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Background: Hand eczema is one of the most common skin disorders and negatively affects quality of life. However, a large-scale multicenter study investigating the clinical features of patients with hand eczema has not yet been conducted in Korea. Objective: To identify the prevalence of various hand diseases, which is defined as all cutaneous disease occurring in hands, and to investigate the clinical features of patients with hand eczema and the awareness about hand eczema in the general population and to compare the prevalence of hand eczema between health care providers and non-health care providers. Methods: To estimate the prevalence of hand diseases, we analyzed the medical records of patients from 24 medical centers. Patients were assessed by online and offline questionnaires. A 1,000 from general population and 913 hand eczema patients answered the questionnaire, for a total of 1,913 subjects. Results: The most common hand disease was irritant contact dermatitis. In an online survey, the lifetime prevalence of hand eczema was 31.2%. Hand eczema was more likely to occur in females (66.0%) and younger (20∼39 years, 53.9%). Health care providers and housewives were the occupations most frequently associated with hand eczema. Winter (33.6%) was the most common season which people experienced aggravation. The 63.0% and 67.0% answered that hand eczema hinders their personal relationship and negatively affects daily living activities, respectively. Conclusion: Hand eczema is a very common disease and hinders the quality of life. The appropriate identification of hand eczema is necessary to implement effective and efficient treatment. (Ann Dermatol 28(3) 335∼343, 2016)

Dear Editor: Eosinophilic pustular folliculitis (EPF) is an inflammatory disease that is characterized by pruriticfollicular papules and pustules. Several reported cases showing an association between EPF and hematological diseases as well as a high proportion of EPF cases in HIV-positive patients suggest that immunological aberrations might play a role in the development of EPF. A 56-year-old man who underwent kidney transplantation 18 years ago presented with multiple papules on cheeks (Fig. 1). He was treated with cyclosporine (150 mg daily) and mycophenolate mofetil (MMF; 1,500 mg daily). Blood analysis yielded a white blood cell count of 12,000 cells/mm3 (12.1% eosinophils). Tests for HIV were also negative. Skin biopsies led to the diagnosis of chronic active folliculitis of the dermis with eosinophilic and lymphocytic infiltration (Fig. 2). With the results suggesting a diagnosis of EPF, we treated the patient with 50 mg per day dapsone. After 3 weeks, the lesions showed gradual resolution. According to recent reports, shifts in the T-helper type 2 (Th2) cytokine expression profile are believed to underlie the pathogenesis. This notion is compatible with the observation that interleukin-5 levels increase in the serum of patients with EPF. On the basis of this theory, cyclosporine and tacrolimus, which demonstrate inhibitory effects on the transcription of proinflammatory cytokine genes, were used to treat EPF; successful results had been obtained1,2. In this case, however, although the patient had used cyclosporine and MMF for many years, EPF still developed. This indicates that aberrant Th2 immune responses alone cannot explain the pathogenesis of EPF. In addition, members of the prostaglandin family operate downstream of cyclooxygenase can be successfully treated with indomethacin, a cyclooxygenase inhibitor3. A previous study reported that a drug of the same class, naproxen, also had a therapeutic effect on EPF4. The symptoms of our patient were alleviated after the administration of dapsone. This indicates that EPF in patients using immunosuppressants can be treated with drugs having anti-inflammatory effects. Dapsone functions as an anti-inflammatory and immunomodulatory agent, and has also been shown as an efficacious treatment option5. The pathogenesis of this case is thought to be similar to those of cases that developed after bone marrow or stem cell transplantation in HIV-negative patients. These patients tended to develop EPF after transplantation, even when the underlying hematologic diseases were in remission. The one thing in common was that used immunosuppressant. Moreover, although the duration of treatment was different, EPF developed after immunosuppressant administration in all cases. There are also some differences in etiology because solid organ transplantations do not cause critical immunological changes similar to that caused by bone marrow or stem cell transplantation. Ironically, the use of immunosuppressants, which are administered to organ transplant recipients, may explain why there has been no report on EPF in transplant recipients until now. As the survival outcomes of transplant recipients improve in the future, EPF infiltration in transplant patients may increasingly occur. For such cases, antiinflammatory drugs such as dapsone and indomethacin should be the first treatment option.The patient was fully informed and consented to the publication of the case. Fig. 1 Multiple papule and plaque with hyperpigmentation and induration on face. Fig. 2 Dense perifollicular eosinophilic and lymphocytic infiltration (H&E, ×100).

