Botulinum Toxin Type A for Facial Wrinkles and Benign Masseter Hypertrophy in Korean Patients / 대한피부과학회지

BACKGROUND: The utilization of botulinum toxin has rapidly expanded into various aesthetic applications. Achieving success with the aesthetic use of neurotoxins depends on several factors, including an understanding of the anatomy, the methods of dilution and the injection technique. Any guidelines representing a consensus for aesthetic treatments using botulinum toxin type A (BTA) have not been published in Korea. OBJECTIVE: We wanted to provide consensus recommendations on the treatment of facial wrinkles and benign masseter hypertrophy using BTA in Korean patients. METHODS: A panel of experienced Korean dermatologists was convened to develop a clinical consensus. The clinical consensus was comprised of the recommendations of the panel and the guidelines on general issues, such as the reconstitution and handling of the BTA, the procedural considerations, the dosing and injection-site standardizations, and the prevention and treatment of unwanted effects. Specific recommendations were provided according to the area of treatment, including glabellar lines, horizontal forehead lines, lateral periorbital wrinkles and benign masseter hypertrophy. RESULTS: The recommended final concentration of BTA was 50 units/ml (5 units/0.1 ml) after reconstitution with physiologic saline. For glabellar lines, the members recommend three injection points (a total of 8 units). For forehead wrinkles, the members recommend nine injections in two rows into the frontalis with 1 unit/point. For crow's feet, the members recommend three injections per side (7 units/side) at the lateral part of the orbicularis oculi. For benign masseter hypertrophy, three injections per side (24~30 units/side) were recommended. CONCLUSION: These consensus recommendations will provide a framework for Korean dermatologists who wish to perform safe and efficacious injection of BTA for facial rejuvenation.

Three Cases of Cutis Marmorata Telangiectatica Congenita

We report 3 cases of unusual cutis marmorata telangiectatica congenita (CMTC). The ages of the first two cases of CMTC were premature babies, born at intrauterine pregnancy of 31 weeks and 34 weeks. the other patient was a 45-year old female. Compared to the age of other cases reported in the literature our patients ages are unusual. It is not surprising that the first two cases of premature babies had typical signs because CMTC is a congenital disorder, usually seen at birth, but the fact that the skin lesion of CMTC appeared already in the early third trimester may provide some clues to the pathogenesis of CMTC. The third case seems to be very rare because most reported cases show that the skin lesion usually disappear gradually over a period of months to years. The site and size of the lesion in the last case was told to have been fixed for 45 years without any change.

Livedoid Vasculitis: a Clinico-Pathological Study of 19 Patients / 대한피부과학회지

BACKGROUND: Livedoid vasculitis is a distinctive dermatosis characterized by recurrent chronic ulceration and infiltrated purpuric papules on the lower limbs. OBJECTIVE: The purpose of this study was aimed at evaluating the clinical and histopathological features of livedoid vasculitis. METHODS: The hospital charts and histopathologic slides of patients with livedoid vasculitis diagnosed at Asan Medical Center from 1989 to 1999 were reviewed. RESULTS: Twelve male and seven female patients were enrolled in this study(M: F=1.7: 1). The mean age at onset was 30.3 years in men and 25.3 years in women. The mean duration of illness was 3.3 years in male patients and 5.7 years in female patients. All the patients were presented with recurrent chronic ulceration and atrophic scarring. Twelve patients(63.2%) complained of severe pain and tenderness of the lesions and 5 patients(26.3%) complained of itching sensation. In three patients(15.8%), the lesions developed or aggravated in summer. Alcohol intake was aggravating factor in two patients(10.5%) and smoking was in one patient(5.3%). In five patients(26.3%), livedoid vasculitis develops in association with several diseases. Associated diseases were diabetes mellitus in 2 patients(10.5%), antiphospholipids antibody syndrome in 2 patients(10.5%), and protein S deficiency in 1 patient(5.3%). Histopathological examination revealed hyalinized blood vessels, partial to complete obstruction of dermal blood vessels with fibrinoid thrombi, endothelial swelling, and extravasation of RBCs in upper and mid-dermis. Panniculitis-like feature was common finding(73%). In six patients(31%), moderate to severe inflammatory reaction was observed in dermis. Five patients were treated with aspirin, dipyridamole, and pentoxifylline, and among them, only 1 patient(20%) were improved. All the treatment response including pentoxifylline alone, or pentoxifylline plus aspirin, dipyridamole, or corticosteroid was unsatisfactory. In cases of three patients whom were treated with low-dose danazol, all the patients(100%) showed marked improvement. One patient was treated with dapsone with improvement. CONCLUSION: Livedoid vasculitis is a distinct dermatosis with characteristic clinico-pathological features. Low-dose danazol or dapsone may be useful therapeutic options in this intractable disease.

