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Augmented reality (AR) is the integration of computer-generated information with the user's environment in real time. AR is used in many industries, including healthcare, where it has gained significant popularity. Recent strides in hardware and software engineering have reduced the cost of AR, while significantly improving the experience for users and developers. One of the first applications of AR technology in perioperative medicine has been in the identification of anatomical structures for regional blocks and peripheral or central vascular access. AR has also been implemented in pediatric care to reduce periprocedural anxiety. In this narrative review, we summarize the current role of AR in anesthesiology, pain medicine, and critical care.

Background: Although squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) can be easily diagnosed clinically, proper diagnosis is sometimes difficult when based on clinical information alone. Objective: To know what causes clinical misdiagnosis between SCC and BCC, and evaluate whether dermoscopy can improve diagnostic accuracy. Methods: Clinical and dermoscopic photographs of inversely diagnosed cases (histologically confirmed BCC with a clinical impression of SCC or vice versa) were randomly presented to six dermatologists and the reasons for each correct or incorrect diagnosis were analyzed. Results: Among 154 cases (SCCs or BCCs), 13 cases were inversely diagnosed; 9 SCCs were clinically misdiagnosed as BCC and 4 BCCs were clinically misdiagnosed as SCC. Clinically, scales, pigmentation and rolled border were meaningful factors to discern two carcinomas. Scales without both pigmentation and rolled border was favored for SCC, but BCC favored vice versa. Ulceration, telangiectasia and translucency contributed as confusing factors for proper diagnosis. Dermoscopy improved overall diagnostic accuracy to odds ratio 2.86. Conclusion: SCC has a higher tendency to be clinically misdiagnosed as BCC than vice versa. Pigmentation and rolled border are factors causing misdiagnosis of SCC as BCC and BCC may be misdiagnosed as SCC in the presence of scaling. Dermoscopy seems to improve the clinical diagnostic accuracy but has limitations for some ambiguous lesions. (Ann Dermatol 30(1) 64∼70, 2018)

Erythema induratum of Bazin (EIB) is a form of tuberculid resulting from hypersensitivity to tuberculosis antigen. EIB occurs most commonly in middle-aged women and is not typically seen in children. Here, we present a rare case of EIB, presenting as a chronic nodular panniculitis, in a 10-year-old Korean boy.

Background: Dinutuximab is a chimeric anti-GD-2 (disialoganglioside) antibody approved for use in post-consolidation care of patients with high-risk neuroblastoma. GD-2 receptors are also expressed in cerebellar neurons, melanocytes, and peripheral sensory nerve fibers in normal human tissue. Given this pattern of expression, pain is a common and often infusion rate-limiting adverse effect, with greater than 50% of patients experiencing severe (Grade 3 or above) pain. Standard pain management for dinutuximab infusions at our center includes initiation of continuous infusion of opioid patient-controlled analgesia along with demand, loading, and boluses doses. Little to no data exist in the literature to describe opioid use in pediatric patients with acute, episodic pain. Therefore, this study aims to characterize opioid use in this setting. Methods: Data were collected retrospectively from the electronic medical record under a study protocol approved by the Institutional Review Board at the University of Michigan, C.S. Mott Children's Hospital. Patients were included in the study if they had a clinical diagnosis of metastatic or relapsed high-risk neuroblastoma, received at least one dinutuximab cycle, and were aged 2-14 at the time of admission. Daily amount of opioids, calculated as the oral morphine equivalent daily dose (MEDD), acetaminophen, and gabapentin administered were calculated. Repeated measures ANOVA was used to evaluate within-subjects changes. Results: The average age of patients was 5.7 years [range 2-14 years]. Four of eleven (36.4%) were female and 7/11 (63.6%) were male. All patients received four days of dinutuximab infusions for an average length of 11.8 hours (SD=2.0) per day. All patients received gabapentin prophylactic treatment and an average of 3387 mg (SD=1275.5). Average total MEDD across all patients was 184.7 mg (SD=137.6) during the inpatient hospitalization. Females (p=0.003) and older patients (p=0.04) had significantly increased daily MEDD as compared to their day 1 intake. All patients experienced a fever spike and received acetaminophen (2915 mg, SD=1737.8) Older patients received higher doses of acetaminophen (p=0.007) Only 1 patient met definition of a chronic opioid user and was discharged with an outpatient opioid prescription. The remaining opioid-naïve patients were discontinued on opioid treatment at the time of discharge. Conclusions: Pediatric patients on dinutuximab therapy received a high MEDD parenteral opioids dose alongside adjunctive analgesics. Future studies are needed to determine opioid requirement trends across gender, age, and cycles in a larger cohort of patients, as well as to determine the risk of chronic opioid use in this patient population. Citation Format: Jola Mehmeti, Jae Eun Choi, Ian Wolfe, Juan Cata, Rajen Mody. Characterization of inpatient opioid use among pediatric neuroblastoma patients during dinutuximab therapy [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2045.

Aggravated melasma after treatment is vulnerable to stimulation, can easily deteriorate, and may be distressing without proper management.To retrospectively assess the effectiveness and safety of combination therapy using low-fluence Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser (QSNY) and long-pulse Nd:YAG laser (LPNY) (dual toning) in patients with rebound melasma.A total of 30 patients with aggravated melasma after previous therapy who were treated with dual toning were enrolled. A total of 10 sessions were conducted at 1-week intervals, followed by maintenance treatment. The results were evaluated using the modified Melasma Area and Severity Index (mMASI) and the physician's global assessment (PGA) before and 2 months after completing the 10 treatment sessions.The baseline mMASI was 10.48 ± 3.64, which significantly decreased to 3.22 ± 1.45 2 months after completing the 10 treatment sessions (p0.001). Twenty-four patients (80%) had PGA grade 4 (76-100% improvement) and 6 patients (20%) had PGA grade 3 (51-75% improvement).Dual toning may be a safe and effective salvage treatment for patients with aggravated melasma after previous treatment. LPNY may stabilize melasma activity to prevent rebound hyperpigmentation via dermal remodeling.