Dear Editor: Colophony, known as rosin, and its derivatives are ubiquitous in our environments. As shown by patch tests, allergies to rosin are relatively common and are increasingly prevalent1. According to previous studies, many of these allergies are due to the rosin content of printing inks, adhesives, chewing gum, and sports grips1. However, rosin is also present in benzoin spray, which is used to provide a mild protective coating to the skin before the application of surgical tape, adhesive straps, casting material, and orthopedic appliances. We present a case of allergic contact dermatitis due to rosin in benzoin spray. A 51-year-old woman was referred for erythematous lesions including yellow blisters on her nose and both cheeks (Fig. 1A). She had undergone rhinoplasty 2 days before her presentation. One day prior, she had received dressings with benzoin spray to protect the skin from the bandages. When she removed the dressings 1 day before her visit, she found severe erythematous lesions with yellow blisters under the area that had been covered with the benzoin spray-treated tape. Contact dermatitis due to the benzoin spray treatment was suspected. After her first visit, she was treated with prednisolone (12.5 mg/day) and clobetasol propionate ointment (0.05%). Four days later, she was discharged because her lesions had improved and the blisters had disappeared (Fig. 1B). We performed patch testing to confirm the diagnosis with the Korean standard and a fragrance series, but not 'as is' patch testing. This was the limitation of our report. Reactions were scored according to the criteria of the International Contact Dermatitis Research Group. Results observed on days 2 and 4 indicated reactions to colophony (grade 2+ with erythema and mild discrete vesicles) and sandalwood oil (grade 1+ with light edema) (Fig. 2). On the basis of these findings and because contact dermatitis was still considered the main diagnosis, we suspected that the rosin in the benzoin spray might have induced the allergic contact dermatitis observed in our patient. Fig. 1 (A) Erythematous lesions with some yellow blisters on the nose and both cheeks. (B) Four days later, the lesions improved. Fig. 2 (A) Reaction on day 2. (B) Results on day 4, showing reactions to colophony (rosin) and sandalwood oil. Right arrow (→): rosin, left arrow (←): sandalwood oil. Benzoin spray consists of the fluid extract of 25% benzoin Sumatra and 75%~80% alcohol that contains aloes, tolu balsam, ethanal, benzoin, rosin, 15%~25% ethyl alcohol, 30%~45% isopropyl alcohol, and isobutene. Rosin chiefly consists of different resin acids, especially abietic acid2. Meaningful conclusions about the prevalence of rosin allergies are difficult to draw from currently published studies. It is certainly a common finding of patch tests performed in clinics, and may be more prevalent in persons who perform particular jobs or receive various types of exposure. Identifying a relevant sensitizing episode may be difficult because rosin is widely used. Among English patients with occupational dermatitis, 4.1% were allergic to colophony, most of whom were employed in the furniture industry3; on the other hand, 1.3% of Swedish house painters were patch-test positive for colophony4. Contact dermatitis due to rosin in benzoin spray has not been reported previously; therefore, we present this case, which indicates that dermatologists should be careful when using benzoin spray in skin dressings.

