Howard Chu

Clinical Diversity of Atopic Dermatitis: A Review of 5,000 Patients at a Single Institute

Purpose Atopic dermatitis (AD) is a chronic eczematous dermatitis that has a high prevalence and diverse clinical features. Although several hypotheses about its multifactorial pathogenesis have been suggested, the cause is not yet fully understood. A better understanding of the clinical features may helpful inelucidating the pathogenesis of AD. Methods This retrospective study analyzed the questionnaires, medical charts, and laboratory examination results of 5,000 patients diagnosed with AD at a single tertiary hospital in Korea. Results The demographics, allergic comorbidities, family history, severity, and treatment experiences of the patients were analyzed. Most of the patients were adults, 76.3% of whom were classified as havingan extrinsic type of AD. The mean eczema area and severity index (EASI) score was found to be 13.68, and adult patients were found to have higher severity than the other age groups. The anatomical involvements were different among the age groups, with more involvements of the head and neck in adults. The patients reported seasonal changes and stress as the factors that aggravated their symptoms the most. Topical steroids and oral cyclosporine were the most used medications at our clinic, whereas 10.1% of the patients underwent allergen-specific immunotherapy. Conclusions This analysis of 5,000 patients would lead to a better understanding of various subtypes and diverse clinical features of AD in Koreans. Distinct characteristics were observed among different age groups; thus, treatment strategies may need to be differentiated accordingly.

A Retrospective Study of Methylprednisolone Mini-Pulse Therapy Combined with Narrow-Band UVB in Non-Segmental Vitiligo

Background: Systemic corticosteroids have been used to arrest the progression of vitiligo. However, side effects have been a constant issue. Objective: We evaluated the clinical efficacy and side effect of oral methylprednisolone (MPD) mini-pulse therapy combined with narrow-band UVB (NBUVB) for adults with non-segmental vitiligo retrospectively. Methods: 32 patients with extensive and/or spreading vitiligo received 0.5 mg/kg MPD on 2 consecutive days per week with NBUVB therapy for at least 3 months. Results: All of the 32 patients (100%) showed progression arrest within 12 weeks. Nineteen out of 32 patients (59.4%) presented repigmentation on more than 25% of lesions. Thirteen patients (40.6%) achieved satisfactory repigmentation in more than 50% of lesions. Only 2 patients discontinued the medication due to gastrointestinal trouble. Conclusion: Oral MPD mini-pulse therapy combined with NBUVB appears effective in arresting vitiligo progression and rapidly inducing repigmentation with minimal side effects.

The use of biodegradable microneedle patches to increase penetration of topical steroid for prurigo nodularis

BackgroundThe stratum corneum is an almost impermeable barrier. Recently, microneedles have been used to increase drug delivery passing the stratum corneum by incorporating the drug within the microneedle or by coating the surface of the microneedle with the drug.ObjectiveThis study was performed to investigate whether applying a biodegradable microneedle patch after topical steroid application increases penetration of the steroid in vitro, as well as treatment efficacy in patients with prurigo nodularis.Materials & methodsIn vitro penetration of topical steroids after biodegradable microneedle patch application was measured using a 3D skin model. To evaluate the treatment efficacy of the combination of biodegradable microneedle and topical steroids, a split-body clinical study was performed.ResultsPenetration of topical steroid in the in vitro skin model was significantly greater in the microneedle-applied skin. In a split-body clinical study with prurigo nodularis patients, the area and height of skin lesions decreased after four weeks of treatment on both sides, however, the microneedle patch side exhibited a significantly greater decrease in both area and height, compared to the control side. The pruritus visual analogue scale was also significantly lower on the microneedle side.ConclusionWe suggest that simply applying a microneedle patch after topical steroid application could be a useful strategy for treating refractory skin diseases such as prurigo nodularis.

Allergen‐specific immunotherapy induces regulatory T cells in an atopic dermatitis mouse model

Several studies have demonstrated that allergen‐specific immunotherapy (SIT) can be an effective treatment for atopic dermatitis (AD). However, there is no relevant mouse model to investigate the mechanism and validate the novel modality of SIT in AD.

