Refractory livedoid vasculitis responding to PUVA: a report of four cases.

Livedoid vasculitis is a chronic disease characterized by recurrent painful irregularly shaped ulcers, which heal with scars, most commonly located on feet or lower extremities. This condition is often resistant to the therapy. We report four cases with refractory livedoid vasculitis that responded to systemic psoralens and ultraviolet A radiation therapy.

Fixed solar urticaria induced by UVA and visible light: a report of a case.

Fixed solar urticaria (FSU) is a rare and less severe subgroup of solar urticaria. It is characterized by urticarial eruptions, which occurs on the same parts of the body following sun exposure. The lesions are reproducible at the same sites with similar morphology and distribution pattern after repeated sun exposure. The action spectrum of FSU is broad (300-700 nm). We reported a case of FSU induced by UVA and visible light. The patient responded well to cetirizine treatment.

Angiocentric T-cell lymphoma of the pancreas presenting as late-onset diabetes mellitus with diabetic retinopathy.

Pancreatic lymphoma presenting with clinical diabetes mellitus (DM) is rare. We report angiocentric T-cell lymphoma of the pancreas in a 65-year-old Thai woman who presented with progressive deterioration of visual acuity of both eyes. She had diabetic retinopathy (DR) diagnosed only 20 months after the diagnosis of DM at the age of 63. She later developed erythematous rashes, fever, and deterioration of consciousness; she eventually died of shock. A skin biopsy and bone marrow examination revealed angiocentric T-cell lymphoma. At autopsy, the pancreas and both eyes were extensively infiltrated by lymphoma. Widespread involvement of nearly all organs but superficial lymphadenopathy was detected. In contrast to other typical cases of long-standing DM, only mild atherosclerosis was noted, and no DR was found. To the best of our knowledge, this is the first case of lymphoma involving the pancreas and both eyes producing clinical DM and DR.

Comparison of phototherapy two times and four times a week with low doses of narrow-band ultraviolet B in Asian patients with psoriasis.

BACKGROUND/AIMS: The optimum narrow-band (TL-01) ultraviolet (UV) B weekly treatment frequency for psoriasis has yet to be defined, especially in Asian patients with TL-01. Our purpose was to compare 2 x weekly and 4 x weekly therapy with narrow-band UVB at low doses for psoriasis vulgaris. METHODS: Sixty-nine patients with moderately severe psoriasis were recruited and allocated to the 2 x weekly or 4 x weekly treatment group. The patients were treated with a new protocol using low doses of narrow-band UVB with varied exposure increments. Outcomes were evaluated by means of Psoriasis Area and Severity Index (PASI) scores, time (weeks), cumulative UVB dose and number of treatments to clearance. RESULTS: No significant difference was found between the two regimens in the PASI score at the end of treatment, in the proportion of patients whose skin cleared during treatment and in the time to clearance (8 weeks). Those who completed treatment achieved clearance after a median of 16 exposures with 2 x weekly treatment compared with 32 exposures with 4 x weekly treatment (P=0.0304), and 12.5 minimal erythema dose multiples (MEDs) compared with 39.7 MEDs (P=0.0470). Acute side effects of the treatment were similar for the two groups (P=0.8462). CONCLUSION: For skin phototype III-V populations, a greater long-term risk is expected, connected with the higher cumulative UVB dose and number of exposures required in the 4x weekly group. Therefore, 4 x weekly phototherapy will no longer be used for psoriasis.

Topical isotretinoin for melasma in Thai patients: a vehicle-controlled clinical trial.

BACKGROUND: Melasma is an acquired hyperpigmentary disorder commonly seen in Orientals. Recently it has been demonstrated that tretinoin (all-trans-retinoic acid) can produce significant clinical improvement of melasma. However, moderate cutaneous side effects (retinoid dermatitis) occurred in a number of patients. OBJECTIVE: To investigate the efficacy of topical 0.05 per cent isotretinoin gel (Isotrex) in the treatment of melasma in Thai patients. METHOD: Thirty patients with moderate to severe melasma entered a 40-week, randomized, vehicle-controlled clinical trial in which they applied either 0.05 per cent isotretinoin gel, or its vehicle base together with a broad spectrum sunscreen (SPF 28) daily to the entire face. They were evaluated clinically (using Melasma Area and Severity Index), and colorimetrically (using our Melasma Area and Melanin Index). RESULTS: After 40 weeks, the average MASI and MAMI scores of the isotretinoin-treated group decreased by 68.2 per cent and 47 per cent respectively, while the corresponding control scores declined 60 per cent and 34 per cent. There was no statistically significant difference between the isotretinoin and vehicle groups. When the MASI and MAMI scores of each visit were compared to their baseline data, a statistically significant reduction of the score was first noted at weeks 4 and 12 respectively. Lightening of melasma, as determined clinically (MASI score), correlated well with pigmentation measurements (MAMI score). Side effects were limited to a mild transient "retinoid dermatitis" occurring in 27 per cent of isotretinoin-treated patients. CONCLUSION: Daily use of broad spectrum sunscreen has a significant lightening effect on melasma in Thai patients. However, there was no statistically significant difference between the isotretinoin and vehicle-treated group.

