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Background: Both medical disputes and the incidence of skin cancer are increasing in Korea. Objective: The aim of this study was to figure out the medical litigation related to skin cancer and propose a method to prevent the medical disputes. Methods: Skin cancer-related judgments were searched by The Supreme Court of Korea’s Written Judgment Management System based on the keywords for skin cancer. The search system included sentenced cases at the Lower Courts, the Appellate Courts, and the Supreme Court from 1997 to 2017. Results: Seven cases were selected as the litigation cases related to skin cancer. Four cases (57.1%) presented malignant melanoma, while the rest presented squamous cell carcinoma, metastatic skin cancer, and peripheral T cell lymphoma (1 case in each). Four cases resulted in death from cancer metastasis, and 3 cases presented as sequelae. The legal issues related to the medical disputes could be categorized as follows: misdiagnosis, delayed diagnosis, performance error, and lack of informed consent. Delayed diagnosis and lack of informed consent were the most common issues (n=4) in the precedents. Five cases (71.4%) were sentenced the awarded amounts to the plaintiff, including 2 cases of settlement decision. The average awarded amount was 42,553,644±27,567,455 Korean won. Conclusion: Physicians should pay attention to the cases of the skin cancer to prevent medical malpractice and disputes. The practices pertaining to proper diagnosis, treatment plans, and obtaining an informed consent should be followed during the course of treating skin cancer. (Ann Dermatol 31(3) 300∼306, 2019)

Background Hyperpigmentation on the face and neck can be a devastating psychological burden in patients with Riehl's melanosis. However, successful treatment of the disease is challenging for clinicians. Objective To evaluate the effectiveness and safety of low-fluence neodymium-doped yttrium aluminum garnet (Nd:YAG) laser in the treatment of Riehl's melanosis and to identify prognostic factors determining the response to laser treatment. Methods We enrolled 10 Korean patients with Riehl's melanosis. The patients received 10~28 treatment sessions at 3-week intervals with low-fluence Nd:YAG laser. Results Among all the patients, seven reached near total improvement, and two and one patient reached marked improvement and minimal improvement, respectively, after low-fluence Nd:YAG laser treatment. The mean number of needed laser treatment sessions to reach marked improvement and near total improvement was 12.1±4.0 (ranged from 6 to 17) and 14.6±4.4 (ranged from 9 to 20), respectively. A further analysis revealed the proportion of patients who reached near total improvement was higher, and the mean number of necessary laser treatment sessions to reach minimal improvement was less in patients with dark brown pigmentation compared to those with light brown pigmentation. Among all patients, three complained of guttate hypopigmentation. However, the hypopigmented lesions spontaneously improved after the interruption of the treatment. Conclusion We found that low-fluence Nd:YAG laser is an effective and safe treatment modality for Riehl's melanosis.

Background: The incidence and mortality rates associated with cutaneous melanoma (CM) have steadily increased over the last 20 years. Even with successful treatment, mela-noma patients usually experience substantial anxiety regard-ing the development of terrible recurrence. To date, few stud-ies have investigated various dermatoses what the patients with CM had anxiety for the recurrence during postoperative surveillance (Dw). Objective: To describe various Dw and to evaluate the risk of subsequent malignant skin disease in pa-tients with CM. Methods: We performed a prospective study between August 2002 and August 2015. Results: Fifty-six pa-tients presented with a total of 68 Dw. Among them, melano-cytic nevus was the most common (n=27), followed by se-borrheic keratosis (n=9) and CM recurrence (n=7). Approximately 5.6% of the lesions were diagnosed as malig-nant skin diseases. This was a single-center study, so the prev-alence of malignant skin diseases following primary melano-ma may not represent that of all patients with CM. Conclusion: The results of this study can be referred by der-matologists dealing with melanoma especially when CM pa-tients have too excessive or unrealistic anxiety for melanoma recurrence during postoperative surveillance of CM. However, the importance of postoperative surveillance must still be emphasized because of real risk of melanoma re-currence and other malignant skin. (Ann Dermatol 29(4) 433 ∼437, 2017)

