Young Seung Jeon

Efficacy of Ultraviolet A1 Phototherapy in Recalcitrant Skin Diseases

BACKGROUND Ultraviolet (UV) radiation has been used for decades to treat a variety of skin diseases. UVA1 was used initially as an effective treatment for acute exacerbated atopic dermatitis. Since then, UVA1 has been attempted for recalcitrant skin diseases. OBJECTIVE This study examined the efficacy of UVA1 phototherapy in three recalcitrant skin diseases. METHODS This retrospective study reviewed the efficacy and follow-up of 26 patients with atopic dermatitis (AD), mycosis fungoides (MF) and localized scleroderma (LS). SUPUVASUN 3000 (Mutzhas Co., Munich, Germany) and SELLAMED 3000 (Sellas Medizinische Gerate GmbH, Gevelsberg, Germany) were the UVA1 equipment used. Irradiation was performed in accordance with the disease. Low-dose (20 J/cm(2)), medium-dose (65 J/cm(2)) and high-dose regimens (100 J/cm(2)) of UVA1 therapy were employed. The frequency of the therapy ranged from 3 to 5 times weekly. The therapeutic effectiveness was assessed according to the clinical examination before and after the last treatment. RESULTS In patients with AD, complete and partial remission was achieved in four (80%) and one (20%) patient, respectively. In patients with MF, complete and partial remission was observed in thirteen (86.7%) and two (13.3%) patients, respectively. In patients with LS, complete and partial remission was observed in three (50%) and three (50%) patients, respectively. CONCLUSION UVA1 phototherapy is an effective treatment modality for acute exacerbated AD, MF and LS.

Efficacy of the 1064-nm Q-switched Nd:YAG laser in melasma

Abstract Background: Melasma is difficult to treat and often recalcitrant to various treatments such as topical preparations and lasers. Objectives: To evaluate the efficacy and safety of the 1064-nm Q-switched Nd:YAG laser in Asian patients with melasma. Methods: Twenty-three Korean patients (skin types III–V) with melasma were treated with the 1064-nm Q-switched Nd:YAG laser at 1-week intervals for 10 weeks. The melasma area and severity index (MASI) score, lightness of melasma, patient satisfaction score and side effects were assessed at baseline, 4, 7, and 10 weeks and 1, 2, and 3 months after the last treatment. Results: A decreased MASI score and increased lightness of melasma were statistically significant at 7 and 10 weeks. Follow-up data was statistically significant at 1, 2, and 3 months after the last treatment (p-value < 0.05). The patient satisfaction score was statistically significant at 4, 7, and 10 weeks. Follow-up data were statistically significant at 1, 2, and 3 months after the last treatment (p-value < 0.05). No significant side effects were noted. Conclusion: The 1064-nm Q-switched Nd:YAG laser is a safe and effective modality for treating melasma in Asian patients.

Acrodermatitis enteropathica with anorexia nervosa

Acrodermatitis enteropathica is a rare hereditary or acquired disorder of hypozincemia. It is characterized by acral and periorificial dermatitis, alopecia, diarrhea and growth retardation. Anorexia nervosa is characterized by low body weight, body image distortion with an obsessive fear and is also associated with various cutaneous findings including acrodermatitis enteropathica. We report a 37‐year‐old female with acrodermatitis enteropathica showing acquired zinc deficiency with anorexia nervosa.

Majocchi's granuloma in a woman with iatrogenic Cushing's syndrome

Dear Editor, Majocchi’s granuloma (nodular granulomatous perifolliculitis) is a localized infection of dermal and subcutaneous tissue by dermatophytes, occurring usually in individuals who have chronic dermatophytosis but may be otherwise healthy. The initiating factor is thought to be physical trauma or immunosuppression that leads to disruption of the infected follicle in the dermis or subcutaneous tissue. Dermatophytes usually do not invade beyond the epidermis. However, direct or indirect mechanical breakage of the skin resulting from scratching or trauma and immunocompromised state may allow penetration of the fungi into the dermis. Cutaneous granuloma produced by infection with superficial fungi is infrequently recognized. Thus, a careful mycological examination is needed to make the diagnosis. A 63-year-old woman with iatrogenic Cushing’s syndrome referred to us with a 3-month history of a solitary gradually enlarging lesion. The lesion developed after being pricked by the grass on the left dorsal aspect of hand which was occasionally discharging yellow pus. On examination of the lesion of the left hand, there was an indurated, well-demarcated erythematous plaque 7 cm × 5 cm in diameter with some exudative crust (Fig. 1). Skin scrapings for KOH did not reveal any pathogens. Histopathological examination showed a ruptured hair follicle, epithelioid cell granulomas with multinucleated giant cells, epithelioid cells and some inflammatory cells. No hyphae and spores were noted within the ruptured hair follicle and epidermis (Figs 2,3), but chlamydospore-like spores were noted within the some multinucleated giant cells which were stained with D-periodic acid-Schiff (D-PAS) (Fig. 4). Several bizarre and irregular shaped hyphae and spores were noted in the dermis stained with Gomori methenamine silver (GMS). But, we did not know exactly what the chlamydospore-like fungal element was. At that time, Trichophyton mentagrophytes was identified by tissue fungal culture. The patient responded favorably to terbinafine (250 mg/day for 3 weeks) with progressive disappearance of the plaque. Majocchi’s granuloma is a uncommon infection of dermal and subcutaneous tissue by dermatophytes usually limited to the superficial epidermis. It may be divided into small perifollicular papular form in healthy individuals and deep plaque or nodular lesions in immunocompromised hosts. The

