Efficacy of 5% Imiquimod Cream on Vulvar Intraepithelial Neoplasia in Korea: Pilot Study

BACKGROUND: Various therapeutic options, including surgery, electrocautery, cryotherapy, 5-fluorouracil treatment, laser therapy, radiotherapy, photodynamic therapy, and interferon-alpha/gamma injection, have been employed to treat vulvar intraepithelial neoplasia (VIN) with varying degrees of success. To truly cure VIN, human papillomavirus elimination is considered important. OBJECTIVE: To investigate the efficacy of 5% imiquimod cream used to treat VIN in Korean patients METHODS: We performed a prospective, uncontrolled, observational study. Nine patients with histologically confirmed VIN applied 5% imiquimod cream to their vulvar lesions three to five times a week until a clinical response was apparent. All lesions were photo-documented, and therapeutic efficacy was assessed in terms of local adverse effects lesion number, size, and hyperpigmentation. RESULTS: The mean treatment duration was 30.2 months, and the median follow-up period after therapy completion was 30 months. Of the nine patients recruited, six (66.6%) experienced complete responses (CR) or partial responses (PR). Hyperpigmented patches in the VIN lesions were evident in five subjects (55.6%), and all experienced either CR or PR. Only three patients (33.3%) suffered from local adverse effects, which were relieved after temporary suspension of therapy, and better outcomes were attained ultimately. CONCLUSION: The imiquimod cream was more efficacious when used to treat VIN of the hyperpigmented type compared with lesions lacking pigmentation. The unifocal nature of a lesion and the development of local adverse effects are useful factors when imiquimod cream is prescribed. However, although the cream is convenient and effective, regional resistance may develop, and close follow-up is essential because VIN may become malignant.

Analysis of Cardiovascular Risk Factors and Metabolic Syndrome in Korean Patients with Psoriasis

BACKGROUND: In previous studies, psoriasis has been reported to be associated with metabolic syndrome. OBJECTIVE: The purpose of this study was to evaluate risk factors for metabolic syndrome in psoriasis patients and to compare the prevalence of metabolic syndrome in psoriasis and control groups. METHODS: All patients (n=490) and controls (n=682) were investigated for cardiovascular risk factors, including central obesity, hypertension, fasting plasma glucose levels, and blood levels of triglycerides and high-density lipoprotein (HDL). RESULTS: We found no statistical association between psoriasis and the prevalence of metabolic syndrome when controlling for age and gender. Among individual components of metabolic syndrome, only increased triglyceride levels was significantly prevalent in patients psoriasis. The incidence of other factors such as central obesity, hypertension, fasting plasma glucose and HDL in the psoriasis group were similar to or lower than those in the control group. Although psoriasis patients with metabolic syndrome had severe and large plaque-type psoriasis, the association of metabolic syndrome with the severity or clinical subtype of psoriasis was not significant after adjusting for age and gender. CONCLUSION: Our results suggest that there is no close correlation between psoriasis and metabolic syndrome in Korean patients.

Delayed Diagnosis of Scrofuloderma Misdiagnosed as a Bacterial Abscess

An 82-year-old woman presented with a four-month history of an ulcerative plaque overlying her left neck. This lesion had developed as a subcutaneous nodule, gradually increased in size, and evolved into ulcers. Before visiting our Dermatology clinic, the patient had been diagnosed as having a bacterial abscess, but treatments with antibiotics were unsuccessful. The presence of a purulent discharge and prominent ulceration caused further confusion as bacterial abscess, and radiologic evaluation on computed tomography also led to the possibilities of secondary lesions from an abscess or malignancy. However, the characteristic appearance of her lesion allowed us to discern cutaneous tuberculosis, especially scrofuloderma. Based on clinical examinations, staining for acid-fast bacilli, and positive findings of polymerase chain reaction, a quick diagnosis of scrofuloderma was made. After that, she was treated successfully with anti-tuberculosis therapy and the ulcer healed. Our case highlights the problem of delayed diagnosis of scrofuloderma presenting as a bacterial abscess. In conclusion, having a high index of suspicion is needed to diagnose cutaneous tuberculosis correctly.

