To investigate the influence of the warnings provided in the package insert of tacrolimus ointment for the treatment of atopic dermatitis (AD) , a survey on its actual use, including the use of topical corticosteroids, was administered to 363 physicians who were familiar with AD treatment in dermatology and pediatrics.

　As for the reason for drug selection, 98.1% (topical corticosteroids) and 60.1% (tacrolimus ointment) of the physicians recommended both topical treatments because "the effect is favorable" , while 21.2% (topical corticosteroids) and 73.2% (tacrolimus ointment) recommended the drugs because "fewer adverse events develop" . In terms of the cancer risk of tacrolimus ointment, 85.4% of the physicians considered it to be safe, but 19.6% had experienced patients' refusal to use it (or their parents) after an explanation of the cancer risk. With respect to the "accountability for warning of cancer risk" in the package insert, 73.5% of the physicians considered that it interferes with prescriptions, and 68.0% considered that it is disadvantageous for patients. This survey revealed that the "accountability for warning of cancer risk" of tacrolimus ointment prevents patients from having the opportunity to undergo effective treatment.

　A 55-year-old man, medicated with a dipeptidyl peptidase-4 inhibitor for type 2 diabetes, presented with itching rash on his whole body 7 years after a diagnosis of systemic lupus erythematosus. Hypereosinophilia and high serum levels of IgE and TARC were present. Histopathologically, the rash was chronic dermatitis. We diagnosed the patient as atopic dermatitis. The rash was improved by treatment with topical steroids and oral antihistaminergic medicine. Simultaneously, eosinophilia and increased TARC were also improved. In addition, anti-BP180 antibody was positive at the onset of rash although there were no blisters and a direct immunofluorescence test was negative. We speculated that Th2 activation might have been induced by the disease state of systemic lupus erythematosus and a dipeptidyl peptidase-4 inhibitor, which led to atopic dermatitis, as well as the appearance of the anti-BP180 antibody.

　A 6-year-old Japanese girl was referred to our department with recurrent episodes of anaphylaxis after ingesting ice cream sweetened with erythritol. We suspected an allergy to erythritol. The results of a skin prick test were negative, but an intradermal skin test and an oral food challenge test were positive, confirming an erythritol allergy. The skin prick test is often false-negative in patients with an erythritol allergy. Furthermore, erythritol is classified as a food, and not as a food additive. Information about erythritol is sometimes omitted when the content is low. Thus, erythritol can be overlooked as an allergen, but should be considered when patients present with recurrent episodes of unexplained anaphylaxis.

　Topical treatment insufficiently controls lupus erythematosus ; therefore, intensive treatments such as immunomodulative drugs are required. Here, we report two cases of intractable discoid lupus erythematosus (DLE) , in which treatment with topical tretinoin resolved symptoms. [Case 1] A 49-year-old man with erythema on his face and upper back was introduced to our hospital. He was diagnosed DLE with clinical symptoms and pathological findings. Treatment with topical steroids and tacrolimus was not efficacious. Therefore, we used topical tretinoin tocoferil, which reduced the disease severity and improved symptoms after 1 month. [Case 2] A 51-year-old man with symptoms of DLE on his scalp and face since 1980. He was diagnosed with DLE and Sjögren's syndrome. Systemic diaminodiphenyl sulfone, topical steroids and tacrolimus were not efficacious. After he began working outdoors routinely, his symptoms worsened. After the initiation of topical tretinoin tocoferil, the skin symptoms resolved, and the erosions disappeared.

　A 59-year-old woman had been treated for pemphigus vulgaris for over 20 years. Currently the treatment is with prednisolone 10 mg/day and azathioprine 100 mg/day. The symptoms were mild ulcers in the oral cavity and erosions on the eyelids. The patient had developed bladder inflammation symptoms, anemia and hematuria 2 years previously. Computed tomography revealed a left renal pelvic tumor and hydronephrosis. Tumor masses in the bladder were detected by both cystoscopy and magnetic resonance imaging. Transurethral bladder tumor resection and ureteroscopy were performed. Malakoplakia was diagnosed as there was some collection of histiocytes with Michaelis-Gutmann bodies. Urinary culture detected Escherichia coli. The bladder masses had disappeared and the size of left renal pelvic tumor had beenreduced by oral administration of antibiotics. We considered that the urinary tract Malakoplakia developed under an immunocompromised condition due to treatment of pemphigus vulgaris.

