The Relationship between Child and Adolescent Atopic Dermatitis, Attachment and the Quality of Parental Life / 대한피부과학회지

BACKGROUND: Atopic dermatitis is one of the psychosomatic disorders that have been reported to have profound effect on the development of characteristics and interpersonal relationships. OBJECTIVE: This study was performed to identify the relationship between childhood and adolescent atopic dermatitis, attachment and the quality of parental life. METHODS: Sixty-eight atopic dermatitis patients and thirty nine healthy control subjects were included in our study. Eczema area and severity index (EASI) were examined for evaluating the severity of atopic dermatitis, Revised Adult Attachment Scale for the evaluation of parent-child attachment, and Parents' Index of Quality of Life in Atopic Dermatitis for evaluating the quality of parental life were used in this study. RESULTS: The rate of unstable attachment was higher for the subjects with atopic dermatitis, as compared to that for the healthy controls (chi-square=6.07, p=0.02). The unstable attachment group in the atopic dermatitis group showed more severe AD on the face, upper extremity and lower extremity, and their total EASI score was higher than that for the stable attachment group of the patient group. The score of the quality of parental life for atopic dermatitis was lower than that for the healthy controls (t=7.09, p<0.01). Among the severity of atopic dermatitis and the child-parental attachment, the former more affected the quality of parental life (r=0.798, p<0.0). CONCLUSION: Although childhood and adolescent atopic dermatitis was related with psychologic factors of the parent-child relationship, the state of atopic dermatitis more directly impacted on the quality of parental life.

A Comparison of the Fraction of Collagen and Elastic Fibers by Image Analysis in Scleredema / 대한피부과학회지

BACKGROUND: Scleredema is a rare connective tissue disorder, characterized by hard and thick skin. It is well known that collagen synthesis is increased in scleredema skin, but there has been no study on the change of elastic fibers. OBJECTIVE: The purpose of this study was to compare the changes of collagen and elastic fibers in scleredema and normal skin. METHODS: We retrospectively evaluated the biopsy specimens of 10 patients diagnosed with scleredema. The control group was selected by matching each scleredema case with same site and similar ages from the biopsy specimens which showed normal dermis. A computerized image analysis system was used to measure the fraction of collagen and elastic fibers and calculate the ratio of elastic fibers to collagen fibers in each group. RESULTS: The skin of scleredema was found to have a significant increase in the percentage of collagen fibers in the dermis compared to the control group. On the other hand, the percentage of elastic fibers was significantly decreased in the scleredema group (p<0.05). CONCLUSION: In contrast to scleroderma which shows an increase in dermal elastic tissue and collagen fibers, we concluded that there is a decrease of elastic fibers in scleredema and that the pathogenesis and molecular involvement are different in the two diseases. we also found that the computerized image analysis system was a useful tool in the measurement of connective tissue components.

A Case of Segmental Morphea with Marked Mast Cell Infiltration / 대한피부과학회지

Mast cell has often been discussed to play an important role in tissue fibrosis, although its significance in the fibrotic process has not been completely elucidated as yet. Mast cells increase in number in the fibrotic conditions including scleroderma, wound healing, hypertrophic scar or keloid. Scleroderma fibroblasts spontaneously release high amounts of stem cell factor(SCF) than normal dermal fibroblasts. Fibroblast-derived SCF stimulates mast cells to release high amounts of monocyte chemoattractant protein-1(MCP-1). MCP-1 upregulates alpha(I) collagen mRNA expression in cultured skin fibroblasts. This effect may be an additional mechanism by which fibroblasts and mast cells interact in the development of fibrosis. Furthermore, human stem cell factor promotes melanocytes hyperplasia and functional activation. A 33-year-old Korean man noted brownish, segmental, indurated, intermittently pruritic and swollen plaque in the left side of T8 dermatome 1 year previously. Skin biopsy specimen showed increased melanin pigments in the basal layer of epidermis, increased dermal collagen fibers, sclerotic dermal collagen & perivascular inflammatory cellular infiltration, including mast cells. We report a case of segmental morphea with marked mast cell infiltration, probably showing the interaction between mast cells and fibroblasts or melanocytes through SCF.

