We report on a 66-year-old female with pyoderma gangrenosum. Since 1984, she had suffered from systemic lupus erythematosus and antiphospholipid antibody syndrome. Some red nodules and ulcers appeared on both of her legs in November, 2005. The nodules were diagnosed as pyoderma gangrenosum by skin biopsy. She was treated with combination therapy of corticosteroid and cyclosporine, which improved the skin ulcers. She then developed “cellulitis” on her right thigh in June, 2006, which was improved by antibiotics, however, the ulcers on her legs exacerbated, and the patient was admitted to our hospital. After the hospitalization, we continued the combination therapy. Thereafter, thrombocytopenia appeared, and cytomegalovirus were detected in white blood cells. The small ulcers healed concomitantly with an increase in the number of platelets and decrease of cytomegalovirus-positive white blood cells. The skin ulcers of both legs and her general condition were stable from March, 2007 with 15mg of prednisolone daily, but she had abdominal distention and oliguria since the end of November, 2007. Her general condition then suddenly exacerbated, and on January, 2008, she passed away. After autopsy, the intestinal involvement was diagnosed as pseudomembranous colitis.

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A 33-year-old woman noticed perniosis on the dorsal part of her hands in the winter of 2008, which disappeared the following Spring without any treatment. She came to our hospital in the Winter of 2009 with erythema on the dorsal part of her hands and swollen fingers. A blood examination revealed positive anti-nuclear antibodies (× 160, homogenous and speckled pattern) with lupus anticoagulant, anticardiolipin β₂GP antibody and IgG anticardiolipin antibody. The skin lesion was biopsied and showed no evidence of liquefaction degeneration and vasculitis. A lupus band test was also negative. Since there were no events of deep venous thrombosis, pulmonary embolism, stroke or pregnancy loss, she did not meet the criteria of antiphospholipid antibody syndrome (APS). She had no evidence of systemic autoimmune disease, which is recognized as an underlying disease of APS. She receives a low-dose of aspirin only and have had no recurrence of perniosis so far.

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A 75-year-old man had suffered from chronic renal failure, hypertension, diabetes mellitus, gastric ulcer, and myocardial infarction over several years. Imidapril-HCL and doxazosin mesilate therapy was begun one year previously. In addition he had taken 11 other medicines. He developed erosion of the oral cavity mucosa in August of 2008. After one week, coin lesions with erythema and erosion appeared on his trunk and limb. A biopsy of the involved glossa showed intra-epidermal bullae formation just above the basal epidermis. His serum was positive for anti-Deg 3 antibody (INDEX, 133). Therapy with 13 kinds of drugs was stopped, and prednisolone (PSL) 60 mg therapy was started. After ten days, only pigmentation of the previous lesions remained. He has presently stopped PSL therapy, but has never had a recurrence of these lesions. This case was assumed to be drug-induced pemphigus (DIP) based on clinical progress. There are 51 previously described DIP cases that had eruption of pemphigus which didn't have S-H groups in the structural formula of the contributory drugs. More than 70 percents of these drugs had active amide groups in their structural formula, like imidapril-HCl or doxazosin mesilate. Most of the eruption types were pemphigus vulgaris, varying from pemphigus foliaceus or pemphigus erythematosus.

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A 37-year-old female developed demarcated erythematous, sclerotic plaques with itching on her lower legs 6 years before her first visit to our clinic. She was treated with topical application of clobetasol propionate ointment, but her lesions did not show any improvement. Since the histopathological examination of biopsy specimens obtained from her skin lesions revealed necrobiosis of collagen in the dermis surrounded by histiocytes, lymphocytes and giant cells, the diagnosis of necrobiosis lipoidica was made. The values of FBS and HbA1c were within normal limits. During our treatment, she complained of arthralgia in her right toes and knee. Because biochemical examinations showed positive reactions for rheumatoid factor and anti-cyclic citrullinated peptide antibody, she was diagnosed as early rheumatoid arthritis. The skin lesions improved by treatments with oral administration of sarpogrelate hydrochloride, topical application of clobetasol propionate, and elastic compression stockings.

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A 69-year-old man, who got burned on the back of his head by falling down into an irori (Japanese hearth) at the age of 2, was referred to our clinic for the evaluation of bleeding on the burn scar. Physical examination revealed a 20×10 mm black ulcerated plaque and a discrete 3 mm black freckle at the center of the extensive burn scar on his parieto-occipital region. A biopsy from the larger plaque revealed them to be a basal cell carcinoma (BCC). Burn scar is a well-known pre-cancerous lesion. In a 24-year- period from 1985 to 2008, we experienced 31 cancers in 30 patients consisting of 28 SCCs and 1 each of BCC, malignant fibrous histiocytoma (MFH), and fibrosarcoma. SCC and MFH developed in one patient. Our review of the Japanese literature uncovered 14 BCC cases in 27 years. In the English literature, 412 cancers on burn scar including 293 SCCs and 48 BCCs were reported from 1923 to 2004. BCC developed on burn scar is relatively rare compared to squamous cell carcinoma (SCC), a most common cancer on burn scar.

