Consensus Guidelines for the Treatment of Atopic Dermatitis in Korea (Part I): General Management and Topical Treatment

BACKGROUND: Since the treatment guidelines for atopic dermatitis (AD) were released by the Korean Atopic Dermatitis Association (KADA) work group in 2006, there have been several advances in AD management. OBJECTIVE: We aimed to establish updated evidence- and experience-based treatment guidelines for Korean AD. METHODS: We collected a database of references from relevant systematic AD reviews and guidelines regarding general AD management such as bathing and skin care, avoidance of exacerbating factors, education and psychosocial support, and the use of moisturizers and topical anti-inflammatory and antipruritic drugs. Evidence for each statement was graded and the strength of the recommendation for each statement classified. Thirty-nine KADA council members participated in three rounds of voting to establish an expert consensus of recommendations. RESULTS: Basic AD treatment includes proper bathing and skin care, avoidance of exacerbating factors, proper education and psychosocial support, and use of moisturizers. The regular use of moisturizer has a steroid-sparing effect and reduces relapse episodes. The short- and long-term use of topical corticosteroids and calcineurin inhibitors improves AD symptoms and should be encouraged to use in an active and proactive treatment. Wet-wrap therapy can be used for rapid recovery of acute exacerbation. Topical antipruritic drugs cannot be recommended for the treatment of AD. CONCLUSION: This report provides up-to-date evidence- and experience-based treatment guidelines for AD regarding general management and topical treatment. In addition, the average agreement scores obtained by a panel of experts based on the Korean healthcare system and patient adherence are presented.

Consensus Guidelines for the Treatment of Atopic Dermatitis in Korea (Part II): Systemic Treatment

BACKGROUND: Since the treatment guidelines for atopic dermatitis (AD) were issued by the Korean Atopic Dermatitis Association (KADA) work group in 2006, there have been further advances in the systemic treatment of AD. OBJECTIVE: We aimed to establish updated evidence- and experience-based systemic treatment guidelines for Korean AD. METHODS: We compiled a database of references from relevant systematic reviews and guidelines regarding the systemic management of AD, including antihistamines, antimicrobials, systemic immunomodulators, allergen-specific immunotherapy, phototherapy, adjunctive treatment, and complementary and alternative medicines. Evidence for each statement was graded and classified based on the strength of the recommendation. Thirty-nine council members of KADA participated in the three rounds of votes and expert consensus recommendations were established. RESULTS: The use of antihistamines is recommended to relieve pruritus and to prevent exacerbation due to scratching in AD patients. Infection should be controlled as needed and long-term medication should be avoided. For moderate to severe AD patients, concomitant active treatments with systemic immunomodulators are indicated. Cyclosporine is the first choice among systemic immunomodulators and others should be considered as second-line alternatives. Allergen-specific immunotherapy could be effective in AD patients with aeroallergen hypersensitivity. Phototherapy can be useful for moderate to severe AD patients and narrow-band ultraviolet B is the most effective option. Complementary and alternative medicines cannot be recommended for treating AD. CONCLUSION: We expect these recommendations to be a reference guide for physicians and AD patients in choosing the appropriate treatment to improve quality of life and decrease unnecessary social medical costs.

Consensus Guidelines for the Treatment of Atopic Dermatitis in Korea (Part I): General Management and Topical Treatment

BACKGROUND: Since the treatment guidelines for atopic dermatitis (AD) were released by the Korean Atopic Dermatitis Association (KADA) work group in 2006, there have been several advances in AD management. OBJECTIVE: We aimed to establish updated evidence- and experience-based treatment guidelines for Korean AD. METHODS: We collected a database of references from relevant systematic AD reviews and guidelines regarding general AD management such as bathing and skin care, avoidance of exacerbating factors, education and psychosocial support, and the use of moisturizers and topical anti-inflammatory and antipruritic drugs. Evidence for each statement was graded and the strength of the recommendation for each statement classified. Thirty-nine KADA council members participated in three rounds of voting to establish an expert consensus of recommendations. RESULTS: Basic AD treatment includes proper bathing and skin care, avoidance of exacerbating factors, proper education and psychosocial support, and use of moisturizers. The regular use of moisturizer has a steroid-sparing effect and reduces relapse episodes. The short- and long-term use of topical corticosteroids and calcineurin inhibitors improves AD symptoms and should be encouraged to use in an active and proactive treatment. Wet-wrap therapy can be used for rapid recovery of acute exacerbation. Topical antipruritic drugs cannot be recommended for the treatment of AD. CONCLUSION: This report provides up-to-date evidence- and experience-based treatment guidelines for AD regarding general management and topical treatment. In addition, the average agreement scores obtained by a panel of experts based on the Korean healthcare system and patient adherence are presented.

