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Background Switching of biologics in patients has become common in clinical practice. Objectives This study investigated the reasons for and effectiveness of switching biologic agents during the treatment of psoriasis. Methods We retrospectively reviewed patients with psoriasis who were treated with biologics at Pusan National University Hospital and Chosun University Hospital from March 2012 to June 2020. We assessed their demographics and treatment characteristics (reasons for switching biologics and efficacy of the first- and second biologic agents). Results Of the 162 psoriatic patients treated with biologic agents for more than 52 weeks, 35 required a switch to another biologic agent. The reasons for switching biologic agents were inefficacy (n = 30), adverse events (n = 2) and others (n = 3). The mean psoriasis area and severity index (PASI) score was 12.1 at the start of the second biologic and 3.4 at 14–16 weeks later. Patients were more likely to switch to another biologic agent when they exhibited a high initial psoriasis area and severity index score and concomitant psoriatic arthritis. Limitations As a retrospective study, there were some limitations such as lack of a placebo control group and the time point of 14–16 weeks being somewhat early to judge the effect of the biologics. Conclusions The most common reason for switching biologic agents in Korea was treatment inefficacy, especially secondary failure. Despite the inefficacy of previous biologic agents, switching to a different agent may be an efficacious approach.

Background: Dermatologic diseases are generally managed at an outpatient clinic and most cases have very low mortality rates. However, some dermatologic diseases are life-threatening and only a few studies have assessed their mortality rates and associated factors. Objective: To investigate the mortality of inpatients with dermatological diseases. Methods: This retrospective study was conducted by reviewing the medical records of patients who died in the dermatology ward at a tertiary hospital in Korea in a period of 17 years. Patient demographics, dermatologic diseases, immediate cause of death, comorbidities, and clinical factors related with mortality were investigated. Results: The total number of inpatients in the dermatology ward during the study period was 740. Thirteen patients (1.76%, 5 men and 8 women) expired while they were admitted in the hospital. The median age of the patients was 63.8 years (range, 18 to 86), and the maximum number of deaths occurred in patients over 70 years old (7 out of 13 patients, 53.8%). Drug reactions were the most common dermatologic complication resulting in admission, followed by bullous disease, generalized pustular psoriasis, and dermatomyositis. Most patients had multiple comorbidities, including hypertension, diabetes mellitus, kidney disease, and angina. Sepsis due to infection was the most common cause of death. Conclusion: Infection was the most important factor contributing to mortality. Old age, immunosuppression, and comorbidities were important factors that contributed to mortality in dermatologic inpatients.

Background: Onychomycosis is a common nail fungal infection that affects the nail bed, plate, and matrix. It accounts for ~50% of all nail diseases. The treatment of onychomycosis includes systemic and topical approaches, which depend on patient compliance, drug penetration and delivery to the nail bed, antifungal efficacy, and tolerance. Efinaconazole is a novel triazole antifungal agent that is active against many pathogenic fungi, and is used for treating onychomycosis. Objective: To confirm the efficacy and safety of 10% efinaconazole solution for treating onychomycosis. Methods: This study was conducted as a 52-week, multicenter, open, single-group, phase 4 clinical trial. A 10% efinaconazole solution was applied on the toenails of each subject before bedtime, once a day for 48 weeks. The subjects visited the test facility every four weeks for the evaluation of the efficacy and safety of the treatment. Results: At 52 weeks of applying 10% efinaconazole solution, the rates of complete cure, mycological cure, complete or almost complete cure, and clinical effectiveness were 16.7%, 95.8%, 38.54%, and 52.1%, respectively. The clinical effects of efinaconazole were seen in more than half of the subjects. No severe adverse reactions related to efinaconazole were observed. Conclusion: The antifungal effect and safety of topically applied 10% efinaconazole solution in patients with mild to moderate toenail onychomycosis caused by dermatophytes was confirmed based on the efficacy and safety evaluation for a complete cure.

