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Background Vitiligo is a common depigmenting disorder caused by the autoimmune destruction of melanocytes. Some evidence suggests the involvement of melanocytes in the auditory system in the disease process. However, the relationship between vitiligo and sensorineural hearing loss (SNHL) remains uncertain. Objective We investigated the association between vitiligo and SNHL. Methods In this systematic review and meta-analysis, EMBASE, MEDLINE, PubMed, and the Cochrane database were searched for studies examining the association between SNHL and vitiligo from inception to June 28, 2020. Results A total of 14 case-control studies with 938 patients with vitiligo were included. The meta-analysis showed a significant association of SNHL with vitiligo (odds ratio [OR] 6.02 [95% confidence interval {CI} 3.41-10.62]). The association remained significant after adjustment of study quality and publication bias, with ORs of 5.30 (95% CI 1.53-18.35), and 3.45 (95% CI 1.75-6.81), respectively. Limitations Heterogenous definition and measurement of hearing loss and racial differences are potential sources of bias. Conclusion The evidence to date supports an association of SNHL with vitiligo. These results suggest audiologic assessment for early recognition and management of hearing loss in patients with vitiligo.

Psoriasis has been associated with the risk of several ocular complications; however, its relationship with retinal diseases remains unknown. This study aimed to investigate the risk of developing retinal diseases in patients with psoriasis. Study participants were recruited from the National Health Insurance Research Database in Taiwan. A total of 11 729 psoriasis patients and 117 290 matched controls were included, showing an incidence rate of 121.15 and 28.34 cases of retinal diseases per 100 000 person-years, respectively. Compared with controls, patients with psoriasis had an adjusted hazard ratio (aHR) of 3.40 (95% confidence interval [CI], 2.63-4.39) for retinal diseases after adjustment for potential confounders. Regarding the individual retinal disease, psoriasis patients had a significantly higher risk of developing retinal detachment (aHR, 5.07; 95% CI, 2.92-8.79), retinal vascular occlusion (aHR, 3.75; 95% CI 2.42-5.82), and retinopathy (aHR, 2.84; 95% CI, 1.99-4.05) than controls. In conclusion, patients with psoriasis had a significantly higher risk of retinal diseases than controls. Further studies are necessary to investigate the pathophysiology underlying the relationship between psoriasis and retinal diseases.

The preliminary results of an innovative surgical technique, which incorporated single-port three-dimensional (3D) videoscope and instruments for endoscopic nipple-sparing mastectomy (E-NSM), were reported. The medical records of patients who underwent single-port 3D E-NSM for breast cancer from August 2018 to September 2020 were analyzed, and the preliminary outcome of this procedure as well as the patient-reported aesthetic results are described in this article. The study enrolled 70 patients who received 80 procedures of single-port 3D E-NSM. The mean operation time was 158 ± 36 min, and the mean blood loss was 41 ± 26 ml. Three procedures (3.8 %) associated with delayed axillary wound-healing, eight cases of transient nipple ischemia (10 %), three cases of partial nipple ischemia/necrosis (3.7 %), and one case of total nipple-areolar complex (NAC) necrosis (1.3 %) were observed. No patient had margin involvement. Satisfaction rates of approximately 90 % were observed in terms of postoperative scar appearance, location, and length. Most of the patients (87.8 %) reported that they would choose the same operation again if given the chance to do so. The overall cost of a single-port 3D E-NSM was 7522 ± 470 U.S. dollars. According to cumulative sum (CUSUM) plot analysis, about 14 cases were needed for surgeons to familiarize themselves with single-port 3D E-NSM and immediate gel implant reconstruction and to decrease their operation time significantly in the initial learning phase. Single-port 3D E-NSM, a safe, efficient, lower-cost procedure, is associated with a good aesthetic result. It is a promising new technique for breast cancer patients indicated for mastectomy, but long-term oncologic safety follow-up evaluation still is needed.

Objective Posttraumatic stress disorder (PTSD) is known as a risk factor for various immune-related disorders; however, the association between PTSD and related autoimmune skin diseases (ASDs) remains unclear. This study aimed to investigate the association of PTSD with the risk of related ASDs. Methods Participants were recruited from the National Health Insurance Research Database in Taiwan. We included 9801 patients with PTSD and 39,204 matched controls to assess the risk of developing ASDs. Cox regression model was used for analyses. Results After adjusting for confounders, we found an increased risk of ASDs among the patients with PTSD (adjusted hazard ratio [aHR] = 3.00, 95% confidence interval [CI] = 2.21-4.07) compared with that among matched controls. Statistically significant associations were found between PTSD and five individual ASDs, including psoriasis (aHR = 3.81, 95% CI = 1.90-7.67), lichen planus (aHR = 31.63, 95% CI = 4.00-249.91), alopecia areata (aHR = 4.77, 95% CI = 2.47-9.20), autoimmune bullous diseases (aHR = 9.55, 95% CI = 1.98-45.99), and vitiligo (aHR = 16.06, 95% CI = 4.48-57.54). Conclusions Patients with PTSD had an increased risk of developing ASDs compared with the matched controls. Further studies are needed for better understanding of the underlying mechanisms.

Increasing evidence suggests a positive association between autoimmune disorders and the subsequent risk of dementia, supporting the idea that neuroinflammation is a major contributor to dementia. However, whether or not adults with vitiligo have an increased risk of dementia remains unclear. We aimed to investigate the association between vitiligo and the subsequent risk of dementia. A total of 1320 patients with vitiligo and 5280 matched controls were identified from the Taiwan National Health Insurance Research Database between 1998 and 2011. Dementia was diagnosed by board-certificated psychiatrists or neurologists in the follow-up period. Cox proportional hazards models were used to estimate the adjusted hazard ratios (aHR) after controlling for age, sex, income-related monthly premium, residence and comorbidities associated with dementia. The incidence rate of dementia (per 100 000 person-years) was 502.8 among patients with vitiligo and 101.9 among the controls. Patients with vitiligo were more likely to develop any type of dementia (aHR, 5.30; 95% confidence interval [CI], 3.30-8.51), Alzheimer's disease (aHR, 12.22; 95% CI, 3.71-40.28) and vascular dementia (aHR, 3.99; 95% CI, 1.31-12.15) compared with the controls. In conclusion, middle-aged and old patients with vitiligo are more likely to develop dementia compared with those without vitiligo. This novel finding reminds physicians to be more careful about signs of dementia when managing patients with vitiligo and provides the basis for further investigations that clarify the underlying mechanisms.

