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This is an abridged edition of English version of the Clinical Practice Guidelines for the Management of Atopic Dermatitis 2021. Atopic dermatitis (AD) is a disease characterized by relapsing eczema with pruritus as a primary lesion. In Japan, from the perspective of evidence-based medicine, the current strategies for the treatment of AD consist of three primary measures: (i) use of topical corticosteroids, tacrolimus ointment, and delgocitinib ointment as the main treatment of the inflammation; (ii) topical application of emollients to treat the cutaneous barrier dysfunction; and (iii) avoidance of apparent exacerbating factors, psychological counseling, and advice about daily life. In the present revised guidelines, the description about three new drugs, namely, dupilumab, delgocitinib, and baricitinib, has been added. The guidelines present recommendations to review clinical research articles, evaluate the balance between the advantages and disadvantages of medical activities, and optimize medical activity-related patient outcomes with respect to several important points requiring decision-making in clinical practice.

Summary Background Baricitinib, an oral selective Janus kinase (JAK)1 and JAK 2 inhibitor, was shown to improve the signs and symptoms of moderate-to-severe atopic dermatitis (AD). Objectives To evaluate the efficacy and safety of baricitinib with background topical corticosteroids (TCS) in patients with moderate-to-severe AD and inadequate response, intolerance or contraindication to ciclosporin A (CA). Methods In this double-blind, randomized, placebo-controlled, phase III study, patients were randomized 1: 1: 2: 1 to placebo (N = 93), baricitinib 1 mg (N = 93), 2 mg (N = 185) or 4 mg (N = 92) with background TCS. The primary endpoint was the proportion of patients receiving baricitinib 4 mg or 2 mg (+ TCS) vs. placebo + TCS who achieved ≥ 75% improvement from baseline in the Eczema Area and Severity Index (EASI 75) at week 16. Results Baricitinib 4 mg + TCS was superior to placebo + TCS for EASI 75 (4 mg: 32%, placebo: 17%, P = 0·031) at week 16 and for improvements in itch, skin pain and number of night-time awakenings owing to itch. Improvements were maintained through 52 weeks of treatment. Treatment-emergent adverse events (TEAEs) were more common with baricitinib than placebo (+ TCS); most were mild or moderate. The most frequent TEAEs with baricitinib 4 mg + TCS were nasopharyngitis, herpes simplex, influenza and headache. No deaths or deep vein thromboses were reported. Conclusions Baricitinib 4 mg + TCS improved the signs and symptoms of moderate-to-severe AD through 52 weeks of treatment in patients with inadequate response, intolerance or contraindication to CA. The safety profile was consistent with previous studies of baricitinib in moderate-to-severe AD. What is already known about this topic? Ciclosporin A is indicated for the treatment of atopic dermatitis that is refractory to topical therapies. However, its use is limited by safety concerns and it may not provide adequate response for some patients. Baricitinib, an oral selective Janus kinase (JAK)1 and JAK2 inhibitor, has been shown to improve the signs and symptoms of moderate-to-severe atopic dermatitis as a monotherapy or in combination with topical corticosteroids. What does this study add? Baricitinib combined with background low- or moderate-potency topical corticosteroids provided improvements in the signs and symptoms of moderate-to-severe atopic dermatitis through 1 year of treatment in patients with a contraindication, intolerance or failure to respond to ciclosporin A. The most common treatment-emergent adverse events with baricitinib 4 mg were nasopharyngitis, herpes simplex, influenza and headache. The safety profile was consistent with previous studies in patients with moderate-to-severe atopic dermatitis.

Dermal papilla cells (DPCs) are one type of mesenchymal cells; they play a key role on hair follicle induction. Their hair inductivity and proliferation abilities are rapidly lost during the 2-dimensional culture. Cell senescence is induced by inadequate culture conditions and telomere shortening. We previously reported that overexpression of TERT coding telomerase reverse transcriptase and BMI1 coding human B-cell-specific Moloney murine leukemia virus insertion region 1 (BMI1) avoided senescence of murine DPC and restored hair inductive activity.To evaluate the function of TERT and BMI1 in the human DPCs (hDPCs).Cultured hDPCs obtained from human scalp hair were transduced with TERT alone (hDP-T), BMI1 alone (hDP-B), both TERT and BMI1 (hDP-TB) and empty vector (hDP-E). The hair inductive activity of those cells was assessed by chamber assay in vivo. Gene expressions were analyzed by quantitative PCR (q-PCR).hDP-TB proliferated more than hDP-T and hDP-B in vitro and only hDP-TB showed hair inductivity in vivo. Moreover, the expressions of VCAN, CTNNB1, LEF1, FGF7 and VEGFA in hDP-TB were elevated compared to those in hDP-E.Overexpression of both TERT and BMI1 extends the life span of cultured hDPCs and ameliorates their hair inducing ability on mouse hair follicles.

This is the English version of guidance for the use of oral Janus kinase (JAK) inhibitors in the treatment of atopic dermatitis. Several cytokines, such as interleukin (IL)-4, IL-13, IL-22, IL-31, thymic stromal lymphopoietin, and interferon-γ, are involved in the pathogenesis of atopic dermatitis. As oral JAK inhibitors hinder the JAK-signal transducers and activators of transcription signal transduction routes involved in the signal transduction of these cytokines, they may be effective for the treatment of atopic dermatitis. In Japan, as oral JAK inhibitors for atopic dermatitis, a JAK1/2 inhibitor, baricitinib, expanded its authorized indications for atopic dermatitis in 2020. Consequentially, a JAK1 inhibitor, upadacitinib, also expanded its indications to atopic dermatitis in 2021, followed by new approval of another JAK1 inhibitor, abrocitinib, for the use under the Japanese health insurance system. Physicians who intend to use them should sufficiently understand and comply with contents of guidelines prepared by the Japanese Ministry of Health, Labour and Welfare to promote optimal use of these drugs. In the treatment with oral JAK inhibitors, it is important to sufficiently consider disease factors, treatment factors and patient backgrounds, and share them with patients to choose treatment options. Points to be considered for drug selection include the efficacy and safety of drugs, age of patients, and dosage and administration of the drug. This guidance was developed for board certified dermatologists, who are specialized in the treatment of atopic dermatitis, and for promoting proper use of oral JAK inhibitors, taking into account a variety of factors in individual patients.

