Skin manifestations and clinical features of drug reaction with eosinophilia and systemic symptoms: a retrospective multicentre study of 125 patients.

BACKGROUND: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe adverse drug reaction generally accompanied by skin manifestations as the first and most frequent symptoms. However, skin manifestations and associated clinical features of DRESS have not been fully explored and evaluated. OBJECTIVES: This study aimed to describe the skin manifestations of DRESS in detail and analyse their association with demographic characteristics and extra-cutaneous clinical features. METHODS: We conducted this retrospective study on patients with DRESS diagnosed between September 2009 and August 2021 at three medical institutes and validated using the RegiSCAR score. Data regarding demographics, skin manifestations and clinical characteristics were retrieved through thorough chart reviews. RESULTS: Among 182 potential cases of DRESS, the validated 125 cases were analysed. A widespread rash extending over more than 50% of the body surface area was observed in 122 patients (97.6%) and typical facial oedema was experienced by 67 patients (53.6%). Polymorphous maculopapules were the most common rash morphology (106, 84.8%): specifically, exfoliative (59, 47.2%), urticarial (57, 45.6%) and purpuric forms (39, 31.2%) were common. Mucosal involvement was observed in 41 patients (32.8%). Patients with carboxamide antiepileptics (carbamazepine and oxcarbazepine) experienced more oedema (P = 0.014) and typical facial oedema than those with allopurinol (P = 0.021). The RegiSCAR score was higher in patients with purpura (P < 0.01). CONCLUSIONS: Skin manifestations of DRESS exhibit a wide range of skin lesions and can vary according to the culprit drugs. Early suspicion and prompt intervention are needed to improve prognosis.

Histopathological predictor of the progression from actinic keratosis to squamous cell carcinoma: quantitative computer-aided image analysis.

BACKGROUND: The current histopathological classifications for actinic keratosis (AK) are subjective, and histopathological factors predicting the progression into invasive squamous cell carcinoma (SCC) remain unclear. OBJECTIVES: To quantitatively assess the histopathological findings of AK and to investigate the predisposing factors for malignant transformation of AK. METHODS: A total of 502 AK specimens were retrospectively reviewed. The AK lesions were divided into the atrophic, intermediate, hypertrophic and bowenoid types. Histopathological features were quantitatively analysed using computer-aided image analysis. RESULTS: The epidermal thickness excluding the horny layer increased with statistical significance (P < 0.001) in order of atrophic, intermediate, hypertrophic and bowenoid type. The proportion of keratinocytic atypia was not significantly different among subtypes, except for the bowenoid type. Five of 498 cases were confirmed to develop into SCC. Bowenoid type, epidermal thickening and higher proportion of keratinocytic atypia were significantly associated with progression to invasive SCC in univariate analysis (OR = 12.571, 95% CI: 1.392-113.57; OR = 1.004, 95% CI: 1.001-1.007; OR = 1.069, 95% CI: 1.011-1.130, respectively). In multivariate analysis, only the proportion of keratinocytic atypia was an independent predisposing factor for progression to invasive SCC (OR = 1.069; 95% CI: 1.011-1.130). CONCLUSIONS: Histopathological subtypes based on the essential change of the epidermis well correlated with the actual epidermal thickness excluding the horny layer. The overall severity of keratinocytic atypia might be an independent risk factor for malignant transformation of AK.

Dermatologist-level classification of malignant lip diseases using a deep convolutional neural network.

BACKGROUND: Deep convolutional neural networks (DCNNs) can classify skin diseases at a level equivalent to a dermatologist, but their performance in specific areas requires further research. OBJECTIVE: To evaluate the performance of a trained DCNN-based algorithm in classifying benign and malignant lip diseases. METHODS: A training set of 1629 images (743 malignant, 886 benign) was used with Inception-Resnet-V2. Performance was evaluated using another set of 344 images and 281 images from other hospitals. Classifications by 44 participants (six board-certified dermatologists, 12 dermatology residents, nine medical doctors not specialized in dermatology and 17 medical students) were used for comparison. RESULTS: The outcomes based on the area under curve, sensitivity and specificity were 0·827 [95% confidence interval (CI) 0·782-0·873], 0·755 (95% CI 0·673-0·827) and 0·803 (95% CI 0·752-0·855), respectively, for the set of 344 images; and 0·774 (95% CI 0·699-0·849), 0·702 (95% CI 0·579-0·808) and 0·759 (95% CI 0·701-0·813), respectively, for the set of 281 images. The DCNN was equivalent to the dermatologists and superior to the nondermatologists in classifying malignancy. After referencing the DCNN result, the mean ± SD Youden index increased significantly for nondermatologists, from 0·201 ± 0·156 to 0·322 ± 0·141 (P < 0·001). CONCLUSIONS: DCNNs can classify lip diseases at a level similar to dermatologists. This will help unskilled physicians discriminate between benign and malignant lip diseases. What's already known about this topic? Deep convolutional neural networks (DCNNs) can classify malignant and benign skin diseases at a level equivalent to dermatologists. The lips are a unique feature in terms of histology and morphology. Previous studies of DCNNs have not investigated tumours on specific locations. What does this study add? This study shows that DCNNs can distinguish rare malignant and benign lip disorders at the same rate as dermatologists. DCNNs can help nondermatologists to distinguish malignant lip diseases. What are the clinical implications of this work? DCNNs can distinguish malignant and benign skin diseases even at specific locations such as the lips, as well as board-certified dermatologists. Malignant lip diseases are rare and difficult for less trained doctors to differentiate them from benign lesions. This study shows that in dermatology, DCNN can help improve decision-making processes for rare skin diseases in specific areas of the body.

