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Vitamin B12 deficiency causes skin hyperpigmentation, subacute combined degeneration of the spinal cord, and megaloblastic anemia. Although vitamin B12 deficiency rarely occurs in well-nourished, healthy, young people, nitrous oxide (N₂O) intoxication is an important cause of vitamin B12 deficiency in this cohort. N₂O, a colorless gas used as an anesthetic since the late 19th century because of its euphoric and analgesic qualities, is now used as a recreational drug and is available via the Internet and at clubs. Here, we describe the case of a 29-year-old woman presenting with skin hyperpigmentation as her only initial symptom after N₂O abuse for approximately 2 years. N₂O intoxication-induced vitamin B12 deficiency was diagnosed based on the skin pigmentation that had manifested over the dorsa of her fingers, toes, and trunk, coupled with myeloneuropathy of the posterior and lateral columns, a low serum vitamin B12 level, an elevated serum homocysteine level, and the N₂O exposure revealed while establishing the patient's history. Symptoms improved significantly with vitamin B12 treatment. We recommend that dermatologists consider N₂O intoxication-induced vitamin B12 deficiency as a potential cause of skin hyperpigmentation and myeloneuropathy of the posterior and lateral columns in young, otherwise healthy patients. Failure to recognize this presentation may result in inappropriate treatment, thus affecting patients' clinical outcomes.

Vitiligo is an autoimmune skin disease that has a major impact on the quality of life of patients. However, a nationwide study of the association between vitiligo and the incidence of inclusive psychiatric diseases has not been conducted in the Asian population. Therefore, this study aimed to analyze the association between vitiligo and the risk of psychiatric disorders using a nationwide database in Taiwan. Data were collected from the National Health Insurance Research Database of Taiwan from 2000 to 2013. In total, 1432 subjects with vitiligo and 5728 age-, sex-and index year-matched controls were enrolled in this study. Patients with vitiligo tend to have more coexisting psychiatric disorders than healthy individuals, regardless of their sex, age group and facility level of care. After adjusting for sex, age, comorbidity, urbanization and facility level of care, the adjusted hazard ratio of overall psychiatric disorders for patients with vitiligo was 2.926 (95% confidence interval [CI], 2.646-3.236; P < 0.001). Among them, the highest adjusted hazard ratios were found for obsessive-compulsive disorder, at 10.790 (95% CI,; P < 0.001). Vitiligo is associated with an increased risk of various psychiatric disorders. By providing a better understanding of the psychosocial burden associated with vitiligo, these results emphasize the need to evaluate the mental health of patients with vitiligo by treating physicians.

Recent studies revealed the risk of bullous pemphigoid (BP) in patients with diabetes mellitus (DM) taking dipeptidyl peptidase 4 (DPP‐4) inhibitors. To clarify the relationship between taking DPP‐4 inhibitors and the risk of BP among patients with DM, we conducted a cohort study by using the National Health Insurance Research Database of Taiwan from 1 January 2009 to 31 December 2015. We identified 6340 patients with DM taking DPP‐4 inhibitors and 25 360 DM patients who had not taken DPP‐4 inhibitors during the 7‐year follow‐up period. Compared with the non‐DPP‐4 inhibitor group, patients taking DDP‐4 inhibitors had a higher risk of BP (adjusted hazard ratio [aHR], 2.382; 95% confidence interval (CI), 1.163–4.883; P = 0.017]. Among the DPP‐4 inhibitors available in Taiwan, vildagliptin showed the highest risk of BP (aHR, 2.849; 95% CI, 1.893–4.215; P < 0.001), followed by saxagliptin (aHR, 2.657; 95% CI, 1.770–3.934; P < 0.001). Subgroup analysis revealed that the higher risk of BP was observed in patients older than 65 years (aHR, 2.403; 95% CI, 1.590–3.627; P < 0.001). This study revealed that treatment with DPP‐4 inhibitors, especially vildagliptin, was significantly associated with an increased risk of BP among DM patients.