Treatment of psoriasis vulgaris with topical vitamin D analogue (calcipotriol): open multicenter study.

Sixty-one psoriasis patients, 46 males and 15 females (mean age: 40 years, range: 20-70 years) with baseline PASI score of 7.16 (+/- 3.66 SD) were enrolled in the study. All subjects were advised to apply calcipotriol ointment twice daily for 6 weeks. Six patients dropped out, five after 2 weeks and one after 4 weeks of treatment. PASI scores of fifty five patients were reduced to 2.16 per cent, 46.78 per cent and 55.55 per cent by 2 weeks, 4 weeks and 6 weeks respectively versus the baseline. Overall clinical assessment showed remission in 7.27 per cent marked improvement 74.54 per cent and slight improvement 18.18 per cent. Mild erythema were observed in fourteen patients (22.95%) that were mostly transient except for one patient. Serum creatinine, calcium and phosphate were normal throughout the study.

Double-blind study of the efficacy of 1 week topical terbinafine cream compared to 4 weeks miconazole cream in patients with tinea pedis.

OBJECTIVE: To compare the efficacy of terbinafine cream for 1 week with the efficacy of miconazole cream for 4 weeks in the treatment of tinea pedis. METHOD: Patients who visited our clinic for tinea pedis and who had positive KOH preparation and positive culture for dermatophyte were treated with terbinafine cream for 1 week and placebo for 3 weeks, or with miconazole cream for 4 weeks. Evaluation was done 1, 2, 3, 4 and 10 weeks after the start of the treatment. Mycological cure was defined as presence of a positive KOH preparation and a positive culture before treatment, and negative results for both after treatment. Clinical efficacy was defined as mycological cure and presence of at most a total signs and symptoms score of two. RESULT: Forty-eight patients were studied. Half of them were treated with terbinafine and placebo and the other half with miconazole. Both groups had an equal distribution as to age, sex, race, duration and seriousness of the fungal infection and previous treatment. Mycological cure and clinical efficacy throughout the evaluation were similar in both treatment groups. After 10 weeks, mycological cure was seen in about 52.6 per cent and 55 per cent, and clinical efficacy in about 47 per cent, 45 per cent in terbinafine and miconazole treatment group respectively. CONCLUSION: In the treatment of tinea pedis local application of terbinafine cream for 1 week is as good as treatment with miconazole cream for 4 weeks.

Erythroderma in Thai patients.

Erythroderma is a clinical manifestation of dermatoses from different causes. Our objective was to determine its incidence, causes and clinicopathological features. Clinical, laboratory, and biopsy materials of 49 patients diagnosed as having erythroderma were reviewed. They were treated in our department over a 10-year period (1985 through 1994). The male-female ratio was 2:1. The mean age at diagnosis was 51.7 years. The most common causative factors were drugs (38.77%) and preexisting dermatoses (26.5%). Hepatomegaly, jaundice and abnormal liver function tests were found more commonly in the drug allergy group, while in cases with preexisting dermatoses nail involvement was a common finding. Clinicopathologic correlation in our study did not inform the etiology because it showed chronic nonspecific dermatitis or psoriasiform dermatitis, without any clue as to its origin. Drug-induced-erythroderma had an acute onset and a good prognosis with rapid resolution when the causative drug was withdrawn, while histopathology and laboratory findings were largely unrewarding.

Phototesting in oriental patients with lupus erythematosus.

Light sensitivity is an important clinical characteristic of several forms of lupus erythematosus (LE). Recently, investigations have been able to induce LE-like lesions in LE patients with UVA as well as UVB, although most of these studies were conducted in Caucasians. Thus, there is insufficient data on phototesting in Oriental patients with LE. The aim of this study was to evaluate light sensitivity in Oriental patients with LE. Fifteen patients with various forms of LE were tested. Patients were evaluated by provocative phototesting, and threshold doses of UVA and UVB radiation that produced erythema and pigmentation were determined. The minimal erythema doses (MED) of UVB, immediate pigment darkening (IPD), and minimal tanning doses (MTD) were within the normal range in LE patients compared to a control group. Skin lesions clinically and histologically compatible with LE were induced in two of six patients with SLE, and four of nine patients with DLE. These lesions developed in about 2 weeks (range 5 to 23 days) after irradiation and lasted approximately 1 to 3 months (47 +/- 24 days). The action spectrum of the induced lesions was within the UVB range in four patients, in the UVA range in one patient, and in the UVB and UVA ranges in one patient. We found no correlation between a positive history for UV sensitivity and phototest reactions. In conclusion, the incidence of positive phototest reactions in Oriental patients with LE seems to be similar to or a little lower than in Caucasians. There was no correlation between a positive history for UV sensitivity and phototest reactions.

