Annals of Dermatology

Online ISSN: 2005-3894
Print ISSN: 1013-9087
Publications
There are several commercially available agents to treat female pattern hair loss (FPHL), including minoxidil solution, anti-androgen agents and mineral supplements. However, these treatments are not always satisfactory. We report the results of a clinical trial of 17α-estradiol (Ell-Cranell® alpha 0.025%) solution to Korean female patients with FPHL. This study was designed to examine the efficacy and safety of Ell-Cranell® alpha 0.025% solution in Korean female patients with FPHL. A total of 53 women, 18 to 55 years old, applied topical Ell-Cranell® alpha 0.025% solution once daily for 8 months. Efficacy was evaluated by the change of hair counts and diameter, subjective assessment, and photographic assessment by investigators. Hair counts and diameter from baseline to 4 and 8 months after treatment increased in treated patients and these changes were statistically significant (p<0.0001). 17α-estradiol (Ell-Cranell® alpha 0.025%) solution showed significant improvement by subjective self-assessment and by investigator photographic assessment. Ell-Cranell® alpha 0.025% solution was well tolerated over 8-months period. This study showed that Ell-Cranell® alpha 0.025% solution is a safe and effective agent for Korean women with FPHL.
 
Changes in the melanin index (MI) during the 8-week study period.
Patient 1: A 41-year-old woman with melasma was treated with 4-n-butylresorcinol 0.1% cream, and her melanin index (MI) decreased from 221.33 to 210.33 (−11.00). The clinical presentation at baseline with the MI: 221.33 (A), after 4 weeks with the MI: 215.33 (B) and after 8 weeks with the MI: 210.33 (C).
Patient 2: A 46-year-old woman with melasma was treated with 4-n-butylresorcinol 0.1% cream, and her MI decreased from 234.00 to 208.00 (−26.00). The clinical presentation at baseline with the MI: 234.00 (A), after 4 weeks with the MI: 213.00 (B) and after 8 weeks with the MI: 208.00 (C).
Patient 3: A 44-year-old woman with melasma was treated with 4-n-butylresorcinol 0.1% cream, and her MI decreased from 223.00 to 189.33 (−33.67). The clinical presentation at baseline with the MI: 223.00 (A), after 4 weeks with the MI: 197.33 (B) and after 8 weeks with the MI: 189.33 (C).  
Melasma is a common acquired symmetrical hypermelanosis that occurs on sun-exposed areas, and it is frequently observed among women. Various treatment modalities have been tried, but none are completely satisfactory. 4-n-butylresorcinol, which is a resorcinol derivative that has an inhibitory effect on both tyrosinase and tyrosinase-related protein-1, was introduced in 1995 and it has received increasing attention as a new hypopigmenting agent. However, the hypopigmenting effect of 4-n-butylresorcinol in human subjects has only been shown in a few studies. The aim of this study was to investigate the hypopigmenting efficacy and safety of 4-n-butylresorcinol 0.1% cream for the treatment of melasma. Twenty patients with melasma were enrolled to this randomized, double-blind, vehicle-controlled, split-face comparative study. The patients were instructed to apply 4-n-butylresorcinol 0.1% cream or vehicle to each side of the face twice daily for 8 weeks. Mexameter measurements were performed along with photography at baseline, 4 weeks and 8 weeks. Adverse events were observed and recorded throughout the study. All the patients completed the study. Mexameter measurements demonstrated that the melanin index of the treated side showed a significant decrease when compared with that of the vehicle-treated side after 4 weeks (p=0.006) and after 8 weeks (p<0.0005). All the adverse reactions were mild and transient. 4-n-butylresorcinol 0.1% cream showed rapid efficacy and it was well tolerated when used for the treatment of melasma.
 
Until recently, the removal of melanocytic nevi has been performed with a CO(2) laser or Er:YAG laser. These lasers have been useful for removing affected spots. However, enlargement of spots or some sequelae, including depressed or hypertrophic scars, could develop as unwanted results. The Q-switched Nd:YAG laser has been used to remove deep-seated melanocytes, such as Ota nevus or tattoos. However, there have been no previous experiments performed to test the efficacy and safety of this laser treatment for melanocytic nevi. The objective of this study was to investigate the efficacy and safety of the 1,064 nm Q-switched Nd:YAG laser for removing melanocytic nevi, including congenital nevomelanocytic and acquired nevomelanocytic nevi. Two thousand and sixty four Korean patients with small melanocytic nevi were treated with a Q-switched Nd:YAG laser from 2005 to 2009. High-resolution photographs were taken in identical lighting and positions before and after the six weeks of treatment to observe the procedural efficacy. About 70% of the nevi treated using a 1,064 nm Q-switched Nd:YAG laser were completely removed after one session. The other 30% were completely treated within three sessions. The appearance of sequelae such as hollow scars noticeably decreased compared to the results seen in CO(2) or Er:YAG laser treatments. Use of the 1,064 nm Q-switched Nd:YAG laser is a safe and effective treatment modality for melanocytic nevi.
 
During the laser surgery. Fig. 2. Immediate after the operation.  
During the laser surgery. Fig. 2. Immediate after the operation.  
Many treatment modalities have been developed for axillary osmidrosis. It is well known that the surgical treatment has the best results. However, there is a high possibility of side effects. The 1,444-nm lipolysis laser has been recently introduced to remove the apocrine glands. So far, subdermal coagulation treatment with a 1,444-nm Nd:YAG laser may be the least invasive and most effective therapy for axillary osmidrosis. However, according to our previous experience, the recurrence rate was 20%~30%. This emphasizes the need for combination of surgical method and non-surgical method and we combined subcutaneous tissue removal and photothermocoagulation with a 1,444-nm Nd:YAG laser. Three patients for bilateral axillary osmidrosis were enrolled. After an incision of about one-third the length of the widest transverse diameter, the apocrine glands were separated from the skin. And then apocrine glands within the marked area were destroyed by irradiation with a 1,444-nm Nd:YAG laser thereafter. All patients exhibited no relapse of axillary osmidrosis and were satisfied with the treatment results. A combination of subcutaneous tissue removal and Interstitial laser photothermocoagulation with a 1,444-nm Nd:YAG laser could be an effective treatment for mild to moderate axillary osmidrosis.
 
Comparison of modified Inaba's method (right axilla) and 1,444 nm Nd:YAG laser treatment (left axilla)
(A) Right axilla, 3 days following modified Inaba's operation. Ecchymosis was observed. (B) Left axilla, 10 days following laser operation; mild ecchymosis was observed. (C) Right axilla, 10 days following modified Inaba's operation; scar or crust was observed. (D) Left axilla, 10 days following laser operation; only mild crust without scarring was observed. Fig. 1. Left axilla of the patient (size: 10×5 cm, three parts).  
(A) Right axilla, 3 days following modified Inaba's operation. Ecchymosis was observed. (B) Left axilla, 10 days following laser operation; mild ecchymosis was observed. (C) Right axilla, 10 days following modified Inaba's operation; scar or crust was observed. (D) Left axilla, 10 days following laser operation; only mild crust without scarring was observed. Fig. 1. Left axilla of the patient (size: 10×5 cm, three parts).  
Bromhidrosis is a disease presenting as malodor caused by interaction between the discharge of apocrine glands and bacteria. The main therapeutic modalities are applying topical agents, liposuction surgery, and elective surgery. Among these, elective surgery is reported to be most effective. However, the efficiency largely depends on surgical technique. Additionally, other side effects, such as hematoma and scarring, are occasionally reported. Currently, CO2 laser and 1,064 nm Nd:YAG laser therapy are used, but as the wavelength is not specific to apocrine glands, these laser therapies have certain limitations. Recently, a 1,444 nm wavelength Accusculpt™ laser (LutronicCorp., Seoul, Korea) has been developed which is now commonly used for facial fat plasty and laser liposuction therapy. The use of this laser for bromhidrosis therapy targeting apocrine sweat glands is currently being discussed. Still, no studies on practical clinical use and side effects of this 1,444 nm wavelength laser have been published. In this report, we treated one bromhidrosis patient with 1,444 nm wavelength Accusculpt™ laser therapy on one side while conventional surgery was performed on the other side using a modified Inaba's method. We compared the efficacy of this laser therapy to the surgical modality by measuring malodor severity and overall satisfaction by questionnaire. We also checked for other complications and recurrence for 12 months after the treatment. This patient was largely satisfied as it has a much shorter down time with the same therapeutic outcome. As subdermal coagulation treatment by 1,444 nm Nd:YAG laser may be less invasive but effective therapy, we would like to recommend this modality as a possible treatment option.
 
