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Patients with bullous pemphigoid are susceptible to serious infections, which are the leading cause of death in these patients. The aims of this population-based cohort study were to investigate the incidence and spectrum of serious infections in patients with bullous pemphigoid and to identify associated risk factors. The outcome measure was any infection requiring hospitalization. Hazard ratios with 95% confidence intervals were estimated using subdistribution hazard models. In total, 12,300 patients with bullous pemphigoid and 49,200 matched controls were identified through the National Health Insurance Research Database in Taiwan. Within 2 years of bullous pemphigoid diagnosis, 5,006 (40.7%) patients developed serious infections, with an incidence of 385.5/1,000 person-years. Patients with bullous pemphigoid were twice as likely to develop serious infections as controls (adjusted hazard ratio, 2.01; 95% confidence interval 1.92–2.10). Systemic corticosteroid use was the strongest risk factor, resulting in a 2-fold increase in the risk for serious infections. Other independent risk factors were advanced age, female sex, low income, and certain comorbidities. In conclusion, this study demonstrated an increased risk of serious infections following a diagnosis of bullous pemphigoid. Prophylaxis of serious infections through active intervention with the risk factors may be essential in reducing the morbidity and mortality associated with bullous pemphigoid.

Urticaria is a prevalent disease with substantial physical, psychological, and economic impacts. With the advent of understandings of the disease and the emerging evidence of treatments, the international guidelines for treating urticaria have been updated in recent years. In order to update the 2014 edition of the Taiwanese Dermatological Association (TDA) consensus of urticaria, a total of 17 dermatologists with extensive experience in urticaria management were invited to and attended the TDA consensus meetings. All the specific aspects of the content were approved by at least 75% of the experts in attendance. Comparing to the former edition, several substantial modifications were made. For diagnosis, D-dimer was added as the recommended routine test in patients with chronic spontaneous urticaria. For pharmacological management, treatment suggestions were simplified. The approved-dosed, the up-dosed second-generation antihistamines, omalizumab, and cyclosporine were listed as the first-line to the fourth-line treatment, respectively. In addition, the management for patients of special considerations, such as the elderly, children, and pregnant women, were all discussed and mentioned in the consensus. We hope the updated TDA consensus can serve as a reference for all physicians and can help the physicians providing up-to-dated managements for these patients.

Polypoid basal cell carcinoma (BCC) is characterized by a stalk connecting the tumor and skin surfaces, with neoplastic cells restricted in the polypoid zone microscopically. A thorough review of polypoid BCC is still lacking. Thus, we performed this scoping review to investigate the clinical manifestations, dermoscopic features, histopathology, treatment, and prognosis of polypoid BCC. A literature search was conducted in the PubMed, Embase, Web of Science, and Cochrane databases until December 23, 2021. Studies reporting at least one patient with polypoid BCC following the pathology and clinical criteria were included. A total of 47 studies with 54 patients with solitary polypoid BCC and 13 patients with multiple polypoid BCCs were included. Solitary polypoid BCC occurred at a relatively younger age, with an equal sex ratio. These tumors most commonly presented as red or flesh-colored pedunculated papules and were commonly distributed over nonsun-exposed areas. Most tumors were managed with excision, and recurrence or metastasis was seldom reported. Most patients with multiple polypoid BCCs had basal cell nevus syndrome and presented with generalized distributed, flesh-colored, or brown papules mimicking skin tags. Typical dermoscopic features of BCC could still be observed in these lesions, including arborizing vessels, blue-gray globules, and ovoid nests, which could aid in early diagnosis. In conclusion, polypoid BCC is a distinct variant of BCC with pedunculated morphology. Physicians should be aware of polypoid BCC and may use dermoscopy to aid in early diagnosis and treatment.