Background Melasma is a common acquired facial pigmentary disorder that is resistant to various modalities of treatment. Recently, the low-fluence 1064-nm Q-switched neodymium-doped yttrium aluminum garnet laser (QSNY) has emerged as the new gold standard of melasma treatment in Asia. Objective To evaluate the efficacy and safety of low-fluence 1064-nm QSNY in Asian patients with melasma. Methods Data of patients with melasma treated with low-fluence QSNY in the department of dermatology at the Korea University Anam Hospital were reviewed retrospectively. A 1064-nm QSNY with 8 mm spot size and fluence of 1.2-2.0 J/cm2 at 10 Hz was used. The results were evaluated using the modified Melasma Area and Severity Index (mMASI) score and the physician's global assessment (PGA). Results A total of 40 Korean patients with Fitzpatrick skin type III to IV were included. Patients were treated for a median of 10 sessions at a median of 1-week intervals. The mean mMASI score decreased by 54.23% from a baseline of 3.19 ± 2.64 to 1.46 ± 1.06 after treatment. On PGA, 1 out of 40 patients (2.5%) showed excellent improvement, 14 (35%) good, 15 (37.5%) fair, 6 (15%) poor, and 4 (10%) no improvement. However, two patients showed mottled hypopigmentation and rebound hyperpigmentation. Conclusion Low-fluence 1064-nm QSNY appears to be a safe and effective treatment for Asian patients with melasma.

Objective The benefits of prostate-specific antigen (PSA)–based prostate cancer screening are controversial. We sought to determine the change in prostate cancer presentation coinciding with the release of the United States Preventative Services Task Force recommendations against screening in a high-volume community-based urology practice. Methods Characteristics of men presenting for an elevated PSA at a community urology practice from August 2011 to August 2015 were queried from a prospectively collected database. A retrospective analysis of presenting PSA, Gleason grade at biopsy, and prostatectomy as well as clinical and pathologic stage was performed. Kruskal-Wallis rank sum and chi-square tests were used for analysis. Results Referrals for elevated PSA decreased from 933 in year 1 to 816 by year 4 (12.5% decrease) with a concomitant reduction in biopsies performed in newly referred men from 461 to 356 (22.8% decrease, P = 0.02). The proportion of men presenting with PSAs>10 increased from 28.1% to 36.8% (P = 0.009). First-time biopsy-positivity rate increased from 48.4% to 62.4% with a rise in the proportion having Gleason≥7 from 51.6% to 69.7% (P = 0.0001). Of the 578 men who underwent radical prostatectomy, there was a 19.4% increase in Gleason≥7 tumors (P = 0.01). Conclusions Our findings demonstrate a decrease in elevated PSA referrals, increase in PSA at the time of referral, decrease in detection of low-risk disease, and increase in detection of intermediate-/high-risk disease in a high-volume, multisite, community-based urology practice, coinciding with the United States Preventative Services Task Force recommendations against PSA screening.

The use of ablative lasers based on the fractional approach is a novel strategy for the treatment of postoperative and acne scars in addition to wrinkles.To evaluate and compare the efficacy of carbon dioxide ablative fractional laser (AFL) and the pulsed dye laser (PDL) for the improvement of surgical scars.Fourteen Korean patients with surgical scars were enrolled for this study. Half of each scar was treated with a 10,600-nm AFL and the contralateral half with the 595-nm PDL. For early intervention of the postoperative scar, the laser treatments were begun after 2 weeks from the Mohs micrographic surgery.Both PDL and AFL produced statistically significant improvements. However, comparatively, there was no statistical difference between them. In each variable, AFL was more effective than PDL in the improvement of pliability and thickness. In contrast, PDL was superior to AFL in the improvement of vascularity and pigmentation.Pulsed dye laser and AFL treatments for surgical scar provide significant improvement. Pulsed dye laser was more effective in color of scar compared with AFL, which showed marked improvement in the contour of scar. Overall improvement was not statistically different in the Vancouver Scar Scale.

TPS5091 Background: Tumors with biallelic CDK12 loss have been identified as a distinct subtype in metastatic castration resistant prostate cancer (mCRPC) and other cancer types. The CDK12 biallelic loss mCRPC genomic signature, distinct from homologous recombination deficient (HRD) and ETS fusion signatures, is characterized by excessive tandem duplications, genomic instability, gene fusion-caused putative neoantigens, and increased tumor T cell infiltration. Early clinical experience with anti-PD-1 immunotherapy in CDK12 loss mCRPC patients (pts) is notable for deep and sustained PSA as well as radiographic responses. We hypothesize that CDK12 biallelic loss is a potential biomarker of immune checkpoint immunotherapy (ICI) efficacy in mCRPC and other cancers. Methods: IMPACT (NCT03570619) is a multi-center, open label, phase 2 study of pts with metastatic cancers that harbor CDK12 biallelic loss. mCRPC pts will be enrolled in cohort A (n = 25) in a Mini-Max Simon Two-Stage design, and all other pts in single-stage cohort B (n = 15). All pts will receive induction therapy with nivolumab 3 mg/kg IV and ipilimumab 1 mg/kg IV q3 weeks for up to 4 cycles, followed by maintenance nivolumab at 480 mg IV q4 weeks (up to 52 weeks in total). Eligible pts must have identified biallelic CDK12 loss on any CLIA/CAP approved next generation sequencing assay and a histologic diagnosis of metastatic prostate adenocarcinoma or other metastatic carcinoma. No prior ICI is allowed. The primary endpoint is the overall response rate (ORR) in cohort A per PCWG3 criteria. An ORR of 30% is targeted in cohort A. Secondary endpoints include safety, secondary efficacy measures, quality of life, and survival measures. Exploratory objectives include tumor whole exome analysis and changes in immune profiles with therapy. Comprehensive and serial monitoring of peripheral blood immune cell populations will be performed via T cell clonal diversity assessment and multi-parametric flow cytometry. Changes in myeloid and lymphoid populations will be assessed from whole blood. Polarization and effector function of T cells and activation of antigen presenting cells will be further characterized from isolated peripheral blood mononuclear cells. Study accrual is ongoing. Clinical trial information: NCT03570619.

