Guideline for the diagnosis, treatment and long-term management of cutaneous lupus erythematosus.

Cutaneous lupus erythematosus (CLE) is an inflammatory, autoimmune disease encompassing a broad spectrum of subtypes including acute, subacute, chronic and intermittent CLE. Among these, chronic CLE can be further classified into several subclasses of lupus erythematosus (LE) such as discoid LE, verrucous LE, LE profundus, chilblain LE and Blaschko linear LE. To provide all dermatologists and rheumatologists with a practical guideline for the diagnosis, treatment and long-term management of CLE, this evidence- and consensus-based guideline was developed following the checklist established by the international Reporting Items for Practice Guidelines in Healthcare (RIGHT) Working Group and was registered at the International Practice Guideline Registry Platform. With the joint efforts of the Asian Dermatological Association (ADA), the Asian Academy of Dermatology and Venereology (AADV) and the Lupus Erythematosus Research Center of Chinese Society of Dermatology (CSD), a total of 25 dermatologists, 7 rheumatologists, one research scientist on lupus and 2 methodologists, from 16 countries/regions in Asia, America and Europe, participated in the development of this guideline. All recommendations were agreed on by at least 80% of the 32 voting physicians. As a consensus, diagnosis of CLE is mainly based on the evaluation of clinical and histopathological manifestations, with an exclusion of SLE by assessment of systemic involvement. For localized CLE lesions, topical corticosteroids and topical calcineurin inhibitors are first-line treatment. For widespread or severe CLE lesions and (or) cases resistant to topical treatment, systemic treatment including antimalarials and (or) short-term corticosteroids can be added. Notably, antimalarials are the first-line systemic treatment for all types of CLE, and can also be used in pregnant patients and pediatric patients. Second-line choices include thalidomide, retinoids, dapsone and MTX, whereas MMF is third-line treatment. Finally, pulsed-dye laser or surgery can be added as fourth-line treatment for localized, refractory lesions of CCLE in cosmetically unacceptable areas, whereas belimumab may be used as fourth-line treatment for widespread CLE lesions in patients with active SLE, or recurrence of ACLE during tapering of corticosteroids. As for management of the disease, patient education and a long-term follow-up are necessary. Disease activity, damage of skin and other organs, quality of life, comorbidities and possible adverse events are suggested to be assessed in every follow-up visit, when appropriate.

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.

Mycoses in Thailand: current concerns.

Scytalidium dimidiatum is the leading cause of fungal foot diseases in Thailand, in contrast to similar studies in which dermatophytes have been identified as the predominant pathogens. By contrast, the prevalence of Candida albicans in our study was only 2.6 approximately 3.0%. Scytalidium fungal foot infection is clinically indistinguishable from that caused by dermatophytes and should be included as a possible cause of treatment failure in tinea pedis and onychomycosis. Without proper culture identification, clinically diagnosed patients would be treated with a standard antifungal regimen leading to minimal response and be interpreted as drug resistant cases resulting in switching of drugs and more aggressive management procedures. Tinea capitis is another health problem in young children. However, for Microsporum canis and some ectothrix organisms, the effectiveness of treatment may be less than endothrix infection. Griseofulvin is still the mainstay antifungal although itraconazole and terbinafine are as effective. Pulse regimen may be another option with advantages of increased compliance and convenience. Two pulses of terbinafine may be sufficient for treating most cases of Microsporum infection, although additional treatment may be needed if clinical improvement is not evident at week 8 after initiating therapy. Chromoblastomycosis is another subcutaneous infection that requires long treatment duration with costly antifungal drugs. The most common pathogen in Thailand is Fonsecaea pedrosoi. Preliminary study of pulse itraconazole 400 mg/d 1 week monthly for 9-12 consecutive months showed promising results. The prevalence of Penicillium marneffei infection is alarming in HIV infected patients living in endemic areas. Diagnosis relies on direct examination of the specimens and confirmation by culture. Treatment regimens include systemic amphotericin B or itraconazole followed by long-term prophylaxis. Treatment outcome depends on the immune status of the patient.

Cutaneous manifestations of Penicillium marneffei infection.

From an almost unknown disease 15 years ago, Penicillium marneffei has emerged to become one of the most common opportunistic fungal pathogens among HIV-infected patients in the endemic area of southern China and northern Thailand. The mode of infection is primarily airborne, with the reticuloendothelial system as the main target. Penicilliosis is a fatal disease and systemic antifungals are the mainstay of therapy. Direct and mycological examinations are sufficient to make a diagnosis and to differentiate P. marneffei from other opportunistic fungi, although advances in serodiagnosis may potentially enhance understanding of the pathogenesis and identification of early asymptomatic cases.

Mitochondrial DNA analysis of Sporothrix schenckii in India, Thailand, Brazil, Colombia, Guatemala and Mexico.

Up to now, 30 mitochondrial DNA(mtDNA)and 4 rDNA types of Sporothrix schenckii strains have been identified. Here, seventy-six isolates of S. schenckii from Mexico, Guatemala, Brazil, Thailand and India were genotyped and studied epidemiologically by mtDNA restriction fragment length polymorphisms(RFLP)and internal transcribed spacer region(ITS)-RFLP analysis and two new mtDNA types, Type 31 and Type 32, were found. Type 30, previously reported by Mora-Cabrera et al. was confirmed to be Type 3 and designated as blank. Of 48 isolates from Mexico, 41 belonged to Group A wherein Type 2(13 isolates), Type 3(10)and Type 28(7)were dominant. All ten isolates from India and Thailand belonged to Group B. The 52 Group A and 24 Group B isolates corresponded to rDNA Type I and Type IV , respectively, reported by Watanabe et al.(Nippon Ishinkin Gakkai Zasshi 45: 165-175, 2004).