Consensus Guidelines for the Treatment of Atopic Dermatitis in Korea (Part II): Systemic Treatment

BACKGROUND: Since the treatment guidelines for atopic dermatitis (AD) were issued by the Korean Atopic Dermatitis Association (KADA) work group in 2006, there have been further advances in the systemic treatment of AD. OBJECTIVE: We aimed to establish updated evidence- and experience-based systemic treatment guidelines for Korean AD. METHODS: We compiled a database of references from relevant systematic reviews and guidelines regarding the systemic management of AD, including antihistamines, antimicrobials, systemic immunomodulators, allergen-specific immunotherapy, phototherapy, adjunctive treatment, and complementary and alternative medicines. Evidence for each statement was graded and classified based on the strength of the recommendation. Thirty-nine council members of KADA participated in the three rounds of votes and expert consensus recommendations were established. RESULTS: The use of antihistamines is recommended to relieve pruritus and to prevent exacerbation due to scratching in AD patients. Infection should be controlled as needed and long-term medication should be avoided. For moderate to severe AD patients, concomitant active treatments with systemic immunomodulators are indicated. Cyclosporine is the first choice among systemic immunomodulators and others should be considered as second-line alternatives. Allergen-specific immunotherapy could be effective in AD patients with aeroallergen hypersensitivity. Phototherapy can be useful for moderate to severe AD patients and narrow-band ultraviolet B is the most effective option. Complementary and alternative medicines cannot be recommended for treating AD. CONCLUSION: We expect these recommendations to be a reference guide for physicians and AD patients in choosing the appropriate treatment to improve quality of life and decrease unnecessary social medical costs.

The Relationship between Anti-Pityrosporum IgE Level and Clinical Manifestations in Atopic Dermatitis Patients with Head and Neck Dermatitis / 대한피부과학회지

BACKGROUND: Head and neck dermatitis is a variant of atopic dermatitis often seen in young adult. Though the pathogenesis of atopic dermatitis is still not well elucidated, Pityrosporum is considered to be one of the triggering factors for head and neck dermatitis. OBJECTIVE: We investigated the relationship between Pityrosporum infection and clinical features of head and neck dermatitis patients. METHODS: We evaluated anti-Pityrosporum IgE levels using RAST method in 68 outpatients with atopic dermatitis and other allergen specific antigens with MAST-CLA techniques. RESULTS: Among the 68 atopic dermatitis, 36 were diagnosed as atopic dermatitis with head and neck dermatitis and 24 out of 36 head and neck dermatitis patients showed RAST positive for Pityrosporum and the level of RAST was higher than atopic dermatitis patients without head and neck dermatitis with correlation coefficient (p<0.05). The severity of erythema and eczematous reaction was also correlated with the positivity of RAST with statistical significance (p<0.05). CONCLUSION: From these results, we speculate Pityrosporum can influence the severity and clinical manifestations in atopic dermatitis patients with head and neck dermatitis.

