Association between vitiligo and risk of retinal detachment: a population-based cohort study in Taiwan.

BACKGROUND: Vitiligo is reportedly associated with several ocular abnormalities. However, the relationship between vitiligo and retinal detachment (RD) remains unclear. OBJECTIVES: To examine the risk of RD in patients with vitiligo. METHODS: A nationwide population-based cohort study was conducted using data from the Taiwan National Health Insurance Database from 2007 to 2018. A total of 21 132 patients with vitiligo were matched in a 1 : 4 ratio with people without vitiligo by age, sex and comorbidity propensity score. Cumulative incidence and Cox proportional hazard models were used to investigate the risk of RD in patients with vitiligo. Subgroup analysis was performed. RESULTS: The cohort with vitiligo had a significantly higher rate of RD than the cohort without vitiligo [adjusted hazard ratio (aHR) 1.44, 95% confidence interval (CI) 1.20-1.72; P < 0.001]. Patients with vitiligo who required treatments such as phototherapy, systemic corticosteroids or immunosuppressants exhibited an even greater risk of RD (aHR 1.57, 95% CI 1.16-2.14; P = 0.004). CONCLUSIONS: Our study revealed a 1.44-fold increased risk of RD in patients with vitiligo, with an even higher risk in patients receiving phototherapy, systemic corticosteroids or immunosuppressants. The risk remained consistently higher over a 10-year follow-up period.

Taiwanese Dermatological Association consensus for the management of atopic dermatitis: A 2020 update.

BACKGROUND/PURPOSE: Atopic dermatitis (AD) is a chronic inflammatory disease commonly seen in children and increasingly recognized in adults. With recent advances in the therapeutic development for AD, the Taiwanese Dermatological Association (TDA) established a committee to update the consensus for AD management in Taiwan. This report describes the 2020 updated consensus for the management of AD. METHODS: A panel of 11 core members was convened to review and discuss aspects of AD management and draft recommendation during the first two meetings. The 2015 TDA consensus and the 2017 European guideline, along with recent peer-reviewed articles, serve as the foundation for the update. In the third meeting, AD expert dermatologists selected on a national scale were invited to vote on the final statements. A total of 27 dermatologists attended the final meeting. The consensus was achieved when ratings of 7-9 (out of a total score of 9) accounted for ≥ 75% of the total votes. RESULTS: Consensus was achieved on the therapeutic options for AD by lines of treatment. A treatment algorithm was presented to illustrate the place of each modality in terms of basic care, acute disease control, and maintenance therapy. Special considerations for the pediatric population, as well as for women during pregnancy and lactation, are discussed. CONCLUSION: Topical corticosteroids with long-term emollient-based therapies remain the cornerstone of AD treatment. Systemic treatments are indicated when topical therapies and phototherapy fail to control the disease. The recent approval of dupilumab and emerging targeted therapies are expected to bring significant clinical benefit for patients whose disease is inadequately managed by existing options.

Psoriasis is not a risk factor for dementia: a 12-year nationwide population-based cohort study.

Studies investigating the risk for dementia in psoriatic patients remain inconclusive. There are a limited number of population-based studies on the association between psoriasis and dementia. This study aims to investigate the risk for dementia in psoriatic patients. This nationwide population-based cohort study was based on data obtained from the Taiwan National Health Insurance Research Database between 2000 and 2012. A total of 111,825 patients with psoriasis and 111,825 age-, sex-, and index date-matched controls were recruited. The hazard ratio (HR) for subsequent dementia in patients with psoriasis was analyzed using a Cox model and a Fine-Gray competing risk model. During 1,358,774 person-years of follow-up, 2688 patients developed dementia in the psoriatic cohort, and 2062 developed dementia in the control cohort. In the multivariate adjusted Cox model, the hazard ratio (HR) of psoriatic patients for dementia was 1.02 [95% confidence interval (CI) 0.96-1.09] relative to the controls. Psoriasis did not increase the risk for dementia (both vascular dementia and degenerative dementia). In the competing risk model, the HR of dementia was 0.96 (95% CI 0.90-1.02) for psoriatic patients. Compared to psoriatic patients who had not received phototherapy or systemic treatment, those psoriatic patients receiving phototherapy or systemic treatment had a lower risk for dementia. However, this phenomenon was not observed in psoriatic patients who were observed for longer than 6 years. Psoriasis was not found to be a risk factor for dementia. Phototherapy and systemic treatment might not have a protective effect against dementia in psoriatic patients.