Post-steroid panniculitis in an adult.

Post‐steroid panniculitis is known to be very rare and most of the reported cases have been in children after corticosteroid therapy. We present a case of post‐steroid panniculitis occurring in a 60‐year‐old man after massive, long‐term administration of corticosteroids for acute exacerbation of chronic obstructive pulmonary disease (COPD). Histopathological examination of a nodule revealed a patchy area of fat necrosis, several multinucleated giant cells containing needle‐shaped clefts. The lesions subsided completely in approximately 12 weeks without any treatment. We suggest that post‐steroid panniculitis is not confined to childhood but also occurs in adulthood.

The Inhibitory Effect of Phytoclear-EL1 on Melanogenesis

BACKGROUND Phytoclear-EL1, an extract from Euphorbia lathyris seeds, has a whitening effect due to inhibition of tyrosinase activity. OBJECTIVE The purpose of this study was to investigate the inhibitory effect of phytoclear-EL1 on melanogenesis. METHODS Cultured B-16 melanoma cells and 30 human volunteers were used for in vitro and in vivo studies, respectively. Phytoclear-EL1 was added to the cultured B-16 melanoma cells, and applied to UVB-induced hyperpigmented lesions of human volunteers twice daily for 7 weeks. Changes in the number of B-16 melanoma cells, as well as changes in morphology, melanin content, and tyrosinase activity, were measured and then compared with the normal control and the 10(-3)M arbutin groups. Also, the effect of phytoclear-EL1 on UVB-induced hyperpigmented lesions was examined through subjective and objective measurements. RESULTS In the in vitro study (p<0.05), the number, melanin content, and tyrosinase activity of cultured B-16 melanoma cells were decreased in the 5microg/ml phytoclear-EL1 group compared to the control group. On objective assessment with a chromameter, the 0.2% phytoclear-EL1 group had a larger difference in the mean L values before and 7 weeks after applying phytoclear-EL1 as compared to the other groups. On subjective assessment by both the researchers and subjects 7 weeks after applying experimental materials, the 0.2% phytoclear-EL1 group and positive control (3% arbutin) had higher scores than the placebo groups. These results demonstrated that phytoclear-EL1 in vivo and in vitro had an inhibitory effect on melanogenesis. CONCLUSION Phytoclear-EL1 may be a candidate extract in the control of hyperpigmentary disorders.

