Blue Wheals and Blue Angioedema Induced by Blue Dyes: A Systematic Review.

BACKGROUND: Blue wheals and blue angioedema, the adverse reactions to blue dye injections with or without anaphylaxis, are poorly defined. OBJECTIVE: The objective is to review the characteristics (ie, sex and age at onset, interval between blue dye injection and symptom onset, clinical manifestations, duration of blue wheals or angioedema), natural courses, and treatments of blue dye adverse reactions. METHODS: A review of the articles published through July 2021 was performed per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations. RESULTS: Across 523 patients (175 studies) with any adverse reactions to blue dye injections, wheals, angioedema, or both occurred in 193 patients (36.9%). Of these 193 patients, 68 patients (35.2%) developed blue wheals or angioedema, 118 (61.1%) had ordinary wheals or angioedema (nonbluish), and 7 had both (3.6%). We reviewed 169 patients with available data (99 with ordinary lesions and 70 with blue lesions). Patent blue violet had the highest rate of inducing blue wheals or angioedema (odds ratio 4.9). Almost half of the patients with blue wheals or angioedema developed systemic symptoms; and of those with systemic symptoms, all except 1 progressed to anaphylaxis. On-demand treatments with antihistamines, corticosteroids, and epinephrine were commonly used and effective. CONCLUSIONS: Using blue dyes can lead to blue wheals or angioedema and systemic reactions. In patients with a history of a severe allergic reaction to a blue dye, repeat administration of a blue dye should be used only after carefully weighing all the risks and benefits.

Efficacy and Safety of Clinacanthus nutans Lindau Cream vs. Podophyllin for the Treatment of Adults with Condyloma Acuminata.

Human papillomavirus (HPV) infection causes condyloma acuminata (CA). Podophyllin is the standard treatment. Clinacanthus nutans Lindau (C. nutans), a medicinal plant, has potent anti-inflammatory and antiviral effects. C. nutans cream is widely used in Thailand to treat the herpes simplex virus. We proposed that C. nutans might also induce CA clearance. There are no studies of C. nutans treatment of CA. This randomized controlled trial at Siriraj Hospital, Thailand, was conducted between January 2018 and December 2019. CA samples were obtained from 10 men with at least two CAs 1 centimeter apart. Each wart was randomized to a 4-week treatment with either C. nutans or podophyllin. The participants were 24 to 72 years old. Most HPV types were low-risk HPVs (HPV 11, HPV 6). Median CA clearance with podophyllin was a 97% CA clearance with podophyllin and 82% with C. nutans. C. nutans may be an alternative treatment for CA.

Sulphur Nuggets.

BACKGROUND: Dermoscopy is a new method to diagnose and manage nail disorders. The definite dermoscopic finding for onychomycosis, however, is still debatable. OBJECTIVE: To identify the dermoscopic features that help differentiate between onychomycosis (OM) and traumatic onychodystrophy (TOD). METHODS: A prospective study of 65 patients with toenail abnormalities was conducted. The patients were classified into OM and TOD groups using mycological tests (potassium hydroxide test, fungal culture, and histological examination). OM was diagnosed from positive results for all tests, while TOD was decided based on negative results for all tests and evidence of foot trauma. Dermoscopic features were recorded and compared between the two groups. RESULTS: Most patients of the 65 patients were female (72.3%), and had a mean age of 67.9 years. Twenty-seven patients (41.5%) were diagnosed with OM, all of which were distal and lateral subungual onychomycosis. TOD, on the other hand, was determined in 38 patients. Dermoscopic findings revealed that the yellow, clumping, sulphur-nugget-like debris in the ruin appearance was significantly associated with onychomycosis (p = 0.002), while ruin appearance without sulphur nugget was not statistically correlated with onychomycosis (p = 0.068). CONCLUSION: The presence of sulphur nuggets in the ruin appearance is a new and helpful dermoscopic feature for onychomycosis diagnosis.

