Publications by authors named "Kanokvalai Kulthanan"

103 Publications

Use of facial care products and frontal fibrosing alopecia: Coincidence or true association?

J Dermatol 2021 Jul 15. Epub 2021 Jul 15.

Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

The increasing incidence of frontal fibrosing alopecia (FFA) suggests that environmental factors may be related to the pathogenesis. Recent studies reported potential association between the use of facial care products and FFA. The aim of this study was to investigate the possible association between the use of facial care products and FFA in Asian females. A total of 250 females (50 FFA patients, 100 pattern hair loss [PHL] patients, and 100 normal controls) were recruited and completed a questionnaire to obtain information approximately facial care products and various environmental factors. Our study revealed the use of moisturizer to be significantly higher in the FFA group compared to normal controls (p < 0.001), and sunscreen use was significantly higher in the PHL group than in the control group (adjusted p < 0.001). Subjects with FFA or PHL reported significantly higher use of both sunscreen and moisturizer compared to normal controls (p < 0.001). This study focused on Asian populations. Our results revealed a high frequency of moisturizer and sunscreen use in both FFA and PHL among Asian females. Therefore, the use of facial care products appears not to be linked to the true disease mechanism of FFA, but rather to appearance-related concerns of patients.
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http://dx.doi.org/10.1111/1346-8138.16063DOI Listing
July 2021

Patient Recovery from COVID-19 Infections: Follow-Up of Hair, Nail, and Cutaneous Manifestations.

Biomed Res Int 2021 19;2021:5595016. Epub 2021 Jun 19.

Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Background: COVID-19 is a pandemic disease worldwide. Although cutaneous manifestations may present in affected patients, there have been limited studies on the cutaneous findings and hair and nail abnormalities after discharge.

Objective: To establish the cutaneous manifestations, hair and scalp disorders, and nail abnormalities in patients who recovered from COVID-19 infections.

Methods: A retrospective chart review and telephone interviews were conducted to determine the cutaneous manifestations, hair and scalp disorders, and nail abnormalities of patients aged over 18 years who were diagnosed with COVID-19 infections at Siriraj Hospital, Bangkok, Thailand, between January and June 2020.

Results: Ninety-three patients with prior COVID-19 infections participated in the study. The COVID-19 severity had been mild for most (71%). Cutaneous manifestations were reported in 8 patients (8.6%), with the common skin conditions being maculopapular rash and urticaria. The onsets of the skin conditions were before admission (1%), during admission (4.3%), and after discharge (3.2%). Increased hair shedding was also reported in 22 patients (23.7%), with a female predominance. Three patients were affected during admission, while the others were affected after discharge. The patients with moderate, severe, and critical COVID-19 infections experienced significantly more hair shedding than those with asymptomatic and mild diseases. Only 2 patients with mild COVID-19 disease reported nail abnormalities (chromonychia and brittle nails).

Conclusions: Cutaneous manifestations, hair disorders, and nail abnormalities can occur in patients with COVID-19 after their discharge from hospital. Patients should therefore be followed up in anticipation of dermatological problems.
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http://dx.doi.org/10.1155/2021/5595016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8238562PMC
July 2021

Clinical practice guidelines for the diagnosis and management of atopic dermatitis.

Asian Pac J Allergy Immunol 2021 Jul 11. Epub 2021 Jul 11.

Division of Dermatology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Atopic dermatitis (AD), a chronic, relapsing dermatitis, is characterized by dry and pruritus skin in patients with a personal or family history of atopy. It affects up to 20% of children and 1-3% of adults in most countries worldwide, and leads to significant treatment costs and morbidity. These guidelines are developed in accordance with evidence-based publications and expert opinions. Following simple algorithms, the guidelines aim to assist adult and pediatric physicians in the better care of patients with AD. As with other diseases, there have been several diagnosis criteria proposed over time. Nonetheless, the classical Hanifin and Rajka criterion with no pathognomonic laboratory biomarkers is still the most widely used worldwide for the diagnosis of AD. The management of AD must be considered case by case to provide suitable care for each patient. Basic therapy is focused on avoiding specific/unspecific provoking factors and hydrating skin. Topical anti-inflammatory treatments such as glucocorticoids and calcineurin inhibitors are suggested for disease flare, and proactive therapy is best for long-term control. Other therapies, including antimicrobial agents, systemic antihistamines, systemic anti-inflammatory agents, immunotherapy, phototherapy, and psychotherapy, are reviewed in these guidelines. Crisaborole, a new topical phosphodiesterase 4 inhibitor, can be used twice daily in AD patients over three months old. Dupilumab, a biological drug for patients with moderate-to-severe AD, may be considered in patients with no improvement from other systemic treatments.
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http://dx.doi.org/10.12932/AP-010221-1050DOI Listing
July 2021

Reply to "Proposal for a new classification of vibratory urticaria/angioedema".

J Allergy Clin Immunol Pract 2021 06;9(6):2543-2544

Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Berlin, Germany (corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany. Electronic address:

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http://dx.doi.org/10.1016/j.jaip.2021.02.037DOI Listing
June 2021

The Pathogenesis of Chronic Spontaneous Urticaria: The Role of Infiltrating Cells.

J Allergy Clin Immunol Pract 2021 06 3;9(6):2195-2208. Epub 2021 Apr 3.

Divison of Pulmonary and Critical Care Medicine and Allergy and Immunology, Department of Medicine, The Medical University of South Carolina, Charleston, SC. Electronic address:

Chronic spontaneous urticaria is characterized by a perivascular non-necrotizing cellular infiltrate around small venules of the skin. It consists primarily of CD4(+) lymphocytes, a prominence of the T helper (Th)2 subtype but also Th1 cells, with Th17 cell-derived cytokines elevated in plasma. There are also neutrophils, eosinophils, basophils, and monocytes. Chemokines derived from mast cells and activated endothelial cells drive the process. Although the role of the cellular infiltrate has not previously been addressed, each constituent can contribute to the overall pathogenesis. It is of interest that CSU responds to corticosteroid, yet, short-term steroids do not affect autoimmunity or degranulation of mast cells, and act on margination of cells along the endothelium and chemotaxis to enter the surrounding dermis. In this review, we address each cell's contribution to the overall inflammatory response, as it is currently understood, with a view toward development of therapeutic options that impede the function of critical cells and/or their secretory products.
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http://dx.doi.org/10.1016/j.jaip.2021.03.033DOI Listing
June 2021

A randomized controlled trial to compare the effectiveness and safety of adsorbent lotion containing tapioca starch, spent grain wax, Butyrospermum parkii extract, argania spinosa kernel oil, aloe barbadensis, rosehip oil, and allantoin with a low-potency topical corticosteroid in the treatment of intertrigo.

