Bridging the Gap: Comparing Patient-Clinician Views on Treatment Goals and Communication in the Management of Atopic Dermatitis Within the Asia-Pacific Region.

INTRODUCTION: It remains unclear how patients with atopic dermatitis (AD) and clinicians perceive the level of patient-clinician communication and if there could be potential lapses. This cross-sectional study aims to compare perspectives between patients with AD and dermatologists regarding communication and treatment expectations in Asia. METHODS: Moderate-to-severe patients with AD and practicing dermatologists were recruited from eight Asia-Pacific territories, including Mainland China, Hong Kong, India, Japan, Singapore, South Korea, Taiwan, and Thailand. Patients and dermatologists completed separate surveys designed to elicit their expectations regarding AD management, and their perceived level of patient-clinician communication. Patients were also asked about their treatment satisfaction and whether they prefer additional treatment beyond what was prescribed. Demographic information and responses were analyzed using descriptive statistics. The study was reviewed by the institutional review board in each territory, and all participants provided informed consent. RESULTS: A total of 1103 patients and 271 dermatologists completed the surveys. Both patients and dermatologists were largely aligned in their top treatment goals in AD management. However, greater proportions of patients prioritized the prevention of exacerbation (78.0% versus 47.2%), minimization of treatment adverse effects (46.4% versus 9.1%), and improvement in mental health (16.0% versus 4.9%), compared with dermatologists. Although patient-clinician communication was observed to be generally good, 10.9% of patients reported dissatisfaction with communication in AD management. The majority of patients were either "very satisfied" or "satisfied" with their latest acute AD treatment, but 65.5% of patients still desired additional treatment. CONCLUSIONS: This multinational study has provided insights on the perspectives of Asian patients and dermatologists in treatment goals, AD management, and communication. In general, both patients and dermatologists were aligned in treatment goals and there was satisfactory patient-clinician communication in most aspects. However, potential areas of improvement have been identified to further enhance patient-centered care.

Pediatric drug reaction with eosinophilia and systemic symptoms: A 12-year retrospective study in a tertiary center.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare and severe adverse drug reaction involving multiple organs. Data on DRESS syndrome among children are currently limited. The purpose of this study was to determine the clinical features, causative drugs, systemic organ involvement, laboratory findings, disease severity score, and treatment outcomes in pediatric DRESS patients. The medical records of all pediatric DRESS patients, based on the RegiSCAR diagnostic criteria and admitted to King Chulalongkorn Memorial Hospital, Bangkok, Thailand from January 2010 to December 2021, were reviewed. Twenty-two cases were identified (males 54.5%) with a median age of 9.5 years. Anticonvulsants (54.5%) and antibiotics (27.3%) were the leading culprit drugs. Skin rash was reported in all cases, followed closely by liver involvement (95.5%). Eosinophilia and atypical lymphocytosis were identified in 54.5% and 31.8% of cases, respectively. The median latency period was 17.5 days. Liver enzyme elevation was detected at an average onset of 20.0 days and hepatocellular type was the most common pattern of liver injury. Nineteen patients (86.4%) were treated with systemic corticosteroids with prednisolone being the most prescribed medication. One case developed Graves' disease after DRESS and multiple relapses of DRESS. One case (4.5%) died due to refractory status epilepticus that was unrelated to DRESS. Anticonvulsants were the major cause of DRESS in pediatric patients. High suspicion for DRESS is crucial in patients receiving these drugs and presenting with fever, rash, and internal organ involvement.

Cost and effectiveness comparison of sirolimus versus standard treatment in Kasabach-Merritt phenomenon: a real-world evidence study in Thailand.

