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.

Interobserver reliability of histopathological features for distinguishing between cutaneous polyarteritis nodosa and superficial thrombophlebitis.

AIMS: Interobserver reliability of histopathological features in differentiation between cutaneous polyarteritis nodosa (cPAN) and superficial thrombophlebitis (ST) by assessment of inter-rater agreement of five histological features was investigated. METHODS AND RESULTS: All sections of cPAN and ST were evaluated independently by three experienced pathologists and one resident of pathology. The histopathological features studied included elastic fibre distribution in the vascular wall, a smooth muscle arrangement pattern, an internal elastic lamina pattern, fibrinoid necrosis and luminal thrombosis. Agreement analysis was performed using the kappa coefficient. Sensitivity, specificity, positive predictive value (PPV), positive likelihood ratio (PLR) and 95% confidence interval (95% CI) of the useful histopathological features were analysed. Of all 62 biopsies, 28 were cPAN and 34 were ST. Reproducibility between four observers was in substantial agreement (κ = 0.73). Elastic fibre distribution in the vascular wall (κ = 0.68), fibrinoid necrosis (κ = 0.63), an internal elastic lamina pattern (κ = 0.51) and a smooth muscle arrangement pattern (κ = 0.46) showed high specificity and PPV for differentiating between cPAN and ST. The smooth muscle arrangement pattern, internal elastic lamina pattern and elastic fibre distribution in the vascular wall may be obscured when extensive inflammation and necrosis occurs. CONCLUSIONS: These aforementioned histopathological features are useful in differentiation between cPAN and ST. The Verhoeff-van Gieson (VVG) elastic stain is an important histochemical study for differentiating between cPAN and ST, particularly in cases with extensive inflammation and necrosis.

Subcutaneous Panniculitis-Like T-Cell Lymphoma Versus Lupus Erythematosus Panniculitis: Distinction by Means of the Periadipocytic Cell Proliferation Index.

The distinction between subcutaneous panniculitis-like T-cell lymphoma (SPTCL) and lupus erythematosus (LE) panniculitis is remarkably challenging. Rimming by lymphocytes with an elevated Ki-67 cell proliferation index has been forwarded as a potential diagnostic finding in biopsies of SPTCL but has not been rigorously compared with biopsies from patients with LE panniculitis. Nineteen and 17 examples of SPTCL and LE panniculitis, respectively, were evaluated for periadipocytic rimming by lymphocytes expressing Ki-67, CD8, and ßF1 and for attributes associated with LE, including clusters of CD123-positive cells. The identification of periadiopocytic rimming using Ki-67, CD8, and ßF1 held sensitivity of 79%, 100%, and 89.5% and specificity of 100%, 52.9%, and 88.2%, respectively (P < 0.01). CD123-positive cells were in both disorders. LE-like histopathology was commonly encountered in SPTCL. In conclusion, an elevated Ki-67 cell proliferation index with rimming is useful for distinguishing SPTCL from LE panniculitis. Notably, many features of LE panniculitis can also be encountered in SPTCL.

Random skin biopsy in the diagnosis of intravascular lymphoma.

BACKGROUND: Random skin biopsy (RSB) is a method for diagnosis of intravascular lymphoma (IVL). However, the indications for RSB to diagnose IVL have not yet been established. The aim of this study was to determine the appropriate indications for RSB to diagnose IVL. METHODS: Thirty-two patients with fever of unknown origin (FUO) and without skin lesion underwent RSB for diagnosis of IVL. Clinical data, including fever, neurological symptoms, hematologic disorders, organomegaly, bone marrow (BM) study, hypoxemia and serum level of lactate dehydrogenase (LDH), were evaluated. RESULTS: Seven of 32 patients were definitively diagnosed with IVL. In addition to FUO, 2 IVL patients also suffered from dyspnea and neurological disorders. Patients who had FUO with accompanying hematologic disorders, high LDH, negative BM study and no lymphadenopathy or hepatosplenomegaly had a significant tendency to have IVL by RSB (P = .03). FUO with hypoxemia was also identified as a significant indication for RSB (P = .02). CONCLUSIONS: RSB is a reliable method for diagnosis of IVL, especially in patients with FUO and any 1 or more of the 4 following abnormalities: (1) hematologic abnormalities; (2) high serum LDH; (3) hypoxemia; and/or, (4) unusual neurological symptoms with co-existing hematologic abnormalities and without lymphadenopathy, hepatosplenomegaly or BM abnormality.