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A 67-year-old man had a 3.5×4.5 cm soft subcutaneous mass in his posterior cervical region. He had no pain or tenderness. The lesion was excised with local anesthesia. Microscopically, the tumor was composed of a mixture of mature fat cells and CD34-positive spindle cells within abundant mucinous matrix with collagen fibers, some mast cells, and capillary vessels. Because of very striking myxoid changes (myxoid material was positive for Alcian-Blue) throughout most of the tumor, we diagnose this tumor as a myxoid variant of spindle cell lipoma.

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We report a case of Japanese spotted fever complicated with respiratory failure and disseminated intravascular coagulatino (DIC). A 65-year-old Japanese female had fever, headache, backache, and joint pain in all four extremities 5 days before her first medical examination. As general fatigue and nausea also developed, she visited the Emergency Department in our University Hospital and was referred to our department. A diagnosis of atypical measles was suspected because of high fever and rice grain-sized erythematous papules scattered on her whole body. After several days she experienced respiratory failure. Her blood examination showed leukocytosis and DIC, and a computed tomography image of her chest revealed pneumonia. A diagnosis of adult respiratory distress syndrome (ARDS) caused by infection was made, and systemic corticosteroid-and immunoglobulin-therapy was started in addition to cephalosporin and minocyclin. As a result of the combination therapy her symptoms improved rapidly. A PCR analysis detected genomic DNA of Rickettsia japonica in a crust obtained from her back lesions. Antibodies against spotted fever group Rickettsia were markedly increased in a paired serum examination. A final diagnosis of Japanese spotted fever complicated with respiratory failure and DIC was made. Cases of Japanese spotted fever are increasing in recent days, and the disease should be always considered as a differential diagnosis in cases of fever and erythematous rash.

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A 62-year-old man who had been taking zonisamide for 5 weeks, developed a generalized macropapular rash, followed by high fever, liver dysfunction, and eosinophilia. DIHS was suspected, and 30 mg/day of prednisolone was started on admission. On the tenth hospitalization day, the patient was moved to our hospital because of worsening of the rash. An examination revealed erythroderma, admixing a small number of pustules and scaling. Cervical lymphadenopathy was remarkable. Laboratory findings included marked leukocytosis, eosinophilia, and elevated ALT and AST. No significant amounts of viral DNA of HHV-6, HHV-7, and EBV were detected in the serum and total blood at four time points, and antibodies against HHV-6 were not elevated at six time points. In contrast, the CMV viral DNA concentration in the serum was increased to 460,000 copies / ml on day 23, and anti CMV IgG antibody was significantly elevated on day 37. A drug-induced lymphocyte stimulation test for zonisamide was positive (438.2 %) on day 58. Our case demonstrated the presence of DIHS in the absence of detectable HHV-6 reactivation, despite of frequent sequential and virological examinations.

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Pressure ulcers are important lesions that affect all branches of medicine, and the stage of the wound seems to correlate with the prognosis of the patient. To answer the question on whether the stage of a pressure ulcer correlates with the patients' prognosis, we have retrospectively surveyed 92 inpatients who had pressure ulcers at Fukuoka University hospital from March 2008 to August 2009. Surveyed points were age, sex, background disease, severity and consequences of the pressure ulcer as assessed by DESIGN-R. Cardiac disease (24%), malignant neoplasms (23%), cerebrovascular disease (21%) were the most frequent background diseases. Of all patients, 49% healed during hospitalization, 34% were discharged without healing, and 17% died without healing. DESIGN-R, a revised tool that enables quantitative evaluation of pressure ulcers, was utilized in the evaluation. The DESIGN-R score did not show statistical correlation with background diseases, age, or consequence. No statistical differences were observed between the first and last DESIGN-R scores in deceased patients. From these findings, we conclude that patients' prognoses can be estimated neither at the first observation of the pressure ulcer, nor by the longitudinal DESIGN-R scores.

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A total of 107 patients with pruritic skin diseases (mean age 52.1±19.0 years, male : female=45 : 62) who visited Kyushu University Hospital and other related institutions from May to December 2008 were enrolled and treated with bepotastine besilate twice daily for at least a week. A questionnaire survey was then conducted and analyzed for the clinical efficacy of the antihistamine in improving pruritus, daytime sleepiness, nocturnal sleeping time, and time to sleep onset. Improvement of daytime and nocturnal pruritus were 88.6% and 89.5% overall, respectively. The urticaria group showed significantly more improvement in daytime and nocturnal pruritus (94.3% and 97.1%, respectively), compared with the eczema/dermatitis group (87.2% and 89.4%, respectively ; p<0.05). Some patients (13.2%) complained of intolerable daytime sleepiness, but 64.3% of such “sleepy” patients wished to continue the use of the antihistamine, perhaps because of the high anti-pruritic efficacy in these patients (92.9%). Time to sleep onset was shortened in 27.2% of all subjects, but nocturnal sleeping time didn't change in 81.8% of patients. The antihistamine was effective for the control of pruritus in patients who had been treated with other antihistamines before examination as well as those who had not. High utility and patient satisfaction was demonstrated, as 79.4% of all subjects wished to continue use of this second generation, non-sedative antihistamine.