The relationship between clinical characteristics including presence of exposed lesions and health-related quality of life (HRQoL) in patients with psoriasis: analysis from the nationwide epidemiologic study for psoriasis in Korea (EPI-PSODE study).

BACKGROUND: Psychological aspect and quality of life should be considered in treating patients with psoriasis. OBJECTIVE: We sought to ascertain which clinical characteristics including presence of exposed lesions are associated with impairment of health-related quality of life (HRQoL) in patients with psoriasis. METHODS: The EPI-PSODE study was a nationwide, multicenter, cross-sectional study conducted in Korea that included 1260 adult patients with psoriasis. In addition to clinical characteristics including presence of exposed lesions, data were collected using the Psoriatic Arthritis (PsA) Screening and Evaluation (PASE), Dermatology Life Quality Index (DLQI), MOS 36-Item Short-Form Health Survey (SF-36), Work Productivity and Activity Impairment Questionnaire Psoriasis (WPAI: PSO) and Medication Satisfaction Questionnaire (MSQ). RESULTS: Patients with a DLQI score > 5 (n = 990) were younger, had an earlier onset of psoriasis, scored higher on the Psoriasis Area and Severity Index (PASI), had higher body surface area (BSA) and had higher PASE scores than patients with DLQI ≤ 5 (n = 266). The group of patients with exposed lesions (n = 871) were younger and male predominance, earlier onset of psoriasis, longer disease duration, higher PASI/BSA score and a higher proportion with drinking and smoking history each than the group of patients without exposed lesions (n = 389). Presence of exposed lesions negatively influenced DLQI, 36-Item Short-Form Health Survey (SF-36) (mental component), presenteeism, total work productivity impairment and total activity impairment in the WPAI: PSO. In multiple regression model, PASI score was the only variable which was significantly associated with all HRQoL measures. Presence of exposed lesions was a significant factor affecting DLQI and SF-36 (mental). CONCLUSION: The presence of exposed lesions has a negative impact on quality of life, mental health and work productivity. Therefore, effective treatments are particularly needed for psoriasis patients with exposed lesions.

Optimal maintenance treatment with calcipotriol/betamethasone dipropionate gel in Korean patients with psoriasis vulgaris: a multicentre randomized, controlled clinical trial.

BACKGROUND: There is a lack of response data for topical treatments for psoriasis vulgaris in Asian patients. OBJECTIVES: To determine the optimal maintenance regimen for topical treatment with calcipotriol monohydrate/betamethasone dipropionate gel in Korean patients with psoriasis vulgaris, by comparing the efficacy of three 8-week maintenance regimens. METHODS: This was a multicentre, prospective, randomized, controlled, parallel-group, open-label, phase 4 clinical trial, conducted in South Korea. Patients with psoriasis vulgaris on the limbs/trunk received once-daily treatment with calcipotriol monohydrate (50 µg/g)/betamethasone dipropionate (500 µg/g) gel for 8 weeks (induction phase). Responders (defined as an Investigator's Global Assessment of Disease Severity (IGA) grade of 'clear' or 'almost clear') were then randomized to receive 8 weeks' maintenance treatment with Xamiol® gel once daily as needed [pro re nata (PRN Group)], once daily every day (Continuous group), or twice weekly - on Saturday and Sunday (Weekend group). The primary endpoint was the percentage of IGA responders at week 16. RESULTS: At the end of the induction phase, 62.18% of patients were IGA responders. At the end of the maintenance phase (week 16), the responder rate was 63.89% for the PRN group, 67.5% for the Continuous group and 31.43% for the Weekend group. The PRN and Continuous groups were statistically superior to the Weekend group (P = 0.0109 and P = 0.0015), but the PRN and Continuous groups did not differ statistically. The incidence of adverse events did not differ significantly between the groups. CONCLUSION: Among Korean patients with psoriasis vulgaris, maintenance treatment with calcipotriol monohydrate/betamethasone dipropionate using a continuous daily regimen or an 'as needed' daily regimen provided similar efficacy, whereas a twice-weekly regimen was significantly less efficacious than either of these regimens.