This is the English version of the Clinical Practice Guidelines for the Management of Atopic Dermatitis 2021. Atopic dermatitis (AD) is a disease characterized by relapsing eczema with pruritus as a primary lesion. In Japan, from the perspective of evidence-based medicine, the current strategies for the treatment of AD consist of three primary measures: (i) use of topical corticosteroids, tacrolimus ointment, and delgocitinib ointment as the main treatment of the inflammation; (ii) topical application of emollients to treat the cutaneous barrier dysfunction; and (iii) avoidance of apparent exacerbating factors, psychological counseling, and advice about daily life. In the present revised guidelines, descriptions of three new drugs, namely, dupilumab, delgocitinib, and baricitinib, have been added. The guidelines present recommendations to review clinical research articles, evaluate the balance between the advantages and disadvantages of medical activities, and optimize medical activity-related patient outcomes with respect to several important points requiring decision-making in clinical practice.

We report a rare case of xanthomatized Sweet's syndrome with myelodysplastic syndrome (MDS) in a patient who presented with erythematous plaques on his chest that were elevated and became yellowish. A diagnosis of MDS with single lineage dysplasia was made during the development of the eruption. Bone marrow biopsy showed an increased number of megakaryoblasts. Histopathologically, there was neutrophil infiltration with leukocytoclasia and the infiltration of xanthomatous cells. Immunohistochemical analysis revealed that the xanthomatized cells were predominantly CD163 positive. We propose that our case of xanthomatized neutrophilic dermatosis is a rare clinicopathological variant of Sweet's syndrome associated with a hematologic disorder.

The goal of a treatment regimen for atopic dermatitis is to reach and maintain a state where the patient exhibits mild symptoms or an absence of symptoms, and the patient should not experience disturbance during daily activities. The basis of a treatment regimen for atopic dermatitis is topical therapy, and currently there exist topical corticosteroids, tacrolimus and delgocitinib. Using these, proactive therapy is performed as maintenance therapy after remission induction therapy. However, in cases of moderate to severe atopic dermatitis, topical drugs alone cannot induce remission and systemic therapies such as cyclosporin, ultraviolet therapy, and dupilumab should be used in combination. In particular, dupilumab has many advantages such as high efficacy, relatively few adverse reactions, and ease of use in elderly patients with severe atopic dermatitis. In this review, we present a treatment algorithm for atopic dermatitis that emphasizes the importance of maintaining remission after induction of remission, and summarizes the characteristics of current medication therapy for atopic dermatitis in Japan.

The "Guidelines for the management of dermatomycosis" of the Japanese Dermatological Association were first published in Japanese in 2009 and the Guidelines Committee of the Japanese Dermatological Association revised it in 2019. The first guidelines was prepared according to the opinions of the Guidelines Committee members and it was of educational value. The revised version is composed of introductory descriptions of the disease concepts, diagnosis, medical mycology and recent advances in treatment, along with clinical questions (CQ), which is intended to help in general practice for dermatologists. The CQ are limited to those involved in therapy but include some of the recently launched antifungal agents. The level of evidence and the degree of recommendation for each item were reviewed by the committee based on clinical studies published by 2018. For rare dermatomycoses, recommendations by the committee are described in the guidelines. In this field, there are still few good quality studies on treatment. Periodic revision in line with new evidence is necessary.

Asteatosis is characterized by decreased stratum corneum water content, and the basic treatment is to keep the skin moisturized. Poor application of moisturizers by patients may reduce treatment efficiency, so it is important to continue application as instructed by dermatologists. Application instructions based on the finger-tip unit are useful for patients, but there is no clear evidence of its efficacy. We investigated the effects of the volume of the moisturizer (Hirudoid® Cream 0.3%) administrated with 1/3 finger-tip unit and 1 finger-tip unit equivalent doses per target lower leg of patients with asteatosis (twice daily, 28 days) on the overall dry skin scores, itch numerical rating scale scores, and skin physiological parameters (stratum corneum water content, transepidermal water loss, and skin pH). Sixty patients were randomized with a 1:1 allocation ratio into two groups: the 1/3 finger-tip unit and 1 finger-tip unit equivalent dose groups. The results showed that 43.3% of the patients in the 1 finger-tip unit equivalent dose group, compared with 13.3% in the 1/3 finger-tip unit equivalent dose group, presented zero overall dry skin scores 1 week later. As the overall dry skin scores improved, the stratum corneum water content also increased. In patients with moderate itching, the itch numerical rating scale scores of the 1 finger-tip unit equivalent dose group decreased significantly compared with those of the 1/3 finger-tip unit equivalent dose group. The results suggested that the application of 1 finger-tip unit equivalent dose of the moisturizer twice daily in clinical practice could induce remission more quickly. With the 1/3 finger-tip unit equivalent dose, prolonged treatment may be necessary to achieve the desired effect; therefore, application adherence is strictly required. In conclusion, the application of a 1 finger-tip unit equivalent dose would be quite reasonable in clinical practice.

Purpose The primary aim of this study was to compare patient reported versus clinician-observed nonulcerative foot conditions in patients attending a diabetic foot clinic and deemed at risk for diabetic foot ulcers. Design Retrospective review of medical records. Subjects and setting The medical records of 126 patients with diabetes mellitus and deemed at risk for developing diabetic foot ulcers were reviewed. All patients received care from a diabetic foot outpatient clinic in a university-based hospital in Tokyo, Japan, between November 2008 and October 2009. Methods We compared patients' self-identified foot complaints with clinically observable conditions affecting the feet of these individuals with diabetes mellitus. Patients' medical records were retrieved, and patient complaints and identified preulcerative signs of the foot were documented. All clinical observations were made by nurse specialists with knowledge of diabetic foot conditions. Nonulcerative diabetic foot conditions we observed included calluses, corns, abnormal nails, fissures, tinea pedis, and tinea unguium. Patient sensitivity to correctly identify these signs was calculated using the following formula: patient-reported foot signs divided by clinically identified preulcerative signs. Results Patient sensitivity for identifying nonulcerative signs varied based on the foot condition was 51.4% for calluses, 47.8% for pincer nails, 44.4% for corns, 33.3% for fissures, 19.4% for nail abnormalities, 3.9% for scales/maceration between the toes, 2.6% for interdigital tinea pedis, and 18.2% for tinea unguium. Conclusion These findings suggest that persons with diabetes vary in their awareness of conditions affecting their feet and enhancing their risk for the development of diabetic foot ulcers. We recommend additional education on foot-related self-care including how often to observe their feet and how to recognize symptoms that may elevate their risk for diabetic foot ulcers.

