A 66-year-old man presented with a dark brown-colored pigment line on his right fourth fingernail for five months. The width of the line was 3.8 mm. The color and shade of the line varied from light to dark, and Hutchinson sign was not observed. Because of irregular lines in dermoscopy, we suspected malignant melanoma, and excisional biopsy was performed. Biopsy specimens showed that atypical melanocytes had formed small nests. A diagnosis of malignant melanoma in situ was made. A 60-year-old woman visited us because of a blackish brown-colored line in her right first toenail for two years. The width of the line was 5 mm. The line had some lightly colored parts. Excisional biopsy specimens showed proliferation of atypical melanocytes, and a diagnosis of malignant melanoma in situ was made. Subungual malignant melanoma in the early stage is difficult to diagnose. We are often at a loss whether to perform surgery or not. We propose an algorithm to distinguish subungual malignant melanoma from longitudinal melanonychia.

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A 40-year-old female patient presented with a history of first noticing eruptions on her back approximately 5 weeks before her initial visit to our hospital. Noticing that the eruptions were spreading, she first visited a nearby hospital. At her first visit to our hospital, she gave a history of having had similar eruptions on the arms approximately 5 years earlier. Although she had undergone workup and treatment, the cause of that eruption remained unknown. On examination, she still had depressed lesions from the earlier episode. She was referred to our hospital for treatment in June 2007. At presentation, she was found to have subcutaneous induration and swelling extending across the right side and center of her back, and tenderness and erythema with infiltration in the lower limbs. The results of laboratory examinations revealed significantly increased serum LDH and ferritin levels, as well as elevation of the serum transaminase (GOT and GPT) levels. Histopathological examination of biopsy specimens revealed a lobular panniculitis with prominent lymphocytic infiltration, and a bean-bag appearance of the cells. Immunostaining revealed that the lymphocytes were CD4 (-), CD8 (+), CD30 (-), CD56 (-), CD68 (+) and EBV (-), and based on the findings, the patient was diagnosed as having subcutaneous panniculitis-like Tcell lymphoma. She was initiated on treatment with prednisolone at the dose of 30 mg/day, which resulted in complete disappearance of the erythema on the lower limbs, gradual resolution of the subcutaneous induration on the back, and reduction of the swelling. On two occasions, when the dose of prednisolone was tapered to 10 mg/day, the serum levels of LDH and ferritin began to increase again and symptoms and signs, such as general malaise, subcutaneous induration and erythema reappeared. Five months have passed since her first visit to our hospital, and although she is still under treatment with 13 mg/day of prednisolone, no other cutaneous lesions have appeared and examinations have revealed no abnormalities in the general condition.

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A male infant aged six months was born with a gestational age of 37 weeks, weight 2,580g and an APGAR score of 8/9. He had been growing normally without any particular diseases. He suddenly came down with high fever, up to 39°C, in the first half of October 2005. Vomiting and erythematous lesions on his right thigh followed on the next day. Because his general condition was getting gradually worse, and the skin lesions extended all over the body, he was admitted to our hospital. Indurated erythema, hemorrhagic bulla, and purpura were seen on his whole body. The skin lesions gradually developed to form so deep gangrenous ulcers with necrosis that some portions of the muscles underneath were exposed. Blood and cutaneous cultures (both aerobic and anaerobic) were positive for Pseudomonas aeruginosa. He was diagnosed as septicemia and ecthyma gangrenosum by Pseudomonas aeruginosa. Respiratory and circulatory management, infusions, intravenous and topical antibiotics, debridements that was performed a total of six times, skin grafts, and hyperbaric oxygen therapy saved his life. He was discharged 92 days after the start of the treatment.

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A 23-year-old Japanese-Brazilian was stung in the right side of his trunk by an insect at a visit to Brazil in January 2008. About one and a half months later, an asymptomatic ulcer appeared on the same site. As a local physician had treated it in vain, he was referred to our outpatient clinic. The nodule with erythema on the right side of the chest was 5 cm in diameter, slightly elevated at the margin, and accompanied by an ulcer. Histopathologically, it showed the picture of a granuloma. A number of amastigotes were observed on a Giemsa staining sample from the tissue exudate. The polymerase chain reaction method and direct sequencing analysis identified the species as Leishmania (Viannia) braziliensis (L. (V.) braziliensis). Therefore, the diagnosis was made as cutaneous leishmaniasis due to L. (V.) braziliensis. A treatment with anti-leishmaniasis agents was planned, because cutaneous leishmaniasis due to L. (V.) braziliensis sometimes induces mucocutaneous leishmaniasis. However, the patient did not visit our outpatient clinic again, and no treatment was performed.

