Ji-Chen Ho

Positive Effect of Modified Goeckerman Regimen on Quality of Life and Psychosocial Distress in Moderate and Severe Psoriasis

Psoriasis is a chronic inflammatory skin disease with a profound effect on quality of life and psychosocial stress. The relationship between clinical improvement and psycho-social impact after treatment is complex. The objective of this study was to compare changes in quality of life and psychosocial distress, and overall cost-effectiveness, in patients with psoriasis receiving the modified Goeckerman regimen (UV irradiation and coal tar) with those receiving conventional treatment. Patients with moderate/severe psoriasis receiving the Goeckerman regimen were followed from admission to discharge. Clinical severity, was evaluated weekly using the Psoriasis Area and Severity Index (PASI). Psoriasis Disability Index (PDI) and Hospital Anxiety and Depression Scale (HADS) questionnaires were applied at admission and one month after discharge. Thirty-six patients with psoriasis receiving conventional treatment and 48 patients receiving the Goeckerman regimen were recruited to the study. The mean PASI score in the Goeckerman group decreased from 27.1 to 6.9 and PDI scores decreased from 25.3 to 13.8. HADS scores for anxiety and depression decreased significantly from 9.8 to 6.3 and 9.1 to 6.8, respectively. In comparison with conventional therapy, the modified Goeckerman regime showed similar clinical efficacy, with additional benefits in improving overall quality of life and psychosocial distress in patients with moderate/severe psoriasis, and more cost-effectiveness.

Bull's eye dermatoscopy pattern at bacillus Calmette-Guérin inoculation site correlates with systemic involvements in patients with Kawasaki disease.

For the past decades, although the rash at the bacillus Calmette–Guérin (BCG) inoculation site has been recognized as a diagnostic clue in Kawasaki disease, the present study is the first known one attempting to characterize BCG inoculation by dermatoscopy in Kawasaki disease and correlate the grade of BCG reaction with systemic involvement. Thirty‐four patients diagnosed with Kawasaki disease by pediatric specialists were enrolled. We performed detailed history taking, laboratory examination, physical examination and dermatoscopy examinations. Based on the BCG reaction pattern by dermatoscopy, we were able to characterize three patterns: (A) Bulls eye pattern in 18 patients; (B) faint homogenous erythema in nine; and (C) central white patch in seven. Patients from group A exhibited the highest elevation of blood aspartate aminotransferase levels (P < 0.05). Notably, three patients from group A had a significantly dilated coronary artery despite i.v. immunoglobulin injection. We concluded that the bulls eye dermatoscopy sign is not only a useful diagnostic clue but also a severity biomarker in patients with Kawasaki disease.

Treatment of Pigmented Basal Cell Carcinoma with 3 mm Surgical Margin in Asians

Background. In Asians, most basal cell carcinomas (BCCs) are pigmented with clear borders. The consensus of 4 mm surgical margin for BCC largely depends on studies in nonpigmented BCCs in Caucasians. However, little is known about recurrences of pigmented BCCs with a narrower surgical margin. We aimed to investigate 5-year recurrence of BCCs, either pigmented or nonpigmented, in Taiwanese with 3 mm surgical margin. Materials and Methods. 143 patients with BCC (M/F = 66/77, average 64 years) were confirmed pathologically from 2002 to 2013. Based on the pathological margin (>1 mm, ≤1 mm, and involved), patients were categorized into the complete excision group (n = 77), histology with close proximity group (n = 43), and unclear surgical margin group (n = 23). Results. Among 143 cases, 105 were pigmented. With standard 3 mm excision, there were 7 recurrences, with 6 of them from nonpigmented BCC group. Logistic regression showed that pigmentation was associated with lower recurrence. Interestingly, 5-year recurrence of completely excised and histology with close proximity BCC (0/77 versus 1/43) was not different statistically. Conclusions. A 3 mm surgical margin is adequate for pigmented BCC. A “wait and see” approach rather than further wide excision is appropriate for BCC with <1 mm free margin.

