Cryolipolysis for abdominal subcutaneous fat reduction: A prospective, multicenter, single arm, clinical study.

Various treatment methods are used for noninvasive body contouring. To evaluate the efficacy and safety of a newly designed cryolipolysis device using a three-dimensional cooling method for abdominal fat reduction. Twenty-five participants with clinically apparent abdominal fat tissue participated in the study. The thickness of fat tissue below the umbilicus level was measured using a caliper at baseline and 12 weeks after the first treatment. The height of abdominal subcutaneous fat tissue on ultrasonography and participant satisfaction were assessed at every visit for 16 weeks. All adverse events (AEs) during the study period were recorded. p values <0.05 were considered statistically significant. Twenty-four participants completed this study; the mean BMI of participants was 29.34 ± 2.36 kg/m2 . The mean thickness of abdominal subcutaneous fat was significantly lower at 12 weeks (40.4 ± 6.8 mm, p < 0.001) than at baseline (49.3 ± 8.5 mm). Differences in the height of abdominal subcutaneous fat compared to that at baseline were 1.02 ± 0.41 cm (12 weeks, p < 0.001) and 1.13 ± 0.44 cm (16 weeks, p < 0.001). Rates of abdominal subcutaneous fat reduction at 12 and 16 weeks compared to that at baseline were 28.45% and 31.13%, respectively. The ratio of abdominal circumference to hip circumference at 12 and 16 weeks was significantly decreased compared to that at baseline. Most participants (95.8%) reported improvement in satisfaction scores at 16 weeks. There were no serious AEs during the entire study period. The study demonstrated the efficacy of a noninvasive cryolipolysis device using a three-dimensional cooling method for reducing abdominal subcutaneous fat.

Efficacy of microneedle radiofrequency therapy in the treatment of senile purpura: A prospective study.

BACKGROUND: Radiofrequency (RF) devices have been used for skin rejuvenation and treating skin laxity. It may also be effective for senile purpura (SP) based on its action of promoting neocollagenesis with minimal epidermal damage. This study aimed to evaluate the efficacy and safety of microneedle RF for treating SP of the forearms in elderly. MATERIAL AND METHODS: In this prospective study, 23 patients who underwent a single session of microneedle RF device (GENIUS, Lutronic Co., Korea) therapy for SP were enrolled. Histopathological features were assessed 1 week before and 8 weeks after therapy. The total amount of collagen and elastic fibers were measured using the computer vision method, and epidermal thickness and the number of blood vessels were analyzed using ImageJ. The clinical improvements were evaluated by blinded evaluators and the patients using investigator global assessment (IGA) and patient global assessment (PGA), respectively. Data regarding the number of purpuric lesions and the size of the largest lesion were collected via a telephone survey. RESULTS: The total amount of collagen and elastic fibers, and mean epidermal thickness tended to improve after RF treatments, although they did not reach statistical significance. The locally estimated scatterplot smoothing curve showed decreasing tendency in both size and number of purpuras as weeks progressed. PGA showed very satisfied in 65% of patients and IGA showed 39% near-total improvement and 43% marked improvement. There were no serious adverse events. CONCLUSIONS: Microneedle RF therapy induces remodeling of dermal circumstances with minimal epidermal impairment. It may be a promising therapeutic option for SP.

The Accuracy of Ultrasonography on the Location of Lipomas in the Forehead.

BACKGROUND: Preoperative recognition of tumor plane is important to avoid surgical complications in surgeries involving the scalp. Ultrasonography is a useful diagnostic tool to detect the depth of tumor noninvasively. However, some findings are not always in accordance with the actual locations of lipomas, especially in the forehead. OBJECTS: To evaluate the accuracy of preoperative ultrasonographic findings for the location of lipomas in the forehead. MATERIALS AND METHODS: The study included 14 patients with lipomas in the forehead who all underwent preoperative ultrasonography and surgical excision of the lesions. The authors compared the diagnostic location of tumors by ultrasonography with the actual location in the surgical field. RESULTS: On ultrasonography, 10 of 14 cases were diagnosed as frontalis-associated lipomas. However, 13 cases were confirmed as frontalis-associated lipomas intraoperatively, and only 1 case as superficial lipoma, which did not correspond with the ultrasonographic finding. The ultrasonographic findings were accurate in 9 of 14 cases (64.3%). CONCLUSION: The accuracy of ultrasonography on the location of lipomas in the forehead is not as high as expected. Therefore, the surgeon must consider the possibility of deep lipoma even if a forehead lipoma is superficial in location on ultrasonography.

