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An innovative foam formulation for the fixed-dose combination of calcipotriol and betamethasone dipropionate (Cal/BD) has recently become available for the treatment of psoriasis vulgaris. Observational studies of patients treated with Cal/BD foam in routine practice have been conducted in several Western countries, but there are limited data on outcomes in Asian patients. We performed a prospective, open-label, noncomparative, noninterventional study to investigate treatment outcomes and satisfaction in adult patients receiving Cal/BD foam for psoriasis vulgaris in dermatological centers and outpatient clinics in Korea. Data were collected at the time of enrollment (Visit 1) and at a routine clinic visit ~4 weeks later (Visit 2). In total, 218 patients were enrolled, of whom 175 were included in the safety analysis set (58.9% male; mean age ± standard deviation 46.7 ± 15.1 years; use of Cal/BD foam at least once daily 74.3%). Of the safety analysis set, 166 patients had at least mild psoriasis (Investigator Global Assessment [IGA] ≥ 2) and were analyzed for treatment outcomes and satisfaction. Of the 166 patients, 71.7% had mild psoriasis (IGA 2) at baseline. The majority (57.8%) achieved an IGA of 0/1 (clear/almost clear) at Visit 2. The Psoriasis Area Severity Index (PASI) and Dermatology Life Quality Index (DLQI) showed significant improvements from Visit 1 to Visit 2 (PASI -2.4 ± 3.0, DLQI -4.5 ± 5.2, both P 0.0001). Most of the patients were satisfied with the Cal/BD foam treatment; 77.0%, 60.0%, and 73.9% were satisfied in terms of effectiveness, ease of use, and global satisfaction, respectively. In the safety analysis set, adverse events were reported in 13 patients (7.4%). In conclusion, this first Korean real-world study of Cal/BD foam shows improvement of lesions and health-related quality of life after 4 weeks of treatment, with high global satisfaction and good overall tolerability and safety.

Background Topical calcineurin inhibitors have been used to treat vitiligo, either alone or in combination with phototherapy; however, the long-term safety of these agents remains controversial. Objective To investigate the risk of lymphoma and skin cancer in vitiligo patients who received topical calcineurin inhibitors or phototherapy. Methods A multicenter retrospective cohort study of 25,694 vitiligo patients who received topical calcineurin inhibitors or phototherapy for 6 weeks or more between 2001 and 2019 was performed. Cumulative doses of topical calcineurin inhibitors and total phototherapy sessions were determined. Outcomes were the development of lymphoma or skin cancer after enrollment, confirmed through chart review and pathology reports. Results During 95,203 person-years, 13 cases of lymphoma, 22 of actinic keratosis, 15 of nonmelanoma skin cancer, and 5 of melanoma were observed. The risk of lymphoma and skin cancer was not significantly increased by topical calcineurin inhibitor dose or phototherapy sessions. The interaction between the topical calcineurin inhibitors and phototherapy was not associated with an increased risk of skin cancer. Limitations Retrospective study, individual follow-up duration less than 4 years, and no adjustment for comorbidities and medication history. Not generalizable to other races. Conclusion The long-term risk of skin cancer or lymphoma was not associated with the use of topical calcineurin inhibitors, phototherapy, and both treatments in combination in patients with vitiligo.

Background/purpose Vitiligo remains a major challenge in dermatology. However, much of the treatment remains unclear, because little evidence is available. We sought to answer some critical questions pertaining to management of vitiligo patients. Methods A modified Delphi process among 31 vitiligo experts was conducted. A total of 12 clinical vitiligo treatment questions without clear answers were collected via a vote. To address each question, two members performed systematic literature reviews and prepared draft statements along with the levels of evidence and strength of recommendation. After reviewing the draft, all expressed their extent of agreement from 1 (strong disagreement) to 9 (strong agreement) for each item. The drafts were revised to reflect suggested comments. Discussion continued until all members agreed with the ultimate decision. Results The consensus process was completed after five rounds. We identified the best answers to 12 key questions, including issues on long-term phototherapy, systemic and topical corticosteroids, topical calcineurin inhibitors, immunosuppressants, excimer laser treatment, and surgical interventions. Conclusion This consensus would complement current guidelines and aid both physician and patient decision-making in the treatment of vitiligo.

The involvement of genital lesions in patients with atopic dermatitis (AD) is poorly understood. Moreover, clinical characteristics, potentially related factors, and impact on the quality of life (QOL) of genital eczema in patients with AD are also largely unknown. This study aims to evaluate the prevalence and burden of genital eczema in patients with AD. A prospective cross-sectional study recruited a total of 220 patients diagnosed with AD. The participants were asked to complete the self-administrated questionnaire asking sociodemographic characteristics, details about their AD, and individual experiences of their genital eczema. Among 220 responders, 99 patients (45.00%) reported that they had experienced genital eczema at some time during the course of AD. Longer disease duration (odds ratio [OR], 2.29; 95% confidence interval [CI], 1.13-4.62; p = 0.02), marital status (OR, 0.43; 95% CI, 0.21-0.89; p = 0.003), involvement of the trunk (OR, 3.44; 95% CI, 1.81-6.52; p = 0.001), and involvement of the nipple (OR, 6.20; 95% CI, 1.39-27.63; p = 0.017) were the significant associated factors for the presence of genital eczema among patients with AD. Of note, the severe impairment of genital eczema-specific QOL was observed in 28.29% of AD patients with genital eczema. Especially, female sex (OR, 2.22; 95% CI, 0.84-5.82; p = 0.04) was more associated with severe impairment of genital eczema-specific QOL. Many patients with AD suffer from the genital presentation of the disease. Moreover, genital involvement of the disease has a significant impact on the QOL of patients with AD. We suggest that more attention should be paid to the genital presentation of the disease to increase QOL and provide further delicate treatment of patients with AD.