BACKGROUND A variety of infectious, inflammatory, and neoplastic dermatoses can develop on the glans penis, and definitive diagnosis in such cases may be difficult owing to their non-specific symptoms and clinical appearance. Furthermore, data on dermatoses of the glans penis in Korea are limited. OBJECTIVE In the present study, we aimed to determine the prevalence of dermatoses of the glans penis in Korea and provide clinical data to assist in making an accurate diagnosis. METHODS We retrospectively reviewed the medical records, clinical photographs, and histologic slides of 65 patients with dermatoses of the glans penis that visited the Pusan National University Hospital between January 2004 and August 2013. RESULTS Twenty-six types of dermatoses were identified: inflammatory dermatosis was the most common (38/65, 58.5%), followed by infectious (13/65, 20.0%), neoplastic (10/65, 15.4%), and other dermatoses (4/65, 6.2%). The most common dermatosis of the glans penis was seborrheic dermatitis, followed by lichen planus, herpes progenitalis, condyloma accuminatum, erythroplasia of Queyrat, Zoon's balanitis, and psoriasis. In the topographic analysis, the most common type of dermatosis was dermatoses that localized to the glans penis (39/65, 60.0%), followed by dermatoses involving the extra-genitalia and glans penis (22/65, 33.9%), and the genitalia (glans penis plus other genital areas) (4/65, 6.2%). CONCLUSION This study shows the usefulness of a topographic approach in the diagnosis of dermatoses of the glans penis in Korea. The findings could be used as baseline data for establishing an accurate diagnosis in Koreans.

Background: The scalp is frequently affected in psoriasis patients, and pruritus can adversely affect the quality of life of affected patients. Few studies have assessed pruritus in scalp psoriasis. Objective: To determine the correlation among the clinical characteristics of pruritus, psoriasis scalp severity index (PSSI), and intraepidermal nerve fiber (IENF) density in psoriatic scalp lesions. Methods: Eighty patients (53 men, 27 women; mean age, 46.4 years; mean PSSI, 19.9) with scalp psoriasis were evaluated by using the PSSI and the Leuven itch scale. Biopsies were obtained from the lesional and nonlesional skin of 19 patients (10 men, 9 women; mean age, 37.8 years; mean PSSI, 25.8). Immunofluorescence staining of protein gene product 9.5 was performed to determine the IENF density. Results: Sixty-four patients (80%) complained of pruritus associated with scalp psoriasis, which negatively affected their quality of life to varying degrees. A moderate positive relation between PSSI score and pruritus intensity was identified (r=0.225 and p=0.044). The IENF density in psoriatic lesions was significantly higher than that in the nonlesional scalp (6.2±1.2 vs. 4.2±1.6, p＜0.001). However, the correlations between IENF density and PSSI score, and IENF density and pruritus intensity were insignificant. Conclusion: These results indicate that pruritus prevalence is high in patients with scalp psoriasis, and pruritus considerably influences the patients’ daily lives and quality of life. In addition, high IENF density in psoriatic scalp lesions may play a role in the development of pruritus in scalp psoriasis. (Ann Dermatol

Background: Basal cell carcinoma (BCC) is the most com-mon form of skin cancer and possesses various clinical features including translucency, ulceration, pigmentation, telangiectasia, and rolled borders. Accordingly, many cutaneous lesions can mimic BCCs and differential diagnosis is difficult. Objective: To clarify the differences in clinical characteristics between BCCs and BCC-mimicking lesions (BMLs), and to determine which clinical characteristics are helpful for an accurate clinical diagnosis of BCC. Methods: We performed clinicopathologic analysis of cutaneous lesions that received a clinical diagnosis of BCC. All lesions included in this study showed more than one of the following characteristics of BCCs: translucency, ulceration, flecked pigmentation, black or blue hue, telangiectasia, and rolled borders. We compared six clinical characteristics between the BCC group and the BML group. Results: Among 48 lesions in the BML group, there were 15 premalignant or malignant lesions and 33 benign lesions. Various dermatoses mimicking BCC that have not been reported in the dermatological literature were identified, including angiosarcoma, vulvar intraepithelial neoplasm, foreign body gra-nuloma, intravascular papillary endothelial hyperplasia, sarcoidosis, and others. Compared to the BML group, the BCC group had a significantly higher frequency of translu-cency (76.3% vs. 52.1%, p＜0.001), ulceration or erosion (44.2% vs. 27.1%, p=0.022), black or blue hue (40.0% vs. 22.9%, p=0.020), and rolled borders (49.5% vs. 14.6%, p＜ 0.001). Cutaneous lesions with two or less clinical features of BCC were significantly more likely to be BMLs. Conclusion: The results of this study could be helpful for the differential diagnosis of BCCs and BCC-mimicking cutaneous lesions. (Ann Dermatol 26(4) 431∼436, 2014)