The incidence of cancers in atopic dermatitis (AD) is not increased, although the Th2-dominant environment is known to downregulate tumor immunity. To gain mechanistic insights regarding tumor immunity in AD, we utilized CCL17 transgenic (TG) mice overexpressing CCL17, which is a key chemokine in AD. Tumor formation and lung metastasis were accelerated in CCL17 TG mice when melanoma cells were injected subcutaneously or intravenously. Flow cytometric analysis showed increases in regulatory T cells (Tregs) in lymph nodes in CCL17 TG mice with high mRNA levels of IL-10 and Foxp3 in tumors, suggesting that Tregs attenuated tumor immunity. The frequency of myeloid-derived suppressor cells (MDSCs), however, was significantly decreased in tumors of CCL17 TG mice, suggesting that decreased MDSCs might promote tumor immunity. Expression of CXCL17, a chemoattractant of MDSCs, was decreased in tumors of CCL17 TG mice. Depletion of Tregs by the anti-CD25 antibody markedly reduced tumor volumes in CCL17 TG mice, suggesting that tumor immunity was accelerated by the decrease in MDSCs in the absence of Tregs. Thus, CCL17 attenuates tumor immunity by increasing Tregs and Th2 cells, while it decreases MDSCs through reductions in CXCL17, which may work as a “safety-net” to reduce the risk of malignant tumors in the Th2-dominant environment.

Skin trait variation impacts quality-of-life, especially for females from the viewpoint of beauty. To investigate genetic variation related to these traits, we conducted a GWAS of various skin phenotypes in 11,311 Japanese women and identified associations for age-spots, freckles, double eyelids, straight/curly hair, eyebrow thickness, hairiness, and sweating. In silico annotation with RoadMap Epigenomics epigenetic state maps and colocalization analysis of GWAS and GTEx Project eQTL signals provided information about tissue specificity, candidate causal variants, and functional target genes. Novel signals for skin-spot traits neighboured AKAP1/MSI2 (rs17833789; P = 2.2 × 10−9), BNC2 (rs10810635; P = 2.1 × 10−22), HSPA12A (rs12259842; P = 7.1 × 10−11), PPARGC1B (rs251468; P = 1.3 × 10−21), and RAB11FIP2 (rs10444039; P = 5.6 × 10−21). HSPA12A SNPs were the only protein-coding gene eQTLs identified across skin-spot loci. Double edged eyelid analysis identified that a signal around EMX2 (rs12570134; P = 8.2 × 10−15) was also associated with expression of EMX2 and the antisense-RNA gene EMX2OS in brain putamen basal ganglia tissue. A known hair morphology signal in EDAR was associated with both eyebrow thickness (rs3827760; P = 1.7 × 10−9) and straight/curly hair (rs260643; P = 1.6 × 10−103). Excessive hairiness signals’ top SNPs were also eQTLs for TBX15 (rs984225; P = 1.6 × 10−8), BCL2 (rs7226979; P = 7.3 × 10−11), and GCC2 and LIMS1 (rs6542772; P = 2.2 × 10−9). For excessive sweating, top variants in two signals in chr2:28.82-29.05 Mb (rs56089836; P = 1.7 × 10−11) were eQTLs for either PPP1CB or PLB1, while a top chr16:48.26–48.45 Mb locus SNP was a known ABCC11 missense variant (rs6500380; P = 6.8 × 10−10). In total, we identified twelve loci containing sixteen association signals, of which fifteen were novel. These findings will help dermatologic researchers better understand the genetic underpinnings of skin-related phenotypic variation in human populations.

A placebo‐controlled, randomized, double‐blind, parallel‐group, comparative, multicenter study was conducted to investigate the efficacy and safety of benzoyl peroxide (BPO) gel, administrated once daily for 12 weeks to Japanese patients with acne vulgaris. Efficacy was evaluated by counting all inflammatory and non‐inflammatory lesions. Safety was evaluated based on adverse events, local skin tolerability scores and laboratory test values. All 609 subjects were randomly assigned to receive the study products (2.5% and 5% BPO and placebo), and 607 subjects were included in the full analysis set, 544 in the per protocol set and 609 in the safety analyses. The median rates of reduction from baseline to the last evaluation of the inflammatory lesion counts, the primary end‐point, in the 2.5% and 5% BPO groups were 72.7% and 75.0%, respectively, and were significantly higher than that in the placebo group (41.7%). No deaths or other serious adverse events were observed. The incidences of adverse events in the 2.5% and 5% BPO groups were 56.4% and 58.8%, respectively; a higher incidence than in the placebo group, but there was no obvious difference between the 2.5% and 5% BPO groups. All adverse events were mild or moderate in severity. Most adverse events did not lead to study product discontinuation. The results suggested that both 2.5% and 5% BPO are useful for the treatment of acne vulgaris.

The dermatophyte antigen kit uses monoclonal antibodies that react with polysaccharides present in the dermatophyte cell wall to detect dermatophyte antigens in specimens based on the principle of immunochromatography. Clinical studies showed that the kit was very useful in the diagnosis of tinea unguium but not tinea pedis. The kit was therefore further developed as an in vitro diagnostic tool for tinea unguium and was approved by the Pharmaceuticals and Medical Devices Agency of Japan. The kit's extraction solution can extract antigens from nail specimens quickly and efficiently. When direct microscopy fails to detect fungal elements in a specimen of suspected tinea unguium, the kit can be used so that positive samples are re-examined by direct microscopy, in order to reduce the likelihood of false-negative detection. In addition, in settings where direct microscopy is unavailable, the kit can be used so that treatment for dermatophytes is withheld when results are negative. Such an approach can reduce both wasteful treatment and medical costs. It is important to note that the kit is used to complement conventional fungus testing methods and that direct microscopy must be used to confirm the final morphological diagnosis of the pathogenic fungal infection. Use of a combination of direct microscopy and this kit should improve the accuracy of diagnosis of tinea unguium.

In the current study, we present guidelines for the diagnosis and treatment of the mucocutaneous lesions of Behcet's disease, which is a chronic inflammatory disease characterized by the involvement of various organs, including mucocutaneous, ocular, vascular, intestinal and central nervous system lesions. It is often identified in the Middle East Mediterranean to East Asia region. Skin manifestations include erythema nodosum, papulopustular lesions and thrombophlebitis, and mucosal manifestations include oral and genital ulcers. These mucocutaneous lesions are characteristically the first signs of Behcet's disease and are important to be recognized for the early diagnosis of the disease. Moreover, these manifestations also recur and persist over the long-term course of the disease. The management of mucocutaneous lesions is important to prevent recurrence. We developed consensus guidelines that provide recommendations for general practitioners and dermatologists and physicians on the management of the mucocutaneous lesions of Behcet's disease.

