Eun Byul Cho

Comparison of the Effectiveness of Nonablative Fractional Laser versus Pulsed-Dye Laser in Thyroidectomy Scar Prevention

Background The anterior neck is the site of open thyroidectomy and where postoperative scarring can cause distress to patients. Both fractional and pulsed-dye lasers are effective and safe methods for preventing and improving surgical scars. Objective This study evaluated the improvement in scar appearance with laser intervention during the wound healing process. We evaluated the effect of nonablative fractional and pulsed-dye lasers on fresh thyroidectomy scars. Methods Patients were treated 3 times at 4-week interval with a follow-up visit at the 6th month. Scars were divided into 2 halves for each optional treatment. At every visit, a questionnaire evaluating the scar and patient satisfaction was completed. Results Thirty patients completed the 6-month process. The mean Vancouver Scar Scale scores improved significantly from 8.0 to 4.6 and 8.2 to 4.7 with nonablative fractional and pulsed-dye lasers, respectively (p<0.001). However, there was no significant difference between the 2 methods (p=0.840). Conclusion There remains no consensus on the optimal treatment of scars. The present study indicates nonablative fractional and pulsed-dye lasers significantly improve scars. Nonablative fractional lasers are non-inferior to pulsed-dye lasers. Further studies are required to corroborate this finding.

Hydroxychloroquine-induced hyperpigmentation.

Dear Editor, Antimalarial agents, including chloroquine and hydroxychloroquine, have been used for the treatment of various rheumatoid diseases and skin disease through their anti-inflammatory and immunemodulating properties. Cutaneous adverse effects such as exacerbation of psoriasis, pruritus and hyperpigmentation have been reported with antimalarial drugs. It is reported that 10–25% of patients treated with antimalarial drugs experience cutaneous hyperpigmentation. However, most reports have described chloroquine-induced hyperpigmentation, and hyperpigmentation due to hydroxychloroquine has been rarely reported. We herein report a case of hydroxychloroquine-induced hyperpigmentation. A 58-year-old woman had a 1-year history of asymptomatic bluish-gray hyperpigmentation on her neck, upper trunk and upper extremities. She was diagnosed with rheumatoid arthritis 4 years prior and treated with hydroxychloroquine 200 mg ⁄ day for 4 years. Physical examination showed bluish-gray macules and patches on her neck, upper trunk and upper extremities (Fig. 1), and the hyperpigmentation became more severe as time passed. The routine laboratory data, including the peripheral blood cells, liver function tests, renal function tests, erythrocyte sedimentation rate and C-reactive protein, were all within normal limits. Histologically, a skin biopsy from the upper back showed hyperkeratosis, focal parakeratosis, spongiosis, epidermal melanin pigment and superficial dermal, yellow to brown colored granular pigment depositions. Also, the pigment was present within macrophages and extracellular regions (Fig. 2). Because clinical and pathological correlation strongly favored the diagnosis of hydroxychloroquine-induced hyperpigmentation, p.o. administration was discontinued. The rheumatoid arthritis treatment was continued with non-steroidal anti-inflammatory drugs (NSAIDs) and bucillamine, and the hyperpigmentation symptom was observed for 2 months. Antimalarial agents can cause various side-effects, but these can be improved by decreasing the dose or by discontinuing the treatment. Cutaneous side-effects of antimalarial therapy include xerosis, pruritus, exacerbation of pre-existing psoriasis, urticarial and lichenoid skin rashes, Stevens–Johnson syndrome, hair discoloration and mucocutaneous hyperpigmentation. Also, there have been rarely reported cutaneous side-effects such as alopecia, erythema annulare centrifugum, bullous pemphigoid eruption and generalized exanthematous pustulosis. It has been reported that patients treated with antimalarials experience bluish-grey hyperpigmentation with no relationship to the patient’s ethnic background, age, sex or type of antimalarial used. The accurate pathogenesis of drug-induced hyperpigmentation is not fully understood; however, four basic mechanisms have been described. First, the accumulation of melanin usually results from either hyperproduction by epidermal melanocytes or in response to a non-specific cutaneous inflammation. Second, hyperpigmentation results from the accumulation of the triggering drug itself. Third, some drugs synthesize special pigments, such as lipofuscin, probably under the direct influence of the drug. Fourth, iron deposits in the dermis, usually resulting from drug-induced damage of dermal vessels with leakage of red blood cells. It has been suggested that antimalarials have an affinity for melanin and can accumulate within the skin. The considered hyperpigmentation is also caused by systemic diseases (e.g. Addison’s disease, hyperthyroidism), dermatological diseases (e.g. mycosis fungoides, pigmented Bowen’s disease), and drugs including NSAIDs, amiodarone, antineoplastic agents and tetracycline. NSAIDs usually result in the fixed drug eruption lesions. Amiodarone-induced hyperpigmentation shows bluish-gray or purple discoloration of sun-exposed areas. However, histological findings shows deposits of amiodarone and lipofuscin in dermal histiocytes. Cytotoxic drugs have the potential to induce a hyperpigmentation. In many cases, cytotoxic drug-induced pigmentation appears on areas of chronic or acute trauma. Minocycline-induced hyperpigmentation may have appearance of localized or diffuse hyperpigmented macules on the anterior sides of lower legs or other sun-exposed areas. Histology on hyperpigmented lesions shows accumulation of melanin, hemosiderin, lipofuscin and minocycline itself. Several reports have mentioned hyperpigmentation as a sideeffect of chloroquine and, less often, hydroxychloroquine. There was a trend toward higher prevalence of hyperpigmentation in those with chloroquine. However, that was not statistically significant. (a) (b)

