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Background Trachyonychia can be refractory to conventional treatments including topical, intralesional or systemic corticosteroids, as well as cyclosporine and retinoids. Therefore, new treatment options are needed for recalcitrant trachyonychia. Objective To evaluate the efficacy and safety of oral alitretinoin for idiopathic recalcitrant trachyonychia. Methods A total of 21 adult patients with 210 nails affected by idiopathic recalcitrant trachyonychia were evaluated in this open-label prospective study. All patients took 30 mg of alitretinoin daily for at least 3 months. Clinical outcomes were assessed using the Physician Global Assessment (PGA) scale proposed by Park et al. (degree of roughness: 0, clear; 1, mild; 2, moderate; 3, marked; 4, severe) at baseline and 1, 3 and 6 months after treatment. Results After 1, 3 and 6 months of treatment, 74.3% (123/210), 98.1% (206/210) and 99.2% (119/120) of nails showed clinical improvement, respectively; 0% (0/210), 22.9% (48/210) and 69.2% (83/120) were completely free from nail abnormalities. The mean PGA score at baseline was 3.4, decreasing significantly to 2.7, 1.3 and 0.7 at 1, 3 and 6 months following treatment, respectively. Limitations A small number of participants and lack of a control group were limitations. Conclusions For the first time, this study evaluated the efficacy and safety of oral alitretinoin for idiopathic recalcitrant trachyonychia in adults. The results suggest that oral alitretinoin can be a good treatment option for adult patients with recalcitrant trachyonychia.

Background: Labial melanotic macules (LMMs) are benign pigmented lesions that usually take the shape of flat asymmetrical macules with tan-brown to black color and variable size. Whereas the dermoscopic features of other pigmented skin lesions have been relatively well described, little is known about LMMs. Objective: To describe the dermoscopic features and find typical and schematic dermoscopic patterns in LMMs. Methods: A retrospective dermoscopic study was conducted on 80 lesions with histopathologically proved LMMs. Results: We described and defined, for the first time to our knowledge, landscape painting patterns found in 65 of 80 melanotic lesions (81.3%), characterized by parallel lines or circle lines, overlapping vessels with background brown pigmentation. The background brown pigmentations were observed in 74 of 80 lesions (92.5%), the parallel lines in 62 (77.5%), the circle lines in 20 (25.0%), and overlapping vessels in 69 (86.3%). The structureless black pigmentations were only presented in 26 of 80 (32.5%). Conclusion: Dermoscopy can be useful for the clinical detection of LMMs, and “Landscape painting patterns” may represent a dermoscopic clue for the diagnosis of these lesions. (Ann Dermatol 30(3) 331∼334, 2018)

Background: The incidence and mortality rates associated with cutaneous melanoma (CM) have steadily increased over the last 20 years. Even with successful treatment, mela-noma patients usually experience substantial anxiety regard-ing the development of terrible recurrence. To date, few stud-ies have investigated various dermatoses what the patients with CM had anxiety for the recurrence during postoperative surveillance (Dw). Objective: To describe various Dw and to evaluate the risk of subsequent malignant skin disease in pa-tients with CM. Methods: We performed a prospective study between August 2002 and August 2015. Results: Fifty-six pa-tients presented with a total of 68 Dw. Among them, melano-cytic nevus was the most common (n=27), followed by se-borrheic keratosis (n=9) and CM recurrence (n=7). Approximately 5.6% of the lesions were diagnosed as malig-nant skin diseases. This was a single-center study, so the prev-alence of malignant skin diseases following primary melano-ma may not represent that of all patients with CM. Conclusion: The results of this study can be referred by der-matologists dealing with melanoma especially when CM pa-tients have too excessive or unrealistic anxiety for melanoma recurrence during postoperative surveillance of CM. However, the importance of postoperative surveillance must still be emphasized because of real risk of melanoma re-currence and other malignant skin. (Ann Dermatol 29(4) 433 ∼437, 2017)

