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Aromatic antiepileptic drugs (AEDs)-induced cutaneous adverse drug reactions (cADRs) add up to the limited use of the AEDs in the treatment and prevention of seizures. Human leukocyte antigen-B (HLA-B) alleles have been linked to AEDs-induced cADRs. We investigated the association between cADRs (including Stevens–Johnson syndrome; SJS/toxic epidermal necrolysis; TEN, drug reaction with eosinophilia and systemic symptoms; DRESS, and Maculopapular eruption; MPE) caused by AEDs (phenytoin, carbamazepine, lamotrigine, phenobarbital and oxcarbazepine) and HLA-B alleles in Thai population. Through the case-control study, 166 patients with AEDs-induced cADRs, 426 AEDs-tolerant patients (AEDs-tolerant controls), and 470 healthy subjects (Thai population) were collected. The HLA genotypes were detected using the polymerase chain reaction-sequence specific oligonucleotide probe (PCR-SSOP) method. We also performed a meta-analysis with these data and other populations. The carrier rate of HLA-B*15:02 was significantly different between AEDs-induced cADRs group and AEDs-tolerant group (Odds ratio; OR 4.28, 95% Confidence interval; CI 2.64–6.95, p p HLA-B*15:02 with AEDs-induced cADRs (OR 4.77, 95%CI 1.79–12.73, p HLA-B*15:02 was associated with SJS/TEN induced by AEDs (OR 10.28, 95%CI 6.50–16.28, p p = 0.001) and carbamazepine (OR 137.69, 95%CI 50.97–371.98, p HLA-B*15:02 and AEDs-induced SJS/TEN was demonstrated with an OR of 10.79 (95%CI 5.50–21.16, p HLA-B*08:01, HLA-B*13:01, and HLA-B*56:02 were significantly higher in the DRESS group compared with the AEDs-tolerant group (p = 0.029, 0.007, and 0.017, respectively). The HLA-B*15:02 allele may represent a risk factor for AEDs-induced cADRs.

Objective: To systemically summarize and meta-analyze the risk of dementia in psoriasis patients. Methods: A systematic review was performed in two databases (EMBASE and MEDLINE). The eligible studies had to be a cohort study or a cross-sectional study that compared either the prevalence or incidence of dementia in patients with psoriasis, versus individuals without psoriasis. Results: Of 791 retrieved articles, seven studies met the inclusion criteria and were included into the meta-analysis. The risk of incident and prevalent dementia were significantly higher in patients with psoriasis, with a pooled risk ratio of 1.16 (95% CI: 1.02-1.33; I2 96%) and 1.36 (95% CI: 1.07-1.72; I2 10%), respectively. Conclusions: This study revealed a slight increase in both the incidence and prevalence of dementia in psoriasis patients. However, dermatologists should carefully observe and periodically screen psoriasis patients for this comorbidity, especially among those who have symptoms and signs of cognitive impairment.

Background Symptomatic dermographism (SD), the most common form of chronic inducible urticaria, presents with transient wheals accompanied by itching in response to scratching. Little is known about available treatment options and their efficacy in SD. Objective To systematically review the efficacy of treatment options for patients with SD. Methods Using predefined search terms, we searched for relevant literature published until September 2019. The systematic review process was consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations. Results The 23 studies identified included 15 randomized controlled trials; 22 and 17 assessed treatment responses in patients with SD by provocation/threshold testing and patient/physician clinical assessment, respectively. Thirteen different treatments were investigated in a total of 430 adult patients. The most frequently studied therapy, first-generation H1-antihistamines, showed variable efficacy and significant side effects. In contrast, second-generation H1-antihistamines (2ndAH1), in all studies, were effective and well tolerated. Monotherapy with an H2-antihistamine (AH2) was not effective, whereas adding an AH2 increased the efficacy of treatment with an H1-antihistamine (AH1). SD improved with omalizumab. All other treatments were only investigated in small, unrepeated, and/or uncontrolled studies. There are no studies on updosing of 2ndAH1. Conclusions The available SD studies are heterogeneous, mostly monocentric, old, small, and unrepeated, pointing to a high need for more and better studies. We suggest that 2ndAH1 should be the first-line treatment. In uncontrolled cases, the combination of AH1 and AH2 may be tried. Even though there is no evidence of its efficacy over standard dosage, updosing of 2ndAH1 may be considered based on the extrapolation of evidence from chronic spontaneous urticaria; omalizumab should be added in recalcitrant patients.

Methotrexate (MTX) is a mainstay drug in the treatment of psoriatic and rheumatologic conditions. Subcutaneous MTX has become a feasible treatment alternative with the development of prefilled syringes or autoinjectors containing MTX solution that can be self-administered by the patient at home. However, MTX prefilled auto-injector pens are still not available in some countries.This study aimed to investigate the stability and sterility of 25 mg/mL MTX solution in a disposable plastic syringe over a 12-week period under light protection at temperatures of 4 °C, 25 °C, and 37 °C.This study was conducted during November 2019 to February 2020 at the Faculty of Medicine Siriraj Hospital, Mahidol University. Stability was evaluated using ultra-high-performance liquid chromatography technique, and sterility was assessed by cultures for bacterial and fungal contamination.Our results revealed that patient-ready syringes containing 25 mg/mL MTX solution can be prepared in advance and kept for up to 12 weeks under light protection, and they can be kept at temperatures ranging from 4 to 37 °C.This system for delivering MTX to patients that are refractory to or intolerant of oral MTX

Background. Uveitis is a known ophthalmologic manifestation of seronegative spondyloarthropathy, including psoriatic arthritis. However, the data is less clear among patients with psoriasis due to the limited number of published studies. Aims. To investigate whether the risk of incident and prevalent uveitis is elevated among patients with psoriasis using systematic review and meta-analysis technique. Methods. The MEDLINE and EMBASE databases were searched from their inception to May 2019. Eligible studies must have included a psoriasis group and a nonpsoriasis group. Eligible studies must also have investigated for prevalent or incident uveitis, and the magnitude of difference between the study groups must have been reported. Pooled risk ratio and 95% confidence interval (CI) were calculated using random-effect generic inverse variance methods. Results. Of 7,107 potentially eligible articles from the EMBASE and MEDLINE databases, 7 studies were included in the meta-analysis. Two of those studies compared the incidence, and 5 studies compared the prevalence of uveitis between the psoriasis and nonpsoriasis groups. For incident uveitis, a total of 5,865,801 patients (222,083 with psoriasis and 5,643,718 without psoriasis) were analyzed. For prevalent uveitis, a total of 1,343,436 patients (37,891 with psoriasis and 1,305,545 without psoriasis) were studied. The risk of incident uveitis was significantly higher among patients with psoriasis with a pooled risk ratio of 1.23 (95% CI: 1.05-1.45, I2=55%). The risk of prevalent uveitis was also significantly higher among patients with psoriasis with a pooled risk ratio of 1.97 (95% CI: 1.68-2.31, I2=0%). Conclusions. The results of this study revealed significantly increased risk of both prevalent and incident uveitis among patients with psoriasis.

