The Prognosis of Post-Scabetic Itch / 대한피부과학회지

Background@#The primary goal of scabies treatment is to eliminate mites; however, but post-scabetic itch persists in many patients. Since long-standing itching can lead to the development of other comorbidities, appropriate interventions are necessary. @*Objective@#This study aimed to investigate the effects of inappropriate (continuous or prolonged) scabicide use and oral steroids on the duration of pruritus in patients with scabies. @*Methods@#The duration of pruritus, use of oral corticosteroids, total immunoglobulin E (IgE) levels, specific IgE levels for house dust mites, and eosinophil counts were evaluated. Post-scabetic itch was defined as itching that persisted for more than 3 weeks, although scabies was no longer detected; 208 participants with post-scabetic itch were included. @*Results@#We recruited 265 participants with confirmatory diagnosis of scabies and 116 with clinical diagnosis. We treated 124 participants with scabicides based on the guidelines, whereas 257 participants were not. The type of scabicide did not affect the duration of pruritus. Scabicide overuse did not shorten the duration of pruritus; however, its prolonged use lengthened the treatment period. Although oral corticosteroids did not shorten the duration of pruritus in the patients, they were effective when the patient had post-scabetic itch. In addition, a positive correlation between the total IgE level and duration of pruritus was observed. @*Conclusion@#This study investigated the effect of treatment modality on the clinical course of scabies. Our findings suggest that overuse of scabicides might be associated with post-scabetic itch, and short-term use of oral corticosteroids may be effective in reducing its duration.

Case Report: Erythema Multiforme Induced by Lithium Contact

Erythema multiforme (EM) is an acute, self-limited mucocutaneous disease with diverse triggering factors, and the recurrences are quite common. A 24-year old male presented with multiple erythematous, itchy papules and plaques on multiple sites. He has worked in a lithium battery factory and experienced the chemical burn 2 weeks ago. A histopathologic examination on right wrist showed a scattered lymphocytic infiltration, vacuolar degeneration, and necrotic keratinocyte. The final diagnosis was EM after occupational lithium exposure. He was treated by oral methylprednisolone and experienced recurrences after returning to the same workplace after remission. Although the precise pathogenesis is unknown, the pathogenesis of EM by lithium is related to the effect of lithium on immune system, different from other etiologies. To our knowledge, our case is the first report of EM following the chemical burn and occupational lithium exposure. We report this as an interesting case of EM.

Multiple Eruptive Epithelioid Hemangiomas on the Right Upper Extremity in an Asian Man

Epithelioid hemangioma is a rare benign vascular neoplasm. Recently, the term “multiple eruptive epithelioid hemangioma” has been proposed for epithelioid hemangioma with distinct features. It is different from usual epithelioid hemangioma because of the multifocal distributions in various body regions with an eruptive onset. In addition, the histopathology of multiple eruptive epithelioid hemangioma shows increased cellular proliferation, mitosis, and nuclear pleomorphism and positive findings for FOS-B compared to classic epithelioid hemangioma. Herein, we report the case of a 59-year-old man with unusual manifestations suitable for multiple eruptive epithelioid hemangioma. He had multiple erythematous to purple-red dome-shaped nodules on the right hand, arm, and shoulder. The initial lesion was a solitary erythematous nodule on the right hand that abruptly extended to the right arm and shoulder. Microscopically, the tumor was a well-demarcated dermal nodule and showed capillary sized vascular structures. Vascular structures had epithelioid endothelial cells with abundant eosinophilic cytoplasm and vesicular nuclei. The tumor cells showed mild nuclear pleomorphism and a few mitosis and feature of resembling cobble stone was observed. In immunohistochemistry, CD31 and CD34 were positive in the endothelial cells.The endothelial cells showed nuclear positivity in FOS-B. Based on the clinical and histopathological findings, the final diagnosis was multiple eruptive epithelioid hemangiomas.This is the first report of multiple eruptive epithelioid hemangiomas in an Asian man after the term had been introduced.

Aryl Hydrocarbon Receptor and Autophagy-Related Protein Microtubule-Associated Protein Light Chain 3Expression in Psoriasis

