Ji Young Ahn

Exacerbation of infliximab‐induced paradoxical psoriasis after ustekinumab therapy

Dear Editor, Tumor necrosis factor-a (TNF-a) inhibitors have been approved for treating plaque psoriasis. Paradoxically, such treatment has been shown to aggravate psoriasis, which is treated by continuing with the same anti-TNF-a therapy or switching to another biologic. Safa et al. reported a case in which paradoxical reaction induced by one biologic was exacerbated by another biologic. We present an interesting case of infliximab-induced paradoxical psoriasis that was aggravated after ustekinumab therapy, a biologic agent that targets the p40 subunit common to interleukin (IL)-12 and IL-23. A 30-year-old man with a 6-year history of psoriasis was referred to our department after treatment with the third infusion of infliximab (Fig. 1a). He had psoriatic lesions on the whole body and was treated with phototherapy and acitretin or cyclosporine. However, the therapies failed to control psoriasis. He was administrated 5 mg/kg infliximab at weeks 0, 2 and 6. Two weeks after the first injection, he developed erythematous patches on the lower extremities, and scattered erythematous patches on the whole body after the third injection. The infliximab was discontinued, and treatment with acitretin in combination with topical corticosteroids and calcipotriol agent was initiated. Even after 1 month, his condition did not improve. Treatment with 45 mg of s.c. ustekinumab at weeks 0 and 4 was initiated. One week after the first injection, scattered erythematous patches with scales appeared on the trunk, lower extremities and scalp (Fig. 1b,c). Two weeks after the second injection, his condition worsened rapidly, and pustules appeared on the palms and soles (Fig. 1d,e). The biologic was discontinued, and treatment with oral cyclosporin and a topical agent was initiated. The skin lesions markedly improved (Fig. 1f). Tumor necrosis factor-a inhibitor-induced psoriasis has been estimated to occur in 1.5–5% of cases, but the mechanisms remain unclear. TNF-a inhibitors induce cytokine imbalance and might induce interferon (IFN)-a overexpression in tissues. They could induce T-cell migration to the dermis and thus promote psoriatic lesion induction. Recently, ustekinumab was found to be an effective therapeutic alternative for patients showing therapeutic failure with TNF-a inhibitors. The mechanism may involve multiple cytokines such as IL-17 and IL-22, which are not solely related to decreased TNF-a. However, paradoxical adverse reactions have been reported, and their pathophysiology remains unknown. Ustekinumab is known to block IL-23 activity and decrease IL-23 and T-helper 17 cell-induced TNF-a levels; however, IFN-a levels continue to increase. This might cause the paradoxical psoriasis. Patients having an inadequate response to at least one biologic agent might have an increased risk of an insufficient response to (a)

Relation between the Peripherofacial Psoriasis and Scalp Psoriasis

Background Facial involvement of psoriasis is known to be one of the clinical manifestations that indicate the severity of the psoriasis and thought to be more closely associated with certain distribution. Centrofacial (CF) psoriasis has been suggested to be related with severity of systemic disease while peripherofacial (PF) psoriasis has been thought to have connection with scalp psoriasis. Objective To analyze the epidemiologic characteristics, clinical features and subjective feelings of patients with facial psoriasis and to find out relationship between scalp psoriasis and facial involvement according to the facial types. Methods One hundred nineteen facial psoriasis patients were categorized into 3 types according to the distribution: PF type, CF type and mixed facial (MF) type. Onset and duration of facial and scalp psoriasis, and their relationship were questioned. Severity and extent of psoriasis on whole body, face, and scalp were rated by clinicians. Results There was no significant difference of whole body psoriasis area and severity index (PASI) and body surface area (BSA) score but scalp PASI and BSA was much higher in PF psoriasis compared to CF psoriasis (scalp PASI, 17.9 vs. 10.1; p=0.005) (scalp BSA, 40.9 vs. 22.2; p=0.002). According to the questionnaire, patients objective feeling about the spreading of scalp lesion to facial area was markedly more prominent in the patients with peripheral involvement (PF+MF, 90.1%; CF, 54.2%; p<0.0001). Conclusion Among subtypes of facial psoriasis, PF psoriasis is closely associated with spreading of scalp lesion into the face rather than reflecting the disease severity.

A Case of Acrodermatitis Continua Accompanying with Osteolysis and Atrophy of the Distal Phalanx That Evoluted into Generalized Pustular Psoriasis.

794 Ann Dermatol Received August 25, 2015, Revised November 11, 2015, Accepted for publication November 25, 2015 Corresponding author: Jai Il Youn, Department of Dermatology, National Medical Center, 245 Eulji-ro, Jung-gu, Seoul 04564, Korea. Tel: 82-2-2260-7315, Fax: 82-2-2277-0915, E-mail: nmcderma@daum.net 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

Survey of disease awareness, treatment behavior and treatment satisfaction in patients with atopic dermatitis in Korea: A multicenter study

In Korea, there is a high dependency on oriental medicine and folk remedies (Korean J Asthma Allergy Clin Immunol, 25, 2005, 110). In addition, inaccurate information available through the Internet is increasing (Korean J Dermatol, 44, 2006, 137). So, there is always a possibility that patients may have difficulty obtaining accurate information about atopic dermatitis (AD). The aim was to determine the awareness, treatment behavior and treatment satisfaction of patients with AD and their caregivers. In October 2017, patients diagnosed with AD at nine hospitals were enrolled in this study. A questionnaire was completed by each patient. A total of 371 subjects were surveyed. In response to the question asking about knowledge of AD, the correct answer rate was 55.4%. Bathing using soap, body scrub and moisturizer showed favorable outcomes. A total of 54.9% patients responded that they were reluctant to use steroid ointment. When asked about their previous treatment, 39.6% reported using oriental medicine and 26.5% had tried folk remedies. The hospital treatment satisfaction score was 6.6. Patients usually applied their knowledge in their daily lives. However, there was a lot of inaccurate knowledge. Therefore, it is important for patients to understand the characteristics of this disease and obtain correct information.

Clinical Efficacy of Oral Cyclosporine on Intractable Hand Eczema: A Retrospective Review of 16 Cases

Vol. 30, No. 4, 2018 475 Received June 9, 2017, Revised July 10, 2017, Accepted for publication August 11, 2017 Corresponding author: Ji Young Ahn, Department of Dermatology, National Medical Center, 245, Eulji-ro, Jung-gu, Seoul 04564, Korea. Tel: 82-2-2260-7315, Fax: 82-2-2260-7314, E-mail: jiyoung.ahn@nmc.or.kr ORCID: https://orcid.org/0000-0002-6766-9978 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

A Case of Acute Generalized Exanthematous Pustulosis after Injection of an Erythropoiesis-Stimulating Agent

100 Ann Dermatol Received July 28, 2016, Revised December 28, 2016, Accepted for publication January 5, 2017 Corresponding author: Mi Youn Park, Department of Dermatology, National Medical Center, 245 Eulji-ro, Jung-gu, Seoul 04564, Korea. Tel: 82-2-2260-7315, Fax: 82-2-2277-0915, E-mail: nmcderma@daum.net 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