Hee Jin Jun

A split-face, evaluator-blind randomized study on the early effects of Q-switched Nd:YAG laser versus Er:YAG micropeel in light solar lentigines in Asians

Abstract Background: Asians are prone to develop epidermal pigmentary lesions as a result of photoaging. Solar lentigines, especially those which are light in color, show somewhat limited response to pigment lasers and intense pulsed light sources. Objectives: We sought to compare the early effects as well as side effects of Q-switched Nd:YAG and Er:YAG micropeel in treating light solar lentigines in Asians. Patient and methods: This was a split-face, evaluator-blind, randomized controlled study. A single session of treatment was performed on Asian patients with light facial lentigines. Q-switched Nd:YAG laser was allocated to one half of the face, and Er:YAG micropeel to the other half. The response to therapy was evaluated by two independent dermatologists with standardized photographs taken 2 weeks and 1 month after the laser treatment. Patients’ satisfaction and preference in treatment were also assessed. Results: Fifteen patients completed the study and were analyzed. A reduction in pigment was observed with both lasers during the study period. The degree of pigment reduction in the Q-switched Nd:YAG treated side of the face was significantly higher than that of the Er:YAG micropeel treated side at 2-week follow-up (p < 0.001). The degree of pigment reduction between the Q-switched Nd:YAG-treated side and the Er:YAG micropeel-treated side was similar at 1-month follow-up (p = 0.110). Conclusion: While there is no perfect therapy for light solar lentigines, a single session of Q-switched Nd:YAG laser and Er:YAG micropeel was shown to reduce pigmentation. The immediate effects (2-week follow-up) were better with the Q-switched Nd:YAG laser but there was no great difference between the two laser types at 1-month follow-up due to the greater degree of post-inflammatory hyperpigmentation following Q-switched Nd:YAG. Both laser types could be applied either singly in turns, or in combination for maximal efficacy in future.

Preceding Annular Skin Lesions in a Patient with Hemophagocytic Lymphohistiocytosis

The cutaneous manifestations of hemophagocytic lymphohistiocytosis (HLH) are variable and nonspecific. A 42-year-old man presented with multiple annular, erythematous patches on the trunk for 3 months. Two months later, he presented with bullae along with high fever. The laboratory examination showed pancytopenia, hypertriglyceridemia, and hypofibrinogenemia. The bone marrow biopsy specimen showed an active hemophagocytosis. On the basis of these findings, a diagnosis of HLH was concluded. After five cycles of chemotherapy, his skin lesion completely resolved. Taking the results together, we suggest that annular skin lesion can be added to the list of cutaneous manifestations of HLH.

Injection-site reaction following 5-azacitidine injection.

Dear Editor: Azacitidine (Vidaza) is a pyrimidine nucleoside analogue of cytidine, which is injected subcutaneously to treat patients with myelodysplastic syndrome (MDS). Among azacitidine recipients, injection-site reactions are one of the most common non-hematological adverse events1. A 76-year-old man with MDS was treated with subcutaneous 5-azacitidine, which was injected into the left lower abdomen. The patient complained of severe pain, and an ecchymotic patch with bulla was visible at the injection-site (Fig. 1) at day 7, even though this therapy had been well tolerated during the initial 6 days of treatment. Histological examination revealed intraepidermal vesicles and massive hemorrhage in the upper dermis, with dense perivascular lymphohistiocytic infiltration in the dermis and subcutis. Two weeks later, the lesion had converted into a necrotic crust, which subsequently healed 1 month later, leaving an atrophic scar. Subsequently, the patient had been treated with 5-azacitidine for 3 months without any adverse events, although 5-azacitidine treatment for MDS was stopped due to a lack of clinical response. Clinicians should consider whether an injection site ecchymotic erythematous patch, with bulla is an injection-site reaction and/or Nicolau syndrome (NS). Fig. 1 An ecchymotic erythematous patch with bulla is visible on the abdomen where the 5-azacitidine was injected. Azacitidine is a hypomethylating agent that is subcutaneously injected to treat patients with MDS. Administration-related skin events are typically erythema and injection-site reactions, such as skin nodules, rash, and pyoderma gangrenosum2. Azacitidine has a cytotoxic effect on all cells (including abnormal hematopoietic cells), and when injected subcutaneously, it can cause direct damage to the skin cells, such as keratinocytes and endothelial cells, subsequently leading to skin necrosis. NS is also characterized by intense pain and erythematous-ecchymotic lesions at the injection-site, and can lead to necrosis of the skin. Various drugs have been reported to be associated with NS, including diclofenac, antibiotics, vitamin K, glucocorticoids, lidocaine, anticonvulsants, and vaccines. However, NS has also been reported following subcutaneous injection of, glatiramer acetate and etanercept3. The pathogenesis of NS is not well understood, although there have been two hypotheses. Firstly, intraarterial or perinervous injections might stimulate the sympathetic nerve, causing an acute vasospasm of the vessel, leading to ischemia. Secondly, periarterial or intra-arterial injections might cause direct trauma to, or inflammation of, the vessel structures, followed by thrombosis and necrosis4. Therefore, histological findings indicative of NS are typically associated with thrombosis and/or necrosis of the eccrine sweat glands. In this case, we could not find any histopathological evidence of thrombosis, and thus the diagnosis of injection-site reaction of 5-azacitidine was made based on a combination of clinical and histopathological findings. Most injection-site erythema/reactions are resolved by simple continuing treatment, and less than 12% of cases require corticosteroids and/or antihistamine2. A correct injection technique, such as syringe aspiration, and injection-site rotation, can help prevent injection-site reaction.