Psoriasis and psoriatic arthritis (PsA) have been recently considered as chronic systemic inflammatory disorders. Over the past decades, enormous evidence indicates that patients with psoriasis and PsA have a higher risk of developing various comorbidities including cardiovascular disease, metabolic disease, cancers, infections, autoimmune disease, and psychiatric diseases. However, reported risks of some comorbidities in those with psoriasis and PsA are somewhat different according to the research design. Moreover, pathomechanisms underlying comorbidities of those with psoriasis and PsA remain poorly elucidated. The purpose of this review is to provide the most updated comprehensive view of the risk of systemic comorbidities in those with psoriasis and PsA. Molecular mechanisms associated with the development of various comorbidities in those with psoriasis and PsA are also reviewed based on recent laboratory and clinical investigations. Identifying the risk of systemic comorbidities and its associated pathomechanisms in those with psoriasis and PsA could provide a sufficient basis to use a multi-disciplinary approach for treating patients with psoriasis and PsA.

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IMPORTANCE: Narrowband UV-B (NBUVB) phototherapy has been the mainstay in the treatment of vitiligo, but its long-term safety in terms of photocarcinogenesis has not been established. OBJECTIVES: To investigate the risks of skin cancer and precancerous lesions among patients with vitiligo undergoing NBUVB phototherapy, based on the number of NBUVB phototherapy sessions. DESIGN, SETTING, AND PARTICIPANTS: This nationwide population-based retrospective cohort study enrolled 60 321 patients with vitiligo 20 years or older between January 1, 2007, and December 31, 2017. Patients and outcomes were identified through nationwide cohort data from the Korean national health insurance claims database, and frequency matching by age and sex was performed. EXPOSURES: The number of phototherapy sessions each patient received between 2008 and 2017. Patients were classified into 5 groups according to the number of phototherapy sessions (0 sessions, 20 105 patients; 1-49 sessions, 20 106 patients; 50-99 sessions, 9702 patients; 100-199 sessions, 6226 patients; and ≥200 sessions, 4182 patients). We also identifed patients who underwent at least 500 phototherapy sessions (717 patients). MAIN OUTCOMES AND MEASURES: Primary outcomes were the development of actinic keratosis, Bowen disease, nonmelanoma skin cancer, or melanoma after enrollment. RESULTS: Among the 60 321 patients with vitiligo in this study (33 617 women; mean [SD] age, 50.2 [14.9] years), the risks of Bowen disease (

Anti-tumor necrosis factor-α (anti-TNF) therapy is used to treat a wide range of chronic inflammatory conditions. However, there has been an increasing number of reports of development of vitiligo and alopecia areata secondary to anti-TNF therapy. In this study, we investigated the risks of vitiligo and alopecia areata in patients with ankylosing spondylitis, Crohn's disease, or ulcerative colitis, who were treated with or without anti-TNF therapy using data from the Korean National Health Insurance Claims database from 2007 to 2016. The study comprised 11,442 patients treated with anti-TNF agents (anti-TNF group), and an equal number of age-, sex-, and disease- matched patients treated without anti-TNF agents (unexposed group). Multivariable Cox proportional hazards models were used to compare the risks of vitiligo and alopecia areata between the two groups. A significantly increased risk of vitiligo (hazard ratio = 1.99, 95% confidence interval = 1.06-3.75) was observed in the anti-TNF group compared to the unexposed group (5.9/10,000 person-years vs. 2.5/10,000 person-years). In subgroup analyses, younger patients and those treated with etanercept showed higher risks of vitiligo. The risk of alopecia areata was not significantly different between the two groups. Our results provide insight on the role of cytokine imbalance in the pathogenesis of vitiligo.

The phenotypic heterogeneity of psoriasis is suspected to reflect differences in its pathogenesis, but not yet completely elucidated. Studies of the Th1 and Th17 cytokines associated with different phenotypes of psoriasis have yielded inconsistent results.To investigate the tissue expression levels of Th1 and Th17 cytokines among patients with chronic plaque psoriasis, acute guttate psoriasis, and healthy control.A total of 20 patients with psoriasis (10 with chronic plaque type and 10 with acute guttate type) and 5 healthy controls were enrolled. The tissue mRNA and protein levels of following cytokines were measured: interleukin (IL)-12, IL-2, interferon (IFN)-γ, IL-23, IL-17A, and IL-22.The tissue mRNA levels of IL-12, IFN-γ, IL-23, IL-17A, IL-22 and the protein levels of IL-12, IL-2, IFN-γ, IL-17A, IL-22 were significantly increased in the psoriasis patients compared with the healthy controls. In comparisons of the subtypes, the tissue mRNA level of IFN-γ was increased in acute guttate psoriasis, whereas the protein levels of IL-12 and IL-17A were significantly increased in chronic plaque psoriasis. The cytokine ratios of IL-17A/IL-2 and IL-22/IL-2 were significantly higher in chronic plaque psoriasis than in acute guttate psoriasis.We confirmed that the tissue levels of Th1 and Th17 cytokines were increased in psoriasis patients compared with healthy controls. The increased IFN-γ mRNA level in acute guttate psoriasis and increased IL-12 and IL-17A protein levels in chronic plaque psoriasis suggest that an imbalance between Th1 and Th17 cytokines may play a role in the phenotypic transition of psoriasis.

SUMMARYNoroviruses (NoVs) are major causal agents of acute gastroenteritis in humans. NoV GII.4 is the predominant genotype globally. However, uncommon and minor types of NoVs are consistently detected and some have been shown to dominate over GII.4. Therefore, the prevalence of dominant and uncommon NoVs makes the identification of these viruses important for the prediction and prevention of pandemics. In this study, the full-genome sequence of a NoV (strain JW) detected in Korea was extensively characterized. The full-length genome was 7510 nucleotides long, and phylogenetic analysis based on the whole-genome sequences, including open reading frame (ORF)1, ORF2, and ORF3, indicated that it belonged to the GII.21 genotype. Strain JW showed maximum identity with strain YO284; however, comparison of the amino acid sequence of ORF2, which functions as an antigen, showed substitutions in several amino acids. GII.21 is not a prevalent epidemiological agent of acute gastroenteritis in humans, but it is consistently found in gastroenteritis patients from several countries. The present study provides the first full-genome sequence analysis of NoV GII.21 isolated from a patient in Korea. Our findings provide not only valuable genome information but also data for epidemiology studies, epidemic prevention, and vaccine development strategies.

