Patients with chronic itch describe their pruritus in a wide variety of ways. However, these subjective descriptions are often not taken into consideration by physicians. This study aimed to validate patients' descriptions of pruritus, and to investigate the relationship between various descriptions of pruritus and the patient burden of chronic pruritus by examining the mediating effects of sleep disturbance and sexual dysfunction on patient's quality of life, as predicted by various descriptions of pruritus. Exploratory and confirmatory factor analyses were performed to identify the factor structure measured by 11 descriptions of pruritus. The study then analysed differences in the degree of sleep disturbance, sexual dysfunction, and quality of life deterioration factors using a structural equation modelling method. Using data from 419 patients with chronic pruritus, 11 descriptions of pruritus were classified into 2 groups: (i) sensory pruritus (i.e. stinging, stabbing, burning, painful, formication, throbbing, and cold) that are linked with descriptions of pruritus patterns; and (ii) affective pruritus (i.e. annoying, unbearable, worrisome, and warm) from patient reports of psychological or emotional distress. The study found that affective pruritus decreases patient's quality of life either directly or indirectly through sleep disturbance. In conclusion, clues about a patients' sleep disturbance or poor quality of life can be obtained through their descriptions of pruritus.

Background: Pediatric alopecia areata (AA) can affect the quality of life (QoL) of patients and their family members.Research on the QoL and burden on family members in pediatric AA is limited.Objective: This nationwide multicenter questionnaire study described the QoL and burden of the family members of patients with pediatric AA.Methods: This nationwide multicenter questionnaire study enrolled AA patients between the ages of 5 and 18 years from March 1, 2017 to February 28, 2018.Enrolled patients and their parents completed the modified Children's Dermatology Life Quality Index (CDLQI) and the modified Dermatitis Family Impact (mDFI).The disease severity was measured using the Severity of Alopecia Tool (SALT) survey scores.Results: A total of 268 patients with AA from 22 hospitals participated in this study.Our study found that the efficacy and satisfaction of previous treatments of AA decreased as the severity of the disease increased.The use of home-based therapies and traditional medicines increased with the increasing severity of the disease, but the efficacy felt by patients was limited.CDLQI and mDFI scores were higher in patients with extensive AA than those with mild to moderate AA.The economic and time burden of the family members also increased as the severity of the disease increased. Conclusion:The severity of the AA is indirectly proportional to the QoL of patients and their family members and directly proportional to the burden.Physicians need to understand these characteristics of pediatric AA and provide appropriate intervention to patients and their family members.

Background Only a few studies have tried to assess factors relevant to the satisfaction of the participants in atopic dermatitis (AD) educational programs. More systematic modeling of this issue is needed. Objective To examine the benefit of a conjoint educational program for AD on patients and caregivers in a clinical setting. Methods In a half-day educational program called “AD school”, 831 people (493 patients and 338 family members) participated for 8 years. Various educational and entertaining programs were provided. The on-site survey was administered to measure participants' satisfaction and perception of the benefit. We applied structural equation modeling to identify the relations among satisfaction and perception. Results A total of 209 family survey data was obtained and analyzed. The survey items were grouped into four categories. The categories were classified as individual education, group education, fun activity, and overall satisfaction (fun, benefit, intention to re-join and recommend to others). According to the model that we built, comprehensive group education was demonstrated to be the most relevant factor affecting overall satisfaction. Conclusion Our holistic approach would allow dermatologists to improve the efficacy of the conjoint educational program for AD.

Chemotherapy is one of the most effective treatments for cancer. However, intracellular delivery of many anticancer drugs is hindered by their hydrophobicity and low molecular weight. Here, we describe highly biocompatible and biodegradable amphiphilic vitamin conjugates comprising hydrophobic vitamin E and hydrophilic vitamin B labeled with dual pH and glutathione-responsive degradable linkages. Vitamin-based micelles (vitamicelles), formed by self-assembly in aqueous solutions, were optimized based on their stability after encapsulation of doxorubicin (DOX). The resulting vitamicelles have great potential as vehicles for anticancer drugs because they show excellent biocompatibility (>94% after 48 h of incubation) and rapid biodegradability (>90% after 2.5 h). Compared with free DOX, DOX-loaded vitamicelles showed a markedly enhanced anticancer effect as they released the drug rapidly and inhibited drug efflux out of cells efficiently. By exploiting these advantages, this study not only provides a promising strategy for circumventing existing challenges regarding the delivery of anticancer drugs but also extends the utility of current DOX-induced chemotherapy.