A Case of Intertriginous Granular Parakeratosis / 대한피부과학회지

Intertriginous granular parakeratosis is a condition presenting with erythematous hyperkeratotic papules and plaques localized to the intertriginous areas such as axilla, groin and perianal area. Although the etiology of granular parakeratosis remains obscure, it is probably caused by a defect in conversion of profilaggrin to filaggrin. The defect results in a failure to degrade keratohyaline granules and to aggregate keratin filaments during cornification. We report a 59-year-old man who presented with erythematous fissured patches on the perianal area for 1 year. Histopathologic examination revealed mild acanthosis and severe parakeratosis with prominent keratohyaline granules in the epidermis and vascular proliferation and RBC extravasation in the dermis.

The Expressions of iNOS and COX-2 in the Paraffin-embedded Skin Lesions of the Patients with Leprosy / 대한피부과학회지

BACKGROUND: Nitric oxide(NO) produced by activated macrophages through the action of iNOS is the key molecule in the killing mycobacterium. Prostaglandins produced by the action of COX-2, also, are the important mediators of inflammation and other pathophysiologic process. A complex relationship is emerging with regard to "cross-talk" between the NO and COX-2 pathways. OBJECTIVE: The purposes of this study were to investigate the expression of iNOS and COX-2 across the spectrum of leprosy in the paraffin-embedded skin lesions, to demonstrate the interaction between iNOS and COX-2 expression, and to demonstrate the differences in the cell types expressing the iNOS or COX-2. METHOD: In the paraffin-embedded skin lesions of 30 new cases of leprosy(TT, n=4; BT, n=4; BL, n=7; LL, n=15), iNOS and COX-2 expression were detected by using immunohistochemical staining. RESULTS: iNOS expression was 2.0-55.8%(mean 15.9%) and the level of expression of iNOS in TT(31.2%) and BT(32.6%) lesions was significantly higher than that of BL(11.1%) and LL(8.6%) lesions(p<0.05). COX-2 expression was 3.6-74.5%(mean 27.1%) and the level of expression of COX-2 in TT(59.2%) lesions was significantly higher than that of BT, BL and LL lesions(p<0.05). There was positive correlation between iNOS and COX-2 expression, that is, the lesions which expressed high level of iNOS also expressed COX-2 highly. The correlation was statistically significant(r=0.535, p<0.05). The overall level of COX-2 expression(27.1%) was higher than that of iNOS expression(15.9%), and when compared the expression of them across the spectrum of leprosy, COX-2 expressed higher than iNOS in TT and LL lesions. CONCLUSION: Both iNOS and COX-2 were expressed in all types of leprosy skin lesions and the level of iNOS expression in TT and BT lesions was significantly higher than that of BL and LL lesions. The level of expression of COX-2 in TT lesions was significantly higher than that of BT, BL and LL lesions. These results suggest that iNOS and COX-2 have important roles in anti-mycobacterial activities in leprosy lesions. The positive correlation between iNOS and COX-2 expression suggests that NO and COX-2 might interact synergistically or additively rather than suppress each other.

A case of desmoplastic trichilemmoma / 대한피부과학회지

Desmoplastic trichilemmoma is a rare variant of trichilemmoma. A 46-year-old woman presented with a verrucous papule on the face. Histologically, well-circumscribed lobular growth with abundant central desmoplastic stroma was seen. Peripheral area of tumor lobules showed the usual feature of trichilemmoma, whereas the center of tumor was replaced by irregular cords and nests of basaloid or malpighian cells entrapped in a dense stroma, mimicking invasive carcinoma. It was diagnosed desmoplastic trichilemmoma by the distinctive histologic appearance and totally excised.

A Case of Sinusoidal Hemangioma / 대한피부과학회지

Sinusoidal hemangioma is a rare variant of cavernous hemangioma. Clinically, it develops in adults and predominantly in females, and presents as a solitary painless subcutaneous nodule. Histological finding of the sinusoidal hemangioma shows a well-circumscribed lobular architecture in the subcutaneous tissue. The lobulated mass is composed of dilated sinusoidal thin-walled vascular channels, which have a pseudopapillary pattern and back-to-back arrangement without much intervening stroma. We report a case of sinusoidal hemangioma which can be differentiated from the other vascular tumors and has never been reported in Korea.