Ultraviolet A1 Phototherapy of Mycosis Fungoides

Dear Editor: The efficacy of ultraviolet A1 (UVA1, 340~400 nm) in the treatment of mycosis fungoides (MF) appears to be equal to or better than psoralen UVA (PUVA), and may be more effective for nodular and thick plaque lesions1. There are several reports regarding the effectiveness of UVA1 for MF1,2. However, no study to date in Asians has described the patient response to UVA1 therapy for the treatment of MF according to a low-, medium-, or high-dose regimen. Fourteen patients with histologically proven MF (9 males, 5 females, mean age 43.8 years, age range 14~67 years) were enrolled in this study. The duration of diseases ranged from 2 months to 10 years (mean, 4.2 years). Ten patients (71.4%) had stage IA, 3 (21.4%) had stage IB, and 1 (7.1%) had stage IVB of the TNM staging system. Patients were treated with low-dose (20 J/cm2), medium-dose (65 J/cm2) or high-dose (100 J/cm2) UVA1. The UVA1 therapy was delivered by a SELLAMED 3000® (Sellas Medizinische Gerate GmbH, Gevelsberg, Germany). The main wavelengths were emitted from 340 nm to 400 nm. The irradiation intensity was 70 mW/cm2. The frequency of therapy was 3 to 5 times per week. Clinical response was graded as complete response (CR, 95~100%), partial response (PR, 50~95%), and no response (<50%). Biopsies were taken after treatment in 5 of 14 patients. Three patients were treated with low-dose UVA1 therapy. CR was observed in 3 patients (100%). None of the 3 patients with CR relapsed over a median period of 62 months after treatment. Seven patients were treated with medium-dose UVA1. Of the 7 patients, CRs and PRs were achieved in six (85.7%), and one (14.3%) patient, respectively. One of the 6 patients with CR relapsed after 30 months. The patient that relapsed achieved a CR after an additional 14 irradiations with medium-dose UVA1, and did not relapse for 34 months. None of the 5 patients with CR relapsed over a median period of 35 months after treatment. Four patients were treated with high-dose UVA1. Two patients exhibited a CR and 2 patients had a PR. In 1 of the 2 patients with CR, the skin lesions relapsed. The relapsed patient showed a CR after 39 treatment sessions of UVA1, but the skin lesions relapsed after another 6 months. This patient again achieved a CR after 11 more irradiations with high-dose UVA1 and did not relapse for 35 months. The other patient who exhibited CR did not relapse at a follow-up of 33 months. Among the 14 patients with MF treated in our study, CRs and PRs were observed in 11 (78.5%) and 3 (21.5%) patients, respectively (Fig. 1). The mean number of treatments in patients with a CR was 22.0 within a mean time of 41.3 months (range, 2~120 months). In this study, CR was observed between 9 and 50 exposures regardless of the dosages of UVA1. In low-dose UVA1 therapy, CR was observed in all 3 patients after a mean number of 16.7 UVA1-irradiations. In medium-dose UVA1 therapy, CR was observed in 6 patients after a mean number of 24.2 UVA1-irradiations. In high-dose UVA1 therapy, CR was observed in 2 patients after a mean number of 36 UVA1-irradiations. Fig. 1 (A) Clinical feature of a patient with mycosis fungoides palmaris et plantaris before treatment (case 1). (B) Complete response of active disease after 13 treatments with low-dose ultraviolet A1. During patient follow-up (range 21 to 88 months), only 2 of 14 patients relapsed. The 2 relapsed patients responded faster to a second course of UVA1 therapy than the first treatment suggesting that acute lesions quickly responded to UVA1 therapy. Five patients were evaluated histopathologically after completed treatment. CRs and PRs were observed in 4 and 1 patients, respectively. No serious adverse effects were observed except for hyperpigmentation (Table 1). Table 1 Characteristics and clinical response of patients with mycosis fungoides treated with UVA1 therapy Currently, phototherapy is a main treatment option in early stage MF. In a meta-analysis study, CR rates ranged from 54% to 91% in patients with MF treated with narrowband ultraviolet B1 (NB-UVB) or PUVA3. In addition, UVA1 phototherapy also has a favorable and fast therapeutic effectiveness in localized thick and nodular lesions. Our study showed a 78.5% overall complete remission rate. The effectiveness of UVA1 can be related to its penetration depth and ability to mediate different forms of apoptosis. Specifically, UVA1 penetrates deeper than PUVA and NB-UVB4,5. Thus, the duration of CR by UVA1 is typically shorter than PUVA and NB-UVB for palmar or plantar MF. In addition, UVA1 can induce both a protein synthesis dependent (programmed cell death) and protein synthesis independent (pre-programmed cell death) apoptotic mechanism6,7. Furthermore, UVA1 phototherapy has no adverse effect of psoralen sensitization. Plettenberg et al.2 demonstrated that medium and high-dose UVA1 phototherapy leads to complete clearance. In another study, one patient with MF (stage III) showed marked improvement after 15 sessions of medium-dose UVA18. These results showed medium-dose UVA1 is sufficient to induce marked apoptosis in dermal T-cells. Zane et al.1 reported that 11 of 13 patients treated with high-dose UVA1 showed CR, with 7 of the patients who exhibited a CR not experiencing recurrence during a mean follow-up of 7.2 months, while the other 4 patients relapsed within 3 months. Yamauchi et al.7 found that malignant T cells are more sensitive than normal cells in UVA1 radiation-induced apoptosis. In addition, good therapeutic responses were observed in both medium- and high-dose UVA1. As a consequence, they did not use the high-dose regimen in the treatment of MF. We also observed the therapeutic improvement in all low-, medium- and high-dose UVA1. Thus, the results of our study suggest that the therapeutic effectiveness for MF may be unrelated to UVA1 dose. UVA1 may cause minimal erythema, burning sensation, dryness and hyperpigmentation as short-term side effects. The long-term side effects such as carcinogenesis have so far not been established. Although high doses of UVA1 induced carcinogenesis in some studies, there have been few reported cases of malignant skin cancer9,10. However, based on this observation, a lower cumulative dose from the use of low- and medium-dose UVA1 is likely advantageous compared with a high-dose UVA1 regimen. Our data indicate that UVA1 phototherapy is a well tolerated therapeutic treatment, with excellent results in patients with MF, irrespective of the dose regimen.