A 18-year old female patient with keratosis pilaris (Patient 4) showed Grade 1 improvement in the skin texture and Grade 2 improvement in dyspigmentation. The patients' self assessment was 'slightly satisfied' (25~50% improvement). (a) Before the first treatment and (b) one month after the last treatment.
A 18-year old female patient with keratosis pilaris (Patient 5) showed Grade 3 improvement in the skin texture and Grade 3 improvement in dyspigmentation. The patients' self assessment was 'very satisfied' (>75% improvement). (a) Before the first treatment and (b) one month after the last treatment.
A 24-year old female patient with keratosis pilaris (Patient 8) showed Grade 4 improvement in the skin texture and Grade 4 improvement in dyspigmentation. The patients' self assessment was 'very satisfied' (>75% improvement). (a) Before the first treatment and (b) one month after the last treatment.
Skin biopsy taken from the skin on the back of Patient 5. (a) Before the first treatment and (b) one month after the last treatment. The features of mild hyperkeratosis, perivascular mononuclear cell infiltration and follicular plugging improved after treatment (H&E, ×100).
Summary of the clinical outcome
Keratosis pilaris (KP) is a keratinization disorder that is characterized by follicular hyperkeratosis, with surrounding erythema. Topical treatments are widely used, but their effects are limited. To evaluate the effectiveness of the Q-switched 1064-nm Nd:YAG laser for the treatment of KP. Total of 12 patients with KP were treated with a Q-switched 1064-nm Nd:YAG laser. Ten sessions of laser treatment were delivered once every two weeks. The entire lesions were treated with the following laser settings: 4.0~5.0 J/cm(2), 4-mm spot size, and three passes. Two dermatologists' clinical evaluations and patients' satisfaction were assessed between before treatment (baseline) and at 1 month after the last treatment. Eleven of the twelve patients showed more than grade 2 (>25%) improvement in texture and dyspigmentation in KP lesions, respectively. A half of the patients (50%) showed more than 50% improvement in the skin texture. Regarding dyspigmentation, five patients (41.7%) showed more than 50% improvement. Eleven out of twelve participants were satisfied (>25% of the Patients' self assessment) with the procedure. No significant adverse effect was observed. Although the Q-switched 1064-nm laser treatment may not be the first line therapy for KP, it might be a new treatment option for the patients with recalcitrant KP.
 
The clinical characteristics and the operative dada of penile verrucous carcinomas
The morphologies and invading site of penile verrucous carcinoma. The exophytic tumor of the glans penis invading the coronoid sulcus is shown in (A) from the patient No. 7 in the Table 1. The exophytic tumor located at glans is shown in (B) from the patient No. 6 in the Table 1.
Verrucous carcinoma (H&E, ×100). Verrucous carcinoma showing hyperkeratosis, parakeratosis, acanthosis with bulbous downward projections into the dermis and well-differentiated tumor cells.
The clinical characteristics and the operative dada of penile verrucous carcinomas
Penile verrucous carcinoma is a rare, well-differentiated and low-grade tumor. The surgeons are deficiently aware about the biological behavior and the clinicopathological characteristic of this disease, which raises difficulties during the treatment. In our present study, the clinical and pathological data of 11 patients with penile verrucous carcinoma, aged between 49 to 85 years was retrospectively analyzed. The tumors exhibited exophytic, papillary, caulifower-like or verrucose lesions of great dimensions measuring between 2 to 10 cm on the penises. The tumors were located at glans in 6 cases, invaded the coronoid sulcus in 4 cases and invaded the shaft of the penis in 1 case. Eight cases underwent partial penectomy, while the other 3 were treated with local excision. The diagnosis of penile verrucous carcinoma was confirmed by histopathologic examination of the specimens with the negative surgical margins in all the cases. Within the period of 12 to 60 months of follow-up, all the patients were disease-free with no case of recurrence and metastasis. The novel knowledge and experience of the treatment of penile verrucous carcinoma will be a useful clinical guide for surgeons in the future.
 
Vitiligo is an acquired depigmentary disorder of the skin that results from the loss of functioning epidermal melanocytes. Most studies on vitiligo have concentrated on the abnormality of melanocytes rather than the abnormality of keratinocytes; however, epidermal melanocytes form a functional and structural unit with neighboring keratinocytes. In fact, direct cell-to cell contact stimulates in vitro proliferation of melanocytes, and growth factors produced by adjacent keratinocytes regulate the proliferation and differentiation of melanocytes. The potential role of keratinocyte-derived cytokines has also been presented. We focused on the structural changes in vitiliginous keratinocytes, which may result in loss of melanocytes, to examine the pathomechanism of vitiligo. The results of a comparison between depigmented and normally pigmented epidermis in patients with vitiligo showed that the keratinocytes in the depigmented epidermis were more vulnerable to apoptosis. Impaired Phosphatidylinositol 3-kinase (PI3K)/serine/threonine protein kinase (Akt) activation followed by reduced nuclear factor-κB activation under increased tumor necrosis factor-α levels was demonstrated as a mechanism for keratinocyte apoptosis. The role of aquaporin 3 in keratinocyte apoptosis was addressed based on the relationship between the PI3K/AKT pathway and the E-cadherin-catenin complex. Apoptotic keratinocytes induced a lower expression of keratinocyte-derived factors, including stem cell factor, in depigmented epidermis, resulting in passive melanocyte death.
 
Immunoblotting analysis using epidermal extracts showed IgA aAbs bound to the 120 kDa antigen. M: protein molecular marker, BP: bullous pemphigoid serum, PV: pemphigus vulgaris serum, Pt: patient serum. 
Chronic bullous disease of childhood (CBDC) is an autoimmune blistering disease that is characterized by Immunoglobulin A (IgA) deposits at the basement membrane zone. IgA autoantibodies (aAbs) from the serum of patients with CBDC react with antigens of 97 kDa (LABD97) and 120 kDa (LAD-1), and both of which are fragments of the extracellular domain of bullous pemphigoid 180 (BP180, type XVII collagen). The CBDC sera reacts with the immunodominant NC16a domain of BP180, which is the major region recognized by IgG aAbs in patients with bullous pemphigoid. A five-year-old boy presented with multiple pruritic tense blisters on the umbilical and inguinal areas for six weeks. The direct immunofluorescence of the perilesional area demonstrated linear deposits of IgA at the basement membrane zone. Using immunoblotting and an enzyme linked immunosorbent assay (ELISA), we identified the IgA aAbs reactive to antigens with a molecular weight of 120 kDa (LAD-1), which is a fragment of the extracellular domain of BP180.
 
Many variants of dermatofibromas have been described, and being aware of the variants of dermatofibromas is important to avoid misdiagnosis. We wanted to evaluate the clinical and pathologic characteristics of 122 cases of dermatofibromas. We retrospectively reviewed the medical records and 122 biopsy specimens of 92 patients who were diagnosed with dermatofibroma in the Department of Dermatology at Eulji Hospital of Eulji University between January 2000 and March 2010. Nearly 80% of the cases occurred between the ages of 20 and 49 years, with an overall predominance of females. Over 70% of the lesions were found on the extremities. The most common histologic variant was a fibrocollagenous dermatofibroma (40.1%). Other variants included histiocytic (13.1%), cellular (11.5%), aneurysmal (7.4%), angiomatous (6.5%), sclerotic (6.5%), monster (4.9%), palisading (1.6%) and keloidal dermatofibromas (0.8%). There were 9 dermatofibromas (7.3%) that were the mixed type with two co-dominant histologic features. The results of this study are consistent with previous reports on the clinical features of dermatofibromas. However, we observed several characteristic subtypes of dermatofibroma and we compared the frequency of the histologic subtypes.
 
