BACKGROUND:With the increasing demand for surgical procedures in dermatology, resident education in surgical dermatology has become important for delivering high-quality treatment. However, it remains unclear if a sufficient number of residency programs with quality standards exist, as there has been little research on this subject in South Korea.OBJECTIVE:To identify the status of surgical dermatology education among residents and assess dermatologists' perceptions of the subject.METHODS:A 35-question survey was developed and distributed to all resident training hospitals and local clinics listed by the Korean Society of Dermatologic Surgery. Only third- and fourth-year residents were included and board-certified specialists from training hospitals and local clinics responded to the surveys.RESULTS:Survey participants included 88 residents and 120 specialists of whom one-quarter of the residents attended regular monthly educational sessions. Most residents (93%) participated in cosmetic procedures, and many performed laser therapy. However, the opportunity for toxin or filler injection was rare, with only 12% of the residents having experience with filler injections. In response, 49% of residents and 32% of specialists said that more cosmetic training was required, whereas 28% of residents and 50% of specialists said that more training for both cosmetic and conventional surgeries was necessary.CONCLUSION:The survey demonstrated a need for more training programs in surgical dermatology during residency and a perception gap between residents and specialists. Therefore, developing educational residency programs that focus on basic dermatologic surgery principles and their applications in cosmetic procedures is essential.

Dear Editor, Alopecia totalis (AT) is a severe form of alopecia areata (AA) that affects the entire scalp. AA treatment depends on patient age, disease phase, and disease severity, and AT usually requires aggressive systemic treatment.1 For treatment of AT, immunomodulating agents, such as steroids and cyclosporine, have been used as off-label treatments. Recently, the oral selective JAK 1/2 inhibitor baricitinib has received Food and Drug Administration approval for AA, but in two previous randomized controlled trials, 19.3%−19.4% of participants had Severity of Alopecia Tool (SALT) scores of ≤20 after 16 weeks of treatment with 4 mg of baricitinib, followed by 35.9%−38.8% achieving the threshold after 36 weeks, reflecting suboptimal outcomes.2 A 26-year-old man presented with AT that had persisted for 15 years (Figure 1). There was a history of atopic dermatitis, asthma, and allergic rhinitis. He had received herbal medicine, oral methotrexate, intralesional corticosteroid injections, and diphenylcyclopropenone contact therapy, but the waxing and waning persisted. Improvement was seen when he took oral tofacitinib for 1 year, but tofacitinib was discontinued due to cardiovascular risk.3 For rapid improvement, baricitinib (4 mg) with methylprednisolone pulse and tapering therapy were prescribed for 16 weeks, and a good response, equivalent to SALT 0, was achieved. Low-dose oral cyclosporine (50−25 mg/day) maintenance was added to minimize the rebound caused by steroid discontinuation. Hair regrowth was maintained after 12 weeks of cyclosporine replacement (Figure 2). For this patient, we aimed to treat AT more effectively by using a combination of drugs that have immunomodulating effects through different mechanisms. In hair follicles of AA, interferon-γ (IFN-γ) secretion increases because of reduced immunotolerance. This is associated with Janus kinase-transducer and activator of transcription protein (JAK-STAT) activation in follicular epithelial cells, as well as interleukin (IL)-15 and major histocompatibility complex (MHC) activation, among others, leading to inflammatory responses by CD8+ NKG2D+ T cells, and IFN-γ is secreted again, repeating the inflammatory cycle.4 Baricitinib blocks this cycle by selectively inhibiting JAK 1/2, suppressing inflammation and causing hair regrowth. Steroids act on glucocorticoid receptor complexes in cell nuclei, participate in gene transcription, and regulate pro-inflammatory cytokines—such as IL-1, IL-2, IL-6, IFN-γ, and tumor necrosis factor alpha (TNF-α)—thereby facilitating anti-inflammatory and immune-regulation effects. Cyclosporine forms a complex with cyclophilin and inhibits the activity of calcineurin phosphatase to block downstream signaling pathways inside CD4+ T cells. It suppresses IL-2 secretion, which stimulates cytokines, such as IFN-γ and granulocyte-macrophage colony-stimulating factors. It depletes CD8+ T cells, which play a major role in AA.5 However, the combination of cyclosporine and baricitinib is not recommended owing to the risk of severe infection and lymphomam without any clinical evidence. In our case, cyclosporine dose was lower than usual dose, and no side effects or hair loss were reported after 5 months of combined treatment with cyclosporine and baricitinib. The side effects of cyclosporine are dose dependent, so it is presumed to be safe at low doses.5 Additionally, black dots, broken hairs, short vellus hairs, and tapering hairs were identified during trichoscopy, and these observations showed improvement after treatment. These findings align with the results of Al-Dhubaibi et al.’s meta-analysis, suggesting that incorporating trichoscopy as an active tool in AA treatment could be advantageous for monitoring progress.6 In conclusion, the combination of baricitinib with appropriate use of conventional immunomodulating therapy may be effective and safe for treating AA, including AT. The authors declare they have no conflicts of interest. The authors received no specific funding for this work. The patient in this manuscript provided written informed consent to publish his case details and clinical pictures. Data sharing is not applicable to this article, as no new data were created or analyzed in this study.