Aim Most studies about the structures of the human skin have been on the general histologic features of the skin. The purpose of this study was to understand the relationship between the microrelief (MR) pattern and histologic structure of the human skin, and to find the usefulness of the three-dimensional reconstruction (3DR) technique of pathological skin tissue. Materials, Subjects, and Methods Human skin specimens were obtained from the medial forearm, abdomen, and volar aspects of the finger tips of cadavers. Two-dimensional surface-viewed images of the skin showing MR patterns were obtained using dry dermoscopy. Histologic structures of the skin were evaluated by 3D images obtained using the 3DR technique. Results MR was deeper and wider in the abdomen than in the medial side of the forearm. In the medial side of the forearm, 10.27 rete ridges were distributed in a plateau, on average. In the abdomen, about 14.37 rete ridges were distributed in a plateau. From 3DR technique, MR pattern thought to be a superordinate concept to rete ridges. Conclusion The 3DR technique was useful and may allow a better understanding of the pathogenetic changes in the skin surface in aging skin.

Background: Parallel-polarized light (PPL) photography evaluates skin characteristics by analyzing light reflections from the skin surface. Objective: The aim of this study was to determine the significance of quantitative analysis of PPL im-ages in rosacea patients, and to provide a new objective eval-uation method for use in clinical research and practice. Methods: A total of 49 rosacea patients were enrolled. PPL images using green and white light emitting diodes (LEDs) were taken of the lesion and an adjacent normal area. The values from the PPL images were converted to CIELAB coor-dinates: L* corresponding to the brightness, a* to the red and green intensities, and b* to the yellow and blue intensities. Results: A standard grading system showed negative cor-relations with L* (r=-0.67862, p=0.0108) and b* (r=-0.67862, p=0.0108), and a positive correlation with a* (r=0.64194, p=0.0180) with the green LEDs for papulopustular rosacea (PPR) types. The xerosis severity scale showed a positive cor-relation with L* (r=0.36709, p=0.0276) and a negative cor-relation with b* (r=-0.33068, p=0.0489) with the white LEDs for erythematotelangiectatic rosacea (ETR) types. In the ETR types, there was brighter lesional and normal skin with white LEDs and a higher score on the xerosis severity scale than the PPR types. Conclusion: This technique using PPL images is applicable to the quantitative and objective assess-ment of rosacea in clinical settings. In addition, the two main subtypes of ETR and PPR are distinct entities visually and optically. (Ann Dermatol 29(2) 167∼172, 2017)

Giant basal cell carcinoma (BCC), defined as a lesion greater than 5 cm at its largest diameter, is a rare variant of BCC. In contrast to small BCC, giant BCC develops on skin that is not exposed to sunlight, including the back, shoulder, groin and thigh. Most of the histopathologic subtypes of giant BCC are micronodular, morpheaform and nodular, but the superficial subtype is rare. Giant superficial BCC arising on the scalp is extremely rare. We report the case of giant superficial BCC with four satellite lesions on the scalp in a 53-year-old male without predisposing factors.

Despite widespread use of silicon dioxide (SiO2) NPs in industry and in our daily lives, no studies so far have evaluated the potential of their skin phototoxicity and sensitization. This study was designed to investigate the potential of phototoxicity and sensitization of SiO2 NPs. Assessment of the potential of skin phototoxicity was carried out using the 3T3 neutral red uptake test, an HSEM, and an animal model. The potential of skin sensitization was evaluated by a non-radioisotope local lymph node assay (non-RI LLNA). Findings from the present study suggest that the HSEM may be a reasonable model system for evaluation of skin phototoxicity of NPs. In addition, our data demonstrate that non-RI LLNA may be a useful method for identification of skin sensitization of NPs. In this study, we showed that SiO2 NPs do not induce phototoxicity or skin sensitization.

Background Egr-1 is known to play an important role in cell growth, differentiation, and cell survival. Human skin dermal fibroblasts (HSDF) may be an important target for adverse effects of tobacco components. However, nicotinic effect for early growth response-1 (Egr-1) expression is unknown in HSDF. Methods Cytotoxicity of nicotine was assessed by cell viability test in HSDF. The expression of Egr-1 protein and mRNA after nicotine treatment was evaluated by Western blotting and real-time reverse transcription–polymerase chain reaction. We also measured the promoter activity of Egr-1 in HSDF after nicotine exposure. Results Early growth response-1 protein and mRNA levels were increased in dermal fibroblasts exposed to nicotine. Nicotine treatment stimulated the promoter activity of Egr-1 in cultured human fibroblasts. Conclusion In this study, we demonstrate that Egr-1 expression is markedly induced in HSDF after exposure to nicotine.

Assessments of skin irritation potentials are important aspects of the development of nanotechnology. Nanosilica is currently being widely used for commercial purposes, but little literature is available on its skin toxicity and irritation potential. This study was designed to determine whether nanosilica has the potential to cause acute cutaneous toxicity, using cultured HaCaT keratinocytes (CHK), a human skin equivalent model (HSEM), and invivo model. Nanosilica was characterized by scanning electron microscopy. We evaluated the cytotoxic effects of nanosilica on CHKs and the HSEM. In addition, we also investigated whether two commercially available nanosilicas with different sizes (7 and 10-20 nm) have different effects. To confirm invitro results, we evaluated the irritation potentials of nanosilicas on rabbit skin. Nanosilicas reduced the cell viabilities of CHKs in a dose-dependent manner. However, the HSEM revealed no irritation at 500 microg/ml of nanosilica. Furthermore, this result concurred with Draize skin irritation test findings. The present study data indicate that nanosilica does not cause acute cutaneous irritation. Furthermore, this study shows that the HSEM used provides more useful screening data than the conventional cell culture model on the relative toxicities of NPs.

