Clinical and Psychological Implications of Genital Vitiligo in a Thai Population.

BACKGROUND: The understanding of genital vitiligo among Thai individuals is limited. OBJECTIVES: This study evaluated the clinical presentation, quality of life, and sexual health consequences of genital vitiligo. METHODS: This cross-sectional, questionnaire-based study involving vitiligo patients aged 18 years or older with past or present genital involvement was conducted at Siriraj Hospital. It also measured aspects of sexual health and quality of life. RESULTS: The mean age of the 41 participants was 48.2 years, and 24 (58.5%) were males. All participants presented with genital vitiligo. In males, the penile shaft (45.8%), scrotum (45.8%), and glans (33.3%) were predominantly affected. In females, the mons pubis (64.7%), labia majora (23.5%), and labia minora (23.5%) were frequently involved. Both sexes reported afflictions in the pubic area (41.5%), inguinal region (36.6%), buttocks (34.1%), and oral mucosa (34.1%). Itching was the principal symptom in 26.8% of the patients. The median Dermatology Life Quality Index scores were significantly different (females 6, males 3.5). Compared with their male counterparts, females exhibited lower self-esteem (41.2% vs 29.2%), greater apprehension about marriage (11.8% vs 8.3%), and embarrassment about sexual activities (23.5% vs 16.7%). Remarkably, 65.9% of patients had not discussed their genital vitiligo with their doctors, and 51.2% of physicians had not inquired about or examined for genital involvement. CONCLUSIONS: Genital vitiligo adversely impacts quality of life and self-esteem, particularly among female patients. The lack of discourse between patients and physicians highlights a need for increased awareness and proactive clinical investigations to enhance patient care and satisfaction.

A retrospective analysis of 65 patients with acrodermatitis continua of Hallopeau.

There are limited data on acrodermatitis continua of Hallopeau (ACH), particularly among Asian populations. The primary aim was to evaluate the clinical features of ACH and treatment approaches in a sizeable multicentre Asian cohort. We analysed data from adult patients diagnosed with ACH. Of 65 patients with ACH, seven patients had ACH with GPP. Females were more frequently affected in both conditions. Five (71.4%) developed GPP 5-33 years after ACH onset, while two (28.6%) developed GPP concurrently with ACH. The onset age for ACH with GPP (27.9 ± 13.6 years) was earlier than that of isolated ACH (39.8 ± 17.3 years). Metabolic comorbidities were common. ACH exhibited a chronic persistent course. Among systemic non-biologics, acitretin was the most frequently prescribed, followed by ciclosporin and methotrexate. Acitretin and ciclosporin demonstrated similar marked response rates, which surpassed that of methotrexate. Regarding biologics, a marked response was more commonly observed with interleukin-17 inhibitors than with tumour necrosis factor inhibitors. Females are predominant in both conditions. The onset age for ACH among Asian patients is earlier (late 30s) than that for Caucasian patients (late 40s). Interleukin-17 inhibitors may be more effective than tumour necrosis factor inhibitors in managing ACH.

The Steatosis-Associated Fibrosis Estimator (SAFE) score for assessing significant liver fibrosis in patients with psoriasis.