Background: Based on clinical and genetic differences, atopic dermatitis (AD) and psoriasis have been classified in two different diseases, but recently, some authors regarded them as in one spectrum. The histological similarities including epidermal hyperplasia between chronic stages of AD and psoriasis supports the presence of two diseases in one spectrum. Objective: We investigated clinical and immunohistopathological characteristics of adult Korean patients with AD showing psoriasiform chronic dermatitis on histopathology. Methods: In total, 59 Korean patients with chronic AD were enrolled. Clinical, laboratory, and histopathological features were compared between AD patients with psoriasiform features and those with non-psoriasiform chronic dermatitis features on histology. In addition, immunohistopathological characteristics were analyzed using antibodies for key regulatory and effector cytokines in psoriasis. Results: Fifteen patients (25.4%) showed a more "psoriasiform" histological appearance. The lesions in patients with psoriasiform features often showed clearer boundaries and noticeable scaling. The interleukin (IL)-23 expression in the psoriasiform chronic dermatitis group was not different from that in the psoriasis group, but the IL-17 expression was less than that in the psoriasis group. In the case of IL-12, multiple dermal inflammatory cells with dendrites were stained in the psoriasiform chronic dermatitis group compared with the 2 other non-psoriasiform subgroups. Conclusion: The results suggest that IL-12 secreted from dermal inflammatory cells might be one of the important factors associated with the formation of psoriasiform features in chronic AD. However, further studies are required to better define the specific role of IL-12.

Vol. 31, No. 2, 2019 231 Received March 9, 2018, Revised March 15, 2018, Accepted for publication March 22, 2018 Corresponding author: Yong Hyun Jang, Department of Dermatology, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea. Tel: 82-53-420-5838, Fax: 82-53-426-0770, E-mail: yhjang@knu.ac.kr ORCID: https://orcid.org/0000-0003-1706-007X This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright © The Korean Dermatological Association and The Korean Society for Investigative Dermatology man hair-follicle growth. Proc Natl Acad Sci U S A 2013; 110:19679-19688. 6. Seo CH, Kwack MH, Lee SH, Kim MK, Kim JC, Sung YK. Poor capability of 3D-cultured adipose-derived stem cells to induce hair follicles in contrast to 3D-cultured dermal papilla cells. Ann Dermatol 2016;28:662-665. 7. Legrand JMD, Roy E, Ellis JJ, Francois M, Brooks AJ, Khosrotehrani K. STAT5 activation in the dermal papilla is important for hair follicle growth phase induction. J Invest Dermatol 2016;136:1781-1791. 8. Harel S, Higgins CA, Cerise JE, Dai Z, Chen JC, Clynes R, et al. Pharmacologic inhibition of JAK-STAT signaling promotes hair growth. Sci Adv 2015;1:e1500973. 9. Zheng Y, Du X, Wang W, Boucher M, Parimoo S, Stenn K. Organogenesis from dissociated cells: generation of mature cycling hair follicles from skin-derived cells. J Invest Dermatol 2005;124:867-876. 10. McElwee KJ, Kissling S, Wenzel E, Huth A, Hoffmann R. Cultured peribulbar dermal sheath cells can induce hair follicle development and contribute to the dermal sheath and dermal papilla. J Invest Dermatol 2003;121:1267-1275.

Alopecia areata (AA) is an autoimmune skin disease characterized by one or more alopecic patches, with a lifetime risk of 2.1% (Mirzoyev et al., 2014Mirzoyev S.A. Schrum A.G. Davis M.D.P. Torgerson R.R. Lifetime incidence risk of alopecia areata estimated at 2.1% by Rochester Epidemiology Project, 1990–2009.J Invest Dermatol. 2014; 134: 1141-1142Abstract Full Text Full Text PDF PubMed Scopus (173) Google Scholar). Hair loss evokes not only a cosmetic problem but also significant psychosocial distress in affected patients (Dubois et al., 2010Dubois M. Baumstarck-Barrau K. Gaudy-Marqueste C. Richard M.A. Loundou A. Auquier P. et al.Quality of life in alopecia areata: a study of 60 cases.J Invest Dermatol. 2010; 130: 2830-2833Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, Liu et al., 2016Liu L.Y. King B.A. Craiglow B.G. Health-related quality of life (HRQoL) among patients with alopecia areata (AA): a systematic review.J Am Acad Dermatol. 2016; 75: 806-812Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar). Several studies have shown that patients with AA had poor self-confidence, had increased rates of depression, and were subject to stigmatization (Aghaei et al., 2014Aghaei S. Saki N. Daneshmand E. Kardeh B. Prevalence of psychological disorders in patients with alopecia areata in comparison with normal subjects.ISRN Dermatol. 2014; 2014: 304370Crossref PubMed Google Scholar, Alfani et al., 2012Alfani S. Antinone V. Mozzetta A. Di Pietro C. Mazzanti C. Stella P. et al.Psychological status of patients with alopecia areata.Acta Derm Venereol. 