Generalized Pustular Psoriasis and Hepatic Dysfunction Associated with Oral Terbinafine Therapy

We report a case of 61-yr-old man with stable psoriasis who progressively developed generalized pustular eruption, erythroderma, fever, and hepatic dysfunction following oral terbinafine. Skin biopsy was compatible with pustular psoriasis. After discontinuation of terbinafine and initiating topical corticosteroid and calcipotriol combination with narrow band ultraviolet B therapy, patient's condition slowly improved until complete remission was reached 2 weeks later. The diagnosis of generalized pustular psoriasis (GPP) induced by oral terbinafine was made. To our knowledge, this is the first report of GPP accompanied by hepatic dysfunction associated with oral terbinafine therapy.

Two Cases of Familial Multiple Lipomatosis / 대한피부과학회지

Familial multiple lipomatosis is a rare hereditary disorder with a proposed autosomal dominant inheritance. Clinically, multiple well-circumscribed, encapsulated lipomas occur on the extremities and trunk. Familial multiple lipomatosis is often confused with multiple symmetric lipomatosis, which is a condition involving a diffuse fatty infiltration around the neck and shoulders. We report two cases of familial multiple lipomatosis with typical clinical features and familial history. To the best of our knowledge, these are the first cases of familial multiple lipomatosis in Korea.

A Case of Eosinophilic, Polymorphic, and Pruritic Eruption Associated with Radiotherapy in a Patient with Breast Cancer / 대한피부과학회지

Eosinophilic, polymorphic, and pruritic eruption associated with radiotherapy (EPPER) is a disorder characterized by polymorphic papules, vesicles, and excoriations accompanied by a local or general itching sensation which can occur in cancer patients treated with radiotherapy. Histopathologic findings include a superficial and deep perivascular lymphohistiocytic infiltration with eosinophils. Most cases have occurred in patients with cervical cancer. To date, only one case of EPPER associated with breast cancer has been reported. We report a case of EPPER in a patient with breast cancer, who presented with eosinophilic, polymorphic, pruritic skin lesions in and around the irradiated left breast.

The Effect of Topical Tacrolimus in the Murine Contact Hypersensitivity and Dermatitis of Repeated Applications Induced by Diphenylcyclopropenone / 대한피부과학회지

BACKGROUND: Topical tacrolimus is widely used for the treatment of inflammatory skin diseases like atopic dermatitis, but there are few studies about the effect of topical tacrolimus for allergic contact dermatitis. Allergic contact dermatitis develops in two phases, the clinically silent sensitization phase, and the clinically apparent elicitation phase. OBJECTIVE: The purpose of this study is to investigate whether topical tacrolimus has an effect on both phases of murine contact hypersensitivity and dermatitis of repeated applications induced by diphenylcyclopropenone (DPCP). METHODS: Hairless mice were treated with topical tacrolimus before and after DPCP challenging. The suppressive effect of topical tacrolimus was measured by skin erythema, ear swelling, weight change and cell numbers of local lymph nodes. In addition, a biopsy was carried out and epidermal hyperplasia was investigated microscopically. TNF-alpha mRNA on the mice which were treated with topical tacrolimus to one side of the ears was measured before and after being chronically challenged with DPCP on both ears. RESULTS: Topical tacrolimus pretreatment dramatically supressed inflammatory reactions in the sensitization phase, and treatment of topical tacrolimus after sensitization dramatically supressed inflammatory reactions in the elicitation phase. Topical tacrolimus also dramatically supressed inflammatory reactions in the repeated DPCP-induced dermatitis. CONCLUSION: The data revealed topical tacrolimus could effectively suppress murine contact hypersensitivity and dermatitis of repeated applications induced by DPCP. Putting these results together, topical tacrolimus can be very effective in not only the treatment but also the prevention of allergic contact dermatitis. Larger studies are needed to determine the clinical relevance.

Primary Cutaneous Mucormycosis in a Immunocompetent Elderly Woman Showing Sporotrichoid Distribution / 대한피부과학회지

Primary cutaneous mucormycosis, a rare form of mucormycosis, develops where a break in the integrity of the skin has occurred as a result of surgery, burns, or other forms of trauma. It is mainly seen in immunocompromised hosts, but can sometimes also occur in immunocompetent hosts too. Various kinds of pathogens including viruses, bacteria, nontuberculous mycobacteria, protozoa, and fungi can show a sporotrichoid spread. However, there has been no report of mucormycosis showing a sporotrichoid distribution. We report a case of primary cutaneous mucormycosis occurring on the dorsal aspect of the right wrist in a 69-year-old immunocompetent woman. In our case, newlydeveloped lesions were distributed in sporotrichoid pattern 5 months after the initial lesion. The patient was successfully treated with a combined therapy of amphotericin B and itraconazole.

