Sue Kyung Kim

Comprehensive understanding of idiopathic guttate hypomelanosis: clinical and histopathological correlation.

Background  The histological findings associated with idiopathic guttate hypomelanosis (IGH) are hyperkeratosis, an atrophic epidermis, and flattened rete ridges. In addition, a decreased melanin content and reduced numbers of melanocytes are reported features. However, there are few recent studies that have been published on the histopathology of IGH and no comparative studies are available on the skin lesions and perilesional skin of patients with IGH.

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.

Toll-like Receptors and Antimicrobial Peptides Expressions of Psoriasis: Correlation with Serum Vitamin D Level

To evaluate the association of Toll-like receptors (TLRs), antimicrobial peptides (AMPs) and vitamin D receptors (VDRs) in psoriasis, lesional (PP) and perilesional skin (PN) from psoriasis, atopic dermatitis (AD) patients and healthy controls (NN) were studied by immunohistochemistry. Compared with PN, AD and NN skin, dysregulated expression of TLRs, AMPs and VDR was detected in PP skin. Noteworthy, our results showed altered correlation between TLR2 and VDR expression in PP and PN skin. Human beta defensin 2 (HBD2) and cathelicidin (LL-37) expressions in the PP skin were higher in serum vitamin D sufficient (VDS) groups than serum vitamin D deficient (VDD) groups. Negative correlation was found between TLR2 and VDR expression in the PP skin of VDD groups. However, positive correlation was noted in the PP skin of VDS groups. Based on the present results, therapies targeting the activity of TLRs, AMPs and vitamin D, including modulation of the TLR-VDR pathways, might provide new therapeutic approaches to the psoriasis and other inflammatory skin diseases.

Clinical comparison of psoriasis in Korean adults and children: correlation with serum anti-streptolysin O titers.

Psoriasis is a relatively common disorder in children and can be triggered by an upper respiratory tract infection. The aim of this study was to compare the clinical features of psoriasis in children and adult. In addition, we evaluated the relationship between anti-streptolysin O (ASO) titers and the clinical features of psoriasis. A total of 30 childhood psoriasis patients and 30 adult psoriasis patients were evaluated. Childhood psoriasis had a facial predominance when compared with the adult psoriasis. The childhood psoriasis patients with high ASO titers had guttate psoriasis more frequently than patients with normal ASO titers. In children with plaque-type psoriasis, psoriasis area and severity index score was increased in the high ASO titer group than normal ASO titer group. In conclusion, if the children with psoriasis show increased ASO titer, the physician should pay attention to the worsening of the psoriasis. Furthermore, early treatment of streptococcal infections might be beneficial in childhood psoriasis.

Orofacial granulomatosis associated with Crohn's disease.

Orofacial granulomatosis (OFG) is a term used to describe swelling of the orofacial area, mainly in the lips, secondary to an underlying granulomatous inflammatory process. OFG has been reported in association with systemic conditions such as sarcoidosis and Crohns disease (CD). OFG may precede gastrointestinal disease, such as CD, by several years and may be the only obvious focus of the disease. Herein, we report a patient with OFG and non-symptomatic ulcerations of the ileocecal valve. The patient received intralesional triamcinolone injections every 2 weeks. After 6 weeks, all oral lesions showed marked improvement. The favourable treatment response of this patient suggests that intralesional triamcinolone can be used as a treatment option for patients with CD that have oral lesions. In addition, patients presenting with OFG should be carefully evaluated for gastrointestinal signs and symptoms.

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.

Neurocristic Cutaneous Hamartoma of the Scalp

Neurocristic cutaneous hamartomas (NCHs) result from aberrant development of the neuromesenchyme. In addition to a dermal melanocytic component, these tumors can contain neuro sustentacular and fibrogenic components. The clinical importance of these lesions includes the potential for misdiagnosis as well as the development of malignant melanomas over a poorly described period of time. We present a rare case of NCH of the scalp in a 1-year-old female.