Merkel cell carcinoma (MCC) is a rare, aggressive skin cancer, of which most research has been conducted in Caucasians. Therefore, the clinicopathological features and prognosis of Merkel cell carcinoma in Asians are still scarce. The aim of this study is to investigate the epidemiology and survival of MCC in South Korea and provide representative information regarding MCC in Asia.

Other SectionsAbstractINTRODUCTIONCASE REPORTDISCUSSIONACKNOWLEDGMENTSAUTHOR CONTRIBUTIONSCONFLICT OF INTERESTFUNDINGDATA AVAILABILITYSUPPLEMENTARY MATERIALSReferences

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.

Other SectionsAbstractINTRODUCTIONCUTANEOUS REJUVENATION; WRINKLES, SKIN TEXTURE, AND ENLARGED PORESACNE SCARSHYPERTROPHIC SCARSSTRIAE DISTENSAESEBORRHEIC DERMATITISCONCLUSIONFUNDINGCONFLICT OF INTERESTAUTHOR CONTRIBUTIONSReferences

To investigate the efficacy and safety of combined treatment with a serum comprising a micro-diamond suspension and micro-gold cage with a 1064 nm picosecond neodymium-doped yttrium aluminum garnet (Nd:YAG) laser for facial skin rejuvenation. Topical serum was applied to the entire face and allowed to penetrate the skin and hair follicles for 20 min. Each participant was then treated with a 1064 nm picosecond Nd:YAG laser on the face. Photographs of each participant were taken at baseline, immediately after treatment, and 2 weeks after treatment using an imaging tool (Mark-Vu®; PSI PLUS, Suwon, Republic of Korea). Global improvement scores by two blinded investigators and participants' satisfaction scores were also assessed. The melanin index (MI), transepidermal water loss (TEWL), and skin hydration were evaluated using a device. Parameters associated with skin rejuvenation were assessed using Mark-Vu®. Adverse events were observed and reported by participants and physicians during the treatment and follow-up visit. At week 2, 40% (4/10) of the participants showed more than moderate clinical improvement in the investigator's global improvement assessment. No significant differences were observed in the MI, TEWL, skin hydration level, or skin parameters of Mark-Vu®. At week 2, 40% of the participants reported a high satisfaction score and minimal side effects. The novel topical facial serum comprising micro-diamond suspension and micro-gold cage is safe and effective when combined with laser treatment for facial rejuvenation.

