We present a case of chronic dermatitis in a 31-year-old woman. Initially, dermatitis appeared on the face followed by extension over the entire body. None of the treatments prescribed at the previous dermatological offices that she consulted was effective. As treatment, we tried shishi-hakuhitou, which is especially effective for dermatitis on the face and for relief of itching. In addition, Keishi-bukuryougan, a representative formulation for the symptom of “oketsu”, was tried. After two weeks of administration of these medications, there was great improvement in the dermatitis on the face and other sites, itching on the entire body and the symptom of “oketsu”. When we encounter a case of difficult-to-treat chronic dermatitis of unknown etiology in terms of Western medicine, Kampo medicine could be an effective therapeutic agent if typical symptoms of Kampo medicine are present.

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A 62-year-old woman presented with a ten-year history of recurrent hard nodules on the hands. Skin biopsy revealed calcium deposition in the dermis, and a diagnosis of calcinosis cutis was made. In addition, laboratory tests revealed positivity for anticentromere antibodies at a titer of 1: 163. Although the patient has not fnlfilled the clinical diagnostic criteria for systemic sclerosis, we consider that the calcinosis might be related to the eanly symptom of systemic sclerosis (limited type).

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We describe a 23-year-old woman with generalized pustular psoriasis during pregnancy. She had been diagnosed at 14 years old and began to be treated with cyclosporin at 17 years old. When she became pregnant at 19 and 22 years old, she had an abortion because of worsening pustular psoriasis. This time, she was 3 months pregnant and visited our hospital for her therapy during the pregnancy. After our explanation about the risks including defective development of the baby and exacerbations of psoriasis, we continued the administration of cyclosporine, based on her and her husband’s request. She had a normal male baby without any trouble. This case suggests that cyclosporin is one of optional therapies for patients with generalized pustular psoriasis during pregnancy when the therapeutic benefit exceeds the risk to the babies and mothers.

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A 66-year-old man had a 30×35 mm non-tender subcutaneous tumor on the occipital region. Findings of light microscopy revealed the nodule to have a cystic construction composed of two types of neoplastic cells: i.e., small, dark epithelial cells that tended to form palisades and to be situated at the peripheries of aggregations of neoplastic cells and large, pale epithelial cells, which tended to be situated within small, dark epithelial cells. On the periphery of the tumor nodule, aggregations of large ovoid cells with eosinophilic cytoplasm were recognized. Results of an immunological study using a panel of antibodies suggested that the tumor nodule was derived from the transitional portion of an eccrine duct and gland while the aggregations of large ovoid cells were derived from an eccrine gland.

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A 71-year-old man presented with a 3-year history of a nodule on the right palm. The lesion was an elevated erosive reddish nodule with a peripheral brownish pigmented macule, measuring 10 mm in diameter, mimicking granuloma pyogenicum. Excisional resection was performed and histopathological findings showed that the tumor was filled with spindle-shaped atypical cells in the dermis with melanin deposits in some parts. A pathological diagnosis of desmoplastic malignant melanoma was established by immunohistochemical findings that showed S-100(+), HMB-45(-), vimentin(+), cytokeratin(-), α-SMA(-), NSE(-). Chest X-P and computed tomography of the head, neck and chest revealed no evidence of metastasis to the lymph nodes or other organs. Classification of Stage II C (pT4b, N0, M0, tumor thickness 12 mm, with ulceration,UICC 2002) was assigned. Additional extensive resection and immunotherapy with interferon-β were performed. There has been no sign of recurrence or metastases in 10 months since surgery.

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A 66-year-old woman who had been diagnosed with left inguinal metastasis of malignant melanoma was referred to our hospital. She presented with a black nodule on her waist that appeared to have regressed spontaneously. Histologic examination revealed many nests of melanoma cells in the epidermis and upper dermis. No melanoma cells were detected in the area of transition to the clinically apparent area of depigmentation, although, interestingly, there were a number of dermal melanophages as well as the underlying melanoma nests. Adjacent to the melanoma on her waist, there was a giant congenital nevus (GCN), which had had a uniformly dark brown color since birth. Regression of the GCN occurred simultaneously with the discovery of melanoma. At the time of her first visit to our hospital, many small black spots on pale brown macula were evident. It was conceivable that an immune response to melanoma cells might cross-react with melanocytic antigen of GCN. She had systemic metastasis of melanoma in bilateral cervical lymphnodes, periaortic lymphnodes and left inguinal lymphnodes. The level of tumor marker 5-S-CD was very high. Excision of the primary lesion and cervical and inguinal lymphadenectomy were performed. Subsequently, DAC-Tam therapy was initiated. After three courses of chemotherapy, the involvement of periaortic lymphnodes disappered and the 5-S-CD level decreased to the normal range. Monthly administration of interferon beta was continued. As of this writing, no recurrence or metastasis has been noted for 15 months after cessation of DAC-Tam therapy.