Epithelial–mesenchymal interaction during photodynamic therapy-induced photorejuvenation

Recently, several clinical studies reported that the photodynamic therapy (PDT) has photorejuvenation effects on the aged skin. Previously, our group introduced evidence of direct effect of PDT on cultured fibroblast (FB). PDT directly stimulated FBs and induced collagen synthesis through activation of extracellular signal–regulated kinase. In this study, we investigated indirect effect of PDT on the human dermal FB during photorejuvenation focused on the epithelial–mesenchymal interaction between keratinocyte (KC) and FB. The “low-level PDT” condition was used for PDT therapy to the cultured KC. Various kinds of cytokines in the supernatants of KC were evaluated by enzyme-linked immunosorbent assay. FBs were stimulated with the KC-conditioned medium (KCM) taken after PDT. The mRNA level of matrix metalloproteinases (MMPs), transforming growth factor (TGF)-β and collagen type Iα in the FB, was determined by real-time polymerase chain reaction. Clinical phtorejuvenation effect was also evaluated from nine patients who had PDT to treat actinic keratoses. Among the FB-stimulating cytokines, a significant elevation of interleukin (IL)-1α, IL-6, and tumor necrosis factor-α level in KCM was noted after PDT compared with controls. After stimulating FB with KCM, the mRNA of MMP-1 was decreased and the mRNA of collagen type Iα was increased compare to control. Clinically, fine wrinkles significantly reduced after PDT. However, coarse wrinkles were not recovered significantly. In conclusion, increased collagen synthesis may be mediated not only by direct effect of PDT on FB but also by indirect effect of PDT on FB through cytokines from KC, such as IL-1α, IL-6, and tumor necrosis factor-α.

Basal Cell Carcinoma Presenting as a Perianal Ulcer and Treated with Radiotherapy

Dear Editor: Basal cell carcinoma (BCC) in the perianal and genital areas accounts for <1% of all BCCs1. If the patient is unsuitable or unwilling to receive surgical treatment, topical photodynamic therapy and radiotherapy can be considered alternative treatment options2. In this report, we describe a case of BCC that presented as a perianal ulcer and showed a good response to radiotherapy. An 83-year-old man presented with an erythematous ulcer on his perianal area for 3~4 years. The skin lesion was slowly growing, but did not cause pain or bleeding. He did not report any gastrointestinal symptoms. He had a medical history of hypertension, diabetes mellitus, subarachnoid hemorrhage. On examination, a single 3.0×3.0 cm-sized, erythematous, asymptomatic ulcer with raised edges was observed on the perianal area (Fig. 1A). Under the clinical impression of Paget disease or Crohn disease, punch biopsy was performed. Histopathologically, nodular masses of basaloid cells extended into the dermis and showed a peripheral palisading pattern, which were consistent with BCC (Fig. 1B). Fig. 1 Initial clinical findings of basal cell carcinoma (BCC) in the perianal area. (A) Single, erythematous, asymptomatic ulcer with raised edge in the perianal area. (B) Histopathological findings. Nodular masses of basaloid cells extending into the dermis. ... He decided to undergo radiotherapy due to the high operative risk associated with his old age and history of subarachnoid hemorrhage. He received 3 Gy per fraction for 3 times a week for a total dose of 51 Gy over 17 fractions. At the end of radiotherapy, no acute radiogenic skin toxicities such as erythema and desquamation were noted. Two months after radiotherapy, the ulcerative lesion showed considerable clinical improvement (Fig. 1C) and still showed no aggravation after 5 month follow-up. The patient refused to undergo an additional skin biopsy; therefore, he scheduled regular follow-up visits. BCC of non-sun-exposed areas is extremely rare. Among the anogenital BCC, the pubis is the most common, followed by the perianal area, the scrotum, and the penis1. Clinical appearance ranged from erythematous papules to noduloplaques, and ulcers. According to a previous report that reviewed 51 anogenital BCCs, ulcerated lesions were seen in 15 cases (29.4%)1. Perianal ulcerative BCC may initially be misdiagnosed as a benign dermatologic or gastrointestinal disease. Perianal Paget disease, cutaneous metastasis of gastrointestinal malignancy and Crohn disease should be excluded3. Radiotherapy can be a treatment option in elderly patients and those with significant medical comorbidities4. In the present case, poor medical conditions and the location, which made it difficult for complete excision, rendered him unsuitable for surgery. However, patients treated with radiotherapy should be closely followed up because BCC treated with radiotherapy recurs more often than that treated with Mohs micrographic surgery; Rowe et al.5 reported that the 5-year recurrence rate of radiotherapy-treated disease is higher (9.8%) than that of Mohs micrographic surgery (5.6%). Also, the potential for radiogenic toxicity in the skin should not be ignored, especially when it might cause severe functional discomfort. In summary, we describe a rare case of BCC that presented as a perianal ulcer. Dermatologists should consider BCC in the differential diagnosis of a painless, ulcerated lesion on the perianal area. We also suggest considering radiotherapy in cases of BCC in the perianal area when surgical treatment is not possible.