A Case of Linear Lichen Planus Associated with Cicatrical Alopecia and Vitiligo / 대한피부과학회지

Lichen planus is a papulosquamous disorder that has numerous clinical variants. Linear lichen-planus (LLP), a variant of lichen planus, consists of itchy linearly distributed, violaceous papules on the extremities. In lichen planopilaris (LPP), involvement of the hair follicles can induce a form of cicatrical alopecia. Half of the LPP cases have or develop characteristic skin or mucosal involvement of lichen planus. Vitiligo is a chronic disorder characterized by a marked absence of melanocytes and melanin in the epidermis. The coexistence of vitiligo and lichen planus is rare. However, this association is of interest because a cell-mediated immune reaction is thought to play a central role in the pathogenesis of both diseases. We report on a 32-year-old woman affected with LLP, accompanied by cicatrical alopecia and vitiligo.

A Case of Lymphangiectatic Pilomatricoma / 대한피부과학회지

Pilomatricoma is a common, benign, adnexal tumor differentiating towards elements of the hair matrix and shaft. The tumor is usually a deep-seated, solitary, firm nodule with overlying normal epidermis. Lymphangiectatic pilomatricoma is a rare variant of pilomatricoma. Clinically it manifests as flaccid, thick-walled bulla with an underlying palpable, hard tumor. Histopathologically, it is a well-circumscribed dermal nodule composed of basophilic cells, shadow cells, and transitional cells. There can also be extraordinary dilatation of lymphatic vessels in the overlying dermis. We report a case of lymphangiectatic pilomatricoma on the left shoulder of 19-year-old girl which occurred after intralesional injection of steroid.

A Case of Erythema Nodosum Associated with Crohn's Disease / 대한피부과학회지

Erythema nodosum is known to be frequently associated with a variety of underlying diseases including drug reactions, infections, sarcoidosis and inflammatory bowel disease. Crohn's disease is an ulcerative, granulomatous, inflammatory disease which may have distinctive mucocutaneous manifestations. In most studies on Crohn's disease, 1 to 2% of the patients had at least one attack of erythema nodosum. However, erythema nodosum associated with Crohn's disease has not yet been reported in the Korean dermatologic literature. We report, herein, an 11- year-old male with Cronh's disease, who presented with erythematous, tender, subcutaneous nodules on his lower extremities. These showed histopathologic findings of erythema nodosum.

Immunohistochemical Study of Human beta Defensin-2 Expression in Superficial Mycosis / 대한피부과학회지

BACKGROUND: Normal human skin is resistant to infection with various kinds of microorganisms by producing anti-microbial chemicals. Human beta defensin-2 (hBD-2) is an anti-microbial peptide that has recently been shown to be expressed in various epithelial cells and inflammatory diseases. However, the expression of hBD-2 in fungus-infected skin is not well-known. OBJECTIVE: This study was performed to investigate the expression pattern of hBD-2 in superficial mycosis. METHODS: Using the immunohistochemical method with formalin-fixed, paraffin-embedded sections, we checked the expression levels and localization of hBD-2 in lesional skin samples of tinea capitis (5 patients), tinea corporis (6 patients), candidiasis (3 patients), Malassezia folliculitis (2 patients), and psoriasis (3 patients) as positive control, and normal skin samples from 6 healthy subjects as negative control. RESULTS: The expression of hBD-2 was not observed in normal skin, but moderate to strong expression of hBD-2 was observed in the epidermis, and the papillary dermal infiltrating cells of psoriasis. In tinea capitis, strong hBD-2 expression was found in the upper spinous layer of epidermis and follicular epidermis, and perifollicular inflammatory cells. In tinea corporis and candidiasis, mild to strong expression of hBD-2 was found in the horny or spinous layer of epidermis and infiltrating inflammatory cells. Strong hBD-2 expression was found in the follicular epidermis and perifollicular inflammatory cells of Malassezia folliculitis. CONCLUSION: These results suggest that hBD-2 plays an important role in cutaneous innate immune defense against fungal infection.

