Fixed Drug Eruption in a Patient Taking Valacyclovir without Cross-Reactivity to Acyclovir.

Fixed drug eruption (FDE) is a well-defined hyperpigmented patch that recurs in a fixed location each time a particular drug is taken. Common causative agents of FDE are non-steroidal anti-inflammatory drugs, non-narcotic analgesics, sedatives, anticonvulsants, sulfonamides, and tetracycline. We report a 33-year-old male who presented with a recurrent, localized, brownish-to-erythematous macule and papules on the peri-philtrum area two hours after taking valacyclovir. Three episodes of valacyclovir ingestion for treatment of Herpes simplex virus infection provoked a similar skin rash at the same site. Histopathology results showed vacuolar degeneration in the basal layer of the epidermis, pigmentary incontinence, and perivascular inflammatory cell infiltration in the papillary dermis. Although patch test and skin prick test showed negative responses to acyclovir and valacyclovir, an intradermal test showed a positive reaction only to valacyclovir. The oral provocation test to acyclovir and valacyclovir showed a positive reaction only to valacyclovir. Through drug history, histopathological examination, patch test, intradermal test, and oral provocation test, we established a final diagnosis of FDE due to valacyclovir without cross-reactivity to acyclovir. To find alternative therapeutic drugs, we suggest diagnostic tests with not only the suspected drugs, but also other drugs in the same class.

Corticosteroid-induced drug reaction with eosinophilia and systematic symptoms successfully treated with a tumor necrosis factor alpha inhibitor.

BACKGROUND: Despite recent advances in the treatment of drug reaction with eosinophilia and systemic symptoms (DRESS), the mainstay of treatment involves discontinuing the culprit drugs and administering topical or systemic corticosteroid. OBJECTIVE: The clinical use of a tumor necrosis factor (TNF)-alpha inhibitor was rarely explored in treatment of DRESS. METHODS: We present a case of corticosteroid-induced DRESS that was successfully treated with a TNF-alpha inhibitor without sequalae. RESULTS: This is the first case report that showed the clinical use of a TNF alpha inhibitor in treating corticosteroids- induced DRESS and immediate hypersensitivity reactions. The HLA-B*5801 was identified as a possible genetic factor associated with a corticosteroid-induced DRESS. CONCLUSIONS: A TNF-alpha inhibitor could be a primary option in treating DRESS, especially in patients with hypersensitivity reaction to corticosteroids.

Effect of Tranexamic Acid Administration on Postoperative Ecchymosis and Edema in Excision of Lipomas.

BACKGROUND: Previous studies have shown that systemic tranexamic acid reduces bleeding during soft tissue surgeries and reduces postoperative ecchymosis and edema experienced by surgical patients. OBJECTIVE: To evaluate the effect of postoperative tranexamic acid administration on the reduction of ecchymosis and edema after lipoma surgery. MATERIALS AND METHODS: A total of 40 patients who underwent lipoma excision were included in the comparative analysis. In the tranexamic acid group (n = 20), 1 g of tranexamic acid was administered daily for 5 consecutive postoperative days. Tranexamic acid was not administered to the control group (n = 20). The severity of ecchymosis and edema at the first visit after surgery was rated on a 4-point scale by 2 blinded dermatologists. RESULTS: The mean interval of the initial visit after surgery was 1.1 ± 0.5 (range: 1-4) days. Mean ecchymosis scores were significantly lower in the tranexamic acid group (0.5 ± 0.8) than in the control group (1.2 ± 1.0) (p < .05). No statistical difference was seen in mean edema scores between groups (0.5 ± 0.6 in tranexamic acid vs 0.7 ± 0.8 in control). CONCLUSION: We observed that postoperative administration of tranexamic acid significantly decreased ecchymosis in lipoma excision.

Treatment of idiopathic onychodystrophy with a 1064 nm picosecond neodymium-doped:yttrium aluminum garnet laser: A retrospective study.