Phytophotodermatitis is a condition caused by sequential exposure to photosensitizing substances present in plants followed by ultraviolet light. Several plants (e.g., limes, celery, fig, and wild parsnip) contain furocoumarin compounds (psoralens). It is important for dermatologists to be aware of phytophotodermatitis because it may be misdiagnosed as cellulitis, tinea, or allergic contact dermatitis. We present five patients with a sharply defined erythematous swollen patch with bullae on both feet. They described soaking their feet in a fig leaves decoction to treat their underlying dermatologic diseases. Within 24 hours, all patients had a burning sensation in their feet, and erythema and edema had developed on the feet dorsa with exception of the portion of the skin covered by the sandals. Histopathologic examinations revealed sub-epithelial blisters with intensive epidermal necrosis. Phytophotodermatitis was ultimately diagnosed and, after several days, the patients' skin lesions began to recover upon treatment with systemic and topical corticosteroids. Unfortunately, since there are no studies providing sufficient evidence on the benefits of fig leaves, they should be used with caution.

BACKGROUND A variety of infectious, inflammatory, and neoplastic dermatoses can develop on the glans penis, and definitive diagnosis in such cases may be difficult owing to their non-specific symptoms and clinical appearance. Furthermore, data on dermatoses of the glans penis in Korea are limited. OBJECTIVE In the present study, we aimed to determine the prevalence of dermatoses of the glans penis in Korea and provide clinical data to assist in making an accurate diagnosis. METHODS We retrospectively reviewed the medical records, clinical photographs, and histologic slides of 65 patients with dermatoses of the glans penis that visited the Pusan National University Hospital between January 2004 and August 2013. RESULTS Twenty-six types of dermatoses were identified: inflammatory dermatosis was the most common (38/65, 58.5%), followed by infectious (13/65, 20.0%), neoplastic (10/65, 15.4%), and other dermatoses (4/65, 6.2%). The most common dermatosis of the glans penis was seborrheic dermatitis, followed by lichen planus, herpes progenitalis, condyloma accuminatum, erythroplasia of Queyrat, Zoon's balanitis, and psoriasis. In the topographic analysis, the most common type of dermatosis was dermatoses that localized to the glans penis (39/65, 60.0%), followed by dermatoses involving the extra-genitalia and glans penis (22/65, 33.9%), and the genitalia (glans penis plus other genital areas) (4/65, 6.2%). CONCLUSION This study shows the usefulness of a topographic approach in the diagnosis of dermatoses of the glans penis in Korea. The findings could be used as baseline data for establishing an accurate diagnosis in Koreans.

BACKGROUND Sublingual immunotherapy (SLIT) with house dust mites (HDM) preparation has recently been proven to be beneficial for treating allergic rhinitis and asthma. However, there has been no report regarding the efficacy and safety of SLIT in Korean patients with atopic dermatitis (AD). OBJECTIVE We intended to investigate the efficacy and safety of SLIT in Korean patients with AD. METHODS A total of 34 patients with AD and immunoglobulin E (IgE)-proven HDM sensitization (Class ≥3) were recruited. Eczema area and severity index (EASI) score, total serum IgE level, specific IgE assays to Dermatophagoides pteronyssinus, D. farinae, and adverse effects were recorded during follow-up. "Responder" was defined as a patient with ≥30% improvement in EASI score after SLIT. RESULTS Twenty-three patients continued SLIT for 12 months or more, whereas 3 patients (8.8%) dropped out because of exacerbation of dermatitis, and 8 patients (23.5%) were lost to follow-up. The average duration of SLIT treatment was 22.4 months (range, 12~32 months). EASI scores reduced significantly after 6 months of treatment (p