A Case of Dermatofibrosarcoma Protuberans on the Face with Various Cutaneous Lesions / 대한피부과학회지

Dermatofibrosarcoma protuberans is a tumor of intermediate malignancy, characterized by its aggressive local growth and marked propensity to recur after surgical excision. Dermatofibrosarcoma protuberans is most frequently located on the trunk or proximal extremities and rarely occurs on the face. In most cases, the tumor initially occurs as an asymptomatic, indurated plaque that slowly increases in size, and then develops multiple firm nodules. We report a case of a 39-year-old female who presented with a 10-year history of asymptomatic, brownish and hypopigmented plaques on the right side of her upper forehead. They gradually extended downwards and erythematous nodules appeared on the superior border of pre-existing brownish plaques 8 months ago. Histopathological examination of a nodule showed spindle-shaped cells with a storiform pattern in the dermis, and that of the plaques showed a parallel pattern. The tumor cells were stained positive for CD 34 upon immunohistochemical staining.

A Case of Speckled Lentiginous Nevus Showing Histopathologic Features of Congenital Melanocytic Nevus / 대한피부과학회지

Speckled lentiginous nevus is characterized by numerous, small, darkly-pigmented speckles on the background of tanned hyperpigmentation. The tan macule or patch of speckled lentiginous nevus shows the histologic features of lentigo simplex. The speckled areas are characterized by various types of nevi including junctional, compound or dermal nevus. However, since speckled lentiginous nevus may present at birth and show the histologic features of congenital melanocytic nevus (CMN), some have speculated that it is a subtype of CMN. We present a case of speckled lentiginous nevus which occurred at birth and showed histologic features of CMN, thus supporting the notion that speckled lentiginous nevus is a subtype of CMN.

The Effects of 5% Imiquimod Cream on Bowen's Disease / 대한피부과학회지

BACKGROUND: Imiquimod is an immune response modifier which works as a Toll-like receptor 7 agonist which induces interferon and other cytokines through the innate immune system and stimulates cell-mediated immunity through T cells. Imiquimod has been shown to be efficacious as a topical treatment for variable cutaneous neoplasms including Bowen's disease. OBJECTIVE: The purpose of this study was to evaluate the efficacy and safety of 5% imiquimod cream for the treatment of Bowen's disease. METHODS: Thirty one lesions from 13 patients with Bowen's disease were treated with 5% imiquimod cream, 3 times per week at night, until complete clearance of lesions had occurred. During the follow-up period, the duration of therapeutic response, clearance rate, side effects and recurrence were recorded. Biopsy specimens from five patients after treatment completion were obtained to confirm tumor clearance. RESULTS: Complete clinical response was obtained in 30 lesions (96.8%) from 12 patients, and a partial clinical response was observed in a palmar lesion of 1 patient. The duration of complete response ranged from 4 to 24 weeks, and mean duration was 11.8 weeks. All patients showed mild to moderate local skin reactions such as erythema, erosion, crusting, itching, burning, and pain. No-one experienced systemic adverse effects during topical application. After 3 to 26 months follow-up of the patients who had shown complete clearance, no-one encountered recurrence. CONCLUSION: 5% imiquimod cream appears to be safe and effective for the treatment of Bowen's disease, and so therefore may be promising future treatment for this condition.

The Side Effects of DPCP Topical Immunotherapy in Alopecia Areata / 대한피부과학회지

BACKGROUND: Diphenylcycloprophenone (DPCP) topical immunotherapy is usually safe and well-tolerated in the treatment of extensive alopecia areata, but some side effects can be problematic to both the physician and the patient. OBJECTIVE: The purpose of this study was to investigate the type and frequency of side effects to DPCP and theirrelation with therapeutic response during DPCP immunotherapy. METHODS: Eighty patients with alopeica areata (>25% of scalp hair), alopecia totalis, and alopecia universalis were treated with DPCP immunotherapy. After sensitization with 2% DPCP, progressively higher concentrations beginning at 0.00001% were applied with an interval of 1 to 2 weeks. During the follow-up period, the onset time and types of side effect and therapeutic response were recorded. RESULTS: Clinically, side effects were experienced by 58.8% of patients and were as follows; dermatitis at the application site (30.0%), dermatitis on a remote site (23.8%), generalized pruritus (13.8%), lymphadenopathy (11.3%), urticaria (8.8%), hyperpigmentation (6.3%), dermographism (2.5%) and vitiligo-like hypopigmentation (1.3%), in order of frequency. There were no serious adverse effects in any of the patients. The patients with better therapeutic response had more side effects than the ones with poor response. Of the many side effects, only lymphadenopathy had any statistical significance with regards to correlation of therapeutic effects and side effects of DPCP. CONCLUSION: DPCP topical immunotherapy in extensive alopecia areata appears to be safe without significant side effects. By noting the common side effects during each treatment period and the side effects which may be sign of better therapeutic response, we think that the patients' compliance and the therapeutic response can be increased.