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Condyloma acuminatum is caused by mucous-specific types of human papilloma virus infection. Especially, Giant condyloma acuminatum is rare, and in many cases it is very difficult to treat. Zinc oxide starch powder mainly consists of Zinc oxide and starch powder. Zinc oxide provides 1) astringency, 2) a protective effect and 3) an antibiotic effect. Starch powder has an absorbent effect. So we proposed that Zinc oxide powder could change the moist environment in the genital region and that it could suppress a proliferation of virus that would lead to a decrease in the tumor size. Here, we report two cases of Giant condyloma acuminatum of the genital region that were effectively treated with Zinc oxide starch powder. A 20-yearold woman presented with a giant cauliflower-like tumor of the perianal region. She had had treatment with topical 5-fluorouracil for about 1 year. She also had been treated for SLE with corticosteroid. After 8 months treatment with topical Zinc oxide starch powder and administration of coix extract, the tumor disappeared with small scars. Also, a 38-year-old man was hospitalized with a giant cauliflower-like tumor on the penis and in the genital area. We also found that he had severe untreated diabetes. He used to be treated with podophyllin. A partial excision of the lesion was performed. After 7 months of topical application of Zinc oxide starch powder and administration of coix extract, the residual tumor collapsed. We propose that Zinc oxide starch powder is a good treatment option because it is 1) painless, 2) easy to handle by patients, 3) useable with other general treatment options, and also 4) inexpensive and commercially available.

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We report a case of malignant syphilis in a 32-year-old HIV-infected man who presented with a number of crusted papulonodular skin lesions scattered on his entire body, accompanied by fever and lymphadenitis. The serological test for syphilis, Treponema pallidum latex immunoassay, showed a positive result. A biopsy specimen from the right upper arm was histopathologically compatible with secondary syphilis and immunohistochemically positive for T. pallidum. Based on these serologic, histopathologic and immunohistochemical findings, a definitive diagnosis of malignant syphilis was made, which was successfully treated with oral antibiotics. Malignant syphilis should be considered when ulceronodular skin lesions are encountered in HIV-infected individuals.

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A 5-month-old boy presented with erythematous patches on the whole body 2 months after his BCG vaccination in the left deltoid area. Histological examination of the left upper arm revealed no epithelioid cell granuloma, but an eczematous reaction. A fite stain for acid-fast bacilli was negative. Cultures for bacteria, fungi and acid-fast bacilli from a biopsy specimen were negative. PCR for M. tuberculosis from a biopsy specimen was negative. Consequently, a diagnosis of tuberculid following BCG vaccination was made. Erythematous lesions had resolved after about 3 months with no therapy.

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A 78-year-old female with a complaint of increasing numbers of purpuric papules on her left lower limb for several days visited to our department. She had a history of herpes zoster in the same location which had been treated with systemic acyclovir injection and local anti-herpes ointment one week prior to her admission. Dermatological examination revealed multiple purpuric papules localized on the left lower limb in a linear pattern. A biopsy was taken from the lesions. According to the clinical and pathological findings, the diagnosis was vasculitis with epidermal necrosis. We present this case because of its rarity, both as a vasculitis with epidermal necrosis and its appearance in the area of healing herpes zoster, as well as moter neutron paresis, including muscle weakness and difficulty in walking.

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Thirteen cases of tinea caused by T. tonsurans that occurred at a clinic in Kumamoto during 4 years from May 2005 are reported. All patients were male, with ages ranging from 11 to 18 years. Eleven of them (3 junior high school students and 8 senior high school students) were Judo club members, one had a brother belonging to a Judo club, and one was an elementary school boy who participated in wrestling. The clinical types of the cases were tinea capitis in 6 cases (black dot type in 4 cases and inflammatory type in 2 cases) and tinea corporis in 8 cases (face in 5 cases, brachium in 1 case, chest in 1 case, and thigh in 1 case). One patient with tinea capitis had tinea corporis as a complication. All patients underwent hair brush tests. In the 6 cases of tinea corporis and tinea capitis that were found positive with the hair brush test, the organism turned negative within 2 to 3 months after treatment with oral terbinafine hydrochloride (TBF). Furthermore, upon examination of 125 members of the 7 groups to which the patients belonged, 15 individuals (12.0%) were found positive with the hair brush test. The treatment and management of the infection should be carried out in a clinic.

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Tethered cord is defined as a low state of the conus medullaris below the second lumbar vertebra. Tethered cord syndrome is a neurological disorder caused by an abnormal stretching of the tethered cord usually seen with growth. We report two cases of tethered cord syndrome associated with pedal hyperkeratotic lesions. The first case was a 64-year-old woman who presented with dislocation of the fifth toe and hyperkeratotic lesions on the right sole. A physical examination revealed a soft normal-colored tumor on the central lower back. The second case was an 82-year-old woman with a complaint of a clavus with malum perforans pedis on the right sole. Hypesthesia of lower extremities were observed in both patients. Magnetic resonance imaging of the spine demonstrated tethered cord syndrome, which caused disturbances of skin sensation. One must be aware that chronic foot lesions, even in older patients, can be signs of neurological disorders due to spinal abnormality such as the tethered cord syndrome.

