Clear cell acanthoma (CCA)-like lesions of the nipple/areola: A clinicopathological study of 12 cases supporting a nonneoplastic eczematous disease.

BACKGROUND: Clear cell acanthoma (CCA) of the nipple/areola has been reported. The CCA-like histology more likely represents a feature of eczematous dermatitis of the nipple/areola. OBJECTIVE: We reviewed cases of CCA-like lesions of the nipple/areola and compared them with classic CCA to clarify their relationship. METHODS: The clinicopathological features of 12 cases of CCA-like lesions of the nipple/areola were compared with classic CCA. The literature on this condition was reviewed, and the results of various treatments were analyzed. RESULTS: CCA-like lesions of the nipple/areola were clinically different from those of classic CCA. Although they shared the glycogen-rich clear epidermal cells with neutrophilic exocytosis, dermal eosinophils appeared to be a distinctive feature. The anatomic site and association with atopic dermatitis suggested that CCA-like lesions of nipple/areola might represent a manifestation of atopic eczema involving nipple/areola. Topical steroids could be effective. LIMITATIONS: This was a retrospective study with limited cases. CONCLUSIONS: Although CCA-like lesions of the nipple/areola shared histopathological features with classic CCA, their clinical changes were consistent with dermatitis. We propose to name this condition CCA-like eczematous dermatitis of the nipple/areola.

Chromoblastomycosis in Taiwan: A report of 30 cases and a review of the literature.

Chromoblastomycosis (CBM) is an implantation mycosis characterized by the presence of pigmented muriform cells in tissue. CBM is endemic in Taiwan, but only three formal cases have been reported to date because of underreporting. To describe and update its epidemiologic features, we report a series of 30 cases between 2003 and 2016 at a single medical center. Patients were predominately male (2.75:1). The mean age of onset was 65.9 years, and disease duration ranged from 2 months to 20 years. Diabetes was the most common comorbidity, and extremities were the most frequent sites of involvement. The lesions presented as papuloplaque, verrucous, cicatricial, targetoid, or mixed types. The dermoscopic features were variable, including red dots, white vague areas, black globules, and sand-like patterns. Among 10 Fonsecaea isolates further identified by sequencing the ITS regions of ribosomal DNA, nine were F. monophora and one was F. nubica. All but one patient received either systemic antifungal agents, surgical excision, or both. Surgical excision achieved a higher complete remission rate than the other forms of treatment did.

Antimicrobial resistance in Mycobacterium abscessus complex isolated from patients with skin and soft tissue infections at a tertiary teaching hospital in Taiwan.

Background: Mycobacterium abscessus complex (MABC) is the most common non-tuberculous mycobacterium that causes complicated skin and soft tissue infections (cSSTIs). The selection of antimycobacterial agents for successful treatment of such infections is a critical issue. Objectives: To investigate the antimicrobial susceptibility patterns of MABC isolates from skin and soft tissue to a variety of antimycobacterial agents. Methods: Sixty-seven MABC isolates were collected and partial gene sequencing of secA1, rpoB and hsp65 was used to classify them into three subspecies: M. abscessus subsp. abscessus (MAB), M. abscessus subsp. massiliense (MMA) and M. abscessus subsp. bolletii (MBO). The MICs of 11 antimycobacterial agents for these 67 isolates were determined using a broth microdilution method and commercial Sensititre RAPMYCOI MIC plates, as recommended by CLSI. Results: In total, 28 MAB, 38 MMA and 1 MBO were isolated from patients with cSSTIs at our hospital. Most MABC strains were resistant to ciprofloxacin, doxycycline, imipenem, linezolid, minocycline, moxifloxacin and trimethoprim/sulfamethoxazole. In addition, most MABC strains were intermediately susceptible or resistant to cefoxitin. Eighteen of the 28 MABs and 1 MBO isolate harboured the T28 polymorphism in the erm(41) gene. Two of the 38 MMA isolates had an rrl A2059G point mutation. Most of the MABC strains were susceptible to amikacin and tigecycline. Conclusions: In Taiwan, amikacin, clarithromycin and tigecycline have good activity against MMA and MAB erm(41) C28 sequevar isolates, whereas amikacin and tigecycline, rather than clarithromycin, have good activity against both MBO and MAB erm(41) T28 sequevar isolates. Clinical trials are warranted to correlate these data with clinical outcomes.