2012; 92: 304-306Crossref PubMed Scopus (42) Google Scholar, Back et al., 2008Back S.J. Park Y.O. Kim K.J. Kim C.D. Seo Y.J. Lee J.H. et al.Quality of life of alopecia areata patients.Korean J Dermatol. 2008; 46: 578-586Google Scholar). However, large scale, in-depth clinical studies on the various factors affecting psychosocial status and quality of life (QOL) in AA patients have rarely been reported. We performed a nationwide questionnaire-based survey to investigate anxiety, depression, and QOL in AA patients and to identify the factors associated with each category. We enrolled patients with AA (≥ 20 years old) diagnosed by a dermatologist between January 2015 and February 2016. We recorded demographic characteristics including age, sex, marital status, educational background, age of onset, disease duration, treatment history (duration of treatment, degree of improvement, satisfaction, recurrence, and adverse effects), associated diseases, medications, and past medical history. Disease severity was assessed using the Severity of Alopecia Tool (i.e., SALT) score based on the percentage of the involved scalp area (S1 = 0%–25%, S2 = 26%–50%, S3 = 51%–75%, S4 = 76%–99%, S5 = 100%). We assessed anxiety and depression using the Beck Anxiety Inventory and Beck Depression Inventory (Beck et al., 1961Beck A.T. Ward C.H. Mendelson M. Mock J. Erbaugh J. An inventory for measuring depression.Arch Gen Psychiatry. 1961; 4: 561-571Crossref PubMed Scopus (28335) Google Scholar, Beck et al., 1988Beck A.T. Epstein N. Brown G. Steer R.A. An inventory for measuring clinical anxiety: psychometric properties.J Consult Clin Psychol. 1988; 56: 893-897Crossref PubMed Scopus (9159) Google Scholar), respectively. QOL was assessed using the hair-specific Skindex-29 questionnaire, as modified by Han et al., 2012Han S.H. Byun J.W. Lee W.S. Kang H. Kye Y.C. Kim K.H. et al.Quality of life assessment in male patients with androgenetic alopecia: result of a prospective, multicenter study.Ann Dermatol. 2012; 24: 311-318Crossref PubMed Scopus (96) Google Scholar. Anxiety, depression, and QOL impairment were categorized as mild, moderate, or severe, based on the score. Univariable and multivariable logistic regression analyses were sequentially performed to identify independent factors associated with anxiety, depression, and QOL impairment, respectively. Pearson correlation analyses were conducted between each item. All analyses were performed using R 3.3.1 (R Foundation for Statistical Computing, Vienna, Austria). The study protocol was designed in accordance with the Declaration of Helsinki and was approved by the institutional review board of each participating hospital, and all participants gave written informed consent. A total of 1,203 AA patients from 15 hospitals participated in this study (see Supplementary Table S1 online). As measured by the Beck Anxiety Inventory, 10.1% of patients had anxiety, and 4.2% had severe anxiety (Table 1). For the Beck Depression Inventory, 40.9% of patients had depression, and 9.4% had severe depression. In the symptoms domain of the hair-specific Skindex-29, 30.3% of patients had impaired QOL, and 9.9% had severely impaired QOL (Table 2). In the functioning domain, 71.3% of patients had impaired QOL, and 48.7% had severely impaired QOL. In the emotions domain, 81.7% of patients had impaired QOL, and 60.2% had severely impaired QOL. In addition, anxiety and depression were positively correlated with each other, and they were also correlated with impairment in symptoms, functioning, and emotions (Figure 1).Table 1Anxiety and depression and associated factors in patients with alopecia areataScaleAnxietySevere Anxietyn%Odds Ratio (95% CI)P-Valuen%Odds Ratio (95% CI)P-ValueBAI1The BAI has 21 items; a score of 0 indicates the lowest and 63 the highest level of anxiety. A score of 22-26 points indicates the individual requires observation and intervention, 27–31 points indicates severe anxiety, and 32 points or greater indicates extreme anxiety (Beck et al., 1988). Total122/1,20310.150/1,2034.2 SexMale36/5766.3Reference11/5761.9ReferenceFemale86/62713.72.526 (1.683–3.863)<0.00139/6276.23.578 (1.864–7.447)<0.001 SeverityS142/6876.1Reference15/6872.2ReferenceS228/24211.62.157 (1.286–3.571)0.00312/2425.02.519 (1.134–5.483)0.020S317/10715.93.039 (1.611–5.529)<0.0014/1073.71.813 (0.507–5.146)0.301S421/10819.43.844 (2.127–6.787)<0.00113/10812.06.392 (2.886–14.010)<0.001S514/5923.74.836 (2.363–9.495)<0.0016/5910.25.270 (1.800–13.744)0.001ScaleDepressionSevere Depressionn%Odds Ratio (95% CI)P-Valuen%Odds Ratio (95% CI)P-ValueBDI2The BDI has 21 items; a score of 0 indicates the lowest and 63 the highest level of depression. A score of 0–9 points indicates no depression; 10–15 points, mild depression; 16–23 points, moderate depression; and 24 points or greater, severe depression (Beck et al., 1961). Total492/1,20340.9113/1,2039.4 SexMale205/57635.6Reference36/5766.3ReferenceFemale287/62745.81.626 (1.279–2.070)<0.00177/62712.32.259 (1.491–3.482)<0.001 SeverityS1223/68732.5Reference31/6874.5ReferenceS2102/24242.11.603 (1.181–2.174)0.00231/24212.83.295 (1.944–5.589)<0.001S366/10761.73.531 (2.314–5.446)<0.00117/10715.94.171 (2.167–7.807)<0.001S468/10863.03.652 (2.396–5.633)<0.00125/10823.16.604 (3.676–11.798)<0.001S533/5955.92.614 (1.520–4.540)<0.0019/5915.33.906 (1.663–8.430)<0.001Abbreviations: BAI, Beck Anxiety Inventory; BDI, Beck depression inventory; CI, confidence interval; S, severity.1 The BAI has 21 items; a score of 0 indicates the lowest and 63 the highest level of anxiety. A score of 22-26 points indicates the individual requires observation and intervention, 27–31 points indicates severe anxiety, and 32 points or greater indicates extreme anxiety (Beck et al., 1988Beck A.T. Epstein N. Brown G. Steer R.A. An inventory for measuring clinical anxiety: psychometric properties.J Consult Clin Psychol. 1988; 56: 893-897Crossref PubMed Scopus (9159) Google Scholar).2 The BDI has 21 items; a score of 0 indicates the lowest and 63 the highest level of depression. A score of 0–9 points indicates no depression; 10–15 points, mild depression; 16–23 points, moderate depression; and 24 points or greater, severe depression (Beck et al., 1961Beck A.T. Ward C.H. Mendelson M. Mock J. Erbaugh J. An inventory for measuring depression.Arch Gen Psychiatry. 1961; 4: 561-571Crossref PubMed Scopus (28335) Google Scholar). Open table in a new tab Table 2Factors associated with impaired quality of life in patients with alopecia areata according to each hair-specific Skindex-29 domainDomains and FactorsImpaired QOLSeverely Impaired QOLn%Odds Ratio (95% CI)P-Valuen%Odds Ratio (95% CI)P-ValueSymptoms365/1,20330.3119/1,2039.9 SexMale148/57625.7Reference48/5768.3ReferenceFemale217/62734.61.568 (1.216–2.027)<0.00171/62711.31.434 (0.968–2.140)0.075 SeverityS1174/68725.3Reference42/6876.1ReferenceS274/24230.61.291 (0.927–1.788)0.12723/2429.51.596 (0.922–2.702)0.087S344/10741.11.872 (1.210–2.874)0.00415/10714.02.255 (1.156–4.200)0.013S455/10850.92.803 (1.833–4.294)<0.00128/10825.94.955 (2.852–8.531)<0.001S518/5930.51.108 (0.598–1.982)0.73511/5918.63.174 (1.446–6.528)0.002Functioning873/1,20371.3604/1,20350.2 SeverityS1459/68765.2Reference277/68739.0ReferenceS2178/24272.91.351 (0.976–1.888)0.074130/24251.11.676 (1.244–2.262)<0.001S392/10786.42.850 (1.655–5.238)<0.00175/10768.63.206 (2.071–5.063)<0.001S492/10883.62.680 (1.574–4.844)<0.00182/10875.04.321 (2.733–7.036)<0.001S552/5983.13.200 (1.515–7.867)0.00540/5963.62.658 (1.514–4.815)<0.001 Disease duration in years<1369/54567.1231/54541.6Reference1–5307/41072.6226/41052.31.458 (1.114–1.909)0.0065–10118/15376.184/15353.41.423 (0.978–2.072)0.065≥1079/9582.463/9566.72.172 (1.360–3.520)0.001Emotions983/1,20381.7724/1,20360.2 SexMale522/62783.3394/62762.8ReferenceFemale461/57680.0330/57657.31.314 (1.032–1.673)0.027 Age in years20–39530/62984.3Reference411/62965.3Reference40–59393/49779.10.632 (0.458–0.869)0.004260/49752.30.680 (0.529–0.873)0.003≥6060/7777.90.641 (0.356–1.202)0.15036/7746.80.816 (0.496–1.355)0.427 SeverityS1521/68775.8Reference355/68751.7ReferenceS2207/24285.51.802 (1.211–2.742)0.004154/24263.61.643 (1.211–2.240)0.002S3102/10795.35.221 (2.281–15.096)<0.00181/10775.72.775 (1.750–4.532)<0.001S4100/10892.63.084 (1.533–7.096)0.00490/10883.34.502 (2.700–7.905)<0.001S553/5989.81.899 (0.841–5.098)0.15644/5974.62.320 (1.279–4.425)0.007 Disease duration in years<1412/54575.6294/54553.9Reference1–5350/41085.4253/41061.71.232 (0.939–1.618)0.1325–10132/15386.3104/15368.01.598 (1.084–2.377)0.019≥1089/9593.773/9576.82.295 (1.384–3.934)0.002Abbreviations: CI, confidence interval; QOL, quality of life; S, severity.The hair-specific Skindex-29 includes domains of symptoms (7 items), emotions (10 items), and functioning (12 items). A 5-point scale is used for scoring: 0 (never), 1 (rarely), 2 (sometimes), 3 (often), and 4 (all the time). The responses were transformed into linear scores ranging from 0 (no effect) to 100 (effect always experienced). The cutoff score proposed by Prinsen et al., 2011Prinsen C.A. Lindeboom R. de Korte J. Interpretation of Skindex-29 scores: cutoffs for mild, moderate, and severe impairment of health-related quality of life.J Invest Dermatol. 2011; 131: 1945-1947Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar was used as the standard for patient grouping: ≥39 (mild), ≥42 (moderate), and ≥52 (severe) for symptoms; ≥24 (mild), ≥35 (moderate), and ≥39 (severe) for emotions; and ≥21 (mild), ≥32 (moderate), and ≥37 (severe) for functioning. Open table in a new tab Abbreviations: BAI, Beck Anxiety Inventory; BDI, Beck depression inventory; CI, confidence interval; S, severity. Abbreviations: CI, confidence interval; QOL, quality of life; S, severity. The hair-specific Skindex-29 includes domains of symptoms (7 items), emotions (10 items), and functioning (12 items). A 5-point scale is used for scoring: 0 (never), 1 (rarely), 2 (sometimes), 3 (often), and 4 (all the time). The responses were transformed into linear scores ranging from 0 (no effect) to 100 (effect always experienced). The cutoff score proposed by Prinsen et al., 2011Prinsen C.A. Lindeboom R. de Korte J. Interpretation of Skindex-29 scores: cutoffs for mild, moderate, and severe impairment of health-related quality of life.J Invest Dermatol. 