Background: Rosacea is a chronic inflammatory skin disease with mounting evidence associating it with systemic disorders. Cancer, induced or facilitated by chronic inflammatory microenvironment, shares common pathogenic mechanisms with rosacea. Objectives: We performed a population-based cohort study to investigate the risk of developing cancer among people with rosacea in Taiwan. Methods: A total of 65,526 patients with rosacea and 262,104 age-, sex-, and comorbidity-matched controls were identified from the Taiwan's National Health Insurance Research Database between 1997 and 2013. All participants were followed up for 2–12 years. Incidence rates (IRs) of overall and specific types of cancer were calculated. Cumulative incidences of cancer were compared between the two cohorts by Kaplan–Meier method and modified log-rank test. Hazard ratios (HRs) adjusted for age, sex, and comorbidities for overall and specific malignancies were estimated using subdistribution proportional hazard models. Results: The IR (per 1000 person-years) of cancer was 2.83 in patients with rosacea and 3.00 in controls. There was no difference in cumulative incidence of cancer between patients with or without rosacea (P = 0.109). The risk of developing cancer did not increase among patients with rosacea (HR = 1.04; 95% confidence interval = 0.98–1.11). In addition, patients with rosacea did not have a significantly increased risk of developing any specific type of cancer. Conclusion: We found no association between rosacea and malignancy. These results did not agree with those reported in previous studies. Further research should be conducted to clarify the association between rosacea and cancer, especially focusing on the pathophysiology.

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Atopic dermatitis (AD) is generally considered a T-helper type 2-dominated disease. Adult AD is often more severe and less manageable by topical therapies and may require systemic immunosuppressants that bear notable side effects and organ toxicities. There is an unmet need for safe and effective long-term therapy in this population. Dupilumab, a fully human monoclonal antibody, dually inhibits interleukin (IL) IL-4 and IL-13 signaling and has demonstrated promising efficacy and acceptable safety profile in several Phase III trials, followed by recent Food and Drug Administration approval for the treatment of moderate-to-severe AD in adults whose disease is inadequately controlled with topical therapies. Dupilumab may also serve as a new treatment option when other systemic medications have failed or are inadvisable. Nevertheless, long-term safety data beyond 1 year and comparison with the existing therapies remain to be investigated. Other emerging agents targeting pruritogenic proteins, chronic inflammation, and epidermal hyperplasia are under vigorous clinical development. In particular, nemolizumab, blocking IL-31-mediated pruritus, has been reported in Phase II trials to provide symptom relief by interrupting the itch-scratch cycle. Accompanied by thorough characterization of different phenotype and endotype subsets, the era of precision medicine could bring new prospects in the optimal treatment of AD.

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Background: Patients with severe alopecia areata (AA), including alopecia totalis (AT) and alopecia universalis (AU), are usually resistant to treatment. While tofacitinib is emerging as a promising therapy for severe AA, little is known about its efficacy and safety in Asians. Objectives: To evaluate the efficacy and safety of tofacitinib for treating severe AA. Methods: We included patients with ≥50% scalp hair loss, disease for ≥6 months, and tofacitinib therapy for ≥4 months. The efficacy, evaluated based on the percent change in severity of alopecia tool (SALT) score, and response time, defined as time from baseline to reach >50% improvement in SALT score, were assessed. Results: We included 35 patients (21 with AA, 3 with AT, and 11 with AU). There were 18 men and 17 women (median age: 39 [range: 12–68] years). After 4–24 months of treatment, 74.3% showed clinical response, with 51.4% of the patients achieving ≥50% hair regrowth. Patients with AA showed higher percent change in SALT score than patients with AT/AU (median [interquartile range]: 60.7% [0–98.2] vs. 41.1% [8.9–98.7], P = 0.047). Initial SALT score was negatively associated with the latest percent change in SALT score (P = 0.025). Duration of disease and current episode were positively associated with response time to tofacitinib (P = 0.018 and 0.026, respectively). Patients tolerated tofacitinib well without serious adverse events. Conclusion: Tofacitinib effectively promoted hair regrowth in Asian patients with severe AA. Randomized controlled trials with larger sample size are needed to confirm the long-term efficacy and safety of tofacitinib for treating severe AA.

