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Polychlorinated biphenyls (PCBs) and 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) are major environmental pollutants, and their effects on the human body critically depend on the aryl hydrocarbon receptor (AhR). The aim of this study was to evaluate the significance of the AhR and its ligands in chronic inflammatory skin diseases such as atopic dermatitis (AD) and psoriasis. Expression of AhR-related mRNA was increased in lesional skin from patients with AD and psoriasis compared to those of normal skin from healthy controls. The AhR and aryl hydrocarbon receptor nuclear translocator were colocalized in the nuclei of keratinocytes at the lower epidermis of psoriatic lesions, which suggested activation of the AhR pathway. After treatment of normal human epidermal keratinocytes with TCDD or PCBs, IL-6 and IL-8 production were increased. The results of this study suggest that AhR is highly expressed in the acute lesional skin of patients with AD and psoriasis, and the AhR pathway is activated especially in psoriasis.

Background Atopic dermatitis (AD) is characterized by itching and eczema-like skin lesions, and its symptoms alleviate with age. Recently, the prevalence of AD has increased among adolescents and adults. The increasing prevalence of AD seems to be related to westernized lifestyles and dietary patterns. Objective The aim of this study was to evaluate the dietary patterns and nutrient intake of patients with AD. Methods The study population consisted of 50 children with AD who visited the Department of Dermatology at Kangnam Sacred Heart Hospital, Seoul, Korea from May 2008 to May 2009. Physical condition and calorie intake were evaluated using the Eczema Area and Severity Index score and Food Record Questionnaire completed by the subjects, and the data were analyzed using the Nutritional Assessment Program Can-pro 3.0 (The Korean Nutrition Society, 2005) program to determine the gap between the actual ingestion and average requirements of 3 major nutrients (i.e. carbohydrates, proteins, and lipids), vitamins (i.e. A, B, C, and E), niacin, folic acid, calcium, iron, phosphorus, and zinc in all subjects. Results The intake rate of proteins was 18.02% (recommended dietary allowance [RDA], 7%~20%), of carbohydrates was 67.7% (RDA, 55%~70%), and of lipids was 14.24% (RDA, 15%~30%). Thirty-one subjects (62%) showed deficiency of folic acid, and 21 subjects (42%), of iron supplements. Conclusion Essential nutrient intake tends to be lower in AD patients than in healthy subjects, and this low intake is closely related to the severity of AD.

Background: It is well known that atopic dermatitis (AD) is related to food hypersensitivity, although its prevalence varies among several studies according to age group, severity, country, survey time, and test method. Objective: To examine the prevalence and status of food hypersensitivity among childhood AD patients in Korea. Methods: A total of 95 patients were enrolled in the study. The history of food hypersensitivity was collected by interviews. The severity of AD was evaluated by eczema area and severity index (EASI). We took blood samples to measure serum total and food-specific immunoglobulin E (IgE) levels. Based on the histories and serum IgE levels, open oral food challenge (OFC) testing was performed to confirm food hypersensitivity. Results: Forty- two (44.2%) of the 95 AD patients had histories of food hypersensitivity. They reported that the most common suspicious foods were egg (n=13, 13.7%), pork (n=9, 9.5%) and cow milk (n=8, 8.4%). The mean EASI score was 16.05±9.76. Thirty-nine (41.1%) of the 95 patients showed elevated serum food-specific IgE levels. The specific IgE levels were elevated for egg (n=17, 17.9%), milk (n=12, 12.6%), peanut (n=10, 10.5%) and wheat (n=8, 8.4%). Fifty-one (53.8%) of 95 patients underwent open OFC, and only 7 (13.7%) of these patients showed positive reactions. Conclusion: The overall prevalence of food hypersensitivity in patients with childhood AD in Korea was 8.3% (7/84). The most common foods causing food hypersensitivity were egg and milk. Among the foods causing hypersensitivity, AD patients in Korea often underestimated peanut, while they overestimated pork. (Ann Dermatol 25(2) 196∼202, 2013)

