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   Table of Contents - Current issue
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October-December 2019
Volume 37 | Issue 4
Page Nos. 181-244

Online since Tuesday, December 17, 2019

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ORIGINAL ARTICLES  

Burnout syndrome among dermatologists and assessment of prevalence and risk factors: A nationwide survey Highly accessed article p. 181
Ezgi Ozkur, Ilknur Kivanc Altunay, Emel Calikoglu, Meltem Onder
DOI:10.4103/ds.ds_46_18  
Background: Burnout is a syndrome of emotional exhaustion, depersonalization, and a sense of low personal accomplishment. Increasing patient volumes and rising health-care systems' productivity targets also pose a risk of burnout in all specialties including dermatology. Objectives: The aim of the present study was to study burnout syndrome in dermatologists and determine related factors. Methods: Dermatologists who were actively working (n = 2005) were E-mailed a questionnaire via the Turkish Dermatology Society, and 422 (21%) completed it anonymously. The first part of the questionnaire comprised demographic and work-related characteristics, and the second part was formed by the Turkish version of the Maslach Burnout Inventory (MBI). The MBI is a 22-item questionnaire for the assessment of burnout in the following three dimensions: emotional exhaustion, depersonalization, and low personal accomplishment. Results: Emotional exhaustion and depersonalization scores of residents were significantly higher (P < 0.001), and personal accomplishment scores were significantly lower (P < 0.001) than that of the other groups. Dermatologists in the private sector had significantly lower scores for emotional exhaustion (P < 0.001) and depersonalization (P < 0.001) and significantly higher scores for personal accomplishment (P < 0.001) than those working in the public sector. Emotional exhaustion and depersonalization scores were significantly higher in participants who worked on weekends, those intended to change workplace, and had at least one chronic illness (P < 0.05 for all comparisons). A positive correlation was found between emotional exhaustion and depersonalization (r = 0.691,P < 0.001), number of patients (r = 0.355,P < 0.001), and number of shifts (r = 0.344,P < 0.001), and there was a negative correlation between personal accomplishment (r = −0.485,P < 0.001), age (r= −0.301,P < 0.001), number of vacation days (r = −0.149, P= 0.002), and years in the profession (r = −0.288,P < 0.001). Conclusion: Our study sheds light on factors that influence burnout and also indicates a need for health-care reforms for dermatologists' satisfaction and burnout, as well as patient satisfaction and quality of care.
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Cutaneous malignant melanoma in Eastern Taiwan: Clinicopathologic analysis of 56 cases p. 187
Kai-Chi Tsai, Sung-Jen Hung, Jen-Hung Wang, Shyh-Jer Huang, Chien-Hsing Wang, Jiunn-Tat Lee, Chia-Yi Lee, Chung-Hsing Chang
DOI:10.4103/ds.ds_13_19  
Background: The incidence, histological subtypes, and tumor behaviors of cutaneous malignant melanoma are quite different in Asian and Western countries. Objectives: Our purpose was to define the epidemiology, tumor behaviors, and possible prognostic predictors of cutaneous melanomas based on an Eastern Taiwanese population. Methods: We conducted a retrospective study to collect cases of cutaneous melanoma at Buddhist Tzu-Chi General Hospital, Hualien, Taiwan, from May 1, 2003, to August 31, 2017. We analyzed mean age at onset, gender, primary tumor locations, histological subtypes, Breslow's thickness, Clark's level, ulceration, lymph nodes, and distant metastatic status. Univariate and multivariate analyses for survival were performed by means of Cox proportional hazard model. Survival curves were plotted by Kaplan–Meier method. Results: A total of 56 cases of cutaneous melanoma were recorded. The male-to-female ratio was 3.67:1. The median survival was 2.82 years (0.63–5.00 years). Acral melanoma (AM) accounts for 69.6% of cases, and feet are the most common location (62.5%). Acral lentiginous melanoma (ALM) is the most common histological type (44.6%), followed by nodular melanoma (33.9%). Poor prognostic factors include older age (≧65 years), male gender, Breslow's thickness >4 mm, distant metastasis, and head-and-neck location. Conclusion: AM is the most common location, and ALM is the most common histological type of cutaneous melanoma in Eastern Taiwan. Melanoma in Eastern Taiwan tends to be delay diagnosed with advanced stage and thicker tumors than Western Taiwan. Prudent palm and sole examinations, improved medical accessibility, and more public educational programs may help encourage the early detection of melanoma.
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The influence of compression strength and patient and wound variables on venous leg ulcers healing p. 194
Vesna Karanikolic, Masa Golubovic, Goran Stevanovic, Irena Jankovic, Aleksandar Karanikolic
DOI:10.4103/ds.ds_10_19  
Background: Venous leg ulcers (VLUs) constitute a worldwide public health problem and have a significant impact on patient quality of life. The treatment is complex, with high failure rates. Objectives: The objective was to identify the influence of compression strength and patient and wound variables on VLUs healing. Methods: A total of 102 patients were supervised for 48 weeks since the commencement of the treatment. The patients were divided into two groups according to two different compression systems, one group with moderate compression pressure of 35–40 mmHg and the second with high pressure >45 mmHg. Results: Deep venous reflux, dermatitis, ulcer infection, duration of the ulcer, and the ulcer size (US) are statistically significantly lower (P < 0.001) in patients with healed wounds. These factors have also shown statistical significance related to prolonged healing time. Patients with VLU in which high pressure was applied, healed considerably faster in relation to VLU in which moderate pressure was applied (P = 0.008). Conclusion: Deep venous reflux, dermatitis, ulcer infection, duration of the ulcer, and the US were independently correlated with worse healing rates. Higher compression pressure leads to faster and higher proportions of VLUs healed. The authors recommended a holistic approach to wound healing with careful and individualized assessment of risk factors among patients with VLUs.
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Dermoscopic profile of pityriasis rosea Highly accessed article p. 199
Ömer Faruk Elmas, Asuman Kilitçi, Emine Müge Acar
DOI:10.4103/ds.ds_14_19  
Background: Pityriasis rosea (PR) is a common, self-limited cutaneous disease characterized by wide distributed erythematous scaly lesions. The diagnosis is usually based on the clinical features. Objectives: Here, we aimed to investigate the dermoscopic features of PR which may provide helpful clues to the diagnosis. Methods: Demographic, clinical, and dermoscopic features of the patients with PR were retrospectively reviewed, and the findings identified were recorded. Results: A total of 100 lesions from 25 different patients were included in the study. The most common dermoscopic finding was peripheral collarette scale (84%), followed by central yellow with peripheral reddish background (40%), peripheral dotted vessels with patchy distribution (35%), diffuse reddish background (31%), scattered dotted vessels (30%), and irregular distributed scales and red globules (20%). Conclusion: To the best of our knowledge, this is the most comprehensive study focusing on the dermoscopic features of PR. Here, we identified new dermoscopic findings which were not described previously for PR. These findings were irregular linear vessels, blood spots, brown globules, and brown structureless areas. It can be concluded that dermoscopy may provide remarkable clues to diagnosis, especially in atypical presentations of the entity.
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BRIEF REPORT Top