Hydroa vacciniforme with ocular involvement.

A 7-year-old Thai boy had several episodes of hydroa vacciniforme which were accompanied by an anterior uveitis with corneal clouding and stellate keratic precipitates. Wearing sunglasses prevented additional eye symptoms despite recurrence of the skin lesions. Repetitive UVA phototesting reproduced the typical skin lesions with fever and malaise. No reproduction of skin lesions was revealed by repetitive UVB phototesting. One should be aware of eye involvement in hydroa vacciniforme, and those who experience the eye involvement should be advised to wear protective sunglasses.

A comparison of erythema efficacy of ultraviolet B irradiation from Philips TL12 and TL01 lamps.

The erythema efficacy of UVB irradiation from Philips TL12 and TL01 lamps has been evaluated and compared. Thirty-seven healthy Thai volunteers were irradiated on the previously unexposed lower back with TL12 and TL01 lamps in doses ranging 100 to 550 mJ/cm2 and 360 to 2020 mJ/cm2, respectively. Erythema was evaluated clinically and measured by a narrow-band spectrophotometer before exposure and 24 h after exposure. The threshold doses of UVB that induced barely perceptible erythema (MEDb) with well-defined border erythema (MEDw) and the steepness of the dose-response curves for erythema (DRAE) were compared. We found that MEDb and MEDw of the TL01 lamps were 4.19 and 4.52 times those of TL12 lamps, which were similar to those calculated from the CIE erythema action spectrum (4.2). However, the DRAE of the two lamps were quite similar. Because the initial dosage of UVB phototherapy is usually given as a percentage of a patient's MED, the initial exposure of TL01-UVB phototherapy should be about 4.2 times that of TL12-UVB.

UVB phototherapy for pityriasis rosea: a bilateral comparison study.

BACKGROUND: Pityriasis rosea is a common self-limiting disease. UV light has been mentioned as helpful, but only a few studies substantiate this possibility. OBJECTIVE: Our purpose was to evaluate the clinical efficacy of UVB phototherapy in pityriasis rosea and the course of the disease after treatment. METHODS: Seventeen patients with extensive pityriasis rosea were treated with unilateral UVB phototherapy in a bilateral comparison study. One joule of UVA was used as a "placebo" on the untreated side. The treatments were given five times per week for 2 weeks. The rate of clearing was monitored by estimation of the severity score. RESULTS: Ten daily erythemogenic exposures of UVB resulted in substantially decreased severity of disease, greater than that on the untreated side in 15 of 17 patients. The overall reduction of severity score showed a significant difference after the third treatment; the UVB irradiation was superior. However, during the follow-up period the two sides were indistinguishable in regard to severity score (p = 0.6784). No significant difference in pruritus was noted between the two sides (p > 0.1638). The duration of disease did not relate to the success of UVB phototherapy. CONCLUSION: During the treatment period UVB phototherapy resulted in decreased severity of disease. However, the itching and the course of the disease were unchanged.

Relationship between skin color and cutaneous response to ultraviolet radiation in Thai.

Predictors of sensitivity to ultraviolet (UV) light, including Fitzpatrick's sun reactive skin types, constitutive skin color and facultative skin color were assessed in 43 healthy Thai volunteers. These predictors were compared with one another and with responses of the skin to UV irradiation, as determined by a minimal erythema dose (MED) of UVB, a minimal immediate pigment darkening dose (MIPDD) of UVA, and a minimal delayed tanning dose (MDTD) of UVA, and by dose-response curves for erythema and pigmentation, as measured objectively with the use of a narrow-band spectrophotometer. The skin type did not correspond well to the constitutive and facultative skin color. There was no correlation between skin type and MED and no relation between skin type and the slope of the dose-response curves for erythema and pigmentation. Constitutional skin color was also not a good predictor of the measured MED, MIPDD and MDTD values but did appear to correlate with the steepness of the dose-response curves for erythema but not for pigmentation. The facultative skin color, however, did not correlate with the dose-response angle of erythema or pigmentation. We have thus found that the skin type is not a good predictor of UV responses in Thai. The constitutive skin color is a better predictor of UV responses of the skin than skin type and that steepness of dose-response curves for erythema is a better measure of the response of the skin to UV irradiation than is a MED measurement.

