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Data illustrating the impact of atopic dermatitis (AD) on lives of adults with AD in South Korea are limited.To assess the AD disease severity and its impact on quality of life (QoL) in patients with AD from South Korea.Patients with AD utilizing the specialist dermatology services of major hospitals in South Korea were assessed for disease severity using Eczema Area and Severity Index (EASI) score, for QoL using Dermatology Life Quality Index (DLQI) (for QoL), and for comorbidities and treatment experience via retrospective review of 12-month medical records. Clinical and sociodemographic characteristics were also measured.Of the 1,163 patients, 695 (59.8%) were men (mean age [years]±standard deviation: 31.6±12.1). Overall, 52.9% (n=615) patients had moderate-to-severe disease (EASI7). The QoL of 72.3% (n=840) patients was affected moderately-to-severely (DLQI score: 6~30). Systemic immunosuppressants were used ≥1 over past 12 months in 51.9% (n=603) patients, and the most commonly used were cyclosporines (45.7%, n=531) and systemic corticosteroids (40.5%, n=471). Approximately, 10.8% (n=126) patients consulted or received treatment for AD-related eye problem. Of these, 40% (n=50) patients reported poor, very poor, or completely blind status; approximately, 16.7% patients (n=192) reported having depression or anxiety; and 35.5% (n=410) reported suicidal ideation or suicidal attempt.A large proportion of patients had moderate-to-severe AD, a compromised QoL, and ocular or mental health comorbidities, indicating a high disease burden despite systemic treatment. These findings highlight the importance of a holistic approach for the evaluation and treatment of patients with AD.

Extraskeletal osteosarcoma (ESOS) is a rare mesenchymal soft-tissue neoplasm that accounts for approximately 1% of all soft-tissue sarcomas. Over 70% of these malignant tumor progress to local recurrence and metastasis. It commonly metastasizes to the lungs, lymph nodes, bone, and skin and has a poor survival outcome. Cutaneous metastasis is exceedingly rare and known to be a sign of widespread metastases. We present a 57-year-old woman who presented with a rapidly growing protuberant mass on the scalp that was finally diagnosed as metastatic ESOS from a primary pancreatic ESOS. To our knowledge, there has been no reported case of pancreatic ESOS metastasizing to the scalp.

Background Epidermal growth factor receptor (EGFR) is overexpressed in many cancers. However, EGFR expression in melanoma and its role are conflicting. Objective This study aimed to evaluate EGFR expression in distant metastatic melanoma and analyze its relationship with histologic and clinical characteristics and survival. Methods Diagnostic tissues from 55 cases of distant metastatic melanoma was evaluated by immunohistochemistry for EGFR expression. Clinicopathologic features and survival outcomes were analyzed according to EGFR expression. Results The positive EGFR expression in distant metastatic melanoma was significantly correlated with the absence of ulceration. The EGFR expression in distant metastatic melanoma was significantly associated with poor survival, under the conditions of male sex and primary cutaneous melanoma without ulceration or Breslow thickness ≤4.0 mm. This study bears limitations of a retrospective study in a single institution. Conclusion EGFR immunostaining had predictive values for survival outcome. The EGFR expression in distant metastatic melanoma in male, no ulcer, or Breslow thickness ≤4.0 mm appeared to be involved in disease progression.

Background Psoriasis is characterized by uncontrolled hyperproliferation, aberrant differentiation, and dermal infiltration of immune cells. Recent studies have reported that Wnt5a and Notch1 signaling are altered in psoriatic skin lesions. Objective We aimed to investigate the interaction of Wnt5a with Notch 1 with respect to inflammation-mediated epidermal hyperproliferation in psoriasis. Methods Expression of Wnt5a and Notch1 signaling-related proteins were examined in psoriatic skin biopsies. Wnt5a was upregulated in human keratinocytes by treating the cells with its recombinant form (rWnt5a). Results In psoriatic lesions, expression of Wnt5a increased while that of Notch1 decreased when compared to that in non-lesional and normal skin. Treatment with rWnt5a increased the proliferation of keratinocytes and increased their secretion of interleukin (IL)-23, IL-12, and tumor necrosis factor (TNF)-α. Further, exposure of keratinocytes to IL-1α, TNF-α, transforming growth factor-α, and interferon-γ downregulated Notch1 as well as HES 1, which is downstream to Notch1, but increased the Wnt5a levels. The upregulated Wnt5a in keratinocytes downregulated both Notch1 and HES1. Conclusion Our data suggest that Wnt5a and Notch1 signaling exert counteracting influences on each other and are involved, in part, in the pathomechanism of psoriasis.

Pseudomyogenic hemangioendothelioma (PMH) is a rare vascular tumor and was recently recognized as a distinct entity. It has a predilection for young male adults and it frequently occurs in distal extremities. Although it is known to follow an indolent course, multi-focal presentation and local recurrence are common. PMH should be differentiated from epithelioid sarcoma, epithelioid hemangioendothelioma, dermatofibrosarcoma protuberans, and rhabdomyosarcoma. Its characteristic immunohistochemical staining pattern and recurrent translocation t(7:19)(q22:q13) are the basis for its diagnosis. Surgical excision is the mainstay treatment, although chemotherapy can be considered in non-operable patients. We present a rare case of a 40-year-old Korean male patient diagnosed with PMH through an excisional biopsy to facilitate the recognition PMH in the clinical practice.

Background Skin cancer is the most common other primary cancer in patients with lymphoma. However, an intriguing association between cutaneous lymphoma and other primary cancers has been suggested in a few studies. Objective This study investigated other primary cancers in patients with cutaneous lymphoma to evaluate the risk for occurrence of each type of cancer. Methods We screened for other primary cancers in 428 patients with cutaneous lymphoma. Clinical features were analyzed according to the lineage and origin of the lymphomas. We calculated the standardized incidence ratio with statistical analysis for each group according to age. Results Among 330 patients with cutaneous T cell lymphoma and 98 with cutaneous B cell lymphoma, a total of 43 cancers in 38 patients were finally included. Other primary cancers were prevalent in patients with cutaneous B cell lymphoma and patients with secondary cutaneous lymphoma. However, those differences were not significant when the age was calibrated by multiple logistic regression. Metachronously higher standardized incidence ratios were observed for primary lung (standardized incidence ratio [SIR], 14.81; 95% confidence interval [CI], 3.05~39.54), skin (SIR, 68.05; 95% CI, 14.03~181.62), and breast (SIR, 12.91; 95% CI, 1.56~41.41) cancers with statistical significance. Conclusion Other primary cancers more preferentially occurred in patients with cutaneous lymphoma. Clinicians should carefully examine patients with cutaneous lymphoma for other cancers, especially lung, skin, and breast cancers.

BACKGROUND AND PURPOSE: Excess subcutaneous fat causes not only cosmetic issues but also substantial systemic health problems. Cryolipolysis is a noninvasive method for substantially reducing subcutaneous fat cells with controlled, localized cooling. This retrospective study aimed to evaluate the efficacy and safety of a cryolipolysis device for body contouring. METHODS: A total of 41 patients underwent noninvasive cryolipolysis (CoolSculpting; ZELTIQ Aesthetics, Pleasanton, CA, USA) from May 2014 to December 2015. The degree of improvement was determined from medical records of patients, including body weight, circumference measurements, and adverse effects. Patient satisfaction was assessed with a questionnaire. RESULTS: The treated regions were the lower abdomen in 26 cases, lower flank in 18, arm in 17, inner thigh in 10, banana line in 9, upper abdomen in 7, lateral thigh in 4, upper back in 2, axilla in 1, lower back in 1, upper flank in 1, and anterior thigh in 1. Circumferential measurements indicated a mean reduction of 0.69 cm. No significant adverse effect, such as scarring, infection, or burn, was observed. The average satisfaction score was 1.88 of 3. CONCLUSION: Noninvasive selective cryolipolysis is an effective and safe treatment modality for reducing excess fat cells.