Lichen Striatus Occurring after Allogenic Peripheral Blood Stem Cell Transplantation in an Adult with Aplastic Anemia

Lichens striatus (LS) is an acquired, self-limiting inflammatory dermatosis that follows the lines of Blaschko. The etiology of the eruption is unknown, but several theories have been proposed with focus on environmental factors, viral infection, cutaneous injury, hypersensitivity, and genetic predisposition. We describe a 19-year-old woman who developed a unilateral linear eruption 17 months after allogenic peripheral blood stem cell transplantation. Histopathology revealed features, which were consistent with LS. To the best of our knowledge, our patient is the first case describing the appearance of LS occurring after allogenic stem cell transplantation. We speculate that this condition represents an unusual form of localized, chronic graft-versus-host disease.

Primary Cutaneous Epithelioid Hemangioendothelioma on the Back / 대한피부과학회지

Epithelioid hemangioendothelioma (EHE) is an uncommon vascular neoplasm that is considered to be a low-grade malignancy with a severity between an angiolymphoid hyperplasia with eosinophilia and an epithelioid hemangiosarcoma. The appearance of cutaneous EHE is extremely rare and only about 20 cases have been reported in the Korean and English literatures. A 70-year-old man presented with an approximately 1-year history of an isolated painful subcutaneous nodule of the back. A histopathologic examination revealed nests and cords of epithelioid eosinophilic cells in hyalinized stroma with intracytoplasmic vacuoles. Tumor cells were strongly positive for the endothelial cell markers CD31 and CD34, and we didn't find any metastatic lesions under radiologic examination. On the basis of these findings, the diagnosis of primary cutaneous EHE was made. To our knowledge, cutaneous EHEs were reported in only 2 cases in the Korean literature, and that of the trunk has not been published previously. Moreover, there is no meta-analytic study about cutaneous EHE. So, we report here a rare case of EHE of the back and review the relevant literature.

Clinical Character istics of Itch in Patients with Adult and Childhood Atopic Dermatitis / 대한피부과학회지

BACKGROUND: Itch is an essential feature of atopic dermatitis (AD). Active AD cannot be diagnosed without a history of itch. There has been no previous study delineating the different characteristics of itch according to age. OBJECTIVE: We wanted to characterize and compare the clinical patterns and the sensory and affective dimensions of itch in adult and childhood AD patients. METHODS: A face-to-face structured questionnaire based on the McGill pain questionnaire was given to 90 patients with AD. The patients were classified into two groups: adult AD patients (> or =15 years old) and childhood AD patients (<15 years old). RESULTS: Eighty-eight percent of the total AD patients experienced itch everyday. This itch was mostly aggravated during the summer and at night in both groups of AD patients. The antecubital fossae, popliteal fossae and neck were the major sites of involvement with itch. More patients perceived the characteristics of itch as crawling, burning and tickling rather than stinging, stabbing and pinching. The majority of AD patients answered that sweat and hot climate aggravated the itch and medications and cold climate alleviated the itch. However, compared with the childhood patients, more adult patients experienced the aggravation of itch by exposure to dust, and the itch was alleviated by taking medications and by concentrating on work. A burning sensation with itch was more frequently reported by the adult patients when compared to that of the childhood patients. CONCLUSION: This study highlights the detailed description and characteristics of itch in adult and childhood AD patients. The proper management of itch according to age may be prerequisite to improve AD patients' quality of life.

Clinical Character istics of Itch in Patients with Adult and Childhood Atopic Dermatitis / 대한피부과학회지

BACKGROUND: Itch is an essential feature of atopic dermatitis (AD). Active AD cannot be diagnosed without a history of itch. There has been no previous study delineating the different characteristics of itch according to age. OBJECTIVE: We wanted to characterize and compare the clinical patterns and the sensory and affective dimensions of itch in adult and childhood AD patients. METHODS: A face-to-face structured questionnaire based on the McGill pain questionnaire was given to 90 patients with AD. The patients were classified into two groups: adult AD patients (> or =15 years old) and childhood AD patients (<15 years old). RESULTS: Eighty-eight percent of the total AD patients experienced itch everyday. This itch was mostly aggravated during the summer and at night in both groups of AD patients. The antecubital fossae, popliteal fossae and neck were the major sites of involvement with itch. More patients perceived the characteristics of itch as crawling, burning and tickling rather than stinging, stabbing and pinching. The majority of AD patients answered that sweat and hot climate aggravated the itch and medications and cold climate alleviated the itch. However, compared with the childhood patients, more adult patients experienced the aggravation of itch by exposure to dust, and the itch was alleviated by taking medications and by concentrating on work. A burning sensation with itch was more frequently reported by the adult patients when compared to that of the childhood patients. CONCLUSION: This study highlights the detailed description and characteristics of itch in adult and childhood AD patients. The proper management of itch according to age may be prerequisite to improve AD patients' quality of life.