Psoriasis is associated with increased risk of bullous pemphigoid: A nationwide population-based cohort study in Taiwan.

Psoriasis may coexist with bullous pemphigoid (BP); however, no cohort studies have investigated the relationship between psoriasis and the risk of BP. This study aims to investigate the relationship between psoriasis and the risk of BP in Taiwan. This cohort study consists of 109 777 psoriatic patients and 109 777 matched non-exposed controls. Psoriatic patients diagnosed between 2002 and 2012 were identified from the Taiwan National Health Insurance Research Database. The age-, sex- and index date-matched non-exposed group was selected from the same database. The relationship between psoriasis and the risk of BP was investigated using Cox proportional hazards analyses. Psoriasis was significantly associated with an increased risk of BP (hazard ratio, 3.05; 95% confidence interval, 2.10-4.43; P < 0.001). The mean interval between the diagnoses of psoriasis and BP was 2.86 years, with the highest occurrence in the first year after psoriasis diagnosis, and gradually decreasing with each year of observation. Psoriatic patients with BP were significantly younger than BP patients in the non-exposed group (71.6 ± 13.9 vs 76.6 ± 7.7 years, respectively; P = 0.030). A higher proportion of patients with coexisting psoriasis and BP received phototherapy (20%). In conclusion, psoriasis was independently associated with a 3.05-fold increased risk of BP, and psoriatic patients with BP were younger, with over one-third of BP cases diagnosed in the first year after incident psoriasis. Therefore, clinicians treating patients with psoriasis may be aware of the possibility of the development of BP.

Risk of skin cancer in psoriasis patients receiving long-term narrowband ultraviolet phototherapy: Results from a Taiwanese population-based cohort study.

BACKGROUND: Narrowband ultraviolet B (NB-UVB) phototherapy is a widely used treatment for various dermatoses. The risk of skin cancer following long-term NB-UVB phototherapy has rarely been explored in skin phototypes III-V. METHODS: We conducted a nationwide-matched cohort study and identified a total of 22 891 psoriasis patients starting NB-UVB phototherapy from the Taiwan National Health Insurance Database during the period 2000-2013. Cumulative incidences of skin cancers were compared between subjects receiving less than 90 UVB treatments (S-cohort, N = 13 260) and age- as well as propensity score-matched subjects receiving more than or equal to 90 UVB treatments (L-cohort, N = 3315). RESULTS: There were no significant differences in the overall cumulative incidences of skin cancers between the two cohorts (log-rank t test, P = 0.691) during the follow-up periods. The S-cohort had a significantly lower prevalence of actinic keratosis when compared with the L-cohort (0.54% vs 1.00%, P = 0.005). CONCLUSION: Long-term NB-UVB phototherapy does not increase skin cancer risk compared with short-term NB-UVB phototherapy in psoriasis patients with skin phototypes III-V.

The Risk of Mortality among Psoriatic Patients with Varying Severity: A Nationwide Population-Based Cohort Study in Taiwan.