Background@#The aryl hydrocarbon receptor (AHR) and autophagy are both important to maintain skin homeostasis.However, they are also involved in skin disorders. So far, their roles in psoriasis pathogenesis are unknown. @*Objective@#We studied the immunohistochemical and gene expression of AHR, CYP1A1, and microtubule-associated protein light chain 3 (LC3) in lesional skin of psoriasis patients to determine correlations among them. @*Methods@#We included 24psoriasis patients and ten healthy volunteers. Skin biopsies were collected. AHR, CYP1A1, and LC3 protein expression was examined by immunohistochemistry, immunofluorescence, and western blotting. AHR, CYP1A1, LC3, ATG5, BECN1 and Nrf2 mRNA levels were measured by quantitative polymerase chain reaction. @*Results@#AHR and CYP1A1 protein expression were higher in psoriasis lesional skin than in normal skin. LC3 protein expression was lower in psoriasis lesions than in normal controls. AHR and CYP1A1 protein expression in psoriasis lesions showed significant positive correlations with mean epidermal thickness and inflammatory cell density. Significant negative correlations were noted between LC3 protein expression in psoriasis lesions and the mean epidermal thickness or inflammatory cell density. A significant negative correlation was found between AHR and LC3 expression in psoriatic skin. AHR, CYP1A1 and Nrf2 mRNA expression were upregulated while LC3, ATG5, and BECN1 mRNA were down-regulated, in psoriatic lesional skin compared with normal controls. @*Conclusion@#AHR and autophagy could play a role in psoriasis pathogenesis by modifying epidermal hyperproliferation and inflammation. AHR and autophagy regulation are potential therapeutic targets in chronic inflammatory skin diseases.

Verrucous Carcinoma of the Nipple, Which Is a Rare Site / 대한피부과학회지

Verrucous carcinoma is a rare, low-grade, well-differentiated variant of squamous cell carcinoma. It occurs mainly on the soles, but has also been reported in other locations, including the buttocks, hand, anus, and genitalia. A 38-year-old woman presented with an asymptomatic skin lesion of the nipple. She first noticed the lesion three months prior. A solitary, cauliflower-shaped, black polypoid mass was observed on her right nipple.Histopathological examination revealed a superficial lesion resembling verruca vulgaris. It was composed of relatively well-differentiated cells with severe epidermal proliferation, and some tumor cells were observed in the dermis. The final diagnosis was verrucous carcinoma. Complete excision of all the lesions was performed. The patient had no recurrence. We report an interesting case of verrucous carcinoma that occurred at a relatively rare site; only one previous report of verrucous carcinoma associated with the breast or nipple was found.

Verrucous Carcinoma of the Nipple, Which Is a Rare Site / 대한피부과학회지

Verrucous carcinoma is a rare, low-grade, well-differentiated variant of squamous cell carcinoma. It occurs mainly on the soles, but has also been reported in other locations, including the buttocks, hand, anus, and genitalia. A 38-year-old woman presented with an asymptomatic skin lesion of the nipple. She first noticed the lesion three months prior. A solitary, cauliflower-shaped, black polypoid mass was observed on her right nipple.Histopathological examination revealed a superficial lesion resembling verruca vulgaris. It was composed of relatively well-differentiated cells with severe epidermal proliferation, and some tumor cells were observed in the dermis. The final diagnosis was verrucous carcinoma. Complete excision of all the lesions was performed. The patient had no recurrence. We report an interesting case of verrucous carcinoma that occurred at a relatively rare site; only one previous report of verrucous carcinoma associated with the breast or nipple was found.

Natural History of Chronic Urticaria in Korea

BACKGROUND@#Data on the natural history and prognostic variables of chronic urticaria (CU) are rare and information about spontaneous remission of CU is limited.@*OBJECTIVE@#This study evaluated the natural history of CU and identified predictors for remission.@*METHODS@#Total 329 Korean patients with CU, who had follow-ups more than 6 months after diagnosis during a 7-year period in the department of dermatology in three university hospitals were enrolled. Clinical data and laboratory findings obtained by medical records and telephone interviews were analyzed, retrospectively.@*RESULTS@#The proportion recovered in 1, 3, and 5 years after the onset of CU was 10.8%, 18.8%, and 32.9%, respectively. The mean duration of CU was 6.3 years. There were no significant differences in median recovery time depending on sex, age group, severity of CU, and type of CU. The presence of angioedema was significantly related to CU severity. There were no differences in prognosis with respect to the presence of dermographism or angioedema. Patients with atopic dermatitis (AD) had a significantly worse prognosis than patients without a history of AD; but not in patients with the history of allergic rhinitis or asthma. Patients with abnormal laboratory findings did not differ significantly in prognosis.@*CONCLUSION@#CU remission rate significantly differ according to the presence of AD. This study provides information about the natural course of CU of Korean patients.