Erosive adenomatosis of the nipple (EAN), also known as nipple adenoma, florid papillomatosis, or papillary adenoma of the nipple, is a benign neoplasm originating from a lactiferous duct of the breast. Although the potential for malignant change is invariably negligible, the nature of the disease is quite intractable despite several treatment methods. Surgical excision is known as the treatment of choice, but this invasive approach is generally not acceptable to the vast majority of patients due to the cosmetic outcomes. Cryosurgery could be an alternative choice to preserve the structure of the nipple-areola complex, though its application has not been studied due to the paucity of cases. A 22-year-old female presented with a unilateral, crater-like erosion of the left nipple with serosanguineous discharge. The skin biopsy revealed proliferation of tubular structures, which corresponded to EAN. She was treated with 4 sessions of cryosurgery (open cryospray with liquid nitrogen) over 6 months, and the skin lesion resolved completely without any recurrence for 12 months. Although further study is required to determine the optimal treatment regimen for EAN, cryosurgery should be considered as an effective option to surgical excision.

Background A poroma typically presents as a solitary, pink-to-red papule or nodule in acral volar areas. However, in nonvolar areas, this typical clinical feature (TCF) can be difficult to identify. Objective We aimed to compare clinical and dermoscopic characteristics between nonvolar poroma (NVP) and volar (ie, typical) poroma (VP). Methods We assessed the clinical and dermoscopic characteristics of 40 patients with poromas who were divided into the NVP and VP groups. Results Of the 40 patients, 20 (50.0%) were allocated to the NVP group and 20 (50.0%) to the VP group. Pigmented variants were more common in the NVP group than in the VP group (60.0% vs 5.0%). The TCF of poroma was observed less frequently in the NVP than the VP group (45.0% vs 85.0%). Approximately one-third (30.0%) of patients with NVP received an initial clinical diagnosis of skin cancer. Dermoscopic patterns associated with melanoma or basal cell carcinoma were more common in the NVP group than in the VP group (65% vs 30%). Conclusions Skin cancer-associated clinicodermoscopic features were more frequently observed in patients with NVP, who simultaneously lost dermoscopic patterns associated to poromas and acquired those associated with skin cancer, than those with VP.

Background Atopic dermatitis (AD) in adults is not uncommon, and its prevalence has been increasing in the recent decades. However, there is a paucity of data about the differences between early-onset and late-onset adult AD. Objective The objective of this study is to investigate the clinical and laboratory characteristics of adult AD, focusing on the differences between early-onset and late-onset adult AD. Methods We retrospectively reviewed the medical records and clinical photos of 214 adult AD patients (≥18 years of age) over a 3-year period. We classified the patients into 2 groups: early-onset (first onset of AD before 12 years of age) and late-onset (first onset of AD at 12 years of age or later). Results Among 214 patients, 151 patients (70.6%) belonged to the early-onset group (mean age 24.5 years), while 63 patients belonged to the late-onset group (mean age 29.5 years). An association with allergic asthma or rhinitis, a family history of atopic disease, elevated total serum IgE, and sensitivity to food allergens were more commonly seen in the early-onset group. The late-onset group had a significant likelihood of nonflexural involvement (38.1% vs 13.2%). There was no significant difference in the mean eczema area severity index score, eosinophil count, and sensitivity to aeroallergens between 2 groups. Conclusion Adult AD shows different clinical and laboratory characteristics depending on the age of onset. This study could help to create awareness about the heterogeneity of AD in adulthood and encourage further studies on clinical outcomes and different therapeutic methods depending on the age of onset.

BACKGROUND The dermoscopic patterns of acral melanocytic nevi (AMNs) are crucial in differentiating them from acral melanoma. Several studies have reported the dermoscopic patterns of acquired acral melanocytic nevi (AAMNs). However, few have investigated the dermoscopic patterns of congenital acral melanocytic nevi (CAMNs). OBJECTIVE To compare the clinical and dermoscopic features of CAMNs and AAMNs. METHODS The present study included 43 patients with CAMNs and 40 with AAMNs. We reviewed their medical records as well as their clinical and dermoscopic findings. RESULTS Congenital acral melanocytic nevis were more asymmetrical than AAMNs (P = 0.002) and presented more frequently as comma-shaped (P = 0.005). Regarding dermoscopic findings, globular pattern (55.8%) was the most common feature of CAMNs, while parallel furrow pattern (37.5%) was the most common feature of AAMNs. The presence of fibrillar, globular, and parallel ridge patterns, and diffuse multi-component pigmentation differed significantly between the groups (P