Background The relationship between alopecia areata (AA) and sleep disorders remains uncertain. This study aims to investigate the bidirectional association between AA and sleep disorders. Methods To assess the risk of developing sleep disorders, we recruited 5648 patients with AA and 22,592 matched controls from the National Health Insurance Research Database (NHIRD) in Taiwan. Similarly, risk of developing AA was assessed in 93,130 patients with sleep disorders (including 7310 patients with obstructive sleep apnea [OSA] and 85,820 patients with non-apnea insomnia) and 372,520 matched controls. Cox regression model was used for the analysis. Results AA patients had a significantly increased risk of developing OSA (adjusted hazard ratio [aHR] 3.80; 95% confidence interval [CI] 2.53–5.71) and non-apnea insomnia (aHR 4.20; 95% CI 3.68–4.79). Conversely, presence of sleep disorders significantly increased the risk of AA development (aHR 4.70; 95% CI 3.99–5.54). Both OSA (aHR 3.89; 95% CI 2.46–6.16) and nonapnea insomnia (aHR 4.77; 95% CI 4.03–5.64) were associated an increased risk of developing AA. Conclusions Patients with AA have a higher risk of developing sleep disorders compared to controls, and vice versa. Further studies are needed to investigate the shared pathogenic mechanism underlying these two conditions.

The effects of cigarette smoking and alcohol consumption on the risk of alopecia areata (AA) are unclear. The aim was to examine the association of cigarette smoking and alcohol consumption with AA. We collected participants from four rounds (2001, 2005, 2009, and 2013) of the Taiwan National Health Interview Survey. Incident AA cases were identified from the National Health Insurance database. Of the 60,055 participants, 154 developed AA during the 647,902 person-years of follow-up. After controlling for confounders, current smokers had a higher risk of incident AA than never smokers [adjusted hazard ratio (aHR) 1.88; 95% confidence interval (CI) 1.22–2.88]. There was a trend toward an increased risk of AA with increasing numbers of years of smoking and cumulative pack-years of smoking among current smokers. The aHRs (95% CIs) of current smokers of > 5 and ≤ 15 cigarettes per day, > 10 and ≤ 20 years of smoking, ≤ 10, and > 10 and ≤ 20 pack-years of smoking were 2.03 (1.17–3.51), 2.25 (1.21–4.18), 1.86 (1.12–3.09), and 2.04 (1.04–4.01), respectively. Conversely, social and regular drinkers had significantly lower risks of AA than never drinkers [aHRs (95% CIs) 0.65 (0.43–0.98) and 0.49 (0.26–0.93), respectively]. Current smokers had an increased risk of developing AA, while alcohol consumption was associated with a decreased risk of AA.

Alopecia areata (AA) has long been associated with thyroid diseases; however, the temporality of their association remains unclear. This study aimed to investigate the bidirectional association between AA and thyroid diseases. In analysis 1, we included 5929 AA patients and 59,290 matched controls to assess the risk of thyroid diseases. In analysis 2, we included 35,071 patients with thyrotoxicosis, 19,227 patients with Graves' disease, 5460 patients with thyroiditis, 3352 patients with Hashimoto's thyroiditis, and their matched controls (1:10) to assess the risk of AA. Incidence of thyroid diseases and AA were the outcomes in analysis 1 and analysis 2, respectively. After adjusting the potential confounders, AA patients had an increased risk of all thyroid diseases, including toxic nodular goiter, (aHR 10.17; 95% confidence interval [CI] 5.32-19.44), nontoxic nodular goiter (aHR 5.23; 95% CI 3.76-7.28), thyrotoxicosis (aHR 7.96; 95% CI 6.01-10.54), Graves' disease (aHR 8.36; 95% CI 5.66-12.35), thyroiditis (aHR 4.04; 95% CI 2.12-7.73), and Hashimoto thyroiditis (aHR 4.35; 95% CI 1.88-10.04). On the contrary, a significantly increased risk of developing AA was observed among patients with thyrotoxicosis (aHR 9.29; 95% CI, 7.11-12.14), Graves' disease (aHR 8.66; 95% CI 6.03-12.42), and thyroiditis (aHR 6.42; 95% CI 3.15-13.11) but not in patients with Hashimoto's thyroiditis. In conclusion, our study found a bidirectional association between AA and thyroid diseases, suggesting shared biological mechanisms underlying these two diseases.

Proton pump inhibitors (PPI) are commonly used drugs. However, little is known about the association between PPI use and rosacea. This study aimed to investigate the association between PPI use and rosacea risk. Patients with prior PPI therapy, including 1067 rosacea cases and 4268 matched controls, were identified from the National Health Insurance Research Database in Taiwan. The cumulative defined daily dose (cDDD) was used to quantify the PPI use. Logistic regression was used for the analyses. After adjustment for potential confounders, PPI use with cDDD of more than 365 was significantly associated with an increased risk of rosacea (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.10-2.15). Rosacea risk was significantly associated with PPI use of cDDD of more than 365 in women (OR, 1.62; 95% CI, 1.08-2.46) but not in men. Stratified by PPI indications, risk of rosacea was significantly associated with PPI use of cDDD of more than 365 for peptic ulcer (OR, 1.58; 95% CI, 1.12-2.21). In conclusion, prolonged PPI use was associated with an increased risk of rosacea, particularly in women and patients with peptic ulcers.

Background Alopecia areata (AA) has long been associated with major depressive disorder (MDD). However, most evidence to date has derived from cross-sectional or case-control studies. Objective To investigate the bidirectional association between AA and MDD among probands and unaffected siblings. Methods Study participants were recruited from the National Health Insurance Research Database in Taiwan. We included 2123 probands with AA, 2298 unaffected siblings, and 9192 matched controls to assess the risk of MDD. We included 16,543 probands with MDD, 17,352 unaffected siblings, and 69,408 matched controls to assess the risk of AA. The Breslow-Cox model was used to calculate the adjusted relative risk. Results Compared with controls, AA probands and unaffected siblings had adjusted relative risks of 8.22 (95% confidence interval [CI], 6.41-10.54) and 2.55 (95% CI, 1.91-3.40), respectively, for MDD. MDD probands and unaffected siblings had adjusted relative risks for AA of 1.66 (95% CI, 1.24-2.22) and 1.64 (95% CI, 1.27-2.12), respectively. Limitation The National Health Insurance Research Database lacked information on disease severity, body mass index, smoking habit, alcohol consumption, and stressful life events. Conclusion Our study demonstrated a bidirectional association between AA and MDD among probands and unaffected siblings, thus suggesting shared familial mechanisms underlying AA and MDD.