Abstract The relationship between cancer and vitiligo has been explored but with inconsistent results. To examine the long-term cancer risk in vitiligo patients, we conducted a retrospective nationwide cohort study. From the National Health Insurance Research Database of Taiwan, a total of 13,824 vitiligo patients were identified and matched with 55,296 reference subjects without vitiligo by age, gender, and propensity score estimated by major comorbidities from 1997 to 2013. Demographic characteristics and comorbidities were compared between these two groups. Incidence rate ratios and hazard ratios (HRs) were calculated to examine cancer risks. The 16-year incidence rates of overall cancers were 621.06 (566.56–675.55) and 726.99 (697.24–756.74) per 100,000 person-years in the vitiligo and reference groups. Patients with vitiligo showed a significantly decreased risk of overall cancers [adjusted HR, 0.85; 95% confidence interval (CI), 0.77 to 0.93, p

Background/Purpose: Atopic dermatitis (AD) is a chronic inflammatory disease commonly seen in children and increasingly recognized in adults. With recent advances in the therapeutic development for AD, the Taiwanese Dermatological Association (TDA) established a committee to update the consensus for AD management in Taiwan. This report describes the 2020 updated consensus for the management of AD. Methods: A panel of 11 core members was convened to review and discuss aspects of AD management and draft recommendation during the first two meetings. The 2015 TDA consensus and the 2017 European guideline, along with recent peer-reviewed articles, serve as the foundation for the update. In the third meeting, AD expert dermatologists selected on a national scale were invited to vote on the final statements. A total of 27 dermatologists attended the final meeting. The consensus was achieved when ratings of 7–9 (out of a total score of 9) accounted for ≥ 75% of the total votes. Results: Consensus was achieved on the therapeutic options for AD by lines of treatment. A treatment algorithm was presented to illustrate the place of each modality in terms of basic care, acute disease control, and maintenance therapy. Special considerations for the pediatric population, as well as for women during pregnancy and lactation, are discussed. Conclusion: Topical corticosteroids with long-term emollient-based therapies remain the cornerstone of AD treatment. Systemic treatments are indicated when topical therapies and phototherapy fail to control the disease. The recent approval of dupilumab and emerging targeted therapies are expected to bring significant clinical benefit for patients whose disease is inadequately managed by existing options.

Abstract The coexistence of inflammatory bowel disease (IBD) and bullous pemphigoid (BP) has been reported. No large-scale study to date has explored the relationship between these diseases. This population-based case-control study examined the association between IBD and BP by using a nationwide database. A total of 5,263 BP patients and 21,052 age- and gender-, hospital visit number-matched controls were identified in the National Health Insurance Research Database of Taiwan (1997–2013). Demographic characteristics and comorbidities including IBD were compared. Logistic regression was conducted to examine the predicting factors for BP. The mean age at diagnosis was 74.88 years and 54.3% of subjects were male. BP patients tended to have more cardiovascular risk factors, autoimmune and neurologic comorbidities, and hematologic cancers than matched controls. There were 20 cases of IBD (0.38%), mostly ulcerative colitis (N = 17, 0.32%) among BP patients, compared to 33 IBD cases (0.16%) among controls (p

Background: Rosacea is a chronic inflammatory skin disease with mounting evidence associating it with systemic disorders. Cancer, induced or facilitated by chronic inflammatory microenvironment, shares common pathogenic mechanisms with rosacea. Objectives: We performed a population-based cohort study to investigate the risk of developing cancer among people with rosacea in Taiwan. Methods: A total of 65,526 patients with rosacea and 262,104 age-, sex-, and comorbidity-matched controls were identified from the Taiwan's National Health Insurance Research Database between 1997 and 2013. All participants were followed up for 2–12 years. Incidence rates (IRs) of overall and specific types of cancer were calculated. Cumulative incidences of cancer were compared between the two cohorts by Kaplan–Meier method and modified log-rank test. Hazard ratios (HRs) adjusted for age, sex, and comorbidities for overall and specific malignancies were estimated using subdistribution proportional hazard models. Results: The IR (per 1000 person-years) of cancer was 2.83 in patients with rosacea and 3.00 in controls. There was no difference in cumulative incidence of cancer between patients with or without rosacea (P = 0.109). The risk of developing cancer did not increase among patients with rosacea (HR = 1.04; 95% confidence interval = 0.98–1.11). In addition, patients with rosacea did not have a significantly increased risk of developing any specific type of cancer. Conclusion: We found no association between rosacea and malignancy. These results did not agree with those reported in previous studies. Further research should be conducted to clarify the association between rosacea and cancer, especially focusing on the pathophysiology.