Subcutaneous panniculitis-like T-cell lymphoma (SPTL) is a distinctive skin lymphoma characterized by neoplastic T-cell infiltration of the subcutaneous tissue, mimicking panniculitis. To describe the clinical and pathologic features of SPTL in Korean patients. Fourteen SPTL patients evaluated over 15 years were retrospectively reviewed. The mean patient age was 35 years (range: 7~73 years), with male predominance (2.5:1). Most patients presented with either nodules or plaques, occurring most commonly on the trunk, with two patients (14%) having hemophagocytic syndrome. Histopathologically, all patients showed infiltrates of small-to-medium pleomorphic cells mimicking panniculitis, with some also showing rimming, bean-bag cells, and fat necrosis. Most patients were positive for CD3 (14/14), CD8 (12/13), TIA-1 (9/9) and βf1 (5/5), but were negative for CD4 (11/12), CD20 (8/8), CD56 (14/14) and Epstein-Barr virus (8/8). Ten patients (71%) received chemotherapy and 2 (14%) died due to the disease, with an average survival time of 4 months. Survival analysis did not reveal any significant prognostic factors. This is the first series of patients with SPTL in Korea. Due to its indolent clinical course and relatively high survival rate, SPTL should be differentiated from cutaneous γδ T-cell lymphoma.
 
Evidence for superior outcome by adhering to therapy guidelines is imperative to their acceptance and adaptation for the optimal management of disease variants. Comparative study of prospective outcomes in simultaneous consideration of independent variables in groups of 150 patients of plaque psoriasis either treated adhering to or in digression of standard guidelines. The psoriasis area severity index (PASI) and the dermatology life quality index (DLQI), prior to and after three months of uninterrupted therapy were examined in treatment groups among 150 patients. Recovery rates of 75% or more in PASI were compared. Independent variables were also examined for their bearing on the outcome. The vast majority was early onset disease phenotype. All three treatment regimens when administered in adherence to the guidelines yielded significantly superior rates of defined recovery both in PASI and DLQI. Compromise of the therapeutic outcome appeared in high stress profiles, obesity, female sex and alcohol, tobacco or smoking habit. Conventional drug therapy of plaque psoriasis yields superior outcome by adhering to the consensus guidelines. Psychiatric address to stress must be integral and special considerations for phenotypic/syndromic variants is emphasized for effective therapy of psoriasis.
 
Subtypes of rosacea and their characteristics* 
Precipitating and relieving factors of rosacea 
Patients with primary and secondary features (%) 
Relationship between degree of sun exposure and each subtype* 
Although rosacea is a chronic cutaneous inflammatory disorder that's commonly seen in adults, the etiology and pathogenesis of the illness remain unclear. A well established diagnostic classification and grading system may play a critical role in performing research and it would serve as a diagnostic reference in the clinical field. We sought to classify the patients with the new standard classification and grading system and we wanted determine the peculiar features and relationships of each subtype. We also analyzed the relationships between the degree of sun exposure and each subtype. We reviewed the medical records and clinical photos of 168 patients who were diagnosed with rosacea from 2002 to 2007 at our hospital. The standard classification and grading system suggested by the National Rosacea Society (NRS) Expert Committee was adopted to evaluate each patient's subtype and the severity. The male:female ratio was 1:2.29. The mean age at the time of diagnosis was 47.8 years. The mean duration of disease was 3.5 years. Sun exposure and hot baths/exercise were the two most common precipitating factors, while the majority of patients did not have any specific factor that relieved their symptoms. According to the NRS classification and grading system, the patients were classified into four subtypes. One hundred sixty two (96.4%) patients were diagnosed with the erythematotelangiectatic subtype irrespective of severity. Eighty five (50.6%) patients had the papulopustular subtype and 24 (14.3%) patients had ocular rosacea. Eight (4.8%) patients displayed mild phymatous change. The degree of sun exposure had significant correlation with the development and severity of the erythematotelangiectatic subtype (p<0.05), while it had no correlation with the papulopustular, ocular and phymatous subtypes. Although the erythematotelangiectatic subtype was the most common subtype of rosacea, many patients also had other subtypes of rosacea simultaneously. Based on our results, we proved that ocular rosacea is an extension of the clinical spectrum of erythematotelangiectatic rosacea. In addition, the results of our study particularly suggest that sun exposure has a different influence on each subtype of rosacea.
 
The pathogenesis of psoriasis may involve the interleukin (IL)-23 and Th17-mediated immune responses. Th17 cells secret IL-17 and IL-22, which mediates dermal inflammation and acanthosis. As inhibitor of nuclear factor κB kinase-α (IKKα) has been previously identified as a primary regulator of keratinocyte differentiation and proliferation, we proposed that IL-17 and IL-22 might affect keratinocyte differentiation by changing the expression of IKKα. We employed HaCaT cells maintained culture medium at a low calcium concentration (0.06 mM) and induced differentiation by switching to the high concentration (2.8 mM) media with IL-17 or IL-22, then compared the IKKα expression and the cell cycle. We employed reconstituted human epidermal skin (Neoderm) and mice ears for the in vivo studies. Elevated calcium concentration induced IKKα expression and terminal differentiation with cell cycle arrest in HaCaT cell cultures. Moreover, IL-17 and IL-22 treatment also induced IKKα in HaCaT cells and reconstituted human epidermis. IKKα induction was also noted, following the injection of IL-17 and IL-22 into mice ears. Although the induction of IKKα was accompanied by keratinocyte differentiation, IL-17 and IL-22 did not affect calcium-mediated differentiation or the cell cycle. Rather, IL-17 and IL-22 appear to contribute to the inflammation occurring via the induction of IKKα from keratinocytes or skin layers.
 
AKR1C3 protein was expressed on normal skin tissue, diabetic skin tissue by western blot analysis. Beta actin used as a loading control in western blot analysis.
The median of normal skin tissues was 0.935 (interquartile range, 0.911 to 0.973), and the median of diabetic skin tissues was 0.698 (interquartile range, 0.671 to 0.781). There were significant differences AKR1C3 protein expression between normal skin and diabetic skin(Mann-Whitney U test, p<0.05).
Representative immunohistochemistry staining for AKR1C3 protein expression in paraffin-embedded normal skin tissue (A: strongly positive immunostaining, ×200), diabetic skin tissue (B: weak positive immunostaining, ×200).
Diabetes is characterized by chronic hyperglycemia, and hyperglycemia can increase reactive oxygen species (ROS) production from the mitochondrial electron transport chain. The formation of ROS in cells induces oxidative stress and activates oxidative damage-inducing genes. There is no research on the protein levels of oxidative damage-related genes AKR1C3 in human diabetic skin. We explored the expression of AKR1C3 in diabetic skin compared with normal skin tissue. To compare the expression of AKR1C3 in normal skin versus diabetic skin. AKR1C3 expression was evaluated by western blotting in 6 diabetic skin tissue samples and 6 normal skin samples. Immunohistochemical staining was carried out to analyze AKR1C3 expression in the 6 diabetic skin tissue samples (July 2009 to December 2011; Department of Plastic and Reconstructive Surgery at Soonchunhyang University Seoul Hospital, Seoul, Korea). The western blotting showed a significant reduction in AKR1C3 protein expression in diabetic skin tissue compared to normal tissue. Immunohistochemical examination of AKR1C3 showed that it was weakly expressed in all diabetic skin samples. We believe that AKR1C3 is related to diabetic skin in altered metabolic states which elevate ROS production.
 
Polymerase chain reaction-restriction fragment length polymorphism analysis of the PTPN22 gene 1858 C/T polymorphism obtained by 2% agarose gel electrophoresis. Lane M shows 100~1,500 bp DNA ladder (Bio Basic Inc.). Lanes 1, 2 and 3 show subjects with homozygous alleles (C/C) with one intact band. Lanes 4, 5 and 6 show subjects with heterozygous alleles (C/T) showing digestion of the 400 bp product into 238 bp and 162 bp bands. No subject with homozygous allele (T/T) was observed.
Demographic characteristics of the study group
Genotype distributions and allele frequencies of PTPN22 +1858 C/T polymorphism in vitiligo patients and healthy control
Vitiligo is an autoimmune polygenic disorder characterized by loss of pigmentation due to melanocyte destruction. The PTPN22 gene +1858 C>T single nucleotide polymorphism (rs2476601) has been shown to be associated with various autoimmune disorders. The aim of this study was to investigate whether the PTPN22 gene +1858 C>T single nucleotide polymorphism is associated with susceptibility to generalized vitiligo in a Turkish population. One hundred and seven patients with generalized vitiligo, and one hundred and twelve gender-, age-, and ethnic-matched controls were enrolled in the study. Genotyping was done by polymerase chain reaction-restriction fragment length polymorphism. The PTPN22 +1858 C>T genotype and allele frequencies of the generalized vitiligo patients did not differ significantly from those of healthy controls. We found no association between the PTPN22 +1858 C>T gene polymorphism and vitiligo susceptibility in Turkish generalized-vitiligo patients.
 
