We report on a 73-year-old man with type 2 diabetes who had psoriasis vulgaris. In 1954, his elder brother developed pulmonary tuberculosis. The patient had received topical and ultraviolet-ray therapies for psoriasis vulgaris, which appeared in 1978. In 2008, the oral administration of cyclosporine was started, and his psoriatic lesions improved. In October 2012, adalimumab treatment was started because his response to cyclosporine had become attenuated, and the course was favorable. Screening examination indicated that he had a latent tuberculosis infection. The prophylactic administration of isoniazid before starting adalimumab was completed in 10 months. During treatment with biological preparations, patients need regular chest X-rays. The present case had chest X-rays at 1, 6, and 12 months after starting adalimumab administration. After 3 months, he was admitted with idiopathic fever. As multiple splenic abscess and septic pulmonary emboli were detected, various antibiotics were administered under a diagnosis of sepsis. However, they were not effective. Gastric juice culture collected after admission revealed the presence of acid-fast bacteria 18 days after admission. The polymerase chain reaction method revealed the presence of tubercle bacilli. The regimen was switched to a combination of 4 anti-tuberculosis drugs, leading to the relief of fever. He was treated for a maximum period of 9 months due to diabetes, as a tuberculosis-preventing strategy for therapy with biological preparations. We think this case represents a warning regarding the use of biological preparations in patients with latent tuberculosis, because the patient developed tuberculosis after the administration of antituberculosis prophylactics following the applicable clinical guidelines. Currently, close monitoring and various examinations are being conducted and secukinumab is being administered. We review the administration of biological preparations after tuberculosis treatment.

An 80-year-old man presented with poliosis that developed suddenly after having surgery for macular degeneration of his right eye about 10 years ago. Vitiligo on his face followed the poliosis, and it gradually spread over most of his body surface during the subsequent years. He had received some phototherapy treatments in another hospital before but these were not successful. He visited the ophthalmology department of our hospital for bilateral uveitis, which occurred with sudden nephelopsia 3 weeks before his visit. Some postinflammatory changes in the anterior region of the eye and a characteristic “sunset-glow” fundus were observed. We carried out a skin biopsy from the vitiligo on his left lower eyelid. In a histological analysis, no melanocytes were observed in the basal layer of the epidermis, and Melan-A was negative in his epidermis. We diagnosed recurrent Vogt-Koyanagi-Harada disease (VKH) ; however, systemic corticosteroid therapy was not carried out,because there were no signs of acute inflammation such as meningism, dysacousis, or retinal detachment. Furthermore,instillation improved the ocular symptoms. Steroid ointment was unsuccessful against the vitiligo. In VKH, some signs of depigmentation such as a “sunset-glow” fundus and vitiligo appear 2-3 months after uveitis, and bilateral vitiligo is often distributed over the eyelid, face, and neck. Although there have been several case reports of VKH with extensive vitiligo, the generalized vitiligo observed in the present case is very rare.

A 69-year-old woman noticed a rapidly growing reddish tumor on the right temple about 2months before her first visit to our hospital. An initial physical examination revealed a reddish and slightly hard tumor measuring 14×13 mm. Dermoscopic findings showed a yellowish-white structure with streaks and linear-irregular vessels. Based on histopathological examination, the tumor was diagnosed as a pilomatricoma with a squamous epithelium. Pilomatricoma is commonly observed as a subcutaneous nodule in young patients. It sometimes develops a variety of clinical manifestations such as the protrusion of a tumor. This report summarizes the statistics for the occurrence of pilomatricoma in elderly patients and emphasizes that dermoscopy is useful for the differential diagnosis of pilomatricoma, especially in atypical cases.

An 85-year-old woman was introduced to our hospital because of a massive subcutaneous tumor in her left lumbar region that occurred after she fell and contused that region in January 2011. She was treated as subcutaneous hematoma by a local doctor, and the tumor had rapidly enlarged since August 2011. When she visited our hospital in September 2011, she presented with a 15×12×8 cm subcutaneous tumor with a glossy surface on her left lumbar region, together with heat. A pleomorphic sarcoma or liposarcoma was suspected by skin biopsy. On this basis, the tumor was resected with a 3-cm margin and the peritoneum was kept. The left iliac crest was resected, because the tumor was adhered to the left ilium. The defective part was reconstructed by an anterolateral thigh flap and a split-thickness skin graft. Myxofibrosarcoma was finally diagnosed by pathological examination of operative specimen. During regular consultations by computed tomography imaging, she had no recurrence and no metastasis, but suddenly died in a sanatorium postoperatively three years and five months after.