BACKGROUND: There is an urgent need for noninvasive tests to identify patients with psoriasis at risk of significant liver fibrosis. OBJECTIVES: To externally validate the ability of the Steatosis-Associated Fibrosis Estimator (SAFE) score to detect significant liver fibrosis in patients with psoriasis using transient elastography (TE) as a reference. METHODS: We analysed data from 75 patients with psoriasis, including TE, SAFE score, Fibrosis-4 Index (FIB-4) and Nonalcoholic Fatty Liver Disease Fibrosis Score (NFS). Significant liver fibrosis was defined as TE values ≥ 7.1 kPa. Diagnostic accuracy was assessed using the area under the receiver operating characteristic curve (AUROC). RESULTS: Fifteen patients (20%) exhibited significant liver fibrosis. The AUROCs for the SAFE and FIB-4 scores were 0.82 [95% confidence interval (CI) 0.67-0.97] and 0.62 (95% CI 0.45-0.79), respectively. The SAFE score outperformed the FIB-4 Index (P = 0.01) but was comparable with the NFS (P = 0.05) in predicting significant fibrosis. Using thresholds of < 0, 0 to < 100 and ≥ 100, the SAFE score categorized 36, 24 and 15 patients into low, intermediate and high-risk groups for significant fibrosis, respectively. The negative predictive value for excluding significant fibrosis with a SAFE score of < 0 was 94.4%, and the positive predictive value for diagnosing significant fibrosis with a SAFE score of > 100 was 53.3%. The duration of psoriasis, joint involvement and methotrexate treatment did not affect the diagnostic ability of the SAFE score whereas age of the patient did. CONCLUSIONS: The SAFE score demonstrated good accuracy in assessing clinically significant fibrosis among patients with psoriasis. This score should prove valuable for risk stratification and patient management in dermatology practice.

Prevalence and clinical characteristics of pruritus, and the factors significantly associated with high pruritic intensity in patients with psoriasis: a cross-sectional study.

Despite the significant prevalence of pruritus in psoriasis, its pathogenesis remains unknown, and research on pruritus in Thai psoriasis patients is limited. Objectives: The objective was to investigate the prevalence and clinical characteristics of pruritus, and the factors significantly associated with high pruritic intensity in Thai psoriasis patients. Material and methods: In a cross-sectional study design, pruritus data were collected from the medical records of patients who attended an outpatient psoriasis clinic in Thailand between 2020 and 2021. Results: The overall prevalence of pruritus was 81.2% among 314 psoriasis patients. Psoriasis patients with pruritus had higher Psoriasis Area Severity Index and Dermatology Life Quality Index scores than those without pruritus. The legs, back, arms, and scalp were the most common areas for pruritus. Pruritus was relieved with topical emollients, topical corticosteroids, and oral antihistamines in 66.3, 63.1, and 52.9% of patients, respectively. Female sex, psoriasis body surface area greater than or equal to 10%, and genital psoriasis were factors that independently predicted high pruritus intensity. Conclusion: Psoriasis patients should be screened and treated for pruritus to improve both psoriasis treatment outcomes and patient quality of life. Further studies are needed to clarify the most effective medications for pruritus in patients with severe psoriasis.

The efficacy of bimatoprost ophthalmic solution combined with NB-UVB phototherapy in non-segmental and segmental vitiligo: a single-blind randomized controlled study.

Bimatoprost ophthalmic solution 0.03% (PGF2α analogues) combined with narrowband ultraviolet B (NB-UVB) was reported to be an effective treatment for vitiligo. To investigate the efficacy and safety of treatment for non-segmental/segmental vitiligo compared among bimatoprost ophthalmic solution 0.01% combined with NB-UVB phototherapy, bimatoprost monotherapy, and placebo. This single-blind randomized controlled study enrolled stable Thai vitiligo patients with at least three similarly sized lesions in the same anatomical area. The treatment duration was 6 months with 1- and 2-month post-treatment follow-ups. The 3 selected lesions on each patient were randomized to receive combination therapy, monotherapy, or placebo. The Vitiligo Area Scoring Index (VASI) was used to evaluate lesion response. Of the 25 initially enrolled subjects, 19 patients were analyzed. There were 13 and 6 non-segmental and segmental vitiligo cases, respectively. Eight and 11 cases had face/neck and non-face/neck lesions, respectively. Non-segmental vitiligo and non-face/neck vitiligo patients in the combination group had significant improvement in VASI score at 3 months, 6 months, and at the 2-month follow-up. No side effects were observed/reported. Bimatoprost combination therapy was shown to be safe and effective for treating Thai patients with non-segmental vitiligo in non-face/neck areas of the body.