The effect of pre-operative topical anaesthetic cream on the ablative width and coagulative depth of ablative fractional resurfacing laser.

Topical anaesthetic cream (TAC) is commonly used as a pre-treatment of ablative fractional resurfacing (AFR) laser. Most of anaesthetic cream contains distilled water as major component. Therefore, pre-operative TAC may interfere the photothermal reaction in the skin treated with fractional carbon-dioxide (FCO2) laser and fractional erbium-doped yttrium aluminium garnet (FEr:YAG) laser. The objective of the study was to compare the ablative width (AW) and coagulative depth (CD) of AFR laser with and without pre-treatment with TAC. Four Thai females who underwent abdominoplasty were included in the study. The excised skin of each subject was divided into four areas. TAC (eutectic mixture of local anaesthesia; EMLA) with 1-h occlusion was applied only on the first and second areas. The first and third areas were treated with FCO2 at 15 mj and 5% density. The second and fourth areas were treated with FEr:YAG at 28 J/cm2 and 5% density. Six biopsied specimens were obtained from each area. A total of 96 specimens (24 specimens from each area) were collected from four patients and examined randomly by two dermatopathologists. The ablative width and coagulative depth from each specimen were determined. In FCO2-treated specimens, the mean AW of the specimens that were pre-treated with TAC and control was 174.86 ± 24.57 and 188.52 ± 41.32 µm. The mean CD of the specimens that were pre-treated with TAC and control was 594.96 ± 111.72 and 520.03 ± 147.40 µm. There were no significant differences in AW and CD between both groups (p = 0.53 and p = 0.15). In FEr:YAG-treated specimens, the mean AW of the specimens that were pre-treated with TAC and control was 381.11 ± 48.02 and 423.65 ± 60.16 µm. The mean CD of the specimens that were pre-treated with TAC and control was 86.03 ± 29.44 and 71.59 ± 18.99 µm. There were no significant differences in AW and CD between both groups (p = 0.16 and p = 0.24). The pre-treatment with TAC provided no statistically difference from the control group on AW and CD of both FCO2 and FEr:YAG laser irradiation. However, there was a tendency to have narrower AW and deeper CD of the areas that were pre-treated with TAC when comparing to that of the control.

Immune response in human chromoblastomycosis and eumycetoma - focusing on human interleukin-17A, interferon-gamma, tumour necrosis factor-alpha, interleukin-1 beta and human beta-defensin-2.

Knowledge regarding host immune response to chromoblastomycosis and eumycetoma is limited, particularly concerning cytokines and antimicrobial peptides production. This was a retrospective study of 12 paraffin-embedded tissue samples from patients diagnosed with chromoblastomycosis or eumycetoma from histological findings and tissue culture. DNA extraction and polymerase chain reaction (PCR) from tissues were done to evaluate human interleukin-17A (IL-17A), interferon-gamma (IFN-γ), tumour necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1ß) and human beta-defensin-2 (HBD-2) expressions. Human beta-actin primer was used for confirming DNA detection, and DNA extracted from psoriasis lesional skin samples was used as positive controls. The twelve paraffin-embedded sections used in this study consisted of five chromoblastomycosis and seven eumycetoma tissues. All PCR reactions showed beta-actin band at 51 bp in all clinical specimens, confirming adequate DNA levels in each reaction. As positive control, the psoriasis skin samples revealed bands for IL-17A at 174 bp, IFN-γ at 273 bp, TNF-α at 360 bp, IL-1ß at 276 bp and HBD-2 at 255 bp. For the chromoblastomycosis and eumycetoma tissues, PCR analyses showed IL-17A band at 174 bp in two eumycetoma tissues and HBD-2 band at 255 bp in a chromoblastomycosis tissue. This study demonstrated IL-17A expression in human eumycetoma and HBD-2 expression in human chromoblastomycosis for the first time. However, their role in immune response remains to be elucidated.

Efficacy and Safety in 1% Clotrimazole Powder, Adjuvant Therapy in Patients with Superficial Fungal Cutaneous Infection in Intertriginous Areas.

