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Background In 2015, the Korean Atopic Dermatitis Association (KADA) working group published consensus guidelines for treating atopic dermatitis (AD). Objective We aimed to provide updated consensus recommendations for systemic treatment of AD in South Korea based on recent evidence and experience. Methods We compiled a database of references from relevant systematic reviews and guidelines on the systemic management of AD. Evidence for each statement was graded and classified based on thestrength of the recommendation. Forty-two council members from the KADA participated in three rounds of voting to establish a consensus on expert recommendations. Results We do not recommend long-term treatment with systemic steroids forpatients with moderate-to-severe AD due to the risk of adverse effects. We recommend treatment with cyclosporine or dupilumab and selective treatment with methotrexate or azathioprine for patients with moderate-to-severe AD. We suggest treatment with antihistamines as an option for alleviating clinical symptoms of AD. We recommend selective treatment with narrowband ultraviolet B for patients with chronic moderate-to-severe AD. We do not recommend treatment with oral antibiotics for patients with moderate-to-severe AD but who have no signs of infection. We did not reach a consensus on recommendations for treatment with allergen-specific immunotherapy, probiotics, evening primrose oil, orvitamin D for patients with moderate-to-severe AD. We also recommend educational interventions and counselling for patients with AD and caregivers to improve the treatment success rate. Conclusion We look forward to implementing a new and updated consensus of systemic therapy in controlling patients with moderate-to-severe AD.

Background Unwanted submental fat (SMF) is aesthetically unappealing, but methods of reduction are either invasive or lack evidence of their use. Objective The authors sought to evaluate the safety and efficacy of a novel triple-layer high-intensity focused ultrasound (HIFU) regimen for SMF reduction. Methods Forty Korean subjects with moderate/severe SMF were evaluated after receiving a session of triple-layer HIFU treatments (using 3.0-, 4.5-, and 6.0-mm focusing transducers). The objective evaluation based on the 5-point Clinician-Reported Submental Fat Rating Scale (CR-SMFRS) and patients' satisfaction based on the 7-point Subject Self-Rating Scale (SSRS) were determined 8 weeks after treatment. Three-dimensional image analysis was also performed. Results At the follow-up visit, the proportion of treatment responders defined as subjects with ≥1-point improvement in CR-SMFRS was 62.5%, and the proportion of patients satisfied with appearance of their face and chin (score ≥4 on the SSRS) was 67.5% of the total patients. The results of 3-dimensional analysis were consistent with clinical observations. Only mild and transient side effects were observed for some patients with no serious adverse effects. Conclusion The triple-layer HIFU regimen including the novel 6.0-mm transducer has benefits for tightening and rejuvenation of the area with unwanted SMF, showing reasonable safety profiles.

Background Atopic dermatitis is a chronic, pruritic, and inflammatory dermatosis that affects approximately 20% of children and 10% of adults worldwide. Dupilumab facial redness is gaining attention as additional cases are coming to light in the medical literature. Objectives and methods Exosomes are nano-sized vesicles that are constantly released by almost all cells. They can travel between cells and transport their cargo (lipids, proteins, and nucleic acids), making them a possible cell-free therapeutic option for various diseases. Herein, we investigated whether topical application of human adipose tissue-derived mesenchymal stem cell-derived exosomes could reduce dupilumab facial redness in patients with severe atopic dermatitis. Results Two patients with atopic dermatitis and refractory dupilumab facial redness were successfully treated with electroporation-assisted topical application of human adipose tissue-derived mesenchymal stem cell-derived exosomes. Six repeated sessions of treatment, with an interval of 1 week between each session, led to marked improvement in erythematous facial lesions. Conclusions We suggest that human adipose tissue-derived mesenchymal stem cell-derived exosomes may serve as an effective agent in the management of dupilumab facial redness. However, further controlled studies with a larger number of patients are necessary to confirm the efficacy and safety of this agent, as well as the optimal treatment protocol.

Although deep learning algorithms have demonstrated expert-level performance, previous efforts were mostly binary classifications of limited disorders. We trained an algorithm with 220,680 images of 174 disorders and validated it using Edinburgh (1,300 images; 10 disorders) and SNU datasets (2,201 images; 134 disorders). The algorithm could accurately predict malignancy, suggest primary treatment options, render multi-class classification among 134 disorders, and improve the performance of medical professionals. The area under the curves for malignancy detection were 0.928 ± 0.002 (Edinburgh) and 0.937 ± 0.004 (SNU). The area under the curves of primary treatment suggestion (SNU) were 0.828 ± 0.012, 0.885 ± 0.006, 0.885 ± 0.006, and 0.918 ± 0.006 for steroids, antibiotics, antivirals, and antifungals, respectively. For multi-class classification, the mean top-1 and top-5 accuracies were 56.7 ± 1.6% and 92.0 ± 1.1% (Edinburgh) and 44.8 ± 1.2% and 78.1 ± 0.3% (SNU), respectively. With the assistance of our algorithm, the sensitivity and specificity of 47 clinicians (21 dermatologists and 26 dermatology residents) for malignancy prediction (SNU; 240 images) were improved by 12.1% (P0.0001) and 1.1% (P0.0001), respectively. The malignancy prediction sensitivity of 23 non-medical professionals was significantly increased by 83.8% (P0.0001). The top-1 and top-3 accuracies of four doctors in the multi-class classification of 134 diseases (SNU; 2,201 images) were increased by 7.0% (P = 0.045) and 10.1% (P = 0.0020), respectively. The results suggest that our algorithm may serve as augmented intelligence that can empower medical professionals in diagnostic dermatology.

Background Several tools can provide a reliable and accurate evaluation of pruritus, including the visual analog scale (VAS), numeric rating scale (NRS), verbal rating scale (VRS), and multidimensional questionnaires such as the Itch Severity Scale (ISS). However, no single method is considered a gold standard. Objective We evaluated the validity and reliability of VAS, NRS, VRS, and ISS and their correlation with a pruritus-specific quality of life instrument, ItchyQoL. Methods A total of 419 patients (215 men and 204 women) with chronic pruritus (mean age, 46.58 years) recorded their pruritus intensity on VAS, NRS, VRS, and ISS. Retest reliability was analyzed in a second assessment 3 hours after the initial assessment. All participants answered ItchyQoL. Results A strong correlation between VAS, NRS, and VRS was found. ISS showed a low intercorrelation validity with these tools. However, ISS was more strongly correlated with ItchyQoL. The retest reliability scores were similar for VAS, NRS, and VRS but lower than the scores obtained for ISS. Limitations Limitations include patient heterogeneity and recall bias. Conclusion The assessment of pruritus is challenging because of the subjective symptoms and the multifactorial nature. Therefore, more studies are needed to determine the best strategy to assess itch intensity.

Nonablative 1,450-nm diode laser (DL) and visible blue light (BL) have been effectively used for acne with superior safety profiles.To evaluate synergistic effects of sequential DL and BL application for acne.A 20-week, randomized split-face study was conducted to compare clinical courses between 2 facial sides either receiving sequential application of DL and BL or BL alone in 24 patients with mild to moderate facial acne vulgaris. Patients were scheduled to receive 3 consecutive sessions at 4-week intervals. Objective assessments, including revised Leeds grades, lesion counts, and sebum output measurements, and patients' subjective satisfaction were investigated.Both combination and BL sides demonstrated steady improvement of inflammatory acne lesions with 62.3% and 35.2% decreases at the 12-week follow-up visit compared with baseline respectively. For noninflammatory lesions and seborrhea, only combination regimen demonstrated improvement. Patients' subjective assessments paralleled objective findings. For safety profiles, no severe adverse effect was observed on both sides, and mild symptoms resolved spontaneously within a day.The combination regimen demonstrated synergistic efficacies for acne and seborrhea, with satisfactory safety profiles. Therefore, a few sessions of these light-based applications would be a viable option for acne treatments.

