A questionnaire-based survey was administered via the Internet to clarify the actual status of mycological tests performed to diagnose tinea unguium. Physicians involved in the medical care for tinea unguium(dermatologists,general internists,and orthopedic surgeons)working at either general practitioner facilities(GP)or hospitals(HP)were asked about the number of patients diagnosed with tinea unguium during the previous month,the number of patients undergoing any mycological tests for diagnostic purposes,and the mycological tests performed,as well as the mycological test sample collectors and testers used,or the reason(s)for not performing mycological tests. The frequency of performing mycological tests to diagnose tinea unguium was extremely high(94-97%)among dermatologists. Among general internists and orthopedic surgeons,however,the rate was low(51-71%). The most commonly performed mycological test was microscopy in all departments evaluated. Mycological test samples were,for the most part,collected by the physician in the dermatology department. In the general internal medicine and orthopedics departments,however,approximately 40% of test samples were collected by the nurse or clinical laboratory technician. Microscopy was performed exclusively by physicians in the dermatology department at both GP and HP. In the general internal medicine and orthopedics departments,however,outsourcing to external test centers at GP and in-house laboratory tests at HP accounted for approximately 50% and 70% of tests,respectively. The most frequent reasons for not performing mycological tests included the “ability to diagnose by visual examination," “absence of mycological testing equipment," "long durations for mycological tests," and “no experience with mycological tests/no knowledge about mycological test methodology" in the general internal medicine and orthopedics departments. Emphasizing the importance of mycological tests and educating healthcare professionals regarding appropriate methods is necessary.

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We reported an-80-year-old female patient with pellagra due to insufficient food intake. One month ago she noticed erythema on the dorsum of her hands. No favorable response was observed with topical corticosteroid ointment prescribed at her former clinic. She had not been able to eat enough food for two years because of a heartburn symptom due to gastroesophageal reflux disease and had lost about 10 kg of weight. General fatigue，drift，and diarrhea continued for several months. When she visited our hospital，sharply-defined reddish-brown erythema with scales，crusts and erosion，characteristic of pellagra，were observed on the dorsum of the hands. Serum nicotinic acid level was at lower limits of normal value，and gastrointestinal symptoms，general fatigue and drift indicated the diagnosis of pellagra. After the oral administrations of nicotinic-acid amide，the eruption disappeared in approximately ten days，and her other symptoms improved in a few days. Among triad of pellagrous symptoms，dermatitis is extremely important for the diagnosis，while dementia and diarrhea have low specificity. Nowadays pellagra is only rarely observed in dermatological clinics. However，it is necessary to include pellagra as one of the possible diagnoses of dermatitis occurred on the exposed skin areas. Also，patients of pellagra are often under a hypoalimentation state combined with vitamins and/or zinc deficiency. After checking overall nutritional status in relation to pellagra，it is important to improve the alimentary condition with food，supplemented with vitamins，zinc and nicotinic acid.

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Sjögren’s syndrome is a disease characterized by involvement of the exocrine glands，such as the lacrimal glands and salivary glands，and is generally recognized as an autoimmune disorder with various other lesions also besides those of the exocrine glands. Various types of cutaneous lesions can be observed in Sjögren’s syndrome. Among the cutaneous lesions observed in primary Sjögren’s syndrome at our clinic in Dokkyo medical university，pernio，photosensitivity，Raynaud’s phenomenon，drug eruption，annular erythema，cheilitis and angular stomatitis are the most frequently found. The cutaneous lesions that are most strongly associated with Sjögren’s syndrome are annular erythema，hyper-gammaglobulinemic purpura，and an insect-bite-like erythema. Amyloidosis cutis atrophicans or anhidrosis，although rare，are closely associated with Sjögren’s syndrome. Moreover，pernio，photosensitivity，drug eruption，leg ulcers and gangrene are also sometimes seen in cases of Sjögren’s syndrome. Erythema nodosum and urticarial vasculitis are cutaneous lesions of Sjögren’s syndrome associated with fever. Systemic corticosteroid treatment is sometimes needed to control cutaneous ulcers caused by cutaneous vasculitis，gangrene，erythema nodosum，urticarial vasculitis，hypergammaglobulinemic purpura and annular erythema. In regular outpatient clinics，we must pay attention to the extraglandular lesions besides the cutaneous lesions in patients with Sjögren’s syndrome.

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