Delayed Diagnosis of Scrofuloderma Misdiagnosed as a Bacterial Abscess

An 82-year-old woman presented with a four-month history of an ulcerative plaque overlying her left neck. This lesion had developed as a subcutaneous nodule, gradually increased in size, and evolved into ulcers. Before visiting our Dermatology clinic, the patient had been diagnosed as having a bacterial abscess, but treatments with antibiotics were unsuccessful. The presence of a purulent discharge and prominent ulceration caused further confusion as bacterial abscess, and radiologic evaluation on computed tomography also led to the possibilities of secondary lesions from an abscess or malignancy. However, the characteristic appearance of her lesion allowed us to discern cutaneous tuberculosis, especially scrofuloderma. Based on clinical examinations, staining for acid-fast bacilli, and positive findings of polymerase chain reaction, a quick diagnosis of scrofuloderma was made. After that, she was treated successfully with anti-tuberculosis therapy and the ulcer healed. Our case highlights the problem of delayed diagnosis of scrofuloderma presenting as a bacterial abscess. In conclusion, having a high index of suspicion is needed to diagnose cutaneous tuberculosis correctly.

Lichen Striatus Occurring after Allogenic Peripheral Blood Stem Cell Transplantation in an Adult with Aplastic Anemia

Lichens striatus (LS) is an acquired, self-limiting inflammatory dermatosis that follows the lines of Blaschko. The etiology of the eruption is unknown, but several theories have been proposed with focus on environmental factors, viral infection, cutaneous injury, hypersensitivity, and genetic predisposition. We describe a 19-year-old woman who developed a unilateral linear eruption 17 months after allogenic peripheral blood stem cell transplantation. Histopathology revealed features, which were consistent with LS. To the best of our knowledge, our patient is the first case describing the appearance of LS occurring after allogenic stem cell transplantation. We speculate that this condition represents an unusual form of localized, chronic graft-versus-host disease.

Analysis of Cardiovascular Risk Factors and Metabolic Syndrome in Korean Patients with Psoriasis

BACKGROUND: In previous studies, psoriasis has been reported to be associated with metabolic syndrome. OBJECTIVE: The purpose of this study was to evaluate risk factors for metabolic syndrome in psoriasis patients and to compare the prevalence of metabolic syndrome in psoriasis and control groups. METHODS: All patients (n=490) and controls (n=682) were investigated for cardiovascular risk factors, including central obesity, hypertension, fasting plasma glucose levels, and blood levels of triglycerides and high-density lipoprotein (HDL). RESULTS: We found no statistical association between psoriasis and the prevalence of metabolic syndrome when controlling for age and gender. Among individual components of metabolic syndrome, only increased triglyceride levels was significantly prevalent in patients psoriasis. The incidence of other factors such as central obesity, hypertension, fasting plasma glucose and HDL in the psoriasis group were similar to or lower than those in the control group. Although psoriasis patients with metabolic syndrome had severe and large plaque-type psoriasis, the association of metabolic syndrome with the severity or clinical subtype of psoriasis was not significant after adjusting for age and gender. CONCLUSION: Our results suggest that there is no close correlation between psoriasis and metabolic syndrome in Korean patients.

Bowenoid Papulosis of the Vulva and Subsequent Periungual Bowen's Disease Induced by the Same Mucosal HPVs

We report the case of a 23-year-old woman who developed bowenoid papulosis of the vulva and subsequent periungual Bowen's disease. She had a history of a long standing periungual wart on her right thumb before the outbreak of periungual Bowen's disease. By HPV DNA chip, human papillomavirus (HPV) 11, 18 and 31 were identified from the periungual lesions, and HPV 11, 18 and 33 from the vulvar lesion. This case supports the theory of anogenital-digital spread of HPV, and proposes that the periungual wart may change into Bowen's disease by mucosal HPVs. To the best of our knowledge, this case is important as the first Korean case of periungual Bowen's disease concurrent with bowenoid papulosis of the vulva.