BACKGROUND Psoriasis is an immune-mediated, chronic inflammatory disease affecting multiple aspects of patients' lives. Its epidemiology varies regionally; however, nationwide epidemiologic data on psoriasis depicting profile of Korean patients has not been available to date. OBJECTIVE To understand nationwide epidemiologic characteristics and clinical features of adult patients with psoriasis visited university hospitals in Korea. METHODS This multicenter, non-interventional, cross-sectional study recruited 1,278 adult patients with psoriasis across 25 centers in Korea in 2013. Various clinical data including PASI, BSA, DLQI, SF-36 and PASE were collected. RESULTS A total of 1,260 patients completed the study (male:female=1.47:1). The mean age was 47.0 years with a distribution mostly in the 50s (24.9%). Early onset (

Background Recently, monoclonal-antibody–conjugated immunomagnetic separation (IMS) procedure combined with quantitative reverse transcription-polymerase chain reaction (qRT-PCR) has been used for quantifying non-cultivated human noroviruses (HuNoVs). Methods We examined the efficacy of 27 commercially available disinfectants and a prototype against GII.4 strain HuNoV through the IMS/qRT-PCR assay. Results The average log reduction in viral titer in vitro varied among the disinfectants. The prototype was the most effective with an average log reduction of 6.86 log. Conclusions The IMS/RT-qPCR assay is an effective method to evaluate the activities of disinfectants against GII.4 HuNoV in vitro. Further work is needed to enhance the virucidal activity of the prototype disinfectant against more resistant HuNoV strains.

Background There is a lack of response data for topical treatments for psoriasis vulgaris in Asian patients. Objectives To determine the optimal maintenance regimen for topical treatment with calcipotriol monohydrate/betamethasone dipropionate gel in Korean patients with psoriasis vulgaris, by comparing the efficacy of three 8-week maintenance regimens. Methods This was a multicentre, prospective, randomized, controlled, parallel-group, open-label, phase 4 clinical trial, conducted in South Korea. Patients with psoriasis vulgaris on the limbs/trunk received once-daily treatment with calcipotriol monohydrate (50 μg/g)/betamethasone dipropionate (500 μg/g) gel for 8 weeks (induction phase). Responders (defined as an Investigator's Global Assessment of Disease Severity (IGA) grade of ‘clear’ or ‘almost clear’) were then randomized to receive 8 weeks’ maintenance treatment with Xamiol® gel once daily as needed [pro re nata (PRN Group)], once daily every day (Continuous group), or twice weekly – on Saturday and Sunday (Weekend group). The primary endpoint was the percentage of IGA responders at week 16. Results At the end of the induction phase, 62.18% of patients were IGA responders. At the end of the maintenance phase (week 16), the responder rate was 63.89% for the PRN group, 67.5% for the Continuous group and 31.43% for the Weekend group. The PRN and Continuous groups were statistically superior to the Weekend group (P = 0.0109 and P = 0.0015), but the PRN and Continuous groups did not differ statistically. The incidence of adverse events did not differ significantly between the groups. Conclusion Among Korean patients with psoriasis vulgaris, maintenance treatment with calcipotriol monohydrate/betamethasone dipropionate using a continuous daily regimen or an ‘as needed’ daily regimen provided similar efficacy, whereas a twice-weekly regimen was significantly less efficacious than either of these regimens.

In Asian countries, acupuncture with gold threads has been widely used in the treatment of pain. However, several reports have suggested that the implanted gold threads can become fragmented and migrate to other parts of the body, damaging surrounding tissues. A 75-year-old female presented with diffuse erythematous edema with multiple vesicles on the right lower leg for 3 days. She had previously suffered from cellulitis on the same region twice for the last 1 year. Her past medical history included acupuncture with gold threads on the back due to lumbar herniated nucleus pulposus (HNP) about 10 years ago. Histopathological examination demonstrated marked subepithelial edema and diffuse perivascular infiltrate of inflammatory cells in the dermis. Simple radiography of the leg revealed numerous radiodense threads in the soft tissue. Since the patient did not receive acupuncture on any other sites except on the back, we hypothesized that the gold threads injected on the back may have migrated through the vessels to the leg. These metal fragments can cause inflammatory reaction and make the tissues more susceptible to secondary infections. The lesion gradually improved after treatment with systemic steroid and antibiotics for 1 week.

Background Psychological aspect and quality of life should be considered in treating patients with psoriasis. Objective We sought to ascertain which clinical characteristics including presence of exposed lesions are associated with impairment of health-related quality of life (HRQoL) in patients with psoriasis. Methods The EPI-PSODE study was a nationwide, multicenter, cross-sectional study conducted in Korea that included 1260 adult patients with psoriasis. In addition to clinical characteristics including presence of exposed lesions, data were collected using the Psoriatic Arthritis (PsA) Screening and Evaluation (PASE), Dermatology Life Quality Index (DLQI), MOS 36-Item Short-Form Health Survey (SF-36), Work Productivity and Activity Impairment Questionnaire Psoriasis (WPAI: PSO) and Medication Satisfaction Questionnaire (MSQ). Results Patients with a DLQI score > 5 (n = 990) were younger, had an earlier onset of psoriasis, scored higher on the Psoriasis Area and Severity Index (PASI), had higher body surface area (BSA) and had higher PASE scores than patients with DLQI ≤ 5 (n = 266). The group of patients with exposed lesions (n = 871) were younger and male predominance, earlier onset of psoriasis, longer disease duration, higher PASI/BSA score and a higher proportion with drinking and smoking history each than the group of patients without exposed lesions (n = 389). Presence of exposed lesions negatively influenced DLQI, 36-Item Short-Form Health Survey (SF-36) (mental component), presenteeism, total work productivity impairment and total activity impairment in the WPAI: PSO. In multiple regression model, PASI score was the only variable which was significantly associated with all HRQoL measures. Presence of exposed lesions was a significant factor affecting DLQI and SF-36 (mental). Conclusion The presence of exposed lesions has a negative impact on quality of life, mental health and work productivity. Therefore, effective treatments are particularly needed for psoriasis patients with exposed lesions.

