Change in Antimicrobial Susceptibility of Skin-Colonizing Staphylococcus aureus in Korean Patients with Atopic Dermatitis during Ten-Year Period

BACKGROUND: A small subset of adolescents atopic dermatitis (AD) tends to persist. This also leads to get more antibiotics exposure with advancing years. Antibiotic resistance has been regarded as a serious problem during Staphylococcus aureus treatment, especially methicillin-resistant S. aureus (MRSA). OBJECTIVE: It was investigated the S. aureus colonization frequency in the skin lesions and anterior nares of adolescent AD patients and evaluated the changes in S. aureus antimicrobial susceptibility for years. METHODS: Patients who visited our clinic from September 2003 to August 2005 were classified into group A, and patients who visited from August 2010 to March 2012 were classified into group B. To investigate the differences with regard to patients' age and disease duration, the patients were subdivided into groups according to age. Lesional and nasal specimens were examined. RESULTS: Among the 295 AD patients, the total S. aureus colonization rate in skin lesions was 66.9% (95/142) for group A and 78.4% (120/153) for group B. No significant changes in the systemic antimicrobial susceptibilities of S. aureus strains isolated from adolescent AD patients were observed during about 10-year period. The increased trend of MRSA isolation in recent adolescent AD outpatients suggest that the community including school could be the source of S. aureus antibiotic resistance and higher fusidic acid resistance rates provides evidence of imprudent topical use. CONCLUSION: Relatively high MRSA isolation and fusidic acid resistance rates in recent AD patients suggest that the community harbors antibiotic-resistant S. aureus.

Efficacy and Safety of Fexofenadine in the Treatment of Pruritus Associated with Eczema / 대한피부과학회지

BACKGROUND: Fexofenadine (Allegra(R)) is a H1-receptor selective antihistamine which exhibits consistent efficacy and safety in the treatment of allergic diseases. We thought that fexofenadine may be useful in treatment of the pruritus associated with eczema. OBJECTIVE: The purpose of this study was to evaluate the efficacy and safety of fexofenadine in the treatment of pruritus associated with eczema. METHODS: In this study, patients with atopic and allergic contact dermatitis were divided into a group given fexofenadine 180 mg once daily with topical prednicarbate treatment group or a topical prednicarbate treatment only group, for 1 week. The primary efficacy parameter was the mean change from baseline in pruritus score, and the secondary parameters were the mean change in the incidence of scratching, the mean change in visual analogue scale (0~100 mm) of pruritus, and a comparison of patient satisfaction. RESULTS: 435 patients were included and the mean age was 32.9 years old. The mean pruritus score at baseline was 3.55 point in fexofenadine group and 3.51 point in the control group. Regarding the mean change in pruritus score, fexofenadine significantly decreased the severity of pruritus compared with the control group (p<0.05). There were no significant differences in the decrease in the incidence of scratching between the two groups. A decrease in pruritus levels utilizing visual analogue scale was significant in the fexofenadine group (p<0.05) and patient satisfaction was significantly higher in the fexofenadine group (p=0.0192). There was no significant difference in the incidence of adverse events between two groups (p=0.6237). CONCLUSION: Fexofenadine administered 180 mg once daily in combination with topical prednicarbate treatment was effective and well tolerated in this study.

Generalized Pustular Psoriasis and Hepatic Dysfunction Associated with Oral Terbinafine Therapy

We report a case of 61-yr-old man with stable psoriasis who progressively developed generalized pustular eruption, erythroderma, fever, and hepatic dysfunction following oral terbinafine. Skin biopsy was compatible with pustular psoriasis. After discontinuation of terbinafine and initiating topical corticosteroid and calcipotriol combination with narrow band ultraviolet B therapy, patient's condition slowly improved until complete remission was reached 2 weeks later. The diagnosis of generalized pustular psoriasis (GPP) induced by oral terbinafine was made. To our knowledge, this is the first report of GPP accompanied by hepatic dysfunction associated with oral terbinafine therapy.