Dermal melanocytosis is a common pigmented skin disease, characterized by an increased number of ectopic melanocytes in the dermis. Rare variants of dermal melanocytosis that do not belong to these four typical groups–nevus of Ota, nevus of Ito, blue nevus, and Mongolian spots–are called dermal melanocyte hamartoma, or congenital dermal melanocytosis (CDM) as it mostly appears from birth. We report a case of CDM on the foot of a young woman with a literature review of previously reported cases of CDM.

BACKGROUND Sublingual immunotherapy (SLIT) with house dust mites (HDM) preparation has recently been proven to be beneficial for treating allergic rhinitis and asthma. However, there has been no report regarding the efficacy and safety of SLIT in Korean patients with atopic dermatitis (AD). OBJECTIVE We intended to investigate the efficacy and safety of SLIT in Korean patients with AD. METHODS A total of 34 patients with AD and immunoglobulin E (IgE)-proven HDM sensitization (Class ≥3) were recruited. Eczema area and severity index (EASI) score, total serum IgE level, specific IgE assays to Dermatophagoides pteronyssinus, D. farinae, and adverse effects were recorded during follow-up. "Responder" was defined as a patient with ≥30% improvement in EASI score after SLIT. RESULTS Twenty-three patients continued SLIT for 12 months or more, whereas 3 patients (8.8%) dropped out because of exacerbation of dermatitis, and 8 patients (23.5%) were lost to follow-up. The average duration of SLIT treatment was 22.4 months (range, 12~32 months). EASI scores reduced significantly after 6 months of treatment (p

Lichens striatus (LS) is an acquired, self-limiting inflammatory dermatosis that follows the lines of Blaschko. The etiology of the eruption is unknown, but several theories have been proposed with focus on environmental factors, viral infection, cutaneous injury, hypersensitivity, and genetic predisposition. We describe a 19-year-old woman who developed a unilateral linear eruption 17 months after allogenic peripheral blood stem cell transplantation. Histopathology revealed features, which were consistent with LS. To the best of our knowledge, our patient is the first case describing the appearance of LS occurring after allogenic stem cell transplantation. We speculate that this condition represents an unusual form of localized, chronic graft-versus-host disease.

BACKGROUND: The oral mucosa is constantly exposed to several irritants and allergens including dental materials, but the role of contact allergy in oral disease is obscure. OBJECTIVE: To analyze positive patch test results in patients with oral diseases and evaluate the clinical relevance of oral diseases with contact allergy to dental materials. METHODS: We retrospectively analyzed patch test results with dental screening series in 44 patients with oral disease from 2004~2011. RESULTS: Oral diseases included oral lichen planus (54.5%), cheilitis (27.3%), burning mouth syndrome (9.1%), and others (9.1%). Thirty-one of 44 patients (70.5%) had positive reactions to one or more allergens. The most commonly detected allergens were gold sodium thiosulfate (25.0%) and nickel sulfate (25.0%), followed by potassium dichromate (22.7%), cobalt (15.9%), palladium (6.8%), mercury (4.5%), copper (4.5%), and methylhydroquinone (4.5%). Six of 24 patients with oral lichen planus had a symptom in areas adjacent to dental materials and positive patch test reactions to allergens contained in the suspected dental materials. CONCLUSION: Patch tests with dental screening series are worth considering for oral diseases, especially for oral lichen planus.