Background While the beneficial effects of topical epidermal growth factor (EGF) on wound healing have been repeatedly reported, there are few reports about the effects of EGF on inflammatory skin diseases including acne. Objective To clarify the effects of EGF on acne, it was investigated whether recombinant human EGF (rhEGF) signalling can affect Propionibacterium acnes-induced cytokine expression in human epidermal keratinocytes. Methods The cultured normal human epidermal keratinocytes (NHK) were co-treated with P. acnes and rhEGF, and mRNA levels of interleukin (IL)-1α, IL-8 and tumor necrosis factor (TNF)-α; toll-like receptor 2 (TLR2); and nuclear factor kappa B (NF-κB) were determined. Specific enzyme-linked immunosorbent assay kits were used to measure the IL-1α, IL-8 and TLR2 expression as well as the NF-κB activation in P. acnes and rhEGF-treated NHK. After infecting the cultured NHK with live P. acnes, an increased expression of IL-1α, IL-8 and TNF-α was detected, which was prevented by rhEGF co-treatment. Results TLR2 and NF-κB activity increased after P. acnes treatment, and rhEGF treatment decreased TLR2 expression and NF-κB activity dose-dependently. The inhibition of EGF receptor by gefitinib attenuated the inhibitory effect of rhEGF on these increased expressions of proinflammatory cytokines and TLR2 and activity of NF-κB in NHK stimulated by P. acnes. Conclusion These results suggest that EGF attenuated P. acnes-induced inflammatory responses, at least in part, through the modulation of TLR2 signalling, and the topical application of rhEGF may be beneficial to relieve the inflammatory reactions of acne.

Cutaneous metastasis from gastric adenocarcinoma is uncommon, and the eyelid is a rare metastatic site. Three patterns of clinical presentation of eyelid metastasis have been described: nodular, infiltrative, and ulcerated. The infiltrative pattern, also known as an inflammatory diffuse pattern or mask-like metastasis, can be easily misdiagnosed as cellulitis or contact dermatitis. Here, we report a case of gastric adenocarcinoma in a 75-year-old man who presented with a localized erythematous plaque on his eyelid that developed four months earlier. The patient had been treated with an antimicrobial agent owing to suspicion of preseptal cellulitis. Gastric adenocarcinoma metastasis was diagnosed on the basis of histopathological examination and immunophenotyping (i.e., cytoplasmic epithelial membrane antigen, cytokeratin- 7, cytokeratin-20, and carcinoembryonic antigen). For patients with malignant neoplasms, persistent skin lesions similar to cellulitis or contact dermatitis should be suspected of metastasis derived from an internal malignancy, even for very rare sites of metastasis.

Background: While the beneficial effects of topical epidermal growth factor (EGF) on wound healing have been repeatedly reported, there are few reports about the effects of EGF on inflammatory skin diseases including acne. Objective: To clarify the effects of EGF on acne, it was investigated whether recombinant human EGF (rhEGF) signalling can affect Propionibacterium acnes-induced cytokine expression in human epidermal keratinocytes. Methods: The cultured normal human epidermal keratinocytes (NHK) were co-treated with P. acnes and rhEGF, and mRNA levels of interleukin (IL)-1α, IL-8 and tumor necrosis factor (TNF)-α; toll-like receptor 2 (TLR2); and nuclear factor kappa B (NF-κB) were determined. Specific enzyme-linked immunosorbent assay kits were used to measure the IL-1α, IL-8 and TLR2 expression as well as the NF-κB activation in P. acnes and rhEGF-treated NHK. After infecting the cultured NHK with live P. acnes, an increased expression of IL-1α, IL-8 and TNF-α was detected, which was prevented by rhEGF co-treatment. Results: TLR2 and NF-κB activity increased after P. acnes treatment, and rhEGF treatment decreased TLR2 expression and NF-κB activity dose-dependently. The inhibition of EGF receptor by gefitinib attenuated the inhibitory effect of rhEGF on these increased expressions of proinflammatory cytokines and TLR2 and activity of NF-κB in NHK stimulated by P. acnes. Conclusion: These results suggest that EGF attenuated P. acnes -induced inflammatory responses, at least in part, through the modulation of TLR2 signalling, and the topical application of rhEGF may be beneficial to relieve the inflammatory reactions of acne. (Ann Dermatol 30(1) 54∼63, 2018)

Granular parakeratosis is a recently recognized disorder of keratinization that is usually confined to intertriginous areas. The histopathologic features are distinctive and diagnostic. Rarely, histopathologic variants such as follicular granular parakeratosis and granular parakeratosis of eccrine ostia have been described. In this report, we describe a rare case of granular parakeratosis mostly confined to eccrine ostia.

The picosecond lasers have shown to effectively treat tattoo pigments that are intractable to previous multiple Q-switched (QS) laser treatments. Therefore we hypothesized that a picosecond laser would show better efficacy with minimal adverse events in the treatment of melasma and post-inflammatory hyperpigmentation (PIH) that are difficult to treat with conventional QS lasers. Two patients with melasma and one patient with PIH were treated with a Picosecond 755-nm Alexandrite Laser (Cyanosure, USA). All patients were Korean with skin type IV and no longer responding to QS laser treatments. Laser treatment was well tolerated in all the patients. Adverse events such as PIH were not reported during 8 weeks of follow up period. After the multiple treatment sessions, one patient reported fair improvement and two patients reported good improvement. Consistent with the clinical results, ex vivo skin model irradiated with a Picosecond 755-nm Alexandrite Laser also showed decreased epidermal keratinocyte necrosis compared with the 532-nm QS Neodymium-Doped Yttrium Aluminium Garnet Laser (Lutronic, Korea) yet decreased melanin content. In conclusion, the Picosecond 755-nm Alexandrite Laser may be useful for effective treatment of intractable melasma and PIH with fewer adverse events in dark Asian skin.

Dear Editor: Epidermolytic acanthoma is a rare benign tumor that was first described in 1970 by Shaprio and Baraf. It usually presents in adulthood as an asymptomatic tumor

