A 7-month-old infant received a BCG vaccination in the upper left arm. After 3 months, scaly erythema appeared at the vaccinated site. He visited our hospital because of the spread of eruption. A biopsy from his back and had revealed parakeratosis with a small abscess and psoriasiform hyperplasia of epidermis. Therefore, treatment with topical corticosteroids was initiated under the diagnosis of psoriasis vulgaris. Eruption was refractory to the therapy at first but improved after 3 months. We concluded this case had psoriasis induced by BCG inoculation. Psoriasis in children has some epidemiological characteristics, such as predominance in girls, high frequency of parental psoriasis, and high genetic prevalence of HLA-Cw6, however, none of these characteristics were found in our case. Treatment options are limited in the practice of infantile psoriasis, and also it is often difficult to avoid mechanical stimuli. We reviewed the characteristics and therapeutic choice of previously reported cases of infantile psoriasis.
A 38-year-old woman presented with a 20-year history of recurrent abdominal pain accompanied with fever lasting for a week. She had experienced diarrhea, followed by knee pain, ankle pain, wrist pain, and painful eruptions in the lower extremities. A dermatological examination revealed tender, reddish nodules on her lower extremities and the dorsa of both wrists. A histopathologic examination confirmed the diagnosis of erythema nodosum. The patient and her father, brother and sister were diagnosed with familial Mediterranean fever (FMF) based on a genetic examination 11 years ago. Erythema nodosum and joint pain reduced after the oral administration of colchicine. Autoinflammatory diseases, including FMF, are important differential diagnoses that should be considered as the underlying cause of urticarial, nodular, or erythematous skin lesions. The early diagnosis and treatment of FMF by colchicine administration are thought to be important in preventing the onset of amyloidosis, which is related to the prognosis of FMF.
We present two female cases of hidradenoma papilliferum on the vulva. The first case was a 40-year-old woman who recognized a subcutaneous nodule measuring 6 mm on the left of her vulva. The nodule was surgically resected and diagnosed as hidradenoma papilliferum histologically. The second case was a 38-year-old woman with a pink-colored pedunculated tumor measuring 1 cm on the left of her vulva, which often bled because of friction from underwear. The tumor was surgically resected and was also diagnosed as hidradenoma papilliferum histologically. It had previously been thought that hidradenoma papilliferum tumors originate from apocrine sweat glands, but recent studies have suggested that they may be derived from the anogenital mammary-like gland (MLG). The MLG is reported to be immunopositive for both estrogen receptor and progesterone receptor, while the majority of the normal eccrine or apocrine glands are not. Our two cases showed both estrogen receptor and progesterone receptor expression in the columnar cells of the tumor, suggesting that these cases of hidradenoma papilliferum may have been derived from the MLG.
We report a case of 76-year-old female patient with rheumatoid arthritis, who presented diffuse large B cell lymphoma (DLBCL) developed on the lower leg. Previously, she had been administrated immunosuppressive treatment with methotrexate (MTX) (8 mg/week) and prednisolone (7. 5 mg/day) for 5 years. Physical examination showed sporadic erythema and nodules on the both lower legs, respectively. Topical therapies failed to treat those lesions. After that, the lesions formed a tumor on the left lower leg and formed ulcers on the right lower leg. Histological examination of the left lower leg showed large sized atypical lymphocytes with CD20-positive proliferated in the entire dermis, which demonstrated the diagnosis with DLBCL. In addition, Epstein-Barr virus (EBV) infection in the tumor cells were confirmed by EBV-encoded small RNA and EBV-latent membrane protein 1. On one hand, histological examination of the right lower leg showed oligoclonal proliferating T cells in the superficial dermis. After withdrawal of MTX therapy, the tumor rapidly regressed without chemotherapy. We diagnosed MTX-associated lymphoproliferative disorder (MTX-LPD) appeared as DLBCL due to the histopathological findings and the characteristic clinical course. When we examine a patient under treatment with MTX,we have to keep in mind that there is more risk of MTX-LPD which may induce malignant lymphoma.