Brown crusted nodules of various sizes, with a gray patch on the right pubic area.
Microscopic view of islands of cells, with peripheral palisading and haphazard arrangement of the more centrally located cells. Retraction spaces are present between the tumor islands and the surrounding stroma. Mucin-containing cystic spaces are visible at the centers of the tumor islands (H&E, ×40).
Reported cases of basal cell carcinama on the non-sun-exposed areas in Korean case literature and present case
Basal cell carcinoma (BCC) is one of the most commonly diagnosed malignant skin tumors and develops characteristically on sun-exposed areas, such as the head and neck. Ultraviolet light exposure is an important etiologic factor in BCCs, and BCCs arising from non-sun- exposed areas are, therefore, very rare. In particular, the axilla, nipple, the genital and perianal areas are not likely to be exposed to ultraviolet light; thus, if BCC develops in these areas, other predisposing factors should be considered. Herein, we report a case of BCC arising on the pubic area in a 70-year-old man. We also performed a survey of the literature and discussed the 19 cases of BCC from non-sun-exposed areas reported to date in Korea.
 
Global Assessment Scale (GAS) scores by the physicians and patients at 16 weeks after treatment. 
Assessment by physicians for erythema, the pigmentary changes and hypertrophic scarring at 16 weeks after treatment. 
There are various treatment options for congenital melanocytic nevus (CMN), including surgical excision, dermabrasions, curettage, laser treatment, chemical peels and cryosurgery. The proper choice of treatment depends on the size, location, thickness and clinical appearance of the nevi, the risk for developing melanoma, the psychological effect and the cosmetic component. THE PURPOSE OF THIS STUDY IS TO EVALUATE THE OUTCOME OF A COMBINATION OF SURGICAL EXCISION WITH ER: YAG laser ablation for treating CMNs. A total of 13 patients were included in this study. The nevus was excised as much as possible and only dermal suturing was performed, without epidermal suturing, for the primary closure. We then ablated the whole lesion, including the suture lines, by using a dual-mode 2,940 nm Er:YAG laser with three to five passes. All the lesions were followed up for 6 months and they were evaluated with respect to the healing status, infection, erythema, scarring, textural change and pigmentary change. Subject satisfaction was scored at the 16(th) week by the patients. Eleven (83%) of the 13 patients were clinically rated as having a good to excellent result by the physicians' Global Assessment Scale (GAS) scores for the lesions' reduction of size, the degree of scarring and the pigmentary change with only a one stage procedure. 10 (77%) of the total 13 patients reported a good to excellent result at four months after treatment. A combination of surgical excision with Er:YAG laser ablation as a one stage procedure is a safe, effective modality and it should be considered as one of the options for treating medium-sized CMNs.
 
Although acne is a common follicular inflammatory dermatosis, studies of the relationship between Malassezia yeasts and acne have rarely been conducted. We sought to identify Malassezia yeasts from acne patients and establish a relationship between specific types of species of Malassezia and acne. Sixty acne patients were enrolled. Each strain obtained was identified as one of eleven species by 26S rDNA PCR-RFLP. We then compared these data with those of age- and sex-matched healthy subjects. Growth of Malassezia was evident in fewer patients with acne (50%) in comparison to controls (70.6%). M. restricta was dominant in patients with acne (23.9%), whereas M. globosa was most common (26.7%) in healthy controls. In the patients group, the rate was the highest (71.7%) in the twenties and, in terms of body site, the rate was the highest (60%) in the chest. In the control group, the rate was the highest (75.0%) in the thirties and in the forehead (85.0%). The detection rate of Malassezia yeasts was conspicuously low in the acne patients group. Statistically significant differences were observed between the patient and the control groups in the twenties and thirties, and in terms of body site, in the forehead and chest.
 
The frequency of co-culture of different Malassezia species in one media.
The recovery rate of Malassezia species according to the body sites
Identified Malassezia species from the body sites -26S rDNA PCR-RFLP analysis 
Malassezia yeasts are normal flora of the skin that are discovered in 75~98% of health subjects, but since its association with various skin disorders have been known, many studies have been conducted in the distribution of the yeasts. To isolate, identify, and classify Malassezia yeasts from the normal human skin of Koreans by using the rapid and accurate molecular biology method (26S rDNA PCR-RFLP) which overcome the limits of morphological and biochemical methods, and to gather a basic database that will show its relation to various skin diseases. Malassezia yeasts were cultured from clinically healthy human skin using scrub-wash technique at five sites (forehead, cheek, chest, upper arm, and thigh) and swabbing technique at scalp in 160 participants comprised of 80 males and 80 females aged from 0 to 80. Identification of obtained strains were placed into the one of the 11 species by 26S rDNA PCR-RFLP. An overall positive culture rate was 62.4% (599/960). As shown in the experiment groups by their age, the positive culture rate was the highest (74.2%) in the age 21~30 and 31~40 (89/120). In the experiment groups by different body areas, the scalp showed the highest positive culture rate of 90% (144/160). On analysis of 26S rDNA PCR-RFLP, M. globosa was the most predominant species in the age 0~10 (32.8%), 11~20 (28.9%), 21~30 (32.3%). M. restricta was identified as predominant species in the age 41~50 (27.9%), 61~70 (31.5%) and 71~80 (24.0%). In the age 31~40 years, M. sympodialis was found to be the most common species (24.6%). According to body site, M. restricta was more frequently recovered in the scalp (56.8%), forehead (39.8%) and cheek (24.0%) and while M. globosa was more frequently recovered in the chest (36.8%). Higher positive culture rates of Malassezia yeasts were shown in male subjects than female counterparts in all body areas except scalp (p<0.05). Especially in this study, M. dermatis, newly isolated Malassezia species from atopic dermatitis patient in Japan, was isolated and identified in 19 cases (1.9%) in healthy subjects. The key is to recognize the existence of a difference in the type of Malassezia species in different ages as well as body areas, which reflects differing skin lipid levels in various ages and different body areas. Moreover, 26S rDNA PCR-RFLP analysis which was opted in this study could provide a sensitive and rapid identification system for Malassezia species, which may be applied to epidemiological surveys and clinical practice.
 
The rate of detecting the Malassezia species according to the age group 
The rate of detecting the Malassezia species according to the body site 
So far, studies on the inter-relationship between Malassezia and Malassezia folliculitis have been rather scarce. We sought to analyze the differences in body sites, gender and age groups, and to determine whether there is a relationship between certain types of Malassezia species and Malassezia folliculitis. Specimens were taken from the forehead, cheek and chest of 60 patients with Malassezia folliculitis and from the normal skin of 60 age- and gender-matched healthy controls by 26S rDNA PCR-RFLP. M. restricta was dominant in the patients with Malassezia folliculitis (20.6%), while M. globosa was the most common species (26.7%) in the controls. The rate of identification was the highest in the teens for the patient group, whereas it was the highest in the thirties for the control group. M. globosa was the most predominant species on the chest with 13 cases (21.7%), and M. restricta was the most commonly identified species, with 17 (28.3%) and 12 (20%) cases on the forehead and cheek, respectively, for the patient group. Statistically significant differences were observed between the patient and control groups for the people in their teens and twenties, and in terms of the body site, on the forehead only.
 
This case-control study concerns a molecular biological method based on the data gathered from a group of Korean subjects to examine the distribution of Malassezia yeasts in seborrheic dermatitis (SD) patients. Cultures for Malassezia yeasts were taken from the foreheads, cheeks and chests of 60 patients with SD and in 60 healthy controls of equivalent age. The purpose of this study is to identify the relationship between certain species of Malassezia and SD. This was done by analyzing the differences in the distribution of Malassezia species in terms of age and body parts of the host with healthy controls. 26S rDNA PCR-RFLP, a fast and accurate molecular biological method, was used to overcome the limits of morphological and biochemical methods. The positive Malassezia culture rate was 51.7% in patients with SD, which was lower than that of healthy adults (63.9%). M. restricta was dominant in patients with SD (19.5%). Likewise, M. restricta was identified as a common species (20.5%) in healthy controls. In the ages 31~40, M. restricta was found to be the most common species (31.6%) among SD patients. According to the results of the study, the most frequently isolated species was M. restricta (19.5%) in patients with SD. There was no statistically significant difference in the distribution of Malassezia species between the SD patients and healthy control groups.
 