Dear Editor: Hypereosinophilic syndrome (HES) is classically defined as (i) persistent eosinophilia of >1,500 eosinophils/mm3 for >6 months; (ii) the absence of any other evident cause of eosinophilia, including allergic diseases and parasitic infections; and (iii) signs or symptoms of organ involvement by eosinophilic infiltration. Skin involvement and cutaneous findings are frequently seen in these patients. Although many other organs other than the skin can also be affected by HES, myopathies associated with HES have rarely been reported1. Here, we report a rare case of focal eosinophilic myositis associated with HES. A 49-year-old woman visited our clinic with a solitary ovoid subcutaneous tender nodule on her right palm that appeared 2 weeks before her visit (Fig. 1). She denied any history of an insect bite or trauma at the site. Routine laboratory tests showed marked elevations in the eosinophil counts (6,730/mm3; reference range, 50~500/mm3), platelet counts (562×103/mm3; reference range, 150~350×103/mm3), and C-reactive protein levels (1.97 mg/dl; reference range, 0~0.6 mg/dl); the other test results were normal. Chest radiography showed mild bilateral pleural effusion. Skin biopsy was then performed, and the patient was referred to the department of allergy to check for the cause of blood eosinophilia. Thorough medical history taking, laboratory examinations, and imaging studies excluded any known causes of hypereosinophilia such as allergic diseases, allergic drug reactions, parasitic infections, human immunodeficiency virus infections, and solid tumors. The skin biopsy showed marked infiltration of eosinophils and lymphocytes in the muscle layer, as well as in the dermis and subcutis (Fig. 2A). The patient later developed a localized erythematous patch on her left calf. The skin biopsy at that site also showed moderate infiltration of eosinophils and lymphocytes in the dermis and subcutis (Fig. 2B). The biopsy specimen was insufficient for the evaluation of the muscle layer. The diagnosis of HES was made. Considering the absence of typical histologic findings of a dermal infiltrate of eosinophils, histiocytes, and eosinophil debris between collagen bundles that form flame figures, a diagnosis of eosinophilic cellulitis was less likely. After treatment with 1 mg/kg methylprednisolone for 2 weeks, the blood eosinophil counts decreased to within the reference range and the skin lesion subsided. The lungs could be another organ involved in HES, taking into account the sudden disappearance of pleural effusion after the treatment. Fig. 1 A solitary well demarcated erythematous to skin colored ovoid subcutaneous nodule on the right palm. Fig. 2 (A) The marked infiltrates composed of numerous eosinophis with a slight admixture of lymphocytes in the perimysium (H&E, ×200). (B) The moderate infiltrates of eosinophils and lymphocytes in the subcutaneous fat layer (H&E, ×200). ... Recently, to overcome problems with the above-mentioned old definition, Simon et al.2 proposed a new definition for HES: (i) blood eosinophilia (>1,500 eosinophils/mm3) on at least two occasions, or evidence of prominent tissue eosinophilia associated with symptoms and marked blood eosinophilia; (ii) absence of secondary causes of eosinophilia, such as parasitic or viral infections, allergic diseases, drug-induced or chemical-induced eosinophilia, hypoadrenalism, and neoplasm. Our case is consistent with this new proposed definition of HES. To our knowledge, this is the first case of focal eosinophilic myositis associated with HES in the Korean dermatological literature3. Furthermore, the palm is a very rare site of involvement, as muscle involvement in focal eosinophilic myositis is usually restricted to the lower legs4.

Background: The treatment of post-inflammatory hyperpigmentation (PIH) remains challenging. Tranexamic acid, a well-known anti-fibrinolytic drug, has recently demonstrated a curative effect towards melasma and ultraviolet-induced PIH in Asian countries. However, the precise mechanism of its inhibitory effect on melanogenesis is not fully understood. Objective: In order to clarify the inhibitory effect of tranexamic acid on PIH, we investigated its effects on mouse melanocytes (i.e., melan-a cells) and human melanocytes. Methods: Melan-a cells and human melanocytes were cultured with fractional CO2 laser-treated keratinocyte-conditioned media. Melanin content and tyrosinase activity were evaluated in cells treated with or without tranexamic acid. Protein levels of tyrosinase, tyrosinase-related protein (TRP)-1, and TRP-2 were evaluated in melan-a cells. Signaling pathway molecules involved in melanogenesis in melanoma cells were also investigated. Results: Tranexamic acid-treated melanocytes exhibited reduced melanin content and tyrosinase activity. Tranexamic acid also decreased tyrosinase, TRP-1, and TRP-2 protein levels. This inhibitory effect on melanogenesis was considered to be involved in extracellular signal-regulated kinase signaling pathways and subsequently microphthalmia-associated transcription factor degradation. Conclusion: Tranexamic acid may be an attractive candidate for the treatment of PIH. (Ann Dermatol 27(3) 250∼256, 2015)

Dear Editor: Adalimumab is a complete human monoclonal anti-tumor necrosis factor α (anti-TNFα) that is generally well tolerated. With increasing use of adalimumab and other anti-TNFα therapies, several cutaneous adverse events have been reported during the therapy, including immune-mediated skin lesions1. A 39-year-old woman who had an 11-year history of Crohn's disease and was treated with adalimumab (40 mg administered subcutaneously every other week) presented at our clinic with multiple achromic macules and patches on the extremities (Fig. 1). The lesions developed abruptly about 12 months after the initiation of adalimumab therapy. The diagnosis of vitiligo was made after the patient's skin turned blue under a Wood's lamp. Laboratory tests were also performed to check for other autoimmune conditions, including thyroid disorders, and no abnormality was diagnosed. The patient denied any family history of vitiligo. She has been treated with a combination therapy of excimer laser and topical tacrolimus without stopping the adalimumab therapy for about 1 year, and has shown minimal response thus far. Fig. 1 Multiple well-demarcated irregularly shaped depigmented macules and patches (A) on the left proximal thigh, (B) dorsum of the right foot, (C) dorsum of the right hand, and (D) right forearm. The role of anti-TNFα inhibitors in the development of vitiligo is complicated and contradictory. There have been several case reports that showed improvement in vitiligo in patients receiving anti-TNFα therapy for other diseases2. The therapeutic effect of anti-TNFα inhibitors on vitiligo might result from stopping the physiological effect of TNFα on melanogenesis. Concretely, it has been reported that TNFα decreases the level of tyrosinase, a rate-limiting enzyme in melanin biosynthesis in vitro3. The melanocytotoxic effect of TNFα in vitiligo has also been demonstrated2. On the contrary, anti-TNFα inhibitors have been associated with the development of a considerable number of autoimmune diseases such as vitiligo, as well as leukocytoclastic vasculitis, systemic lupus erythematosus, psoriasis-like lesions, and alopecia areata1. Several theories were proposed to explain the mechanisms underlying the development of autoimmunity during treatment with anti-TNFα inhibitors. In vivo, nucleosome numbers (major autoantigens released during apoptosis) increase in patients receiving anti-TNFα therapies. This could lead to the subsequent induction of autoantibodies4. To our knowledge, only two cases of vitiligo have been attributed to adalimumab use. The first case was that of newly developed vitiligo after 8 months of adalimumab therapy for Crohn's disease; this was similar to our case5. In the second case, there was rapid deterioration of vitiligo within 3 months of adalimumab therapy for managing ankylosing spondylitis4. In our case, it could not be determined whether vitiligo was caused by adalimumab therapy or if it developed in association with Crohn's disease because the concomitant occurrence of vitiligo with inflammatory bowel disease has been rarely reported. The long duration of Crohn's disease, and the sudden onset and rapid spreading of cutaneous lesions support the former possibility. Previous reports and our case suggest that anti-TNFα agents, including adalimumab, can induce vitiligo development. Dermatologists should be aware of this possibility for an earlier detection and treatment of vitiligo in patients receiving anti-TNFα therapy.

Dear Editor: The Harlequin syndrome, first described by Lance et al.1 in 1988, represents an uncommon disorder of the sympathetic nervous system. It is characterized by unilateral diminished sweating and heat- or exercised-induced facial flushing. We present the case of one patient with this remarkable syndrome, including a review of the literature. A 43-year-old woman presented to our clinic with a peculiar pattern of facial flushing. She has been experiencing flushing and sweating on the left side of her face after physical exercise or after taking a hot bath (Fig. 1). The symptoms started about 2 years ago, after she had undergone an endoscopic surgery for the removal of a solitary pulmonary nodule. She has no other medical history besides chronic pancreatitis. She has never been treated for her symptoms before visiting our clinic. On examination at rest, no asymmetric facial flushing or sweating was noted. Neurological examination was normal, and signs of ptosis or miosis were absent. Laboratory tests, including complete blood count, erythrocyte sedimentation rate, glucose, sodium, potassium, and creatinine, revealed no abnormality. As the symptom had appeared only after the endoscopic surgery, we suspected that there might have been an accidental damage to the sympathetic nerve innervating the right facial area during the surgery. The patient was reassured of the benign nature of her complaints and was asked to avoid any aggravating factors. Most cases of Harlequin syndrome are primary in nature. This syndrome is most common in women, and social embarrassment is the main problem of affected persons. In about one-sixth of patients with Harlequin syndrome, the disorder is caused by an underlying disease or a structural lesion (i.e., secondary Harlequin syndrome). The iatrogenic type of Harlequin syndrome, like our case, is recently being reported with a higher frequency. Ten such cases have been reported: one occurring after internal jugular vein catheterization, five after paravertebral thoracic anesthetic blocks, three after surgical resection of a neck mass, and one after thoracic sympathectomy. Physicians should focus on taking the patient's medical history for related factors such as a previous malignancy, as well as recent surgery or anesthesia-related problems. Clinical and neurological examinations are also required, and imaging techniques such as computed tomography or magnetic resonance imaging of the brain, spinal cord, and the carotid arteries and the lung apex should be performed to exclude the presence of a structural lesion. Usually, a patient with a primary or iatrogenic Harlequin syndrome does not need any treatment. If the symptoms are not acceptable, a contralateral sympathectomy may be considered2. Recently, a novel approach to the management of Harlequin syndrome, by using repeated stellate ganglion blocks, was proposed as a less invasive alternative treatment3. To our knowledge, a clinical presentation of Harlequin syndrome has not been previously reported in the Korean dermatological literature. We hope that this report would make dermatologists properly aware of this rare syndrome. Fig. 1 She experienced flushing on the left side of her face following physical exercise.