J Cosmet Dermatol 2021 Apr 3. Epub 2021 Apr 3.

Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Background: Intertrigo is an inflammatory skin-fold condition. Candida infections may occur concurrently or afterward. Topical corticosteroids may reduce inflammation but exacerbate Candida infections. The treatment is contentious.

Objective: To evaluate the efficacies and safety of adsorbent lotion containing tapioca starch, spent grain wax, Butyrospermum parkii extract, argania spinosa kernel oil, aloe barbadensis, rosehip oil, and allantoin for the treatment of mild-to-moderate intertrigo, relative to 1% hydrocortisone cream.

Methods: This randomized, double-blinded study enrolled 40 intertrigo patients. Twice daily, 20 patients applied adsorbent lotion while the remainder used 1% hydrocortisone cream. Efficacy evaluation, skin biophysical measurements, skin tolerability, safety, and visual analog scale (VAS) patient-satisfaction scores were evaluated at baseline and Week 2.

Results: The adsorbent lotion showed higher complete cure rates for color, partial epidermal loss, papules/pustules/vesicles/patches, dryness, and scaling than the corticosteroid without statistical significance. Adsorbent lotion demonstrated significantly higher reduction in pruritus than the corticosteroid treatment. Reduction of erythema level using Mexameter and VAS patient-satisfaction scores were not statistically different between adsorbent lotion and hydrocortisone cream. No adverse effects or superimposed infections were reported.

Conclusions: The anti-inflammatory efficacies of adsorbent lotion and low-potency steroid were equivalent. The lotion was safe and produced excellent pruritus reduction. Patient satisfaction was high.
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http://dx.doi.org/10.1111/jocd.14125DOI Listing
April 2021

The global impact of the COVID-19 pandemic on the management and course of chronic urticaria.

Allergy 2021 03 29;76(3):816-830. Epub 2020 Dec 29.

Urticaria Center of Reference and Excellence (UCARE), Department of Dermatology and Venereology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.

Introduction: The COVID-19 pandemic dramatically disrupts health care around the globe. The impact of the pandemic on chronic urticaria (CU) and its management are largely unknown.

Aim: To understand how CU patients are affected by the COVID-19 pandemic; how specialists alter CU patient management; and the course of CU in patients with COVID-19.

Materials And Methods: Our cross-sectional, international, questionnaire-based, multicenter UCARE COVID-CU study assessed the impact of the pandemic on patient consultations, remote treatment, changes in medications, and clinical consequences.

Results: The COVID-19 pandemic severely impairs CU patient care, with less than 50% of the weekly numbers of patients treated as compared to before the pandemic. Reduced patient referrals and clinic hours were the major reasons. Almost half of responding UCARE physicians were involved in COVID-19 patient care, which negatively impacted on the care of urticaria patients. The rate of face-to-face consultations decreased by 62%, from 90% to less than half, whereas the rate of remote consultations increased by more than 600%, from one in 10 to more than two thirds. Cyclosporine and systemic corticosteroids, but not antihistamines or omalizumab, are used less during the pandemic. CU does not affect the course of COVID-19, but COVID-19 results in CU exacerbation in one of three patients, with higher rates in patients with severe COVID-19.

Conclusions: The COVID-19 pandemic brings major changes and challenges for CU patients and their physicians. The long-term consequences of these changes, especially the increased use of remote consultations, require careful evaluation.
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http://dx.doi.org/10.1111/all.14687DOI Listing
March 2021

Cold urticaria - What we know and what we do not know.

Allergy 2021 04 24;76(4):1077-1094. Epub 2020 Dec 24.

Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany.

Cold urticaria (ColdU) is a common form of chronic inducible urticaria characterized by the development of wheals, angioedema or both in response to cold exposure. Recent research and guideline updates have advanced our understanding and management of ColdU. Today, its pathophysiology is thought to involve the cold-induced formation of autoallergens and IgE to these autoallergens, which provoke a release of proinflammatory mediators from skin mast cells. The classification of ColdU includes typical and atypical subtypes. We know that cold-induced wheals usually develop on rewarming and resolve within an hour and that anaphylaxis can occur. The diagnosis relies on the patient's history and cold stimulation testing. Additional diagnostic work-up, including a search for underlying infections, should only be done if indicated by the patient's history. The management of ColdU includes cold avoidance, the regular use of nonsedating antihistamines and the off-label use of omalizumab. However, many questions regarding ColdU remain unanswered. Here, we review what is known about ColdU, and we present important unanswered questions on the epidemiology, underlying pathomechanisms, clinical heterogeneity and treatment outcomes. Our aim is to guide future efforts that will close these knowledge gaps and advance the management of ColdU.
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http://dx.doi.org/10.1111/all.14674DOI Listing
April 2021

A Double-Blinded, Randomized, Vehicle-Controlled Study of the Efficacy of Moisturizer Containing Licochalcone A, Decanediol, L-Carnitine, and Salicylic Acid for Prevention of Acne Relapse in Asian Population.

Biomed Res Int 2020 16;2020:2857812. Epub 2020 Oct 16.

Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Many topical agents are available for treating the acute phase of acne; however, few agents have been proven beneficial during the maintenance phase. To evaluate the efficacy and safety of moisturizer containing licochalcone A, 1,2-decanediol, L-carnitine, and salicylic acid during the maintenance phase of mild to moderate acne in Thai patients. One hundred and ten patients with mild to moderate acne vulgaris were initially treated with a fixed combination of adapalene 0.1%/benzoyl peroxide 2.5% gel once daily for 8 weeks. Fifty patients who achieved at least 50% reduction in lesion counts or at least a 2-grade improvement in the Investigator's Global Assessment (IGA) grade from baseline were enrolled in the maintenance phase, which was an investigator-masked, left-right comparison, randomized, controlled, intraindividual study. Moisturizers with and without the active study ingredients were applied twice a day to each side of the face, respectively, for 12 weeks. Assessments included acne lesion counts, acne severity by IGA scoring, skin bioengineering measurements, and skin tolerability as assessed by both patient and physician. The treatment group had a significant reduction in the mean counts of noninflammatory, inflammatory, and total lesions compared to the vehicle group at week 12 and also between baseline and week 12. There was no significant difference in the mean scores for skin dryness, stinging/burning, or pruritus at any time point between groups. Moisturizer containing licochalcone A, 1,2-decanediol, L-carnitine, and salicylic acid reduced acne lesions and prevented the development of new lesions during the maintenance phase. This trial is registered with ClinicalTrials.gov registration no. NCT04002024.
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http://dx.doi.org/10.1155/2020/2857812DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7603542PMC
May 2021

A double-blinded, randomized, split-side, vehicle-controlled study of the efficacy of cleanser containing Acanthus ebracteatus Vahl., Suregada multiflora, and Acacia concinna in patients with atopic dermatitis: A pilot study.

Asian Pac J Allergy Immunol 2020 Oct 17. Epub 2020 Oct 17.

Center of Applied Thai Traditional Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Background: Barrier repair therapy is the key management approach for both eczematous and non-lesional skin of atopic dermatitis. The use of appropriate cleansers to enhance skin hydration is an adjunctive treatment that increases topical drug penetration. Anti-inflammatory properties of various medicinal plants in tropical Asia have been reported.

Objective: Investigate the efficacy of herbal cleanser containing a combination of herbal extracts from Acanthus ebracteatus Vahl., Suregada multiflora, and Acacia concinna on seemingly intact skin in patients with atopic dermatitis by measuring improvements in the skin barrier function.

Methods: This 2-week pilot study was a split-side, randomized, double-blinded, vehicle-controlled trial. All patients (n = 30) were asked to use both a cleanser with an active formulation containing the herbal extracts and a vehicle- controlled cleanser on each side of mid-volar forearm. Biophysical assessments including transepidermal water loss (TEWL), skin hydration, skin pH, and skin roughness were performed at baseline and upon study completion.

Results: Compared to baseline, the median percentage change in TEWL at the end of the study was significantly greater for the active side 10.4 (-19, 20.7) g/m2h than the control side -13.2 (-28.7, 9.1) g/m2h; p = 0.01. The median percentage change of skin hydration, skin pH, and skin roughness of the active side compared to the control side had no a statistical significance.

Conclusions: This cleanser is beneficial when used as adjunctive therapy. Further studies should evaluate its anti- sinflammatory properties in the remedy or active phase of atopic dermatitis or other inflammatory skin diseases.
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http://dx.doi.org/10.12932/AP-050519-0554DOI Listing
October 2020

Vibratory Angioedema Subgroups, Features, and Treatment: Results of a Systematic Review.

J Allergy Clin Immunol Pract 2021 02 19;9(2):971-984. Epub 2020 Sep 19.

Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Berlin, Germany. Electronic address:

Background: Vibratory angioedema (VA) is a subtype of chronic inducible urticaria that manifests with erythematous wheals or angioedema after skin exposure to vibration. Because the condition is rare, the available information is limited.

Objective: To systematically review the clinical manifestations and treatment options of VA.

Methods: Relevant literature published until August 2020 was searched using the terms "vibratory urticaria," "vibratory angioedema," "vibratory-induced angioedema," and "vibratory-induced urticaria." Preferred Reporting Items for Systematic Reviews and Meta-analysis recommendations were applied to this systematic review.

Results: On the basis of review of 22 studies (16 case reports, 4 case series, and 2 cohort studies) that had a combined total of 83 patients, we propose that VA be classified as hereditary VA (33.7%) and acquired VA (66.3%). Vibration-induced itching was frequent in both subgroups. Patients with hereditary VA more commonly had wheals and systemic symptoms, whereas patients with acquired VA more frequently had angioedema, burning, pain, or tingling. Although many VA treatments are used, there is little information on their efficacy. Most patients do not achieve complete control.

Conclusions: The novel VA classification proposed could help clinicians with the diagnostic workup of patients with VA. Because of the paucity of reported cases, firm recommendations for the treatment of VA are currently not possible. For patients with acquired VA, we suggest second-generation H-antihistamines as the first-line treatment. Controlled therapeutic trials are needed and should be performed.
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http://dx.doi.org/10.1016/j.jaip.2020.09.009DOI Listing
February 2021

Relationship Between Depression and Quality of Life Among Vitiligo Patients: A Self-assessment Questionnaire-based Study.

Clin Cosmet Investig Dermatol 2020 4;13:511-520. Epub 2020 Aug 4.

Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Background: Vitiligo is a common chronic autoimmune disease that is characterized by progressive loss of skin color due to melanocyte destruction. In addition to the physical effects of vitiligo, this condition exerts adverse psychological effects and causes social stigmatization. Earlier studies reported that individuals with vitiligo suffer from poor quality of life (QoL), but data about the QoL of Thai vitiligo patients is scarce.

Objective: This study aimed to investigate the QoL and prevalence of depression in Thai vitiligo patients, association between QoL and depression, and factors associated with QoL and depression among Thai people with vitiligo.

Methods: This cross-sectional self-assessment questionnaire-based study was conducted at the phototherapy and vitiligo clinics of the Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University (Bangkok, Thailand). QoL was assessed using the Dermatology Life Quality Index (DLQI) questionnaire, and depression was evaluated via the Patient Health Questionnaire (PHQ-9).