Multiple sharply demarcated erythematous plaques on the abdomen (A) and back (B) prominent nail pitting (C), scalp involvement (D), and extremities (E).
Histopathologic examination from the skin lesion revealed marked acanthosis, epidermal hyperplasia, and Munro's microabscess (H&E, ×100).
Reported cases of interferon-associated psoriasis in viral hepatitis
A 56-year-old man with chronic hepatitis C was treated with pegylated interferon alfa-2a in combination with ribavirin. However, psoriatic lesions appeared and worsened dramatically during therapy. Because of the extensive skin eruptions, he stopped therapy for chronic hepatitis C and subsequently started narrow-band ultraviolet B phototherapy and topical calcipotriol/betamethasone dipropionate ointment. After this, the psoriasis improved in a slow but comprehensive manner. Our case suggests that physicians should keep in mind the possibility of psoriasis as a side effect of interferon treatment for chronic hepatitis C.
 
Well defined multiple papules and nodules on lips (A) and tongue (B).  
Tissue from lips: (A) Nerves of dermis were enlarged and hypercellular (H&E, ×20). (B) Fascicles of Schwann cells were arranged in interlacing patterns (H&E, ×200).  
M918T mutation in the exon 16 of RET (arrows).  
Tissue from lips: (A) Immunohistochemical staining of the tumor body was positive for the S-100 protein (×40). (B) Immunohistochemical staining of the capsule was positive for EMA (×40).  
Multiple endocrine neoplasia type 2B (MEN 2B) is a rare disease caused by germline mutations in the RET proto-oncogene and is transmitted in an autosomal dominant fashion. It is characterized by medullary thyroid carcinoma, pheochromocytoma and mucosal neuroma developing in the tongue, lip, intestinal tract, palate etc. Among these neoplasias, mucosal neuroma generally develops from early childhood. Therefore, early detection and proper treatment can minimize the disease course. Here we describe a 9-year-old male who presented with multiple verrucous papules and nodules on his lips, tongue and gingiva that were there since birth. Histologic findings of his lips and tongue showed well-defined nerve bundles and DNA analysis revealed a M918T mutation at codon 918 of the RET oncogene. He was diagnosed early as having MEN 2B according to his genetic and phenotypic features.
 
Correlation between serum IL-31 protein level and IL-31 mRNA level in atopic dermatitis patients versus those of the controls 
IL-31 serum levels in patients with extrinsic and intrinsic types of AD versus those of non-atopic controls. AD: atopic dermatitis, ADe: allergic or extrinsic type of AD, ADi: non-allergic or intrinsic type of AD. 
(A) RT-PCR analysis of IL-31 expression using RNA extracted from skin biopsies. This analysis showed an increase in IL-13 mRNA in some atopic patients (1∼13). (B) The band intensity was quantified with ImageJ software (NIH), and the percentages were the ratio of optical intensity normalized to the GAPDH signal. The level of IL-31 mRNA in the controls (N1∼N4) was undetectable. (C) The IL-31 protein level in the serum from the patients in the RT-PCR experiment. Patients 1∼4, 9∼12 are ADe and patients 5∼8, and 13 are ADi. (D) Boxplot of IL-31/GAPDH mRNA(%) in pruritus score 0∼4 and 5∼10 levels. RT-PCR: reverse trascriptase polymerase chain reaction, GAPDH: glyceraldehyde-3-phosphate dehydrogenase, ADe: allergic or extrinsic type of AD, ADi: non-allergic or intrinsic type of AD. 
Severe pruritus is the primary symptom in atopic dermatitis (AD). Recently, the novel cytokine IL-31 has been implicated in the itching associated with AD. We performed this study to determine whether IL-31 serum levels are elevated in AD patients and to better characterize the relationship between serum IL-31 level and other established laboratory parameters. We recruited 55 AD patients, 34 with allergic type AD and 21 with non-allergic type AD, and 38 healthy, non-atopic controls. We checked the laboratory values, severity score, and serum IL-31 levels in all patients and controls, and IL-31 mRNA levels in lesion skin were measured in 13 subjects with AD and in four controls. AD patients displayed significantly higher levels of serum IL-31 that were associated with serum IgE, disease severity, and subjective itch intensity. In AD patients, IL-31 mRNA levels from the lesional skin samples also correlated with serum IL-31 level. IL-31 is likely one of the many mediators inducing inflammation and pruritus in AD. Although our limited sample size prevents us from making any definitive conclusions, our data demonstrate a strong correlation between IL-31 mRNA level and serum IL-31 protein level, which has never been reported before. Moreover, we found correlations between serum IL-31 level and serum IgE, eosinophil cationic protein, disease severity, and subject itch intensity in certain degrees in AD patients.
 
Percentage of correct answers of all questionnaires according to demographic characteristics 
Demographic information of patients with atopic dermatitis according to the treatment history by dermatology specialists 
Patients with atopic dermatitis (AD) should be relatively well informed about the disorder to control their condition and prevent flare-ups. Thus far, there is no accurate information about the disease awareness levels and therapeutic behavior of AD patients. To collect data on patients' knowledge about AD and their behavior in relation to seeking information about the disease and its treatment. We performed a questionnaire survey on the disease awareness and self-management behavior of AD patients. A total of 313 patients and parents of patients with AD who had visited the The Catholic University of Korea, Catholic Medical Center between November 2011 and October 2012 were recruited. We compared the percentage of correct answers from all collected questionnaires according to the demographic and disease characteristics of the patients. Although dermatologists were the most frequent disease information sources and treatment providers for the AD patients, a significant proportion of participants obtained information from the Internet, which carries a huge amount of false medical information. A considerable number of participants perceived false online information as genuine, especially concerning complementary and alternative medicine treatments of AD, and the adverse effects of steroids. Some questions on AD knowledge had significantly different answers according to sex, marriage status, educational level, type of residence and living area, disease duration, disease severity, and treatment history with dermatologists. Dermatologists should pay more attention to correcting the common misunderstandings about AD to reduce unnecessary social/economic losses and improve treatment compliance.
 
Pincer nail is a nail deformity characterized by transverse overcurvature of the nail plate. Pincer nail can affect a patient's quality of life due to its chronic, recurrent course; however, there have been no clinical studies on the pincer nail condition in Korean patients. The purpose of this study was to characterize the clinical findings and treatment of pincer nail. In addition, possible etiological factors were considered, and treatment efficacy was evaluated. The medical records and clinical photographs of 35 patients (12 males, 23 females) who were diagnosed with pincer nail between August 1, 2005 and July 31, 2009 were studied. Patient age ranged from 10 to 77 (52.09±17.26) years, and there was a predominance of female (23 out of 35 patients, F:M=2:1). The mean duration of the disorder was 7.45 years (range 0.25~40); 85% had pincer nail for at least 1 year. In addition, 40% had a history of previous treatment and recurrence. There were 82.8% patients with the common type of pincer nails. The most commonly involved nails were both great toenails. Among 35 patients, nail grinding was started in 30 patients, and 25 patients showed clinical improvement with nail grinding. The width index increased and the height index decreased after treatment. The mean follow up period was 8.42 months (range 1~27), and 7 patients showed recurrence after 8.8 months (range 2~20). Among 35 patients, 5 patients were treated with nail extraction with matricectomy, and the symptoms resolved immediately. The mean follow up period was 7.6 months (range 0~19), and recurrence was not observed. Onychomycosis was also present in 37.1% of patients, and itraconazole pulse therapy for 3 months was added. The results of this study demonstrate the clinical features of pincer nail in Korean patients. The findings show that the common type of pincer nail was most common, and nail grinding as a conservative treatment greatly improved pincer nails despite a risk of recurrence. When onychomycosis was also present, oral antifungal therapy added to nail grinding resulted in a more rapid change in nail thickness and clinical improvement.
 