Rosacea has been reported to be associated with psychiatric disorders. Nevertheless, a nationwide study of the relationship between rosacea and comorbid psychiatric diseases in an Asian population has not been conducted. The aim of this study was to clarify the role of rosacea in the various psychiatric disorders by using a nationwide database in Taiwan. Data were obtained from the National Health Insurance Research Database of Taiwan from 2000 to 2013. In total, 7881 patients with rosacea and 31 524 age‐ and sex‐matched controls were enrolled. Patients with rosacea tended to have more coexisting psychiatric disorders. After adjusting for age, sex, comorbidity and residence/regions, the adjusted hazard ratio (HR) of psychiatric disorders for patients with rosacea was 2.761 (95% CI = 2.650–2.877, P < 0.001). Among them, the highest adjusted HR are phobic disorder and obsessive–compulsive disorder of 7.841 (95% CI = 7.526–8.170, P < 0.001) and 6.389 (95% CI = 6.132–6.657, P < 0.001), respectively. The National Health Insurance Research Database of Taiwan does not include the information about rosacea subtypes, severity and laboratory parameters. In conclusion, rosacea is related to various psychiatric disorders. In addition to anxiety and depression, patients are also at increased risk of phobic disorder and obsessive–compulsive disorder.

Hidradenitis suppurativa (HS) has been reported to be associated with metabolic syndrome and coronary artery disease (CAD). Nevertheless, a nationwide study of this relationship in the Asian population has not been conducted. The aim of the present study was to clarify the cardiovascular disease risk factors, and the occurrence of CAD and cerebral infarction among patients with HS by using a nationwide database in Taiwan. We obtained data from the National Health Insurance Research Database of Taiwan. After adjusting for confounding factors, we used Cox proportional hazards analysis to reveal the risk of incident hypertension (HTN), diabetes mellitus (DM), dyslipidemia, CAD and cerebral infarction in HS patients. We identified 478 patients with newly diagnosed HS and 1912 patients in the control cohort during the 10‐year follow‐up period. Compared with the controls, HS patients had a higher risk of dyslipidemia (adjusted hazard ratio [aHR], 3.858; 95% confidence interval [CI], 2.785–5.346; P < 0.001), HTN (aHR, 1.910; 95% CI, 1.463–2.493; P < 0.001), DM (aHR, 1.709; 95% CI, 1.127–2.591; P = 0.012). Regarding comorbidities, our results also revealed a higher risk of CAD in HS patients (aHR, 2.722; 95% CI, 1.628–4.553; P < 0.001), but not cerebral infarction (aHR, 0.514; 95% CI, 0.119–2.231; P = 0.375). Our results indicate that there is a higher risk of dyslipidemia, HTN, DM and CAD in HS patients.

A n 80-year-old man visited our clinic with a two-day history of multiple painful, erythematous eruptions of the skin that had evolved into blisters with a linear distribution over his left flank. We diagnosed herpes zoster involving the left T11-12 dermatomes and prescribed oral famciclovir. The eruptions dried and healed in two weeks but were followed by a painless, reducible bulge, measuring 15 × 10 cm, in the left flank ( Figure 1A). The bulge became more prominent when the patient stood or coughed. Abdominal sonography showed no evidence of an intra-abdominal mass. Electromyography was consistent with denervation limited to the left lumbar paraspinal muscles (T11-12 myotomes). We diagnosed a postherpetic pseudohernia. After 10 weeks, the bulge had completely resolved ( Figure 1B).Herpes zoster is caused by reactivation of varicella-zoster virus, which usually involves a solitary posterior root ganglion and sensory nerve fibres. Its symptoms include pain, itchiness, sensitivity of the skin and rash in affected dermatomes.1 Clinically significant motor deficit is rare, although subtle involvement of the paraspinal muscles has been described in up to 35% of instances of thoracic herpes zoster.2 The pathogenesis may be related to direct spread of virus to anterior horn cells, ventral roots or both.Motor deficits related to infection with varicellazoster virus have also been described in the distributions of cranial nerves (e.g., Ramsay Hunt syndrome caused by herpes zoster affecting the geniculate ganglion), peripheral motor nerves (paralysis of limbs) and visceral nerves (dysfunction of the bladder). Most patients with pseudohernia after herpes zoster will recover in one year, without substantial sequelae. Clinical images Postherpetic pseudoherniaChih-Tsung Hung MD, Wei-Ming Wang MD PhD A BClinical images are chosen because they are particularly intriguing, classic or dramatic. Submissions of clear, appropriately labelled high-resolution images must be accompanied by a figure caption and the patient's written consent for publication. A brief explanation (250 words maximum) of the educational significance of the images with minimal references is required.