A Randomized, Split-Face, Comparative Study of a Combined Needle Radiofrequency/Intense Pulsed Light Device in Moderate-to-Severe Acne Patients.

BACKGROUND: Radiofrequency (RF) and intense pulsed light (IPL) have been reported as efficient adjuvant treatment modalities for acne vulgaris. OBJECTIVE: We sought to evaluate the clinical efficacy and safety of a combined needle RF and vacuum IPL device for acne treatment without the use of other conventional topical or oral agents. METHODS: This randomized, split-faced study was designed to include patients with moderate to severe acne vulgaris. Comedone extraction was performed on both parts of the face prior to laser treatment. One side of the face was treated with RF and IPL in 2-week intervals, while the other side was left untreated as a control. Two independent blinded investigators evaluated the patients for improvement using clinical photographs. We also assessed for possible adverse effects. RESULTS: The study included 44 patients with acne vulgaris (27 men and 17 women). Their ages ranged from 19-39 years (average, 23 years). At the final 12-week follow-up visit, the acne reduction rate was 34.80% (±33.45%; range, 30.92%-19.03%) on the treated side and 13.76% (±37.58%; range, 28.26%-23.27%) in the control group compared to baseline, constituting a significant difference. The difference in reduction rate between the treated and control sides was 21.03% (±25.09%), with the treated side experiencing more significant improvement (p<0.05). In the assessment of adverse events, one patient experienced mild surrounding erythema that spontaneously improved. CONCLUSION: Combined treatment of needle RF and IPL could improve acne lesions.

Incidence and survival rates of primary cutaneous malignancies in Korea, 1999-2019: A nationwide population-based study.

Primary cutaneous malignancies are among the most commonly diagnosed types of cancer worldwide. We aimed to examine the incidence and 5-year survival rates of all types of primary cutaneous malignancies in the Korean population. Data from the Korean Nationwide Cancer Registry from 1999 to 2019 were analyzed. The crude incidence rates, age-standardized incidence rates, and 5-year relative survival rates of each type of skin cancer were calculated. A total of 89 965 patients were diagnosed with primary cutaneous malignancies, which was a 7-fold increase from 1999 to 2019. The age-standardized incidence rates increased 3.4-fold in basal cell carcinoma (3.7/100 000 person-years), 2.0-fold in squamous cell carcinoma (1.6/100 000 person-years), 12.0-fold in Bowen disease (1.2/100 000 person-years), and 1.8-fold in malignant melanoma (0.7/10 000 person-years) in 2019. Average annual percentage changes in age-standardized incidence rates were statistically significant in basal cell carcinoma (15.8%), Bowen disease (5.8%), squamous cell carcinoma (5.1%), malignant melanoma (1.2%), melanoma in situ (1.1%), dermatofibrosarcoma protuberans (1.2%), mycosis fungoides (0.5%), primary cutaneous CD30+ T-cell proliferations (0.5%), adnexal and skin appendage carcinoma (0.4%), extramammary Paget's disease (0.2%), and Merkel cell carcinoma (0.2%). The 5-year relative survival rates were the highest in basal cell carcinoma (103.3%), followed by dermatofibrosarcoma protuberans (99.7%) and mycosis fungoides (96.6%), and lowest in angiosarcoma (24.7%). The 5-year relative survival rates steadily increased in extramammary Paget's disease (23.6%), cutaneous B-cell lymphoma (21.3%), mycosis fungoides (20.2%), extranodal NK/T-cell lymphoma, nasal type (18.1%), and malignant melanoma (16.1%) from 1996-2000 to 2015-2019. Most primary cutaneous malignancies have increased in incidence and survival rates in the Korean population, but to varying extents depending on the type of skin cancer.

Cutaneous Cytomegalovirus Infection Presenting As Recalcitrant Bullous Pemphigoid Lesion.

