A 11-year-old boy visited our division due to aggravation of skin rash on the face after applying Almeta^® ointment. The patient had sharply defined edematous erythema from nasal to buccal region when he was examined. Patch test revealed positive reaction for alclometasone dipropionate, the active ingredient of Almeta^® ointment. A diagnosis of contact dermatitis due to alclometasone dipropionate was made. Patch test for other steroids external preparations revealed positive reaction for dexamethasone propionate, budesonide, hydrocortisone butyrate, and hydrocortisone butyrate propionate. These results were considered as cross-reaction.

View full abstract

A 16-year-old girl case of contact dermatitis due to using a commercially gummed sticker inside of the socks around bilateral lower limbs was reported. She visited our department of hospital on May 7th, 2002, because of complaining erythema with pigmentation and purpura around lower limbs accompanying with serous papules on the upper limbs and trunk for one week. She has no specific family history and no past history. Histopathological examination biopsied from the lower limb revealed mononuclear cell infiltration around the blood vessels in the upper dermis with exocytosis in the irregularly elongated epidermis. Patch test using the sticker showed positive reactions, whereas more detail patch test examination using each material was not able to be carried out. It is thought that scattered serous papules seen on the upper limbs and trunk occurred as id reaction or autosensitization. Blood examination revealed no abnormality except for leucocytosis (10,300/mm³), polycytemia (528×10⁴/mm³), and hyperimmunoglobulin E (950 IU/ml). This sticker made by Hakugen Co, Ltd (Tokyo, Japan) was consisted of complex jellymer of polyacryl sodium chloride/triethanolamine (CH₂·CH·COONa)n, (CH₂·CH·COON(C₂H₄OH)₃)n (5-15%) and ethylalcohol (10-30%), glycerin (less than 15%) and flavor with small amount of water.

View full abstract

A 19-year-old male visited our hospital with a week-long history of appetite loss and nausea. A diagnosis of diabetic ketoacidosis was made after physical and laboratory examinations. He also had had pruritic red papules with reticular pigmentation on his back for a week. Histological examination revealed superficial perivascular dermatitis with slight liquefactive degeneration. We considered that these signs indicated a lichenoid tissue reaction. On the basis of these findings a diagnosis of prurigo pigmentosa was made. Blood glucose levels decreased to a normal range after insulin treatment was started. However, the severe pruritus and the red papules did not disappear. Therefore, we administered minocycline to resolve the skin manifestations. We report herein a case of prurigo pigmentosa associated with diabetic ketoacidosis and review previous reports of Japanese patients.

View full abstract

In July 1998, a 26-year-old female visited us presenting skin lesions in both axillary areas, which appeared around the term of her first delivery and became worse gradually over a period of one month. She had dark red rice-grain sized papules with a scale-making annular arrangement in the axillary areas and military-sized papules at the flexor sides of her arms. Later she had military-sized pustules on her eruptions. A biopsy specimen revealed acanthosis with regular elongation of the rete ridges and subcorneal pustules, and she was diagnosed as pustular psoriasis at the time. Her skin lesions deteriorated and she was treated with 25 mg of oral prednisolone per day and PUVA. Both treatments had little effect and oral prednisolone was tapered. In June 1999, she was found to have periodontitis. After beginning dental treatment, no new eruptions appeared and oral prednisolone was stopped in May 2000. The eruptions recurred on her trunk and upper extremities in August 2001. She became pregnant with her second child in August 2002; since then pustules have appeared. She was treated only with corticosteroid ointments and the eruptions subsided. In May 2003, she delivered a low birth weight-child by Cesarean section and the skin lesions disappeared completely three months later. These findings strongly suggested a diagnosis of impetigo herpetiformis. Delivery of the low birth weight-child seems to be related to the severe impetigo herpetiformis she had from an early stage of the second pregnancy.