Multiple, pin-head sized, non-follicular pustules with an erythematous base on the trunk in case 36 (A) and the big folds of lower extremities in case 10 (B).  
Comparison of clinical findings between 2 groups 
Histopathologic findings of 36 patients with acute generalized exanthematous pustulosis 
Acute generalized exanthematous pustulosis (AGEP) is a rare and severe subtype of drug eruption, characterized by acute, extensive, non-follicular, sterile pustules on an erythematous background, accompanied by fever and leukocytosis. The purpose of this study was to characterize AGEP in Korean patients in terms of clinical, laboratory, and pathologic findings. Thirty-six patients (M:F=17:19) with AGEP were identified from an extensive review of medical records over a 15 year period. All patient cases were confirmed by biopsy and fulfilled the diagnostic criteria. The patient ages ranged from 4~80 years (37.6+/-19.4). The incubation period was 1~23 days. The duration of disease was 5~14 days. Neutrophilia (36/36), high CRP (14/36), and eosinophilia (30/36) were common laboratory findings. A history of drug administration existed in 23 of 36 patients; herbal medications, lacquers and radiocontrast media were the unique causative drugs. Spongioform subcorneal or intraepidermal pustules in the epidermis was observed in all patients. Thirty-six patients were subdivided into 2 groups: group A (n=23) was strongly associated with known agents; and group B (n=13) had no identified causative agents. There was no significant difference between the 2 groups. OUR RESULTS DEMONSTRATE THE CHARACTERISTIC FEATURES OF AGEP IN KOREAN PATIENTS AS FOLLOWS: lower identification of causative agents; herbal medications, lacquers, and radiocontrast media were the main causative agents; and no significant differences existed between the 2 groups.
 
The role of cathelicidin in the pathogenesis of rosacea and possible therapeutic implications. UV light increases the synthesis of vitamin D which induces cathelicidin expression in keratinocytes. ER stress is an alternative inducer of cathelicidin production. Increased protease activity in rosacea skin is possibly due to demodex mite colonization: Chitin released from mites triggers TLR2 receptor activation and increased protease activity. Subsequently, enhanced protease activity leads to increased cleavage of cathelicidin LL-37 and further fragments. These fragments trigger inflammation, erythema and telangiectasias. Doxycycline, azelaic acid and retinoids mediate their beneficial effects in rosacea possibly by interfering with this pro-inflammatory system through different mechanisms. UV: ultraviolet, ER: endoplasmic reticulum, TLR: Toll-like receptor.
Chronic inflammatory skin diseases such as atopic dermatitis, psoriasis or rosacea are very common. Although their exact pathogenesis is not completely understood all three diseases are characterized by dysregulation of cutaneous innate immunity. Cathelicidin LL-37 is an important effector molecule of innate immunity in the skin and atopic dermatitis, psoriasis or rosacea show defects in cathelicidin expression, function or processing. In atopic dermatitis, cathelicidin induction might be disturbed resulting in defective antimicrobial barrier function. In contrast, psoriasis is characterized by overexpression of cathelicidin. However to date it is unclear whether pro- or anti-inflammatory functions of cathelicidin predominate in lesional skin in psoriasis. In rosacea, cathelicidin processing is disturbed resulting in peptide fragments causing inflammation, erythema and telangiectasias. In this review, the current evidence on the role of cathelicidin LL-37 in the pathogenesis of inflammatory skin diseases will be outlined. As cathelicidin LL-37 might also serve as a future treatment target potential novel treatment strategies for those diseases will be discussed.
 
Characteristics and serum 25-hydroxyvitamin D levels of patients with atopic dermatitis 
Mean serum 25-hydroxyvitamin D concentration in the atopic dermatitis (AD) and control groups. *p<0.05. 
Correlations between SCORAD, body mass index (BMI), vitamin D concentration, and serum LL-37 levels. Significant inverse correlations were found between BMI and vitamin D levels, and between SCORAD scores and serum LL-37 levels. 
Vitamin D insufficiency could be associated with the prevalence of atopic dermatitis (AD). To examine vitamin D status and the relations between serum 25-hydroxyvitamin D levels, SCORAD score, serum LL-37 level, and body mass index (BMI) in Korean AD patients, and to explore whether these associations differ between adults and children. Serum 25-hydroxyvitamin D levels, serum LL-37, and clinical features were analyzed in a total of 72 Korean patients with AD (39 adults and 33 children) and 140 healthy control subjects (70 adults and 70 children). Serum 25-hydroxyvitamin D levels were significantly reduced in children with AD (15.06±4.64 ng/ml) compared with normal children in the control group (16.25±6.60 ng/ml) (p=0.036). Significant inverse correlations were found between BMI and 25-hydroxyvitamin D level (r=-0.315, p=0.007) and between the SCORAD score and serum LL-37 level (r=-0.3, p=0.011) in the total AD patients. The results showed that serum vitamin D levels were lower in children with AD than in healthy children; however, the same relation was not observed between adults with AD and healthy adults. Serum 25-hydroxyvitamin D concentration was not significantly correlated with AD severity or serum LL-37 levels in our study population.
 
Cell viability of vitamin U at different concentrations in 3T3-L1 cell lines. The results show a slight decrease in viability with higher concentrations of vitamin U. However, no statistically significant differences were observed.
Effect of vitamin U on the inhibition of adipocyte differentiation in Oil Red O staining, triglyceride (TG) assay and glycerol-3-phosphate dehydrogenase (G3PDH) activity assay. Oil droplets were abundant in differentiated adipocytes, and the number of oil droplets decreased with vitamin U treatment in a concentration-dependent manner (A, B). Consistent with the appearance of formed oil droplets, vitamin U significantly reduced cellular TG levels in a concentration-dependent manner (C). We found that vitamin U resulted in a significant inhibition of intracellular G3PDH (D). *Significant at p<0.05. ND: non-differentiated, NT: non-treated, Vit U: vitamin U, OD: optical density, G3PDH: glycerol-3-phosphate dehydrogenase.
Effects of vitamin U on the expressions of PPAR-γ, C/EBP-α, ADD-1, adipsin, FAS and LPL in 3T3-L1 adipocytes. The mRNA levels of C/EBP-α, ADD-1 and adipsin decreased, and both the mRNA and protein levels of PPAR-γ remarkably decreased with vitamin U treatment (A, B). DM: differentiated media, Vit U: vitamin U, PPAR-γ: peroxisome proliferator-activated receptor γ, C/EBP-α: CCAAT/enhancer binding protein α, FAS: fatty acid synthase, ADD-1: adipocyte differentiation and determination factor 1, LPL: lipoprotein lipase.
Effect of vitamin U on activation of AMP-activated protein kinase (AMPK) detected using western blotting. Protein levels of phosphorylated AMPK increased with vitamin U treatment in a dose-dependent manner during adipogenic differentiation (A, B). DM: differentiated media, Vit U: vitamin U, AMPK: AMP-activated protein kinase, ND: non-differentiated, NT: non-treated. *Significant at p<0.05.
Primer sequences for reverse transcription PCR
S-methylmethionine sulfonium chloride was originally called vitamin U because of its inhibition of ulceration in the digestive system. Vitamin U is ubiquitously expressed in the tissues of flowering plants, and while there have been reports on its hypolipidemic effect, its precise function remains unknown. This study was designed to evaluate the anti-obesity effect of vitamin U in 3T3-L1 pre-adipocyte cell lines. We cultured the pre-adipocyte cell line 3T3L1 to overconfluency and then added fat differentiation-inducing media (dexamethasone, IBMX [isobutylmethylxanthine], insulin, indomethacin) and different concentrations (10, 50, 70, 90, 100 mM) of vitamin U. Then, we evaluated changes in the levels of triglycerides (TGs), glycerol-3-phosphate dehydrogenase (G3PDH), AMP-activated protein kinase (AMPK), adipocyte-specific markers (peroxisome proliferator-activated receptor γ [PPAR-γ], CCAAT/enhancer-binding protein α [C/EBP-α], adipocyte differentiation and determination factor 1 [ADD-1], adipsin, fatty acid synthase, lipoprotein lipase) and apoptosis-related signals (Bcl-2, Bax). There was a gradual decrease in the level of TGs, C/EBP-α, PPAR-γ, adipsin, ADD-1 and GPDH activity with increasing concentrations of vitamin U. In contrast, we observed a significant increase in AMPK activity with increasing levels of vitamin U. The decrease in bcl-2 and increase in Bax observed with increasing concentrations of vitamin U in the media were not statistically significant. This study suggests that vitamin U inhibits adipocyte differentiation via down-regulation of adipogenic factors and up-regulation of AMPK activity.
 