Object The aim of this study was to evaluate the results of surgical treatment of adult craniopharyngioma with a special focus on the endocrinological outcomes and tumor recurrence in cases of pituitary preservation. Methods Between 1993 and February 2008, 41 patients underwent 47 surgical procedures for craniopharyngioma. The male/female ratio was 26:15 and the median age was 45.8 years (range 17–65 years). The median follow-up period was 10.56 years (range 6.2–14.9 years). Patients presented with visual disturbance before 30 (63.8%) of 47 procedures and with endocrinological disturbance before 12 (26%) procedures. Surgery was performed via a subfrontal/pterional approach in 31 procedures (66%), bifrontal interhemispheric in 6 (12.8%), transcallosal/transventricular in 5 (10.6%), combined in 1 (2.1%), and transsphenoidal in 4 (8.5%). The tumor was totally removed in 36 procedures (76.6%), subtotally in 10 (21.3%), and partially in 1 (2.1%). Results Postoperatively, the rates of visual improvement and aggravation were 50 and 33.3%, respectively. Of 24 patients in whom the pituitary stalk was preserved, complete hormone replacement was needed in 14 (58.3%), partial replacement in 2 (8.3%), and no replacement in 8 (33.3%). The rate of tumor recurrence was 24.4%. The recurrence-free survival rate was significantly different between patients in whom complete tumor resection was accomplished and those in whom tumor resection was incomplete. Stalk preservation did not affect the recurrence-free survival rate. The morbidity and mortality rates were 8.5 and 2.1%, respectively. Conclusions The pituitary stalk must be preserved with maximal tumor resection whenever possible to increase the chance of intact anterior pituitary function being maintained. The results of the present study show that pituitary stalk preservation may not be related to increased recurrence rates.

© Mary Ann Liebert, Inc. 2014. Background: Atypical antipsychotics decrease irritability in autism. They also affect the cytokine network. Psychological stress, depression, and, possibly, autism spectrum disorder (ASD) are associated with the production of pro-inflammatory cytokines. We sought to determine if risperidone treatment led to changes in plasma cytokine levels. Methods: Forty-five subjects from an open-label study of risperidone treatment of children and adolescents with ASD, ages 4-18 years, had an analysis of 27 different cytokines at baseline and after 8 weeks of treatment using multiplex assays (Millipore) and read on the Luminex 100™platform. We examined changes in each of the cytokine levels in the entire group, and also compared changes in cytokines in responders versus nonresponders. Results: After 8 weeks of risperidone treatment, 2 of the 27 plasma cytokines showed statistically significant decreases in median levels: Eotaxin (p=0.0003) and monocyte chemoattractant protein-1 (MCP-1) (p=0.0024). Six of the 48 subjects met two criteria for responders to risperidone, and the median values of interleukin (IL)-5 were significantly higher (p=0.005) in the overall responder group than in nonresponders. Conclusions: Two cytokines, eotaxin and MCP-1, which have previously been identified as abnormally elevated in children with autism, decreased during treatment with risperidone. This suggests a possible mechanism of action of risperidone treatment and a balancing of the immune system in affected subjects in this very preliminary study.

A 79-year-old woman presented with a 2-year history of recurrent ulcerated lesion on the scalp vertex. There was no history of skin disease or trauma on the affected area. Clinical examination revealed a walnut-sized central crusted ulcer surrounded by erythematous, elevated indurative border (Fig. 1A). The histological features showed invasion of the dermis by irregular masses of epidermal cells that were predominantly mature squamous cells showing relatively slight atypicality. The depth of microscopic invasion was 3 mm. There was no presence of perivascular or perineural invasions (Fig. 2). A diagnosis of well-differentiated SCC was made on the basis of these clinical and histological findings. Because of her age and refusal of surgery, we decided to treat her with chlorine PDT. At first, we considered topical PDT with chlorine. But as the optimal topical agent could not penetrate to the needed full depth, we planned instead systemic chlorine PDT. Pretreatment evaluation included a history and physical examination, routine laboratory evaluation and photographic documentation. She has no photosensitivity and there were no signs to imply any other systemic diseases including internal malignancy. No further systemic workup was performed as is usual with cutaneous SCC. The patient was admitted to the hospital and the photosensitizer Radachlorin Ⓡ (RADA-PHARMA, Moscow, Russia) was injected intravenously for 30 minutes at a dose 0.9 mg/kg. Laser irradiation was carried out for 2 hours after the injection. As a light source we used a fiber coupled diode laser ‘LAHTA-MILON

Phacomatosis pigmentokeratotica (PPK) is a rare syndrome defined by the association of an organoid nevus occasionally with sebaceous differentiation, a speckled lentiginous nevus, and other extracutaneous anomalies. A preterm male infant of only 830 g at 27 week gestational age had an organoid nevus showing sebaceous differentiation. Also, he had multiple speckled-lentiginous nevus. Correlating the observed clinical presentation with the histopathological findings, the diagnosis of PPK was established. There have been less than 10 cases of PPK without extracutaneous manifestation. We present an uncommon case of a preterm patient with PPK who had no extracutaneous abnormalities.

The association between neutrophil:lymphocyte ratio (NLR) and poor long-term outcomes in patients with non–small-cell lung cancer (NSCLC) has been demonstrated in numerous studies. The benefit of perioperative administration of anti-inflammatory drugs on these outcomes has not been well established. Our aim in this retrospective study was to investigate the effects of postoperative nonsteroidal anti-inflammatory drug (NSAID) administration and NLR on tumor recurrence and survival in patients' undergoing surgical resection for NSCLC. This retrospective study included perioperative data from 1139 patients who underwent surgical resection for stages I–III NSCLC. Perioperative data such as baseline characteristics, adjuvant or neoadjuvant therapy, pre- and postoperative NLR, and NSAID use (ketorolac, ibuprofen, celecoxib, or in combination) were included. We evaluated the association between preoperative NLR and NSAID use on recurrence-free (RFS) and overall survival (OS). In all, 563 patients received an NSAID as a part of their postoperative management. The majority of patients received ketorolac (n = 374, 67.16%). Ketorolac administration was marginally associated with better OS (P = 0.05) but not with RFS (P = 0.38). Multivariate analysis (n = 1139) showed that preoperative NLR >5 was associated with a reduction in RFS (hazard ratio [HR] = 1.37; 95% confidence interval [CI] = 1.05–1.78; P = 0.02) and OS (HR = 1.69; 95% CI = 1.27–2.23; P = 0.0003). However, after accounting for tumor stage, NLR ≥5 was a predictor of RFS and OS only in patients with stage I NSCLC. To conclude, preoperative NLR was demonstrated to be an independent predictor of RFS and OS in a subset of patients with early stage NSCLC. Ketorolac administration was not found to be an independent predictor of survival.