SummaryBackground Little is known about factors affecting the quality of life (QoL) of patients with vitiligo, and previous studies have shown conflicting results. Objectives To explore the QoL of patients with vitiligo and to identify factors affecting QoL. Methods A nationwide questionnaire-based study was conducted with 1123 patients with vitiligo recruited from 21 hospitals in Korea from July 2015 to June 2016. Data were collected using a structured questionnaire for demographic information and the Skindex-29 instrument. Mild or severely impaired QoL in patients with vitiligo was assessed according to each domain (symptoms, functioning and emotions) of Skindex-29. Multivariate logistic regression analyses were performed to determine the factors associated with QoL. Results Of the enrolled participants, 609 were male and 514 female, with a mean age of 49·8 years (range 20–84). The median duration of disease was 3·0 years (range 0–60). Using multivariate logistic regression modelling, the involvement of visible body parts and a larger affected body surface area were consistently associated with QoL impairment in all three domains of Skindex-29. Additionally, the QoL of patients aged 20–59 years, who potentially had a more active social life than older patients, was associated with functional impairment. Furthermore, a higher educational background was associated with emotional impairment. Conclusions A multitude of factors significantly influence the QoL of patients with vitiligo. A better appreciation of these factors would help the management of these patients.

The incidence of overall cancer has increased over time. The incidence of top-ranking cancers has changed in the 1990s and the 2000s. However, few studies have evaluated the trends in metastatic skin cancers during this period. We evaluated the recent trends in incidence, peak age and location of metastatic skin cancers from 1991 to 2010. This 20-yr survey was divided into two decades to determine the trends by comparing the statistics. Out of 694,466 outpatients (1991-2010), 174 (0.025%) were diagnosed with metastatic skin cancer. The incidence of metastatic skin cancer increased significantly from 20.64 per 100,000 outpatients in the 1990s to 28.70 per 100,000 outpatients in the 2000s (P = 0.030). The peak age of skin metastasis shifted from the 40s to the 50s in women, and from the 50s to the 60s in men. The percentage of metastatic skin cancers originating from intra-abdominal organs increased from 10% in the 1990s to 23.1% in the 2000s (P = 0.027). The percentage of metastatic skin cancers located on the abdomen increased from 7.1% in the 1990s to 15.4% in the 2000s (P = 0.011). The higher proportion of metastatic skin cancers located on the abdomen may be related to the increase in skin metastases from intra-abdominal organs.

Summary Background. Primary cutaneous lymphoma (PCL) is an extranodal non-Hodgkin lymphoma with primary involvement of the skin. Epidemiological data on PCLs according to the World Health Organization/European Organization for Research and Treatment of Cancer classification (WHO-EORTC) has not been investigated in Korea to date. Aim. To evaluate the demographic characteristics, clinical and histological features, and survival data of patients with PCL according to the WHO-EORTC classification. Methods. In total, 93 patients with PCL were retrospectively identified from an extensive review of medical records over a 16-year period. Results. The tumours found included primary cutaneous CD30+ lymphoproliferative disorders, extranodal natural killer/T-cell lymphoma and primary cutaneous diffuse large B-cell lymphoma. We found that 81.6% of the patients had primary cutaneous T-cell and natural killer-cell lymphoma, and 16.2% had primary cutaneous B-cell lymphoma, with 2.2% having precursor haematological neoplasms. The median age was 52 years (range 3–95) and the male : female ratio was 1 : 1.16. The 5-year survival rate was 92.5%. Conclusions. The incidence rates of many PCL subtypes in Koreans differ from those of other countries.

Background: Although phenotypic heterogeneity of psor-iasis is suggested by the alternate activation of either T-helper (Th)1-related or Th17-related cytokines, little is known about the mRNA levels of inflammatory cytokines. Objective: To investigate whether there is differential expression of Th1-related and Th17-related inflammatory cytokine genes 1) between psoriatic patients and healthy controls, and 2) be-tween patients with different psoriasis phenotypes. Methods: Twenty-five patients with psoriasis (10 with guttate psoriasis and 15 with plaque psoriasis) and 5 healthy volunteers were enrolled in this study. The mRNA levels of circulating cyto-kines (interleukin [IL]-2, IL-12p40, interferon-γ, IL-17A, IL-22, and IL-23R) were measured by real-time reverse tran-scription polymerase chain reaction. Results: The compar-ison between psoriatic and healthy control samples revealed that IL-12p40, IL-17A, and IL-22 mRNA levels were sig-nificantly higher (approximately 4∼6 folds) in the patients with psoriasis. The mRNA levels of these six cytokines in the blood did not differ between the guttate and plaque psoriasis groups. Conclusion: We found that the mRNA levels of blood inflammatory cytokines (IL-12p40, IL-17A, and IL-22) were significantly elevated in patients with psoriasis com-pared to the levels in healthy controls, but they did not sig-nificantly differ between patients with guttate and plaque type psoriasis. (Ann Dermatol 29(4) 422∼426, 2017)

Background. The clinical and histopathologic classification of anetoderma are not well characterized.Objective. We aimed to investigate the clinical and histopathologic characteristics of anetoderma and to correlate clinical phenotypes with immunohistopathologic findings.Methods. We retrospectively reviewed the medical records of 30 patients with anetoderma and performed immunohistochemistry for elastin, fibrillin-1, metalloproteinase- (MMP-) 2, MMP-7, MMP-9, and MMP-12, and tissue inhibitor of metalloproteinase- (TIMP-) 1 and TIMP-2.Results. Protruding type (n= 17) had a longer disease duration and more severe loss of elastin, without changes in fibrillin, than indented type (n= 13). MMP-2 and MMP-9 showed significantly higher expressions in the dermis compared with controls (p< 0.05). MMP-7 and MMP-12 showed little expressions in both anetoderma and control tissue. TIMP-1 was highly expressed in anetoderma lesions and controls. TIMP-2 expression was variable.Conclusions. Our findings suggest that protruding type anetoderma may represent a more advanced stage and that MMP-2 and MMP-9 could be responsible for elastic fiber degradation in anetoderma.

