Suteeraporn Chaowattanapanit

Background: Skin-related hospitalisation in the oldest-old may reflect not only cutaneous disease but also broader geriatric vulnerability and acute-care needs. Nationwide evidence comparing skin-related admission phenotypes is limited. Methods: We did a nationwide retrospective cohort study using Thai National Health Security Office inpatient claims from 2017 to 2024. Skin-related admissions among adults aged 80 years or older were identified from ICD-10 primary discharge diagnoses and grouped into five phenotypes. We estimated population-based admission rates and used hospital-clustered modified Poisson regression to compare claims-recorded geriatric vulnerability and hospital outcomes, with infection-related admissions as the reference. Additional models adjusted for concurrent acute systemic illness. Findings: Of 1,048,523 diagnosis-eligible admissions, 31,325 (2·99%) were skin related. Infection-related admissions were most frequent (19,660 [62·8%]), followed by pressure ulcer or wound-related admissions (9,001 [28·7%]); overall rates were broadly stable during 2017–24. Pressure ulcer or wound-related admissions had the highest prevalence of any core claims-recorded vulnerability marker (2,578 [28·6%]) and acute systemic illness (3,209 [35·7%]), and were strongly associated with vulnerability (adjusted risk ratio [aRR] 7·76, 95% CI 7·04–8·55). Compared with infection-related admissions, they were associated with in-hospital death (aRR 4·77, 4·16–5·47), prolonged stay (1·97, 1·87–2·08), and high reimbursement cost (2·30, 2·15–2·46). Associations persisted after adjustment for acute systemic illness. Skin malignancy was associated mainly with high reimbursement cost. Interpretation: Skin-related admissions in the oldest-old represent heterogeneous inpatient burden. Pressure ulcer or wound-related admissions could signal multidomain geriatric vulnerability and prompt integrated wound, acute medical, geriatric, and transition-of-care pathways.

The Vinyl adhesive tape (VAT) technique with methylene blue (MTB) may be useful as an adjunctive microscopic method for diagnosis of superficial fungal skin infections. A cross‐sectional study was conducted between 2022 and 2025 on adults with dermatophytosis, pityriasis versicolor, and cutaneous candidiasis confirmed by skin scraping with potassium hydroxide (KOH). VAT technique with MTB staining was performed at the same lesion. Data on clinical characteristics, hyphal index, and time to microscopic identification were recorded. The primary objective was the positivity rate of VAT technique with MTB in patients with superficial fungal skin infections confirmed by skin scraping and direct microscopy with KOH. Secondary objectives included identifying factors associated with positive results and comparing time to microscopic identification. Among 208 participants (mean [SD] age, 50.87 [19.36] years; 44% female), the overall positivity rate of VAT technique with MTB was 89.4% (186/208), with positivity rates of 83.3% (105/126) for dermatophytosis, 100% (41/41) for pityriasis versicolor, and 97.6% (40/41) for cutaneous candidiasis. In dermatophytosis, factors significantly associated with positive MTB results included onset of presentation equal or less than a week (adjusted OR 5.26, p = 0.023) and high hyphal index (adjusted OR 8.24, p = 0.002). For dermatophytosis, KOH microscopy yielded a shorter time to identification, whereas for pityriasis versicolor, the VAT technique with MTB was faster. Among KOH‐confirmed cases, the VAT technique with MTB showed the highest positivity rate in pityriasis versicolor, followed by cutaneous candidiasis, whereas the positivity rate was lower in dermatophytosis.

Background: Data on the incidence of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) in Thailand, where high-risk HLA alleles are prevalent, remain limited. Existing prognostic scores, including SCORTEN, may not capture all mortality determinants. Objective: To estimate the incidence and identify factors associated with in-hospital mortality in adult patients with SJS/TEN in Thailand. Methods: We conducted a retrospective cohort study using the nationwide Thai National Health Security Office database. Adults hospitalized with SJS/TEN were identified by International Statistical Classification of Diseases, 10th Revision codes between 2017 and 2024. Cox regression with time-varying coefficients was used to examine mortality risk factors. Results: A total of 7237 incident cases were identified (83.9% SJS). Median age was 57 years (interquartile range 42-69), and 50.5% were female. The estimated incidence was 17.3/million (95% confidence interval [CI], 16.9-17.7), with a decline over time. In-hospital mortality was 4.1% for SJS and 15.5% for TEN. Independent factors associated with mortality beyond SCORTEN included invasive ventilation (hazard ratio [HR], 14.99; 95% CI, 7.08-31.75), liver disease (HR, 2.49; 95% CI, 1.13-5.46), renal disease (HR, 2.46; 95% CI, 1.96-3.04), and myocardial infarction (HR, 1.90; 95% CI, 1.19-3.04). Mortality risk also increased progressively with age (≥60 years) and varied by hospital type. Time-varying analysis showed that TEN, liver disease, and ventilation had the strongest early impact, whereas infections, particularly skin and soft tissue infections, emerged later (HR at day 28, 2.64; 95% CI, 1.37-5.09). Conclusions: The incidence of SJS/TEN in Thailand is high. Mortality is influenced by factors beyond established scoring systems, with effects that evolve over time.

