Basic Therapeutic Approach for Patients with Plaque Psoriasis:Korean Expert Consensus Using the Modified Delphi Method

Background@#Currently, there is no consensus on the treatment of psoriasis in Korean patients. @*Objective@#This study aimed to establish a consensus on the basic therapeutic principles for Korean patients with plaque psoriasis. @*Methods@#Using the modified Delphi method, a steering committee proposed 53 statements for the first Delphi round, which covered five subjects: (1) the goal of treatment and evaluation of disease severity, (2) topical therapy, (3) phototherapy, (4) conventional systemic therapy, and (5) biologic therapy. The panel of dermatologists scored the level of agreement for each statement on a ten-point scale with scores ranging from 1 (strongly disagree) to 10 (strongly agree). After discussing the results of the first round, the committee reformulated 41 statements. Finally, consensus was defined as more than 70% of the second round scores being ≥7. @*Results@#The panel participants strongly agreed that the ideal treatment goals for Korean patients with plaque psoriasis should include complete skin clearance and high dermatological quality of life. A strong consensus was also reached on the use of topical agents for psoriasis of any severity, the consideration of phototherapy before biologics therapy, the conventional systemic agents for moderate-to-severe psoriasis, and the recommendation of biologic for retractable psoriasis to conventional systemic therapy and phototherapy. @*Conclusion@#This modified Delphi panel established an expert consensus on the therapeutic approach for Korean patients with plaque psoriasis. This consensus may improve the treatment outcomes for psoriasis in Korea.

Clinical Differences of Androgenetic Alopecia between Adolescents and Adults / 대한피부과학회지

Background@#Androgenetic alopecia (AGA) is characterized by terminal hair miniaturization, which progressively decreases hair density and thickness. Genetic predisposition and the role of androgen in AGA have been widely accepted; however, its definite mechanism has not been clarified. AGA may also occur in adolescents, although its clinical characteristics including the disease prevalence have not yet been fully established. @*Objective@#To analyze the clinical differences of AGA between adolescents and adults. @*Methods@#Six-hundred fourteen patients with AGA were recruited and information about age, sex, and family history, comorbidities were collected. @*Results@#A total of 74.5% of adolescents and 66.4% of adults had family history of AGA, with “paternal only” as the most common pattern. A total of 27.3% of adolescents and 44.5% of adults had comorbidities, with seborrheic dermatitis being the most common. Other common comorbidities were acne, folliculitis, and atopic dermatitis in adolescents, dyslipidemia, hypertension, mood disorder, and diabetes mellitus in adults. A total of 12.7% and 15.0% of adolescents and adults, respectively, had abnormal serum testosterone levels, and 5.5% of adolescents and 7.5% of adults had abnormal serum dehydroepiandrosterone sulfate (DHEA-S) levels. Regardless of age, the proportion of patients with abnormal testosterone levels was higher in the female group than in the male group. @*Conclusion@#AGA showed paternal predominance in family history regardless of sex or age, suggesting paternal history as an important factor of AGA. Testosterone and DHEA-S abnormalities were found in patients with AGA, indicating a need for further studies on therapeutic effects associated with differences in hormonal profiles.

An Analysis of the Clinical and Photobiological Characteristics of Solar Urticaria:A 15-year Retrospective Study / 대한피부과학회지