A Case of Reticulated Acropigmentation of Dohi / 대한피부과학회지

Reticulated acropigmentation of Dohi(RAD) is a dyschromic disorder that has an autosomal dominant pattern of inheritance. RAD is characterized by the intermingled hyperpigmented and hypopigmented macules and its bilaterally symmetrical distribution on the back of the hands and feet, wrists, knees, and elbows. Histologically, there is excess of melanin in the basal layer alternating with others in which melanin was totally absent. We report a case of reticulated acropigmentation of Dohi developed sporadically with typical clinical and pathological features.

A Case of Acantholytic Acanthoma / 대한피부과학회지

Acantholytic acanthoma is a benign tumor of epidermal keratinocytes. It presents as a solitary asymptomatic papule in which acantholysis is a histologic hallmark. Its histologic finding is so much similar to those of other acantholytic dermatoses such as Hailey-Hailey disease and pemphigus vulgaris. But the clinical features including the solitarity and asymptomaticity do not fit into any specific acantholytic dermatoses. We describe a 49-year-old female patient with this peculiar benign tumor on her calf.

A Case of Onychia and Paronychia by Sternotrophomonas maltophilia / 대한피부과학회지

Sternotrophomonas maltophilia is an ubiquitous organism which has been isolated from water, soil, animals, plant material, foods and hospital equipment. The most common sites of contamination were sink drains, faucets and other items frequently in contact with water. S. maltophilia is associated with bacteremia, pulmonary infection, wound infection, mucocutaneous and soft tissue infection and endocarditis. Infection is primarily seen during severe neutropenia and in other immunocompromised condition. We report a case of onychia and paronychia caused by S. maltophilia in a patient whose occupation is the cleaner.

Two Cases of Epidermolysis Bullosa Acquisita with Atypical Distribution of Eruptions / 대한피부과학회지

We herein report two patients with epidermolysis bullosa acquisita(EBA), who had showed the atypical clinical features. A 25-year-old male presented with multiple pruritic vesicles, erosion and crusts which occurred more severely on the face than any other sites of the skin and healed with atrophic scar formation. Histopathologically, there was a subepidermal neutrophilic blister with moderate perivascular lymphohistiocytic infiltrates in the dermis, and the diagnosis of EBA was confirmed by means of direct immunofluorescence and salt-split direct immunofluorescence test performed on the perilesional skin. The other patient was a 24-year-old female who had had multiple painful ulcerative lesions on the oral mucosa for 4 months. After then, vesicles and bullae developed to progressively generalize to the anterior neck, chest and lower leg. Histolopathologic examination of peribullous skin showed a subepidermal bulla with neutrophils and eosinophils. The salt-split skin direct immunofluence test showed IgG and IgM binding to the dermal side only. We diagnosed this patient as nonscarring inflammatory EBA. Both patients were treated with prednisolone, colchicine, and dapsone resulting in clinical improvement, but their skin lesions recurred several months after discontinuing medication.

Squamous Cell Carcinoma Arising from Chronic Ulcers in Leprosy Patients : Clinical and Histopathologic Study / 나학회지