Background Psoriatic arthritis (PsA) is chronic seronegative inflammatory arthritis that causes irreversible joint damage. Early recognition of PsA in patients with psoriasis is important for preventing physical disability and deformity. However, diagnosing PsA in a busy dermatology outpatient clinic can be difficult. Objective This study aimed to validate the Psoriatic Arthritis Screening and Evaluation (PASE) questionnaire for the detection of PsA in Korean patients with psoriasis. Methods The PASE questionnaire was prospectively given to 148 patients diagnosed with psoriasis but without a previous diagnosis of PsA. All patients underwent radiologic and laboratory examinations, and a subsequent clinical evaluation by a rheumatologist. Results Eighteen psoriasis patients (12.2%) were diagnosed with PsA according to the Classification Criteria for Psoriatic Arthritis. The PASE questionnaire scores of differed significantly between PsA and non-PsA patients. Receiver operator characteristic analysis showed an area under the curve of 0.82 (95% confidence interval: 0.72, 0.92) for PASE score. A PASE score cut-off of 37 points had a sensitivity of 77.8% and specificity of 82.3% for the diagnosis of PsA. Conclusion The PASE questionnaire is a simple and convenient screening tool for detecting PsA in Korean dermatology clinics. A PASE questionnaire score of 37 points appears to be an appropriate cut-off for screening Korean psoriasis patients.

Dear Editor: In case 1, a 41-year-old woman presented with a 3-year history of recurrent pustules on erythematous skin. The patient had been treated with methotrexate, sulfasalazine and cyclosporine for psoriatic arthritis and generalized pustular psoriasis (GPP) for 2 years. However, these treatments failed to yield satisfactory improvement. Physical examination revealed the presence of extensive erythematous patches with pustules over the entire body (Fig. 1A) and inflammatory arthritis was noted in the distal interphalangeal, sacroiliac and knee joints. We decided to use infliximab (3 mg/kg) to treat the GPP and psoriatic arthritis. The patient's pustular lesions cleared quickly within 48 hours after the first injection. After the second injection of infliximab (3 mg/kg), marked improvement in arthralgia was observed (Fig. 1B). She has since been receiving infliximab 3 mg/kg every 8 weeks as maintenance therapy. No recurrence of pustules or arthritis symptoms has been detected during 12 months of follow-up. Fig. 1 Pustular psoriasis in case 1 (A). Marked improvement was observed after the second injection of infliximab (B). In case 2, a 39-year-old woman with a 20-year history of plaque type psoriasis was admitted to our department for lower limb cellulitis. Rapid resolution of cellulitis was achieved after systemic antibiotic treatment (cefazolin 6 g/day). Three days after antibiotic treatment, she experienced abrupt onset of pustules on erythematous skin affecting more than 90% of body (Fig. 2A, B). She was initially treated with infliximab (3 mg/kg) combined with acitretin (30 mg/day) for pustular flares. Within 48 hours of the first infusion, the pustules were resolved, but diffuse erythema on the trunk and extremities remained (Fig. 2C, D). The patient received acitretin (20 mg/day) for maintenance after a single dose of infliximab. No relapse of the pustules has been noted, but mild psoriatic plaques have followed. Fig. 2 Generalized pustular papules on the entire body in case 2 (A, B). Near remission of a pustular eruption was seen 48 hours after infliximab infusion (C, D). Infliximab is a chimeric immunoglobulin G1 anti-tumor necrosis factor-α monoclonal antibody that is effective in treating moderate to severe psoriasis and psoriatic arthritis1. Several studies have documented a rapid improvement in recalcitrant GPP with infliximab (5 mg/kg)2,3. Because infliximab has a faster onset of action than that of other modalities including biologics, some researchers recommended that infliximab be used as the first-line treatment modality in patients with severe and acute GPP4. Both patients in the current study experienced dramatic resolution of pustules within 48~72 hours of infliximab infusion without any serious adverse events. Although the optimal infliximab dose and maintenance regimen for GPP has not yet been established, low dose (3 mg/kg) of infliximab showed excellent response in the current cases. In an earlier report, there was no significant difference between the 3 mg/kg treatment group and the 5 mg/kg treatment group for moderate to severe psoriasis5. However, more research is needed and we believed that low dose infliximab with or without acitretin may have an effect on acute GPP. Since infliximab appears to offer the advantage of rapid response and reduced morbidity, we may consider it extremely effective and well tolerated in adult patients with severe and acute GPP. However, since GPP tends to relapse frequently, large population studies are needed to evaluate the efficacy of maintenance infliximab therapy for GPP with recurrent pustular episodes.