Recently, a novel hyaluronic acid (HA) filler containing the epidermal growth factor (EGF) was developed. The objective of this study was to evaluate the rheological properties, preclinical efficacy and biocompatibility of the EGF-containing HA filler (HA-EGF filler) using a photoaged mouse model. The rheological properties of the new HA-EGF filler were assessed. Twenty-four female hairless mice (SKH1) underwent photoaging induction with 8 weeks of ultraviolet-B irradiation. The mice were randomly divided into four groups and intradermally injected 100 mu l of phosphate-buffered saline, HA-EGF filler, HA filler or polynucleotide (PN) into the dorsal region. We examined the effect of fillers on photoaged skin by dermoscopic examination. Furthermore, histological evaluation with immunohistochemical staining was performed to determine the biocompatibility and collagen formation at the 10th week. A real-time quantitative polymerase chain reaction analysis and western blot test assessed the expression of collagen I/III, matrix metalloproteinases (MMPs) and transforming growth factor. The viscosity and elasticity of the HA-EGF filler were lower than those of the HA filler. Histological evaluation revealed no significant differences in the collagen synthesis between the HA-EGF, HA and PN filler groups. No inflammation was observed during the experimental period. The HA-EGF filler induced type I/III collagen production and downregulated the expression of MMP-1, 3 and 9. Our results suggest that the novel HA-EGF filler may be an additional therapeutic option for photoaged skin, which works by inducing collagen synthesis. Based on these preclinical results, further well-controlled clinical studies are required.

A 53-year-old man presented with an erythematous papular skin eruption. Ten days prior to the appearance of the lesions, he had received the second dose of the coronavirus disease 2019 (COVID19) vaccine (ChAdOx1 nCoV-19 [AstraZeneca]). He denied taking any medication or supplements within 2 months before and after the second vaccination. He also denied history of any other contact or exposure. After the first injection of the COVID-19 vaccine, no adverse events occurred. Physical examination showed well-demarcated erythematous macular patches distributed symmetrically over the axillary and inguinal areas, with skin desquamation and swelling in the scrotal area and on the glans penis (Figure 1A-C). Systemic signs were absent. The blood test results were normal. Findings of direct microscopy with 10% potassium hydroxide (KOH) and wound culture were negative. The patient refused to undergo a skin biopsy. Based on these findings and the patient's history, we considered symmetric drugrelated intertriginous and flexural exanthema (SDRIFE)–like eruption. Methylprednisolone 30 mg/day was administered for 1 week, and the dose was tapered to 15 mg/day for another week with topical corticosteroid cream. After 2 weeks, his condition resolved.

Since the advent of the theory of selective photothermolysis, the importance of targeting the chromophore and minimizing the surrounding damage has been extensively discussed. Picosecond-domain laser (ps-laser) treatment with a wide range of wavelengths is an emerging option for various pigmented lesions; however, no definitive treatment choice has been confirmed. The authors aimed to investigate the efficacy and safety of a ps-laser with a 785-nm wavelength for the treatment of facial pigmented lesions in Asians. Three Korean patients with facial pigmented lesions were recruited for the study. A 785-nm ps-laser with a fractionated and an unfractionated handpiece was utilized to administer the treatment. The clinical outcome was evaluated by a clinician by comparing pre- and post-treatment photographs. All patients exhibited a significant improvement in pigmented lesions including freckles, lentigines, and melasma, after three to four sessions of treatment. No adverse events, including post-inflammatory hyperpigmentation or hypopigmentation were observed. In conclusion, this novel 785-nm Ti:sapphire ps-laser may be an effective and safe modality for treating pigmented lesions in skin of color.