BACKGROUND While a considerable number of cases with papulopustular rosacea (PPR) are resistant to conventional medications, therapeutic regimens are not currently established. Pulsed dye laser (PDL) and fractional microneedling radiofrequency (FMR) have previously demonstrated satisfactory results for anti-angiogenesis, anti-inflammation, and dermal remodeling. AIMS To evaluate the efficacy and safety of novel combination regimen with low-dose oral isotretinoin, PDL, and FMR in the treatment of recalcitrant PPR. PATIENTS AND METHODS A retrospective study was undertaken for recalcitrant PPR patients to evaluate the clinical course of novel combination regimen. Twenty-five PPR patients who had failed in previous first-line therapies were enrolled. They were treated with three sessions of PDL and FMR consecutively at 4-week intervals, maintaining daily oral administration of 10 mg isotretinoin for 8 weeks. Objective assessments, erythema index measurement, and patients' subjective satisfaction were evaluated at each visit and 16 weeks after the final treatment. RESULTS At the final follow-up visit, the number of papules and pustules decreased by 71%, and erythema index by 54% compared with baseline (P

Background: The effects of diabetes mellitus (DM) on mortality and morbidities in burn patients have not been sufficiently elucidated. Objective: The present study aimed to investigate the effects of DM on the mortality, length of hospital stay, and number of operations in burn patients. Methods: A retrospective cohort study was performed using medical records of 3,220 burn patients. Multiple logistic regression, linear regression, and Poisson regression models were used to determine whether DM increases mortality in patients with burn injury, whether DM prolongs length of hospital stay in burn survivors, and whether DM increases the number of operations in burn survivors, respectively. Results: After adjusting for potential confounding factors, DM significantly increased odds of death in burn patients (adjusted odds ratio 3.225 [95% confidence interval 1.405∼7.400], p=0.006). DM also increased the mean length of hospital stay in burn survivors (adjusted mean ratio 1.312 [95% confidence interval 1.198∼1.437], p＜0.001). Furthermore, DM significantly increased the mean number of operations in burn survivors (adjusted mean ratio 1.576 [95% confidence interval 1.391∼ 1.785], p＜0.001). Conclusion: DM increases mortality, elongates hospital stay and makes more operations required in patients with burn injury. (Ann Dermatol 31(1) 51∼58, 2019)

Background The diagnostic performance of convolutional neural networks (CNNs) for diagnosing several types of skin neoplasms has been demonstrated as comparable with that of dermatologists using clinical photography. However, the generalizability should be demonstrated using a large-scale external dataset that includes most types of skin neoplasms. In this study, the performance of a neural network algorithm was compared with that of dermatologists in both real-world practice and experimental settings. Methods and findings To demonstrate generalizability, the skin cancer detection algorithm (https://rcnn.modelderm.com) developed in our previous study was used without modification. We conducted a retrospective study with all single lesion biopsied cases (43 disorders; 40,331 clinical images from 10,426 cases: 1,222 malignant cases and 9,204 benign cases); mean age (standard deviation [SD], 52.1 [18.3]; 4,701 men [45.1%]) were obtained from the Department of Dermatology, Severance Hospital in Seoul, Korea between January 1, 2008 and March 31, 2019. Using the external validation dataset, the predictions of the algorithm were compared with the clinical diagnoses of 65 attending physicians who had recorded the clinical diagnoses with thorough examinations in real-world practice. In addition, the results obtained by the algorithm for the data of randomly selected batches of 30 patients were compared with those obtained by 44 dermatologists in experimental settings; the dermatologists were only provided with multiple images of each lesion, without clinical information. With regard to the determination of malignancy, the area under the curve (AUC) achieved by the algorithm was 0.863 (95% confidence interval [CI] 0.852–0.875), when unprocessed clinical photographs were used. The sensitivity and specificity of the algorithm at the predefined high-specificity threshold were 62.7% (95% CI 59.9–65.1) and 90.0% (95% CI 89.4–90.6), respectively. Furthermore, the sensitivity and specificity of the first clinical impression of 65 attending physicians were 70.2% and 95.6%, respectively, which were superior to those of the algorithm (McNemar test; p < 0.0001). The positive and negative predictive values of the algorithm were 45.4% (CI 43.7–47.3) and 94.8% (CI 94.4–95.2), respectively, whereas those of the first clinical impression were 68.1% and 96.0%, respectively. In the reader test conducted using images corresponding to batches of 30 patients, the sensitivity and specificity of the algorithm at the predefined threshold were 66.9% (95% CI 57.7–76.0) and 87.4% (95% CI 82.5–92.2), respectively. Furthermore, the sensitivity and specificity derived from the first impression of 44 of the participants were 65.8% (95% CI 55.7–75.9) and 85.7% (95% CI 82.4–88.9), respectively, which are values comparable with those of the algorithm (Wilcoxon signed-rank test; p = 0.607 and 0.097). Limitations of this study include the exclusive use of high-quality clinical photographs taken in hospitals and the lack of ethnic diversity in the study population. Conclusions Our algorithm could diagnose skin tumors with nearly the same accuracy as a dermatologist when the diagnosis was performed solely with photographs. However, as a result of limited data relevancy, the performance was inferior to that of actual medical examination. To achieve more accurate predictive diagnoses, clinical information should be integrated with imaging information., Seung Seog Han and colleagues compare the performance of a neural network algorithm with that of dermatologists in diagnosis of skin neoplasms., Author summary Why was this study done? The diagnostic performance of artificial intelligence based on deep learning algorithms has been demonstrated to be superior to or at least comparable with that of dermatologists. However, the difference in diagnostic efficiency between algorithms and dermatologists was determined using experimental reader tests with limited clinical information related to the photographed skin abnormalities. Most studies performed internal validation, which indicates that both the training and validation images were selected from the same source. In addition, only a small number of disorders have been validated in the previous studies. Thus, practical limitations and biases have complicated translation to actual practices. What did the researchers do and find? The performance of the neural network algorithm was compared with that of standard dermatologic practice for diagnosing almost all types of skin neoplasms on a large scale. The algorithm could successfully screen malignancy, without lesion preselection by a dermatologist. Under experimental settings, in which only images were provided for diagnosis, the performance of the algorithm was comparable with that of the 44 dermatologists who performed the reader test. However, the performance of the algorithm was inferior to that of the attending physicians who actually consulted with patients. This highlights the value of clinical data, in addition to visual findings, for accurate diagnosis of cutaneous neoplasms. What do these findings mean? Given photographs of abnormal skin findings, the algorithm can work ceaselessly to determine the need for dermatologic consultation at a performance level comparable with that of dermatologists. To further improve the algorithm’s performance, metadata, such as past medical history, should be integrated with the clinical images.

