Onychomycosis: A study of self-recognition by patients and quality of life.

Background: Onychomycosis accounts for approximately half of all nail disorders and is usually asymptomatic. Objectives: To evaluate patients’ recognition of fungal nail disease, concomitant fungal skin diseases, complications, and quality of life. Methods: Patients from the fungal nail clinic were enrolled between May 2011 and April 2012. Patients’ awareness of diseased nails was evaluated and the Dermatology Life Quality Index (DLQI) questionnaire was used to evaluate the impact of dermatologic disease on quality of life. Results: A total of 110 patients with onychomycosis were enrolled in the study, of which 64 (58.2%) were female and the mean age was 60.8 years. The number of patients who were able to recognize the presence of onychomycosis was 71 (64.5%), while 32 (29.1%) and 7 (6.4%) were diagnosed by a dermatologist and other physicians, respectively. Multivariate analysis showed that patient recognition of the disease was signifi cantly associated with female sex and young age. The mean DLQI score was 3.6. Limitation: Patient recall bias including the duration of fungal nail infection, long-term past history and previous treatment was a limitation of this study that affected DLQI scores. Conclusion: About half of onychomycosis patients, especially elderly males, could not recognize the disease by themselves. It is important for physicians to educate patients with risk factors for onychomycosis to recognize this condition early to prevent concomitant infection and complications, and to improve patients’ well-being.

Prevalence and clinical characteristics of adult-onset atopic dermatitis with positive skin prick testing to mites.

Background The clinical role of house dust mite (HDM) in atopic dermatitis (AD) is still controversial. Objective The aim of the study is to assess the prevalence, clinical relevance and characteristics of adult-onset AD patients with positive skin prick tests (SPT) to mites. Methods The case record forms of adult-onset AD patients who underwent SPT at the Skin Allergy Clinic, Siriraj Hospital were reviewed. Results Forty-one of 62 patients (66.1%) had positive SPT to mites. The frequency of intrinsic AD among adult-onset AD was 4.8% (3/62). SPT to HDM tended to be positive in patients who had personal or family history of atopy, positive SPT to several specific antigens or who presented with elevated serum IgE, chelitis, recurrent conjunctivitis and perifollicular accentuation, respectively. Conclusion The prevalence of adult-onset AD patients with mite sensitivity was high. There were some notable features that tended to be present in mite sensitive adult-onset AD patients.

Dermatology life quality index in Thai patients with systemic sclerosis: A cross-sectional study.

Background: Systemic sclerosis (SSc) is a multisystem disorder that affects various organ systems. Although SSc patients have both physical and psychological illness, psychological distress is sometimes underestimated as most physicians usually pay more attention to physical problems. Aims: To evaluate dermatology-specific health-related quality of life (QoL) in Thai patients with SSc. Methods: SSc patients, who attended the Department of Dermatology, Siriraj Hospital, Bangkok, Thailand, between August 2009 and April 2010, were enrolled. The demographic data and skin manifestations of the patients were recorded. Skin thickness of each patient was analyzed by modified Rodnan skin score. QoL was evaluated by using the validated Thai version of dermatology life quality index (DLQI) questionnaire. Results: A total of 80 patients of SSc were enrolled in this study. Twelve patients had limited SSc, while 68 patients had diffuse SSc. The mean (SD) disease duration before period of evaluation was 9 (12.8) years. The mean total of DLQI score was 6.3 (range, 0-23). Patients with low DLQI score have longer disease duration than patients with high DLQI score (P<0.05). Pain/pruritus was the most significant problem to the patients. Salt and pepper appearance was the cutaneous finding that had association with high DLQI score. Conclusions: SSc had moderate impact on patient's dermatology-specific health-related QoL. Pain, pruritus, and obvious skin findings caused a significant impairment to SSc patients. Therefore, the treatment of pain and pruritus and prominent cutaneous findings should be taken into account to improve QoL of SSc patients.

Cutaneous adverse reactions to sulfonamide antibiotics.

