Clinical practice guidelines for the diagnosis and management of atopic dermatitis.

Atopic dermatitis (AD), a chronic, relapsing dermatitis, is characterized by dry and pruritus skin in patients with a personal or family history of atopy. It affects up to 20% of children and 1-3% of adults in most countries worldwide, and leads to significant treatment costs and morbidity. These guidelines are developed in accordance with evidence-based publications and expert opinions. Following simple algorithms, the guidelines aim to assist adult and pediatric physicians in the better care of patients with AD. As with other diseases, there have been several diagnosis criteria proposed over time. Nonetheless, the classical Hanifin and Rajka criterion with no pathognomonic laboratory biomarkers is still the most widely used worldwide for the diagnosis of AD. The management of AD must be considered case by case to provide suitable care for each patient. Basic therapy is focused on avoiding specific/unspecific provoking factors and hydrating skin. Topical anti-inflammatory treatments such as glucocorticoids and calcineurin inhibitors are suggested for disease flare, and proactive therapy is best for long-term control. Other therapies, including antimicrobial agents, systemic antihistamines, systemic anti-inflammatory agents, immunotherapy, phototherapy, and psychotherapy, are reviewed in these guidelines. Crisaborole, a new topical phosphodiesterase 4 inhibitor, can be used twice daily in AD patients over three months old. Dupilumab, a biological drug for patients with moderate-to-severe AD, may be considered in patients with no improvement from other systemic treatments.

Clinical practice guideline for diagnosis and management of urticaria.

Urticaria is a common skin condition that can compromise quality of life and may affect individual performance at work or school. Remission is common in majority of patients with acute spontaneous urticaria (ASU); however, in chronic cases, less than 50% had remission. Angioedema either alone or with urticaria is associated with a much lower remission rate. Proper investigation and treatment is thus required. This guideline, a joint development of the Dermatological Society of Thailand, the Allergy, Asthma, and Immunology Association of Thailand and the Pediatric Dermatological Society of Thailand, is graded and recommended based on published evidence and expert opinion. With simple algorithms, it is aimed to help guiding both adult and pediatric physicians to better managing patients who have urticaria with/without angioedema. Like other recent guideline, urticaria is classified into spontaneous versus inducible types. Patients present with angioedema or angioedema alone, drug association should be excluded, acetyl esterase inhibitors (ACEIs) and non-steroidal anti-inflammatory drugs (NSAIDs) in particular. Routine laboratory investigation is not cost-effective in chronic spontaneous urticaria (CSU), unless patients have clinical suggesting autoimmune diseases. Non-sedating H1-antihistamine is the first-line treatment for 2-4 weeks; if urticaria was not controlled, increasing the dose up to 4 times is recommended. Sedating first-generation antihistamines have not been proven more advantage than non-sedating antihistamines. The only strong evidence-based alternative regimen for CSU is an anti-IgE: omalizumab; due to very high cost it however might not be accessible in low-middle income countries. Non-pharmacotherapeutic means to minimize hyper-responsive skin are also important and recommended, such as prevention skin from drying, avoidance of hot shower, scrubbing, and excessive sun exposure.

Pathergy Test: The Comparison of Clinical vs. Histopathological Evaluation.

OBJECTIVE: Behcet's disease is an inflammatory disease of unknown etiology. Pathergy test is the only diagnostic test for Behcet's disease. The evaluation can be done either clinically and/or histopathologically. In the present study, we compare the sensitivity and specificity of clinical vs. histopathological evaluation of the pathergy test. MATERIAL AND METHOD: This was a retrospective study in patients who underwent pathergy tests at Phramongkutklao Hospital, Thailand between January 1, 2011 and December 31, 2013. Fifty-eight cases met the inclusion criteria and were included into the study. All basic demographic data were obtained from the medical records. The sensitivity, specificity, and accuracy of the test were evaluated. RESULTS: There were 33/58 (56.9%) cases with the final diagnosis as Behcet's disease. The sensitivity, specificity, and accuracy of the clinical evaluation of pathergy test were 30.3%, 64%, and 44.8% respectively. Upon using the histopathological evaluation, the sensitivity, specificity, and accuracy were 100%, 16%, and 63.8%, respectively. CONCLUSION: Our results showed that the histopathological evaluation of pathergy test helped to improve the accuracy and sensitivity, but the specificity was low. We suggest the use of histological evaluation of the pathergy test in cases where Behcet's disease is highly suspected especially in areas where the disease is uncommon.

