Reflective practice (RP) plays a crucial role in encouraging learners to think critically and consciously about their performances. Providing constructive feedback can further enhance RP. But non-Western learners might face different learning barriers compared to learners in the West, where RP originated. In this retrospective study, we assessed RP and feedback performances on Thai medical students’ patient history-taking skills. We applied RP and peer feedback, along with feedback from the instructors, during the history-taking sessions of the ten-week introduction course for fourth-year medical students. Twelve history-taking sessions were used for the analysis. Two instructors assessed students’ reflective performance and categorised them into one of the six stages of Gibbs’ reflective cycle; their feedback performances were analysed using Pendleton’s model. We investigated the correlations between students’ overall grade point average (GPAX) and patient history-taking scores on the Objective Structured Clinical Examination (OSCE). Students’ opinions of the RP teaching method were also collected. All (n = 48) students participated in our study. The students’ mean age was 21.2 ± 0.5 years. The majority of the students were female (64.6%). The data indicated that 33 and 4% of the participants were categorised into the evaluation stage and action plan stage of Gibbs’ reflective cycle, respectively. In addition, 22 and 15% of the participants were able to state what their peers did well and suggest how peers could improve their skills, respectively. All students passed the minimum passing level of four history-taking OSCE stations. Participants agreed that RP was a useful tool (mean 9.0, SD 0.1), which enhanced their thought processes (mean 8.4, SD 0.2) and future performances (mean 8.2, SD 0.2). However, there was no correlation between the students’ highest Gibbs’ reflection levels and their history-taking OSCE scores. RP, together with feedback, proved to be a useful technique to help fourth-year Thai medical students improve their reflection skills, enhance their medical knowledge, and improve patient history-taking skills. Further study with longer monitoring is required to further explore negative and positive influential factors affecting students’ achievement of better reflection performances.

Background: Exosomes have gained attention for their potential in skin rejuvenation. Currently, most exosome products are available for topical administration, and the use of subdermal injection as a route of administration has not been approved. Aims: The purpose of this case report is to describe a case of skin necrosis that occurred following an intradermal injection of lyophilized exosomes. Materials and Methods: We hereby report a case of a middle‐aged man who experienced adverse effects after receiving an intradermal injection of lyophilized exosomes. Multiple injections of an exosome product were administered to treat enlarged facial pores. Shortly after the injection, the patient felt pain and noticed several dark red bumps. Three days after injection, the lesions transformed into palpable, painful, non‐blanchable purplish papules and nodules, accompanied by central, tiny crusted erosions. The residual product was injected into the upper arm using an intradermal method. Similar lesions also appeared, and a skin biopsy showed necrotic keratinocytes, leukocytoclastic vasculitis, and eccrine necrosis. Results: There are few reports available regarding complications, especially those related to intradermal exosomes. These complications include multiple foreign‐body granulomatous reactions at the injection sites. In our case, oral prednisolone was administered for a duration of 7 days. After the treatment, the lesions exhibited notable improvement, eventually leaving post‐inflammatory hyperpigmentation. Conclusion: Utilizing exosomes through unapproved methods should be avoided due to the possibility of adverse reactions that could cause aesthetic issues.

Acne vulgaris is a prevalent dermatological condition that is often treated with isotretinoin, a potent medication effective in moderate to severe cases. However, its use requires careful monitoring because of its potential hepatotoxic effects. Isotretinoin has been associated with transient elevations in liver enzyme levels, with mild abnormalities observed in up to 11% of cases. Severe elevations (grade ≥ 3), indicating potential liver dysfunction, occur infrequently, with an incidence of approximately 0.2% to 0.5%. The mechanisms underlying isotretinoin-induced liver injury involve oxidative stress and genetic susceptibility, primarily manifesting as idiosyncratic drug-induced liver injury. Most enzyme abnormalities occur within the initial months of treatment, and their clinical significance varies, with many cases resolving without intervention. A review of large cohort studies highlighted the incidence of abnormal liver function tests, including elevated alanine aminotransferase and aspartate aminotransferase levels. These abnormalities are often present within the first 3 months of therapy, particularly at higher cumulative doses. The role of routine liver function monitoring is debated, with recommendations favoring baseline and early follow-up tests and further testing guided by clinical indicators. Alanine aminotransferase may serve as a more specific marker for liver injury compared to other markers, such as aspartate aminotransferase. This review highlights the importance of evidence-based guidelines to balance effective acne treatment with the risk of isotretinoin-induced hepatotoxicity. Standardizing monitoring protocols and integrating genetic and oxidative stress markers may enhance safety and therapeutic outcomes. Further research is essential to refine these strategies and address gaps in long-term hepatotoxicity data.