Characteristics of subjective recognition and computer-aided image analysis of facial erythematous skin diseases: a cornerstone of automated diagnosis.

BACKGROUND: Rosacea and seborrhoeic dermatitis are common diseases that cause facial erythema. They have common features and are frequently misdiagnosed. OBJECTIVES: To extract characteristic features of erythrotelangiectatic rosacea (ETR), papulopustular rosacea (PPR) and seborrhoeic dermatitis (SEB) through computer-aided image analysis (CAIA) and compare them with subjectively recognized features and to use these findings to construct a decision tree for differential diagnosis. METHODS: Thirty-four clinical photos of patients with facial erythema were assessed: 12 patients were classified as showing ETR, 12 as PPR and 10 as SEB. Five dermatologists blinded to the original diagnosis gave their impressions of each photo. The mean, SD and T-zone to U-zone (T/U) ratios of the erythema parameter a* (a* of the L*a*b* colour space) were calculated for each photo using CAIA. These CAIA parameters were compared between impression groups. The most closely related CAIA parameter for each disease was established using the receiver-operating characteristic curve analysis. A decision tree which predicts the diagnosis from given CAIA parameters was constructed. RESULTS: All the photos classified as PPR generated impressions of PPR. However, approximately 30% of the photos classified as ETR generated impressions of SEB and vice versa. PPR was characterized by a large SD of erythema of the cheek, ETR was characterized by a large mean erythema of the U-zone, and SEB was characterized by a large T/U ratio of mean erythema. Fifteen additional photos were examined: the decision tree predicted the original diagnosis for 14, but incorrectly predicted one case of ETR as SEB. CONCLUSIONS: The CAIA result of facial erythema is well correlated with the actual clinical diagnosis. The accuracy of differential diagnosis using a decision tree with CAIA parameters is as good as that of global examination impressions of dermatologists.

A new therapeutic option for facial seborrhoeic dermatitis: indole-3-acetic acid photodynamic therapy.

BACKGROUND: Indole-3-acetic acid (IAA) is a newly introduced photosensitizer of photodynamic therapy (PDT) for acne, presenting sebum-reducing, anti-inflammatory and antimicrobial activity. OBJECTIVE: This study was designed to evaluate the efficacy and safety of IAA-PDT in the treatment of facial seborrhoeic dermatitis. METHOD: In this prospective, single-blinded, 6-week trial, 23 patients with facial seborrhoeic dermatitis were treated with IAA-PDT with green light (520 nm) three times with 1-week intervals. Patients were evaluated at baseline, week 1, 2, 3 and week 6 (3 weeks after last treatment). Efficacy was determined by Seborrhoeic dermatitis Area and Severity Index (SASI), patient's assessment of the symptoms (4-point scale of itchiness, burning, erythema, scale and tightness), sebum secretion rate (measured with Sebumeter(®)), Erythema Index (EI, measured with Mexameter(®)) and physician's photographic assessment. Safety was evaluated by questionnaire at each visit. RESULT: For the 22 subjects completing the trial, SASI and total symptom significantly improved at week 2, which lasted until week 6. Sebum excretion was significantly reduced at week 2 and stayed reduced until week 6. EI presented continuous reduction throughout the study. Photographic assessment showed significant improvement at each visit. The procedure was painless, and no adverse event was observed during and after the treatment. CONCLUSION: IAA-PDT is a safe and effective therapeutic option for facial seborrhoeic dermatitis.

The skin surface pH and its different influence on the development of acne lesion according to gender and age.