Asteatosis is common in elderly people due to a decrease in the moisture content of the epidermal stratum corneum through a loss of skin barrier function caused by aging. Because itching often accompanies asteatosis, this condition may cause a decrease in quality of life. Care staff in elderly care facilities have many opportunities to provide care for residents. In this study, we examined how educational training on skin care changed the thoughts and actions of care staff in these facilities and how these changes impacted the skin conditions of residents. The subjects for the training were all care staff in facilities because these staff work most closely with facility residents. We performed skin care training for the subjects and investigated changes in the skin conditions of the residents before and after the training. The training promoted the understanding of skin care among the care staff and improved the skin symptoms of residents with asteatosis. However, there were no changes in the severity of itchiness based on a verbal rating scale and in interviews of residents. This study showed that skin care training for the care staff in facilities is effective to improve skin conditions of residents. In addition, it was suggested that a full grasp of the residents’ skin symptoms based upon an interview on itching alone was difficult, and thus there is a need to observe skin conditions directly.

The Dermatophyte Test Strip visualizes mycotic antigens by immunochromatography. It allows easy and fast detection of dermatophytes. A multicenter, single-arm, comparative clinical study was designed to evaluate the capacity of Dermatophyte Test Strip to detect dermatophytes in suspected tinea unguium specimens in comparison with direct microscopy and polymerase chain reaction (PCR). Signed consent was obtained from 222 subjects and all subjects completed the study. With the Dermatophyte Test Strip, dermatophytes were detected in 201 of 222 (90.5%) specimens but not in 21 of 222 (9.5%) specimens. With direct microscopy, dermatophytes were detected in 170 of 222 (76.6%) specimens but not in 52 of 222 (23.4%). Of the 45 specimens that showed inconsistent results between the two methods, PCR gave further results for 40 specimens, of which 37 (92.5%) specimens were positive and three (7.5%) were negative for dermatophytes. The positive concordance rate, negative concordance rate and overall concordance rate between the Dermatophyte Test Strip and direct microscopy were 81.1%, 66.7% and 79.7%, respectively. When inconsistent results were corrected using the results of PCR, these rates were 97.5%, 71.4% and 95.0%, respectively. When five specimens that could not be tested by PCR because no piece for the PCR test was left were excluded from analysis, these rates were 99.0%, 78.9% and 97.2%, respectively. The present results indicate good detection capacity of the Dermatophyte Test Strip. The Dermatophyte Test Strip provides a reliable, convenient and quick method to test for tinea unguium.

Androgenetic alopecia is an androgen-induced pattern of progressive hair loss, which occurs in genetically predisposed people. This study aimed to determine long-term safety, tolerability and efficacy of dutasteride 0.5 mg, an inhibitor of 5-α-reductase, in Japanese male patients with androgenetic alopecia. This was a multicenter, open-label, prospective outpatient study (clinicaltrials.gov NCT01831791, GSK identifier ARI114264) in which patients took dutasteride 0.5 mg p.o. once daily for 52 weeks. Primary end-points included adverse event assessment, incidence of drug-related adverse event and premature discontinuations. Secondary end-points included hair growth, hair restoration and global improvement in hair. A total of 120 patients were enrolled, of whom 110 completed 52 weeks of treatment. Nasopharyngitis, erectile dysfunction and decreased libido were the most frequently reported adverse events and most adverse events were mild. Drug-related adverse events were reported with an incidence of 17%, none of which led to study withdrawal. Hair growth (mean target area hair count at week 52), hair restoration (mean target area hair width at week 52) and global appearance of hair (mean of the median score at week 52) improved from baseline during the study. As a potential future treatment option for male androgenetic alopecia, dutasteride 0.5 mg exhibited long-term safety, tolerability and efficacy within this study population.

Poor adherence to medication is a major public health challenge. Here, we aimed to determine the adherence to oral and topical medications and to analyze underlying associated factors using the translated Japanese version of Morisky Medication Adherence Scale‐8 regarding urticaria treatment. Web‐based questionnaires were performed for 3096 registered dermatological patients, along with a subanalysis of 751 registered urticaria patients in this study. The adherence to oral medication was significantly associated with the frequency of hospital visits. Variables that affected the adherence to topical medication included age and experience of drug effectiveness. The rate of responses that “It felt like the symptoms had improved” varied significantly among the dermatological diseases treated with oral medications. Dermatologists should be aware that adherence to the treatment of urticaria is quite low. Regular visits and active education for patients with urticaria are mandatory in order to achieve a good therapeutic outcome by increasing the adherence.

Background and Objectives Solar lentigines are commonly found in sun‐exposed areas of the body including hands, neck, or face. This study evaluates the efficacy of an intense pulsed light (IPL) device, with wavelengths between 500 and 635 nm and delivered with a targeted tip, for the treatment of solar lentigines on Japanese skin. Study Design/Materials and Methods Forty Japanese patients with solar lentigines received one IPL treatment with a targeted treatment tip that emits wavelengths between 500 and 635 nm and contact cooling. Pulses were delivered through a targeted tip to each lentigo until mild swelling and a gray color were observed. Digital photographs and gray level histogram values were taken pre‐ and post‐treatment, and patient assessments were recorded post‐treatment. Results Significant improvement was observed for all patients in digital photographs and mean values of gray level histograms (P

Dear Editor, Recent studies have shown that adherence to treatment is an important factor for good therapeutic outcome in various chronic disorders such as hypertension and diabetes.1,2 In dermatology, patient nonadherence to therapy is also very problematic and has been associated with poor therapeutic outcomes in common skin diseases.3–5 Although there is no ‘gold standard’ to measure medication adherence, an eight-item self-reported scale called the Morisky Medication Adherence Scale-8 (MMAS-8) has been developed by Morisky et al.1 MMAS-8 originally targeted oral medication for hypertensive patients, but it is now applied to measure medication adherence in a wide range of disorders such as diabetes and osteoporosis.2,6 However, there are no reports of studies investigating dermatological adherence using this scale. Therefore, this study assessed medication adherence for oral and topical remedies using a translated version of MMAS-8 together with other socioeconomic background factors in 3096 Japanese dermatological patients. This study was conducted among patients registered in a monitoring system established by Macromill Inc. (Tokyo, Japan). The registered individuals (n = 4144) were prescreened in terms of skin diseases and their intention to participate in this study. In total 3096 eligible patients were enrolled, 1327 with atopic dermatitis, 751 with urticaria, 237 with psoriasis and 781 with tinea. Our web-based questionnaire included the following items: age, sex, marital status, annual income, employment status, educational status, smoking habit, alcohol consumption, frequency of hospital visits, main healthcare institution, oral or topical medication, experience of the effectiveness of oral medication, experience of the effectiveness of topical medication, experience of adverse events associated with oral medication, experience of adverse events associated with topical medication, overall satisfaction with treatment, MMAS-8 for oral medication and MMAS-8 for topical medication. The original MMAS-8 was translated into Japanese according to international guidelines.7 Forward translation of the original questionnaire was undertaken by translation from English into Japanese to produce a version that was semantically and conceptually as close as possible to the original questionnaire. Translation was carried out by two qualified independent linguistic translators; both are native speakers of Japanese and proficient in English. Back translation from Japanese into English was then carried out by another translator, who is a native speaker of English and proficient in Japanese. The back translation form was sent to the original author. Inconsistencies were resolved after repeated discussion among the original author, the English translator and the Japanese investigators and a final version was generated. According to the MMAS-8 score (range 0–8), adherence was defined as high (score 8), medium (score 6 to