Cytomegalovirus (CMV) infection is common among immunocompromised hosts; however, its cutaneous manifestation is considered rare in comparison to internal organ involvement. Clinical manifestations of cutaneous CMV infection generally include perioral or perianal ulcerations. On the other hand, autoimmune bullous dermatosis can have bullae and ulcerations similar to those caused by cutaneous CMV infection. Autoimmune bullous dermatosis requires treatment with immunosuppressive agents for relatively long periods, which may cause reduction of immunocompetence. Because of this iatrogenic immunosuppression, patients with autoimmune bullous dermatosis subsequently acquire increased risk for opportunistic infections. However, cases of bullous pemphigoid (BP) complicated by cutaneous CMV infection are rarely reported. Herein, we report the case of an 88-year-old male who had BP and subsequently recalcitrant perianal skin lesions, which were eventually diagnosed as cutaneous CMV infections.

Comparative Study of Efficacy Between Cyclosporine and Alitretinoin in Patients With Chronic Hand Eczema.

Background: Systemic remedies such as cyclosporine, methotrexate, and retinoids are off-license treatment options that are considered for severe chronic hand eczema (CHE) that is resistant to first-line treatment. Objectives: The objective of this study was to determine the optimal treatment of CHE patients, including those with atopic dermatitis, and to compare the efficacy between cyclosporine and alitretinoin. Methods: This study was retrospective and included CHE patients who visited the Department of Dermatology at Hanyang University Seoul Hospital in Korea between March 2013 and February 2020. Results: A total of 95 CHE patients was included in this study. In the cyclosporine treatment group, there were more patients with severe baseline Investigator Global Assessment (IGA) (P = 0.033) and higher immunoglobulin E (IgE) level (P = 0.019). The mean recurrence duration was 15.9 weeks in the alitretinoin group and 22.9 weeks in the cyclosporine group, the difference between which was not statistically significant. In a subgroup analysis according to treatment drug, only the low IgE group showed a better recurrence profile for alitretinoin treatment compared to cyclosporine treatment (P = 0.039). When comparing the cumulative recurrence rate during the treatment period and subsequent follow-up periods, the cyclosporine group showed a greater incidence of recurrence than the alitretinoin group in all follow-up periods. The results of our study are consistent with the previously reported efficacy of alitretinoin. Despite the rapid response in the cyclosporine group, 12 weeks of CHE treatment with alitretinoin showed superior efficacy compared to cyclosporine treatment. Conclusions: Both alitretinoin and cyclosporine groups showed efficacy in patients with CHE. Cyclosporine is an alternative treatment of CHE that is refractory to alitretinoin or relapses after its use, especially in the presence of atopic dermatitis.

Risk of tuberculosis infection and serial changes in interferon-gamma release assays in elderly patients with psoriasis receiving biologic therapy.

Elderly patients constitute a significant proportion of patients with psoriasis. Nonetheless, treatment for older patients is more challenging than that for younger ones. Biologic agents are preferable to other systemic drugs for elderly patients with moderate-to-severe psoriasis owing to their high efficacy and favorable tolerability. However, there are limited data on tuberculosis infection risk in elderly patients with psoriasis receiving biologic therapy. This study aimed to evaluate the risk of active tuberculosis and latent tuberculosis infection, assess the serial interferon-gamma release assay results, and evaluate treatment compliance and adverse effects of latent tuberculosis infection treatment in elderly patients with psoriasis on biologic therapy. In this single-center retrospective study, medical charts of elderly patients (age ≥ 65 years) with psoriasis who were treated with a biologic agent (guselkumab, adalimumab, secukinumab, or ustekinumab) between January 2015 and December 2020 were reviewed. We analyzed the results of chest X-rays and those of whole-blood interferon-gamma release assays performed for latent tuberculosis infection screening at baseline (IGRA0) and subsequently at follow-up after initiating biologic therapy (IGRA1). In total, 90 patients underwent IGRA0; 46 (51.11%) of them had latent tuberculosis infection before starting biologic therapy. Overall, four and two patients experienced seroconversion and active tuberculosis during biologic therapy, respectively. The interferon-gamma release assay reversion rate was 29.1%, and the interferon-gamma level significantly decreased in all patients after latent tuberculosis infection treatment (p = 0.004). Latent tuberculosis infection treatment was well tolerated in elderly patients (completion rate, 100%). The risk of latent tuberculosis infection in elderly patients with psoriasis on biologic therapy was comparable to that previously reported for all age groups. However, the active tuberculosis rate was relatively higher.

Intralymphatic Histiocytosis Associated with Osteoarthritis: A Case Report.