BACKGROUND: Skin pH is one of the important physiological parameters of the skin. Changes in the pH play a role in the pathogenesis of several skin diseases, including acne. PURPOSE: To assess the correlation between the pH and the age, and between the pH and the development of acne lesions, in a large acne patients group. We also evaluated the difference between the genders. METHODS: A total of 540 patients clinically diagnosed with acne vulgaris were included. The clinical digital photographs were taken, and the acne lesions were counted. The pH was measured, using the skin-pH-meter . Area-weighted pH was calculated and statistical analysis was performed, according to age and gender. RESULTS: The female had higher pH than the male acne patients. The T-zone had higher pH than that of the U-zone. In female acne patients, age and the area-weight pH showed a positive correlation. Male acne patients had more inflammatory lesions. And U-zone showed more acne lesions than T-zone. There are negative correlations between the area-weight pH and the number of acne lesions, in the T-zone of the female acne patients and positive correlation at the inflammatory lesions on the T-zone of male acne patients. CONCLUSIONS: This is the first study to evaluate the correlations between pH, age, gender, and acne development in a large acne patients group using an objective, bioengineering method within the viewpoint of skin pH. We could expect that there are gender differences in the correlation between pH, age, and acne development. From this result, we could provide a clue to the treatment of acne, that maintaining the pH balance according to the difference of gender and age is an essential consideration.

Subjective facial skin type, based on the sebum related symptoms, can reflect the objective casual sebum level in acne patients.

BACKGROUND: The relationship between the subjective skin type and the casual sebum level was not fully clarified. OBJECTIVES: To investigate the characteristics of subjective skin type and to find the relationship between the subjective skin types and the skin type-related symptoms, casual sebum level, along with the objective skin type. METHODS: Seven hundred and nine patients, clinically diagnosed with acne, were included. The questionnaire and the casual sebum level measurement were performed. The determining symptoms of each subjective skin type were investigated. The 95% confidence interval of casual sebum level of each subjective skin type was calculated. RESULTS: The most frequent subjective skin type was the combination type. The dryness, tightness, and oiliness can be conclusive symptoms in determining the subjective skin type. The mean and the 95% confidence interval of the casual sebum level was highest in the oily skin type, followed by the combination, normal, and dry skin type. CONCLUSION: We found that the subjective skin type was determined by the skin type-related symptoms. The 95% confidence intervals of the casual sebum level of each subjective skin type were established. Based on the skin type-related symptoms, the casual sebum level of acne patients can be estimated.

Facial sebum affects the development of acne, especially the distribution of inflammatory acne.

BACKGROUND: The increased sebum secretion has been considered as one of the pathogenic factors of acne. OBJECTIVE: The goal of this study was to assess the correlation between the casual sebum level and the severity of acne using objective measuring methods in a large acne patients group. We also investigated the influence of age or gender on the correlation. METHODS: A total number of 914 acne patients were recruited. The standard digital photographs were taken, and the acne lesions were counted as comedones or inflammatory lesions. The casual sebum level was measured using the Sebumeter SM 815(®) . The correlation analysis was performed. RESULTS: The casual sebum level showed positive correlation with the number of acne lesions. The casual sebum level markedly influenced the number of inflammatory lesions and the acne lesions located in the U-zone. In the young acne patients, the casual sebum level showed significant correlations in the U-zone, whereas in the old acne patients, there were significant correlations in the T-zone. The male acne patients were more influenced by the casual sebum level. CONCLUSION: This was the first study to report the significant correlations between the casual sebum level and the number, proportion and location of acne lesions in a large acne patients group, using an objective, bioengineering method. Moreover, we also found that the influence of sebum was prominent on the inflammatory lesions. In addition, both age and gender influenced the correlation between the casual sebum level and the acne.

Sebum, acne, skin elasticity, and gender difference - which is the major influencing factor for facial pores?

BACKGROUND: Enlarged facial pores have been esthetic problems and have become a matter of cosmetic concern. Several factors are supposed to be related to the enlargement of facial pores, although scientific evaluations were not performed yet. OBJECTIVE: To assess the correlation between facial pores and possible relating factors such as age, gender, sebum secretion, skin elasticity, and the presence of acne, using objective bioengineering instruments. METHODS: Sixty volunteers, 30 males and 30 females, participated in this study. Various parameters of facial pores were assessed using the Robo Skin Analyzer. The facial sebum secretion and skin elasticity were measured using the Sebumeter and the Cutometer, respectively. These data were compared and correlated to examine the possible relationship between facial pores and age, sebum secretion and skin elasticity, according to gender and the presence of acne. RESULTS: Male gender and the existence of acne were correlated with higher number of facial pores. Sebum secretion levels showed positive correlation with facial pores. The R7 parameter of skin elasticity was negatively correlated with facial pores, suggesting increased facial pores with decreased skin elasticity. However, the age and the severity of acne did not show a definite relationship with facial pores. CONCLUSION: Male, increased sebum and decreased skin elasticity were mostly correlated with facial pore development. Further studies on population with various demographic profiles and more severe acne may be helpful to elucidate the potential effect of aging and acne severity on facial pores.

Ultraviolet-induced red fluorescence of patients with acne reflects regional casual sebum level and acne lesion distribution: qualitative and quantitative analyses of facial fluorescence.