Despite the effectiveness of low-fluence Q-switched Nd:YAG laser (QSNY) treatment in melasma, adverse events, including mottled hypopigmentation (MH) and rebound hyperpigmentation (RH) have been reported.To compare the effectiveness and safety of combination therapy using low-fluence QSNY and long-pulse Nd:YAG laser (LPNY) (Dual toning), with low-fluence QSNY monotherapy (QS toning), in Asian melasma patients.Patients were treated for 10 sessions at 1-week intervals with QSNY (6 mm spot); 2.5-3.0 J/cm(2) for QS toning (n = 177) or 2.1-2.5 J/cm(2) for dual toning (n = 183). The dual toning group was immediately treated with LPNY (7 mm spot, 15-17 J/cm(2)). The results were evaluated using the modified Melasma Area and Severity Index (mMASI) score and the physician's global assessment.MH or RH were significantly lower (1.1% vs. 14.1%) and the treatment efficacy was improved (median decrease of mMASI, 3.6 vs. 3.0) in the dual toning group compared with the QS toning group. Periorbital melasma showed distinctively high rates of adverse events in the QS toning group (23.9% vs. 5.7%), which were significantly reduced in the dual toning group (2.9%).Dual toning could represent a safe and effective treatment for Asian melasma patients, as it is associated with minimal adverse events and improved treatment efficacy compared with QS toning monotherapy.

While the Q-switched Alexandrite laser (QSAL) and the Q-switched neodymium: yttrium-aluminum-garnet (QSNY) laser have been widely used in treating nevus of Ota, few studies compared them.To compare the efficacies of the QSAL and the QSNY laser in the treatment of nevus of Ota in Korean patients.A retrospective multicenter study was conducted in 76 patients with nevus of Ota. Thirty-one patients were treated with a QSAL (5.5-8.0 J/cm(2), 4-mm spot size) and 45 patients were treated with QSNY laser (6.0-12.0 J/cm(2), 2-mm spot size). Treatment outcomes were categorized into five grades and the results were compared with the relevant variables taken into account using multivariate logistic regression analysis.QSAL treatment was more likely to achieve a better response compared with that with QSNY laser treatment. The odds ratio of achieving an excellent response, compared with the odds ratio of having a poor response, was 12.213-times more likely when a QSAL was used than when a QSNY laser was used (p = 0.026).The QSAL tends to be more efficient than the QSNY laser in the treatment of nevus of Ota in Korean patients. Further controlled, prospective comparison studies are needed.

Objective Preliminary evidence suggests that omega-3 fatty acids may reduce hyperactivity in children with autism spectrum disorder (ASD). We sought to examine the feasibility of a novel, Internet-based clinical trial design to evaluate the efficacy of this supplement. Method E-mail invitations were sent to parents of children aged 5 to 8 years enrolled in the Interactive Autism Network. All study procedures, including screening, informed consent, and collection of outcome measures took place over the Internet. The primary outcome measures were parent- and teacher-rated changes in hyperactivity on the Aberrant Behavior Checklist (ABC-H). Results During the 6-week recruitment period, 57 children from 28 states satisfied all eligibility criteria and were randomly assigned to 1.3 grams of omega-3 fatty acids or an identical placebo daily for 6 weeks. Outcome assessments were obtained from all 57 participants and 57 teachers, and the study was completed in 3 months. Children in the omega-3 fatty acid group had a greater reduction in hyperactivity ( − 5.3 points) compared to the placebo group ( − 2.6 points), but the difference was not statistically significant (1.9-point greater improvement in the omega-3 group, 95% CI = − 2.2 to 5.2). Adverse events were rare and not associated with omega-3 fatty acids. Participant feedback was positive. Conclusion Internet-based, randomized controlled trials of therapies in children with ASD are feasible and may lead to marked reductions in the time and cost of completing trials. A larger sample size is required to definitively determine the efficacy of omega-3 fatty acids. Clinical trial registration information—Omega-3 Fatty Acids for Hyperactivity Treatment in Autism Spectrum Disorder; http://clinicaltrials.gov; NCT 01694667.

This article does not have an abstract.

Nonablative fractional photothermolysis has been reported to show early promise in the treatment of hypertrophic scars, but there are few reports on ablative fractional photothermolysis for the treatment of hypertrophic scars.To evaluate and compare the efficacy and safety of Er:YAG fractional laser (EYFL) and CO2 fractional laser (CO2FL) for treatment of hypertrophic scars.Thirteen patients with hypertrophic scars were treated with 2,940 nm EYFL, and ten were treated with 10,600 nm CO2FL. An independent physician evaluator assessed the treatment outcomes using Vancouver scar scale (VSS) and 5-point grading scale (grade 0, no improvement; grade 1, 1-25%; grade 2, 26-50%; grade 3, 51-75%; grade 4, 76-100% improvement). Patients are queried about their subjective satisfaction with the treatment outcomes.After the final treatment, average percentage changes of VSS were 28.2% for EYFL and 49.8% for CO2FL. Improvement was evident in terms of pliability, while insignificant in terms of vascularity and pigmentation. Based on physician's global assessment, mean grade of 1.8 for EYFL and 2.7 for CO2FL was achieved. Patient's subjective satisfaction scores paralleled the physician's objective evaluation.CO2FL is a potentially effective and safe modality for the treatment of hypertrophic scars, particularly in terms of pliability.