2011; 131: 1945-1947Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar was used as the standard for patient grouping: ≥39 (mild), ≥42 (moderate), and ≥52 (severe) for symptoms; ≥24 (mild), ≥35 (moderate), and ≥39 (severe) for emotions; and ≥21 (mild), ≥32 (moderate), and ≥37 (severe) for functioning. In this nationwide survey, we found that AA patients had psychosocial comorbidities, including anxiety and depression. These findings have been described in previous studies using various instruments (Alfani et al., 2012Alfani S. Antinone V. Mozzetta A. Di Pietro C. Mazzanti C. Stella P. et al.Psychological status of patients with alopecia areata.Acta Derm Venereol. 2012; 92: 304-306Crossref PubMed Scopus (42) Google Scholar, Colon et al., 1991Colon E.A. Popkin M.K. Callies A.L. Dessert N.J. Hordinsky M.K. Lifetime prevalence of psychiatric disorders in patients with alopecia areata.Compr Psychiatry. 1991; 32: 245-251Crossref PubMed Scopus (159) Google Scholar). Colon et al. performed psychiatric interviews and found that AA patients had elevated rates of generalized anxiety disorder (39%) and major depressive disorder (39%). A study using the Minnesota Multiphasic Personality Inventory showed that depression and anxiety scores in AA patients were significantly higher than in control individuals (Alfani et al., 2012Alfani S. Antinone V. Mozzetta A. Di Pietro C. Mazzanti C. Stella P. et al.Psychological status of patients with alopecia areata.Acta Derm Venereol. 2012; 92: 304-306Crossref PubMed Scopus (42) Google Scholar). In this study, we also showed that the involvement of more than 50% (S3, S4, and S5) of the scalp and female sex were both independent factors affecting both anxiety and depression. We confirmed that AA patients have markedly impaired QOL in all aspects of symptoms, functioning, and emotions. Our results suggested that AA could affect patients’ QOL more than vitiligo or androgenetic alopecia, compared with the previous studies using the similar study protocol in Korea (Bae et al., 2018Bae J.M. Lee S.C. Kim T.H. Yeom S.D. Shin J.H. Lee W.J. et al.Factors affecting quality of life in patients with vitiligo: a nationwide study.Br J Dermatol. 2018; 178: 238-244Crossref PubMed Scopus (42) Google Scholar, Han et al., 2012Han S.H. Byun J.W. Lee W.S. Kang H. Kye Y.C. Kim K.H. et al.Quality of life assessment in male patients with androgenetic alopecia: result of a prospective, multicenter study.Ann Dermatol. 2012; 24: 311-318Crossref PubMed Scopus (96) Google Scholar). More patients with AA have impaired QOL than patients with vitiligo (symptoms: 30.3% vs. 14.6%, functioning: 71.3% vs. 48.8%, and emotions: 81.7% vs. 65.0%) (Bae et al., 2018Bae J.M. Lee S.C. Kim T.H. Yeom S.D. Shin J.H. Lee W.J. et al.Factors affecting quality of life in patients with vitiligo: a nationwide study.Br J Dermatol. 2018; 178: 238-244Crossref PubMed Scopus (42) Google Scholar). For hair-specific Skindex-29, the mean score of each domain was higher in AA patients than androgenetic alopecia patients (symptoms: 27.4 vs. 27.3, functioning: 38.7 vs. 24.0, and emotions: 48.7 vs. 32.1) (Han et al., 2012Han S.H. Byun J.W. Lee W.S. Kang H. Kye Y.C. Kim K.H. et al.Quality of life assessment in male patients with androgenetic alopecia: result of a prospective, multicenter study.Ann Dermatol. 2012; 24: 311-318Crossref PubMed Scopus (96) Google Scholar). We also found that sex, age, disease severity, and longer duration were associated with QOL impairment in AA patients. However, linear correlations between severity and these impairments were not obvious. Previously, a Serbian study also showed that disease severity was not associated with the symptoms and emotions domains of the Skindex-29 in AA patients (Jankovic et al., 2016Jankovic S. Peric J. Maksimovic N. Cirkovic A. Marinkovic J. Jankovic J. et al.Quality of life in patients with alopecia areata: a hospital-based cross-sectional study.J Eur Acad Dermatol Venereol. 2016; 30: 840-846Crossref PubMed Scopus (20) Google Scholar). Moreover, a US study pointed out that patients rated their hair loss as more severe than did the dermatologist, and clinical hair loss severity did not reliably predict the degree of subjective distress (Reid et al., 2012Reid E.E. Haley A.C. Borovicka J.H. Rademaker A. West D.P. Colavincenzo M. et al.Clinical severity does not reliably predict quality of life in women with alopecia areata, telogen effluvium, or androgenic alopecia.J Am Acad Dermatol. 