A 21-year-old man developed tiny wheals surrounded by diffuse erythema associated with tingling or irritation after exercise or emotional stress. He had a positive acetylcholine skin test with numerous satellite lesions and generalized punctate urticaria following exercise challenge. Hypohidrosis was also found by these challenge tests. Thus, the diagnosis of cholinergic urticaria with hypohidrosis was made. Histological examination revealed no abnormalities, including the number and structure of sweat glands and ducts. Treatment consisted of advice to take hot baths for 1 week, resulting in an increase in sweating and improvement of symptoms. This treatment can be an option for therapy of cholinergic urticaria associated with hypohidrosis that is not controllable by various drugs.

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A 53-year-old Japanese man presented with an approximately 3-week history of edema of both hands and fingers accompanied by pain and slight hemorrhagic erythema from the left thumb to the middle fingertips. The use of several analgesics or topical steroid therapy could not relieve these symptoms. Laboratory values obtained at the first visit to our department were abnormal, including hypereosinophilia (1748/μl). We made the tentative diagnosis of episodic angioedema with eosinophilia. However, after his first visit, he developed foot edema, livedo reticularis of the right ring finger, and bloody phlegm. The eosinophil count had greatly increased (7951/μl) and laboratory data indicated disseminated intravascular coagulation (DIC). A causative organism could not be identified despite examinations that included bone marrow aspiration. Finally, we assigned the diagnosis of hypereosinophilic syndrome (HES). We treated the HES with oral predonisolone (60 mg) and DIC with gabexate mesilate. Although it is difficult to make the diagnosis of HES at the first visit, it is important to list HES as a differential diagnosis when we see a patient with atypical edema of the hands, as in this case.

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We report a case of bullous pemphigoid associated with lung cancer who developed an autoantibody against desmoglein 3. A 65-year-old man was referred to our outpatient department. At the first examination we observed dry diffuse erythema on his trunk extending to the lower limbs and edematous annular erythema from his upper back to upper arms. Several pea-sized vesicles were scattered on the erythema. Histopathology of a vesicle revealed subepidermal blister formation. Indirect immunofluorescence staining detected circulating anti-basement membrane zone IgG antibodies. In addition,by ELISA,the patient was found to be positive against BP180 as well as desmoglein 3. We suggested that he should undergo an extensive examination of the entire body. As a result, the diagnosis of lung cancer (T1N3M0, stage III b, cytodiagnosis of squamous cell carcinoma) was made. We should consider the presence of an internal malignancy and development of autoantibody against desmoglein 3 in patients with bullous pemphigoid.

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We report two cases of cutaneous ulcer caused by application of povidone-iodine solution over a long period. Case 1: A 46-year-old man in whom erythema with bulla formation on an amputation stump of the right lower leg was diagnosed as herpes infection in June 2004 developed multiple ulcers after application of 10% Isodine^®solution and Cadex^®ointment over a period of two months. Case 2: A 72-year-old man who underwent an operation for phimosis in October 2005 developed an ulcer of the glans penis after application of Isodine^®Kizugusuri for a period of one month. In 48-hour closed patch tests with antiseptic and/or antibacterial agents and several topical applications, Isodine^® solution as is, Cadex^®ointment as is and U-Pasta^®ointment as is showed positive reactions in Case 1, and Isodine^® solution as is, 10% aq and Cadex^®ointment as is showed positive reactions in Case 2. In both cases, the positive reactions of povidone-iodine preparations on day 3 were stronger than those on day 2 and continued until day 7. We diagnosed both cases as irritant and allergic contact dermatitis and ulceration. When a cutaneous ulcer has not healed within a few weeks, patch tests with antiseptics should be performed.

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A 20-year-old man presented with deep wrinkles on his forehead and cheeks, cutis vertices gyrata of the scalp, clubbed digits, and bilateral painful joint swelling of the hands, ankles, and knees. There was no family history of similar symptoms. Clubbed digits were evident when he was in elementary school. Since the age of 16, he had been treated for polyarthritis in an orthopedic clinic. Examination of bone X-ray showed periosteal thickening of bones in the limbs and hands. Imaging analysis of the whole body showed nothing remarkable. From these findings, a diagnosis of primary pachydermoperiostosis was made. Anemia developed at the age of 25 years, followed by. thrombocytopenia at the age of 28 years. Examination of bone marrow aspirate revealed a dry tap. Bone marrow biopsy specimen was comprised of fatty replacement of marrow with little hematopoietic tissue. From these observations, aplastic anemia was suspected. Although anemia and thrombocytepenia initially improved with steroid therapy, blood values gradually worsened during tapering of steroid.

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In 1955, this 74-year-old man received Grenz-ray therapy for inguinal tinea. In 1995,an intractable ulcer appeared in his left inguinal region. The diagnosis was Bowen’s disease. In 2005, he noticed new small ulcer in the left inguinal region and a nodule on his left thigh; these lesions were diagnosed as squamous-and basal-cell carcinoma, respectively. This case suggests that various types of skin cancer may be attributable to Grenz radiotherapy after 50 years latency. We review the literature on skin cancers that developed after Grenz radiotherapy and discuss the relationship between exposure to Grenz rays and skin cancer.

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Case 1 was a 56-year-old Japanese male who noticed a nodule that had developed on the left scrotum. Case 2 was a 54-year-old Japanese male with a painless nodule within the scrotum. These nodules differed in appearance and were surgically removed. Microscopically, both tumors were comprised of interlacing bundles of smooth muscle cells and were identified as solitary genital leiomyomas. These patients had no signs of recurrence after surgery.