Dear Editor: The malignant transformation of a giant congenital nevus (GCN) is extremely rare, and when it is discovered, the transformation may have already occurred during childhood. Benign proliferative nodules (PNs) in GCN may clinically and histologically mimic a malignant melanoma (MM), but clinically, PNs usually present at birth with multiple nodules, which is in contrast to MMs, and histologically, most patients with PNs do not present with the characteristics that are associated with malignancy, including mitotic activity, nuclear pleomorphism, and pagetoid spreading. Furthermore, even though some cases might display these features, they soon disappear1. A one-day-old female child presented with GCN on her lower abdomen, genitalia, anus, and legs. Prenatal ultrasonography revealed an imperforate anus, but no genital abnormalities. Dark brown plaques and some PNs that covered the involved areas were seen during a physical examination (Fig. 1). Satellite nevi were encountered on her scalp, axillae, and ankles. A diagnostic biopsy on a PN was performed, and the histological examination presented a proliferative dermal nodule in a GCN (Fig. 2A). The nevus cells had formed nests in the dermo-epidermal junction and the upper dermis (Fig. 2A, B). They were homogenous without nuclear atypia, pleomorphisms, mitoses, or pagetoid spreading into the epidermis. The melanocytic cells in the dermal nodule showed more dense cellularity than in the background lesion (Fig. 2C), and these cells were more pigmented and larger, and most of them were epithelioid cells that showed little pleomorphism and low-grade cytologic atypia. The features of necrosis were not found. All of these histological features was consistent with a benign PN within a GCN. Immunohistochemical analysis showed that the PN was positive for HMB45 (Fig. 2D), Melan A (Fig. 2E), and SOX-10 (Fig. 2F), which detect melanocytic tumors and Ki-67 protein of less than 2% (Fig. 2G). The patient was transferred to the plastic surgery department and she underwent a staged excision. Fig. 1 A giant congenital nevus with proliferative nodules on lower abdomen, genitalia, anus and lower legs. Fig. 2 (A) Histopathology of the proliferative nodule showed a proliferative dermal nodule in a giant congenital nevus (H&E, ×40). (B) Congenital nevus cells formed nests at the dermo-epidermal junction and upper dermis (H&E, ×200). ... Congenital nevi occur in 1% of newborn infants. Some authors have stated that GCN can be distinguished histologically from acquired nevi by the presence of nevoid cells in the lower two-thirds of the dermis1. Other authors have reported that the nevus cells subsequently migrate deeper into the dermis2. GCN has a 2%~42% risk of malignant transformation, and is associated with a 6%~14% lifetime risk of developing melanoma3. True congenital melanomas are very rare and they are supposed to develop secondary to the transplacental spread of maternal melanomas, arise de novo in uterus, present as prenatal growths on congenital nevi, or arise from neurocutaneous melanosis. A PN within a congenital nevus is also uncommon. Compared with congenital nevus cells, PN cells are larger and more pigmented, they have large nucleoli and a storiform pattern, and they can form nests. These cells have been called "melanoma stimulant cells"4. The etiology of them is unknown, and they may be a monoclonal proliferation of melanocytic cells. PNs within GCN grow rapidly, show satellitosis5, and they often bring up diagnostic difficulty. In a study of the cells in PNs in GCN, the cells showed high malignancy, but they did not present the typical antigens expressed in MMs, and their subsequent behavior was benign5. But, because the possibility of malignant transformation of this cells is unclear, surgical procedure is recommended to exclude congenital melanoma. We presented the current case to underline the development of benign PN within GCN and to suggest its differential diagnosis from congenital MM.

Background Fractional laser resurfacing treatment has been extensively investigated and is widely used. However, the mechanism underlying its effects is poorly understood because of the ethical and cosmetic problems of obtaining skin biopsies required to study the changes after laser treatment. Objective To evaluate the usefulness of human skin explants for the investigation of fractional photothermolysis. Methods Full-thickness discarded skin was treated in 4 ways: no treatment (control), fractional carbon dioxide laser, fractional Er:YAG laser, and fractional 1,550-nm erbium-doped fiber laser. Both treated and non-treated skin samples were cultured ex vivo at the air-medium interface for 7 days. Frozen tissue was sectioned and stained with hematoxylin & eosin for histologic examination and nitro blue tetrazolium chloride for viability testing. Results Skin explants cultured for up to 3 days exhibited histologic changes similar to those observed in in vivo studies, including microscopic treatment zones surrounded by a thermal coagulation zone, re-epithelialization, and formation of microscopic epidermal necrotic debris. However, the explant structure lost its original form within 7 days of culture. The viability of skin explants was maintained for 3 days of culture but was also lost within 7 days. Conclusion The skin explant model may be a useful tool for investigating the immediate or early changes following fractional photothermolysis, but further improvements are required to evaluate the long-term and dermal changes.

Background The survival and growth of melanocytes are controlled by the binding of stem cell factor to its cell surface receptor c-kit+ (CD117). We have observed that c-kit+ melanocytes existed in some lesions of vitiligo, while Melan A+ cells were absent. Objective To verify possible relation between c-kit+ expression and treatment response in non-segmental vitiligo lesions Methods Skin biopsies were done from the center of the 47 lesions from the 47 patients with non-segmental vitiligo. Expression of c-kit+ and Melan A, and amounts of melanin in the epidermis were assessed in each lesion, and treatment responses to excimer laser were evaluated. Results Thirty-five of the 47 lesions (74.5%) had c-kit+ phenotypes. There was significant difference of c-kit staining value between good responders in 3 months of excimer laser treatment (average of 24 sessions) and the others. Conclusion c-Kit expression in vitiliginous epidermis may be related to better treatment responses to excimer laser.