Effectiveness and safety of zinc oxide nanoparticle-coated socks compared to uncoated socks for the prevention of pitted keratolysis: a double-blinded, randomized, controlled trial study.

BACKGROUND: Pitted keratolysis (PK) and bromodosis have negative impacts on the quality of life especially for military personnel. The antibacterial efficacy and safety of zinc oxide nanoparticles (ZnO-NPs) make them a suitable additive for textiles. We aim to establish the ability of ZnO-NP-coated socks to prevent PK and bromodosis in a real-life setting. MATERIALS AND METHODS: A double-blinded, randomized, controlled trial was conducted in January 2019. Naval cadets assigned to a 14-day field training course were randomly allocated to either a ZnO-NP-coated or an uncoated-sock group. They completed questionnaires evaluating behavioral risk factors and self-assessed foot odor levels using a visual analogue scale (VAS); intervention-blinded dermatologists also performed foot examinations. They reassessed their odor levels and had their feet re-examined upon completion of the training course. RESULTS: The 148 cadets enrolled for the study were allocated to two groups of 74 each. The ZnO-NP-coated sock participants demonstrated significantly less PK development than uncoated socks (P = 0.05). There was a reduction of the foot odor levels in both groups, as measured by the VAS, without statistical difference. However, the uncoated sock group experienced more foot odor with a significantly greater negative effect on their daily lives (P = 0.04) than the ZnO-NP-coated sock group. CONCLUSIONS: ZnO-NP-coated socks proved their efficacy in inhibiting the development of PK for military personnel.

Fingernail onychomycosis caused by Microsporum canis in a teenager.

A healthy 15-year-old girl presented with a total dystrophic nail plate and subungual hyperkeratosis over her left 3rd fingernail. Her 2-year-old shorthair cat had circular erythematous patches of alopecia on the left aspect of its forehead. Fungal culture from the affected nail and her cat both grew Microsporum canis. The girl was treated with terbinafine with clinical and mycological cure.

Randomized, controlled trial testing the effectiveness and safety of 2.5% and 5% benzoyl peroxide for the treatment of pitted keratolysis.

BACKGROUND: The appropriate dosage and duration of topical benzoyl peroxide gel (BP) treatment of pitted keratolysis (PK) is controversial. OBJECTIVE: To compare the effectiveness and safety of topical 2.5% and 5% BP for the treatment of PK. MATERIALS AND METHODS: This randomized, controlled trial was conducted at Chumpol Naval Rating School, Chonburi, Thailand. Naval rating cadets with PK were randomly assigned to either a 2.5% or a 5% BP group and were requested to apply the related medication on each sole once daily, for 2 weeks. RESULTS: All 42 and 47 participants who were treated with 2.5% and 5% BP, respectively, were included in the later analysis. Self-evaluation of the foot odor level using a visual analog scale (VAS) showed significant decreases for both groups (p<.001). The pitted lesions were evaluated by dermatologists and found to have improved in the 2.5% and 5% BP groups (69.0% versus 63.8%, respectively; p=.457). Side effects did not statistically differ between the two groups (p>.05). CONCLUSIONS: Either 2.5% or 5% BP can be used for the treatment of PK and foot malodor. Due to the similarities in their efficacies and side effects, the use of 2.5% BP may be preferable.

Methylchloroisothiazolinone and/or Methylisothiazolinone Contact Allergies in Thailand.

