Developing and Application of a Novel Triage Tag

PURPOSE: Triage tags help prioritize the treatment for disaster patients based on the severity of the illness and help distribute limited resources during a time of disaster. In this study, we developed a novel triage tag and evaluated its feasibility during a hospital-based disaster drill. METHODS: For the first stage, we developed a new triage tag. The most commonly used triage tags (Medical Emergency Triage-TAG and SMART tag) were analyzed. We reassembled their advantages and invented a novel triage tag (NT tag). The second stage involved an evaluation of the quality of NT tag. The NT tag was used in a hospital-based disaster drill held in a single center with 22 mock patients. After the drill, hospital staffs were asked to complete a questionnaire which included visibility, comprehensibility, and ease of use with respect to the new NT tag. A five-category Likert scale was used to quantify the answer. RESULTS: The NT tag was successfully developed considering 6 quality indexes: visibility, expandability, flexibility, solidity, space, and fixity. Forty-two out of ninety (46.7%) subjects answered the questionnaire. Approximately 21% of participants had previous disaster drill experience and 33% had previous education of the SMART triage system. The visibility scale of the severity category was on average 3.3 (standard deviation (SD): 1.0), the comprehensiveness of the severity category was 3.6 (SD:0.9), the ease to understand patient information was 2.2-4.2, the ease to follow up symptoms and vital signs was 2.3-4.1. Eighty and percent of participants preferred to use the NT tag in a future disaster situation or disaster drill. CONCLUSION: We successfully developed a novel triage tag. The NT tag showed moderate feasibility.

Three Cases of Pseudopelade of Brocq that Had Been Misdiagnosed as Seborrheic Dermatitis / 대한피부과학회지

Pseudopelade of Brocq is a rare, idiopathic, slowly progressive hair disorder that results in cicatricial alopecia. It is characterized by multiple, small, discrete, asymmetrical, smooth alopecic patches that show little clinical inflammation. Mild pruritus and diminished lesional sensation may also be present. In addition, mild perifollicular erythema may be detected. Seborrheic dermatitis presents as chronic, papular, scaly lesion of skin, and this can be seen on the scalp. Clinically, this disease is characterized by oily, erythematous, scaly lesion. Although both diseases originally have different clinical characteristics, the early and mild scalp lesions of both diseases sometimes mimic each other. Herein, we report on 3 cases of pseudopelade of Brocq that were misdiagnosed and treated as seborrheic dermatitis.

Amiodarone Induced Blue-gray Pigmentation / 대한피부과학회지

Amiodarone (AD) is a benzofuran derivative that has been used for the treatment of recurrent arrhythmia and as a coronary vasodilator in Europe since 1964. AD-related hyperpigmentation develops after an average of 20 months of continuous AD treatment and with a minimal total dose of 160 g AD in less than 10% of the patients. A 49-year-old man presented with asymptomatic blue-gray patches that had slowly developed on the face over the previous 3 months. He had been taken amiodarone continuously for 39 months (cumulative dose: 974 g). A skin lesion biopsy from the face showed many dermal melanophages containing brown granules. The AD was discontinued and he begin using sunscreen and is courrently being followed-up. The skin discoloration was still evident, but slightly diminished at five month's follow up.

Vitiligo-like Depigmentation Associated with Metastatic Melanoma of an Unknown Origin

Although malignant melanoma usually occurs after the diagnosis of vitiligo-like depigmentation, the latter is rarely followed by the former. We herein report on such a case in which recognition of the vitiligo-like depigmentation preceded diagnosing the metastatic melanoma by several months. A 56-year-old woman had first developed vitiligo-like depigmentation on the forehead, eyelids, neck and back 18 months previously and thereafter she detected a hard mass in the left axilla 2 months previously. Based on the histologic findings, the axillary mass was diagnosed as metastatic melanoma. To evaluate the primary tumor focus, thorough examinations that included PET-CT, bone scan and sigmoidoscopy were performed, but we couldn`t find any the original primary tumor. Our case suggests that the vitiligo-like depigmentation could be a sign that heralds metastatic melanoma.