Jae Wan Park, Young Gue Koh, Sun Hye Shin, Young-Jun Choi, Won-Serk Kim, Hyun Ho Yoo, Jung Ok Lee, You Na Jang, Jaeyoung Kim, Kapsok Li, Beom Joon Kim, Kwang Ho Yoo,. Med Laser 2022;11:1-7. https://doi.org/10.25289/ML.2022.11.1.1

BACKGROUND:Assessing the area involved in a skin disease, i.e. the body surface area (BSA), is essential in diagnosing disease severity, including in psoriasis. However, in psoriasis, BSA tends to be overestimated by physicians and has shown high inter-rater and intrarater variability. Furthermore, there are no reports suggesting the cause and clinical significance of overestimating BSA in psoriasiss.AIM:To investigate the errors in estimating BSA in psoriasis by comparing physicians' results with those of computer-assisted image analysis (CAIA) and to provide suggestions regarding the clinical implications of such errors.METHODS:Using 43 images, 36 physicians visually estimated BSA in psoriasis, and subsequently, the images were evaluated using a CAIA program (ImageJ); the BSA values determined by the physicians and CAIA were then compared and matched. The BSA percentage was also graded on a scale from 0 to 6, as follows: Grade 0 = no lesion, Grade 1 = 1%-9%, Grade 2 = 10%-29%, Grade 3 = 30%-49%, Grade 4 = 50%-69%, Grade 5 = 70%-89% and Grade 6 = 90%-100%. Each grade range was divided, with the bottom and top 50% defined as the 'first half' and 'second half,' respectively.RESULTS:The mean proportion of correct assessments by physicians was 49.4%. Physicians tended to overestimate the BSA of psoriatic lesions by 8.76% ± 8.82% compared with CAIA. The largest estimation error (proportion incorrect 75.7%) was observed in Grade 3 (30%-49% involvement). Estimates in the second half of the range demonstrated a higher proportion of inaccuracies compared with those in the first half. An overestimating error occurred in certain morphological characteristics of the psoriatic lesions.CONCLUSIONS:The inaccuracy of BSA estimation by physicians may be related to the fact that information from the human eye is perceived to be exaggerated compared with the actual size. Further research into using artificial intelligence technology is needed to reduce quantification error and develop an ideal BSA assessment system. Additionally, education and training are needed for physicians to measure BSA accurately.

Dear editor A 25-year-old female patient presented with a flesh-colored mass on the posterior aspect of her left earlobe (Figure 1A). On physical examination, the mass was asymptomatic, over 2 cm in width and height, pale colored, firm and very harden. As the mass occurred on the site of an ear-piercing over several years and extended beyond the margins of the piercing, the mass was diagnosed as a mature keloid. We treated the keloid using a combination of a pneumatic injector device (INNOJECTORTM, Amore-Pacific. Seoul, Korea) (Figure 1B) and a CO2 fractional laser (eCO2TM, Lutronic Corporation, Goyang, Korea). A 0.1 ml shot of normal saline was administered into the scar at 1 cm intervals with two passes (total four shots) using a pneumatic needlefree injection device. Then, a total of two passes of fractional CO2 laser were performed with parameters: 50 mJ, 20 W, density: 100/cm. Five treatment sessions within 2-week intervals were performed. For clinical assessment, one independent evaluator assessed the lesion using the Vancouver Scar Scale (VSS) at each visit. After four treatment sessions, the keloid showed marked improvement with a VSS score from 6 to 2 (Figure 1A). No adverse events occurred, and the pain was very mild during the procedure. Written informed consent was obtained from the patient for the publication of images and case details. A pneumatic injector device uses a high-velocity jet (up to 180 m/s) with a 0.1-mm diameter nozzle to puncture the skin and deliver drugs to the necessary depth without the use of a needle. The mechanism of pneumatic needle-free injectors is micro-trauma. The particles of medicine induce dermal micro-trauma that stretches fibroblasts while leaving the surrounding tissue intact as they stimulate growth factors and inhibit collagen breakdown. In this case, we injected normal saline, which released the fibrotic strand and induced new collagen deposition by triggering the wound healing process. Furthermore, providing adequate but not excessive hydration of keratinocytes, could prove to be a possible mechanism for reducing scar tissue. Kwon et al. demonstrated increases in the skin thickness and collagen fibers after needle-free jet injection of normal saline in a mouse model. Hyaluronic acid (HA) is a common constituent of the extracelluar matrix, located throughout the epidermis and dermis, and serves important functions during wound healing process. We hypothesized the pneumatic needle-free injection-induced bursts of normal saline provide hydration by inducing more HA formation around the scar tissue. Also, micro-trauma by pneumatic needle-free injector would induce wound healing process, stimulating collagen production, remodeling, and extracellular matrix neoformation. In addition to the pneumatic needle-free injection device, we used a CO2 fractional laser. Nowak et al. reported the release of bFGF and inhibition of TGF-β1 in keloidal cells. Also, it has been found to act on fibroblasts in vitro by stimulating basic fibroblast growth factor (bFGF) and inhibiting transforming growth factor-β1 (TGF-β1), which may lead to normalized wound healing. When using CO2 fractional laser after wound healing and collagen remodeling phase, this laser leads to decrease in TGF-β1 and increase in bFGF, resulting in dermal collagen changes. The treatment of keloids remains challenging despite the availability of various treatment options. Lack of in vivo study or