Effect of Weight Reduction on Treatment Outcomes for Patients with Atopic Dermatitis

Background@#Several epidemiological studies have shownthat the atopic tendency increases in the obese population. @*Objective@#The aim of this study was to confirm the effect ofweight reduction on improvement of atopic dermatitis (AD)symptoms and to investigate the relationship between AD severityand the level of serum adipokines. @*Methods@#Forty subjectswho were AD outpatients were recruited for this study.Obese patients were divided into a weight maintenancegroup and weight reduction group. During the study period,patient information was collected that included measuredbody mass index (BMI), Eczema Area and Severity Index(EASI), and visual analogue scale for pruritus. Adiponectin,leptin, eosinophil count, and total immunoglobulin E werealso tested. @*Results@#In the weight reduction group, there wasa significant improvement in the EASI score, however, no significantimprovement was determined in the weight maintenancegroup. BMI and EASI showed positive correlation.The adiponectin level was lower in AD patients compared tohealthy controls, and it was significantly lower in obese patients compared with normal weight patients. Serum levels ofleptin were significantly different among control, obese patientgroup, and normal weight patient group. There was nostatistically significant relationship between serum adipokinelevel and EASI. @*Conclusion@#In our study, weight reductionwas associated with significant improvement of ADsymptoms. Related adipokine levels were significantly differentamong the control, normal weight AD patient group, andobese AD patient group.

Increased 1-Deoxysphingolipids and Skin BarrierDysfunction in the Skin of X-ray or Ultraviolet BIrradiation and Atopic Dermatitis Lesion Could BePrevented by Moisturizer with Physiological LipidMixture

Background@#Skin diseases characterized by epithelial barrierdysfunction show altered sphingolipid metabolism,which results in changes in the stratum corneum intercellularlipid components and structure. Under pathological conditions,1-deoxysphingolipids form as atypical sphingolipidsfrom de novo sphingolipid biosynthesis. @*Objective@#Thisstudy investigated the potential role of 1-deoxysphingolipidsin skin barrier dysfunction secondary to X-ray and ultravioletB (UVB) irradiation in vitro and in vivo. It was also evaluatedchanges in the expression of 1-deoxysphingolipids in lesionalhuman skin of atopic dermatitis. @*Methods@#In thisstudy, the changes in these 1-deoxysphingolipids levels ofskin and serum samples were investigated in skin barrier dysfunctionassociated with X-ray and UVB irradiation in vitroand in vivo. @*Results@#Increased 1-deoxysphingolipids were observed in cultured normal human epidermal keratinocytesafter X-ray irradiation. X-ray or UVB irradiation increased theproduction of 1-deoxysphingosine in a reconstituted 3-dimensional(3D) skin model. Interestingly, treatment with aphysiological lipid mixture (multi-lamellar emulsion containedpseudoceramide), which can strengthen the epidermalpermeability barrier function, resulted in decreased1-deoxysphingosine formation in a reconstituted 3D skinmodel. Further investigation using a hairless mouse modelshowed similar preventive effects of physiological lipid mixtureagainst 1-deoxysphingosine formation after X-ray irradiation.An increased level of 1-dexoysphingosine in the stratumcorneum was also observed in lesional skin of atopic dermatitis. @*Conclusion@#1-deoxysphingosine might be a novelbiomarker of skin barrier dysfunction and a physiological lipidmixture treatment could prevent 1-deoxysphingosine productionand consequent skin barrier dysfunction.

2,3,7,8-Tetrachlorodibenzo-p-Dioxin Regulates the Expression of Aryl Hydrocarbon Receptor-Related Factors and Cytokines in Peripheral Blood Mononuclear Cells and CD4+ T cells from Patients with Atopic Dermatitis and Psoriasis

Background@#Aryl hydrocarbon receptor (AhR), a ligand-activated transcription factor, is important for xenobiotic metabolism and binds to various endogenous and exogenous ligands in the skin. However, the functional role of AhR in patients with psoriasis (PS) and atopic dermatitis (AD) remains unclear. Objective: We aimed to determine whether AhR-regulated factors (AhR, CYP1A1, interleukin [IL]-17, IL-22) were affected by AhR ligands (2,3,7,8-tetrachlorodibenzo-p-dioxin, TCDD) in chronic inflammatory skin diseases such as PS and AD. Methods: The expression levels of AhR-related factors were determined by quantitative PCR, western blotting, and immunocytochemistry. Specific siRNA targeting AhR was used to inhibit gene expression in human peripheral blood mononuclear cells (PBMC). Cytokine assays were performed to determine the protein production of CD4+ T cells. @*Results@#In comparison with healthy controls, TCDD-treated PBMCs and CD4+ T cells from patients with PS and AD showed an increase in AhR gene levels as well as significantly increased expression of AhR-related factors (such as AhR, CYP1A1, IL-17, and IL-22). In contrast, 6-formyl indolo [3,2-b] carbazole (FICZ) inversely affected the differentiation of CD4+ T cells and their cytokine expression levels as compared with TCDD. CD4+ T cells from patients with AD and PS showed higher expression levels of AhR, CYP1A1, IL-17, and IL-22. Conclusion: Our results suggest that TCDD-induced AhR-related factor upregulation in AD and PS patients may increase the expression of AhR-regulatory genes, thereby contributing to the development of AD and PS.