Results: Among the 104 vitiligo patients that were recruited, the mean DLQI score was 7.46, and the prevalence of depression (PHQ-9 ≥9) was 13.5%. Factors significantly associated with a higher mean DLQI score were skin phototype IV compared to phototype III, active disease, new lesions within the last three months, lesions involving upper extremities, and PHQ-9 ≥9 (<0.05). Moderate correlation was found between DLQI score and PHQ-9 score (Pearson's correlation coefficient: 0.524, <0.001). Factors significantly associated with depression were working status and developing new lesions within the last three months (<0.05). Patients with new lesions were 4.12 times more likely to be depressed than those without new lesions (OR: 4.12, 95%CI: 1.20-14.16; =0.025).

Conclusion: Developing new lesions, active disease, dark skin phototype (IV), and lesion on upper extremity had significant adverse effects on QoL. Vitiligo patients who were employed and who had new vitiligo lesions are significantly more likely to be depressed.
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http://dx.doi.org/10.2147/CCID.S265349DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7414931PMC
August 2020

Cholinergic Urticaria: Clinical Presentation and Natural History in a Tropical Country.

Biomed Res Int 2020 24;2020:7301652. Epub 2020 May 24.

Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Background: Cholinergic urticaria (CholU) is a subset of chronic inducible urticaria characterized by the recurrent pinpoint-sized wheals that are induced by exercising or increasing core body temperature. Currently, the data of CholU in tropical climate is still limited.

Objective: To investigate the clinical features and natural course of CholU in a tropical country.

Materials And Methods: This retrospective chart review study analyzed the data of CholU patients aged over 18 years who visited Siriraj Urticaria Clinic, Siriraj Hospital, Bangkok, Thailand, between January 2007 and September 2019. Demographic data, clinical presentations, and results of provocation tests and other laboratory investigations were evaluated and compared with other studies reported in temperate zones.

Results: Sixteen out of 2,175 chronic urticaria patients (0.7%) were diagnosed with CholU. The median age of CholU patients was 28.0 ± 11.7 years with male predominance (56.3%). Three patients (18.8%) had a history of atopy. Fifteen patients (93.8%) were positive to the exercise provocation test. Nonsedating antihistamine drugs were a main treatment (73.8%). Six patients (37.5%) were in remission at the time of the study, with a mean duration 4.3 years. The Kaplan-Meier survival analysis demonstrated that 12.5%, 35.5%, and 67.9% of patients would have disease remission within 1 year, 5 years, and 13 years, respectively.

Conclusions: The prevalence of CholU differs in each geographic region and is found to be low in tropical countries with a median duration 4.3 years. The prevalence of atopy and anaphylaxis with CholU is also lower in tropical countries than in temperate.
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http://dx.doi.org/10.1155/2020/7301652DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273400PMC
March 2021

Symptomatic Dermographism: A Systematic Review of Treatment Options.

J Allergy Clin Immunol Pract 2020 10 28;8(9):3141-3161. Epub 2020 May 28.

Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany. Electronic address:

Background: Symptomatic dermographism (SD), the most common form of chronic inducible urticaria, presents with transient wheals accompanied by itching in response to scratching. Little is known about available treatment options and their efficacy in SD.

Objective: To systematically review the efficacy of treatment options for patients with SD.

Methods: Using predefined search terms, we searched for relevant literature published until September 2019. The systematic review process was consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations.

Results: The 23 studies identified included 15 randomized controlled trials; 22 and 17 assessed treatment responses in patients with SD by provocation/threshold testing and patient/physician clinical assessment, respectively. Thirteen different treatments were investigated in a total of 430 adult patients. The most frequently studied therapy, first-generation H-antihistamines, showed variable efficacy and significant side effects. In contrast, second-generation H-antihistamines (2AH), in all studies, were effective and well tolerated. Monotherapy with an H-antihistamine (AH) was not effective, whereas adding an AH increased the efficacy of treatment with an H-antihistamine (AH). SD improved with omalizumab. All other treatments were only investigated in small, unrepeated, and/or uncontrolled studies. There are no studies on updosing of 2AH.

Conclusions: The available SD studies are heterogeneous, mostly monocentric, old, small, and unrepeated, pointing to a high need for more and better studies. We suggest that 2AH should be the first-line treatment. In uncontrolled cases, the combination of AH and AH may be tried. Even though there is no evidence of its efficacy over standard dosage, updosing of 2AH may be considered based on the extrapolation of evidence from chronic spontaneous urticaria; omalizumab should be added in recalcitrant patients.
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http://dx.doi.org/10.1016/j.jaip.2020.05.016DOI Listing
October 2020

Clinical characteristics and management of chronic spontaneous urticaria in patients refractory to H-Antihistamines in Asia, Middle-East and Africa: Results from the AWARE-AMAC study.

World Allergy Organ J 2020 Apr 30;13(4):100117. Epub 2020 Apr 30.

Novartis Pharma AG, Basel, Switzerland.

Background: Chronic urticaria (CU) is a condition characterized by recurrent itchy hives and/or angioedema for ≥6 weeks. Most of the data about CU come from western countries with very little information available about CU in Asia, Africa, and the Middle East.

Methods: AWARE-AMAC is a 24-month prospective, observational, real-world, non-interventional study in patients aged ≥18 years from Asia, the Middle East, and Africa (AMAC) with CU refractory to H1-antihistamines (H1-AH). The main objective was to describe the real-world experience with CU, including clinical characteristics, presence of angioedema, treatment patterns (shifts between treatment classes and changes within a treatment class), investigator-assessed disease control, and the impact on quality of life. Subgroups of interest were type of CU at Baseline and treatment class (based on 2013 urticaria guidelines). There were no mandatory visits and diagnostic/monitoring procedures additional to routine practice, except the patient diary (7-day Urticaria Activity Score) and patient reported outcome assessments.