Dear Editor: Dermatologists instinctively consider syphilid when viewing discrete macular or papular lesions on the palms, which may be an important clue in distinguishing syphilid from other disorders. The lack of clinical analysis on syphilid eruptions on the palm prompted us to investigate specific clues in differentiating syphilid from other disorders. We analyzed the characteristics of patients with syphilid (n=34) or syphilid-like eruptions (n=39) on the palms through a retrospective comparison, by using clinical photos and medical records from Pusan National University Hospital (PNUH) between January 2002 and July 2011. The study was approved by the ethics committee of PNUH, and voluntary informed consent was obtained in written form from all of the participants. The syphilid-like group consisted of patients with discrete macular or papular lesions on the palms, mimicking typical syphilid but with negative treponemal and nontreponemal test. The definition for the syphilid-like group was based on the description in Fitzpatrick's textbook: "Palmoplantar lesions may be macular or papular, discrete or diffuse, and non-scaling, slightly scaly, or hyperkeratotic." 1 The syphilid-like group (n=39) included 10 (25.6%) patients with eczematous dermatitis, 8 (20.5%) with erythema multiforme, 6 (15.4%) with psoriasis, 3 (7.7%) with pityriasis rubra pilaris, 2 (5.1%) with drug eruption, and 10 (25.6%) with other skin conditions (Table 1). Table 1 Clinical comparison of patients in the syphilid group and those in the syphilid-like group Concerning palmar lesions, the differences between the two groups were analyzed in terms of symptoms, color, bilaterality, and scale types. For comparative analysis, cross-tabulation and independent t-test were used with PASW ver. 18.0 for Windows (IBM Co., Armonk, NY, USA). A p-value of ≤0.05 was set as the level of statistical significance. The patients in the syphilid-like group (30 of 39, 76.9%) were more symptomatic than those in the syphilid group (16 of 34, 47.1%) (p=0.008). Concerning the color of lesions, more dusky red lesions were found in the syphilid group than in the syphilid-like group (35.3% vs. 10.3%, p

Dear Editor: Dermoscopy is a noninvasive and extremely useful diagnostic tool for a variety of skin diseases1. A few reports have documented that dermoscopy is also useful for the diagnosis of some zoonotic infestations including scabies and spider spines2,3. In the latter, dermoscopic findings allow the identification of spider spines clinically mimicking scabies. Here, we report a case of the successful identification and removal of a fish bone under the fingernail with the aid of dermoscopy. A 51-year-old woman presented with a 7-day history of pain in the right thumb. She had trimmed a black rockfish caught by her husband, and felt pain afterwards. When she came to our department after failing to remove the bone herself, it was difficult to find the fish bone with the naked eye (Fig. 1A). However, we were able to find a linear foreign body embedded under the nail plate using dermoscopy (Fig. 1B). The foreign body was easily removed using fine forceps. Fig. 1 (A) It was difficult to locate the foreign body with the naked eye. (B) Dermoscopic findings revealed the foreign body to be compatible with a fish bone spine and focal abscess pocket. Having the fingers pricked by a fish bone or thorn is not uncommon. Sometimes the removal of these foreign bodies can be difficult, and persistently disabling secondary infections can occur in cases of residual fragments4. However, it is often difficult to detect subungual white foreign bodies like fish bones and white hairs with the naked eye. Imaging approaches including routine X-ray, computed tomography, and magnetic resonance imaging can be helpful, but seem too extreme considering their expense and limited availability5. Using dermoscopy, we were able to identify the exact location of the colorless foreign body under the nail plate and remove it easily. In conclusion, dermoscopy can be a useful diagnostic tool for the detection of white foreign bodies such as fish bones in the subungual space.