Multiple and Recalcitrant Warts Treated with Oral Acitretin

BACKGROUND: Acitretin, a synthetic retinoid, has been used to treat patients with psoriasis, Darier's disease, ichthyosis, keratosis pilaris etc. Some trials have suggested that oral acitretin may be useful for the treatment of warts. OBJECTIVE: The purpose was to determine whether oral acitretin is effective in the treatment of multiple and recalcitrant warts. METHODS: 25 patients with multiple and recalcitrant warts were enrolled. We administered acitretin, 30 mg daily in adults, and 0.5 mg/kg daily in children. At the end of the treatment, 21 patients were examined to determine the efficacy of the treatment. RESULTS: Of the 21 patients, 10 patients (48%) showed a complete response, 3 (14%) showed a moderate response, 4 (19%) showed a partial response, and 4 (19%) showed no response. Therefore, the patients showing more than a moderate response were 62% (13 of 21). An abnormal laboratory finding was not detected and adverse effects were common but tolerable in most patients. CONCLUSION: Oral acitretin may be useful for the treatment of extensive and reclacitrant warts, especially verruca plantaris.

Vasopressin-induced Skin Necrosis / 대한피부과학회지

Intravenous vasopressin is a commonly used modality for the control of bleeding of the esophageal varices. The ischemic cutaneous necrosis by vassopressin can be occurred at extravasated sites, or proximal to an intravenous catheter site, or at isolated pressure points. We report a case of cutaneous necrosis which occurred at intravenous catheter sites and at distant sites from direct intravenous flow during vasopressin therapy.

A Case of Botryomycosis Occurring at the Axilla of the Patient with Acute Myeloid Leukemia / 대한피부과학회지

Botryomycosis is a rare bacterial infection that may mimic fungal disease both clinically and histologically. Cutaneous botryomycosis usually appears as nodules, sinuses, fistulae, abscesses, and ulcers with seropustular secretion. Histopathological findings are characterized by chronic nonspecific inflammatory lesions composed of neutrophils, lymphocytes, eosinophils and plasma cells. The characteristic suppurative foci contained granuloma with a basophilic center and an eosinophilic periphery. Successful treatment often requires a combination of both surgical debridement and long-term antimicrobial therapy. The predisposing factor included skin trauma, postoperative complication, diabetus mellitus, liver disorder, long-term steroid therapy, alcholism, and cystic fib rosis. Here we report a patient who had suppurative nodule with induration at the axilla. Staphylococcus aureus was cultured from the lesion. Our patient responded to systemic antimicrobial therapy and surgical debridement.

Analysis The Prognostic Factors of Alopecia Areata / 대한피부과학회지

BACKGROUND: Alopecia areata usually has a complete recovery rate in most patients, but others eventually develop the severe chronic form. Unfortunately, its course and response rates are variable and unpredictable. OBJECTIVE: To identify patient and treatment factors predictive of therapeutic success and to develop a practical model for predicting patient response. METHODS: The medical records of 189 patients with alopecia areata from 1998 to 2001 at the Department of Dermatology, Chungnam National university hospital were reviewed. Most patients were treated by corticosteroids (topical, intralesional, and systemic). RESULTS: Variables independently associated with clinically significant regrowth were the duration between initiation of therapy, baseline extent of alopecia areata. 1. Both partial response and no response (PR+NR): long duration between initiation of therapy (>3month; especially >12 months), baseline extent of alopecia areata (>25%; especially 100%- alopecia totalis and universalis) and male patients. 2. Duration between initiation of therapy: Cosmetically acceptable hair regrowth was obtained in 6% of patients over 12 months, 57% with 4 to 12 months and 97% 0 to 3 months. So, it is better to start treating within 3 months; and at least within 12 months. 3. Baseline extent of alopecia areata: Cosmetically acceptable hair regrowth was obtained in 27% of patients with alopecia totalis/universalis, 64% with 26 to 99%, and 94% with below 25% alopecia areata. So, it showed a good response when below 25 %, but a poor response at above 25%, specially for 100%. CONCLUSION: These findings suggest that when the duration between initiation of therapy (>12 months) and the baseline extent of alopecia areata increases, the therapeutic effect decreases. A predictive model (decision tree) has been developed to assist with patient prognostication and counseling.