Sorafenib (Nexavar®, BAY 43-9006) is a novel, orally administered multi-kinase inhibitor that has recently been approved for the treatment of metastatic renal cell carcinoma. It is also used to delay disease progression in patients with advanced solid organ malignancies and metastatic melanoma. Sorafenib is associated with a relatively high incidence of dermatologic adverse events. The commonly occurring dermatologic adverse events associated with sorafenib include hand-foot skin reaction, facial erythema, splinter subungual hemorrhages, alopecia, pruritus and xerosis. We report here on a case of a 50-year-old man who was diagnosed with metastatic hepatocellular carcinoma. He developed both facial erythema and hand-foot skin reaction after the administration of sorafenib.
 
We developed an ethanol extract of peanut sprouts (EPS), a peanut sprout-derived natural product, which contains a high level of trans-resveratrol (176.75 µg/ml) and was shown to have potent antioxidant activity. We evaluated the potential anti-inflammatory activity of EPS by measuring its antioxidant potential in skin. The anti-inflammatory activity of EPS was tested using two models of skin inflammation: oxazolone (OX)-induced contact dermatitis in mice and compound 48/80-treated HaCaT cells. As biomarkers of skin inflammation, cyclooxygenase-2 (COX-2) and nerve growth factor (NGF) levels were measured. OX-induced contact dermatitis was suppressed markedly in mice that were treated with an ointment containing 5% EPS as evidenced by a decrease in the extent of scaling and thickening (p<0.05) and supported by a histological study. COX-2 (messenger RNA [mRNA] and protein) and NGF (mRNA) levels, which were upregulated in the skin of OX-treated mice, were suppressed markedly in the skin of OX+EPS-treated mice. Consistent with this, compound 48/80-induced expression of COX-2 (mRNA and protein) and NGF (mRNA) in HaCaT cells were suppressed by EPS treatment in a dose-dependent manner. As an inhibitor of NF-κB, IκB protein levels were dose-dependently upregulated by EPS. Fluorescence-activated cell sorting (FACS) analysis revealed that EPS scavenged compound 48/80-induced reactive oxygen species (ROS) in HaCaT cells. EPS exerts a potent anti-inflammatory activity via its anti-oxidant activity in both mouse skin and compound 48/80-treated HaCaT cells in vitro. Compound 48/80-treated HaCaT cells are a useful new in vitro model of skin inflammation.
 
Cure rate and recurrence rate of total enrolled patients 
Cure rate and recurrence rate by subtypes 
Adverse events by treatment intervals 
Literature reviews of cryotherapy for viral warts 
Viral warts are a common infectious disease and liquid nitrogen cryotherapy is one of the most common methods for treatment of these warts. Hand-foot viral warts frequently recur and reduce quality of life as well. To find the ideal treatment interval between cryotherapy sessions that can influence not only the cure rate but also the recurrence rate for hand-foot viral warts. A retrospective study was designed to compare a 2 week interval and a 3 week interval between cryotherapy sessions on hand-foot viral warts with respect to cure rate, recurrence rate, treatment number, duration of treatment, mean time to recurrence and adverse events. A total of 560 patients were enrolled. The overall cure rate was 75.7% and the recurrence rate was 19.6%. The mean time to recurrence was 7.8 months (range 1~26 months). For the 2-week and 3-week groups, cure rates were, respectively, 76.6% (196) and 75.0% (228); recurrence rates were 13.3% (26) and 25.0% (57). The mean time to recurrence was 9.8 months and 6.9 months, respectively. Adverse events were not statistically different. We suggested that 2-week cryotherapy is optimal not only because of the rapid cure but also because of the lower recurrence rate and similar adverse events.
 
Although tinea unguium in children has been studied in the past, no specific etiological agents of onychomycosis in children has been reported in Korea. The purpose of this study was to investigate onychomycosis in Korean children. We reviewed fifty nine patients with onychomycosis in children (0~18 years of age) who presented during the ten-year period between 1999 and 2009. Etiological agents were identified by cultures on Sabouraud's dextrose agar with and without cycloheximide. An isolated colony of yeasts was considered as pathogens if the same fungal element was identified at initial direct microscopy and in specimen-yielding cultures at a follow-up visit. Onychomycosis in children represented 2.3% of all onychomycosis. Of the 59 pediatric patients with onychomycosis, 66.1% had toenail onychomycosis with the rest (33.9%) having fingernail onychomycosis. The male-to-female ratio was 1.95:1. Fourteen (23.7%) children had concomitant tinea pedis infection, and tinea pedis or onychomycosis was also found in eight of the parents (13.6%). Distal and lateral subungual onychomycosis was the most common (62.7%) clinical type. In toenails, Trichophyton rubrum was the most common etiological agent (51.3%), followed by Candida albicans (10.2%), C. parapsilosis (5.1%), C. tropicalis (2.6%), and C. guilliermondii (2.6%). In fingernails, C. albicans was the most common isolated pathogen (50.0%), followed by T. rubrum (10.0%), C. parapsilosis (10.0%), and C. glabrata (5.0%). Because of the increase in pediatric onychomycosis, we suggest the need for a careful mycological examination of children who are diagnosed with onychomycosis.
 
Clinical manifestations of the patient. (A) Numerous fingertipsized bullae and vesicles with crusts on both soles. (B) Solitary vesicle on right thumb finger.  
Family pedigree and genetic study of patient. (A) The patient, his father, and his sister were affected. His mother was unaffected. (B) Replacement of the nucleotide thymine to cytosine in KRT5, exon 2. (C) The same mutation was detected in the patient and father. This differed from the mother and control as observed by restriction enzyme analysis using Pst I.  
Schematic representation of the mutation sites on keratin 5 and 14 in Weber-Cockayne type epidermolysis bullosa simplex from literature and this case.  
Blister formation on suprabasal layer with scanty inflammatory cell infiltration in the skin biopsy (H&E, ×40).  
Epidermolysis bullosa simplex (EBS), an inherited genetic disorder, is most often caused by a dominant-negative mutation in either the keratin 5 (KRT5) or the keratin 14 (KRT14) gene. These keratin mutants result in a weakened cytoskeleton and cause extensive cytolysis. It is important to analyze the KRT5 or KRT14 genes of the patient and their family members by mutational analysis in order to identify genetic defects as well as the need for genetic counseling. In this study, we present a 5-year-old Korean boy who had been developing blisters and erosions on the palms of his hands and soles of his feet since infancy. In addition, while his younger sister and father showed similar clinical manifestation, his mother did not. The patient was diagnosed with EBS based on clinical manifestation, which is characterized by the presence of blisters restricted to the palms and soles, histological findings, and mutational analysis. Mutational analysis of the patient's DNA revealed a thymine-to-cytosine transition at codon 608 in the KRT-5 gene, resulting in a leucine-to-proline substitution in the keratin 5 protein. The same mutation was identified in the paternal, but not maternal, DNA. Here, we report a case of Weber-Cockayne type EBS with vesicles and bullae restricted to the palms and soles with a novel, paternally inherited mutation in KRT5 gene (exon2, c.608T>C).
 