Vol. 28, No. 4, 2016 499 Received June 11, 2015, Revised July 15, 2015, Accepted for publication July 20, 2015 Corresponding author: Margaret Song, Department of Dermatology, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 49241, Korea. Tel: 82-51-240-7337, Fax: 82-51-245-9467, E-mail: smargie@ hanmail.net This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright © The Korean Dermatological Association and The Korean Society for Investigative Dermatology http://dx.doi.org/10.5021/ad.2016.28.4.499

They are characterized by petechiae, pigmentation, and occasionally, telangiectasia, and typically localized to the lower limbs. The cause of PPDs is largely unknown. These dermatoses are histopathologically similar to perivascular lymphocyte infiltration, erythrocyte extravasation, and hemosiderin deposition. Although clinical subclassification attempts to account for clinical variations between PPDs, overlapping categories may make differentiation challenging. We describe 2 patients with PPD with extensive cutaneous involvement of both arms and legs, initially diagnosed as angioma serpiginosum. A 16-year-old female patient (case 1) presented with a 4-month history of asymptomatic red-brown hyperpigmented patches on the arms and legs. She had no history of a bleeding disorder, and her medical and family history was unremarkable. She reported no trauma to the area and denied intake of any medication. Upon clinical examination, welldemarcated, brownish pigmentation over the extremities, especially on the arms, was observed (Fig. 1a∼c). Dermoscopy showed multiple small purpuric globules over an

Erythrodermic psoriasis (EP) is a very severe variant of psoriasis whose management poses a challenge to physicians, as currently available therapies often provide unsatisfactory results. Many biologics have been used to treat chronic plaque psoriasis, the most common form of psoriasis; however, their effectiveness for EP is poorly understood. A recently developed biologic, golimumab, has been extensively studied for the treatment of moderate-to-severe active rheumatoid arthritis, psoriatic arthritis, active ankylosing spondylitis, and chronic plaque psoriasis. However, no clinical trials have been performed for EP. Here, we report the case of a 32-year-old man who presented with severe psoriasis that previously failed to respond satisfactorily to methotrexate, cyclosporine, retinoid, narrow-band ultraviolet B phototherapy, and topical agents (i.e., steroids and calcipotriol). Skin lesions worsened progressively and developed into erythroderma. Psoriatic arthritis was also detected. Conventional therapies lacked efficacy. Therefore, we administered golimumab 50 mg. The skin lesions improved significantly according to the Psoriasis Area and Severity Index score after the first administration; lesions improved further throughout the treatment course. Although additional studies are required to fully evaluate the efficacy and safety of golimumab, this agent may be an alternative treatment strategy for some patients with recalcitrant EP.

Background: Despite efforts to treat trachyonychia, there is no promising treatment modality. Objective: This study evaluated the efficacy and safety of calcipotriol plus betamethasone dipropionate ointment on trachyonychia. Methods: A total of 39 patients with 432 nails affected by trachyonychia were enrolled. All patients applied calcipotriol/betamethasone ointment once daily without occlusion for 6 months. Outcome measures were assessed by physician’s global assessment (degree of roughness: 0, clear; 1, mild; 2, moderate; 3, marked; 4, severe) at all time points. Results: After 6 months of therapy, 98.6% (426/432) of nails showed significant clinical improvement; 4.2% were completely free from nail lesions. The mean physician global assessment score decreased significantly from 3.5 to 1.7 points (p＜ 0.05). No serious side effects were reported, except mild pruritus and erythema in 2 patients. Conclusion: This is the first study to prospectively evaluate the efficacy and safety of calcipotriol/betamethasone ointment for the treatment of trachyonychia. The results indicate topical calcipotriol/betamethasone is an effective and safe treatment for symptom improvement of trachyonychia. (Ann Dermatol 27(4) 371∼375, 2015)