A Case of Biphasic Amyloidosis in Systemic Sclerosis / 대한피부과학회지

Primary cutaneous amyloidosis is a disorder in which amyloid deposition occurs in the skin without associated deposits in internal organs. The most common types are macular amyloidosis and lichen amyloidosis. The co-occurrence of both types is termed biphasic amyloidosis and has rarely been reported so far. Moreover, only a few cases of amyloidosis development in the patients of systemic sclerosis have been reported. e report a 42-year-old female with systemic sclerosis, presented with pruritic skin lesions with hyperpigmentation on the back and lower extremities. Histopathologic examination revealed amyloid deposits which were restricted to the upper dermis and confirmed by Congo red staining, polarizing microscopy and transmission electron microscopy. There was no evidence of systemic amyloidosis.

A Case of Tufted Angioma Arising within a Nevus Flammeus / 대한피부과학회지

Tufted angioma is an uncommon, slowly-progressive vascular tumor, found typically in infants, young children and sometimes at birth or during adulthood. It shows a characteristic histopathologic finding, the so-called "cannonball" appearance. Various tumors can be developed in the nevus flammeus, such as pyogenic granuloma, basal cell carcinoma, squamous cell carcinoma, giant proliferative hemangioma and lymphangioma circumscriptum. Tufted angioma can be also accompanied with nevus flammeus and the coexistence of tufted angioma and nevus flammeus is a very rare condition. We report a case of tufted angioma arising within nevus flammeus in the left axilla of a 47 year-old female.

A Study on Utilization of Alternative Medicine for Patients with Atopic Dermatitis / 대한피부과학회지

BACKGROUND: Alternative medicine - sometimes called complementary or supplementary medicine - may be defined as forms of therapy or examination that have no scientific basis and whose effect or diagnostic reliability has not been demonstrated by scientific methods. Recently, alternative medicine has been used in various chronic diseases including atopic dermatitis (AD) and has attracted attention in the mass media. Several studies on the use of alternative medicine in patients with AD have been performed in western countries, however only a few studies have been conducted in Korea. OBJECTIVE: The purpose of this study was to investigate the use of alternative medicine in AD patients. METHOD: A total of 100 patients with AD were enrolled on the study, and interviewed with a questionnaire about their past history of AD and the use of alternative medicine. RESULTS: The results obtained are summarized as follows: 1. 84 out of 100 patients (84.0%) reported previous or current use of more than one type of alternative medicine. 2. The most common type of alternative medicine used was herbal remedies (73.8%). Spa and bath therapies (47.6%), health food preparations (39.3%) and diet therapy (25.0%) were also commonly used. 3. The frequency of alternative medicine used was related to onset and severity of AD. 4. The most common reason for using alternative medicine was `I wish to try everything' (60.2%), and the most common source of information on alternative medicine was relatives and friends who did not have the disease (41.4%). 5. The therapeutic effect of alternative medicine was found to be excellent in 25.3% of patients, but no change was seen in 58.6% of patients. 6. The most common side effect of alternative medicine was aggravation of symptoms. Other side effects included urticaria, diarrhea, fever and chills. 7. The average monthly cost for alternative medicine was 210, 000 won/person. CONCLUSION: The use of various types of alternative medicine in patients with AD is very common. However, these tend to be used impulsively and without caution or adequate knowledge. Therefore, dermatologists need to be aware of the benefits and adverse effects of alternative medicines.

Assessment of the Quality of Life in Patients with Varicose Veins for Evaluation of Treatment Effect / 대한피부과학회지

BACKGROUND: Varicose veins are the most common venous condition of the lower extremities. Treatment for varicose veins varies from surgery to minimally invasive techniques such as radiofrequency endovenous occlusion (RFEO), ambulatory phlebectomy (AP), sclerotherapy and endovenous laser treatment (EVLT). However, there is no method to assess the quality of life (QOL) of patients with varicose veins and the effect of treatment on the QOL. OBJECTIVE: The purpose of this study was to assess the QOL of patients with varicose veins and to evaluate the effect of treatment on the QOL. METHOD: A total of 72 patients with varicose veins were interviewed with the Aberdeen varicose vein questionnaire (AVVQ), was asked 25 questions relating to the symptoms and concerns of their condition. Follow-up was done with questionnaires again, 8 weeks after treatment. RESULTS: The results obtained are summarized as follows: 1. Of the 32 patients the distribution of age was 40-49 years of age (37.5%), followed by 50-59 years of age (27.8%) and 30-39 years of age (19.4%). The mean age was 47.7 years old. 2. 30 patients (41.8%) had suffered with varicose veins for less than 5 years, and 24 patients (33.3%) for 6-10 years. 3. According to the CEAP classification, the most common type of varicose vein was the C1AEPAS (31.9%). 4. Treatment method of varicose veins were sclerotherapy in 60 patients (83.3%), AP in 10 patients (13.9%), and RFEO in 2 patients (2.8%). 5. AVVQ scores correlated with symptoms and concern scores, and also with the clinical grade. 6. After treatment, AVVQ scores demonstrated a highly significant increase. CONCLUSION: This study confirms that varicose veins have a significant impact on the overall QOL, and that QOL shows a significant improvement after treatment. Therefore, assessment of QOL in patients with varicose veins can be a valid measure for the evaluation of treatment effect.