BACKGROUND Pruritus is commonly associated with skin disorders. The 5-D itch scale was developed as a specific questionnaire for pruritus. OBJECTIVE This study aimed to evaluate the validity, reliability, and sensitivity to change of the Thai 5-D itch scale in Thai patients. METHODS The Thai Dermatology Life Quality Index (DLQI), patient's global assessment of disease severity (PatGA-VAS), Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL), and seven-day urticaria activity score (UAS7) were evaluated as correlation with Thai 5-D itch scale. Seventy-five stable patients (42 chronic urticaria patients and 33 eczema patients), who had no change in disease severity after 4-weeks were assessed for test-retest reliability. RESULTS Of 130 pruritus patients who were treated at Department of Dermatology, Siriraj Hospital, 65 patients were diagnosed with chronic urticaria. The others were diagnosed with eczema. The validity of Thai 5-D itch scale correlated strongly with Thai DLQI total score (r = 0.76, p < 0.0001) and PatGA-VAS (r = 0.79, p < 0.0001). The strong reliability of Thai 5-D itch scale was demonstrated as intraclass correlation coefficient of 0.90. The changes in Thai 5-D itch scale was correlated with the changes in PatGA-VAS and UAS7 which indicated that the Thai 5-D itch scale had good sensitivity to change (r = 0.66) and (r = 0.67), respectively. CONCLUSIONS The Thai 5-D itch scale is a questionnaire with good validity, reliability and sensitivity to change to evaluate pruritus in Thai patients. This will support the use of 5-D itch scale in practice, in other languages.

BACKGROUND Adult female acne (AFA) may be different from adolescent acne, and may be a sign of polycystic ovary syndrome (PCOS). The objective of the study was to investigate the clinical characteristics of AFA, and the factors significantly associated with PCOS in AFA. METHODS AFA patients aged 25 years or older were enrolled. History taking and dermatologic examinations were performed by dermatologists. PCOS was diagnosed by gynaecologists. Perimenopausal acne (aged 45 years or older) and the Dermatology Life Quality Index (DLQI) were also evaluated. RESULTS Among 208 patients, mean age was 31.8 ± 7.1 years and 47.1%, 26.9%, and 26% had persistent, late-onset, and recurrent acne, respectively. The common aggravating factors included pre-menstruation (72.6%) and stress (53.8%). Recurrent acne was significantly aggravated by cosmetic products. Higher body mass index (BMI) was positively correlated with acne severity. Acne lesions were predominately located on both cheeks (87.0%) and at the perioral area (81.7%). PCOS was identified in 48.1%. Younger age (≥25 to

The Angioedema Activity Score (AAS) is recommended by the EAACI/GA2LEN/EDF/WAO guidelines for urticaria as the standard measure for assessing disease activity in patients with recurrent angioedema (RAE). To date, it has been translated into 80 languages for use in 52 countries, but it has not been formally validated in Asian patient populations. As RAE may be different in Asian and non-Asian patients, it is important to validate and characterize the reliability of tools to assess RAE disease activity in Asian patients. This study proposed to demonstrate the validity and reliability of the AAS in Asian patients. Accordingly, this study aimed to generate and validate the Thai version of the AAS and to characterize its reliability in Asian patients, specifically in Thailand. A structured translation was conducted with approval from the original authors. The Patient Global Assessment of Disease Activity (PGA-DA) was used as an instrument to compare with the Thai version of the AAS. In total, 86 patients with RAE participated in the study. Seventy-six (88%) patients had RAE with chronic spontaneous urticaria. The Thai AAS was found to be a valid and reliable instrument, with high convergent and known-groups validities, excellent internal consistency, and good test-retest reliability. The validity and reliability of the AAS for assessing RAE disease activity in Asian patients have been demonstrated by our study, making it the first to do so. This will help promote the use of the AAS, in clinical trials and practice, in Asia. It will also facilitate the comparison of disease activity in patients with RAE inside and outside Asia in future studies. However, a limitation of this study was its small number of patients.

Background Although ultraviolet A1 (UVA1) phototherapy is available for nearly 30 years, only few studies have been conducted for plaque-type psoriasis. Objectives To determine the efficacy and safety of UVA1 phototherapy in psoriasis by assessing the clinical and histological outcomes. Methods This open study enrolled 15 patients with moderate to severe plaque-type psoriasis. All of the patients had skin type IV. A whole-body UVA1 device consisting of 24 lamps, was irradiated at a medium dose of 50 J/cm2 three-times weekly for 30 sessions. Topical and systemic psoriasis treatments were discontinued before and during treatment; patients could only use emollients and antihistamines until 1-month post-completion. Psoriasis Area and Severity Index (PASI) scores were determined at baseline; at sessions 10th, 20th and 30th; and 1 month after treatment. Four-millimetre punch biopsies were obtained from the same psoriasis lesion at baseline and session 30th. Changes in histopathological gradings and polymorphonuclear, lymphocyte and Langerhans cell numbers were monitored. Results Twelve patients completed the study. The mean age was 41.3 years (range: 25-71). The median PASI scores at baseline, session 30th and 1-month post-treatment were 16 (8.2, 43.3), 11 (4.4, 43.3) and 9.2 (2.7, 36.4), respectively. Although the PASI scores had improved significantly by 1-month post-treatment (P = .006), the histological parameters demonstrated minimal changes. All patients tolerated the phototherapy well and the most common side effect was skin tanning. Conclusions While medium-dose UVA1 phototherapy demonstrated some efficacy in moderate to severe plaque-type psoriasis. However, it might not be an excellent choice.

Background Several treatment options for cold urticaria (ColdU) have been studied and reported, but systematic reviews and meta-analyses are limited. Objectives We sought to meta-analyze and review the efficacy and safety of ColdU treatments. Methods We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Suitable reports were identified by searching PubMed, Scopus, and Web of Science. Our systematic review included 16 studies, 9 of which met the eligibility criteria for the meta-analysis. We analyzed the effects of treatments on critical temperature thresholds (CTTs) and critical stimulation time thresholds (CSTTs), as well as on rates of complete response and adverse events. Results Our pooled meta-analyses showed that nonsedating second-generation H1-antihistamines (nsAHs) are effective in the treatment of ColdU and that updosing of nsAHs significantly reduced CTTs relative to their own standard doses and placebos. In 4 studies involving CSTTs, updosing of nsAHs also resulted in significantly better CSTTs than their own standard doses or placebos. Omalizumab resulted in a marked reduction of CTTs in H1-antihistamine–resistant patients. Of 118 adverse events in 8 studies, standard-dose nsAHs, updosed nsAHs, and omalizumab produced lower numbers of adverse events than first-generation antihistamines. Conclusions Our study showed that greater dosages of nsAHs were more effective than standard dosages in controlling ColdU symptoms. Increasing the dosages was not significantly associated with higher adverse event rates. Omalizumab at 150 and 300 mg every 4 weeks was shown to be effective for patients with ColdU refractory to antihistamines.

Atopic dermatitis (AD), a chronic, relapsing dermatitis, is characterized by dry and pruritus skin in patients with a personal or family history of atopy. It affects up to 20% of children and 1-3% of adults in most countries worldwide, and leads to significant treatment costs and morbidity. These guidelines are developed in accordance with evidence-based publications and expert opinions. Following simple algorithms, the guidelines aim to assist adult and pediatric physicians in the better care of patients with AD. As with other diseases, there have been several diagnosis criteria proposed over time. Nonetheless, the classical Hanifin and Rajka criterion with no pathognomonic laboratory biomarkers is still the most widely used worldwide for the diagnosis of AD. The management of AD must be considered case by case to provide suitable care for each patient. Basic therapy is focused on avoiding specific/unspecific provoking factors and hydrating skin. Topical anti-inflammatory treatments such as glucocorticoids and calcineurin inhibitors are suggested for disease flare, and proactive therapy is best for long-term control. Other therapies, including antimicrobial agents, systemic antihistamines, systemic anti-inflammatory agents, immunotherapy, phototherapy, and psychotherapy, are reviewed in these guidelines. Crisaborole, a new topical phosphodiesterase 4 inhibitor, can be used twice daily in AD patients over three months old. Dupilumab, a biological drug for patients with moderate-to-severe AD, may be considered in patients with no improvement from other systemic treatments.

