[in Japanese]

View full abstract

A 71-year-old Japanese man noticed some painful lesions on his ear and nose with fever in July 2010. He was diagnosed with relapsing polychondritis (RP) and oral prednisolone was commenced at 20 mg/day. While the amount of prednisolone was gradually reduced, he was diagnosed with disseminated non-tuberculous mycobacterial infection by Mycobacterium intracellulare in March 2012 and three-drug combination therapy was started. Despite this therapy, fever and skin eruptions appeared and he was referred to our Department of Dermatology in August 2013. He presented asymptomatic nodules on his neck, upper limbs, and trunk. Cultures of the skin lesions for aerobic and anaerobic bacteria, fungi, and mycobacteria were all negative. Histological findings of the nodules demonstrated diffuse neutrophilic infiltration with nuclear dust in the dermis without vasculitis. Thus, he was diagnosed with Sweet's syndrome. Soon after the diagnosis, a bone marrow aspiration revealed myelodysplastic syndrome (MDS). After the dose of prednisolone was increased, the skin eruptions improved temporarily. However, after that he had recurrent flares of multiple invasive erythematous plaques and nodules on his face,neck, trunk, and extremities and he died following respiratory dysfunction in January 2014. Although three different types of skin eruptions occurred during only four months, histological findings of all the biopsies showed dense neutrophilic dermal infiltration which is typical of Sweet's syndrome. We report here a case of Sweet's syndrome in a patient with RP and MDS.

View full abstract

A 35-year-old woman presented a 7-year history of indurated painful erythematous lesions on the leg. A histopathological examination revealed necrotizing vasculitis and thrombosis of small muscular arteries in the subcutaneous tissue. Fibrinoid degeneration was observed with infiltration of lymphocytes and histiocytes in and around the vessel wall of the affected artery,which was found to have a clear internal elastic lamina by Elastica van Gieson staining. Laboratory and systemic abnormalities were absent, leading to the diagnosis of cutaneous polyarteritis nodosa. We treated her with an oral non-steroidal anti-inflammatory drug, diaminodiphenyl sulfone, together with vasodilators and prednisolone without any beneficial effects. However, after she started to drink Bidens pilosa (B. pilosa) tea, the skin lesions were much improved without any recurrence. B. pilosa tea is recognized as an effective remedy for livedo vasculopathy. We recently demonstrated that the antioxidant-rich B. pilosa extract decreases reactive oxygen species and increases nitric oxide in human dermal endothelial cells. B. pilosa tea may be a useful adjunct for the treatment of microcoagulopathy in cutaneous polyarteritis nodosa.

View full abstract

We report a case of Buerger's disease that was effectively treated by a sympathetic block using clipping. A 67-year-old Japanese man, who was a heavy smoker, experienced episodes of Raynaud's phenomenon in the first and second fingers of his left hand, induced by cold and warm stimuli. Examinations performed at a local hospital, such as blood test and contrast-enhanced computed tomography (CT), revealed no abnormal findings. Thereafter, he visited our department. Digital subtraction angiography revealed arterial stenosis in the left radial artery, which led to a definitive diagnosis of Buerger's disease. As specialists indicated neither percutaneous transluminal angioplasty nor distal bypass, we confirmed the safety of CT-guided thoracic sympathetic ganglion block administered by a pain clinician. We noted skin temperature elevation on thermography but no side effects such as Horner's sign. As no side effect of the sympathetic block was observed, we prescribed respiratory surgery with an endoscopic thoracic sympathectomy (ETS) to block the sympathetic nerve. An operation of ETS in combination with clipping was performed. The skin perfusion pressure of the left radialis indicis was elevated soon after the sympathetic block was established during operation. Buerger's disease tends to cause stenosis in the peripheral artery, resulting in the off-label indication of angioplasties. We encountered a case of Buerger's disease that improved after treatment with sympathetic block via ETS in combination with clipping, without any side effects. We evaluated the effectiveness of sympathetic block using clipping as an alternative therapy for Buerger's disease in an upper limb.