BACKGROUND: Laser treatment has emerged as a novel treatment modality for onychodystrophy. Only a few small series have assessed the efficacy of laser treatment in onychodystrophy, most of which were case reports. The therapeutic effect of the 1064 nm neodymium-doped:yttrium aluminum garnet (Nd:YAG) laser for onychodystrophy has been demonstrated. Recently, the picosecond Nd:YAG (PSNY) laser has been introduced to improve various skin disorders. AIMS: The aim of this study was to verify the efficacy of a 1064 nm PSNY in management of idiopathic onychodystrophy. METHODS: We present a case series of dystrophic nails treated with a PSNY for onychodystrophy improvement. Planimetry using ImageJ software was used to calculate lesion reduction and proximal clear nail growth. Clinical improvement was assessed using a 5-point Global Assessment Scale (GAS). Adverse events were also assessed. RESULTS: Twenty-five patients (11 males and 14 females) with a total of 128 nails (94 finger nails and 34 toe nails) were treated. The mean treatment number was 8.7 ± 6.2, and the mean total duration of treatment was 33.4 ± 34.6 weeks. The average proportion of the lesion area decreased significantly (from 65.9% to 46.6%) after PSNY treatment (P < .001). The mean GAS (3.16 ± 1.18) exhibited fair improvement, and there were no serious adverse events. CONCLUSION: The 1064 nm PSNY laser can provide fair improvement for onychodystrophy with a good prognosis at least during the follow-up period and optimal cosmetic results in Asian patients.

Auricular keloid management in Asian skin: Clinical outcome of intralesional excision and postoperative triamcinolone acetonide intralesional injection.

BACKGROUND: Various options such as surgical excision, steroid injection, cryotherapy, pressure dressing, and radiation therapy are available for the treatment of auricular keloids. In particular, auricular keloid therapy using surgical excision is important because recurrence rates are low compared with keloids occurring in other parts of the body. AIMS: We aimed to evaluate the clinical outcomes of intralesional excision followed by postoperative triamcinolone acetonide intralesional injection (TA ILI) as auricular keloid treatments. METHODS: We conducted a surgery records and chart review of patients who underwent auricular keloid treatment with intralesional excision and TA ILI. Reduction in height and volume was assessed by two blinded dermatologists. We also analyzed the recurrence rate over a 2-year period and evaluated patient satisfaction using an 11-point questionnaire (0-10). RESULTS: Eighteen Korean patients (2 males and 16 females) with a mean age of 26.5 years and a total of 20 lesions were evaluated. Lesion types by descending frequency were lobular (n = 10, 50%), anterior/posterior button (n = 3, 15%), wrap-around (n = 3, 15%), dumbbell (n = 2, 10%), and sessile (n = 2, 10%). The total recurrence rate was 5% (1/20) within the 24-month follow-up period. Significant reduction (> 50%) in height and volume was achieved in 95% of patients. No serious or persistent adverse events were reported during the follow-up period. CONCLUSION: We confirmed that TA ILI after intralesional excision can be effective for auricular keloid management. A low recurrence rate similar to that of postoperative radiation therapy was obtained with an effective surgical procedure and minimal postoperative treatment.

Epidermal Growth Factor Attenuated the Expression of Inflammatory Cytokines in Human Epidermal Keratinocyte Exposed to Propionibacterium acnes.

BACKGROUND: While the beneficial effects of topical epidermal growth factor (EGF) on wound healing have been repeatedly reported, there are few reports about the effects of EGF on inflammatory skin diseases including acne. OBJECTIVE: To clarify the effects of EGF on acne, it was investigated whether recombinant human EGF (rhEGF) signalling can affect Propionibacterium acnes-induced cytokine expression in human epidermal keratinocytes. METHODS: The cultured normal human epidermal keratinocytes (NHK) were co-treated with P. acnes and rhEGF, and mRNA levels of interleukin (IL)-1α, IL-8 and tumor necrosis factor (TNF)-α; toll-like receptor 2 (TLR2); and nuclear factor kappa B (NF-κB) were determined. Specific enzyme-linked immunosorbent assay kits were used to measure the IL-1α, IL-8 and TLR2 expression as well as the NF-κB activation in P. acnes and rhEGF-treated NHK. After infecting the cultured NHK with live P. acnes, an increased expression of IL-1α, IL-8 and TNF-α was detected, which was prevented by rhEGF co-treatment. RESULTS: TLR2 and NF-κB activity increased after P. acnes treatment, and rhEGF treatment decreased TLR2 expression and NF-κB activity dose-dependently. The inhibition of EGF receptor by gefitinib attenuated the inhibitory effect of rhEGF on these increased expressions of proinflammatory cytokines and TLR2 and activity of NF-κB in NHK stimulated by P. acnes. CONCLUSION: These results suggest that EGF attenuated P. acnes-induced inflammatory responses, at least in part, through the modulation of TLR2 signalling, and the topical application of rhEGF may be beneficial to relieve the inflammatory reactions of acne.

Evaluation of a novel device, high-intensity focused ultrasound with a contact cooling for subcutaneous fat reduction.

