Hyo Sang Song

Photodynamic therapy with ablative carbon dioxide fractional laser for treating Bowen disease.

Background Topical photodynamic therapy (PDT) has been increasingly used to treat malignant skin tumors including the Bowen disease. However, patients could be displeased with the long incubation time required for conventional PDT. Objective We evaluated the efficacy and safety of PDT with a short incubation time of ablative CO2 fractional laser pretreatment for treating Bowen disease. Methods Ten patients were included. Just before applying the topical photosensitizer, all lesions were treated with ablative CO2 fractional laser, following the application of methyl aminolevulinate and irradiation with red light (Aktilite CL 128). Histological confirmation, rebiopsy, and clinical assessments were performed. Adverse events were also recorded. Results Five of the ten (50%) lesions showed a complete response (CR) within three PDT sessions. After four treatment sessions, all lesions except one penile shaft lesion (90%) achieved clinical and histological CR or clinical CR only. The average number of treatments to CR was 3.70±1.70. The treatments showed favorable cosmetic outcomes and no serious adverse events. Conclusion The results suggest that pretreatment with an ablative fractional CO2 laser before PDT has similar treatment efficacy and requires a shorter photosensitizer incubation time compared with the conventional PDT method.

Fractional carbon dioxide laser-assisted photodynamic therapy for patients with actinic keratosis.

A relatively long incubation time is needed for photosensitizer absorption in conventional photodynamic therapy (PDT) for actinic keratosis (AK). The use of ablative CO2 fractional lasers (AFXLs) to increase drug delivery could shorten the incubation time. Here, we aimed to compare the efficacy between AFXL‐assisted PDT with a short incubation time and conventional PDT for AK.

Imatinib mesylate-induced hyperpigmentation of the nose and palate.

Dear Editor: Imatinib mesylate, a tyrosine kinase inhibitor targeting c-kit and platelet-derived growth factor, has been used for the treatment of hematologic malignancies. Its cutaneous adverse effects are diverse, including maculopapular exanthema, vasculitis, and Stevens-Johnson syndrome1. A well-established pigmentary change is hypopigmentation, which is characterized by generalized skin lightening, vitiligo-like lesions, and hair graying2. However, paradoxical hyperpigmentary changes were rarely observed3,4. We present a case of hyperpigmentation of the nose and hard palate associated with imatinib mesylate. A 58-year-old man was referred for discoloration of the nose. He was diagnosed with chronic myelogenous leukemia and was treated with imatinib mesylate (Gleevec; Novartis, Basel, Switzerland). Not long after imatinib treatment, he noticed insidious pigmentary changes on his nose. He had no history of skin eruptions or use of other medication. Physical examination revealed an ill-defined, slate-gray patch on the nose and on the hard palate, which suggested a diagnosis of dermal pigmentary disorders including acquired bilateral nevus of Ota-like macules (Fig. 1). Biopsy of the lesional skin and perilesional normal skin of the nose was performed. Fontana-Masson staining showed increased basal pigmentation and dermal melanophages in the lesional skin compared with the perilesional normal skin (Fig. 2A). Imunohistochemical staining with the NKI/beteb antibody confirmed the absence of melanocytes in the dermis (Fig. 2B). Therefore, the pigmentation was speculated to be imatinib-associated hyperpigmentation. Although hypopigmentation is a well-known pigmentary change due to imatinib treatment, paradoxical hyperpigmentation has been rarely reported. In hyperpigmentation, the changes are not generalized like hypopigmentary changes. The disorder pigmentation is localized in the oral cavity, including the hard palate and gum, nose, ear lobe, or nails3,4. The present case was consistent with these features, and the patient showed localized pigmentation on the nose and hard palate. There has been no report about the prognosis of this pigmentary change. In case of hypopigmentation, it could be reversible when the doses are tapered or the treatment is stopped2. Our patient is continuing imatinib treatment, and there has been no change in the pigmentation. It has been suggested that imatinib-induced hypopigmentation is mediated by c-kit inhibition, resulting in reduced tyrosinase activity in melanocytes5. The mechanism of this paradoxical hyperpigmentation is unclear. However, an in vitro study has shown the stimulating effect of imatinib on the tyrosinase activity of cultured melanocytes, which suggests the target-dependent stimulating effects of imatinib mesylate on pigmentation. Further studies are required to elucidate these pigmentary changes related to imatinib mesylate medication. Herein, we report a case of paradoxical hyperpigmentation of the nose and hard palate after imatinib mesylate treatment, warranting further evaluation of this mechanism. Fig. 1 Ill-defined slate grey-colored pigmentation on nose (A) and palate (B). Fig. 2 (A) Increased epidermal pigmentation and dermal melanophages in the lesional skin (L) compared with perilesional normal skin (N) (Fontana-Masson stainining, ×200). (B) There were no melanocytes in the dermis (gp100, ×200).