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A 44-year-old woman had fallen, causing impairment of movement so severe that she could not walk or prepare food for herself and faced starvation. She was admitted to the hospital through the emergency department because of loss of consciousness. Necrotizing fasciitis on the right thigh associated with diabetic ketoacidosis was diagnosed. She was administered insulin and antibiotics, and she regained consciousness. Local findings were not improved. We performed surgical debridement for her necrotizing fasciitis. The operative examination revealed pyomyositis of the tensor fasciae latae muscle, and thus a silicon sump drain (Bird) was placed for continuous irrigation. Irrigation was performed for a week after surgery. Local findings and physical status were improved. We concluded that continuous irrigation is useful to treat pyomyositis associated with severe diabetes mellitus.

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We report a 58-year-old woman with necrotizing fasciitis who developed at the site of subcutaneous insulin injection. Diabetes mellitus due to Cushing syndrome was treated with insulin injection. Skin erythema, induration, warmth, and severe pain were detected on her left upper arm and abdomen, then the patient underwent surgical debridements because necrotizing fasciitis was suspected. Blood culture and cultures of the subcutaneous tissue obtained in the operating room yielded Streptococcus agalactiae. Local inoculation of Group B streptococcus by subcutaneous insulin injection was the likely portal of entry in this patient.

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A vegetating plaque developed on the posterior surface of the right ear lobe of a 71-year-old Japanese man 7 months previous to presentation. The vegetating plaque was accompanied by ulcer formation. The ulceration worsened at the time of each of several biopsies. Histopathological findings revealed pseudoepitheliomatous hyperplasia and the infiltration of neutrophils, lymphocytes and plasma cells into the dermis. The diagnosis of pyoderma vegetans was made. Oral administration of prednisolone at 40 mg/day was effective. But ulceration recurred after discontinuation of prednisolone administration. However, the ulcer dramatically improved within two weeks after oral administration of cyclosporine at 3 mg/kg/day.

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A 41-year-old man noticed painful erythema on his right lower abdomen. Similar lesions, discharging pus, appeared subsequently over his bilateral lower extremities and axilla during the last two years since his initial onset. Therefore, we diagnosed this patient as ectopic pyoderma chronica. Consequent surgical resection of those lesions successfully introduced a significant improvement towards this patient. However, a differential diagnosis of pyoderma gangrenosum, which can be comparable both by clinically and histologically with pyoderma chronica, initially led us to the standard regimens for pyoderma gangrenosum: i.e. oral betamethasone, salazosulfapyridine, cyclosporine; those medications failed to provide remarkable benefit for this patient.

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A 37-year-old woman had purchased “Saburon^® granules” in a drugstore one month ago and took it because of headache. Just after administration, she felt distress in her pharynx. Facial swelling, flushing over the entire body, and dyspnea caused her to consult a doctor of internal medicine. Her condition was diagnosed as anaphylactic shock. She was referred to our department for further examination. Aspirin intolerance was suspected, but none of the tests for aspirin intolerance was positive. She developed erythema on the trunk after she ate cinnamon bread in the hospital. This episode made us consider the possibility that her symptom was caused by cinnamon cortex, which is commonly contained in both cinnamon bread and Saburon^® granules. Skin tests were performed and led to the diagnosis of anaphylactic shock caused by cinnamon cortex.

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Recently, itraconazole pulse therapy (400 mg/day) has become standard therapy for tinea unguium because the drug concentration in nails remains above the MIC after completion of pulse therapy. Nonetheless, since replacement of the affected nails with new, intact nails is often incomplete by the end of this therapy, close follow-up is essential for reliable evaluation of the therapeutic outcome. We recently conducted a study in which patients rated as responders to this therapy at 6 months after the start of treatment were followed for a longer period of time (3 years) after completion of therapy to evaluate treatment outcome (cure or recurrence /relapse) at this time-point. None of the patients had recurrence or relapse later than 12 months after the 6-month assessment of therapeutic response. In all cases, the affected nails were completely replaced with new, intact nails by 18 months. Then these patients were retrospectively compared with patients treated with two other regimens using itraconazole therapy that were used before 400 mg/day pulse therapy was approved, i.e., 200 mg/day pulse therapy and 100 mg/day continuous therapy. The comparison revealed that 400 mg/day pulse therapy was more effective than either of the other two previously used therapies, particularly for severe tinea unguium.