The conventional treatment of Kasabach-Merritt Phenomenon (KMP) consists of corticosteroids with vincristine/vinblastine or others. The aim of the study is to compare the first-year direct costs and effectiveness between sirolimus and conventional treatment. A retrospective case-control study of KMP patients was conducted at a mean age of 9 months (1 day to 12 years) between 2000 and 2022 from four tertiary centers in Thailand. The direct costs, hematologic and clinical complete response (HCR, CCR), hospitalization, length of stay, and complications were compared. Of 29 patients, 13 underwent sirolimus (four upfront and nine were refractory to the conventional). The first-year total cost had no statistically significant difference between sirolimus VS conventional treatment (8,852.63 VS 9,083.56 USD: p value: 0.94). The therapeutics achievement was the same in both HCR (244.75 VS 168.94 days; p value: 0.60) and CCR (419.77 VS 399.87 days; p value: 0.90). The subgroup analysis of the first-line sirolimus (n = 4) compared with the conventional (n = 25) showed a more reduced total cost (4,907.84 VS 9,664.05 USD; p value: 0.26) rendered net total cost of -4,756.21 USD per patient (cost saving). A more significant contrast of therapeutic achievement by reduction of both HCR (11.67 VS 224.20 days; p value: 0.36) and CCR (38.50 VS 470.88 days; p value: 0.04) was shown. The sirolimus had no difference in hospitalization, length of stay, and complications. Even though, it was unable to identify significant differences in cost-effectiveness. Sirolimus is suitable for all patients who have diagnosis of KMP either for rescue therapy or first-line treatment.

A 595 nm pulsed dye laser as an adjuvant intervention for post-comedone extraction erythema and comedone reduction: A randomized, split-face controlled trial.

BACKGROUND: Comedone extraction provides greater satisfaction for acne treatment than conventional treatment alone; however, post-comedone extraction erythema (PCEE) remains a concern for patients. OBJECTIVES: To evaluate the efficacy of pulsed-dye laser (PDL) in PCEE and comedone reduction. METHODS: Mild-to-moderate acne patients were randomly allocated in split-face fashion. Three comedones were extracted on each facial side. On the PDL-treated side, 595-nm PDL was delivered to the entire side with an additional shot on three comedone-extracted sites. Erythema index (EI) and total acne lesion counts (TALC) were evaluated at baseline, week 2 and 4. The comprehensive acne severity scale (CASS) was assessed by three blinded independent pediatric dermatologists. Participant satisfaction surveys were completed at the end of the study. RESULTS: Thirty-five participants (age 12.9-24.2 years) showed no differences in the EI and TALC at baseline on both sides. At weeks 2 and 4, the EI on the PDL-treated side was significantly lower (p < 0.001) with a greater EI reduction (p < 0.001) when compared to the control side regardless of gender and menstruation. There was significantly lower TALC on the PDL-treated side at week 2 (p < 0.001) and week 4 (p = 0.02). No complications were noted with high participant satisfaction reported (median 8; IQR 7-9). PDL remained significantly associated with EI improvements after controlling for gender, menstruation cycle, and examination stress. CONCLUSION: PDL can be an adjunctive intervention for the treatment of PCEE and comedone reduction due to its effectiveness and high participant satisfaction.

Unveiling the potential: Enhancing caregiver knowledge through video education to address topical corticosteroid concerns in children with eczematous dermatitis.

BACKGROUND: Concerns about the use of topical corticosteroids (TCS) in pediatric eczematous dermatitis management often hinder effective treatment. Limited data exist regarding the prevalence of these concerns and the effectiveness of interventions. This study aimed to assess the prevalence of TCS concerns among caregivers and determine the effectiveness of video education in mitigating these concerns. METHODS: A single-center prospective study was conducted from 2022 to 2023, involving caregivers of children under 18 years with eczematous dermatitis. Baseline and post-intervention questionnaires were administered after a 4-week period. Caregivers received video education on TCS use, and the TOPICOP score was evaluated before and after viewing the video. RESULTS: The study included 150 caregivers, 85.3% female and 74% had a child with atopic dermatitis. The prevalence of TCS concerns among Thai caregivers was 62%. Following video education, the prevalence of TCS concerns significantly decreased to 10.7%. Mean belief score decreased from 43.81 ± 13.45 to 31.85 ± 16.56, mean worry score decreased from 56.22 ± 18.27 to 40.41 ± 18.55 and mean total TOPICOP score decreased from 50.02 ± 12.65 to 36.13 ± 13.52 (p-value <.001). The intervention also resulted in reduced disease exacerbations, duration of the rash, and duration of TCS use. The optimal TOPICOP cut-off score to predict TCS concerns was identified as 43.06. CONCLUSION: Video education effectively alleviated TCS concerns among caregivers, addressing beliefs, worries, disease exacerbations, and side effects. Integration of this intervention into the management of pediatric eczematous dermatitis can yield optimal outcomes.