Objectives To examine the correlations between elements of feet-washing behavior, presence of tinea pedis (TP), and patients' background characteristics in order to identify a concrete intervention method to prevent TP. Design and participants A cross-sectional study of 30 patients with diabetes (16 with TP) who were admitted to or visited the university hospital. Main outcome measures The presence of TP was confirmed by the detection of dermatophytes by direct microscopy. Data on elements of feet-washing behavior, such as scrubbing between the toes, were collected by observing recorded videos of participants normally washing their feet as they do at home. The patients' background characteristics included demographic data; diabetes-related factors; patient knowledge regarding diabetes, foot problems, and TP prevention; purpose for feet washing; and any difficulties in feet washing. Main results The number of times patients scrubbed between their toes while washing with soap was significantly lower in patients with TP (odds ratio, 0.95; P = .036; with a cutoff value of 35 times) and those who had difficulty in reaching their feet with their hands (B = -14.42, P = .041). Conclusions An effective foot-washing protocol should include specific instructions for patients to scrub between their toes at least 35 times in all 8 spaces while washing with soap. Appropriate advice is also needed for individuals who have difficulty reaching their feet with their hands. Education about appropriate foot-washing behavior may potentially prevent TP.

Objective: The aim of this study was to examine the accuracy of visual diagnosis of tinea pedis (Athlete's foot) and tinea unguium (fungal nail infection), as well as to provide information on skin abnormalities that could help identify these diseases in aged care facilities (long-term care facilities (LTCFs) and nursing homes). Method: A multicentre, cross-sectional observational study was conducted in a LTCF and two nursing homes. A dermatologist observed the skin abnormalities in the participants' interdigital and plantar areas, to screen for tinea pedis, and in the participants' toenails, to screen for tinea unguium. If abnormalities were noted, samples such as scales or toenails were collected and examined using direct microscopy. The accuracy of the macroscopic observation for each skin abnormality was examined. Results: A total of 173 residents were recruited. The accuracy of clinical diagnosis using macroscopic observation was relatively low. The sensitivities and specificities for clinical diagnosis were 0.37 and 0.95 for tinea pedis in the interdigital areas, 0.47 and 0.94 for tinea pedis in the plantar areas, and 0.80 and 0.61 for tinea unguium in toenails, respectively. Scales in the plantar areas and discoloration of the toenails were more frequently observed in residents with tinea pedis and tinea unguium than in those without them. Conclusion: Several skin abnormalities were observed in the residents recruited in this study, but there was insufficient correlation with tinea pedis and tinea unguium to be used for screening.

The prevalence of skin mycoses in the elderly remains unclear. The proportion of people with skin eruptions who are positive for mycoses using direct microscopy is not known. The purpose of this study is to identify the prevalence of skin eruptions and skin mycoses (e.g. candidiasis and tinea) in the buttocks and feet, which are common sites of skin mycoses in residents of long-term care facilities. This multi-site cross-sectional study used visual inspection and direct microscopy to diagnose the type of skin eruption. Subjects were residents of facilities covered by long-term care insurance schemes in Japan. Of the 171 residents enrolled in this study, 72.5% had a skin eruption. Only 4.8% of participants had tinea in the buttocks; 2.4% had buttock candidiasis. In those with a nail abnormality, 58.3% of residents had tinea unguium. For tinea pedis, residents who had any form of interdigital or plantar region skin eruption, 22.5% and 31.4% of residents were positive, respectively. The prevalence of observed skin mycoses was: buttock candidiasis 1.8%; buttock tinea 3.5%; tinea unguium 56.2%; interdigital tinea pedis 20.5%; and plantar tinea pedis 22.5%. The very low proportion of residents with mycoses in the buttocks suggests that anti-inflammatory agents, such as steroids, should be used as first choice. Our observation that not all residents with skin eruptions on the feet had tinea, should remind clinicians to perform direct microscopy before initiating antifungal treatments.

SummaryBackground The direct microscopy, fungal culture and histopathology that are necessary for the definitive diagnosis of tinea unguium are disadvantageous in that detection sensitivity is affected by the level of skill of the person who performs the testing, and the procedures take a long time. Objectives The Dermatophyte Test Strip, which was developed recently, can simply and easily detect filamentous fungi in samples in a short time, and there are expectations for its use as a method for tinea unguium screening. With this in mind, we examined the detection capacity of the Dermatophyte Test Strip for tinea unguium. Methods The presence or absence of fungal elements was judged by direct microscopy and Dermatophyte Test Strip in 165 nail samples obtained from residents in nursing homes for the elderly. Moreover, the minimum sample amount required for positive determination was estimated using 32 samples that showed positive results by Dermatophyte Test Strip. Results The Dermatophyte Test Strip showed 98% sensitivity, 78% specificity, 84·8% positive predictive value, 97% negative predictive value and a positive and negative concordance rate of 89·1%. The minimum sample amount required for positive determination was 0·002–0·722 mg. Conclusions The Dermatophyte Test Strip showed very high sensitivity and negative predictive value, and was considered a potentially useful method for tinea unguium screening. Positive determination was considered to be possible with a sample amount of about 1 mg.

Oral antifungal drugs are used primarily to treat tinea unguium; however, they are also useful for other types of tinea. For example, a combination of topical and oral antifungal drugs is effective in hyperkeratotic tinea pedis that is unresponsive to topical monotherapy. In cases of tinea facialis adjacent to the eyes, ears, or mouth, or widespread tinea corporis, or tinea cruris involving the complex skin folds of the external genitalia, it is difficult to apply topical drugs to all the lesions; therefore, oral antifungal drugs are necessary. Oral antifungal drugs are also useful not only for tinea but for widespread pityriasis versicolor and Malassezia folliculitis, candidal onychomycosis, and candidal paronychia and onychia. Topical antifungal drugs are in fact unsuitable for some mycoses. In tinea capitis, for example, irritation by topical drugs is likely to enhance inflammation; therefore, oral antifungal drug monotherapy is preferable. In interdigital tinea pedis with erosion or contact dermatitis, topical drugs are difficult to use because they tend to cause irritant dermatitis, resulting in exacerbation of the condition. In such cases, treatment should begin with a combination of topical corticosteroid therapy and oral antifungal drugs active against dermatophytes. Topical antifungal drugs are used after the complications resolve. A combination of topical and oral antifungal drugs can shorten the treatment period, thus improving patient adherence to topical treatment. Oral antifungal drugs are useful because of their wide range of applications in the treatment of dermatomycosis.