Angiolymphoid Hyperplasia with Eosinophilia and Kimura's Disease: a Clinico-Pathologic Study in Korea / 대한피부과학회지

BACKGROUND: There has been considerable controversy about the relationship between angiolymphoid hyperplasia with eosinophilia(ALHE) and Kimura's disease. Recent reports have suggested that they are two different diseases. OBJECTIVE: The purposes of this study was aimed at evaluating the clinical and histopathological characteristics of ALHE and Kimura"s disease and differential points between them. METHODS: The hospital charts and histopathologic slides of 5 patients with ALHE and 2 patients with Kimura's disease diagnosed at Asan Medical Center from 1989 to 2000 were reviewed. We also reviewed the previously published reports of the patients with ALHE and Kimura's disease in Korea. In total, we studied 14 cases of ALHE and 29 of Kimura's disease. RESULTS: 1.Eight male and six female patients(M:F=1.3:1) were enrolled in ALHE group and twenty-four male and five female(M:F=4.8:1) in Kimura's disease. The mean age at diagnosis of ALHE was 25 years in men and 40 years in women. The mean age of Kimura's disease was 30 years in men and 33 years in women. 2.Head and neck were the most frequently involved sites in ALHE(92.9%) and Kimura's disease(89.7%). Especially, among the sites, the ear(57.1%) in ALHE and the mandible(44.8%) in Kimura's disease were the most commonly involved. One patient(7.1%) with ALHE and three(10.3%) with Kimura's disease had the lesions bilaterally. 3.Pruritus was the most common symptom in both the diseases. Lymphadenopathy was present in only one patient with ALHE, whereas 51.7% of patients with Kimura's disease had it. One patient with ALHE had underlying arteriovenous malformation. One case showing pregnancy-associated Kimura's disease was reported. Gastric lymphoma was followed in one case of Kimura's disease. 4.Laboratory investigation showed hypereosinophilia in 41.7% of patients with ALHE(5/12) and 96.4% of Kimura's disease(27/28). Elevated IgE was in 2 cases of ALHE(2/4) and 5 cases of Kimura's disease(5/6). 5.Histopathological examination revealed that angioproliferating lesion comprised of plump epithelioid or histiocytoid endothelial cells and accompanying eosinophils and lymphocytes characterized ALHE. In contrast, Kimura's disease was characterized by deeper lesions showing proliferation of vascular structure with less plump endothelial cells and more fibrotic stroma with many lymphoid follicular structures 6.ALHE was improved with CO2 laser, electrocautery, excision, embolization of underlying arteriovenous malformation and dapsone. However, Kimura's disease tended to recur despite various treatment modalities. CONCLUSIONS: In Korea, Kimura's disease was more common than ALHE. ALHE and Kimura's disease may be different diseases because they showed different clinical and histopathological features.

The Expression of Elafin and Its Implication in the Inflammatory and Keratinizing Disorders of the Skin / 대한피부과학회지

BACKGROUND: Elafin is a serine proteinase inhibitor first discovered in keratinocytes from psoriatic epidermis. The molecular structure of elafin contains two different functional domains; one for the proteinase inhibitor, which is directed against elastase and proteinase-3, and the other for transglutaminase substrate. As this unique structural characteristic implies, elafin would be expected to have two distinct biologic functions in tissues. But, the roles and biological features of elafin have not been extensively studied in the skin. OBJECTIVES: This study was designed to demonstrate the immunohistochemical localization of elafin in inflammatory and keratinizing skin disorders, and to elucidate its biological functions. MATERIALS AND METHODS: The pre-elafin sequence was amplified by PCR using a human epidermal cDNA library and expression construct which was ligated into an expression vector. Then, the expressed proelafin sequence was purified and injected intradermally into rabbits to raise a polyclonal antibody. The skin biopsy samples of various skin diseases and normal controls were used for immunohistochemical staining to detect elafin expression. RESULTS: 1)Expression of elafin was observed in infected epidermis, and is believed to be involved in the defense mechanism of the skin. 2)In dermal and subcutaneous inflammatory diseases, epidermal elafin expression was influenced by the location of the inflammation. 3)Elafin was expressed in bullous dermatoses accompanied by acantholysis or spongiosis of epidermal cells. 4)Expression of elafin was upregulated in papulosquamous skin diseases which was characterized by epidermal hyperplasia and abnormal differentiation. 5)Elafin was expressed in keratinizing skin diseases that was accompanied by abnormal differentiation of epidermal cells. 6)Expression of elafin was demonstrated in skin tumors that showed proliferation of suprabasal cells. The intensity of expression is not related to the degree of malignancy, but to the degree of differentiation of tumor cells. CONCLUSION: Induction of elafin expression may play an important role in protecting the skin components against tissue damage. Elafin expression is related to the abnormal proliferation and differentiation of suprabasal cells. This means that elafin may be used as a marker of these conditions.