Topical corticosteroid phobia in adolescents with eczema and caregivers of children and adolescents with eczema: A cross-sectional survey.

Steroid phobia is an increasing phenomenon that affects treatment adherence. The purpose of this study was to assess the prevalence and associated factors of steroid phobia among adolescents with eczema and the caregivers of children and adolescents with eczema by using questionnaires and TOPICOP© scale. The prevalence of steroid phobia is approximately 12% and 37% in the adolescent and caregiver groups, respectively. Caregivers who obtained information about topical corticosteroid (TCS) from dermatologists and whose children had fewer number of flares, demonstrated less concern about using TCS.

Late sequelae of drug reaction with eosinophilia and systemic symptoms (DRESS) cause thyroid dysfunction and thyroiditis: review of literature.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is one of the severe cutaneous adverse drug reactions (SCARs) with high mortality rate and variable long term sequelae, especially in thyroid dysfunction and thyroiditis. In this article, we review clinical course, culprit drugs, onset of diagnosis, and type of thyroid dysfunction in DRESS patients. There were a total of 51 cases including 12 children (aged less than 18 years old) and 39 adults from our review. The most common thyroid dysfunction was Hashimoto's thyroiditis (41/51=80.4%) including anti-thyroid antibody positive (29/51=56.9%), possible/compatible with Hashimoto's thyroiditis (12/51=23.5%) both in the children (n=12) and adult (n=39), Graves' disease/hyperthyroidism (7/51=13.7%) and non-specific hypothyroidism (3/51=5.9%), respectively. The most common culprit drugs and onset of thyroid dysfunction after DRESS diagnosis in children aged less than 18 years include antiepileptic drugs (phenytoin, phenobarbital, carbamazepine) (range 0-8 months, median 2 months) and sulfa groups (sulfasalazine, sulfamethoxazole, sulfonamide) (range 1-4 months, median 2 months). Data of prevalence, type, and clinical course of thyroid dysfunction from DRESS is important for clinicians to recognize for monitoring its sequelae and provide plans for treatment.

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.

Practical Recommendations for the Topical Treatment of Atopic Dermatitis in South and East Asia.

INTRODUCTION: There is some evidence to suggest that the prevalence of atopic dermatitis (AD) in Asia is rising. We have therefore developed an algorithm for the topical treatment of AD throughout South and East Asia for use by primary care physicians, pediatricians and dermatologists. METHODS: Nine AD experts from South and East Asia and one from Europe developed the algorithm based upon treatment guidelines, relevant literature and local treatment practices. The algorithm outlines current best practice for the use of emollients, topical corticosteroids (TCS) and topical calcineurin inhibitors (TCI), with the intention of simplifying the treatment regimen of mild-to-moderate AD in South and East Asia. RESULTS: Patients with AD should bathe and cleanse affected skin to remove crusts and scales daily. Emollients should also be applied daily as a maintenance treatment. When selecting appropriate topical anti-inflammatory treatment for AD flares, several factors should be taken into consideration, including the patient's age, attitude to treatment options and site of AD lesions. Given the concerns regarding the risk of skin atrophy with use of TCS, a TCI should be used to treat AD lesions in sensitive skin areas: pimecrolimus is recommended for mild-to-moderate AD in these locations, while tacrolimus should be considered for moderate and severe cases. Either pimecrolimus or tacrolimus is recommended for flares in other, non-sensitive body locations. A proactive or intermittent maintenance treatment strategy involving regular emollient use and twice-weekly application of a TCI to previously affected areas is encouraged to reduce the risk of flares. CONCLUSIONS: The algorithm proposed here is intended to simplify the topical treatment of mild-to-moderate AD in daily practice in South and East Asian countries.