The Association between Psoriasis Area and Severity Index and Cardiovascular Risk Factor in Korean Psoriasis Patients

Background Psoriasis is associated with increased risk of cardiovascular morbidities, especially in severe cases. Severity of the disease has been known to be associated with higher prevalence of these risk factors. However, in the absence of robust measurements, studies to date relied mostly on treatment spectrum as a proxy for the severity. Objective To evaluate the relationship between psoriasis area and severity index (PASI) and cardiovascular risk factors in Korean patients. Methods Presence of diabetes mellitus (DM), hypertension, smoking history was surveyed through questionnaires and serum lipid profile analysis were done after fasting overnight. The severity of psoriasis was assessed using PASI scores: mild, <10; moderate to severe, ≥10. Cardiovascular risk factors such as smoking, hypertension, diabetes and dyslipidemia were compared between the mild group and moderate to severe group. The prevalence of diabetes and hypertension was compared among these two groups of psoriasis patients and the general population based control; age and gender were matched among three groups accordingly prior to analysis. Results A total of 256 patients with plaque type psoriasis were included. Between mild group and moderate to severe group, significant differences of cardiovascular risk factors including lipid profile were not discovered except in triglyceride level. Comparing to general population, prevalence of diabetes was found significantly higher in psoriasis patients while that of hypertension was similar. Conclusion Our results suggest that among cardiovascular risks, presence of DM and triglyceride level seem to be associated with the presence of psoriasis in Korean psoriasis patients, while other factors may not contribute meaningfully.

Heredity of acne in Korean patients

Acne is a chronic inflammatory disease of the pilocebaceous unit that presents with various spectrum and severity. Genetic backgrounds and environmental factors are also considered to be relevant, but few studies have focused on Korean patients. A cross‐sectional epidemiologic study on family history of Korean acne patients was performed to analyze family history of acne, and to compare the severity and characteristics of acne in association with family history. A total of 221 patients were enrolled, 98 male (44.3%) and 123 female (55.7%). Patients were grouped as patients with (A+) or without (A‐) family history of acne. In a second analysis, patients with any experience of acne treatment were evaluated. Severity of acne was measured with Burtons grading system and Korean Acne Grading System (KAGS). Female patients had a higher tendency to have family history than males (P = 0.002). Group A+ had statistically significant earlier onset of acne (P = 0.002). In inexperienced patients, patients with family history showed a relatively earlier onset (P = 0.084). This study confirmed the role of heredity in acne. Family history of acne is associated with earlier onset of the disease, and more non‐inflammatory lesions.

Three Cases of Lichen Nitidus Associated with Various Cutaneous Diseases

Lichen nitidus (LN) is an uncommon, usually asymptomatic cutaneous eruption characterized by the presence of multiple, small, flesh-colored papules. The epidemiologic and pathophysiologic characteristics of LN have not yet been defined. Furthermore, LN has rarely been described in association with other cutaneous diseases. We herein report 3 cases of LN associated with various cutaneous diseases, including lichen striatus, oral lichen planus, and psoriasis vulgaris.