Quantitative Analysis of Face and Neck Skin Tightening by Microfocused Ultrasound With Visualization in Asians.

BACKGROUND: Previous studies of microfocused ultrasound with visualization (MFU-V) on facial and neck laxity were largely based on masked physician assessments, histological analysis, and safety profile. More quantitative studies are needed. OBJECTIVE: To evaluate the 800 treatment lines of MFU-V on skin tightening effect of face and neck in Asians using 2 quantitative analysis systems at 0, 90, and 180 days after treatment. MATERIALS AND METHODS: Total 25 subjects were recruited in this prospective study. Subjects were treated with MFU-V to the face and neck using 2 different transducers: 4 MHz, 4.5-mm focal depth and 7 MHz, 3.0-mm focal depth with total 800 lines. The subjects were evaluated by skin complexion analysis and 3-dimensional imaging system at 0, 90, and 180 days. Mean brow height lift and submental lift were calculated. RESULTS: All 25 subjects completed treatment and received the follow-up examinations at 90 and 180 days. Two of the 25 subjects were male. Mean patient age was 53.3 years (range: 39.8-61.1 years). Wrinkles, texture, and pores were 3 variables relevant to analysis of skin laxity. Only mean wrinkles score reduction at 90 days was statistically significant (p = .0222). There was a mean 0.47 mm brow lift at 90 days (p = .0165), but there was a 0.12 mm decrease in brow height compared to baseline at 180 days (p = .6494). At 90 days, a mean 26.44 mm submental lift was noted (p = .0217). And at 180 days, a mean 13.76 mm submental lift was noted (p = .243). CONCLUSION: This study showed that the most prominent change after the 800-line MFU-V treatments in Asians was the significant submental lift at 90 days. Other noninvasive or minimally invasive treatment modalities can be considered to combine with MFU-V for the optimal treatment response. Additional MFU-V treatments can be considered 3 months after the first treatment.

Taiwanese Dermatological Association consensus for the definition, classification, diagnosis, and management of urticaria.

BACKGROUND/PURPOSE: This report describes the 2014 consensus of the Taiwanese Dermatological Association regarding the definition, classification, diagnosis, and management of urticaria. This consensus is distributed to practices throughout Taiwan to provide recommendations for diagnostic and therapeutic approaches for common subtypes of urticaria, in order to improve the quality of life of urticaria patients. The consensus, thus, serves as an important reference for dermatologists throughout Taiwan. METHODS: All the consensus contents were voted on by the participating dermatologists, with approval by no less than 75% being required for inclusion. The consensus provides a comprehensive overview of urticaria, including recent advances in identifying its causes and the processes by which it develops. RESULTS: All the consensus meeting attendees agreed to a definition of urticaria, which states that it is characterized by the sudden appearance of wheals (also known as hives), angioedema, or both. Most of the experts (16 out of 19, or 84.2%) agreed that chronic urticaria is defined as the sudden occurrence of wheals and/or angioedema for a period of ≥ 6 weeks. In addition, the consensus attendees also approved the Urticaria Activity Score system or the Urticaria Activity Score for 7 days system as the recommended method for assessing disease activity in spontaneous urticaria. CONCLUSION: It was also determined that the treatment goal for patients with any form of urticaria should be complete cessation of suffering from all urticaria symptoms. The recommended treatment algorithms for chronic spontaneous urticaria and acute urticaria were finally proposed and approved by 100% (19/19) and 84.2% (16/19) of the consensus attendees, respectively.

Evaluation of Laser-Assisted Trans-Nail Drug Delivery with Optical Coherence Tomography.