A Case of Subcutaneous Panniculitic T-cell Lymphoma Involved in Skin and Central Nervous System / 대한피부과학회지

Subcutaneous panniculitic T-cell lymphoma(SPTCL) is categorized as a rare subtype of peripheral T-cell lymphoma. It is characterized by primary involvement of the subcutaneous fat in a manner mimicking panniculitis with/without hemophagocytic syndrome. They share a generally aggressive course and are highly associated with Epstein-Barr virus infection. EBV infection plays an important role in the tumorigenesis and may be related to cutaneous lymphoma with hemophagocytic manifestations. We have seen a patient, a 67-year-old woman with tender erythematous nodules on both upper extremities and abdomen. With time, the skin lesion showed ulcerative change on her right thigh. She has also suffered from fever, weight loss, arthralgia, and general weakness without hepatosplenomegaly or lymphadenopathy for 4 months. During the admission, she complained of nausea, vomiting and dysarthria. On the MRI examination, we found a multi-focal solid lesion on her brain. The histopathological findings of the biopsy from her abdominal skin lesion showed a septal and lobular, histiocytic panniculitis with bean bag cells and atypical lymphoid cells identified as NK like T-cells and also dense diffuse infiltrates localized in the lower dermis and subcutaneous tissue, with minimal epidermal and upper dermal infiltrates without destructive change of blood vessels. The infiltrating atypical lymphoid cells expressed the phenotype of LCA, CD45RO, CD3, CD8, CD56 and also positive for EBV by in situ hybridization. Our case showed a clonal TCR gamma gene rearrangement by polymerase chain reaction. She was subjected to a course of treatment(cyclophosphamide, vincristine, prednisolone and radiation therapy) under the diagnosis of SPTCL. but died of sepsis due to urinary tract infections after 2 months.

The Relationship among the Clinical Evaluation, Total IgE, and Allergen-Specific IgE of MAST-CLA in Atopic Dermatitis / 대한피부과학회지

BACKGROUND: Even though the cause of atopic dermatitis is still unknown, it is considered an allergic reaction whose onset is frequently and strongly associated with both hereditary and environmental factors. The multiple allergosorbent test-chemiluminescent assay(MAST-CLA) is a new assay for serum allergen-specific IgE, and allows up to 35 allergens to be tested simultaneously. Furthermore, the MAST-CLA has shown good sensitivity, specificity, and a correlation with the RAST and skin prick test. OBJECTIVE: The purpose of this study was to find total IgE and allergen-specific IgE and to evaluate the correlations between clinical status and abnormal immunologic findings in MAST-CLA on atopic dermatitis patients. METHODS: Our study was designed by analyzing outpatients with atopic dermatitis via physical examination, questionnaires and the MAST-CLA with a total IgE and 35 allergen-specific IgE in 100 patients. RESULTS: The results were as follows; 1. Among the subjects(mean age=11.6 years, mean age of onset=28.7 months olds), 87% of patients showed elevated serum total IgE levels(more than class level 2) and 72% revealed at least more than one allergen-specific IgE by MAST-CLA. 2. The positive allergens rate, in descending order, were D. farinae 58%, D. pteronyssynus 54%, house dust 43%(aeroallergens), egg white 31%, milk 30%, and crab 22%(food allergens). 3. Good correlation was obtained between total IgE levels and number of positive allergen-specific IgE in MAST-CLA, with 0.497 correlation coefficient(p0.05). CONCLUSION: Our data suggested that MAST-CLA is a sensible and useful method to investigate the causative allergen-specific IgE and to evaluate in patients with atopic dermatitis with additional benefit of a non-isotopic technique and therefore not very expensive

A Case of Primary Cutaneous CD30+/ALK- Anaplastic Large Cell Lymphoma / 대한피부과학회지

Primary cutaneous CD30(Ki-1) positive anaplastic large cell lymphoma(ALCL) is a rare subset of cutaneous lymphoma, with a much better prognosis. ALCL is a heterogeneous process that may have a T-cell, B-cell, or indeterminant(null) phenotype and which may or may not express the anaplastic lymphoma kinase(ALK) oncoprotein. We report a case of ALCL in a 72 year old man. About 4 months ago, multiple erythematous firm ulcerative mass and satellite nodules developed on the right lower leg. The skin lesions rapidly increased in number and size. Some lesions became painful and centrally ulcered. The histologic findings showed a diffuse infiltrate of large lymphocytes with large nuclei, prominent and multiple nucleoli, and ample cytoplasm. Immunohistochemical stainings for CD30, CD5 were positive but stainings for LCA, CD3, CD45RO, CD20, cytokeratin, EMA, and ALK were negative. Therefore, we diagnosed our case as CD 30+/ALK- ALCL.

