A 73-year-old Japanese male had suffered from acne on the face during adolescence. The discharge of pus had repeated on the nose for the past 30 to 40 years. The patient had been treated with oral antibiotics every time the inflammation was exacerbated. Subsequently, tumors developed and enlarged gradually on the nose. Several months before the first visit, the tumors worsened, showing inflammatory changes. At the first visit, a huge skin-colored to pale reddish cauliflower-like pedunculated tumor was observed on the nose. The clinical manifestations led to the diagnosis of giant rhinophyma. For cosmetic improvement, surgical resection was performed using a high-wave laser instrument. Histological examination of the resected tumor showed enlarged sebaceous glands, an infiltration of inflammatory cells including mast cells, the proliferation of small-sized vessels, and fibrosis around hair follicles and sebaceous glands in the dermis. A severe rhinophyma like this presented case is relatively rare in Japan. We discuss the pathogenesis of severe rhinophyma and the available therapeutic methods.

A 77-year-old Japanese woman went to neighboring mountain to pick up wild plants and noticed multiple reddish papules with itching on the left forearm in the evening of the day. Gradually, the area of eruption expanded on the trunk and extremities. Upon examination, 183 erythematous lesions were found, and 31 of them were with ticks. All ticks were removed by forceps easily, and they were identified as larval Amblyomma testudinarium. She was treated with 100 mg/day of minocycline, 5 mg/day of levocetirizine, and topical diflucortolone valerate. Eruption were improved, however, annular erythema which resembled erythema mirgans of Lyme disease appeared after seven days from onset. Serum samples obtained at 7th day were examined at National Institute of Infectious Diseases, but antibodies against Borrelia garinii, or Borrelia afzelii were negative. Lyme disease-like nnular erythema observed after tick (A. testudinarium and I. persulcatus) bites without clear evidence of borrelial infection has been reported as tick-associated rash illness or TARI. Our case is compatible with this condition. Interestingly, some ticks were found in the seborrheic keratosis located on the lower legs, and the lesion rapidly protruded. In case of multiple tick bites, one have to be careful with the presence of ticks in such keratotic lesions.

A 75-year-old female was diagnosed with bullous pemphigoid (BP) showing a typical clinical appearance and the presence of serum anti-BP180 antibody. She was treated with systemic corticosteroids at a previous hospital ; however, the treatment was discontinued because of a surgical operation on her Achilles tendon. Although the treatment with corticosteroids was restarted after the operation, her skin eruptions worsened and she was referred to our hospital. At the first visit, there were widespread papuloerythema and bullae over the body that were positive for Nikolsky's sign. Also, she had an erosion on the lips. Histopathological and immunofluorescent examinations of her eruption revealed inflammatory cell infiltrates and vacuolar changes at the epidermo-dermal border, necrotic epidermal cells, and the linear deposition of anti-IgG and C3 at the basement membrane, suggesting the coexistence of BP and Stevens-Johnson syndrome/toxic epidermal necrolysis. The serum examination showed positivity for cytomegalovirus (CMV) DNA. We discontinued all the causative drugs and started her on corticosteroid pulse therapy, a high dose of intravenous immunoglobulins, and an anti-CMV drug. Her eruptions improved within a month. We speculate that Stevens-Johnson syndrome/toxic epidermal necrolysis was complicated by the reactivation of CMV as an immune reconstitution inflammatory syndrome due to the discontinuation of corticosteroids during the treatment of BP.

A 56-year-old man noticed a tender subcutaneous nodule on the sole of the left foot two months prior to the first visit. The patient had not been diagnosed with diabetes mellitus. Ultrasound on the foot found a heterogeneous hypoechoic nodule with thin hyperechoic septa. On histology, the plantar subcutaneous nodule demonstrated a proliferation of spindle-shaped cells in company with increased collagen bundles. The spindle cells were positive for alpha-smooth muscle actin and muscle-specific actin (HHF-35), leading to the diagnosis of plantar fibromatosis. In addition, the patient had multiple keloids (two on the right thigh and one on the right shoulder). Plantar fibromatosis, also known as Ledderhose disease, is a relatively rare disease in the field of dermatology and shows reactive fibroblastic proliferation in the plantar aponeurosis with collagen overproduction. We discuss a possible pathogenetic relationship between plantar fibromatosis and keloid.

We report the case of a 70-year-old man who showed an elastic-soft, solid tumor of his left nasal ala and cheek. Histopathological examination showed that the tumor was filled with myxoid material and surrounded by fibrous tissue. The tumor consisted of small thin-walled blood vessels and spindle-shaped cells. Immunohistochemically, the tumor cells were negative for S-100 protein, alpha-smooth muscle actin, and desmin, while they were positive for CD34. Based on these clinical and histologic findings, we diagnosed the tumor as a superficial angiomyxoma. Carney complex is characterized by the triad of myxomas, endocrine overactivity and spotty pigmentation. The most serious component of Carney complex is cardiac myxoma. The appearance of a superficial angiomyxoma warrants an echocardiogram to rule out the presence of cardiac myxoma.