Studies investigating the risk for dementia in psoriatic patients remain inconclusive. There are a limited number of population-based studies on the association between psoriasis and dementia. This study aims to investigate the risk for dementia in psoriatic patients. This nationwide population-based cohort study was based on data obtained from the Taiwan National Health Insurance Research Database between 2000 and 2012. A total of 111,825 patients with psoriasis and 111,825 age-, sex-, and index date-matched controls were recruited. The hazard ratio (HR) for subsequent dementia in patients with psoriasis was analyzed using a Cox model and a Fine-Gray competing risk model. During 1,358,774 person-years of follow-up, 2688 patients developed dementia in the psoriatic cohort, and 2062 developed dementia in the control cohort. In the multivariate adjusted Cox model, the hazard ratio (HR) of psoriatic patients for dementia was 1.02 [95% confidence interval (CI) 0.96-1.09] relative to the controls. Psoriasis did not increase the risk for dementia (both vascular dementia and degenerative dementia). In the competing risk model, the HR of dementia was 0.96 (95% CI 0.90-1.02) for psoriatic patients. Compared to psoriatic patients who had not received phototherapy or systemic treatment, those psoriatic patients receiving phototherapy or systemic treatment had a lower risk for dementia. However, this phenomenon was not observed in psoriatic patients who were observed for longer than 6 years. Psoriasis was not found to be a risk factor for dementia. Phototherapy and systemic treatment might not have a protective effect against dementia in psoriatic patients.

The relationship between cancer and vitiligo has been explored but with inconsistent results. To examine the long-term cancer risk in vitiligo patients, we conducted a retrospective nationwide cohort study. From the National Health Insurance Research Database of Taiwan, a total of 13,824 vitiligo patients were identified and matched with 55,296 reference subjects without vitiligo by age, gender, and propensity score estimated by major comorbidities from 1997 to 2013. Demographic characteristics and comorbidities were compared between these two groups. Incidence rate ratios and hazard ratios (HRs) were calculated to examine cancer risks. The 16-year incidence rates of overall cancers were 621.06 (566.56–675.55) and 726.99 (697.24–756.74) per 100,000 person-years in the vitiligo and reference groups. Patients with vitiligo showed a significantly decreased risk of overall cancers [adjusted HR, 0.85; 95% confidence interval (CI), 0.77 to 0.93, p p p = 0.026). The results were consistent across different subgroups of patients, including male gender, ages more than 40 years, and those receiving long-term systemic disease-modifying antirheumatic drugs and phototherapies. Information related to phenotype, disease duration, vitiligo lesion sites, family history of vitiligo or cancer, occupation, and personal lifestyle was not included in the database. Vitiligo is associated with reduced risks of BCC and SCC, as well as internal malignancies.

Background: Obesity and metabolic diseases including diabetes, hyperlipidemia, and hypertension are reportedly associated with an increased risk of psoriasis. However, few prospective studies have investigated the association of obesity and metabolic diseases with the risk of psoriasis. Objective: To examine whether obesity or metabolic diseases increase the risk of psoriasis. Methods: Participants were collected from 4 rounds (2001, 2005, 2009, and 2013) of the Taiwan National Health Interview Survey. Incident cases of psoriasis were identified from the National Health Insurance database. Participants were followed from the time of the National Health Interview Survey interview until December 31, 2017, or until a diagnosis of psoriasis was made or the participant died. The Cox regression model was used for the analyses. Results: Of 60,136 participants, 406 developed psoriasis during 649,506 person-years of follow-up. Compared to participants with a BMI of 18.5–22.9, the adjusted hazard ratios (aHR) of psoriasis were 1.34 (95% CI 1.05–1.71) for a BMI of 25.0–29.9 and 2.70 (95% CI 1.95–3.72) for a BMI ≥30. Neither individual nor multiple metabolic diseases were associated with incident psoriasis. Participants with a BMI ≥30 were at significantly higher risk of both psoriasis without arthritis (aHR 2.60; 95% CI 1.85–3.67) and psoriatic arthritis (aHR 3.96; 95% CI 1.45–10.82). Conclusion: Obesity, but not metabolic diseases, significantly increased the risk of psoriasis.

Several studies have shown a strong association between atopic diseases and autism spectrum disorder (ASD). However, the risk of atopic diseases in individuals having ASD-affected siblings has never been investigated. This nationwide population-based cohort study included 2762 individuals with ASD-affected siblings and 11,048 controls. Diagnoses of atopic diseases, including asthma, atopic dermatitis, allergic rhinitis, and allergic conjunctivitis, were ascertained from 1996 or the birth data to the end of 2011. Individuals with ASD-affected siblings had a higher risk for asthma, atopic dermatitis, allergic rhinitis, allergic conjunctivitis, and multiple atopic diseases compared with controls. In conclusion, individuals with ASD-affected siblings were more likely than were the controls to develop atopic diseases, suggesting shared familial mechanisms underlying the two conditions.

Background: Bullous pemphigoid (BP) is a common autoimmune blistering skin disease with substantial mortality. Objective: To identify whether the use of immunosuppressants was associated with reduced mortality in BP patients. Methods: The data for this study were obtained from the National Health Insurance Research Database in Taiwan from January 1, 1997 to December 31, 2013. Those BP patients receiving any immunosuppressant for ≥28 days per month for 3 consecutive months were defined as the immunosuppressant cohort. In total, 452 BP patients on immunosuppressants were matched 1:4 by age, sex, propensity score of comorbidities, and use of tetracycline with 1,808 BP patients taking only corticosteroids. Results: The immunosuppressant cohort had a significantly lower 5-year mortality rate than the corticosteroid cohort (0.57 vs. 0.67). In the multivariable regression analysis adjusted for covariates, the use of immunosuppressants significantly reduced the risk of mortality (hazard ratio [HR]: 0.78, 95% confidence interval [CI]: 0.68–0.90, p < 0.001). Hyperlipidemia also reduced risk of mortality. However, age, diabetes, renal disease, chronic obstructive pulmonary disease, cerebrovascular disease, and dementia were significant risk factors for mortality. In the subgroup analysis, the risk of mortality decreased most substantially in those aged Conclusion: Immunosuppressant use was associated with a 22% reduced risk of BP mortality. The effects were more substantial in those aged

