Leena Chularojanamontri

The Simplified Psoriasis Index (SPI): A Practical Tool for Assessing Psoriasis

The Simplified Psoriasis Index (SPI) is a summary measure of psoriasis with separate components for current severity (SPI-s), psychosocial impact (SPI-p), and past history and interventions (SPI-i). It derives from the Salford Psoriasis Index but replaces Psoriasis Area and Severity Index (PASI) with a composite weighted severity score designed to reflect the impact of psoriasis affecting functionally or psychosocially important body sites. Two complementary versions are available, differing only in that current severity (SPI-s) is either professionally (proSPI-s) or patient self-assessed (saSPI-s). This study examined the criterion and construct validity and response distribution of proSPI-s, saSPI-s, and SPI-p in 100 patients with plaque psoriasis. A further 50 patients were assessed for test-retest reliability of these three components. Interrater reliability of proSPI-s was assessed in 12 patients, each assessed by 12 assessors (144 assessments). There was close correlation between PASI and proSPI-s (r=0.91); SPI-p was closely correlated with the Dermatology Life Quality Index (r=0.89). Strong intrarater (proSPI-s, saSPI-s, SPI-p, and SPI-i) and interrater (proSPI-s) reliability was demonstrated (all intraclass correlation coefficients >0.75). There were wide response distributions for all three components. We believe that both professional (proSPI) and self-assessed (saSPI) versions can readily be introduced into routine clinical practice.

Correlation between plasma D-dimer levels and the severity of patients with chronic urticaria

Background Beside autoimmunity, coagulation pathway is also involved in the pathogenesis of chronic urticaria (CU). Previous studies showed that plasma D-dimer levels paralleled the severity of the disease. To date, there are no data concerning D-dimer level in Thai patients with CU. Objective This study aimed to find the relationship between plasma D-dimer levels and the disease severity of Thai CU patients. The secondary objective is to analyze plasma D-dimer level in each group of patients who performed autologous plasma skin testing (APST) and autologous serum skin testing (ASST). Methods We retrospectively reviewed case record forms of chronic idiopathic urticaria (CIU) patients aged at least 18 years in Skin Allergy Clinic, Siriraj Hospital Mahidol University, Bangkok, during June 2008 to June 2011. Results Of 120 patients, plasma D-dimer level was abnormal in 58 patients (48.3%). The study showed statistically significant positive correlation between disease severity and plasma D-dimer level (p < 0.05, r = 0.537). There was no statistically significant difference in plasma D-dimer level between APST positive and negative groups, and also between ASST positive and negative groups. In APST negative group, plasma D-dimer level was elevated in 29 patients (47.5%) and correlated with disease severity. Conclusion This study showed elevated plasma D-dimer levels in nearly half of Thai patients with CIU. There was a positive correlation between plasma D-dimer levels and the severity of disease activity. Investigation for plasma D-dimer level may be an alternative way to evaluate disease severity in patients with CIU.

Clinical features of the extrinsic and intrinsic types of adult-onset atopic dermatitis

Background Most study concerning the prevalence and dermatological manifestations of the extrinsic and the intrinsic form of atopic dermatitis (AD) were performed in children and adult AD related to the early-onset AD extending to adult life. Adult-onset AD is a subgroup of AD. Apart from the typical eczematous flexural distribution pattern of AD, this group may also have nontypical morphology and localization. Objective The purpose of this study was to compare the clinical and diagnostic features of Thai patients with extrinsic and intrinsic type of adult-onset AD. Methods We retrospectively studied case records of patients diagnosed as adult-onset AD at the skin allergy clinic, Department of Dermatology, Siriraj Hospital, Mahidol University, Bangkok, Thailand from June, 2006 to May, 2008. The diagnosis of AD was made according to the criteria of Hanifin and Rajka and the severity of AD in each patient were assessed using the eczema area and severity index and the Rajka and Langeland score. Results Fifty six patients were enrolled. Eighty-seven percent of patients were extrinsic AD (eAD). Females predominated in both groups. Patients with eAD more commonly had typical lichenified/exudative eczematous lesions, especially on the antecubital and popliteal areas, when compared with patients with intrinsic AD (iAD). Nummular and follicular lesions were more commonly seen in iAD group than the eAD group. The most common area of involvement in the iAD was non-flexural area, followed by flexural area and extensor area. The severity of both iAD and eAD did not show a significant difference. Conclusion The eAD type of adult-onset AD was more common than the iAD type. Patients with eAD frequently had flexural lichenification whereas the iAD group tended to have nonflexural area involvement. The severity of both iAD and eAD did not show a significant difference.

Metabolic syndrome and psoriasis severity in South-East Asian patients: An investigation of potential association using current and chronological assessments

Although studies regarding prevalence of metabolic syndrome (MS) in Asian psoriatic patients are limited and show varying results, a previous report describes a significant increase in prevalence of MS in Thai psoriatic patients, as compared with rates in the general population. However, no significant association between MS and psoriasis severity using the Psoriasis Area and Severity Index (PASI) was found, which differs from the findings of Korean and Japanese studies. This study aimed at re‐evaluating the association between MS and psoriasis severity in Thai patients using current assessment (PASI) and chronological assessment (historical course and interventions). A total of 273 psoriatic patients were recruited. After controlling for age and sex, 96 patients were assigned to the MS group and 96 patients to the non‐MS group. Similar to the previous study, no significant differences were identified between metabolic and non‐metabolic patients regarding PASI, age of onset, disease duration and family history of psoriasis. However, the numbers of hospitalizations (P = 0.018) and interventions (P = 0.028) were significantly higher in metabolic patients than in non‐metabolic patients. Further, a greater number of metabolic components was significantly associated with a higher number of hospitalizations (P = 0.012), pustular or erythrodermic psoriasis episodes (P = 0.049), and interventions (P = 0.005). Body mass index of 23 kg/m2 or more, abdominal obesity and high blood pressure were associated with an increased risk of treatment failure. Using chronological assessment, our study supported that MS negatively affects psoriasis severity and treatment outcomes. Screening for MS is highly recommended for psoriatic patients.