A Survey on the Topical Steroid Prescriptions of Dermatologists / 대한피부과학회지

BACKGROUND: A recent survey on dermatology outpatients, which assessed their knowledge and behavior for topical steroid use, showed that topical steroids were often used without sufficient information or guidelines. OBJECTIVE: Our study aimed to evaluate the general pattern of which dermatologists prescribe topical steroids, the prevalence of topical steroid phobia among the dermatology outpatients and the way dermatologists managed such patients. METHODS: 236 dermatologists, including those in private clinics and those in the secondary and tertiary hospitals, were asked via mail or e-mail to fill in a questionnaire on their topical steroid prescription. RESULTS: About sixty percent of the total respondents answered that they prescribed topical steroid to more than half of their outpatients, with excluding those patients who came to the office for cosmetic purposes. Most respondents informed their patients about their prescription of topical steroids (85.61%), they explained the mechanism of its action and the clinical effects (65%), the potency and duration of application (70%), and the side effects (82%). But most respondents forgot or did not tell their patients about their steroid formulation (46%), the optimal amount to apply (74%) and the means and duration of optimal storage (82%). 45% of the respondents assumed that more than half of the outpatients to have topical steroid phobia. Yet 80% of the respondents replied that less than 10% of their outpatients had experienced side effects of topical steroids. 73% of the respondents in private clinics and 62% in secondary and tertiary hospitals were influenced by the patients' negative attitude on topical steroid prescription. CONCLUSION: The results show that the information on topical steroids, in terms of formulation, the optimal amounts to apply and the means and duration of optimal storage, were not sufficiently provided by dermatologists. The topical steroid phobia of patients has been exaggerated despite the low incidence of side effects.

A Case of Papuloerythroderma of Ofuji Improved by Cyclosporine and Topical Tacrolimus / 대한피부과학회지

Papuloerythroderma of Ofuji isa rare and unique form of erythroderma and usually affects elderly Asian men. Various therapeutic approaches have been tried and both systemic corticosteroids and PUVA have been reported to be most effective. A 57-year-old man presented with itchy erythematous papules forming erythroderma that did not affect skin folds. His lesion did not respond to topical corticosteroids and antihistamines for 2 weeks. We used cyclosporine and topical tacrolimus. He completely recovered several days later and there has been no sign of recurrence for nearly 1 year.

Hair Follicular Expression of Integrin Alpha-6 Subunit and p63 in Hair Loss / 대한피부과학회지

BACKGROUND: Integrins have a crucial function in the attachment of cells to the extracellular matrix and as important transducers of signals from the extracellular matrix to the matrix cells of the hair follicle. Recent evidence has suggested that p63 is essential for the development of epidermis and skin appendages. OBJECTIVE: To investigate the possibility that integrin alpha-6 and p63 may be involved in the pathogenesis of various conditions of hair loss. METHODS: The expressions of integrin alpha-6 subunit and p63 were examined by immunohistochemical staining of 76 scalp biopsy samples, including 21 male pattern hair loss (MPHL), 19 female pattern hair loss (FPHL), 23 alopecia areata (AA) and 13 female telogen effluvium (TE). In each staining section, the percentage of positive cells and the localization of expression were evaluated. RESULTS: Among the four hair loss groups, MPHL and AA showed nearly negative immunoreactivities of alpha-6 integrin in the basal sides of follicle epithelium. On the other hand, TE immunoreactivity represented very similar pattern of normal control and FPHL samples showed weak outer root sheath staining which was definitely different from that of MPHL. Immunohistochemical staining of p63 in AA and TE revealed relatively strong reactivity compared to MPHL and FPHL. Interestingly, TE p63 immunoreactivity was mainly confined to inner 2/3 outer root sheath. CONCLUSION: These data may explain the somewhat causal and developmental role of integrin alpha-6 and p63 in the occurrence of hair loss. Since both integrin alpha-6 and p63 are necessary for hair follicle growth and maintenance, it is worthwhile taking more concern over these proteins.