The nail provides a functional protection to the fingertips and surrounding tissue from external injuries. The nail plate consists of three layers including dorsal, intermediate, and ventral layers. The dorsal layer consists of compact, hard keratins, limiting topical drug delivery through the nail. In this study, we investigate the application of fractional CO2 laser that produces arrays of microthermal ablation zones (MAZs) to facilitate drug delivery in the nails. We utilized optical coherence tomography (OCT) for real-time monitoring of the laser-skin tissue interaction, sparing the patient from an invasive surgical sampling procedure. The time-dependent OCT intensity variance was used to observe drug diffusion through an induced MAZ array. Subsequently, nails were treated with cream and liquid topical drugs to investigate the feasibility and diffusion efficacy of laser-assisted drug delivery. Our results show that fractional CO2 laser improves the effectiveness of topical drug delivery in the nail plate and that OCT could potentially be used for in vivo monitoring of the depth of laser penetration as well as real-time observations of drug delivery.

Insights into the poor prognosis of allopurinol-induced severe cutaneous adverse reactions: the impact of renal insufficiency, high plasma levels of oxypurinol and granulysin.

OBJECTIVE: Allopurinol, an antihyperuricaemic agent, is one of the common causes of life-threatening severe cutaneous adverse reactions (SCAR), including drug rash with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome (SJS) and toxic epidermal necrosis (TEN). The prognostic factors for allopurinol-related SCAR remain unclear. This study aimed to investigate the relationship of dosing, renal function, plasma levels of oxypurinol and granulysin (a cytotoxic protein of SJS/TEN), the disease severity and mortality in allopurinol-SCAR. METHODS: We prospectively enrolled 48 patients with allopurinol-SCAR (26 SJS/TEN and 22 DRESS) and 138 allopurinol-tolerant controls from 2007 to 2012. The human leucocyte antigen (HLA)-B*58:01 status, plasma concentrations of oxypurinol and granulysin were determined. RESULTS: In this cohort, HLA-B*58:01 was strongly associated with allopurinol-SCAR (p<0.001, OR (95% CI) 109 (25 to 481)); however, the initial/maintenance dosages showed no relationship with the disease. Poor renal function was significantly associated with the delayed clearance of plasma oxypurinol, and increased the risk of allopurinol-SCAR (p<0.001, OR (95% CI) 8.0 (3.9 to 17)). Sustained high levels of oxypurinol after allopurinol withdrawal correlated with the poor prognosis of allopurinol-SCAR. In particular, the increased plasma levels of oxypurinol and granulysin linked to the high mortality of allopurinol-SJS/TEN (p<0.01), and strongly associated with prolonged cutaneous reactions in allopurinol-DRESS (p<0.05). CONCLUSIONS: Impaired renal function and increased plasma levels of oxypurinol and granulysin correlated with the poor prognosis of allopurinol-SCAR. Allopurinol prescription is suggested to be avoided in subjects with renal insufficiency and HLA-B*58:01 carriers. An early intervention to increase the clearance of plasma oxypurinol may improve the prognosis of allopurinol-SCAR.

Prognostic factors for Taiwanese patients with cutaneous melanoma undergoing sentinel lymph node biopsy.

BACKGROUND/PURPOSE: Sentinel lymph node biopsy (SLNB) is a standard procedure in the management of clinically node-negative melanoma. However, few studies have been performed on SLNB in Asia, which is an acral melanoma-prevalent area. This study evaluated the clinicopathologic prognostic factors of disease-free survival (DFS) and overall survival (OS) in Taiwanese patients with cutaneous melanoma who received wide excision and SLNB. The prognosis of patients with false-negative (FN) SLNB was also evaluated. METHODS: Malignant melanoma cases were reviewed for 518 patients who were treated between January 2000 and December 2011. Of these patients, 127 patients with node-negative cutaneous melanoma who received successful SLNB were eligible for inclusion in the study. RESULTS: The SLNB-positive rate was 34.6%. The median DFS was 51.5 months, and the median OS was 90.9 months at the median follow-up of 36.6 months. Multivariate analysis revealed that patients whose melanoma had a Breslow thickness greater than 2 mm had a significantly shorter DFS than patients whose melanoma had a Breslow thickness of 2 mm or less [hazard ratio (HR), 3.421; p = 0.005]. Independent prognostic factors of OS were a Breslow thickness greater than 2 mm (HR, 4.435; p = 0.002); nonacral melanoma (HR, 3.048; p = 0.001); and an age older than 65 years (HR, 2.819; p = 0.036). During the follow-up period, 13 of 83 SLN-negative patients developed a regional nodal recurrence. The SLNB failure rate was 15.7% and the FN rate was 22.8%. Compared to patients with a true-positive SLNB, patients with FN SLNB had a significantly shorter DFS (p = 0.001) but no significant difference in OS (p = 0.262). CONCLUSION: Except for the pathologic subtypes, prognostic factors in Taiwan are similar to those used in other melanoma-prevalent countries. Identifying and closely monitoring patients at risk of nodal recurrence after a negative SLNB is important.