Livedoid vasculopathy (LV) is an uncommon, chronic, and recurrent thrombo-occlusive vascular disorder. Data specific to LV in Thai population remains scarce. This study aimed to evaluate the clinical course and treatment outcomes of LV in Thai patients, and to perform a literature review for studies that reported on anticoagulant treatment in LV. Seventy-four patients with a mean age of 37.6 ± 14.7 years were included. The female to male ratio was 5.2:1, and the median follow-up was 10.5 months. Most patients had primary LV disorder. Forty-eight patients were improved with treatments, with a median duration of 11.4 months. Combination treatments were commonly used, including anti-inflammatories, antiplatelets, and immunosuppressants. Add-on therapy with anticoagulant or psoralen plus ultraviolet-A (PUVA) led to disease improvement in a majority of the patients treated. Kaplan-Meier analysis demonstrated that 38.5%, 53.7%, and 57.9% would have disease improvement at 1, 2, and 3 years, respectively. Of 39 studies (n = 219) that reported on anticoagulant treatment in LV, anticoagulant drug was used as monotherapy in 104 patients. The mean duration of anticoagulant treatment was 7.2 ± 3.8 months, which led to disease improvement in 97 patients (93.3%). Bleeding side effect was found in 9 patients (8.7%). The highest incidence of LV was found among females aged 30 to 40 years. Combination therapy with anti-inflammatory drugs, antiplatelet drugs, and immunosuppressants led to disease improvement. The observed efficacy of add-on PUVA or anticoagulant is promising and should be further investigated. Further studies are needed to guide the development of an LV management guideline.

Continuously updated information is helpful for evaluating the safety of long-term systemic drug use in psoriasis patients with concomitant hepatitis B virus (HBV) infection. To investigate the impact of long-term systemic treatment for psoriasis on liver disease in psoriasis patients with HBV infection. Data of patients during 10-year period were recorded and analyzed. Sixty-six patients (46 males and 20 females) with a mean age of 58.5 ± 13.1 years were recruited. Our study estimated that the 5-year cumulative risks of developing cirrhosis and HCC were 30% and 5%, respectively, in patients receiving systemic treatments for psoriasis. Risks of cirrhosis and HCC were not significantly different between systemic and topical treatment groups. Thirty patients were prescribed systemic treatments (acitretin, methotrexate, ciclosporin, and anti-tumor necrosis factors). Three HBsAg+ patients developed viral reactivation (two patients with methotrexate and one patient with ciclosporin). The effects of systemic treatments for psoriasis on liver outcome in patients with coexisting HBV infection are needed to be determined. HBsAg+ patients are more likely to develop viral reactivation during systemic treatment for psoriasis than HBsAg- patients. Monitoring of liver enzymes and HBV DNA every 3 months is recommended during treatment and for 6 to 12 months after drug discontinuation.

BACKGROUND Direct immunofluorescence (DIF) findings in patients with livedoid vasculopathy (LV) may have benefits for disease differentiation when clinical presentations and/or histopathological findings are inconclusive. AIM To investigate DIF findings in patients with a clinical and histopathological diagnosis of LV. METHODS DIF findings of 62 patients with LV were analysed, and the published literature in the PubMed database was also reviewed and summarized. RESULTS This study demonstrated deposition of immunoreactants in blood vessels (BVs) in 59 of the 62 patients (95.2%), and almost all cases were positive for a combination of multiple immunoreactants. Complement C3 and IgM formed the most common combination. The most common pattern was deposition in BVs and at the dermoepidermal junction (DEJ) (59.3%), followed by deposition in BVs alone (40.7%). Immunoreactant deposition in BVs involved superficial BVs with or without deep BVs. The median age of patients with positive DIF findings was significantly higher than that of patients with negative DIF findings for LV (P

Objective: To compare the efficacy and safety of a generic desoximetasone cream (Topoxy) with the reference form, Topicorte, for the treatment of scalp psoriasis. Methods: A randomised, double-blind, controlled study was conducted. Altogether, 105 patients with psoriasis lesions covering more than 10% of the scalp were randomised into three groups. The first, second and third groups received a placebo, Topoxy and Topicorte, respectively. The scalp psoriasis severities were assessed at weeks 0, 2, 4 and 8, using the Investigator Global Assessment (IGA) scale and Total Sign Score (TSS). The safety profiles of the products were assessed by the patients and physicians. Results: Topoxy and Topicorte were significantly more effective than the placebo in achieving at least a two-grade improvement in the IGA score from baseline at weeks 2, 4 and 8, and there were no significant differences between Topoxy and Topicorte. The TSS of both creams were significantly lower than that of the placebo at weeks 2, 4 and 8. All patients tolerated well to the therapy. Conclusion: Topoxy and Topicorte had comparable efficacies for scalp psoriasis., The medications were superior to the placebo in all parameters, and had a good safety profile.

Many topical agents are available for treating the acute phase of acne; however, few agents have been proven beneficial during the maintenance phase. Objective. To evaluate the efficacy and safety of moisturizer containing licochalcone A, 1,2-decanediol, L-carnitine, and salicylic acid during the maintenance phase of mild to moderate acne in Thai patients. Methods. One hundred and ten patients with mild to moderate acne vulgaris were initially treated with a fixed combination of adapalene 0.1%/benzoyl peroxide 2.5% gel once daily for 8 weeks. Fifty patients who achieved at least 50% reduction in lesion counts or at least a 2-grade improvement in the Investigator’s Global Assessment (IGA) grade from baseline were enrolled in the maintenance phase, which was an investigator-masked, left-right comparison, randomized, controlled, intraindividual study. Moisturizers with and without the active study ingredients were applied twice a day to each side of the face, respectively, for 12 weeks. Assessments included acne lesion counts, acne severity by IGA scoring, skin bioengineering measurements, and skin tolerability as assessed by both patient and physician. Results. The treatment group had a significant reduction in the mean counts of noninflammatory, inflammatory, and total lesions compared to the vehicle group at week 12 and also between baseline and week 12. There was no significant difference in the mean scores for skin dryness, stinging/burning, or pruritus at any time point between groups. Conclusions. Moisturizer containing licochalcone A, 1,2-decanediol, L-carnitine, and salicylic acid reduced acne lesions and prevented the development of new lesions during the maintenance phase. This trial is registered with ClinicalTrials.gov registration no. NCT04002024.

Background Vitamin D has been reported to be associated with many allergic diseases. There are a limited number of the studies of vitamin D supplementation in patients with chronic spontaneous urticaria (CSU). This study aims to study the relationship between vitamin D and CSU in terms of serum vitamin D levels, and the outcomes of vitamin D supplementation. Methods A literature search of electronic databases for all relevant articles published between 1966 and 2018 was performed. The systematic literature review was done following Preferred Reporting Items for Systematic Reviews and Meta-analysis recommendations. Results Seventeen eligible studies were included. Fourteen (1321 CSU cases and 6100 controls) were concerned with serum vitamin D levels in CSU patients. Twelve studies showed statistically significant lower serum vitamin D levels in CSU patients than the controls. Vitamin D deficiency was reported more commonly for CSU patients (34.3–89.7%) than controls (0.0–68.9%) in 6 studies. Seven studies concerned with vitamin D supplementation in CSU patients showed disease improvement after high-dosages of vitamin D supplementation. Conclusion CSU patients had significantly lower serum vitamin D levels than the controls in most studies. However, the results did not prove causation, and the mechanisms were not clearly explained. Despite the scarcity of available studies, this systematic review showed that a high dosage of vitamin D supplementation for 4–12 weeks might help to decrease the disease activity in some CSU patients. Well-designed randomized placebo-controlled studies are needed to determine the cut-off levels of vitamin D for supplementation and treatment outcomes.