Outcomes of autologous non-cultured melanocyte keratinocyte transplantation in vitiligo and nevus depigmentosus.

BACKGROUND: Melanocyte-keratinocyte transplantation procedure (MKTP) is an effective surgical technique for restoring skin pigmentation in all types of vitiligo and leukoderma patients who are unresponsive to medical and/or phototherapy treatment. Data specific to the outcomes of MKTP among Thai vitiligo and nevus depigmentosus patients are currently scarce. OBJECTIVES: To evaluate the efficacy and safety of MKTP in patients with vitiligo or nevus depigmentosus at the short-term (≤6 months) and long-term (≥12 months) follow-up. MATERIALS AND METHODS: A retrospective review of the medical records of vitiligo or nevus depigmentosus patients who underwent MKTP at the Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand during 2016 to 2019 was conducted. Repigmentation outcomes were evaluated by Vitiligo Area Scoring Index (VASI). RESULTS: Twenty-five patients had 27 MKTP surgeries on 32 anatomically-based lesions. The mean age was 32.4 years, the mean age at onset was 25.5 years, and 19 patients were male. Segmental vitiligo, non-segmental vitiligo, and nevus depigmentosus had significantly improved VASI scores at the short-term follow-up (-74.2% ± 23.2%, -100%, and -62.5% ± 17.6%, respectively) and the long-term follow-up (-81% ± 27.7%, -95.0% ± 7.0%, and -83.3% ± 14.4%, respectively). CONCLUSION: MKTP is a safe and effective method for treating refractory vitiligo and nevus depigmentosus in Thai patients.

How do we treat psoriasis patients with hepatitis C infections in real-world situations? A retrospective analysis of 34 patients.

BACKGROUND: There is still relatively limited data on psoriasis and hepatitis C virus (HCV) infections. OBJECTIVE: This study investigated the clinical characteristics and treatment of psoriasis patients with HCV infections in real-world practice. METHODS: Medical records of all psoriasis patients with HCV infections who attended the outpatient clinic at Siriraj Hospital over a 10-year period were retrospectively reviewed. RESULTS: Of 34 patients, 26 and 8 patients were men and women, respectively with a mean age of 57.0 ± 8.7 (range, 42.2-77.2) years. The median age of psoriasis onset was 42.7 ± 12.7 (range, 8-67.25) years. With a median follow-up period of 13.6 years, cirrhosis and hepatocellular carcinoma were found in 67.6% and 29.4% of the patients, respectively. The interferon used for HCV treatment exacerbated the psoriasis in 20% of those patients. Conventional treatments and anti-tumor necrosis factors (anti-TNFs) were used in strict collaboration with hepatologists. No patients experienced a worsening of their HCV infection. CONCLUSION: Despite a limited number of patients, a male predominance and late-onset psoriasis were frequently observed. Although, interferon therapy for HCV can exacerbate psoriasis, it is not contraindicated. All conventional treatments and anti-TNFs can be used, provided that there is strict collaboration with hepatologists.

Impact of long-term systemic treatment for psoriasis on liver disease in psoriasis patients with coexisting hepatitis B virus infection.

Continuously updated information is helpful for evaluating the safety of long-term systemic drug use in psoriasis patients with concomitant hepatitis B virus (HBV) infection. To investigate the impact of long-term systemic treatment for psoriasis on liver disease in psoriasis patients with HBV infection. Data of patients during 10-year period were recorded and analyzed. Sixty-six patients (46 males and 20 females) with a mean age of 58.5 ± 13.1 years were recruited. Our study estimated that the 5-year cumulative risks of developing cirrhosis and HCC were 30% and 5%, respectively, in patients receiving systemic treatments for psoriasis. Risks of cirrhosis and HCC were not significantly different between systemic and topical treatment groups. Thirty patients were prescribed systemic treatments (acitretin, methotrexate, ciclosporin, and anti-tumor necrosis factors). Three HBsAg+ patients developed viral reactivation (two patients with methotrexate and one patient with ciclosporin). The effects of systemic treatments for psoriasis on liver outcome in patients with coexisting HBV infection are needed to be determined. HBsAg+ patients are more likely to develop viral reactivation during systemic treatment for psoriasis than HBsAg- patients. Monitoring of liver enzymes and HBV DNA every 3 months is recommended during treatment and for 6 to 12 months after drug discontinuation.