Efficacy of tofacitinib in patients with moderate-to-severe psoriasis who had inadequate responses to prior biologics p. 205
Yi-Wei Huang, Tsen-Fang Tsai
DOI:10.4103/ds.ds_22_19  
This retrospective observational study examined the effect of tofacitinib in two Phase 3 controlled studies. Patients (n = 15) were randomized to receive either tofacitinib 5 or 10 mg or placebo, twice daily. Most patients in both groups were responsive to tofacitinib at week 16. Four patients (25%) used two or more biological agents before tofacitinib. Two of these refractory patients demonstrated a response. In conclusion, tofacitinib provides a comparable therapeutic effect in both prior biologics responders and nonresponders during the initial 16 weeks, especially those exposed to etanercept. Tofacitinib remains a treatment choice in refractory patients who failed multiple previous biologics.
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CASE REPORTS Top

Eruptive melanocytic nevi after toxic epidermal necrolysis: A case report and literature review p. 209
Yu-Wen Tsao, Yu-Hung Wu
DOI:10.4103/ds.ds_5_19  
Eruptive melanocytic nevi (EMN), developing after severe bullous disease or adverse drug eruption, are rare. We report a case involving a 20-year-old female student who had an episode of toxic epidermal necrolysis. She developed EMN on her limbs and abdomen half a year after recovery. The nevi appeared rapidly over several months, eventually stabilizing over the ensuing 3 years. Dermoscopy showed regular pigmented networks, which were pathologically consistent with junctional nevus. Although most eruptive nevi were stable in number and morphology, there was one previous report of malignant transformation. Patients with this condition should thus be closely followed.
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Graft-versus-host disease after orthotopic liver transplantation: A case report and review of the literature p. 213
Wei-Ti Chen, Tseng-Tong Kuo, Kang-Ling Kuo, Ching-Sheng Yang
DOI:10.4103/ds.ds_2_19  
Graft-versus-host disease (GVHD) after liver transplantation (LT) is a rare complication with high mortality and is clinically characterized by fever, skin rash, and diarrhea. The clinical manifestations of GVHD after LT are nonspecific and may resemble viral infection or adverse drug reaction, posing a diagnostic and therapeutic challenge. We report a 60-year-old male who presented with generalized erythematous to violaceous macules and papules accompanied by fever and diarrhea after orthotopic LT. A skin biopsy and human leukocyte antigen typing of peripheral blood confirmed a Grade 2 GVHD. Clinical manifestations and diagnosis of GVHD following LT are discussed. While potentially under-recognized, clinicians should be aware of this rare but potentially fatal complication, as prompt intervention may improve outcomes in LT.
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An unusual variant of perniosis: A case series of “cold-associated perniosis of the thighs” without equestrian activity p. 217
Pinar Incel Uysal, Neslihan Akdogan, Servet Guresci, Sezer Kulacoglu, Başak Yalçin
DOI:10.4103/ds.ds_8_19  
The role of cold exposure in the etiology of perniosis was clearly identified among susceptible individuals. However, few authors have newly reported purple-red “equestrian-type lesions” localized on thighs in patients without equestrian activity and suggested to use the reputation; “cold-induced perniosis of thighs.” We conducted a retrospective chart review of patients who have presented to our department with cold perniosis-like lesions exclusively localized on the thighs. Clinical and histopathological features of five female patients aged 16–31 years without equestrian activity indicated the diagnosis of cold-induced perniosis of the thighs. Cold-associated perniosis may be appropriate diagnosis for the patients presenting with symmetrically distributed painful, itching, or burning violaceous plaques and patches on the thighs for several weeks. The condition primarily affects overweight women and does not require outdoor activity. Microscopic presentation of the disorder is variable and very similar to acral idiopathic perniosis and chilblain lupus erythematosus.
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Pazopanib as a new culprit in neutrophilic eccrine hidradenitis p. 222