Intralymphatic histiocytosis (ILH) is a rare cutaneous condition with uncertain pathogenesis. It is characterized by dilated lymphatic vessels that contain histiocytes within their lumina. Although the etiology of ILH remains unknown, it has been associated with various inflammatory and neoplastic diseases, such as rheumatoid arthritis (RA), reaction to metal joint implants and Merkel cell carcinoma, breast cancer and colon cancer. An 83-year-old female presented with an erythematous patch on the left forearm that had appeared six months previous. She had suffered from osteoarthritis (OA) and the cutaneous lesion was located in the vicinity of the affected joint. Skin biopsy from the lesion showed dilated dermal vessels and some ectatic vessels that contained many mononuclear histiocytes. Based on the clinical and histopathological findings, we diagnosed her with ILH with OA. Two sessions of intralesional triamcinolone acetonide injection (5 mg/ml) were administered to treat the skin lesion, which gradually improved over a period of a few months. We here report a rare case of ILH associated with degenerative OA.

Differential microRNA profiles in elderly males with seborrheic dermatitis.

Seborrheic dermatitis (SD) is one of the most common skin diseases characterized by inflammatory symptoms and cell proliferation, which has increased incidence in patients older than 50 years. Although the roles of microRNAs (miRNAs) have been investigated in several diseases, miRNA profiles of patients with SD remain unknown. This study aimed to identify differentially expressed miRNAs (DEMs) in lesions of elderly male patients with SD. We used a microarray-based approach to identify DEMs in lesions compared to those in non-lesions of patients with SD. Furthermore, Gene Ontology and pathway enrichment analysis were performed using bioinformatics tools to elucidate the functional significance of the target mRNAs of DEMs in lesions of patients with SD. Expression levels of two miRNAs-hsa-miR-6831-5p and hsa-miR-7107-5p-were downregulated, whereas those of six miRNAs-hsa-miR-20a-5p, hsa-miR-191-5p, hsa-miR-127-3p, hsa-miR-106b-5p, hsa-miR-342-3p, and hsa-miR-6824-5p-were upregulated. Functions of the SD-related miRNAs were predicted to be significantly associated with typical dermatological pathogenesis, such as cell proliferation, cell cycle, apoptosis, and immune regulation. In summary, SD alters the miRNA profile, and target mRNAs of the DEMs are related to immune responses and cell proliferation, which are the two main processes in SD pathogenesis.

Automated detection of superficial fungal infections from microscopic images through a regional convolutional neural network.

Direct microscopic examination with potassium hydroxide is generally used as a screening method for diagnosing superficial fungal infections. Although this type of examination is faster than other diagnostic methods, it can still be time-consuming to evaluate a complete sample; additionally, it possesses the disadvantage of inconsistent reliability as the accuracy of the reading may differ depending on the performer's skill. This study aims at detecting hyphae more quickly, conveniently, and consistently through deep learning using images obtained from microscopy used in real-world practice. An object detection convolutional neural network, YOLO v4, was trained on microscopy images with magnifications of 100×, 40×, and (100+40)×. The study was conducted at the Department of Dermatology at Veterans Health Service Medical Center, Seoul, Korea between January 1, 2019 and December 31, 2019, using 3,707 images (1,255 images for training, 1,645 images for testing). The average precision was used to evaluate the accuracy of object detection. Precision recall curve analysis was performed for the hyphal location determination, and receiver operating characteristic curve analysis was performed on the image classification. The F1 score, sensitivity, and specificity values were used as measures of the overall performance. The sensitivity and specificity were, respectively, 95.2% and 100% in the 100× data model, and 99% and 86.6% in the 40× data model; the sensitivity and specificity in the combined (100+40)× data model were 93.2% and 89%, respectively. The performance of our model had high sensitivity and specificity, indicating that hyphae can be detected with reliable accuracy. Thus, our deep learning-based autodetection model can detect hyphae in microscopic images obtained from real-world practice. We aim to develop an automatic hyphae detection system that can be utilized in real-world practice through continuous research.

Hydrochlorothiazide use and the risk of skin cancer in patients with hypertensive disorder: a nationwide retrospective cohort study from Korea.