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Cyclosporine A (CyA) is widely used for psoriasis, but it has adverse effect of hypertension, renal damage, and gingival overgrowth. We have tried telmisartan, an angiotensin II receptor blocker, to treat hypertension complicating CyA treated psoriasis. Ten patients were entried and 3 had no history of hypertention medication, and 7 had had preceding treatment with nifedipine and switched to telmisartan. Telmisartan was prescribed 20 to 40mg per day. In two out of 7 switched patients, blood pressure were upregulated after 4 weeks requiring addition of nifedipine, but controlled after 8 weeks. Average of serum creatinine levels were elevated after 4 weeks, but returned to the original level after 8 weeks. Nine patients had shown gingival overgrowth, and switching to telmisartan brought improvement in two patients. Improvement of gingival overgrowth was also obtained by dental treatment. Telmisartan is an effective antihypertension depressant and may help improving the gingival overgrowth caused by combination of CyA and nifedipine.

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Hyperkeratotic tinea pedis is intractable. Since complete remission by topical therapy with antifungal agents alone is difficult to secure, concomitant use of oral antifungal drugs is required in many cases. On the other hand, there are many elderly patients with hyperkeratotic tinea pedis, and physicians are often reluctant to use oral antifungal drugs because of problems with concomitant use of other drugs and side effects. Therefore, occlusive dressing techniques and combined therapy with urea ointment have been attempted, and 70-80% efficacy was reported. We examined the effect and safety of liranaftate cream combined with 5% salicylic acid ointment administered for 8 weeks in 16 patients with hyperkeratotic tinea pedis. In the clinical assessment of skin symptoms, prominent improvement was seen in 31.3%, moderate improvement in 31.3%, and slight improvement in 37.4% of the patients. As for the transition of the skin symptom score, we compared “scale” and “hyperkeratosis” and found a significant decrease in 8 weeks after. On the other hand, the score for “erythema” and “itching” hardly changed after treatment. The mycological improvement was 86.7%. When improvement of both skin symptoms and the results of fungus findings were considered for the overall evaluation of efficacy, the therapy was assessed as useful or highly effective in 81.3% of the patients. No side effects were observed in any patient during or after treatment, not even skin irritability due to salicylic acid ointment. Since salicylic acid ointment is also recommended for tinea pedis by health insurance providors, it seemed worthwhile to attempt its use as combination therapy with Liranaftate for hyperkeratotic tinea pedis.

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The efficacy and safety of application of camellia oil spray (Atopico^® Skin Health Care Oil) in conjunction with a conventional treatment for patients with atopic dermatitis was evaluated in a randomized controlled trial (RCT). A total of 39 patients with atopic dermatitis were enrolled in this study. The patients were assigned to two groups, one that applied purified water spray as a control for two weeks followed by application with camellia oil spray for two weeks, and one that applied camellia oil spray for two weeks followed by application of purified water spray for two weeks. There was no restriction of the frequency of the use of camellia oil spray. These procedures were performed without any modification in the routine treatment of any patients. No significant difference in improvement of the grade of clinical manifestations with the treatment was demonstrated. However, the results of a questionnaire regarding their impression of the treatment showed significant improvement (p<0.01). Efficacy of the treatment was evaluated in 71.8% of the patients. No adverse reactions were observed in any cases. These results suggest that treatment with camellia oil spray is useful for patients with atopic dermatitis.

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Reports on clinical efficacy and safety of generic medicines are scarce in Japan. This multi-center open-labeled collaborative study was conducted to investigate the therapeutic effect, safety and usefulness of Nedoril^® 125 mg Tablets, one of the generic medicines, for toenail onychomycosis. In 98 patients suffering from onychomycosis in the big toe with opacity ratio greater or equal to 5, the medicine was orally administered once a day for 24 weeks, and clinical findings (opacity ratio, thickening), mycological factor, compliance, adverse events and laboratory test values were recorded before and 4, 8, 12, 16 and 24 weeks after the administration. Of a total of 98 patients, 87, after exclusion of 11 who did not go to the clinic for personal reasons, were included in the safety analysis, and 79, after exclusion of 8 who stopped the study within 12 weeks for adverse events, were included in the therapeutic effect and usefulness analysis. The clinical improvement rate of the affected nail area was 84.8%, the total effect determined by the clinical improvement rate and the mycological effect was 74.4%, safety determined by the incidence of adverse events and abnormal laboratory test values was 88.5%, and usefulness determined by total effect and safety was 72.1%. These results suggest that Nedoril^® 125 mg Tablets is a highly useful therapeutic generic medicine for patients with toenail onychomycosis.

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