Background Acetaminophen (APAP) has been associated with the development of atopic diseases. However, little is known about the relationship between prenatal APAP exposure and atopic dermatitis (AD) in offspring. Objective To investigate the association between prenatal APAP exposure and AD risk in offspring. Methods In this study, 2029 study pairs (AD-affected children and their mothers) and 5,058 control pairs were identified between 1998 and 2008 from the Taiwan Longitudinal Health Insurance Database. Maternal APAP exposure during pregnancy was assessed. Results After adjustment for potential confounders, there was a significant association between risk of offspring AD and exposure to acetaminophen in the first trimester (OR 1.16; 95% CI 1.05-1.28), the second trimester (OR 1.14; 95% CI 1.03-1.27), both first and second trimesters (OR 1.30; 95% CI 1.13-1.51), both first and third trimester (OR 1.20; 95% CI 1.04-1.39), any trimester (OR 1.12; 95% CI 1.00-1.26), and all three trimesters (OR 1.32; 95% CI 1.08-1.62) in a dose-response manner. Conclusions Prenatal exposure to acetaminophen was associated with an increased incidence of offspring AD.

Background: There have been some reports on the coexistence of psoriasis and atopic dermatitis; however, the longitudinal relationship between these two diseases remains unclear. Objective: This study aimed to investigate the bidirectional association between psoriasis and atopic dermatitis. Methods: This cohort study recruited patients from the National Health Insurance Research Database in Taiwan. We included 8,206 patients with psoriasis and 32,824 matched controls to assess the risk of atopic dermatitis and 25,743 patients with atopic dermatitis and 102,972 matched controls to assess the risk of psoriasis. Cox regression model was used for the analyses. Results: After adjusting for potential confounders, patients with psoriasis had a higher risk of atopic dermatitis (adjusted hazard ratio [aHR] 13.01; 95% CI 10.23–16.56) than the controls. Patients with atopic dermatitis had a higher risk of psoriasis (aHR 10.37; 95% CI 6.85–15.69) than the controls. Stratified analyses revealed similar results in both sexes and all age groups. Conclusion: Our study demonstrated a bidirectional association between psoriasis and atopic dermatitis, suggesting that psoriasis and atopic dermatitis are not mutually exclusive and may share some biological mechanisms.

This nationwide population-based cohort study investigates the risk of hearing loss in patients with alopecia areata using claims data from the National Health Insurance Research Database in Taiwan.

Higher bullous pemphigoid (BP) risk has been reported to be associated with dipeptidyl peptidase 4 inhibitor (DPP4i). The aim of this study is to examine the association between BP risk and DPP4i treatment.We conducted a nationwide cohort study based on the Taiwan National Health Insurance Database between 2000 and 2015. 124,619 diabetic patients who were receiving DPP4i therapy were matched 1: 1 with diabetic patients who had never received DPP4i by age, sex, duration of diabetes, insulin usage, and propensity score-matching of comorbidities.The 6-year cumulative incidence of BP in the DPP4i-treated cohort was significantly higher than that in the non-DPP4i group (0.74 per 1000 vs 0.38 per 1000, P = 0.001). Modified Cox regression analysis revealed that DPP4i treatment (HR: 2.15, 95% CI: 1.18-3.91, P = 0.01), age (HR: 1.06, P 0.001), renal disease (HR: 2.32, P 0.001), and metformin user (HR: 1.93, P = 0.006) were associated with increased BP risk.DPP4i users had a 2.2-fold increase in the risk of BP, and the risk was the highest in those with concomitant use of DPP4i and insulin.

Background Narrowband ultraviolet B (NB-UVB) phototherapy is a widely used treatment for various dermatoses. The risk of skin cancer following long-term NB-UVB phototherapy has rarely been explored in skin phototypes III-V. Methods We conducted a nationwide-matched cohort study and identified a total of 22 891 psoriasis patients starting NB-UVB phototherapy from the Taiwan National Health Insurance Database during the period 2000-2013. Cumulative incidences of skin cancers were compared between subjects receiving less than 90 UVB treatments (S-cohort, N = 13 260) and age- as well as propensity score-matched subjects receiving more than or equal to 90 UVB treatments (L-cohort, N = 3315). Results There were no significant differences in the overall cumulative incidences of skin cancers between the two cohorts (log-rank t test, P = 0.691) during the follow-up periods. The S-cohort had a significantly lower prevalence of actinic keratosis when compared with the L-cohort (0.54% vs 1.00%, P = 0.005). Conclusion Long-term NB-UVB phototherapy does not increase skin cancer risk compared with short-term NB-UVB phototherapy in psoriasis patients with skin phototypes III-V.

Background An association between alopecia areata (AA) and atopic dermatitis (AD) has been reported in previous studies. However, the temporality of this relationship remains unclear based on prior cross-sectional and case-control studies. Objective This study aimed to investigate the bidirectional association between AA and AD. Methods Participants were recruited from the National Health Insurance Research Database of Taiwan. In analysis 1, we included 12 022 AA patients and 48 088 matched controls to assess the association between AA and AD risks. In analysis 2, 40 307 AD patients and 161 228 matched controls were included to assess the association between AD and AA risks. A Cox regression model was used to calculate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs). Results Compared with controls, AA patients had a significantly increased risk of developing AD (aHR: 5.47; 95% CI: 4.76-6.28) after adjustment for potential confounders. Likewise, AD patients had a significantly increased risk of developing AA (aHR: 6.00; 95% CI: 5.04-7.14). Conclusions Our study demonstrated a bidirectional association between AA and AD, suggesting that these two diseases may share common pathogenic mechanisms. This finding has implications for follow-up and screening of AA patients for AD and vice versa.