The Effects of 5% Imiquimod Cream on Verruca Plana / 대한피부과학회지

BACKGROUND: Verruca plana is a cutaneous human papillomavirus (HPV) infections. Although various treatments such as destructive methods or immunomodulating agents have been used, none are uniformly effective or prevent recurrence. Ideal treatment for verruca plana should target on an increasing local immune response to the HPV infection. Recently, imiquimod, a topical immune- response modifier, has been successfully used in the treatment of external anogenital warts. OBJECTIVE: The aim of this study was to determine the efficacy and safety of 5% imiquimod cream for the treatment of verruca plana. METHOD: Seven patients with verruca plana were treated with 5% imiquimod cream 3 times a week. at night, for 16 weeks or until complete clearance of lesions had occured. During the follow- up period, the onset time of effects, clearance rate, side effects, and recurrence rate were recorded. At 16 weeks after treatment, a clearance rate was determined by a 3 scale rating; complete-100% clearance / partial-less than 100% clearance / failure-no clearance. RESULTS: The onset time of effects ranged from 1 to 4 weeks (mean-1.7 weeks). The clearance rate at 16 weeks after treatment were as follows; complete-4 (57.1%), partial-2 (28.6%), and failure - 1 (14.2%). No patient showed systemic side effects or long-term adverse effects such as pigmentary disorders or scarring. In the subjective local skin reactions, itching was the only symptom and was common (4/7, 57.1%). With objective skin reactions, erythema was the most common (4/7, 57.1%), followed by erosion and scabbing (2/7, 28.6%). In long-term follow-up of those patients who showed complete clearance, no one encountered recurrence. CONCLUSION: This data demonstrates that 5% imiquimod cream is an effective and promising treatment modality for verruca plana. Because it is non-destructive, safe, and easy to use, it resulted in an excellent cosmetic outcome.

Wall Structure and Composition Changes of Primary Varicose Veins of the Legs: A Histopathologic Study / 대한피부과학회지

BACKGROUND: Many factors have been implicated in the etiology of varicose veins. Among them, the most widely advanced are weakness of the vascular wall due to defective smooth muscle and connective tissue metabolism, dysfunction of the endothelium, valvular incompetence, and hemodynamic stress. However, the etiology remains unclear. OBJECTIVE: This study was performed to analyze the wall structure and composition changes of primary varicose veins of the legs. METHODS: Varicose vein samples were collected from 13 patients having primary varicose veins who underwent ambulatory phlebectomy. Control veins(below the age of 50 years) were collected from 2 patients with no history or clinical evidence of varicose vein. Samples were stained with hematoxylin and eosin, Masson's Trichrome, Van Gieson stains and immunohistochemical stains for collagen type IV, alpha-smooth muscle actin antigen were performed. Tissue samples were examined by light microscopy for comparative histological changes and different components of the varicose vein wall as compared to control veins. RESULTS: In the varicose vein, there was intimal hypertrophy in almost all the sections examined. The thickness of intima varied at different places. There were hyperplasia of smooth muscle cell and collagen in the varicose vein. Collagen type IV exhibited an accumulation especially in the subendothelial region of varicose vein. CONCLUSION: Dilatation and varicosities are not due to deficiency in the vein wall components, but rather to hemodynamic response. Modulation in the extracellular proteins may be the cause for the development of varices.

Reconstruction of Facial Defects with Subcutaneous Island Pedicle Flap / 대한피부과학회지

Subcutaneous island pedicle flap is based on the basic principle of V-Y advancement and closure. This advancement flap involves the isolation of a segment of skin as an island disconnected from the peripheral epidermal-dermal attachment. Subcutaneous island pedicle flap offers several distinct advantages over various transposition flap and skin graft. Moreover its design and execution are straightforward, being a conceptual extension of the elliptical excision technique. Four cases of malignant tumors on the face were removed by Mohs surgery, followed by reconstruction of defects with subcutaneous island pedicle flap. In our cases, there were no significant complications and the results were cosmetically acceptable. Subcutaneous island pedicle flap is a simple and satisfactory alternative for the reconstruction of medium-sized defects in the face.