Background Delayed pressure urticaria (DPU) is characterized by recurrent erythematous and often painful swelling after the skin is exposed to sustained pressure. Treatment is challenging. Antihistamines, the first-line and only approved treatment, are often not effective. Objective To systematically review the treatment options for DPU. Method A literature search of electronic databases for all relevant articles published till April 29, 2019, was conducted using the search terms "delayed pressure urticaria" and "pressure urticaria." This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. Results Twenty-one studies (8 randomized controlled trials [RCTs], 10 retrospective cohort studies, and 3 open-label prospective studies) were included. Second-generation H1 antihistamines (sgAHs) were effective in 3 RCTs. The combination of an sgAH and montelukast (2 RCTs) or an sgAH and theophylline (1 non-RCT) was more effective than the sgAH alone. The disease improved with omalizumab (4 non-RCTs), sulphones (3 non-RCTs), oral prednisolone (1 RCT and 2 non-RCTs), intravenous immunoglobulin (1 non-RCT), and gluten-free diet (1 non-RCT). There are no studies on updosing of antihistamines over standard dosage in DPU. Conclusions Overall, the quality of studies on DPU is low. Because of the lack of other evidence, antihistamines remain the first-line therapy. Updosing of sgAHs could be considered in patients with uncontrolled symptoms on the basis of the extrapolation of evidence from chronic spontaneous urticaria, even though there is no evidence of its efficacy over standard dosage. Addition of montelukast may be considered. Omalizumab or sulphones may be used in treatment-resistant patients. High-quality DPU studies should be conducted.

Objective: To assess the clinical utility of the Psoriasis Epidemiology Screening Tool (PEST), the Early Arthritis for Psoriatic Patients (EARP) questionnaire, and the Siriraj Psoriatic Arthritis Screening Tool (SiPAT) as screening tools for psoriatic arthritis (PsA), and to identify factors significantly associated with PsA. Methods: This cross-sectional study included adult psoriasis patients who attended the outpatient clinic at Siriraj Hospital and had not been diagnosed with PsA during 1 March 2017 to 28 February 2018. Participants completed the EARP, PEST, and SiPAT, after which musculoskeletal history was taken, and examination and radiography were performed. Diagnosis of PsA was based on Classification Criteria for Psoriatic Arthritis. Receiver operator characteristic (ROC) curves, sensitivity, and specificity were used to determine assessment tool performance. Logistic regression analysis was used to identify factors associated with PsA. Results: Eighty-seven patients with a mean age of 45.90±14.75 years were enrolled. Twenty-six (29.88%) patients were diagnosed as PsA. According to ROC values, EARP had the best discriminative power (0.83) for distinguishing between psoriatic patients with and without PsA (SiPAT: 0.78, PEST: 0.77). SiPAT had the highest sensitivity (92.3%), followed by EARP (84.6%) and PEST (50.0%); whereas, PEST had the highest specificity (82.0%), followed by EARP (62.3%) and SiPAT (54.1%) for detecting PsA. Multivariate analysis revealed body surface area involvement >10% to be the only independent predictor of PsA (OR: 2.99, 95% CI: 1.09-8.21). Conclusion: SiPAT is an effective and simple to use tool for screening PsA in psoriasis patients. Body surface area involvement >10% is a significant predictor of PsA.

There is still relatively limited data on psoriasis and hepatitis C virus (HCV) infections.This study investigated the clinical characteristics and treatment of psoriasis patients with HCV infections in real-world practice.Medical records of all psoriasis patients with HCV infections who attended the outpatient clinic at Siriraj Hospital over a 10-year period were retrospectively reviewed.Of 34 patients, 26 and 8 patients were men and women, respectively with a mean age of 57.0 ± 8.7 (range, 42.2-77.2) years. The median age of psoriasis onset was 42.7 ± 12.7 (range, 8-67.25) years. With a median follow-up period of 13.6 years, cirrhosis and hepatocellular carcinoma were found in 67.6% and 29.4% of the patients, respectively. The interferon used for HCV treatment exacerbated the psoriasis in 20% of those patients. Conventional treatments and anti-tumor necrosis factors (anti-TNFs) were used in strict collaboration with hepatologists. No patients experienced a worsening of their HCV infection.Despite a limited number of patients, a male predominance and late-onset psoriasis were frequently observed. Although, interferon therapy for HCV can exacerbate psoriasis, it is not contraindicated. All conventional treatments and anti-TNFs can be used, provided that there is strict collaboration with hepatologists.

Purpose To review the clinical features and natural courses of cold urticaria (ColdU) in a tropical country. Methods A retrospective chart review was performed of patients who visited Siriraj Urticaria Clinic, Siriraj Hospital, Bangkok, Thailand, and were diagnosed with ColdU between 2007 and 2018. Data on provocation and threshold tests, clinical courses, and laboratory work-up were analyzed and compared with data reported by studies in temperate countries. Results Of 1,063 chronic urticaria patients, 27 (2.5%) were diagnosed with ColdU, with a mean age of symptom onset of 34.8 years. Half of the patients had a history of atopy, and 1 (3.7%) had a history of anaphylaxis. All patients were positive to 1 of 3 provocation tests: an ice cube test; TempTest 4.0; or a tray filled with ice, salt and water. Thirteen patients underwent the ice cube test, and all had positive results. TempTest was performed on 15 patients, 8 of whom had positive results, with a mean critical temperature threshold (CTT) of 21.0°C. All of the 7 patients who had a negative TempTest result later produced positive results to the immersion of their hand and forearm in a tray filled with ice, salt, and water. All patients were treated with H₁-antihistamines, the vast majority (96.3%) being non-sedating H₁-antihistamines. Some (14.8%) needed to be administered oral corticosteroids, ciclosporin, or omalizumab. Six patients (22.2%) were in remission. A Kaplan-Meier survival curve demonstrated 5-year and 10-year remission rates of 13.8% and 42.6%, respectively. Conclusions The rate of anaphylaxis in patients with ColdU in a tropical country was lower than those reported by other studies conducted intemperate climates. On the other hand, the number of female patients, mean age at symptom onset, atopy rate, rate of concomitant chronic spontaneous urticaria and mean CTT were higher.

BACKGROUND: There is accumulating evidence that early onset psoriasis (EOP; presenting at or before 40 years of age) and late onset psoriasis (LOP; presenting after 40 years of age) are different diseases.OBJECTIVES AND METHODS: We aimed to identify potential differences between EOP and LOP by assessing immunocytochemistry involved (PP) and uninvolved (PN) skin (n=31) and demographics, psoriasis phenotype and psychological parameters (n=340) in a cross-sectional study. We categorized patients who developed psoriasis before age 40y in the EOP group, whilst those whose psoriasis occurred after age 50y were included in the LOP group.RESULTS: Immunocytochemistry revealed (17 EOP; 14 LOP) a greater lymphocytic infiltrate in PP skin of EOP than LOP (p=0.03), with a higher epidermal CD4(+) /CD8(+) ratio in LOP (1.3) compared to EOP (0.5; p=0.002). In 340 psoriasis patients (278 EOP; 62 LOP), we found a lower association with a positive 1(st) or 2(nd) degree family history of psoriasis (35.6% vs 62%; OR 0.33, 95% CI 0.18-0.59) and lower likelihood of having parents with EOP (OR=0.093, 95% CI 0.012-0.74) in LOP compared with EOP. EOP patients were more likely to have received biologic therapy (13.3%, EOP vs 3.5% LOP; P=0.042), whilst LOP patients had a higher likelihood of having type 2 diabetes (adjusted OR 3.43, 95%CI 1.004-11.691) and autoimmune thyroiditis (adjusted OR 5.05, 95%CI 1.62-15.7). LOP patients also had greater anxiety than EOP (mean HADS-A score LOP 8±5; EOP 5±5, p=0.006).CONCLUSIONS: Our findings provide further evidence for the difference between EOP and LOP. This article is protected by copyright. All rights reserved.