　An 89-year-old woman presented with fever, labial mucosal erosion and erythema on the trunk and extremities. The erythema was round and exudative. The patient had had a common cold before the symptoms appeared and Herpes simplex virus antigen was positive for the labial mucosa. The drug-induced lymphocyte stimulation test (DLST) was also positive for multiple medicines. Erythema exsudativum multiforme (EEM) due to HSV and/or a drug was suspected. The rash disappeared quickly after steroid pulse therapy followed by oral predonisolone (PSL) 40 mg/day. PSL was slowly tapered to 10 mg/day over several weeks when the rash recurred. A computed tomography scan demonstrated systemic lymphadenopathies. A skin biopsy test from the thigh revealed vacuolar alteration and a dense perivascular lymphocytic infiltrate in the dermis. An inguinal lymph node biopsy showed dense atypical lymphocytic infiltrate and a diagnosis of angioimmunoblastic T-cell lymphoma (AITL) was made after immunostaining. AITL should be included as one of the differential diagnoses when the clinical course of the case is not typical for EEM.

　A 74 year-old man, who was suffering from glaucoma, was treated with four ophthalmic drugs. As intraocular pressure increased despite treatment, Glanatec^® ophthalmic solution was prescribed in addition to the four drugs. One year later, physical examination revealed erythema and edema of the upper and lower eyelids, and erythema from the inner canthus to the nasolabial fold. Since contact dermatitis was suspected, the patient was admitted to our hospital. We performed patch and scratch patch testing for all five ophthalmic drugs. Only the Glanatec^® ophthalmic solution showed a positive reaction. After Glanatec^® ophthalmic solution was discontinued, the symptoms rapidly subsided. To further investigate, we performed patch and scratch patch testing for the ingredients of Glanatec^® ophthalmic solution. Only ripasudil hydrochloride hydrate, which is the active ingredient, showed a positive reaction. The patient was diagnosed as having contact dermatitis due to ripasudil hydrochloride hydrate contained in Glanatec^® ophthalmic solution.

　Immediate-type allergies caused by formaldehyde are rare but mostly severe, exhibiting general symptoms, while the time period between allergen exposure and onset is characteristically longer than normal immediate-type allergies. A 73-year-old woman, presented at her local dental clinic with a chief complaint of left maxillary tooth pain. The patient was diagnosed with acute suppurative pulpitis and underwent pulpectomy under local anesthesia. Five hours later, erythema and pruritus of the extremities appeared. After that, the patient repeatedly experienced mild fatigue during each session and visited our department 4.5 hours after the sixth session when erythema appeared in her abdominal region. Although 30 mg of prednisolone was administered, the erythema spread to her back and thighs, and blood pressure became unmeasurable. A prick test performed with formaldehyde, which was used at the initial consultation at the dental clinic and from the second treatment onwards, revealed a positive reaction. Formalin-specific IgE was class 4 (Index 36.90 UA/ml) , indicating a positive result. Thus, the patient was diagnosed with an immediate-type allergy caused by the formaldehyde contained in the root canal treatment. If anaphylactic symptoms appear after dental treatment, immediate-type allergies due to formaldehyde contained in root canal treatments should be considered.

　A 41-year-old Japanese female visited our clinic because of repeated erythema on her neck and chest, and facial swelling. A mild steroid ointment relieved the skin rash, but it relapsed after application of the ointment was stopped. Patch tests using Japanese standard allergens 2008 were positive for the fragrance mix, and patch tests of its components produced positive results for cinnamic aldehyde and cinnamic alcohol. These findings prompted the patient to tell us that she used to use essential oils in her daily life. Patch tests of all of the essential oils that she brought to our clinic produced positive results for lavender oil, an ointment containing lavender oil, organic cinnamon powder, and an oil containing cinnamon bark. The precise results for the lavender oil were as follows : 5% pet. and 10% pet. : positive ; 1% pet. and 2% : pet. : negative. The two main components of lavender oil, linalool and linalyl acetate, were negative on both patch testing and photo patch testing. We diagnosed the patient with allergic contact dermatitis due to essential lavender oil, which she had dripped on her pillow at night. We assumed that the sensitization of the patient's skin to lavender oil was caused by oxidized linalool and linalyl acetate, which appeared after air exposure.