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

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

Background The relationship between autoimmune connective tissue disease (ACTD) and atopy is controversial. Objectives To investigate the risks of ACTDs in patients with atopic triad diseases, including atopic dermatitis, allergic rhinitis, and asthma, by using a nationwide data base. Methods A cohort of 155,311 patients newly diagnosed with atopic dermatitis, allergic rhinitis, or asthma in 2002-2011 was obtained from the Taiwan National Health Insurance Research Database. An age- and sex-matched control group was selected from the same data base. The association between atopy and ACTD was investigated by using Cox proportional hazards regression analyses. Results Atopic dermatitis, allergic rhinitis, and asthma were present in 12.1, 78.6, and 26.3%, respectively, of the patients with atopy. The presence of atopic diseases increased the overall risk of ACTDs (incidence rate ratio 1.85 [95% confidence interval {CI}, 1.52-2.25]). The hazard ratio (HR) for ACTDs remained higher after adjusting for age, sex, urbanization level, socioeconomic status, and comorbidities. Individual risks of systemic lupus erythematosus (HR 1.58 [95% CI, 1.06-2.37]), rheumatoid arthritis (HR 1.74 [95% CI, 1.31-2.33]), and Sjogren syndrome (HR 2.49 [95% CI, 1.71-3.63]) were also higher. The coexistence of atopic triad diseases increased the risk of ACTDs from 1.80 (95% CI, 1.48-2.21) for one atopic disease to 3.29 (95% CI, 1.22-8.88) for three atopic diseases. Conclusion The presence of atopic triad diseases is significantly associated with risks of systemic lupus erythematosus, rheumatoid arthritis, and Sjogren syndrome, and their coexistence exacerbates this risk. To our knowledge, this was the first study that reported an increased risk of Sjogren syndrome among patients with atopy.

Asian population-based data evaluating all-cause mortality and cause-specific mortality in patients with psoriasis are limited. This study aimed to evaluate the risk of all-cause mortality (stratified according to onset status, disease severity, and concomitant psoriatic arthritis) and cause-specific mortality in patients with psoriasis. Our study cohort consisted of 80,167 patients with newly diagnosed psoriasis between 2001 and 2012 in the National Health Insurance Database. Vital status and cause of death were ascertained from the National Death Registry of Taiwan. All-cause and cause-specific crude mortality rates and standardized mortality ratios were estimated. A total of 7,198 deaths were identified during the follow-up period (508,505 person-years). The standardized mortality ratios were 1.53 for severe psoriasis (95% confidence interval = 1.45-1.60), 1.47 for early-onset psoriasis (95% confidence interval = 1.34-1.61), and 1.47 for patients with psoriatic arthritis (95% confidence interval = 1.36-1.58). In the cause-specific mortality analysis, the absolute and excess risks of death were highest for malignancies (3.6 and 1.57 deaths per 1,000 patient-years, respectively) and circulatory system diseases (3.0 and 1.44 deaths per 1,000 patient-years, respectively). Patients with severe psoriasis, early-onset psoriasis, and psoriatic arthritis had higher all-cause mortality risks. In particular, patients with psoriasis had higher excess risks of mortality from malignancies and circulatory system diseases.

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

Background Endoscopic assisted breast surgery was associated with small and inconspicuous scar and endoscopic assisted breast conserving surgery (E-BCS) for breast cancer was increasingly performed as well. The clinical outcomes, learning curve analysis and patient reported cosmetic result of E-BCS for breast cancer were reported along with a review of the current literature. Methods A retrospective study analyzing the outcomes of E-BCS for breast cancer patients through an endoscopic breast surgery database in a single institution from June 2009 to May 2019 was performed and a literature review through Pubmed and Medline was conducted as well. Results 100 consecutive breast cancer patients who underwent E-BCS were analyzed. The mean age of patients was 52.5 years old. Furthermore, the mean pathologic tumor size was 1.6 cm and majority of patients had early stage (13% stage 0, 56% stage I, and 30% stage II) breast cancer. The mean operation time of E-BCS in the current study was 133 ± 50 min and in learning curve analysis, after accumulation of 15 consecutive cases the operation time significantly decreased. The morbidities of E-BCS were minor and most of them were skin flap related. The margin involvement rate was 4%. About 98% of patients surveyed were satisfied with the incision length, location and scar appearance of E-BCS whereas all of them were satisfied with E-BCS in general. With a mean follow-up of 29.2 ± 24.4 months, 3% of patients developed locoregional recurrences, 3% had distant metastasis and there were 2 mortalities observed. Conclusion In our preliminary experience, E-BCS is a promising surgical technique for selected early breast cancer patients with low morbidity, acceptable oncological outcomes and high patient satisfaction.

Background: Increasing evidence suggests a positive association between attention-deficit hyperactivity disorder (ADHD) and atopic diseases. However, the risk of atopic diseases in unaffected siblings of patients with ADHD has not been investigated. Objective: To investigate the risk of developing atopic diseases among unaffected siblings of ADHD probands. Methods: Using data from the Taiwan National Health Insurance Research Database, 20,170 unaffected siblings of patients with ADHD born between 1980 and 2000 and 80,680 age-, birth time-, and residence-matchedcontrols were included in this study. Diagnoses of atopic diseases, including asthma, atopic dermatitis, allergic rhinitis, and allergic conjunctivitis, were ascertained from 1996 or the birth time until the end of 2011. Results: Breslow-Cox proportional hazard regression analyses with adjustment for demographic data showed that compared with the controls, unaffected siblings of patients with ADHD had a higher risk of developing asthma (relative risk [RR], 1.19; 95% confidence interval [CI], 1.15–1.24), atopic dermatitis (RR, 1.10; 95% CI, 1.04–1.16), allergic rhinitis (RR, 1.17; 95% CI, 1.14–1.21), allergic conjunctivitis (RR, 1.13; 95% CI, 1.09–1.17), and any of these atopic diseases (RR, 1.13; 95% CI, 1.10–1.15). Conclusion: The unaffected siblings of ADHD probands were more likely to develop atopic diseases compared with the controls, suggesting shared risk factors for both diseases.

Background Phototherapy might increase bone mineral density. However, it is unknown whether phototherapy can reduce the risk of fractures in patients with vitiligo. Objectives To investigate the effect of phototherapy on fracture risks in vitiligo patients aged 40 or older. Methods This population-based cohort study used the 2000–2010 Taiwan National Health Insurance Research Database (NHIRD) to identify 3863 patients newly diagnosed with vitiligo between 2003 and 2009 at age ≥40 years. Study subjects were classified into three cohorts: (1) frequent phototherapy; (2) infrequent phototherapy; and (3) no phototherapy. Patients were followed until the first hip or vertebral fracture or 31 December 2010. Data were analysed using Cox regression models and also stratified by age and gender. Results Frequent phototherapy decreased the fracture risks (adjusted hazard ratio (aHR) = 0.32, p = 0.009) in vitiligo patients. Stratification by age and gender confirmed the fracture prevention effect of frequent phototherapy in patients aged 40–64 years (aHR = 0.14, p = 0.016) and in female patients (aHR = 0.31, p = 0.024). Conclusions This study provides the first evidence that frequent phototherapy can reduce the risk of fractures among middle-aged and among female vitiligo patients.