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There are limited studies regarding childhood and adolescent psoriasis in Taiwan. A total of 86 pathologically confirmed cases diagnosed from 1989 to 2017 were retrospectively reviewed. Mean disease onset age was 10.51 years, and plaque psoriasis was the most common type. Compared to studies on Caucasian and other Asian populations, we found a lower estimated prevalence, higher rate of psoriasis limited to the nail at presentation, and higher prevalence of psoriatic arthritis. The most common comorbidities were related to atopy and metabolic syndrome. Positive family history of psoriasis and psoriasis preceded by infection were significantly associated with moderate-to-severe disease.

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Although biologic agents have emerged as the preferred strategy for moderate-to-severe psoriasis, sparing around injection sites may be an underreported effect and represent inadequate systemic efficacy with fair local response of biologic treatment for psoriasis. Herein, we report six cases of extensive psoriasis presenting injection site sparing at biologics administration sites.

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Background/Objective: Secukinumab is an effective treatment for psoriasis, and it has been reported to be effective in patients who failed on multiple prior biologics. However, treatment failure of secukinumab is possible and the alternative management in these patients remains poorly studied. Methods: We reviewed the treatment efficacy of all patients with moderate-to-severe psoriasis who used secukinumab as monotherapy and did not reach Psoriasis Area Severity Index 75 (PASI 75) response at week 16 (primary failure) or later (secondary failure). The treatment response of these patients during subsequent treatments was recorded. Optimal PASI improvement between weeks 12 and 20 and at the end of observation period was recorded. Results: Traditional systemic treatment (n = 4), etanercept (n = 1), adalimumab (n = 6), secukinumab weekly reloading (n = 2), or ustekinumab (n = 4) was administered in 16 patients (one with both ustekinumab and adalimumab). Six patients reached PASI 75 at week 16, including three (50%) with adalimumab. PASI 75 response was maintained in four patients at the end of observation period. Two (50%) of them used adalimumab, one used methotrexate plus acitretin, and the other used secukinumab. Conclusion: Adalimumab demonstrates better response in patients with refractory psoriasis to secukinumab. Traditional systemic medication and re-loading of secukinumab can also provide some benefits.

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Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening severe cutaneous adverse drug reactions, and SJS/TEN in infancy is rare. Here, we present a case of a 4-month-old infant with generalized exanthema, flaccid blisters, and mucosal erosions. He was diagnosed with TEN within 2 days using a granulysin quick screen test and subsequently verified with histopathologic findings. Transmission of cephalexin through breastfeeding was suspected to be a possible cause based on drug history, breastfeeding history, and lymphocyte transformation test. The patient survived with only skin hyperpigmentation remaining.

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Acquired reactive perforating collagenosis (ARPC) is a rare condition caused by transepidermal elimination of collagen, elastin fibers and keratin. To date, the pathogenesis of ARPC remains unknown. Different hypotheses were proposed, including superficial microtrauma due to pruritus and subsequent scratching, diabetes-induced microangiopathy, epidermal and dermal abnormalities in metabolic disorders, dermal microdeposits in patients with chronic renal failure and vasculopathy underlying chronic venous insufficiency and hypertension. In the past two decades, oral allopurinol had been found to be effective in treating ARPC. We report a case of a 36-year-old pregnant woman with itchy skin lesions on the trunk and four limbs since 36 weeks of her gestation. Initially, she was prescribed with oral antihistamine and topical steroid but did not respond well. Skin biopsy was performed and was compatible with ARPC. Normal renal and liver function tests were noted, and the HLA-B5801 test was negative. We treated the patient with allopurinol. Significant improvement was noticed at 1-month follow-up. To the best of our knowledge, this is the first case successfully treating ARPC induced by pregnancy with allopurinol. On careful follow-up of laboratory data and HLA-B5801 test screening, allopurinol may be another effective treatment option for ARPC patients after pregnancy.