BACKGROUND: The ultraviolet (UV)-induced red fluorescence of patients with acne has been considered to be caused by Propionibacterium acnes. OBJECTIVES: To study the correlation of the facial red fluorescence with the casual sebum level and the number of acne lesions and to investigate the difference in clinical features, according to both distribution and proportion of fluorescence. METHODS: A total of 878 patients clinically diagnosed with acne vulgaris were included. Inflammatory and noninflammatory acne lesions were counted separately. UV fluorescent photography and casual sebum level measurements were performed. UV-induced fluorescence patterns were classified according to the facial distribution. The proportions of UV-induced red fluorescence were calculated. RESULTS: We identified six different fluorescence distribution patterns in the T-zone (the forehead, nose and chin) and three different patterns in the U-zone (both cheeks). The proportion of fluorescence in the U-zone showed a positive correlation with the casual sebum level and the number of acne lesions. In the T-zone, the fluorescence proportion correlated with the casual sebum level, but not with the number of acne lesions. As the patients' age and the age at onset increased, the distribution of fluorescence changed from the upper part of the T-zone to the lower part, and to the centre of the face in the U-zone. CONCLUSIONS: Our results support the hypothesis that the origin of facial red fluorescence is sebum. In patients with acne, analyses of the pattern and proportion of UV-induced red fluorescence can be useful for evaluating the sebum secretion and selecting efficient treatment modalities.

The objective evaluation of the severity of psoriatic scales with desquamation collecting tapes and image analysis.

BACKGROUND: Assessment of psoriatic scales is important to determine the severity of psoriasis. However, there are very limited numbers of objective, quantitative and observer-independent tools for measuring the severity of psoriasis. OBJECTIVE: To determine whether the bioengineering parameters of the psoriatic scale can be used to assess the severity of psoriasis instead of the psoriatic severity index of scales (PSIs) score. METHODS: Thirty-four patients with psoriasis were included. A representative lesion from each patient was selected and bioengineering parameters were measured using the Corneofix(®). Simultaneously, the severity of the scales was assessed by the PSIs score using clinical photographs of the lesions. In addition, skin color and elasticity parameters were also measured using the Colorimeter(®), the Mexameter(®) and the Cutometer(®). RESULTS: Statistical differences in the scale parameters were observed between the PSIs 2 and 3 scores. Among the scale parameters, the percent area and area in µm(2) were negatively correlated with the PSIs score. In addition, the Colorimeter(®) a, b parameters and the Cutometer(®) R9 parameters were significantly correlated with the PSIs score. CONCLUSIONS: The results of this study showed that the severity of psoriatic scales could be measured objectively using the Corneofix(®).

Matrix² coils in embolization of intracranial aneurysms: 1-year outcome and comparison with bare platinum coil group in a single institution.

BACKGROUND AND PURPOSE: The endosaccular occlusion by using BPC has been useful in the treatment of intracranial aneurysms, but its limited durability remains a deep-seated drawback. The Matrix² coil, one of the bioactive-coated coils, had been developed to improve this limited durability. To evaluate durability of Matrix² coils after embolization of intracranial aneurysms, we retrospectively compared 1-year outcomes with that of BPC groups. MATERIALS AND METHODS: A group of 121 aneurysms in 114 patients were embolized by using Matrix² coils between April 2006 and September 2008. The BPC group consisted of 151 aneurysms in 137 patients embolized by using BPCs alone between October 2007 and October 2008. The initial outcomes including packing densities, occlusion grades, and periprocedural complications, and the 1-year outcomes on MR angiography were retrospectively compared between the 2 groups. RESULTS: The Matrix² coil group and BPC group with similar baseline demographic characteristics revealed comparable initial outcomes. The rates of overall recurrence, major recanalization, and retreatment were 17.4%, 14.0%, and 10.7% versus 7.3%, 5.3%, and 4.6%, respectively (P = .066). However, the rates of subgroups with aneurysm volumes between 50 and 200 mm³ were 23.7%, 13.1%, and 10.5% versus 2.2%, 0%, and 0% (P = .022), respectively. The rates of subgroups with packing attenuation <30% were 38.3%, 31.9%, and 23.4% versus 13.3%, 11.7%, and 10% (P = .025), respectively. There were no differences in packing attenuation (P = .152), initial occlusion grade (P = .098), and 1-year outcomes (P = .209) according to the length of Matrix² coils used. CONCLUSIONS: Overall, initial and 1-year outcomes of the Matrix² coil group were comparable to those of the BPC group. However, in certain subgroups of aneurysm volume and packing attenuation, the 1-year durability of Matrix² coils was inferior to that of the BPC group.