Background@#Solar urticaria (SU) is a rare type of photodermatosis characterized by the appearance of itchy wheals and erythema within minutes after exposure to sunlight or artificial light. Only a few studies have analyzed the clinical and photobiological features of SU in Asia. @*Objective@#We aimed to analyze the clinical and photobiological characteristics of SU. @*Methods@#We retrospectively investigated the medical records of patients with SU who visited the Department of Dermatology at the Konkuk University Medical Center between January 2005 and October 2020. @*Results@#Of the 52 patients, 43 (82.7%) were men, and 9 (17.3%) were women. The mean age at onset was 17.5 years (5∼47 years), and the mean threshold time was 21.2 minutes. Among the 36 patients who underwent phototesting, the action spectrum predominantly responsible for SU was ultraviolet (UV) A only in 14 (38.9%) patients and visible light (415 nm) only in nine (25.0%) patients. Three patients (8.3%) were induced by both UVA and visible light (415 nm). In eight (22.2%) patients, the symptoms were triggered only by natural sunlight. Serum immunoglobulin E (IgE) levels were measured in 39 patients, and 21 (53.8%) patients showed elevated IgE levels. Oral antihistamine (48.1%) was the most widely used treatment, followed by oral cyclosporine (15.4%) and phototherapy (11.5%). @*Conclusion@#SU is an uncommon type of photodermatosis in Korea, with a greater prevalence in men. In this study, UVA was found to be the predominant action spectrum responsible for SU.

The Economic Burden of Psoriasis in Korea / 대한피부과학회지

Background@#Psoriasis is a chronic disease that can have accompanying comorbidities including arthritis, metabolic syndrome, and cardiovascular diseases. Patients with psoriasis tend to frequently visit medical institutions, and their economic burden for medical services is high. @*Objective@#To investigate the economic burden of psoriasis in Korea. @*Methods@#The Korean Society for Psoriasis conducted a multi-center field survey of the patients and analyzed the national insurance claim data. Also, we discussed the medical environment of psoriasis in Korea based on the results. @*Results@#The economic burden of psoriasis patients is substantial and varied by the type of medical institute. Patients also paid the indirect and intangible medical costs. Biological agents, which is used in patients with severe psoriasis, led to an increase in the cost. @*Conclusion@#This is the first study to estimate the economic burden of psoriasis in Korea comprehensively. To improve the medical environment of psoriasis and alleviate the burden of patients, discussion on the more efficient health policy and medical insurance criteria for psoriasis would be needed.

An Analysis of the Clinical and Photobiological Characteristics of Solar Urticaria:A 15-year Retrospective Study / 대한피부과학회지

Background@#Solar urticaria (SU) is a rare type of photodermatosis characterized by the appearance of itchy wheals and erythema within minutes after exposure to sunlight or artificial light. Only a few studies have analyzed the clinical and photobiological features of SU in Asia. @*Objective@#We aimed to analyze the clinical and photobiological characteristics of SU. @*Methods@#We retrospectively investigated the medical records of patients with SU who visited the Department of Dermatology at the Konkuk University Medical Center between January 2005 and October 2020. @*Results@#Of the 52 patients, 43 (82.7%) were men, and 9 (17.3%) were women. The mean age at onset was 17.5 years (5∼47 years), and the mean threshold time was 21.2 minutes. Among the 36 patients who underwent phototesting, the action spectrum predominantly responsible for SU was ultraviolet (UV) A only in 14 (38.9%) patients and visible light (415 nm) only in nine (25.0%) patients. Three patients (8.3%) were induced by both UVA and visible light (415 nm). In eight (22.2%) patients, the symptoms were triggered only by natural sunlight. Serum immunoglobulin E (IgE) levels were measured in 39 patients, and 21 (53.8%) patients showed elevated IgE levels. Oral antihistamine (48.1%) was the most widely used treatment, followed by oral cyclosporine (15.4%) and phototherapy (11.5%). @*Conclusion@#SU is an uncommon type of photodermatosis in Korea, with a greater prevalence in men. In this study, UVA was found to be the predominant action spectrum responsible for SU.