Endoscopic Frontal Sinus Surgery / 대한이비인후과학회지

Surgery on the frontal sinus or frontal recess remains a challenge for rhinologist because of its variability and complex anatomy. Its location, relatively complex and narrow frontal recess also make visualization difficult and predispose it to stenosis. Significantly, serious complications are possible due to the anterior ethmoidal artery, orbit and anterior cranial fossa. An understanding of frontal sinus and frontal recess anatomy is essential to perform endoscopic frontal sinus surgery. This paper examines frontal sinus anatomy and then variable procedures of endoscopic frontal sinus surgery. The selection of less invasive procedure as possible after assessment of the patient's history, diagnostic endoscopy, and the CT scan makes successful endoscopic treatment of frontal sinus diseases.

Effectiveness of Suppressive Therapy with Levothyroxine in Benign Thyroid Nodules / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The effectiveness of suppressive therapy with Levothyroxine in benign thyroid nodule is controversial. The favorable response varies between 9-68%. The aim of this study was to evaluate the effect of Levothyroxine suppressive therapy on benign thyroid nodules in comparison with untreated patients. SUBJECTS AND METHOD: A total 98 patients diagnosed with benign thyroid nodules by high resolution ultrasonography and fine needle aspiration cytology from January 2001 to June 2007 was evaluated retrospectively. The case group included 55 patients who received Levothyroxine suppressive therapy for longer than 6 months with documentation of thyroid stimulating hormone (TSH) suppression level. The control group included 43 patients who were followed up without any treatment. We measured TSH, free T4, and thyroid nodule volume by ultrasound every 6 months. RESULTS: In 13 patients (23.6%) of the case group, nodule volume decreased more than 50% after the Levothyroxine suppressive therapy. In 10 (23.2%) of the control group, nodule volume decreased more than 50 % after the follow-up of 6 months. There was no significant difference between the two groups. The change of nodule volume was not related to the TSH suppression level, the number of nodule or the type of nodule. CONCLUSION: We concluded that Levothyroxine suppressive therapy was not effective in volume reduction of benign thyroid nodules.

Neoadjuvant Chemotherapy Followed by Concurrent Chemoradiation in Locally Advanced Head and Neck Squamous Cell Carcinoma / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Surgery with postoperative radiotherapy has been the standard treatment for locally advanced head and neck squamous cell carcinoma (HNSCC). However, the prognosis still remains dismal. To increase survival rate and organ preservation rate, alternative approach is needed. Incorporating the taxane regimen into the treatment of HNSCC, the new treatment strategy of sequential therapy has been introduced. The purpose of this study is to determine the efficacy of neoadjuvant chemotherapy, followed by concurrent chemoradiotherapy for the HNSCC. SUBJECTS AND METHOD: Between January 2001 and June 2005, 19 patients with HNSCC were treated with neoadjuvant chemotherapy, followed by concurrent chemoradiotherapy. The sites of primary tumors were hypopharynx in eight patients, oropharynx in six patients, and larynx in five patients. Neoadjuvant chemotherapy included 70 mg/m2 of docetaxel on day 1, 70 mg/m2 of cisplantin on day 2 and 800 mg/m2 of 5-fluorouracil on day 2-4. The cycles were repeated every three weeks. Concurrent chemoradiotherapy starts after two cycles of neoadjuvant chemotherapy. Radiation dose was 200 cGy/dayx5/week with a total of 6,000-7,000 cGy, and the concurrent chemotherapy of 20 mg/m2 of docetaxel or 20 mg/m2 of cisplantin was given weekly. RESULTS: The median follow-up was 21 months. The overall 2-year survival rate was 70.1% and the 2-year organ preservation rate was 59.4%. The survival rate and organ preservation rate of larynx cancer patients were higher than those of hypopharynx and oropharynx cancer patients, but it was not statistically significant (p=0.09, 0.16). The patients of the lower stage showed higher survival rate and organ preservation rate, but it was not statistically significant (p=0.19, 0.48). The most common Grade 3 or 4 toxicities of neoadjuvant chemotherapy were leukopenia, anorexia, nausea and vomiting, whereas the most common Grade 3 or 4 toxicities during concurrent chemoradiotherapy were mucositis, stomatitis, and leukopenia. One patient died due to sepsis during treatment. CONCLUSION: Neoadjuvant chemotherapy with three combined regimens followed by concurrent chemoradiotherapy might be effective treatment modality for HNSCC. Further studies with large number of patients and longer follow-up will be needed.