Bullae and Sweat Gland Necrosis in the Differential Diagnosis for Vibrio vulnificus Infection in an Alcoholic Patient

Bullae and sweat gland necrosis remain rare cutaneous manifestation, and these conditions can be misdiagnosed as Vibrio vulnificus infections or other soft tissue infections because of their low index of suspicion. A 46-yr-old man with a history of continued alcohol consumption presented with erythematous and hemorrhagic bullous lesions on his left arm. The patient reported that after the ingestion of clams, he slept for 12 hr in a heavily intoxicated state. Then the skin lesions started as a reddish patch that subsequently became hemorrhagic bullae. V. vulnificus infection, cellulitis, and necrotizing fasciitis were considered in initial differential diagnosis. However, on the basis of sweat gland necrosis on histopathologic examinations and negative results on bacterial cultures, we made the diagnosis of bullae and sweat gland necrosis. Therefore, bullae and sweat gland necrosis should also be considered in chronic alcoholic patients who present with bullae and a previous history of unconsciousness.

Giant Piloleiomyoma of the Forehead

Cutaneous piloleiomyomas are benign smooth muscle tumors arising from the arrector pili muscles. Piloleiomyomas appear as firm dermal papules of skin color or with a reddish to brown surface, and are commonly located on the extremities. Histologically, these lesions are composed of interlacing bundles of smooth muscle cells in the reticular dermis. Our case presented with an unusually large nodule on the forehead that was accompanied by intermittent pain. Histological analysis was compatible with piloleiomyoma and the lesion showed haphazardly arranged bundles of smooth muscle in the dermis. We describe herein an interesting case of a giant piloleiomyoma occurring on the forehead.

Vulval Metastasis from Squamous Cell Carcinoma of the Cervix Clinically Presenting as Lymphangioma Circumscriptum

Patients with cervical cancer may develop local recurrence or distant metastasis, and the rate of these events is increased in proportion to the clinical stage. Cutaneous metastasis of cervical cancer is very rare and only a few cases have been reported in Korean literature. It is common at the abdominal wall, vulva, and anterior chest wall and mainly presents as an asymptomatic dermal or subcutaneous nodule, ulcer or plaque. We herein report on an interesting case of vulval metastasis from squamous cell carcinoma of the cervix with an unusual clinical manifestation resembling lymphagioma circumscriptum.

Analysis of Operative Time in Mohs Microscopic Surgery: Single Institution Experience / 대한피부과학회지

BACKGROUND: Mohs micrographic surgery (MMS) is a precise method of treating skin cancer. There have been many studies about the advantages and disadvantages of MMS. However, no study has yet been carried out regarding the length of surgery. OBJECTIVE: The purpose of this study was to report our experience with MMS for the treatment of skin cancers and to analyze the operative time of MMS. METHODS: We analyzed 50 cases of skin cancers treated by MMS at the Dermatosurgery Clinic in Pusan National University Hospital between April 2009 and November 2009. RESULTS: The minimum and maximum operative times of MMS were 88 and 356 minutes, respectively, and the mean operative time was 171.4 minutes. The mean number of stages was 1.7 (range, 1~4). The mean operative time per stage was 93.9, 62.9, 57.2, and 53 minutes for the 1st, 2nd, 3rd, and 4th stages, respectively. The time percentages for a pathologic consult to the Department of Pathology per stage was 42%, 50%, 52%, and 57% for the 1st, 2nd, 3rd, and 4th stages, respectively; therefore, the consultation to the Department of Pathology occupied a high percentage of the operative time. The mean operative time of repair for surgical defects was 44.4 minutes. LIMITATIONS: The results of this study are based on the experience of a single surgical team in a single institution. CONCLUSION: The results of our study reveal that MMS is a time-consuming operation. Further studies are required to shorten the operation time of MMS.

Clinical Character istics of Itch in Patients with Adult and Childhood Atopic Dermatitis / 대한피부과학회지

BACKGROUND: Itch is an essential feature of atopic dermatitis (AD). Active AD cannot be diagnosed without a history of itch. There has been no previous study delineating the different characteristics of itch according to age. OBJECTIVE: We wanted to characterize and compare the clinical patterns and the sensory and affective dimensions of itch in adult and childhood AD patients. METHODS: A face-to-face structured questionnaire based on the McGill pain questionnaire was given to 90 patients with AD. The patients were classified into two groups: adult AD patients (> or =15 years old) and childhood AD patients (<15 years old). RESULTS: Eighty-eight percent of the total AD patients experienced itch everyday. This itch was mostly aggravated during the summer and at night in both groups of AD patients. The antecubital fossae, popliteal fossae and neck were the major sites of involvement with itch. More patients perceived the characteristics of itch as crawling, burning and tickling rather than stinging, stabbing and pinching. The majority of AD patients answered that sweat and hot climate aggravated the itch and medications and cold climate alleviated the itch. However, compared with the childhood patients, more adult patients experienced the aggravation of itch by exposure to dust, and the itch was alleviated by taking medications and by concentrating on work. A burning sensation with itch was more frequently reported by the adult patients when compared to that of the childhood patients. CONCLUSION: This study highlights the detailed description and characteristics of itch in adult and childhood AD patients. The proper management of itch according to age may be prerequisite to improve AD patients' quality of life.