Background: Superficial fungal cutaneous infection is commonly found in intertriginous area. Objective: To assess 1% clotrimazole powder (1% CP) efficacy for adjuvant treatment of superficial fungal cutaneous infection in intertriginous areas. Material and Method: The study performed as an open-label, randomized, comparative study for evaluating the effects of 1% clotrimazole cream (1% CC) with 1% CP in patients infected with dermatophytes (DMPs) or Candida spp. in intertriginous area, comparing to patients treated with 1% CC as control by demonstrating complete cure rate at 4, 8, and 12 weeks as well as relapse rates during a 24-week period including patient satisfaction. Results: Sixty-seven patients with mean age of 54.6 years were included in this study. Of those, 61.2% were males. Thirty-five patients were infected with DMPs and 32 with Candida spp. The complete cure rates of experimental group were significantly higher than the control group, as observed within four weeks (p = 0.01), especially for dermatophyte infection (p = 0.039). Two cases had recurrent candidiasis in the control group. In both groups, relapse up to 24 weeks were not statistically different. Additionally, there was no difference in patients' satisfaction towards convenience of drug application. Conclusion: Using of the 1% CP could be suggested as an adjuvant therapy and possibly preventive agent for superficial fungal cutaneous infection in intertriginous areas.

Melanocytic matricoma: two cases of a rare entity in women.

Melanocytic matricoma is a rare cutaneous adnexal tumor occurring in humans with only 13 cases reported in the literature. The typical lesion is a circumscribed pigmented nodule on sun-damaged skin. Most cases have occurred in elderly men. The tumor contains a mixed population of matrical cells, supramatrical cells, shadow or ghost cells, and dendritic melanocytes. We report two cases of melanocytic matricoma in two elderly women with unusual histopathological features such as cystic degeneration and focal granulomatous inflammation, which are considered to be atypical for this entity.

Detection of mitotic figures and G2+ tumor nuclei with histone markers correlates with worse overall survival in patients with Merkel cell carcinoma.

BACKGROUND: High mitotic figure count (MFC) correlates with low survival rate in Merkel cell carcinoma (MCC). However, the prognostic impact of histone biomarkers as surrogates of MFC in MCC is unknown. We evaluated the prognostic significance of the immunodetection of mitotic figures and of G2+ tumor nuclei with histone-associated mitotic markers H3K79me3T80ph (H3KT) and phosphohistone H3 (PHH3) in MCC. METHODS: Immunohistochemical analyses of H3KT and PHH3 and proliferative marker Ki-67 were performed in a series of 21 cases of MCC. The significance of the pathologic data and immunoreactivity with these markers was evaluated with Pearson correlation and paired Student t-test. Univariate Cox proportional hazards regression models were performed to assess the relationships between these markers and survival. RESULTS: H3KT detected a higher number of mitotic figure (p<0.0001) and G2+ tumor nuclei (p<0.0052) than did PHH3. Furthermore, the MFC combined with G2+ tumor nuclei detected with H3KT compared to PHH3 and manual MFC was a significant predictor of impaired survival in patients with MCC (p=0.035; HR=1.0172), corresponding to a 1.72% increased risk of death for each unit increase in H3KT. CONCLUSIONS: Biomarker analysis of proliferative rates with histone markers may have relevance in stratifying risk in patients with MCC.

Organomegalies as a predictive indicator of leukemia cutis in patients with acute myeloid leukemia.

BACKGROUND: Leukemia cutis (LC) is an extramedullary acute myeloid leukemia (AML) infiltrate. No previous study has described the clinical characteristics and outcomes of Thai patients diagnosed with AML with LC. MATERIALS AND METHODS: We conducted a 7-year retrospective case-control study on Thai AML patients at Siriraj Hospital from November 2013 to July 2020. Patients were divided into LC and non-LC groups. Initial clinical presentations and laboratory findings were examined to identify LC-associated factors. Overall survival (OS) and relapse-free survival (RFS) were assessed. Pathological tissues underwent re-evaluation to validate the LC diagnoses. RESULTS: The study included 159 patients in a 2:1 ratio (106 non-LC and 53 LC). The LC group had a mean ± SD age of 54.3 ± 15.5 years; females were predominant. Three-fifths of the LC patients had intermediate-risk cytogenetics; 20.4% had an adverse risk, and 10.2% had a favorable risk. Most were classified as AML-M4 and AML-M5. Leukemic nodules were the primary finding in 58.5% of the cases, mainly on the legs. In the multivariate analysis of predictive factors associated with LC, organomegalies, specifically hepatomegaly, and lymphadenopathy, remained significant factors associated with LC [OR 4.45 (95%CI 1.20, 16.50); p = 0.026 and OR 5.48 (95%CI 1.65, 18.20); p = 0.005], respectively. The LC group demonstrated a significantly reduced OS (log-rank test p = 0.002) (median OS of 8.6 months vs. 32.4 months). RFS was considerably lower in the LC group (log-rank test p = 0.001) (median duration of 10.3 months vs. 24.4 months in the non-LC). CONCLUSIONS: AML patients who developed LC tended to experience notably poorer prognoses. Therefore, it is imperative to consider aggressive treatment options for such individuals. The presence of organomegalies in AML patients serves as a strong predictor of the possible occurrence of LC when accompanied by skin lesions.