Background: Previous studies showed conflicting results regarding the mortality risk in psoriasis patients with respect to disease severity and presence of psoriatic arthritis. This study aimed to determine the mortality risk in patients with mild and severe psoriasis and patients with psoriatic arthritis (PsA). Methods: A nationwide population-based cohort study was conducted based on data from the Taiwan National Health Insurance Research Database between 2002 and 2012. Incident psoriasis subjects were classified into two groups: psoriasis without arthritis and psoriasis with arthritis. Patients who had received systemic therapy and/or phototherapy were classified as having severe psoriasis; otherwise, patients were classified as having mild psoriasis. Control subjects without psoriasis were selected to match each psoriasis patient from the database within the same observational period. Cox proportional hazards analysis was used to compare the hazard ratio (HR) of time to death. Results: A total of 106,701 patients with psoriasis were included in this study. After controlling for demographics and comorbidities, psoriasis patients had a higher mortality risk compared with the control group (HR 1.41; 95% confidence interval (CI) 1.36 to 1.46). Compared with psoriasis alone, the mortality risk was not increased for PsA (HR = 1.01; 95% CI 0.93 to 1.10). Besides, severe psoriasis did not increase mortality risk compared with mild psoriasis (HR = 1.0; 95% CI 0.95 to 1.06). Conclusions: Patients with psoriasis had a higher mortality risk compared with control subjects, whereas psoriasis severity and presence of PsA had no impact on mortality risk in psoriasis patients.

Risk of fractures in vitiligo patients treated with phototherapy-A retrospective population-based cohort study.

BACKGROUND: Phototherapy might increase bone mineral density. However, it is unknown whether phototherapy can reduce the risk of fractures in patients with vitiligo. OBJECTIVES: To investigate the effect of phototherapy on fracture risks in vitiligo patients aged 40 or older. METHODS: This population-based cohort study used the 2000-2010 Taiwan National Health Insurance Research Database (NHIRD) to identify 3863 patients newly diagnosed with vitiligo between 2003 and 2009 at age ≥40 years. Study subjects were classified into three cohorts: (1) frequent phototherapy; (2) infrequent phototherapy; and (3) no phototherapy. Patients were followed until the first hip or vertebral fracture or 31 December 2010. Data were analysed using Cox regression models and also stratified by age and gender. RESULTS: Frequent phototherapy decreased the fracture risks (adjusted hazard ratio (aHR)=0.32, p=0.009) in vitiligo patients. Stratification by age and gender confirmed the fracture prevention effect of frequent phototherapy in patients aged 40-64 years (aHR=0.14, p=0.016) and in female patients (aHR=0.31, p=0.024). CONCLUSIONS: This study provides the first evidence that frequent phototherapy can reduce the risk of fractures among middle-aged and among female vitiligo patients.

EGb-761 prevents ultraviolet B-induced photoaging via inactivation of mitogen-activated protein kinases and proinflammatory cytokine expression.

BACKGROUND: EGb-761 is an antioxidant and anticarcinogen; however, its role as a photoprotector remains unknown. OBJECTIVE: To determine whether EGb-761 photoprotects human dermal fibroblasts and BALB/c mice skin against ultraviolet B (UVB) light irradiation. METHODS: To simulate chronic photodamage, shaved BALB/c mice were exposed to UVB irradiation (90mJ/cm(2)) thrice weekly for 3 months. EGb-761 (2mg/cm(2)) was topically applied 1h before irradiation to evaluate its effect. The mechanisms by which EGb-761 protects the skin from photodamage were evaluated by immunohistochemical analysis, enzyme-linked immunosorbent assay (ELISA), and Western blotting. RESULTS: In BALB/c mice, the signs of photoaging or photodamage, such as coarse wrinkle formation, epidermal hyperplasia, and elastic fiber degeneration, markedly reduced with the topical application of EGb-761. Western blot and ELISA revealed that the activation of MMP-1 in cultured fibroblasts markedly diminished after pretreatment with EGb-761. In addition, EGb-761 inhibited UVB-induced overexpression by the fibroblasts of the proinflammatory cytokines, such as interleukin (IL)-1α, IL-1ß, IL-6, and tumor necrosis factor-α. The phosphorylation of the mitogen-activated protein kinase (MAPK) signal transduction pathway components, including extracellular signal-regulated kinase, C-Jun N-terminal kinase, and p38, which are induced by UV irradiation, was significantly inhibited in vivo and in vitro. EGb-761 also diminished the generation of UVB-induced reactive oxygen species (ROS). CONCLUSIONS: EGb-761 photoprotects mice and cultured fibroblasts, inhibits the UVB-induced phosphorylation of MAPK pathway components, and reduces the expression of the proinflammatory cytokines by suppressing ROS generation. Thus, topically applied EGb-761 may be a promising photoprotective agent.