View full abstract

A 12-year-old boy riding a bicycle collided with a parked car during daylight hours in July and was found to have fallen on his face. He was diagnosed as having brain injury with a fracture of the frontal bone by a medical practitioner and also had ulcers and blisters on the both thighs. He was transferred to our hospital. He had hexagonal grille-shaped ulcers and blisters on the extensor surfaces of both thighs. The hexagonal grille-pattern of the ulcers and blisters matched the design of the manhole cover on which he had fallen. These findings suggested that he suffered from contact burns caused by the hot manhole cover. The burns included both superficial and deep dermal burns covering 4％ of his body surface area, with a burn index of 2. The wounds healed in one and a half months with conservative therapy, but a hypertrophic scar remained. The possible reasons why the wounds were deep are as follows. First, the patient had contact with a hot manhole cover on a summer day. Second, the contact continued presumably for one to two hours due to the disturbance of consciousness after his collision with a parked car. Third, his thighs directly contacted the manhole cover because he wore short pants.

View full abstract

A 47-year-old man noticed progressively increasing yellowish-orange pigmentation of the palms and soles since 2012. He had no appreciable disease in his past history or family history. At the initial visit, the physical examination also revealed yellow-orange discoloration of his face including upper and lower eyelids. The bulbar conjunctivae were not yellow and he had no hepatic dysfunction. He began to drink vegetable juice in 2010, and has been drinking it more than 900 ml daily since 2011. We considered this case as carotenosis caused by excessive intake of large amount of carotene containing juice due to the history. Although carotenosis is usually revealed yellow discoloration of the skin most commonly seen on the palms and soles, it can also appears on the face that has amount of subcutaneous tissue. Carotenaemia usually has yellow skin without of any other systemic symptoms, but it is known to be accompanied by medical disorders such as diabetes, hypothyroidism, renal dysfunction and anorexia nervosa and we should pay attention to them.

View full abstract

A 71-year-old man was referred to our department due to a painful nodule on the left temporal area. The tumor had been increasing in size for 7 years since its onset. Physical examination revealed a dome-shaped reddish nodule measuring 1.5 cm in diameter on the left aspect of the scalp. There was also a smaller reddish nodule with a peculiar appearance in the same region. Histopathologically, the specimen from the larger nodule showed a nodular lesion composed of multiple basophilic nests surrounded by basaloid cells and with an eosinophilic hyaline sheath between the nests in the whole dermis, forming a so-called jigsaw puzzle structure. Based on these characteristic findings, a diagnosis of cylindroma was established. The smaller reddish nodule showed pathological findings compatible with senile angioma, but the clinical manifestation was not typical in view of its size. Although he had no familial history of specific skin tumors including cylindroma and adnexal skin tumors, the possibility of Brooke-Spiegler syndrome (BSS) was considered because of his past history of parotid gland tumor. In the Japanese literatures, there have been reports of some sporadic cases of BSS who had cylindroma accompanied with other adnexal tumors, parotid grand tumor or lung cancer. These observations may suggest that sporadic cases of cylindroma might have a localized or systemic mutation in the CYLD gene.

View full abstract

A 69-year-old man was referred to us with a 6-month history of a projecting lesion on his back, which had been suspected to be a malignant fibrous histiocytoma based on the results of a needle biopsy. Histopathologically, at the time of a wide resection, the tumor had a clear boundary between the tumoral component and the surrounding adipocytic component, and he was diagnosed as having dedifferentiated liposarcoma. However, reexamination of the case revealed no atypical cells suggesting liposarcoma in the adipose component. Immunohistochemically, the tumor cells were positive for cyclin dependent kinase-4, but negative for murine double minute-2 (MDM2). In addition, fluorescence in situ hybridization failed to reveal the amplification of the MDM2 gene, leading to the final diagnosis of undifferentiated pleomorphic sarcoma.

View full abstract

A 79-year-old man was referred to our clinic complaining of multiple dark-brown painful nodules on the right waist and hip. Four months prior to visiting our clinic, he experienced a severe trauma on this site due to falling after losing consciousness. A biopsy specimen revealed a diffuse proliferation of atypical epithelioid cells with a slit-like appearance and extravasation of red blood cells. On immunohistology, the atypical tumor cells were strongly positive for CD31 and vimentin as well as AE1/AE3 and CAM5.2, leading to a diagnosis of epithelioid angiosarcoma. Investigation by positron emission tomography-computed tomography revealed osteolytic metastatic lesions in the pubic and ischial bones. Palliative radio-chemotherapy was performed, but he passed away 11 months after the first visit. Epithelioid angiosarcoma is a rare tumor,and in this case we needed to differentiate it from the metastatic lesions of a primary malignant epithelial tumor.