BACKGROUND: Non-invasive devices for fat reduction involving high-intensity focused ultrasound (HIFU) are attracting attention. HIFU can deliver energy to the desired depth and can ablate subcutaneous adipose tissue (SAT), but purpura and pain may still limit its use. OBJECTIVES: The aim of this study was to investigate the effects of a novel HIFU device for fat destruction with a contact cooling system compared to HIFU without contact cooling. METHODS: A group of three pigs were administered a series of four HIFU treatments with or without contact cooling over a period of 12 weeks. Energy fluence parameters ranged from 60 to 300 J/cm2 . Immediately after the treatment and at 1, 4, and 12 weeks, the tissue was studied by hematoxylin and eosin (H&E), Masson-trichrome, toluidine blue, CD68 staining, and transmission electron microscopy. Three human volunteers also received treatment with this HIFU device with cooling and were evaluated subjectively and objectively by computed tomography (CT). RESULTS: HIFU treatment with a contact cooling decreased the skin surface temperature and prevented epidermal damage. Ecchymosis was observed on the non-cooled area immediately after HIFU treatment, but not on the cooled area. Histological analyses on both areas (cooled and non-cooled) revealed disrupted adipocytes in the treatment area immediately, at 1 and 4 weeks following treatment. Lipophagic histiocytic fat necrosis was evident at 4 weeks. Finally, at 12 weeks all inflammation subsided, and the lobules were markedly atrophied with reduced SAT thickness. The human volunteers experienced reduction of a few centimeter-range reduction in waist circumference after 4 weeks and pain was tolerable without bruising. CONCLUSIONS: HIFU treatment with a cooling system efficiently destroyed adipocytes. This novel HIFU device with an added contact cooling system may provide an effective, safe and less painful treatment as a non-invasive device for fat reduction. Lasers Surg. Med. 48:878-886, 2016. © 2016 Wiley Periodicals, Inc.

Hesperidin, A Popular Antioxidant Inhibits Melanogenesis via Erk1/2 Mediated MITF Degradation.

Regulation of melanogenesis has been the focus of treatment for hyperpigmentary skin disorders. Although hesperidin is one of the most well-known, naturally occurring flavonoids with antioxidant and anti-inflammatory effect, its anti-melanogenic effect is not known. The present study aims to determine the anti-melanogenic effect of hespiridin as well as its underlying molecular mechanisms. Melanin contents were measured in normal human melanocytes and B16F10 melanoma cells. Protein and mRNA levels of tyrosinase, microphthalmia-associated transcription factor (MITF), tyrosinase related protein-1 (TRP-1) and TRP-2 were determined. Melanogenesis-regulating signals were examined. In results, hesperidin strongly inhibited melanin synthesis and tyrosinase activity. Hesperidin decreased tyrosinase, TRP-1, and TRP-2 protein expression but increased phospho-extracellular signal-regulated kinase 1/2 (p-Erk1/2) expression. Specific inhibitor of Erk1/2 or proteasome inhibitor reversed the inhibition of melanogenesis induced by hesperidin. Taken together, hesperidin, a popular antioxidant, stimulated Erk1/2 phosphorylation which subsequently degraded MITF which resulted in suppression of melanogenic enzymes and melanin synthesis.

Treatment of nevus of Ota using low fluence Q-switched Nd:YAG laser.

BACKGROUND: Nevus of Ota, caused by dermal melanocytosis, is cosmetically troublesome in Asian patients. The destruction of dermal melanocytosis using Q-switched laser systems carries a high risk of postinflammatory hyperpigmentation/hypopigmentation. METHODS: To determine the usefulness, safety, and adverse problems of low fluence 1064 nm Q-switched Nd:YAG laser in the treatment of nevus of Ota, 19 Korean patients (five male and 14 female; Fitzpatrick skin type IV) who were clinically diagnosed as having nevus of Ota were enrolled in the present study. Low fluence laser treatments were performed with a collimated Q-switched Nd:YAG laser at intervals of two weeks. The fluence of laser treatments was set at 2.5 J/cm(2) and adjusted based on patient response to the previous treatment session and sensitivity to pain. Treatment was applied until the lesions showed mild erythema. RESULTS: The mean number of total treatment sessions was 17.1 (range 6-32). Among the 19 patients, 18 reached near total improvement, while one patient failed to reach near total improvement after 11 treatment sessions. The mean fluence of treatment was 2.5 J/cm(2) (range 2.0-5.0 J/cm(2) ). Five patients complained of delayed eyelid response. Post-therapy hyperpigmentation was observed in one patient. CONCLUSION: Low fluence 1064 nm Q-switched Nd:YAG laser is an effective modality for the treatment of nevus of Ota with a low incidence of side effects. It is an easy to perform treatment with low downtime.