We describe a case of recalcitrant chronic urticaria successfully controlled by warfarin. A 53-year-old female had suffered from urticaria and angioedema for 6 months. She had been treated with antihistamines, H2-receptor antagonist,leukotriene receptor antagonist, diaminodiphenyl sulfone, prednisolone, and cyclosporine; however, no medicine suppressed the urticaria. Previous reports have demonstrated that thrombin protein synthesis is enhanced in patients with chronic urticaria. Moreover, warfarin, which inhibits the synthesis of thrombin and coagulation proteins, has been reported to suppress urticaria. Based on these findings, the patient was administered 1 mg per day of warfarin in addition to cyclosporine, olopatadine, and the H2-blocker famotidine. Three days later, the dose of warfarin was increased from 1 to 2 mg per day, and it was subsequently increased by 1 mg every week. The prothrombin time international normalized ratio (PTINR) was maintained at around 1. 3 when she was administered 4 mg per day of warfarin. At the start of warfarin administration, the UAS7 score, which was originally defined at our institute, was 42 points. Notably, the UAS7 decreased to 7 points 25 days later, upon the administration of 4 mg per day of warfarin. Subsequently, this score dropped to 0. Cyclosporine was discontinued at the 30th week, and subsequently warfarin was stopped at the 50th week, followed by the discontinuation of famotidine and olopatadine. During 14 months after the end of the treatment, there was no relapse of any symptoms, such as itching, erythema, or wheals. The present case report demonstrates the effectiveness of warfarin treatment for recalcitrant chronic urticaria.

A 69-year-old woman presented with purpuric lesions after a bout of fever, vomiting and hematuria. On her first visit,she presented with numerous purpura on her lower legs. Blood tests showed elevation of Immunoglobulin (Ig) A and biliary enzymes. Abdominal computed tomography showed stones in the gallbladder and bile duct. Purpura and biliary enzymes level were improved after a drainage tube was placed into the bile duct by endoscopic retrograde biliary drainage (ERBD). A skin biopsy of the purpura showed leukocytoclastic vasculitis with perivascular infiltrates of neutrophils in the superficial dermis, establishing the diagnosis of anaphylactoid purpura (AP). Immunohistochemical staining showed deposition of IgA on the vascular wall. However, after several days, purpura recurred with another elevation of biliary enzymes. At this time,ERBD stent was found to be inadvertently displaced and was replaced. Since then, purpura on the skin as well as biliary enzymes levels improved again. There has been reports of APassociated with gallstones and cholecystitis. In our case,purpura was improved twice right after proper treatment of cholelithiasis, suggesting that it may have caused APin this case. When seeing an adult patients with AP, we should consider cholecystitis as one of its cause.

A 77-year-old man noticed itchy edematous erythema on his trunk and extremities. He was treated with oral prednisolone (PSL) at 10 mg/day at the dermatological clinic he first visited, but it was ineffective. Since his serum anti-BP180 antibody was 860 U/ml (standard value : ＜9.0 U/ml), he was diagnosed with bullous pemphigoid (BP). PSL was increased to 20 mg/day, but the BP symptoms became worse, and he had laboratory data of WBC 11300/μl and CRP 16.82 mg/dl. Because the exudation of his skin lesions had been increasing, especially from his left foot, he was referred to our department. He had steroid-resistant BP complicated with necrotizing cellulitis (NC) of his left foot. He was immediately admitted to our department, and we performed debridement of the infectious necrotic tissue on the dorsum of his left foot under local anesthesia, cleaned the wound, administered meropenem hydrate and clindamycin by intravenous drip, and continued oral PSL treatment for BP. The NC improved to some extent, but the BP worsened. Therefore, we added high-dose intravenous immunoglobulin (IVIG) therapy, and the BP improved relatively soon. Thereafter, we performed patch grafting for the ulcer on the dorsum of the left foot, using the “shave wheals technique” to obtain the skin for grafting, and the ulcer healed smoothly. When steroid-resistant BP is complicated with a severe infection, it is hard to increase the dose of steroids or add other immunosuppressants. Recently, an IVIG preparation was approved in Japan as an effective treatment for steroid-resistant BP. In addition, the effectiveness of IVIG in combination therapy with antibiotics for severe infections has been reported before. To our knowledge, our present case is the first report about steroid-resistant BP complicated with NC treated with high-dose IVIG in combination therapy worldwide. We think that high-dose IVIG is an effective treatment for steroid-resistant BP complicated with a severe infection.

