An 85-year-old man was treated for psoriasis vulgaris by application of steroid ointment and administration of etretinate for 10 years. He visited our office three times due to erythroderma. On the first visit, we considered a focal infection based on an increase in white blood cells, neutrophils, and C-reactive protein. His skin condition improved after treatment with antibiotics and application of steroid and vitamin D ointments. On the second visit, he had to be admitted. Due to infection in the periodontal area, his teeth were pulled out, and he was treated for periodontal disease. He was also treated with application of steroid and vitamin D ointments. Subsequently, his general and skin conditions improved. On the third visit,he presented with periodontal disease and a painless inflammation of the gallbladder. After treatment of the periodontal disease with antibiotics and application of steroid and vitamin D ointments, the skin condition and the painless inflammation of the gallbladder improved. Subsequently, he continued to visit our office for treatment of periodontal disease with antibiotics,and external application of steroid and vitamin D ointments ; his skin condition has improved. Thus, we have reported a case of psoriatic erythroderma that improved after dental therapy and antibiotics. The importance of treating bacterial infections in psoriatic erythroderma should be recognized.

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Case 1: A 35-year-old female patient noted an annular hyperkeratotic plaque on her left cheek approximately 15 years prior to her visit. There was a parakeratotic column associated with a hair follicle in the plaque. Case 2:A 69-year-old male patient noted brownish hyperkeratotic plaques on the four extremities approximately 19 years prior to his visit. The number of plaques increased, and they appeared also on the abdomen. There was a parakeratotic column associated with a hair follicle in the plaque. We diagnosed these cases as porokeratosis with cornoid lamellae associated with hair follicles. Cornoid lamellation has rarely been reported to occur in infundibula or in acrosyringia, but in the two patients reported here, cornoid lamellae was clearly seen at hair follicles.

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Milia-like idiopathic calcinosis cutis usually occurs on the hands and feet of young patients with Down syndrome. We report on a 12-year-old boy with Down syndrome who presented with milia-like whitish small papules on his hands, feet and face. He also had palpebral syringoma, which often develops in Down syndrome. Histological examination of the hand lesions revealed localized, oval-shaped calcium deposits under the epidermis without cellular components. There was concomitant proliferation of epithelial cells similar to sweat ducts adjacent to the calcium deposit, suggesting that abnormal sweat ducts may be involved in the pathogenesis of this rare type of calcinosis.

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Fibrous hamartoma of infancy (FHI) is a relatively rare subcutaneous soft tissue tumor in children. We report on a 1- year-old girl with a fibrous hamartoma on the right upper arm. The subcutaneous tumor was first noticed at the age of 5 months and had grown gradually. When the patient was 11 months old, hypertrichosis was noticed on the tumor surface. The tumor had a diameter of around 17 mm and was elastic hard. The surface of the mass was smooth, and its movability was good. The surgical resection was performed when the girl was 12 month old. Histopathologically, an organoid structure was apparent, consisting of mature fat tissue and complicating fibrous trabeculae, as well as an increased concentration of immature mesenchymal cells. The histological diagnosis was fibrous hamartoma of infancy (FHI). Five years and nine months after the operation, no recurrence has been noticed. We suggest that FHI should be included in a differential diagnosis of subcutaneous tumors in infants.

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An 80-year-old man was admitted for severe anemia due to bleeding from a gastrointestinal stromal tumor (GIST). He also presented with multiple subcutaneous tumors on trunk and extremities. He was referred to us under a suspicion of neurofibromatosis 1 (NF1) because the association of GIST and NF1 is as high as 5 - 25%. However, he did not manifest any skin lesions suggestive of NF1. His son and grandson had similar subcutaneous tumors. In a histological examination, the tumors from the patient and his son were diagnosed as typical angiolipoma, allowing us to diagnose them as a rare familial angiolipomatosis. Angiolipoma is a common disease, but this case led us to a rare familial disease. Therefore, it is important to ask about additional family cases during interviews of patients with common diseases.

