Evaluation of a Novel Dermal Cooling System for the Treatment of Benign Pigmented Lesions in Asians.

OBJECTIVE: Our study aimed to evaluate the efficacy of this novel dermal cooling system (DCS) in reducing pigmentation in benign pigmented lesions in Asian patients and its potential side effects. METHODS: It was a prospective open-label single-center study. Asian patients, with the presence of benign pigmented lesions mainly including lentigines, melasma, nevus spilus, ephelides, café au lait, and seborrheic keratosis were recruited for a novel DCS. The DCS provided localized cooling of the epidermal layer below freezing but was less intense than cryotherapy. Each patient received DCS at Week 0 and repeated at 4-week intervals up to 10 sessions. Global aesthetic improvement scores (GAIS) by blinded physicians and subjects were recorded at 2, 6, and 12 months posttreatment follow-up. RESULTS: Eighty-one patients were recruited with a total of 305 sessions performed and 1716 lesion sites treated. At 2-month posttreatment, 76.5% and 58.6% treatment sites showed obvious to marked improvement respectively and the improvement sustained at 6 and 12 months. Only minor adverse events were reported. Erythema and edema were the most commonly anticipated effects immediately after treatment. The pain was minimal. Postinflammatory hyperpigmentation was only reported in 2.2% (38/1716) treated sites. CONCLUSION: To our knowledge, this study was the first study to demonstrate that this novel DCS was an effective, safe, and well-tolerated treatment for benign pigmented lesions in Asians.

The use of fractional radiofrequency in Asian patients to improve skin texture.

BACKGROUND AND OBJECTIVES: Fractional radiofrequency devices have been demonstrated to improve skin texture, such as smoothness, rhytides, brightness, and atrophic acne scars, by increasing dermal thickness, dermal collagen content, and dermal fibrillin content. The objective of the study is to assess the efficacy and adverse effects of this device on Asian patients of skin type III and IV with skin textural changes. MATERIALS AND METHODS: The study was designed as a prospective, open-labeled single-arm study, which was conducted with 20 Chinese patients aged 21-60 years and having irregularities in their skin texture, rhytides, and acne scars. The patients received six treatments at intervals of 4 weeks. Treatment was initiated with the maximum energy tolerated, which was then adjusted during the course of treatment if the patients felt excessive discomfort. A total of two passes were delivered in each session. Physician assessment results and standardized photographs were collected at the baseline, after all treatment visits, and at 1, 2, and 6 months after the final treatment visit. RESULTS: A total of 17 patients completed the study according to the established protocol. At the 6-month follow-up, 71% of patients were satisfied and 24% of patients were very satisfied with the received treatments, and the treatment physician reported varying degrees of improvement based on the global assessment scale in 60% of the subjects. While the anticipated side effects, such as erythema, edema, pinpoint bleeding, scab formation, and flare of acne, were noted in the patients, no serious adverse effects occurred. CONCLUSION: The use of fractional radiofrequency improves skin texture and is safe for use in Asian patients of skin type III and IV. No long-term serious adverse effects were noted.

HLA-B*15:11 status and carbamazepine-induced severe cutaneous adverse drug reactions in HLA-B*15:02 negative Chinese.

BACKGROUND: HLA-B*15:11 is associated with carbamazepine (CBZ)-induced severe cutaneous adverse drug reactions (SCARs) in Japanese and some Asian populations, but such data remains relatively limited in Chinese. Routine HLA-B*15:02 screening is mandatory before CBZ commencement, however, SCARs related to CBZ were still observed in non-HLA*B-15:02 carriers. OBJECTIVE: We aimed to find out the prevalence of HLA-B*15:11 in Chinese patients and its associations with CBZ-induced SCARs. METHOD: We screened 8,328 blood samples collected for HLA allele typing before CBZ commencement during the period of January 2014 to December 2019. In HLA-B*15:02 negative Chinese patients, HLA-B*15:11 status were further screened, and the incidence of SCARs in the CBZ group was compared with the control group without CBZ use. RESULT: In this cohort, 1416 out of 8328 patients (17%) tested HLA-B*15:02 positive and were advised to avoid CBZ, while 80 (0.96%) were found to be HLA-B*15:11 positive. In 6911 (83%) patients who tested HLA-B*15:02 negative, 70 (1.01%) were HLA-B*15:11 positive. Five out of 70 (7.14%) patients had SCARs. The incidence of SCARs in HLA-B*15:11 carriers who received CBZ was significantly higher than those without CBZ (17.4% [4/23] vs. 2.13% [1/47], P = 0.037*). The odds ratio was 9.68 (95% CI 1.02-92.4, P = 0.048*). These included: one Stevens-Johnson syndrome (SJS), two DRESS, and one MPE after CBZ use, while one developed MPE after phenytoin use in control. CONCLUSION: HLA-B*15:11 is a potential risk factor of CBZ-induced SCARs in HLA-B*15:02 negative Chinese patients. Further screening of HLA-B*15:11 status in those HLA-B*15:02 negative patients is recommended to avoid undesirable SCARs.