Prevalence and associated factors of comorbid skin diseases in patients with schizophrenia: a clinical survey and national health database study.

OBJECTIVES: To examine the epidemiology of and possible risk factors for skin diseases in patients with schizophrenia. METHODS: All of 337 patients with schizophrenia were recruited from the therapeutic community of a psychiatric hospital and underwent a detailed skin examination. The National Health Insurance Research Database (NHIRD) was used to compare the prevalence of skin diseases between patients with schizophrenia and those without. RESULTS: In the clinical survey, fungal infection (61.4%) and dermatitis (46.9%) were the most common skin diseases. Clozapine users had a lower risk of fungal infection than those on typical antipsychotics [odds ratio (OR)=0.49, 95% confidence interval (CI)=0.30-0.81]. Obese patients were more likely to have fungal infections than those without (OR=1.93, 95% CI=1.20-3.09), and those with diabetes had an increased risk of bacterial infection than those without (OR=2.0, 95% CI=1.06-3.75). NHIRD revealed that the overall prevalence of skin diseases, including infections, dermatitis, hyperkeratosis, pilosebaceous disease, androgenic alopecia, xerosis and stasis, were higher in patients with schizophrenia than in those without (75.1% vs. 72.6%, P=.01). CONCLUSIONS: The prevalence of skin diseases is high in patients with schizophrenia, for whom proper skin care is necessary to improve their life quality.

The risk of developing non-melanoma skin cancer, lymphoma and melanoma in patients with psoriasis in Taiwan: a 10-year, population-based cohort study.

BACKGROUND: Hospitalized psoriasis patients are known to have a higher risk of malignancy (e.g., nonmelanoma skin cancer [NMSC], lymphoma, and melanoma) than the general population; currently, it is unclear whether this risk is affected by psoriasis severity. The aim of this study was to compare the cancer risk of patients with mild and severe psoriasis and the general population. METHODS: Data for this retrospective population-based cohort study were obtained from the Taiwan National Health Insurance Research Database. This study included 7061 patients with a first-time diagnosis of psoriasis. All study individuals were followed up until the end of 2007. The crude incidence density ratio and standardized incidence ratio (SIR) of NMSC, melanoma, and lymphoma were determined. RESULTS: Among psoriasis patients, the most common cancer was NMSC (density ratio: 7.5); women were at a higher risk of NMSC than men (density ratios: 8.08 vs. 7.0). Psoriasis patients in the south geographic group or in the 50- to 59-year-old age group were most likely to develop NMSC. The NMSC SIR was higher among patients with severe psoriasis than among patients with mild psoriasis (SIR: 3.72 vs. 7.08). The lymphoma and melanoma SIR among patients with severe psoriasis was also high (lymphoma SIR: 4.85; melanoma: 11.01). CONCLUSIONS: Psoriasis carries an elevated risk of NMSC and lymphoma. This effect is modified by the severity of psoriasis, age, gender, and geographic location.

Insights into the mechanism of Piper betle leaf-induced contact leukomelanosis using C57BL/6 mice as the animal model and tyrosinase assays.