Severe cutaneous adverse reactions related to systemic antibiotics.

BACKGROUND: Systemic antibiotics are a major cause of severe cutaneous adverse reactions (SCARs). The selection of alternative antibiotics and management for SCARs patients with underlying infections can be challenging. METHODS: We retrospectively analyzed 74 cases of SCARs, including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug rash with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP), related to use of systemic antibiotics in Taiwan from January 2006 to January 2012. We analyzed the causative antibiotics, clinical features, organ involvements, and mortality. We also assessed patient tolerability to alternative antibiotics after the development of antibiotic-related SCARs. RESULTS: The most common causes of SCARs were penicillins and cephalosporins for SJS/TEN and AGEP; glycopeptides for DRESS. Fatality was more frequent in the SJS/TEN group. In patients with SJS/TEN, higher mortality was associated with old age and underlying sepsis before the development of SCARs. The majority of patients with penicillin- or cephalosporin-related SCARs were able to tolerate quinolones, glycopeptides, and carbapenems. CONCLUSIONS: Complicated underlying conditions and infections may increase mortality in patients with antibiotic-related SCARs. The selection of structurally different alternative drugs is important to avoid recurrence.

Genetic variants associated with phenytoin-related severe cutaneous adverse reactions.

IMPORTANCE: The antiepileptic drug phenytoin can cause cutaneous adverse reactions, ranging from maculopapular exanthema to severe cutaneous adverse reactions, which include drug reactions with eosinophilia and systemic symptoms, Stevens-Johnson syndrome, and toxic epidermal necrolysis. The pharmacogenomic basis of phenytoin-related severe cutaneous adverse reactions remains unknown. OBJECTIVE: To investigate the genetic factors associated with phenytoin-related severe cutaneous adverse reactions. DESIGN, SETTING, AND PARTICIPANTS: Case-control study conducted in 2002-2014 among 105 cases with phenytoin-related severe cutaneous adverse reactions (n=61 Stevens-Johnson syndrome/toxic epidermal necrolysis and n=44 drug reactions with eosinophilia and systemic symptoms), 78 cases with maculopapular exanthema, 130 phenytoin-tolerant control participants, and 3655 population controls from Taiwan, Japan, and Malaysia. A genome-wide association study (GWAS), direct sequencing of the associated loci, and replication analysis were conducted using the samples from Taiwan. The initial GWAS included samples of 60 cases with phenytoin-related severe cutaneous adverse reactions and 412 population controls from Taiwan. The results were validated in (1) 30 cases with severe cutaneous adverse reactions and 130 phenytoin-tolerant controls from Taiwan, (2) 9 patients with Stevens-Johnson syndrome/toxic epidermal necrolysis and 2869 population controls from Japan, and (3) 6 cases and 374 population controls from Malaysia. MAIN OUTCOMES AND MEASURES: Specific genetic factors associated with phenytoin-related severe cutaneous adverse reactions. RESULTS: The GWAS discovered a cluster of 16 single-nucleotide polymorphisms in CYP2C genes at 10q23.33 that reached genome-wide significance. Direct sequencing of CYP2C identified missense variant rs1057910 (CYP2C9*3) that showed significant association with phenytoin-related severe cutaneous adverse reactions (odds ratio, 12; 95% CI, 6.6-20; P=1.1 × 10(-17)). The statistically significant association between CYP2C9*3 and phenytoin-related severe cutaneous adverse reactions was observed in additional samples from Taiwan, Japan, and Malaysia. A meta-analysis using the data from the 3 populations showed an overall odds ratio of 11 (95% CI, 6.2-18; z=8.58; P < .00001) for CYP2C9*3 association with phenytoin-related severe cutaneous adverse reactions. Delayed clearance of plasma phenytoin was detected in patients with severe cutaneous adverse reactions, especially CYP2C9*3 carriers, providing a functional link of the associated variants to the disease. CONCLUSIONS AND RELEVANCE: This study identified CYP2C variants, including CYP2C9*3, known to reduce drug clearance, as important genetic factors associated with phenytoin-related severe cutaneous adverse reactions.

