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Hepatitis B virus (HBV) infection is a critical public health issue worldwide. The prompt recognition of skin diseases associated with HBV enables the earlier diagnosis of undetected HBV infection. This review article aims to provide a guide for physicians to increase awareness of possible HBV infection when encountering skin diseases. The frequencies of HBV infection were highest in telangiectasia macularis multiplex acquisita, followed by mixed cryoglobulinemia (MC), polyarteritis nodosa (PAN), and Gianotti-Crosti syndrome (GCS). Serology tests for HBV are recommended for patients with the above diseases. Lichen planus is not associated with HBV according to the most recent evidence. Chronic urticaria and porphyria cutanea tarda are associated with HBV infection although the detection rate of HBV was only 2% in these two diseases. The mechanism behind the associations between HBV and these skin disorders remains unknown and virus-associated immune-mediated processes or direct injury caused by viral replication are frequently proposed. The clinical manifestation was not discrepant between the HBV-associated skin disorder and the non-HBV-associated counterpart. The duration of HBV infection did not show any statistically significant correlations with the development of skin disorders. Antiviral medication yielded improvement in HBV-associated PAN, MC and GCS.

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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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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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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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Pretibial myxedema (PTM) is an infiltrative dermopathy seen in Graves' disease. It is also infrequently associated with hypothyroidism. Here, we describe a rare case of PTM with hypothyroidism in which thyroid-stimulating hormone receptor antibodies were found. An 82-year-old female presented with a 1-year history of a large pruritic plaque which was present over both her legs and feet. Histopathology of a skin biopsy showed markedly increased dermal mucin. These changes were suggestive of PTM. This case provides evidence that an autoimmune mechanism could play a central pathogenetic role in such cutaneous manifestations.

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Background: Pityriasis rosea (PR) is a common, self-limited cutaneous disease characterized by wide distributed erythematous scaly lesions. The diagnosis is usually based on the clinical features. Objectives: Here, we aimed to investigate the dermoscopic features of PR which may provide helpful clues to the diagnosis. Methods: Demographic, clinical, and dermoscopic features of the patients with PR were retrospectively reviewed, and the findings identified were recorded. Results: A total of 100 lesions from 25 different patients were included in the study. The most common dermoscopic finding was peripheral collarette scale (84%), followed by central yellow with peripheral reddish background (40%), peripheral dotted vessels with patchy distribution (35%), diffuse reddish background (31%), scattered dotted vessels (30%), and irregular distributed scales and red globules (20%). Conclusion: To the best of our knowledge, this is the most comprehensive study focusing on the dermoscopic features of PR. Here, we identified new dermoscopic findings which were not described previously for PR. These findings were irregular linear vessels, blood spots, brown globules, and brown structureless areas. It can be concluded that dermoscopy may provide remarkable clues to diagnosis, especially in atypical presentations of the entity.

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Nail dermoscopy in recent years has become an auxiliary noninvasive tool for the diagnosis of nail diseases. It detects the differentiating characteristics of the nail units and assesses in the management of nail diseases. Dermoscopy may not be a diagnostic tool for all nail diseases; however, it is very useful for early observation with high magnification. This article discusses the important and common dermoscopic manifestations of nail disease cases in the daily practice. Currently, the indications of dermoscopy include viral, bacterial, fungal, inflammatory, pigmented, traumatic nail diseases, nail tumors, and connective tissue disease.

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Background: Preservatives are widely used in personal and industrial products. Frequent and sustained exposure to preservatives can cause contact allergy. Objective: We investigated the prevalence of contact allergic reactions to common preservatives in Taiwan over a 20-year period. Methods: A retrospective analysis was conducted among patients with allergic contact dermatitis who underwent patch testing at our clinic between 1996 and 2015. Patients who showed positive reactions to preservatives were enrolled. The location of the reaction, likely source of the allergen, and patient occupation, sex, and age were recorded. Thirteen common preservatives, including methylchloroisothiazolinone/methylisothiazolinone (MCI/MI), MI, formaldehyde (FA), paraben mix, and quaternium-15, were investigated. Results: Of 757 enrolled patients, 151 showed at least one positive reaction to preservatives. Allergy to MCI/MI (12.5%), the most frequent allergen in the standard series, showed a steeply increasing trend over time. FA (4.8%) and paraben mix (2.1%) were the next common allergens. Cosmetic products were the most common source of exposure (63.6%), while hairdressers and massage therapists were most commonly associated with occupational contact dermatitis. A sharp increase of sensitivity to MCI/MI was observed after 2006 and that of allergy to MI after 2013. Conclusions: In Taiwan, the prevalence of contact allergy to MCI/MI, MI, and parabens has increased in recent years. Individuals who are frequently exposed to cosmetic products should consider precautions against sensitization.