A variety of applications of human adipose tissue stem cell-derived exosomes have been suggested as novel cell-free therapeutic strategies in the regenerative and aesthetic medical fields. This study evaluated the clinical efficacy and safety of adipose tissue stem cell-derived exosomes as an adjuvant therapy after application of fractional CO2 laser for acne scars. A 12-week prospective, double-blind, randomized, split-face trial was performed. A total of 25 patients received 3 consecutive treatment sessions of fractional CO2 laser to the whole face, with a follow-up evaluation. Post-laser treatment regimens were applied; for each patient, one side of the face was treated with adipose tissue stem cell-derived exosomes gel and the other side was treated with control gel. Adipose tissue stem cell-derived exosomes-treated sides had achieved a significantly greater improvement than the control sides at the final follow-up visit (percentage reduction in echelle d'evaluation clinique des cicatrices d'acne scores: 32.5 vs 19.9%, p < 0.01). Treatment-related erythema was milder, and post-treatment downtime was shorter on the applications of human adipose tissue stem cell-derived exosomes-treated side. In conclusion, the combined use of this novel material with resurfacing devices would provide synergistic effects on both the efficacy and safety of atrophic acne scar treatments.

Background: Since primary skin cancers in organ transplant recipients (OTRs) are rare, little is known about the characteristics and risk factors of skin cancer in OTRs. Objectives: To improve understanding of primary skin cancers in OTRs. Methods: The database of the Asan Medical Center was searched for OTRs diagnosed with primary post-transplant skin cancers from January 1990 to December 2018.The standardized incidence ratios (SIR), defined as the ratio of the observed number of cancers divided by the expected number of cancers were determined for each cancers. Results: Of 13,469 OTRs, 113 (0.8%) were diagnosed with skin cancers over the 28 years. The most common skin cancer was squamous cell carcinoma, followed by basal cell carcinoma and Kaposi’s sarcoma. The cumulative incidence of skin cancers at 28 years was 5.3%. Over the 10 year period from January 2009 to December 2018, the SIR for premalignant in situ skin lesions increased, whereas the SIR for skin cancers decreased, and the types of post-transplant skin cancers became more diverse. Age at transplantation and treatment with more than two immunosuppressive agents were risk factors for the development of new skin cancers in OTRs. Conclusion: Over the most recent 10 year period, post-transplant skin cancers have been found earlier and to be more diverse than in previous periods. Older age and treatment with more than two immunosuppressive agents increase the risk of post-transplant skin cancers.

BACKGROUNDThe aim of this study was to validate the performance of algorithm (http://rcnn.modelderm.com) for the diagnosis of benign and malignant skin tumors.METHODSWith external validation dataset (43 disorders; 40,331 clinical images from 10,426 patients; January 1, 2008 – March 31, 2019), we compared the prediction of algorithm with the clinical diagnosis of 65 attending physicians at the time of biopsy request.RESULTSFor binary-task classification of determining malignancy, the AUC of the algorithm was 0.863(95% CI 0.852-0.875) with unprocessed clinical photographs. The sensitivity/specificity of the algorithm at the predefined high-sensitivity and high-specificity threshold were 79.1%(76.9-81.4)/76.9%(76.1-77.8) and 62.7%(59.9- 65.5)/90.0%(89.4-90.6), respectively. The sensitivity/specificity calculated by the clinical diagnosis of attending physicians were 88.1%/83.8%(Top-3) and 70.2%/95.6%(Top-1), which were superior to those of algorithm.For multi-task classification, the mean Top-1,2,3 accuracies of the algorithm were 42.6±20.7%, 56.1±22.8%, 61.9±22.9%, and those of clinical diagnosis were 65.4±17.7%, 73.9±16.6%, 74.7±16.6%, respectively.In the reader test with images from 30-patients batches, the sensitivity / specificity of the algorithm at the predefined threshold were 66.9%±30.2% / 87.4%±16.5%. The sensitivity / specificity derived from the first diagnosis of 44 the participants were 65.8%±33.3% / 85.7%±11.0%, which were comparable with those of the algorithm (Wilcoxon signed-rank test; P=0.61 / 0.097).CONCLUSIONSOur algorithm could diagnose skin tumors at dermatologist-level when diagnosis was made solely with photographs, demonstrating its potential as a mass screening tool in telemedicine setting. However, due to limited data relevancy, the performance was inferior to that of actual medical examination. Clinical information should be integrated with imaging information to achieve more accurate predictions.

In Korea, there is a high dependency on oriental medicine and folk remedies (Korean J Asthma Allergy Clin Immunol, 25, 2005, 110). In addition, inaccurate information available through the Internet is increasing (Korean J Dermatol, 44, 2006, 137). So, there is always a possibility that patients may have difficulty obtaining accurate information about atopic dermatitis (AD). The aim was to determine the awareness, treatment behavior and treatment satisfaction of patients with AD and their caregivers. In October 2017, patients diagnosed with AD at nine hospitals were enrolled in this study. A questionnaire was completed by each patient. A total of 371 subjects were surveyed. In response to the question asking about knowledge of AD, the correct answer rate was 55.4%. Bathing using soap, body scrub and moisturizer showed favorable outcomes. A total of 54.9% patients responded that they were reluctant to use steroid ointment. When asked about their previous treatment, 39.6% reported using oriental medicine and 26.5% had tried folk remedies. The hospital treatment satisfaction score was 6.6. Patients usually applied their knowledge in their daily lives. However, there was a lot of inaccurate knowledge. Therefore, it is important for patients to understand the characteristics of this disease and obtain correct information.

Malignancy is a concern in cardiac transplant recipients, but the temporal trends of de novo malignancy development are unknown.The goal of this study was to describe the temporal trends of the incidence, types, and predictors of de novo malignancy in cardiac transplant recipients.The authors analyzed the temporal trends of post-transplant incidence, types, and predictors of malignancy using 17,587 primary adult heart-only transplant recipients from the International Society for Heart and Lung Transplantation registry. The main study outcomes included the incidence of, types of, and time to de novo malignancy.The risk of any de novo solid malignancy between years 1 and 5 after transplantation was 10.7%. The cumulative incidence by malignancy type was: skin cancer (7.0%), non-skin solid cancer (4.0%), and lymphoproliferative disorders (0.9%). There was no temporal difference in the time to development according to malignancy type. However, the cumulative incidence of de novo solid malignancy increased from 2000 to 2005 vs. 2006 to 2011 (10.0% vs. 12.4%; p 0.0001). Survival in patients after de novo malignancy was markedly lower than in patients without malignancy (p 0.0001). Older recipients and patients who underwent transplantation in the recent era had a higher risk of de novo malignancy.More than 10% of adult heart transplant recipients developed de novo malignancy between years 1 and 5 after transplantation, and this outcome was associated with increased mortality. The incidence of post-transplant de novo solid malignancy increased temporally, with the largest increase in skin cancer. Individualized immunosuppression strategies and enhanced cancer screening should be studied to determine whether they can reduce the adverse outcomes of post-transplantation malignancy.

Background While device-based acne treatments are widely applied for patients not tolerating conventional medications, related controlled studies have been still limited. Recently, non-ablative 1450-nm diode laser (DL) and fractional microneedling radiofrequency (FMR) have been effectively used for acne, in addition to well-recognized dermal remodelling effects. Objective To compare the clinical course of acne treatment between DL and FMR. Methods Twenty-five Korean patients with mild-to-moderate facial acne completed treatments with DL and FMR through a 20-week, randomized split-face study. One randomly assigned half side of each patient's face received DL and the other side by FMR. Treatments were scheduled to receive three consecutive sessions at 4-week intervals. Objective assessments including revised Leeds grades, lesion counts, sebum output measurements, and patients' subjective satisfaction were investigated. Results Both DL and FMR demonstrated steady improvement of acne and seborrhoea during treatment sessions. While results between two devices were similar during treatment sessions, FMR was superior to DL in the 12-week follow-up. Patients' subjective assessments for seborrhoea improvement were similar between two devices, while those for acne, skin texture, and acne scars were more satisfactory for FMR. For safety profile, no significant difference was observed between two regimens, while mild postinflammatory hyperpigmentation was observed only in DL side. Conclusion Both DL and FMR demonstrated efficacies for acne and seborrhoea, with reasonable safety profile. FMR was more effective than DL for the long-term maintenance, and subjective assessments for texture and scar improvements. Therefore, a few sessions of these devices would be a viable option for acne treatments.

