Epidemiologic Survey of Onychomycosis in Koreans: Multicenter Study / 대한의진균학회지

BACKGROUND: Although there have been many studies about onychomycosis, no study about Koreans in onychomycosis has been reported in Korea. OBJECTIVE: The purpose of this study was to investigate the onychomycosis in Koreans. METHODS: From April, 2009, to March, 2010, 1,893 patients with onychomycosis who visited the department of dermatology at 10 university hospitals were evaluated. RESULTS: Of 1,893 patients with onychomycosis, 93.8% were toenail onychomycosis, 2.2% fingernail onychomycosis, and 4.0% onychomycosis in both toenails and fingernails. Among the age groups, the incidence rate was highest over the sixties (35.6%). The ratio of male to female patients was 1.3:1. Distal and lateral subungual onychomycosis (80.3%) was the most common clinical type of onychomycosis. Combination therapy of oral terbinafine or itraconazole and topical amorolfine nail lacquer was most common in the treatment of onychomycosis. The most common reasons for combination therapy in onychomycosis were higher cure rate due to synergistic activity (40.2%), followed by shortened treatment duration (12.8%), patient compliance (12.3%), and prevention of recurrence and reinfection (1.7%). CONCLUSION: Because of the increase in onychomycosis, we suggest the need of standard treatment guidelines for Korean patients with onychomycosis.

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.

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.

Clinical Observation of Cutaneous Sarcoidosis / 대한피부과학회지

BACKGROUND: Sarcoidosis is a chronic idiopathic disorder characterized by the formation of noncaseating granulomas. Multiple organs may be involved, including the skin, lung, lymphatic systems, liver, spleen and eyes. On average, 25% of sarcoidosis cases have cutaneous involvement. OBJECTIVE: The purpose of this study was to investigate the clinical characteristics of cutaneous sarcoidosis and the involvement of systemic organs according to clinical types of skin lesions. METHODS: A total of 32 patients diagnosed by histologic examination at Hospital from 2001 to 2009 with cutaneous sarcoidosis were enrolled in this study. The clinical features were obtained by reviewing medical records, clinical photographs and radiological images. RESULTS: The male to female ratio was 1 : 3 and 78.2% of patients were in their fifth to seventh decades. The most common cutaenous lesions were nodules (56.3%), especially the subcutaneous type (21.9%). The most frequently involved organ type was intrathoracic (71.9%), followed by the peripheral lymph nodes (25%), spleen (6.3%), and eyes (6.3%). Most patients with subcutaneous nodules, erythema nodosa, lupus pernio and discoid lupus-like plaques showed systemic involvement, whereas most patients with nodules or papules did not show systemic involvement. Of particular note, patients with subcutaneous nodules and lupus pernio showed more frequent involvement of the peripheral lymph nodes, spleen and intrathoracic region. CONCLUSION: In this study, patients with subcutaneous nodules and plaques showed more frequent systemic involvement, while most patients with nodules or papules showed no systemic involvement.

Auricular Granuloma Annulare Induced by Repeated Occupational Traumas / 대한피부과학회지

Granuloma annulare (GA) is a benign granulomatous disease. Although its etiology is not well understood, there are some reports about GA occurring after specific conditions such as sunburn, a tuberculin test, insect bites, viral diseases and trauma. Especially, in case of the auricular region which is vulnerable to trauma, it seems that GA has some relation with trauma. In 1992, Mills and Chetty proposed that repetitive minor trauma may be an important cause of auricular GA. Among the 5 cases of auricular GA that have been reported in the English literatures, 3 cases are assumed to be associated with repetitive minor trauma. Herein, we report on two cases of auricular GA that were thought to be associated with repetitive minor trauma.

Oral Hairy Leukoplakia Which Occurred as a Presenting Sign of Acute Myeloid Leukemia in a Child

Oral hairy leukoplakia (OHL) is caused by the reactivation of a previous Epstein-Barr virus (EBV) infection in the epithelium of the tongue. Most lesions are characterized by corrugated whitish patches on the lateral border of the tongue. It is frequently associated with AIDS, but cases in patients with other immunosuppressed states have also been reported. In leukemia patients, OHL is rarely encountered, and appears only after chemotherapy. We report a case of OHL which occurred as a presenting sign of acute myeloid leukemia (AML) in a previously healthy 15-year-old child. A 15-year-old boy presented with a whitish patch on the left lateral border of the tongue. The biopsy specimen revealed papillomatosis, hyperkeratosis, acanthosis and ballooning degeneration in the stratum spinosum. The patient was EBV seropositive, and PCR analysis of EBV DNA in the lesional tissue was positive. After the diagnosis of OHL in dermatologic department, the patient was referred to pediatrics due to the abnormal peripheral blood smear, and was diagnosed with AML.