An E-mail Survey of General Awareness and Usage Status of Topical Minoxidil Solution in Alopecia Patient / 대한피부과학회지

BACKGROUND: Topical minoxidil solution is very well known and easily obtainable stuff in Korea. Even though it is an useful and effective medication for keep the hairs, there are still some misunderstandings exist. OBJECTIVE: To assess the general awareness and usage status of topical minoxidil solution in alopecia patients. METHODS: E-mails with questionnaire file were sent to 3,875 patients who visited the hair clinic. 202 replied questionnaires were enrolled in this study. The questionnaire consisted of 30 items concerning the general evaluation of the awareness and usage status of topical minoxidil. RESULTS: The proper candidates for the minoxidil solution including male pattern hair loss, female pattern hair loss, and some alopecia areata felt that it was relatively effective. But most patients who had not seen a doctor misunderstood the usage and side effects of topical minoxidil. Also this group's satisfaction of topical minoxidil solution was lower than that of the group who had consulted a doctor. Some patients with heart problems (10.4%) had been used topical minoxidil solution without any caution. CONCLUSION: Although topical minoxidil solution is an over-the-counter medicine, careful explanation of its usage and side effects should be provided before application. To make sure and increase its exact effectiveness, the role of dermatologist should be emphasized.

A Survey of the Awareness, Knowledge, and Behavior of Topical Steroid Use in Dermatologic Outpatients of the University Hospital / 대한피부과학회지

BACKGROUND: Topical steroids are a widely used therapeutic agent in dermatology. However, little objective data has been collected in order to assess the awareness, knowledge and behavior of patients regarding the use of topical steroids. OBJECTIVE: The goal of this study was to investigate the current state of awareness, knowledge, and behavior of patients regarding topical steroid use. METHODS: A written questionnaire was distributed to 570 outpatients who visited the dermatologic clinics of the University Hospital. Of these, 504 were appropriate and thus were included in this study for further statistical analysis. The questionnaire consisted of 26 items concerning the overall evaluation of the awareness, and behavior of outpatients regarding their use of topical steroids. RESULTS: The results demonstrated that of 504 patients included in the analysis, 53.8% bought topical steroids with a dermatologist's prescription, whereas 33.6% obtained their topical steroids without prescription. The patient recognition rate of brand name, therapeutic effects, and side effects of topical steroids was 58%, 77% and 26%, respectively. Twenty percent of patients who have used topical steroids complained of side effects, the most common of which being pruritus (7.5% of cases). More than half of the patients said they obtained their information about topical steroids from sources other than the dermatologist. More than three quarters of patients (77%) applied topical steroids 1-2 times per day, whereas the overusers (4%) and the long-term users (16%) were applying topical steroids more than 5 times a day and longer than 16 weeks, respectively. CONCLUSION: The results indicate that topical steroids have been used without sufficient information and guidelines. Taken together, it is suggested that dermatologists should more thoroughly explain the therapeutic effects, indications, and side effects of topical steroids to their patients.