Dear Editor: A 54-year-old woman presented with mildly stinging, painful, grouped nodules on the left vulvar area. It shows unilateral localized grouped papulonodular lesions, resembling a zosteriform aspect (Fig. 1). The patient had a history of stage IV rectal adenocarcinoma with liver and lung metastases treated 17 months earlier with ultra-low anterior resection and chemotherapy. The patient also received external pelvic irradiation of 180 cGy/day, up to total 6,300 cGy/35 fractions, for recurrent adenocarcinoma at the anastomosis site. She presented with a zosteriform eruption on the left vulvar area during hospitalization, with no prior history of herpes zoster. The skin lesions exhibited predominantly nodular infiltration, inadequate for the tzanck test. A skin punch biopsy was performed under the differential diagnosis of herpes zoster on the left S2 dermatome, postherpetic granuloma, and cutaneous metastasis. Histopathology revealed metastatic adenocarcinoma (Fig. 2). The chest computed tomography (CT), abdomen CT, and positron emission tomographic-CT images showed consistent results of an increasing size of lung and hepatic nodules with lymph node metastasis. Pain around the vulva area was aggravated after repetitive chemotherapy and radiotherapy. Wide excision was performed to resect the visible cutaneous nodules with patient consent. The patient died eight months after the diagnosis of cutaneous metastasis, which was three years after the initial diagnosis of rectal adenocarcinoma. While the mean survival time from the diagnosis of cutaneous metastasis of colorectal cancer is 18 months1, our patient died in a shorter time span. Cutaneous metastasis from an internal malignancy is rare and can appear in many different forms, including the multiple nodular type, inflammatory or erysipeloid form, sclerodermoid form, alopecia neoplastica, or bullous form. The nodular type is the most common clinical appearance, while the zosteriform pattern is very rare2. The exact mechanism of zosteriform cutaneous metastasis is unknown. A Koebner-like phenomenon at the site of herpes zoster, invasion of the perineural lymphatic or dorsal root ganglion, direct invasion of tumor cells, and accidental surgical implantation have all been proposed 2,3. Colonofiberscopy and magnetic resonance imaging revealed an ulcerated fungating mass located on the left posterolateral wall of rectum. The metastatic lesion of the vulva was observed about 17 months later after a laparoscopic resection. However, an asymptomatic skin lesion may have appeared earlier. It is possible that the metastatic skin lesions may have been due to direct seeding of the tumor cells to the left side, but the exact mechanism remains unclear. The patient was undergoing chemotherapy when the metastatic lesions were observed, and herpes zoster occurs more frequently in immunosuppressed patients. It has been reported that many patients with cutaneous metastasis of zosteriform distribution are initially misdiagnosed with herpes zoster and treated with antiviral drugs4. Considering the pain and unilaterality, this may be easily misdiagnosed as herpes zoster. Herein, we report an unusual case of cutaneous metastasis of rectal adenocarcinoma that mimicked herpes zoster. This must be considered in any patient with a history of malignant neoplasm experiencing non-healing zosteriform lesions. Therefore, early biopsy for suspicious skin lesions is very important. Fig. 1 Stinging painful erythematous grouped nodules on the left vulvar area. Fig. 2 Dermal infiltration by intestinal type atypical glands, showing metastatic skin adenocarcinoma (H&E, ×100).

Dear Editor: Ordinary photography may not fully represent patients' skin status, but digital photography using a consistent and appropriate light-emitting diode (LED) illuminator could provide more objective and reliable images and colorimetric data1. Previous studies have shown that parallel-polarized light (PPL) images taken with green LED show more significant quantitative differences, depending on the state of the skin, than those taken with white LED2,3. This study aimed to determine the skin diseases appropriate for an analytic technique using PPL images taken with green and white LEDs. This study was approved by the Institutional Review Board (IRB) at the Korea University College of Medicine Anam Hospital (IRB ED13197). Between September 2013 and August 2014, 73 subjects were enrolled in a prospective study. Among the subjects, 10 or more had one of the following diseases: acne, atopic dermatitis, nummular eczema, rosacea, seborrheic dermatitis, senile pruritus, and xerotic dermatitis (Table 1). Subjects taking systemic or topical medications that can interfere with the skin status, including diuretics, corticosteroids, retinoids, and H2 anti-histamine agents, were excluded. Subjects with underlying conditions that may affect the skin surface, such as pregnancy, nutrient deficiency, thyroid dysfunction, serious diseases (e.g., malignancies), and skin disorders requiring treatment, were also excluded. Subjects were recruited regardless of sex and age. Table 1 Demographic data of the patients A digital, single-lens reflex camera (EOS-500D; Canon Inc., Tokyo, Japan) equipped with a macro lens (SP MF 90 mm F/2.8 Di Macro 1:1; Tamron Co., Ltd., Saitama, Japan) was used, and a rotatable polarizing filter was placed over the camera lens. The same in-house skin conductance meter as that in the previous study was used3. PPL photographs were taken with a polarizing, filtered camera, with green and white LED illuminators attached respectively at each side of the camera at an angle of 45° (Fig. 1). All photographs were obtained under the same conditions, with the same settings and distances with either green or white LED illuminators. Photographs were taken of every skin lesion and surrounding normal skin in each subject. Fig. 1 A schematic diagram of the equipment. PL: polarized light, LED: light-emitting diode. Disease severity was evaluated using a 5-point investigator's global assessment scale, and dryness was graded for severity with a score from 0 to 6 using the xerosis severity scale4. Commission Internationale de l'Eclairage LAB (CIELAB) values were obtained from the PPL images by converting sRGB to CIELAB coordinates based on a previous study5. Equations and a matrix conversion were derived using graphics software (Adobe Photoshop Elements; Adobe Systems Inc., San Jose, CA, USA) and a spreadsheet program (Excel 2010; Microsoft Corp., Redmond, WA, USA). Statistical software IBM SPSS Statistics version 21.0 for Windows (IBM Co., Armonk, NY, USA) was used for statistical analyses. All values were tested by Pearson or Spearman correlation with statistical significance set at p

Aim Aneurysmal fibrous histiocytoma (AFH) is a variant of fibrous histiocytoma, which has a cleft-like cavernous blood-filled space in the tumor. It appears as a single reddish black tumor with variable levels of pain and size from its bleeding. And, it must be differentiated from other similar looking malignant conditions such as malignant melanoma. The visual mimicry of AFH to melanoma was raised by some careful dermatologists, but never be confirmed objectively by colorimetric analysis. Materials, Subjects, and Methods In this study, we simply analyzed conventionally photographed digital images of thirty-seven cases of fibrous histiocytomas, including three AFH cases into colorimetrically useful color space, CIELAB, of which coordinates are L*, a*, and b* representing lightness, red to green, and yellow to blue axis, respectively. In addition, we also analyzed the clinical digital images of seven cases of malignant melanomas. Using statistical package, each coordinates of CIELAB were compared using Wilcoxon rank sum test between AFH and melanomas. The CIELAB coordinates of AFH and non-aneurysmal fibrous histiocytomas were compared statistically as well. Results Comparing with banal fibrous histiocytomas, the colors of AFH showed significantly smaller a* and b* coordinates (P = 0.008, 0.008, respectively), which implies more green and blue hue of AFH lesion. Rather, they were more like melanomas (P = 0.2839, 0.2040, respectively). As for L*, there were no significant differences for all comparisons. Conclusions As a result, more objective analysis of the digital images using colorimetric color space confirmed the visual mimicry of AFH to melanoma.