With the increase in rates of vaccination against COVID-19, various cutaneous reactions have been reported after vaccination, including pityriasis rosea (PR) (Catala et al., 2021Catala A Munoz-Santos C Galvan-Casas C Roncero Riesco M Revilla Nebreda D Sola-Truyols A et al.Cutaneous reactions after SARS-COV-2 vaccination: A cross-sectional Spanish nationwide study of 405 cases.Br J Dermatol. 2021; Crossref PubMed Scopus (136) Google Scholar; Johansen et al., 2021Johansen M Chisolm SS Aspey LD Brahmbhatt M. Pityriasis rosea in otherwise asymptomatic confirmed COVID-19-positive patients: A report of 2 cases.JAAD Case Rep. 2021; 7: 93-94Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar; Marcantonio-Santa Cruz et al., 2021Marcantonio-Santa Cruz OY Vidal-Navarro A Pesque D Gimenez-Arnau AM Pujol RM Martin-Ezquerra G Pityriasis rosea developing after COVID-19 vaccination.J Eur Acad Dermatol Venereol. 2021; Crossref PubMed Scopus (19) Google Scholar; McMahon et al., 2021McMahon DE Amerson E Rosenbach M Lipoff JB Moustafa D Tyagi A et al.Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: A registry-based study of 414 cases.J Am Acad Dermatol. 2021; 85: 46-55Abstract Full Text Full Text PDF PubMed Scopus (535) Google Scholar). It is easy to overlook because the incidence of PR as a side effect of COVID-19 vaccination is extremely low, accounting for about 0.96% of all cutaneous reactions (McMahon et al., 2021McMahon DE Amerson E Rosenbach M Lipoff JB Moustafa D Tyagi A et al.Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: A registry-based study of 414 cases.J Am Acad Dermatol. 2021; 85: 46-55Abstract Full Text Full Text PDF PubMed Scopus (535) Google Scholar). A 29-year-old man presented with a herald patch on his right chest 2 hours after the second dose of mRNA-1273 COVID-19 vaccination (Figure 1A). Within 2–3 days, multiple skin lesions rapidly disseminated to the upper trunk and extremities (Figure 1B). He had no other systemic symptoms and no previous history of COVID-19 infection. Skin biopsy showed focal parakeratosis, spongiosis, and superficial perivascular inflammatory infiltrates (Figure 1C). Based on the clinical and histological features he was diagnosed with PR. According to Ogata et al. (Ogata et al., 2021Ogata AF Cheng CA Desjardins M Senussi Y Sherman AC Powell M et al.Circulating SARS-CoV-2 Vaccine Antigen Detected in the Plasma of mRNA-1273 Vaccine Recipients.Clin Infect Dis. 2021; Crossref PubMed Scopus (81) Google Scholar), the SARS-CoV-2 viral spike protein antigen is detected as early as day 1 post-vaccination, and peak levels are detected after an average of 5 days. Based on the literature, the time lapse between COVID-19 vaccination and skin lesions ranges 5–17 days, with an average of 12.7 days. However, our patient developed PR after only 2 hours of receiving the vaccination, which is a very short time interval. This case did not enable a conclusion to be made that a true causal link exists between PR and vaccination. This is because the short interval of 2 hours may be insufficient for the vaccine to circulate throughout the bloodstream and induce an appropriate immune response. However, in this patient, the skin lesions occurred after the second dose of the vaccination, and it is possible that PR may occur sooner in such cases than after the first dose of the vaccination. Johnston et al. (Johnston et al., 2021Johnston MS Galan A Watsky KL Little AJ. Delayed Localized Hypersensitivity Reactions to the Moderna COVID-19 Vaccine: A Case Series.JAMA Dermatol. 2021; 157: 716-720Crossref PubMed Scopus (99) Google Scholar) recently reported that delayed localized cutaneous reactions may occur sooner after the second administration of the vaccine. Moreover, a previous history of PR is not generally related to recurrence or onset of the lesion, and is not an important consideration for this patient because there was no history of PR. Therefore, in the future, researchers should study the onset duration of cutaneous reactions that occur following the administration of the first and second doses of the COVID-19 vaccine. None. This study was performed in accordance with the Helsinki Declaration and the patient provided written informed consent for the publication of his case details. None. The authors have no conflicts of interest to declare.