Background The natural course of atopic dermatitis (AD) in infancy, childhood, and adolescence is not yet completely known. Objective To investigate the prevalence and risk factors of atopic dermatits among 19-year-old Korean male subjects. Methods All 19-year-old Korean males must undergo medical examination for conscription. We precisely evaluated the prevalence of AD in three Korean provinces using the information from this physical checkup. AD was diagnosed by experienced dermatologists according to the Hanifin and Rajka criteria. The disease severity was assessed by the scoring of atopic dermatitis (SCORAD) index. In order to investigate the risk factors for AD, a questionnaire was administered to all subjects regarding parental atopic history, geographical characteristics of past habitation, past economic status, number of siblings, parental occupation, etc. Results The point prevalence in the Korean provinces ranged from 1.15% to 1.44%. In multivariable analysis, a parental history of AD was a significant risk factor in all 3 disease-onset groups (infancy, childhood, and adolescent onset). In the infancy-onset group, low economic status was also a significant risk factor for AD. The SCORAD index was significantly higher in AD subjects with early onset and those living in small-sized habitations. Moreover, erythema, edema, lichenification, dryness of skin, and sleep loss appeared to be more severe in early-onset cases. Conclusion The younger the age of disease onset, the more severe the clinical outcomes in 19-year-old male subjects. In addition, active AD treatment at younger ages might affect the prevalence and the severity of AD in adulthood.

Mast cells and their mediators play important roles in chronic spontaneous urticaria (CSU) pathogenesis. Transglutaminase 2 (TG2) is expressed in activated mast cells and contributes to airway inflammation in allergic asthma.To investigate the role of TG2 in CSU.Patients with CSU (n = 72) and healthy controls (n = 51) were evaluated. Skin biopsy specimens were obtained from 5 patients with CSU and 2 healthy controls. Cord blood-derived human mast cells and peripheral blood-derived human mast cells were activated with IgE. TG2 activity and inflammatory mediators, such as histamine, leukotriene C4, and cytokines, were measured in serum or supernatant from cultured mast cells by enzyme-linked immunosorbent assay. Colocalization of mast cells and TG2 was determined in skin tissues by immunofluorescence.TG2 activity was significantly higher in serum samples from patients with CSU than in serum samples from healthy controls (P.001). Colocalization of mast cell surface marker c-kit and TG2 was significantly increased in the lesional skin of patients with CSU compared with that in healthy controls. The levels of histamine, leukotriene C4, tumor necrosis factor α, transforming growth factor β, and interleukins 4, 5, and 6 were significantly higher in patients with CSU than in healthy controls (P.001). Serum TG2 levels had positive correlations with each inflammatory mediator (P.001). TG2 activity was increased in cord blood-derived human mast cells (CBMCs) and peripheral blood-derived human mast cells activated with IgE compared with those without activation (P.05).Our findings suggest that TG2 expressed in and released from mast cells plays an important role in CSU pathogenesis.

Objectives To investigate longitudinal changes in behavior and quality-of-life (QoL) in children with sleep disordered breathing (SDB) after adenotonsillectomy (AT). Methods This study prospectively enrolled 148 children who underwent AT for SDB. Caregivers filled out Korean attention deficit hyperactivity disorder (ADHD) rating scale (K-ARS) and Korean version of the obstructive sleep apnea-18 (KOSA-18) at preoperative 1 day, postoperative 1 month, and postoperative 6 months. Longitudinal changes in K-ARS and KOSA-18 were evaluated and compared among subgroups. Results Both K-ARS and KOSA-18 scores improved immediately at postoperative 1 month and were maintained at postoperative 6 months. The mean preoperative K-ARS scores of the non-ADHD, ADHD-trait, and overt-ADHD groups showed uniformly immediate and sustained improvements. Also, the mean preoperative KOSA-18 scores of the small, moderate, and large impact groups were significantly improved both at postoperative 1 month and 6 months. The changes in behavior and QoL showed no significant differences with regard to the aforementioned factors. Conclusion After AT, we may expect immediate and sustained improvements in behavior and QoL in children with SDB regardless of preoperative symptom severity. Moreover, by performing AT, improvements in behavior and QoL are expected regardless of sex, age, allergic trait, or concurrent coblation-assisted turbinoplasty. These findings may help our colleague physicians counselling pediatric SDB patients and their caregivers.

Nonablative lasers have been widely used to improve photodamaged skin, although the mechanism underlying dermal collagen remodeling remains unclear.To investigate the effects and the molecular mechanisms of long-pulse neodymium-doped yttrium aluminum garnet (Nd:YAG) laser irradiation on dermal collagen remodeling in association with different pulse durations.Five hairless mice were pretreated with ultraviolet B irradiation for 8 weeks. The dorsal quadrant of each mouse was then irradiated twice at 1-week intervals at a pulse duration of 1 ms, 12 ms, or 50 ms, and a constant fluence of 20 J/cm(2). The levels of dermal collagen, mRNAs of procollagens, matrix metalloproteinases (MMPs), tissue inhibitor of metalloproteinases (TIMPs), and various growth factors were analyzed after 4 weeks.Long-pulse Nd:YAG treatment increased the dermal collagen level. A substantial increase in the level of procollagens, MMPs, TIMPs, and various growth factors was also observed irrespective of pulse duration, with a trend toward maximal increase at a pulse duration of 12 ms.Long-pulse 1,064-nm Nd:YAG laser irradiation promotes wound-healing process, which is characterized by the induction of growth factor expression and subsequent increase in MMPs and TIMPs, followed by matrix remodeling as confirmed by new procollagen production.

Background: Despite the autologous serum skin test (ASST) and autologous plasma skin test (APST) is widely used test accessing whether a patient with chronic spontaneous urticaria (CSU) has autoreactivity or not, the clinician often encounter difficulty making correlation between the test result and clinical implications. Objective: This study was aimed to find any clinical and laboratory findings related to the ASST and APST response. Agreement and correlation between the two tests was also analyzed. Methods: A retrospective study was conducted on 300 CSU patients who underwent ASST, APST. The subjects were divided into four groups according to the skin test result. Also, the degree of serum and plasma response was recorded. Results: Both ASST and APST positive group had shorter duration of the disease, higher incidence of at least one episode of angioedema than negative group. There were no significant differences in the positivity for autoantibodies including antinuclear, ds-DNA, and thyroid-related between the two groups. The predicted positive rate of ASST and APST according to age showed bimodal peak and decreasing pattern according to disease duration. Predicted positivity of both tests declined with increase in total immunoglobuline E (IgE) level. In the correlation study, the two tests showed high correlation coefficients. Conclusion: ASST and APST positivity may be related to disease duration and severity of CSU. The two tests showed a generally consistent result. Autoreactivity may be gradually lost as disease continues. We suggest the autoreactivity in CSU could arise independently from IgE mediated immune process. (Ann Dermatol 32(4) 280∼288, 2020)