The Patch Test as a Useful Tool for Avoiding Suspected Allergens in Patients with Hand Eczema / 대한피부과학회지

BACKGROUND: Hand eczema is a common skin disease in the general population. The etiology of hand eczema is obscure and many causative factors have been proposed. However, there are only a few reported studies of the relevance of contact allergy in hand eczema. Objective: The purpose of this study was to evaluate the diagnostic value of the patch test for patients with hand eczema. METHODS: We analyzed the clinical characteristics and the results of the patch tests of the 37 patients with hand eczema and we then compared these with the clinical subtypes. RESULTS: 26 patients (70.3%) showed a positive test to one or more allergens. The common allergens were nickel sulfate (35.1%), mercury ammonium chloride (21.6%), and cobalt chloride (18.9%). The positive rates for a patch test were 82.4% for the vesicular form, 77.8% for the fissured form, 20.0% for the hyperkeratotic form and 66.7% for pompholyx, respectively. We found more significant improvement of the clinical symptoms in the vesicular group (57.1%) than that in the non-vesicular group (9.3%) after avoiding the verified allergens. CONCLUSION: This study shows that the patch test is a useful tool for the detection of contact allergens and it must be performed for the patients with hand eczema, and especially for those patients with the vesicular type.

The Patch Test as a Useful Tool for Avoiding Suspected Allergens in Patients with Hand Eczema / 대한피부과학회지

BACKGROUND: Hand eczema is a common skin disease in the general population. The etiology of hand eczema is obscure and many causative factors have been proposed. However, there are only a few reported studies of the relevance of contact allergy in hand eczema. Objective: The purpose of this study was to evaluate the diagnostic value of the patch test for patients with hand eczema. METHODS: We analyzed the clinical characteristics and the results of the patch tests of the 37 patients with hand eczema and we then compared these with the clinical subtypes. RESULTS: 26 patients (70.3%) showed a positive test to one or more allergens. The common allergens were nickel sulfate (35.1%), mercury ammonium chloride (21.6%), and cobalt chloride (18.9%). The positive rates for a patch test were 82.4% for the vesicular form, 77.8% for the fissured form, 20.0% for the hyperkeratotic form and 66.7% for pompholyx, respectively. We found more significant improvement of the clinical symptoms in the vesicular group (57.1%) than that in the non-vesicular group (9.3%) after avoiding the verified allergens. CONCLUSION: This study shows that the patch test is a useful tool for the detection of contact allergens and it must be performed for the patients with hand eczema, and especially for those patients with the vesicular type.

The Efficacy of Topical Calcineurin Inhibitors for Treating Lichen Striatus / 대한피부과학회지

BACKGROUND: Lichen striatus is a well-known, acquired, self-healing, linear inflammatory dermatosis. The therapeutic approach that is usually adopted is topical steroid, even though the prolonged use of this may lead to several side-effects, and particularly cutaneous atrophy. OBJECTIVE: The purpose of this study was to evaluate the efficacy of topical calcineurin inhibitors for the treatment of lichen striatus. METHODS: Twenty nine patients received topical application of calcineurin inhibitors twice a day up to the marked disappearance of the cutaneous lesions. RESULTS: Six (20.7%) of 29 patients achieved a complete response after a mean treatment period of 2.5 months. A good response was observed in 8 patients (27.6%) and a partial response was seen in 8 patients (27.6%). Of the 29 patients, 22 patients (75.9%) had more than a 50% response without any severe adverse effects. No significant differences in the therapeutic responses were found with regard to the patients' ages, the duration of the disease and the length of the treatment periods. CONCLUSION: Our results show that topical calcineurin inhibitors may well represent a useful therapeutic alternative for the treatment of lichen striatus.

Postauricular Island Pedicle Flap ("Flip-Flop" Flap) for Reconstruction of the External Ear Defect / 대한피부과학회지

About six percent of head and neck cancers occur on the external ears. Excision of the cancer can cause changes of morphology and poor cosmesis. Reconstruction of ear defects presents a unique and notable challenge to the dermatologic surgeons. This is due to the complex architecture of the external ear which is difficult to duplicate surgically. Several methods are available for reconstruction of defects to the external ear. However, the diversity of external ear shapes shows how difficult it is to achieve a certain solution to this problem. Postauricular island pedicle flap was initially reported as a technique for reconstruction of small defects of the concha after excision, and has since been used successfully in the repair of more extensive defects involving not only the concha, but also the antihelix and external auditory meatus. We report two cases of auricular squamous cell carcinoma in which the skin defect is reconstructed by a postauricular island pedicle flap ("flip-flop" flap).