BACKGROUND/AIMS: Recent studies have shown a cumulative dose-dependent association between the use of hydrochlorothiazide (HCTZ) and skin cancer, including melanoma and non-melanoma skin cancer (NMSC) in Western Europe. However, whether this pattern is present in East Asia countries is unknown. The aim of this study was to examine the association between HCTZ use and the risk of skin cancer among a cohort of hypertensive patients in South Korea. METHODS: This was a retrospective, population-based cohort study using the database from the Health Insurance Review and Assessment Service between January 1, 2007 and June 30, 2017 in South Korea. We identified patients diagnosed with melanoma and NMSC in the cohorts of essential hypertensive patients who were treated with HCTZ or antihypertensive agents other than HCTZ. Using Cox proportional hazards regression models, the hazard ratios (HR) for skin cancer associated with HCTZ users were calculated. RESULTS: The risk of melanoma was significantly lower in HCTZ-users compared with non-HCTZ users (HR, 0.85; 95% confidence interval [CI], 0.75 to 0.97; p = 0.016), and the risk of NMSC was lower in the HCTZ users but no statistically significant association was seen (HR, 0.96; 95% CI, 0.91 to 1.02; p = 0.236). High cumulative doses (≥ 50,000 mg) of HCTZ were associated with decreased risk of both NMSC (HR, 0.20; 95% CI, 0.10 to 0.38; p < 0.001) and melanoma (HR, 0.18; 95% CI, 0.04 to 0.70; p = 0.001), respectively. CONCLUSION: High cumulative use of HCTZ may have a chemopreventive effect against the development of melanoma and NMSC with clear cumulative dose-response and duration-response relationships in South Korea.

A Correlation between Serum Level of Alkaline Phosphatase and Acne Severity in Children and Adolescents: A Retrospective Cross-Sectional Study.

BACKGROUND: Acne is a chronic inflammatory disease of the pilosebaceous unit and usually affects adolescents when the peak concentrations of growth hormone, insulin-like growth factor 1, and androgen are demonstrated. The activity of alkaline phosphatase (ALP), which increases physiologically in growing children and adolescents, in the pilosebaceous unit has been reported. However, the correlation between the serum level of ALP and the number of acne lesions has not been studied. OBJECTIVE: The present cross-sectional study was designed to evaluate the correlation between serum level of ALP and the numbers of non-inflammatory and inflammatory acne lesions in children and adolescents. METHODS: For this study, 202 pediatric and adolescent patients clinically diagnosed with acne vulgaris were included. Age, sex, serum level of ALP, number of non-inflammatory acne lesions, number of inflammatory acne lesions, and number of total acne lesions were evaluated. Additionally, the serum level of dehydroepiandrosterone sulfate was evaluated in 117 patients. Multiple regression analysis was performed. Multicollinearity was quantified using the variance inflation factor. RESULTS: In the 202 patients, serum level of ALP was the only independent factor that significantly affected both the number of non-inflammatory acne lesions and of total acne lesions (regression coefficient=0.089 and 0.086, respectively, p<0.001). CONCLUSION: There was a significant correlation between serum level of ALP and the extent of acne (non-inflammatory acne lesions and total acne lesions).

The KAAACI/KDA Evidence-Based Practice Guidelines for Chronic Spontaneous Urticaria in Korean Adults and Children: Part 1. Definition, Methodology and First-line Management.

Chronic spontaneous urticaria (CSU) is defined as the occurrence of spontaneous wheals, angioedema, or both for >6 weeks in the absence of specific causes. It is a common condition associated with substantial disease burden both for affected individuals and societies in many countries, including Korea. CSU frequently persists for several years and requires high-intensity treatment; therefore, patients experience deteriorations in quality of life and medication-associated complications. During the last decade, there have been major advances in the pharmacological treatment of CSU and there is an outstanding need for evidence-based guidelines that reflect clinical practice in Korea. The guidelines reported here represent a joint initiative of the Korean Academy of Asthma, Allergy and Clinical Immunology and the Korean Dermatological Association, and aim to provide evidence-based guidance for the management of CSU in Korean adults and children. In Part 1, disease definition, guideline scope and development methodology as well as evidence-based recommendations on the use of antihistamines and corticosteroids are summarized.

The KAAACI/KDA Evidence-Based Practice Guidelines for Chronic Spontaneous Urticaria in Korean Adults and Children: Part 2. Management of H1-Antihistamine-Refractory Chronic Urticaria.