Background Eruptive pseudoangiomatosis (EP) is a rare, benign, spontaneously regressing exanthema of unknown etiology, characterized by an eruption of distinctive erythematous papules. This study was performed to evaluate the etiologic, clinical, and histopathologic characteristics of EP in Koreans. Methods Patients diagnosed with EP during 2005–2010 were included in a retrospective study. Diagnoses were based on clinical findings and confirmed by histology. Biopsies were re-examined. Patient gender, age at onset, disease duration, lesion location, season of occurrence, concomitant diseases, occupation, previous related events, disease course, responses to treatment, and laboratory findings were analyzed. Results A total of 32 patients were identified. Mean age at onset was 50.06 ± 17.12 years. Two patients developed lesions after outdoor activities. Two patients presented with simultaneous occurrences in family members. One patient reported having taken herbal medicine. One subject experienced systemic contact dermatitis caused by eating a lacquer chicken dish just before the lesions developed. All patients had typical erythematous papules measuring 2–5 mm. Lesions were usually located on exposed sites. No prodromal or systemic symptoms were observed. Routine laboratory tests were within normal ranges, except in one patient with known hyperlipidemia. Most patients were treated with oral antihistamine and topical steroid, or oral prednisolone. Eight patients did not receive any treatment. Mean disease duration was 1.64 ± 1.41 months in the treatment group and 1.20 ± 1.24 months in the no-treatment group (P > 0.05). Conclusions Any clear relationship between EP and exposure to allergens or insect bites has yet to be elucidated. In patients in whom EP occurs on non-exposed sites, drugs and food should be considered as possible causative agents. Intravascular neutrophil infiltration on histology can be helpful in diagnosing EP.

Background: Psoriasis and psoriatic arthritis (PsA) are included in the group of immune-mediated inflammatory diseases (IMIDs) caused by systemic inflammation; however, indicators for monitoring inflammatory activity in patients with psoriasis, such as the Psoriasis Area and Severity Index (PASI), are limited. Objective: To determine whether the Psoriatic Arthritis Screening and Evaluation (PASE) questionnaire can be used to monitor disease activity in patients with psoriasis. Methods: This was a multicenter, noninterventional, cross-sectional study. Demographic factors and PASI and PASE scores were collected to investigate associations between each. Results: PASE data were available for 1,255 patients, of whom 498 (39.7%) had a score of ≥37. Compared with the group with PASE score ＜37, the group with score ≥37 had a higher proportion of women (34.9% vs. 48.8%, p＜0.0001), older mean age at diagnosis (36.4 vs. 41.7 years, p＜0.0001), more severe disease activity using PASI and body surface area measures (p=0.0021 and p=0.0008, respectively), and higher mean body mass index (23.7 vs. 24.1, p=0.0411). In a multiple linear regression model, PASE score was positively associated with cutaneous disease activity (p＜0.0001). Conclusion: After risk-adjustment, PASE was positively associated with PASI, which suggests that PASE can be sensitive to disease activity. Since psoriasis is regarded as one of the IMIDs, PASE may be utilized as a tool not only to screen PsA but also to monitor disease activity. (Ann Dermatol 31(1) 29∼36, 2019)

Summary Background Various types of external stress cause the skin and central neuroendocrine system to express corticotropin-releasing hormone (CRH)–proopiomelanocortin (POMC) axis-related hormones. However, the precise role of the CRH–POMC axis-related hormones in various skin tumours is unclear. Objectives This study examined expression patterns of the CRH–POMC axis-related hormones in skin tumours. Methods The production of CRH, adrenocorticotropic hormone (ACTH) and α-melanocyte-stimulating hormone (α-MSH) in various tumour cell lines including HaCaT and primary keratinocytes was examined using an enzyme-linked immunosorbent assay. Immunohistochemical analysis of the skin tumours was also performed. Results CRH, ACTH and α-MSH were strongly expressed in malignant skin tumour cell lines such as G-361 and DX-3 (both malignant melanoma, MM). However, normal and haematological malignancy cell lines did not express the CRH–POMC axis-related hormones. Immunohistochemical analysis of the skin tumours showed that MM (80%), squamous cell carcinoma (SCC, 70%) and basal cell carcinoma (BCC, 10%) had strong immunoreactivity (++/+++) for CRH. Strong ACTH and α-MSH expression was observed in MM (70% and 50%, respectively), SCC (80% and 60%, respectively) and BCC (70% and 50%, respectively). Conclusions We report that an increase in the level of the CRH–POMC axis-related hormones is associated with malignant skin tumours such as MM. These results highlight the importance of the CRH–POMC axis-related hormones in the malignant tendency of skin tumours.

This study was designed to estimate the prevalence and personal or family history of atopic dermatitis in school children in 3 areas of Korea: urban (Seoul), industrial (Ulsan) and rural (Chunchon). On the basis of dermatologists' physical examinations and the questionnaires completed by parents or guardians, the prevalence of atopic dermatitis was estimated to be 3.3% in the industrial area, 6.6% in the rural area and 7.8% in the urban area. The frequency of atopic dermatitis decreased with age and was significantly lower in the industrial area than in the rural and urban areas.

A 17-year-old woman presented with asymptomatic, multiple plaques around the right mandibular area of the face extending from the cheek to the neck. These lesions had gradually increased in size and number for 8 years, and then were stationary. When she came to us, there were a few skin-colored or pale yellowish papules and plaques ranging from 0.2 to 1 cm in diameter (Fig. 1). The patient stated that initially the papules developed discretely, and then these papules were confluent and grouped slowly with new lesions. The most recent lesions were skin-colored papules which were soft to the touch, the older lesions were yellowish plaques with firm consistency and a smooth shiny surface. The patient's general condition had been good at the initial visit and the laboratory findings including blood cell counts, urinalysis, and routine blood chemistry tests were all within normal limits. A roentgenogram of the mandibular area did not reveal any significant findings. The presumptive clinical diagnosis of connective tissue nevus was made. Histologic examination of biopsy specimen taken from the neck showed lobules of fat cells embedded among the collagen bundles at the level of papillary dermis and collagen bundles were proliferated irregularly (Fig. 2). The individual fat cells were mature and of normal size. The lobules were not encapsulated and did not communicate with the subcutaneous fat tissue. The epidermal changes of the lesions consisted of mild hyperkeratosis with follicular plugging and slightly increased numbers of capillaries were observed around the dermal fat cells (Fig. 3). Therefore, it was diagnosed as nevus lipomatosus superficialis (NLS) which developed multiple lesions very rarely on the face. After surgical removal of the lesion, no evidence of recurrence has been observed 1 year postoperatively.