BACKGROUND Onychophagia is a common disorder affecting 20% to 30% of the general population. It is defined as habitual nail biting and can cause various changes in the nail units. However, to date, there has been a paucity of data focusing on nail deformities related to onychophagia. This study was performed to investigate the clinical characteristics of onychophagia in Korea. METHODS This study included 53 patients with onychophagia who visited the Pusan National University Hospital (Busan and Yangsan) over a 10-year period (2011-2020). We retrospectively reviewed medical records and clinical and dermoscopic photographs. RESULTS All 10 fingernails were affected in 37.7% of the patients. The left thumbnail was the most predominantly affected site (81.1%). Clinical findings showed that short nails with ragged distal borders were the most common presentation (100.0%), followed by generalized or patchy rough areas (50.9%), linear and pinpoint hemorrhage (32.1%), longitudinal melanonychia (30.2%), transverse groove (28.3%), brittleness (28.3%), macrolunula (24.5%), washboard nail (13.2%), and pterygium (3.8%). Of the patients, 88.7% had periungual complications, such as periungual exfoliation (77.4%), absent or ragged cuticle (52.8%), hyponychial hyperkeratosis (37.7%), and paronychia (15.1%). CONCLUSIONS Although onychophagia is a common disorder, its clinical characteristics have not been reported in the literature. The results of this study may be helpful in managing patients with onychophagia.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder that can have many cutaneous manifestations including malar rash, discoid rash or oral ulcer. Isolated unilateral involvement of face is uncommon in SLE. It lacks typical clinical features of LE, and may impose a diagnostic challenge for clinicians. Herein we report a case of 62-year-old woman presenting with a 2-year history of erythematous patches on left cheek and eyelid. Initially, she was diagnosed as having recurrent blepharitis or cellulitis that did not respond to conventional treatment with ophthalmic medicaments. As time went by, the patches spread to her left cheek, and she was referred to our dermatologic department. Histopathologic examination was consistent with LE. Further physical and laboratory tests have found that she had oral ulcers, proteinuria, thrombocytopenia and abnormal titer of anti-nuclear antibody satisfying the diagnosis of SLE. From this case, we think unilateral erythematous patches on face could be a rare manifestation of SLE and more intention should be paid to this type of patients, because unilateral facial symptom may mimic other dermatoses.

Segmental nevus depigmentosus and segmental vitiligo can be difficult to differentiate from each other. Differential diagnosis of these two diseases is important because they have significantly different prognoses and psychological effects. The purpose of this study is to identify clinical clues that may be helpful in differentiating these two diseases. We enrolled 63 patients with segmental nevus depigmentosus and 149 patients with segmental vitiligo. Sex, age of onset, sites involved, dermatomal distribution, margin of lesion and presence of poliosis were evaluated in both groups. The age of onset was less than 10 years in 96.8% of segmental nevus depigmentosus and 28.9% of segmental vitiligo cases. Trunk (36.5%) and cervical (38.1%) dermatomes were the most commonly involved in segmental nevus depigmentosus and face (67.1%) and trigeminal (64.4%) dermatomes in segmental vitiligo. The average number of dermatomes involved in truncal lesions was different in segmental nevus depigmentosus and segmental vitiligo (2.71 vs 1.62, P = 0.001). Segmental vitiligo on the face, neck and trunk appeared closer to the axis than segmental nevus depigmentosus (P < 0.001). Segmental nevus depigmentosus and segmental vitiligo showed significantly different margins (90.5% and 41.6% serrated, respectively; P < 0.001). We observed clinical differences between patients with segmental nevus depigmentosus and those with segmental vitiligo. Distribution (site, distance to axis, dermatome), vertical width, margin of lesion and presence of poliosis can be helpful in differentiating segmental nevus depigmentosus and segmental vitiligo.

Background Evidence suggests that psoriasis may be associated with metabolic syndrome and an increased risk of cardiovascular disease. Objective To determine whether ustekinumab reduces systemic and vascular inflammation associated with metabolic syndrome and cardiovascular disease, measured using 18 F-fluorodeoxyglucose positron emission tomography/computed tomography ( 18 F-FDG PET/CT). Methods Patients with psoriasis and healthy controls underwent baseline 18 F-FDG PET/CT imaging. Among the patients with psoriasis, moderate to severe psoriasis was treated with ustekinumab, and the patients underwent 18 F-FDG PET/CT again after a Psoriasis Area and Severity Index of 75 was achieved. Results After a Psoriasis Area and Severity Index of 75 was achieved with ustekinumab treatment, standardized uptake values were reduced in the liver, spleen, and five parts of the aorta ( P Limitations Our study does not provide outcome data concerning cardiovascular events or metabolic syndrome; it only shows surrogate markers in a limited (Korean) population. Conclusion Ustekinumab treatment was significantly associated with decreased systemic and vascular inflammation related to metabolic syndrome and cardiovascular disease among patients with psoriasis.