Background: Hand eczema is one of the most common skin disorders and negatively affects quality of life. However, a large-scale multicenter study investigating the clinical features of patients with hand eczema has not yet been conducted in Korea. Objective: To identify the prevalence of various hand diseases, which is defined as all cutaneous disease occurring in hands, and to investigate the clinical features of patients with hand eczema and the awareness about hand eczema in the general population and to compare the prevalence of hand eczema between health care providers and non-health care providers. Methods: To estimate the prevalence of hand diseases, we analyzed the medical records of patients from 24 medical centers. Patients were assessed by online and offline questionnaires. A 1,000 from general population and 913 hand eczema patients answered the questionnaire, for a total of 1,913 subjects. Results: The most common hand disease was irritant contact dermatitis. In an online survey, the lifetime prevalence of hand eczema was 31.2%. Hand eczema was more likely to occur in females (66.0%) and younger (20∼39 years, 53.9%). Health care providers and housewives were the occupations most frequently associated with hand eczema. Winter (33.6%) was the most common season which people experienced aggravation. The 63.0% and 67.0% answered that hand eczema hinders their personal relationship and negatively affects daily living activities, respectively. Conclusion: Hand eczema is a very common disease and hinders the quality of life. The appropriate identification of hand eczema is necessary to implement effective and efficient treatment. (Ann Dermatol 28(3) 335∼343, 2016)

Background Mannitol containing monophasic filler with higher crosslinking has not been well studied for moderate and severe nasolabial fold (NLF) correction. Objective To compare the efficacy and safety of a novel mannitol containing hyaluronic acid (HA) filler (HA-G) with biphasic HA filler (HA-P) for moderate and severe NLF correction. Methods Thirteen subjects with symmetric moderate to severe NLF received HA-G (in one NLF) and HA-P (in other NLF) and were evaluated for 24 weeks. Results At both 12 and 24 weeks, the mean improvement in Genzyme 6-point grading scale from baseline was significantly greater in the side of face that was treated with HA-G than HA-P (1.96±0.91 vs. 1.54±0.73 at week 12; p=0.044, 1.88±0.78 vs. 1.3±0.79 at week 24; p=0.027, respectively). At 12 weeks, the mean Global Aesthetic Improvement Scale score was 2.92±0.93 for HA-G and 2.31±0.95 for HA-P (p=0.008). Both fillers were well tolerated. Conclusion The HA filler HA-G provides better efficacy and similar local tolerability compared with HA-P in 6 months following treatment for moderate and severe NLF.

Dear Editor: Grover's disease (GD) is a dermatosis of unknown aetiology that mostly affects men over 40 years-of-age. It is visually characterized by erythematous excoriated papules, which are usually located on the trunk, and is histologically characterized by acantholysis and dyskeratosis. GD has been reported in patients with chronic renal failure, malignancies, and in those with renal and bone marrow transplants1. A 56-year-old man complained of pruritic skin eruptions on his back and on both of his shins, which lasted for 3 months (Fig. 1). He had received a liver transplant 5 months previously for alcoholic liver cirrhosis. He had been taking mycophenolatemofetil, tacrolimus, and methylprednisolone for immunosuppression. Fig. 1 Brownish hyperkeratosis papules on the back (A) and both shins (B). His skin lesions comprised numerous brownish papules, about 2~5 mm in size, which were predominantly located on the backand on both shins. The patient showed no other abnormalities of the skin appendages or mucosa. There was no family history of skin disease. A biopsy of a brownish papule on the back showed epidermal hyperplasia with parakeratotic hyperkeratosis (Fig. 2). The epidermis showed suprabasalacantholysis and dyskeratotic keratinocytes. Corps ronds and grains were also evident along with a slight perivascular lymphohistiocytic infiltration of the dermis. The clinical and histological evidence was compatible with a diagnosis of GD, Darier's disease or Hailey-Hailey disease. The late onset, and the lack of family history and other characteristics consistent with Darier's disease, led to a final diagnosis of GD. The patient was treated with topical calcipotriol, although no clinical improvement was observed. Fig. 2 Histopathology of popular lesions (H&E). (A) Multifocal area of suprabasalclefting and acantholysis (×40). (B) Suprabasalclefting with corps ronds and grain (×200). The aetiology of GD is unknown. This disease is clinically and histologically indistinguishable from Darier's disease and Hailey-Hailey disease, although no mutations in the SERCA2 or SPCA1 genes have been detected in GD2. GD is frequently associated with exposure to heat and sunlight, sweating, and fever. Drugs, ionizing radiation, infection (Malassezia furfur or Demodexfolliculorum) and severe dermatosis (atopic dermatitis, allergic contact dermatitis, and asteatotic eczema) are also associated with GD3. GD has been reported in patients infected with human immunodeficiency virus, and in those with renal failure, haematologic malignancies, and solid carcinomas1. Also, the onset of GD after bone marrow transplantation (eight cases)4,5 and kidney transplantation (one case)1 has been described. To our knowledge, this is the first report of GD developing in a patient after liver transplantation followed by immunosuppressive treatment. Although it is unclear whether the aetiological mechanism underlying GD is immunologic, the immunosuppression may act as a trigger. Our case suggests that GD should be considered as a differential diagnosis in patients presenting with skin eruptions after liver transplantation with immunosuppression. The onset of GD after liver transplantation suggests an immunological mechanism. Further studies will be helpful to identify the relationship between GD and immunological mechanism.

Background Topical calcineurin inhibitors (TCIs) have been successfully used to treat seborrheic dermatitis (SD) patients. Meanwhile, treatment of atopic dermatitis (AD) with low-dose, intermittent TCI has been proved to reduce disease flare-ups. This regimen is known as a maintenance treatment. Objective The aim of this trial was to investigate the efficacy and tolerability of a maintenance treatment with tacrolimus ointment in patients with facial SD. Methods During the initial stabilization period, patients with facial SD or AD applied 0.1% tacrolimus ointment twice daily for up to 4 weeks. Clinical measurements were evaluated on either in the whole face or on separate facial regions. When an investigator global assessment score 1 was achieved, the patient applied tacrolimus twice weekly for 20 weeks. We also compared our results with recent published data of placebo controlled study to allow an estimation of the placebo effect. Results The time to the first relapse during phase II was similar in both groups otherwise significantly longer than the placebo group. The recurrence-free curves of two groups were not significantly different from each other; otherwise the curve of the placebo group was significantly different. There were no significant differences between the 2 groups in the number of DEs, and treatment days for disease exacerbations (DEs). The adverse event profile was also similar between the 2 groups. During the 20 weeks of treatment, the study population tolerated tacrolimus ointment well. Conclusion The results of this study suggest that maintenance treatment with tacrolimus may be effective in preventing the occurrence of facial SD exacerbations.

Dear Editor: Congenital melanocytic nevus (CMN) is a melanocytic nevus that is either present at birth or appears during the latter stages of infancy1. Nevus sebaceous has been described as the hamartomatous locus of an embryologically defective pilosebaceous unit2. Here, we describe how we used the pinhole technique with an erbium-doped yttrium aluminium garnet (erbium : YAG) laser to treat nevi lesions in different patients. A 25-year-old male was diagnosed with CMN on his nose at birth (Fig. 1A). Emla cream (AstraZeneca AB, Sodertalje, Sweden) was applied to the treatment area prior to starting the procedure. The erbium : YAG laser (Action Er : YAG; Lutronic Corporation, Goyang, Korea) was used in continuous-wave mode, with 1-mm spot size and output power of 0.2 mJ/cm2. Multiple small holes measuring 1 mm in diameter were made on the periphery of the CMN lesion. A hydrocolloid dressing (DuoDERM Extra Thin CGF dressing; ConvaTec, ER Squibb & Sons, Princeton, NJ, USA) was applied to the lesions for ≥2 weeks after treatment. After performing 5 laser sessions at 4-week intervals, the cutaneous lesions resolved. There was no evidence of recurrence at the 1-year follow-up examination (Fig. 1B). Fig. 1 Congenital melanocytic nevus (CMN) in a 25-year-old man. (A) Before treatment: a solitary, 1-cm brown patch is visible on the right alar area of the nose. (B) One year after the final treatment session, the skin lesions resolved with minimal scarring. ... A 5-month-old infant was referred to our outpatient unit for CMN on the forearm (Fig. 1C). We performed the pinhole method of treatment using the erbium : YAG laser (Lutronic) in continuous-wave mode, with 1-mm spot size and output power of 0.2 mJ/cm2 (Fig. 1D). After receiving 6 treatment sessions at 2-month intervals, slight superficial pigmentation persisted (Fig. 1E). A 40-year-old woman presented with nevus sebaceous lesions on the right side of her forehead (Fig. 2A). We performed the pinhole method of treatment using the erbium : YAG laser (Lutronic) in continuous-wave mode, with 1-mm spot size and output power of 0.2 mJ/cm2. After receiving 5 treatment sessions at 4-week intervals, the patient showed marked improvement with only mild hypopigmentation (Fig. 2B). No recurrence was noted at the 6-month follow-up examination (Fig. 2C). Fig. 2 Nevus sebaceous lesions in a 40-year-old woman. (A) Before treatment, two 2.5-cm, well-demarcated, yellow, verrucous plaques were visible on the right side of the forehead. (B) Deep line- and doughnut-shaped holes were created to remove the nevus sebaceus ... Herein, we described how nevi lesions were effectively treated using the pinhole method. This simple method involves making multiple small holes at 2~5-mm intervals using a CO2 laser that penetrates the epidermis and deeper dermis3. The holes produced using the pinhole method are surrounded by untreated areas that promote rapid epidermal repair, thereby reducing the downtime and likelihood of side effects4. The other advantages of performing the pinhole method with ablative lasers are that this laser is easy to use and inexpensive, as ablative lasers are usually available in most dermatology clinics. To the best of our knowledge, this is the first report on the application of the pinhole method for the treatment of CMN and nevus sebaceous, so it is difficult to compare the advantages and disadvantages of the pinhole method with those of conventional treatment methods. Therefore, it is necessary to conduct further studies with a large sample to confirm the effectiveness and safety of the pinhole method. In conclusion, we suggest using the pinhole method with erbium : YAG laser as an alternative therapy for treating nevi lesions.