Background: Sulfonamides are divided into two main groups which are sulfonamide antibiotics and sulfonamide non-antibiotics. The wide use of sulfonamide antibiotics leads to increasing incidence of sulfonamide cutaneous reactions. Objective: The purpose of this study is to explore the cutaneous manifestations induced by sulfonamide antibiotics in a large number of Thai patients, including human immunodeficiency virus (HIV) and non-HIV infected individuals. The second purpose is to determine the risk factors for development of sulfonamide cutaneous reactions. Methods: We retrospectively studied 191 patients with sulfonamide antibiotics cutaneous reactions attending the adverse drug reaction center, Siriraj Hospital, Bangkok between 2006 and 2010. Results: Majority of the patients was female (59.7%).Maculopapular rash was the most common cutaneous manifestation (37.7%), followed by fixed drug eruption (22%), angioedema with or without urticaria (12.6%) and urticaria alone (12%). Among those with known HIV serology, maculopapular eruption occurred more frequently in the HIV positive group while fixed drug eruption occurred more frequently in HIV-negative group. Conclusion: From our study, there were no significant determination factors to develop serious drug reactions. However, the HIV-positive status and lower level of CD4 count had a tendency to increase risk of developing serious cutaneous reactions.

Clinical features and course of pemphigus in Thai patients.

Background: Pemphigus is a rare, organ-specific autoimmune disease. The epidemiology and clinical course vary between reports from different countries. Objective: To evaluate clinical manifestations, investigation and clinical course of Thai patients with pemphigus. Methods: Demographic data, clinical presentations, laboratory investigations and treatment outcomes in 124 pemphigus patients who had attended the specialized autoimmune skin clinic at Siriraj Hospital during the period from January 1991 to December 2009 were retrospectively studied. Results: Of the 124 pemphigus patients, 79% were diagnosed with pemphigus vulgaris (PV) and 15.3% with pemphigus foliaceus (PF). The male to female ratio was approximately 1:2 in both groups. The mean age of onset was 45.4 years in PV patients and 57.4 years in PF patients. Oral mucosal involvement at the onset of disease was presented in 37.8% of PV patients. The sensitivity and specificity of DIF in the diagnosis of pemphigus was 97.8% and 98.3% while that of IIF was 94.7% and 98.4%. Disease control was achieved in 93.9% of PV patients and 94.7% of PF patients. Remission (off therapy) was achieved in 31.6% of patients in both groups. Conclusions: PV is the most common subtype of pemphigus in Thailand and usually affects females more than males. The disease usually occurs in the fifth decade of life and mucosal involvement is common. Immunofluorescence studies yields very high sensitivity and specificity. Corticosteroids are the mainstay of treatment. The majority of patients attain disease control and one-third of them achieve remission (off therapy).

Prevalence and clinical features of Thai patients with bullous pemphigoid.

Background: Bullous pemphigoid (BP) is a rare, subepidermal autoimmune blistering disease. Studies from different regions show discrepancies in clinical features and courses. Objectives: To reveal clinical characteristics, investigations and clinical outcomes of Thai patients with BP and to evaluate the association of BP with malignancy, diabetes mellitus and neurologic diseases. Methods: Patients diagnosed as BP who had visited the autoimmune skin clinic at Siriraj Hospital between 1991 and 2009 were retrospectively studied. Results: Fifty-eight patients were enrolled. Mean age of onset was 69.3 years. The female to male ratio was 2.7:1. Fifteen percent of the patients had mucosal involvement and 38.9% showed peripheral blood eosinophilia. The sensitivity of the direct and indirect immunofluorescence test in the diagnosis of BP was 95.7% and 73.5%, respectively. The frequency of diabetes mellitus in BP patients was significantly higher than that in the general population (p < 0.001). BP patients had a significantly higher chance of having neurologic diseases compared with other autoimmune vesiculobullous disease patients (adjusted odd ratios 4, 95% confidence interval 1.2-13.3). Disease control was achieved in 89.7% of the patients. One-year and three-year remission rate was 6.4% and 66.3%, respectively. Conclusions: BP usually occurred in the seventh and eighth decade of life and affected females more than males. BP is associated with diabetes mellitus and neurologic diseases. Corticosteroids are the mainstay of the treatment. Two-thirds of patients are likely to be in remission within three years.

