The patient was a 13-year-old female who had begun to develop otherwise asymptomatic pigmented macules on the right side of her neck 2 years earlier. They had spread toward the right posterior aspect of her neck, and when they failed to resolve, she was examined by a local physician. At the initial examination, numerous fingernail-sized, oval, light brown to gray pigmented macules were observed from the right side of the neck to the right posterior neck area. A histopathological examination revealed increased melanin pigmentation of the basal layer of the epidermis and mild liquefaction degeneration at the epidermal-dermal junction. Melanin deposition and mild perivascular lymphocytic infiltration were observed in the dermis. The patient had no history of medication, and a metal patch test was positive for iridium tetrachloride. We made a diagnosis of ashy dermatosis. The patient is currently being treated with oral ascorbic acid and tranexamic acid, and her course is being followed, but there has been no improvement in the skin rashes.
A 66-year-old man presented with red-brownish hyperkeratotic papules along Blaschko's lines on the left side of the trunk as well as the left upper and lower extremities. There were no other lesions on the skin, mucosa, or nails. The patient did not complain of any worsening of the symptoms during the summer. A previous treatment with topical steroids was ineffective. A skin biopsy of the keratotic papule obtained from the epigastrium showed irregular hyperkeratosis, a suprabasal cleft with several acantholytic cells, and dyskeratosis in the form of corps ronds in the epidermis. Based on the clinical and histological findings, we diagnosed the patient as having unilateral Darier's disease. Topical vitamin D3 was not effective. Upon the administration of systemic etretinate and topical adapalene, the hyperkeratotic papules became flattened but persisted.
A 9-year-old Japanese girl presented with wave-like or linear indurative pigmentation on her trunk which appeared when she was 4 years old. Several months ago, other linear indurative pigmentation appeared on her upper right arm and neck. In addition small brown-red papules appeared on her trunk and lim of right side. The skin lesions distributed along the Blaschko's lines. She was diagnosed as lichen striatus from the clinical findings and histopathology. Her skin lesions improved by the treatment of heparinoid-containing moisturizer, although they recurred by discontinuation of the treatment.
A 73-year-old woman visited our clinic with itchy micro-papules and erythema with pigmentation mainly on the trunk. Her symptoms did not improve upon the administration of anti-allergy agents and corticosteroids for 2 years. Histopathologically, the epidermis was atrophic, and a loss of the rete ridges together with liquefaction was detected in the basal layer. There was an epithelioid cell granuloma with epithelioid histiocytes and multinucleated giant cells without caseation in the upper dermis. We diagnosed this case as having lichen nitidus based on the gross and histopathological
findings. We stopped the treatment with amlodipine besylate, and the eruptions had improved completely without post-inflammatory pigmentation 2 months later. We considered this to represent the case with a lichen nitidus-type drug eruption induced by amlodipine besylate, although the drug-induced lymphocyte-stimulating test was negative.
An 83-year-old woman visited our outpatient clinic because an ulcer on her left lower leg became exacerbated. She had been treated by a general practitioner but the ulcer did not improve. A physical examination revealed a 20 mm diameter ulcer surrounded by telangiectasia. Histopathological findings taken by the periphery of the ulcer showed an infiltration of numerous inflammatory cells composed of neutrophils, histiocytes, and lymphocytes in the whole dermis through to the subcutaneous tissue. In the abscess, some basophilic substances with multiple spiculae were seen. Only Streptococcus intermedius (S. intermedius) was identified by a bacterial culture, and no acid-fast bacilli were detected. Contrast-enhanced computed tomography revealed a localized ischemic area immediately around the lesion, while blood flow was well maintained at the distal sites of the feet. Although the ulcer temporarily expanded for several days after beginning the oral administration of levofloxacin, it subsequently began to gradually improve without any change to the treatment regimen. Previously, S. intermedius has been reported to be involved in abscess formation in deep tissues such as the internal organs, but there have been few reported cases of this pathogen in the dermatological field. Although our present case had the special condition of localized blood flow obstruction because of vascular abnormalities around the ulcer area, we propose that S. intermedius should be considered as a pathogenic microorganism that could induce a deep ulcer.
An 86-year-old woman who is a farm worker was referred to our department with a subcutaneous cyst tumor on the left hand. She had taken an antidiabetic agent for her diabetic mellitus. When we performed a skin biopsy of this cyst tumor, yellowish-white pus was observed. A mycological culture of the pus showed grayish-black colonies. Histopathologically, numerous spores and hyphae were positive for Grocott and periodic acid-Schiff staining within granulomas. Based on a molecular biological analysis of the mycological culture using the polymerase chain reaction technique, we identified Exophiala jeanselmei as the causative agent of this case of phaeohyphomycosis. She took terbinafine hydrochloride (125 mg/day) and the lesion became flattened 2 weeks later. There was no recurrence of the lesion during the following 6 months. We considered that this case was due to diabetes and a slight injury incurred during the farm work. Although the clinical features were typical of phaeohyphomycosis, it was difficult to distinguish the lesion from an epithelial tumor and epidermal cyst on the first examination. When we suspect phaeohyphomycosis, we should examine mycological tests carefully.