Treatment with TNF-α inhibitor rectifies M1 macrophage polarization from blood CD14+ monocytes in patients with psoriasis independent of STAT1 and IRF-1 activation

BACKGROUND Psoriasis is a systemic inflammatory disease with dramatic responses to TNF-α inhibitors. TNF-α is mainly produced by macrophages. However, how macrophage polarization contributes to psoriasis remains unknown. OBJECTIVE We aimed to investigate the molecular mechanisms of macrophage polarization in psoriasis. METHODS 8 patients with moderate to severe psoriasis (Male/Female: 4/4, average age: 47.9 years old) and 8 healthy controls (Male/Female: 4/4, average age: 49.3 years old) were recruited. Their peripheral CD14+ monocytes were isolated with magnetic beads and then were differentiated into macrophages. The differential macrophage polarization was compared among normal controls, psoriatic patients before and after TNF-α inhibitors. The U937 cells were used to investigate the mechanisms by which TNF-α altered the macrophage polarization. RESULTS The ratio of M1 to M2a macrophage polarization was higher in psoriatic patients comparing with that in controls. The decreasing M1/M2a ratio was parallel to decreasing PASI severity score after adalimumab treatment. Consistently, TNF-α blockage decreased M1/M2a ratio in U937 cells. The induction of STAT1 and IRF-1 in polarized U937 M1 cells was inhibited by TNF-α inhibitor. However, STAT1 and/or IRF-1 interference could not resume M1 polarization. In skin, the increased M1 and M2 infiltration in lesions returned to baseline after successful treatment with TNF-α inhibitor. CONCLUSIONS Increased M1 polarization is associated with higher disease severity in psoriasis, resuming to baseline after successful treatment by TNF-α inhibitors. TNF-α blockage inhibits M1 polarization through STAT1- and IRF-1-independent pathways. Macrophage polarization may contribute to disease progression in psoriasis.

Cutaneous manifestations of subcutaneous and systemic fungal infections in tropical regions: a retrospective study from a referral center in southern Taiwan

Deep cutaneous fungal infections, including subcutaneous mycoses and systemic fungal infection with cutaneous involvement, cause significant morbidity and mortality in light of increasing immunocompromised patients and global warming. Although a few studies reviewed deep fungal infections in temperate regions, a relevant study in tropical regions is lacking. We evaluated features of deep cutaneous fungal infections in southern Taiwan among the tropical regions.

No Significant Reduction of Circulating Endothelial-Derived and Platelet-Derived Microparticles in Patients with Psoriasis Successfully Treated with Anti-IL12/23

Psoriasis is associated with atherosclerosis, in which circulating microparticles play an important role. In severe psoriasis, there was an increase of endothelial- and platelet- microparticles which could be decreased by anti-TNFα. However, whether anti-IL-12/23 treatment would decrease the level of microparticles remains unknown. Our study showed that, despite the clinical improvement of psoriasis after IL-12/13 blockage, the increased levels of circulating CD41a and CD31 microparticles were unchanged after anti-IL-12/23. This result suggested that anti-IL12/23 treatment may not alter the development of cardiovascular disease in patients with psoriasis.

Prurigo Nodularis Is Associated with Depression and Anxiety in Chronic Hemodialysis Patients

BACKGROUND: Prurigo nodularis is a chronic pruritic disorder characterized by papulonodular lesions and uncontrollable scratching. Prurigo nodularis exerts a substantial physical and psychological burden on patients. The possible association among prurigo nodularis, mood disorders, and chronic renal failure has never been investigated. This study aims to clarify the relationship between dermatological complications and mental illness. METHODS: We evaluated the psychological status of patients with prurigo nodularis that were/were not undergoing hemodialysis. The subjects were categorized into four groups (N=18), each based on the presence of prurigo nodularis and hemodialysis therapy: one group with prurigo nodularis and no associated systemic diseases; one with prurigo nodularis and chronic hemodialysis; one hemodialysis group without prurigo nodularis, and a control group of healthy subjects. Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) tests were used to measure depression and anxiety status, respectively. RESULTS: Patients with prurigo nodularis were significantly with increased BDI-II and BAI scores. Hemodialysis patients with prurigo nodularis demonstrated the highest average scores for the BDI-II and BAI. There was signifi cant association between BDI-II and BAI scores. Conclusion: Patients with prurigo nodularis, especially those undergoing hemodialysis were associated with underlying psychological distress. Thus, it would be of help to detect a subgroup of patients suffering from psychiatric diseases.