2012; 66: e97-e102Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar). A Brazilian study reported that disease severity did not influence the mental health subscale score (de Hollanda et al., 2014de Hollanda T.R. Sodre C.T. Brasil M.A. Ramos E.S.M. Quality of life in alopecia areata: a case-control study.Int J Trichology. 2014; 6: 8-12Crossref PubMed Scopus (24) Google Scholar). Our findings are in line with those of previous studies, which do not seem to be related to race or cultural background. The Severity of Alopecia Tool score would not be sufficient to assess the severity of AA, and other factors more than clinical hair loss severity should be considered in treating AA patients. There are some limitations to our study. First, we included only adult patients to use uniform, validated instruments. Second, there could be selection bias, because only patients who visited the hospital were included in the study. Third, all participants were Korean. Fourth, we did not consider the specific location or distribution pattern of alopecic patches. However, our study was performed throughout the country, and dermatologists conducted both the physical examination and the survey process. Therefore, the results should be highly reliable. In conclusion, we found that AA patients would have psychosocial problems including anxiety, depression, and impaired QOL in the domains of symptoms, functioning, and emotions. Also, we determined the independent factors influencing anxiety, depression, and QOL. The involvement of more than 50% of the scalp markedly affects anxiety, depression, and QOL; however, the clinical severity was not linearly correlated with those impairments. Therefore, dermatologists should consider these psychosocial aspects when treating AA patients. Hee Seong Yoon: http://orcid.org/0000-0001-8997-9697 Oh Sang Kwon: http://orcid.org/0000-0003-0464-5124 Jung Min Bae: https://orcid.org/0000-0001-5975-8519 The authors state no conflict of interest. We thank all patients who participated in this study. This study was supported by the Korean Hair Research Society of the Korean Dermatological Association. 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Background: Several tools can provide a reliable and accurate evaluation of pruritus, including the visual analog scale (VAS), numeric rating scale (NRS), verbal rating scale (VRS), and multidimensional questionnaires such as the Itch Severity Scale (ISS). However, no single method is considered a gold standard. Objective: We evaluated the validity and reliability of VAS, NRS, VRS, and ISS and their correlation with a pruritus-specific quality of life instrument, ItchyQoL. Methods: A total of 419 patients (215 men and 204 women) with chronic pruritus (mean age, 46.58 years) recorded their pruritus intensity on VAS, NRS, VRS, and ISS. Retest reliability was analyzed in a second assessment 3 hours after the initial assessment. All participants answered ItchyQoL. Results: A strong correlation between VAS, NRS, and VRS was found. ISS showed a low intercorrelation validity with these tools. However, ISS was more strongly correlated with ItchyQoL. The retest reliability scores were similar for VAS, NRS, and VRS but lower than the scores obtained for ISS. Limitations: Limitations include patient heterogeneity and recall bias. Conclusion: The assessment of pruritus is challenging because of the subjective symptoms and the multifactorial nature. Therefore, more studies are needed to determine the best strategy to assess itch intensity.

Background Increasing evidence suggests a pivotal role for neuronal inflammation in response to replicating varicella zoster virus in the development of postherpetic neuralgia (PHN). Objective In this study, we investigated the value of serum levels of various inflammatory markers in acute herpes zoster (HZ) as predictors for the development of PHN. Methods A total of 116 patients with acute HZ were enrolled in this study. We measured scores on the pain visual analogue scale (VAS) at baseline and at 1, 3, and 6 months after diagnosis of HZ. We defined PHN as pain greater than 1 on the VAS lasting for more than 6 months. Serum samples for laboratory assay, including complete blood count were obtained at the initial visit. Correlations between the levels of each inflammatory marker and the development of PHN were evaluated. Results Levels of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), lymphocyte count, and albumin showed significant correlations with development of PHN in univariate analysis. Levels of ESR, CRP, and lymphocyte count also showed significant correlations in multivariate analysis. ESR level showed stronger correlations with development of PHN than levels of CRP and lymphocyte count. Conclusion In this study, we confirmed that elevated ESR was an independent and significant predictor of PHN in patients with acute HZ. To validate these results, further well-designed, randomized clinical trials are needed.