Mucocutaneous Telangiectasia as a Diagnostic Clue of Hereditary Hemorrhagic Telangiectasia: An Activin Receptor-Like Kinase-1 Mutation in a Korean Patient

Dear Editor: Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome, is an autosomal dominant vascular disorder manifested by variable-sized arteriovenous malformations (AVMs) of the skin, central nervous system, and respiratory, gastrointestinal, and urogenital tracts1,2. A 43-year-old woman visited our dermatology clinic with a 3-year history of increasing numbers of purpuric, punctate, and tiny macules of the lip, oral cavity, and fingers (Fig. 1A~C). The patient had no history of recurrent epistaxis; however, her mother had recurrent epistaxis and brain AVMs. No other abnormalities were detected in laboratory workups, particularly to detect visceral AVMs, including computed tomography scans of the chest and abdomen, brain magnetic resonance imaging, and gastrointestinal endoscopy. Under clinical suspicion, we performed a mutation analysis for HHT in the patient and her mother. The mutation c.940C>T (p.His314Tyr) in activin receptor-like kinase-1 (ACVRL1) was confirmed in both the patient and her mother, confirming the diagnosis of HHT (Fig. 1D). Interestingly, this genetic alteration, previously reported in a Western pedigree3, is a novel point mutation in a Korean family. The cutaneous lesions were well improved by pulsed dye laser (Fig. 2). Fig. 1 (A~C) Typical cutaneous telangiectasias at characteristic sites: lip, oral cavity, and fingers. (D) Presence of the mutation c.940C>T (p.His314Tyr) in activin receptor-like kinase-1. Fig. 2 Skin lesions on the tongue showed excellent response after a single treatment using pulsed dye laser (Vbeam Perfecta; Candela Laser Corporation, Wayland, MA, USA): (A) before treatment and (B) after treatment. Clinically, HHT is diagnosed by the Curacao criteria, which include spontaneous and recurrent epistaxis, mucocutaneous telangiectasias, visceral AVMs, and family history of HHT in a first-degree relative1,3. HHT is definitively diagnosed when three of the criteria are satisfied, whereas a suspected diagnosis is given when two of the criteria are met. In molecular diagnosis, mutations are found in approximately 85% of HHT families; most of these cases involve mutations in the endoglin (HHT1) or ACVRL1 (HHT2) genes4. Mutations of the endoglin gene on chromosome 9, which cause HHT1, were not detected in this family. The prevalence of specific vascular abnormalities varies according to genotype; patients with HHT1 have a higher prevalence of pulmonary and cerebral AVMs, while hepatic AVMs occur more commonly in HHT2 patients4. In our case, although the patient and her mother did not fulfill the criteria for a definitive diagnosis, HHT was strongly suspected because of the patients typical mucocutaneous lesions. Therefore, targeted genetic testing for the endoglin and ACVRL1 genes should be performed to establish an early diagnosis if there are characteristic cutaneous features and/or a family history of HHT. The cutaneous stigmata, which are characterized by an accumulation of small-caliber and superficial vessels, can cause cosmetic concerns and a risk for bleeding1,2,5. In our case, treatment with pulsed dye laser resulted in dramatic improvement of the skin lesions, similar to results reported by Halachmi et al.2. Multiple treatments and follow-up visits can be necessary because of the lower response of HHT than non-HHT telangiectasia and the possible accumulation of new vascular lesions2. In conclusion, to initially rule out an HHT diagnosis, genetic study is an available option. Because of the superficial nature of vascular lesions, shorter wavelength vascular lasers such as the pulsed dye laser can be considered an effective and safe treatment option for HHT.

Xanthoma-like multiple yellowish nodular colloid degeneration on the face and scalp