Efficacy of 1% Clotrimazole Powder Monotherapy for Treating Tinea Cruris: A Comparative Randomized Study.

INTRODUCTION: A rise in tinea cruris among Thai Naval Cadets has been observed. Clotrimazole powder has been shown to be effective as an adjunct treatment for tinea cruris; however, its efficacy as a monotherapy is limited. OBJECTIVES: The aim is to determine the efficacy of 1% clotrimazole cream versus 1% clotrimazole powder in treating tinea cruris. MATERIAL AND METHODS: A randomized trial was conducted at the Thai Naval Rating School, Chonburi, Thailand. Naval rating cadets with suspected tinea cruris were randomly assigned to one of two groups: 1% clotrimazole cream or 1% clotrimazole powder, and they were instructed to apply the related medication to the affected lesion twice daily for 4 weeks. Clinical and symptomatic evaluations were carried out at 4 and 8 weeks. RESULTS: All 17 and 14 participants who received 1% clotrimazole cream and powder, respectively, were included. After 4 weeks, the clinical cure rates were 76.5% in the cream group and 85.7% in the powder group (P = .664). All participants were clinically cured within 8 weeks. The self-evaluation of itch severity using a visual analog scale (VAS) revealed no significant difference between the two groups (P = .343). The dermatology quality of life index decreased as clinical improvement was achieved in both the clotrimazole cream and powder groups (6.0 vs. 7.5 score reductions, respectively; P = .765). The score for sweat reduction was higher in the 1% clotrimazole powder group compared to the cream group (5.0 vs. 4.0, respectively; P = .006). CONCLUSION: Monotherapy with 1% clotrimazole powder showed comparable efficacy to 1% clotrimazole cream. Furthermore, the powder treatment reduced sweat more effectively compared to the cream.

A case series of sarcoidosis with pulmonary involvement: various clinical and radiographic manifestations.

BACKGROUND: Sarcoidosis is a multisystem granulomatous disease of unknown etiology. The disease is rare in East Asian populations. Patients have many clinical presentations and 90% of patients have pulmonary involvement. There are few reports in Thailand that collected the data about chest imaging and pathological findings of sarcoidosis. MATERIAL AND METHOD: The data of patient with sarcoidosis with pulmonary involvement, who followed-up between September 2008 and December 2011, were retrospectively reviewed. RESULTS: Ten patients with sarcoidosis and pulmonary involvement were reviewed. Three patients presented with abnormal chest x-ray without respiratory symptom or other organ involvement. One patient was suspected to be sarcoidosis secondary to etanercept therapy. The majority of patients had cutaneous involvement. The most common finding on chest x-ray is bilateral hilar lymphadenopathy (90%). Seven patients had stage 2 disease and three patients had stage 1 disease. The diagnoses of all patients were confirmed by histopathology and exclusion of tuberculosis and fungal infection. Spirometry showed normal in seven patients, irreversible obstruction in one patient, and impaired diffusing capacity in six patients. There was no indication of systemic corticosteroids or immunosuppressive drug in most patients. CONCLUSION: Sarcoidosis has various clinical manifestations. The pulmonary and cutaneous involvement is common and the diagnosis is made by a combination of clinical, radiological, and histopathologic findings. The treatment of systemic corticosteroids is not required in most patients. The patients should be regularly followed-up in order to follow the course of disease.

Generalized granuloma annulare presenting with lesions resembling eruptive xanthoma.

Generalized granuloma annulare (GGA) and eruptive xanthoma are dermatological diseases that occasionally share some clinical and histological similarities. Associated underlying medical conditions and clinical course are essential guides to the proper diagnosis. The authors reported a case ofdisseminatedyellowish-redpapules in a 24-year-old female with high levels of serum fasting blood sugar triglycerides, and cholesterol. The provisional diagnosis was eruptive xanthoma but histopathology and immunoperoxidase study revealed granuloma annulare. The remission of the skin lesions soon after control of dyslipidemia and diabetes mellitus is not typical for the usual GGA, which has a chronic relapsing course and a poor response to treatment. Further studies are required to differentiate these two entities when they come into the clinicopathological mimicry.