Quite a few patients with chronic spontaneous urticaria (CSU) are refractory to H1-antihistamines, even though the dose of H1-antihistamines is increased up to 4-fold. CSU that is not controlled with H1-antihistamines results in increased disease burden. Several immunomodulators have been used to manage these patients. The guidelines reported herein are connected to Part 1 of the KAAACI/KDA Evidence-Based Practice Guidelines for Chronic Spontaneous Urticaria in Korean Adults and Children, and aimed to provide evidence-based recommendations for the management of H1-antihistamine-refractory CSU. Part 2 focuses on the more commonly used additional treatment options for refractory CSU, including omalizumab, cyclosporine, leukotriene receptor antagonist, dapsone, methotrexate, and phototherapy. The evidence to support their efficacy, dosing, safety, and selection of these agents is systematically reviewed. To date, for patients with refractory CSU, the methodologically sound data to evaluate the use of omalizumab has been growing; however, the evidence of other immunomodulators and phototherapy is still insufficient. Therefore, an individualized stepwise approach with a goal of achieving complete symptom control and minimizing side effects can be recommended. Larger controlled studies are needed to elevate the level of evidence to select a rational therapeutic agent for patients with refractory CSU.

The Reappraisal of the Slide-Swing Skin Flap: A Versatile Technique for Surgical Defects.

BACKGROUND: The slide-swing skin flap is a combination of transposition and adjacent skin sliding and can be used to close large, round defects with a flap that is smaller than the primary defect to produce aesthetically good results. OBJECTIVE: To evaluate the efficacy and safety of the slide-swing skin flap for various surgical defects caused by skin tumor excisions. METHODS: This retrospective case series, which includes 33 Asian patients between the ages of 25 and 86 years, describes the slide-swing skin flap after primary excision for malignant or premalignant skin conditions. The outcomes were assessed 12 weeks after surgery using the patient and observer scar assessment scale (POSAS). RESULTS: Patients were 25 male and 8 female, and the causes of surgery were various malignant skin tumors including malignant melanoma, dermatofibrosarcoma protuberans, and malignant nodular hidradenoma. Tumors were on the lower limb in eleven patients, back in nine patients, chest in five patients, face in three patients, buttock in three patients and two patients had tumors in other locations. The mean defect size was 3.5×3.1±1.9×2.2 cm (range, 1.4×0.9~9.0×12.0 cm). The mean patient POSAS total score was 9.7±3.0 and mean patient overall opinion score was 1.8±0.7. The mean observer POSAS total score was 11.0±2.7 and mean observer overall opinion score was 1.9±0.5. All flaps survived and postoperative recoveries were uneventful. CONCLUSION: The slide-swing skin flap is highly versatile and can be used to cover various surgical defects, irrespective of size and location, with excellent functional and cosmetic results.

Efficacy and Safety of Alitretinoin Therapy in Korean Elderly Patients with Chronic Hand Eczema: A Retrospective Single Center Study.

BACKGROUND: Chronic hand eczema (CHE) tends to be refractory to conventional therapy. Previous clinical trials have found that alitretinoin is an effective and well-tolerated treatment for CHE. However, there is a relative lack of data on the effectiveness of alitretinoin in elderly patients. OBJECTIVE: The aim of this study was to investigate the efficacy and safety of oral alitretinoin in elderly patients with moderate to severe CHE in Korea. METHODS: We retrospectively investigated 46 CHE patients who were treated with either 10 mg or 30 mg of alitretinoin between June of 2016 and July of 2018. The physician's global assessment (PGA) was used to evaluate treatment efficacy. All adverse events were retrospectively evaluated with respect to laboratory testing, including complete blood cell count, fasting blood chemistry, lipid profile, and liver and thyroid function tests. RESULTS: The mean patient age in this study was 71.0±5.1 years. The treatment period was over eight weeks. A total of 38 of 46 patients (82.6%) exhibited clinical improvement with PGA ratings of 'clear' or 'almost clear.' There were 13 patients (28.3%) who experienced an adverse effect, with the most common being headache (13.0%) and gastrointestinal symptoms (8.7%) followed by xerosis (6.5%). A total of 13 patients developed or exhibited worsening hypertriglyceridemia (28.3%). CONCLUSION: Alitretinoin can be considered a safe and effective treatment option in elderly patients with moderate to severe CHE.