BACKGROUND: Methylchloroisothiazolinone, in combination with methylisothiazolinone (MCI/MI), and MI alone are common preservatives. The incidences of MCI/MI and MI-alone contact allergies have risen markedly worldwide, leading to changes in their use in products. OBJECTIVES: The aim of the study was to determine the incidences of positive patch test reactions and factors associated with MCI and/or MI contact allergies during the recent decade in Thailand. METHODS: Medical records of patients who underwent patch testing at Siriraj Hospital from 2009 to 2018 were retrospectively reviewed. The incidences of positive reactions, histories, and clinical data of MCI/MI and MI-alone contact allergy patients were analyzed. RESULTS: Of 2789 patients undergoing patch testing, most were female (76.1%). The mean ± SD age was 42.7 ± 15.7 years. Positive reactions to MCI/MI increased from 2009 to 2016 before declining. The MCI/MI contact allergy was most common in females, middle-aged patients, and those with metal allergy histories, with the hands and arms being the predominant sites. However, MI-alone contact allergy was more common in males and mainly at the trunk. Its incidence significantly declined for the last 5 years. CONCLUSIONS: The incidences of MCI/MI and MI-alone contact allergies began to decline because the Food and Drug Administration Thailand regulations restricted their use. The risk factors for the allergies reported in this study provide important information for patient care.

Photopatch testing in a tropical country, Thailand: 20 years' experience.

BACKGROUND: Photoallergic contact dermatitis is one of the important parts of photodermatoses. The investigation of choice is photopatch testing. However, reports with photopatch test results from Asian countries are scarce. The objective of this study was to determine the prevalence of positive photopatch test reactions and to ascertain the common photoallergens among Thai patients during 1998-2018. METHODS: We retrospectively reviewed the records of 339 patients who were clinically suspected of having photoallergic contact dermatitis and had undergone photopatch testing. RESULTS: A total of 44 photoallergic contact reactions in 38 patients (11.2%) were found. The positive photoallergic reactions were mainly found with organic ultraviolet filters and fragrances. CONCLUSIONS: Organic ultraviolet filter chemicals especially benzophenone-3 and fragrances were found to have a high prevalence of photoallergic contact reactions. Monitoring of the photoallergens employed in photopatch tests should be conducted periodically to provide the best patient care.

A Double-Blinded, Randomized, Vehicle-Controlled Study of the Efficacy of Moisturizer Containing Licochalcone A, Decanediol, L-Carnitine, and Salicylic Acid for Prevention of Acne Relapse in Asian Population.

Many topical agents are available for treating the acute phase of acne; however, few agents have been proven beneficial during the maintenance phase. Objective. To evaluate the efficacy and safety of moisturizer containing licochalcone A, 1,2-decanediol, L-carnitine, and salicylic acid during the maintenance phase of mild to moderate acne in Thai patients. Methods. One hundred and ten patients with mild to moderate acne vulgaris were initially treated with a fixed combination of adapalene 0.1%/benzoyl peroxide 2.5% gel once daily for 8 weeks. Fifty patients who achieved at least 50% reduction in lesion counts or at least a 2-grade improvement in the Investigator's Global Assessment (IGA) grade from baseline were enrolled in the maintenance phase, which was an investigator-masked, left-right comparison, randomized, controlled, intraindividual study. Moisturizers with and without the active study ingredients were applied twice a day to each side of the face, respectively, for 12 weeks. Assessments included acne lesion counts, acne severity by IGA scoring, skin bioengineering measurements, and skin tolerability as assessed by both patient and physician. Results. The treatment group had a significant reduction in the mean counts of noninflammatory, inflammatory, and total lesions compared to the vehicle group at week 12 and also between baseline and week 12. There was no significant difference in the mean scores for skin dryness, stinging/burning, or pruritus at any time point between groups. Conclusions. Moisturizer containing licochalcone A, 1,2-decanediol, L-carnitine, and salicylic acid reduced acne lesions and prevented the development of new lesions during the maintenance phase. This trial is registered with ClinicalTrials.gov registration no. NCT04002024.

Randomized controlled trial comparing long-pulsed 1064-Nm neodymium: Yttrium-aluminum-garnet laser alone, topical amorolfine nail lacquer alone, and a combination for nondermatophyte onychomycosis treatment.