Immunohistochemical Comparison of IL-36 and the IL-23/Th17 Axis of Generalized Pustular Psoriasis and Acute Generalized Exanthematous Pustulosis

Background Cutaneous pustular disorders include generalized pustular psoriasis (GPP) and acute generalized exanthematous pustulosis (AGEP). Objective To identify differences between GPP and AGEP, here we immunohistochemically evaluated interleukin (IL)-36 and the IL-23/Th17 axis. Methods This retrospective comparative immunohistochemical study was completed using 11 biopsies of 11 cases of GPP and 11 biopsies of 11 cases of AGEP. Through staining with the anti-IL-36-alpha (IL-36α), anti-IL-36 receptor antagonist (IL-36Ra), anti-nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), anti-IL-23, anti-IL-17, and anti-IL-8 antibodies, main expression location and intensity were visualized in the epidermis and dermis. Results In both diseases, diffuse IL-36α expression was observed in the epidermis. IL-36Ra expression was observed in the dermal perivascular area as well as in the epidermis. NF-κB expression was observed in the epidermis and perivascular dermal area. Diffuse IL-23 and IL-17 expression was seen in the whole epidermis and the perivascular dermal area. IL-8 was expressed in the subcorneal pustules and parakeratotic area. Contrary to other cytokines, IL-23 expression in the epidermis of patients with GPP was more intense than only that in patients with AGEP. Conclusion Common pathomechanisms might exist in the development of GPP and AGEP based on these immunohistochemical results, but further studies are needed.

In vivo time-sequential histological study focused on melanocytes: suggestion of golden time for intervention to prevent post-laser pigmentary changes

Post‐inflammatory pigmentary changes after laser treatments are challenging adverse effect.

Prevention of Thyroidectomy Scars in Asian Adults With Low-Level Light Therapy.

BACKGROUND Abnormal wound-healing after thyroidectomy with a resulting scar is a common dermatologic consultation. Despite many medical and surgical approaches, prevention of postoperative scars is challenging. OBJECTIVE This study validated the efficacy and safety of low-level light therapy (LLLT) using an 830/590 nm light-emitting diode (LED)-based device for prevention of thyroidectomy scars. METHODS AND MATERIALS Thirty-five patients with linear surgical suture lines after thyroidectomy were treated with 830/590 nm LED-LLLT. Daily application of 60 J/cm2 (11 minutes) for 1 week starting on postoperative day 1 was followed by treatment 3 times per week for 3 additional weeks. The control group (n = 15) remained untreated. Scar-prevention effects were evaluated 1 and 3 months after thyroidectomy with colorimetric evaluation using a tristimulus-color analyzer. The Vancouver Scar Scale (VSS) score, global assessment, and a subjective satisfaction score (range: 1–4) were also determined. RESULTS Lightness (L*) and chrome values (a*) decreased significantly at the 3-month follow-up visit in the treatment group compared with those of controls. The average VSS and GAS scores were lower in the treatment group, whereas the subjective score was not significantly different. CONCLUSION Light-emitting diode based LLLT treatment suppressed the formation of scars after thyroidectomy and could be safely used without noticeable adverse effects.

Gene Mutation Analysis in a Korean Patient with Early-Onset and Recalcitrant Generalized Pustular Psoriasis

Dear Editor: Generalized pustular psoriasis (GPP) is a multisystemic inflammatory disorder showing extensive pustular eruptions over the entire body1. Recently genetic studies with GPP patients have shown mutations in interleukin-36 receptor antagonist (IL-36RN)2,3,4. A 17-year-old girl visited the emergency department with generalized pustules. Three days before visit, she complained of a febrile sensation followed by extensive pustular eruptions on whole body. Physical examination revealed pustular patches covering >90% of body surface area that formed a more aggressive pattern comparing with the previous attack (Fig. 1). Fever (39.1℃), leukocytosis (white blood cell count, 27,000/µl), increased erythrocyte sedimentation rate (59 mm/h), and increased C-reactive protein level (14.52 mg/dl) were noted. She was diagnosed with GPP at 4 years of age and had undergone regular follow-up. Flare-ups, large and small, had occurred along with extensive pustules. Whenever the patient suffered from acute flare-ups, systemic corticosteroids, methotrexate, cyclosporin, and even infliximab was used to effectively control symptoms. Recently, however, her symptoms had worsened with systemic symptoms such as high-grade fever, malaise, and myalgia. Skin lesions were also more extensive pustules. On the contrary, the empirical treatments were ineffective. In particular, the efficacy of infliximab, which was initially high, had gradually decreased, requiring additional medication. We considered this patients condition recalcitrant and tried to determine a genetic problem. Genomic DNA extracted from her blood mononuclear cells was subjected to nucleotide sequencing and polymerase chain reaction using the primers as previously described4. The patient was heterozygous for a point mutation in intron 3 designated as c.115+6T>C, which led to the skipping of exon 3 at the transcript level and the production of a premature termination codon (Fig. 2A). This finding is partially compatible with that of a Japanese report in which a c.115+6T>C mutation was observed but differed in that no c.368C>G or c.28C>T mutation was noted in this case4. Furthermore, at the protein level, we observed overexpression of IL-36 on the keratinocytes below the pustular lesions using polyclonal anti-IL-36α/IL-1F6 antibody (diluted 1 : 200; RD therefore, we conducted gene mutation analysisto detect heterozygousity of point mutation in intron3. Compound heterozygosity or homozygous mutations have been reported in Europe and Japan4. On the other hand, in our case, only 1 point mutation in intron 3 was noted, and no mutations at the other 3 sites that were reported in earlier cases were found. We regard our patient as the first Korean GPP case in which the mutation was confirmed at the genetic and protein levels. We propose that physicians must consider gene mutation analysis for patients with early-onset and recalcitrant GPP. Fig. 1 More extensive and aggressive pustular patches (A) covering >90% of the body surface area compared to those observed in the previous attack (B). Fig. 2 Mutation c.115+6T>C observed in a Korean patient (A). At the protein level, a higher expression of interleukin-36 (IL-36) is noted on keratinocytes below the pustules (B) compared to those of psoriasis vulgaris (C) (B, C: polyclonal anti-IL-36α/IL-1F6 ...