Journal of Cutaneous PathologyVolume 44, Issue 6 p. 602-603 LETTER TO THE EDITOR Coexistence of psoriasis and epidermolysis bullosa acquisita: Evaluation of the integrity of the basement membrane Sun Young Moon MD, Sun Young Moon MD Department of Dermatology, Kyungpook National University School of Medicine, Daegu, KoreaSearch for more papers by this authorDong Hyuk Eun MD, Dong Hyuk Eun MD Department of Dermatology, Kyungpook National University School of Medicine, Daegu, KoreaSearch for more papers by this authorHan Jin Jung MD, Han Jin Jung MD Department of Dermatology, Kyungpook National University School of Medicine, Daegu, KoreaSearch for more papers by this authorJun Young Kim MD, Jun Young Kim MD Department of Dermatology, Kyungpook National University School of Medicine, Daegu, KoreaSearch for more papers by this authorTae-In Park MD, PhD, Tae-In Park MD, PhD Department of Pathology, Kyungpook National University School of Medicine, Daegu, KoreaSearch for more papers by this authorWeon Ju Lee MD, PhD, Weon Ju Lee MD, PhD Department of Dermatology, Kyungpook National University School of Medicine, Daegu, KoreaSearch for more papers by this authorSeok-Jong Lee MD, PhD, Seok-Jong Lee MD, PhD Department of Dermatology, Kyungpook National University School of Medicine, Daegu, KoreaSearch for more papers by this authorDo Won Kim MD, PhD, Do Won Kim MD, PhD Department of Dermatology, Kyungpook National University School of Medicine, Daegu, KoreaSearch for more papers by this authorMan-Hoon Han MD, Corresponding Author Man-Hoon Han MD one-many@hanmail.net Department of Pathology, Kyungpook National University School of Medicine, Daegu, KoreaEmail: one-many@hanmail.net; yhjang@knu.ac.krSearch for more papers by this authorYong Hyun Jang MD, PhD, Corresponding Author Yong Hyun Jang MD, PhD yhjang@knu.ac.kr orcid.org/0000-0003-1706-007X Department of Dermatology, Kyungpook National University School of Medicine, Daegu, KoreaEmail: one-many@hanmail.net; yhjang@knu.ac.krSearch for more papers by this author Sun Young Moon MD, Sun Young Moon MD Department of Dermatology, Kyungpook National University School of Medicine, Daegu, KoreaSearch for more papers by this authorDong Hyuk Eun MD, Dong Hyuk Eun MD Department of Dermatology, Kyungpook National University School of Medicine, Daegu, KoreaSearch for more papers by this authorHan Jin Jung MD, Han Jin Jung MD Department of Dermatology, Kyungpook National University School of Medicine, Daegu, KoreaSearch for more papers by this authorJun Young Kim MD, Jun Young Kim MD Department of Dermatology, Kyungpook National University School of Medicine, Daegu, KoreaSearch for more papers by this authorTae-In Park MD, PhD, Tae-In Park MD, PhD Department of Pathology, Kyungpook National University School of Medicine, Daegu, KoreaSearch for more papers by this authorWeon Ju Lee MD, PhD, Weon Ju Lee MD, PhD Department of Dermatology, Kyungpook National University School of Medicine, Daegu, KoreaSearch for more papers by this authorSeok-Jong Lee MD, PhD, Seok-Jong Lee MD, PhD Department of Dermatology, Kyungpook National University School of Medicine, Daegu, KoreaSearch for more papers by this authorDo Won Kim MD, PhD, Do Won Kim MD, PhD Department of Dermatology, Kyungpook National University School of Medicine, Daegu, KoreaSearch for more papers by this authorMan-Hoon Han MD, Corresponding Author Man-Hoon Han MD one-many@hanmail.net Department of Pathology, Kyungpook National University School of Medicine, Daegu, KoreaEmail: one-many@hanmail.net; yhjang@knu.ac.krSearch for more papers by this authorYong Hyun Jang MD, PhD, Corresponding Author Yong Hyun Jang MD, PhD yhjang@knu.ac.kr orcid.org/0000-0003-1706-007X Department of Dermatology, Kyungpook National University School of Medicine, Daegu, KoreaEmail: one-many@hanmail.net; yhjang@knu.ac.krSearch for more papers by this author First published: 20 April 2017 https://doi.org/10.1111/cup.12940Citations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume44, Issue6June 2017Pages 602-603 RelatedInformation

Vol. 30, No. 1, 2018 105 Received September 19, 2016, Revised December 26, 2016, Accepted for publication January 18, 2017 Corresponding author: Weon Ju Lee, Department of Dermatology, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea. Tel: 82-53-420-5838, Fax: 82-53-426-0770, E-mail: weonju@knu.ac.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright © The Korean Dermatological Association and The Korean Society for Investigative Dermatology Fig. 1. (A) Polyonychia on the deformed distal phalanx of the right second toe. (B) One year after the operation. https://doi.org/10.5021/ad.2018.30.1.105