Diagnostic significance of colloid body deposition in direct immunofluorescence.

Background: Colloid bodies (CB) in direct immunofluorescence (DIF) studies are usually found in interface dermatitis. Furthermore, CB can be found in various skin diseases and even in normal skin. Aim: To evaluate the diagnostic value of CB deposits in DIF studies. Methods: From 1996-2007, data from 502 patients where DIF studies showed immunoreactants at CB were enrolled. The definite diagnoses of these patients were based on clinical, histopathological and immunofluorescent findings. The results of DIF studies were analyzed. Results: Immunoreactants at CB were detected in 44.4%, 43.8%, 4.2%, 3.8%, and 2.2% of interface dermatitis, vasculitis, autoimmune vesiculobullous disease, panniculitis, and scleroderma/morphea, respectively. The most common immunoreactant deposit of all diseases was Immunoglobulin M (IgM). Brighter intensity and higher quantity of CB was detected frequently in the group with interface dermatitis. Conclusions: Immunoreactant deposits at CB alone can be found in various diseases but a strong intensity and high quantity favor the diagnosis of interface dermatitis. CB plus dermoepidermal junction (DEJ) deposits are more common in interface dermatitis than any other disease. Between lichen planus (LP) and discoid lupus erythematosus (DLE), CB alone is more common in LP; whereas, CB plus DEJ and superficial blood vessel (SBV) is more common in DLE. The most common pattern in both diseases is CB plus DEJ. The quantity and intensity of CB in LP is higher than in DLE.

Eosinophilic fasciitis: A case report and literature review.

Eosinophilic fasciitis (EF) is a rare scleroderma-like syndrome. There has been no previous published report of EF in a Thai patient. We described a 41 year-old Thai man who presented with symmetric induration of the skin of forearms, arms, hands, fingers, lower aspects of the legs, and feet. Physical examination revealed bilateral symmetrical woody induration of the skin with peau d’orange appearance. A groove sign was positive on the flexural surface of both arms. Laboratory testing revealed a peripheral eosinophil count of 54%. The skin and superficial fascia biopsy specimen from the inner aspect of the left forearm was consistent with EF. He was treated with prednisolone, methotrexate, and colchicine. He experienced a gradual improvement within 4 months. A history of acute onset of scleroderma-like syndrome and careful physical examination can lead us to the diagnosis of EF.

Comparative identification of protein profiles and major allergens of saliva, salivary gland and whole body extracts of mosquito species in Thailand.

Allergic reactions to mosquito bites, such as generalized urticaria or severe local reactions are common problems worldwide. The diverse sources of allergen prepared from different mosquito body parts usage are a major obstacle to obtaining safe and effective tests and immunotherapy for mosquito bite allergy. Thus, the reactions are often not recognized and allergen immunotherapy is seldom used for severe reaction to mosquito bites. In a search for appropriate allergen sources, the protein profiles of saliva, salivary glands and whole body extracts were comparatively analyzed from 4 common mosquito species of Thailand and/or South East Asia; viz. Culex quinquefasciatus, Aedes aegypti, Aedes albopictus and a zoophilic strain, Anopheles minimus. The major allergens in the extracts which elicited specific IgE responses in the pooled sera of subjects allergic to mosquito bites were identified. It was concluded that mosquito saliva was the best source of allergens. Additionally, both species-specific and species-shared allergens of the 4 mosquito species were identified. The major saliva allergens having MWs of 36, 32 and 22 kDa were identified. The identificstion of major allergens should facilitate the production of specific recombinant allergens and contribute to improvement in the diagnosis and specific immunotherapy of Thai mosquito bite allergy patients.

Role of omalizumab in a patient with hyper-IgE syndrome and review dermatologic manifestations.