Comparison of efficacy between long-pulsed Nd:YAG laser and pulsed dye laser to treat rosacea-associated nasal telangiectasia

ABSTRACT Background: Rosacea is characterized by erythema on face, especially erythema and linear telangiectasia on the nose. Currently, various vascular lasers are used for treatment, and among them, are long-pulsed Nd:YAG(LPNY) and pulsed dye laser (PDL). Objectives: This study compared the efficacy of LPNY and PDL in treating rosacea-associated nasal telangiectasia. Methods: Patients with rosacea who showed erythema and telangiectasia on the nose were included. Each patient was treated with PDL on the left side of the nasal bridge, and LPNY on the right side, three times with 4-week intervals. At the end of the treatment, two independent dermatologists evaluated overall treatment response compared with baseline. Results: The physician’s assessment of treatment concluded that good improvement was seen in six PDL and seven LPNY patients, and excellent improvement five PDL and four LPNY patients. There was no significant difference (p = 0.62, 95%CI) between the groups. Overall improvement was similar; however, LPNY induced a greater response in thick, dilated vessels, while erythema with mild telangiectasia was more responsive to PDL. Conclusion: Both LPNY and PDL are effective in treating rosacea-associated nasal telangiectasia. If LPNY is used properly to avoid side effects with careful consideration, it can also be used as a good modality.

A Study on Vitamin D and Cathelicidin Status in Patients with Rosacea: Serum Level and Tissue Expression

Background Rosacea is a chronic inflammatory disease characterized by centrofacial erythema. Excess cathelicidin is suggested to be important to the pathophysiology of the disease. Recently, presence of a vitamin D response element was revealed in the cathelicidin gene promoter. Objective The aim of this study was to determine whether vitamin D and cathelicidin are associated with rosacea, both serologically and histopathologically. Methods Subjects with rosacea and without chronic skin disorders were enrolled in the patient and control groups, respectively. Serum 25-hydroxy-vitamin D and cathelicidin levels were measured. Tissue expression of cathelicidin and vitamin D receptor were measured with immunostaining-intensity-distribution index. Results The mean serum 25-hydroxyvitamin D level of patients with rosacea was 12.18±5.65 ng/ml, which is lower than that of the controls (17.41±6.75 ng/ml). Mean serum cathelicidin levels in patients with rosacea and the controls were 85.0±26.1 ng/ml and 55.0±23.3 ng/ml, respectively. Cathelicidin expression in rosacea tissue was significantly higher than that in control tissue (5.21 vs. 4.03). No significant difference was observed in vitamin D receptor expression. Conclusion Higher cathelicidin expression in rosacea supports the hypothesis that an abnormal inflammatory response of the innate immune system is important in pathogenesis of rosacea, but the role of high cathelicidin serum levels is complicated. Serum vitamin D was lower in patients with rosacea, although serum cathelicidin was higher than that of the controls. This suggests that the role of vitamin D level in the pathogenesis of rosacea merits further investigation.

Imatinib Mesylate-Induced Erythema Multiforme: Recurrence after Rechallenge with 200 mg/day Imatinib.