Dear Editor: Eosinophilic pustular folliculitis (EPF) is an inflammatory disease that is characterized by pruriticfollicular papules and pustules. Several reported cases showing an association between EPF and hematological diseases as well as a high proportion of EPF cases in HIV-positive patients suggest that immunological aberrations might play a role in the development of EPF. A 56-year-old man who underwent kidney transplantation 18 years ago presented with multiple papules on cheeks (Fig. 1). He was treated with cyclosporine (150 mg daily) and mycophenolate mofetil (MMF; 1,500 mg daily). Blood analysis yielded a white blood cell count of 12,000 cells/mm3 (12.1% eosinophils). Tests for HIV were also negative. Skin biopsies led to the diagnosis of chronic active folliculitis of the dermis with eosinophilic and lymphocytic infiltration (Fig. 2). With the results suggesting a diagnosis of EPF, we treated the patient with 50 mg per day dapsone. After 3 weeks, the lesions showed gradual resolution. According to recent reports, shifts in the T-helper type 2 (Th2) cytokine expression profile are believed to underlie the pathogenesis. This notion is compatible with the observation that interleukin-5 levels increase in the serum of patients with EPF. On the basis of this theory, cyclosporine and tacrolimus, which demonstrate inhibitory effects on the transcription of proinflammatory cytokine genes, were used to treat EPF; successful results had been obtained1,2. In this case, however, although the patient had used cyclosporine and MMF for many years, EPF still developed. This indicates that aberrant Th2 immune responses alone cannot explain the pathogenesis of EPF. In addition, members of the prostaglandin family operate downstream of cyclooxygenase can be successfully treated with indomethacin, a cyclooxygenase inhibitor3. A previous study reported that a drug of the same class, naproxen, also had a therapeutic effect on EPF4. The symptoms of our patient were alleviated after the administration of dapsone. This indicates that EPF in patients using immunosuppressants can be treated with drugs having anti-inflammatory effects. Dapsone functions as an anti-inflammatory and immunomodulatory agent, and has also been shown as an efficacious treatment option5. The pathogenesis of this case is thought to be similar to those of cases that developed after bone marrow or stem cell transplantation in HIV-negative patients. These patients tended to develop EPF after transplantation, even when the underlying hematologic diseases were in remission. The one thing in common was that used immunosuppressant. Moreover, although the duration of treatment was different, EPF developed after immunosuppressant administration in all cases. There are also some differences in etiology because solid organ transplantations do not cause critical immunological changes similar to that caused by bone marrow or stem cell transplantation. Ironically, the use of immunosuppressants, which are administered to organ transplant recipients, may explain why there has been no report on EPF in transplant recipients until now. As the survival outcomes of transplant recipients improve in the future, EPF infiltration in transplant patients may increasingly occur. For such cases, antiinflammatory drugs such as dapsone and indomethacin should be the first treatment option.The patient was fully informed and consented to the publication of the case. Fig. 1 Multiple papule and plaque with hyperpigmentation and induration on face. Fig. 2 Dense perifollicular eosinophilic and lymphocytic infiltration (H&E, ×100).

Dear Editor: Cafe au lait macules (CALMs) are benign epidermal pigmented lesions that can be idiopathic or associated with neurocutaneous syndromes, whereas facial telangiectasia is characterized by small dilated vessels that are visible on the surface of the skin. A 15-year-old boy presented with a CALM on his cheek (Fig. 1A). We performed 6 sessions of pinhole treatment every 4 weeks using erbium : YAG laser (Er : YAG Action; Lutronic, Goyang, Korea) set to a continuous wave mode with a spot size of 1 mm and a fluence of 0.2 mJ/cm2. The lesion showed marked improvement with mild erythema, and there was no recurrence at the 12-month follow-up (Fig. 1B). Fig. 1 A cafe au lait macule in a 15-year-old boy. (A) Before treatment, a 4×0.5-cm brown patch was evident on the patient's cheek. (B) This lesion showed marked improvement with only mild erythema at 1 year after final treatment (6 treatment ... A 55-year-old female presented with a 10-year history of telangiectasia on the right cheek (Fig. 2A). The telangiectasia was treated using the pinhole method using a CO2 laser (UM-L25; Union Medical Engineering, Uijeongbu, Korea) in continuous wave mode; the parameters were 1-mm spot size and 1.0-W output power. Multiple small holes, measuring 1 mm in diameter, were made down to the papillary dermis. These holes were made approximately 3 mm apart all over the telangiectasia area (Fig. 2B). The telangiectasia showed significant improvement after 1 treatment session (Fig. 2C). No recurrence was noted at the 3-month follow-up. Fig. 2 Facial telangiectasia in a 55-year-old woman. (A) Telangiectasia on the right cheek before treatment. (B) Multiple deep holes were made in line with the course of the vessels. (C) The telangiectasia showed significant improvement 1 month after 1 treatment ... We used 2 different ablative lasers, erbium : YAG and CO2 laser in the treatment of CALM and telangiectasia. The CO2 laser is used in cases where there is a concern about bleeding, whereas the erbium : YAG laser is used in cases where the accurate assessment of depth and width is important because the coagulation layer of the CO2 laser could interfere with this evaluation. The pinhole method, a manual type fractionated laser treatment, is a new way of using the conventional ablative laser. The pinhole method with ablative lasers involves making multiple small holes that penetrate from the epidermis to the deeper dermis at 2 to 5-mm intervals1,2. In cases of telangiectasia, treating only some points with the pinhole technique is sufficient for treating the entire affected surface. Blood vessels are like pipes and some coagulated, obstructed points in them can shut down the functioning of the entire structure; however, the treatment modality for CALM does not appear to correspond well with this suggested theory. Therefore, in our patients' cases, the CALM was successfully removed after multiple treatment sessions, whereas the telangiectasia was successfully treated after only 1 session. The holes produced through the pinhole method are surrounded by untreated areas that aid in rapid epidermal repair, thereby reducing the downtime and side effects3,4. The other advantages of using this pinhole technique with ablative lasers are that is easier to use and less expensive than the treatment modality involving pulsed dye laser, as ablative lasers are usually available in most dermatology clinics. In conclusion, the pinhole method using the erbium : YAG laser could be beneficial for treating CALMs, which have been proven difficult to treat with other methods. Furthermore, the pinhole method using the CO2 laser can be used an effective treatment alternative for telangiectasia.