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A 62-year-old female who had noticed a tumor at the back of her head in 2005 visited our hospital after resection at the climic in June 2006 under a diagnosis of malignant melanoma (T4bN0M0, stage Ⅱ C), which was treated by expanding resection in July 2006. She was treated with DAV-feron chemotherapy three times. During follow-up, in July 2011,laboratory result showed increased 5-S-cysteinyldopa (31.5nmol /l), and an abnormal uptake of PET-CT was shown in the left deep cervical lymph node and in a part of an enlarged uterus. She was observed in the Gynecology Department of our hospital for multiple uterine myomas from July 2010, but magnetic resonance imaging revealed a new solid lesion in the left side of her uterus and enlarged uterine myomas after menopause. The patient underwent a total hysterectomy plus bilateral salpingo-oophorectomy in September 2011. Solid blackish masses were noticed in the myoma, and the final diagnosis was metastasis of malignant melanoma involving a uterine myoma. After she was treated with CDV chemotherapy for a total of three times after surgery, the serum level of 5-S-cysteinyldopa became normal, and the abnormal uptake of PET-CT disappeared completely at both neck and uterus. Although she did not have subjective or objective symptoms such as atypical genital bleeding, metastasis was revealed by increased 5-S-cysteinyldopa levels and diagnostic imaging, and she was successfully treated. In patients with melanoma it is important to pay attention to subjective symptoms and never miss signs of metastasis.

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We report a case of an 87-year-old female who presented with a swelling of her right leg associated with erythema, ulcers and secondary infection. She had been treated as a case of cellulitis by intravenous administration of antibiotics at a regional orthopedic clinic. However, the lesion was refractory and never showed an improvement, so she visited our hospital. At first inspection, irregularly shaped and moth-eaten ulcers covered with yellow necrotic tissue were present on her right leg associated with erythematous swelling and bad smell. Because the ulcers were refractory to various treatments, biopsy tissues were removed; the biopsy revealed findings compatible with those of malignant lymphoma. Further investigations,including immunohistochemical studies and radiological examinations, indicated peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS) as the final diagnosis. Since primary cutaneous PTCL-NOS is considered rare, we suggest that refractory leg ulcers should be carefully examined so that prompt and adequate treatment will be administered, especially for patients presenting similar complications caused by various disorders.

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A 45-year-old man was diagnosed with atopic dermatitis when he was 15 years old. He has received treatments intermittently but showed an insufficient response. He developed a tumor on his back six months prior to presentation in our hospital, and more tumors developed gradually. At his visit to our hospital, a physical examination revealed xerosis of his whole body, scaly erythema, pigmentation, many scratch marks, and four reddish nodules or tumors on his back and waist. Skin biopsy showed infiltration of large abnormal lymphocytes from the dermis to subcutaneous tissue. Immunohistochemically, the tumor cells were positive for CD3, CD4, CD30, and CD45RO, but were negative for CD8, CD20, and ALK. Southern blotting revealed gene rearrangement of TCR-Cb1. PET-CT and lymph node biopsy showed no evidence of extracutaneous disease. Based on these results, we diagnosed primary cutaneous ALCL associated with atopic dermatitis, and the patient was treated with local radiotherapy. The cutaneous lesions responded to this treatment. However, he developed swelling of neck lymph nodes and was subsequently treated with systemic chemotherapy (CHOP and ESHAP). The prognosis of PCALCL is generally excellent, with an average 10-year survival rate of 90%. Nevertheless, our patient died 21 months after we diagnosed him. We suggest that PCALCL in patients with severe atopic dermatitis has an aggressive clinical course.