Subcutaneous Panniculitis-like T-Cell Lymphoma With Hemophagocytic Lymphohistiocytosis Syndrome in Children and Its Essential Role of HAVCR2 Gene Mutation Analysis.

BACKGROUND: We identified 3 adolescents with alpha-beta subtype subcutaneous panniculitis-like T-cell lymphoma. CASE PRESENTATION: Three patients presented with prolonged fever, abnormal skin lesions, and cytopenia described in the context. All had the same disease entity, which showed the prolonged duration of B systemic symptoms till diagnosis, difficulty to distinguish from autoimmune diseases, presence of hemophagocytic lymphohistiocytosis syndrome, good response, and remained on long-term remission with nonchemotherapy treatment, which included oral corticosteroid and cyclosporin. CONCLUSIONS: Although diagnosis can only be "highly suspected" with pathologic review, some cases may need multiple serial skin biopsy to clarify diagnosis because of the discrete distribution of specific histology. T-cell receptor gene rearrangement, which demonstrates a monoclonal pattern of alpha and beta chain gene, is the essential requirement for specific diagnosis. The role of molecular analysis by identification of germline hepatitis A virus cellular receptor 2 (HAVCR2) gene mutation can be much valuable in classifying susceptible patients.

Dermatologic manifestations in pediatric patients after liver and HSCT: A 20-year retrospective cohort study.

LT and HSCT are now potentially curative treatments for many medical conditions. Dermatologic manifestations are one of the sequelae after transplantation. To study the prevalence and associated risk factors of dermatologic manifestations after pediatric LT and HSCT. A 20-year retrospective cohort study was conducted in children, aged ≤15 years, who received LT or HSCT from January 1, 1997, to December 31, 2017. Medical records were reviewed for data collection until December 31, 2018. A total of 70 LT and 51 HSCT recipients were included. The percentages of overall dermatologic manifestations after LT and HSCT were 64.3% and 64.7%, respectively. Viral infection was the most common manifestation in both groups, with mucocutaneous HSV infection as the most prevalent. One HSCT recipient developed leukemia cutis. GVHD was revealed in 27.5% of HSCT recipients. Impetigo and xerosis were significantly observed in patients using azathioprine and prednisolone. Approximately two-thirds of pediatric LT and HSCT recipients experienced dermatologic manifestations, potentially associated with immunosuppressive agents. Thus, regular skin examination and optimized immunosuppression would be beneficial in these recipients.

Sun protection behavior and knowledge of patients attending laser clinic to prevent adverse events of laser: A cross-sectional, single-center, tertiary care study.

BACKGROUND: Limited data of sun protection knowledge in laser treatment patients exists therefore, preventative information should be provided by dermatologists to minimize harmful effects. OBJECTIVE: To assess sun protection knowledge-behavior and knowledge to prevent adverse events from laser therapy among patients who visited a laser clinic at a tertiary university hospital in Bangkok, Thailand. METHODS: This is a self-reported questionnaire, cross-sectional survey. All participants from the Laser Clinic in KCMH were recruited into the study. RESULTS: A Total of 385 patients were enrolled into the study; 80.5% female participants. Patients who never received laser treatment significantly lacked proper sun protection knowledge to prevent adverse events of lasers when compared to those who previous received laser treatments regarding the application of sunscreen after laser treatment (56.6% vs 17.4%, P < .001), consistent application of sunscreen 4-6 weeks prior to receiving laser treatment (60.5% vs 18.9%, P < .001), application of topical corticosteroid after laser (67.1% vs 54.1%, P = .048), and sun protection in the post laser area (41.9% vs 20.4%, P < .001). CONCLUSION: The attitude and knowledge of sun protection to prevent adverse events were significantly different among the group of educational levels and previous history of laser treatment.

Clinical Features and Treatment Outcomes among Children with Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A 20-Year Study in a Tertiary Referral Hospital.