Background: Recent epidemiologic studies have shown that environmental contaminants such as air pollution and tobacco smoke play an important role in the pathophysiology of atopic dermatitis (AD). Objective: The aim of this study was to evaluate the relationship between the severity of AD and indoor air pollution. Methods: The study population consisted of 425 children from 9 kindergartens, Korea. The authors surveyed the prevalence of AD and evaluated disease severity by the eczema area and severity index (EASI) score and investigator’s global assessment (IGA). After measuring indoor air pollution, a program to improve indoor air quality was conducted in 9 kindergartens. Seven months later, the prevalence and disease severity were evaluated. Results: The initial prevalence of AD was 8% and the mean EASI score was 2.37. The levels of particulate material 10 (PM10) and carbon dioxide (CO2) were higher in some kindergartens compared to the normal values. Subsequent to the completion of the indoor air quality improvement program, the mean PM10 level was significantly decreased from 182.7 to 73.4 μg/m 3 . After the completion of the program, the prevalence of AD and the mean EASI were decreased, and the changes were both statistically significant. The mean number of hospital visits decreased from 1.3 per month during the first survey to 0.7 per month during the second survey, which was statistically significant. Conclusion: Indoor air pollution could be related to AD. The reduction of PM10 through improving indoor air quality should be considered in kindergartens and schools in order to prevent and relieve AD in children. (Ann Dermatol 25(3) 292∼297, 2013)

Dear Editor: Scabies is a contagious skin infestation caused by Sarcoptes scabiei burrowing into the epidermis. Scabies can cause clinical eruptions and intense pruritus with nocturnal exacerbation1. The presence of typical skin lesions and nocturnal pruritus enable rapid diagnosis and treatment1. Clinical eruptions, including scabietic nodules and visible skin burrows, can be the pathognomonic lesions of scabies2. However, infants and young children may present with atypical skin nodules, vesicles, and pustules that tend to be more generalized. These atypical manifestations often can be confused with seborrheic dermatitis, eczematous dermatitis, impetigo, multiple arthropod bites, and Langerhans cell histiocytosis (LCH)3. Here, we report the case of a 6-month-old infant with scabies who was misdiagnosed with LCH on the basis of histopathologic findings and clinical manifestations. A 6-month-old girl presented with a 1-month history of erythematous to brownish papules and nodules on her trunk (Fig. 1A). The patient was initially treated with topical corticosteroid cream under a diagnosis of contact dermatitis. However, the lesions quickly spread to the patient's hands and feet, with scales and erythematous patches (Fig. 1B). Therefore, she underwent abdominal punch biopsy. Histopathologic findings showed cellular infiltrate within the upper dermis with a perivascular distribution consisting of histiocytes, lymphocytes, and eosinophils (Fig. 2A). The histiocytes in the upper dermis stained positive for CD1a and S-100 (Fig. 2B, C). Therefore, she was diagnosed with LCH on the basis of histopathologic findings and clinical manifestation. However, at that time, her mother complained of pruritus and presented with scabietic nodules on the interdigital web and periumbilical area. Dermoscopy-assisted skin scraping was performed on both the palm of the patient and periumbilical area of her mother, revealing mites and eggs in both lesions (Fig. 2D). Therefore, the patient's lesions were scabietic and not due to LCH. The patient was treated with 10% crotamiton cream and achieved complete remission after 1 week. After 1 month, the patient experienced relapse of the skin lesions on her hands and feet. Skin scraping was performed again and showed positive findings for scabies. The patient was re-treated with crotamiton 10% cream. At the last follow-up of 8 months, she was relapse free. Fig. 1 (A) The patient had several erythematous to brownish papules and nodules on her trunk on the initial visit. (B) Scales and erythematous patches on the palm of the patient after 1 month from the initial visit. Fig. 2 (A) The dermal infiltration was composed of Langerhans cells admixed with lymphocytes and eosinophils (H&E stain, ×200). (B, C) Immunophenotyping demonstrated the majority of the histiocytic cells to be S-100 (B, ×40) and CD1a ... Infantile scabies can have diverse skin manifestations, making it difficult to correctly diagnose on the basis of clinical findings alone. The histopathologic findings of scabies are also nonspecific and are insufficient for diagnosis; they include eczematous reactions in the epidermis and perivascular area, and inflammatory cell infiltrate in the dermis4. The infiltrate usually comprises numerous histiocytes positive on CD1a and S-100 staining. Therefore, these findings can be often misdiagnosed as LCH. Meanwhile, Langerhans cell hyperplasia has been reported to be present in scabies4. The presence of scattered CD30+ cells, which appears in scabies, can aid the differential diagnosis4. In addition, using electron microscopy to assess the presence or absence of Birbeck granules, which is the hallmark of LCH, can also aid diagnosis5. In conclusion, clinicians should be aware of confusing infantile scabies with LCH. Careful history taking including exposure to scabies and performing CD30 staining, electron microscopy, and dermoscopy will aid diagnosis.

