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.

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.

Nasalis Island Pedicle Flap for Reconstruction of the Nasal Defect / 대한피부과학회지

BACKGROUND: Reconstruction of surgical defects of the nose is often challenging. There are many repair options for a nasal defect, including second-intention healing, primary closure, a skin graft and a skin flap. Among these, the nasalis island pedicle flap is a random pattern advancement flap that has satisfactory vascular supplies from the underlying muscular structure. OBJECTIVE: We wanted to describe the surgical technique of creating a nasalis island pedicle flap and to report on our experience with the postoperative cosmetic outcome. METHODS: Fourteen patients diagnosed with non-malignant melanoma skin cancer on the nose were treated with Mohs micrographic surgery (MMS). The surgical defects were reconstructed with a nasalis island pedicle flap. The size of the tumor and the postoperative surgical defects, the local complications and the cosmetic outcomes were assessed. RESULTS: The size of the primary defects ranged from 0.8 to 2.3 cm at the greatest dimension (with a mean of 1.51 cm). Five cases were located on the nasal ala, three on the nasal dorsum, two on the nasal root, two on the nasal side wall and two on the nasal tip. During the follow-up period, there was no significant postoperative bleeding, necrosis and infection. There was no tumor recurrence and most of the patients showed minimal discernable scarring with satisfactory aesthetic outcomes. CONCLUSION: A nasalis island pedicle flap provided aesthetically pleasing results, and it could be an useful method to reconstruct surgical defects in the nose after MMS.

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.

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.

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.

Improvement in Diagnostic Accuracy of Hemangioma and Vascular Malformation through Multidisciplinary Clinic

PURPOSE: It is difficult to provide accurate diagnosis and proper treatment for vascular anomalies, because vascular anomalies have a wide spectrum of lesion with various symptoms. Furthermore, vascular anomalies often require the services of a wide range of specialists. So, many patients have been discouraged by the lack of expertise and treatment options available to them. In this study, we aimed to describe the scope of the Vascular Malformation clinic (VAM clinic), a multidisciplinary clinic for hemangioma and vascular malformation patients and investigate of diagnostic accuracy of VAM clinic. METHODS: 68 patients have included in a retrospective, medical record review study in the VAM clinic from may 2002 to august 2009. Data included the types of diagnoses of patients seen in the clinic, locations of lesions, comparison of accuracy of diagnoses at other clinic and initial diagnoses at VAM clinic and types of recommended treatments. RESULTS: Initial diagnosis at VAM clinic showed 94.2% accuracy, while diagnosis at other clinic only showed 12.5% accuracy. Head and neck is most frequently occurred lesions in patients of VAM clinic. And VAM clinic is able to provide various and proper treatments to patients. CONCLUSION: Hemangiomas and vascular malformations can present with various medical problems. VAM clinic, the multidisciplinary clinic provided accurate diagnoses and proper treatments to patients.

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.

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 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.

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.

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.

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.

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.

Addison's Disease due to Adrenal Tuberculosis Confirmed by PCR / 대한피부과학회지

Addison's disease, or primary adrenal insufficiency, results from progressive destruction of the adrenal glands. The common causes of Addison's disease are idiopathic autoimmune atrophy and tuberculosis of the adrenals glands. Adrenal insufficiency caused gradual adrenal destruction is characterized by an insidious onset of fatigability, weakness, anorexia, nausea, weight loss, and cutaneous manifestations, such as hyperpigmentation of the skin, especially in sun-exposed areas, palmar creases, frictional areas, recent scars, and oral mucosa, and longitudinal pigmented bands in the nails. After diagnosing Addison's disease, determining the underlying adrenal abnormality is important for the appropriate treatment of the disease. To date, there have been no reports regarding the cause of Addison's disease confirmed in the Korean dermatologic literature. We report here a case of Addison's disease secondary to adrenal tuberculosis confirmed by a tuberculosis-polymerase chain reaction (TB-PCR).

Two Cases of Papillon-Lefevre Syndrome / 대한피부과학회지

Papillon-Lefevre syndrome is an extremely rare genodermatosis characterized by palmoplantar keratoderma and premature loss of teeth. It is inherited as an autosomal recessive trait, and is known to be caused by a loss-of-function mutation in the cathepsin C gene. Mutations of this gene may result in epithelial defects producing keratoderma and secondary periodontitis recalcitrant to traditional treatment, causing subsequent premature loss of teeth. In addition, patients may have increased susceptibility to infection. Histopathologic features are nonspecific, so diagnosis has been made through characteristic skin and teeth findings in many reported cases. Oral retinoids are the mainstay of treatment, but the safety of oral retinoids in children remains controversial due to their side effects in skeletal development. Therefore, a multidisciplinary approach is important for the care of patients with this syndrome. We present two cases of Papillon-Lefevre syndrome. To our knowledge, this condition has not been reported previously in the Korean dermatologic literature.

A Case of Oculo-auriculo-vertebral (OAV) Syndrome / 대한피부과학회지

We present a patient with various features of oculo-auriculo-vertebral syndrome (OAVS), also known as Goldenhar's syndrome. In general, multiple accessory tragi in a linear distribution from the preauricular skin to the mandible or to the lateral neck suggest a diagnosis of OAVS. However, in most cases, an accessory tragus is an isolated developmental defect without an associated congenital syndrome. A female infant presented with a solitary, skin colored, sessile papule on the right lower cheek, microtia, and ear deformity since birth. A biopsy specimen showed numerous irregularly spaced hair follicles with a prominent connective tissue framework in the subcutaneous fat, but without central cartilage. Multiple congenital anomalies, including ocular lipodermoid, sensorineural hearing loss, and vertebral deformity, were found on further evaluation.

Scalp Metastasis in a Patient with Endometrial Adenocarcinoma / 대한피부과학회지

Cutaneous metastasis of visceral carcinomas is rare among them, endometrial carcinoma accounts for less than 1% of all cases. A 71-year-old woman with FIGO stage IIIA endometrial adenocarcinoma presented with scalp metastasis 1 month after initial radical radiotherapy. Histopathologic examination showed multiple glandular structures composed of columnar epithelial cells with foci of squamous differentiation, which were similar to primary endometrial adenocarcinoma. Metastatic evaluation revealed widespread extrapelvic metastasis in the lung, bones, and skin. Endometrial carcinoma is usually characterized by local and lymphatic spread. Rarely, extensive disease shows hematologic spread for example, to the scalp, as in this case.

A Childhood Case of Pigmented Spindle Cell Nevus for Whom Dermoscopy Was Used as an Adjuvant Diagnostic Tool / 대한피부과학회지

Pigmented spindle cell nevus (PSCN) is a solitary heavily pigmented macule or papule that usually occurs on the lower legs of women in the second decade of life. Histologically, fascicles of uniform, elongated, pigmented nevoid cells at the dermo-epidermal junction tend to fuse with neighboring nests. PSCN should be differentiated from Spitz nevus, dysplastic nevus, and malignant melanoma. For making the differential diagnosis of PSCN from malignant melanoma of nevoid cells, the overall symmetry, relative uniformity, maturation with depth and no nuclear atypia are important clues. A 3-year-old girl presented with a black papule on the anterior aspect of the ankle. We diagnosed PSCN by the histologic findings and the specific "starburst" dermoscopic pattern.