Dear Editor: Colophony, known as rosin, and its derivatives are ubiquitous in our environments. As shown by patch tests, allergies to rosin are relatively common and are increasingly prevalent1. According to previous studies, many of these allergies are due to the rosin content of printing inks, adhesives, chewing gum, and sports grips1. However, rosin is also present in benzoin spray, which is used to provide a mild protective coating to the skin before the application of surgical tape, adhesive straps, casting material, and orthopedic appliances. We present a case of allergic contact dermatitis due to rosin in benzoin spray. A 51-year-old woman was referred for erythematous lesions including yellow blisters on her nose and both cheeks (Fig. 1A). She had undergone rhinoplasty 2 days before her presentation. One day prior, she had received dressings with benzoin spray to protect the skin from the bandages. When she removed the dressings 1 day before her visit, she found severe erythematous lesions with yellow blisters under the area that had been covered with the benzoin spray-treated tape. Contact dermatitis due to the benzoin spray treatment was suspected. After her first visit, she was treated with prednisolone (12.5 mg/day) and clobetasol propionate ointment (0.05%). Four days later, she was discharged because her lesions had improved and the blisters had disappeared (Fig. 1B). We performed patch testing to confirm the diagnosis with the Korean standard and a fragrance series, but not 'as is' patch testing. This was the limitation of our report. Reactions were scored according to the criteria of the International Contact Dermatitis Research Group. Results observed on days 2 and 4 indicated reactions to colophony (grade 2+ with erythema and mild discrete vesicles) and sandalwood oil (grade 1+ with light edema) (Fig. 2). On the basis of these findings and because contact dermatitis was still considered the main diagnosis, we suspected that the rosin in the benzoin spray might have induced the allergic contact dermatitis observed in our patient. Fig. 1 (A) Erythematous lesions with some yellow blisters on the nose and both cheeks. (B) Four days later, the lesions improved. Fig. 2 (A) Reaction on day 2. (B) Results on day 4, showing reactions to colophony (rosin) and sandalwood oil. Right arrow (→): rosin, left arrow (←): sandalwood oil. Benzoin spray consists of the fluid extract of 25% benzoin Sumatra and 75%~80% alcohol that contains aloes, tolu balsam, ethanal, benzoin, rosin, 15%~25% ethyl alcohol, 30%~45% isopropyl alcohol, and isobutene. Rosin chiefly consists of different resin acids, especially abietic acid2. Meaningful conclusions about the prevalence of rosin allergies are difficult to draw from currently published studies. It is certainly a common finding of patch tests performed in clinics, and may be more prevalent in persons who perform particular jobs or receive various types of exposure. Identifying a relevant sensitizing episode may be difficult because rosin is widely used. Among English patients with occupational dermatitis, 4.1% were allergic to colophony, most of whom were employed in the furniture industry3; on the other hand, 1.3% of Swedish house painters were patch-test positive for colophony4. Contact dermatitis due to rosin in benzoin spray has not been reported previously; therefore, we present this case, which indicates that dermatologists should be careful when using benzoin spray in skin dressings.

A wedge-shaped anterior hairline extension is a very rare skin manifestation usually associated with congenital anomalies including a Tessier number 10 cleft. Other associated conditions are the Tessier number 9 cleft, the Fraser syndrome, and the Manitoba oculotrichoanal syndrome (MOTA syndrome). The Tessier number 10 cleft features include a coloboma of the middle third of the upper eyelid, and an eyebrow divided into two portions. The medial eyebrow portion may be absent and the lateral portion is angulated vertically, joining the hairline of the scalp. This creates a wedge-shaped anterior hairline extension. Herein we report on a case of a wedge-shaped anterior hairline extension associated with the Tessier number 10 cleft.

Background Subcutaneous panniculitis-like T-cell lymphoma (SPTL) is a distinctive skin lymphoma characterized by neoplastic T-cell infiltration of the subcutaneous tissue, mimicking panniculitis. Objective To describe the clinical and pathologic features of SPTL in Korean patients. Methods Fourteen SPTL patients evaluated over 15 years were retrospectively reviewed. Results 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. Conclusion 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.

Tumor of the follicular infundibulum (TFI) is an uncommon benign adnexal tumor that usually presents as a solitary keratotic papule on the face or scalp of elderly patients. Histopathologically, it typically manifests as a plate-like fenestrated proliferation of monomorphic pale-staining cells. A 76-year-old male presented with about a 2 cm, well-defined, yellowish to brownish, slightly elevated, twisted and bent, interrupted, cord-like plaque on his left lower abdomen. Microscopic examination revealed a sharply demarcated plate-like proliferation of pale cells localized in the papillary dermis with multiple connections to the overlying epidermis. The histopathological features were compatible with TFI, except for foci of sebaceous differentiation. There has been one previous case report of TFI with sebaceous differentiation in the English medical literature. Herein, we report on a singular case of TFI with sebaceous differentiation.

Dear Editor: Epidermolytic acanthoma (EA) was first reported in 1970 when six patients with solitary tumors clinically resembled warts were observed. Histologically these tumors showed epidermolytic hyperkeratosis (EH) without features of other epidermal tumors1. The exact etiology of EA remains unknown, but immunosuppression is thought to be associated with EA although case report is lacking. A 64-year-old man presented with a solitary papule on his scrotum. The lesion first appeared 7 years earlier and had gradually grown over time, but had not triggered symptoms such as itching or pain. This patient had no history of similar skin lesions. He had received a kidney transplant 7 years previously, and noted the scrotal lesion occurred immediately after starting an immunosuppressive regimen, consisted of tacrolimus (1 mg/day), azathioprine (50 mg/day), and deflazacort (6 mg/day). In addition, this patient also had type 2 diabetes and hypertension, both of which were controlled by medication. There was no family history of skin disease. Physical examination showed a solitary, brownish, verrucous, and keratotic papule, 1 cm in diameter, on the left side of the scrotum (Fig. 1). Histologic examination of a shave biopsy specimen of the lesion showed orthokeratotic hyperkeratosis, papillomatosis, and acanthosis. Hypergranulosis was also noted, and the cells of the granular and upper spinous layers contained numerous, large, clear, perinuclear space with basophilic keratohyaline granules and eosinophilic materials (Fig. 2). As a result of these clinical and histological findings, the patient was diagnosed with isolated EA. The scrotal lesion resolved after ablative CO2 laser treatment, with no evidence of recurrence during a 1-year follow-up period. Fig. 1 A solitary, brown papule, measured 1 cm in diameter, with a verrucous surface on the scrotum. Fig. 2 Histologic examination of the scrotal lesion showing epidermolytic hyperkeratosis: vacuolar degeneration, increased keratohyaline-like bodies, hypergranulosis and compact hyperkeratosis (A: H&E, ×40, B: H&E, ×400). EA is a solitary tumor that histologically shows EH without features of other epidermal tumors. EA is considered to be an acquired benign tumor, typically occurs in middle-aged adults. The lesions are characteristically brownish papules less than 1 cm in diameter with a verrucous surface. EA can be classified into solitary and disseminated subtypes, called isolated epidermolytic acanthoma (IEA) and disseminated epidermolytic acanthoma (DEA), respectively. Isolated lesions may occur anywhere on the body, but the disseminated subtype usually occurs on the back and the genitoscrotal area. EA is characterized histologically by EH, which consists of random-sized clear spaces around the nuclei in the stratum spinosum and granulosum, reticulated, lightly-staining material forming indistinct cellular boundaries, a markedly thickened granular zone containing an increased number of small and large, irregularly shaped basophilic keratohyaline-like bodies, and compact hyperkeratosis2. EH may be congenital or acquired. Congenital EH includes bullous congenital ichthyosiform erythroderma, systemized epidermal nevus, and hereditary palmoplantar keratosis, whereas acquired EH include IEA and DEA. The etiology of EA remains unknown and the differences between IEA and DEA in the pathogenesis are also unclear. Mutations in the keratin 1 and 10 genes have been observed in IEA3. EA may also be induced by exogenous factors, such as viruses or trauma. Human papillomavirus (HPV) was thought to be a cause of EA, because of the wart-like appearance, but these lesions have not been found to contain HPV DNA4. Immunosuppression has been known to be associated with the pathogenesis of DEA. Immunosuppression could inhibit immune surveillance, preventing abnormal keratinocyte clones from being recognized or removed. Alternatively, immunosuppression may allow latent abnormal keratinocyte clones to proliferate. To date, DEA with disseminated superficial porokeratosis and verruca vulgaris has been observed in a kidney transplant patient5, and DEA has also been observed after PUVA6. Although our patient had a solitary lesion and the possibility of coincidental occurrence of IEA may exist, this case suggests that IEA could be associated with immunosuppression, because the skin lesion had appeared immediately after commencing immunosuppressive treatment. Further case reports and studies are needed to elucidate the relationship between immunosuppression and EA.

