Seong Hun Moon

Treatment of onychomycosis with a 1,064-nm long-pulsed Nd:YAG laser

Abstract Background: There are various treatment modalities of onychomycosis. Of these, however, oral antifungal therapies are complicated by potential drug interactions and systemic effects, and the surgical treatment can result in prolonged pain. Therefore, a new, safe and effective therapy is needed that can improve the aesthetic appearance of the nails. Objective: The purpose of this study was to evaluate the effect of treatment of onychomycosis with a 1,064-nm long-pulsed Nd:YAG laser. Methods: 13 patients (31 toenails, 12 fingernails) received five treatment sessions at 4-week intervals with a 1,064-nm long-pulsed Nd:YAG laser. Parameters for each treatment were 6 mm spot size, 5 J/cm2 fluence, 0.3 ms pulse duration and 5 Hz pulse rate. Results: Of the 13 patients, 8 (61.5%) were women and 5 were men. The mean age of the patients was 62. Of the 43 nails, 4 (9.3%) achieved a complete cure (9.3%), 8 had excellent treatment outcomes (18.6%) and 31 had good treatment outcomes (72%). None of the 13 patients experienced any discomfort except for a mild burning sensation and there were no adverse effects. Conclusions: Our results demonstrate that the 1,064-nm long-pulsed Nd:YAG laser could be a safe and effective treatment modality in the management of patients with onychomycosis.

Toxic epidermal necrolysis with isolated neutropenia related to the use of levetiracetam

and placebo groups for mean change in hair diameter. For patients’ self-assessments, the minoxidil group was significantly superior to the placebo group using the Mann–Whitney U-test (P = 0.013). The adverse reactions were mild and not statistically significantly different between groups. Topical minoxidil has been used to treat androgenetic alopecia. We also demonstrated that it could be used for eyebrow hypotrichosis. In this trial, minoxidil lotion was superior to placebo for beard enhancement based on the global photographic scores, mean change from baseline in hair count and patients’ self-assessments. There was no statistically significant difference between groups for changes in hair diameter from baseline. This can be explained by: (i) the increase in hair count, especially non-terminal hairs; and (ii) measurement of hair was done on both terminal and non-terminal hairs. The exact mechanism of minoxidil in promoting hair growth is still unclear but there are many hypotheses. In conclusion, minoxidil 3% lotion is effective and safe for beard enhancement.

A Case of Multiple Desmoplastic Trichoepithelioma.

Dear Editor: A 23-year-old woman presented with multiple, progressively growing, asymptomatic, depressed macules on face for 2 years. Physical examination revealed three yellowish to skin-colored annular atrophic macules 2~5 mm in size without elevated border on both cheeks (Fig. 1). She had no family or past history that scar might occur such as acne, chickenpox, herpes infection or prior laser treatment. Laboratory data including blood cell counts, biochemistry and urinalysis were unremarkable. Histopathology showed narrow strands of basaloid tumor cells in a fibrous stroma with adjacent embedded keratinous cysts (Fig. 2). The tumor strands were distributed from the upper to the deeper dermis. We performed additional exicisional biopsy with immunohistochemical staining in order to differentiate from malignant neoplasms including morpheic basal cell carcinoma (BCC) and microcystic adnexal carcinoma (MAC). Carcinoembryonic antigen (CEA), epithelial membrane antigen (EMA), CD23, and CK19 were negative, and CK20 showed focal positive. From these findings, she was diagnosed with desmoplastic trichoepithelioma (DTE), and remaining lesions were completely removed. Fig. 1 (A, B) Cutaneous examination revealed multiple yellowish to skin-colored annular, depressed macules on both cheeks. Fig. 2 (A) Biopsy specimen of left cheek reveals atrophic epidermis with upper and mid dermal cellular infiltration (H&E, ×40). (B) Tumor strands embedded in dense fibrous stroma are composed of small basaloid cells one to two cells thick (H&E, ... DTE is a rare benign skin appendageal neoplasm. It is a distinct variant of trichoepithelioma based upon its unique clinical and histopathological characteristics1. Clinically, it typically shows 3~8 mm diameter, annular, yellowish or skin-colored asymptomatic plaques, with an elevated border and a depressed or atrophic center on face1. It almost develops as a solitary lesion, although rare cases of patients with multiple lesions have been reported2. Histopathologically, DTE is characterized by following features. First, epithelial strands consist of small basaloid cuboidal cells in a one to three-cell-thick layer. Second, many keratinous cysts have a peripheral border of basaloid cuboidal cells, and sometimes have several calcification foci. Finally, stroma appears as dense fibrous stroma1. Differential diagnosis includes MAC, BCC, and scar. Although MAC presents with many horn cysts and epithelial cords, it is distinguished by ductal differentiation and infiltration to the subcutis or deeper structures3. Therefore, when biopsy is superficial, MAC can be misdiagnosed as DTE3. Assessing EMA and CEA immunohistochemistry may identify ductal differentiation and CD23 expression in MAC1. CK19 demarcates follicular bulge stem cells and its positivity favors MAC over DTE4. Both DTE and morpheic BCC can exhibit basaloid cells in strands and sclerotic stroma. However, neither cellular atypia nor peripheral palisading are seen in DTE, and morpheic BCC is not usually associated with horn cyst formation1. Also, in most DTE, retained or increased CK20-positive Merkel cells are found, but not in morpheic BCC5. Scar should be considered if multiple depressed macules appear, but it can be easily differentiated based upon its histopathology. The treatment of choice is surgical excision and Mohs micrographic surgery is recommended to achieve clear surgical margins. In our case, because multiple lesions had developed and tumor strands extended into the deep dermis, total excision was performed to exclude malignancy. Therefore, initial proper biopsy is important to make an accurate diagnosis and treatment in patients with multiple scar-like depressed macules on face. Herein, we report a rare case of multiple DTE, which should be differentiated from malignancy histopathologically.