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Social media provides a readily accessible means to promote user-generated content, broaden interpersonal connections, and encourage social collaboration. In this paper, we will review the use of popular social media platforms within dermatology along with the potential benefits and harms of these platforms when used by dermatology providers and their patients. Social media has also found a place in medicine and presents new opportunities and challenges for health care professionals. In dermatology specifically, social media has become a platform for patient education, public outreach, and professional development and networking. Although there are many risks associated with social media use in dermatology, there is also opportunity to promote public health, patient education, and professional interactions.

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Background: Data on seasonal variation and viral etiology in Pityriasis rosea (PR) have been conflicting. The aim of this study was to investigate the association of PR and other herpetic infections, taking seasonal changes into account. Methods: The data were collected retrospectively from electronic health registry systems in Sivas in the Central Anatolia region of Turkey between 2008 and 2016. According to their clinical types, other herpetic infections were investigated. Environmental factors such as humidity, temperature, and rainfall for the relevant period were added into the model. Time series methods (augmented Dickey–Fuller unit root test and regression analysis) were used in the analysis. Results: A total of 1207 PR patients were included in the study. The number of PR patients was calculated to be 0.462 times that of the same period in the previous year. The incidence of PR increased significantly when the rate of infections caused by varicella-zoster virus decreased and the rate of infections caused by herpesvirus Type 1 and humidity increased (P < 0.05). Conclusion: Environmental factors such as humidity are important in the emergence of the PR. Furthermore, the incidence of PR may be inversely affected by varicella-zoster infections contrary to the relationship between PR and herpesvirus Type 1 infections.

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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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Many febrile diseases caused by ribonucleic acid virus infection demonstrate cutaneous manifestations with preceding prodromes. This review provides a flowchart highlighting the diagnostic clues of viral exanthem. Besides febrile prodromes, patients with chikungunya virus have severe arthralgias and macular hyperpigmentation on the noses. Coronavirus disease 2019 demonstrates unique acrocyanosis and pseudofrostbite besides erythematous rash and urticaria, suggesting abnormal coagulation. Dengue fever should be suspected when patients in the tropical region present with biphasic fever, headache, retroorbital pain, and centrifugal morbilliform rash. Dengue hemorrhagic fever, a potentially fatal complication, results from systemic vascular leakage. High-temperature fever and sudden-onset severe headache raise the possibility of Ebola virus infection. Patients with hand-foot-and-mouth disease may experience morbilliform or vesicular eruption, especially over the hands, feet, and oral mucosa. In acute human immunodeficiency virus infection, maculopapular eruptions often appear on the face and neck after prodromes. Primary human T-lymphotropic-III virus infection can induce widespread maculopapular or roseola-like exanthem, sparing the hands and feet. Cutaneous manifestations of rotavirus include generalized maculopapular rash, Sweet's syndrome, Henoch–Schonlein purpura, Gianotti–Crosti syndrome, and acute hemorrhagic edema. Rubella is usually suspected when low-grade fever and lymphadenopathy are accompanied by a discrete pinpoint-sized maculopapular rash, which spreads and diminishes faster than measles. Cough, coryza, and conjunctivitis followed by morbilliform eruptions and Koplik's spots are diagnostic of measles. Exanthem of Zika virus comprised of small pruritic papules that extend downwards. Laboratory testing is helpful in making a definitive diagnosis. Viral isolation, measurement of immunoglobulin M (IgM) or IgG, and/or reverse transcription polymerase chain reaction are useful diagnostic tools with favorable sensitivity and specificity.

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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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Background: Onychomycosis is a common infectious nail problem but shares similar clinical presentation with some other noninfectious disorders, such as psoriasis and lichen planus. A correct diagnosis is essential to proper management. There are three common tests used in the outpatient clinic, including direct potassium hydroxide (KOH) examination, nail plate histology study, and fungal culture. Objective: This study aimed to compare the accuracy and feasibility among these three tests in the diagnosis of onychomycosis. Materials and Methods: We retrospectively reviewed the patients diagnosed with onychomycosis and had positive result of any of the three tests from June 2005 to June 2015. The age, gender, and results of the diagnostic methods were collected and analyzed. Results: A total of 459 patients were enrolled. The positive rates were significantly different between nail plate histology study (93.0%, 427/459), KOH examination (67.3%, 309/459), and fungal culture (42.1%, 193/459) (P < 0.05). Conclusions: Nail plate histology study has the highest positive rate in the diagnosis of onychomycosis than KOH examination and fungal culture. However, KOH examination is most inexpensive and is the fast way to obtain the result with moderate reliability. A combination of two or three diagnostic tests could provide useful information to the clinician to manage onychomycosis appropriately.