Contemporary population‐based data on incidence trends and in‐hospital outcomes of pemphigus vulgaris remain limited, particularly in Southeast Asia. This study aimed to characterize incidence patterns and identify factors associated with severe in‐hospital outcomes. We conducted a nationwide retrospective cohort study using Thailand's national administrative health database from 2015 to 2024. Incident cases were defined using a two‐year washout period. Crude and age‐standardized incidence rates were estimated, and temporal trends were evaluated using Poisson regression. Hospitalization analyses were restricted to index hospitalizations. Severe in‐hospital outcomes were defined as a composite of in‐hospital mortality, invasive mechanical ventilation, renal replacement therapy, or shock. Associations with severe in‐hospital outcomes were evaluated using multivariable logistic regression, with sensitivity analyses accounting for repeated admissions using generalized estimating equations. A total of 2 542 incident adult cases were identified, corresponding to a mean annual incidence of 6.03 per 1 000 000 population. Incidence increased over time (adjusted incidence rate ratio 1.20; 95% CI 1.18–1.22), was higher with advancing age, and among females (female‐to‐male ratio 1.41:1). Increasing age‐standardized incidence rates suggested that the temporal increase was not fully explained by population aging. This trend was accompanied by increasing annual hospitalizations. Among 1 537 index hospitalizations, 8.1% experienced severe in‐hospital outcomes. Acute kidney injury, malnutrition, and infection were associated with severe in‐hospital outcomes. In sensitivity analyses accounting for repeated admissions, advancing age and cardiovascular comorbidity were also associated with increased risk. Pemphigus vulgaris demonstrates a rising incidence beyond the effects of population aging, accompanied by increasing hospitalizations and a growing burden of severe in‐hospital outcomes. These findings support early identification of high‐risk patients and appropriate clinical management.

Background: Dysregulation of the skin microbiome is implicated in acne pathogenesis. Objective: To evaluate the efficacy of probiotics in the management of acne. Methods: Searches were conducted in 3 databases through June 30, 2024. Clinical trials that compared probiotics with controls and investigated their efficacy in acne were included. Primary outcomes were standardized mean differences (SMDs) for the change from baseline to posttreatment in total lesion count (TLC), noninflammatory lesion count (NILC), and inflammatory lesion count (ILC). Secondary outcomes included Global Acne Grading System (GAGS) scores, Investigator’s Global Assessment, erythema, and sebum levels. Results: Thirteen studies comprising 18 study arms and 1453 participants were included. There were no significant reductions in TLC (SMD, −0.22; 95% confidence interval [CI]: −0.50 to 0.07; I ² = 75%), NILC (SMD, −0.20; 95% CI: −0.48 to 0.08; I ² = 72%), or ILC (SMD, −0.13; 95% CI: −0.34 to 0.09; I ² = 52%) with probiotics compared with controls. However, oral probiotics were associated with a significant reduction in GAGS scores (SMD, −0.47; 95% CI: −0.81 to −0.13; I ² = 67%) versus controls. Subgroup analyses indicated that this effect was most prominent in mild-to-moderate acne patients who received oral probiotics containing Lactobacillus species combined with other strains for a minimum of 12 weeks. Conclusions: Probiotics did not demonstrate a significant reduction in acne lesion counts. However, they were associated with improvements in acne severity as measured by GAGS scores. These findings should be interpreted with caution given the heterogeneity across studies and the fluctuating natural course of acne.

Background: Tinea corporis and tinea cruris are frequently misdiagnosed, and studies utilizing deep learning for their diagnosis remain scarce. Objectives: This study primarily aimed to develop a deep learning model trained on images from diverse clinical settings to distinguish dermatophytosis from non-dermatophytosis. A secondary objective was to compare its diagnostic performance with that of physicians. Methods: This retrospective diagnostic study analyzed clinical images of dermatophytosis (tinea corporis/cruris) and non-dermatophytosis (eczema, psoriasis, and lichen planus). Dermatophytosis was confirmed by the presence of hyphae, whereas non-dermatophytosis was diagnosed based on clinical and histological findings. The deep learning model utilized a multitask learning approach, integrating classification and segmentation. Adaptive weighting facilitated area-of-interest segmentation, improving attention to relevant features. Model performance was compared with physicians using a 20-image quiz from the test dataset. Results: A total of 1400 images (600 dermatophytosis, 840 non-dermatophytosis) from 580 Thai patients, predominantly with Fitzpatrick skin types III and IV, were analyzed. In the test dataset, the model achieved an AUC of 0.84 (95% CI: 0.80–0.88), a sensitivity of 0.80 (95% CI: 0.74–0.85), a specificity of 0.71 (95% CI: 0.65–0.76), an accuracy of 0.74 (95% CI: 0.70–0.78), and an F1-score of 0.71 (95% CI: 0.66–0.76). AUC values for deep learning, dermatologists (n = 15), and non-dermatologists (n = 11) on the image quiz were 0.80, 0.78, and 0.75, respectively. Conclusions: The deep learning model demonstrated effective diagnostic performance for tinea corporis/cruris in Asian skin types, performing comparably to dermatologists as evaluated using a 20-image quiz derived from the test dataset.