The efficacy of UVA1 phototherapy in psoriasis: Clinical and histological aspects.

BACKGROUND: Although ultraviolet A1 (UVA1) phototherapy is available for nearly 30 years, only few studies have been conducted for plaque-type psoriasis. OBJECTIVES: To determine the efficacy and safety of UVA1 phototherapy in psoriasis by assessing the clinical and histological outcomes. METHODS: This open study enrolled 15 patients with moderate to severe plaque-type psoriasis. All of the patients had skin type IV. A whole-body UVA1 device consisting of 24 lamps, was irradiated at a medium dose of 50 J/cm2 three-times weekly for 30 sessions. Topical and systemic psoriasis treatments were discontinued before and during treatment; patients could only use emollients and antihistamines until 1-month post-completion. Psoriasis Area and Severity Index (PASI) scores were determined at baseline; at sessions 10th, 20th and 30th; and 1 month after treatment. Four-millimetre punch biopsies were obtained from the same psoriasis lesion at baseline and session 30th. Changes in histopathological gradings and polymorphonuclear, lymphocyte and Langerhans cell numbers were monitored. RESULTS: Twelve patients completed the study. The mean age was 41.3 years (range: 25-71). The median PASI scores at baseline, session 30th and 1-month post-treatment were 16 (8.2, 43.3), 11 (4.4, 43.3) and 9.2 (2.7, 36.4), respectively. Although the PASI scores had improved significantly by 1-month post-treatment (P = .006), the histological parameters demonstrated minimal changes. All patients tolerated the phototherapy well and the most common side effect was skin tanning. CONCLUSIONS: While medium-dose UVA1 phototherapy demonstrated some efficacy in moderate to severe plaque-type psoriasis. However, it might not be an excellent choice.

Proteomics in Psoriasis.

Psoriasis has been thought to be driven primarily by innate and adaptive immune systems that can be modified by genetic and environmental factors. Complex interplay between inflammatory cytokines and T-cells, especially Th1 and Th17 cells, leads to abnormal cell proliferation and psoriatic skin lesions. Nevertheless, such mechanisms do not entirely represent the pathogenesis of psoriasis. Moreover, earlier and better biomarkers in diagnostics, prognostics, and monitoring therapeutic outcomes of psoriasis are still needed. During the last two decades, proteomics (a systematic analysis of proteins for their identities, quantities, and functions) has been widely employed to psoriatic research. This review summarizes and discusses all of the previous studies that applied various modalities of proteomics technologies to psoriatic skin disease. The data obtained from such studies have led to (i) novel mechanisms and new hypotheses of the disease pathogenesis; (ii) biomarker discovery for diagnostics and prognostics; and (iii) proteome profiling for monitoring treatment efficacy and drug-induced toxicities.

Postinflammatory hyperpigmentation: A comprehensive overview: Treatment options and prevention.

Postinflammatory hyperpigmentation (PIH) occurs after various dermatoses, exogenous stimuli, and dermatologic procedures. The clinical course of PIH is chronic and unpredictable, although the probability of resolution of epidermal hyperpigmentation is better than those of dermal hyperpigmentation. PIH can be prevented or alleviated. When it does occur, the underlying inflammatory conditions should be sought and treated as the first step to reduce the progression of inflammation and PIH (which is an inflammatory consequence). If the inflammatory conditions subsides or there is no evidence of inflammation at the time of diagnosis, the treatments of PIH should be considered as the next step. Understanding the available treatment options helps the physician choose the appropriate treatment for each patient. Having a reproducible model for PIH is essential for the development of treatment modalities. The second article in this 2-part continuing medical education series on PIH specifically addresses the evidence that supports medical and procedural treatments of PIH and other forms of acquired hyperpigmentation. It also describes a PIH model and provides an algorithm for clinical practice along with discussion about the prevention of PIH.