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Background: Psoriasis has been reported to impact patients' health-related quality of life. Limited data are available on patients' perception of this disease and the importance of clear/almost clear skin as a treatment goal in Taiwan. Objectives: A clear about Psoriasis worldwide survey was conducted among patients with moderate-to-severe psoriasis to assess patients' perspective on the impact of psoriasis on their personal and professional lives, treatment satisfaction, and the importance of achieving clear/almost clear skin. Here, we report the data for the Taiwanese patient population. Methods: A 20-min survey consisting of multiple choice questions and validated scales to assess disease severity and patient' quality of life was conducted between October 2015 and March 2016. Patients (age ≥18 years) with medically diagnosed moderate-to-severe psoriasis (Psoriasis Area and Severity Index [PASI] score ≥10 or PASI >5 to <10, plaques on visible or sensitive areas), not participated in any online surveys on psoriasis in the past 4 weeks were included in the survey. Results: Eighty-four respondents (male, 56%) with an average PASI score of 17.1 were analyzed. The majority of respondents (77%) had not achieved clear/almost clear skin and 71% believed that it is unachievable. Overall, 20% of patients did not feel comfortable telling their doctor that they want clear/almost clear skin, and 32% had never discussed it. Furthermore, 19% of patients were dissatisfied with their current treatment and 46% were uncertain if they were satisfied or dissatisfied. Overall, 96% of respondents experienced either discrimination or humiliation in daily life and 51% felt that psoriasis affected their professional life. Conclusions: The results of this survey demonstrate that, despite significant progress in the management of psoriasis, the treatment satisfaction level of patients remains suboptimal in Taiwan. The data highlight the need for patients to discuss their treatment goals with clinicians.

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Background/Objectives: Psoriasis is an inflammatory skin disease characterized by erythematous squamous plaques. It has negative physical, psychological, and social effects. Psychiatric comorbidities such as anxiety and depression can accompany to psoriasis. In our study, we aimed to evaluate the anxiety sensitivity (AS) in psoriasis patients. Methods: We included 89 psoriasis patients, 44 controls with nonpsychodermatological disease and 59 healthy volunteers to study. Dermatological examinations were performed, and the Psoriasis Area and Severity Index (PASI) values were calculated. Participants completed a sociodemographic information form, Beck Anxiety Inventory and AS Index-3. Results: Both the psoriasis group and the control group with nonpsychodermatological disease had higher anxiety scores than the healthy control group. Psoriasis patients were found to have higher AS scores than both control group with nonpsychodermatological disease and healthy controls. When the psoriasis group was divided into two groups according to the presence of systemic disease or psoriatic arthritis; there was no difference between the groups in terms of psychometric measurements. Furthermore, there was no significant correlation between PASI scores and disease duration and psychometric evaluations. Conclusion: Our study is the first to show that the AS of psoriasis patients is significantly higher than healthy controls and of those with nonpsychodermatological diseases. It is not clear that high AS in these patients is a predisposing factor to the disease or a consequence of the disease.

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Olmutinib (HM61713) is a third-generation tyrosine kinase inhibitor active against mutant EGFR, including T790M in nonsmall cell lung cancer. The most common side effect of olmutinib to date includes diarrhea, rash, nausea, and pruritus. To the best of our knowledge, it is the first case of psoriasis-like lesions that occurred after treatment with olmutinib. Although the pathogenesis for skin manifestations is presently unknown, we present this case to increase awareness of this unique cutaneous side effect.

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Pembrolizumab is a checkpoint inhibitor to treat cancers by boosting overall immunity with T-cell disinhibition. However, this nonselectively enhanced immunity could trigger de novo or aggravate autoimmune diseases. Only a few reports showed exacerbation of psoriasis after pembrolizumab. We reported a psoriatic patient with esophageal cancer experiencing exacerbation of psoriasis and general myalgia soon after pembrolizumab induction. These adverse effects failed initially to acitretin but responded successfully and durably to cyclosporine subsequently, suggesting immune targeting regimen could be a treatment choice for pembrolizumab-induced psoriasis. We briefly reviewed and discussed the limited numbers of reports regarding this scenario.

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Travel-related cutaneous diseases are very common, and among them, myiasis ranks in the fourth place. Hereby, we present a case of a 28-year-old Taiwanese woman infested by Dermatobia hominis during honeymoon trip to Amazonas region and Peru. The diagnosis was confirmed by extracting the larva intraoperatively. The epidemiology, distinctive life cycle, clinical features, auxiliary diagnostic tools, therapeutic methods, and prophylactic measures of human botfly infestation will be discussed in the article. Owing to the progressive increment of international travels and ecological explorations, raising awareness of tropical diseases should be more emphasized.

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A 40-year-old female presented with rapid-onset generalized erythematous eruption with pustules agminated over the flexural areas and the flanks for 2 days. In skin histopathology, extensive subcorneal pustules, spongiosis and neutrophilic exocytosis, papillary dermal edema, and perivascular and interstitial mixed-cell infiltrates were observed. No psoriasis history but irregular intake of numerous kinds of Chinese herbal medications and the last-modified regimen including Radix Aucklandiae 14 days before the onset of pustular eruption were unveiled. Patch test showed positive result with only Radix Aucklandiae. Thus, acute generalized exanthematous pustulosis induced by Radix Aucklandiae was diagnosed.