BACKGROUND: Studies of the laser treatment of nondermatophyte mold (NDM) onychomycosis are limited. Long-pulsed neodymium:yttrium-aluminum-garnet (Nd:YAG) 1064-nm laser has been introduced as an adjuvant dermatophyte onychomycosis treatment. AIMS: To investigate the efficacy and safety of long-pulsed Nd:YAG 1064-nm laser for NDM onychomycosis treatment, compared with topical amorolfine nail lacquer alone and a combination treatment. PATIENTS/METHODS: This randomized controlled trial was conducted at the Nail Clinic, Siriraj Hospital. Patients diagnosed with NDM were included and randomly assigned to three treatment groups: laser at 1 month interval (1064-nm Nd:YAG at a fluence of 35 J/cm2 , pulse width 30 ms, and pulse rate 1.0 Hz); topical amorolfine nail lacquer alone; and a combination treatment. RESULTS: Sixty patients completed the study. The patients treated with the laser, amorolfine, and the combination achieved mycological cure rates of 35%, 60%, and 65%, respectively (P = .05), while 10%, 30%, and 30% of the patients in the respective groups were clinically cured. The mean durations to the mycological cures in the patients treated with laser, amorolfine, and the combination were 5.9, 4.8, and 5.2 months, respectively. By comparison, the corresponding mean durations to the clinical cures were 6.9, 6.5, and 5.9 months. Both the times to the mycological cures and the clinical cures did not differ significantly between the groups (P = .290 and P = .309, respectively). There were no serious complications with the laser treatment. CONCLUSIONS: Laser alone achieved only a 30% mycological cure rate for NDM onychomycosis. The combination treatment yielded similar outcomes to the topical treatment alone.

Acne beliefs, treatment-seeking behaviors, information media usage, and impact on daily living activities of Thai acne patients.

BACKGROUND: Acne is a very common skin disease. Information on it is readily available and accessed by most patients. Nevertheless, they tend to have misunderstandings about the disease. AIMS: This study investigated Thai acne patients' perceptions of, and beliefs, about acne; their treatment-seeking behaviors; and the data sources available to them. PATIENTS/METHODS: A cross-sectional, questionnaire-based study was conducted among teenage and adult acne patients at the skin clinics of the Department of Dermatology and the Department of Pediatrics, Siriraj Hospital, January-December 2017. RESULTS: A total of 330 patients with a mean age of 23.89 ± 7.19 years (range: 9-51 years) were enrolled. Hormonal factors were the most common determinant thought to worsen acne (80.6%), followed by dirt (72.4%), inadequate sleep (65.5%), cosmetics (58.2%), and stress (55.8%), whereas frequent facial washing and exercise were the least common (4.8% each). The most common information source utilized by patients was friends (40.9%), followed by digital media (36.8%). Both males and females felt their acne greatly affected their quality of life. Before visiting the hospital, most patients used vitamin supplements and over-the-counter drugs as treatment. CONCLUSIONS: Some patients had good conceptions of certain aspects of acne, such as the influence of hormones or food, whereas others had misunderstandings about the effects of poor hygiene on acne. Friends and websites were the most common information resources exploited by patients. Acne substantially impaired the quality of patients' lives.

Contact allergy to hair cosmetic allergens in Thailand.

BACKGROUND: Hair cosmetics such as hair dyes, bleaching, waving, and cleansing products are composed of numerous chemical ingredients. Allergic reactions to these contact allergens, other than p-phenylenediamine, are rarely reported. OBJECTIVES: To study the incidence of patch test reactions to hair cosmetic allergens and identify the factors associated with hair cosmetic allergy in Thailand. METHODS: We retrospectively reviewed the case records of patients who underwent patch testing from 2009 to 2018. Patients with at least one positive patch test reaction to a potential contact allergen associated with hair cosmetic ingredients were studied. RESULTS: Overall, 2842 patients were patch tested. Of the hair cosmetic allergen categories, preservatives had the highest rate of positive reactions, followed by surfactants and hair dyes. Perming agents were less problematic in comparison. The hands, head, and neck were the predominately affected sites of allergic reactions to hair cosmetic ingredients. CONCLUSIONS: Preservatives, surfactants, and hair dyes are important contact allergens, whereas perming agents are less likely to cause allergic reactions. Hair cosmetic ingredients are regulated by national agencies, which influences their extent of exposure and rates of contact allergies. Further continuous observation of hair cosmetic allergy is needed to provide the best patient care.