Multiple Adnexal Neoplasms Arising in Nevus Sebaceous / 대한피부과학회지

Nevus sebaceous occurs almost on the scalp and face and shows characteristically well demarcated yellowish patch or plaque. With time, benign or malignant skin tumors secondarily may be developed within nevus sebaceous lesion. We herein report a case of nevus sebaceous superimposed with 4 rare types of tumors; sebaceous epithelioma, syringocystadenoma papilliferum, tubular apocrine adenoma, and trichoblastoma.

A Case of Eruptive Vellus Hair Cyst: Facial Variant / 대한피부과학회지

Eruptive vellus hair cysts(EVHCs) are small, red or brown colored cystic papules that usually occur on the chest and proximal extremities of children and adults. Although EVHCs, facial variant, is rare and chracteristic in its location and color, histopathological findings of facial variant are not different from those of typical EVHC. We report a case of EVHC, facial variant which occured on the face of 23-year-old man with asymptomatic, bluish papules. The lesions first appeared at the age of 19 years and had increased in number thereafter.

The Clinical Efficacy of a Multi-Lamellar Emulsion Containing Pseudoceramide in Childhood Atopic Dermatitis: An Open Crossover Study

BACKGROUND: The abnormal barrier function in atopic dermatitis(AD) is caused by a reduction in the amounts of ceramides in the intercellular lipids in the stratum corneum(SC). Replenishing the SC via the topical application of ceramides and pseudoceramides leads to effective recovery of the barrier function of skin. OBJECTIVES: An open clinical crossover evaluation was conducted to investigate the effects in AD of a multi-lamellar emulsion(MLE) that contained pseudoceramide(PC-9s). METHODS: The study group included 30 AD patiendaverage age: 4.4 yr, range: 1-8 yr), who applied MLE or a commercial moisturizing cream(CMC, 5% urea) alternately for four weeks each. We divided the subjects into two subgroups and started with different treatments in each subgroup. Treatment efficacy was evaluated using the average subjective satisfaction scores for each symptom and the global clinical response. In addition, the SCORAD(Scoring AD) index was adopted to evaluate the severity of AD as objectively as possible. The patients were evaluated using this index every other week. RESULTS: Although the SCORAD improved in both subgroups, the patients had better results (p<0.05) when applying MLE(31-35% decrease) than CMC(13% increase to 14% decrease). The subjective satisfaction scores of the symptoms and signs of patients, including itching, erythema, and dry skin, were higher in the MLE group than in the CMC group, and the global response to treatment was also better in the MLE group. During the follow-up period, AD improved in all patients. MLE was more effective than CMC in our patients. CONCLUSIONS: The topical application of a multi-lamellar emulsion containing pseudoceramide is an effective regimen for improving symptoms of AD.

A Case of Multiple Sebaceous Hyperplasia in a Renal Transplant Patient Receiving Cyclosporine / 대한피부과학회지

Sebaceous hyperplasia occurs on the face in persons over 40 years of age. Cyclosporine in dermatologic diseases can be used for the treatment of psoriasis, pyoderma gangrenosum, lichen planus, graft-versus-host disease, epidermolysis bullosa acquisita, Behcet's disease, and paraneoplastic pemphigus. etc. The side effects of cyclosporine in mucocutaneous tissue, were hypertrichosis, gingival hypertrophy, acneiform eruption, keratosis pilaris, flushing, angioedema, urticaria, and anaphylaxis have also been reported with the use of cyclosporine. Development of sebaceous hyperplasia is related to the process of dysplastic epithelial proliferation. We experienced a case of sebaceous hyperplasia in a renal transplant patient receiving cyclosporine. After carbon dioxide laser was done, lesions were cleared without any scar.