Case 1. A 46-year-old man presented with digestive symptoms and was diagnosed with intussusception during the treatment of malignant melanoma on the back. A lesion was detected in the small intestine and it was histologically diagnosed as a small intestinal metastasis of malignant melanoma. Case 2. A 37-year-old man, who had a 7-cm ulcerative lesion detected by endoscopy during an examination for anemia, was histologically diagnosed with a small intestinal metastasis of malignant melanoma. He had a 3-year history of a pigmented lesion on his left lower leg, and histopathological findings of the skin lesion revealed a regression stage of malignant melanoma. Thus, we regarded it as a primary lesion. It is rare to diagnose metastases of malignant melanoma to the small intestine in living patients. However, there have been many such case reports in autopsy subjects. In Japan, relatively large numbers of malignant melanoma with acute abdomen have been reported. We must pay much attention to the small intestinal metastasis of malignant melanoma because it may cause serious symptoms,such as intussusception and gastrointestinal perforation, although it is difficult to detect the metastases.

An 83-year-old female had been treated with immunosuppressive agents including glucocorticoid steroids for 20 years due to rheumatoid arthritis. She noticed hair loss and underwent a medical check at a nearby dermatological clinic. Her scalp lesions worsened and erythema with scale appeared on the back of her right hand after the use of a steroid ointment. Direct microscopic examination of individual hair roots and the scale from her scalp and hand showed the presence of fungal elements,and she was diagnosed with kerion celsi and tinea manus. Microsporum gypseum was identified by fungal culture. She started treatment with oral terbinafine at 125 mg/day ; however, her itching and tenderness worsened, and thick and yellowish scutula (so-called favosa) appeared on the scalp. The dose of terbinafine was increased to 250 mg/day, after which her symptoms got better, and she finally healed 5 months later. We thought that the patient may have been refractory to treatment with a standard dose of terbinafine, or even have developed favosa, because she was immunosuppressed due to her treatment for rheumatoid arthritis.

Case 1 : A 58-year-old Japanese man ate raw meat of“amago (red-spotted masu trout, Oncorhynchus masou macrostomus)”and noticed a subcutaneous induration on his left trunk a month later. On his first visit to our hospital, he presented with the induration together with itching and heat sensation on the abdomen. Although a histopathological examination showed the presence of eosinophilic substances in the lower dermis, no larvae were found in the specimen. The skin induration improved after treatment with oral ivermectin (0.2mg/kg). Case 2: A 57-year-old Japanese man presented with linear indurative erythema together with itching on his abdomen 10 days after he ate raw meat of “pit viper (Gloydius blomhoffii)”. The eruption was found to extend to the lateral region. The indurative erythema involved small blisters. Upon incision of the lesion, no larvae were found in the pathological specimen. The lesions disappeared after three cycles of treatment with oral ivermectin (0.2mg/kg). Although the larvae were not found in either case, specific anti-Gnathostomia doloresi antibodies were detected in both patients' sera using a multiple-dot enzyme-linked immunosorbent assay (DotELISA). Therefore, these cases were diagnosed as creeping disease due to Gnathostomia doloresi.

A 47-year-old Japanese woman presented with a 7-day history of pruritic erythema on the palm and lower legs. The lesion developed 1 day after the initiation of combination therapy of daclatasvir plus asunaprevir for chronic hepatitis C, and enlarged gradually. Dermatological examination found an erythematous maculopapular eruption on the extremities and closely aggregated vesicles on her palm. A skin biopsy from the palm revealed interface dermatitis. She was diagnosed with drug eruption based on her clinical appearance, medical history, and histopathologic features. All skin lesions resolved after discontinuing the medication and steroid administration. We consider the possibility that her symptoms were drug-related,but not caused by an allergic mechanism, because of the early onset and course of drug eruption.

To evaluate the clinical outcomes and therapeutic effects on patients with pemphigus vulgaris (P. vulgaris) and P. foliaceus,we analyzed the treatments and clinical courses of 17 cases of pemphigus diagnosed and treated in Sapporo Medical University Hospital from 2008 through 2014. Seven cases (41.2%) of the patients achieved complete remission off therapy after a mean treatment period of 32.9 months. Eventually, 13 out of the 17 cases (76.5%) were successfully treated with less than 0.2 mg/kg/day or 10 mg/day prednisolone. Reduction to these doses was described as the target outcome of treatment in the guidelines for pemphigus of the Japanese Dermatological Association. However, five out of seven patients with P. foliaceus and five out of ten patients with P. vulgaris required optional therapies in addition to prednisolone. Our study revealed that approximately 80% of pemphigus patients attained the low therapeutic amount of corticosteroid recommended as a target dose range in the guidelines of the Japanese Dermatological Association, indicating that it is essential to treat pemphigus in accordance with the applicable clinical guidelines.