Psychodermatology is a specialty that highlights admix between psychiatry and dermatology. It is emerging as a new subspecialty in dermatology. The skin and central nervous systems are related through their common embryonic origin – ectoderm. They also have common neuromodulators, peptides, and biochemical systems of internal information. Psychiatry is more focused on the internal invisible symptoms, and dermatology is focused on the external visible signs. This connection between skin disease and psyche has unfortunately been underemphasized. Increased pathophysiological understanding of these issues, with biopsychosocial approaches and clinics of psychodermatology would be highly beneficial. Multicenter research such as prospective case–controlled studies and therapeutic trials about the association of skin and psyche can provide more insight into this unexplored and exciting field of medicine.

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Background: Intralesional steroid treatment for alopecia areata (AA) has been developed for decades, yet the optimal concentration of triamcinolone acetonide (TrA) is not well-established. Objectives: This review aims to determine the optimal concentration of intralesional TrA in treating patchy AA. Methods: We conducted a systematic review and meta-analysis, and searched the Cochrane Library, Embase, and PubMed databases on July 4, 2021, to identify randomized or nonrandomized comparative studies reporting the response rates and/or adverse events among AA patients treated with various concentrations of TrA. The meta-analysis of proportions and odds ratios was analyzed using random-effects modeling. Results: Nineteen studies and a total of 783 participants were included. The estimated response rate of 5 mg/dl (74.82%, 95% confidence interval [CI] 64.99%–83.50%) was shown to be more efficacious than 2.5/3.33 mg/dl (38.64%, 95% CI 16.98%–62.99%) but similar to 10 mg/dl (71.06%, 95% CI 59.72%–81.20%), while pooled estimate of odds ratios revealed higher efficacy with 10 mg/dl than 5 mg/dl (odds ratio = 1.64, 95% CI 1.05–2.58, P = 0.031). The rates of skin atrophy were 18.05% (95% CI, 10.32%–27.38%), 11.49% (95% CI, 2.86%–24.84%), and 3.85% (95% CI, 1.27%–14.01%) in groups 10, 5, and 2.5/3.33 mg/dl, respectively. Higher concentration is associated with more skin atrophy in a dose-dependent fashion (P = 0.012). Heterogeneity among studies in the meta-analyses was high. Conclusion: The optimal intralesional concentration of TrA for patchy AA is probably 10 mg/dl with acceptable adverse events.

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Vogt–Koyanagi–Harada disease (VKHD) is a major vision-threatening autoimmune disease. One of its associated features is vitiligo. Little study has been done on the association between vitiligo and the disease activity of VKHD. The authors searched available literature on the relationship between vitiligo and ophthalmic disease activity in VKHD in terms of pathogenesis, clinical presentations, risk factors as well as disease activity. Among the findings is that early treatment of VKHD may be associated with full recovery. The reversal of poliosis and vitiligo is associated with the remission of uveitis, but the reverse does not hold true, whereby the worsening of vitiligo may not reflect the worsening of uveitis. It is also found that there may be an association between immunotherapy and Vogt–Koyanagi–Harada-like disease. In summary, vitiligo is an immune-mediated cutaneous manifestation which may contribute to diagnostic and treatment strategies in VKHD. Future research on genetic differences in vitiligo is still needed and may contribute to specific monitoring and therapeutic approach in this disease.

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Background: Extramammary Paget's disease (EMPD) is a rare malignancy occurring on apocrine sweat gland-bearing skin with occasional association with internal cancers. Its epidemiological characteristics are different between populations in Asian and Western countries. Objectives: The aim of this study was to report the clinical experience of EMPD in a single medical center in Taiwan, compare our results with previous literature, and provide strategies for diagnostic workup. Methods: Medical records and biopsies of 34 Taiwanese patients with EMPD, treated in a single medical center in Kaohsiung, Taiwan, from January 2000 to December 2019, were reviewed. The clinicopathological features, biological behavior, management, and follow-up courses of these patients were analyzed. Results: We found a male predominance in our 34 patients with EMPD, and most patients were diagnosed in their 70s. Only four patients (11.8%) had an associated malignancy while the rest had a primary cutaneous lesion. Most patients (22, 64.7%) underwent wide excision (22, 64.7%), with the rest adopting other various therapeutic modalities. The 5-year overall survival rate was 76.5%, and the statistically significant prognostic factors for survival were lymph node involvement (P < 0.001) and dermal invasion (P = 0.022). Conclusion: In summary, this single-center study described the clinical and histopathologic features of patients with EMPD in Taiwan with a review of literature. We also proposed a complete systemic workup when the diagnosis was made and an extended follow-up period as long as 5 years after the initial treatment.

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With the rapid outbreak of the coronavirus disease 2019 (COVID-19) pandemic, considerable concerns about the safety of systemic treatments of immune-mediated dermatologic disorders has been raised by dermatologists and their patients. We aimed to perform a rapid review of latest American and European guidelines on the use of systemic treatments in patients with immune-mediated dermatologic disorders and confirmed COVID-19 infection and to provide recommendations to inform practice. Based on the current limited guidelines and evidence, systemic corticosteroids should not be abruptly discontinued and the lowest effective dose should be continued. Systemic immunosuppressants (including methotrexate, cyclosporine, azathioprine, cyclophosphamide, and leflunomide), biologics, and sulfasalazine should be withheld in patients with confirmed COVID-19 infection. Whether to continue Janus kinase inhibitors should be determined following a shared decision-making process between dermatologists and patients after considering patients' medical conditions and risk for severe COVID.