View full abstract

We reported on a 26-year-old woman with subcutaneous granuloma annulare revealing multiple nodules on the dorsal aspect of the right foot. One year before her first visit, some nodules developed on her right foot, and the number of nodules had been increasing. Eight firm nodules were seen in the plaque of the child's fist-sized erythema. We tentatively diagnosed them as venous stone or multiple follicular cyst. We examined four nodules histopathologically and all specimens showed degeneration of collagen fibers with mucin depositions surrounded by the infiltration of histiocytes and lymphocytes. Although the diagnosis of subcutaneous granuloma annulare was made, it was necessary to discriminate it from rheumatoid nodule because the serum level of rheumatoid factor of this patient was elevated.

View full abstract

Hydroxyurea is an antimetabolite agent used in the treatment of myeloproliferative disorders such as chronic myeloid leukemia (CML). However, the adverse effects of hydroxyurea rarely involve cutaneous ulceration but have been reported in a few patients during long-term therapy. We had the opportunity to treat such a condition in a 57-year-old male who had been diagnosed with CML since 1997. Immediately after confirmation of the diagnosis, he was given hydroxyurea at a dose of 1000-1500 mg/day for twelve consecutive months. Then he developed painful cutaneous ulcers on the lateral aspect of the left ankle joint and right foot. Accordingly, he was treated with several topical medications, but without improvement. To evaluate the etiology of the ulcers and proper management of the disease, the patient was referred to us and admitted to our hospital. Histopathological findings of a biopsy specimen taken from the lesion revealed infiltration of inflammatory cells into the deeper dermis. Furthermore, marked hyperplastic changes of blood vessels and collagen tissue were seen. No signs of any degenerative changes or vasculitis were observed. The above evidence indicated that hydroxyurea-induced cutaneous ulcers had occurred in this patient. In managing the disease, hydroxyurea therapy was abandoned and routine wound care with topical medications was provided for two months, at which time the lesions were completely healed. The ulcers did not recur during the next 42 months of follow-up while he was receiving interferon-α treatment for CML.

View full abstract

We report a case of low-grade sebaceous carcinoma showing local recurrences. The patient was an 85-year-old woman who presented with two yellowish nodules on her nucha. A tumor on her nucha had been resected two years ago in another clinic but had recurred twice. Local excision was carried out, but another local recurrence was seen three months later. Histopathologically, the tumor was architecturally well-circumscribed and somewhat symmetric, but the neoplastic cells showed mild to moderate atypia cytologically. Based on a newly proposed classification of sebaceous tumors, we diagnosed our case as low-grade sebaceous carcinoma.

View full abstract

A 74-year-old woman with a history of radiation therapy for cancer of the uterine cervix in 2000 is reported. Beginning in autumn 2001, a black lesion had been observed at the pudendum. Because the lesion had shown a tendency to expand, she presented at the Department of Dermatology at Fujisawa City Hospital on July 24th, 2002. A diagnosis of Bowen's disease was made based on skin biopsy. She came to our hospital for the purpose of surgical intervention on August 8th, 2002. At the first examination, a horseshoe-shaped, black plaque was seen from the bilateral labium to the perineum. Surgical procedures were performed in August and September 2002. Five months later, recurrence was noted and re-operations were performed in June and December 2003. However, a residual tumor was found and the patient currently is undergoing radiation therapy.

View full abstract

We report a 32-year-old male fisherman with Vibrio vulnificus (V. vulnificus) infection after a stingray injury. His chief complaint was swelling of the right dorsum pedis following the injury, causing sharp pain. Around noon on September 7, 2003, while fishing on the seashore of the Yatsushiro Sea, Kumamoto, the patient was stung on the foot by a stingray. Because of sharp pain, he consulted our emergency department where the wound was washed and disinfected. An antibiotic as well as adrenal cortex hormone and other medications were administered. On the next day, because the sharp pain had persisted and he felt very ill, he consulted us and was hospitalized. Gram's stain of humor from the wound was negative, but V. vulnificus and Vibrio parahaemolyticus were detected on culture. We diagnosed V. vulnificus infection after stingray injury and doubled the doses of IPM/CS, MINO, and immunoglobulin medication. Repeated cleansing with acidic electrolyzed water was performed. The patient was discharged without sequelae on September 25. His condition improved after a slight illness since there was no underlying disease and because an antibiotic was administered during the early stage along with washing and disinfecting the wound.