Norovirus is one of the major causes of non-bacterial gastroenteritis in humans. The aim of this study was to analyze the amino acid variation of open reading frame 2 of GII.4 variants in South Korea during the period from November 2006 to December 2012. Sixty-nine complete nucleotide sequences of open reading frame 2 were obtained from 113 GII.4 strains. The GII.4 2006b variants were detected predominantly between 2006 and 2009; however, new GII.4 variants, which were termed the 2010 variant and the 2012 variant, emerged in 2010 and 2012, respectively. The number of GII.4 2006b variants steadily decreased until 2012, whereas the number of gastroenteritis cases caused by the new variants increased between 2010 and 2012. The amino acid sequence in the ORF2 region obtained in this study was compared with other GII.4 variants isolated in various countries. Amino acid variations were observed primarily at epitope sites and the surrounding regions. Amino acids 294, 359, 393, and 413 of the P2 subdomain were the most variable sites among the GII.4 variants. The information in this study can be useful in basic research to predict the emergence and determine the genetic functions of new GII.4 variants.

Dear Editor: Rower et al.1 defined progressive cribriform and zosteriform hyperpigmentation (PCZH) in 1978 as a disease that fulfils the following criteria: 1) cribriform pigmented macules that form a zosteriform distribution, 2) no history of skin disease or injury that would suggest postinflammatory hyperpigmentation, 3) an onset that arises well after birth, followed by gradual extension, 4) an onset that has no association with other skin diseases or internal abnormalities, and 5) characterized histologically by a mild increase in melanin pigment in the basal layer without nevus cells. In 1980, Simoes and Piva2 described the progressive zosteriform macular pigmented lesion (PZMPL) as a chronic pigmentary dermatosis with similar clinical findings to PCZH. Although PZMPL is not completely understood, it is thought to be a variant of PCZH. PZMPL is distinguishable from PCZH because it presents with pruritus as a prodromal symptom and is characterized clinically by its abrupt spreading and histologically by pigmentary incontinence. A 12-year-old boy presented with congenital brown pigmented skin lesions along Blaschko's lines on the right side of his trunk and upper extremities (Fig. 1). He complained of occasional mild itching. The lesions had recently extended to the left side across the midline. The histopathological findings showed increased levels of melanin pigment in the basal layer and focal pigmentary incontinence in the upper dermis (Fig. 2). Fig. 1 Linear macular pigmented lesion extending from right to left, across the midline of the trunk. Fig. 2 (A) Increased pigmentation in the basal layer and some melanophages in the upper dermis (H&E, ×400), (B) Immunohistochemical staining is positive for Fontana-Masson (×200). The etiology of PZMPL is unknown. It has been speculated that its pathogenesis might be the same as other diseases that develop along Blaschko's lines. Among the many inherited and some acquired skin conditions that develop along Blaschko's lines, sporadic cases like the present one are often explained as inherited mosaicism. Further studies of similar cases are necessary to determine the pathogenesis of the disease. PCZH arises after birth and follows the dermatomes. In terms of its hyperpigmentation and its asymptomatic nature, the case described in this report seems to align with the characteristics of PCZH, but the cribriform arrangement of small scattered macules is one particular characteristic of PCZH that differs from the extensive patches seen in the present case3. The similarities of PZMPL to the present case include the presence of extensive plaques along Blaschko's lines and macules that converged and became bigger. Simoes and Piva2 reported that PZMPL is accompanied by itching, and that the condition remains static for a certain period of time followed by an abrupt enlargement of the lesions, which is similar to the present case. The histological features, the extensive patches along Blaschko's lines, and the abrupt enlargement of the skin lesions suggested a diagnosis of PZMPL. Since the first case of PZMPL described by Simoes and Piva2 three more cases have been investigated, including the present one. Given that the diagnosis of PZMPL is not well established, we hope that this case report contributes towards elucidating a standard definition, the pathophysiology, and the progression of PZMPL. We recommend that dermatologists consider this disease when they encounter patients with chronic hyperpigmented dermatoses.

Eruptive pseudoangiomatosis (EP) is a rare, benign, spontaneously regressing exanthema of unknown etiology, characterized by an eruption of distinctive erythematous papules. This study was performed to evaluate the etiologic, clinical, and histopathologic characteristics of EP in Koreans.Patients diagnosed with EP during 2005-2010 were included in a retrospective study. Diagnoses were based on clinical findings and confirmed by histology. Biopsies were re-examined. Patient gender, age at onset, disease duration, lesion location, season of occurrence, concomitant diseases, occupation, previous related events, disease course, responses to treatment, and laboratory findings were analyzed.A total of 32 patients were identified. Mean age at onset was 50.06 ± 17.12 years. Two patients developed lesions after outdoor activities. Two patients presented with simultaneous occurrences in family members. One patient reported having taken herbal medicine. One subject experienced systemic contact dermatitis caused by eating a lacquer chicken dish just before the lesions developed. All patients had typical erythematous papules measuring 2-5 mm. Lesions were usually located on exposed sites. No prodromal or systemic symptoms were observed. Routine laboratory tests were within normal ranges, except in one patient with known hyperlipidemia. Most patients were treated with oral antihistamine and topical steroid, or oral prednisolone. Eight patients did not receive any treatment. Mean disease duration was 1.64 ± 1.41 months in the treatment group and 1.20 ± 1.24 months in the no-treatment group (P0.05).Any clear relationship between EP and exposure to allergens or insect bites has yet to be elucidated. In patients in whom EP occurs on non-exposed sites, drugs and food should be considered as possible causative agents. Intravascular neutrophil infiltration on histology can be helpful in diagnosing EP.