Although studies regarding prevalence of metabolic syndrome (MS) in Asian psoriatic patients are limited and show varying results, a previous report describes a significant increase in prevalence of MS in Thai psoriatic patients, as compared with rates in the general population. However, no significant association between MS and psoriasis severity using the Psoriasis Area and Severity Index (PASI) was found, which differs from the findings of Korean and Japanese studies. This study aimed at re-evaluating the association between MS and psoriasis severity in Thai patients using current assessment (PASI) and chronological assessment (historical course and interventions). A total of 273 psoriatic patients were recruited. After controlling for age and sex, 96 patients were assigned to the MS group and 96 patients to the non-MS group. Similar to the previous study, no significant differences were identified between metabolic and non-metabolic patients regarding PASI, age of onset, disease duration and family history of psoriasis. However, the numbers of hospitalizations (P = 0.018) and interventions (P = 0.028) were significantly higher in metabolic patients than in non-metabolic patients. Further, a greater number of metabolic components was significantly associated with a higher number of hospitalizations (P = 0.012), pustular or erythrodermic psoriasis episodes (P = 0.049), and interventions (P = 0.005). Body mass index of 23 kg/m2 or more, abdominal obesity and high blood pressure were associated with an increased risk of treatment failure. Using chronological assessment, our study supported that MS negatively affects psoriasis severity and treatment outcomes. Screening for MS is highly recommended for psoriatic patients.

There are limited data regarding omalizumab in the treatment of recalcitrant chronic spontaneous urticaria (CSU) in Asian populations. This study evaluated the effectiveness and the proper dosage of omalizumab for Asian CSU patients in a real-life setting.We retrospectively reviewed recalcitrant CSU patients seeking treatment at the Skin Allergy Clinic, Siriraj Hospital during the 3-year period. All patients were treated with omalizumab as an add-on therapy. Standard seven-day urticaria activity score (UAS7) and medication score were used to assess omalizumab response.Of 13 patients, 9 patients (70%) responded well to 150 mg omalizumab injection every month, whereas 4 patients requiring updosing to 300 mg. In the 150 mg group, one patient achieved complete symptom control without antihistamine intake. Most of them required antihistamines without prednisolone and ciclosporin. Onset of omalizumab was fast, usually within the first week. Though only two patients in the 300 mg group achieved complete absence of symptoms, ciclosporin and oral corticosteroids could be discontinued. No patients reported adverse effects.Omalizumab at an initial dosage of 150 mg was effective in the treatment of recalcitrant CSU among Asians. Updosing to 300 mg was required to achieve satisfactory outcomes.

This patient had a two-month history of four clinical manifestations of drug hypersensitivity reactions (DHR): maculo papular eruption, Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), acute generalized exanthematous pustulosis (AGEP) and toxic epidermal necrolysis (TEN). The eliciting drugs were rifampicin, possibly gabapentin, levofloxacin, meropenam and/or colistin. Thus, the patient might develop a multiple drug hypersensitivity syndrome. The TEN-like lesion appeared after stopping drugs for two days. A different manifestation of DHR in dependence of drug use suggests that the distinct manifestations of DHRs are due to the stimulation of T cells with distinct functions. The simultaneous appearance of AGEP and DRESS symptoms might be due to the simultaneous stimulation of two (or more) different T cell subsets, which are functionally dominant. Lastly, the appearance and further propagation of symptoms after therapy-stop is a common but somewhat neglected problem in DHR, which raises questions regarding the cause of persisting T cell activation.

Background This retrospective observational study aimed to investigate the long-term safety, drug survival, and factors associated with the survival of acitretin in a real-world setting. Methods Data of adult patients with psoriasis who attended Siriraj Hospital between 2012 and 2017 and were treated with acitretin were reviewed. Demographic data and clinical courses were recorded. The Kaplan-Meier curve and Cox regression were used to calculate drug survival and the factors associated with drug survival, respectively. Results Of 104 patients, 56 and 48 were male and female, respectively, with a mean treatment duration of 3.2 years. The mean cumulative dose per patient was 19.28 ± 7.84 mg/day. Acitretin was administered to 73, 39, 24, and six patients for more than 1, 3, 5, and 10 years, respectively. Most side effects were mild and tolerable; only nine patients withdrew acitretin due to side effects. No patients developed clinical features of cirrhosis or uncontrolled hyperlipidemia. The drug survival rates were 79%, 69.5%, 61.2%, 57.6%, and 53.5% at 1, 2, 3, 4, and 5 years, respectively, higher than those of previous studies. Patients without obesity, metabolic syndrome, and dyslipidemia did not have a significantly longer acitretin survival compared to patients with these comorbidities. Conclusions Long-term, low-dose acitretin in patients with psoriasis is unlikely to cause significant liver or lipid problems. In countries with difficulty accessing biological agents for psoriasis, acitretin may have a high drug survival rate due to its long-term safety. This study has several limitations: its retrospective nature, single-center study design, and small sample size.

The HLA-B∗15:02 allele has been reported to have a strong association with carbamazepine-induced Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) in Thai patients. The HLA-B alleles associated with carbamazepine-induced maculopapular exanthema (MPE) and the drug reaction with eosinophilia and systemic symptoms (DRESS) among the Thai population have never been reported. The aim of the present study was to carry out an analysis of the involvement of HLA-B alleles in carbamazepine-induced cutaneous adverse drug reactions (cADRs) in the Thai population. A case-control study was performed by genotyping the HLA-B alleles of Thai carbamazepine-induced hypersensitivity reaction patients (17 MPE, 16 SJS/TEN, and 5 DRESS) and 271 carbamazepine-tolerant controls. We also recruited 470 healthy Thai candidate subjects who had not taken carbamazepine. HLA-B∗15:02 showed a significant association with carbamazepine-induced MPE (P=0.0022, odds ratio (OR) (95% confidence interval [CI]) = 7.27 (2.04–25.97)) and carbamazepine-induced SJS/TEN (P=4.46×10−13; OR (95% CI) = 70.91(19.67–255.65)) when compared with carbamazepine-tolerant controls. Carbamazepine-induced SJS/TEN also showed an association with HLA-B∗15:21 allele (P=0.013; OR (95% CI) = 9.54 (1.61–56.57)) when compared with carbamazepine-tolerant controls. HLA-B∗58:01 allele was significantly related to carbamazepine-induced MPE (P=0.007; OR (95% CI) = 4.73 (1.53–14.66)) and DRESS (P=0.0315; OR (95% CI) = 7.55 (1.20–47.58)) when compared with carbamazepine-tolerant controls. These alleles may serve as markers to predict carbamazepine-induced cADRs in the Thai population.

Topical tacrolimus has demonstrated efficacy in vitiligo. This study compared the efficacy and safety of 0.1% tacrolimus ointment with 0.1% mometasone furoate cream in adult vitiligo. We enrolled patients with symmetrical, nonacral vitiligo, and the patients on each side were randomized to receive either 0.1% tacrolimus ointment or 0.1% mometasone furoate cream, applied twice daily for 6 months. Repigmentation outcome at 6 months was compared with baseline. Of 18 cases, 22% and 33% in tacrolimus and mometasone groups, respectively, displayed more than 50% repigmentation ( p > 0.05). Telangiectasia was presented in one-third of cases on the mometasone-treated side. Both treatments were effective in vitiligo; however, 0.1% tacrolimus ointment has fewer adverse effects.