Background Although a 1450-nm diode laser has been shown to be effective for acne, the conventional high-energy stamp-only regimen is often associated with pain and hyperpigmentation, especially for dark-skinned individuals. Aims To evaluate whether the novel dual regimen has clinical advantages for acne treatments compared with conventional regimen in Asian patients. Patients and methods Twenty-four Korean patients with facial acne were treated with a 1450-nm diode laser through a 20-week, randomized, split-face study. The patients were treated with three consecutive sessions at 4-week intervals. One half of the face received a dual regimen consisting of low-fluence stamping mode (5-6 J/cm2 ) for inflammatory acne lesions only, followed by 4-5 passes of moving mode for the full face. The other side received a single-pass treatment of conventional high-fluence stamp mode (14-15 J/cm2 ). Evaluations for acne, sebum secretion measurements, and safety profiles were performed. Results At the final 12-week follow-up evaluations, the dual-mode side demonstrated better improvements in both inflammatory and noninflammatory lesion counts, acne severity assessments, and reduction in sebum secretion compared with stamp-only side. Subjective satisfaction for the improvement for acne, seborrhea, and texture correlated well with objective assessments. In addition, degrees of pain and treatment-related side effects were remarkably decreased in the novel dual mode. Conclusion This novel dual regimen of the 1450-nm laser demonstrated improved efficacies for acne and seborrhea with satisfactory safety profiles. Therefore, this regimen would be a viable option for acne treatments either as monotherapy or as combination therapy.

Summary Background There are insufficient data on the long-term outcome of a combination therapy that comprises phototherapy and topical administration of tacrolimus. Aim To evaluate the clinical efficacy according to the duration of treatment and in vitro results of a combination therapy involving topical tacrolimus and an excimer laser in the treatment of vitiligo. Methods In total, 276 patients with nonsegmental vitiligo were treated with an excimer laser twice weekly, or with tacrolimus ointment twice daily, or both. The melanin contents and levels of melanogenic enzymes were measured in cultured human melanocytes treated with tacrolimus and/or excimer laser. Results After adjusting for potential confounders, the combination of tacrolimus plus excimer laser was significantly more effective than either tacrolimus or excimer laser alone (P 6 months might not provide a better final outcome than monotherapy.

Ginseng has been shown to promote hair growth in several recent studies. However, its effects on human hair follicles and its mechanisms of action have not been sufficiently elucidated. This study aimed to investigate the hair growth-promoting effects of red ginseng extract (RGE) and its ginsenosides. The proliferative activities of cultured human hair follicles treated with RGE and ginsenoside-Rb1 were assessed using Ki-67 immunostaining. Their effects on isolated human dermal papilla cells (hDPCs) were evaluated using cytotoxicity assays, immunoblot analysis of signaling proteins, and the determination of associated growth factors. We examined the ability of RGE and ginsenosides to protect hair matrix keratinocyte proliferation against dihydrotestosterone (DHT)-induced suppression and their effects on the expression of androgen receptor. The in vivo hair growth-promoting effect of RGE was also investigated in C57BL/6 mice. Both RGE and ginsenoside-Rb1 enhanced the proliferation of hair matrix keratinocytes. hDPCs treated with RGE or ginsenoside-Rb1 exhibited substantial cell proliferation and the associated phosphorylation of ERK and AKT. Moreover, RGE, ginsenoside-Rb1, and ginsenoside-Rg3 abrogated the DHT-induced suppression of hair matrix keratinocyte proliferation and the DHT-induced upregulation of the mRNA expression of androgen receptor in hDPCs. Murine experiments revealed that the subcutaneous injection of 3% RGE resulted in more rapid hair growth than the negative control. In conclusion, RGE and its ginsenosides may enhance hDPC proliferation, activate ERK and AKT signaling pathways in hDPCs, upregulate hair matrix keratinocyte proliferation, and inhibit the DHT-induced androgen receptor transcription. These results suggest that red ginseng may promote hair growth in humans.

Background Topical application of epidermal growth factor (EGF) promotes wound healing and may reduce the risk of laser-induced postinflammatory hyperpigmentation (PIH). Objective To investigate the effect of an EGF-containing cream on the incidence of laser-induced PIH. Methods Twenty-five Korean patients with senile lentigines were recruited and underwent 532-nm Q-switched Nd:YAG laser treatment. Postoperatively, patients applied either an EGF-containing cream or a control cream to the laser-treated area. Skin color and transepidermal water loss (TEWL) were measured on Days 0, 3, 7, and 35 using a Mexameter and Tewameter, respectively. Results The EGF-containing cream resulted in a nonsignificant reduction in the laser-induced increase in TEWL (p = .052 on Day 7) but significantly decreased the melanin index and incidence of PIH on Day 35 (p = .031 and p = .027, respectively). Conclusion Epidermal growth factor-containing creams may be an effective measure to prevent laser treatment-induced PIH in Asian patients.

Assessment of exposure to cosmetic products via the skin is important for evaluating the risks associated with the use of these products. However, few exposure studies have been conducted with babies, particularly in Asia. The aim of our study was to assess the exposure to selected cosmetic products in babies under the age of 36 months, over both winter and summer months. We evaluated exposure for seven cosmetic baby care products identified in a previous web-based survey as being commonly used by Korean parents. Parents were instructed to use their baby's products as per their usual habit, recording usage for each product on a daily basis over a 14-day period. Products were weighed at the start and completion of the study, with the change in weight used to determine the total amount of product used. Descriptive statistics for daily exposure were calculated. In this study, daily exposure for different products was influenced by sex, age groups and seasons. Of specific note, 3.51% of the lotion in a wet wipe was transferred to the skin. In conclusion, we provide baseline exposure data for baby products, with exposure being based on parents' usual use of the products.

Objectives/Hypothesis To describe our tracheostomy procedure using a vertical skin incision and a horizontal intercartilaginous incision and to compare our postoperative results with those in the recent literature. Study Design Retrospective chart review and literature review. Methods One hundred eleven children underwent tracheostomy using a vertical skin incision and a horizontal intercartilaginous incision over a 9-year period. A retrospective chart review was undertaken with respect to the following variables: demographics, weight, primary diagnosis, surgical indication, follow-up duration, decannulation, interval between tracheostomy and decannulation, and complications experienced. In addition, the outcomes were compared to results from a literature review. Results Of the 111 patients, 56 had a history of prolonged intubation, 52 had upper airway obstruction, and three underwent tracheostomy for tracheobronchial toileting. Three (2.7%) patients experienced early major complications without major sequelae, and 14 (12.6%) experienced late major complications. Twenty-one (18.9%) patients were decannulated during the follow-up period, whereas 17 (17.8%) died of their primary disease or tracheostomy-related complications (15 died of their primary disease and two died of tracheostomy-related complications). The complication rates showed overall no differences, but our patient series showed significantly less stomal granulation tissue formation and non-significant trend for less suprastomal collapse as compared with previous literature. Conclusions Pediatric tracheostomy using a vertical skin incision and horizontal intercartilaginous incision is comparable with the conventional procedure in terms of complication and mortality rates. Future randomized controlled studies are mandatory to directly compare conventional tracheotomy using a vertical skin incision and a horizontal intercartilaginous incision with our procedure. Level of Evidence 4. Laryngoscope, 125:485–492, 2015