Results: The focus of the current manuscript is on patients with chronic spontaneous urticaria (CSU), who formed 98% of the sample. Patients were predominantly female (69.6% female, mean age ± SD 39.8 ± 13.29 years). Time since current diagnosis (Mean ± SD) was 28.6 ± 49.06 months. Amongst patients with CSU, 31.0% had comorbid chronic inducible urticaria (CINDU) and 46.4% had a history of angioedema. 91.9% received H1-AH therapy (±other treatments). The most frequently prescribed treatment classes at Baseline were any/combination of medications, not classified under the other 7 treatment classes, named "Others" (30.5%) followed by, omalizumab (OMA; 23.6%) and second-generation H1-AH monotherapy (sgAH; 15.1%). At Month 12, the most prescribed treatment classes (>15%) for patients were OMA (23.5%) and "Other" (21.3%); 19.7% received "No drug". At Month 24, OMA (22.5%), and "Other" (17.9%) were most frequently prescribed; 28.6% received "No drug". Overall, 79.5% of patients had some type of change in treatment. Over the study period, improvement in self-reported QoL increased, which was mirrored by better disease control.

Conclusion: In AMAC countries, the non-recommended "Other" treatment class played a major role in the initial management of CU patients. High usage of H1-AH (±other treatments) and OMA was observed. Treatment changes were observed in a majority of patients. Treatment escalation from sgAH was mostly via OMA. Improvement of disease control and QoL was achieved during the study period.

Trial Registration: Observational study (NA).
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http://dx.doi.org/10.1016/j.waojou.2020.100117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7200453PMC
April 2020

The validity and reliability of the Thai-version of 5-D itch scale.

Asian Pac J Allergy Immunol 2020 Mar 29. Epub 2020 Mar 29.

Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Background: Pruritus is commonly associated with skin disorders. The 5-D itch scale was developed as a specific questionnaire for pruritus.

Objective: This study aimed to evaluate the validity, reliability, and sensitivity to change of the Thai 5-D itch scale in Thai patients.

Methods: The Thai Dermatology Life Quality Index (DLQI), patient's global assessment of disease severity (PatGA-VAS), Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL), and seven-day urticaria activity score (UAS7) were evaluated as correlation with Thai 5-D itch scale. Seventy-five stable patients (42 chronic urticaria patients and 33 eczema patients), who had no change in disease severity after 4-weeks were assessed for test-retest reliability.

Results: Of 130 pruritus patients who were treated at Department of Dermatology, Siriraj Hospital, 65 patients were diagnosed with chronic urticaria. The others were diagnosed with eczema. The validity of Thai 5-D itch scale correlated strongly with Thai DLQI total score (r = 0.76, p < 0.0001) and PatGA-VAS (r = 0.79, p < 0.0001). The strong reliability of Thai 5-D itch scale was demonstrated as intraclass correlation coefficient of 0.90. The changes in Thai 5-D itch scale was correlated with the changes in PatGA-VAS and UAS7 which indicated that the Thai 5-D itch scale had good sensitivity to change (r = 0.66) and (r = 0.67), respectively.

Conclusions: The Thai 5-D itch scale is a questionnaire with good validity, reliability and sensitivity to change to evaluate pruritus in Thai patients. This will support the use of 5-D itch scale in practice, in other languages.
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http://dx.doi.org/10.12932/AP-100120-0738DOI Listing
March 2020

Delayed Pressure Urticaria: A Systematic Review of Treatment Options.

J Allergy Clin Immunol Pract 2020 06 13;8(6):2035-2049.e5. Epub 2020 Mar 13.

Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Berlin, Germany. Electronic address:

Background: Delayed pressure urticaria (DPU) is characterized by recurrent erythematous and often painful swelling after the skin is exposed to sustained pressure. Treatment is challenging. Antihistamines, the first-line and only approved treatment, are often not effective.

Objective: To systematically review the treatment options for DPU.

Method: A literature search of electronic databases for all relevant articles published till April 29, 2019, was conducted using the search terms "delayed pressure urticaria" and "pressure urticaria." This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations.

Results: Twenty-one studies (8 randomized controlled trials [RCTs], 10 retrospective cohort studies, and 3 open-label prospective studies) were included. Second-generation H antihistamines (sgAHs) were effective in 3 RCTs. The combination of an sgAH and montelukast (2 RCTs) or an sgAH and theophylline (1 non-RCT) was more effective than the sgAH alone. The disease improved with omalizumab (4 non-RCTs), sulphones (3 non-RCTs), oral prednisolone (1 RCT and 2 non-RCTs), intravenous immunoglobulin (1 non-RCT), and gluten-free diet (1 non-RCT). There are no studies on updosing of antihistamines over standard dosage in DPU.

Conclusions: Overall, the quality of studies on DPU is low. Because of the lack of other evidence, antihistamines remain the first-line therapy. Updosing of sgAHs could be considered in patients with uncontrolled symptoms on the basis of the extrapolation of evidence from chronic spontaneous urticaria, even though there is no evidence of its efficacy over standard dosage. Addition of montelukast may be considered. Omalizumab or sulphones may be used in treatment-resistant patients. High-quality DPU studies should be conducted.
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http://dx.doi.org/10.1016/j.jaip.2020.03.004DOI Listing
June 2020

Angioedema Activity Score (AAS): A Valid and Reliable Tool to Use in Asian Patients.

Biomed Res Int 2019 31;2019:9157895. Epub 2019 Oct 31.

Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Berlin, Germany.

The Angioedema Activity Score (AAS) is recommended by the EAACI/GALEN/EDF/WAO guidelines for urticaria as the standard measure for assessing disease activity in patients with recurrent angioedema (RAE). To date, it has been translated into 80 languages for use in 52 countries, but it has not been formally validated in Asian patient populations. As RAE may be different in Asian and non-Asian patients, it is important to validate and characterize the reliability of tools to assess RAE disease activity in Asian patients. This study proposed to demonstrate the validity and reliability of the AAS in Asian patients. Accordingly, this study aimed to generate and validate the Thai version of the AAS and to characterize its reliability in Asian patients, specifically in Thailand. A structured translation was conducted with approval from the original authors. The Patient Global Assessment of Disease Activity (PGA-DA) was used as an instrument to compare with the Thai version of the AAS. In total, 86 patients with RAE participated in the study. Seventy-six (88%) patients had RAE with chronic spontaneous urticaria. The Thai AAS was found to be a valid and reliable instrument, with high convergent and known-groups validities, excellent internal consistency, and good test-retest reliability. The validity and reliability of the AAS for assessing RAE disease activity in Asian patients have been demonstrated by our study, making it the first to do so. This will help promote the use of the AAS, in clinical trials and practice, in Asia. It will also facilitate the comparison of disease activity in patients with RAE inside and outside Asia in future studies. However, a limitation of this study was its small number of patients.
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http://dx.doi.org/10.1155/2019/9157895DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6874972PMC
April 2020

Angioedema quality of life questionnaire (AE-QoL) - interpretability and sensitivity to change.