Given the relative scarcity of data concerning the efficacy of methotrexate under daily life conditions in psoriasis, this study aimed to investigate the effectiveness of methotrexate in Asian psoriatic patients and to identify factors associated with clinical response. This observational retrospective cohort study included adult psoriatic patients who had been treated with or were going to start methotrexate. Psoriasis Area and Severity Index (PASI) scores at baseline and at 3, 6 and 12 months were recorded. At 3 months, patients achieving 50% or more reduction from baseline PASI score were defined as responders. One hundred, 74 and 61 patients were followed for 3, 6 and 12 months, respectively. Mean follow-up time was 15.3 ± 10.2 months. A reduction in PASI score of at least 75% was achieved in 26%, 32.5% and 45.2% at 3, 6 and 12 months, respectively. At 12 and 24 months, Kaplan-Meier analysis showed 68.7% and 52.1% probability of drug survival, respectively. Male sex, body mass index (BMI) of less than 25 kg/m2 and absence of abdominal obesity were factors associated with response to treatment in univariate analysis. Male sex was the only significant factor in multivariate analysis. The effectiveness of methotrexate in clinical practise seemed to be lower than in clinical trials, but effectiveness increased with longer duration of treatment. Problems associated with methotrexate use in clinical practise may be due to medication adherence rather than lack of medication effectiveness. Female sex, abdominal obesity and BMI of 25 kg/m2 or more might decrease response to methotrexate.

Omalizumab has been approved for the treatment of recalcitrant chronic spontaneous urticaria (CSU). However, it remains unanswered whether omalizumab modifies a CSU course. We aimed to study a course of CSU after omalizumab treatment in an Asian population. Medical records of recalcitrant CSU patients who attended Siriraj Hospital between 2013 and 2017 were reviewed. All patients receiving omalizumab treatment were followed after the first injection for at least 1 year. Of 15 patients receiving omalizumab treatment, 11 patients (73.3%) responded well to 150 mg while the rest required 300 mg. The median follow-up period was 18 months (range, 13.5-25.3). Three patterns of response were proposed and measured: excellent (disease remission over than 6 months) was found in 20%; good (injection interval extended longer than 6 months) was found in 27%; and modest (frequently required injections) was found in 53%. The mean duration of complete remission was 33 weeks (range, 26-38). Two-thirds of patients had disease relapse and required omalizumab injections to control symptoms. The other third did not show relapses for at least 69 weeks of the follow-up period. After 1 year of treatment, Kaplan-Meier curves estimated that a higher percentage (86.7%) of recalcitrant CSU patients receiving omalizumab treatment would be free of symptoms (weekly Urticaria Activity Score = 0) without prednisolone and/or cyclosporin as compared with 42% of patients not receiving omalizumab treatment. In conclusion, patients seem to be easily and safely manageable with omalizumab. Prednisolone and cyclosporin could be discontinued in all patients. Further studies are needed to conclude whether omalizumab can exactly modify CSU.

Elderly people tend to be sicker than young people. They also take more medications, increasing the risk of adverse drug reactions (ADRs), which are one of the leading causes of morbidity and mortality in this age group. Knowledge of cutaneous ADRs from medicine use in the elderly population is limited.The aim of this study was to investigate demographic data, causative drugs and cutaneous manifestations of ADRs in elderly patients.A retrospective analysis was conducted involving elderly patients aged60 years with cutaneous ADRs in the period from 2002 to 2012. We analyzed data with respect to demographic data, clinical data, outcomes, and risk factors for serious reactions.A total of 400 patient records were included. The mean age was 73.6 years, and 53 % were women. The common reactions were maculopapular rash (65 %) and angioedema with/without urticaria (11.3 %). Antibiotics (42.8 %) and non-steroidal anti-inflammatory drugs (9.5 %) were common causative drugs. Serious cutaneous ADRs were found in 16.5 %.Our results show that multiple underlying medical conditions, especially cerebrovascular diseases, are risk factors for serious cutaneous ADRs in elderly patients. These findings emphasize the need for awareness about cutaneous drug reactions in elderly patients.

It is believed that moisturizers can improve the efficacy of treatment for psoriasis. This study sought to analyze the active ingredients and properties of moisturizers that claimed to be suitable for psoriasis. Moisturizers for psoriasis were identified on electronic markets using the search terms “moisturizers” and “psoriasis.” Forty-seven moisturizers that claimed to be suitable for psoriasis were identified. Vitamin E was the most common ingredient used for emollient properties. Of the 47 moisturizers, 35 (74%) contained anti-inflammatory properties and 12 (26%) contained keratolytic properties. Coal tar, low-potency corticosteroids, and botanical extracts were added for anti-inflammatory properties while salicylic acid, lactic acid, and ≥ 10% urea cream were used for keratolytic effect. Although it seems that each active ingredient added into moisturizers for psoriasis can decrease the severity of psoriasis, there is a lack of well-done studies on the over-the-counter preparations. Therefore, the recommendations to use them are currently not evidence-based.

Purpose This study aimed to systemically review literature relating to factors that could potentially predict a favorable response to cyclosporine A (CsA) treatment for chronic spontaneous urticaria (CSU). Methods A systematic literature review was done according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations. Results A total of 13 studies (404 patients with CSU and 200 healthy patients) were included. There were only 1 randomized controlled trial (RCT) and 12 non-RCTs. Our systematic review showed that positive autologous serum skin test results, positive baseline basophil histamine release assays, positive baseline basophil activation test responses, elevated baseline plasma D-dimer levels, elevated baseline serum interleukin (IL)-2, IL-5, and tumor necrosis factor-alpha (TNF-α) levels, and low baseline serum IgE levels might assist in predicting favorable CsA responses in CSU patients. Decreased plasma D-dimer levels; and decreased serum IL-2, IL-5, and TNF-α levels were reported to be correlated with clinical improvement after CsA treatment. Conclusions Since most positive results were from non-RCT articles and some data were still inconsistent, this systematic review identified no reliable practical biomarker for predicting CsA treatment response in patients with CSU. There were no positive predictors with good consistency and mechanical plausibility.

Background The prevention and confirmation of drug-induced severe cutaneous adverse reactions (SCARs) are difficult. Objective To determine the benefit of HLA-B allele prescreening and the measurement of drug-specific IFN-γ-releasing cells in the prevention and identification of the culprit drug in patients with SCARs. Methods A total of 160 patients with SCARs were recruited from 6 university hospitals in Thailand over a 3-year period. HLA-B alleles were genotypically analyzed. The frequencies of drug-specific IFN-γ-releasing cells in patients with SCARs were also measured. Results The drugs commonly responsible for SCARs were anticonvulsants, allopurinol, beta-lactams, antituberculosis agents, and sulfonamides. If culprit drugs had been withheld in patients carrying known HLA-B alleles at risk, it would have prevented 21.2% of SCAR cases, mainly allopurinol- and carbamazepine-related SCARs. Culprit drug-specific IFN-γ-releasing cells could be identified in 45.7% (53 of 116) of patients with SCARs caused by 5 major drug groups, particularly in patients diagnosed with drug reactions with eosinophilia and systemic symptoms (DRESS) (50.0%), followed by Stevens-Johnson syndrome/toxic epidermal necrolysis (46.0%), and acute generalized exanthematous pustulosis (31.3%). According to our study, high frequencies of drug-specific IFN-γ-releasing cells were significantly demonstrated in patients who suffered from DRESS phenotype, having anticonvulsants or the drugs belonging to the “probable” category based on the Naranjo algorithm scale, as the culprit drugs. Conclusions HLA-B prescreening would succeed in preventing only a minority of SCAR victims. Drug-specific IFN-γ-releasing cells are detectable in almost half of patients. Better strategies are required for better SCAR prevention and culprit drug confirmation.