Background Psoriatic arthritis (PsA) is chronic seronegative inflammatory arthritis that causes irreversible joint damage. Early recognition of PsA in patients with psoriasis is important for preventing physical disability and deformity. However, diagnosing PsA in a busy dermatology outpatient clinic can be difficult. Objective This study aimed to validate the Psoriatic Arthritis Screening and Evaluation (PASE) questionnaire for the detection of PsA in Korean patients with psoriasis. Methods The PASE questionnaire was prospectively given to 148 patients diagnosed with psoriasis but without a previous diagnosis of PsA. All patients underwent radiologic and laboratory examinations, and a subsequent clinical evaluation by a rheumatologist. Results Eighteen psoriasis patients (12.2%) were diagnosed with PsA according to the Classification Criteria for Psoriatic Arthritis. The PASE questionnaire scores of differed significantly between PsA and non-PsA patients. Receiver operator characteristic analysis showed an area under the curve of 0.82 (95% confidence interval: 0.72, 0.92) for PASE score. A PASE score cut-off of 37 points had a sensitivity of 77.8% and specificity of 82.3% for the diagnosis of PsA. Conclusion The PASE questionnaire is a simple and convenient screening tool for detecting PsA in Korean dermatology clinics. A PASE questionnaire score of 37 points appears to be an appropriate cut-off for screening Korean psoriasis patients.

Dear Editor: In case 1, a 41-year-old woman presented with a 3-year history of recurrent pustules on erythematous skin. The patient had been treated with methotrexate, sulfasalazine and cyclosporine for psoriatic arthritis and generalized pustular psoriasis (GPP) for 2 years. However, these treatments failed to yield satisfactory improvement. Physical examination revealed the presence of extensive erythematous patches with pustules over the entire body (Fig. 1A) and inflammatory arthritis was noted in the distal interphalangeal, sacroiliac and knee joints. We decided to use infliximab (3 mg/kg) to treat the GPP and psoriatic arthritis. The patient's pustular lesions cleared quickly within 48 hours after the first injection. After the second injection of infliximab (3 mg/kg), marked improvement in arthralgia was observed (Fig. 1B). She has since been receiving infliximab 3 mg/kg every 8 weeks as maintenance therapy. No recurrence of pustules or arthritis symptoms has been detected during 12 months of follow-up. Fig. 1 Pustular psoriasis in case 1 (A). Marked improvement was observed after the second injection of infliximab (B). In case 2, a 39-year-old woman with a 20-year history of plaque type psoriasis was admitted to our department for lower limb cellulitis. Rapid resolution of cellulitis was achieved after systemic antibiotic treatment (cefazolin 6 g/day). Three days after antibiotic treatment, she experienced abrupt onset of pustules on erythematous skin affecting more than 90% of body (Fig. 2A, B). She was initially treated with infliximab (3 mg/kg) combined with acitretin (30 mg/day) for pustular flares. Within 48 hours of the first infusion, the pustules were resolved, but diffuse erythema on the trunk and extremities remained (Fig. 2C, D). The patient received acitretin (20 mg/day) for maintenance after a single dose of infliximab. No relapse of the pustules has been noted, but mild psoriatic plaques have followed. Fig. 2 Generalized pustular papules on the entire body in case 2 (A, B). Near remission of a pustular eruption was seen 48 hours after infliximab infusion (C, D). Infliximab is a chimeric immunoglobulin G1 anti-tumor necrosis factor-α monoclonal antibody that is effective in treating moderate to severe psoriasis and psoriatic arthritis1. Several studies have documented a rapid improvement in recalcitrant GPP with infliximab (5 mg/kg)2,3. Because infliximab has a faster onset of action than that of other modalities including biologics, some researchers recommended that infliximab be used as the first-line treatment modality in patients with severe and acute GPP4. Both patients in the current study experienced dramatic resolution of pustules within 48~72 hours of infliximab infusion without any serious adverse events. Although the optimal infliximab dose and maintenance regimen for GPP has not yet been established, low dose (3 mg/kg) of infliximab showed excellent response in the current cases. In an earlier report, there was no significant difference between the 3 mg/kg treatment group and the 5 mg/kg treatment group for moderate to severe psoriasis5. However, more research is needed and we believed that low dose infliximab with or without acitretin may have an effect on acute GPP. Since infliximab appears to offer the advantage of rapid response and reduced morbidity, we may consider it extremely effective and well tolerated in adult patients with severe and acute GPP. However, since GPP tends to relapse frequently, large population studies are needed to evaluate the efficacy of maintenance infliximab therapy for GPP with recurrent pustular episodes.