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

Background: Previous studies showed conflicting results regarding the mortality risk in psoriasis patients with respect to disease severity and presence of psoriatic arthritis. This study aimed to determine the mortality risk in patients with mild and severe psoriasis and patients with psoriatic arthritis (PsA). Methods: A nationwide population-based cohort study was conducted based on data from the Taiwan National Health Insurance Research Database between 2002 and 2012. Incident psoriasis subjects were classified into two groups: psoriasis without arthritis and psoriasis with arthritis. Patients who had received systemic therapy and/or phototherapy were classified as having severe psoriasis, otherwise, patients were classified as having mild psoriasis. Control subjects without psoriasis were selected to match each psoriasis patient from the database within the same observational period. Cox proportional hazards analysis was used to compare the hazard ratio (HR) of time to death. Results: A total of 106,701 patients with psoriasis were included in this study. After controlling for demographics and comorbidities, psoriasis patients had a higher mortality risk compared with the control group (HR 1.41, 95% confidence interval (CI) 1.36 to 1.46). Compared with psoriasis alone, the mortality risk was not increased for PsA (HR = 1.01, 95% CI 0.93 to 1.10). Besides, severe psoriasis did not increase mortality risk compared with mild psoriasis (HR = 1.0, 95% CI 0.95 to 1.06). Conclusions: Patients with psoriasis had a higher mortality risk compared with control subjects, whereas psoriasis severity and presence of PsA had no impact on mortality risk in psoriasis patients.

Background Alcohol consumption and smoking have long been suspected of increasing the risk of developing psoriasis. Most evidence to date has derived from cross-sectional or case-control studies. Objective We sought to investigate the effects of alcohol and smoking on incident psoriasis. Methods Alcohol consumption, smoking status, and other covariates were collected from four rounds (2001, 2005, 2009, and 2013) of the Taiwan National Health Interview Survey. Incident psoriasis was identified from the National Health Insurance database. Cox regression model was used for the analysis. Results Of 60,136 subjects, 242 (0.40%) developed psoriasis. After controlling for demographics and comorbidities, alcohol consumption was not significantly associated with psoriasis risk. Conversely, psoriasis risk was higher for current smokers than never smokers (adjusted hazard ratio 1.47 [95% confidence interval 1.04-2.07]). The risks were higher among subjects who smoked >25 cigarettes per day and for >20 pack-years. In subgroup analysis, current smoking was significantly associated with risk of psoriasis without psoriatic arthritis but not psoriatic arthritis alone. Limitations Alcohol consumption was not assessed based on the number of drinks consumed. Conclusion Current smoking increased the risk of psoriasis, particularly augmented for individuals who smoked >25 cigarettes per day and for >20 pack-years, while alcohol consumption was not significantly associated with psoriasis development.

The risk of psoriasis in diabetic patients has rarely been explored.We sought to investigate the association between antidiabetic therapies and psoriasis.The incidence of psoriasis was compared between a representative diabetic cohort and a matched nondiabetic cohort. We next conducted a nationwide cohort study with 1,659,727 diabetic patients using the National Health Insurance Research Database of Taiwan 1997 through 2011. Multivariate conditional logistic regression was used for nested case-control analyses.Incidence rates of psoriasis among diabetic patients and nondiabetic matched control subjects were 70.2 (95% confidence interval [CI] 59.5-80.9) and 42.3 (95% CI 39.5-45.5) per 100,000 person-years, respectively (P.0001). Frequent insulin use was associated with higher risk of incident psoriasis (adjusted odds ratio 1.29, 95% CI 1.18-1.42) after adjusting for comorbidities, disease duration, and number of hospital visits. Among diabetic patients without history of insulin use, frequent use of thiazolidinedione was associated with lower risk of psoriasis (adjusted odds ratio 0.87, 95% CI 0.77-0.99).The National Health Insurance Research Database did not contain information regarding disease severity, diet, body mass index, lifestyle, or family history.Among diabetic patients, regular insulin use is associated with psoriasis development. Frequent use of thiazolidinedione may be associated with modest reduction in psoriasis risk.

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

Background: Skin diseases are among the most common public health problems and cause a significant burden. For policymakers and clinicians, comprehensive and detailed information is necessary to better allocate resources needed to care for skin diseases. This study was conducted to characterize the ambulatory practice of dermatologists in Taiwan. Methods: The study data were drawn from the datasets of Taiwan's National Health Insurance Research Database for 2013, with 623,614 records of ambulatory care visits representing 1/500 of all the claims in Taiwan for 2013. The analysis of these visits included the patient demographics, diagnoses, prescriptions, and procedures. Results: We identified 31,547 visits to dermatologic clinics, which accounted for 5.1% of all the ambulatory care visits in 2013. The three most commonly encountered diseases were contact dermatitis and other eczema, unspecified cause (34.3%, n = 10,811), acne (17.3%, n = 5452), and dermatophytosis (12.9%, n = 4065). Topical glucocorticoids (38.8%, n = 12,248), systemic antihistamines (35.4%, n = 11,172), and systemic antibiotics (15.2%, n = 4809) were the three most commonly prescribed drug categories. Clobetasol, a very potent glucocorticoid, was the most commonly prescribed medication (20.9%, n = 6579). In 22.9% of visits (n = 7248), combined glucocorticoid/antifungal preparations were prescribed. Conclusion: This study characterizes the current state of ambulatory dermatologic care in Taiwan. The results raise concerns about the misuse of very potent glucocorticoids and combined glucocorticoid/antifungal preparations in dermatologic practices. Keywords: Dermatology, Health care systems, Outpatient care, Skin diseases, Taiwan