Changing trends of contact allergens in Thailand: A 12-year retrospective study.

BACKGROUND: Contact allergen prevalences often change. Continual surveillance is necessary to detect trends in sensitization rates and emerging allergens. OBJECTIVE: To identify the prevalence of, and trends in, the positive reactions to each allergen in the baseline series during a 12-year period in Thailand. METHODS: The medical records of 2803 patients who underwent patch testing at the Contact Dermatitis Clinic, Siriraj Hospital, between 2006 and 2018, were retrospectively reviewed. The baseline series used by the clinic was adapted from the European and the International baseline series. The patch testing results were subdivided into 2-year blocks in order to compare the prevalences of each allergen. RESULTS: The prevalences of positive reactions to nickel, fragrance mixes I and II, dichromate, cobalt, carba mix, methyldibromo glutaronitrile, paraben mix, neomycin sulfate, methylisothiazolinone (MI), epoxy resin, N-isopropyl-N-phenyl-4-phenylenediamine and the corticosteroids significantly decreased. Methylchloroisothiazolinone (MCI)/MI was the only allergen associated with a significant increase of positive reactions, from 2.4% to 10.7%. However, the proportion of positive reactions to MCI/MI decreased in the final 2-year period. CONCLUSIONS: Approximately half of the substances in the screening patch test series showed a decline in the number of positive reactions, whereas MCI/MI showed an increasing prevalence.

Methylchloroisothiazolinone and/or methylisothiazolinone in cosmetic products-A market survey.

BACKGROUND: There was a global epidemic of methylchloroisothiazolinone (MCI) and/or methylisothiazolinone (MI) contact allergy from 2009 to 2015. In response, the Thai Ministry of Public Health regulated the use of MCI/MI in cosmetics. OBJECTIVE: To survey the presence of MCI/MI and MI alone, as labelled on cosmetics sold on the Thai market, before and after the ministerial directive. METHODS: The presence of MCI and/or MI in leave-on and rinse-off cosmetics sold on the market, based on the labelling of ingredients in 3445 products, was analysed. RESULTS: Before the implementation date, most leave-on products contained MCI/MI. After the regulations came into force, the only leave-on cosmetic subcategories that complied with the law were facial skin-care, sunscreen and make-up products. MCI/MI and MI alone were found on the labels of both leave-on and rinse-off products, the presence of each varying between product subcategories. CONCLUSIONS: Despite the ministerial regulations restricting their use, MCI and/or MI are still found in cosmetics sold on the Thai market. Dermatologists should be aware of this situation, and counsel patients to avoid products containing MCI and/or MI.

Cost-effectiveness analysis and safety of erythromycin 4% gel and 4% chlorhexidine scrub for pitted keratolysis treatment.