Rare case of cutaneous involvement of Lennert lymphoma as an initial manifestation

Dear Editor, Lennert lymphoma (LL), classified as a “lymphoepithelioid cell variant of the peripheral T-cell lymphomas, unspecified” in the World Health Organization classification, is a rarely reported subtype of lymphoma first described by Lennert and Mestdagh in 1968. A 65-year-old man presented with generalized erythematous papules on the entire trunk and both upper extremities. He had been diagnosed with interstitial granulomatous dermatitis (IGD) for the same cutaneous manifestation 1 year prior (Fig. 1a,b) and treated with systemic steroid and dapsone showing little clinical improvement. He complained of fever, weight loss and poor appetite of 1 month in duration. On physical examination, multiple lymph nodes were enlarged on palpation, which was confirmed using computed tomography. Skin punch biopsy and gun biopsy of an enlarged lymph node were performed. A biopsy taken 1 year previously revealed perivascular lymphoid infiltration with granulomatous areas in the dermis (Fig. 1c). The granulomatous areas were surrounded by lymphoid cells without prominent atypia intermingled with clusters of epithelioid histiocytes (Fig. 1d). Rebiopsy of the papule on the back was performed during the most recent presentation, which revealed several granulomatous cellular infiltrations around blood vessels and skin appendages in the dermis. The infiltrations consisted of atypical small lymphoid cells admixed with epithelioid histiocytes. Immunohistochemical staining of the skin showed positivity for CD3, CD8 and CD68, and negativity for CD4 (Fig. 1e–h). Biopsy of the inguinal lymph node showed diffuse effacement of lymph node architecture and infiltrate composed of epithelioid cells and atypical lymphocytes, similar to the skin (Fig. 1i,j). Lymph node immunohistochemical findings were similar to those of the skin. Additional study for T-cell receptor gene rearrangement revealed monoclonality in a skin specimen. We concluded that our patient had LL with cutaneous involvement. In spite of systemic chemotherapy, he died from complication after 3 months. Clinically, because LL is primarily a nodal disease, cutaneous involvement of LL, which is infrequent with an incidence of 4–11%, rarely precedes other clinical signs or symptoms. Additionally, its manifestations are variable and non-specific, including asymptomatic erythematous papules, nodules and small plaques on the trunk and extremities. When the granulomatous dermatitis with no evidence of cellular atypia precedes a diagnosis of lymphoma, the initial cutaneous signs possibly represent a generalized granulomatous response to a distant focus of lymphoma. There are also similar cases that have been reported as peripheral T-cell lymphoma with granulomatous reaction. Therefore, comparison of both skin and lymph node specimens and molecular analysis may be mandatory for accurate diagnosis of lymphoma as in our case. In addition, the diagnoses of IGD should be carefully confirmed after evaluating the possibility of other lymphoproliferative disorders. In our case, the initial presentation of LL was only skin lesion prior to the characteristic nodal findings and it could be an educational case showing clinical course serially from initial cutaneous manifestation of LL. From this point of view, we emphasize the need for a high index of suspicion of an underlying lymphoma in the presence of non-specific granulomatous dermatitis as initial presentation.