Background EGb-761 is an antioxidant and anticarcinogen; however, its role as a photoprotector remains unknown. Objective To determine whether EGb-761 photoprotects human dermal fibroblasts and BALB/c mice skin against ultraviolet B (UVB) light irradiation. Methods To simulate chronic photodamage, shaved BALB/c mice were exposed to UVB irradiation (90 mJ/cm2) thrice weekly for 3 months. EGb-761 (2 mg/cm2) was topically applied 1 h before irradiation to evaluate its effect. The mechanisms by which EGb-761 protects the skin from photodamage were evaluated by immunohistochemical analysis, enzyme-linked immunosorbent assay (ELISA), and Western blotting. Results In BALB/c mice, the signs of photoaging or photodamage, such as coarse wrinkle formation, epidermal hyperplasia, and elastic fiber degeneration, markedly reduced with the topical application of EGb-761. Western blot and ELISA revealed that the activation of MMP-1 in cultured fibroblasts markedly diminished after pretreatment with EGb-761. In addition, EGb-761 inhibited UVB-induced overexpression by the fibroblasts of the proinflammatory cytokines, such as interleukin (IL)-1α, IL-1β, IL-6, and tumor necrosis factor-α. The phosphorylation of the mitogen-activated protein kinase (MAPK) signal transduction pathway components, including extracellular signal-regulated kinase, C-Jun N-terminal kinase, and p38, which are induced by UV irradiation, was significantly inhibited in vivo and in vitro. EGb-761 also diminished the generation of UVB-induced reactive oxygen species (ROS). Conclusions EGb-761 photoprotects mice and cultured fibroblasts, inhibits the UVB-induced phosphorylation of MAPK pathway components, and reduces the expression of the proinflammatory cytokines by suppressing ROS generation. Thus, topically applied EGb-761 may be a promising photoprotective agent.

Objectives To examine the epidemiology of and possible risk factors for skin diseases in patients with schizophrenia. Methods All of 337 patients with schizophrenia were recruited from the therapeutic community of a psychiatric hospital and underwent a detailed skin examination. The National Health Insurance Research Database (NHIRD) was used to compare the prevalence of skin diseases between patients with schizophrenia and those without. Results In the clinical survey, fungal infection (61.4%) and dermatitis (46.9%) were the most common skin diseases. Clozapine users had a lower risk of fungal infection than those on typical antipsychotics [odds ratio (OR)=0.49, 95% confidence interval (CI)=0.30–0.81]. Obese patients were more likely to have fungal infections than those without (OR=1.93, 95% CI=1.20–3.09), and those with diabetes had an increased risk of bacterial infection than those without (OR=2.0, 95% CI=1.06–3.75). NHIRD revealed that the overall prevalence of skin diseases, including infections, dermatitis, hyperkeratosis, pilosebaceous disease, androgenic alopecia, xerosis and stasis, were higher in patients with schizophrenia than in those without (75.1% vs. 72.6%, P =.01). Conclusions The prevalence of skin diseases is high in patients with schizophrenia, for whom proper skin care is necessary to improve their life quality.

Systemic sclerosis is a life-threatening autoimmune disease characterized by vasculopathy, which results in myocardial involvement in an extremely high percentage of patients. Nevertheless, there have been no large-scale epidemiological studies about the risk of acute myocardial infarction in patients with systemic sclerosis. The aims of this study were to evaluate the hazard ratio (HR) and risk factors of acute myocardial infarction in patients with systemic sclerosis, as well as to compare the risks of acute myocardial infarction among systemic sclerosis patients taking different immunosuppressors.The study cohort included 1344 patients with systemic sclerosis and 13,440 (1:10) age-, sex-, and comorbidity-matched controls during the period between 1997 and 2006, from the National Health Insurance Research Database. We compared the risk of acute myocardial infarction between patients with systemic sclerosis and controls and calculated the adjusted HRs for acute myocardial infarction in systemic sclerosis patients taking immunosuppressors and not taking immunosuppressors.The incidence rates of acute myocardial infarction were 535 and 313 cases per 100,000 person-years for systemic sclerosis cohort and reference cohort, respectively (P.001, unadjusted). After adjusting for age, sex, and underlying medical diseases on Cox proportional hazards model, systemic sclerosis was found to be an independent risk factor for acute myocardial infarction (HR 2.45). Other risk factors included hypertension (HR 2.08) and diabetes (HR 2.14). The multivariate adjusted HR for acute myocardial infarction did not decrease among the systemic sclerosis patients taking systemic steroids, penicillamine, cyclophosphamide, azathioprine, methotrexate, or cyclosporine.Systemic sclerosis is independently associated with an increased risk of acute myocardial infarction. Immunosuppressors do not lower the risk of acute myocardial infarction in our study.

Dermatophytes are the main pathogen of superficial skin fungal infections. On rare occasions, they can cause deep and extensive infections, especially in immunocompromised hosts. We reported a 48-year-old patient with liver cirrhosis and chronic renal failure who developed an extensive deep dermatophytosis with possible hematogenous dissemination. Skin histopathology showed extensive involvement of hair follicles and dermis by fungal elements. The pathogen was cultured from both skin biopsy specimen and central venous line. It was identified as Trichophyton rubrum by morphology and further conformed by sequencing of internal transcribed spacers of ribosomal DNA. The patient died quickly before the identification was available.

Background Although the link between tuberculosis (TB) and biologics use is well established, the risk of TB among patients with psoriasis exposed to traditional systemic therapies remains elusive. Objectives The aim is to investigate the association between traditional systemic therapies and TB among patients with psoriasis. Methods We conducted a retrospective cohort study on the risk of active TB among patients with psoriasis and psoriatic arthritis, using the National Health Insurance Research Database of Taiwan, 1996 through 2008. Standardized incidence ratios of TB were analyzed in comparison with age- and gender-matched general population. Logistic regression was used in a nested case-control analysis to estimate the odds ratios of TB related to exposure to traditional systemic agents during the year before TB development. Results Among the 81,266 patients in the psoriasis cohort, 497 new active TB cases were identified. The incidence rate of TB was 102 cases per 100,000 person-years among patients with psoriasis (standardized incidence ratio 1.22, 95% confidence interval 1.18-1.33). The risk of TB was higher in patients with severe disease (standardized incidence ratio 1.52, 95% confidence interval 1.46-1.74). To facilitate comparisons with the 497 active TB cases, a total of 1988 matched control subjects were selected for a nested case-control study. Patients taking systemic corticosteroids and nonsteroidal anti-inflammatory drugs were associated with higher incidence of TB, especially frequent users, after adjustment for multiple TB risk factors, drug exposures, hospital visits, and level of urbanization. Stratified analyses of current users and new users of these drugs revealed similar results. Finally, traditional systemic antipsoriatic treatment was not associated with TB on any of the analyses. Limitation The National Health Insurance Research Database did not contain information regarding severity of psoriasis, smoking status, alcohol use, diet, laboratory parameters, chest radiograph, or history of recent contact with an individual with TB. Misclassification of disease cannot be ruled out in a registry-based database. The accessibility of health care may be associated with the level of urbanization, which could confound the effect of drugs in multivariate analyses. Conclusions Severe psoriasis may be associated with an elevated TB risk. Traditional systemic therapies do not seem to be strongly associated with TB occurrence.