BACKGROUND Becker's nevus (BN) can be a distressing cosmetic handicap for patients and a treatment challenge for physicians. Various treatment modalities have been used, but repigmentation commonly occurs after treatment. OBJECTIVE To evaluate the efficacy of long-pulse alexandrite laser in the treatment of BN. MATERIALS AND METHODS Eleven Korean patients with Fitzpatrick skin type III to V were included in this study. A long-pulsed alexandrite laser with a wavelength of 755 nm and a pulse duration of 3 ms was used. Patients were treated with a fluence of 20 to 25 J/cm2 and a spot size of 15 to 18 mm. Cryogen spray cooling was not used. RESULTS Two patients had excellent responses, five had good responses, and four had fair responses. Hair density simultaneously decreased with treatment in all patients. Although mild hypopigmentation was observed in some patients, and partial hypertrophic scarring was observed in one patient, the outcomes were cosmetically acceptable. No repigmentation was noted during the follow-up period. CONCLUSION A long-pulsed alexandrite laser without cryogen spray cooling is an effective and safe alternative in the treatment of BN.

Tinea incognito is a dermatophytic infection induced by immunosuppressive agents that lacks the classic features of a typical fungal infection. Although the treatment of tinea incognito is simple and relatively easy, its clinical manifestation varies and can masquerade as various skin disorders, causing misdiagnosis and thus preventing prompt and appropriate treatment. Here, we report an interesting case of tinea incognito occurring after topical steroid administration in an immunosuppressed patient with dermatitis artefacta. A 40-year-old female patient who had been taking systemic glucocorticoid for 4 years for chronic inflammatory demyelinating polyneuropathy presented with itching multiple erythematous erosive lesions on the face and upper chest for 2 months. Initial biopsy produced nonspecific findings. The skin lesion was aggravated and became polycyclic and erythematous; after azathioprine was added, her chronic inflammatory demyelinating polyneuropathy became aggravated. A second biopsy confirmed hyphae in the cornified layer. Complete remission was achieved after admonishing oral terbinafine and topical amorolfine.

Background: Pigmented purpuric dermatoses (PPD) are a spectrum of disorders characterized by a distinct purpuric rash. Although PPD can be easily diagnosed, the disease entity remains an enigma and a therapeutic challenge. Objective: The purpose of this study was to investigate the characteristics and clinical manifestations of PPD and to elucidate the relationship between assumed etiologic factors and the clinical manifestations of PPD and treatment responses. Methods: Retrograde analyses were performed to identify appropriate PPD patients who visited Korea University Medical Center Anam Hospital from 2002 to 2012. Results: Information on 113 patients with PPD was analyzed, and 38 subjects with skin biopsy were included for this study. Schamberg's disease was the most frequent clinical type (60.5%). Concomitant diseases included hypertension (15.8%), diabetes (10.5%), and others. Associated medication histories included statins (13.2%), beta blockers (10.5%), and others. Possibly associated etiologic factors were recent upper respiratory infection (5.3%), high orthostatic pressure due to prolonged standing (2.6%), and strenuous exercise (2.6%). A total of 36 patients (94.7%) were treated with one or more treatment methods, including oral antihistamines, pentoxifylline, topical steroids, and/or phototherapy. There was no significant difference in disease progress according to underlying diseases, medications, or association factors (p＞0.05). Conclusion: Our overall results were grossly consistent with the existing literature, excluding several findings. Although a possible relationship between PPD and cardiovascular disease or cardiovascular medication was proposed at the beginning of the study, no statistically significant correlations were found according to the specific clinical types and treatment responses (p＞ 0.05). (Ann Dermatol 27(4) 404∼410, 2015)

Dear Editor: Myofibroma is an uncommon, benign myofibroblastic neoplasm of vascular origin, mostly occurring on the skin. It can also involve skeletal muscles, bones, or viscera, which can be fatal. As about 90% of myofibromas develop before the age of 2 years, it was previously termed infantile myofibroma. Adult-onset myofibroma is rare and is distinguishable from the infantile form. It is exclusively solitary and confined to the dermis and subcutis. However, a few cases of adult multiple myofibromas have been reported1,2. Herein, we report a rare and unusual case of adult multiple myofibromas occurring on a preexisting atrophic patch. A 62-year-old healthy woman presented with multiple firm subcutaneous nodules under a preexisting atrophic patch on the left thigh (Fig. 1). The patch was soft and heterogeneous, composed of atrophic and hypertrophic portions, and was >10 years old. During the last 3 years, multiple firm nodules developed under the patch. She had no history of trauma, burns, or treatment. Two incisional biopsies were performed on the nodule and the patch. Histopathological examination of the nodule showed well-circumscribed, biphasic tumors composed of intersecting fascicles of spindle cells and a vascular compartment resembling a hemangiopericytoma with polygonal cells (Fig. 2A~C). The tumor cells were positive for smooth muscle actin (SMA) staining and were negative for CD34, desmin, and S-100 staining (Fig. 2D, E), consistent with a myofibroma. Histopathological examination of the patch showed mild epidermal and dermal atrophy; however, these findings were not diagnostic. A small tumor suggestive of myofibroma was incidentally found in the dermis; this tumor was not clinically noticeable (Fig. 2F). She is currently being observed without excision, showing no remarkable change for 1 year. Fig. 1 Multiple firm subcutaneous nodules under the atrophic and telangiectatic soft patch on the left thigh. Fig. 2 Skin biopsy of the nodule showed well-circumscribed, biphasic tumors (A: H&E, ×12.5) composed of intersecting fascicles of spindle cells (B: H&E, ×200) and a vascular compartment with polygonal cells (C: H&E, ×200). ... Myofibromas are histologically well-circumscribed, biphasic- patterned tumors consisting of spindle and vascular portions; however, monophasic variants can occur. A myofibroma shows an arrangement of interlacing fascicles of spindle-shaped cells resembling myofibroblasts, and vascular foci resembling hemangiopericytoma with polygonal cells. Spindled cells express vimentin and SMA and are usually negative for desmin3. In our patient, the preexisting patch was clinically suspected to be smooth muscle hamartoma; however, the pathologic results were not diagnostic. The patch included a small myofibroma in the dermal layer, which implied that multiple myofibromas would continue to develop under the patch. Kim et al.4 previously reported a case of multiple myofibromas with congenital smooth muscle hamartoma on the thigh of a woman, which had very similar clinical manifestation as our case. The pericytes in vascular foci are considered to be the origin of spindle-shaped neoplastic cells that show myofibroblastic differentiation. However, the pericytes can also differentiate into other mesenchymal cells; their differentiation into smooth muscle cells was demonstrated in ultrastructural studies of hemangiopericytomas5. Therefore, smooth muscle hamartoma might develop from multipotent pericytes that later create myofibromas. Although the patch was not diagnosed in our case, we suggest the possibility that the preexisting patch and the myofibromas might have originated from the same parental cells before differentiation. Further investigations may help find their possible relation.