Reconstruction with Burow's Graft After Mohs' Micrographic Surgery of Facial Basal Cell Carcinoma / 대한피부과학회지

BACKGROUND: In reconstruction of facial defects, large defects or defects with insufficient skin laxity could pose a challenge. Burow's graft is a modified full-thickness skin graft which utilizes adjacent skin as the donor site. OBJECTIVE: To describe the surgical technique of Burow's grafts and to report our experience with the postoperative cosmetic outcome. METHODS: This is a retrospective review of 16 cases of basal cell carcinoma, reconstructed with Burow's grafts after Mohs' micrographic surgery. Burow's graft was performed in surgical defects which were too large for primary closure. Burow's grafts were then placed on the remaining primary defects and sutured. The size of the tumor and postoperative surgical defects, local complications, and cosmetic outcomes were assessed. RESULTS: The size of primary defects ranged from 0.9 to 3.5 cm (with a mean of 1.98 cm) in greatest diameter. Seven cases were located on the nose, 3 on the cheek, 2 on the ear, 2 on the temple, and one on the eyebrow and lower eyelid. During the follow-up period, partial graft necrosis occurred in 2 patients but there was no evidence of acute bleeding, hematoma, or infection. There was no tumor recurrence and most of the patients showed minimally discernable scarring with satisfactory aesthetic outcomes. CONCLUSION: Burow's graft could be recognized as a useful reconstructive method in large skin defects and in areas with limited skin laxity. It provides an aesthetically pleasing result, and it is also simple and easy to perform.

A Case of Amelanotic Melanoma: Dermoscopic Features / 대한피부과학회지

Amelanotic melanoma is a subtype of malignant melanoma that lacks clinically visible pigmentation. The absence of recognizable pigmentation obscures the clinical hallmark of the more typical form of malignant melanoma. Because it mimics various non-pigmented benign and malignant skin diseases, clinicians have difficulty diagnosing this lesion. An incorrect or delayed diagnosis can result in a worse outcome because the prognosis of melanoma depends on the tumor thickness and tissue invasion at the time of diagnosis. Therefore, early diagnosis is crucial for treating amelanotic melanoma. Dermoscopy is a useful non-invasive technique for diagnosing not only pigmented skin lesions, but also non-pigmented skin lesions because this modality can visualize vascular structures that are not discernible to the naked eye. Analyzing the dermoscopic vascular structures of amelanotic melanoma helps make an early diagnosis. We report here on a case of amelanotic melanoma for which the diagnosis was aided by performing dermoscopy as an adjuvant tool.

Angiomyxolipoma (Vascular Myxolipoma) of Subcutaneous Tissue

Lipoma is the most common neoplasm of mesenchyme, and several subtypes have been described that vary according to their location and the presence of other tissue elements. Angiomyxolipoma is a very rare variant that consists of an admixture of adipose and myxoid elements with numerous vascular structures. It should be differentiated from other subtypes of benign and malignant lipomas. Here the case of a 69-year-old male is described who presented with a solitary asymptomatic mass on the left iliac crest. The histopathologic findings showed alternating nests of myxoid and adipose tissue containing dilated blood vessels, which was consistent with angiomyxolipoma.

A Case of Oculocutaneous Albinism Induced by Tyrosinase Mutation / 대한피부과학회지

Oculocutaneous albinism (OCA) is a group of inherited disorders of the melanin synthesizing system, and these are characterized by hypopigmentation of the hair, skin and eyes, with a normal number of melanocytes. The defect of melanin biosynthesis is caused by genetic mutation of such enzymes as tyrosinase (TYR), and tyrosinase-related protein (TYRP), which affect tyrosine convert to melanin pigment. There are at least four types of OCA from OCA1 to OCA4. The different types of OCA are caused by mutations in different genes. The most severe form, OCA1A, is distinguishable from other forms owing to a complete lack of melanin pigment throughout the patient's whole life. But among other types, except OCA1A, it is hard to identify the correct type according to only the clinical findings because their clinical phenotypes usually overlap. Therefore, molecular study is a useful tool for the typing and diagnosis of OCA. We experienced a case of a 10-month-old male toddler who has pale skin, straw-colored hair, nystagmus and visible choroidal vessels. Under the clinical impression of OCA, the correct subtyping was made on the basis of genetic analysis of the chromosomes and we found a new TYR gene frame-shift mutation.