Pyoderma Gangrenosum: A Clinical Study / 대한피부과학회지

BACKGROUND: Pyoderma gangrenosum (PG) is a rare noninfectious skin disorder characterized by chronic recurrent painful ulcers. Because of its low incidence and diagnostic difficulty, there were few comprehensive studies of the clinical features of PG in Korea. OBJECTIVE: Our purpose was to delineate the clinical features of PG. METHODS: 22 patients who presented with PG at 6 hospitals of Catholic Medical Center over ten years were enrolled in this study. We reviewed all medical records of the patients. RESULTS: The mean age was 47.9 years. The male to female ratio was 1:1.4. Cases in children account for 2 out of twenty two. Sixty-one percent of the patients had lesions on their lower legs. The typical ulcerative variant was found in 19 patients, bullous PG in 3 patients. An association with other internal diseases was noted in 9 patients. Two cases were developed in heavy alcoholics. 15 patients were treated with systemic corticosteroid, 12 cases with systemic corticosteroid only, one case with systemic corticosteroid and cyclosporine, one case with systemic corticosteroid and dapsone, one case with systemic corticosteroid, cyclosporine and colchicine. 1 patient was treated with cyclosporine and colchicine, 1 patient with colchcine, rifampicin and antibiotics. Five cases were treated with antibiotics only. In the only systemic corticosteroid therapeutic group, the response rate was 83%. 3 patients experienced recurrence and 3 patients showed positive pathergy reactions. CONCLUSION: PG is a rare disease with the ulcerative variant being most frequent. The lower legs were the most commonly affected sites. PG was accompanied with systemic disease in 46% of the cases. Comparing with foreign literature, the response rate of treatments was generally fine and the recurrence rate was low.

Tuberculosis Verrucosa Cutis in a Patient with Pulmonary Tuberculosis / 대한피부과학회지

Tuberculosis verrucosa cutis is a common form of cutaneous tuberculosis. Most cases of tuberculosis verrucosa cutis appear as secondary infections of skin, however concomitant primary internal organ involvement rarely occurs. To our knowledge, only three cases of coexistence of tuberculosis verrucosa cutis and pulmonary tuberculosis have been reported in literatures to date. We report on another case of tuberculosis verrucosa cutis, which occurred in a middle-aged, Korean woman with pulmonary tuberculosis, and review the literatures.

A Case of Graves' Disease Showing a Triad of Ophthalmopathy, Pretibial Myxedema and Thyroid Acropachy / 대한피부과학회지

Graves' disease is an autoimmune disorder of the thyroid gland and the most common cause of hyperthyroidism. Classic clinical findings include ophthalmopathy (exophthalmos), dermopathy (pretibial myxedema) and thyroid acropachy. The triad of Graves' clinical findings occurs in less than 1% of Graves' patients. We present a case of Graves' disease with the clinical triad of exophthalmos, pretibial myxedema, and thyroid acropachy.

A Case of Lupus Miliaris Disseminatus Faciei on the Neck / 대한피부과학회지

Lupus miliaris disseminatus faciei (LMDF) is an eruption of discrete red-brown, dome-shaped papules, histologically characterized by epithelioid cell granulomas. Although it is thought that LMDF might occur by an unusual reaction to pilosebaceous units, the exact reason for facial predominant occurrence is not clear. There have been extrafacial reports of LMDF on the axillae, shoulders, arms, hands, groins and legs together with facial lesions, but reports on LMDF solely involving the extrafacial areas have not been made. Herein we report a rare case of LMDF on the neck of a patient without any facial manifestations.

A Case of Aquired Smooth Muscle Hamartoma with Follicular Spotted Appearance / 대한피부과학회지

Smooth muscle hamartoma is a benign hamartomatous condition, presenting clinically as a skin-colored or hyperpigmented patch or plaque and histologically as dermal smooth muscle hyperplasia. It is thought that Becker's nevus and smooth muscle hamartoma are distinct entities at either end of a spectrum. It can either be congenital or acquired We herein report a case of acquired smooth muscle hamartoma with follicular spotted appearance. We consider it as a rare clinical variant of smooth muscle hamartoma, which is clearly different from Becker's nevus.

A Case of Trichofolliculoma of the Back / 대한피부과학회지

Trichofolliculoma is an adnexal tumor originating from the hair follicle. It commonly involves the face, scalp or neck, but is very rarely found on other sites. We herein report a case of trichofolliculoma in a 47-year-old female who presented with a 1 year history of a single asymptomatic nodule on her back.