Objective To identify the factors associated with toenail onychomycosis in patients with diabetes. Methods In this cross-sectional, observational study, the presence and severity (area of nail involvement and nail thickness) of toenail onychomycosis and related factors were examined. One hundred and thirteen patients with diabetes were surveyed at the Diabetic Foot Outpatient Clinic at the University hospital. Toenails of all patients enrolled in the survey were examined whether onychomycosis was present or absent by mycological examination. The severity of onychomycosis was assessed by clinical evaluation, using the area of nail involvement and the nail thickness. Results Fifty eight (51.3%) patients had toenail onychomycosis. The presence of onychomycosis was significantly associated with not washing of feet every day (the unadjusted model, OR: 3.45, 95% CI: 1.24–9.65, P =0.018). The median area of nail involvement was 50.0% (range 5.0–100.0%). A larger area of involvement was significantly related to a lower toe brachial index ( β =−67.46, P =0.040). The median nail thickness with onychomycosis was 1.14mm (range 0.68–9.86mm). Increasing thickness was significantly correlated with higher hemoglobin A 1 c levels ( β =0.98, P =0.003). Conclusions This study suggested that daily washing of feet may reduce the risk of onychomycosis in patients with diabetes. This suggested that education regarding the importance of the washing of feet every day and support for continuous self-care might be effective in the prevention of onychomycosis in patients with diabetes. Furthermore, good control of blood glucose might prevent increasing nail thickness. This study may highlight importance of early nursing educational intervention to improve patients' daily life style for prevention of onychomycosis induced diabetic foot ulcers.

Sarcoidosis is a chronic multisystem disease of unknown origin, which is characterized by T-helper-1 (Th1)-mediated immune responses. On the other hand, atopic dermatitis (AD) is characterized by Th2-mediated immune responses. We recently experienced an interesting case of AD in which the patient experienced a significant resolution of AD after the onset of sarcoidosis. We herein describe the details of his clinical course and discuss the impact of negative cross-regulation between Th1 and Th2 immune responses.

Cutaneous candidiasis is a common skin infection caused by the Candida species, especially in intertriginous areas, and neutrophils usually infiltrate histopathologically. We describe a case of secondary cutaneous candidiasis which spread extensively to the trunk and extremities and showed marked dermal eosinophilia. This case and a similar reported case suggest that Candida can sometimes cause cutaneous inflammation predominantly composed of eosinophils.

Adherence is defined as the extent to which a person's behavior corresponds with recommendations from health care providers. Adherence to treatment is an important factor for a good therapeutic outcome.This study aimed to examine the adherence of patients with tinea pedis and to clarify the factors related to it.We assessed medication adherence for oral and topical drugs using a translated version of the Morisky Medication Adherence Scale-8 (MMAS-8) together with other background factors in 445 Japanese patients with tinea pedis, using a questionnaire in a web-based monitoring system.Overall, high, medium and low adherence rates as assessed by MMAS-8 were 8.7%, 31.7% and 59.6% for oral medication, and 8.6%, 17.4% and 74.0% for topical medication, respectively. The adherence level was significantly higher for oral medication than for topical medication. Subgroup analyses showed that the adherence level for topical medication was significantly higher when topical and oral medications were used in combination than when topical medication was used alone. A low adherence level was shown in employed patients, those for whom their oral medication had not been effective and those with topical medication who had visited their hospital less often than once every six months.Patient adherence to therapy can be effectively improved by selecting highly effective medication while considering the prescription of topical and oral antifungal medications concomitantly, by carefully selecting a therapy plan for employed patients and by encouraging patients to visit their doctor regularly.

© 2015 Z. Background: Patients' high adherence to medication is indispensable for the management of skin diseases including atopic dermatitis. We previously showed poor medication adherence in Japanese dermatological patients. Objective: This study was conducted to determine the level of adherence to oral or topical medication in Japanese patients with atopic dermatitis, attempting to characterize the socioeconomic status of those patients with poor adherence. Methods: A web questionnaire survey on demographic data as well as adherence level was conducted on patients registered in the monitoring system. Adherence level was assessed with Morisky Medication Adherence Scale-8 (MMAS-8). Among a total of 3096 respondents with dermatological disorders, data of 1327 subjects with atopic dermatitis were extracted and analyzed. Results: More than 80% of subjects felt that both oral and topical medications were safe and efficacious, while less than 60% of them were satisfied with their treatment. Levels of adherence to oral and topical treatments were evaluated with MMAS-8, giving scores of 4.6 and 4.2, respectively. Demographic factors such as gender, marital status, state of employment, alcohol consumption, frequency of hospital visits, and experience of drug effectiveness had a significant impact on the degree of adherence to treatment. Conclusion: Medication adherence level in Japanese subjects with atopic dermatitis was relatively low compared with that of other chronic diseases. Our survey has characterized patients with poor adherence, who are good targets for interventions to maximize potentially limited healthcare resources.

© 2015 Japanese Dermatological Association. Previously we assessed the medication adherence for oral and topical remedies by a translated Japanese version of the Morisky Medication Adherence Scale-8 (MMAS-8) together with socioeconomic backgrounds in 3096 Japanese dermatological patients, and found the medication adherence, especially to topical drugs, was poor in these patients. In order to elucidate the disease-specific sociomedical factors, we further sub-analyzed the medication adherence in 237 psoriasis patients and compared it with that in other dermatological diseases such as atopic dermatitis, urticaria or tinea. This study was conducted among patients registered in monitoring system and 3096 eligible patients were enrolled. Our web-based questionnaire included the following items such as age, sex, annual income, main health-care institution, experience of effectiveness by oral or topical medication, overall satisfaction with treatment, and MMAS-8 for oral or topical medication. Mean adherence score by MMAS-8 was 5.2 for oral and 4.3 for topical medication. More patients with psoriasis used a university hospital and fewer used a private clinic compared with those with the other skin disease patients. Experience of drug effectiveness by oral medication and overall satisfaction with treatment was lower in psoriasis patients than in other patients. In oral medication, significantly better adherence was observed in those of higher age and with higher annual income. The adherence to medication, especially to topical drugs, was poor in 237 psoriasis patients. We speculated that some severe psoriasis patients were not sufficiently treated systemically and were resistant to topical therapy, leading to poor adherence.