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The efficacy of local treatment of refractory alopecia areata with squaric acid dibutylester (SADBE) undertaken at the Department of Dermatology of Dokkyo Medical University Hospital for the past 6 years was analyzed. The analysis included 152 patients (males : females= 65 : 87) with a mean age of 32.4 years (2-83 years). The pathological type was AA simplex in 9, AA multiplex in 100, AA totalis in 22, and AA universalis in 21 patients. The average morbidity period was 2.1 years. The therapeutic effect was “extremely effective” in 29 (20%) patients, “effective” in 63 (43%) patients, “slightly effective” in 35 (24%) patients, “ineffective” in 14 (10%) patients, and “unknown” in 4 (3%) patients. Thus, the treatment was “slightly effective” or better in 87.6% of the patients. The results of analysis of the therapeutic outcomes of local treatment of refractory alopecia areata with SADBE undertaken at our hospital are reported herein, along with the results of analysis of the delayed skin reaction to SADBE in patients with alopecia areata.

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Certain second-generation antihistamines are known to have the ability to suppress the production or release of substance P (SP) in addition to their antihistaminic capacity. Here we investigated the effects of olopatadine hydrochloride on plasma SP levels and circulating Th17 cell numbers as well as the clinical severity of atopic dermatitis (AD). Fifteen patients with AD were enrolled in this study and treated with olopatadine hydrochloride (5mg twice a day) for 2 weeks. Before and after the treatment, the clinical AD score was evaluated by a visual analogue scale (VAS) for pruritis and by atopic dermatitis scores (SCORAD) for severity. The percentage of Th17 cells was measured by flow cytometry after intracellular staining for IL-17. Significant reductions of VAS and SCORAD scores were observed after the therapy. The plasma levels of SP were significantly reduced after the administration of olopatadine hydrochloride. In 7 of 9 patients monitored, Th17 cell numbers were decreased, suggesting that Th17 cell numbers parallel disease activity. These findings suggest that the therapeutic effect of olopatadine hydrochloride for AD is related to plasma SP levels, and partly related to Th17 cell numbers.

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We performed sequential topical therapy with calcipotriol ointment (Dovonex^® Ointment 0.005%) and betamethasone butyrate propionate ointment (Antebate^® Ointment 0.05%) for 9 weeks in 19 patients with psoriasis vulgaris (PS) to assess the clinical usefulness of this therapy in terms of the symptom score and quality of life (QOL). During the induction phase of the sequential topical therapy, both drugs were applied twice daily for a two to four-week period. During the following transitional phase, calcipotriol ointment alone was applied on weekdays, while both of these drugs were applied twice daily on weekends for an additional two to four weeks. During the maintenance phase, calcipotriol ointment alone was applied for another two to four weeks. Skin symptoms were assessed using the score of the modified psoriasis area and severity index (PASI) scoring system, which excludes assessment of the face and head from the PASI scoring system, and a visual analog scale (VAS) score reported by the subjects. QOL in PS patients was assessed using the Dermatology Life Quality Index (DLQI Japanese version). The mean modified PASI score was 20.2 at baseline, was reduced by 60% to 8.1 on completion of the induction phase (P<0.01), and subsequently decreased over time to 4.4 on completion of the maintenance phase (a 78% decrease from baseline, P<0.01). The severity of skin lesions and itching measured by VAS also decreased significantly. Total DLQI score was 9.2 at baseline, and was reduced to 3.1 at the completion of observation (P<0.01) ; in particular, the aspects of symptoms and feelings, daily activities, and leisure were significantly improved (P<0.01). Neither local irritation nor abnormal changes in serum calcium levels were noted. The present study suggested that this sequential topical therapy for psoriasis vulgaris promptly improved skin symptoms, subsequently provided long-term remission, and improved QOL in terms of mentality, daily activities, and behavior.

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OBJECTIVE : To evaluate the efficacy of the H1-antihistamine, olopatadine hydrochloride in the treatment of acute and chronic pruritic skin diseases, and to determine the usefulness of decreasing ratio of visual analogue scale (VAS) values (VAS before treatment/VAS after treatment) as an early prediction tool of itch control. METHODS : One hundred and eighteen patients suffering from acute and chronic pruritic skin disorders such as atopic dermatitis (AD), eczema, and urticaria were treated with oral administration of olopatadine hydrochloride (5 mg, twice a day) for more than 2 weeks. Effectiveness of the treatment was evaluated by the ratio of VAS values before and after treatment. Satisfaction levels of the patients were also assessed by questionnaire. RESULTS : In all patient groups of AD, eczema and urticaria, over 50% of patients showed a decrease in VAS ratios to 30% and below at the first visit (within 2 weeks) after starting treatment with olopatadine hydrochloride. Increased satisfaction levels of the patients were also observed. When patients were divided into two groups (VAS value ratios over 30% or below 30% at the first visit after treatment), the mean VAS value ratio before treatment was not significantly different between the two groups. But when effectiveness of the treatment was evaluated based on individual decreasing ratios of VAS values at the first visit after treatment, a tendency of insufficient itch control was observed in the patients whose VAS value ratios were below 50%. CONCLUSIONS : These results suggest that olopatadine treatment shows effectiveness in pruritic skin diseases within 2 weeks. Our data also indicate that a decreasing ratio of VAS values might serve as an early prediction tool of itch control after H1-antihistamine treatment.

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