Clinicopathologic analysis of coxsackievirus a6 new variant induced widespread mucocutaneous bullous reactions mimicking severe cutaneous adverse reactions.

BACKGROUND: The cutaneous manifestations of human enterovirus (HEV) infection are usually limited, such as hand-foot-mouth disease. By comparison, Stevens-Johnson syndrome (SJS) is a life-threatening severe cutaneous adverse reaction (SCAR), mainly caused by drugs. During the HEV outbreaks in 2010-2012 in Taiwan, we identified 21 patients who developed widespread blistering mucocutaneous reactions without any suspected drug causality. METHODS: We screened possible pathogen(s) for detecting human herpes virus (HHV1-HHV7), HEV, or Mycoplasma pneumoniae infections using throat swab virus cultures, real-time PCR, DNA sequencing, immunochemistry and electron microscopy analyses. RESULTS: Coxsackievirus A6 (CVA6) DNA was identified in the blistering skin lesions in 6 of 21 patients. Cytotoxic T lymphocytes and natural killer cells expressing granulysin predominantly infiltrated into the skin lesions, sharing the histopathological features with SJS. Intact CVA6 viral particles were identified in the blister fluids and skin lesions by electron microscopy. The phylogenetic analysis of the viral genome showed the CVA6 DNA sequence sharing higher similarity (97.6%-98.1%) to CVA6 strains reported from Finland at 2008. CONCLUSIONS: This study identifies a new variant of CVA6 as the causative agent for severe mucocutaneous blistering reactions mimicking SCAR. An awareness of this unusual presentation of HEV infection is needed in the epidemic area.

A rapidly recurring cutaneous xanthogranuloma-like histiocytic tumor: a diagnostic challenge.

Xanthogranuloma (XG) is a benign cutaneous histiocytic tumor occurring mainly in young children. Onset in adulthood is rarely observed. We encountered an unusual case of an XG-like cutaneous tumor on the scalp of a 50-year-old man. The tumor recurred with multiple satellite nodules soon after surgical excision. This unusual clinical behavior has not previously been described for XG and caused a diagnostic challenge; it was unclear whether the tumor was an atypical XG or a malignant dermal tumor mimicking an XG. Our analyses favored an XG-like dermal histiocytic tumor. A longer follow-up and reports of similar cases will reveal its true nature.

Evaluation of moisture-related attenuation coefficient and water diffusion velocity in human skin using optical coherence tomography.

In this study, time-resolved optical coherence tomography (OCT) scanning images of the process of water diffusion in the skin that illustrate the enhancement in the backscattered intensities due to the increased water concentration are presented. In our experiments, the water concentration in the skin was increased by soaking the hand in water, and the same region of the skin was scanned and measured with the OCT system and a commercial moisture monitor every three minutes. To quantitatively analyze the moisture-related optical properties and the velocity of water diffusion in human skin, the attenuation coefficients of the skin, including the epidermis and dermis layers, were evaluated. Furthermore, the evaluated attenuation coefficients were compared with the measurements made using the commercial moisture monitor. The results demonstrate that the attenuation coefficient increases as the water concentration increases. Furthermore, by evaluating the positions of center-of mass of the backscattered intensities from OCT images, the diffusion velocity can be estimated. In contrast to the commercial moisture monitor, OCT can provide three-dimensional structural images of the skin and characterize its optical property, which together can be used to observe morphological changes and quantitatively evaluate the moisture-related attenuation coefficients in different skin layers.