Both CCL27 and CCL28 are ligands for CCR10 and attract CCR10(+) lymphocytes. We previously demonstrated that CCL27 and CCL28 were strongly expressed in sera and lesional keratinocytes of patients with atopic dermatitis and psoriasis vulgaris. However, the regulation of CCL27 and CCL28 production in keratinocytes has not been well documented. In this study, we showed that CCL27 and CCL28 expression and production by a human keratinocyte cell line, HaCaT cells, were strongly induced by inflammatory cytokines tumor necrosis factor-alpha and interleukin-1beta. CCL27 production was downregulated by inhibitors of p38 mitogen-activated protein kinase and nuclear factor-kappa B (NF-kappaB). By contrast, CCL28 production was downregulated by inhibitors of extracellular signal-regulated kinase and NF-kappaB. Our study results suggest that CCL28 produced by keratinocytes is mediated by different signal pathways from CCL27 and that both CCL27 and CCL28 are involved in the pathogenesis of inflammatory skin diseases.

SummaryEotaxin-2/CCL24 and eotaxin-3/CCL26 are CC chemokines and their receptor, CC chemokine receptor 3 is preferentially expressed on eosinophils. It was reported that vascular endothelial cells and dermal fibroblasts produced CCL26. However, the regulation of CCL24 and CCL26 production in keratinocytes has not been well documented. We investigated the expression and production of CCL24 and CCL26 in the human keratinocyte cell line, HaCaT cells. Reverse transcription and polymerase chain reaction was performed using these cells and Enzyme-linked immunosorbent assay was carried out using supernatant of these cells. The production of CCL24 in HaCaT cells was slightly enhanced by IL-4 and that of CCL26 was strongly enhanced by IL-4 and IL-13. Furthermore, TNF-α generated a synergistic effect on IL-4 enhanced CCL26 production. Dexamethasone, IFN-γ and the p38 mitogen-activated protein kinase inhibitor SB202190 inhibited IL-4 enhanced CCL26 production. IL-4 enhanced production of CCL26 was inhibited by leflunomide and JAK inhibitor 1, but not by JAK3 inhibitor, which indicates that it is mediated by JAK1-STAT6-dependent pathway. This result also strongly suggests the involvement of the type 2 IL-4 receptor in IL-4 enhanced production of CCL26. These results suggest that keratinocytes are involved in the migration of CC chemokine receptor 3 positive cells such as eosinophils in a Th2-dominant situation like atopic dermatitis.

Summary Background Although there have been several reports on the prevalence of atopic dermatitis (AD) in Japanese schoolchildren based on questionnaires, there has been no nation-wide study of the frequency of this condition diagnosed by dermatologists in regular health check-ups of schoolchildren. Objectives The objective of this work was to evaluate precisely the prevalence of AD in elementary schoolchildren in Japan based on regular health check-ups by dermatologists. Methods In 2001/2, elementary schoolchildren: first graders (age 6–7 years) and sixth graders (age 11–12 years) were examined by dermatologists in eight prefectures of Japan (Hokkaido, Iwate, Tokyo, Gifu, Osaka, Hiroshima, Kochi and Fukuoka). In each prefecture, public elementary schools were randomly selected from urban and rural districts. We planned to examine about 700 schoolchildren in each of urban first, urban sixth, rural first and rural sixth grades from the eight areas, a total of 22 400 children (700 × 4 × 8). AD was diagnosed by the dermatologists based on the Japanese Dermatological Association criteria for the disease. Results The point prevalence of AD was 11·2% overall (2664 of 23 719) ranging from 7·4% (Iwate) to 15·0% (Fukuoka) in the eight areas. Seventy-four per cent, 24%, 1·6% and 0·3% of those afflicted were in the mild, moderate, severe and very severe groups, respectively. Overall, the prevalence of first graders was slightly higher than that of sixth graders (11·8% vs. 10·5%, P

CCR4, a member of the CC chemokine receptor family, is believed to play an important role in the pathogenesis of atopic dermatitis. To examine whether CCR4 single nucleotide polymorphism (SNP) is associated with susceptibility to atopic dermatitis, we investigated the allele and genotype frequencies of C1014T SNP of CCR4 in 198 Japanese patients with atopic dermatitis and controls by a PCR-restriction fragment length polymorphism method. There was no significant difference in allele or genotype frequencies between patients with atopic dermatitis and controls. Serum IgE levels and peripheral blood eosinophil counts were not significantly different among genotypes. There was also no significant difference in allele or genotype frequencies between the patient subgroup with and without asthma, with mild or moderate disease, with and without family history of atopic dermatitis, or with and without family history of atopic disorders. C1014T SNP of CCR4 does not appear to be associated with susceptibility to atopic dermatitis in Japanese patients.

CCR4, a member of the CC chemokine receptor family, is believed to play an important role in the pathogenesis of atopic dermatitis. To examine whether CCR4 single nucleotide polymorphism (SNP) is associated with susceptibility to atopic dermatitis, we investigated the allele and genotype frequencies of C1014T SNP of CCR4 in 198 Japanese patients with atopic dermatitis and controls by a PCR-restriction fragment length polymorphism method. There was no significant difference in allele or genotype frequencies between patients with atopic dermatitis and controls. Serum IgE levels and peripheral blood eosinophil counts were not significantly different among genotypes. There was also no significant difference in allele or genotype frequencies between the patient subgroup with and without asthma, with mild or moderate disease, with and without family history of atopic dermatitis, or with and without family history of atopic disorders. C1014T SNP of CCR4 does not appear to be associated with susceptibility to atopic dermatitis in Japanese patients. Key words: atopic dermatitis; CCR4; single nucleotide polymorphism.

We describe a patient with hypereosinophilic syndrome, who had severe cutaneous eruptions. Immunohistochemical study revealed that dermal endothelial cells in the lesional skin of this patient expressed eotaxin, which indicates eotaxin plays a part in inducing eosinophil migration into cutaneous tissue in hypereosinophilic syndrome.