The Economic Burden of Psoriasis in Korea / 대한피부과학회지

Background@#Psoriasis is a chronic disease that can have accompanying comorbidities including arthritis, metabolic syndrome, and cardiovascular diseases. Patients with psoriasis tend to frequently visit medical institutions, and their economic burden for medical services is high. @*Objective@#To investigate the economic burden of psoriasis in Korea. @*Methods@#The Korean Society for Psoriasis conducted a multi-center field survey of the patients and analyzed the national insurance claim data. Also, we discussed the medical environment of psoriasis in Korea based on the results. @*Results@#The economic burden of psoriasis patients is substantial and varied by the type of medical institute. Patients also paid the indirect and intangible medical costs. Biological agents, which is used in patients with severe psoriasis, led to an increase in the cost. @*Conclusion@#This is the first study to estimate the economic burden of psoriasis in Korea comprehensively. To improve the medical environment of psoriasis and alleviate the burden of patients, discussion on the more efficient health policy and medical insurance criteria for psoriasis would be needed.

A Comparative Study for Evaluating the Diagnostic Capacity of the Dermatophyte Test Strip for Tinea Unguium / 대한피부과학회지

Background@#Both direct microscopic examination and fungal culture are standard diagnostic methods for tinea unguium diagnosis. However, the accuracy of these tests is low and the results tend to be dependent on the skills of the performer. The Dermatophyte Test Strip, a newly developed diagnostic tool that is used to detect dermatophytes, facilitates the diagnosis of tinea unguium using immunochromatography.Objective We compared the diagnostic capacity of the Dermatophyte Test Strip and conventional diagnostic methods for the detection of dermatophytes in clinically suspected tinea unguium specimens in Korea. @*Methods@#Direct microscopic examination and the Dermatophyte Test Strip were performed on all specimens. If the results differed between the two methods, we used polymerase chain reaction (PCR) analysis to confirm the dermatophyte presence. @*Results@#Of the 120 specimens, 77 (64.2%) showed positive results on the Dermatophyte Test Strip and 66 (55.0%) on the direct microscopic examination. PCR analysis was performed on the 27 specimens whose results differed between the two tests, and all these specimens showed positive results on PCR analysis. When comparing the results of direct microscopy adjusted with PCR with those of the Dermatophyte Test Strip, the positiveegative/overall concordance rates were 100%, 81.4%, and 93.3%, respectively, while the kappa coefficient was 0.85 (95% confidence interval, 0.75∼0.95). @*Conclusion@#This study suggests that the Dermatophyte Test Strip, a practical diagnostic kit that detects dermatophytes without using other technical instruments, may be a valuable diagnostic tool for tinea unguium and may reduce the unnecessary use of antifungal agents.

A Rare Case of Bilateral Frontal Linear Scleroderma (En Coup de Sabre) / 대한피부과학회지

No abstract available.

Synergistic Effect of H1-Antihistamines on Topical Corticosteroids for Pruritus in Atopic Dermatitis: A Systematic Review and Meta-Analysis

BACKGROUND: Although oral antihistamines (H1-histamine receptor antagonists) are the main treatment option for pruritus in general skin dermatosis, their effect in treating pruritus of atopic dermatitis (AD) has not yet been established. OBJECTIVE: We conducted a systematic review and meta-analysis to evaluate the effectiveness of combined therapy of H1-antihistamines and topical steroids. METHODS: We systematically searched MEDLINE, Embase, and CENTRAL databases for articles published from 1967 to 2015. We identified 1,206 studies and assessed their titles, abstract, and full-text. Random effects meta-analysis was used to calculate mean differences (MD) with 95% confidence intervals (CI). RESULTS: Two studies satisfying the inclusion criteria of antihistamine therapy with mandatory topical steroid use were selected. Comparing antihistamine monotherapy with combination therapy, patients treated with the addition of antihistamine to topical corticosteroids showed a statistically significant clinical improvement (standard MD, −0.24; 95% CI, −0.42 to −0.05; p=0.01). CONCLUSION: H1-antihistamines may have a synergistic effect when combined with topical steroids by influencing various associative factors of chronic pruritus in AD.