Association between peripheral vascular endothelial dysfunction and livedoid vasculopathy.

BACKGROUND: Livedoid vasculopathy (LV) is a disease characterized by multiple painful and recurrent ulcerations on the feet, accompanied by atrophic scars. Many researchers suggest that a hypercoagulable status is the pathogenetic factor for LV. However, the cause of LV remains elusive. OBJECTIVE: We sought to determine if endothelial dysfunction is present in patients with LV. METHODS: This prospective study included 16 patients with LV and active ulcers and 16 matched control subjects. We reviewed detailed clinical parameters, including antinuclear antibody, high-sensitivity C-reactive protein, protein C, protein S, homocysteine, anti-SSA, anti-SSB, anticardiolipin antibody, and serum lipid profiles. Flow-mediated vasodilation of the brachial artery was used as an indicator of vascular endothelial function using high-resolution 2-dimensional ultrasonic imaging. RESULTS: Blood pressure, blood biochemistry, high-sensitivity C-reactive protein, and homocysteine were not significantly different in patients with LV and control subjects. Nitroglycerin-mediated vasodilation was not significantly different in patients with LV and control subjects. However, flow-mediated vasodilation was much less in patients with LV than in the control group (3.58 ± 2.32% vs 7.51 ± 2.40%, P < .001). LIMITATIONS: The study was performed at a single site with a limited sample size. CONCLUSION: Peripheral vascular endothelial dysfunction was demonstrated in patients with LV by reduction of brachial flow-mediated vasodilation.

Ultrasound-guided foam sclerotherapy for treating incompetent great saphenous veins--results of 5 years of analysis and morphologic evolvement study.

BACKGROUND: Varicose veins of the lower leg is a common disease and is associated with long-term morbidity. It has been treated using high ligation with stripping and endovenous laser surgery of the great saphenous vein (GSV). OBJECTIVES: To investigate the clinical outcomes of GSV insufficiency after ultrasound-guided foam sclerotherapy (UGFS) using 3% sodium tetradecyl sulfate (STS). METHODS: Between 2005 and 2009, patients with symptomatic varicose veins secondary to GSV insufficiency were enrolled; 3% STS foam was injected into the GSV under ultrasound visualization. Ultrasound examinations and clinical follow-up were performed at 3- to 6-month intervals. Follow-up visits continued through April 2011. RESULTS: Two hundred 88 limbs of 233 patients were enrolled. The mean follow-up interval was 37.8 months. Occlusion was achieved for 89.6% of the incompetent veins in two sessions of UGFS. The mean number of therapy sessions per leg was 1.53. The internal diameters of the treated veins reduced to 66.9% 3 months and 32.7% at 12 months. CONCLUSIONS: UGFS is effective in sealing incompetent GSV segments. It is a minimally invasive procedure and can be redone several times in cases of recurrence. UGFS is simpler and less painful than stripping surgery and endovenous laser treatment.

Clinical aspects and genetic analysis of Taiwanese patients with the phenotype of hyper-immunoglobulin E recurrent infection syndromes (HIES).