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The patient was a 67-year old man. A year previously, he had noticed a non-mobile subcutaneous nodule in his right thigh. Magnetic resonance imaging (MRI) showed a restiform shadow in the subcutaneous fat tissue. Peripheral blood studies revealed that the eosinophil count was within normal range. On biopsy, an ivory-white, flat, ribbon-like worm (plerocercoid larvae) was detected and identified as Sparganum mansoni serologically by ELISA. The restiform shadow observed by MRI was considered to be the worm body. With a migratory subcutaneous mass with eosinophilia, we have well-appreciated clues for a correct diagnosis of parasitic disease. However, the current case indicates that we must also consider sparganosis mansoni as a possible parasitic disease even in the case of a non-migratory subcutaneous mass with a restiform-or linear-like shadow in MRI findings.

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Case 1: A 26-year-old male who developed oral aphtae and genital ulcers was diagnosed as having Behçet disease by an internist and the systemic administration of corticosteroids was effective in July 2004. After he took Pabron^® S, PA^®, Dasen^®and Cravit^®, an itchy sensation in the genital area first appeared, and then ulcers in the genital area and an oral bulla appeared. He visited our department for treatment of dysphagia in October. Histopathologically, erythema of the penis shaft revealed a cleft of the epidermodermal junction and some necrotic keratinocytes. The results of a patch test using 30% Cravit^®in petrolatum at the lesional site were positive. We diagnosed case 1 as fixed drug eruption due to Cravit^®. Case 2: A 17-year-old male developed erythema with itching of the left thumb, right knee and genital area and oral aphtae in June 2005. One month after they had improved spontaneously, the same eruptions recurred and he visited our department. Although Behçet disease was suspected, interface changes and many necrotic keratinocytes in the epidermis of the folliculitis-like papule of the right knee were seen histopathologically. The results of a patch test using 30% Eve^®A in petrolatum at the lesional site were positive. We diagnosed case 2 as fixed drug eruption due to Eve^®A. In both cases, detailed medical examination by interview and histopathological findings were useful for diagnosis.

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This 77-year-old man had a subcutaneous tumor, 4 cm in diameter, at the flexor side of the upper left arm. He reported no pain or tenderness. Histologically, the tumor returned no pathological findings. MRI revealed that the long head tendon was absent between the tuberosities; the tumor showed the same signal intensity as the muscle. Consequently, a diagnosis of rupture of the long head tendon of biceps brachii was made. This should be included in the differential diagnosis of subcutaneous tumors on the upper arm.

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We analyzed varicella-zoster virus (VZV) DNA and RNA of gene 29 and gene 62 by PCR and RT-PCR, respectively, in the peripheral blood lymphocytes of 10 patients with herpes zoster who were admitted to Sapporo Medical University Hospital and treated by vidarabin (600 mg/day for 5 days). Among the 10 patients, 3 severe and one intermediate cases had a high titer (128 fold) by the complement fixation test and their blood lymphocytes contained VZV DNA and RNA. However, viral nucleic acids were not detectable on the 7th to 10th days after admission in any of the cases. These results showed that nucleic acids of VZV were detectable in patients with severe and intermediate herpes zoster in the early phase of the disease with a high titer on the complement fixation test and that 5-day-treatment by vidarabin might be effective for clearance of the virus.

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The efficacy of the macrolide antibiotic roxithromycin (Rulid^®: RXM) for acne was evaluated and compared with that of minocycline hydrochloride (Minomycin^®: MINO). Thirty-two patients aged over 16 years old with inflammatory acne were divided into two groups of 16 patients each. One group received a normal dose of RXM (300 mg/day) for two weeks and the second group received a normal dose of MINO (200 mg/day) for 2 weeks. Each group then received administration of the respective drugs at half the dose for the next 6 weeks. The number and severity of papules,pustules,nodules and cysts significantly decreased in both groups after treatment, and the level of improvement of symptoms was similar in the two groups. Forty-four strains of Propionibacterium acnes (P. acnes) were isolated from lesions, and the MIC₉₀of these strains was 0.2mg/l for RXM and 0.8mg/l for MINO. The susceptibility of P. acnes to RXM did not differ significantly from previous reports and the percentage of RXM-resistant strains was low. No serious adverse reactions were observed with either treatment. These results confirm that administration of a normal dose for 2 weeks followed by long-term administration of a half-dose is useful in treatment of acne.

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In recent years, itraconazole capsules and terbinafine tablets have become a common treatment for onychomycosis in Japan as well as elsewhere. Although there is much interest in determining which drug has superior efficacy, it is difficult to apply the results from comparative studies done in Europe and America to those of Japan because the dosage and administration are different. In this study, onychomycosis patients in 14 facilities were evaluated to compare the efficacy and safety of three treatments: itraconazole pulse therapy (400 mg), itraconazole continuous therapy (100 mg, 6 months), and terbinafine continuous therapy (125 mg, 6 months). Although the overall clinical results evaluated after 6 months of observation did not differ significantly among the three treatment groups, the itraconazole pulse therapy group had the highest cure rate with disappearance of nail opacity and negative mycological detection. Although no significant differences were observed among the groups in adverse event rates during the period of observation, the rate in the terbinafine continuous therapy group was the highest. The itraconazole pulse therapy group had a significantly higher treatment completion ratio compared with the 2 groups receiving continuous therapy. We concluded that itraconazole pulse therapy required shorter periods of treatment and higher rates of treatment completion, while the efficacy and safety of itraconazole and terbinafine were nearly equal in cases with treatment completion.

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