Diagnostic performance of transient elastography for detection of methotrexate-induced liver injury using Roenigk classification in Asian patients with psoriasis: a retrospective study.

Liver biopsy, the gold standard for monitoring methotrexate-induced liver fibrosis in psoriasis patients, has potential morbidity and mortality. Transient elastography (TE) has been widely used as an alternative non-invasive method. Currently, psoriasis-specific data of TE comparing to Roenigk histopathology is lacking. This retrospective study assessed the diagnostic performance of TE in the detection of methotrexate-induced liver injury and liver fibrosis in Asian psoriasis patients. Risk factors that associated with liver injury by TE and histopathology were also determined. Psoriasis patients who had received methotrexate and undergone both TE and liver biopsy (gold standard) examinations between 2005 and 2016 were enrolled. Ten of 41 patients developed methotrexate-induced liver injury (Roenigk grade ≥3a) and two of them had significant liver fibrosis (Metavir fibrosis stage ≥2). Area under the receiver operating characteristic curve (AUROC = 0.78) indicated that TE was capable of identifying patients with and without liver injury. Using a cut-off TE value of 7.1 kilopascal (kPa), this ultrasound-based elastography yielded 50% sensitivity and 83.9% specificity for detecting methotrexate-induced liver injury and had 50% sensitivity and 76.9% specificity for identifying significant liver fibrosis. A total cumulative dosage of methotrexate, age, gender, metabolic syndrome, and metabolic components were not significantly associated with TE values ≥7.1 kPa and Roenigk grade ≥3a. Thus, using clinical context, laboratory information, and a cut-off TE value of 7.1, TE is an attractable non-invasive tool for identify psoriasis patients who have a low probability of methotrexate-induced liver injury and significant liver fibrosis. Liver biopsy can be reserved for selected patients.

The impact of oral Polypodium leucotomos extract on ultraviolet B response: A human clinical study.

BACKGROUND: There is a rationale for adding systemic photoprotective agents to the current photoprotection regimen. OBJECTIVE: This study was designed to objectively evaluate the molecular and photobiologic effects of oral administration of Polypodium leucotomos extract (PLE). METHODS: In all, 22 subjects with Fitzpatrick skin phototype I to III were enrolled. On day 1, subjects were irradiated with visible light, ultraviolet (UV) A1, and UVB (using 308-nm excimer laser). Evaluation was done immediately and 24 hours after irradiation. On days 3 and 4, irradiation and evaluation process was repeated after ingestion of PLE. RESULTS: Clinical assessments and colorimetry data showed a decrease in UVB-induced changes in 17 of 22 subjects post-PLE administration; histology findings demonstrated such a decrease in all 22 subjects. LIMITATIONS: Only 2 doses of PLE were given. Furthermore, subjects with skin phototypes I to III only were studied. CONCLUSION: The results suggest that PLE can potentially be used as an adjunctive agent to lessen the negative photobiologic effects of UVB.

Vogt-Koyanagi-Harada syndrome: Perspectives for immunogenetics, multimodal imaging, and therapeutic options.