Clinicopathologic Observation of Odontogenic Sinus Tracts Draining to the Skin / 대한피부과학회지

BACKGROUND: An odontogenic sinus tract draining to the skin is the most common type of cutaneous fistula that occurs on the face. This lesion can be a diagnostic challenge to clinicians who are not familiar with cutaneous fistula since many patients with an odontogenic sinus tract draining to the skin do not have any symptom such as toothache. OBJECTIVE: Our purpose was to determine the characteristic features of an odontogenic sinus tract draining to the skin. METHODS: Eleven patients who presented with an odontogenic sinus tract draining to the skin at the Dermatologic Department of Pusan National University Hospital during the last ten years were enrolled in this study. We reviewed all the medical records of the patients. RESULTS: The mean age was 51.8 years. The male to female ratio was 1.2:1. Nine patients (82%) had lesions on their chins or the mandibular region. The most common tooth with endodontic infection was the lower first premolar tooth (36%), and the most common clinical feature was pyogenic granuloma-like solitary papule (64%). The panoramic view showed radiolucent periapical abscesses in all the patients. Skin biopsy showed chronic granulomatous inflammation, and fistular tracts were present in three patients. Only 1 of 11 patients (9%) had toothache, and two patients had prior therapies for prosthetic dentures or caries, respectively. Nine patients (82%) were treated ineffectively, and their first visit was to adermatologic clinic (91%) or an otolaryngologic clinic (9%). After the diagnosis of odontogenic sinus tract draining to the skin, eight patients (73%) were treated completely by root canal therapy or extraction of teeth. CONCLUSION: In this study, most patients had no toothache or history of dental disease, and they were treated inappropriately, even in dermatologic clinics. The results of this study will help reduce the incidence of inappropriate management for odontogenic sinus tract draining to the skin at dermatologic departments.

Reconstruction with O-Z Flap and Double O-Z Flap after Mohs' Micrographic Surgery for Skin Cancer of the Face / 대한피부과학회지

BACKGROUND: The O-Z flap is a kind of rotational flap that consists of a combination of two opposing rotation flaps. The double O-Z flap is a variant of the O-Z flap applied in multiple adjacent surgical defects that can simplify closure by combining closure into one technique. OBJECTIVE: To report our experience with the O-Z flap and double O-Z flap in the reconstruction of surgical defects of the face after Mohs' micrographic surgery (MMS), using postoperative clinical and cosmetic results. METHODS: Sixteen patients diagnosed with non-malignant melanoma skin cancer on the face were treated with MMS. The resultant surgical defects were reconstructed with an O-Z flap in 14 patients and with a double O-Z flap in 2 patients. Clinical outcomes were reviewed, and cosmetic results were scored as excellent, good, fair, poor, or very poor. RESULTS: In the 14 patients using O-Z flap, 6 cases were located on the temple, 4 on the forehead, 2 on the cheek, and 1 of each on the nose and philtrum. Of the two patients using double O-Z flap, one had two adjacent basal cell carcinomas on the cheek, and the other had two adjacent squamous cell carcinomas on the forehead. The size of the primary defects ranged from 1.1 to 2.5 cm in greatest diameter (mean, 1.93 cm). There were no significant local complications. There was no tumor recurrence, and 14 of 16 patients showed satisfactory aesthetic outcomes scored as excellent or good. CONCLUSION: O-Z flap reconstruction was effective for the closure of surgical defects with limited skin laxity in the face. The double O-Z flap is ideally suited to combine closure of adjacent surgical defects into one technique without exerting undue tension or distorting the surrounding structures. We found these flaps were simple to construct and provided aesthetically pleasing results. Therefore, they could be useful reconstructive options in facial skin defects after MMS.

A Case of Granulomatous Mycosis Fungoides / 대한피부과학회지

Granulomatous mycosis fungoides is a rare type of cutaneous T-cell lymphoma. The patients with this illness do not present with distinct clinical findings, so the diagnosis depends on the demonstration of a malignant lymphoid infiltration in combination with a granulomatous tissue reaction. A 38-year-old woman presented with erythematous to purple-colored, focally atrophic, scaly plaques on the right inguinal area and diffuse erythematous scaly patches and multiple erythematous papules on the trunk. The histopathological findings showed non-necrotizing granulomatous infiltrates admixed with an atypical lymphocytic component and epidermotropism. Herein, we report a case of granulomatous mycosis fungoides.