Nodular Basal Cell Carcinoma Successfully Treated with Intralesional 5-Aminolevulinic Acid Injection-Photodynamic Therapy

Dear Editor: Basal cell carcinoma (BCC) is now frequently treated with photodynamic therapy (PDT), because of favorable treatment response and cosmetic outcome1. However, it is less effective in nodular BCC than in superficial BCC due to limited penetration of the photosensitizer. We recently successfully treated a thick lesion of classic Kaposi sarcoma with intralesional 5-aminolevulinic acid (ALA) injection PDT2. Intralesional injection (ILI)-PDT has also been tried in various cutaneous diseases with good clinical outcomes3. To our knowledge only one case of nodular BCC treated with 5-ALA ILI-PDT has been reported4. Herein, we report another case of nodular BCC successfully treated with 5-ALA ILI-PDT after a relatively short incubation time. A 63-year-old man presented with a 1×0.8 cm-sized brownish papule with a rolled border on the right perinasal area, initially noted six months previously (Fig. 1a). Histopathological examination showed islands of atypical basaloid tumor cells with peripheral palisading, extending into the reticular dermis (Fig. 2a). In an attempt to treat the thick tumor with a shortened incubation time, we utilized 5-ALA ILI-PDT. Twenty-percent 5-ALA solution (Levulan Kerastick®; DUSA Pharmaceuticals, Wilmington, MA, USA) was injected into the lesion (about 0.3 ml/cm2). After 90 minutes, it was irradiated with red light from a Waldman PDT 1200 L lamp (Herbert Waldmann GmbH & Co. KG, Villingen-Schwenningen, Germany) at a light dose of 100 J/cm2, a fluence of 100 mW/cm2 and an emission wavelength of 580 to 740 nm. PDT was delivered repeatedly five times, at two to eight week intervals over six months. During the treatment, there were no noticeable side effects except mild pain during injection. Upon the follow-up visit eight months after the initial treatment, the lesion was cleared, leaving a faintly erythematous scar on the treated site (Fig. 1b). Skin biopsy showed only signs of chronic dermatitis and fibrosis without abnormal tumor cells, confirming the remission histopathologically (Fig. 2b). Fig. 1 (a) A brownish papule on the right side of the nose before photodynamic therapy, (b) resolution of the skin lesion after 5 sessions of treatment. Fig. 2 (a) Atypical basaloid tumor cells extending into the mid-dermis, the tumor thickness measuring 1.3 mm (H&E, ×100), (b) after 5 sessions of treatment, no tumor cell is seen (H&E, ×100). Previous trials of topical PDT in treatment of BCC have shown promising results1. However, insufficient uptake of the photosensitizer to deeply located tumor cells has sometimes led to poor response. To facilitate transcutaneous absorption, various methods of pretreatment were introduced, such as curettage, debulking, tape stripping, microdermabrasion and laser ablation5. These techniques may produce substantial bleeding, consequently washing off the photosensitizer applied superficially on the tumor. Sotiriou et al.3 suggested that the photosensitizer may penetrate the target tissue deeply enough if it is directly injected into the tumor itself. We agree with this idea, because ILI causes only minimal bleeding at the puncture site. It may also shorten the incubation time required before adequate absorption is achieved, since it allows direct infiltration into the tumoral tissue. Therefore, the long incubation time, one of the major drawbacks of topical PDT, could be reduced with ILI of the photosensitizer. However, the cost and prolonged treatment time, compared with simple excision, would discourage the use of ILI-PDT in a small BCC lesion. Further studies of ILI-PDT in nodular BCC with larger lesions are warranted for the evaluation of treatment efficacy and recurrence.