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We examined the usefulness of switching from concomitant treatment with maxacalcitol lotion (Oxarol^® Lotion 25 μg/g) and clobetasol propionate lotion (Dermovate^® Scalp Lotion 0.05%) to maxacalcitol lotion alone for sequential treatment in 20 patients with scalp psoriasis. The period of examination was divided into three parts : an introductory period (2-4 weeks), a transition period (4-6 weeks), and a maintenance period (4 weeks), for a maximum of 14 weeks. In addition, when improvement of skin eruption was achieved, the treatment was moved to the next step. In the introductory period, clobetasol propionate lotion in the morning and maxacalcitol lotion in the night were applied topically, each once daily. In the transition period, maxacalcitol lotion for weekdays and clobetasol propionate lotion for Saturdays and Sundays were applied topically, each twice daily. In the maintenance period, maxacalcitol lotion was applied topically twice daily. Compared with the onset of application, all of the evaluation periods featured significant improvements in skin appearance scores, based on symptoms such as erythema, infiltration/thickening, and scaling, as well as total score (p<0.001 : t-test). The general rate of improvement in the maintenance period (final period) was 40.0%, corresponding to moderate or better improvement, and 95.0%, corresponding to mild or better improvement. Although the transition and maintenance periods exhibited tendencies toward slight increases in scores compared with the introductory period, they were not significant and could be maintained with maxacalcitol lotion alone. Overall, there were no local or systemic side effects of these lotions, and none of the patients discontinued participation in the study. From the results of this study, it was concluded that sequential therapy using maxacalcitol lotion and clobetasol propionate lotion was a useful treatment for scalp psoriasis.

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We used end-of-study patient questionnaires to evaluate the effect of drug administration guidance on drug adherence in patients given cetirizine hydrochloride powdered syrup (Zyrtec^® Powdered Syrup) for treatment of pruritic skin diseases. Patients were randomly assigned to one of two groups. Patients in Group 1 were told that they would be prescribed a pleasant-tasting powdered medicine that was well accepted by many patients. Patients in Group 2 were told only that they would be prescribed a powdered medicine. One hundred eight adults (48 male, 60 female) with pruritic skin diseases participated in this study, including 93 patients with eczema/dermatitis, 13 with urticaria, and 2 with prurigo. The mean age was 59±20 years (range : 18 to 92 years). Most patients reported taking the medication at bedtime or after dinner (Group 1, 83% vs. Group 2, 97%, P=not significant [NS]). In both groups, drug adherence status was good, with most patients (Group 1, 69% ; Group 2, 66%, respectively ; NS) reporting few missed doses. Pleasant, agreeable taste was cited as the reason for not forgetting to take the drug by 81% of patients in Group 1 compared to 40% of patients in Group 2 (p<0.05). Sleepiness disturbed daily life activities in 14% of Group 1 and 15% of group 2. In Group 1, 70% of patients described themselves as very much satisfied or satisfied with the drug, compared to 49% in Group 2 (p<0.05). Similarly, significantly more Group 1 patients wished to be prescribed the same drug for their next treatment, compared to Group 2 patients (59% vs. 32%, respectively ; p<0.05). No adverse events were reported. These results indicate that appropriate drug adherence guidance can increase the usefulness of cetirizine hydrochloride powdered syrup as a formulation for adults.

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The effectiveness of Itraconazole pulse therapy for onychomycosis is well known. In this study, we followed-up patients not only at the end of the pulse therapy but also for up to 6 months later, and conducted a questionnaire survey on their QOL and level of satisfaction. The QOL was assessed using the Dermatology Life Quality Index (DLQI). Of the 19 patients who started on Itraconazole pulse therapy, 15 were prescribed a third course of therapy, 13 visited our hospital in the third month, and 9 in the sixth month. The opacity ratio (1-10) decreased significantly from 5.8 at the first examination to 3.6 and 1.2 at 3 and 6 months, respectively. The overall clinical response rate of cure or complete response was 61.6% at 3 months, which increased to 88.8% at 6 months, indicating symptomatic improvement even after therapy discontinuation. Regarding the QOL, the symptoms and emotional state improved, with no significant difference between those evaluated at 3 and 6 months, and the overall QOL score was low, showing little impairment of the QOL. Although 30.8% of the patients felt that the cost of treatment was high, 76.9% were satisfied with the therapeutic effect, and 84.6% answered that they would choose Itraconazole pulse therapy the next time they received treatment for onychomycosis. All patients, except one, who were followed-up for 6 months achieved cure or complete response, and all were satisfied with the therapeutic effects. From these results, we conclude that Itraconazole pulse therapy is a very effective treatment for onychomycosis in terms of therapeutic responses and patient satisfaction.

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CM-N800 is a portable household iontophoresis product having four modes, including “anode” and “cathode.” To investigate its safety, clinical tests were performed for a month on 22 women. None of the subjects experienced adverse reactions that resulted in discontinuation of the trial. In addition, favorable moisturizing effects were noted in 17 out of 22 individuals.

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