Fang-Ying Wang, Wei-Ti Chen, Meng-Han Shen, Wen-Hung Chung, Chun-Bing Chen
DOI:10.4103/ds.ds_6_19  
Neutrophilic eccrine hidradenitis (NEH) usually manifests as asymptomatic or painful infiltrated erythematous papules or plaques of variable sizes. It is characterized by dense neutrophilic infiltration and necrosis of the eccrine secretory coils in histopathology. The condition is most commonly reported in patients with hematologic malignancy, who have been undergoing chemotherapy. Direct drug toxicity to the eccrine glands has been proposed to be the cause of NEH. Although several drugs have been reported to induce NEH, the tyrosine kinase inhibitors have only rarely been identified as culprits in the literature. Here, we present a case of pazopanib-related NEH in a patient with uterine adenocarcinoma, in which NEH recurred after the reintroduction of pazopanib. To the best of our knowledge, this is the first report of a case of pazopanib-related NEH.
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IgG/IgA pemphigus presenting with mixed clinical features of pemphigus erythematosus and IgA pemphigus p. 226
Shih-Jyun Yang, Hua-En Lee, Chih-Hao Chang, Chun-Bing Chen
DOI:10.4103/ds.ds_12_19  
IgG/IgA pemphigus is a phenotype of atypical pemphigus with variable clinical, histological, and immunological manifestations. We describe a unique case of IgG/IgA pemphigus in a 58-year-old male presenting with mixed features of pemphigus erythematosus and IgA pemphigus. The diagnosis is made based on the histopathological examination and intercellular deposition of IgG and IgA throughout the epidermis on direct immunofluorescence test. The patient responded favorably to the combination therapy of dapsone and low-dose systemic steroids.
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Cutaneous Mycobacterium haemophilum infection with jarisch–herxheimer reaction: A case report from Taiwan p. 229
Chi-Hui Wang, Chun-Wei Lu, Yun Fu, Ting-Shu Wu, Chin-Fang Lu, Hong-Shang Hong
DOI:10.4103/ds.ds_7_19  
Mycobacterium haemophilum is a slow-growing and iron-dependent nontuberculous mycobacterium that can cause cutaneous ulcerations or nodular lesions. The diagnosis of cutaneous M. haemophilum infection is currently extremely rare in Taiwan. An 80-year-old Chinese man taking oral prednisolone for months presented with multiple erythematous as well as indurated and painful nodules over his right forearm. The diagnosis of M. haemophilum infection was confirmed through positive acid-fast staining – a technique used in histopathology and species identification – which was performed using molecular methods. Notably, Jarisch–Herxheimer reaction developed promptly during the antimicrobial therapy. Ideal skin culture conditions and specific molecular identification techniques are required for optimal detection of M. haemophilum.
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CORRESPONDENCE Top

High-dose-rate brachytherapy for the treatment of nonmelanoma skin cancer p. 233
Ya-Yun Huang, Cheng-Che Lan, Jen-Yang Tang
DOI:10.4103/ds.ds_50_18  
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Hypohidrosis as a clue to the early diagnosis of fabry disease and prevention of late complications p. 235
Tzu-Chien Hsu, Chao-Chun Yang, Chou-Ching Ling, Chaw-Ning Lee
DOI:10.4103/ds.ds_15_19  
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Dual effects of 5α-reductase inhibitor dutasteride on androgenetic alopecia and acne vulgaris p. 237
Taisuke Ito, Yukiko Kito, Yurika Masuda, Reiko Kageyama, Yoshiki Tokura
DOI:10.4103/ds.ds_11_19  
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Successful surgical treatment for squamous cell carcinoma on the finger of a hemodialysis patient using narrow tourniquet application p. 239
Miho Kabuto, Toshihiro Tanaka, Noriki Fujimoto
DOI:10.4103/ds.ds_9_19  
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A case of kaposi sarcoma with focal clear cell change p. 241
Chao-Yu Liao, Chi-Shun Yang, Yi-Ju Chen
DOI:10.4103/ds.ds_23_19  
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Leuprorelin acetate granuloma: A Taiwanese case report treated with intralesional triamcinolone acetonide p. 243
Pai-Shan Cheng
DOI:10.4103/ds.ds_34_19  
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Author Index  
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