Major identifiable causes of leukocytoclastic vasculitis include certain infections and medications. Amongst antithyroid drugs, methimazole (MMI) is rarely implicated as a culprit drug. We report the first case, in Thailand, of MMI-induced leukocytoclastic vasculitis in a 41-year-old Thai female who had received MMI for relapsed Graves’ disease. MMI was discontinued and cholestyramine at a dose of 4 g four times daily was given instead. Her rashes on both legs resolved dramatically at 1-week follow-up. However, thyroid function test revealed unimproved thyrotoxicosis. She subsequently underwent radioiodine ablation as a definitive treatment. There were neither recurrent skin lesions nor other systemic involvements during the 3-month follow-up period. Notably, the most crucial step in the management of drug-induced leukocytoclastic vasculitis is the discontinuation of the offending drug in order to avoid further progression of the disease. The administration of immunosuppressive agents may not be necessary in patients with mild severity and non-vital organ involvement.

Cutaneous malignancy is one of the leading causes of cancer-related morbidities and mortalities. Patient self-screening is helpful for early detection. Among educational pedagogies, game-based learning (GBL) has received increasing attention in recent years. We appraised the effectiveness of GBL, using Wordwall, to enhance cognitive performances pertaining to fundamental knowledge of cutaneous malignancies and perspectives on the intervention compared with a digital pamphlet. This multi-center study utilized a quasi-experimental research design and was conducted between February and April 2022. Participants were recruited and randomly assigned into a game group and a pamphlet group with a 1:1 ratio. Fundamental knowledge of cutaneous malignancies was assessed with pre- and post-intervention tests consisting of ten multiple choice questions with four alternative answers. These tests asked about prominent or pathognomonic features of cutaneous malignancies. During the five-day intervention period, recognition scores of participants in the game group were recorded. Perspectives on the interventions were also collected for analysis. A total of 94 participants were included, 60 (63.8%) were female. The mean age was 19.8 years (standard deviation [SD]=0.8). The increase in knowledge scores of the participants in the game group and pamphlet group was 2.57 (SD=1.30) and 2.36 (SD=1.52), respectively. In the game group, the mean best recognition score (13.89, SD=2.83) was significantly higher than the mean first recognition score (9.53, SD=2.48) with a p-value <0.001. The overall satisfaction among the participants in the game group and pamphlet group was 4.41 (SD=0.57) and 4.23 (SD=0.59), respectively. This study suggests potentiality of GBL to enhance knowledge and recognition performances of common cutaneous malignancies with high satisfaction. Embedding this approach in the primary prevention of cutaneous malignancies might be a promising option to prevent cancer-related morbidities and mortalities.

Melasma is a chronic, acquired hypermelanosis that primarily affects the face. Platelet-rich plasma (PRP) and tranexamic acid (TXA) are promising treatments for melasma. However, only a few randomized clinical trials have examined the efficacy and safety of combining these therapies for melasma. We aimed to compare the efficacy and safety of combining PRP and oral TXA with those of PRP alone in the treatment of facial melasma. A randomized controlled trial was conducted at Walailak University Hospital, Nakhon Si Thammarat, Thailand, between March and September 2023. Participants with mixed-type melasma were randomly allocated in a 1:1 ratio to either group A (PRP injection alone without placebo) or group B (PRP injection with oral TXA). Therapeutic efficacy and safety assessments were performed over a 12-week follow-up period. The study included 26 participants (mean age: 45.9 years, standard deviation (±SD): 5.0) who were predominantly female (84.6%). In group A, the modified Melasma Area and Severity Index (mMASI) scores significantly decreased from a median of 4.30 interquartile range (IQR): 4.10) to 3.60 (IQR: 3.10) between week 0 and week 12, respectively. In group B, the median mMASI decreased from 6.40 (IQR: 7.80) to 3.60 (IQR: 3.70) over the same period. The median change in mMASI scores in group B (2.90, IQR: 2.40) was significantly larger than in group A (0.90, IQR: 0.60) (p < 0.001, U = 160.50). However, there were no significant differences in the physicians' global assessment (PGA), melasma quality of life scale (MelasQoL) or patient satisfaction during follow-up. Four patients (15.4%) experienced transient erythema and swelling. In group B, 1 participant (7.7%) experienced transient mild gastrointestinal discomfort after receiving oral TXA. The combination of intradermal PRP injection and oral TXA is effective for melasma, even in patients with poor prognostic treatment response factors. No serious adverse reactions were observed in either group.