Background: Limited information is available regarding dermatoscopic differences between non-aggressive and aggressive types of basal cell carcinoma (BCC). Objective: To investigate dermatoscopic differences between non-aggressive and aggressive types. Methods: We evaluated 145 histopathologically confirmed BCCs from 141 patients. Histopathologic types and aggressiveness from 4 mm punch biopsy and their dermatoscopic findings were evaluated. We assessed the statistical significance of dermatoscopic differences between non-aggressive and aggressive types. To objectively predict aggressiveness, we created a “dermatoscopic index of BCC aggressiveness” in which 1 point was added and subtracted for each dermatoscopic finding significantly higher in aggressive and non-aggressive types, respectively. Results: Large blue-gray ovoid nests were found more frequently in non-aggressive type than aggressive one (85/105 [80.9%] vs. 21/40 [52.5%], p=0.001). Compared to non-aggressive type, aggressive type had more multiple blue-gray globules (29/40 [72.5%] vs. 57/105 [54.3%], p=0.046), arborizing telangiectasia (29/40 [72.5%] vs. 48/105 [45.7%], p=0.004), and concentric structure (11/40 [27.5%] vs. 12/105 [11.4%], p=0.018). Regarding dermatoscopic index, cases of aggressive type with a score of 1 were most common (n=18, 45.0%), followed by a score of 2 (n=14, 35.0%). Limited number of aggressive type of BCCs and the effect of width on the determination of histopathologic aggressiveness. Conclusion: Aggressive type BCCs more often exhibited multiple blue-gray globules, arborizing telangiectasia, and concentric structure, while the non-aggressive type exhibited large blue-gray ovoid nests more frequently. Score exceeding 2 on the dermoscopic index can be screening criteria for aggressiveness. These dermatoscopic features and dermoscopic index could be useful for assessing aggressiveness of BCCs before surgery. (Ann Dermatol 27(6) 682∼687, 2015)

Dear Editor: Recently, the term chronic spontaneous urticaria (CSU) is used to indicate spontaneous and persistent wheals, independent of external physical stimuli1. CSU is classified into two groups according to the presence of autoantibodies: chronic autoimmune urticaria (CAU) and chronic idiopathic urticaria (CIU)2. Several treatment methods are available for patients with CSU. However, CSU can be resistant to conventional treatment, including high-dose antihistamines (up to 4-fold dose of H1 antihistamines). Autologous whole blood (AWB) injection, a prevalent method to treat allergic rhinitis, atopic dermatitis, and viral disease, is scientifically unproven3,4. Few reports have documented the clinical improvement of CSU after injection of AWB5,6. Although its mechanism of action remains widely unknown, we believe that AWB injection may desensitize the patient against triggering factors including autoanti-bodies. The aim of this study was to evaluate the efficacy of AWB injection in treating CSU, and to compare its efficacy on CAU and CIU. The study was approved by the hospital ethics committee (E-2013096), and all patients gave their informed consent. We treated 22 patients with CSU, who had uncontrolled urticaria most days of the week despite antihistamine therapy for >6 weeks, by administering AWB injections for 8 consecutive weeks. Patients who had developed urticarial due to foods, drugs, or physical and environmental factors, female patients who were pregnant or lactating, patients with any severe systemic disease, and patients who had taken any immunosuppressive agent within 4 weeks of entry were excluded from the study. The patients were classified into two groups after autologous serum skin test (ASST): positive (CAU) and negative (CIU). After the cessation of antihistaminic treatment for at least 3 days, ASST was performed. A wheal with a diameter at least 1.5 mm greater than that of a saline-induced wheal at 30 min was considered positive. We took venous blood samples and immediately administered a gluteal intramuscular AWB injection. The volume of injection was 2.5 ml at week 0, and 5 ml/week for the subsequent injections. All patients underwent laboratory examinations before treatment, including complete blood count, liver and renal function tests, urinalysis, and D-dimer analyses. Only antihistamines were allowed during the AWB injection phase for worsening pruritus or wheals. The outcome measures were pruritus intensity; wheal number, size, and duration; and sleep and daily activity interference by using score values from 0 to 3. The sum of all six severity parameters were calculated to obtain the urticaria activity score (UAS)7 every week, and the UAS at week 0 and week 8 was compared between responders and non-responders. The consumption of antihistamines was calculated at the endpoint. A "responder" was defined as a patient with >30% improvement of UAS after repeated AWB injections5. In total, 8 of 22 patients (36.4%) with CSU were responders to AWB injection; 2 of 7 (28.6%) CAU and 6 of 15 (40.0%) CIU patients were considered responders (Table 1). There was no significant difference in responder ratios between the CAU and CIU groups. The antihistamine consumption at week 8 did not show any significant differences compared with baseline (data not shown). Between responders and non-responders, we found that CSU patients with a high baseline UAS improved markedly after repeated AWB injections (p=0.019); however, there was no difference with respect to disease duration, sex, age, ASST result, D-dimer, and C-reactive protein level (Table 2). No patients experienced serious adverse events; however, minor adverse events such as bruising and injection pain were noted. Table 1 Efficacy of AWB injection after 8 week of treatment Table 2 Comparison between responders and non-responders to autologous whole blood injection among 22 CSU patients Although desensitization with repeated AWB injections theoretically provided better efficacy in patients with CAU than in those with CIU, our results showed that there were no significant differences between groups at the endpoint. Mori and Hashimoto8 reported that an ASST-positive patient was completely cured after AWB injections; however, the patient remained ASST positive. These findings suggest that the underlying mechanism of AWB injections is attributed to other pathogenetic factors. Unlike in previous reports5,8, AWB injection did not cause a dramatic response in patients with antihistamine-resistant CSU regardless of the skin test results to autologous serum. Nevertheless, the most important finding of this study is that AWB injection might be more efficient in treating patients with CSU who had high disease activity at baseline. Therefore, AWB injections may be an option in treating patients with antihistamine-resistant CSU who have high disease activity. Further studies are required to reinforce the current results concerning AWB injection in patients with CSU, and evaluate its efficacy, duration, treatment interval, and dose.