A Case of Acquired Digital Fibrokeratoma / 대한피부과학회지

Acquired digital fibrokeratornas are uncommon, benign, acquired, firm, hyperkeratotic projectic projections, mostly arising at the finger, toe, and distal portion of extremity. We experienced a case of acquired digital fibrokeratoma arising the 4th tae in 37-year old male. Tumor mass was 2 X 1.5cm in size, round hyperkeratotic protruded mass. Histopathologically, the epidermis of the tumor showed compact hyperkeratosis, focal hypergranulosis, and irregular acanthosis. Thick collagen bundles and dilated capillaries were predominantly oriented in the direction of the longitudinal axis of the lesion. After simple excision was done, a new lesion appeared 2 months later.

A Clinical and Histopathological Study of Cutaneous Squamous Cell Carcinoma / 대한피부과학회지

BACKGROUND: The cutaneous squamous cell carcinoma(SCC) is a malignant proliferation of the keratinocyte of the epidermis. It may have the potential to metastasize distally in contrast to the cutaneous basal cell carcinoma (BCC). Our lives were being lengthened gradually and our society was being polluted by many causative factors. Because many kinds of cutaneous malignant tumors occurred to the aged and resulted from the severe pollution, a lot of people have been interested in SCC. OBJECTIVE: In this study we investigated the recent trend of the cutaneous squamous cell carcinoma in clinical and histopathological aspects. METHODS: Seventy one cases of SCC who had visited the Department of Dermatology, Chungnam University Hospital during the last 17 years(between 1983 and 1999) were confirmed in histopatho-logical review. The observation of occurrence rate in years, age and sex distribution, onset, site, cause, histopathological malignancy and treatment was done, retrospectively. RESULTS: 1. The occurrence of the cutaneous squamous cell carcinoma in males was one and half times more than in females(M>F :1.63x). Age distribution showed almost above 60 years old(about 74%). 2. The common sites (in decreasing order) were face(56%), extremities(upper>lower), other sites and most etiologic factors were idiopathic(71%), in 2 cases metastatic. 3. Histopathologically, the subtype of SCC was verrucous(7%), acantholytic(10%), spindle cell(6%), and the degree of differentiation was well-, moderate-, poor-differentiated (respectively 25%, 32%, 20%), and SCC invaded to full dermis(84%) and subcutis(9%). 4. Various treatments were done and among them the simple excision(53%) was common. 5. One case recurred and four cases metastasized to adjacent lymph node. One case expired. CONCLUSION: We investigated the recent trend of the cutaneous squamous cell carcinoma through our cases of SCC who had visited the department of dermatology, chungnam university hospital.

A Case of Pilomatricoma Showing Rapid Enlargement Due to Intradermal and Intratumoral Hemorrhage

Pilomatricoma, known as calcifying epithelioma of Malherbe, is a deep dermal or subcutaneous tumor showing slow growth. There are some reports showing rapid enlargement of the tumors as a result of variable amounts of bleeding into the intratumoral cystic space and into the superficial dermis. We report an uncommon case of a rapidly enlarged pilomatricoma due to simultaneous in tratumoral and intradermal hemorrhage.

A Case of Unilateral Multiple Piloleiomyoma, of which the Pain was Ameliorated with Oral Nifedipine / 대한피부과학회지

We report a case of multiple piloleiomyoma in a 50-year-old man. About 30 years ago, multiple red colored firm papules with pain developed on the left lower leg. The skin lesions gradually increased in number and size arranging in a group. Some lesion became more painful after cold exposure. About a few years ago, new lesions developed on the left back and flank abdomen. The histologic findings showed poorly demarcated and were composed of interlacing bundles of smooth muscle fibers with varying amounts of collagen bundles being intermingled. Masson's trichrome and smooth muscle actin stain showed typical leiomyoma, and s-100 stains revealed an increased amount of nerve fibers interlacing within muscle fibers and the surrounding tissue. We diagnosed our case as unilateral multiple piloleiomyoma arising from arrector pilorum muscle. Pain was ameliorated with oral nifedipine alone.