There have been no long-term complications or life-threatening adverse effects related to botulinum toxin treatment for any cosmetic indications. Nevertheless, there are well-known, mild side effects of botulinum toxin treatment on the upper face, though most of them are self limited with time. However, excluding brow ptosis, reports about site specific side effects are few and anecdotal. We experienced cases of exaggeration of wrinkles after botulinum toxin injection for forehead horizontal lines, and report them here. In our cases, new appearance of a noticeable glabellar protrusion following botulinum toxin injection on the forehead was observed in 2 patients. Also, a new deep wrinkle on one side of the forehead just above the eyebrow appeared in another 2 patients. The exaggerated wrinkles nearly disappeared without treatment by week 4 in all subjects. These exaggerations of wrinkles may be caused by hyperactivity and overcompensation of untreated muscles. With the increasing availability of diverse botulinum toxin for cosmetic purposes, physicians and patients should be aware of this temporary change after therapeutic injections. We recommend explaining this possible effect prior to injection, for better understanding of treatment for cosmetic indications.

Erdheim-Chester disease (ECD) is a rare, non-Langerhans cell histiocytosis of unknown etiology, characterized by multi-organ involvement. ECD is usually diagnosed on the basis of characteristic radiologic and histopathological findings. Lesions may be skeletal and/or extraskeletal in location, and may include the skin, lung, heart, and central nervous system. We describe here a 68-year-old man with multiple yellowish plaques and a pinkish nodule on his face and scalp. He had been previously diagnosed with diabetes insipidus, and recently complained of coughing and dyspnea. Imaging studies showed multiple osteosclerotic lesions of the bones, a moderate amount of pericardial effusion, and multifocal infiltrative lesions in the perirenal space. Histopathological examination of the skin lesions revealed dermal infiltration of foamy histiocytes with multinuclear giant cells. Moreover, laparoscopic biopsy of the perirenal tissue revealed fibrosis with infiltrating foamy histiocytes being CD68-positive and S100-negative. Based on these findings, he was diagnosed with ECD with extraskeletal manifestations, and treated with interferon-alpha.

Background Angioimmunoblastic T-cell lymphoma (AITL) is a complex lymphoproliferative disorder and often mimics a viral infection with frequent skin involvement. Epstein-Barr virus (EBV) and human herpes virus (HHV)-6 are reported to be associated with AITL, but there are conflicting results. Objective We evaluated the association of EBV and HHV-6 with AITL. Methods We reviewed the clinical, histological and immunophenotypical features of 19 cases of AITL. Among them, 11 lymph node biopsies of AITL were examined for HHV-6, -7, and -8 by polymerase chain reaction (PCR) using virus-specific primers. In situ hybridization of EBV early region RNA (EBER) was performed and T cell receptor (TCR) gene rearrangement was also investigated in some cases. Results Among these 19 cases, maculopapular, plaque or nodular skin lesions accompanied AITL in 12 cases. Clonal TCR gene rearrangement was seen in 8/9 cases tested. EBER in situ hybridization was positive in 8 cases (57.1%). Among 7 cases with skin biopsies, five cases were consistent with cutaneous involvement of AITL, 1 case was a drug eruption, and the other case was Kaposi's sarcoma. Except a HHV-8 (+) case who also had Kaposi's sarcoma, all of these cases were negative for HHV-6, -7 and -8. Conclusion Skin manifestation seems to be a cardinal component of AITL, be it in the context of presentation, progression or recurrent disease. Recognition of clinicopathological features of skin lesions in AITL as diagnostic clues should be stressed among dermatologists. The lack of HHV-6, -7 and -8 in lymph node biopsy of AITL argues against a pathogenic role for HHVs in AITL.

Background: The characterization of progenitor/keratinocyte stem cells (KSC) remains an unachieved goal. A previous study showed that rapid adhering cells to collagen IV had the characteristics of putative progenitor/KSCs. Objective: The purpose of this study was to investigate the genetic expression of rapid adhering cells compared to non adhering cells to determine the characteristic of KSCs. Methods: We isolated rapid adhering cells representative of KSCs from non adhering cells representative of transient amplifying cells. In addition, we differentiated cells from human tonsilar keratinocytes utilizing the adhering capability of the KSCs to collagen IV. Annealing control primer based differentially displayed polymerase chain reaction (PCR) was performed as well as Western blot analysis. Results: The levels of mitochondria-related gene expression were low in the rapid adhering cells compared to the non adhering cells. Mitochondrial complex I, COX IV, peroxiredoxins (I, II and IV) and mitochondrial membrane potential were all low in the rapid adhering cells compared to the non adhering cells. Conclusion: Using an adhesion method on human collagen IV-coated plates, our results suggest that reduced mitochondrial function may be an important characteristic of KSCs. (Ann

Background: Acquired bilateral nevus of Ota-like macules (ABNOM) is a dermal pigmented lesion common in individuals of Oriental origin. The Q-switched Nd:YAG laser (QSNYL) has been used successfully to treat a variety of benign, dermal, pigmented lesions, including nevus of Ota lesions. The similarity between ABNOM and nevus of Ota suggested that QSNYL may also be effective in the former. Objective: To determine the efficacy and side-effect profiles of QSNYL treatment of ABNOM in Korean patients. Methods: Of 42 Korean patients with ABNOM, 29 were treated with QSNYL (1,064 nm, 3 mm spot size, fluence 8∼ 9.5 J/cm 2 ), for up to 10 sessions each. Clinical photographs were taken before and after treatment. Lesion clearance was graded and complications such as hyperpigmentation, scarring, hypopigmentation, and erythema were assessed. Results: Of the 29 treated patients, 19 (66%) showed excellent or good results. Of the patients who were treated more than 3 times, 76% showed good to excellent results. Two patients experienced post-laser hyperpigmentation (PLH), which persisted for more than one month, but no patient experienced persistent erythema or hypertrophic scarring. Conclusion: QSNYL is safe and effective in the treatment of ABNOM in Korean patients. Short-interval repetitive treatment is especially useful in improving therapeutic results and reducing PLH. (Ann Dermatol 21(3) 255∼260, 2009)

Merkel cell carcinoma is a rare aggressive primary cutaneous neuroendocrine skin cancer arising from the basal epidermis. Although the majority of patients with non-melanoma skin cancer are cured by local treatment, patients with Merkel cell carcinoma have a poor outcome characterized by locoregional and distant relapse. No standard treatment protocol for Merkel cell carcinoma exists. But, there is mounting evidence that combined treatment, incorporating adjuvant radiotherapy, improves the outcome (locoregional control and disease-free survival) compared with surgery alone in most patients. Herein we report a case of Merkel cell carcinoma treated with wide local excision and post-operative radiotherapy.