Dear Editor: Dermoscopy is a noninvasive and extremely useful diagnostic tool for a variety of skin diseases1. A few reports have documented that dermoscopy is also useful for the diagnosis of some zoonotic infestations including scabies and spider spines2,3. In the latter, dermoscopic findings allow the identification of spider spines clinically mimicking scabies. Here, we report a case of the successful identification and removal of a fish bone under the fingernail with the aid of dermoscopy. A 51-year-old woman presented with a 7-day history of pain in the right thumb. She had trimmed a black rockfish caught by her husband, and felt pain afterwards. When she came to our department after failing to remove the bone herself, it was difficult to find the fish bone with the naked eye (Fig. 1A). However, we were able to find a linear foreign body embedded under the nail plate using dermoscopy (Fig. 1B). The foreign body was easily removed using fine forceps. Fig. 1 (A) It was difficult to locate the foreign body with the naked eye. (B) Dermoscopic findings revealed the foreign body to be compatible with a fish bone spine and focal abscess pocket. Having the fingers pricked by a fish bone or thorn is not uncommon. Sometimes the removal of these foreign bodies can be difficult, and persistently disabling secondary infections can occur in cases of residual fragments4. However, it is often difficult to detect subungual white foreign bodies like fish bones and white hairs with the naked eye. Imaging approaches including routine X-ray, computed tomography, and magnetic resonance imaging can be helpful, but seem too extreme considering their expense and limited availability5. Using dermoscopy, we were able to identify the exact location of the colorless foreign body under the nail plate and remove it easily. In conclusion, dermoscopy can be a useful diagnostic tool for the detection of white foreign bodies such as fish bones in the subungual space.

Dear Editor: Recently, the term chronic spontaneous urticaria (CSU) is used to indicate spontaneous and persistent wheals, independent of external physical stimuli1. CSU is classified into two groups according to the presence of autoantibodies: chronic autoimmune urticaria (CAU) and chronic idiopathic urticaria (CIU)2. Several treatment methods are available for patients with CSU. However, CSU can be resistant to conventional treatment, including high-dose antihistamines (up to 4-fold dose of H1 antihistamines). Autologous whole blood (AWB) injection, a prevalent method to treat allergic rhinitis, atopic dermatitis, and viral disease, is scientifically unproven3,4. Few reports have documented the clinical improvement of CSU after injection of AWB5,6. Although its mechanism of action remains widely unknown, we believe that AWB injection may desensitize the patient against triggering factors including autoanti-bodies. The aim of this study was to evaluate the efficacy of AWB injection in treating CSU, and to compare its efficacy on CAU and CIU. The study was approved by the hospital ethics committee (E-2013096), and all patients gave their informed consent. We treated 22 patients with CSU, who had uncontrolled urticaria most days of the week despite antihistamine therapy for >6 weeks, by administering AWB injections for 8 consecutive weeks. Patients who had developed urticarial due to foods, drugs, or physical and environmental factors, female patients who were pregnant or lactating, patients with any severe systemic disease, and patients who had taken any immunosuppressive agent within 4 weeks of entry were excluded from the study. The patients were classified into two groups after autologous serum skin test (ASST): positive (CAU) and negative (CIU). After the cessation of antihistaminic treatment for at least 3 days, ASST was performed. A wheal with a diameter at least 1.5 mm greater than that of a saline-induced wheal at 30 min was considered positive. We took venous blood samples and immediately administered a gluteal intramuscular AWB injection. The volume of injection was 2.5 ml at week 0, and 5 ml/week for the subsequent injections. All patients underwent laboratory examinations before treatment, including complete blood count, liver and renal function tests, urinalysis, and D-dimer analyses. Only antihistamines were allowed during the AWB injection phase for worsening pruritus or wheals. The outcome measures were pruritus intensity; wheal number, size, and duration; and sleep and daily activity interference by using score values from 0 to 3. The sum of all six severity parameters were calculated to obtain the urticaria activity score (UAS)7 every week, and the UAS at week 0 and week 8 was compared between responders and non-responders. The consumption of antihistamines was calculated at the endpoint. A "responder" was defined as a patient with >30% improvement of UAS after repeated AWB injections5. In total, 8 of 22 patients (36.4%) with CSU were responders to AWB injection; 2 of 7 (28.6%) CAU and 6 of 15 (40.0%) CIU patients were considered responders (Table 1). There was no significant difference in responder ratios between the CAU and CIU groups. The antihistamine consumption at week 8 did not show any significant differences compared with baseline (data not shown). Between responders and non-responders, we found that CSU patients with a high baseline UAS improved markedly after repeated AWB injections (p=0.019); however, there was no difference with respect to disease duration, sex, age, ASST result, D-dimer, and C-reactive protein level (Table 2). No patients experienced serious adverse events; however, minor adverse events such as bruising and injection pain were noted. Table 1 Efficacy of AWB injection after 8 week of treatment Table 2 Comparison between responders and non-responders to autologous whole blood injection among 22 CSU patients Although desensitization with repeated AWB injections theoretically provided better efficacy in patients with CAU than in those with CIU, our results showed that there were no significant differences between groups at the endpoint. Mori and Hashimoto8 reported that an ASST-positive patient was completely cured after AWB injections; however, the patient remained ASST positive. These findings suggest that the underlying mechanism of AWB injections is attributed to other pathogenetic factors. Unlike in previous reports5,8, AWB injection did not cause a dramatic response in patients with antihistamine-resistant CSU regardless of the skin test results to autologous serum. Nevertheless, the most important finding of this study is that AWB injection might be more efficient in treating patients with CSU who had high disease activity at baseline. Therefore, AWB injections may be an option in treating patients with antihistamine-resistant CSU who have high disease activity. Further studies are required to reinforce the current results concerning AWB injection in patients with CSU, and evaluate its efficacy, duration, treatment interval, and dose.