Coexistence of Porokeratosis of Mibelli and Disseminated Superficial Actinic Porokeratosis(DSAP)

There have been several reports of more than one type of porokeratosis occurring in the same family or the same individual. We hope to support the view of different phenotypic expressions of a common genetic aberration by describing an additional case of porokeratosis of Mibelli on the perianal area and DSAP on the face, forearms occurring in a 45-year-old man.

A Case of Neutrophilic Eccrine Hidradenitis / 대한피부과학회지

Neutrophilic eccrine hidradenitis(NEH) is a self-limited inflammatory dermatosis primarily induced by chemotherapeutic agents. The pathogenesis and possible cause of NEH remain unknown. NEH may represent as a reaction pattern to chemotherapeutic agents or bacterial infection. Also it is developed on palmoplantar areas in healthy children or young adults. In some cases it is developed as a paraneoplastic phenomenon. We report a case of neutrophilic eccrine hidradenitis that developed in a patient suffering from aplastic anemia after or during treatment with cyclosporine, oxymetholone and folic acid.

Expression of Elafin in the Epidermis of Cutaneous Fungal Infection / 감염

BACKGROUND: Elafin is a serine proteinase inhibitor first discovered in keratinocytes from hyperproliferative human epidermis. In addition to the proteinase inhibiting domain, elafin contains multiple transglutaminase substrate domains which enable cross-linking to extracellular and cell envelope proteins. Several characteristics of elafin suggest potential anti-microbial activity. Elafin is absent in normal skin at protein level, but is induced in inflammatory and infectious dermatoses which threat the epidermal integrity by vesicopustule formation and neutrophilic cell infiltration. Cutaneous fungal infection is one of the well-known examples of diseases characterized by such condition. The purpose of this study was to check out the possibility that elafin may be involved in the pathomechanism of fungal infection. METHODS: The biopsy samples taken from 10 cases of superficial fungal infections, 10 cases of deep and systemic mycoses, 2 cases of slide culture specimens of Candida species, were used for the immunohistochemical tissue staining for elafin expression. Polyclonal anti-elafin was used in 1:300 dilution. As control, biopsy smaples of normal skin, ichthyosis, psoriasis were used for the staining for elafin expression. RESULTS: In the normal and ichthyotic epidermis, elafin expression was virtually negative. In superficial mycoses except candidiasis, elafin was expressed in the spinous layer of infected epidermis, and fungal structures in the stratum corneum were stained with elafin antisera. In the cases of dermatophytosis of ichthyosis patients, while fungal hyphae were stained with elafin antisera, epidermal cell did not express elafin. In candidial esophagitis, elafin was expressed in the esophgeal mucosa, but spores were not stained with elafin anti-sera. In slide culture of Candida species, spores were not stained with elafin antisera, also. In cases of systemic and deep mycoses, fungal hyphae and spores were stained with elafin antisera and epidermis adjacent to severe dermal inflammatory reaction showed elafin expression. CONCLUSION: Elafin may have certain role in systemic and cutaneous fungal infection to contribute to high resistance of the epidermis against proteolysis and fungal infections, and it is shown that elafin or elafin-like protein may also be produced and utilized by fungi themselves.

A Case of Granuloma Gluteale Infantum / 대한피부과학회지

Granuloma gluteale infantum has been applied to a condition arising as a complication of primary irritant dermatitis. Plastic pants, and the use of topical corticosteroids to treat diaper dermatitis are believed to be important precipitating factors. Candida albicans has been considered as an etiologic agent. The characteristic lesions are violaceous, oval nodules, occuring on the convexities of the diaper area in 2- to 9-month-old infants with a history of diaper dermatitis. We report a case of granuloma gluteale infantum that developed in a 3 month-old infant who had multiple violaceous nodules over the diaper area of the genitocrural region.