Clinical Character istics of Itch in Patients with Adult and Childhood Atopic Dermatitis / 대한피부과학회지

BACKGROUND: Itch is an essential feature of atopic dermatitis (AD). Active AD cannot be diagnosed without a history of itch. There has been no previous study delineating the different characteristics of itch according to age. OBJECTIVE: We wanted to characterize and compare the clinical patterns and the sensory and affective dimensions of itch in adult and childhood AD patients. METHODS: A face-to-face structured questionnaire based on the McGill pain questionnaire was given to 90 patients with AD. The patients were classified into two groups: adult AD patients (> or =15 years old) and childhood AD patients (<15 years old). RESULTS: Eighty-eight percent of the total AD patients experienced itch everyday. This itch was mostly aggravated during the summer and at night in both groups of AD patients. The antecubital fossae, popliteal fossae and neck were the major sites of involvement with itch. More patients perceived the characteristics of itch as crawling, burning and tickling rather than stinging, stabbing and pinching. The majority of AD patients answered that sweat and hot climate aggravated the itch and medications and cold climate alleviated the itch. However, compared with the childhood patients, more adult patients experienced the aggravation of itch by exposure to dust, and the itch was alleviated by taking medications and by concentrating on work. A burning sensation with itch was more frequently reported by the adult patients when compared to that of the childhood patients. CONCLUSION: This study highlights the detailed description and characteristics of itch in adult and childhood AD patients. The proper management of itch according to age may be prerequisite to improve AD patients' quality of life.

Three Cases of Churg-Strauss Syndrome Diagnosed after Presence of Cutaneous Manifestation / 대한피부과학회지

Churg-Strauss syndrome (CSS) is an uncommon disorder that is characterized by asthma or allergic rhinitis, fever, systemic vasculitis, extravascular granulomas and hypereosinophilia. Cutaneous manifestations of CSS are one of the most common extra-pulmonary findings, and they occur in approximately 60% of the cases. Other manifestations include pulmonary infiltrates and heart, kidney, gastrointestinal tract, peripheral and central nervous system involvement and the patients also complain of systemic symptoms, including malaise, fever, myalgia and weight loss. The diagnosis of CSS is difficult because the manifestations vary with the disease stage and delayed treatment can lead to fatal major organ damage. We report here on 3 cases of CSS that were first diagnosed by the dermatologic department and with consultation from other departments. So, we want to remind dermatologists that if the patients of asthma or other allergic diseases have purpuric skin lesion, then CSS should be included in the differential diagnosis.

Primary Cutaneous Epithelioid Hemangioendothelioma on the Back / 대한피부과학회지

Epithelioid hemangioendothelioma (EHE) is an uncommon vascular neoplasm that is considered to be a low-grade malignancy with a severity between an angiolymphoid hyperplasia with eosinophilia and an epithelioid hemangiosarcoma. The appearance of cutaneous EHE is extremely rare and only about 20 cases have been reported in the Korean and English literatures. A 70-year-old man presented with an approximately 1-year history of an isolated painful subcutaneous nodule of the back. A histopathologic examination revealed nests and cords of epithelioid eosinophilic cells in hyalinized stroma with intracytoplasmic vacuoles. Tumor cells were strongly positive for the endothelial cell markers CD31 and CD34, and we didn't find any metastatic lesions under radiologic examination. On the basis of these findings, the diagnosis of primary cutaneous EHE was made. To our knowledge, cutaneous EHEs were reported in only 2 cases in the Korean literature, and that of the trunk has not been published previously. Moreover, there is no meta-analytic study about cutaneous EHE. So, we report here a rare case of EHE of the back and review the relevant literature.