Hyper-IgE syndrome (HIES) is a rare idiopathic primary immunodeficiency. It is characterized by a triad of findings, including high levels of serum IgE, recurrent skin abscesses and pneumonia and leads to pneuma-tocele formation. The diagnosis of HIES is complicated by a diversity of clinical and immunological spectrums and a heterogeneous set of genetic defects. The National Institute of Health (NIH) developed a scoring system for HIES in which a score greater than 14 indicates a probable diagnosis. Our patient presented with recurrent multiple ab-scesses on her scalp, recalcitrant eczema, candida onychomycosis, alopecia universalis, and highly elevated levels of serum IgE. Using the NIH scoring system, a 30 total-point score in this patient indicated the likelihood of carrying the HIES genotype. To our knowledge, there are no specific treatments of HIES. The humanized recombinant mo-noclonal antibody against IgE, subcutaneous omalizumab, was successfully used in this patient.

Comparison of topical methylprednisolone 1% versus placebo in stevens – johnson syndrome and/or toxic epidermal necrolysis.

Objective: To study the efficacy of topical methylprednisolone compared with placebo in patients with Stevens-Johnson syndrome (SJS) and/or toxic epidermal necrolysis (TEN). Methods: Thirty-six patients were prospectively studied at Siriraj Hospital. The clinical severity score for ocular involvement was classified as mild, moderate and severe. In 12 patients with moderate severity, 1% methylprednisolone eye drop was added four times daily in one eye and 0.5% normal saline as placebo in another eye for one week. In 2 severe cases, these medications were added every 2 hours till bedtime for one week and four times daily for another week. Results: The average age of 14 patients was 50 ± 16.2 years (± SD), with female preponderance (12). Common precipitating factors were carbamazepine, nevirapine, phenytoin and dimenhydrinate. The common associated diseases were HIV. Five patients were not given systemic corticosteroid due to infection, and minimal skin involvement. The total severity score change in each group was the same at one month. In an average of 7.6 months follow up, most patients recovered normal appearance except for two eyes of the placebo group and one eye of the methylprednisolone group. The percentage of dry eye in the Schirmer test and the rose bengal score in the topical methylprednisolone eyes were not significantly less than in the control eyes. However, less tear production was statistically significant in patients with systemic corticosteroid. Conclusion: Topical corticosteroid might be used cautiously in early stages of SJS or TEN.

Urticarial vasculitis: etiologies and clinical course.

Out of 64 patients diagnosed with urticarial vasculitis (UV), 49 (76.6%) presented with their first at-tack of UV. The others experienced recurrent attacks with a mean number of 3.3 past recurrences. Fifteen pa-tients had angioedema (23.4%) and 16 (25%) suffered systemic involvement. The most common abnormal labora-tory finding was an increased erythrocyte sedimentation rate. Six of 62 patients (9.7%) had decreased C3 levels. A cause could be identified in 19 patients (29.7%). The most common identified cause was infection; other causes included drugs, malignancy and systemic lupus erythematosus (SLE). The prevalence of immunoreactant deposits in the skin lesions measured by DIF was 54.7% (35 of 64 patients). The median disease duration of each episode was 85 days. The probability that patients were free of symptoms within one year was 70%. Patients with an idio-pathic cause had a statistically significant longer course duration of each episode than the group with upper respi-ratory tract infection. Compared to reports from Western countries, our patients seemed to have less severe symp-toms and a lower percentage of hypocomplementemic UV and SLE.

Acute urticaria: etiologies, clinical course and quality of life.

One hundred patients with acute urticaria were prospectively studied over a 2-year period with respect to etiology, clinical features and outcome, including the patient's quality of life using a Thai version of the Dermatologic Life Quality Index (DLQI). Twenty-one patients (21%) turned out to have chronic and 79 acute urticaria. Itchy sensations had the highest mean DLQI score translating to the highest negative impact on the quality of life. In more than half of the patients, the cause of the acute urticaria could not be identified. The most common identified causes of acute urticaria were infections (36.7%), followed by drugs, foods and insect bite reactions. Among those with acute urticaria, sixteen percent had co-existing angioedema, and one fourth had systemic symptoms, the most common being dyspnea. Patients with extensive wheals tended to have co-existing angioedema and also a statistically significant higher percentage of systemic symptoms, higher mean pruritus and mean DLQI scores than those with less body surface area involvement. Fifty-six percent of the patients with acute urticaria had complete remissions within 1 week; 78.5%, within 2 weeks and 91.1%, within 3 weeks.