Chondroid syringoma with marked calcification.

Chondroid syringoma is an uncommon benign neoplasm in the skin. It is composed of epithelial and myoepithelial cells embedded in a matrix with varying amounts of mucoid and cartilaginous material. Chondroid syringoma is classified into 2 types, the apocine type and the eccrine type. Several cases of the eccrine type chondroid syringoma with ossification and calcification have been reported, but the apocrine type chondroid syringoma with calcification has not been reported. In this report, we describe a case of apocrine type chondroid syringoma with calcification.

Foreign Body Reaction due to a Retained Cuff from a Central Venous Catheter.

Dear Editor: Foreign body reaction is a tissue response to extraneous materials such as injected materials or implanted medical devices1. Here, we report a unique foreign body reaction caused by a retained cuff from a central venous catheter. A 63-year-old male patient with a history of end-stage renal disease presented with an asymptomatic, firm mass on the right chest for several months. One year ago, because of swelling and tenderness on the continuous ambulatory peritoneal dialysis (CAPD) catheter site, his CAPD catheter was removed, and a hemodialysis (HD) catheter was inserted through the right internal jugular vein. The CAPD catheter was reinserted after 2 weeks, and the HD catheter was removed by manual traction after 2 months. The patient visited our clinic with a 2 cm, skin-colored, subcutaneous mass on the right chest (Fig. 1). On incisional biopsy, there was an odorous, pus-like drainage and pieces of foreign material (Fig. 1). Histological examination showed groups of fibers with adjacent granulation tissue (Fig. 2). He was referred to the Department of General Surgery, and the catheter remains were completely removed. He had no complications. Fig. 1 (A) A solitary, 2 cm-sized, firm, skin-colored subcutaneous mass on the right chest. (B) Great chunks of pieces of foreign material (catheter cuff) identified during biopsy. Fig. 2 (A) Histopathology showing foreign body from the catheter cuff with adjacent granulation tissue (H&E, ×100). (B) Higher magnification view showing a granulomatous reaction with lymphocytes, histiocytes, multinucleated giant cells, and ... Venous access catheters are used for treatments such as HD and chemotherapy. Many catheters have polyester cuffs at the end for anchorage to the subcutaneous tissue. The catheters can be removed by traction or with a cutdown procedure2,3. When catheters are removed by traction, parts of the cuffs can break off and be retained in the subcutaneous tissue in 10%~50% of cases2. The reported complications of retained cuffs include infection, abscess, discharge, and delayed healing2,3. Our patient had an odorous, pus-like drainage; however, we did not perform bacterial culture or Gram stain. Antibiotics were given, and the wound site healed without complications. Retained cuffs are clinically insignificant unless infection occurs2,3,4. In a study by Kohli et al.3, 428 cuffed central venous catheters were removed by traction, and catheter cuffs were retained in only 41 (10%) of the patients. Of these 41 retained catheter cuffs, only 3 required removal. One was removed because the cuff migrated to the exit site, inhibiting healing. The other two were removed because of persistent erythema and swelling at the cuff site and for cosmetic purposes3,4. Currently, catheter manufacturers recommend removing all retained cuffs with a cutdown procedure2,3,4. However, while retained cuffs rarely cause problems, the cutdown procedure has risks of infection and scarring3,4. Therefore, as the risks associated with the cutdown procedure are greater than those of non-removal of the retained cuffs, Kohli et al.3 recommend leaving behind the retained cuffs3,4. In our case, owing to the patients request, the retained cuff resulting from traction removal was completely removed by using a cutdown procedure, and there were no complications. In the Korean literature, there have been many cases of foreign body reactions due to materials such as fillers, and bee sting; however, there has been no reported case due to catheters5. We report this as a rare case of a foreign body reaction caused by a retained cuff from a central venous catheter.

Subcorneal Milia-Like Idiopathic Calcinosis Cutis: A Rare Presentation

von Kossa stain. Calcium deposits were also noted in the stratum corneum and the stratum spinosum, but there were no calcium deposits within the dermis. The calcification was not in continuum with the acrosyringium. Calcified sweat ducts were not observed. In the 4 months since the punch biopsy, no signs of recurrence or new lesions have appeared. Calcinosis cutis comprises several subtypes, including milia-like idiopathic calcinosis cutis. Milia-like idiopathic calcinosis cutis appear as smooth, round papules resembling milia, sometimes surrounded by erythema. Twothirds of patients with milia-like idiopathic calcinosis cutis have shown an association with Down syndrome 2 . Only 8