Treatment of Facial Seborrheic Dermatitis with Pimecrolimus Cream 1%: An Open-Label Clinical Study in Korean Patients

Pimecrolimus cream 1% has shown to be effective in patients with a variety of inflammatory cutaneous disorders. And it might be a useful modality in the treatment of seborrheic dermatitis. This prospective study was aimed at assessing the efficacy and tolerability of pimecrolimus cream 1% in the treatment of facial seborrheic dermatitis. Twenty patients were instructed to apply pimecrolimus cream 1% for 4 consecutive weeks. Assessment of the disease severity was performed at baseline and at week 1, 2, and 4. Clinical assessments of erythema, scaling, and pruritus were measured using a 4-point scale (0-3). Global assessments of the disease severity by patients and investigators were performed at each visit. Mean clinical scores of erythema, scaling, and pruritus significantly improved by 87.4%, 91.9%, and 91.5% respectively at week 4 (p<0.001). Improvements in the global assessment of disease severity determined by patients and investigators also showed excellent results. No specific adverse events other than transient burning and tingling sensations were noted. The relapse of facial seborrheic dermatitis was mostly observed between 3 to 8 weeks after the discontinuation of pimecrolimus. We suggest that the topical application of pimecrolimus cream 1% can be an effective and safe alternative for treatment of facial seborrheic dermatitis.

The Effect of Topical Tacrolimus in the Murine Contact Hypersensitivity and Dermatitis of Repeated Applications Induced by Diphenylcyclopropenone / 대한피부과학회지

BACKGROUND: Topical tacrolimus is widely used for the treatment of inflammatory skin diseases like atopic dermatitis, but there are few studies about the effect of topical tacrolimus for allergic contact dermatitis. Allergic contact dermatitis develops in two phases, the clinically silent sensitization phase, and the clinically apparent elicitation phase. OBJECTIVE: The purpose of this study is to investigate whether topical tacrolimus has an effect on both phases of murine contact hypersensitivity and dermatitis of repeated applications induced by diphenylcyclopropenone (DPCP). METHODS: Hairless mice were treated with topical tacrolimus before and after DPCP challenging. The suppressive effect of topical tacrolimus was measured by skin erythema, ear swelling, weight change and cell numbers of local lymph nodes. In addition, a biopsy was carried out and epidermal hyperplasia was investigated microscopically. TNF-alpha mRNA on the mice which were treated with topical tacrolimus to one side of the ears was measured before and after being chronically challenged with DPCP on both ears. RESULTS: Topical tacrolimus pretreatment dramatically supressed inflammatory reactions in the sensitization phase, and treatment of topical tacrolimus after sensitization dramatically supressed inflammatory reactions in the elicitation phase. Topical tacrolimus also dramatically supressed inflammatory reactions in the repeated DPCP-induced dermatitis. CONCLUSION: The data revealed topical tacrolimus could effectively suppress murine contact hypersensitivity and dermatitis of repeated applications induced by DPCP. Putting these results together, topical tacrolimus can be very effective in not only the treatment but also the prevention of allergic contact dermatitis. Larger studies are needed to determine the clinical relevance.

Adult-onset Eruptive Pseudoangiomatosis / 대한피부과학회지

BACKGROUND: Eruptive pseudoangiomatosis (EPA) is a rare, benign, spontaneously regressing childhood exanthem. It is characterized by the sudden onset of several bright red angioma-like papules surrounded by pale halos with a distinct histopathology from true angiomas. OBJECTIVE: This study was performed to evaluate the clinical and histopathologic characteristics of EPA occuring in adults. METHODS: Ten adult patients who visited Pusan National University Hospital and Mok Hye-Soo . Jang Ho-Sun Dermatology Clinic from March 2005 to September 2006 were evaluated. We prospectively evaluated the sex, age, onset season, past medical history including immunosuppressive abnormalities, systemic disorders and other diseases including allergies. We also investigated the relations of mosquito biting, patients' occupations and outdoor activities to occurrence of EPA. In addition, simultaneous occurrence in family members, the clinical, histopathologic, laboratory findings, disease courses and responses to treatment were evaluated. Based on medical records, photographs and pathologic slides, we retrospectively diagnosed another 20 EPA patients suspected as insect bite from October 2003 to March 2005. The same questions were inquired as for the 10 patients who prospectively underwent evaluation. RESULTS: In the study, female predominance (76.7%) was observed and the average age of onset was 54.2 years. Interestingly, there was no child patient during the period of study. Multiple, 2~5 mm sized, red angiomatous papules surrounded by pale halos occurred on exposed areas such as the arms (86.7%), legs (50%), and face (46.7%), although it could also occur to a non-exposed area. EPA occuring in adults usually appeared in summer (80%). The mean disease duration was 3.4 weeks. Although EPA spontaneously regressed, it had the potential of recurrence (46.7%). Histopathologic findings showed dilated dermal blood vessels without the evidence of increase in numbers, and perivascular lymphocytes infiltration. Inside the lumen of dermal blood vessels, plump endothelial cells were found. CONCLUSION: EPA occuring in adults usually happened to exposed sites in summer, so it can be misdiagnosed as insect bite. We suggest that dermatologists should be concerned about EPA in adults and conduct further investigation to have a better understanding of the disease.