Validation of the diagnostic criteria for atopic dermatitis in the adult Thai population.

Atopic dermatitis is a chronic inflammatory skin disorder, for which it is difficult to obtain epidemiologic findings. In a previous study, we suggested the following diagnostic criteria for atopic dermatitis in the adult Thai population: visible flexural dermatitis, a history of flexural dermatitis, a rash of more than six months duration and visible dry skin. However these criteria were not validated against physicians' diagnoses. In the present study, we validated these diagnostic criteria for atopic dermatitis in the Thai population in a clinical setting. A case-controlled study was performed on a total of 259 patients; 33 subjects with active atopic dermatitis, 26 with inactive atopic dermatitis, 100 controls presenting with an inflammatory skin disorder other than atopic dermatitis and 100 controls without any skin disease. Each patient was examined according to the above criteria. Sensitivity, specificity, relative value, positive predictive value, and negative predictive value were calculated for each individual criterion and for composite criteria. Our data confirmed that in order to achieve satisfactory sensitivity and specificity for diagnosing atopic dermatitis in Thai people older than 13 years, a patient must have a history of flexural dermatitis plus two or more of the other mentioned criteria.

Adult-onset atopic dermatitis: a cross-sectional study of natural history and clinical manifestation.

The previously reported prevalence of adult-onset atopic dermatitis (AD) varied from 13% to 47%. There were a few reports of clinical features of adult-onset AD. The purpose of this article was to study the clinical features of Thai patients with adult-onset AD. We recruited prospective patients from the outpatient Department of Dermatology, Siriraj hospital, Mahidol University in Bangkok, Thailand, from June, 2006 to May, 2007. The diagnosis of AD was made according to the criteria of Hanifin and Rajka and the severity of AD in each patient was assessed using the Rajka and Langeland score. Fifty nine patients were enrolled. The majority of the patients developed their dermatitis during their third decade. Typical lichenified/exudative lesions were found in all cases. Non-typical morphologic variants were found in 76.3%. The most common were nummular lesions. The main sites of involvement were the flexural area. The common sites of non-flexural involvement were the trunk, extensors and hands. The severity of AD was moderate in 64.4% of cases. A personal history of atopy was found in 84.7% of cases. Skin prick testing showed positive results (mostly to multiple allergens) in 25 of 29 patients (86.2%). Elevated serum total immunoglobulin E was detected in 6 of 10 patients (60%). It is concluded that adult-onset AD is not a rare but under-recognized eczematous condition.

Dermatology life quality index in Thai patients with acne.

Objective: Acne is an inflammatory disease of pilosebaceous units. Major complications of acne are scarring and psychosocial effects. When compared to other chronic illnesses, patients with acne have been shown to have levels of social, psychological, and emotional impairments similar to those with serious diseases. This study is aimed to assess the effects of acne, including acne severity and acne scar on the patient’s quality of life using a Thai version of the Dermatology Life Quality Index (DLQI). Methods: One hundred and ten patients with acne who attended the Dermatology Outpatient Clinic, Siriraj Hospital, were asked to complete the Thai version of the DLQI questionnaires by themselves. Clinical severity of acne and acne scars were assessed. Results: Of 110 patients, 80 (72.7%) were females with a mean (SD) age of 26.0 (6.6) years and a range of 16-52 years. Most of the patients were students. The mean total DLQI score was 8.95 (range 0-24). Questions concerning embarrassment had the highest mean DLQI score, which meant the greatest impairment of the quality of life. The others that also had high mean DLQI scores were questions which represented social activities, itchy/sore/painful/stinging skin, and treatment difficulties, respectively. Concerning personal relationship problems, female patients had significant higher mean DLQI scores than male patients (p<0.05), which implied that women might be more concerned about the visual effects of their acne lesions than men. Most patients with mild acne (63%) had low DLQI scores. However, some patients with mild acne also had a high DLQI score which implied that even mild acne can pose a significant problem. QOL scores were lower in patients with mild rather than severe acne scar. Conclusion: Physicians should not underestimate the QOL impairment of patients with acne. The use of this simple questionnaire may help physicians to recognize the presence of psychiatric distress and may help facilitate further inquiries and/or referral to a psychologist.