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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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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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Background: The severity of chronic urticaria (CU) may be associated with the D-dimer level, and CU patients often have other autoimmune disorders. The autologous serum skin test (ASST) is believed to identify autoimmune/autoreactive diseases in CU patients. Aim: This study evaluated whether the levels of D-dimer, total immunoglobulin E (IgE), and autoimmune markers, such as antithyroid peroxidase (TPO) and antithyroglobulin (TG), differ between ASST-positive and ASST-negative patients among CU patients. In addition, the study assessed whether these laboratory findings were related to CU severity. Methods: The study enrolled 54 adults with CU (16 ASST positive, 38 ASST negative). D-dimer, total IgE, autoimmune marker (anti-TPO and anti-TG), and thyroid hormone levels and the urticaria activity score (UAS) were measured. Results: The levels of D-dimer, total IgE, anti-TPO, and anti-TG and the thyroid function test result showed no difference between the ASST-positive and ASST-negative groups. The UAS was higher in the ASST-positive group than in the ASST-negative group, but the ASST-positive group showed a better treatment response. The UAS was higher in patients with an elevated D-dimer level than in those with a normal level. Total IgE was related to the UAS in only the ASST-negative group, and anti-TPO and anti-TG levels were not related to the UAS. Conclusions: There were no associations between the ASST response and the D-dimer level, total IgE level, thyroid function test results, and thyroid autoantibody levels. However, our findings suggest that the ASST response, D-dimer level, and total IgE level are potential predictors of CU severity.

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Background: Psoriasis is frequently associated with obesity and cardiovascular diseases. Adipocytokines have been implicated in the pathogenesis of psoriasis and its cardiometabolic comorbidities. Objectives: The aim of this study was to assess the roles of leptin, resistin, and high-molecular-weight (HMW) adiponectin in psoriasis as well as their relationship with Psoriasis Area and Severity Index (PASI), obesity, and insulin resistance. Materials and Methods: Forty-six psoriasis patients and equivalent age-, sex-, and body mass index (BMI)-matched controls were recruited in this study. PASI, waist and hip circumferences, and waist/hip ratio (WHR) were recorded, and total body fat mass (TBFM) values were measured using a bioimpedance body composition analyzer. Fasting serum leptin, resistin, and HMW adiponectin levels were measured, and homeostasis model assessment values for insulin resistance (HOMA-IR) were calculated. Results: After the adjustment for anthropometric variables, leptin levels did not differ significantly between the groups (P = 0.736). The patient group showed significantly elevated resistin and lower HMW adiponectin levels (P = 0.007, P= 0.010, respectively). The correlation of serum leptin, resistin, and HMW adiponectin with PASI was not significant (r = −0.100, P= 0.506; r = −0.053, P= 0.726; r = −0.103, P= 0.494, respectively). HOMA-IR positively correlated with leptin and negatively correlated with HMW adiponectin (r = 0.426, P < 0.001; r = −0.393, P < 0.001, respectively). The correlation of leptin and resistin with BMI was direct while that of HMW adiponectin with BMI was inverse (r = 0.532, P < 0.001; r = 0.240, P= 0.021; r = −0.408, P < 0.001, respectively). No significant differences were detected regarding TBFM, and waist and hip circumferences (P = 0.187, P = 0.090, P= 0.543, respectively). However, WHR was significantly higher in the patient group (P = 0.015). Conclusion: Altered adipocytokine levels in psoriasis patients suggest a possible role of adipocytokines in the relationship between psoriasis and its metabolic comorbidities. Fat distribution is also different from the healthy population with similar TBFM values, and abdominal obesity, which is an independent cardiovascular risk factor, is more prevalent in psoriasis patients.