Effect of combination of 1064 nm Q-switched Nd:YAG and fractional carbon dioxide lasers for treating exogenous ochronosis.

We describe three cases of exogenous ochronosis of the malar areas due to long-term application of skin-lightening agents for melasma, effectively treated by combination of Q-switched Nd:YAG and the fractional carbon dioxide lasers. None of these lasers has been reported to be used to effectively treat ochronosis before. The Q-switched Nd:YAG laser is capable of disintegrating dermal ochronotic fibers, thereby facilitating their phagocytosis and elimination via lymphatics. The fractional carbon dioxide laser is believed to assist transepidermal elimination of the onchronotic material. We believe successful treatment of ochronosis is possible when both mechanisms are applied.

Opinions and perceptions on acne: a community-based questionnaire study in Thai students.

OBJECTIVE: To evaluate the opinions and perceptions on acne and the effect of acne on the quality of life in Thai teenagers. MATERIAL AND METHOD: Five hundred ninety seven students of five high schools in Bangkok were administered a self-reported questionnaire about acne. Of these, 537 students were further examined by dermatologists to grade acne severity. RESULTS: The study population consisted of 392 (65.7%) female and 205 (34.3%) male. More than half believed that inadequate sleep, stress, sweat/exercise/hot weather; cosmetics, pre-menstrual period, oily food, and sun exposure aggravated their acne. Regarding Dermatology life quality index (DLQI), the question concerning embarrassment had the highest mean DLQI score, which reflect the most impact by acne. CONCLUSION: Some of the Thai adolescents still had misconceptions about the disease. Even mild acne can have an extremely large effect on their quality of life.

Systematic Literature Review of Herpes Zoster Disease Burden in Southeast Asia.

INTRODUCTION: Herpes zoster (HZ; i.e., shingles) is caused by the reactivation of varicella zoster virus leading to a painful dermatomal rash. An increasing trend in cases of HZ is evident worldwide; however, there is a lack of comprehensive reviews for Southeast Asian countries. METHODS: We performed a systematic literature review of articles published until May 2022 that reported HZ epidemiology, clinical management, and health economic data in six Southeast Asian countries: Indonesia, Malaysia, the Philippines, Singapore, Thailand, and Vietnam. Literature searches were conducted in Medline, Scopus, Embase, and gray literature. Articles written in English or local languages were considered for inclusion. RESULTS: In total, 72 publications were included in the study; 22 were case studies and over 60% originated in Singapore and Thailand. Only two studies (data from Thailand) reported incidence of HZ. The proportion of patients reported with HZ was 0.68-0.7% among dermatology clinics, 0.14% at one emergency department (5.3% of dermatology cases) in Singapore, and 3% of admissions at another hospital in Singapore. Pain was the most common symptom associated with HZ, reported in 74.21-100% of patients. HZ complications were reported in 10.2-21.2% of patients, and the proportions with postherpetic neuralgia and HZ ophthalmicus were 6.3-50% and 4.98-28.57%, respectively. Additionally, there is a lack of comprehensive, up-to-date HZ economic data, with only six studies identified for the Philippines, Singapore, and Thailand. CONCLUSIONS: Overall, there are limited data reporting incidence and prevalence of HZ in Southeast Asia at a national level. High rates of complications, symptoms, and abundance of case reports suggest substantial healthcare resource utilization for patients with HZ and highlight the need for further research in Southeast Asia assessing the societal impact.

A case report of limited Wegener's granulomatosis presenting with a chronic scalp ulcer.