Vogt-Koyanagi-Harada syndrome (VKH) is a bilateral, diffuse granulomatous uveitis associated with neurological, audiovestibular, and dermatological systems. The primary pathogenesis is T-cell-mediated autoimmune response directed towards melanocyte or melanocyte-associated antigens causing inflammation of the choroidal layer. This phenomenon usually leads to diffuse inflammatory conditions throughout most parts of eye before ocular complications ensue. The diagnosis is achieved mainly by clinical features according to the revised diagnostic criteria of VKH published in 2001, without confirmatory serologic tests as a requirement. However, ancillary tests, especially multimodal imaging, can reliably provide supportive evidence for the diagnosis of early cases, atypical presentations, and evaluation of management. Prompt treatment with systemic corticosteroids and early non-steroidal immunosuppressive drug therapy can lessen visually threatening ocular complications and bring about good visual recovery. Close monitoring warrants visual stabilization from disease recurrence and ocular complications. This article review aims not only to update comprehensive knowledge regarding VKH but also to emphasize three major perspectives of VKH: immunogenetics as the major pathogenesis of the disease, multimodal imaging, and therapeutic options. The role of anti-vascular endothelial growth factor therapy and drug-induced VKH is also provided.

Clinical characteristics of Thai patients with psoriasis.

OBJECTIVE: To reveal the clinical manifestations, aggravating factors, factor associated with severity, and treatment of psoriasis in Thai patients. MATERIAL AND METHOD: The data of psoriasis patients who had been visited Dermatologic outpatient clinic, Siriraj Hospital between July 2002 and July 2008 were retrospectively reviewed. RESULTS: One thousand eighty two patients were studied. The male to female ratio was 1.2:1 and the peak age of onset was in the 40 to 49 year-old age group. The most common aggravating factor was stress (50%), followed by trauma (39%) and weather condition (35%). The majority of patients had plaque type (72.8%). Male gender, smoking, alcohol intake, and nail abnormalities were related to severe psoriasis (PASI > 10). CONCLUSION: The present study demonstrated the demographic data of Thai psoriasis patients in a large number of population. These data would be beneficial for national public health development of Thailand in order to provide the better care for Thai psoriasis patients.

Cutaneous anaplastic large cell lymphomas: a report of 9 cases from Thailand.

BACKGROUND: Anaplastic large cell lymphoma (ALCL) is one type of lymphoma, which is characterized by the proliferation of pleomorphic large atypical lymphoid cells expressing CD30 antigen. ALCL involving skin can be either primary cutaneous disease or cutaneous involvement secondary from systemic disease. Data of clinical manifestation of cutaneous ALCL in Thai patients is limited. ALCL in Thai patients may differ from other groups of patients. OBJECTIVE: To study the clinical manifestation of cutaneous ALCL in patients of Faculty of Medicine Siriraj Hospital, Thailand. MATERIAL AND METHOD: Medical records of nine patients with histopathologic diagnosis of ALCL from skin biopsy at Faculty of Medicine Siriraj Hospital were reviewed. RESULTS: Of nine patients, four patients were diagnosed as primary cutaneous ALCL, four patients as systemic ALCL with secondary skin involvement, and one patient as combined primary cutaneous ALCL and lymphomatoid papulosis. Three primary cutaneous ALCL patients had no recurrence of disease during 6-year follow-up. However all systemic ALCL patients died at one day to 1.5 years after diagnosis. CONCLUSION: Clinical manifestation and clinical course of Thai patients with anaplastic large cell lymphoma corresponded with the data from other patient population.

A recalcitrant acrodermatitis continua of Hallopeau successfully treated with etanercept.

Acrodermatitis continua of Hallopeau (ACH) is considered as a localized form of pustularpsoriasis that is usually refractory to the treatment. The condition is characterized by sterile pustules, onychodystrophy, anonychia, and osteolysis of distal phalanges. The authors report a case of recalcitrant ACH who previously failed to topical corticosteroid, methotrexate, acitretin, and phototherapy and rapidly responded to etanercept in combination with acitretin. The primary varicella infection occurred during the therapy. The patient was able to discontinue etanercept within four months after starting the treatment. The lesion was then under-controlled by acitretin and topical clobetasol ointment with an 8-month clinical remission.