View full abstract

Here, we report two cases of squamous cell carcinoma (SCC) who were treated with cetuximab(Cet) in combination with either chemotherapeutic agents or radiation therapy. Case 1 was an 85-year-old male who had a parotid lymph node metastasis from a primary SCC lesion on the temporal area. After three courses of Cet + fluorouracil + cisplatin therapy, the metastatic lesion showed a complete remission as assessed by clinical and radiological evaluations. However, the chemotherapy was discontinued because of hyponatremia. One month after the last chemotherapy, the lesion recurred. Subsequently, the treatment was changed to Cet + radiation (Cet-R) and the patient's condition became stable, with no further growth of the lesion during the next seven months. Case 2 was an 89-year-old female who had a huge tumor on the right side of her forehead, leading to difficulty in opening her right eyelid. After Cet-R therapy, the tumor was remarkably reduced in size, leaving a shallow ulceration that allowed her to open her right eyelid. Both cases showed successful results from the Cet-based treatments without any serious adverse events except hyponatremia in case 1. Although large-scale studies would be required to further evaluate these therapies, Cet-based chemo or radiotherapy may have promise as a new method for the treatment of advanced SCC, especially in older patients for whom surgery or conventional chemotherapies may be unsuitable.

View full abstract

Ivermectin is the main treatment of scabies for patients whose weight is over 15 kg, according to the Guidelines for the Diagnosis and Treatment of Scabies (Third Edition) of the Japanese Dermatological Association. However, for patients less than 15 kg in weight, medicines without well-established effects and safety are abundant, resulting in some confusion among dermatologists. Phenothrin lotion is expected to be useful for the treatment of infants with scabies, but its clinical use has not been widely reported. An accumulation of experience regarding its use would be of clinical importance. An outbreak of scabies occurred in a child welfare facility. Nine children and one adult staff member were diagnosed as having normal scabies. There were 3 infants aged 2 years and 2 infants aged 3 years. Each of them had a body weight of less than 15 kg. Insect bodies were detected by dermoscopy in 4 cases ; as a result, the diagnosis of scabies in children became easier and it also helped to build a relationship of trust. Five patients who were younger than 3 years old were treated by phenothrin lotion and crotamiton cream. One patient was suspected to develop contact dermatitis or a Mazzotti reaction caused by phenothrin lotion. This patient received the lotion only once. In the other 4 patients, phenothrin lotion was applied twice in 2 weeks. All of them were cured. Other patients were also cured by treatment with a focus on ivermectin. The outbreak subsided within 2 months. Sebum deficiency was observed in almost all of the patients owing to the use of phenothrin lotion in combination with crotamiton cream during winter. After humectants were applied, no significant deterioration of the rash was observed and the humectants contributed to the improvement of skin symptoms. Our experience suggests that phenothrin lotion is a topical agent with a high efficacy and safety for the treatment of scabies in infants with a body weight of 15 kg or less. Therefore, it could be a suitable first-line treatment for such cases.

View full abstract

A 77-year-old man had received corticosteroid substitution therapy for secondary adrenocortical insufficiency caused by frequent oral administration of prednisolone for his repeated bronchial asthma attacks and had acquired steroid-induced diabetes mellitus due to the corticosteroid treatments. He had rubefaction, swelling, and local heat on the right ring finger and dorsal hand, and was diagnosed with cellulitis when he was hospitalized for an acute exacerbation of his chronic heart failure. Despite antibiotic treatment, similar skin lesions appeared on his right upper arm, left hand, and left leg. Skin biopsies of the lesions showed histological findings of erythema nodosum and loxoprofen, a nonsteroidal anti-inflammatory drug, was given orally. However, the treatment had to be terminated due to an exacerbation of his bronchial asthma attacks. In the meantime, his skin lesions further deteriorated, forming multiple abscesses and ulcers that required surgical debridement. Cryptococcus neoformans and Micrococcus species were then cultured from the subcutaneous abscesses and/or ulcers on his right hand and right upper arm. Further, methicillin-resistant Staphylococcus aureus (MRSA) and Citrobacter koseri were cultured from the skin abscesses and ulcers on his left leg. Cryptococcus fungus bodies were confirmed in the previous skin biopsy specimen after reexamination. The intravenous administration of fluconazole, doripenem, and vancomycin was ineffective, but switching from fluconazole to amphotericin B significantly improved his skin lesions. Orally administered itraconazole was also effective after his discharge and during follow-up.