The Effect of Detergents on the Morphology and Immunomodulatory Activity of Malassezia furfur

BACKGROUND: Several workers have found that Malassezia are capable of suppressing cytokine release and downregulating the phagocytic function of monocytes. But lipid-depleted Malassezia furfur (M. furfur) extracts have also been shown to induce increased production of TNF-alpha, IL-6 and IL-1beta in monocytes. We thought that the detergents in shampoos or soaps could change the composition of the lipid in the M. furfur cell wall. OBJECTIVE: We studied whether detergents affect the morphology of M. furfur and if the inflammatory cytokine profiles change in the monocytes treated with detergent-treated M. furfur. METHODS: Commonly used detergents such as sodium lauryl sulfate, ammonium lauryl sulfate and tween-80 were respectively added to the modified Leeming-Notman's media. M. furfur was cultivated in each media (detergent-added or untreated). Thereafter, the surface morphology of the yeast was evaluated by scanning and transmission electron microscopy. The cytokine profiles of monocytes, which were treated by M. furfur with or without detergents, were also evaluated. RESULTS: The detergent- treated M. furfur were similar to the lipid-extracted form of M. furfur on the electron microscopic study, with a recessed, withered surface and with thinner and rather electron transparent cell walls than the detergent-untreated M. furfur. The levels of TNF-alpha were higher in monocytes treated with detergent-treated Malassezia than that in the monocytes treated with the detergent-untreated Malassezia (p <0.05). CONCLUSION: According to the findings in this study, it could be inferred that the detergents in shampoos or soaps affect the lipid layers of the Malassezia cell wall and these lipid-extracted Malassezia induce or aggravate some inflammatory conditions. But to correlate the relationship between detergents and Malassezia-associated diseases, in vivo experiments that will focus on short-term contact with detergents in real life conditions should be done.

The Effect of Detergents on the Morphology and Immunomodulatory Activity of Malassezia furfur

BACKGROUND: Several workers have found that Malassezia are capable of suppressing cytokine release and downregulating the phagocytic function of monocytes. But lipid-depleted Malassezia furfur (M. furfur) extracts have also been shown to induce increased production of TNF-alpha, IL-6 and IL-1beta in monocytes. We thought that the detergents in shampoos or soaps could change the composition of the lipid in the M. furfur cell wall. OBJECTIVE: We studied whether detergents affect the morphology of M. furfur and if the inflammatory cytokine profiles change in the monocytes treated with detergent-treated M. furfur. METHODS: Commonly used detergents such as sodium lauryl sulfate, ammonium lauryl sulfate and tween-80 were respectively added to the modified Leeming-Notman's media. M. furfur was cultivated in each media (detergent-added or untreated). Thereafter, the surface morphology of the yeast was evaluated by scanning and transmission electron microscopy. The cytokine profiles of monocytes, which were treated by M. furfur with or without detergents, were also evaluated. RESULTS: The detergent- treated M. furfur were similar to the lipid-extracted form of M. furfur on the electron microscopic study, with a recessed, withered surface and with thinner and rather electron transparent cell walls than the detergent-untreated M. furfur. The levels of TNF-alpha were higher in monocytes treated with detergent-treated Malassezia than that in the monocytes treated with the detergent-untreated Malassezia (p <0.05). CONCLUSION: According to the findings in this study, it could be inferred that the detergents in shampoos or soaps affect the lipid layers of the Malassezia cell wall and these lipid-extracted Malassezia induce or aggravate some inflammatory conditions. But to correlate the relationship between detergents and Malassezia-associated diseases, in vivo experiments that will focus on short-term contact with detergents in real life conditions should be done.

A Case of Acute Generalized Exanthematous Pustulosis Induced by Ingestion of Lacquer Chicken Broth / 대한피부과학회지

Lacquer has been widely used for decorating or protecting furniture, floors, tea-pots and ornaments in East Asia (Korea, Japan and China), and it is a common cause of contact dermatitis that occurs after direct skin contact. Lacquer chicken broth has been considered as a folk medicine or health food in East Asia, and especially in Korea. Thus, systemic contact dermatitis accompanied by cutaneous eruptions and systemic symptoms is not uncommon after ingesting lacquer chicken broth. The clinical manifestations of systemic contact dermatitis by ingesting lacquer chicken broth are mainly maculopapular eruptions (65%), erythema multiforme-like eruptions (32%) and erythrodermic eruptions (19%) and these lesions can also present in the form of pustules, purpuras, wheals and blisters. However, there are few reported cases of acute generalized exanthematous pustulosis (AGEP) occurring after ingesting lacquer chicken broth without a past history for drugs, viral infection and contact allergy to mercury. We herein describe a case of AGEP accompanied by erythema multiforme-like lesions occurringafter ingesting lacquer chicken broth in a 64-year-old female patient.