Health Qual Life Outcomes 2019 Oct 26;17(1):160. Epub 2019 Oct 26.

Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany.

Background: The Angioedema Quality of Life (AE-QoL) is the first patient reported outcome measure developed for the assessment of quality of life (QoL) impairment in patients with recurrent angioedema (RAE). This study aimed to evaluate the clinimetric properties of the AE-QoL in Thai patients and to establish categories of QoL impairment assessed by the AE-QoL.

Methods: The validated Thai version of the Dermatology Life Quality Index (DLQI) and Patient Global Assessment of Quality of Life (PGA-QoL) were used to comparatively evaluate the Thai version of AE-QoL. Spearman correlations between the Thai AE-QoL and two other standard measurements (DLQI and PGA-QoL) were investigated to determine convergent validity. The Thai DLQI and PGA-QoL were used to categorize patients according to their QoL. Known-group validity of the Thai AE-QoL was later analyzed. The reliability of the Thai AE-QoL was investigated using Cronbach's alpha and intraclass correlation. Three different approaches including the distribution method, receiver operating characteristic curve analysis, and the anchor based-method were used for the interpretability.

Results: A total of 86 patients with RAE with a median age of 38.0 ± 15.1 years (range 18-76) were enrolled. Of those, 76 patients (88%) had RAE with concomitant wheals, and 10 patients (11.6%) had RAE only. The AE-QoL assessed RAE-mediated QoL impairment with high convergent validity and known-groups validity, high internal consistency and test-retest reliability, and good sensitivity to change. Although the AE-QoL did not differentiate between patients with moderate and large effect as measured by PGA-QoL or DLQI in this study, AE-QoL total values of 0-23, 24 to 38, and ≥ 39 could define patients with "no effect", "small effect", and "moderate to large effect" of RAE on their QoL, respectively.

Conclusions: This study supports the validity and reliability of the Thai version of the AE-QoL, which is a very different language from the original version. Categories allow to classify the effect of RAE on patients' QoL as "none", "small", and "moderate to large". Further studies are needed to confirm the applicability of AE-QoL in other Asian populations".
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http://dx.doi.org/10.1186/s12955-019-1229-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6815453PMC
October 2019

Factors Predicting the Response to Cyclosporin Treatment in Patients With Chronic Spontaneous Urticaria: A Systematic Review.

Allergy Asthma Immunol Res 2019 Sep;11(5):736-755

Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Purpose: This study aimed to systemically review literature relating to factors that could potentially predict a favorable response to cyclosporine A (CsA) treatment for chronic spontaneous urticaria (CSU).

Methods: A systematic literature review was done according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations.

Results: A total of 13 studies (404 patients with CSU and 200 healthy patients) were included. There were only 1 randomized controlled trial (RCT) and 12 non-RCTs. Our systematic review showed that positive autologous serum skin test results, positive baseline basophil histamine release assays, positive baseline basophil activation test responses, elevated baseline plasma D-dimer levels, elevated baseline serum interleukin (IL)-2, IL-5, and tumor necrosis factor-alpha (TNF-α) levels, and low baseline serum IgE levels might assist in predicting favorable CsA responses in CSU patients. Decreased plasma D-dimer levels; and decreased serum IL-2, IL-5, and TNF-α levels were reported to be correlated with clinical improvement after CsA treatment.

Conclusions: Since most positive results were from non-RCT articles and some data were still inconsistent, this systematic review identified no reliable practical biomarker for predicting CsA treatment response in patients with CSU. There were no positive predictors with good consistency and mechanical plausibility.
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http://dx.doi.org/10.4168/aair.2019.11.5.736DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6658402PMC
September 2019

Cold Urticaria: Clinical Features and Natural Course in a Tropical Country.

Allergy Asthma Immunol Res 2019 Jul;11(4):538-547

Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Purpose: To review the clinical features and natural courses of cold urticaria (ColdU) in a tropical country.

Methods: A retrospective chart review was performed of patients who visited Siriraj Urticaria Clinic, Siriraj Hospital, Bangkok, Thailand, and were diagnosed with ColdU between 2007 and 2018. Data on provocation and threshold tests, clinical courses, and laboratory work-up were analyzed and compared with data reported by studies in temperate countries.

Results: Of 1,063 chronic urticaria patients, 27 (2.5%) were diagnosed with ColdU, with a mean age of symptom onset of 34.8 years. Half of the patients had a history of atopy, and 1 (3.7%) had a history of anaphylaxis. All patients were positive to 1 of 3 provocation tests: an ice cube test; Temp 4.0; or a tray filled with ice, salt and water. Thirteen patients underwent the ice cube test, and all had positive results. Temp was performed on 15 patients, 8 of whom had positive results, with a mean critical temperature threshold (CTT) of 21.0°C. All of the 7 patients who had a negative Temp result later produced positive results to the immersion of their hand and forearm in a tray filled with ice, salt, and water. All patients were treated with H₁-antihistamines, the vast majority (96.3%) being non-sedating H₁-antihistamines. Some (14.8%) needed to be administered oral corticosteroids, ciclosporin, or omalizumab. Six patients (22.2%) were in remission. A Kaplan-Meier survival curve demonstrated 5-year and 10-year remission rates of 13.8% and 42.6%, respectively.

Conclusions: The rate of anaphylaxis in patients with ColdU in a tropical country was lower than those reported by other studies conducted intemperate climates. On the other hand, the number of female patients, mean age at symptom onset, atopy rate, rate of concomitant chronic spontaneous urticaria and mean CTT were higher.
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http://dx.doi.org/10.4168/aair.2019.11.4.538DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6557767PMC
July 2019

Treatments of cold urticaria: A systematic review.