HLA-B*58:01 screening to prevent allopurinol-induced severe cutaneous adverse reactions in Chinese patients with chronic kidney disease.

Human leukocyte antigen (HLA)-B*58:01 allele is a significant risk factor for allopurinol-induced severe cutaneous adverse reactions (SCARs) which is potentially fatal. In some studies, chronic kidney disease (CKD) was also implicated to compound the risk of SCARs. We aim to investigate if pre-treatment HLA-B*58:01 screening can prevent allopurinol-induced SCARs in Chinese patients with CKD and its cost-effectiveness. We prospectively recruited Chinese CKD patients who required allopurinol during 2011-2015 and performed pre-treatment HLA testing (HLA screening group). Patients tested positive for HLA-B*58:01 were refrained from allopurinol while those tested negative were prescribed allopurinol. The incidence of SCARs in the HLA screening group was compared with the historical control in previous 5 years and the cost-effectiveness of HLA testing was analyzed. In the historical control (2006-2010), 3605 patients on allopurinol were screened, 22 out of 1027 (2.14%) CKD Chinese patients newly started on allopurinol developed SCARs, including 6 SJS/TEN. In the HLA screening group, 28 out of 192 patients (14.6%) tested HLA-B*58:01 positive were advised to avoid allopurinol; 156 out of 164 HLA-B*58:01-negative patients received allopurinol and none developed SCARs. The incidence rate of SCARs was significantly lower in the HLA screening group compared with controls (0% vs 2.14% respectively, p = 0.037*). The targeted HLA screening approach was associated with lower healthcare costs compared with no HLA screening (US$ 92,430 vs US$ 281,226). Pre-treatment HLA-B*58:01 screening is cost-effective to target on patients with CKD in Chinese to prevent allopurinol-induced SCARs.

Fractional 1064 nm Picosecond Laser in Treatment of Melasma and Skin Rejuvenation in Asians, A Prospective Study.

BACKGROUND AND OBJECTIVES: Facial melasma is a disfiguring pigmentation and occurs frequently with aging skin. Topical treatment alone was often suboptimal. A recent study showed that fractional picosecond laser has promising result in benign pigmentary lesions. This study aims to investigate the efficacy and safety of 1064 nm picosecond laser in treatment of facial melasma and skin rejuvenation in Asian skin. STUDY DESIGN/MATERIALS AND METHODS: Patients of Asian descent seeking treatment for facial melasma and skin rejuvenation were screened and recruited. Each patient received up to nine laser treatments at 4-6 weeks intervals with a fractionated nonablative 1064 nm picosecond laser. Baseline and posttreatment modified Melasma Area Severity Index (mMASI) and Global Aesthetic Improvement Scale (IGAS) were assessed by blinded investigators based on the clinical photographs. Subject overall satisfaction was assessed by the questionnaires after treatment. All adverse events were documented. RESULTS: Twenty patients were recruited with a median age of 52.7 ± 8.2 years. Three subjects had Fitzpatrick skin type III and 17 had skin type IV. All subjects received nine laser sessions. Over 70% of patients were satisfied with the treatment outcomes. There was a statistically significant improvement in mMASI which reduced from 10.8 at baseline to 2.7 and 3.6 at 6 and 12 weeks post-treatment, respectively (both P < 0.01). For skin rejuvenation, 70% reported at least a moderate improvement at 6 weeks of post-treatment. No major side-effect was reported. Erythema was the most frequent transient response, while some reported edema (1.1%). Both resolved spontaneously. None reported hypo- or hyperpigmentation after treatment. The overall mean pain scare (VAS) was 1.92. CONCLUSION: Fractionated non-ablative 1064 nm picosecond laser was effective in treatment of melasma and skin rejuvenation. It was also safe and well tolerated. Importantly, there was no hypo or hyperpigmentation reported. Lasers Surg. Med. 00:00-00, 2021. © 2021 Wiley Periodicals LLC.