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Background: Altered microbiota of the gastrointestinal tract have been implicated in both atopic dermatitis (AD) and inflammatory bowel disease (IBD). However, the relationship between AD and IBD has been unclear. Objectives: The objective of this study was to systemically assess the evidence on the association of AD with IBD. Methods: We conducted a systematic review and meta-analysis of observational studies on the association of AD with IBD. We searched MEDLINE, Embase, CENTRAL, Web of Science, and Airiti Library from inception to May 24, 2019, for relevant studies. The outcomes were the odds and risk of Crohn's disease (CD) and ulcerative colitis (UC) in patients with AD. Results: We included five case–control studies and one cohort study. We identified significant associations of AD with prevalent CD (odds ratio [OR]: 1.55, 95% confidence interval [CI]: 1.11–2.15) and UC (OR: 2.49, 95% CI: 1.04–5.98). One Danish cohort study found no increased risk for incident CD (hazard ratio [HR]: 0.69, 95% CI: 0.34–1.30) and UC (HR: 0.94, 95% CI: 0.61–1.43) in patients with AD. Conclusion: The current limited evidence supports an association of AD with prevalent IBD. Digestive symptoms in patients with AD, for example, chronic diarrhea and abdominal pain, shall not be overlooked, and gastroenterology counseling may be needed.

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Background: Rosacea is a common chronic inflammatory dermatosis that affects about 10% of the population. Although various environmental stimulants and endogenous factors have been shown to stimulate the innate immune response and abnormal neurovascular signaling in the etiology, the variety of clinical forms leads to a poor understanding of the pathophysiology of rosacea. Objectives: In this study, we aimed to determine the relationship between rosacea disease and the intestinal microbiome. Methods: For this purpose, 20 patients with clinical diagnosis of rosacea in the Education and Research Hospital of Sakarya University and 10 healthy volunteers with age and sex matched to the control group were included. 16s ribosomal RNA sequence and metagenomic analyses were performed from fecal samples. Results: We determined the relationships between various changes in the rosacea clinic and intestinal microbiome. According to the results of metagenomic DNA analysis in rosacea patients according to healthy volunteers, Lachnospira, Lachnoclostridium, Roseburia, and Roseburia intestinalis were found to be higher and Coriobacteriaceae, Ruminococcaceae, Butyricimonas virosa, and Clostridiales bacteria were found to be higher. Conclusion: These differences were thought to be related to indirect dysbiotic pathways with rosacea clinic. Since only one study examining the relationship between rosacea and intestinal microbiome can be reached in the literature, it is needed to have more and more sampling studies in order to make sense of the microorganisms that stand out.

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Background: Atopic dermatitis (AD) is a prevalent skin disease in Asia. Attitudes and practice vary among the Asian cities. Objectives: This study aimed to survey similarities and differences in dermatologists' attitudes and practice in Asian cities. Methods: A questionnaire survey was sent to 118 dermatologists in Singapore, Malaysia, Thailand, Taiwan, and Hong Kong. Results: About 30.8% of respondents from Taiwan and 44.4% of respondents from Hong Kong saw most of their patients presenting with severe AD. This is significantly higher than respondents from Singapore, Malaysia, and Thailand (4%–12%). Majority of the respondents would use topical corticosteroids in infants and children with AD. About 55.6% of the respondents from Hong Kong used topical calcineurin inhibitors in AD, which is a significantly lower than the other countries. Top 3 most prescribed antibiotics in infected AD were cephalexin, cloxacillin, and amoxicillin/clavulanic acid combination. Most respondents used oral corticosteroids in severe AD. Many respondents from Singapore and Malaysia use cyclosporin (70%–92%), azathioprine (80%–100%), and methotrexate (72%–75%). Fewer respondents from Thailand, Taiwan, and Hong Kong used cyclosporin (22.2%–59%), azathioprine (0%–66.7%), and methotrexate (8%–25.6%). A large majority of respondents from Singapore, Taiwan, and Malaysia use phototherapy in management of AD (90%–100%). About 24% of respondents from Thailand and 33.3% of respondents from Hong Kong use phototherapy in AD. Conclusion: Compared to the previous study, there is improvement in the proportion of dermatologists in Asia using topical calcineurin inhibitors and phototherapy. This may signify better access to these treatment modalities throughout the region. Educational programs that allow a patient-centered approach should be recommended as an adjunct to medical therapy. The management of AD among Asians requires a holistic approach while considering accessibility and cultural differences.

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Background: Acne vulgaris is a prevalent cutaneous disorder that significantly affects patient quality of life. There have been several reports of successful acne treatment using lasers. However, few studies have reported the use of radiofrequency (RF) lasers for acne. Objective: The purpose of this study was to evaluate the efficacy and safety of a noninvasive monopolar RF laser in the treatment of acne vulgaris on the face. Methods: A randomized, prospective, split-face study was performed. Eleven participants were recruited. Patients were treated with the RF laser on one half of the face and no laser treatment on the other half. Two treatments were performed at 2-week intervals. Patients returned for follow-up 2 weeks after the final treatment. Results: After 4 weeks, the lesion counts of papules, comedones, red macules, and the sebumeter measured values all significantly decreased on the treated area compared to those on untreated areas. In the photograph analysis, the grade of acne (using Cook's acne grading method) also significantly improved after treatment. Patients reported tolerable pain and mild erythema with laser treatment. However, there were no permanent adverse events. Conclusion: Treatment with the noninvasive RF laser successfully reduces acne lesions (papules, comedones, and red macules) and sebum secretion without severe adverse events.

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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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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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