Wegener's granulomatosis (WG) is manifested by granulomatous necrotizing inflammatory lesions involving multiple organs. Limited WG is classification of WG with the absence of disease features that pose immediate threats to either a critical individual organ or to the patient's life. The most common skin lesions are palpable purpura, necrotic ulcerations, papules and nodules with many histological pattern, leukocytoclastic vasculitis, granulomatous vasculitis, and palisading granulomas. We report a patient with a limited form of WG who presented with a chronic large scalp ulcer that rapidly responded to an immunosuppressive therapy.

Generalized morphea: a case report.

Generalized morphea is a subtype of localized scleroderma that lacks systemic manifestations. It is a rare condition in which idiopathic sclerosis of the skin occurs in a widespread manner. We report a 37-year old Thai female who presented with multiple hypopigmented lesions on right leg and right arm with a skin biopsy showing the typical sclerotic change. The patient responded to treatment with topical calcipotriol.

Anaphylactic reaction to phuk-waan-ban in a patient with latex allergy.

Phuk-waan-ban, Euphorbiaceae Sauropus androgynus (Linn) Merr, belongs to the family Euphorbiaceae, which is the same as the rubber tree, Euphorbiaceae Hevea brasiliensis. The young leaves are edible. To the best of the authors knowledge, this is the first report of anaphylactic reaction to Phuk-waan-ban in latex allergic patients. Contact urticaria and anaphylactic reactions to latex-containing rubber products are being recognized with increasing frequency in all kinds of medical disciplines. The prevalence and incidence are both increasing. Recently, a number of reports have been published describing anaphylactic reactions to food items in patients with latex allergy. The authors present a patient with occupational natural rubber allergy who developed an anaphylactic reaction with urticarial rash 20-30 minutes after ingestion of phuk-waan-ban. The diagnostic work up showed specific IgE to latex (CAP class 3). Positive skin prick tests to latex and cooked and raw phuk-waan-ban crude extract confirmed allergic reactions. Moreover, the cross-reaction between phuk-waan-ban and latex can be confirmed by using IgE inhibition test.

Efficacy and safety of tacrolimus ointment in pediatric Patients with moderate to severe atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is an immunological skin disease. It is common in pediatric populations and often requires topical steroid treatment. Moderate to severe AD may not respond to topical steroids. They often require systemic steroids, which may result in growth retardation. Protopic, a non-steroid, tacrolimus based ointment which is a calcinurin inhibitor has been proved to be effective in caucacian with AD. OBJECTIVE: To evaluate safety and efficacy of 0.03% tacrolimus ointment (Protopic&) in moderate to severe AD in pediatric patients age 2-12 years. MATERIAL AND METHOD: This was a one month multicenter open-label clinical trial using tacrolimus ointment twice daily in 61 subjects with moderate to severe AD from September to December 2004. Efficacy assessments were measured by Physician's Global Evaluation of Clinical Response (PhGECR), Eczema area and Severity Index (EASI), Patient's Global Evaluation of Clinical Response (PaGECR), and Quality of Life (QOL). Safety assessment was measured by incidence rate of adverse events. RESULTS: Fifty-eight patients completed the studies. Twenty-two patients were male; thirty-nine patients were female. Twenty-nine patients had moderate AD. Thirty-two patients had severe AD. Three cases had discontinued treatment at the third week due to increase in severity. Over all PhGECR were significantly increased, 94% showed moderate improvement in PhGECR at week 4 or end of treatment (EOT)and 83% had better improvement in PaGECR at EOT Within 7 days, tacrolimus demonstrated rapid onset in reduction of EASI score and itch in patients. Mean QOL were significantly decreased at the end of the present study. Incidence of adverse events included application site burning (21%), itching (17%), pruritus (9%), infections(3%), and erythema and folliculitis (2%). Burning sensation, erythema, pruritus and itching were resolved after the first week. CONCLUSION: Topical tacrolimus ointment is effective and safe in moderate to severe AD. It significantly improved PhGECR, EASI, PaGECR, and QOL in pediatric patients after the first week of treatment and continued through the end of the study. The major adverse events were burning, itching, and pruritus, which were resolved within the first week of therapy.

Scleroderma with Nodular Scleroderma.

