We report a case of malignant melanoma of the right neck with lung metastasis, which was found 22 years after the primary lesion excision, lymph node dissection, and adjuvant therapy. A 47-year-old woman was given a diagnosis of malignant melanoma of the right neck in 1987, and underwent surgical excision and cervical lymph node dissection, as well as OK432 local administration. The tumor had a Breslow tumor thickness of 0.6 mm and was identified as pT1aN0M0, Stage IA. Since no local recurrence or metastasis were observed after a year, she stopped periodic follow-up examinations. Twenty-two years after the initial treatment, an abnormal shadow was detected by chest X-ray and PET/CT revealed a nodule at the posterior segment of the right lung (S2). A right superior lobe resection and mediastinal lymph node dissection were performed. Metastatic malignant melanoma of the lung and lymph node metastases were diagnosed by histological examination. No recurrence or metastasis have been found after 6 courses of DAC-Tam therapy. Because malignant melanoma can metastasize even after 22 years, it is necessary to carefully monitor patients with malignant melanoma.

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We reported three cases of minimal basal cell carcinoma (BCC) whose size were less than 2 mm in diameter. Case 1, a 45-year-old woman, presented with a small, black nodule, 1.5 mm in diameter, on her cheek. Case 2, a 79-year-old man, presented with a small, black nodule, 2 mm in diameter, on his cheek. Case 3, a 58-year-old man, presented with a small, black nodule, 2 mm in diameter, on the bridge of his nose. Each tumor was removed with a margin of 1-2 mm, which is narrower than usually recommended for treatment of BCC. All three tumors showed typical dermascopic and histopathological findings corresponding to solid type BCC. No recurrences have been observed for more than two years. Dermoscopic examination is useful for early diagnosis of BCC, allowing even minute BCC lesions to be removed when they are small.

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A 52-year-old man noticed a subcutaneous nodule on his left neck and the nodule was excised. Histopathological examination revealed that the tumor had been situated in the deeper dermis to subcutaneous tissue, and there were large and small cells with atypical nuclei in solid growth. On immunohistochemical examination, the tumor cells were positive for Melan-A, and HMB-45. We predicted that the tumor was metastatic melanoma. However physical examination revealed no lesion that suggested primary melanoma, and various imaging examinations revealed no metastatic lesion. We diagnosed this case as primary dermal melanoma (PDM). PDM has recently been described as a truly new variant of melanoma that is confined to the dermis and/or subcutis and histologically simulates a cutaneous metastasis. Moreover, most PDM patients have a better survival rate. In our case, we performed an expanding resection and lymph node dissection of the neck with subsequent postoperative chemotherapy. There has been no recurrence or metastasis for 54 months following the operation.

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We report a case of perianal Bowen's disease in a 61-year-old woman with a complete response to 5% topical imiquimod. She presented with a brownish plaque in the perianal area. A biopsied specimen showed epidermal hyperkeratosis, acanthosis, proliferation of atypical keratinocytes, abnormal mitosis and multinucleated cells, which led to the diagnosis of Bowen's disease. The lesion completely disappeared after application of 5% topical imiquimod three times a week for 8 weeks. No relapse was observed either clinically or histologically three months after the treatment.

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Two cases of Atypical fibroxanthoma are reported. A 75-year-old man had noticed a small hemorrhagic nodule on the left temple for about 6 months. It had enlarged rapidly over a period of a few months. A 68-year-old white man had noticed a reddish nodule, which had rapidly enlarged, on the top of his bald head. The histological examination of the resected tissues from both patients showed poorly margined tumoral lesions in the dermis and partly subcutaneous tissue. These tumors consisted mainly of atypical fibroblasts or histiocyte-like spindle cells, with scattered mitosis. Immunohistochemical findings revealed that tumor cells were positive for vimentin, CD10, and focally for CD99, and negative for cytokeratins, S100 protein, desmin and CD34. We diagnosed these cases as atypical fibroxanthoma based upon these findings. Both patients showed no findings of recurrence or metastasis. Although atypical fibroxanthoma is often difficult to distinguish histologically from other malignant tumors, immunohistochemical staining can be a helpful tool in the differential diagnosis.

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An 89-year-old man had a pain in the anus after he ate fish. He consulted a surgeon, and a fish bone was removed from his anus. A week later, he again had increasing pain in the anus. In spite of subsequent antibiotic therapy, his conditions became worse. Computed tomography showed a gas shadow in the perianal and right scrotal area. On admission to the emergency center of our hospital, he developed extensive erythema with severe swelling and necrosis around his scrotum. We performed surgical debridement with antibiotic treatment followed by colostomy six days later. He was discharged on the 90th hospital day with a small residual skin ulcer. Despite removing the fish bone, it was not possible to prevent the development of Fournier's gangrene. In this case, earlier admission with intensive care may have avoided the need for colostomy when a fish bone was found in the anus.

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A 79-year-old man with complete right bundle branch block underwent permanent pacemaker implantation in the left chest wall in 1989. In May 2010, erythema, swelling and purulent drainage appeared along the pacemaker leads site, which did not improve despite antibiotic treatment. Bacterial culture from the site yielded no growth. The pacemaker generator and leads were removed, and a new device was placed in the right chest wall. However, symptoms persisted and a new abscess appeared at the new pacemaker site. Since culture of a needle aspirate from the abscess revealed Mycobacterium abscessus, the entire pacemaker system was removed by thoracotomy and additional treatment was continued. Reports of pacemaker infection due to mycobacterium are extremely rare, but caution should be exercised in long-lasting and antibiotic-resistant cases.