The Simplified Psoriasis Index (SPI) is a summary measure of psoriasis with separate components for current severity (SPI-s), psychosocial impact (SPI-p), and past history and interventions (SPI-i). It derives from the Salford Psoriasis Index but replaces Psoriasis Area and Severity Index (PASI) with a composite weighted severity score designed to reflect the impact of psoriasis affecting functionally or psychosocially important body sites. Two complementary versions are available, differing only in that current severity (SPI-s) is either professionally (proSPI-s) or patient self-assessed (saSPI-s). This study examined the criterion and construct validity and response distribution of proSPI-s, saSPI-s, and SPI-p in 100 patients with plaque psoriasis. A further 50 patients were assessed for test–retest reliability of these three components. Interrater reliability of proSPI-s was assessed in 12 patients, each assessed by 12 assessors (144 assessments). There was close correlation between PASI and proSPI-s (r=0.91); SPI-p was closely correlated with the Dermatology Life Quality Index (r=0.89). Strong intrarater (proSPI-s, saSPI-s, SPI-p, and SPI-i) and interrater (proSPI-s) reliability was demonstrated (all intraclass correlation coefficients >0.75). There were wide response distributions for all three components. We believe that both professional (proSPI) and self-assessed (saSPI) versions can readily be introduced into routine clinical practice.

BACKGROUND: Beside autoimmunity, coagulation pathway is also involved in the pathogenesis of chronic urticaria (CU). Previous studies showed that plasma D-dimer levels paralleled the severity of the disease. To date, there are no data concerning D-dimer level in Thai patients with CU. OBJECTIVE: This study aimed to find the relationship between plasma D-dimer levels and the disease severity of Thai CU patients. The secondary objective is to analyze plasma D-dimer level in each group of patients who performed autologous plasma skin testing (APST) and autologous serum skin testing (ASST). METHODS: We retrospectively reviewed case record forms of chronic idiopathic urticaria (CIU) patients aged at least 18 years in Skin Allergy Clinic, Siriraj Hospital Mahidol University, Bangkok, during June 2008 to June 2011. RESULTS: Of 120 patients, plasma D-dimer level was abnormal in 58 patients (48.3%). The study showed statistically significant positive correlation between disease severity and plasma D-dimer level (p < 0.05, r = 0.537). There was no statistically significant difference in plasma D-dimer level between APST positive and negative groups, and also between ASST positive and negative groups. In APST negative group, plasma D-dimer level was elevated in 29 patients (47.5%) and correlated with disease severity. CONCLUSION: This study showed elevated plasma D-dimer levels in nearly half of Thai patients with CIU. There was a positive correlation between plasma D-dimer levels and the severity of disease activity. Investigation for plasma D-dimer level may be an alternative way to evaluate disease severity in patients with CIU.

Biologic therapies, the anti-cytokines in particular, have proved to be a significant addition to the dermatologist’s armamentarium for the management of severe skin disease. This article summarizes the mechanism of action, dosage, approved indications, off-label uses and the future of biologic therapies in dermatology.

Objective: Cardiac involvement in drug rash with eosinophilia and systemic symptoms (DRESS) syndrome varies considerably between 4% and 21%. Here we present our case and review literatures for its diagnosis and management. An algorithm for diagnosis of cardiac involvement in DRESS syndrome is proposed in this article. Data sources: Data regarding DRESS-associated myocarditis and eosinophilic myocarditis were gather primarily from MEDLINE database. Results: DRESS syndrome is a hypersensitivity reaction which is due to massive T cell stimulation resulting in cytotoxicity and eosinophil activation and recruitment. It is characterized by fever, morbilliform rash, and various systemic symptoms, in particular hepatitis. Hypersensitivity myocarditis (acute eosinophilic myocarditis) which is typically related to a drug reaction can lead to acute necrotizing eosinophilic myocarditis, cardiac thrombosis and fibrotic stage. Cardiac symptoms range from no symptoms to cardiogenic shock. Diagnosis is based on history, clinical findings, cardiac biomarkers andcardiac imaging techniques. Endomyocardial biopsy is done in a minority of patients for definite diagnosis. If suspected, drug discontinuation and suppression of immune reactions are the first therapies. Corticosteroids are the cornerstone of systemic treatments and should be initiated at the time of diagnosis of DRESS syndrome. Additional therapy and ventricular assist devices could be considered in refractory cases. Conclusions: According to its high morbidity and mortality, patients with DRESS syndrome should be carefully monitored or screened for cardiac involvement. Multidisciplinary care is important for a successful treatment outcome.

Liver biopsy, the gold standard for monitoring methotrexate-induced liver fibrosis in psoriasis patients, has potential morbidity and mortality. Transient elastography (TE) has been widely used as an alternative non-invasive method. Currently, psoriasis-specific data of TE comparing to Roenigk histopathology is lacking. This retrospective study assessed the diagnostic performance of TE in the detection of methotrexate-induced liver injury and liver fibrosis in Asian psoriasis patients. Risk factors that associated with liver injury by TE and histopathology were also determined. Psoriasis patients who had received methotrexate and undergone both TE and liver biopsy (gold standard) examinations between 2005 and 2016 were enrolled. Ten of 41 patients developed methotrexate-induced liver injury (Roenigk grade ≥3a) and two of them had significant liver fibrosis (Metavir fibrosis stage ≥2). Area under the receiver operating characteristic curve (AUROC = 0.78) indicated that TE was capable of identifying patients with and without liver injury. Using a cut-off TE value of 7.1 kilopascal (kPa), this ultrasound-based elastography yielded 50% sensitivity and 83.9% specificity for detecting methotrexate-induced liver injury and had 50% sensitivity and 76.9% specificity for identifying significant liver fibrosis. A total cumulative dosage of methotrexate, age, gender, metabolic syndrome, and metabolic components were not significantly associated with TE values ≥7.1 kPa and Roenigk grade ≥3a. Thus, using clinical context, laboratory information, and a cut-off TE value of 7.1, TE is an attractable non-invasive tool for identify psoriasis patients who have a low probability of methotrexate-induced liver injury and significant liver fibrosis. Liver biopsy can be reserved for selected patients.

SummaryBackground Allopurinol is a frequent cause of severe cutaneous adverse reactions (SCARs), such as drug reaction with eosinophilia and systemic symptoms (DRESS), Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). The reactions can potentially be fatal. As drug rechallenge in patients with a history of drug-induced SCARs is contraindicated, in vitro testing may have a diagnostic role as a confirmation test. Objectives To study the diagnostic value of interferon (IFN)-γ enzyme-linked immunospot (ELISpot) assay as a confirmatory test in patients with a history of allopurinol-induced SCARs. Methods Peripheral blood mononuclear cells (PBMCs) from 24 patients with a history of allopurinol-induced SCAR (13 DRESS, 11 SJS/TEN) and 21 control subjects were incubated with allopurinol or oxypurinol in the presence or absence of antiprogrammed death ligand 1 antibody (anti-PD-L1). The numbers of IFN-γ-releasing cells after stimulation in each group were subsequently measured with ELISpot. Results The numbers of IFN-γ-releasing cells in allopurinol-allergic subjects were significantly higher than in control subjects when stimulating PBMCs with oxypurinol 100 μg mL−1, especially when adding anti-PD-L1 supplementation. According to the receiver operating characteristic curve results, the optimal discriminatory power of IFN-γ ELISpot in confirming diagnosis of allopurinol-induced SCARs can be obtained using 16 spot-forming cells per 106 PBMCs as a cut-off value upon oxypurinol/anti-PD-L1 stimulation (79·2% sensitivity and 95·2% specificity). Conclusions The measurement of oxypurinol/anti-PD-L1-inducing IFN-γ-releasing cells yields a high diagnostic value in distinguishing between allopurinol-allergic and control subjects. This technique is beneficial in confirming diagnosis of allopurinol-induced SCARs in patients whose reaction develops while taking multiple drugs.