Dear Editor: Soft fibroma (acrochordon, fibroepithelial polyp, or skin tag) is a common pedunculated skin neoplasm and usually appears as a furrowed papule, filiform lesion, or large bag-like protrusion. Soft fibromas primarily occur on the neck, axillae, and groin. However, it may present at unusual sites of the body such as the penis, urethra, and vulva. Moreover, a few reports on soft fibromas occurring on the breast and nipple have been published1. Herein, we report a rare and interesting case of a soft fibroma arising from the nipple, showing an unusual cauliflower-like appearance. A 51-year-old obese woman presented with a 25-year history of a painless pedunculated polyp originating from her right nipple. The lesion measured 2.4×2.3×1.4 cm and demonstrated a verrucous and cauliflower-like surface (Fig. 1A, B). Neither acanthosis nigricans nor epidermal nevus was observed on the adjacent skin. Dermoscopy revealed irregular epidermal projections and focal dotted vessels (Fig. 1C). Total surgical excision of the polyp, sparing the right nipple, was performed. Histopathological analysis showed papillomatosis, hyperkeratosis, and regular acanthosis of the epidermis with fibrocollagenous tissue in the dermis (Fig. 1D). On the basis of these findings, we diagnosed the lesion as a soft fibroma. Fig. 1 (A) A large solitary pedunculated polyp originating from the right nipple. (B) The polypoid lesion measuring 2.4×2.3×1.4 cm and demonstrating a cauliflower-like surface. (C) Dermoscopic findings showing irregular epidermal projections ... There have been only a few reports on soft fibromas of the nipple presenting with bullous formation or comprising a large elastic mass with a short pedicle2,3. Furthermore, there has been no report of a large and cauliflower-like soft fibroma of the nipple in the Korean literature. Because the clinical manifestations of soft fibroma of the nipple are nonspecific, histological examination is required for differential diagnosis, including pedunculated seborrheic keratosis, pleomorphic fibroma, nevoid hyperkeratosis of nipple and areola, and verruca vulgaris. In our case, the unusual clinical presentation of the cauliflower-like nipple tumor made the diagnosis of the lesion difficult. However, the histopathological findings provided important clues for making an accurate diagnosis. Thus, we have described a rare and interesting case of a cauliflower-like soft fibroma of the nipple.