The gene expression levels of inflammatory biomarkers in cultured human sebocytes treated with ultraviolet A (UVA) radiation (2 J/cm 2 , 3 J/cm 2 , and 5 J/cm 2 ) did not show significant changes compared to those in the controls. However, gene expression of tumor necrosis factor (TNF)-α was significantly decreased in UVA-treated sebocytes (3 J/cm 2 or 5 J/cm 2 ) compared to the control (*p<0.05). In addition, matrix metalloproteinase (MMP)-9 gene expression was significantly decreased in UVA-treated cells (2 J/cm 2 , 3 J/cm 2 , and 5 J/cm 2 ) compared to the control (*p<0.05). The expression level of each gene was normalized to that of β-actin and presented as a relative ratio. Error bars represent standard errors calculated based on three independent experiments. IL: interleukin, hBD: human β-defensin. 
The protein expression levels of interleukin (IL)-1β, IL-6, and IL-8 in cultured human sebocytes treated with ultraviolet A (UVA) radiation and light at wavelengths of 650 nm and 830 nm did not show significant change compared to those in the controls. The expression of tumor necrosis factor (TNF)-α protein was insignificantly decreased in sebocytes treated with UVA radiation and light at a wavelength of 650 nm compared to the control. Expression levels are presented as relative ratios. Error bars represent standard errors calculated based on three independent experiments. 
The gene expression of inflammatory biomarkers in cultured sebocytes treated with light at a wavelength of 650 nm did not show a significant change compared to that in the control. The expression level of each gene was normalized to that of β-actin and presented as a relative ratio. Error bars represent standard errors calculated based on three independent experiments. IL: interleukin, TNF-α: tumor necrosis factor-α, MMP: matrix metalloproteinase, hBD: human β-defensin. 
The gene expression levels of inflammatory biomarkers in cultured human sebocytes treated with light at a wavelength of 830 nm did not show a significant change compared to those observed in the control. The expression level of each gene was normalized to that of β-actin and presented as a relative ratio. Error bars represent standard errors calculated based on three independent experiments. IL: interleukin, TNF-α: tumor necrosis factor-α, MMP: matrix metalloproteinase, hBD: human β-defensin. 
Sebum production in cultured sebocytes treated with ultraviolet A (UVA) radiation and light at wavelengths of 650 nm and 830 nm showed an insignificant decrease compared to that in the control. Sebum production levels are presented as relative ratios. Error bars represent standard errors calculated based on three independent experiments. 
The effectiveness of ultraviolet (UV) radiation, visible light, or infrared light therapy for the treatment of acne is the subject of ongoing scientific debate. This study was conducted to investigate changes in sebum production and the expression of inflammatory cytokines, matrix metalloproteinases (MMPs), and antimicrobial peptides (AMPs), following exposure of cultured human sebocytes to UVA radiation and light at wavelengths of 650 nm and 830 nm. Reverse transcription polymerase chain reaction assays were performed to measure the gene expression levels of inflammatory cytokines (interleukin [IL]-1β, IL-6, IL-8, and tumor necrosis factor-α), MMPs (MMP-1, MMP-3, and MMP-9), and AMPs (psoriasin, hBD-2, hBD-3, and LL-37) in cultured sebocytes after exposure to UVA radiation (2 J/cm(2), 3 J/cm(2), and 5 J/cm(2)) and light at wavelengths of 650 nm (14 J/cm(2), 29 J/cm(2), and 87 J/cm(2)) and 830 nm (5 J/cm(2), 10 J/cm(2), and 30 J/cm(2)). Expression of inflammatory cytokine proteins and sebum production were measured using enzyme-linked immunoassays and a lipid analysis kit, respectively. Exposure of cultured sebocytes to UVA radiation and light at wavelengths of 650 nm and 830 nm did not show a significant increase in the expression of inflammatory cytokines, MMPs, or AMPs. Sebum production was not significantly decreased after exposure to UVA radiation and light at both wavelengths. We propose that UVA radiation, visible light, and infrared light can be used to target Propionibacterium acnes for the treatment of acne, without an increase in the expression of inflammatory biomarkers and sebum production.
 
Mean duration from vesicle formation to when the lesion crust fell off.
Repeated measures of mean VAS scores of the control and experimental groups from day 0 to 14. Differences in VAS were marginally significant between the two groups according to the repeated measure of ANOVA (p=0.095). VAS: visual analogue scale.
The control group (group A). (A) Erythematous grouped vesicles appeared in a unilateral fashion following right ophthalmic division of the trigeminal nerve. (B) Three weeks after the LED treatment, the skin lesion moderately improved, but there still remained the erythematous scarring and hyperpigmentation. LED: light-emitting diode.
The experimental group (group B). (A) Grouped vesicles and crust appeared in a unilateral fashion following left ophthalmic division of the trigeminal nerve, involving primarily the left forehead, which were extended to ipsilateral nose at the baseline. (B) 3 weeks after the LED treatment, the skin lesion markedly improved. LED: light-emitting diode.
Demographic profile and concomitantly used medications of patients with herpes zoster ophthalmicus
Background: Skin lesions and pain are the most distinctive features of herpes zoster. Light-emitting diode (LED) therapy is an effective treatment known for its wound-healing effects. Objective: To determine whether the LED treatment affects wound healing and acute pain in acute herpes zoster ophthalmicus. Methods: We recruited 28 consecutive Korean patients with acute herpes zoster ophthalmicus for the study. In the control group (group A), 14 subjects received oral famcyclovir. In the experimental group (group B), 14 subjects received oral famcyclovir and 830 nm LED phototherapy on days 0, 4, 7, and 10. In order to estimate the time for wound healing, we measured the duration from the vesicle formation to when the lesion crust fell off. The visual analogue scale (VAS) was used for the estimation of pain on days 4, 7, 10, and 14. Results: The mean time required for wound healing was 13.14±2.34 days in group B and 15.92±2.55 days in group A (p=0.006). From day 4, the mean VAS score showed a greater improvement in group B, compared with group A. A marginal but not statistically significant difference in the VAS scores was observed between the two groups (p=0.095). Conclusion: LED treatment for acute herpes zoster ophthalmicus leads to faster wound healing and a lower pain score.
 
Patient demographics and family history of AA 
Comorbid disorders 
Serologic test results 
Probability of abnormal laboratory findings 
Alopecia areata (AA) is a common dermatologic condition with a broad spectrum of clinical features and age of onset, classically characterized by nonscarring patches of hair loss. In the past, early-onset (before adolescence) AA has been associated with various autoimmune diseases, especially atopic diseases and lupus erythematosus and demonstrates a worse prognosis compared with late onset AA. To evaluate the differences in the comorbidity profile of AA with regard to age at onset. We completed a retrospective study of 871 Korean AA patients seen at our department within the last 10 years. After these patients were subdivided according to onset before or after age 13 years, the two groups were compared on the basis of their comorbid disorders, family history of AA, and hematologic test results. Our results demonstrate that significantly more patients in the early-onset group had a personal history of atopic dermatitis or family history of AA. These findings are consistent with previous reports associating early-onset AA with autoimmune diseases and a family history of AA in different ethnic populations. Most of the serologic test values showed no significant differences between the groups and the results were considerably affected by age. This study is significant because it is a large group study in Korean AA patients, and Korean AA patients with an onset age before adolescence show similar clinical manifestations to other ethnic populations.
 
Characteristics of the patients with pityriasis rosea treated with UVA1 phototherapy and the treatment regimen
Clinical features of pityriasis rosea before (A) and after (B) UVA1 phototherapy. The patient was subsequently treated with UVA1 5 times, commencing at 10 J/cm 2 and increasing to a maximum 30 J/cm 2 , and the cumulative dose was 110 J/cm 2 .  
Clinical features of pityriasis rosea before (A) and after (B) UVA1 phototherapy. The patient was subsequently treated with UVA1 8 times, commencing at 10 J/cm 2 and increasing to a maximum 30 J/cm 2 , and the cumulative dose was 160 J/cm 2 .  
Pityriasis rosea severity score (PRSS) during UVA1 phototherapy. The data is shown as means±SDs. The asterisk indicates a statistically significant difference between the baseline values and the measured values. n=14, *p<0.05; † p< 0.01, paired-t test (vs. T0).
UVA1 phototherapy has recently demonstrated high levels of efficacy and tolerability for treating a variety of inflammatory and neoplastic skin diseases. The purpose of the present study was to assess the clinical efficacy of UVA1 (340~400 nm) phototherapy for treating pityriasis rosea and to assess the course of the disease after treatment. Fifteen patients with extensive pityriasis rosea were treated with low-dose UVA1 phototherapy (starting at 10~20 J/cm(2) and then it was increased to 30 J/cm(2)). The treatments were given 2~3 times a week until complete clearance of lesions was achieved or until there was partial improvement without further amelioration, in spite of 5 additional treatments. The rate of clearing was monitored by estimating the pityriasis rosea severity (PRSS) score and the pruritus score. The extent of disease (PRSS) in all 15 patients lessened during the study (30.1+/-3.6 vs. 2.0+/-1.6, respectively, p<0.05). The overall reduction of the PRSS showed a significant improvement after the second or third treatment. The pruritus of 12 of 15 patients lessened during the treatment period, and it was unchanged in the remaining 3 patients. The mean previous duration of disease was 11.2+/-4.9 days and this did not interfere with the successful outcome of UVA1 phototherapy. This study shows that UVA1 phototherapy is a useful, well-tolerated treatment option for patients suffering from pityriasis rosea with extensive eruptions and considerable pruritus.
 
Top-cited authors
Young Lee
  • Chungnam National University
M-B Kim
  • Pusan National University
Thomas Bieber
  • Universitätsklinikum Bonn
Hei sung Kim
  • Catholic University of Korea
Jun Young Lee
  • Pohang University of Science and Technology