Introduction: Psoriasis and eczema are chronic inflammatory skin diseases. Environmental factors play an important role in the pathogenesis and exacerbation of both conditions. Objective: This study aimed to investigate factors associated with exacerbation in psoriasis and eczema and compare those factors between both diseases, with the aim of identifying the significant differences between the two conditions. Methods: A cross-sectional study was conducted on adult patients diagnosed with psoriasis and eczema. Demographic characteristics, clinical data, and aggravating factors were collected and compared between both groups. Demographic characteristics and clinical data were analyzed using descriptive statistics, while aggravating factors were analyzed by regression analysis. Results: A total of 280 patients participated in this study: 192 psoriasis patients and 88 eczema patients. In 97.3% of psoriasis patients and 99.7% of eczema patients, aggravating factors were reported during disease exacerbation. Mental stress and inadequate sleep were significantly associated with psoriasis exacerbation, while humid environment and dust were significantly associated with eczema exacerbation rather than psoriasis exacerbation. Conclusion: Internal factors, such as mental stress and inadequate sleep, have a greater influence on the worsening of psoriasis, whereas external factors, including humid environment and dust, have a more significant impact on eczema flare-ups than on psoriasis exacerbation.

Reactive pustular eruptions (RPEs) can manifest in a variety of conditions, including pustular psoriasis (PP) and adult-onset immunodeficiency syndrome due to anti-interferon-γ autoantibody (AOID). These RPEs can be attributed to different causes, one of which is genetic factors. However, the genetic basis for pustular skin diseases remains poorly understood. In our study, we conducted whole-exome sequencing on a cohort of 17 AOID patients with pustular reactions (AOID-PR) and 24 PP patients. We found that 76% and 58% of the AOID-PR and PP patients, respectively, carried rare genetic variations within the filaggrin (FLG) gene family. A total of 12 out of 21 SNPs on FLG had previously received clinical classifications, with only p.Ser2706Ter classified as pathogenic. In contrast, none of the FLG3 SNPs identified in this study had prior clinical classifications. Overall, these variations had not been previously documented in cases of pustular disorders, and two of them were entirely novel discoveries. Immunohistochemical analysis of skin biopsies revealed that FLG variants like p.Ser860Trp, p.Gly3903Ter, p.Gly2440Glu, and p.Glu2133Asp caused reductions in FLG levels similar to the pathogenic FLG p.Ser2706Ter. These results highlight rare FLG variants as potential novel genetic risk factors contributing to pustule formation in both AOID and PP.

Pustular skin diseases, with pustular psoriasis (PP) being the prototype, are immune-mediated diseases characterized by the presence of multiple pustules, resulting from neutrophil accumulation in the layer of epidermis. Sterile skin pustular eruption, like PP, is also observed in 20–30% of patients with adult-onset immunodeficiency syndrome (AOID) and anti-interferon γ autoantibodies (IFN-γ), leading to challenges in classification and diagnosis. While the mechanism underlying this similar phenotype remains unknown, genetic factors in relation to the immune system are suspected of playing an important role. Here, the association between human leukocyte antigen (HLA) genes, which play essential roles in antigen presentation, contributing to immune response, and the presence of skin pustules in AOID and PP was revealed. HLA genotyping of 41 patients from multiple centers in Thailand who presented with multiple sterile skin pustules (17 AOID patients and 24 PP patients) was conducted using a next-generation-sequencing-based approach. In comparison to healthy controls, HLA-B*13:01 (OR = 3.825, 95%CI: 2.08–7.035), C*03:04 (OR = 3.665, 95%CI: 2.102–6.39), and DQB1*05:02 (OR = 2.134, 95%CI: 1.326–3.434) were significantly associated with the group of aforementioned conditions having sterile cutaneous pustules, suggesting a common genetic-related mechanism. We found that DPB1*05:01 (OR = 3.851, p = 0.008) and DRB1*15:02 (OR = 3.195, p = 0.033) have a significant association with pustular reaction in AOID patients, with PP patients used as a control. A variant in the DRB1 gene, rs17885482 (OR = 9.073, p = 0.005), was observed to be a risk factor for PP when using AOID patients who had pustular reactions as a control group. DPB1*05:01 and DRB1*15:02 alleles, as well as the rs17885482 variant in the DRB1 gene, were proposed as novel biomarkers to differentiate PP and AOID patients who first present with multiple sterile skin pustules without known documented underlying conditions.