Fixed solar urticaria.

BACKGROUND: Three unusual cases of solar urticaria limited to fixed skin sites are described. OBJECTIVE: Our objective was to study the clinical course and several therapeutic regimens for fixed solar urticaria. METHODS: Phototesting and in vitro activation of a plasma factor were performed. RESULTS: Wheals in a patchy pattern were strictly localized to the same circumscribed skin areas; they were reproducible in their pattern and location by irradiation. The action spectra ranged from 320 to 700 nm, 320 to 585 nm, and 400 to 560 nm. In one patient inhibition was found by wavelengths between 280 and 320 nm. Intradermal injection of the patients' plasma activated by in vitro irradiation induced wheals only in the affected skin sites. The patients showed a good therapeutic response to H1-antihistamines or repeated exposures to natural sunlight. CONCLUSION: The term fixed solar urticaria is proposed for this peculiar type of solar urticaria.

Solar urticaria induced by UVA and inhibited by visible light.

An 18-year-old woman developed urticaria approximately 10 minutes after exposure to sunlight. The action spectrum was in the UVA range. Simultaneous irradiation of the skin with UVA and visible light wavelengths shorter than 460 nm induced wheals approximately 10 minutes after the end of the exposure, no matter how long the exposure time. Urticaria induced by UVA radiation was completely inhibited by immediate reirradiation of test sites with visible light wavelengths shorter than 460 nm. Visible light irradiation before exposure to eliciting wavelengths revealed no inhibitory effect, nor was an inhibitory effect found by pre- or postirradiation of test sites with visible light wavelengths longer than 530 nm. These findings suggest that the inactivation of a photoproduct or some subsequent step involved in the pathogenesis of the urticarial reaction was inhibited by visible light wavelengths shorter than 460 nm but not by visible light wavelengths longer than 530 nm.

Stevens-Johnson syndrome and toxic epidermal necrolysis in Thailand.

BACKGROUND: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are potentially life-threatening illnesses that have often been linked to drug exposure. METHODS: We looked retrospectively for all cases of SJS and TEN that were admitted to Siriraj Hospital between 1981 and 1990 to determine the drug etiology. RESULTS: Fifty-eight cases of SJS and 20 cases of TEN were identified. Eight patients initially had an SJS-like aspect, which subsequently evolved into TEN. A culpable drug was determined in 60 patients (77%). The mean time from first drug administration to onset of SJS or TEN was 6.8 +/- 6.5 days (range, 1 to 28 days). A longer incubation period was observed with thiacetazone (10.5 +/- 5.6 days), phenytoin (12 +/- 8.5 days), and carbamazepine (11.3 +/- 3.4 days). CONCLUSIONS: The culprit drugs included the following: antibiotics, 32 cases (penicillin, sulfonamides, tetracycline, erythromycin); anticonvulsants, nine (phenytoin, carbamazepine, barbiturates); antitubercular drugs, eight (thiacetazone); analgesics, four (acetylsalicylic acid, fenbufen); sulfonylurea, two; allopurinol, one; and others, four. The most frequent underlying diseases justifying the ingestion of one or more drugs in our patients were infections (52.7%), followed by pulmonary tuberculosis (10.8%), and by seizures (8.1%). The total mortality rate was 14%; 5% for SJS, and 40% for TEN. Mortality was not affected by the type of drug responsible.

Evaluating the UVA protection of commercially available sunscreens.

Because the protection factor of sunscreens concerns only UVB protection, usually only a little is known about the protection offered in the UVA range. Photoprotection against ultraviolet A (UVA) by five commercially available sunscreens and their components was evaluated in humans, with erythema and pigmentation used as end points. Because UVA-induced tanning obscures a UVA-erythema, quantitative analysis of UVA-erythema cannot be used as the end point in this study. All products provided low UVA protection factor (1.02-1.9). The sunscreen which contain 3 per cent Parsol 1789 was the most effective product and significantly better than the other (p < 0.0001).

Hydroa vacciniforme: an unusual clinical manifestation.

Hydroa vacciniforme is a rare, chronic photodermatosis with onset in childhood that is characterized by recurrent vesiculation, necrosis, and vacciniform scarring limited to sun-exposed skin. We report a case of nonvesicular hydroa vacciniforme in which only extensive crusting associated with hypertrophic scarring on sun-exposed skin was present. Multiple exposures to UVA, however, reproduced lesions with the typical clinical and histologic features of hydroa vacciniforme. Results of blood, urine, and fecal porphyrin studies were normal.