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Japanese spotted fever and scrub typhus (Tsutsugamushi disease) are two representative forms of rickettsiosis commonly seen in Japan. We report a case of Japanese spotted fever and a case of scrub typhus, both of which developed at the same time of season. We focused on the differences in clinical manifestations and treatments between these two similar disorders. Case 1 : A 59-year-old woman admitted to our hospital with complaints of general myalgia, high fever and rash on August 2009. She had a mild fever with fatigue lasting for a week before the consultation. Examination identified two papules with central necrosis on her lower back. Disseminated erythema was observed on her trunk and extremities, including both palms. Lymphadenopathy was absent. A blood test showed elevation of C-reactive protein, thrombocytopenia and hepatic dysfunction. Since Japanese spotted fever was suspected, treatments with intravenous minocycline and oral levofloxacin were started. All the symptoms disappeared in 2 weeks following these treatments. Diagnosis was confirmed by the elevated titers of specific antibody in the serum against Rickettsia japonica. Case 2 : A 59-year-old man was referred to our department because of high fever and rash on August 2009. Examination identified a necrotic ulcer on his right back. Disseminated erythema was observed on his trunk and extremities but not in the palms. Computed tomography (CT) revealed generalized lymphadenopathy in the axillae, para-aortic and abdominal nodes. Under a tentative diagnosis of scrub typhus, he was treated with intravenous minocycline. All the symptoms disappeared in approximately 2 weeks by the treatment. A final diagnosis was made by the elevated serum levels of IgM specific for Orientia tsutsugamushi.

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A 77-year-old-female presented with a single painless, erythematous papule, which had appeared approximately three years prior to the visit. Although the lesion was treated with various topical therapies, an additional papule appeared followed by ulceration. A biopsy specimen showed an epithelioid cell granuloma and asteroid body. Moreover, a fungal culture identified Sporothrix schenckii. We diagnosed this case as fixed cutaneous sporothricosis. Two weeks after the patient was treated with potassium iodide, the lesion healed completely. After the treatment, no recurrence has been seen. We misdiagnosed this case, and sporotrichosis was not considered as a differential diagnosis at the first time. The reason was : (1) this case was the fixed cutaneous type of sporotrichosis, (2) recently, the number of the sporotrichosis cases has been decreasing in Japan. Based on our experience and due to the diversity of the clinical forms, sporotrichosis is considered to be a differential diagnosis for non-healing ulcer, erythematous plaque, or nodule.

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We report a 37-year old male presented erythematous swelling on his forehead with fever of 40 degrees. The patient had suffered no previous illness. Laboratory investigations showed consumptive coagulopathy with clinical manifestations of shock and development of renal failure. A rapid detection kit for the group A streptococcal antigen showed positive results from exudate in the necrotic area of the right eyelid, and we diagnosed him as toxic shock-like syndrome (TSLS). We administered penicillin and clindamycin and started plasma exchange and continuous hemodifiltration with intensive supporting care, leading to a successful outcome. TSLS is a life-threatening infection, but early diagnosis and appropriate therapy may reverse this threat. A rapid detection kit for the group A streptococcal antigen might be useful test for early diagnosing TSLS.

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We evaluated the efficacy and safety of fractional laser therapy for facial acne scars. 29 patients were treated with a 1550 nm erbium-glass fractional laser (Fraxel^® II, Solta Medical Inc. Hayward. CA). With the first pulse energy of 20-60 mJ, 2-7 treatment sessions (mean ; 3.9) were performed for each patient 4 weeks apart. The safety population, which completed more than three treatment sessions, included 21 patients. Clinical evaluation of the photographs that were taken before and after the treatment by independent dermatologists indicated marked efficacy in more than 80% of patients, including “very effective” in 29% (6/21) and “effective” in 52% (11/21). Similarly, patient satisfaction with this treatment was good, including “very satisfied” in 33% (7/21) and “satisfied” in 52% (11/21). Erbium-glass fractional laser showed excellent results for small scars, although only fair results for big and deep scars. Side effects were limited to transient postinflammatory hyperpigmentation in only one patient. We conclude that fractional laser therapy represents an effective and safe treatment for improving acne scars in Japanease patients.

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Add-on effects of calcipotriol (Dovonex^®) ointment on skin symptoms and adherence were assessed in 23 patients with chronic plaque psoriasis, whose disease improvement had not been adequate with topical corticosteroids. Objective skin symptoms were improved both at 4 weeks and 8 weeks. Approximately 60% of the patients recognized improvement at 8 weeks and 55% of patients answered that they began to follow doctors' directions more precisely, indicating that the improvement of the skin symptoms was due to improved adherence as well as the pharmacological efficacy. Sixty-seven percent of the patients showed satisfaction with adding the new topical therapy. Addition of topical calcipotriol to psoriatic patients who are not fully satisfied with topical corticosteroids is one practical way to improve the skin symptoms and adherence of those patients.

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