A Prospective Study in the Treatment of Lentigines in Asian Skin Using 532 nm Picosecond Nd:YAG Laser.

BACKGROUND AND OBJECTIVE: To evaluate safety and efficacy of treatment with the picosecond Nd:YAG 532 nm for lentigines in Asian skin. STUDY DESIGN/MATERIALS AND METHODS: This was a prospective, open-label cohort study, using a novel picosecond 532-nm laser for the treatment of facial lentigines. Subjects received up to three laser treatments every 4-6 weeks and were assessed at 4 and 12 weeks after final treatment. Primary endpoint was degree of improvement in lentigines at 12 weeks after the final treatment, assessed by treating investigator based on Physicians Global Assessment. Secondary end-points included degree of improvement in lentigines at 12 weeks after final treatment, assessed by subject (Subject's Global Assessment), and change in mean relative Melanin index (MI) value at 3 months after final treatment as compared to baseline as assessed by mexameter measurement. RESULTS: A total of 20 patients (3 male, and 17 female) of Asian-descent with Fitzpatrick skin type III and IV, with lentigines on the face were included in this study. A total of 89 lesions were treated with the laser setting of 532-nm, 750 picoseconds, fluence of 0.2-0.5 J/cm 2 , and spot size of 4 mm. One hundred and thirty-seven treatment sessions were given in total. Eighteen patients (90%) achieved a moderate to significant improvement at 12-week follow-up based on a 5-grade physician global assessment scale. The improvement rate of relative MI (MI in the lesion minus normal skin) was 33.30 ± 18.71 and 37.63 ± 19.25% at 4- and 12-week follow-up. Post-inflammatory hyperpigmentation (PIH) occurred in 14 of 137 sessions (10.2%), and hypopigmentation occurred in one patient with five lesions (3.6%). CONCLUSION: This study demonstrates that using picosecond Nd:YAG laser 532 nm for removal of solar lentigines in darker skin type appears to be safe and effective. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc. LIMITATIONS: Small study group.

Efficacy and safety of picosecond 755-nm alexandrite laser with diffractive lens array for non-ablative rejuvenation in Chinese skin.

BACKGROUND AND OBJECTIVES: The picosecond alexandrite laser with diffractive lens array (DLA) offers the dual advantages of a picosecond pulse duration and the fractionated delivery of laser energy. This study explores the efficacy and safety of the DLA for treatment of multiple aesthetic concerns associated with photoaging of the face including skin texture irregularities, dyspigmentation, enlarged pore size, rhytides, and skin laxity. METHODS: This prospective, evaluator-blinded trial enrolled Fitzpatrick skin type III-IV patients with mild to moderate signs of facial photoaging. Patients received six full face treatments at 4 week intervals for a total of 107 treatments. Standardized photography was obtained at baseline and at 1, 2, and 3 month follow-up visits. Two independent blinded evaluators rated each of the five signs of photoaging on a 10-point visual analog scale (VAS) at each follow-up visit compared to baseline. A global aesthetic improvement score was also assigned at each follow-up visit. Secondary outcomes included patient-rated pain and heat sensation on a 10-point VAS, and overall satisfaction. Adverse events were noted after each treatment and at each follow-up visit. RESULTS: A total of 18 Chinese patients age 35-59 completed the study. A statistically significant improvement in skin texture and dyspigmentation scores was noted at the 1 month follow-up that was sustained at 3 months. No significant improvements wer--e observed in pore size, rhytides, or skin laxity. The mean pain score was 5.1 ± 2 and mean heat sensation was 3.6 ± 2.1. Expected transient erythema and edema occurred in 95.3% (102/107) and 1.9% (2/108) of treatments, respectively, and resolved in hours. No incidences of post-inflammatory hyperpigmentation (PIH) were noted at the 1, 2, and 3 month visits. CONCLUSION: The 755-nm picosecond laser with DLA is a safe and effective non-ablative modality for targeting facial skin texture irregularities and dyspigmentation in Chinese skin. Patients tolerated the treatment well with adverse effects limited to transient erythema and edema. Lasers Surg. Med. 51:8-13, 2019. © 2018 Wiley Periodicals, Inc.

A Unique Pattern of Staphylococcal Scalded Skin Syndrome-Like Erosions in Patients with Atopic Dermatitis: Dermatitis flammeus.