Comparison between Malassezia Folliculitis and Non-Malassezia Folliculitis

Background Among the various types of folliculitis, differentiation of Malassezia folliculitis (MF) from other forms of folliculitis is important because it is usually treated with antifungal agents. Objective We attempted to find a method to enhance the detection rate of MF, and examined the differences in the clinical manifestation between MF and non-MF (NMF). Methods We performed a retrospective study involving patients with folliculitis who were previously diagnosed with MF or NMF on the basis of serial tissue sectioning and diastase-Periodic acid-Schiff (d-PAS) staining findings. The clinical features of MF and NMF were compared. Results Among a total of 100 folliculitis patients, 20 were diagnosed with MF and 80 with NMF. Tissues from the 80 patients with NMF were sectioned serially into 10 slices and stained with hematoxylin and eosin stain; among these, 10 had many round-to-oval yeast organisms in the hair follicles that confirmed MF. Finally, d-PAS staining was used to detect the presence of yeast in the NMF slides. Notably, among the 70 d-PAS-stained samples, yeast organisms were found in 6 samples, confirming MF. As a result, the diagnosis of 16 patients changed from NMF to MF. Compared with NMF, MF showed major involvement of the trunk and low involvement of the face and legs as well as male predilection. Conclusion Physicians should consider serial sectioning and/or d-PAS staining of folliculitis lesions, particularly of those on the trunk of male patients, even if no yeast organisms are detected initially.

Nipple eczema, an indicative manifestation of atopic dermatitis? A clinical, histological, and immunohistochemical study.

Abstract:Nipple eczema exhibits as a minor manifestation of atopic dermatitis (AD) or occurs as a single skin symptom on the nipple. To characterize the relationship between nipple eczema and AD, a clinical evaluation and an immunohistochemical study were performed. All cases of nipple eczema were confirmed histopathologically. We divided the patients with nipple eczema into 2 groups, namely, those with AD and those without AD, and compared several clinical features. Upon histological examination, the degree of inflammation was subjectively graded as mild, moderate, or severe by 2 separate investigators. Immunohistochemical stainings were performed by using antiinterleukin (IL)-4, anti-IL-13, anti-CD4, and anti-CD8 antibodies, and the results were scored semiquantitatively. In 43 cases evaluated, 12 were nipple eczema with AD. The clinical analysis and histological examination showed no significant differences between the groups. There were consistent findings of IL-4 expressions throughout the epidermis and IL-13 expression mainly in the perivascular area of the dermis. Although CD4 and CD8 were expressed in the cells in the dermis, CD8 expression was detected in the serocrusts of the epidermis. Expression levels of IL-4, IL-13, CD4, and CD8 exhibited no significant differences between the nipple eczema group with AD and the nipple eczema group without AD. Although nipple eczema may accompany AD, we found no definite differences in the degree or pattern of inflammation and cytokine expression level regardless of whether AD was present or not. Serocrust formation seemed to be mainly a collection of CD8-positive cells.

Topical photodynamic therapy may not be effective for actinic cheilitis despite repeated treatments

ejd.2013.2199 Auteur(s) : Sue Kyung Kim, Hyo Sang Song, You Chan Kim maychan@ajou.ac.kr Department of Dermatology, Ajou University School of Medicine, 5 Wonchon-Dong, Yeongtong-Gu Suwon 443- Suwon Republic of Korea As actinic cheilitis (AC) is considered a premalignant condition, proper treatment is important. Several studies have reported that many AC lesions remain after 1–2 sessions of photodynamic therapy (PDT). Therefore, we performed repeated treatments with PDT to increase the efficacy [...]