Background: Chronic urticaria (CU) has negative impacts on patients’ daily lives. The Chronic Urticaria Quality of Life Questionnaire (CU-Q 2 oL) evaluates quality of life impairment attitudes among chronic urticarial patients. Although the CU-Q 2 oL has been validated in several languages, the minimal clinical important difference (MCID) of the CU-Q 2 oL has never been determined. Objective: This study aimed to investigate the validity, reliability, responsiveness to change, and MCID of the Thai CU-Q 2 oL. Methods: The Thai CU-Q 2 oL was translated with permission from the authors of the original Italian version. The Thai CU-Q 2 oL, the validated Thai Dermatology Life Quality Index (DLQI), and the Urticaria Activity Score were assessed for 166 patients to evaluate validity and internal consistency. The three questionnaires were then administered to 124 patients to determine the test-retest reliability, responsiveness, and MCID of the Thai CU-Q 2 oL. Results: The Thai CU-Q 2 oL contained only three domains, whereas the Italian version revealed six domains. Nevertheless, the total variance of the Thai CU-Q 2 oL (60.5%) was very close to that of the Italian version (60.0%). The validity of the Thai CU-Q 2 oL was shown by strong correlations between CU-Q 2 oL and DLQI scores. The Thai CU-Q 2 oL also had high internal consistency and test-retest reliability. Distribution-based, receiver operating characteristic analysis, and anchor-based approaches yielded MCID values of 3.9–8.0, 15, and 21.1, respectively. Conclusions: The Thai CU-Q 2 oL is a valid and reliable instrument. We propose that a difference in the Thai CU-Q 2 oL score of 15 (MCID) is the smallest change patients perceive as a meaningful improvement. DOI 10.12932/AP0674.34.2.2016

Background: Different clinical features of skin diseases have been addressed between aging patients and non-aging patients. However, data focusing on the clinical features of chronic urticaria (CU) in aging patients especially in the Asian population are still limited. Objective: This study aimed to investigate the clinical characteristics of CU in aging and non-aging patients in the Asian population. Methods: Case records of 1622 CU patients attending the Urticaria Clinic, Department of Dermatology, Siriraj Hospital, Mahidol University, Thailand between 2000 and 2013 were retrospectively reviewed. All CU patients older than 60 years were recruited. Twice the number of CU patients who were non-aging were enrolled using a systematic sampling method. Results: Of the 1622 CU patients, 67 (4.1%) were aging patients. From these, 134 non-aging patients with CU were recruited. The majority of patients for both groups were female, with 67.2% and 77.6% of the aging and non-aging groups, respectively. In both groups, the most common cause of CU was chronic spontaneous urticaria. In the aging group, positive autologous serum skin test, anti-thyroid antibodies and antinuclear antibodies were found more commonly than in the non-aging group, without a statistically significant difference. The mean duration of the disease tended to be shorter in the aging group. Conclusion: Our study showed that CU in aging patients was uncommon (4.1%). Aging patients with CU seemed to have shorter disease duration and higher percentages of autoantibodies than non-aging patients with CU without a statistically significant difference. Keywords: Asian population, chronic urticaria, aging, clinical characteristics, laboratory investigations DOI 10.12932/AP0708

Background “Tender cutaneous nodules of the legs” is a common manifestation in dermatology. Histopathological investigation is usually required for this condition, because clinical data are frequently insufficient to make a definite diagnosis. Objective To identify and analyze the causes of patients presenting with tender leg nodules and to reveal clinical clues that could help to differentiate causes. Materials and methods The medical records and histopathological slides of patients presenting with tender cutaneous nodules of the legs between January 2005 and December 2007 were retrospectively reviewed. Results Of the total of 154 patients, 122 (79.2%) were female. Definite diagnoses were categorized into four groups: inflammation (84.4%); infection (5.8%); tumor (6.5%); and nonspecific (3.2%). The most common cause in the inflammation group was erythema nodosum. The infections found were Acremonium spp., Penicillium sp., Mycobacterium abscessus, Mycobacterium fortuitum and Mycobacterium leprae. The tumors included leiomyoma, leukemia cutis, and lymphomas. Clinical data that correlated with and could be used as clues for the inflammation group were female sex (P = 0.03, OR 6.43) and lower leg involvement (P = 0.03, OR 7.14). Limitations The retrospective manner of this study is a limitation. Conclusion Various inflammatory conditions, infections, and tumors can present as tender cutaneous nodules of the legs. Female sex and lower leg involvement were clinical data that could be used as clues for the diagnoses in the inflammation group. However, histopathological investigation is still crucial to determine a definite diagnosis in patients presenting with tender cutaneous nodules of the legs.

Background Most study concerning the prevalence and dermatological manifestations of the extrinsic and the intrinsic form of atopic dermatitis (AD) were performed in children and adult AD related to the early-onset AD extending to adult life. Adult-onset AD is a subgroup of AD. Apart from the typical eczematous flexural distribution pattern of AD, this group may also have nontypical morphology and localization. Objective The purpose of this study was to compare the clinical and diagnostic features of Thai patients with extrinsic and intrinsic type of adult-onset AD. Methods We retrospectively studied case records of patients diagnosed as adult-onset AD at the skin allergy clinic, Department of Dermatology, Siriraj Hospital, Mahidol University, Bangkok, Thailand from June, 2006 to May, 2008. The diagnosis of AD was made according to the criteria of Hanifin and Rajka and the severity of AD in each patient were assessed using the eczema area and severity index and the Rajka and Langeland score. Results Fifty six patients were enrolled. Eighty-seven percent of patients were extrinsic AD (eAD). Females predominated in both groups. Patients with eAD more commonly had typical lichenified/exudative eczematous lesions, especially on the antecubital and popliteal areas, when compared with patients with intrinsic AD (iAD). Nummular and follicular lesions were more commonly seen in iAD group than the eAD group. The most common area of involvement in the iAD was non-flexural area, followed by flexural area and extensor area. The severity of both iAD and eAD did not show a significant difference. Conclusion The eAD type of adult-onset AD was more common than the iAD type. Patients with eAD frequently had flexural lichenification whereas the iAD group tended to have nonflexural area involvement. The severity of both iAD and eAD did not show a significant difference.

Background: Colloid bodies (CB) in direct immunofluorescence (DIF) studies are usually found in interface dermatitis. Furthermore, CB can be found in various skin diseases and even in normal skin. Aim: To evaluate the diagnostic value of CB deposits in DIF studies. Methods: From 1996-2007, data from 502 patients where DIF studies showed immunoreactants at CB were enrolled. The definite diagnoses of these patients were based on clinical, histopathological and immunofluorescent findings. The results of DIF studies were analyzed. Results: Immunoreactants at CB were detected in 44.4%, 43.8%, 4.2%, 3.8%, and 2.2% of interface dermatitis, vasculitis, autoimmune vesiculobullous disease, panniculitis, and scleroderma/morphea, respectively. The most common immunoreactant deposit of all diseases was Immunoglobulin M (IgM). Brighter intensity and higher quantity of CB was detected frequently in the group with interface dermatitis. Conclusions: Immunoreactant deposits at CB alone can be found in various diseases but a strong intensity and high quantity favor the diagnosis of interface dermatitis. CB plus dermoepidermal junction (DEJ) deposits are more common in interface dermatitis than any other disease. Between lichen planus (LP) and discoid lupus erythematosus (DLE), CB alone is more common in LP; whereas, CB plus DEJ and superficial blood vessel (SBV) is more common in DLE. The most common pattern in both diseases is CB plus DEJ. The quantity and intensity of CB in LP is higher than in DLE.