The effect of vitamin D on allergic conditions is unclear. In particular, large-scale, population-based studies examining this relationship in adult Asian populations are lacking.To evaluate the association between serum vitamin D levels and allergic conditions in the general adult Korean population.A cross-sectional study was performed by using data collected from 15,212 individuals 19 years or older who participated in the Korean National Health and Nutrition Examination Survey from 2008 to 2010. The confounder-adjusted mean serum 25-hydroxyvitamin D (25[OH]D) levels of participants with and without allergic conditions (including atopic dermatitis, asthma, allergic rhinitis, and increased total and allergen-specific serum IgE) were compared by using multiple linear regression analyses. Multiple logistic regression analyses with confounder adjustment estimated the odds ratios (ORs) for developing each condition according to adequate, inadequate, or deficient serum 25(OH)D levels.After adjusting for potential confounders, mean serum 25(OH)D levels were significantly lower in participants diagnosed with atopic dermatitis than in those without this diagnosis (mean ± SE, 18.58 ± 0.29 ng/mL vs 19.20 ± 0.15 ng/mL; P = .02). Compared with participants with adequate vitamin D levels (≥20 ng/mL), confounder-adjusted ORs of atopic dermatitis were significantly higher in those with inadequate (12-19.99 ng/mL) or deficient (12 ng/mL) levels (OR [95% CI], 1.50 [1.10-2.06] and 1.48 [1.04-2.12], respectively; P = .02). This relationship was not observed in participants with the other allergic conditions.Vitamin D-insufficient adult individuals within the general Korean population have an increased likelihood of atopic dermatitis, but not asthma, allergic rhinitis, or IgE sensitization.

Chemotherapy-induced alopecia (CIA) is a frequent complication in patients with cancer. There are an increasing number of reports of permanent CIA.We investigated the clinical characteristics of CIA, including permanent CIA in childhood.We collected data on 159 pediatric patients who had undergone high-dose conditioning chemotherapy followed by hematopoietic stem cell transplantation and 167 control subjects, using a questionnaire, medical record reviews, and phototrichograms.Alopecia began at 1.5 ± 1.4 months and was sustained until 2.2 ± 1.6 months after chemotherapy initiation. Hair regrowth started 2.6 ± 1.6 months after chemotherapy ceased and lasted for 7.3 ± 4.9 months. The mean hair density and thickness were 198.3 ± 47.4/cm(2) and 76.3 ± 18.4 μm in the patient group and 229.6 ± 34.5/cm(2) and 79.5 ± 12.4 μm in the control group, respectively (both, P .001). In all, 19 (12%) patients experienced permanent CIA. Thiotepa use was identified as a significant risk factor for permanent CIA (odds ratio 7.57, P = .002).Cross-sectional study in a single-center is a limitation.CIA is common in pediatric patients. Use of thiotepa is strongly associated with permanent CIA.

Hyaluronic acid (HA) fillers are frequently used for the correction of facial soft-tissue defects.To compare the efficacy and safety of a novel monophasic HA filler (mono-HA), and a well-studied biphasic HA filler (bi-HA), in the treatment of moderate to severe nasolabial folds.In this randomized, evaluator-blinded, split-face comparative study, subjects were randomized for injections with mono-HA or bi-HA on the left or right side of the face. Efficacy was determined by calculating the change in the Wrinkle Severity Rating Score (WSRS) relative to baseline. Local safety was assessed on the basis of subject diary entries which recorded erythema, swelling, induration, pruritus, irritation, mass, hematoma, pain, and dryness.At week 24, the mean improvement in the WSRS from baseline was 2.18 ± 0.42 for the mono-HA side and 2.16 ± 0.41 for the bi-HA side. Both fillers were well-tolerated and adverse reactions were mild and transient in most cases.Mono-HA has a non-inferior efficacy to bi-HA in the treatment of moderate to severe nasolabial folds.

Background: The injection of botulinum toxin is now commonly used for many therapeutic and cosmetic purposes but because of its increased use more adverse events are being reported. Objective: To retrospectively evaluate and analyze the safety of botulinum toxin injections in terms of purpose and the type of toxin administered. Materials and methods: Data were collected on 1819 patients who underwent a total of 5310 treatments between 2005 and 2011 at a single tertiary medical center. Information on the dosage, treatment purpose, type of botulinum toxin, and any adverse events associated with these treatments were collected and analyzed. The generalized estimating equation (GEE) with the logistic link function was used to estimate the overall frequencies of adverse events. A multivariable GEE with the logistic link function was used to identifythe factors associated with adverseevents.Results :A mong the 5310 botulinum toxin treatments in our study cohort, 2258 of which (42.5%) were used to treat hemifacial spasm, 184 adverse events (3.73%) were recorded, 114 (2.26%) muscle-related, and 71 (1.47%) muscle-unrelated. The highest number of adverse events (8.29%) was associated with the treatment of blepharospasm and the lowest (1.07%) with masseter hyperplasia. By multivariate analysis, the odds ratio for females was 1.577 (95% confidence interval [CI] = 1.052–2.364; p = 0.027) and for the dose was 1.006 (95% CI = 1.002–1.010; p = 0.005). When compared with upper face wrinkles, the odds ratio was 2.510 (95% CI = 1.400– 4.499; p = 0.002) for blepharospasm, 0.375 (95% CI = 0.202–0.695; p = 0.002) for cervical dystonia, and 0.114 (95% CI: 0.015–0.862; p = 0.035) for masseter hyperplasia. Conclusion: When injecting botulinum toxin for cosmetic purposes, practitioners should be cautious, especially when targeting the areas around the eyes, as these treatments are prone to cause adverse events.

Background: For periorbital rejuvenation, injection of botulinum toxin A (BoNT/A) is known to improve both static as well as dynamic wrinkles. A microneedle fractional radiofrequency (MFR) device was recently developed and is a novel and promising tool. Objective: This study compares the effects of these two treatment modalities on periorbital static wrinkles and lines. Methods: Twelve healthy women aged 20-59 years with periorbital wrinkles participated in this study. Each patient received one session of intradermal injection of BoNT/A on the left periorbital area and three sessions of MFR on the right. Clinical improvement, skin elasticity and subjective satisfaction were evaluated at every visit (baseline, 3, 6 and 18 weeks). Results: BoNT/A injection showed superior effects at 3 and 6 weeks. However, the MFR device showed better improvement at 18 weeks. In skin biopsies, the expression of procollagen 3 and elastin was increased on the MFR side compared to the untreated skin and the BoNT/A injection side. The patient satisfaction surveys at 3 weeks showed better satisfaction on the BoNT/A treatment side compared to the MFR treatment side. At 18 weeks, there were no significant differences in patient satisfaction between the two sides. Conclusion: BoNT/A injection rapidly improved periorbital wrinkles, but the effect decreased up to week 18. Compared to BoNT/A injection, MFR therapy showed gradual and long-term improvement in periorbital rejuvenation.

Riehl's melanosis presents as a diffuse gray-brown to black hyperpigmentation around face. The treatment of this disease is challenging and quite limited despite patients' excessive psychological stresses.In this prospective pilot study, we evaluated the efficacy and safety for a novel combination therapy based on low-fluence Q-switched 1064 nm Nd:YAG laser, hydroquinone cream and oral tranexamic acid for recalcitrant Riehl's melanosis.Totally eight patients with Riehl's melanosis who had failed improvements previously received multiple sessions (10-18 times) of combination treatment regimen. The primary endpoint was clinical score by the physician and the secondary endpoints were clinical score by the patients, instrumental analysis using melanin and erythema values, and histopathological score.Among eight patients, three received "Almost clear" grade, the other five patients received "Marked improvement" grade at final visits. No serious adverse events and post-treatment downtime was observed. Mean Melanin and Erythema Indexes also showed significant decreases compared with baseline. Histopathologic examination confirmed a significantly greater reduction of melanin content in melanophages.This combination method can be a viable option for Asian patients having Riehl's melanosis with high risk of post-inflammatory hyperpigmentation, maintaining low-dose laser irradiation.

