Checking the fungal elements using potassium hydroxide （KOH） direct examination is essential for the diagnosis and observation of the disease course of tinea unguium. Dermoscopy is also useful for observation. Treatment is either oral or topical administration of antifungal drugs. In Japan, most of the tinea unguium cases are caused by Trichophyton rubrum and Trichophyton mentagrophytes. In Japan, along with the rapid increase in the number of elderly people, studies have shown that the prevalence of tinea unguium increases with age. As the forerunning country in the world, we can prescribe the topical drugs 10% efinaconazole and 5% luliconazole for tinea unguium. We can develop new strategies against tinea unguium, but this topical treatment has a risk of nail discoloration. Thus, correct diagnosis of tinea unguium by dermatologists is important, and KOH direct examination is essential for not only diagnosis but also observation during treatment.

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The efficacy and safety of a combination topical gel containg calcipotriol/betamethasone dipropionate (Cal/BDP gel) and Cal/BDP combination ointment (Cal/BDP ointment) were compared in Japanese patients with psoriasis vulgaris. A total of 206 patients with psoriasis vulgaris were randomly assigned to the Cal/BDP gel group (n=101) or the Cal/BDP ointment group (n=105). Each investigational product was applied to two target lesions on the scalp and body once daily for 4 weeks, and improvement of the each lesions from baseline was assessed. The primary endpoint was the overall improvement (rates of subject defined ‘substantial resolution’ of clinical signs and/or at least ‘moderately improved’ in the general change of the lesion) for the target lesion on the scalp at Week 4. Impressions of the patients about the use of the medications (ease of application and stickiness) were also assessed. At Week 4, the overall improvement for the target lesion on the scalp was 97.9% in the Cal/BDP gel group and 96.0% in the Cal/BD ointment group, whereas the rates for the target lesion on the body were 80.9% and 95.0%, respectively. In terms of both “ease of application” and “stickiness”, Cal/BDP gel received significantly superior ratings compared with Cal/BDP ointment for the target lesions on both the scalp and body. All adverse reactions were mild in both groups. Thus, Cal/BDP gel demonstrated high therapeutic effect in patients with psoriasis vulgaris and was assessed as superior for use at hairy sites such as the scalp. Accordingly, it is considered that this topical gel product will improve adherence to treatment and show a superior therapeutic effect in the actual clinical setting.

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Yokuinin is an herbal medicine called kampo, which contains extract of Coix seeds, and is thought to modulate the immune response, making it effective for viral warts. Yokuinin is approved as both an over-the-counter (OTC) and prescription drug in Japan. Many commercial advertisements promote yokuinin for warts in Japan, and many patients with seborrheic keratosis, known as senile warts, ask dermatologists for a prescription. To determine whether its use is appropriate for treatment of seborrheic keratosis, approved indications for all formulations containing yokuinin were examined. The Igaku Chuo Zasshi and PubMed databases were searched for evidence of efficacy of yokuinin for seborrheic keratosis. Thirty-six prescription drugs and 172 OTC drugs were identified for assessment of indications. Among prescription drugs, two yokuinin extracts were indicated for verruca vulgaris and verruca plana juvenilis, and two makyoyokukanto formulations were indicated for warts. All 37 OTC drugs that primarily contained yokuinin were indicated for warts. Igaku Chuo Zasshi identified 453 manuscripts that discussed yokuinin and PubMed identified six. Three manuscripts mentioned both yokuinin and seborrheic keratosis, but none reported clinical evidence of efficacy for seborrheic keratosis. Based on these results, yokuinin is indicated for viral warts, but not for senile warts. Dermatologists should educate patients accordingly. Key words: Yokuinin, seborrheic keratosis, warts, indication, efficacy

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A physician-led clinical study was conducted to investigate the utility of tinea antigen detection kit, available for diagnosis of tinea unguium. We compared the results of microscopic inspection and those of investigated test kit. Both were performed on each of 126 enrolled patients who were either suspected of tinea unguium or who were recommended for differential diagnosis from tinea unguium. The concordance rate of the two tests, the primary endpoint, was 88.9%, showing sufficient clinical utility of the test kit. Participating dermatologists evaluated positively the convenience of the investigated kit and many regarded the test kit of being feasible and useful in actual clinical settings. As the use of topical antifungal agents have become more generally prevalent, greater accuracy in the diagnosis of nail tinea is called for. The investigated test kit seems to be able to be a supplement to microscopic inspection to improve the accuracy of the diagnosis, reducing patient burden, and yielding potential health economic benefits.

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A 55-year-old woman presented with a 2-year history of a painful nodule on her frontal scalp. The nodule gradually increased in size, and an increase in pain prompted her to visit our hospital. Physical examination revealed a dome-shaped, smooth-faced pink nodule measuring 10 x 8 mm in size. Dermoscopy showed prominent arborizing vessels against a pink background. The lesion was completely excised and histopathologically diagnosed as a cylindroma. Additionally, small dense collections of flesh-colored papules measuring 2-3 mm in size were seen on her forehead, nasolabial fold, and lower jaw. One of these was excised and histopathologically diagnosed as a trichoepithelioma. The papules did not seem to coincide with the site of a hair follicle but appeared to be milia-like cysts when observed using dermoscopy. The patient’s mother, a younger sister, two sons and a daughter related having the same symptoms and were diagnosed as having trichoepitheliomas based on assessment of a small papule present on her 29-year-old son’s face. Gene analyses from the proband and the eldest son showed a non-sense mutation in the CYLD gene, and a dominant mode of inheritance was indicated. Brooke -Spiegler syndrome is characterized by cylindromatosis with multiple trichoepitheliomas, and is a condition in which women are more severely affected than man. Long-term follow-up is necessary for this syndrome.

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