Prevalence and clinical manifestations of cutaneous findings in patients with adult-onset immunodeficiency due to anti-interferon gamma autoantibodies: an eight-year retrospective study.

BACKGROUND: Cutaneous findings in adult-onset immunodeficiency due to anti-interferon gamma autoantibodies (anti-IFN-γ autoAbs) are common. Currently, data on this topic are scarce. METHODS: We retrospectively reviewed medical records of 202 skin episodes from 77 patients diagnosed with adult-onset immunodeficiency due to anti-IFN-γ autoAbs. The exclusion of drug eruptions left 180 episodes from 74 patients for further analysis. RESULTS: Reactive dermatosis was diagnosed in 66.1%, followed by disseminated skin infection (18.3%) and local skin infection (15.6%). Neutrophilic dermatosis (ND) tended to appear on the upper part of bodies, while leg lesions were common in the non-ND. Disseminated infection occurred more frequently with ND. Mycobacterium abscessus was the most common pathogen of concomitant infection. Remission was achieved in 21.6% and was significantly associated with females. CONCLUSION: Reactive dermatosis was the most common skin manifestation. ND was found in the upper part of bodies and associated with disseminated infection. Drug-free remission was scarcely achieved.

Mycobacterium fortuitum cutaneous infection from amateur tattoo.

A case of cutaneous Mycobacterium fortuitum infection after receiving an amateur tattoo is reported. A few days after tattooing, an otherwise healthy 25-year-old Thai male presented with multiple discrete erythematous papules confined to the tattoo area. He was initially treated with topical steroid and oral antihistamine without improvement. Skin biopsy was carried out, and the histopathology showed mixed cell granuloma with a foreign body reaction (tattoo color pigments). The acid-fast bacilli stain was positive. The tissue culture grew M. fortuitum two weeks later. He was treated with clarithromycin 1,000 mg/day and ciprofloxacin 1,000 mg/day for 10 months with complete response. From the clinical aspect, tattoo-associated rapidly growing mycobacterium infection might be difficult to differentiate from the pigment-based skin reactions. Skin biopsy for histopathology and tissue culture for Mycobacterium probably will be needed in arriving at the diagnosis.

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.

Clinical Clues to Differentiate between Dermatophyte Onychomycosis (DP-OM) and Dermatophytoma-Like Traumatic Onychodystrophy (DP-TO).

Background: Dermatophytoma is a recalcitrant condition of onychomycosis (OM). It presents as a white- or yellow-colored fungal mass that appears linear/triangular or round on a nail plate. Traumatic onychodystrophy (TO) can present with dermatophytoma-like lesions. Typically, OM and TO are not clinically distinguishable. Mycological testing is the gold standard for differentiating these disorders. Objectives: This study is aimed at differentiating between the clinical and dermoscopic factors related to dermatophytoma onychomycosis (DP-OM) and dermatophytoma-like traumatic onychodystrophy (DP-TO). Methods: A retrospective study was conducted of patients with dermatophytoma-like nail lesions who visited the Siriraj Nail Clinic between January 2010 and July 2020. The diagnosis of DP-OM was made by direct microscopy, fungal cultures, and histopathology of nail clippings. Results: A total of 36 nails were included in the study. Thirteen nails were DP-OM, and 23 nails were DP-TO. The demographic data and risk factors for the 2 groups were not significantly different. Dermatophytoma lesions were found on the lateral side of nails in 12 cases of DP-OM (92.3%) and 11 cases of DP-TO (47.8%; P = 0.008). DP-OM was associated with longitudinal striae adjacent to dermatophytoma (69.2% vs. 30.4%; P = 0.024), sulfur-nugget-like subungual debris (23.1% vs. 0%; P = 0.040), and scale on the ipsilateral foot (69.2% vs. 8.7%; P < 0.001). DP-TO was associated with a homogenous, whitish discoloration (47.8% vs. 7.7%; P = 0.014) and a sharp edge of the onycholytic area (43.5% vs. 0%; P = 0.005). Conclusions: The lateral location of dermatophytoma, adjacent striae, sulfur-nugget-like debris, and scale on the ipsilateral foot were significantly associated with DP-OM. Dermoscopic examination (dorsal and hyponychium views) and foot examination are beneficial for distinguishing between DP-OM and DP-TO.