In Vitro Test to Confirm Diagnosis of Allopurinol‐Induced Severe Cutaneous Adverse Reactions

Allopurinol is a frequent cause of severe cutaneous adverse reactions (SCARs), such as drug reaction with eosinophilia and systemic symptoms (DRESS), Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). The reactions can potentially be fatal. As drug rechallenge in patients with a history of drug‐induced SCARs is contraindicated, in vitro testing may have a diagnostic role as a confirmation test.

Generalized molluscum contagiosum in an HIV patient treated with diphencyprone.

BACKGROUND Diphencyprone is a universal contact immunotherapy. The mechanism of action is based on an induction of the delayed-type hypersensitivity. Diphencyprone has been used in various forms for treatments of recalcitrant and facial warts, and alopecia areata. However, this treatment modality has not been generally used in immunocompromised patients. MAIN OBSERVATION The present report demonstrated the efficacy of diphencyprone immunotherapy on the treatment of generalized molluscum contagiosum in a human immunodeficiency virus (HIV)-infected patient. Minimal and transient side effects including pruritus, postinflammatory hyperpigmentation and irritation were noted. CONCLUSION Diphencyprone contact immunotherapy appears to be a possible alternative treatment of widespread molluscum contagiosum in immunocompromised patients.

Responsiveness to change and interpretability of the simplified psoriasis index

The Simplified Psoriasis Index (SPI) is a summary measure of psoriasis with separate components for current severity (weighted for functionally or psychosocially important sites), psychosocial impact, and past behavior. The current severity components of the professionally assessed SPI (proSPI-s) and self-assessed SPI (saSPI-s) have each been shown to be valid and reliable. Their responsiveness to change and equivalence to the current standard (Psoriasis Area and Severity Index, PASI) were investigated. Responsiveness and minimum clinically important differences (MCIDs) were derived from PASI changes from baseline at weeks 4 (n=100) and 10 (n=65) in patients commencing therapy for psoriasis. Receiver operating characteristic (ROC) analysis confirmed that both measures detected responsiveness well (area under the curve (AUC)=0.72-0.96). On ROC and PASI-based anchor analysis, MCIDs equated to mean absolute and percentage changes of 5 and 60% (proSPI-s), and 7 and 70% (saSPI-s). Satisfactory response as defined by 75% reduction in PASI equated to 85 and 95% reductions in proSPI-s and saSPI-s, respectively. PASI-equivalent cutoff scores for mild (PASI<10) and severe (PASI>20) psoriasis were <9 and >18 for proSPI-s (n=300) and <10 and >20 for saSPI-s (n=200; AUC=0.86-0.96). These studies further support the validity of SPI for use in routine clinical practice.

Guttate psoriasis is associated with an intermediate phenotype of impaired Langerhans cell migration.

An episode of guttate psoriasis can be an isolated event, can recur as guttate episodes, or develop into chronic plaque psoriasis (CPP). A previous study revealed that early‐onset (before age 40 years) CPP is associated with inhibition of epidermal Langerhans cell (LC) migration.

Diagnostic significance of colloid body deposition in direct immunofluorescence.

BACKGROUND Colloid bodies (CB) in direct immunofluorescence (DIF) studies are usually found in interface dermatitis. Furthermore, CB can be found in various skin diseases and even in normal skin. AIM To evaluate the diagnostic value of CB deposits in DIF studies. METHODS From 1996-2007, data from 502 patients where DIF studies showed immunoreactants at CB were enrolled. The definite diagnoses of these patients were based on clinical, histopathological and immunofluorescent findings. The results of DIF studies were analyzed. RESULTS Immunoreactants at CB were detected in 44.4%, 43.8%, 4.2%, 3.8%, and 2.2% of interface dermatitis, vasculitis, autoimmune vesiculobullous disease, panniculitis, and scleroderma/morphea, respectively. The most common immunoreactant deposit of all diseases was Immunoglobulin M (IgM). Brighter intensity and higher quantity of CB was detected frequently in the group with interface dermatitis. CONCLUSIONS Immunoreactant deposits at CB alone can be found in various diseases but a strong intensity and high quantity favor the diagnosis of interface dermatitis. CB plus dermoepidermal junction (DEJ) deposits are more common in interface dermatitis than any other disease. Between lichen planus (LP) and discoid lupus erythematosus (DLE), CB alone is more common in LP; whereas, CB plus DEJ and superficial blood vessel (SBV) is more common in DLE. The most common pattern in both diseases is CB plus DEJ. The quantity and intensity of CB in LP is higher than in DLE.

Clinical differences between early- and late-onset psoriasis in Thai patients.

There is a paucity of data regarding clinical differences between early‐onset psoriasis (EOP) and late‐onset psoriasis (LOP) in Asian populations. This study aimed to investigate clinical differences between EOP (onset at the age of <40 years) and LOP (onset at the age of ≥40 years) in Thai patients.