SUMMARY Atopic dermatitis (AD) is a chronic and relapsing inflammatory skin disease characterized by the predominant infiltration of T cells, eosinophils and macrophages in lesional skin. Recently, eotaxin-2/CCL24 and eotaxin-3/CCL26 were identified as CC chemokines that signal exclusively via the CCR3 receptor and have eosinophil-selective chemoattractant activity, as does eotaxin/CCL11. We previously reported that serum levels of thymus and activation-regulated chemokine (TARC)/CCL17 and macrophage-derived chemokine (MDC)/CCL22 were correlated with the severity of AD. In this report, we investigated the participation of eotaxin-2/CCL24 and eotaxin-3/CCL26 in AD, first measuring the serum levels of eotaxin-2/CCL24 and eotaxin-3/CCL26 in 30 patients with AD, 20 patients with psoriasis vulgaris and 20 healthy controls. The serum levels of eotaxin-3/CCL26 (but not eotaxin-2/CCL24) were significantly higher in patients with AD than in either healthy controls or patients with psoriasis vulgaris; furthermore, the eotaxin-3/CCL26 levels in patients with moderate and severe AD were significantly higher than eotaxin-3/CCL26 levels in patients with mild AD. The serum eotaxin-3/CCL26 levels tended to decrease after treatment, but there was no significant difference between groups. Moreover, the serum eotaxin-3/CCL26 levels were significantly correlated with the serum TARC/CCL17 and MDC/CCL22 levels, eosinophil numbers in peripheral blood and the scoring AD (SCORAD) index. Our study strongly suggests that serum levels of eotaxin-3/CCL26, but not of eotaxin-2/CCL24, have a notable correlation with disease activity of AD and that eotaxin-3/CCL26, as well as TARC/CCL17 and MDC/CCL22, may be involved in the pathogenesis of AD.

We described a 5-year-old Japanese girl with epidermolytic palmoplantar keratoderma and examined her for a keratin 9 gene mutation. Physical examination disclosed diffuse yellowish hyperkeratosis with an erythematous border limited strictly to the palms and soles. Histological examination revealed hyperkeratosis with vacuolar degeneration in the spinous and granular layers of the epidermis. Sequence analysis demonstrated an A to G transition at the middle position of codon 160 in the 1A domain of the keratin 9 gene. The amino acid at codon 160 was deduced to have changed from asparagine (Asn) to serine (Ser). This is the first case with an Asn160Ser mutation in a Japanese. The substitution of Ser for Asn at codon 160 of the keratin 9 gene is assumed to be fatal for keratin filament assembly regardless of race or ethnicity.

Interleukin (IL)-13 plays an important role in the induction of immunoglobulin E (IgE) and in the pathogenesis of atopic dermatitis (AD). We investigated the allele and genotype frequencies of three IL-13 single nucleotide polymorphisms (SNPs) (A704C and C1103T in the promoter region and G4257A in exon 4) in Japanese patients with AD. For A704C and C1103T SNPs, there were no significant differences in allele or genotype frequencies between AD patients and controls. For G4257A SNP, A allele was significantly increased in AD patients (39.5%) compared with controls (29.4%) (P = 0.016). The same proportion of each genotype and allele was observed in the patient subgroup with and without asthma. Serum IgE levels and peripheral eosinophil counts were not significantly different among genotypes in G4257A SNP. There was also no significant difference in allele or genotype frequencies between AD patients with mild disease and those with severe disease, between those with family history of AD and those without it, or between those with family history of atopic disorders and those without it. This result suggests that 4257A allele is associated with susceptibility to AD and that it may function in the pathogenesis of AD itself, presumably by other mechanisms than inducing IgE production.

Interleukin-12 (IL-12) is believed to play an important role in inducing Th1-type cytokine profiles. Atopic dermatitis (AD) and psoriasis vulgaris (PsV) are considered to be Th2 and Th1 type disease, respectively. The IL-12 p40 subunit gene (IL12B) is located at chromosome 5q31-33 and linkage findings of AD on 5q31 were reported. Recently single nucleotide polymorphism (SNP) (1188A/C) of IL12B has been reported. In function, it has been reported that this SNP is associated with IL12B mRNA expression levels. To learn whether this SNP is associated with susceptibility to AD or PsV, we investigated the genotype and allele frequencies of the SNP in AD patients, in PsV patients and in controls, examining 164 AD patients, 143 PsV patients and 100 healthy individuals in Japanese population. Genotyping was performed using the polymerase chain reaction-restriction fragment length polymorphism method. The A allele was decreased in AD patients (40.9%, p=0.031) and increased in PsV patients (60.1%, p=0.035) compared with controls (50.5%). This suggests that IL12B SNP is associated with susceptibility to AD and PsV, presumably by affecting the Th1/Th2 balance.

A new multisource phase-controlled radiofrequency (MPCRF) device is widely used for skin tightening and rejuvenation in Asia.To evaluate the efficacy of MPCRF objectively and histologically.An MPCRF device with real-time impedance control was evaluated. Ten Japanese patients were treated one side of the face, and the untreated side served as a control. Three-dimensional (3-D) imaging was performed to evaluate the posttreatment volume change. An independent observer assessed the 3-D images. Histologic evaluations of elastin were performed by Victoria Blue staining in 5 Japanese patients.Objective assessments evaluated by a 3-D color schematic representation showed improvement in skin laxity after the final treatment in all patients. The treated side improved markedly compared with the untreated side; however, even the untreated side slightly improved. The elastin density was significantly increased compared with controls in all 5 Japanese patients (p = .0013). Induced elastin appeared to be relatively thin elastic fibers without irregular elastic fibers, such as solar elastosis. Side effects were not observed, and the patients reported feeling comfortable throughout the study.Multisource phase-controlled radiofrequency treatments provide stimulation of elastin and skin-tightening results safely and effectively, and thus are beneficial for improving skin laxity and rhytides.

The purpose of the present study was to assess the difference in foot temperature between tinea unguium-positive older adults with subungual hyperkeratosis and tinea unguium-negative older adults with subungual hyperkeratosis to develop a temperature-based screening method for tinea unguium.The present cross-sectional, observational study investigated 51 residents with subungual hyperkeratosis in two facilities covered by long-term care insurance between October 2011 and December 2011. One dermatologist recorded the clinical signs of abnormal toenails. Nail specimens were collected from all abnormal nails, and the presence of tinea unguium was confirmed when fungus was detected by direct microscopy. Foot temperature was measured by infrared thermography. A receiver operating characteristic curve was used to assess the ability to determine whether residents with subungual hyperkeratosis have tinea unguium and to determine the cut-off point.Among the people with subungual hyperkeratosis, the mean toe temperature in the tinea unguium-positive group (30.2 ± 2.6°C) was significantly lower than that in the tinea unguium-negative group (32.8 ± 3.2°C, P = 0.001). The area under the receiver operating characteristic curve was 0.74 (95% confidence interval 0.621-0.876), and the threshold temperature was set at 33.0°C, resulting in a sensitivity of 81.8% and specificity of 65.7%.Our study suggests that foot temperature can be used to screen for tinea unguium in people with subungual hyperkeratosis. This non-invasive and simple screening method would help clinicians to set priorities in terms of carrying out direct microscopy to diagnose tinea unguium in elderly residents in care facilities.