Pigmented purpuric dermatosis (PPD) is a chronic disorder characterized by distinct petechial hemorrhage and brownish pigmentation. The cause of PPD is unclear, but several underlying conditions are associated with it. Previous reports suggest that venous insufficiency (VI) might be related to PPD; however, a clear correlation remains unelucidated.To elucidate the causal relationship between PPD and VI.A total 118 patients diagnosed with PPD in the Department of Dermatology, Pusan National University Hospital from November 2006 to July 2019 were retrospectively reviewed. Doppler ultrasonography of the lower extremities was performed in 56 PPD patients, who were then divided into two groups: PPD with and without VI. We compared the clinical features between the two groups. In the PPD with VI group, we assessed the correspondence ratios between PPD and VI lateralities, and between the PPD distribution and the veins involved.VI was detected in 35 of the 56 patients (62.5%). The PPD with VI group was significantly associated with wider distribution, darker coloration and longer disease duration. There was a positive correlation of laterality between PPD and VI, and between PPD distribution and the vein involved.This findings suggest that VI is a clear provoker of PPD.

Background: When physicians see an umbilical nodule, most of them instinctively recall the Sister Mary Joseph nodule. Therefore, dermatologists need to recognize umbilical dermatoses that can be mistaken for the Sister Mary Joseph nodules. This study aimed to describe the different kinds of benign umbilical tumors as well as elucidate the factors that can be used to distinguish the Sister Mary Joseph nodule from these tumors. Methods: The “benign umbilical tumor” group included 19 patients, whereas the “Sister Mary Joseph nodule” group comprised 30 patients (2 from our department, 28 from PubMed search). We compared the clinical and dermoscopic findings between 2 groups. Results: In the “benign umbilical tumor” group, the most common diagnosis was dermatofibroma (5/19), followed by keloid (3/19), and soft fibroma (3/19). These tumors had various colors (red, brown to black, and flesh colored) and exhibit characteristic surface changes (eg, verrucous changes in epidermal nevi and verrucae). Conversely, most Sister Mary Joseph nodules have an erythematous color, oozing or ulceration on the surface, and nearby satellite lesions. Furthermore, the dermoscopic findings of Sister Mary Joseph nodules showed a polymorphous vascular pattern and a white or milky-red, amorphous area. Benign lesions showed different dermoscopic patterns: pigment networks with white areas (dermatofibromas), thrombosed capillaries (verrucae), and the “pore sign” (epidermal cysts). Conclusions: Various cutaneous tumors can be mistaken for the Sister Mary Joseph nodule when they develop on the umbilicus; the clinical and dermoscopic differences found in this study may be useful for establishing a differential diagnosis.

Background A melanoacanthoma (MA) is a pigmented variant of seborrheic keratosis. Owing to the pigmentation, MAs may mimic the clinical appearance of malignant melanomas (MMs). However, the dermoscopic patterns of MAs and MA-like MMs have rarely been compared. Objective To elucidate the clinical and dermoscopic differences between MAs and MA-like MMs. Methods This study included 77 MA and 33 MA-like MM patients. We retrospectively reviewed the medical records, clinical findings, and dermoscopic findings of the two groups. Results Crypts and comedo-like openings (71.4%) in MAs and the blue-white veil (60.6%) in MMs were the most common dermoscopic findings. Crypts, comedo-like opening, milia-like cysts, fissures, and hairpin vessels appeared more frequently in MAs ( P < .05). However, atypical pigment networks, blue-white veils, pseudopods and streaks, and atypical vessels were more common in MMs ( P < .05). MAs often showed melanoma-specific dermoscopic findings, especially blue-white veils (22.1%). Furthermore, fissures (42.4%), crypts (21.2%), and comedo-like openings (15.2%) were observed in MMs, although they are typically benign patterns. Conclusion Differences in dermoscopic patterns might provide important clues for the differential diagnosis of MA-like lesions. However, MAs such as MMs and true-benign MAs may overlap clinically in appearance and on dermoscopy. Several benign patterns were frequently observed in MMs (fissures, globular pattern, crypts, comedo-like openings, cerebriform appearance, and milia-like cysts), and several malignant patterns were observed in MAs (blue-white veil, pseudopod, and atypical pigment network). Importantly, if any of the melanoma-associated features or atypical vessels are present, the lesion should be biopsied to establish a diagnosis.