We describe the clinical features of a novel complication in patients with atopic dermatitis (AD). Twenty patients, mean age 23 years, with AD who presented with staphylococcal scalded skin syndrome (SSSS)-like lesions were included between January 2008 and September 2010. Skin lesions followed a triphasic progression pattern from erythema to hyperpigmentation and then erosions. A symmetric and predominant flexural involvement was observed. Pseudomonas aeruginosa (PA) (38.9%) and Staphylococcus epidermidis (38.9%) were the most frequently cultured bacteria from skin swabs. Complete resolution was evident in all cases, and the recurrence rate was 35%. In conclusion, a unique complication characterized by triphasic progression to painful erosions was found in a cluster of AD patients. We propose the new term "dermatitis flammeus" to describe this phenomenon, with PA being one of the etiologies.

Treatment of Seborrhoeic Dermatitis in Asia: A Consensus Guide.

Seborrhoeic dermatitis (SD) is common in Asia. Its prevalence is estimated to be 1-5% in adults. However, larger population-based studies into the epidemiology of SD in Asia are lacking, and the aetiology of SD may differ widely from Western countries and in different parts of Asia. In addition, clinically significant differences between Asian and Caucasian skin have been reported. There is a need to define standardized clinical diagnostic criteria and/or a grading system to help determine appropriate treatments for SD within Asia. With this in mind, experts from India, South Korea, Taiwan, Malaysia, Vietnam, Singapore, Thailand, the Philippines, Indonesia, and Italy convened to define the landscape of SD in Asia at a meeting held in Singapore. The consensus group developed a comprehensive algorithm to aid clinicians to recommend appropriate treatment of SD in both adults and children. In most cases, satisfactory therapeutic results can be accomplished with topical antifungal agents or topical corticosteroids. Non-steroidal anti-inflammatory agents with antifungal properties have been shown to be a viable option for both acute and maintenance therapy.

A retrospective analysis on the management of pigmented lesions using a picosecond 755-nm alexandrite laser in Asians.

BACKGROUND AND OBJECTIVES: Photo-aging in Chinese often presents with benign pigmentary lesions. Q-switched lasers for pigmentary lesions in Asians had reported a risk of post-inflammatory hyperpigmentation (PIH) up to 25%. Longer pulse widths in the millisecond domains were advocated with reduced risk of PIH. Recently, picosecond lasers of various wavelengths were introduced with proven efficacy in tattoo removal. The objective of this study is to assess the efficacy and safety of a novel picosecond 755-nm alexandrite laser for the treatment of benign pigmented lesions in Asians retrospectively. METHODS: A list of all patients who received picosecond 755-nm alexandrite laser treatment at a private dermatology center in Hong Kong was included. Those who had any other laser or topical treatment during the period of picosecond laser treatment were excluded. The age, skin phototype, type of pigmentary lesion, number of treatments performed was recorded. The baseline and most recent standardized photographs were assessed by trained physicians for comparison. A score of 0-4, representing poor 0-24%, fair 25-49%, good 50-74%, excellent 75-95%, and complete 95%+ improvement was given. Adverse events associated with the laser treatment were also recorded. All patients were followed up until 6 months after the last laser session. RESULTS: A total of 13 subjects were included in the present study. The number of treatment sessions received ranged from one to seven. The benign pigmentary lesions consist of Nevus of Ota, café-au-lait patches, lentigines, Becker's nevus, Hori's macules, and nevus spilus. Among patients with Nevus of Ota, one patient achieved complete clearance after four treatments and two other patients had excellent clearance after three and four sessions, respectively. Patients with café-au-lait had fair to good clearance after one to seven treatment sessions. One patient who has Hori's macules was resistant to laser treatments and a fair response was achieved after eight treatments. In the present series, two patients (4.8%) developed transient hypopigmentation, which had improved upon subsequent follow-up in both cases and none had post-inflammatory hyperpigmentation. CONCLUSIONS: The novel picosecond 755-nm alexandrine laser is effective for the treatment of benign pigmentary lesions in Chinese, especially for the clearance of Nevus of Ota. Picosecond laser appears to be associated with a much lower risk of PIH for treatment of pigmentary lesions in Asians.

Relation between endothelial progenitor cells and arterial stiffness in patients with psoriasis.