Dear Editor: Soft fibroma (acrochordon, fibroepithelial polyp, or skin tag) is a common pedunculated skin neoplasm and usually appears as a furrowed papule, filiform lesion, or large bag-like protrusion. Soft fibromas primarily occur on the neck, axillae, and groin. However, it may present at unusual sites of the body such as the penis, urethra, and vulva. Moreover, a few reports on soft fibromas occurring on the breast and nipple have been published1. Herein, we report a rare and interesting case of a soft fibroma arising from the nipple, showing an unusual cauliflower-like appearance. A 51-year-old obese woman presented with a 25-year history of a painless pedunculated polyp originating from her right nipple. The lesion measured 2.4×2.3×1.4 cm and demonstrated a verrucous and cauliflower-like surface (Fig. 1A, B). Neither acanthosis nigricans nor epidermal nevus was observed on the adjacent skin. Dermoscopy revealed irregular epidermal projections and focal dotted vessels (Fig. 1C). Total surgical excision of the polyp, sparing the right nipple, was performed. Histopathological analysis showed papillomatosis, hyperkeratosis, and regular acanthosis of the epidermis with fibrocollagenous tissue in the dermis (Fig. 1D). On the basis of these findings, we diagnosed the lesion as a soft fibroma. Fig. 1 (A) A large solitary pedunculated polyp originating from the right nipple. (B) The polypoid lesion measuring 2.4×2.3×1.4 cm and demonstrating a cauliflower-like surface. (C) Dermoscopic findings showing irregular epidermal projections ... There have been only a few reports on soft fibromas of the nipple presenting with bullous formation or comprising a large elastic mass with a short pedicle2,3. Furthermore, there has been no report of a large and cauliflower-like soft fibroma of the nipple in the Korean literature. Because the clinical manifestations of soft fibroma of the nipple are nonspecific, histological examination is required for differential diagnosis, including pedunculated seborrheic keratosis, pleomorphic fibroma, nevoid hyperkeratosis of nipple and areola, and verruca vulgaris. In our case, the unusual clinical presentation of the cauliflower-like nipple tumor made the diagnosis of the lesion difficult. However, the histopathological findings provided important clues for making an accurate diagnosis. Thus, we have described a rare and interesting case of a cauliflower-like soft fibroma of the nipple.