BACKGROUND: At the present time, more than 100 cases of squamous cell carcinoma (SCC) developing in neurotrophic ulcers of leprosy have been reported. But the histopathologic features and the differences between SCC in leprosy and de novo SCC was not described. OBJECTIVE: The purpose of this study was to evaluate the characteristics of SCC in leprosy and to investigate growth dynamics of SCC in ulcers in leprosy. METHODS: We reviewed the clinical features and the degree of histopathologic differentiation of 13 cases of SCC in ulcers of leprosy patients presenting at the KLCA from 1986 to 1998. And immunohistochemical staining with PCNA(proliferating cell nuclear antigen) and TUNEL staining were done in paraffin-embedded tissue sections from 18 sites of 13 cases of SCC in ulcers of leprosy. RESULTS: 1. The average duration of leprosy and of an ulcer prior to diagnosis of SCC was 43 years and 19 years, respectively. 2. Histopathologic grading of 13 cases was performed as follows:10 cases were well-differentiated and 3 cases were moderately-differentiated. 3. The PCNA LI(labelling index) was 47.26+/-7.38% in well-differentiated group and 48.86+/-9.39% in moderately -differentiated group. 4. The apoptotic index(AI) was 45.57+/-8.68% in well- differentiated group and 29.38+/-1.06% in moderately differentiated group. The AI in de novo SCC was 45.09+/-6.18%. CONCLUSION: (1) Malignant change in chronic ulcer in leprosy may be found more often if patients are examined with care. (2) Our leprosy case with SCC is a 63-year-old male with past history of lepromatous leprosy of 43 year duration having ulcer problems for 19 years before presenting with SCC on an average. (3) High-degrees of malignancy in SCC of leprosy patients might be caused by extended cell survival due to decreased apoptosis rather than increased cell proliferation.

TNFalpha Expression in the Paraffin-embedded Tissues of Leprosy / 대한피부과학회지

BACKGROUND: Tumor necrosis factor alpha (TNFalpha ) plays various roles in the pathogenesis of leprosy. Expression of TNFalpha according to the clinical type of leprosy has been studied in the patient serum, stimulated PBMC, and the skin lesions, but these results were controversial. Also, all studies of the skin lesions have been limited because of a small number of frozen tissues. OBJECTIVE: The purposes of this study were to estimate the availability of paraffin-embedded skin tissue of leprosy for the detection of TNFalpha mRNA and protein, to analysis the TNFalpha expression according to the clinical types of leprosy and lepra reaction, and to demonstrate various TNFalpha -positive cells in the skin lesions. METHODS:In the paraffin-embedded tissues of 17 new cases of leprosy, TNFalpha mRNA expression was detected by in situ hybridization with digoxigenin labelled oligonucleotide probe cocktail and TNFalpha protein expression by immunohistochemical stain. In addition, serum TNFalpha level was estimated by ELISA for the evaluation of the relationship between before and after lepra reaction. RESULTS: 1. The density of TNFalpha mRNA-positive cells ranged from 8 to 26 percent (mean 17 percent) and that of TNFalpha protein-positive cells ranged from 3 to 8 percent (mean 7 percent). They were the highest in borderline lepromatous leprosy lesions. The density of TNFalpha -positive cells was significantly higher by in situ hybridization than by immunohistochemical stain. 2. The TNFalpha -positive cells in paraffin-embedded skin lesion were CD8 positive lymphocytes, CD68 positive macrophages, endothelial cells, histiocytes, Schwann cells, and keratinocytes. The number of these cells before leprosy treatment was not significantly different from that after leprosy treatment. 3. The density of CD8-positive cells was significantly higher in lesions without lepra reaction than in lesions with lepra reaction, and that of CD68-positive cells was significantly higher in lepromatous leprosy lesions than in borderline lepromatous leprosy lesions. 4. Serum TNFalpha level was higher during lepra reaction than before lepra reaction and the high level continued even after resolution of lepra reaction. CONCLUSION: It suggested that the paraffin-embedded tissue in leprosy is an effective and available material for detecting expression of TNFalpha mRNA and protein. Also, in situ hybridization was more sensitive than immunohistochemical stain. The number of TNFalpha -positive cells was the highest in borderline lepromatous leprosy lesions. With further refinement, this may be an easier application of study for TNFalpha expression in leprosy.

The Apoptosis and Expressions of p53, bcl-2, bax, PCNA, and cyclin D1 in Porokeratosis, Actinic Keratosis, and Squamous Cell Carcinoma / 대한피부과학회지