Primary Cutaneous Mucormycosis in a Immunocompetent Elderly Woman Showing Sporotrichoid Distribution / 대한피부과학회지

Primary cutaneous mucormycosis, a rare form of mucormycosis, develops where a break in the integrity of the skin has occurred as a result of surgery, burns, or other forms of trauma. It is mainly seen in immunocompromised hosts, but can sometimes also occur in immunocompetent hosts too. Various kinds of pathogens including viruses, bacteria, nontuberculous mycobacteria, protozoa, and fungi can show a sporotrichoid spread. However, there has been no report of mucormycosis showing a sporotrichoid distribution. We report a case of primary cutaneous mucormycosis occurring on the dorsal aspect of the right wrist in a 69-year-old immunocompetent woman. In our case, newlydeveloped lesions were distributed in sporotrichoid pattern 5 months after the initial lesion. The patient was successfully treated with a combined therapy of amphotericin B and itraconazole.

A Case of Erythema Nodosum Associated with Crohn's Disease / 대한피부과학회지

Erythema nodosum is known to be frequently associated with a variety of underlying diseases including drug reactions, infections, sarcoidosis and inflammatory bowel disease. Crohn's disease is an ulcerative, granulomatous, inflammatory disease which may have distinctive mucocutaneous manifestations. In most studies on Crohn's disease, 1 to 2% of the patients had at least one attack of erythema nodosum. However, erythema nodosum associated with Crohn's disease has not yet been reported in the Korean dermatologic literature. We report, herein, an 11- year-old male with Cronh's disease, who presented with erythematous, tender, subcutaneous nodules on his lower extremities. These showed histopathologic findings of erythema nodosum.

A Case of Pigmented Eccrine Poroma on the Scalp of Child / 대한피부과학회지

Eccrine poroma is a common benign tumor originating from the epidermal sweat duct units. It occurs primarily on feet and hands. However there have been some sporadic cases occurring in other areas, including the scalp. Eccrine poroma occurs mostly in people over 40 years of age, although it can occur at any ages. In general, eccrine poroma lacks melanin pigment clinically and melanocytes on microscopic examination, but either black or yellow skin, melanin granules and melanocytes can be found dispersed within the tumor. We report a case of pigmented eccrine poroma occuring on the scalp of 14-year-old girl. In our case, the patient was much younger than those of the usual onset age and the lesion was located on an unusual occuring site. In addition, the lesion contained melanocytes and melanins.

A Case of Lymphangiectatic Pilomatricoma / 대한피부과학회지

Pilomatricoma is a common, benign, adnexal tumor differentiating towards elements of the hair matrix and shaft. The tumor is usually a deep-seated, solitary, firm nodule with overlying normal epidermis. Lymphangiectatic pilomatricoma is a rare variant of pilomatricoma. Clinically it manifests as flaccid, thick-walled bulla with an underlying palpable, hard tumor. Histopathologically, it is a well-circumscribed dermal nodule composed of basophilic cells, shadow cells, and transitional cells. There can also be extraordinary dilatation of lymphatic vessels in the overlying dermis. We report a case of lymphangiectatic pilomatricoma on the left shoulder of 19-year-old girl which occurred after intralesional injection of steroid.

A Case of Linear Lichen Planus Associated with Cicatrical Alopecia and Vitiligo / 대한피부과학회지

Lichen planus is a papulosquamous disorder that has numerous clinical variants. Linear lichen-planus (LLP), a variant of lichen planus, consists of itchy linearly distributed, violaceous papules on the extremities. In lichen planopilaris (LPP), involvement of the hair follicles can induce a form of cicatrical alopecia. Half of the LPP cases have or develop characteristic skin or mucosal involvement of lichen planus. Vitiligo is a chronic disorder characterized by a marked absence of melanocytes and melanin in the epidermis. The coexistence of vitiligo and lichen planus is rare. However, this association is of interest because a cell-mediated immune reaction is thought to play a central role in the pathogenesis of both diseases. We report on a 32-year-old woman affected with LLP, accompanied by cicatrical alopecia and vitiligo.