BACKGROUND: Nodular scleroderma is a rare variant of scleroderma which can occur in connection with systemic sclerosis or morphea. A biopsy from the lesion can demonstrate the scleroderma pattern, i.e., keloid pattern or mixed type. Treatment is challenging, and several treatments modalities have been reported with unsatisfactory results. MAIN OBSERVATIONS: We present a case of systemic sclerosis in a 50-year-old female who developed nodular scleroderma in the absence of deterioration of the scleroderma condition. Although no additional treatment was given, the lesions remained stable without progression. CONCLUSIONS: Although this condition is rare, it has been reported sporadically, and clinicians should be able to recognize this variant in cases of scleroderma presenting with firm nodules or plaques.

Cutaneous granuloma in systemic lymphoma: a case report in Thailand.

A 68-year-old woman presented with multiple erythematous infiltrative nodules and plaques on her face, trunk and extremities, 7 months after having complete remission from chemotherapy treatment of non-Hodgkin's lymphoma. Biopsy from the skin lesion showed tuberculoid granuloma without lymphoma. Special stains and culture were negative for micro-organism. Immunohistochemistry revealed polymorphic T and B cells infiltration without evidence of malignancy. The skin lesions subsided completely after corticosteroid treatment. Two months later, she developed brain involvement of lymphoma that responded well to radiation and chemotherapy.

Large Papillomatous and Pedunculated Nevus Sebaceous.

We present a 6-week-old female infant from the Lao People's Democratic Republic with a large, red, exophytic scalp mass and numerous flesh-colored verrucous plaques on her face and the right half of her body since birth. The clinical and pathological findings are consistent with the new phenotype of the large, polypoid types of nevus sebaceous.

Food-dependent, exercise-induced anaphylaxis: first case report in Thailand.

A forty-year-old military personnel presented with generalized urticaria, syncope, shortness of breath and headache associated with jogging after ingestion of a taro-filled bun and a red bean-filled bun. Skin prick test was positive for bread, taro and wheat but negative for red bean and preservative. Exercise challenge tests were performed. Exercise alone failed to induce any allergic reaction but exercise following ingestion of a taro-filled bun and a red bean-filled bun induced generalized urticaria. Since the patients stopped taking these types of food, the urticaria has not returned. This is the first case report of food-dependent, exercise-induced anaphylaxis in Thailand.

Linear atrophoderma of moulin: a case report and review of the literature.

Linear atrophoderma of Moulin (LAM) is a rare dermatosis in childhood and early adolescence. The exact etiology of LAM is still obscure. Several treatment modalities were reported but none was consistently successful. We report a case of LAM in which a favorable outcome was obtained with topical calcipotriol. The relevant literature is also reviewed.

Measuring herpes zoster, zoster-associated pain, post-herpetic neuralgia-associated loss of quality of life, and healthcare utilization and costs in Thailand.

OBJECTIVES: This study aimed to measure the herpes zoster-associated burden of illness, healthcare utilization, and costs among Thai patients. METHODS: This prospective cohort study of 180 patients aged ≥ 50 years and healthy, or ≥ 20 years and immunosuppressed, with zoster rash, was conducted in Bangkok and its environs, Thailand, during 2007-2008. Each patient was followed for six months for zoster-associated rash, pain, quality of life (QoL), and healthcare utilization and costs. RESULTS: A total of 180 subjects were enrolled in the study. Their mean ± standard deviation (SD) age was 58.9 ± 13.8 years. Of the 180 patients enrolled, 138 (76.7%), 34 (18.9%) and eight (4.4%) patients were elderly, HIV-infected, and receiving immunosuppressive agents, respectively; 35 (19.4%) had post-herpetic neuralgia (PHN), and 13 (7.2%) had zoster ophthalmicus. The severity of zoster pain was moderately highly correlated with activities of daily living (ADL), at 0.68 ≤ ρ ≤ 0.76. Most patients required only one or two outpatient visits. The mean ± SD total of direct healthcare costs was 3083.4 ± 5047.0 Thai baht or ∼ 1.1% of annual income per capita. CONCLUSIONS: Herpes zoster contributes a significant burden of illness to both patients and the wider community.