Pyogenic granuloma (PG), also known as lobular capillary haemangioma, is a relatively common benign vascular lesion of the skin and mucosa. Although spontaneous resolution may occur, treatment is often recommended to avoid ulceration and recurrent bleeding. In young children, local ablative therapies for PG include cryosurgery and laser treatment, but their use in dangerous or problematic lesions in areas such as the face may lead to cosmetic complications. Therefore, safe and effective options for treatment of facial PG in children are needed. A 4-year-old boy presented with a 3-month history of a solitary, vivid red, matchhead-sized, pedunculated papule on his left cheek, which was clinically diagnosed as PG. The patient was prescribed ingenol mebutate 0.015% cream, to be applied to the lesion once daily for 3 days. The patient returned to the clinic after 1 week with minor redness and irritation of the skin, but improvement of the lesion. The patient continued treatment once daily for another 3 days, with resolution of the lesion (Fig. 1). There were no signs of recurrence after 5 months of follow-up. Topical application of ingenol mebutate induces both chemoablative and immunostimulatory effects. A previous study also showed that the use of ingenol mebutate led to a reduction of vascularization in the lesion, as demonstrated by a decrease in median haemoglobin levels in treated areas. These immunomodulatory and antiangiogenetic properties of ingenol mebutate suggest that a therapeutic effect is likely in PG. The most consistently reported adverse effects of ingenol mebutate are erythema, flakiness, crusting, pruritus, and pain, with effects peaking between days 3 and 8 and mostly resolving by day 15. Severe skin reactions may include swelling, postulation, and ulceration. No persistent systemic absorption was reported during long-term followup. Our patient had minor redness and irritation at the site of application, which resolved spontaneously without any other treatment. Application of ingenol mebutate to children requires medical supervision or it can be done at home by the parents. Although the precise cost analysis of relevant comparators for PG treatment may be difficult due to differences between countries, topical ingenol mebutate is more expensive than topical timolol; however, relatively longterm treatment with a month of twice-daily use is required with timolol. Ingenol mebutate is also more expensive than cryotherapy and laser therapy; however, these treatments are associated with pain, scarring and local adverse effects, which can represent a challenge when dealing with paediatric patients. In conclusion, we report a patient with facial PG successfully treated with ingenol mebutate. Our case suggests that because of its short-term application, ingenol mebutate may be considered as a meaningful option for uncooperative paediatric patients who may be afraid of treatment, especially on facial and other exposed lesions causing unexpected cosmetic complications. Further studies are needed to clarify the underlying mechanism of action of ingenol mebutate, and to confirm its effectiveness in PG.

Vol. 29, No. 6, 2017 809 Received August 5, 2016, Revised November 7, 2016, Accepted for publication November 9, 2016 Corresponding author: Weon Ju Lee, Department of Dermatology, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea. Tel: 82-53-420-5838, Fax: 82-53-426-0770, E-mail: weonju@knu.ac.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright © The Korean Dermatological Association and The Korean Society for Investigative Dermatology Fig. 1. (A, B) Ill-demarcated, indurated erythema in the left zygomatic area. https://doi.org/10.5021/ad.2017.29.6.809

Background: Unlike giant congenital melanocytic nevi (CMN), small and medium-sized CMN (smCMN) are not generally considered as a precursor lesion for malignant melanoma (MM), but we often confront MM arising from smCMN in a clinical setting. Objectives: The purpose of this study is to investigate clinicopathological features of MM arising from smCMN and to compare their features with non CMN-MM. Methods: A retrospective study has been conducted based on the medical records of patients with MM arising from smCMN from 2011 to 2017. Their sex, age, Breslow thickness (BT), type of melanoma and metastasis were identified and these findings were compared with those of invasive MM arising from non CMN skin. Results: MM was found in 10 of 380 (2.6%) smCMN and they comprised 10 of 121 (8.3%) total invasive MM of the same period. They developed more in female and showed earlier onset age (49.2 years), thinner mean BT (4.7mm) than those of non CMN-MM (62.8 years, 5.7mm, respectively). Most of them were nodular melanoma (80.0%). The rates of nodal and distant metastasis (20%, 0%) were both lower than those of non CMN-MM (27.0%, 4.5%, respectively). Conclusion: MM occurred at a relatively higher frequency than expected in smCMN which should also be paid more attention to prevent delay in the treatment of potential MM. Limitation: This is a single center study done by small number of patient from a university-setting hospital.

To the Editor: Since 1983, topical diphenylcyclopropenone (DPCP) immunotherapy has been used for the treatment of alopecia areata (AA). Despite several reports showing positive results,1,2 there are still questions about its efficacy. In this study, we aimed to evaluate the efficacy of topical DPCP treatment for AA by performing a systematic review and quality analysis of relevant articles.