A 27-year-old woman, who had been diagnosed with pustular psoriasis at the age of 5 years, was started on infliximab (IFX) therapy when she was 26. Thereafter, she maintained clear skin with regard to the psoriasis area and the severity index. This therapy was discontinued after the 16th IFX administration because she was pregnant. Starting at the 20th gestational week, when numerous pustules and edematous erythema arose, she received GMA/GCAP twice a week for a total of 10 times. With this treatment, her severity score improved from 11 to 5. Because her symptoms relapsed after delivery at 32 gestational weeks, GMA/GCAP was given again without a good response. However, the eruptions promptly improved in response to re-administration of IFX with pretreatment. GMA/GCAP is considered to be relatively safe and effective for pregnant patients. Meanwhile, because the effects of IFX on pregnant women remain unclear, planned pregnancies recommended and an IFX therapy regimen should be considered.
A 56-year-old woman with pemphigus foliaceus had been treated with a combination of steroid and calcineurin inhibitor for about ten years. She fell outdoors and injured her right knee. Her wound developed a rash and multiple subcutaneous nodules. We took a skin biopsy and found a cyst formation covered with a capsula fibrosa. Mycelia were identified by Grocott staining. Tissue culture and genetic analysis revealed a Scedosporium apiospermum infection, so she was diagnosed with deep cutaneous mycosis by Scedosporium apiospermum. We partially excised the subcutaneous nodules and treated her orally with itraconazole. The lesion began to contract. We concluded that the trauma triggered a local infection and that the lesion developed because she was in an immunocompromised state caused by prolonged immunosuppressive therapy.
Atopic dermatitis (AD) is a chronic inflammatory skin disorder with periods of flares and remissions. The long-term therapeutic concept for AD was conventionally based on daily application of emollients and symptomatic anti-inflammatory agents on demand, termed as " reactive" treatment, however long-term remission is difficult to achieve. Recently, " proactive" treatment has been suggested as a new therapeutic concept for the long-term maintenance of AD. We herein described adult patients with moderate to severe AD who were shifted from reactive to proactive treatment and compared their characters between successfully changed to proactive treatment and failed to be shifted one. 16 patients who had received reactive treatment applied corticosteroid ointment to eczematous lesions twice daily for 4-8 weeks. After the remission, the patients changed to proactive treatment applying tacrolimus ointment on the previous affected areas twice weekly for 12 weeks. 9 patients (56%) completed proactive treatment without severe relapse and their mean Severity Scoring of Atopic Dermatitis (SCORAD) during proactive treatment was lower than that during reactive treatment (20.2 vs. 14.8; P=0.008). 7 patients (44%) discontinued the treatment because of the relapse or irritation due to tacrolimus ointment. Mean SCORAD for 6 months during reactive treatment in completed group was 20.2, whereas 30.5 in discontinued group (P=0.005). As for the detail of SCORAD during this period, mean affected area and visual analog scale (VAS) of pruritus and sleep loss between continued and discontinued groups showed significant difference; mean affected area was 15.0±4.3% vs. 27.5±11.5 (P=0.028), mean VAS was 3.3±0.9 vs. 5.8±1.9 (P=0.012). These results indicated that proactive treatment with tacrolimus ointment is effective for better disease control and recommended for moderate AD patients who presented as mean SCORAD around 20, less than 20% affected area and less than 5 VAS.
The patient was a slightly obese 20-year-old male (169 cm, 83 kg). He noticed a walnut-sized erythema on the extensor surface of his right forearm one morning and found his smartphone connected to a plug on his bed. When he visited our clinic a week later, the erythema had expanded into a deep skin ulcer, 34.5 mm×26.0 mm in size, covered with a necrotic mass. The ulcer epithelized with six weeks of topical treatment, leaving a scar. The burn was assumed to have been caused by direct contact with the smartphone being charged or activated during sleep. A warning of possible thermal burn by smartphones was published by National Consumer Affairs Center of Japan in February of 2014.