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Background: Radiotherapy treatment was used as a skin-directed therapy for early- and advanced-stage cutaneous T-cell lymphoma (CTCL) refractory to other skin-directed or systemic therapies. Materials and Methods: From January 1990 to January 2017, eight patients with CTCL were treated with local radiation therapy. The median age of these patients was 41 years, and the female-to-male ratio was 1:3. The average disease course was 9.2 years. The patients were classified as Stage Ia (three patients), Ib (one patient), IIb (three patients), and III (one patient). Five patients received electron radiotherapy, and three patients received electron and photon radiotherapy. The mean number of treated lesions was 5.2 (range, 2–14 lesions). A median dose of 46 Gy (range, 40–50 Gy) was used. Results: After radiotherapy, complete and partial remission of the irradiated lesion was observed in 81% and 19% of all treated lesions, respectively. The treatment response in the early stage of disease was statistically significant (P = 0.0427). Local relapse was observed in eight lesions (two lesions in the irradiation field and six lesions outside of the irradiation field) after complete remission. A significantly lower recurrence rate was observed in the early stages of the disease (P = 0.0373). Radiotherapy resulted in long-lasting remission with early-stage CTCL. In addition, radiotherapy helped manage symptoms (pain, itching, and hyperkeratosis) in patients with advanced-stage disease. Conclusion: Localized conventional radiotherapy is effective for the treatment of early- and advanced-stage CTCL that is refractory to other skin-directed or systemic therapies, and the treatment is not associated with severe complications.

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Purpose: The aim of the study is to investigate the effect of MicroRNA-21 (miR-21) and its interaction with epidermal growth factor (EGF) and shikonin on the proliferation, and apoptosis of HaCaT cell line. Materials and Methods: HaCaT cells were cultured under different concentrations of EGF and shikonin, and to calculate their optimal effect dosages. The transfection was performed using Lipofectamine2000, and then gene expression of miR-21 was detected by quantitative real-time polymerase chain reaction (RT-PCR). MTT assay and flow cytometry were applied to test cell proliferation and apoptosis. Western blot and RT-PCR were used to detect the proliferation (proliferating cell nuclear antigen [PCNA], NF-κB/IKKβ) and apoptosis (caspase-3/caspase-9, bcl-2) signals of HaCaT cell. Results: MTT assay showed that miR-21 mimic and EGF promoted, whereas, shikonin and miR-21 inhibitor inhibited cell viability of HaCaT cell. MiR-21 was upregulated by miR-21 mimic and EGF, while downregulated by shikonin and miR-21 inhibitor. Besides, EGF and miR-21 mimic promoted proliferation-associated signals (PCNA, NF-κB/IKKβ) expression, which were suppressed by shikonin and miR-21 inhibitor. Yet, shikonin and miR-21 inhibitor induced apoptosis-related signals (caspase-3/caspase-9, bcl-2) expression while reversed by EGF and miR-21 mimic which were confirmed by the result of flow cytometry. Conclusions: MiR-21 promotes the process of EGF-induced cell growth of HaCaT. The antagonized effect of shikonin in EGF-induced proliferation and apoptosis might be mediated by suppressing the expression of miR-21.

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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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Background: Psoriasis is a chronic inflammatory skin disease that has been associated with various inflammatory comorbidities such as cardiovascular disease and uveitis. Asthma involves inflammation of the airway. The two diseases share cytokine-mediated inflammatory mechanisms. Objectives: The main objective of the study was to examine the association of psoriasis with asthma. Methods: We conducted a systematic review and meta-analysis of observational studies that examined the association of psoriasis with asthma. We searched MEDLINE, Embase, and CENTRAL from inception to May 2, 2019 for relevant case–control, cross-sectional, or cohort studies. The risk of bias of included studies was assessed by using the Newcastle–Ottawa Scale. The random-effects model meta-analysis was used to calculate the odds ratio (OR) for case–control/cross-sectional studies and hazard ratio (HR) for cohort studies. Results: We included six case–control/cross-sectional (one case–control and five cross-sectional studies) and one cohort studies. Three studies were rated with a high risk of bias in case definition, representativeness of the cases, selection of controls, definition of controls, and ascertainment of exposure. Psoriasis was associated with significantly increased odds (OR 1.29; 95% confidence interval [CI] 1.20-'1.37) and risk (HR 1.38; 95% CI 1.23-'1.54) for asthma. A subgroup analysis revealed increased odds for asthma in both pediatric and adult patients with psoriasis (pooled OR being 1.24 [95% CI 1.10-'1.41] and OR 1.38 [95% CI 1.27-'1.50], respectively). Conclusion: The current evidence indicates a significant association of psoriasis with asthma. When psoriasis patients present with respiratory symptoms for shortness of breath, wheezing, and chest tightness, referral to pulmonologist may be considered.

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