Bullae and Sweat Gland Necrosis in the Differential Diagnosis for Vibrio vulnificus Infection in an Alcoholic Patient

Bullae and sweat gland necrosis remain rare cutaneous manifestation, and these conditions can be misdiagnosed as Vibrio vulnificus infections or other soft tissue infections because of their low index of suspicion. A 46-yr-old man with a history of continued alcohol consumption presented with erythematous and hemorrhagic bullous lesions on his left arm. The patient reported that after the ingestion of clams, he slept for 12 hr in a heavily intoxicated state. Then the skin lesions started as a reddish patch that subsequently became hemorrhagic bullae. V. vulnificus infection, cellulitis, and necrotizing fasciitis were considered in initial differential diagnosis. However, on the basis of sweat gland necrosis on histopathologic examinations and negative results on bacterial cultures, we made the diagnosis of bullae and sweat gland necrosis. Therefore, bullae and sweat gland necrosis should also be considered in chronic alcoholic patients who present with bullae and a previous history of unconsciousness.

Dapsone Hypersensitivity Syndrome That Occurred during Treatment of Pediatric Patient with Erythema Elevatum Diutinum

Herein, we report a case of an 8-year-old girl with dapsone hypersensitivity syndrome (DHS) that occurred during the treatment of erythema elevatum diutinum. She had fever, gross hematuria, and malaise for three weeks after initiation of dapsone therapy. Five days after stopping dapsone treatment, she returned to the emergency clinic because of high fever, emesis, diarrhea, upper respiratory symptoms, and worsening of exanthematous eruptions. A diagnosis of DHS was made, and it improved with oral prednisone. We recommend that pediatric patients who are treated with dapsone need to be observed carefully for the development of DHS.

Various Nail Disorders Misdiagnosed and Treated as Onychomycosis / 대한피부과학회지

BACKGROUND: Treatment of onychomycosis should be commenced after mycological confirmation due to the side effects and long duration of oral antifungal agents. However, many doctors treat patients with nail disorders that resemble onychomycosis without any mycological examination (ME) in clinical practice. OBJECTIVE: To investigate the various nail disorders misdiagnosed as onychomycosis and to evaluate the performing ratios of appropriate diagnostic procedures of onychomycosis. METHODS: The study was performed in a total of 48 patients who had a history of being misdiagnosed and treated for onychomycosis. We investigated the characteristics of each patient, the specialty of their previous doctor, and their previous treatment modality and duration. Whether or not they had previously received proper diagnostic procedures was also investigated. All of the data were collected by questionnaires, and their final diagnoses were also recorded. RESULTS: Among the 48 patients, 31 (31/48, 64.7%) were female, and the mean age of the patients was 45.5+/-15.7. Eighteen patients (18/48, 37.5%) were referred from dermatologists and 30 (30/48, 65.2%) from non-dermatologists. The results of the questionnaires revealed that only 10 of the dermatologists (10/18, 55.6%) performed ME before initiating treatment for onychomycosis, and none of the non-dermatologists did it. The duration of incorrect previous systemic anti-fungal treatment was also significantly longer when administered by non-dermatologists as compared with dermatologists (p=0.042), and over half of the patients (30/46, 65.2%) were treated with fluconazole. Onycholysis (22/48, 45.8%) and trachyonychia (18/48, 37.5%) were the most common final diagnoses, but various nail disorders such as pitting nail, median nail dystrophy, and subungual melanoma were also included. CONCLUSION: To avoid misdiagnosis and incorrect anti-fungal treatment, people with nail disorders that resemble onychomycosis should be recommended to visit dermatologists, and the doctors should perform appropriate mycological examinations in these patients.

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.

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.