Mechanical stimulation is known to affect cell proliferation, differentiation, and regeneration. Here, the authors demonstrate that stretching mouse skin recruits macrophages and polarizes them into M2 cells that facilitate hair regeneration through the release of growth factors, including HGF and IGF-1

Background/Objective: Numerous studies have suggested that dermatologists are superior to nondermatologists in managing skin diseases. However, it is still not known whether the public are convinced that dermatologists should be the primary caretakers for the skin. This study sought to characterize the delivery of skin care services, with a particular focus on the epidemiology of skin diseases and the distributions of patients and their visits to dermatologists and nondermatologists. Methods: The cohort datasets were drawn from Taiwan's National Health Insurance Research Database (NHIRD) and contained all the original claims data for one million beneficiaries enrolled in 2010. We analyzed the epidemiologic profiles of this population-based cohort for 2013. Descriptive statistics were applied to examine the epidemiology of skin diseases and the distributions of visits and patients according to physician specialty. Results: We identified 989,039 persons who remained in the cohort in 2013. Of those, 351,330 (or 35.5%) had skin diseases, and made 989,514 ambulatory care visits in 2013. Visits to dermatologists accounted for 62.2% of these visits. Among the patients with skin diseases, 52.6% of patients made visits to dermatologists, compared with 32.6% who visited nondermatologists and 14.8% who visited both in 2013. In this cohort, dermatitis and eczema had the highest prevalence (16.2%), followed by fungal infections (6.3%) and pruritus (5.5%). Conclusion: Dermatologists play major roles in providing skin care services in Taiwan. This finding might be partially explained by the weak role of primary care physicians and the perceptions of patients toward dermatologists and nondermatologists in Taiwan. Keywords: Healthcare utilization, Skin diseases, Epidemiology, Taiwan

Abstract Alopecia areata (AA) is an organ‐specific autoimmune disorder. Defective immune system related disorders are prone to increase the risk of cancer formation. However, the association among AA and variety of cancer types had never been studied. A nationwide population‐based matched cohort study was conducted to evaluate the cancer risk in patients with AA. Records from Taiwan National Health Insurance Research Database were analyzed. Cases of AA from 1997 to 2013 and cancers registered in the catastrophic illness profile from the same time period were collected. The standard incidence ratio (SIR) of each cancer was calculated. In total, 2099 cancers among 162,499 patients with AA and without prior cancers were identified. The overall cancer risks in AA patients were slightly decreased, especially among male subjects (SIR: 0.89). Refer to individual cancer, the cancer risk of nonmelanoma skin cancer (NMSC) (SIR: 0.59), upper GI cancer (SIR: 0.70), liver cancer (SIR: 0.82), uterine, and cervix cancer (SIR: 0.84) were significantly lower in patients with AA. In contrast, AA patients were inclined to have lymphoma, breast cancer, kidney, and urinary bladder cancer with the SIR of 1.55, 2.93, and 2.95, respectively. Age stratified analyses revealed female AA patients younger than 50 years old have even higher risk of breast cancer (SIR: 3.37). Further sensitivity analysis showed similar results after excluding major autoimmune disorders. Cancer risk in AA patients is organ specific, and it is not associated with the underlying autoimmune disorders in patients with AA.

Background: Effective management of psoriasis is a cause for much concern. In Taiwan, there is a lack of consensus on management strategies for psoriasis, especially the principles of drug prescribing in psoriatic patients. Objectives: The Taiwanese Dermatological Association convened Expert Panel meetings three times between 2012 and 2015 to discuss the management strategies for treatment of psoriasis in order to fill the knowledge gap and provide a reference tool for Taiwanese dermatologists. Results: This paper reports the final output from the three meetings, with the aim of aiding clinical decision making in terms of principles of prescribing, including dosing strategies, efficacy profiles, and safety concerns in connection with eight categories of antipsoriatic treatment: topical agents, phototherapy, nonbiologic conventional systemic agents, licensed biologic systemic agents, newly emerging therapies, combination therapy, transitional therapy, and traditional Chinese medicine. Conclusion: The Expert Panel, comprising distinguished Taiwanese dermatologists, succeeded in developing a consensus about the management of psoriasis in Taiwanese patients. Unavailability of data in certain areas may suggest a possibility of new directions in research.