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Background: Biologic therapies have become the gold standard for the treatment of moderate-to-severe psoriasis and psoriatic arthritis. However, concerns for opportunistic infections exist, especially for tuberculosis (TB) in endemic areas. Previously, tumor necrosis factor inhibitors were reported to carry higher risks of latent TB infection (LTBI) reactivation or new active TB, followed by anti-interleukin (IL)-12/23 and IL-17 agents in Taiwan. Objectives: The objective of the study is to provide real-world clinical rate of seroconversion of serial QuantiFERON-TB gold in-tube (QFT-GIT) tests, for detection of LTBI and newly-acquired TB, in psoriasis patients while receiving IL-23 inhibitors in an intermediate TB burden country. Methods: The local risk management plan required regular monitoring of TB while receiving biologics for psoriasis. This retrospective cohort evaluated consecutive psoriasis patients who received guselkumab or risankizumab between 2015 and 2021 in a tertiary referral center in Taiwan. Results: A total of 144 patients were included, with negative baseline QFT-GIT in 88% and positive in 13%. After receiving at least 6 months of anti-IL-23 drugs, persistently seropositive was found in 15 patients (10%), persistently seronegative in 125 patients (87%), seroconversion in 1 patient (0.6%), and seroreversion in 3 patients (1.9%). The seroconversion rate was 1% (1/127) in individuals under anti-IL-23 medications for at least 12 months. No case of LTBI reactivation was identified. Conclusion: In psoriasis patients under anti-IL-23 therapy, serial interferon-gamma release assays demonstrated a low seroconversion rate (<1%). Anti-IL-23 agents may be a favorable choice for psoriasis patients with a higher risk of TB infection and LTBI reactivation or those who reside in endemic regions.

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Background: Although alcohol use has been determined as a predisposing factor for psoriasis, research findings have been inconsistent. Objectives: This study investigated whether alcohol intake is causally linked to psoriasis. Methods: The presence of rs671 polymorphism in the aldehyde dehydrogenase 2 (ALDH2) gene was investigated in 258 psoriasis patients and 605 healthy controls. The rs671 was employed as an instrumental variable for predicting alcohol use. Mendelian randomization (MR) was utilized to assess the causality between genetically determined alcohol consumption and psoriasis using the two-stage least-square (2SLS) approach. A replication study of MR analysis with inverse-variance weighting (IVW), MR-Egger regression, and weighted median methods was performed using openly accessible alcohol consumption and psoriasis summary statistics from the UK Biobank. Results: Between psoriasis and controls, there were no significant differences in genotype and allele frequencies for the ALDH2 rs671 polymorphism. The G allele of the rs671 was positively linked with alcohol intake. The ALDH2 rs671 genetically determined alcohol intake was not linked to the risk of psoriasis in the 2SLS analysis (β = −0.011, P = 0.960). The MR replication study also found no evidence of genetic propensity to greater alcohol consumption increasing the risk of psoriasis (β = −0.00065, P = 0.6002 in IVW; β = −0.00099, P = 0.6851 in MR-Egger; and β = −0.00181, P = 0.3558 in weighted median analysis). Conclusion: ALDH2 rs671 may not have a role in psoriasis susceptibility in Taiwanese. The MR analysis found no causality between alcohol consumption and psoriasis.

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Background: Images are essential for dermatology. However, if a photograph has poor quality, it causes problems in conveying information. Objectives: This study aimed to evaluate the efficiency of photographs in a part of the current literature. Methods: One hundred and eighteen written descriptions and their related photographs were extracted from 89 articles selected from the journal Case Reports in Dermatological Medicine. Frequencies and confidence intervals (CIs) of mentioning 11 features, namely location, side, amount, distribution, dimension, figure, edge, color, touch perception, subjective symptom, and elementary lesion, in the written descriptions were calculated. The photographs were also evaluated to detect features other than touch perception and subjective symptom. Fifty articles randomly selected from five high-impact journals were also reviewed. Results: Touch perception and subjective symptom were mentioned only in 35.6% and 46.6% of the written descriptions, respectively. Distribution and edge were distinguishable in the photographs only in half of the cases, however other features in more than 90%. According to multinomial CIs, the written descriptions were superior only in terms of location, whereas the photographs were superior in terms of side, distribution, dimension, figure, edge, and color. Some features, such as touch perception and subjective symptom, were mentioned less frequently in the reviewed articles of the high-impact journals. Conclusion: The contribution of the photographs to the written descriptions in case reports was clear. However, the low rate for determining sharpness of edges in the photographs was a sign indicating low-quality images. In conclusion, the present study and similar studies will guide more efficient usage of developing image modalities for online publication in dermatology.

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