Introduction An association between psoriasis and sexual dysfunction (SD) has been explored. However, the risk of SD after the diagnosis of psoriasis relative to the age‐matched general population remains unknown. Aim To clarify the risk of developing SD in male patients with psoriasis. Methods From 2000 to 2001, we identified 12,300 male patients with newly diagnosed psoriasis and 61,500 matching controls from National Health Insurance Database in Taiwan. Main Outcome Measures The two cohorts were followed up until 2008, and we observed the occurrence of SD by registry of SD diagnosis in the database. Stratified Cox proportional hazard regressions were used to calculate the 7‐year SD risk for these two groups. Results Of the 73,800 sampled patients, 1,812 patients (2.46%) experienced SD during the 7‐year follow‐up period, including 373 (3.03% of patients with psoriasis) in the study group and 1,439 (2.34% of patients without psoriasis) in the comparison group. The hazard ratio (HR) for SD for patients with psoriasis was 1.27 times (95% confidence interval [CI], 1.11–1.46; P = 0.001) as high as that for patients without psoriasis after adjusting for age, monthly income, number of health‐care visits, systemic treatment, and other comorbidities. Stratified analysis showed that the risk of SD was higher in patients older than 60 years old (HR: 1.42, 95% CI: 1.12–1.81) and patients with psoriatic arthritis (HR: 1.78, 95% CI: 1.08–2.91). However, the risk of SD was not significantly elevated in patients receiving systemic treatment, including retinoid, methotrexate, and cyclosporine. Conclusions Male patients with psoriasis are at increased risk of developing SD. Physicians should pay attention to the impact of psoriasis on psychosocial and sexual health, especially in old‐aged patients.

A link between rosacea and inflammatory bowel disease (IBD) has been proposed with unknown mechanisms. Epidemiologic evidence of this association needs to be examined.In this nationwide cohort study, a total of 89,356 patients with rosacea and 178,712 matched patients without rosacea between 1997 and 2013 were identified in the Taiwanese National Health Insurance Research Database. Cumulative incidences of IBD were compared between these 2 cohorts. Frailty Cox proportional hazard model was used and subgroup analyses were conducted to examine the risk factors for IBD.The 15-year cumulative incidences of IBD were 0.036% (95% confidence interval [CI] 0.00%-1.57%) and 0.019% (95% CI 0.00%-0.83%) in rosacea and nonrosacea cohorts, respectively (P = .05). Rosacea (adjusted hazard ratio 1.94, 95% CI 1.04-3.63, P = .04) and male gender (adjusted hazard ratio 3.52, 95% CI 2.03-6.11, P .01) were independently associated with IBD, after adjustment for major comorbidities. Multivariate subgroup analyses revealed consistent results. The incidence rates of IBD decreased with increasing antibiotic use in patients with rosacea, but without statistical significance.Information related to lifestyle, diet, alcohol, and smoking was not included in the database.Patients with rosacea may have an increased risk of IBD.

Epidemiologic studies have identified cholecystectomy as a possible risk factor for cancers in Western countries. The aim of this study was to estimate the risk of hepato-biliary cancer after cholecystectomy in Taiwan.Based on the Taiwan National Health Insurance Research Database, 2,590 cholecystectomized patients without prior cancers in the period 1996-2008 were identified from a cohort dataset of 1,000,000 randomly sampled individuals. The standard incidence ratio (SIR) of each cancer was calculated.After a median follow-up of 4.82 years, 67 liver cancer and 17 biliary tract cancer patients were diagnosed. Patients who received cholecystectomy had higher risks of liver cancer (SIR, 3.29) and biliary tract cancer (SIR, 8.50). Cholecystectomized patients aged ≤60 years had higher risks of liver cancer (SIR, 11.14) and biliary tract cancer (SIR, 55.86) compared to those aged60 years (SIR, 2.31 and 5.67). Female cholecystectomized patients had higher risks of liver cancer (SIR, 4.18) and biliary tract cancer (SIR, 10.56) than males (SIR, 2.96 and 7.26). Cholecystectomized patients with cirrhosis had higher SIR of liver cancer than patients without cirrhosis (SIR, 33.84 vs. 1.41).Cholecystectomy may be associated with an increased risk of hepato-biliary cancer. Further and regular surveillance should be performed on such patients.

Background Hospitalized psoriasis patients are known to have a higher risk of malignancy (e.g., nonmelanoma skin cancer [NMSC], lymphoma, and melanoma) than the general population; currently, it is unclear whether this risk is affected by psoriasis severity. The aim of this study was to compare the cancer risk of patients with mild and severe psoriasis and the general population. Methods Data for this retrospective population-based cohort study were obtained from the Taiwan National Health Insurance Research Database. This study included 7061 patients with a first-time diagnosis of psoriasis. All study individuals were followed up until the end of 2007. The crude incidence density ratio and standardized incidence ratio (SIR) of NMSC, melanoma, and lymphoma were determined. Results Among psoriasis patients, the most common cancer was NMSC (density ratio: 7.5); women were at a higher risk of NMSC than men (density ratios: 8.08 vs. 7.0). Psoriasis patients in the south geographic group or in the 50- to 59-year-old age group were most likely to develop NMSC. The NMSC SIR was higher among patients with severe psoriasis than among patients with mild psoriasis (SIR: 3.72 vs. 7.08). The lymphoma and melanoma SIR among patients with severe psoriasis was also high (lymphoma SIR: 4.85; melanoma: 11.01). Conclusions Psoriasis carries an elevated risk of NMSC and lymphoma. This effect is modified by the severity of psoriasis, age, gender, and geographic location.