BACKGROUND:The coronavirus disease-2019 (COVID-19) outbreak has presented unique dermatologic challenges due to respiratory protective equipment (RPE)-related skin conditions.OBJECTIVE:To objectively evaluate the effects of RPE including medical masks and respirators on the skin barrier by measuring various physiological properties of the skin.METHODS:A cross-sectional study was designed. Twenty healthy healthcare workers were included in this study. Skin parameters including skin hydration, transepidermal water loss (TEWL), erythema, sebum secretion, pH, and skin temperature were measured in the RPE-covered and RPE-uncovered areas of the face 4 and 8 hours after wearing RPE and 14 hours after not wearing RPE.RESULTS:Skin hydration, TEWL, erythema, pH, and skin temperature increased in the RPE-covered areas after wearing RPE for 4 and 8 hours. By contrast, in the RPE-uncovered areas, skin hydration decreased and TEWL, erythema, and pH showed minimal changes over time. Based on the repeated-measure analysis, the changes in skin physiological properties over time were significantly different between RPE-covered and RPE-uncovered areas.CONCLUSION:We observed that skin physiological characteristics change with the prolonged use of RPE such as medical masks and respirators. These changes may lead to various adverse skin reactions after long-term use.

Dermal fillers have become popular due to the increased demand for skin rejuvenation products. Polycaprolactone (PCL), a newly developed bioresorbable medical polymer, has emerged as a durable and safe dermal filler. However, available PCL fillers cause irritation; carrier gels can coagulate PCL particles, block the injection needle, and cause nonhomogeneity of particle suspensions that could be responsible for the observed side effects. To relieve pain, premixing PCL filler with lidocaine. However, this formulation changes the property of the CMC portion of the PCL filler, and possibly results in an uneven suspension of the PCL particles. Hence, a particle-free PCL homogeneously solubilized in water was developed to overcome these limitations. This study aimed to assess the in vivo safety, biodegradability, and neocollagenesis ability of a novel PCL filler, DLMR01 using a rat model. Fillers were characterized after injecting a vehicle control or DLMR01 using a digital camera, folliscope, and a three-dimensional profiling system. Biopsy was performed to evaluate biocompatibility and neocollagenesis. Skin elasticity was measured using a Cutometer. DLMR01 caused no needle occlusion by particle aggregation or laborious injectability. Filler nodules dispersed to surrounding tissues within 6 hours without further granuloma formation. Histological inspection revealed no tissue residual material or foreign body reaction during the 12-week test period. DLMR01 increased dermal thickness, collagen regeneration, and skin elasticity. In conclusion, this study demonstrates the potential of DLMR01 for dermal rejuvenation in a rat model.