J Allergy Clin Immunol 2019 04 15;143(4):1311-1331. Epub 2019 Feb 15.

Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Berlin, Germany. Electronic address:

Background: Several treatment options for cold urticaria (ColdU) have been studied and reported, but systematic reviews and meta-analyses are limited.

Objectives: We sought to meta-analyze and review the efficacy and safety of ColdU treatments.

Methods: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Suitable reports were identified by searching PubMed, Scopus, and Web of Science. Our systematic review included 16 studies, 9 of which met the eligibility criteria for the meta-analysis. We analyzed the effects of treatments on critical temperature thresholds (CTTs) and critical stimulation time thresholds (CSTTs), as well as on rates of complete response and adverse events.

Results: Our pooled meta-analyses showed that nonsedating second-generation H-antihistamines (nsAHs) are effective in the treatment of ColdU and that updosing of nsAHs significantly reduced CTTs relative to their own standard doses and placebos. In 4 studies involving CSTTs, updosing of nsAHs also resulted in significantly better CSTTs than their own standard doses or placebos. Omalizumab resulted in a marked reduction of CTTs in H-antihistamine-resistant patients. Of 118 adverse events in 8 studies, standard-dose nsAHs, updosed nsAHs, and omalizumab produced lower numbers of adverse events than first-generation antihistamines.

Conclusions: Our study showed that greater dosages of nsAHs were more effective than standard dosages in controlling ColdU symptoms. Increasing the dosages was not significantly associated with higher adverse event rates. Omalizumab at 150 and 300 mg every 4 weeks was shown to be effective for patients with ColdU refractory to antihistamines.
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http://dx.doi.org/10.1016/j.jaci.2019.02.005DOI Listing
April 2019

Relationship between vitamin D and chronic spontaneous urticaria: a systematic review.

Clin Transl Allergy 2018 4;8:51. Epub 2018 Dec 4.

2Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Background: Vitamin D has been reported to be associated with many allergic diseases. There are a limited number of the studies of vitamin D supplementation in patients with chronic spontaneous urticaria (CSU). This study aims to study the relationship between vitamin D and CSU in terms of serum vitamin D levels, and the outcomes of vitamin D supplementation.

Methods: A literature search of electronic databases for all relevant articles published between 1966 and 2018 was performed. The systematic literature review was done following Preferred Reporting Items for Systematic Reviews and Meta-analysis recommendations.

Results: Seventeen eligible studies were included. Fourteen (1321 CSU cases and 6100 controls) were concerned with serum vitamin D levels in CSU patients. Twelve studies showed statistically significant lower serum vitamin D levels in CSU patients than the controls. Vitamin D deficiency was reported more commonly for CSU patients (34.3-89.7%) than controls (0.0-68.9%) in 6 studies. Seven studies concerned with vitamin D supplementation in CSU patients showed disease improvement after high-dosages of vitamin D supplementation.

Conclusion: CSU patients had significantly lower serum vitamin D levels than the controls in most studies. However, the results did not prove causation, and the mechanisms were not clearly explained. Despite the scarcity of available studies, this systematic review showed that a high dosage of vitamin D supplementation for 4-12 weeks might help to decrease the disease activity in some CSU patients. Well-designed randomized placebo-controlled studies are needed to determine the cut-off levels of vitamin D for supplementation and treatment outcomes.
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http://dx.doi.org/10.1186/s13601-018-0234-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6278169PMC
December 2018

Cost-effectiveness analysis and safety of erythromycin 4% gel and 4% chlorhexidine scrub for pitted keratolysis treatment.

J Dermatolog Treat 2019 Sep 11;30(6):627-629. Epub 2018 Dec 11.

a Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University , Bangkok , Thailand.

Studies of Pitted keratolysis (PK) treatment are limited. To study cost-effectiveness and to compare the safety of 4% chlorhexidine scrub with 4% erythromycin gel, for PK infections. This cohort study was conducted on naval rating cadets with a clinical diagnosis of PK at Chumpol Naval Rating School, Thailand in 2016. Participants were randomly treated with either 4% erythromycin gel or 4% chlorhexidine scrub for 4 weeks. The clinical examinations were evaluated at the baseline and at 1 and 2 months after treatment. A decision-tree model was used to evaluate the costs, resource utilization and outcomes as quality-adjusted life-years (QALYs). Of 344 naval rating cadets, 125 (36.3%) were diagnosed with PK. Sixty-four were treated with erythromycin. Approximately 80% of participants had complete resolution Foot odor were significantly improved at 2 months ( < .001) for both groups. No adverse effects were reported. Total cost for 4 weeks' treatment with the erythromycin gel and chlorhexidine scrub was US$77.34, US$51.9, respectively. Chlorhexidine treatment and erythromycin gel had 0.1526 and 0.1425 QALYs, respectively. treatment of PK with either 4% chlorhexidine scrub or 4% erythromycin gel had similar outcomes. However, using chlorhexidine scrub was more cost-effective.
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http://dx.doi.org/10.1080/09546634.2018.1543846DOI Listing
September 2019

Economic Burden of the Inadequate Management of Allergic Rhinitis and Urticaria in Asian Countries Based on the GA²LEN Model.

Allergy Asthma Immunol Res 2018 Jul;10(4):370-378

Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology and Allergy, Allergy-Centre-Charité, Berlin, Germany.

Purpose: Across Hong Kong, Malaysia, the Philippines, Singapore, Thailand and Vietnam, (referred to as Asia) approximately 30-53 million individuals of the 151 million employed suffer from allergic rhinitis (AR) and urticaria. It is estimated that approximately 90% of patients with these allergic conditions are insufficiently treated, impacting the socioeconomic burden in terms of absence from work and decreased productivity. This study aims to estimate the socioeconomic burden of allergies in Asia and the cost savings that their adequate management can provide. Due to the limited availability of regional data, this study focused AR and urticaria in selected countries.

Methods: Published literature, information from statistical bureaus, clinician surveys and extrapolation of selected data from the European Union were used to determine the socioeconomic costs of AR and urticaria.