View full abstract

We report a case of congenital cutaneous candidiasis in a 2526 g female infant born at 37 weeks and 6 days of gestation without newborn asphyxia or muddiness of the amniotic fluid. Many scales and erythemas and some pustules were noted on her trunk and extremities at birth. Direct KOH examination of the scales revealed pseudomycelia and spores. Candida albicans was identified by slide cultures from the scales. Values for all examinations (including blood examinations, chest X-ray and ultrasound tomography) were nearly normal. She was treated with topical application of terbinafine hydrochloride cream. However, blood examination showed a slight elevation of CRP and β-D-glucan after one day. Therefore, she was intravenously administered fluconazole. She recovered completely without evidence of recurrent candidiasis.

View full abstract

A diagnosis of cutaneous tuberculosis is completed by verification of the existence of Mycobacterium tuberculosis at the lesion site by Ziel-Neelsen stain and/or a culture method such as the use of Ogawa medium. It usually takes a couple of weeks to identify acid-fast bacilli with these methods. Recently, DNA-DNA hybridization and the amplified Mycobacterium tuberculosis direct test have been used clinically as a new method for the rapid diagnosis of Mycobacterium tuberculosis. However, these methods are useless for cases in which culture methods are unsuccessful. Using the nested PCR method, we proved the existence of Mycobacterium tuberculosis in lesions of 4 cases of cutaneous tuberculosis, i. e., 3 cases of scrofuloderma and 1 case of tuberculosis verrucosa cutis. Furthermore, we determined the causative agents as Mycobacterium tuberculosis by sequencing amplified DNA products. We report, herein, that nested PCR with a direct sequencing method is an easier and more sensitive method than the currently used PCR method to identify the causative agents in cutaneous tuberculosis.

View full abstract

Among numerous cases seen at Keio University Hospital, several outstanding cases of the author's subspecialty, i. e. Japanese skin diseases, dermatomycoses, autoimmune bullous diseases and connective tissue diseases, were reviewed to let the readers know in what way they have contributed to the progress of Dermatology from the author's standpoint of view. Our case with eosinophilic pustular folliculitis (Ofuji) impressed us with the excellent effect of oral indomethacin that later was established as the first choice of treatment. Although DDS and minomycin are established as the choice of treatment, our case of prurigo pigmentosa (Nagashima) showed that it can be spontaneously curable. An isolate of Exophiala jeanselmei from the case of chromoblastomycosis has contributed a lot to the understanding of the classification and characterization of the black fungi. A child case of so called IgA pemphigus revealed that for the first time mucous membrane can be involved and has contributed a lot to the characterization of this new entity. Finally, a long standing observation of a patient with LE/SjS allowed us to know the relationship between annular erythema and anti-SS-A/SS-B autoantibodies. Further clinical studies using clinical material to understand the pathogenesis, to explore new diagnostic tools and to find out new treatment, will be expected.

View full abstract

[in Japanese]

View full abstract

The present state of the treatment of psoriasis at our clinic was reviewed, mainly in relation to cyclosporine (Neoral^®) therapy. Cyclosporine (Neoral^®) is confirmed to be effective in treating psoriasis, and it is, therefore, used by many medical institutions. Because cyclosporine (Neoral^®) therapy sometimes involves great cost, the optimal dosage regimen should be selected through good communication between the doctor and the patient, according to the severity of the patient's condition, age, duration of disease, occupation, and socioeconomic background. Therefore, it is desirable that cyclosporine (Neoral^®) is administered using a dosage regimen capable of reducing the economic burden on each patient while maintaining its therapeutic effectiveness, such as low-dose oral therapy and administration on alternate days.

View full abstract