A rotavirus G1P[8] strain C1-81 was isolated from a 5-month-old female infant admitted to hospital with fever and severe diarrhea in Incheon, South Korea. To investigate its full genomic relatedness and its group, the full genome of strain C1-81 was determined. Based on a full genome classification system, C1-81 was shown to possess the typical Wa-like genotype constellation: G1-P[8]-I1-R1-C1-M1-A1-N1-T1-E1-H1. On the basis of sequence similarities, the strain was shown to be the closest related strain to contemporary human rotavirus strains with recent strains isolated in Asia. This C1-81 strain showed the highest degree of nucleic acid similarity (98.8% and 97%) to G1 B4633-03 and P[8] (Thai-1604 and Dhaka8-02), respectively. This is the first report that group A rotavirus was analyzed with G1P[8] in South Korea. The study of the complete genome of the virus will help understanding of the evolution of rotavirus.

Editor: In 1896, Fordyce1 described whitish spots on the vermilion border of the lips, oral mucosa and, rarely, genital mucosa. Fordyce's spots are ectopically located sebaceous glands1-4. To date, few reports have been published to describe the clinicopathologic study of Fordyce's spots in the Korean population. We herein review the clinicopathologic characteristics of Korean patients with Fordyce's spots. Data were collected retrospectively from the medical records of patients diagnosed with Fordyce's spots between January 2000 and December 2009 in the Department of Dermatology of 4 medical centers in Korea. We reviewed biopsy slides, treatment regimens, and other relevant information. Sixteen patients were finally enrolled in this study. All patients were confirmed with Fordyce's spots following biopsy. This study was approved by the Institutional Review Board of the Catholic University of Korea. Distribution of the patients' age, sex, incubation period, symptoms, signs, anatomical locations, and treatment were evaluated. Histopathologically, the morphology of Fordyce's spots, distribution, and existence of sebaceous ducts-whether they opened onto the skin surface or not-were investigated. The male to female ratio was 11 : 5. The average patient age was 34.3 years and ranged from 17~67 years (mean±S.D., 34.3±15.0 years). The average age was 41.1 years old in men and 19.4 years old in women. Duration of illness prior to diagnosis ranged from several days to five years, and the mean incubation period was 1.9 years. Most patients were asymptomatic. However, one patient with concurrent contact dermatitis complained of pruritus. The observed lesions were multi-centric and whitish to yellowish in color. Slightly elevated papules and plaques with sizes ranging from 1 to 3 mm were seen. In 8 patients, the lesions were found on the upper lip (50%), on both lips in 4 (25%), and on the lower lip in two (12.5%) (Fig. 1A, B). The spots mostly presented on the vermilion portion of the lips. The lesions in one patient presented on the buccal mucosa (Fig. 1C) and glans penis, respectively. The family history of the patient was unknown. Two patients were treated with a carbon dioxide (CO2) laser, 1 with electrodessication (E/D), 5 with excision of the lesions, and 7 were put on observation. Among those treated, no recurrence was reported (Table 1). Fig. 1 Multiple, pin-head-sized, whitish to yellowish papules on the vermilion border of both lips in case 9 (A), upper lip in case 11 (B), and buccal mucosa in case 8 (C). Table 1 Epidemiologic and clinical characteristics of 16 study patients with Fordyce's spots Histologically, the size of sebaceous glands ranged from 1.62±0.55 mm. The glands were located in both the upper dermis (81.3%) and lower dermis (18.7%). The sebaceous glands of Fordyce's spots mostly do not associate with hair follicles. Sebaceous ducts of Fordyce's spots have been observed to open directly onto the surface of the skin (81.3%, Fig. 2). Fig. 2 Sebaceous glands in the dermis on the lip in case 11 (A) and in case 13 (B). Fordyce's spots open directly onto the surface and do not associate with hair follicles (H&E, ×100).

Case 1 A 16-year-old Korean man presented with asymptomatic erythematous striae-like bands on his back which had been present for 6 months and had migrated to his shoulder ( Fig. 1a). He had no history of corticosteroid therapy, rapid gain or loss of weight, debilitating infection or illness. Histopathologically, fine, fragmented elastic fibers were shown in the dermis, but there were no clumped elastic fibers ( Fig. 2a). Electron microscopy showed an irregular, fragmented, electron-dense granular substance and a fragmented, electron-lucent substance between the normal collagen fibers, and no microfibrils ( Fig. 3a). This indicates the degeneration of elastic fibers. Figure 1. Asymptomatic, palpable, erythematous bands extending horizontally across the middle and lower back and propagating to the shoulder. (b) Asymptomatic, palpable, yellowish, striae-like bands extending horizontally across the middle and lower back Download figure to PowerPoint Figure 2(a). The number of elastic fibers was decreased, and fine, fragmented, elastic fibers were observed in the dermis (Verhoeff’s stain, × 200). (b) Massive, well-demarcated, clumped, elastic fibers were observed in the mid-dermis (Verhoeff’s stain, imes; 200) Download figure to PowerPoint Figure 3(a). Electron micrograph showing irregular, fragmented, electron-dense granular substance (arrow) and fragmented, electron-lucent substance (asterisks) between normal collagen fibers (C) (original magnification, × 39,100). (b) Electron micrograph showing fragmented, electron-dense granular substance (arrow) and numerous microfibrils (asterisks) near the substance. No abnormalities were seen in the collagen fibers (C) (original magnification, × 39,100) Download figure to PowerPoint Case 2 An 18-year-old Korean man presented with asymptomatic yellowish striae in the lumbar area which had been present for 2 years ( Fig. 1b). He had no specific medical history. Massive, well-demarcated basophilic fibers were observed in the dermis with light microscopy. These fibers were stained positively with elastic stain ( Fig. 2b). Electron microscopy showed a fragmented, electron-dense granular substance and numerous microfibrils near the substance ( Fig. 3b), which suggests active elastogenesis.