Results: Many patients in Asia suffer from perennial allergies and experience symptoms of AR and urticaria for up to 298 days per year. An estimate of the indirect costs of patients insufficiently treated for AR and urticaria amounts to USD 105.4 billion a year, which equates to USD 1,137-2,195 per patient due to absenteeism and presenteeism. Adherence to guideline-approved treatment can lead to estimated savings of up to USD 104 billion.

Conclusions: The current study suggests that within Asia, the socioeconomic impact of AR and urticaria is similar to that seen in the European Union in spite of the lower wages in Asia. This is due to the mainly perennial allergens prevailing in Asia, whereas the sensitization patterns observed in the European Union are dominated by seasonal exposure to pollen. These results underline the need for governmental initiatives to increase public awareness on the prevention and treatment of these and other allergic diseases as well as greater research funding and large-scale studies to reduce their growing socioeconomic burden in coming years.
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http://dx.doi.org/10.4168/aair.2018.10.4.370DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6021592PMC
July 2018

The humoral immunity to epidermal and dermal antigens in psoriasis: a downstream rather than an upstream event.

Clin Exp Med 2018 Aug 10;18(3):453-456. Epub 2018 May 10.

Medical Proteomics Unit, Office for Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, 6th Floor - SiMR Building, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.

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http://dx.doi.org/10.1007/s10238-018-0503-8DOI Listing
August 2018

Food-dependent cold urticaria: A new variant of physical urticaria.

J Allergy Clin Immunol Pract 2018 Jul - Aug;6(4):1400-1402. Epub 2018 Apr 24.

Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany. Electronic address:

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http://dx.doi.org/10.1016/j.jaip.2018.04.010DOI Listing
November 2019

Cutaneous toxicities of epidermal growth factor receptor inhibitors: A prospective study in 60 Asian patients.

Asian Pac J Allergy Immunol 2019 Mar;37(1):12-18

Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Background: Several prospective studies have been conducted in epidermal growth factor receptor (EGFR) inhibitor-related cutaneous reactions in Caucasian patients, but prospective studies in Asian populations are scarce.

Objective: To investigate the cutaneous side effects of EGFR inhibitors in Asian cancer patients and to assess tumor response to dermatologic manifestations.

Methods: Sixty patients with lung or colorectal cancer who were receiving EGFR inhibitors were prospectively followed for at least one year by oncologists and dermatologists.

Results: Of 60 patients (33 males, 27 females), 46 lung cancer patients received erlotinib (n=29) and gefitinib (n=17). Cetuximab was prescribed in 14 colorectal cancer patients. Fifty-eight patients (58/60, 96.7%) developed cutaneous reactions. The most common reactions were xerosis (82.8%), acne (79.3%), and skin desquamation (62.1%). Most reactions were mild and well-tolerated. Of 14 patients who had severe reactions, temporary treatment interruption was necessary in 3 patients and a decreasing dose was required in another 3 patients. There were no statistically significant differences in type, severity, or number of cutaneous reactions between responders (29/58) and non-responders (29/58) to EGFR inhibitors. At median follow-up time of 11.92±1.08 months, no patient died from cutaneous toxicities. Nine patients died from cancer and 11 patients lost to follow-up.

Conclusion: In this Asian population, almost all patients (96.7%) developed cutaneous toxicities of EGFR inhibitors. Xerosis, acne, and desquamation were common in Asian cancer patients. Most reactions were mild and well tolerated. Due to limited number of patients, this study did not show significant associations between cutaneous toxicities and tumor response.
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http://dx.doi.org/10.12932/AP-140317-0047DOI Listing
March 2019

Prevalence and Clinical Correlation of Superficial Fungal Foot Infection in Thai Naval Rating Cadets.

Mil Med 2018 09;183(9-10):e633-e637

Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, Thailand.

Background: Superficial fungal foot infection is one of the most important dermatological diseases currently affecting military personnel. Many Thai naval rating cadets are found to suffer from superficial fungal foot infections and their sequels.

Objective: To investigate prevalence, potent risk factors, responding pathogens and clinical correlation of superficial fungal foot infection in Thai naval rating cadets training in Naval rating school, Sattahip, Thailand.

Materials And Methods: This cross-sectional study was performed in August 2015. Validated structured questionnaire was used regarding information about behaviors and clinical symptoms. Quality of life was assessed by Dermatology Quality of Life Index (DLQI) questionnaire and clinical presentation demonstrated by Athlete's foot severity score (AFSS). Laboratory investigations including direct microscopic examination and fungal culture were performed and recorded. All of the participants were informed and asked for their consent.

Results: A total of 788 Thai naval rating cadets with a mean age of 19 yr were enrolled. There were 406 (51.5%) participants suspected of fungal skin infection from questionnaire screening. After clinical examination, 303 participants (38.5%) were found to have foot lesions (AFSS ≥1). Superficial fungal foot infection was diagnosed with microscopic examination and fungal culture in 57 participants, giving a point prevalence of 7.2%. Tinea pedis was diagnosed in 54 participants with the leading causative organism being Trichophyton mentagrophytes (52.8%). Other 3 participants were diagnosed as cutaneous candidiasis. Wearing combat shoes more than 8 h was found to be a predisposing factor (p = 0.029), taking a shower less than two times a day (p = 0.008), and wearing sandals during shower (p = 0.055) was found to be protective against infection. Most fungal feet infection cases noticed their feet abnormalities (p < 0.001) including scales (p < 0.001), vesicles (p = 0.003) and maceration at interdigital web spaces (p < 0.001). Mean DLQI in superficial fungal foot infection cases was 3.35. Participants who had foot lesions (AFSS ≥1) were concerned of their foots unpleasant odor demonstrated significantly higher mean DLQI than those without odor (4.2 vs. 2.28; p < 0.001).

Conclusion: Superficial fungal foot infection is found as 7.2% of naval rating cadets. Wearing combat shoes more than 8 h was found to be a predisposing factor. In addition to skin manifestations including scales, vesicles, and maceration, superficial fungal foot infection also exhibited an unpleasant foot odor which affected quality of life. Self-foot-examination and life style modification should be promoted to prevent fungal infection.
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http://dx.doi.org/10.1093/milmed/usx187DOI Listing
September 2018