Naproxen-induced pseudolymphoma syndrome: a case report

Drug-induced pseudolymphoma syndrome is a rare form of adverse cutaneous drug reaction. Its clinical and histological presentation may mimic mycosis fungoides, which sometimes leads to misdiagnosis and unnecessary treatments. We describe the case of a 65-year-old man with a generalized pruritic and confluent maculopapular eruption. His history of skin lesions was concordant with medication and resolved after discontinuation. However, microscopic examination showed characteristic features of mycosis fungoides, including Pautrier-like microabscesses and cerebriform nuclei of atypical lymphocytes. The immunohistochemical study showed CD4/CD8 infiltrate ratio to be 1 in the epidermis. The histopathological result of a second skin biopsy was compatible with drug eruption. This experience demonstrates that combining clinical history, histological and immunohistochemical findings is crucial for a definite diagnosis of PLS.

Bacteriological examination of inflamed epidermal cysts: a survey between 2008 and 2009 at a hospital in southern Taiwan

Abstract Background Inflamed epidermal cysts are common clinical conditions, and they frequently form abscesses. We designed a study to delineate the bacteriology of inflamed epidermal cysts. Methods We enrolled 61 adult patients with inflamed epidermal cysts characterized by surface erythema, with or without tenderness, or localized abscess formation within the cyst cavity. Incision and drainage of the cysts were performed, and the contents were sent for aerobic and anaerobic bacterial culture. The locations of the cyst and culture results were recorded for statistical analysis. Results A total of 61 cysts and 122 cultures were obtained. The most common locations of the inflamed cysts were the face, neck, and scalp (34.4%), followed by the trunk (32.8%), then the buttocks, inguinal areas, perineum, and axillae (16.4%), and the extremities (16.4%). The culture results were positive in 88.5% of patients, and anaerobes were more frequently isolated than were aerobes. Pure aerobes represented 31.1% of the cultures; pure anaerobes, 36.1%, and combined aerobes and anaerobes, 21.3% ( n = 13). The most common anaerobic organisms found were Propionibacterium spp (40.8%), followed by Peptostreptococcus spp (36.7%), Staphylococcus saccharolyticus (14.4%), Prevotella (4.1%), Bacteroides fragilis (2.0%), and Fusobacterium spp (2.0%). The most commonly isolated aerobes were Staphylococcus spp (40%), followed by Enterobacter spp (11.3%), Proteus mirabilis (8.5%), Citrobacter diversus (8.5%), Klebsiella pneumoniae (5.7%), Corynebacterium (5.7%), Morganella morganii (2.9%), Enterococcus faecalis (2.9%), group A β-hemolytic streptococcus (2.9%), Pseudomonas aeruginosa (2.9%), and Providencia rettgeri (2.9%). Conclusions Both aerobic and anaerobic microorganisms were present in the inflamed epidermal cysts, although the anaerobic bacteria, specifically, Propionibacterium spp and Peptostreptococcus spp, were isolated slightly more frequently. Antibiotics directed against anaerobes may be considered in the treatment regimen for inflamed epidermal cysts.

Multiple mobile and firm subcutaneous nodules on bilateral shins

A 40-year-old woman presented with a 10-year history of multiple subcutaneous nodules on the lower extremities. The first subcutaneous nodule occurred on the left shin, and over the last year, had increased in number and spread to the proximal extremities. The general condition of the patient was otherwise healthy, except that she was diagnosed with descending colon cancer and underwent surgery 2 years ago. A physical examination revealed mobile, firm, subcutaneous and asymptomatic nodules symmetrically distributed over the bilateral shins. The size of these nodules ranged from 2 mm to 4 mm in diameter; the number of the nodules was more than 20 (Figure 1). One subcutaneous nodule was taken from the right shin for histological examination. The epidermis and dermis were unremarkable. There were well-demarcated, round-shaped nodules encapsulated by fibrous tissue (Figure 2). Lipo membranous fat necrosis appeared to be associated with focal calcification in the center of the nodule (Figure 3). The skin lesions persisted during a 6-month follow-up.