Background: A Pyrosequencing assay has been used in identification of fungal species such as Candida or Aspergillus and diagnosis of pathogenic bacteria such as Helicobacter pylori but there has been no report on successful isolation and identification of Malassezia yeasts using the pyrosequencing method. Objective: Examine the applicability and plausibility of the pyrosequencing method in identification of the Malassezia species. Methods: At internal transcribed spacer (ITS) sites 1 and 2, three primers were developed using Pyrosequencing Assay Design Software (Biotage AB). Pyrosequencing was performed on 11 standard strains and 83 genomic DNA samples obtained from 66 healthy controls aged from 1 to 80. Results: The eleven Malassezia standard species and 83 genomic DNA samples were successfully identified using the pyrosequencing assay. Conclusion: The pyrosequencing method is a new tool for analysis of Malassezia yeasts, and its precision and rapidity suggests its clinical applicability. (Ann Dermatol 25(1) 73∼ 79, 2013)

A wedge-shaped anterior hairline extension is a very rare skin manifestation usually associated with congenital anomalies including a Tessier number 10 cleft. Other associated conditions are the Tessier number 9 cleft, the Fraser syndrome, and the Manitoba oculotrichoanal syndrome (MOTA syndrome). The Tessier number 10 cleft features include a coloboma of the middle third of the upper eyelid, and an eyebrow divided into two portions. The medial eyebrow portion may be absent and the lateral portion is angulated vertically, joining the hairline of the scalp. This creates a wedge-shaped anterior hairline extension. Herein we report on a case of a wedge-shaped anterior hairline extension associated with the Tessier number 10 cleft.

Background Subcutaneous panniculitis-like T-cell lymphoma (SPTL) is a distinctive skin lymphoma characterized by neoplastic T-cell infiltration of the subcutaneous tissue, mimicking panniculitis. Objective To describe the clinical and pathologic features of SPTL in Korean patients. Methods Fourteen SPTL patients evaluated over 15 years were retrospectively reviewed. Results The mean patient age was 35 years (range: 7~73 years), with male predominance (2.5:1). Most patients presented with either nodules or plaques, occurring most commonly on the trunk, with two patients (14%) having hemophagocytic syndrome. Histopathologically, all patients showed infiltrates of small-to-medium pleomorphic cells mimicking panniculitis, with some also showing rimming, bean-bag cells, and fat necrosis. Most patients were positive for CD3 (14/14), CD8 (12/13), TIA-1 (9/9) and βf1 (5/5), but were negative for CD4 (11/12), CD20 (8/8), CD56 (14/14) and Epstein-Barr virus (8/8). Ten patients (71%) received chemotherapy and 2 (14%) died due to the disease, with an average survival time of 4 months. Survival analysis did not reveal any significant prognostic factors. Conclusion This is the first series of patients with SPTL in Korea. Due to its indolent clinical course and relatively high survival rate, SPTL should be differentiated from cutaneous γδ T-cell lymphoma.

Tumor of the follicular infundibulum (TFI) is an uncommon benign adnexal tumor that usually presents as a solitary keratotic papule on the face or scalp of elderly patients. Histopathologically, it typically manifests as a plate-like fenestrated proliferation of monomorphic pale-staining cells. A 76-year-old male presented with about a 2 cm, well-defined, yellowish to brownish, slightly elevated, twisted and bent, interrupted, cord-like plaque on his left lower abdomen. Microscopic examination revealed a sharply demarcated plate-like proliferation of pale cells localized in the papillary dermis with multiple connections to the overlying epidermis. The histopathological features were compatible with TFI, except for foci of sebaceous differentiation. There has been one previous case report of TFI with sebaceous differentiation in the English medical literature. Herein, we report on a singular case of TFI with sebaceous differentiation.