Usefulness of Monopolar Thermal Radiofrequency Treatment for Periorbital Wrinkles

BACKGROUND: Over the past 10 years, monopolar radiofrequency (MRF) technology has been widely used by dermatologists as a valuable modality to effectively tighten and rejuvenate photoaged skin. It also has the benefit of a short recovery time. OBJECTIVE: Using an objective parameter, this study aimed to assess the efficacy and safety of MRF, which is the basic modality of radiofrequency technologies, for treatment of periorbital wrinkles in Korean patients. METHODS: We enrolled 70 middle-aged female patients with periorbital wrinkles for this study. Each patient underwent triple sessions of MRF treatment in the periorbital region, separated by 2-week intervals. Clinical photographs were obtained, and the areas of wrinkles were measured using a Robo Skin Analyzer CS50 (Inforward Inc., Japan) at baseline and 4 weeks after the final treatment session. RESULTS: Significant reduction in the mean area of periorbital wrinkles was detected at 1-month follow-up (80.64±28.96 mm2) compared to baseline (95.08±31.93 mm2). The improvement ratio of the wrinkle area was 15.19%. Pain during procedure seemed to be tolerable without any local anesthesia for all patients. Transient mild erythema was the only side effect reported during the study. CONCLUSION: In conclusion, MRF could still be an attractive modality for Korean patients with periorbital wrinkles if the treatment is conducted repeatedly with sufficient energy and proper intervals.

Mycosis Fungoides Responsive to Oral Alitretinoin and Ultraviolet B Phototherapy: A Case Report / 대한피부과학회지

Mycosis fungoides is the most common type of cutaneous T-cell lymphoma. Patients with early stage disease usually respond well to conventional therapies, with a relatively favorable prognosis. However, a few patients are refractory to treatment and need alternative strategies, even at the patch and plaque stages. We report the case of a middle-aged woman with long-standing and refractory mycosis fungoides that responded to combination therapy with the 308-nm excimer laser and oral alitretinoin.

Two Cases of Actinic Cheilitis Clinically Mistaken for Candidal Infection / 대한의진균학회지

Candidiasis is a common fungal infection that usually affects the oral cavity. It is occasionally difficult to diagnose candidiasis because of its various clinical manifestations. Moreover, chronic inflammation of the lips can obscure clarification of its disease entity in patients with chronic cheilitis. Here we aimed to investigate patients with refractory chronic cheilitis who were initially diagnosed with candidiasis. We screened patients with lip lesions that were clinically suspected to have candidiasis. Our two 65-year-old patients with refractory chronic cheilitis were initially diagnosed with candidal infection. Punch biopsies were performed of the lesions and a diagnosis of actinic cheilitis was made in both patients. Since we did not note prominent improvement after conservative treatment and cryotherapy, we applied 0.015% ingenol mebutate gel for further treatment and then observed significant improvement.

Gene Expression Analysis of Inflammatory Cytokines in Korean Psoriatic Patients

BACKGROUND: Although phenotypic heterogeneity of psoriasis is suggested by the alternate activation of either T-helper (Th)1-related or Th17-related cytokines, little is known about the mRNA levels of inflammatory cytokines. OBJECTIVE: To investigate whether there is differential expression of Th1-related and Th17-related inflammatory cytokine genes 1) between psoriatic patients and healthy controls, and 2) between patients with different psoriasis phenotypes. METHODS: Twenty-five patients with psoriasis (10 with guttate psoriasis and 15 with plaque psoriasis) and 5 healthy volunteers were enrolled in this study. The mRNA levels of circulating cytokines (interleukin [IL]-2, IL-12p40, interferon-γ, IL-17A, IL-22, and IL-23R) were measured by real-time reverse transcription polymerase chain reaction. RESULTS: The comparison between psoriatic and healthy control samples revealed that IL-12p40, IL-17A, and IL-22 mRNA levels were significantly higher (approximately 4∼6 folds) in the patients with psoriasis. The mRNA levels of these six cytokines in the blood did not differ between the guttate and plaque psoriasis groups. CONCLUSION: We found that the mRNA levels of blood inflammatory cytokines (IL-12p40, IL-17A, and IL-22) were significantly elevated in patients with psoriasis compared to the levels in healthy controls, but they did not significantly differ between patients with guttate and plaque type psoriasis.