Background: Increasing evidence suggests a pivotal role for neuronal inflammation in response to replicating varicella zoster virus in the development of postherpetic neuralgia (PHN). Objective: In this study, we investigated the value of serum levels of various inflammatory markers in acute herpes zoster (HZ) as predictors for the development of PHN. Methods: A total of 116 patients with acute HZ were enrolled in this study. We measured scores on the pain visual analogue scale (VAS) at baseline and at 1, 3, and 6 months after diagnosis of HZ. We defined PHN as pain greater than 1 on the VAS lasting for more than 6 months. Serum samples for laboratory assay, including complete blood count were obtained at the initial visit. Correlations between the levels of each inflammatory marker and the development of PHN were evaluated. Results: Levels of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), lymphocyte count, and albumin showed significant correlations with development of PHN in univariate analysis. Levels of ESR, CRP, and lymphocyte count also showed significant correlations in multivariate analysis. ESR level showed stronger correlations with development of PHN than levels of CRP and lymphocyte count. Conclusion: In this study, we confirmed that elevated ESR was an independent and significant predictor of PHN in patients with acute HZ. To validate these results, further well-designed, randomized clinical trials are needed. (Ann Dermatol 30(2) 158∼163, 2018)

Background: Topical tacrolimus is an effective anti-inflammatory therapy for acute and chronic states of atopic dermatitis (AD) in both adults and children. Topical tacrolimus has particular use at sensitive areas such as the face, anogenitals, and skin folds of neck and extremities. However, many AD patients also experience aggravated symptoms on trunk. Objective: The aim of this study was to investigate the efficacy and safety of topical tacrolimus for AD patients with truncal lesions. Methods: AD patients with truncal lesions who were aged ≥2 years were recruited from 20 centres in Korea. They received treatment with topical tacrolimus ointment twice daily during 4 weeks. The primary end point was change of the local eczema area and severity index (EASI) of the trunk from baseline to day 28. The secondary end points were changes in the patient global assessment (PGA) score and itch visual analogue scale (VAS) score of the trunk between baseline and day 28. Results: Two hundred and ninety- one patients were recruited, and 176 patients completed the full 4-week treatment course. By the end of the treatment, the mean local EASI of the trunk (2.2±4.71) was significantly decreased from that at baseline (4.71±4.03, p＜0.001). PGA (1.71±1.15) and itch VAS score of the trunk (2.61±2.19) on day 28 were also profoundly decreased compared with the baseline (2.96±1.07 and 5.15±2.47, respectively). No serious adverse events were observed during the study period. Conclusion: Topical tacrolimus is an effective and safe therapy for truncal lesions in AD patients. (Ann Dermatol 30(2) 173∼178, 2018)

Chronic spontaneous urticaria (CSU) is a complex idiopathic disease of the skin with various cellular infiltrations. Although mast cells are key effector cells in the pathogenesis of CSU, CD4+ T helper 2 cells also have particular roles in the development and maintenance of CSU. Periostin is known as a downstream molecule of interleukin (IL)-4 and IL-13, key cytokines of type 2 immune responses. In this study, we examined periostin and IL-13 levels in the sera of patients with CSU (n=84) and healthy normal controls (NCs, n=43). Periostin levels were significantly lower in the CSU group than in NCs (71.4±21.8 vs 85.1±22.4 ng/mL, P=0.04). Periostin levels were also lower in the severe CSU group than those in mild CSU (59.7±18.0 vs 73.4±22.0 ng/mL, P=0.04). However, IL-13 levels were significantly higher in patients with CSU than in NCs (508.5±51.2 vs 200.7±13.3 pg/mL, P=0.001). In conclusion, periostin and IL-13 may be independently related to the pathogenesis of CSU.

Facial psoriasis is often observed in moderate to severe degrees of psoriasis. While we previously demonstrated construct validity of the facial Psoriasis Log-based Area and Severity Index (fPLASI) system for the cross-sectional evaluation of facial psoriasis, its reliability and accuracy to detect clinical improvement has not been confirmed yet. The aim of this study is to analyze whether the fPLASI properly represents the range of improvement for facial psoriasis compared with the existing facial Psoriasis Area and Severity Index (fPASI) after receiving systemic treatments in clinical practice settings. The changing severity of facial psoriasis for 118 patients was calculated by the scales of fPASI and fPLASI between two time points after systemic treatments. Then, percentage changes (ΔfPASI and ΔfPLASI) were analyzed from the perspective of both the Physician's Global Assessment of effectiveness (PGA) and patients' Subjective Global Assessment (SGA). As a result, the distribution of the fPASI was more heavily clustered around the low score range compared with the fPLASI at both first and second visits. Linear regression analysis between ΔfPASI and ΔfPLASI shows that the correlation coefficient was 0.94, and ΔfPLASI represented greater percentage changes than ΔfPASI. Remarkably, degrees of clinical improvement measured by the PGA matched better with ΔfPLASI, while ΔfPASI underestimated clinical improvements compared with ΔfPLASI from treatment-responding groups by the PGA and SGA. In conclusion, the fPLASI represented clinical improvement of facial psoriasis with more sensitivity and reliability compared with the fPASI. Therefore, the PLASI system would be a viable severity measurement method for facial psoriasis in clinical practice.

The most characteristic feature of melasma is the hyperpigmentation of facial area, but recent studies revealed that the melasma lesion is more erythematous than the perilesional area (1,2). In add...

Dear Editor: Here, we describe a case of acquired dermal melanocytosis involving the dorsum in an Asian woman. A 45-year-old Korean woman presented with a 3-year history of a relatively well-demarcated, pale, blue-grayish, asymptomatic round patch on her interscapular back area (Fig. 1). Hypertrichosis was not observed within the lesion. Physical examination revealed no other similar lesions elsewhere. The patient denied any history of preceding inflammatory changes, trauma, bruises, tattoos, or metal contact on her back. She also denied taking heavy metals or any medicines that may result in hyperpigmentation and had no family history of similar skin lesions. Histopathologic examination revealed multiple spindle-shaped brown pigment-containing cells scattered among collagen fibers in the dermis (Fig. 2A, B). Immunohistochemical staining demonstrated these cells were positive for S100 protein (Fig. 2C) and negative for HMB-45 (data not shown). In addition, the brown pigment stained positive with Fontana-Masson stain, which is indicative of melanin (Fig. 2D), but not with Perls Prussian blue stain for hemosiderin (data not shown). Furthermore, immunohistochemistry revealed CD68-positive cells scattered in the dermis (Fig. 2E). Therefore, the patient was diagnosed with acquired dermal melanocytosis of the back, but no treatment was administered in accordance with the patient's wishes. Fig. 1 A relatively well-demarcated pale blue-grayish round patch on the interscapular area. Fig. 2 Histopathologic examinations and immunohistochemistry. (A, B) Multiple spindle-shaped brown pigment-containing cells scattered among collagen fibers in the dermis (HE A: ×100, B: ×200). (C) Immunohistochemical staining showed ... Dermal melanocytosis is defined by the presence of melanin-containing dendritic melanocytes in the dermis and can be differentiated on the basis of lesion onset and location1. Congenital forms of dermal melanocytosis include Mongolian spot, nevus of Ota, and nevus of Ito. Acquired forms of dermal melanocytosis include nevus of Hori and nevus of Sun, which involve the bilateral and unilateral malar areas, respectively. Acquired dermal melanocytosis located in areas besides the face is very rare; previously reported non-facial sites include the extremities and back1,2. Some of these reported cases were associated with malignancies including melanoma, physical trauma, oral estrogen, and eczema2. Although the pathogenesis of acquired dermal melanocytosis is unclear, one possibility is that dermal melanocytes may pre-exist in an immature state; they subsequently become activated by various stimuli including ultraviolet exposure, sex hormones, and inflammation3,4. This is supported by the observation that dermal melanocytes are also found in the normal-appearing skin neighboring the lesions of acquired dermal melanocytosis5. Nevertheless, the origin of the pre-existing dermal immature melanocytes is not fully understood. They may descend from the basal layer of the epidermis, migrate from hair bulbs, or improperly migrate during the embryonic period4. Acquired dermal melanocytosis does not usually fade; the pigment persists in contrast with Mongolian spots. This persistence may be associated with the extracellular sheath encircling dermal melanocytes, which has been observed in ultrastructural studies4. The extracellular sheaths of Mongolian spots usually fade over time, whereas those of nevus of Ota gradually thicken over time. Extracellular sheaths are also observed in acquired dermal melanocytosis and presumably play a role in protecting dermal melanocytes4. In conclusion, we report a case of acquired dermal melanocytosis with an unusual location that has not been described previously.