Dear Editor: Epidermolytic acanthoma (EA) was first reported in 1970 when six patients with solitary tumors clinically resembled warts were observed. Histologically these tumors showed epidermolytic hyperkeratosis (EH) without features of other epidermal tumors1. The exact etiology of EA remains unknown, but immunosuppression is thought to be associated with EA although case report is lacking. A 64-year-old man presented with a solitary papule on his scrotum. The lesion first appeared 7 years earlier and had gradually grown over time, but had not triggered symptoms such as itching or pain. This patient had no history of similar skin lesions. He had received a kidney transplant 7 years previously, and noted the scrotal lesion occurred immediately after starting an immunosuppressive regimen, consisted of tacrolimus (1 mg/day), azathioprine (50 mg/day), and deflazacort (6 mg/day). In addition, this patient also had type 2 diabetes and hypertension, both of which were controlled by medication. There was no family history of skin disease. Physical examination showed a solitary, brownish, verrucous, and keratotic papule, 1 cm in diameter, on the left side of the scrotum (Fig. 1). Histologic examination of a shave biopsy specimen of the lesion showed orthokeratotic hyperkeratosis, papillomatosis, and acanthosis. Hypergranulosis was also noted, and the cells of the granular and upper spinous layers contained numerous, large, clear, perinuclear space with basophilic keratohyaline granules and eosinophilic materials (Fig. 2). As a result of these clinical and histological findings, the patient was diagnosed with isolated EA. The scrotal lesion resolved after ablative CO2 laser treatment, with no evidence of recurrence during a 1-year follow-up period. Fig. 1 A solitary, brown papule, measured 1 cm in diameter, with a verrucous surface on the scrotum. Fig. 2 Histologic examination of the scrotal lesion showing epidermolytic hyperkeratosis: vacuolar degeneration, increased keratohyaline-like bodies, hypergranulosis and compact hyperkeratosis (A: H&E, ×40, B: H&E, ×400). EA is a solitary tumor that histologically shows EH without features of other epidermal tumors. EA is considered to be an acquired benign tumor, typically occurs in middle-aged adults. The lesions are characteristically brownish papules less than 1 cm in diameter with a verrucous surface. EA can be classified into solitary and disseminated subtypes, called isolated epidermolytic acanthoma (IEA) and disseminated epidermolytic acanthoma (DEA), respectively. Isolated lesions may occur anywhere on the body, but the disseminated subtype usually occurs on the back and the genitoscrotal area. EA is characterized histologically by EH, which consists of random-sized clear spaces around the nuclei in the stratum spinosum and granulosum, reticulated, lightly-staining material forming indistinct cellular boundaries, a markedly thickened granular zone containing an increased number of small and large, irregularly shaped basophilic keratohyaline-like bodies, and compact hyperkeratosis2. EH may be congenital or acquired. Congenital EH includes bullous congenital ichthyosiform erythroderma, systemized epidermal nevus, and hereditary palmoplantar keratosis, whereas acquired EH include IEA and DEA. The etiology of EA remains unknown and the differences between IEA and DEA in the pathogenesis are also unclear. Mutations in the keratin 1 and 10 genes have been observed in IEA3. EA may also be induced by exogenous factors, such as viruses or trauma. Human papillomavirus (HPV) was thought to be a cause of EA, because of the wart-like appearance, but these lesions have not been found to contain HPV DNA4. Immunosuppression has been known to be associated with the pathogenesis of DEA. Immunosuppression could inhibit immune surveillance, preventing abnormal keratinocyte clones from being recognized or removed. Alternatively, immunosuppression may allow latent abnormal keratinocyte clones to proliferate. To date, DEA with disseminated superficial porokeratosis and verruca vulgaris has been observed in a kidney transplant patient5, and DEA has also been observed after PUVA6. Although our patient had a solitary lesion and the possibility of coincidental occurrence of IEA may exist, this case suggests that IEA could be associated with immunosuppression, because the skin lesion had appeared immediately after commencing immunosuppressive treatment. Further case reports and studies are needed to elucidate the relationship between immunosuppression and EA.

There have been no long-term complications or life-threatening adverse effects related to botulinum toxin treatment for any cosmetic indications. Nevertheless, there are well-known, mild side effects of botulinum toxin treatment on the upper face, though most of them are self limited with time. However, excluding brow ptosis, reports about site specific side effects are few and anecdotal. We experienced cases of exaggeration of wrinkles after botulinum toxin injection for forehead horizontal lines, and report them here. In our cases, new appearance of a noticeable glabellar protrusion following botulinum toxin injection on the forehead was observed in 2 patients. Also, a new deep wrinkle on one side of the forehead just above the eyebrow appeared in another 2 patients. The exaggerated wrinkles nearly disappeared without treatment by week 4 in all subjects. These exaggerations of wrinkles may be caused by hyperactivity and overcompensation of untreated muscles. With the increasing availability of diverse botulinum toxin for cosmetic purposes, physicians and patients should be aware of this temporary change after therapeutic injections. We recommend explaining this possible effect prior to injection, for better understanding of treatment for cosmetic indications.