A Case of Pigmented Purpuric Lichenoid Dermatitis of Gougerot-Blum Treated by Pentoxifylline / 대한피부과학회지

The pigmented purpuric lichenoid dermatitis of Gougerot-Blum is a subtype of the pigmented purpuric dermatoses characterized by small red-brown lichenoid papules that coalesce to form plaque lesions. This disorder usually persists for months to years and is resistant to conventional therapy. Pentoxifylline has been used to treat various dermatologic diseases, but its effectiveness in pigmented purpuric lichenoid dermatitis has not been reported. We tried oral pentoxifylline treatment, 400mg twice a day on a 63-year-old man with pigmented purpuric lichenoid dermatitis. A response was observed within 2 weeks. And after 8weeks, the skin lesion showed much improvement and therapy was discontinned. Four month later, he had a recurrence on the leg. He was treated again with pentoxifylline and after 3 weeks, the recurrent lesion showed resolution.

A Case of Lipoma of the Toe / 대한피부과학회지

Lipoma is a common benign soft tissue tumor. It is frequently located on the trunk, chest, upper thigh, upper arm, and shoulder. Lipoma of the toe was reported mainly in children. We present a rare case of digital lipoma which occured in a 56 year old female patient. Clinically, lipoma of the toe is often missdiagnosed as digital myxoid cyst or subungal exostosis.

A Case of Hobnail Hemangioma

Hobnail hemangioma(HH) is a benign acquired vascular tumor of endothelial origin which should be differentiated from other malignant vascular neoplasm such as Kaposi's sarcoma or angiosarcoma. We report a case of hobnail hemangioma in a 21-year-old woman who had a dusky-red patch on her left shin. Histologically, ectatic vascular channels with a single layer of plumped endothelial cells were seen and the vascular channels seemed to dissect the collagen bundles. She underwent treatment with surgical excision with primary closure.

A Case of Acquired Transient Heterochromia of the Scalp Hair / 대한피부과학회지

Heterochromia is the presence of more than one distinct color of hair in a person. It is known to be related with genetic background, but definite cause of this disorder has not been found. Several cases of heterochromia of the scalp hair have been reported and each case has different pattern, distribution and course. We report a 6-month-old infant with acquired transient heterochromia of the scalp hair who has unusual pattern and course different from previously reported case.

Abnormalities of beta-Catenin Gene in Pilomatricomas / 대한피부과학회지

BACKGROUND: beta-Catenin muations were reported to play a causal role in the development of pilomatricomas. In a recent study in Caucasians, 75% of pilomatricomas had beta-Catenin mutations. OBJECTIVE: We investigated the causal role of beta-Catenin gene mutations in pilomatricomas of Koreans. METHODS: This study included 20 formalin-fixed, paraffin-embedded pilomatricomas in Koreans. Basophilic nucleated tumor cells were microdissected and, as normal controls, infiltrating inflammatory lymphocytes were microdissected from the same histologic specimens. Sequencing analysis of exon 3 of the beta-Catenin gene (CTNNB1) was performed. Immunostaining for beta-Catenin and Lef-1 was performed by the avidin-biotin-peroxidase method. RESULTS: Sequencing analysis found missense mutations (S37Y, S37C, S33C, S33F, and S37F) in CTNNB1 in 6 samples (30%) of 20 pilomatricomas. All pilomatricomas revealed intense expression of nuclear Lef-1 and nuclear and cytoplasmic beta-Catenin. CONCLUSION: Frequencies of beta-Catenin mutations were lower in our study compared with the results in Caucasians. The immunohistochemical results suggest the abnormalities in Wnt-wingless pathway resulting in stabilization or constitutive expression of beta-Catenin, but the absence of CTNNB1 mutations in 70% of our cases suggests adenomatous polyposis coli gene inactivation, or the involvement of other components of the Wnt-wingless pathway.