BACKGROUND: Hyper-immunoglobulin E recurrent infection syndromes (HIES) has characteristic features and identified mutations. This study investigated clinical features and causal candidate mutations in Taiwanese patients with the HIES phenotype on referral base over 23 million inhabitants. PATIENTS AND METHODS: Clinical manifestations of the HIES phenotype, severity scoring, immunological functions and candidate genes of signal transducer and activator of transcription 3 (STAT3), tyrosine kinase 2 (TYKZ), and dedicator of cytokineses 8 (DOCK8) were analyzed. RESULTS: Between 1985 and 2009, six sporadic and two siblings met HIES criteria (onset age: 2-54 months; severity score: 31-65) out of 187 patients with primary immunodeficiencies. Five patients with the autosomal dominant (AD)-HIES phenotype presented as pneumatocoele, bronchiectasis, retained primary teeth, minor trauma fracture, scoliosis, coronary aneurysm, and lymphoma. Three with the autosomal recessive (AR)-HIES phenotype and impaired lymphocyte proliferation function had herpes simplex virus infection, molluscum contagiosum, and cerebral vasculitis. Notably in one patient with the AR-HIES phenotype, unintentional lead component in traditional application herbs for accelerating wound healing deposited in basal ganglia and aggravated involuntary movement relative to cerebral vacculitis. Those with mildly elevated memory T cells and decreased memory B cells trended to develop arteritis. Of five AD-HIES patients, three were mortalities from acute myocardial infarction, Proteus mirabilis, and Staphylococcus aureus sepsis. Only one had de novo novel STAT3 (Gln 469 Arg) mutation with "relative" lower HIES STAT3 score. CONCLUSIONS: Known genetic defects responsible for the HIES phenotype are not so common in Taiwan. This may infer genetic variations in different ethnicities although selection bias and under-diagnosis for HIES with known genetic defects could be contribution factors.

Identifying prognostic factors for drug rash with eosinophilia and systemic symptoms (DRESS).

Drug rash with eosinophilia and systemic symptoms (DRESS) is a severe cutaneous drug reaction. Although the severity-of-illness score (SCORTEN) has been proposed for toxic epidermal necrolysis (TEN) for 10 years, a prognostic score for DRESS is still lacking. To identify prognostic factors of DRESS patients during hospitalization in one medical health system in Taiwan. We retrospectively reviewed all patients with DRESS diagnosed by dermatologists in Chang Gung Memorial Hospital (CMGH) Health System from 2001 to 2010. To study prognostic factors, we collected data at early disease and maximal disease stages. 91 individuals, including 13 dead patients, were evaluated. Five independent prognostic factors of death were found: heart rate > 90/min, white blood cells >12,000/mm(3) and respiratory rate >20/min (at early disease stage), coagulopathy and gastrointestinal bleeding (at maximal disease stage). In addition, systemic inflammatory response syndrome (SIRS) occurred at a much higher percentage among non-survivors throughout hospitalization. We found tachycardia, leukocytosis, tachypnea, coagulopathy, gastrointestinal bleeding and SIRS were associated with a poor outcome in DRESS patients. DRESS patients with persistent SIRS during hospitalization were also associated with a higher mortality risk. Early recognition and prompt intervention in these factors may improve outcome.

Reduction in osmidrosis using a suction-assisted cartilage shaver improves the quality of life.

BACKGROUND: Axillary osmidrosis is a benign disorder that causes functional and emotional problems in Asian patients. Surgical treatments have proven effective in treating this disease, but changes in quality of life after surgical procedures have not been investigated so far. OBJECTIVE: To evaluate quality of life in patients with osmidrosis before and after surgery with suction-assisted cartilage shaver using the Dermatology Life Quality Index (DLQI). METHODS: Seventy patients with axillary osmidrosis (aged 14-49, 8 men and 62 women) who were treated using a suction-assisted cartilage shaver at the Department of Dermatology, Chang Gung Memorial Hospital, from May 2006 to November 2008 were included. Patients completed the DLQI before and 6 to 35 (mean 18.3) months after treatment. Scores for patient satisfaction and improvement were also investigated. RESULTS: Mean DLQI score before treatment was 11.3 (range 5-27). After 6 to 35 (mean 18.3) months of postoperative follow-up, DLQI scores (mean 0.8, range 0-4) declined significantly (93% reduction). Fifty-nine patients (84.2%) reported odor reduction of 90% or more; 24 patients (34.3%) were greatly satisfied, and 41 were (58.6%) absolutely satisfied with this procedure. CONCLUSION: Our data demonstrate that the suction-assisted cartilage shaver can greatly improve functional and social disabilities in patients with axillary osmidrosis. The authors have indicated no significant interest with commercial supporters.