BACKGROUND: Apoptosis is an important negative growth regulatory mechanism in tumors. In some malignancies, the apoptotic index(the percentage of apoptotic cells/bodies in the total number of tumor cells) may reflect the degree of carcinogeneity. In cells lacking functional p53, there is reduced susceptibility to apoptosis, thereby facilitating tumor growth. The bcl-2 gene product is a potent inhibitor of apoptosis and increases proliferation. The bcl-2/bax ratio is the critical determinant for the induction or inhibition of apoptosis. Proliferating cell nuclear antigen(PCNA) is present in nuclei throughout the cell cycle and is synthesized in the late G1 and S phases. Cyclin D1 is a major regulator of the G1 restriction point and may act as an oncogene; it is altered in several neoplasms. OBJECTIVE: Our purposes were to investigate the apoptotic index and the correlation between the apoptotic index and p53, bcl-2, bax, PCNA, and cyclin D1 in porokeratosis, actinic keratosis, and squamous cell carcinoma. METHODS: We investigated the apoptotic index by TUNEL and the expression of p53, bcl-2, bax, PCNA, and cyclin D1 by immunohistochemistry in 12 cases of porokeratosis, 18 cases of actinic keratosis, and 7 cases of squamous cell carcinomas. RESULTS: 1. The apoptotic index(%) in the epidermis central to the cornoid lamella was significantly higher than that of the peripheral epidermis in porokeratosis, 36.4+/-10.37 vs 24.4+/-8.76(p=0.004). 2. The apoptotic index(%) of actinic keratosis was significantly higher than that of porokeratosis, 37.4+/-7.73 vs 28.3+/-8.01(p=0.008). The apoptotic index(%) of squamous cell carcinoma was significantly higher than that of actinic keratosis, 45.1+/-6.18 vs 37.4+/-7.73(p=0.029). 3. p53 had significant positive correlation to the apoptotic index in porokeratosis and squamous cell carcinoma(p=0.002, 0.018). In actinic keratosis, the apoptotic index had significant positive correlation to cyclin D1(p=0.005). CONCLUSIONS: Actinic keratosis is more frequently evolved in malignant tumors than porokeratosis, which is supported by a significantly higher apoptotic index(%). Also the apoptotic index(%) of cutaneous malignant tumors was significantly higher than that of precancerous lesions. Apoptosis and p53, rather than proliferation, may provide the pathogenesis and progression into malignant tumors in porokeratosis. Apoptosis and cyclin D1 may provide the pathogenesis in actinic keratosis. In squamous cell carcinoma, p53-mediated apoptosis may be the key to pathogenesis in tumorigenesis and its proliferation.

Comparison of Local Bath-PUVA with Steroid Treatment in Palmoplantar Pustular Psoriasis and Dyshidrotic Eczema / 대한피부과학회지

BACKGROUND: Local bath-PUVA(LB-PUVA) therapy has been recently tried for the treatment of palmoplantar pustular psoriasis and chronic eczema with successful results. However it has not been reported that the effectiveness of LB-PUVA was compared with that of steroid treatment which is the most available treatment. OBJECTIVES: The purpose of this study was to assess the effectiveness, symptom-free interval, recurrence rate and side effects of local bath-PUVA(LB-PUVA) therapy in palmoplantar pustular psoriasis and dyshidrotic eczema which had been resistant to conventional treatments and to compare these results with those of the steroid treatment. METHODS: Twenty four patients with palmoplantar pustular psoriasis, dyshidrotic eczema and palmoplantar keratoderma were treated with local bath-PUVA and the control group of twenty patients with systemic and topical steroid. 1. Local bath-PUVA therapy After a 15-minute bath in 1mg/L of methoxsalen solution(0.0001%), the palms or soles or both were exposed immediately to UVA radiation by UV/PUVA200. The initial standard dose was 1.5 J/cm2, and the patients were treated three times a week. 2. Systemic and topical steroid therapy The patients treated with 10-15mg of oral prednisolone once a day and high-potency steroid(Dermovate ointment) to the lesion topically for 4-8 weeks. The efficacy, symptom-free interval and side effects were assessed for 6-12 months after termination of the treatments. RESULTS: The following results were obtained from this study. 1. In the objective study, severity scores before and after treatment significantly differed in palmoplantar pustular psoriasis treated with local bath-PUVA (p<0.001). 2. In the subjective study, steroid treatment was more effective than LB-PUVA treatment for dyshidrotic eczema and palmoplantar pustular psoriasis. 3. Remission period was significantly longer (mean 9.1+/-2.8 months vs. 5.2+/-3.1 months) and recurrence rate, lower (26.7% vs. 68.9%) after LB-PUVA treatment than after steroid treatment in palmoplantar pustular psorisis and dyshidrotic eczema. 4. One patient with palmoplantar keratoderma was effectively treated by LB-PUVA. CONCLUSION: Local bath-PUVA therapy can be used as an effective and safe treatment method of palmoplantar pustular psoriasis and possibly palmoplantar keratoderma.