A Case of Intramucosal Nevus Occuring in the Gingiva / 대한피부과학회지

Nevus cell nevi and melanocytic nevi are much less common in the oral cavity than on the skin. In the oral cavity, the intramucosal(intradermal) nevus is the most common type, followed by the common blue nevus and the compound nevus. We describe a case of a 32-year-old woman who had an intramucosal nevus with pigmented, verrucous surface arising from the gingiva. The lesion had been excised completely and showed no evidence of recurrence.

Analysis of the Effects of Macrophage Colony Stimulating Factor with Image Analysis in Tattoo Removal Using Alexandrite Laser Surgery / 대한피부과학회지

BACKGROUND: Tattoos are acquired pigmented lesions of the skin, and the Q-switched alexandrite laser has been shown to be effective in removing blue-black as well as green, red and mauve colored tattoos. Following the laser therapy, macrophage phagocytes the altered pigment. Macrophage-colony stimulating factor(M-CSF) may influence the macrophage activities. OBJECTIVE: This study was conducted to evaluate the potential adjunctive effect of M-CSF in tattoo removal with laser treatment. METHOD: A prospective study was taken, in 8 guinea pigs and 8 mice, to evaluate the clinical and histopathological clearing of tattoo pigment following the laser treatment of the tattoo at the M-CSF injection site. RESULTS: 1) Clinically, the tattoo resolved more rapidly with Alexandrite laser therapy in the M-CSF treated group. 2) Histopathologically, by using image analysis, there was no significant difference in the relative ratio of dermal tattoo pigment and tattoo containing cells, between laser treated(1.54% in guinea pig, 1.09% in mouse) and laser with M-CSF treated group(1.44% in guinea pig, 0.95% in mouse). CONCLUSION: Our study reveals the role of M-CSF as an adjuvant in tattoo removal using Alexandrite laser surgery. However, further prospective animal studies and human trials, are needed to evaluate the action mechanism of M-CSF at the intradermal injection.

Statitical Techniques Reported in Korean Dermatology Journals During 1990-1994

BACKGROUND: Effective evaluation of an article's scientific merit requires familiarity with the methodology described, especially when quantitative techniques, such as statistical procedures, are invoked to clarify research findings or to summarize data. OBJECTIVE: The purpose of this study was to describe the frequency with which various statistical concepts were reported in journals important to dermatology. From these results, dermatologists can identify the major statistical skills needed to critically evaluate their literature. METHODS: All 376 original articles of the Korean Journal of Dermatology(KJD) and the Annals of Dermatology(KAD) during 1990-1994 were chosen for review. Each article was re-viewed to determine the statistical content. RESULTS: The two most commonly used statistical techniques in the two journals were mean and standard deviation. The t-test was the next most frequently used statistical technique in the reviewed journals, followed by non-parametric, chi-square test, orphan p, ANOVA, and correlation/regression. CONCLUSION: These results indicate the need for wider education about the use of descriptive and basic comparative statistics. It is impossible to evaluate the dermatological literature critically without these skills.

A Case of Primary Cutaneous Mucormycosis in a Immunocompetent Patient / 대한피부과학회지

Mucormycosis is an infectious disease caused by fungi of the order Mucorales. Almost all patients have a serious uriderlying condition such as diabetes mallitus, imrnunosuppression, starvation, burn, but a few cais have been reported in previously heilthy subjects. In order to successfully treat this infection, diagnosis must be prompt and acior. panied by aggressive debridement and parenteral administration of amphotericin B. We report a case of primary cutaneous mucormycosis in 58-year-old man. The lesion was a well-circumscribed erythematous plaque with central necrcis Histopathologically, a biopsy revealed broad, nonsptate with branches occuring at right anghles.