Psoriasis is associated with many comorbidities. An understanding of these comorbidity patterns can help foster better care of patients with psoriasis.To identify the heterogeneity of psoriasis comorbidities using latent class analysis (LCA).LCA was used to empirically identify psoriasis comorbidity patterns in a nationwide sample of 110,729 incident cases of psoriasis (2002-2012) from the National Health Insurance database in Taiwan.The mean age of incident psoriasis was 46.1 years. Hypertension (28.8%), dyslipidemia (18.9%), and chronic liver disease/cirrhosis/hepatitis (18.1%) were the top three comorbidities in patients with psoriasis. LCA identified four distinct comorbidity classes among these patients, including 9.9% of patients in the "multi-comorbidity" class, 17.9% in the "metabolic syndrome" class, 11.3% in the "hypertension and chronic obstructive pulmonary disease (COPD)" class, and 60.9% in the "relatively healthy" class. Psoriatic arthritis was evenly distributed among each class. Relative to membership in the "relative healthy" class, an increase of one year of age had a higher probability of membership in the "multi-comorbidity" (odds ratio [OR], 1.25), "metabolic syndrome" (OR, 1.11), or "hypertension and COPD" (OR, 1.34) classes. Relative to membership in the "relative healthy" class, compared to women, men had a higher probability of membership in the "multi-comorbidity" (OR, 1.39), "metabolic syndrome" (OR, 1.77), or "hypertension and COPD" (OR, 1.22) classes.We observed four distinct classes of psoriasis comorbidities, including the "multi-comorbidity", "metabolic syndrome", "hypertension and COPD", and "relatively healthy" classes, as well as the clustering of liver diseases with metabolic syndrome and clustering of COPD with hypertension.

Malignant peripheral nerve sheath tumors (MPNSTs) are rare sarcomas that are strongly associated with neurofibromatosis type I (NF-1). We describe a 71-year-old woman with no stigmata of neurofibromatosis, who presented with recurrent subcutaneous tumor on her left upper back. She received two excisional biopsies on the back of her trunk at our hospital and both pathology reports revealed neurofibromas. Three years after the last skin biopsy, a rapidly growing subcutaneous tumor emerged at the same site. This tumor was totally resected and the histopathology showed an ill-defined tumor in the dermis and subcutaneous tissue. The tumor was composed of spindle cells in a myxoid stroma with a transition from the area of typical neurofibroma to the hypercellular area. The hypercellular area consisted of atypical, hyperchromatic spindled cells with frequent mitotic figures. She was therefore diagnosed with MPNST.

Background: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare drug-related skin conditions that are potentially life-threatening with a 20–30% mortality rate. A severity-of-illness score specified for SJS and TEN, SCORTEN, was developed in 2000. Until now, no study of SCORTEN has been conducted in Asian with SJS or TEN. The goal of the present study is to evaluate the performance of SCORTEN in predicting in-hospital mortality in Taiwanese patient with SJS or TEN. Methods: A sample of 51 patients with the diagnosis of SJS or TEN was reviewed from the chart. Performance of the SCORTEN was assessed using logistic regression. Results: The hospital mortality rate predicted by the SCORTEN was similar to the observed mortality rate. The performance of SCORTEN was well on each of the first 5 days of hospitalization, and best on the first day. There were two cases with active tuberculosis and five with diabetes mellitus among our eight deceased patients. Conclusion: The performance of SCORTEN is well in Taiwanese patients with SJS or TEN, especially on the first day of admission. The SCORTEN predicts a relatively accurate in-hospital mortality rate. We suggest that the SCORTEN should always be obtained during the first 24 hours, and can be repeated if the patient's condition deteriorates quickly in the first 5 days. Pre-existing conditions, such as tuberculosis and pre-existing diabetes, may need more consideration in future studies.

Endometriosis has been associated with the risk of several autoimmune diseases; however, its relationship with alopecia areata (AA) remains unknown. This study aimed to investigate the risk of AA in patients with endometriosis. Participants were recruited from the National Health Insurance Research Database in Taiwan. We identified female patients with endometriosis between January 1, 1998 and December 31, 2011. For each patient with endometriosis, four control subjects were included in the control group matched for age, sex, monthly premium, and residence. Patients and control subjects were followed up until AA diagnosis, death, or December 31, 2013, whichever occurred first. The Cox regression model was used for the analyses. Overall, we included 35,123 patients with endometriosis and 140,492 control subjects. Compared with control subjects, patients with endometriosis had an adjusted hazard ratio of 5.60 (95% confidence interval 4.03–7.79) for AA after controlling for age, socioeconomic status, and comorbidities. In conclusion, patients with endometriosis had a significantly increased risk of AA. Further studies are necessary to investigate the pathophysiology underlying the relationship between endometriosis and AA.