Background: Studies of Pitted keratolysis (PK) treatment are limited. Objectives: To study cost-effectiveness and to compare the safety of 4% chlorhexidine scrub with 4% erythromycin gel, for PK infections. Materials and methods: This cohort study was conducted on naval rating cadets with a clinical diagnosis of PK at Chumpol Naval Rating School, Thailand in 2016. Participants were randomly treated with either 4% erythromycin gel or 4% chlorhexidine scrub for 4 weeks. The clinical examinations were evaluated at the baseline and at 1 and 2 months after treatment. A decision-tree model was used to evaluate the costs, resource utilization and outcomes as quality-adjusted life-years (QALYs). Results: Of 344 naval rating cadets, 125 (36.3%) were diagnosed with PK. Sixty-four were treated with erythromycin. Approximately 80% of participants had complete resolution Foot odor were significantly improved at 2 months (p < .001) for both groups. No adverse effects were reported. Total cost for 4 weeks' treatment with the erythromycin gel and chlorhexidine scrub was US$77.34, US$51.9, respectively. Chlorhexidine treatment and erythromycin gel had 0.1526 and 0.1425 QALYs, respectively. Conclusions: treatment of PK with either 4% chlorhexidine scrub or 4% erythromycin gel had similar outcomes. However, using chlorhexidine scrub was more cost-effective.

Long-term safety and drug survival of acitretin in psoriasis: a retrospective observational study.

BACKGROUND: This retrospective observational study aimed to investigate the long-term safety, drug survival, and factors associated with the survival of acitretin in a real-world setting. METHODS: Data of adult patients with psoriasis who attended Siriraj Hospital between 2012 and 2017 and were treated with acitretin were reviewed. Demographic data and clinical courses were recorded. The Kaplan-Meier curve and Cox regression were used to calculate drug survival and the factors associated with drug survival, respectively. RESULTS: Of 104 patients, 56 and 48 were male and female, respectively, with a mean treatment duration of 3.2 years. The mean cumulative dose per patient was 19.28 ± 7.84 mg/day. Acitretin was administered to 73, 39, 24, and six patients for more than 1, 3, 5, and 10 years, respectively. Most side effects were mild and tolerable; only nine patients withdrew acitretin due to side effects. No patients developed clinical features of cirrhosis or uncontrolled hyperlipidemia. The drug survival rates were 79%, 69.5%, 61.2%, 57.6%, and 53.5% at 1, 2, 3, 4, and 5 years, respectively, higher than those of previous studies. Patients without obesity, metabolic syndrome, and dyslipidemia did not have a significantly longer acitretin survival compared to patients with these comorbidities. CONCLUSIONS: Long-term, low-dose acitretin in patients with psoriasis is unlikely to cause significant liver or lipid problems. In countries with difficulty accessing biological agents for psoriasis, acitretin may have a high drug survival rate due to its long-term safety. This study has several limitations: its retrospective nature, single-center study design, and small sample size.

Effectiveness of and factors associated with clinical response to methotrexate under daily life conditions in Asian patients with psoriasis: A retrospective cohort study.

Given the relative scarcity of data concerning the efficacy of methotrexate under daily life conditions in psoriasis, this study aimed to investigate the effectiveness of methotrexate in Asian psoriatic patients and to identify factors associated with clinical response. This observational retrospective cohort study included adult psoriatic patients who had been treated with or were going to start methotrexate. Psoriasis Area and Severity Index (PASI) scores at baseline and at 3, 6 and 12 months were recorded. At 3 months, patients achieving 50% or more reduction from baseline PASI score were defined as responders. One hundred, 74 and 61 patients were followed for 3, 6 and 12 months, respectively. Mean follow-up time was 15.3 ± 10.2 months. A reduction in PASI score of at least 75% was achieved in 26%, 32.5% and 45.2% at 3, 6 and 12 months, respectively. At 12 and 24 months, Kaplan-Meier analysis showed 68.7% and 52.1% probability of drug survival, respectively. Male sex, body mass index (BMI) of less than 25 kg/m2 and absence of abdominal obesity were factors associated with response to treatment in univariate analysis. Male sex was the only significant factor in multivariate analysis. The effectiveness of methotrexate in clinical practise seemed to be lower than in clinical trials, but effectiveness increased with longer duration of treatment. Problems associated with methotrexate use in clinical practise may be due to medication adherence rather than lack of medication effectiveness. Female sex, abdominal obesity and BMI of 25 kg/m2 or more might decrease response to methotrexate.