A Clinical Observation on Systemic Lupus Erythematosus / 대한피부과학회지

BACKGROUND: Systemic lupus erythematosus(SLE) is a clinical syndrome of unknown causes characterized by inflammat.ion and multisystem involvement. Since Hargravas describe the LE cell in 1948, a profound change has occured in the concept of SLE. Many studies of the large series have been reported in the West, but few collective studies have been reported in Korea. OBJECTIVE: The goal of this study was to elucidate the clinical and laboratory characteristics of SLE in Korean people. METHODS: We carried out retrospective study of 64 patients, who were diagnosed as SLE on the base of the 1982 revised bacteria for the SLE by American Collepe of Rheumatology(formerly, American Rheumatism Association), at Korea University Hospital from 1982 to 1991. The results were compared with those of previous studies in Korea and western countries. RESULTS: 1. In 64 patients with SLE, female patients outnumbered male by 6.1 to 1 and the mean age of onset was 28.6 years. 2. The initial manifestations were arthritis or arthralgia, 25%; fatigue, malaise, weight, loss, 21.8%; facial rash or blush, 12.5%, fever, 12.5%. 3. The major clinical manifastations were hematologic(90.6 %), muccutaneous(89%), musculoskeleta (79.7%), and renal(73.4%) involvemant. 4. The ANA test were positive in 83.9% of the patients, and homoenous pattern was most common. There was no significant difference of organ involvement according to the nuclear patterns of ANA, but cardiopulmonary, renal involvement, hypocomplement,emia and positive anti-ds DNA were less frequent in ANA neghative group. 5. In 73.7% of the patients, the titers of anti-ds DNA antibody was elevated. The amount of anti-ds DNA Ab in serum did not always correlate with disease activity. 6. Photosensitivity, arthritis or arthralgia and CNS manifestatioris were less common, but hematologic findings, including anenia and leukopenia were more common in Korean than western reports. CONCLUSION: Patients with SLE are heterogenous in the natural h story of their disease, which is not an uncommon disease in Korea. Continued efforts to clarify the immunopathologic basis for SLE should eventually lead to more effective treatment.

Quantification of Nucleolar Organizer Regions in Skin Tumors

BACKGROUND: Nucleolar organizer regions (NORs) have recently attracted much attention because of claims that their frequency within nuclei is significantly higher in malignant cells than in normal, reactive, or benign neoplastic cells. OBJECTIVE: The purpose of this paper is to analyze a method allowing selection of the best morphometric criterion for quantifying AgNOR proteins under conventional observation conditions by light microscopy. METHOD: We tried to investigate the various parameters including NORs counting in cutaneous tumors using image analysis system. RESULTS: There were significant differences in mean nucleus area per a AgNOR, nucleus area between the benign and potentially malignant group. But the conventional counting of AgNORs is not able to differentiate between the two groups. We could discriminate squamous cell carcinoma from Bowen's disease using parameters of mean ratio of AgNORs area per nucleus area, mean ratio of greatest AgNORs area per nucleus area, coefficient of variation (C V) of nucleus area, and mean area of largest AgNORs. In squamous cell carcinoma and keratoacanthoma, C V of nucleus area has shown a significant difference. CONCLUSION: Study of AgNORs using image analysis system is a useful tool for the diagnosis of cutaneous tumors.

A case of Ki-1 positive large-cell lymphoma / 대한피부과학회지

In 1985, Stein et al, indentified an anaplastic large-cell malignant lymphoma that was distinctive because of the diffuse dermal infiltration of pleomorphic large lymphocytes, sinus growth pattern, and reactivity with the monoclonal antibody Ki-1(CD30). The clinical feature; distinguishing anaplastic large-cell Ki-1 lymphoma include a young median age, frequent peripheral adenopathy with sparing of the mediastinum, and extranodal disease with skin the most common sitc of involvement. We report a case of Ki-1 postive large-cell lymphoma in a 74-year-old male patient who presented with multiple ulcerated nodules on the right shin area.

Two cases of allergic contact dermatitis to sodium fusidate / 대한피부과학회지

Sodium fusidate, obtained by fermentation of the fungus, Fusidium coccineum, has a steroid structure and shows a very high antitaphycoccal activity. The allergic potentirl of sodium fusidate is low and few cases of contact allergy to sodium fusidate have been reported. We present two cases of allergic contact dermatitis to Fucidin cintentione developed postoperative dressing of a skin biopsy and the other after laser treatment of a vascular nevi. The patch test results showed positive reaction to sodium fusidate in both cases.

A case of allergic contact dermatitis due to clindamycin solution / 대한피부과학회지

Contact allergy to clindamycin is rare, especially in relation to its widespread use in topical formulation. Neverthless, when patients using topical clindamycin complain of itching, patch testing with this preparation and its separate ingredients should be considered. We report a case of allergic contact dermatitis due to clindamycin solution for acne vulgaris therapy in a 24-year-old woman.

A case of eccrine epithelioma / 대한피부과학회지

Eccrine epithelioma is an exceedingly rare cutaneous tumor ancit is believed to represent the maligant counterpart of the eccrine dermal syringoma. It occirs as an infiltrating basaloid growth, usually on the scalp or head, that frequently recur, apparrntly because of inadequate excision. We report a case of this tumor in a 60-year-old female, who showed a well demarcated, tender nodule on her left parietal scalp which had been present for three years. Histopat.hologically, the tumor was composed of strands of darkly staining epithelial cell embedded in a dense fihrcus stroma with ductal differentiation and cyst formation.