Autologous serum skin test in chronic idiopathic urticaria: prevalence, correlation and clinical implications.

Some cases of chronic idiopathic urticaria (CIU) have histamine-releasing IgG autoantibodies in their blood. This disease subgroup is called "autoimmune urticaria". To date, the autologous serum skin test (ASST) is the best in vivo clinical test for the detection of basophil histamine-releasing activity in vitro. This study aimed to find the prevalence of ASST positive cases in Thai patients with CIU, to identify factors related to the positivity of ASST and to find the clinical implications of ASST in CIU. A retrospective study was performed among 85 CIU patients who attended the Urticaria Clinic at the Department of Dermatology, Siriraj Hospital and were willing to perform ASST, from January 2002 to December 2003. Twenty-one (24.7%) patients had a positive ASST. There was no significant difference between patients with positive ASST and negative ASST as to the severity of the disease (wheal numbers, wheal size, itching scores and the extent of body involvement) as well as the duration of the disease.

Direct immunofluorescence study in Thai patients with scleroderma.

OBJECTIVE: Previous reports of direct immunofluorescence (DIF) studies of the skin biopsies in scleroderma were either negative or positive at various percentages and patterns. The present study was designed to evaluate the positive yield and pattern of DIF in Thai patients with scleroderma and its possible clinical correlation. MATERIAL AND METHOD: Twenty-two patients with localized or systemic sclerosis, who attended the Department of Dermatology, Siriraj Hospital, from 1996 to 2002, were enrolled in the present study. Skin biopsy was performed for DIF studies. RESULTS: Nine out of 22 patients were diagnosed with systemic sclerosis (SS), eleven with morphea, and two with overlapping syndrome. Fifteen of 22 patients (68%) had positive DIF findings; seven of nine (78%) patients with SS, six of eleven (55%) patients with morphea and two of two (100%) with overlapping syndrome. The common sites of deposit in SS, morphea and overlapping syndrome were dermo-epidermal junction and epidermal nuclei. The common immunoreactant deposit in all groups was IgM. There was no significant difference in the comparison of DIF findings with duration of biopsy lesion, clinical correlation, and the positive result of serum antinuclear antibody (ANA) in the three groups of patients. CONCLUSION: Positive DIF yield in the present study was higher than previous reports from Western countries. Similar to the study reported from Western country, there was no statistical significant difference in comparison of DIF findings with the duration of lesion, clinical correlation, and the positive result ofserum ANA in our three groups of patients. However; patients with SS had a tendency to give more frequently positive ENS and DEJ deposits than those with morphea.

Assessment of dermographism at different anatomical regions by dermographometer.

OBJECTIVE: Classic dermographism refers to the ability of the skin to produce a linear wheal with a scratch pressure of 4,900 gm/cm2. The authors manufactured a dermographometer to have precise and consistent measurement and tested it on different body regions to find the best location. MATERIAL AND METHOD: Twenty two patients with dermographism were enrolled. The pressure was applied to the volar aspect of the left forearm using the dermographometer and to the right forearm by the pen head. Then the pressure was applied to the upper back, abdomen, and shin using the dermographometer. The time onset and size of wheal, erythema and flare were recorded. RESULT: The positive yield at the left forearm by the dermographometer was 72.7% and the positive yield at the right forearm by the pen head was 68.2%. The positive yield of back, abdomen and shin were 68.2%, 68.2% and 13.6%, respectively. CONCLUSION: The dermographometer gave a comparable positive yield in diagnosing dermographism with the pen head and the dermographometer. The volar forearm, back and abdomen are the sensitive areas to produce dermographism while the shin is the least sensitive area. The site of the body that is most appropriate in testing is the forearm as it is easy to approach.