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This case report describes a follow-up of a male patient who overcame 2 episodes of crisis type of chronic ATL. The onset was at end of October 1991, and the treatment at the Kumamoto University Hospital with recombinant interleukin-1β (rIL-1β) began in June 1992 under the diagnosis of crisis type of chronic ATL. The patient reached complete remission (CR) 5 months after beginning treatment, and all laboratory test values normalized within 10 months. The CR state was maintained for 13 years without any treatment for ATL. However, in November 2007, red papules and nodules on the extremities as well as lung disorder recurred ; the condition was again diagnosed as a crisis type of chronic ATL. Combination therapy with low doses of oral Sobuzoxane + Etoposide was started in March, 2008. The treatment provided excellent results for the skin and lung conditions, leading to CR of the ATL after 6 months. The patient was in CR even 2 years later, when he died of multiorgan failure secondary to pyelonephritis. The reason for the effectiveness of his treatment is unknown, apart from the fact that rIL-1β treatment was chosen instead of chemotherapy. Moreover, ATL cells had infiltrated intracutaneously, and an evident granulomatous reaction was apparent in both pre-treatment biopsies performed in 1992 and 2008, which might be important points to consider.

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The antimycotic drug liranaftate has been shown to have anti-inflammatory effects, but its mechanism of action is largely unknown. Many polycyclic aromatic hydrocarbons and other external chemicals bind to the cytosolic aryl hydrocarbon receptor (AhR), which is abundantly expressed in cultured human keratinocytes. Liranaftate induced nuclear translocation of AhR and nuclear factor-erythroid 2-related factor-2 (Nrf2) from the cytoplasm in the keratinocytes and upregulated mRNA for NAD(P)H : quinone oxidoreductase 1 (Nqo1) and Nrf2. TNFa-induced reactive oxidative species (ROS) and IL-8 production were effectively inhibited by liranaftate. Knockdown of AhR abolished liranaftate-induced Nqo1 and Nrf2 expressions as well as the inhibitory action on IL-8 production, suggesting an AhR-dependent mechanism of action. Additionally, liranaftate upregulated the mRNA expressions of skin barrier proteins such as filaggrin, loricrin and involucrin in an AhR-dependent fashion. These anti-inflammatory effects may partly explain the rapid and potent clinical efficacy against tinea by liranaftate.

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Sequential application of both tacrolimus ointment and heparinoid external preparation has been performed for atopic dermatitis treatment. There are, however, no data about the application order of these two preparations. The aim of this study was to examine the influence of application order of tacrolimus ointment and heparinoid external preparation on the tacrolims concentrations in skin. We applied the tacrolimus ointment (Protopic^® ointment 0.1%) followed to heparinoid external preparation (Hirudoid^® ointment, Hirudoid^® cream or Hirudoid^® lotion) on the dorsal skin of NOA/Jcl mice as an atopic dermatitis model, and vice versa. After 3 hours application, we measured the tacrolimus concentration in skin by LCMS/MS. No significant differences in tacrolimus concentrations were observed between tacrolims ointment application followed to heparinoid external preparation group and heparinoid external preparation application followed to tacrolims ointment group. This finding suggests that application order of tacrolimus ointment and heparinoid external preparation has no influence on the clinical efficacy of tacrolimus.

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Combination therapy with jumihaidokutoh (Shi-Wei-Bai-Du-Tang, JHT), a Chinese herbal extract preparation that contains cherry (Prunus jamasakura Siebold) bark and a topical antibacterial agent (clindamycin phosphate), was administered to 44 women with moderate to severe acne vulgaris for 12 weeks, while oral antibiotics were prohibited. The inflammatory skin eruptions showed an effect of at least “improved” in 34 patients, and a cumulative improvement rate of 77.3% was achieved. No adverse reactions due to the study drug were observed. Thus, the clinical usefulness of the combination therapy with cherry bark-containing JHT and a topical antibacterial agent was demonstrated. In order to elucidate the mechanism of action of the study drug, estrogen secretion from dermal fibroblasts was measured in response to water extracts of cherry bark and bokusoku (Xiang Shi, Quercus acutissima Carruthers) bark, which was used as a control. A marked production of 17 β-estradiol was observed with the cherry bark extract, but not with the bokusoku extract. This result suggested that one of the mechanisms of action of the cherry bark-containing JHT extract preparation is to antagonize the action of testosterone, an exacerbating factor of acne vulgaris, by inducing estrogen production in the local skin.

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