We evaluated the recent trend in the incidence of premalignant and malignant skin lesions between 1991 and 2006. Among 571,057 newly registered dermatology out-patients from our 8 affiliated university hospitals, 2,598 were diagnosed with a premalignant (899, 0.16%) or malignant skin lesions (1,699, 0.30%). Of 899 premalignant cases, 71.2% were actinic keratosis (AK), and 24.6% were Bowen's disease. Of 1,699 malignant cases, 46.2% were basal cell carcinoma, followed by squamous cell carcinoma (19.1%) and melanoma (7.1%). This 16-yr survey was divided equally into two time periods to compare the incidence of premalignant and malignant skin lesions at different time settings. Between 1991 and 1998, the incidence of cutaneous premalignancy was 0.10% which doubled during 1999-2006. For cutaneous malignancy, the incidence was 0.25% during 1991-1998 and 0.34% in 1999-2006. Incidence of AK among the new outpatients was 0.07% in 1991-1998 which staggered up to 0.15% in 1999-2006. These findings show an increase of both premalignant and malignant skin lesions, AK in particular in the dermatology outpatient-based incidence.

A 49-year-old woman presented with a 30-year history of asymptomatic plaque on her right temple. The histological examination revealed nests of nevus cells throughout the entire dermis. Bony spicules were seen just beneath the nevus cell nests in the lower dermis. Cutaneous ossification is an unusual event. Herein, we present a case of intradermal melanocytic nevus with unusual ossification (nevus of Nanta). To the best of our knowledge, this is the first such case report in the Korean literature.

Patients with the autosomal-dominant form of multiple familial trichoepithelioma develop numerous tumours on the face, neck and upper trunk, beginning in childhood. Malignant transformation of such lesions is quite rare; only one case of "malignant trichoepithelioma" has been reported previously, inferring pilomatrix carcinoma on a histological observation. We report here the case of a patient who developed a malignant neoplasm in a long-standing trichoepithelioma lesion on her buttock. Histopathology revealed a transformation zone between the trichoepithelioma and a malignant tumour mass. This case also showed several features of a malignant neoplasm of trichoblastic origin.

Spitz nevus is a benign melnocytic lesion with many histologic similarities to malignant melanoma. To our knowledge, a Spitz nevus with multiple satellite lesions has not been reported. This paper reports a case of Spitz nevus with multiple satellite lesions on the abdomen of a 19-year-old Korean woman.

Purpose Vitiligo prevalence and its associated comorbidities rate have been reported variably among different populations. We aimed to determine the prevalence of vitiligo in Korea along with the baseline rate of comorbidities and compared the risks to the general population using hospital visit information of the total population in Korea. Materials and methods We assessed demographic characteristics of vitiligo patients in Korean population from 2009 to 2011 in a nationwide data from Health Insurance Review Assessment Service. Patients who had at least one visit to Korea's primary, secondary, or tertiary referral hospitals with International Classification of Diseases, 10th Revision, Clinical Modification diagnosis code for vitiligo were identified. As a supplementary study, comorbidities associated with vitiligo were selected for further review to calculate relative risks compared to the general population. Results The annual prevalence of vitiligo determined by hospital-visiting rate in Korea was 0.12% to 0.13% over a three year period. In sync with other previous epidemiological studies, there was bimodal distribution among the age groups and no difference between genders. Also, vitiligo in Korean population was associated with various autoimmune/non-autoimmune diseases such as thyroiditis, atopic dermatitis, and psoriasis. Conclusion This study was by far the most comprehensive review on prevalence of vitiligo using a data of total population in Korea. The prevalence is within a range of those reported in previous literatures, and increased risk of comorbidities such as thyroid diseases and psoriasis in vitiligo might aid clinicians in the initial work up of vitiligo patients and concurrent follow ups.

Sir, Granular cell tumours first described by Abrikossoff (1), are uncommon and usually present as small non-tender solitary nodules. We report here for the first time a case of a granular cell tumour with marked osseous metaplasia on the back of a 68-year-old man. The lesion showed typical features of a granular cell tumour, with the unusual feature of prominent bone formation under microscopic examination. To our knowledge, ossification has not previously been reported in a granular cell tumour.

Background: Cholinergic urticaria is a type of physical urticaria characterized by heat-associated wheals. Several reports are available about cholinergic urticaria; however, the clinical manifestations and pathogenesis are incompletely understood. Objective: The purpose of this study was to investigate the clinical characteristics of cholinergic urticaria in Korea. Methods: We performed a retrospective study of 92 patients with cholinergic urticaria who were contacted by phone and whose diagnoses were confirmed by the exercise provocation test among those who had visited The Catholic University of Korea, Catholic Medical Center from January 2001 to November 2010. Results: All 92 patients were male, and their average age was 27.8 years (range, 17∼51 years). Most of the patients had onset of the disease in their 20s and 30s. Non-follicular wheals were located on the trunk and upper extremities of many patients, and the symptoms were aggravated by exercise. Eight patients showed general urticaria symptoms and 15 had accompanying atopic disease. Forty-three patients complained of seasonal aggravation. Most patients were treated with first and second- generation antihistamines. Conclusion: Dermatologists should consider these characteristics in patients with cholinergic urticaria. Further investigation and follow-up studies are necessary to better understand the epidemiological and clinical findings of cholinergic urticaria. (Ann Dermatol 26(2) 189∼194, 2014)

Background It was previously thought that persons with genetic predispositions to vitiligo develop the condition after exposure to various precipitating environmental factors. However, in many cases, the aggravating factors of vitiligo have not been clearly identified. Objective To identify the aggravating factors of vitiligo in the working environment and daily life. Methods A total of 489 vitiligo patients were recruited from 10 institutions in South Korea; patients were provided with a questionnaire about environmental factors and behavior patterns in the workplace and in daily life, and their association with vitiligo. Results Ninety-five of the 470 enrolled patients (20.2%) answered that environmental risk factors in daily life and in the workplace affected the development of vitiligo. The most frequently attributed causes were trauma and burn (13.6%), followed by sunlight (12.8%), stress (12.8%), cleaning products/disinfectant/chemicals (4.9%), and hair dye (2.1%). Conclusion Vitiligo of the hand and foot was associated with frequent exposure to aggravating materials and overexposure to sunlight, along with frequent trauma of these areas, all of which could be considered important risk factors of vitiligo. The development of vitiligo could potentially be controlled through the early detection of aggravating factors.