Dear Editor: Hyperkeratotic hand eczema (HHE) is defined as a lesion of hand dermatitis that shows thick hyperkeratotic plaques with or without deep fissures. This diagnosis was established in 2%~5% of patients with hand dermatitis1,2. HHE is considered to have multiple causes, such as exposure to repetitive irritation, atopy, contact allergy, and friction3. Previous studies have revealed that contact sensitization is less common in HHE2. Here, we report a case of chronic HHE associated with contact sensitization to black rubber mix and thiuram mix. A 50-year-old nonatopic male patient presented with chronic HHE that had been refractory to previous treatments for the last 2 years. Physical examination revealed relatively well-demarcated erythematous scaly plaques on the palmar sides of both hands (Fig. 1A). He was a salesman who had always driven a car to his meetings. For 3 years, he had been wearing his work gloves, which had rubber on the palmar side, to prevent his hand from sliding off the steering wheel while driving because of his palmar hyperhidrosis (Fig. 2A). He had received eczema treatment with potent topical corticosteroid creams and moisturizer at local clinics; however, his symptoms did not improve. Then, he was referred to our hospital. We performed patch tests with a thin-layer rapid use epicutaneous (TRUE) test kit (Mekos Laboratories AS, Hillerod, Denmark). There were positive reactions to thiuram mix(++) and black rubber mix(++) at 48 h, and additional positive reactions to p-tertbutylphenol formaldehyde resin(+) and p-phenylenediamine(+) at 96 h (Fig. 2B). He was advised to apply a topical steroid with medium potency and to drive without wearing gloves, and his symptoms improved 2 weeks later (Fig. 1B). Thereafter, he underwent use tests with the work gloves, which worsened his symptoms. Fig. 1 (A) Localized scaly yellowish plaques on the palmar sides of both hands. (B) Two weeks after avoiding exposure to the offending allergen. Fig. 2 (A) Blue rubber dotted work gloves. (B) Positive patch test reactions to thiuram mix(++), black rubber mix(++), p-tertbutylphenol formaldehyde resin(+), and p-phenylenediamine(+) at 96 h. A hyperkeratotic morphology is known to be less frequently associated with contact sensitization, irritant exposure, and atopic dermatitis1. Thus, strongly positive reactions to more than two materials during the patch test have clinical implications. We made a diagnosis of HHE due to repetitive use of the work gloves on the basis of the patient's history, patch tests, and use tests. Thiurams are accelerants that are commonly used to manufacture natural rubber latex products. These mixes are present in natural or synthetic rubber products making up materials that are used either at work or at home4. Many tire workers are sensitized to black rubber mix. Concerning nonoccupational exposure, it has been shown that black rubber footgear and the rubber tips of walking sticks can also cause contact dermatitis5. Positive reaction to p-tertbutylphenol formaldehyde resin is related to contact with waterproof glue, bonded leather, and construction materials, whereas that to p-phenylenediamine is related to contact with permanent or semipermanent hair dyes, dyed textiles, and cosmetics; however, these are less relevant compared with our case. In conclusion, this report suggests that patients with HHE should be comprehensively evaluated through history taking and correctly treated by avoiding the suspicious material.

Background: Previous clinical trials with evening primrose oil in atopic dermatitis (AD) treatment have shown different results. In addition, the optimal dose and duration of treatment with evening primrose oil have not yet been determined. Objective: The aim of this study is to investigate the dose-response treatment effects of evening primrose oil on clinical symptoms of AD and serum concentrations of polyunsaturated fatty acids. Methods: Forty AD patients were enrolled for the study and randomly divided into 2 groups: those who received evening primrose oil 160 mg daily for 8 weeks and those who received 320 mg of evening primrose oil twice daily for 8 weeks. We evaluated the Eczema Area Severity Index (EASI) scores of all AD patients at weeks 0, 2, 4 and 8. In addition, we measured the levels of serum fatty acids, including C16 : 0 (palmitic), C18 : 2n (linoleic), C18 : 3n (linolenic) and C20 : 4 (arachidonic acid) using gas chromatography. Results: The serum fatty acid levels C18 : 3n and C20 : 4 were higher in the 320 mg group than in the 160 mg group, with statistical significance. After evening primrose oil treatment, EASI scores were reduced in the 2 groups. The improvement in EASI scores was greater in the 320 mg group than in the 160 mg group. There were no side effects seen in either group during the study in the 2 groups. Conclusion: The results of this study suggest that the 320 mg and 160 mg groups may be equally effective in treating AD patients and show dose-dependent effects on serum fatty acid levels and EASI scores. (Ann Dermatol 25(3) 285∼291, 2013)