had LL with cutaneous involvement. In spite of systemic chemotherapy, he died from complication after 3 months. Clinically, because LL is primarily a nodal disease, cutaneous involvement of LL, which is infrequent with an incidence of 4–11%, rarely precedes other clinical signs or symptoms. Additionally, its manifestations are variable and non-specific, including asymptomatic erythematous papules, nodules and small plaques on the trunk and extremities. When the granulomatous dermatitis with no evidence of cellular atypia precedes a diagnosis of lymphoma, the initial cutaneous signs possibly represent a generalized granulomatous response to a distant focus of lymphoma. There are also similar cases that have been reported as peripheral T-cell lymphoma with granulomatous reaction. Therefore, comparison of both skin and lymph node specimens and molecular analysis may be mandatory for accurate diagnosis of lymphoma as in our case. In addition, the diagnoses of IGD should be carefully confirmed after evaluating the possibility of other lymphoproliferative disorders. In our case, the initial presentation of LL was only skin lesion prior to the characteristic nodal findings and it could be an educational case showing clinical course serially from initial cutaneous manifestation of LL. From this point of view, we emphasize the need for a high index of suspicion of an underlying lymphoma in the presence of non-specific granulomatous dermatitis as initial presentation.