AIM: To determine the probable causative factors, clinical features, and treatment outcomes of Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS-TEN overlap in children. METHODS: A 20-year database review of all children diagnosed with SJS/TEN/SJS-TEN overlap at the King Chulalongkorn Memorial Hospital, Thailand. RESULTS: 36 patients (M : F, 16 : 20) with the mean age of 9.2 ± 4.0 years were identified. There were 20 cases of SJS, 4 cases of SJS-TEN overlap, and 12 cases of TEN. Drugs were the leading cause for the diseases (72.3%); antiepileptics were the most common culprits (36.1%). Cutaneous morphology at presentation was morbilliform rash (83.3%), blister (38.9%), targetoid lesions (25.0%), and purpuric macules (2.8%). Oral mucosa (97.2%) and eye (83.3%) were the 2 most common mucosal involvements. Majority of the cases (77.8%) were treated with systemic corticosteroids, intravenous immunoglobulin, or both. Treatment outcomes between those who received systemic therapy and those who received only supportive care were comparable. Skin and eye were the principal sites of short-term and long-term complications. CONCLUSIONS: SJS/TEN are not common but are serious diseases which lead to significant morbidities in children. Early withdrawal of suspicious causes and meticulous supportive care are very important. This study found that the systemic therapy was not superior to supportive care because the treatment outcomes for both groups were comparable.

Randomized, controlled trial split-faced study of 595-nm pulsed dye laser in the treatment of acne vulgaris and acne erythema in adolescents and early adulthood.

The high prevalence of acne vulgaris in teenagers has increased comorbidities. Lasers offer alternative options for acne treatment because they have rapid action, low systemic adverse effects, and do not require everyday treatment. To study the efficacy and patients' satisfaction of 595-nm pulse dye laser (PDL) treatment of acne vulgaris and acne erythema in adolescents and early adulthood, we designed a blocked-randomized, split-faced 595-nm PDL (fluence 8 J/cm3 pulse duration 10 ms, spot size 7 mm, 2 session every 2 weeks) study in patients with mild to moderate acne by comparing the laser-treated and non-treated side. The acne lesion counts, acne erythema grading, and acne severity grading were evaluated at baseline and 2, 4, and 8 weeks. Thirty patients were recruited. The results showed no statistically significant difference except the papule count at week 4 which was -1.828 on the treated side and 0.103 on the non-treated side of the face, P-value 0.0018. There was no statistically significant difference of acne severity grading and acne erythema grading between both sides of the face. The mean scores of patients' satisfaction on the laser-treated side were 75, 81, and 81%, respectively. The PDL treatment in this study reveals no significant improvement in acne therapy; however, the patients were satisfied with this laser treatment.

Pseudochromhidrosis: report and review of literature.

Chromhidrosis is a rare condition where colored sweat comes from the apocrine or eccrine glands. Pseudochromhidrosis is an uncommon condition where colored sweat is related to specific dye-producing bacteria, drugs, dyes, or chemical agents. This article provides a literature review of the various etiology, investigation, treatment, and prognosis. We propose an investigative algorithm to assist dermatologists, pediatric dermatologists, and general practitioners to diagnose this uncommon condition. The treatment options rely on the primary etiology such as removing dyes and chemical agents first and then treating the chromogenic bacteria. Topical and oral erythromycin seems to be the most effective treatment both in unidentified and identified chromogenic bacteria cases. Results and prognosis were excellent and without recurrence.

Nail Scabies: An Unusual Presentation Often Overlooked and Mistreated.

Nail scabies is an interesting clinical presentation of scabies. Although it is usually found concomitant with characteristic dermatologic manifestations, it may present as an isolated finding in the immunocompromised host. This condition is commonly mistaken with other diseases such as nail dystrophy, nail psoriasis and onychomycosis. We report two cases of unusual nail presentations that provide clues to diagnosis. Also, literature on unusual nail and dermatologic presentations was reviewed to recognize dermatologist consideration for appropriate treatment options.

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.