View full abstract

A 59-year-old woman with uncontrolled diabetes mellitus had been habitually scratching the vulva because of itch since 2013. She had fever, pain, and swelling of her genital area in September 2015. Four days later, she visited a clinic nearby and was diagnosed as having cellulitis and candidiasis of the vulva. Oral antibiotics and topical antifungal cream were prescribed but did not improve the symptoms. Therefore, she visited our department five days after the onset of her symptoms. On arrival, she had pain and swelling of the genital area. Computed tomography showed the presence of free air in the soft tissue of the vulva. Diagnosis of Fournier's gangrene was made, and we performed an emergency surgical debridement with antibiotic treatment. Because of the fast progression of necrosis, additional surgical debridements on the 5th, 7th, and 21st days were performed. Also, coloplasty was performed during the 3rd surgery. On the 42nd and 50th days, a defect of the abdominal skin was reconstructed by split-thickness skin grafting. The postoperative course was uneventful, and she was discharged on the 93rd day after hospitalization. There have been 183 reported cases of Fournier's gangrene, but only 11 (6％) of those cases were women.

View full abstract

Here, we report 3 cases of necrotizing fasciitis that were successfully treated by minimal surgical debridement. Case 1 :a 73-year-old woman had bruised her right hand, and redness rapidly spread to the right upper arm. Initial debridement was performed on her right hand, and administration of an antibiotic was started. The redness and fever diminished in 10 days. Case 2 : a 39-year-old man was admitted to our hospital because of purpura and necrosis accompanied by tenderness over a wide area from the right knee to the thigh. Since he also had severe diabetes, we limited initial debridement by incision only to the markedly necrotic site. The inflammatory response was improved after the administration of an antibiotic and strict general care for a few days. Case 3 : a 73-year-old man was aware of a swelling of the dorsal side of the right hand since his first visit 2 days before. The swelling and redness rapidly expanded to the entire right upper arm, and he suffered from septic shock. In addition to an incision to his right hand, intensive care including the intravenous administration of antibiotics and endotoxin adsorption therapy were performed. He recovered from septic shock and was fully recovered within a month after admission. In conclusion, proper debridement is required for the treatment of necrotizing fasciitis.

View full abstract

A 45-year-old woman with sudden deafness was administered prednisolone sodium succinate (PSL-SS) at 60 mg/day and developed itchy disseminated erythematous eruptions on her trunk and both axillas after 3 days. We suggested a drug eruption caused by PSL-SS and started a treatment with betamethasone (BMZ) at 4 mg/day orally instead. Her skin symptoms improved within a week, but her deafness continues even now. A histologic examination of the erythema on her abdomen revealed a liquefaction degeneration of the epidermal-dermal junction and a moderate perivascular lymphocytic and eosinophilic infiltration in the dermis. A patch test showed positive reactions to prednisolone tablet, prednisolone sodium acetate ointment, and PSL-SS. Methylprednisolone tablet and ointment also showed positive reactions. BMZ ointments showed negative reactions. We diagnosed that she had a delayed-type reaction caused by prednisolone and a cross-reaction to methylprednisolone. We, dermatologists have to know not only the drug reactions caused by corticosteroids but also the classification of synthetic corticosteroids. To the best of our knowledge, the determination of a corticosteroid preparation that can be safely administered to patients via the patch testing of topical steroid preparations is easy and has a high positive rate.

View full abstract

A number of consumers who had used the cosmetic ingredient containing rhododenol (4-(4-hydroxyphenyl)-2-butanol,Trade name ; rhododenol), which is a melanin inhibitor, released from Kanebo Cosmetics Inc. (Tokyo, Japan) develoved leukoderma patches on their face, neck and hands. This condition is called rhododenol-induced leukoderma. In most cases,partial repigmentation of the affected area is observed after discontinuation of product. However, there are still number of patients, who suffered refractory depigmentation. We have experienced 13 cases with rhododenol-induced leukoderma treated with a 308 nm monochromatic excimer lamp targeted ultravilolet(UV)B phototherapy. Ten cases have shown repigmentation following irradiation without sever adverse reaction. We conclude that therapy with a 308-nm monochromatic excimer lamp are effective and safe for the rhododenol-induced leukoderma, especially in more resistant sites.

View full abstract