BACKGROUND/OBJECTIVES: Steamed piper betle leaves (PBL) were once used by many Taiwanese women to treat pigment disorders on the face. Most women claimed a quick, favourable response at first, only to be overcome with facial leukomelanosis later. METHODS: C57BL/6 mice were randomly assigned to different groups to study if PBL could cause the following effects: contact dermatitis, leukomelanosis, or hair bleaching. Intracellular melanin content was measured by tyrosinase assays. RESULTS: Most steamed PBL-treated mice developed contact dermatitis and postinflammatory hyperpigmentation (PIH) on their shaved backs. About half developed bleached hair to varying extents. The steamed PBL did not only bleach the hairs, but also, unexpectedly, stimulated melanocyte replication, indicated by the fact that the number of functional melanocytes in the tail epidermis increased significantly after treatment (P = 0.007). Using tyrosinase assays PBL extract at the undiluted concentration showed limited inhibition of melanogenesis, probably via melanocytotoxicity. CONCLUSIONS: The leukomelanosis observed in patients might be the consequence of PIH combined with a mixed reaction (hyper- and hypopigmentation), probably due to the different volatile chemicals that surface after steaming the PBL. This conflicting mixed reaction suggests that counteractive ingredients might exist in PBL. PBL, if purified, might be a promising source of a novel bleaching agent.

The risk of cancer in patients with psoriasis: a population-based cohort study in Taiwan.

BACKGROUND: An association between psoriasis and malignancy has been explored. However, no studies have been reported regarding cancer risk in Asian psoriasis populations. OBJECTIVES: The aim of this study was to investigate the risk of cancer development in association with psoriasis. The effects of age at diagnosis, treatment modalities, and observation time were also evaluated. METHODS: Data for this retrospective population-based cohort study were obtained from the Taiwan National Health Insurance Research Database (NHIRD). This study included 3,686 patients with first-time diagnosis of psoriasis between 1996 and 2000. Another 200,000 patients without psoriasis served as the comparison group. All enrolled subjects were followed-up until the end of 2007. Cumulative incidences and hazard ratios (HRs) of cancer development were determined. RESULTS: Among the 3,686 psoriasis patients, 116 had incident cancers. The 7-year cumulative incidence of cancer among psoriasis patients was 4.8%. The adjusted HR for developing a cancer in association with psoriasis was 1.66 (95% confidence interval [CI], 1.38-2.00). Cancer risk was higher in male patients than in female patients (adjusted HR 1.86 vs.1.14, respectively). Certain cancers were significantly associated with psoriasis, including those of the urinary bladder and skin, followed by oropharynx/larynx, liver/gallbladder, and colon/rectum. Patients with psoriasis had an increased adjusted HR for cancer that varied by age. Younger patients with psoriasis tended to have the greatest risk of cancer. Finally, systemic phototherapy and oral medication did not significantly increase the risk of cancer. Phototherapy with UVB appeared to reduce the risk of cancer in psoriasis (adjusted HR, 0.52; 95% CI, 0.29-0.95; P = .03). LIMITATIONS: NHIRD did not contain information regarding severity of psoriasis, status of smoking, alcohol use, family history of cancer, or diet. Misclassification of disease cannot be ruled out in a registry-based database. CONCLUSIONS: Psoriasis carries an elevated risk of malignancies, especially in younger and in male patients. This effect is independent of systemic treatment for psoriasis. Finally, phototherapy with UVB did not increase, but rather reduced, the risk of cancer in psoriasis.

Epidemiological study of psoriasis in the national health insurance database in Taiwan.

The aim of this study was to determine the prevalence, treatment modalities and comorbidity of psoriasis in Taiwan. A nationally representative cohort of 1,000,000 individuals from the National Health Insurance database was followed up for the years 2000 to 2006. Their claims data was used for an epidemiological study. The mean one-year prevalence of psoriasis was 0.23% for men and 0.16% for women, respectively. The prevalence of psoriasis increased more rapidly in male patients aged 30 years and over and reached its peak in patients aged 70 years and over, regardless of sex. Overall, 98.4% of patients received treatment with topical corticosteroids, while 13.1% used Chinese herbal medicines and 13.6% received systemic treatment. Patients with psoriasis had a higher comorbidity of diabetes, hyperlipidaemia, and hypertension. In conclusion, in contrast to Caucasians, the prevalence of psoriasis in Taiwanese people is high er in men than in women and the prevalence increases significantly in patients over 70 years of age.