Vulval Metastasis from Squamous Cell Carcinoma of the Cervix Clinically Presenting as Lymphangioma Circumscriptum

Patients with cervical cancer may develop local recurrence or distant metastasis, and the rate of these events is increased in proportion to the clinical stage. Cutaneous metastasis of cervical cancer is very rare and only a few cases have been reported in Korean literature. It is common at the abdominal wall, vulva, and anterior chest wall and mainly presents as an asymptomatic dermal or subcutaneous nodule, ulcer or plaque. We herein report on an interesting case of vulval metastasis from squamous cell carcinoma of the cervix with an unusual clinical manifestation resembling lymphagioma circumscriptum.

Mybacterium chelonae Infection Occurring at the Site of Bee Sting Therapy / 대한피부과학회지

Mycobacterium chelonae is a rapidly growing atypical mycobacterium found in soil and water. In a healthy person, it causes cutaneous infection after an invasive procedure or surgery. Herein, we present a case of a 52-year-old man with multiple erythematous plaques and nodules on the back and left arm, and these occurred at the site of bee sting therapy by a herbal medical doctor. The histologic findings showed a granulomatous infiltration composed of numerous neutrophils, lymphocytes, eosinophils, histiocytes and multinucleated giant cells. Acid fast bacilli were detected by Ziehl-Neelsen stain and Mycobacterium chelonae infection was confirmed by an INNO-LiPA mycobacteria kit. The patient was treated with 1 g of clarithromycin and 200 mg of doxycycline for 6 months and his condition improved considerably.

Three Cases of Churg-Strauss Syndrome Diagnosed after Presence of Cutaneous Manifestation / 대한피부과학회지

Churg-Strauss syndrome (CSS) is an uncommon disorder that is characterized by asthma or allergic rhinitis, fever, systemic vasculitis, extravascular granulomas and hypereosinophilia. Cutaneous manifestations of CSS are one of the most common extra-pulmonary findings, and they occur in approximately 60% of the cases. Other manifestations include pulmonary infiltrates and heart, kidney, gastrointestinal tract, peripheral and central nervous system involvement and the patients also complain of systemic symptoms, including malaise, fever, myalgia and weight loss. The diagnosis of CSS is difficult because the manifestations vary with the disease stage and delayed treatment can lead to fatal major organ damage. We report here on 3 cases of CSS that were first diagnosed by the dermatologic department and with consultation from other departments. So, we want to remind dermatologists that if the patients of asthma or other allergic diseases have purpuric skin lesion, then CSS should be included in the differential diagnosis.

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.

Giant Piloleiomyoma of the Forehead

Cutaneous piloleiomyomas are benign smooth muscle tumors arising from the arrector pili muscles. Piloleiomyomas appear as firm dermal papules of skin color or with a reddish to brown surface, and are commonly located on the extremities. Histologically, these lesions are composed of interlacing bundles of smooth muscle cells in the reticular dermis. Our case presented with an unusually large nodule on the forehead that was accompanied by intermittent pain. Histological analysis was compatible with piloleiomyoma and the lesion showed haphazardly arranged bundles of smooth muscle in the dermis. We describe herein an interesting case of a giant piloleiomyoma occurring on the forehead.

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.

Nephrogenic Fibrosing Dermopathy Improved after Renal Transplantation / 대한피부과학회지

Nephrogenic fibrosing dermopathy (NFD) is a rare cutaneous fibrosing disorder that primarily affects patients with a history of renal disease. NFD manifests with induration, thickening and hardening of the skin with brawny hyperpigmentation. Lesions are typically symmetrical and usually develop on the limbs and trunk. Flexion contractures of the joints may be a feature of the disease. Histopathological features of NFD include proliferation of dermal fibroblasts and dendritic cells, thickened collagen bundles, increased elastic fibers and focal mucin deposition. Although the pathogenesis remains largely unknown, some of the factors implicated in the pathogenesis include renal dysfunction, circulating fibrocytes, vascular injury, and gadolinium which is a contrast material used in magnetic resonance imaging. Currently, no definitive or uniformly effective therapies are available for the treatment of NFD. We herein describe the case of a 44-year-old female NFD patient who undergoes significant improvement of skin lesions and associated joint contracture after renal transplantation.