The Clinical Profile of Patients with Psoriasis in Korea: A Nationwide Cross-Sectional Study (EPI-PSODE)

BACKGROUND: Psoriasis is an immune-mediated, chronic inflammatory disease affecting multiple aspects of patients' lives. Its epidemiology varies regionally; however, nationwide epidemiologic data on psoriasis depicting profile of Korean patients has not been available to date. OBJECTIVE: To understand nationwide epidemiologic characteristics and clinical features of adult patients with psoriasis visited university hospitals in Korea. METHODS: This multicenter, non-interventional, cross-sectional study recruited 1,278 adult patients with psoriasis across 25 centers in Korea in 2013. Various clinical data including PASI, BSA, DLQI, SF-36 and PASE were collected. RESULTS: A total of 1,260 patients completed the study (male:female=1.47:1). The mean age was 47.0 years with a distribution mostly in the 50s (24.9%). Early onset (<40 years) of psoriasis accounted for 53.9% of patients. The mean disease duration was 109.2 months; mean body mass index was 23.9 kg/m²; and 12.7% of patients had a family history of psoriasis. Plaque and guttate types of psoriasis accounted for 85.8% and 8.4%, respectively. Patients with PASI ≥10 accounted for 24.9%; patients with body surface area ≥10 were 45.9%. Patients with DLQI ≥6 accounted for 78.8%. Between PASI <10 and PASI ≥10 groups, significant difference was noted in age at diagnosis, disease duration, blood pressure, waist circumference of female, and treatment experiences with phototherapy, systemic agents, and biologics. CONCLUSION: This was the first nationwide epidemiologic study of patients with psoriasis in Korea and provides an overview of the epidemiologic characteristics and clinical profiles of this patient population.

In Vitro Anti-Malassezia Activity of Castanea crenata Shell and Oil-Soluble Glycyrrhiza Extracts

BACKGROUND: A new shampoo with anti-Malassezia properties obtained from various plants is required to provide seborrheic dermatitis patients with a wider range of treatment options. OBJECTIVE: The aim of this study was to obtain in vitro susceptibility profiles of Malassezia restricta and M. globosa, the most important pathogenic organisms in the development of seborrheic dermatitis, to the plant extracts used in commercial anti-dandruff shampoos. METHODS: Minimal inhibitory concentrations (MICs) were determined for eight candidate plant extracts and two plant-derived natural products diluted with Leeming and Notman medium to final concentrations of 0.016 to 1 mg/ml. RESULTS: Castanea crenata shell, Camellia sinensis leaf, and oil-soluble Glycyrrhiza extracts presented relatively low MIC values (≤0.5 mg/ml) against both strains. The C. crenata shell and oil-soluble Glycyrrhiza extracts demonstrated especially high anti-Malassezia activity, suggesting their potential use in the treatment of seborrheic dermatitis. The extracts also showed fungistatic activity against other common facultative pathogenic yeasts, Cryptococcus and Candida. CONCLUSION: C. crenata shell and oil-soluble Glycyrrhiza extracts could potentially be used as active ingredients in anti-seborrheic and anti-dandruff shampoo formulations. They could be helpful for repeated treatments and regular prophylaxis of scalp seborrheic dermatitis.

Drug Reaction with Eosinophilia and Systemic Symptom Syndrome Induced by Lamotrigine

Drug reaction with eosinophilia and systemic symptom (DRESS) syndrome is a type of severe adverse drug-induced reaction. Dermatologists should make a quick diagnosis and provide appropriate treatment for DRESS syndrome to reduce mortality rates, which can be as high as 10%. We present the case of a 47-year-old man with schizoaffective disorder treated with lamotrigine who developed DRESS syndrome to emphasize the importance of close observation of patients with drug eruption. He was consulted for erythematous maculopapular rashes on the trunk that developed 3 weeks after starting lamotrigine. A few days later, he developed generalized influenza-like symptoms. The skin rashes spread over his entire body, and the sense of itching was rapidly aggravated within a few days. Increased liver enzyme levels and significant eosinophilia were found on laboratory test results. His condition was diagnosed as DRESS syndrome, and he was treated with systemic and topical corticosteroids for 2 weeks.