A 61-year-old man suffering from epilepsy was treated with lamotrigine and valproic acid. He had also been suffering from liver dysfunction caused by anticonvulsants for 1 year. He had a fever of over 38 ℃ on the 26 th day of the treatment with lamotrigine and valproic acid, followed by disseminated erythema with scales. He had a rash and scales over his whole body including his face on the 29 th day. He visited our clinic on the 36 th day. Based on the clinical features, drug-induced
hypersensitivity syndrome (DIHS) caused by lamotrigine was suspected. Hence, lamotrigine was stopped and oral prednisolone (20 mg/day) was administered. His anti-HHV-6 IgG titer rose from 20× to 160× during the 3 weeks from the initial visit, suggesting the reactivation of HHV-6. A drug-induced lymphocyte stimulation test for lamotrigine was positive. The diagnosis of DIHS was made based on the standard criteria, excluding lymphadenopathy. It has been reported that most cases of severe drug eruption induced by lamotrigine were caused by either an overdose of the drug or its use in combination with valproic acid. In our case, despite the treatment following the recommended dosages of lamotrigine when combined with valproic acid, the patient suffered from DIHS. In addition, his symptoms recurred after the dose of prednisolone was decreased. Consequently, it is difficult to anticipate the occurrence of DIHS, even though we pay attention to the dosage of lamotrigine or other drugs used in combination with lamotrigine.
In recent years, the incidence of herpes zoster has been increasing in Japan, partly due to the aging of the population. In children, the coverage of varicella vaccination was only 30％ until the initiation of routine vaccination in October 2014. Between July 2010 and December 2013, a follow-up survey on the rate of varicella infection in children due to the familial transmission of infection from patients with herpes zoster was performed in one dermatological clinic. Among 78 patients with herpes zoster, 9 were associated with the secondary development of varicella in 10 of 96 children. Secondary infection due to transmission from a sibling with varicella was observed in one child. Among all the children, the rate of varicella infection due to familial transmission from patients with herpes zoster was 11.5％. In terms of the familial relationship, elder brother-to-younger sister transmission of infection was observed in 1 case, parent-to-child transmission in 4 cases, and grandparent-grandchild transmission in 4 cases. The rate of varicella infection among the children was not associated with the sex or generation of patients with herpes zoster. Herpes zoster in the trigeminal and cervical nerve areas, as compared with that in other anatomical areas, was associated with a high varicella infection rate in the children (odds ratio, 1.7). In addition, the rate of varicella infection due to transmission from patients with herpes zoster in the ocular nerve area was particularly high (22.2％). The number of blisters caused by herpes zoster was not associated with the rate of varicella infection. The rate of varicella infection among children aged 0 years was 12.5％, which was 1.5 times as high as the infection rate in children aged 1-5 years. In 3 children, varicella developed within 10 days of the development of blisters in patients with herpes zoster. Therefore, the varicella zoster virus is considered to be discharged in the saliva some days before the development of eruptions in herpes zoster.
We evaluated the scores of itch, severity, satisfaction, and adherence in atopic dermatitis (AD) patients after they switched from a fatty ointment to a water-in-oil emulsion ointment formulation of the “very strong” class of topical corticosteroids. Thirty-four patients were enrolled during the fall/winter (Period 1) and 22 patients were enrolled during the spring/summer (Period 2), including 10 patients who prematurely discontinued the water-in-oil emulsion treatment. The itch score measured by a visual analog scale and the severity scores measured by the Severity Scoring of Atopic Dermatitis (SCORAD) and Eczema Area and Severity Index (EASI) questionnaires significantly decreased during both periods. The changes in these scores during Period 2 were significantly greater than those during Period 1. The “effectiveness” and “general satisfaction” scores measured by the Abbreviated Treatment Satisfaction Questionnaire for Medication (TSQM-9) both significantly increase during Period 2, and the changes in these scores were significantly greater during Period 2 than during Period 1. There was no significant difference in the “convenience” score measured by the TSQM-9. There was no significant change in the category ratio of adherence measured using the Morisky Medication Adherence Scale (MMAS) between before and after the administration of the water-in-oil preparation. In summary, the itch score, patient satisfaction score, and severity of AD were improved in AD patients by changing ointment to a water-in-oil emulsion formulation, especially during the spring and summer period.