Mybacterium chelonae Infection Occurring at the Site of Bee Sting Therapy / 대한피부과학회지

Mycobacterium chelonae is a rapidly growing atypical mycobacterium found in soil and water. In a healthy person, it causes cutaneous infection after an invasive procedure or surgery. Herein, we present a case of a 52-year-old man with multiple erythematous plaques and nodules on the back and left arm, and these occurred at the site of bee sting therapy by a herbal medical doctor. The histologic findings showed a granulomatous infiltration composed of numerous neutrophils, lymphocytes, eosinophils, histiocytes and multinucleated giant cells. Acid fast bacilli were detected by Ziehl-Neelsen stain and Mycobacterium chelonae infection was confirmed by an INNO-LiPA mycobacteria kit. The patient was treated with 1 g of clarithromycin and 200 mg of doxycycline for 6 months and his condition improved considerably.

Dapsone Hypersensitivity Syndrome That Occurred during Treatment of Pediatric Patient with Erythema Elevatum Diutinum

Herein, we report a case of an 8-year-old girl with dapsone hypersensitivity syndrome (DHS) that occurred during the treatment of erythema elevatum diutinum. She had fever, gross hematuria, and malaise for three weeks after initiation of dapsone therapy. Five days after stopping dapsone treatment, she returned to the emergency clinic because of high fever, emesis, diarrhea, upper respiratory symptoms, and worsening of exanthematous eruptions. A diagnosis of DHS was made, and it improved with oral prednisone. We recommend that pediatric patients who are treated with dapsone need to be observed carefully for the development of DHS.

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.

A Case of Multiple Eccrine Spiradenoma with Zosteriform Distribution / 대한피부과학회지

Eccrine spiradenoma is a benign tumor which probably originats in the coil of the eccrine sweat gland. It usually presents as a solitary, slowly-growing, sometimes painful, reddish-brown, and intradermal or deeply subcutaneous nodule on the head and trunk. More than 97% of eccrine spiradenoma appear as solitary lesions. Occasionally, it may appear as multiple lesions, however they are rarely arranged in a linear or zosteriform distribution. A search of literature revealed only 17 internationally reported cases of linear or zosteriform eccrine spiradenomas, including 4 Korean cases. We herein present an unusual case of eccrine spiradenoma, showing multiple, large nodules with zosteriform distribution.

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.

SADBE (Squaric acid dibutylester) Immunotherapy in Alopecia Areata / 대한피부과학회지

BACKGROUND: To date, highly variable results for use of topical Squaric acid dibutylester (SADBE) in the treatment of alopecia areata have been reported. Furthermore, there are no reports on SADBE in Korean dermatologic literature yet. OBJECTIVE: The purpose of this study was to evaluate the efficacy and the tolerability of SADBE in the treatment of severe alopecia areata. METHOD: A total of 22 cases of severe alopecia areata were enrolled in this study. After sensitization of the patients with 2% SADBE in acetone, the subsequent on-going treatments were done with 0.00001% to 2% SADBE with an interval of 1 to 2 weeks. The sensitization rate, the therapeutic efficacy and side effects of SADBE during the treatment course were evaluated. The efficacy was evaluated by 5 rating scales and we continued to check the recurrence of the lesions in the patients who had shown complete regrowth. RESULTS: The mean sensitization rate was 1.55. The treatment frequency at the time of initial hair regrowth ranged from 5 to 21 (mean-10.2). In the 22 patients who were treated for 6 months, more than 90% regrowth in 10 patients (45.5%) was observed, good or fair results (50-89% regrowth) in 3 patients (13.6%), and less than 49% regrowth in 9 patients (40.9%). In this study, only the duration of disease and being recurrent or not, among many prognostic factors, were statistically significant (p<0.05, chi2 -test). In half of the patients, various side effects were observed. Most common side was severe eczema at the sensitization site. Side effects during the treatment course were as follows; severe contact dermatitis, remote dermatitis, generalized pruritus, lymphadenopathy, and dermographism. But the result of side effects was not enough to give up treatment. Of the 10 patients who showed more than 90% regrowth, 4 patients had a recurrence of the lesion in their follow-up period (mean-4.75 months). CONCLUSION: The SADBE immunotherapy is effective and well-tolerated in Korean patients with severe alopecia areata.