Editor Colloid milium and colloid degeneration encompass a spectrum of rare dermatologic diseases that share a common histopathological finding of dermal colloid depositions. Nodular colloid degeneration or paracolloid is a rare subtype that presents as nodular, plaque-like lesions usually on chronically sun-exposed skin. We present a case of nodular colloid degeneration or paracolloid that occurred on the face and scalp. A 67-year-old male presented with multiple asymptomatic 0.3–2 cm-sized dark yellowish papules on his face and scalp (Fig. 1). The lesions started to occur several years ago and he was treated with various methods, including laser therapies, such as CO2 laser and fractional CO2 laser, topical steroid, systemic steroid and oral doxycycline. No improvements were observed with the medications and the laser therapies only temporarily removed the lesions and they recurred shortly afterwards. Skin biopsy was done, which revealed solar elastosis, mild superficial perivascular lymphocytic infiltration and accumulation of homogeneous amorphous materials in the papillary to mid dermis (Fig. 2). Congo red stain was negative and no birefringence was observed under polarized microscopy. Periodic acid-Schiff stain was also negative for the amorphous material, and no collagen damage was demonstrated in Verhoeff–Van Gieson stain. In addition, Ziehl–Neelsen stain and TB PCR was done, which were both negative. Laboratory tests including complete blood count, routine chemistry and ANA were done, which did not show any abnormalities. The clinical and histological findings were compatible with the diagnosis of nodular colloid degeneration, multiple type. The patient did not want any aggressive treatments; thus, only the use of sunscreen was recommended. The spectrum of colloid milium and colloid degeneration may include up to five distinct variants depending on the literature. The five variants are adult-onset type, juvenile form, nodular colloid degeneration or paracolloid, pigmented form and acral keratosis with eosinophilic dermal deposits, in which the adult-onset type is the most common. Nodular colloid degeneration or paracolloid is clinically manifested by asymptomatic solitary or multiple nodules or plaque-like lesions that occur on sun-exposed areas, although an exceptional case that occurred on the penis has been reported. Histologically, the epidermis is flattened with well-preserved hair follicles and sebaceous glands. An amorphous eosinophilic homogeneous material is observed in the dermis, in which a grenz zone may be formed. The deposits of amorphous colloid-like material have many irregular clefts and are predominantly acellular with only occasional pyknotic nuclear debris and scattered nuclei of fibroblasts. Since the first report by Labadie in 1927, only 9 reports of 11 cases have been made worldwide, although it may have been underdiagnosed due to the rarity and unfamiliarity. Table 1 summarizes the cases of the previous reports in the English literature. The current case is the 12th case of nodular colloid degeneration, which presented with multiple lesions on the face and scalp. The clinical features are unique and relatively dissimilar to the previously reported cases, in which the yellowish lesions clinically resemble plane xanthoma. The cause for the discrete yellowish composition is unclear, and further studies may be required to elucidate the pathogenesis. The clinical presentation of the current case is distinct and unusual, differentiating from other entities under the spectrum Figure 1 Multiple asymptomatic 0.3–2 cm-sized dark yellowish papules on (a) face and (b) scalp. Figure 2 (a) Accumulation of homogeneous amorphous eosinophilic materials is observed in the papillary to mid dermis (H&E, 940). (b) The amorphous colloid-like material has many irregular clefts and is predominantly acellular with some scattered nuclei (H&E, 9200).

Successful treatment of lichen amyloidosis accompanied by atopic dermatitis by fractional CO2 laser

ABSTRACT Lichen amyloidosis (LA) is a subtype of primary cutaneous amyloidosis that is presented as persistent, multiple-grouped hyperkeratotic papules usually located on the shins, back, forearms or thighs. The treatment of LA has been considered to be difficult, and of the various methods available, recent studies have reported the efficacy of fractional CO2 lasers. LA may be accompanied by atopic dermatitis (AD) in which the treatment options may be more limited. Herein, we report three cases of LA accompanied by AD treated by a fractional CO2 laser.

Delayed Treatment of Generalized Morphea due to Misdiagnosis as Vitiligo at an Oriental Medical Clinic

Vol. 29, No. 5, 2017 649 Received April 7, 2016, Revised June 29, 2016, Accepted for publication September 23, 2016 Corresponding author: Do Young Kim, Department of Dermatology, Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea. Tel: 82-2-2228-2080, Fax: 82-2-393-9157, E-mail: dykim@yuhs.ac This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons. org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright

Pachydermodactyly: A Benign Cutaneous Condition that May Be Misdiagnosed as a Joint Disorder

Pachydermodactyly is a rare, benign form of digital fibromatosis characterized by asymptomatic soft tissue swelling of the lateral aspects of the proximal interphalangeal (PIP) joints of the fingers. A 17-year-old male presented with a 4-year history of symmetrical thickening of PIP joints of all fingers, most prominent on second to fourth fingers (Figure 1). He had …

Treatment of Chronic Facial Erythema of Dermatomyositis with Intense Pulsed Light Therapy

Dermatomyositis is an idiopathic inflammatory myopathy that may include persistent facial erythema, which is refractory to topical and systemic treatments. In previous reports a pulsed dye laser was effective in the treatment of these skin lesions. We report the first case of the use of intense pulsed light therapy for treatment of cutaneous lesions in dermatomyositis, which showed satisfactory results without aggravation of the disease activity or other complications.