A Case of Vitamin K1 Dermatitis / 대한피부과학회지

Vitamin K1 is a naturally-occurring vitamin used to treat certain coagulation disorders, and cutaneous adverse reaction to vitamin K1 are infrequently reported. The cutaneous adverse reaction caused by vitamin K1 is called vitamin K1 dermatitis, and includes erythematous plaques, peudoscleroderma, contact dermatitis on epicutaneously exposed skin, and localized urticarial lesions. Vitamin K1 dermatitis can easily be overlooked because of it's low incidence and various morphology, therefore, awareness of past history is important. Most cases of vitamin K1 dermatitis previously reported have been associated with liver diseases, primarily alcoholic liver cirrhosis and viral hepatitis. However vitamin K1 dermatitis can be seen, not only in patients with liver function disturbances, but also in patients without liver disease. We report a case of vitamin K1 dermatitis in a woman who had no liver dysfunction (confirmed by skin test).

A Case of Vitamin K1 Dermatitis / 대한피부과학회지

Vitamin K1 is a naturally-occurring vitamin used to treat certain coagulation disorders, and cutaneous adverse reaction to vitamin K1 are infrequently reported. The cutaneous adverse reaction caused by vitamin K1 is called vitamin K1 dermatitis, and includes erythematous plaques, peudoscleroderma, contact dermatitis on epicutaneously exposed skin, and localized urticarial lesions. Vitamin K1 dermatitis can easily be overlooked because of it's low incidence and various morphology, therefore, awareness of past history is important. Most cases of vitamin K1 dermatitis previously reported have been associated with liver diseases, primarily alcoholic liver cirrhosis and viral hepatitis. However vitamin K1 dermatitis can be seen, not only in patients with liver function disturbances, but also in patients without liver disease. We report a case of vitamin K1 dermatitis in a woman who had no liver dysfunction (confirmed by skin test).

Immunohistochemical Study of Human beta Defensin-2 Expression in Superficial Mycosis / 대한피부과학회지

BACKGROUND: Normal human skin is resistant to infection with various kinds of microorganisms by producing anti-microbial chemicals. Human beta defensin-2 (hBD-2) is an anti-microbial peptide that has recently been shown to be expressed in various epithelial cells and inflammatory diseases. However, the expression of hBD-2 in fungus-infected skin is not well-known. OBJECTIVE: This study was performed to investigate the expression pattern of hBD-2 in superficial mycosis. METHODS: Using the immunohistochemical method with formalin-fixed, paraffin-embedded sections, we checked the expression levels and localization of hBD-2 in lesional skin samples of tinea capitis (5 patients), tinea corporis (6 patients), candidiasis (3 patients), Malassezia folliculitis (2 patients), and psoriasis (3 patients) as positive control, and normal skin samples from 6 healthy subjects as negative control. RESULTS: The expression of hBD-2 was not observed in normal skin, but moderate to strong expression of hBD-2 was observed in the epidermis, and the papillary dermal infiltrating cells of psoriasis. In tinea capitis, strong hBD-2 expression was found in the upper spinous layer of epidermis and follicular epidermis, and perifollicular inflammatory cells. In tinea corporis and candidiasis, mild to strong expression of hBD-2 was found in the horny or spinous layer of epidermis and infiltrating inflammatory cells. Strong hBD-2 expression was found in the follicular epidermis and perifollicular inflammatory cells of Malassezia folliculitis. CONCLUSION: These results suggest that hBD-2 plays an important role in cutaneous innate immune defense against fungal infection.

A Case of Speckled Lentiginous Nevus Showing Histopathologic Features of Congenital Melanocytic Nevus / 대한피부과학회지

Speckled lentiginous nevus is characterized by numerous, small, darkly-pigmented speckles on the background of tanned hyperpigmentation. The tan macule or patch of speckled lentiginous nevus shows the histologic features of lentigo simplex. The speckled areas are characterized by various types of nevi including junctional, compound or dermal nevus. However, since speckled lentiginous nevus may present at birth and show the histologic features of congenital melanocytic nevus (CMN), some have speculated that it is a subtype of CMN. We present a case of speckled lentiginous nevus which occurred at birth and showed histologic features of CMN, thus supporting the notion that speckled lentiginous nevus is a subtype of CMN.