A 91-year-old woman was referred to our hospital because of appetite loss, anemia, and blastic cells in the peripheral blood identified by laboratory examination. Hematologists diagnosed her as having acute myeloid leukemia (they mostly suspected the M5 form of acute monocytic leukemia) based on the findings of a bone marrow biopsy. She also presented with a painful erythematous plaque on her left forearm. As no efficacy of the administration of systemic antibiotics had been observed, a skin biopsy was performed. Histopathologically, many tumoral mononuclear cells with slight nuclei atypia, which were stained by CD68, were observed in the whole dermis and the subcutaneous layer. Despite beginning chemotherapy (azacytidine therapy), her skin symptoms rapidly worsened, and the chemotherapy was terminated. She was referred to palliative care due to the rapid deterioration of her general condition. Because the infiltration of leukemia into skin is considered to be a significant sign for the poor prognosis of the leukemia, dermatologists should perform a skin biopsy to diagnose the infiltration of skin by acute myeloid leukemia.

A 77-year-old woman visited us complaining of a nasal macule that had been gradually enlarging for 14 months. Previous topical corticosteroid application was ineffective. Physical examination revealed a hemorrhagic erythematous lesion with crust measuring 36×30 mm in diameter on the right side of her nose. On dermoscopy, telangiectasia and arborizing vessels were conspicuous without any pigmented spots or dots. Histopathologically, atypical basaloid cells were found to be proliferating in nests with peripheral palisading. However, melanin granules in the nests and peritumoral melanophages were not found, leading us to the diagnosis of non-pigmented basal cell carcinoma. Further immunohistological examination elucidated that Melan-A-positive melanocytes existed in the tumor nests ; however, they were not stained by tyrosinase and Fontana-Masson staining. These results indicated that the inhibition of eumelanin biosynthesis in melanocytes would explain the hypopigmented nature of her basal cell carcinoma.

A 12-year-old boy, who belonged to a football team, visited a dermatology clinic with an erythematous lesion on his left knee in May 2015. Because the KOH examination performed by the previous doctor did not detect any fungi, topical corticosteroid was applied to the lesion but resulted in no improvement. Therefore, he was referred to our outpatient clinic in June 2015. Physical examination revealed a hyperkeratotic erythematous lesion measuring 6 × 5 cm in diameter on the left knee without black-dot ringworm. We performed a direct KOH examination again for corneocytes in the erythematous area, but no fungus was detected. Meanwhile, the growth of Trichophyton tonsurans (T. tonsurans) was confirmed by a skin-tissue culture including follicular tissue taken from the lesion. Additionally, a polymerase chain reaction analysis of DNA extracts from the cultured fungus showed an exact match for T. tonsurans, and we eventually diagnosed this case as having tinea corporis on the left knee caused by T. tonsurans. Because various clinical manifestations of tinea corporis caused by T. tonsurans have been reported, we must perform thorough examinations to make a definitive diagnosis.

Perianal streptococcal dermatitis (PSD) is a superficial cutaneous infection of the perianal area that is caused mainly by group A beta-hemolytic Streptococcus and characterized by persistent perianal erythema and itching. PSD has almost exclusively been described in children. Only five cases of PSD have been reported in Japan so far. We report herein an additional three adult cases of PSD with accompanying redness of scrotal skin, miliary erythema of the neck, inguinal streptococcal dermatitis, candidiasis, or generalized itching. Since several skin conditions such as contact dermatitis, seborrheic dermatitis, or candidiasis can mimic the presentation of PSD, it seems likely that, as in children, PSD is probably also prone to misdiagnosis in adults, leading to the underestimation of its incidence. PSD should be studied further to better define its epidemiology and etiology in Japan.

Topical trichloroacetic acid (TCA) is a well-known treatment for genital warts, condyloma acuminatum. However, there have been few reports dealing with its use for warts other than genital warts, such as common or plantar warts. In two Japanese children, topical 45％ TCA application successfully cured multifocal recalcitrant warts on the fingers and toes that were resistant to conventional treatments such as cryotherapy, topical salicylic acid, topical glutaraldehyde, topical vitamin D₃, or systemic coix seed extract. No adverse events were observed. Cryotherapy with liquid nitrogen is currently the most popular therapy for common and plantar warts. However, severe pain associated with cryotherapy often reduces patients' adherence to the treatment. Based on our experience of these two cases, topical 45％ TCA therapy may be superior to cryotherapy with a much better adherence and clinical effectiveness. Further investigation is warranted to determine the safety, effectiveness, and suitable concentrations of TCA for the treatment of intractable warts.