Dear Editor: n nImatinib mesylate (Gleevec; Novartis AG, Basel, Switzerland), a selective tyrosine receptor kinase inhibitor, is increasingly used for treating chronic myeloid leukemia, Philadelphia chromosome-positive acute lymphoblastic leukemia, and high-grade gastrointestinal stromal tumors (GISTs)1. Several cases of cutaneous reactions after imatinib use have been reported1. We report a case of EM after imatinib administration for the treatment of a GIST. n nA 66-year-old woman was referred for pruritus from the department of oncology. She received a diagnosis of a GIST, for which she received adjuvant imatinib therapy after gastric wedge resection. She noticed a pruritic rash on her trunk after 5 weeks of 400 mg/day imatinib therapy. Physical examination revealed generalized variable-sized erythematous wheal-like patches with some targetoid lesions on the trunk, face, and extremities (Fig. 1). Immunoglobulin (Ig) G and IgM antibodies to the herpes simplex virus were not detected. A skin biopsy from the trunk revealed vacuolar degeneration, tagging of lymphocytes along the dermal-epidermal junction, and perivascular lymphocytic and some eosinophilic infiltrations in the upper dermis (Fig. 2A). Some dyskeratotic and necrotic keratinocytes were obvious in the epidermis (Fig. 2B); therefore, EM was diagnosed. As imatinib was the only medication administered to the patient, it was considered the most probable cause. Imatinib was discontinued, and oral steroid and antihistamine were prescribed. For 2 weeks, 30 mg/day steroid, tapered to 5 mg/day, was administered. One month after the discontinuation of imatinib therapy, the rash was fully cured. Imatinib treatment was restarted at a lower dose of 100 mg/day without steroids; no skin lesion developed for 2 months. However, when the dose was increased to 200 mg/day without oral steroids, a similar rash developed. The patient could continue imatinib therapy with a gradual dose escalation from 100 to 200 mg/day with concomitant 5 mg/day oral steroids. No additional skin lesions were detected during 5 months of follow-up. n n n nFig. 1 n nClinical manifestations of the patient. (A) Generalized erythematous variable-sized wheal-like patches on the trunk. (B) Several lesions showing the typical targetoid appearance. n n n n n nFig. 2 n nHistopathological findings of the lesion. (A) Vacuolar degeneration, tagging of lymphocytes along the dermal-epidermal junction, and perivascular lymphocytic and a few eosinophilic infiltrations in the upper dermis (H&E, ×200). (B) Spongiosis ... n n n nIt is estimated that approximately 7%~21% of patients treated with imatinib experience variable degrees of skin eruptions2. There are a few reports of imatinib-induced EM. Park et al.3 reviewed patients with cutaneous eruptions after imatinib therapy, and 2 of 10 patients (20%) had EM-like drug eruptions. The cutaneous adverse effects of imatinib are dose dependent and seemingly related to a pharmacological effect of the drug1,2. The most common skin reactions are maculopapular rashes1,2, and these are spontaneously relieved with a minimal dose of antihistamine or topical steroids. Several uncommon or severe reactions such as Stevens-Johnson syndrome have also been reported; however, they seem to be an idiosyncratic adverse reaction of hypersensitivity4. These reactions require the concomitant use of oral steroids, and immediate discontinuation of imatinib therapy is imperative4,5. n nHere, we observed a case of imatinib-induced EM. We noted a dose-dependent relation; thus, we consider that imatinib-induced EM is related to a pharmacological effect of imatinib. The skin lesion subsided and did not recur only with the concomitant use of low-dose oral steroids. As imatinib is a very effective therapeutic agent and alternative treatment options are limited, recognition of adverse cutaneous reactions after imatinib therapy and the appropriate management required is helpful.

The expression and role of krüppel-like factor 4 in psoriasis.

Background Krüppel-like factor 4 (KLF4) is a transcription factor that regulates a diverse array of cellular processes, including development, differentiation, proliferation, and apoptosis. Although its function in keratinocytes has been widely studied, its exact role in psoriasis has not been elucidated. Objective We designed this study to investigate epidermal expression levels of KLF4 and the change in KLF4 expression after treatment in patients with psoriasis. Methods We compared the expression levels of KLF4 in the basal, suprabasal, and superficial epidermal layers, in psoriatic lesional, non-lesional, and normal skin, using an immunoreactivity intensity distribution index (IRIDI). In addition, we measured the change in KLF4 expression on the basis of the IRIDI and by reverse transcription polymerase chain reaction (RT-PCR) analysis after treatment. Results The combined IRIDI scores in psoriatic lesional skin were significantly higher than the scores in both non-lesional and normal skin. The psoriatic epidermis, particularly the suprabasal layer, showed a significantly increased IRIDI score compared to that of non-lesional and normal skin, which was significantly decreased after treatment. RT-PCR analysis exhibited a slight increase in KLF4 mRNA expression level after treatment; however, this increase was not significant. Conclusion These data indicate that KLF4 could regulate epidermal proliferation and differentiation. Moreover, we believe that KLF4 may play an important role in the physiological reaction to counteract abnormal differentiation and proliferation of keratinocytes.

Two Cases of Thrombosis of the Palmar Digital Vein

Palmar digital vein thrombosis causing one or more nodules seems to be a relatively rare condition, judging by the dearth of reports in the literature. It should always be considered in a patient who presents with a painful, firm, blue nodule located at or in close proximity to one of the flexion crease of the finger. Common lesions presenting as one or more solid digital nodules are ganglions, epidermal inclusion cysts, giant cell tumors, and lipomas. Thrombosis of the palmar digital veins should, however, be part of the differential diagnosis of palmar digital nodules because it is possible to manage it conservatively. We report two cases of thrombosis of palmar digital vein in a 33-year-old woman and a 78-year-old man.