A 48-year-old man presented with marked hypopigmentation. He came to our hospital because of exertional dyspnea, and he was diagnosed with nonspecific interstitial pneumonia by biopsy. We thought that he was suffering from Hermansky-Pudlak syndrome due to his albinism and agnogenic interstitial pneumonia. His bleeding time was prolonged and his platelet aggregation activity was low. We confirmed the diagnosis by identifying a mutation in HPS1 through a genetic examination. Two years after the first medical examination, one brown nodule appeared on the lower part of his pinna. He was diagnosed with malignant melanoma from an excisional biopsy. However, we could only perform extended resection because of his poor respiratory state, and he died after 6 months. Albinism such as Hermansky-Pudlak syndrome is associated with a high risk of skin cancer caused by ultraviolet radiation, but there have been few reports of malignant melanoma with this syndrome.

A 25-year-old female patient was referred to our department for the treatment of a linear brown plaque on the left side of her face, which was present since birth ; one part of the plaque had been prominent for several years. Physical examination revealed a 25×5 mm plaque verruciformis and a 3×3 mm red node with bleeding on the plaque. A biopsy of the plaque verruciformis, including the red node, and histopathological examination revealed nevus sebaceus and sebaceoma,respectively. Subsequently, the remainder of the plaque was removed. We examined 94 patients who had nevus sebaceus at our hospital from 1997 to 2016. In total, secondary tumors developed in 11 patients. Combining our findings with those of other studies, secondary malignant tumors occurred in less than 0.5% of sebaceous nevus among patients younger than 20 years old, whereas malignant tumors occurred in more than 60% of sebaceous nevus among those older than 50 years.

A 75-year-old man presented with a 2-week history of fever, generalized lymphadenopathy and asymptomatic maculopapular rash. A skin biopsy of the indurated erythema on the back revealed a massive infiltrate of small lymphocytes with irregular nuclei in the dermis and around the cutaneous appendages. Immunohistochemical staining demonstrated that the atypical lymphocytes were positive for CD3, CD4, CD10, bcl-6 and PD-1. Therefore, angioimmunoblastic T-cell lymphoma (AITL) was suspected. The histopathological features of right inguinal lymph node biopsy confirmed the diagnosis of AITL. Although approximately 50％ of patients with AITL develop skin eruptios, the skin eruptios and its histological features are non-specific findings and AITL is typically diagnosed based on the histopathological findings from a lymph node biopsy. However, in our case, the immunohistochemical markers of the cutaneous manifestation of AITL aided in its diagnosis. We investigated the previously reported cases of cutaneous manifestations of AITL in Japan.

A 61-year-old man was diagnosed as having idiopathic pulmonary fibrosis and had started to take oral corticosteroid in 2011. He then underwent a left lung transplantation in August, 2015. Thereafter, immunosuppressive medications were initiated. He visited our outpatient clinic in December, 2015 with a complaint of a non-pruritic brownish macule on his buttocks. With a diagnosis of tinea corporis, we prescribed an anti-fungal cream that improved his lesion promptly. However, multiple small nodules with crust on the top appeared on his buttocks and soles in March, 2016. A skin biopsy,genetic analysis, and fungal culture identified Trichophyton rubrum (T. rubrum) as a causative agent. We finally diagnosed him as having granuloma trichophyticum caused by T. rubrum. The lesions healed after treatment with oral fluconazole for about 2 months. Recently reported cases of granuloma trichophyticum have often included post organ transplantation patients like our case. Since the number of patients undergoing organ transplantation is increasing, dermatologists should keep this fungal infection in mind.

New treatments for advanced melanoma such as immune checkpoint blockades contribute to an improved long-term survival of the disease. However, the response evaluation of immune checkpoint blockades is difficult, and the decision about when to stop the drug in progressive disease (PD) cases is difficult, too. We analyzed 8 patients with advanced melanoma who changed to palliative care following immune checkpoint blockade (nivolumab or ipilimumab) between July 2014 and June 2016. Two of the patients were male and 6 were female. The mean age was 69.3 years. The BRAF V600E mutation was not detected in 6 patients. The mean number of administrations and period of the immune checkpoint blockades from PD determination to the last dosage were 2.4 times and 36.1 days, respectively. The mean period from the last dosage to death was 36.1 days. We should change from immune checkpoint blockade to another treatment or palliative care in PD cases, but we often continued it beyond PD when there was no other treatment available.

Bathing and cleansing of the body are essential to maintaining good hygiene, but when done in excess, can promote dry skin among the elderly. In order to assess the appropriate conditions for bathing and body cleansing for the elderly, we conducted a survey of bathing practices at 105 hospital wards. The results demonstrated that in most wards surveyed (55%), bathing was performed twice weekly. Further, we cleansed the right lower leg of 41 hospitalized patients twice per week and the left lower leg of the same patients daily, and assessed the condition of their lower leg skin after 2 weeks. The findings showed that while skin hydration, rate of dermal evaporation, and skin pH of the left lower leg skin had significantly increased. Likewise, macroscopic inspection failed to reveal any changes in skin condition.