A Case of Subcutaneous Abscess with Mycobacteria chelonae Infection / 대한피부과학회지

We describe localized subcutaneous abscesses on the right axilla of a 34-year-old woman due to M.chelonae infection in the previous incision and drainage site. The infection responded to treatment with anti-Tb medication. Mycobacterium chelonae is one of the rapidly growing atypical mycobacteria, belonging to Runyon group IV, which is ubiquitous in the environment. Primary cutaneous infections have been described after skin injury in immunocompetent patients and produce chronic nodule or draining abscesses. Disseminated infections have been reported in immunocompromised patients.

Two Cases of Tubular Apocrine Adenomas / 대한피부과학회지

Tubular apocrine adenoma(TAA) is a rare tumor characterized by papillary projection and apocrine differentiation. We report two cases of tubular apocrine adenomas. One patient was a 13-year-old male who had had a finger-tip sized asymptomatic cystic mass on his scalp since birth. Microscopically, the mass was composed of various sized cystic spaces and tubular structures lined by two layers of epithelia with nonvillous intraluminal papillary projections, decapitation secretions and connection with the epidermis. The other patient was a 55-year-old female who had had a 1.3x0.3cm sized dark red hard nodule on the left forearm since birth. Histopathologic finding showed a well circumscribed dermal neoplasm that predominantly consisted of multiple tubular structures lined by double layers of epithelial cells with decapitation secretions and intraductal papillary projections, and accompanied by underlying apocrine nevus. In both cases, immunohistochemical and enzyme studies showed positive findings in EMA, CEA, pancytokeratin, lysozyme, alkaline phosphatase, GCDFP-15.

Two Cases of Metastatic Adenocarcinoma of the Skin / 대한피부과학회지

A 73-year-old male was presented with a walnut-sized erosive plaque on the lower lip and several skin colored nodules on the neck, the left shoulder and the arm. The other case was a 74-year-old male who had been diagnosed as metastatic lung cancer of unknown origin was consulted for several ulcerative nodules on the face and the left lateral neck. Both patients were finally diagnosed as metastatic adenocarcinoma each from the lung and stomach by histopathologic finding and immunohistochemical studies.

A Case of Melkersson-Rosenthal Syndrome (Chilitis granulomatosa) / 대한피부과학회지

A 43-year-old female had diffuse swelling with erythematous papules on the lower lip and an erythematous patch on the chin for 1 year. The lesions were nonpururitic, non-tender and odontogenic infection was combined. A Histopathological study of the biopsy specimen of the chin showed noncaseating epithelioid granuloma through the entire dermis. Special stains showed no evidence of fungal organism or acid fast bacilli. Theses clinical and histopathologic findings indicated the diagnosis of cheilitis granulomatosa. Odontogenic infectious sources were removed and antibiotics and dapsone oral medication have been used and the lesions showed improvement.

A Case of Malignant Melanoma Arising from Melanocytic Nevus / 대한피부과학회지

Malignant melanoma is a tumor arising from the melanocytes of the skin, eyes and juxtacutaneous mucous membrane. By several reports, about 20 30% of all melanomas have arisen from the preexisting nevi. Early diagnosis and intervention is the only method known to alter dramatically the course of malignant melanoma. Increased awareness of the importance of early diagnosis has focused the identification of persons at high risk for the development of melanomas. There has been some indication in medical literature that common acquired melanocytic nevi may be an important risk factor of cutaneous melanoma and nevus counts are a better risk marker than sun exposure and phenotypic traits. We report a 58-year-old man who had many melanocytic nevi on his entire body since childhood and malignant melanoma arising from one of the preexisting melanocytic nevi on the back.