A Case of Multiple Eccrine Spiradenoma with Zosteriform Distribution / 대한피부과학회지

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

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

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

The Effects of 5% Imiquimod Cream on Verruca Plana / 대한피부과학회지

BACKGROUND: Verruca plana is a cutaneous human papillomavirus (HPV) infections. Although various treatments such as destructive methods or immunomodulating agents have been used, none are uniformly effective or prevent recurrence. Ideal treatment for verruca plana should target on an increasing local immune response to the HPV infection. Recently, imiquimod, a topical immune- response modifier, has been successfully used in the treatment of external anogenital warts. OBJECTIVE: The aim of this study was to determine the efficacy and safety of 5% imiquimod cream for the treatment of verruca plana. METHOD: Seven patients with verruca plana were treated with 5% imiquimod cream 3 times a week. at night, for 16 weeks or until complete clearance of lesions had occured. During the follow- up period, the onset time of effects, clearance rate, side effects, and recurrence rate were recorded. At 16 weeks after treatment, a clearance rate was determined by a 3 scale rating; complete-100% clearance / partial-less than 100% clearance / failure-no clearance. RESULTS: The onset time of effects ranged from 1 to 4 weeks (mean-1.7 weeks). The clearance rate at 16 weeks after treatment were as follows; complete-4 (57.1%), partial-2 (28.6%), and failure - 1 (14.2%). No patient showed systemic side effects or long-term adverse effects such as pigmentary disorders or scarring. In the subjective local skin reactions, itching was the only symptom and was common (4/7, 57.1%). With objective skin reactions, erythema was the most common (4/7, 57.1%), followed by erosion and scabbing (2/7, 28.6%). In long-term follow-up of those patients who showed complete clearance, no one encountered recurrence. CONCLUSION: This data demonstrates that 5% imiquimod cream is an effective and promising treatment modality for verruca plana. Because it is non-destructive, safe, and easy to use, it resulted in an excellent cosmetic outcome.

Two Cases of Early Stage Mycosis Fungoides Treated with Acitretin and Narrow Band UVB Phototherapy / 대한피부과학회지

Early stage mycosis fungoides (MF) has been treated with skin directed therapies including topical steroids, phototherapy (UVB), photochemotherapy (PUVA), topical nitrogen mustard, or total skin electron beam therapy. Recently, several studies have been reported that treat early-stage MF with narrow band UVB (NBUVB), which is an effective and convenient modality compared to other alternatives. Herein, we describe two cases of early stage MF treated with NBUVB. During the remission induction therapy, oral acitretin combined with NBUVB was used for several weeks to clear the MF, followed by treatment with only NBUVB for maintenance.

A Study on Utilization of Alternative Medicine for Patients with Atopic Dermatitis / 대한피부과학회지

BACKGROUND: Alternative medicine - sometimes called complementary or supplementary medicine - may be defined as forms of therapy or examination that have no scientific basis and whose effect or diagnostic reliability has not been demonstrated by scientific methods. Recently, alternative medicine has been used in various chronic diseases including atopic dermatitis (AD) and has attracted attention in the mass media. Several studies on the use of alternative medicine in patients with AD have been performed in western countries, however only a few studies have been conducted in Korea. OBJECTIVE: The purpose of this study was to investigate the use of alternative medicine in AD patients. METHOD: A total of 100 patients with AD were enrolled on the study, and interviewed with a questionnaire about their past history of AD and the use of alternative medicine. RESULTS: The results obtained are summarized as follows: 1. 84 out of 100 patients (84.0%) reported previous or current use of more than one type of alternative medicine. 2. The most common type of alternative medicine used was herbal remedies (73.8%). Spa and bath therapies (47.6%), health food preparations (39.3%) and diet therapy (25.0%) were also commonly used. 3. The frequency of alternative medicine used was related to onset and severity of AD. 4. The most common reason for using alternative medicine was `I wish to try everything' (60.2%), and the most common source of information on alternative medicine was relatives and friends who did not have the disease (41.4%). 5. The therapeutic effect of alternative medicine was found to be excellent in 25.3% of patients, but no change was seen in 58.6% of patients. 6. The most common side effect of alternative medicine was aggravation of symptoms. Other side effects included urticaria, diarrhea, fever and chills. 7. The average monthly cost for alternative medicine was 210, 000 won/person. CONCLUSION: The use of various types of alternative medicine in patients with AD is very common. However, these tend to be used impulsively and without caution or adequate knowledge. Therefore, dermatologists need to be aware of the benefits and adverse effects of alternative medicines.