Background A minority of infantile hemangiomas showing minimal or arrested growth (IH-MAGs) have been recognized in the literature. Nevertheless, the clinical features and treatment outcomes of IH-MAGs have not been well investigated. Objective This study aimed to understand the clinical characteristics of IH-MAGs better and their response to treatment with topical timolol maleate. Methods We retrospectively reviewed medical records and clinical images of patients with IH-MAGs. Treatment response with topical timolol was assessed in both IH-MAGs and classic infantile hemangiomas (IHs) groups. Results Of the 1,038 patients with IHs, only 31 (3.0%) were diagnosed with IH-MAGs. Lesions with non-proliferative components were more frequently distributed in the lower half of the body (61.5%) than those with proliferative components (16.7%). In 14 patients treated with topical timolol, the global assessment scale showed more significant and rapid improvement than in those with classic IHs. Conclusion Although the prevalence of IH-MAGs may be relatively low, understanding their clinical features will help in differential diagnosis. Furthermore, these type of lesions might be more responsive to topical timolol than classic IHs.

Mohs micrographic surgery (MMS) in cases where the tumor margin is poorly defined to the naked eye can lead to the need to take an increased number of Mohs stages.To evaluate the usefulness of dermoscopy in determining MMS surgical margins of BCCs with a history of ablative laser treatment.Patients were randomly allocated to naked eye (The lateral margin involvement rate at the first MMS stage was significantly lower in the dermoscopy group than in the naked eye group (4.7% vs. 29.0%;The results demonstrated that lateral margin was mostly controlled within the first MMS stage with dermoscopy. Dermatosurgeons could focus on the deep margin after the first MMS stage; thus, the performance of MMS could be improved with dermoscopic assistance in post-laser BCC patients.

Background: Various therapeutic modalities have been implemented for wart treatment, with limited efficacy. Recently, resistant warts treated using quadrivalent human papilloma virus (HPV) vaccine have been reported, although original articles on the efficacy of quadrivalent HPV vaccine on warts are rare. Objective: We performed the present study to evaluate the efficacy of quadrivalent HPV vaccine in the treatment of multiple warts. Methods: We retrospectively reviewed 30 patients from our centers. Patient demographics, clinical features such as duration of disease, number and location of lesions, therapeutic response, and adverse reactions were assessed. Results: Regarding therapeutic response, 14 patients (46.67%) showed "Complete response", 5 (16.67%) showed "Partial response", and 11 (36.67%) showed "No response". There were no statistically significant differences in sex, age, disease duration, and lesion number and location between the three groups divided by treatment response. No severe adverse events after quadrivalent HPV vaccination were noted. Conclusion: The advantage of quadrivalent HPV vaccine in the treatment of warts is that it is more convenient and less painful. HPV vaccine might be a good alternative to conventional destructive methods for incompetent cases such as those including multiple warts, dangerous lesion locations, and uncooperative patients.

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: Psoriasis is a chronic skin disease associated with psychiatric co-morbidities, especially depression. Early detection of psychological vulnerability in patients with psoriasis seems to...

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)

Atrial natriuretic peptide (ANP) is a powerful vasodilating peptide secreted by cardiac muscle cells, and endothelial progenitor cells (EPCs) have been reported to stimulate cutaneous wound healing by mediating angiogenesis. To determine whether ANP can promote the EPC-mediated repair of injured tissues, we examined the effects of ANP on the angiogenic properties of EPCs and on cutaneous wound healing. In vitro, ANP treatment enhanced the migration, proliferation, and endothelial tube-forming abilities of EPCs. Furthermore, small interfering RNA-mediated silencing of natriuretic peptide receptor-1, which is a receptor for ANP, abrogated ANP-induced migration, tube formation, and proliferation of EPCs. In a murine cutaneous wound model, administration of either ANP or EPCs had no significant effect on cutaneous wound healing or angiogenesis in vivo, whereas the coadministration of ANP and EPCs synergistically potentiated wound healing and angiogenesis. In addition, ANP promoted the survival and incorporation of transplanted EPCs into newly formed blood vessels in wounds. These results suggest ANP accelerates EPC-mediated cutaneous wound healing by promoting the angiogenic properties and survival of transplanted EPCs.