Pancreatic panniculitis: a cutaneous presentation as an initial clue to the diagnosis of pancreatic cancer.

BACKGROUND: Pancreatic panniculitis is a rare complication of pancreatic diseases, including pancreatic carcinoma. It is clinically manifested by erythematous subcutaneous nodules typically located on the legs which can occur before or at the onset of pancreatic disease. CASE REPORT: An 81-year-old woman presented with painful subcutaneous nodules at both shins, recurrent epigastric pain, anorexia and significant weight loss. Physical examination revealed mild pallor, palpable epigastric mass and multiple tender erythematous subcutaneous nodules discrete to both lower extremities. The skin biopsy showed lobular panniculitis with marked subcutaneous fat necrosis and ghost adipocytes compatible with pancreatic panniculitis that was an important clue for further investigations. Elevations of serum amylase and serum lipase were then noted. Computed tomography of the abdomen revealed pancreatic cancer with duodenal involvement and multiple liver metastases. CONCLUSION: Pancreatic panniculitis is associated with pancreatic cancer and represents an important clue to the diagnosis.

Overall Prevalence and Prevalence Compared among Psoriasis Treatments of Onychomycosis in Patients with Nail Psoriasis and Fungal Involvement.

BACKGROUND: Whether nail psoriasis can increase the risk of onychomycosis is still being debated, and data relating to the prevalence of onychomycosis among psoriasis patients receiving different treatments is limited. OBJECTIVES: To investigate the overall prevalence and prevalence compared among psoriasis treatments of onychomycosis in patients with nail psoriasis and fungal involvement. METHODS: A prospective study of three groups of nail psoriasis being treated with only topical medication, methotrexate, or biologics (25 patients per group, 150 nails) was conducted at Siriraj Hospital (Bangkok, Thailand) during November 2018 to September 2020. Demographic data, psoriasis severity, and nail psoriasis severity were recorded. The nail most severely affected with psoriasis on each hand was selected for mycological testing. Potassium hydroxide, periodic acid-Schiff stain, and fungal culture were performed. RESULTS: The prevalence of onychomycosis in nail psoriasis was 35.3%. Among the treatment groups, the prevalence of onychomycosis was significantly higher in the methotrexate group than in the topical treatment and biologic treatment groups (p = 0.014). Candida spp. was the main causative organism, followed by Trichophyton rubrum. Thumb was most commonly affected (59.3%). The most common abnormality of the nail matrix and the nail bed was pitted nail (71.3%) and onycholysis (91.3%), respectively. Multivariate analysis revealed diabetes, wet-work exposure, and methotrexate treatment to be predictors of onychomycosis. CONCLUSIONS: Several factors, including psoriasis treatment, were shown to increase the risk of onychomycosis in nail psoriasis. Further research is needed to determine whether biologic agents, especially interleukin-17 inhibitors, can increase risk of onychomycosis and Candida infection/colonization of the nails.

The Correlations between Clinical Features, Dermoscopic and Histopathological Findings, and Treatment Outcomes of Patients with Pitted Keratolysis.

BACKGROUND: Pitted keratolysis (PK) is a superficial bacterial infection diagnosed mainly by clinical manifestations. Current data on its dermoscopic and histopathological findings, and the correlation of those findings, are limited. OBJECTIVES: To evaluate the clinical manifestations, dermoscopic, and histopathological findings of PK and to determine the correlations. METHODS: Forty naval cadets with PK and five cadets with normal feet were enrolled this cohort study and provided informed consent. Dermoscopy was independently applied and evaluated by 2 dermatologists. Shave biopsies were performed on 37 patients with PK. RESULTS: Pits were the most common dermoscopic finding (88.1%). The dermoscope had more sensitivity for the detection of PK than the naked eye examinations. Apart from the pits and the presence of bacteria, the most common histopathological finding for PK was color alteration of keratin. The presence of bacteria correlated with interrupted dermatoglyphic lines and the color alteration of keratin. Moreover, the presence of bacteria at the base of pits was related to worse treatment outcomes. CONCLUSIONS: Dermoscopy is a useful tool for PK diagnosis. Color alteration of keratin is another histopathological finding for PK. The presence of bacteria is associated with worse treatment outcomes.