Erdheim-Chester disease (ECD) is a rare, non-Langerhans cell histiocytosis of unknown etiology, characterized by multi-organ involvement. ECD is usually diagnosed on the basis of characteristic radiologic and histopathological findings. Lesions may be skeletal and/or extraskeletal in location, and may include the skin, lung, heart, and central nervous system. We describe here a 68-year-old man with multiple yellowish plaques and a pinkish nodule on his face and scalp. He had been previously diagnosed with diabetes insipidus, and recently complained of coughing and dyspnea. Imaging studies showed multiple osteosclerotic lesions of the bones, a moderate amount of pericardial effusion, and multifocal infiltrative lesions in the perirenal space. Histopathological examination of the skin lesions revealed dermal infiltration of foamy histiocytes with multinuclear giant cells. Moreover, laparoscopic biopsy of the perirenal tissue revealed fibrosis with infiltrating foamy histiocytes being CD68-positive and S100-negative. Based on these findings, he was diagnosed with ECD with extraskeletal manifestations, and treated with interferon-alpha.

Background: Acquired bilateral nevus of Ota-like macules (ABNOM) is a dermal pigmented lesion common in individuals of Oriental origin. The Q-switched Nd:YAG laser (QSNYL) has been used successfully to treat a variety of benign, dermal, pigmented lesions, including nevus of Ota lesions. The similarity between ABNOM and nevus of Ota suggested that QSNYL may also be effective in the former. Objective: To determine the efficacy and side-effect profiles of QSNYL treatment of ABNOM in Korean patients. Methods: Of 42 Korean patients with ABNOM, 29 were treated with QSNYL (1,064 nm, 3 mm spot size, fluence 8∼ 9.5 J/cm 2 ), for up to 10 sessions each. Clinical photographs were taken before and after treatment. Lesion clearance was graded and complications such as hyperpigmentation, scarring, hypopigmentation, and erythema were assessed. Results: Of the 29 treated patients, 19 (66%) showed excellent or good results. Of the patients who were treated more than 3 times, 76% showed good to excellent results. Two patients experienced post-laser hyperpigmentation (PLH), which persisted for more than one month, but no patient experienced persistent erythema or hypertrophic scarring. Conclusion: QSNYL is safe and effective in the treatment of ABNOM in Korean patients. Short-interval repetitive treatment is especially useful in improving therapeutic results and reducing PLH. (Ann Dermatol 21(3) 255∼260, 2009)

Merkel cell carcinoma is a rare aggressive primary cutaneous neuroendocrine skin cancer arising from the basal epidermis. Although the majority of patients with non-melanoma skin cancer are cured by local treatment, patients with Merkel cell carcinoma have a poor outcome characterized by locoregional and distant relapse. No standard treatment protocol for Merkel cell carcinoma exists. But, there is mounting evidence that combined treatment, incorporating adjuvant radiotherapy, improves the outcome (locoregional control and disease-free survival) compared with surgery alone in most patients. Herein we report a case of Merkel cell carcinoma treated with wide local excision and post-operative radiotherapy.

Neuroendocrine carcinoma is known to have features of neuroendocrine and epithelial differentiation through immunohistochemical and biochemical investigation. Cutaneous metastatic neuroendocrine carcinoma must be differentiated from Merkel cell carcinoma, a primary cutaneous neuroendocrine carcinoma and metastatic carcinoma from other visceral disease. Cutaneous metastases from neuroendocrine carcinomas of a variety of sites including the uterus, vulva, gall bladder and fallopian tubes have been reported. We report a 58-year-old Korean man with a metastatic skin tumor on his scalp from rectal neuroendocrine carcinoma. (Ann Dermatol (Seoul) 19(4) 163～165, 2007)