Cutaneous Pili Migrans in the Sole of a Pediatric Patient / 대한피부과학회지

Cutaneous pili migrans is a rare condition in which a hair shaft migrates under the superficial skin. We report a case in which a 2-year-old boy presented with an unusually shaped long hair strand that had penetrated the epidermis of the sole. We discuss the structure and fragility of skin in children, which may predispose their skin to invasion by a foreign body, viz., a long hair strand.

Pedunculated Nodules as a Variant of Dermatofibrosarcoma Protuberans

Dermatofibrosarcoma protuberans (DFSP) is a rare disease of dermal fibroblastic origin that accounts for less than 5% of all soft tissue sarcomas in adults. DFSP grows slowly and is an asymptomatic lesion at the initial diagnosis. Herein, we report a case of multiple pedunculated nodules as a variant of DFSP. A 47-year-old man presented with a 7-month history of multiple well-circumscribed, firm, pedunculated nodules on the inguinal area. Histopathologic examination results showed densely packed uniform spindle cells with a storiform and cartwheel pattern, and positivity for CD34. Wide excision and skin graft were performed and at the 6-month follow-up, there was no evidence of recurrence or metastasis.

Pedunculated Nodules as a Variant of Dermatofibrosarcoma Protuberans

Dermatofibrosarcoma protuberans (DFSP) is a rare disease of dermal fibroblastic origin that accounts for less than 5% of all soft tissue sarcomas in adults. DFSP grows slowly and is an asymptomatic lesion at the initial diagnosis. Herein, we report a case of multiple pedunculated nodules as a variant of DFSP. A 47-year-old man presented with a 7-month history of multiple well-circumscribed, firm, pedunculated nodules on the inguinal area. Histopathologic examination results showed densely packed uniform spindle cells with a storiform and cartwheel pattern, and positivity for CD34. Wide excision and skin graft were performed and at the 6-month follow-up, there was no evidence of recurrence or metastasis.

Clinical and Histopathological Investigation of Seborrheic Keratosis

BACKGROUND: Seborrheic keratosis (SK) is one of the most common epidermal tumors of the skin. However, only a few large-scale clinicohistopathological investigations have been conducted on SK or on the possible correlation between histopathological SK subtype and location. OBJECTIVE: The aim of this study was to analyze the clinical and histopathological features of a relatively large number of cases of diagnosed SK. METHODS: Two hundred and seventy-one pathology slides of skin tissue from patients with clinically diagnosed SK and 206 cases of biopsy-proven SK were analyzed. The biopsy-proven cases of SK were assessed for histopathological subclassification. The demographic, clinical, and histopathological data of the patients were collected for analysis of associated factors. RESULTS: The most frequent histopathological subtype was the acanthotic type, followed by mixed, hyperkeratotic, melanoacanthoma, clonal, irritated, and adenoid types; an unexpectedly high percentage (9.2%) of the melanoacanthoma variant was observed. The adenoid type was more common in sun-exposed sites than in sun-protected sites (p=0.028). Premalignant and malignant entities together represented almost one-quarter (24.2%) of the clinicopathological mismatch cases (i.e., mismatch between the clinical and histopathological diagnoses). Regarding the location of SK development, the frequency of mismatch for the sun-exposed areas was significantly higher than that for sun-protected areas (p=0.043). CONCLUSION: The adenoid type was more common in sun-exposed sites. Biopsy sampling should be performed for lesions situated in sun-exposed areas to exclude other premalignant or malignant diseases.