Background: The rapid development of information and communication technology has replaced traditional books by electronic versions. Most print dermatology journals have been replaced with electronic journals (e-journals), which are readily used by clinicians and medical students. Objective: The objectives of this study were to determine whether e-readers are appropriate for reading dermatology journals, to conduct an attitude study of both medical personnel and students, and to find a way of improving e-book use in the field of dermatology. Methods: All articles in the Korean Journal of Dermatology published from January 2010 to December 2010 were utilized in this study. Dermatology house officers, student trainees in their fourth year of medical school, and interns at Korea University Medical Center participated in the study. After reading the articles with Kindle 2, their impressions and evaluations were recorded using a questionnaire with a 5-point Likert scale. Results: The results demonstrated that gray-scale e-readers might not be suitable for reading dermatology journals, especially for case reports compared to the original articles. Only three of the thirty-one respondents preferred e-readers to printed papers. The most common suggestions from respondents to encourage usage of e-books in the field of dermatology were the introduction of a color display, followed by the use of a touch screen system, a cheaper price, and ready-to-print capabilities. Conclusion: In conclusion, our study demonstrated that current e-readers might not be suitable for reading dermatology journals. However, they may be utilized in selected situations according to the type and topic of the papers. (Ann Dermatol 26(6) 700∼705, 2014)

Sir, Kimura’s disease (KD) is a rare, chronic inflammatory disorder that occurs predominantly in Asian males and is characterized by recurrent painless swellings involving the subcutaneous tissues, mainly in the head and neck region. It is also associated with eosinophilia and elevated levels of serum IgE. The histological features of KD are hyperplastic lymphoid tissue with well-developed lymphoid follicles, marked infiltration of eosinophils and vascular proliferation. Treatment is known to be difficult. We report here a case of KD that was treated successfully with an ultra-long pulsed dye laser (PDL).

This article does not have an abstract.

The distinction of a spitz nevus from a melanoma can be difficult and in some cases, impossible. A misdiagnosed spitz nevus can metastasize and lead to fatal outcomes, especially in children. A 5-yr-old girl presented with a 1-yr history of a solitary pinkish nodule on her left hand. On physical examination, she had a palpable left axillary lymph node. We performed biopsy and checked 3 sentinel lymph nodes (SLN) on her axillary area. The biopsy specimen showed multiple variably sized and shaped nests with large spindle or polygonal cells and SLN biopsy showed 3 of 3 lymph nodes that were metastasized. Under the diagnosis of spitzoid melanoma, she was treated with excision biopsy and complete left axillary lymph nodes were dissected. She received interferon-α2b subcutaneously at a dose of 8 MIU per day, 3 times weekly for 12 months, and shows no recurrence.

The platelet-rich plasma (PRP) has been advocated as a way to introduce increased concentrations of growth factors and other bioactive molecules to injured tissues in an attempt to optimize the local healing environment. A 94-yr-old woman with various comorbidities presented with a two-week history of severe cutaneous ulcer on the left dorsum of foot. It was caused by recurrent mechanical trauma and did not respond to several wound debridement and simple dressings. However, after she was completed on seven times of autologous PRP treatments, we observed complete healing of the skin lesion within 3 months. Herein, we report a case of recalcitrant cutaneous ulcer with various comorbidities and discuss about the promising possibility of autologous PRP as an effective alternative therapeutic modality.

Destructions of vertebral body due to various medical situations including acute fracture, tumor, post-traumatic deformity and infection lead to progressive destruction of vertebral body, kyphotic deformities and further neurological defecits. Titanium mesh cages (TMCs) with cancellous autograft bone after corpectomy of the thoracolumbar spine provide immediate structural support to the anterior column. The aim of this study was to evaluate the radiological, neurological and clinical outcomes of the patients with the TMCs-bone graft composite after thoracolumbar corpectomy. Sixteen patients underwent reconstruction using titanium mesh cages in thoracolumbar corpectomy between July 2000 and February 2005. The radiological and clinical course was documented over a mean follow-up duration of 28.2 months. The degree of kyphosis, construct height and the subsidence of the cage in relation to the vertebral endplates were measured preoperatively, early postoperatively, and at the latest follow-up. The mean kyphotic angle of 3.9 o before surgery was reduced to −2.6o immediately after surgery, and at the last follow-up to be 3.4. There was a significant difference between the preoperative versus postoperative kyphotic angle (p=0.003). The mean construct height of the involved vertebrae before surgery was 41.6 mm and the mean construct height immediate after surgery and at follow-up were 47.9 and 41.5 mm, respectively. There was a significant difference between the preoperative versus postoperative construct height (p