An 81-year-old female noticed a subcutaneous nodule on her left buttock almost 1 year before her first visit to us. Because of its rapid growth, the lesion was resected. On histological examination, a proliferation of small round tumor cells was observed in the deep dermis and the subcutaneous tissue. Nuclear atypia and mitotic figures were also detected in the tumor cells. The tumor cells were positive for cytokeratin 20 and chromogranin A. An analysis by PET-CT scanning showed no other systemic involvement, indicating the diagnosis of primary Merkel cell carcinoma arising on the buttock. We performed an additional wide resection. However, a left inguinal lymphadenopathy was noticed 6 months later, which was histologically diagnosed as a lymph node metastasis of Merkel cell carcinoma. A subsequent left inguinal lymph node dissection revealed no residual Merkel cell carcinoma and the patient has been free from recurrence for 6 months after the final operation. Merkel cell carcinoma preferentially develops on sun-exposed areas and its occurrence on the buttock is rare.
We statistically analyzed the clinical parameters and laboratory data in patients with cellulitis/erysipelas in order to predict the clinical course and trends. The younger patients were predominantly male, while the older patients were predominantly female. During a pretreatment period, the C-reactive protein (CRP) values remained elevated as long as the pretreatment period was increased, whereas the white blood cell (WBC) counts and body temperature tended to decrease. When treatment was initiated earlier after the disease onset, the CRP values tended to decrease after reaching a peak ; in contrast, the WBC counts and temperature decreased early after the initiation of treatment, irrespective of the time of the disease onset. Eight point eight±6.0 days were required for the CRP values to drop below 2 mg/dl, while the WBC count and temperature required 4.9±5.9 days and 5.7±5.5 days respectively, to normalize. The maximum CRP values and WBC counts showed strong and significant positive correlations with the time required for these values to decrease. As the maximum CRP value increased, the treatment period became longer ; furthermore, the procalcitonin level greatly influenced the time required for the CRP value to decrease. Continuous usage of anti-inflammatory agents slightly decreased the maximum temperature ; however, it did not greatly influence other trends. Patients that presented with a highly deviated treatment period, lesional area, maximal CRP value, WBC count, temperature, or time required for their reduction (extreme cases) tended to be older and to have higher procalcitonin values in comparison to the usual cases. Furthermore, sepsis was significantly more frequent in the extreme cases. On the other hand, there were no significant differences between the usual cases and the cases whose laboratory values remained within the normal limits (normally-valued cases) ; these cases accounted for one quarter of the patients in the study population.
Improving treatment adherence in atopic dermatitis patients has been highlighted as a major issue by the Clinical Practice Japanese Guidelines for the Management of Atopic Dermatitis 2016. Lotion formulations have gained attention for superior sensation on application, and we hypothesized that switching from ointments to lotions would contribute to improved treatment adherence. This study investigated the efficacy, safety, and sensation on application of betamethasone butyrate propionate lotion and the treatment adherence during continuous eight-week monitoring of patients who switched from a steroid ointment of the same class (‘very strong’steroids), for external use on the trunk and limbs. Switching to betamethasone butyrate propionate lotion yielded significant improvements in the severity scoring of atopic dermatitis index,thymus and activation-regulated chemokine levels, visual analog scale scores, lack-of-sleep index, and dermatology quality of life index. Questionnaire responses revealed high ratings for the sensation on application, suggesting that the lotion contributed to improved adherence. The results of this study indicate that switching to a lotion may be an effective option for the treatment of atopic dermatitis on the trunk and limbs.
Dr. Gilliet is Professor of Dermatology and Chairman of the Department of Dermatology at the Lausanne University in Switzerland. Over the past 15 years Dr. Gilliet's laboratory has focused on translational research studying inflammatory skin diseases. In particular, Dr. Gilliet's lab has discovered mechanisms how dendritic cells initiate and drive inflammation in skin diseases including psoriasis and lupus based the complex formation of self-DNA with antimicrobial peptides. These studies provided a paradigm shift in the understanding on how sterile inflammation is regulated at the site of disease.