Patients with psoriasis are prone to premature atherosclerosis. We hypothesize that depletion of circulating endothelial progenitor cells (EPC) is related to patients with psoriasis and can contribute to the development of atherosclerosis. Thirty-five plaque-type psoriasis patients (41.9 ± 5.5 years, 30 men) and 20 age- and sex-matched controls were studied. Four subpopulations of EPC, namely, CD34(+) EPC, CD133(+) EPC, CD34(+) /kinase insert domain-containing receptor (KDR)(+) EPC and CD133(+) /KDR(+) EPC were measured by flow cytometry. Arterial stiffness in psoriasis patients was assessed by heart to ankle pulse wave velocity (haPWV), augmentation index (AI) and carotid intima media thickness (IMT). Patients with psoriasis had a lower level of CD34(+) EPC (7.85 ± 2.49% vs 6.26 ± 2.13%, P = 0.02) compared with healthy controls. In patients with psoriasis, level of CD34(+) EPC was negatively related with haPWV (r = -0.43 P = 0.01) and Psoriasis Area and Severity Index (r = -0.39 P = 0.02). Multivariate regression analysis further demonstrated that haPWV was independently associated with level of CD34(+) EPC. Each percentage decrease in CD34(+) EPC accounted for an increase in haPWV of +0.02 m/s. The result demonstrated that patients with psoriasis had reduced CD34(+) EPC compared with controls. Importantly, CD34(+) EPC was independently related with haPWV in these patients. This finding suggests that EPC reduction is associated with the development of arterial stiffness in patients with psoriasis.

Psychosocial perception of adults with onychomycosis: a blinded, controlled comparison of 1,017 adult Hong Kong residents with or without onychomycosis.

BACKGROUND: A survey was conducted amongst 1,017 Hong Kong residents ages 18 and over to determine their knowledge of fungal nail infections (onychomycosis) and the psychosocial impact of the disease on the relationships, social lives and careers of sufferers. METHODS: The Fungal Nail Perception Survey was conducted by email and online between May 29th and June 10th, 2013. Participants were shown three photographs of people with and without onychomycosis of the toenails. Respondents were asked ten questions (repeated for each picture) to ascertain their perceptions of the people in the pictures. Questions were related to perceptions around the ability of sufferers and non-sufferers to form relationships with others, social activities of sufferers and non-sufferers, perceptions of the effect of the disease on the potential for career success, and awareness of fungal nail disease and health. The sub-population who themselves suffered from onychomycosis were asked about self-perception as well as their perception of others with onychomycosis. RESULTS: Compared with non-sufferers, survey respondents perceived those with onychomycosis as less likely to be able to form good relationships. They also indicated that they would be more likely to exclude sufferers than non-sufferers from social activities and that they would be more likely to feel uncomfortable when sitting or standing beside an infected person than beside an uninfected person. Respondents perceived people with onychomycosis to be less able to perform well in their chosen career than with someone without onychomycosis. Interestingly, those respondents who themselves were infected felt socially excluded, upset and embarrassed by their infection. CONCLUSIONS: Onychomycosis may lead to stigmatization and social exclusion. Misconceptions of onychomycosis are high and education about the disease needs to be improved. Early recognition and treatment of the disease is essential to avoid complications and improve treatment outcomes, which would lead to reduced psychosocial impact on those with fungal nail infections.

Reactive and infective dermatoses associated with adult-onset immunodeficiency due to anti-interferon-gamma autoantibody: Sweet's syndrome and beyond.

Immunodeficiency due to anti-interferon-gamma autoantibody (anti-IFN-γ autoAb) is an emerging adult-onset immunodeficiency syndrome predominantly found in Southeast Asians. It is associated with severe or disseminated infections caused by non-tuberculous mycobacteria (NTM) and other opportunistic pathogens. We describe 3 patients with anti-IFN-γ autoAb who developed reactive and infective dermatoses, and thoroughly review the existing literature on dermatoses associated with the immunodeficiency syndrome. Case 1 developed Sweet's syndrome associated with Mycobacterium chelonae lymphadenitis and penicilliosis. Case 2 suffered from multiple episodes of lobular panniculitis during recurrent infections by NTM, Penicillium marneffei and Burkholderia pseudomallei. Both cases responded to immunomodulating agents including corticosteroid and non-steroidal anti-inflammatory drugs. Case 3 had direct skin invasion by M. chelonae and responded to prolonged anti-mycobacterial therapy. A novel working algorithm is proposed for the diagnosis and treatment of these patients who may be encountered by the dermatologist and histopathologist in clinical practice.