Background The Atopic Dermatitis Antecubital Severity (ADAS) score is a new objective scale for the assessment of the severity of atopic dermatitis (AD). It is calculated by multiplying the intensity of inflammatory signs by the size of an antecubital eczema lesion. Aim To test the validity, reliability, and sensitivity to changes of the ADAS score compared with those of the Eczema Area and Severity Index (EASI) score. Methods Forty patients with AD were enrolled and treated with a moisturizer. At baseline, and in weeks 1 and 2, two independent evaluators measured the ADAS score, the EASI score, and the investigator's global assessment score rated on a six-point scale. Results The ADAS score showed a higher validity than the EASI score. The superiority of the ADAS to the EASI was prominent in mild AD. Inter-evaluator reliability was excellent in both the ADAS score and the EASI. The sensitivity to changes was higher in the ADAS score than in the EASI score. Conclusions The ADAS score may be used as a simple scoring system with good validity, reliability, and sensitivity to changes, especially in patients with mild-to-moderate AD.

Postherpetic neuralgia (PHN) is one of the most severe sequelae of herpes zoster events. Several risk factors have been reported for PHN, including old age, severe skin rash, and intense pain. This study therefore aims to evaluate the usefulness of the Self-completed Leeds Assessment of Neuropathic Symptoms and Signs pain scale (S-LANSS) in conjunction with previously reported risk factors for predicting PHN. A group of herpes zoster patients (N = 305) were included in the cohort study. Subjects were asked for their demographic information, clinical symptoms and signs, intensity of pain by visual analog scale (VAS), and S-LANSS. They were followed up in clinical visits or via telephone for 12 months. Nineteen patients (6.2%) suffered from PHN in this study. Using logistic regression, 3 risk factors for PHN were identified: age ≥70 years, high VAS scores, and high S-LANSS scores. Prediction of PHN using VAS (≥8) and S-LANSS (≥15) criteria achieved a sensitivity of 78.9% and specificity of 78.0%. Prediction of PHN in elderly patients (≥70 years), using the criteria of VAS (≥6) and S-LANSS (≥15) as well, achieved 100% sensitivity and 57.1% specificity. S-LANSS could be a useful prediction tool for PHN, particularly if combined with previously well-known risk factors and VAS. Perspective Among acute herpes zoster patients, subjects with characteristics of neuropathic pain showed high frequency of PHN. The tools for screening neuropathic pain like S-LANSS could be helpful for predicting PHN and enabling early intervention of pain management.

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 Skin cancer is the most common malignancy to arise after organ transplantation in Caucasians, but limited data are available on its incidence in Asian transplant recipients. Objective We sought to assess the incidence of skin cancer after organ transplantation in a Korean cohort. Methods A cohort study was conducted to determine the incidence and risk factors for skin cancers among kidney, liver, heart, or pancreas transplant recipients, treated at the Asan Medical Center in Seoul, Korea. Results The cumulative incidences of skin cancer were 0.70% at 5 years, 1.66% at 10 years, and 2.31% at 15 years. For all skin cancers, squamous cell carcinoma, basal cell carcinoma, and Kaposi sarcoma, the standardized incidence ratios between the recipients and the Korean general population were 30.9 (95% confidence interval, 12.4-63.6), 61.9 (12.8-180.8), 11.9 (0.3-66.1), and 565.2 (68.4-2041.6) after the end of the fifth posttransplantation year, respectively. Limitations We cannot exclude the possibility of both the underestimation because of potential missing cases and the overestimation because of the ascertainment bias. Conclusion The incidence of posttransplantation skin cancer is very low in Korean patients. However, the risk of skin cancer in organ transplant recipients may be considerably higher than that in the Korean general population.

Background: Physicians can play a crucial role in the knowledge that patients have about a disease and its prognosis. Recently, patients with atopic dermatitis (AD) are increasingly turning from western medicine to oriental herbal medicine. However, their awareness of AD and attitude toward Western medicine and oriental herbal medicine clinics are scarcely reported. Objective: The aim of this study was to determine the understanding of AD among patients and their parents and to identify their awareness of and attitude toward Western medicine and oriental herbal medicine as treatments for AD. Methods: An online questionnaire was administered to 500 consenting respondents with AD (age, 16∼49 years) and parents of children with AD (age, 0∼15 years). Results: The mean percentage of correct answers to questions about AD was 52.54%. A parental history of AD was independently associated with higher respondent`s knowledge about the disease and its treatment. The satisfaction with treatment outcomes was highest among patients treated at private clinic of dermatology specialists (49.4%), while lowest among those treated at oriental herbal medicine clinics (38.4%). Many participants were aware that oriental herbal medicine requires a longer treatment period for a cure and does not burden the skin, while steroid phobia was seen in most of participants. Conclusion: Physicians need to educate AD patients and their parents about the disease and its treatment. Misconceptions for Western medicine and oriental herbal medicine among AD patients and parents should be corrected to improve their prognosis. (Ann Dermatol 28(6) 725∼732, 2016)

Non-ablative bipolar and monopolar radiofrequency devices have been shown to be effective for the treatment of facial wrinkles. Recently, novel fractionated microneedle radiofrequency (FMRF) devices have been introduced. The aim of this study was to evaluate the clinical effectiveness and safety of FMRF for the treatment of periorbital wrinkles. Eleven women, aged 34-59 years, with periorbital wrinkles underwent three sessions of FMRF at 3-week intervals with a follow-up period of 3 months after treatment. Clinical improvement was evaluated using the Fitzpatrick Wrinkle Classification System (FWCS) and subjective satisfaction on a visual analog scale (VAS). The FWCS scores demonstrated significant improvement in periorbital wrinkles after treatment (P < 0.001). A satisfaction VAS score of more than 5, indicating high satisfaction, was obtained from 10 of 11 patients (91%) 3 months after treatment, and the mean satisfaction VAS score (n = 11) was 6.7. Patients undergoing treatment reported minimal pain, and neither long-lasting side-effects nor significant downtime was noted. This clinical study suggests that FMRF is a safe and tolerable method for successful treatment of periorbital wrinkles.