A 33-year-old man developed purpura and pain in his lower legs 4 days before he was admitted to the hospital. A diagnosis of IgA vasculitis was made by skin biopsy of the purpura on the leg. He was treated using steroid therapy. However, he developed severe abdominal pain and ascites. Many ulcers on the intestine were found by endoscopy of the upper and lower gastrointestinal tract. Skin purpura exacerbated and ascended to his neck. A XIII inhibitor was started, but purpura and abdominal symptom did not improve. He then received steroid pulse therapy and endoxan therapy,which improved abdominal pain and purpura, and the steroid dose was reduced gradually. The activity of vasculitis was considered to be related to the serum CRP, D-dimer, and XIII levels. Three days after discharge, he developed perforation of the small intestinal, necessitating emergency intestinal resection and anastomosis. The cause of small intestinal perforation was unclear. Lower digestive tract ulceration due to IgA vasculitis may have remained even though the skin manifestation and ulcers of the upper gastrointestinal tract improved. During therapy for IgA vasculitis, if the amount of steroid is reduced, it is important to evaluate the lower digestive tract by abdominal ultrasonography and CT because endoscopy of the lower gastrointestinal tract cannot be performed frequently. Skin Research, 20 : 65-72, 2021

A 77-year-old man noted a hemorrhagic nodule on the lumbar region approximately 2 years ago. Physical examination revealed an elevated blacknodule measuring 13×10 mm on the right side of the lumbar region. An approximately 4 mm blackmacule was found at the upper right of the elevated nodule and a 3 mm brown to blackmacule was located lateral to the elevated nodule. Excisional biopsy of the elevated nodule was performed and we diagnosed malignant melanoma based on the pathological findings. The entire lesion including the two small lesions was excised with a 2 cm margin down to the deep fascia. As the two small macules were clinically suspected to be satellite lesions, we suspected stage IIIC melanoma. However, histopathological examination of the entire lesion revealed that they were not satellite lesions because there was inflammatory cell infiltration and fibrosing stroma without atypical melanocyte proliferation. We concluded that the elevated nodule and two small macules in the vicinity were originally a single lesion, and these separated lesions may have formed as a result of spontaneous regression. For the reasons stated above, the final diagnosis was stage IIB melanoma. Skin Research, 20 : 73-79, 2021

A 58-year-old woman diagnosed with seborrheic dermatitis was referred with pruritic scalp and perineal rashes accompanied by extensive scalp hair loss and pain on excretion. Although she underwent routine management with topical steroids, topical anti-fungal agents, oral antihistamines,and zinc supplementation, her skin rash continued to worsen. Clinical and biopsy features were consistent with the diagnosis of seborrheic dermatitis. It was further speculated that unfavorable dietary habits and a poor gut environment, compounded by inherent frailty and the stress of recent lifestyle changes, had a strong influence on herworsening symptoms. Afterstopping all local and systemic medications, she was put on a gluten-, casein-, and sugar-free balanced diet, and prescribed a course of Chinese herbal medicine to improve and stabilize the intestinal environment. After two weeks of treatment, the skin rash started to improve and after six months it disappeared. Based on the pathology, lifestyle-related habits, eating habits, and gut environment, new solutions can be found. Skin Research, 20 : 80-86, 2021

A woman in her 90s without a history of renal dysfunction was diagnosed with herpes zoster 3 days before admission, and began taking valacyclovir at a dose of 3,000 mg per day and NSAIDs. Three days later, she developed impaired consciousness and involuntary movement, and visited our hospital. Laboratory tests on admission revealed a serum creatinine level of 3.36 mg/dl, suggesting renal dysfunction. Based on her symptoms and current valacyclovir treatment, the patient was diagnosed with acyclovir-induced neurotoxicity. Valacyclovir was discontinued and her symptoms rapidly improved. The serum acyclovir level on the next day of admission was 4.0220 μg/ml. Elderly patients often have reduced creatinine clearance even if the serum creatinine level is within the normal range. As acyclovir is mainly excreted by the kidneys, acyclovir-induced neurotoxicity can be caused by the combination of other renally excreted drugs in elderly patients. Therefore, the accurate evaluation of renal function and proper use of co-administered drugs are important,especially when treating elderly patients with herpes zoster. Skin Research, 20 : 87-91, 2021

A 32-year-old male had congenital myotonic dystrophy (DM). He presented with a bleeding nodule on the penis that developed several months ago. Clinical examination revealed a 20×13 mm, yellowish-brown, pedunculated nodule on the base of the penis. Dermoscopy demonstrated blue-gray ovoid nests and shiny white areas. An excised specimen exhibited a polypoid nodule,within which irregularly-shaped, solid nests of basophilic cells extended from the epidermis to the dermis. Tumor cells had round to oval, hyperchromatic, atypical nuclei. The periphery of the tumor nests exhibited a palisading arrangement. There were clefts between the tumor nests and the surrounding stroma, accompanied by mucin deposits. The present case was consistent with polypoid basal cell carcinoma (BCC). DM is known to be accompanied by multiple calcifying epitheliomas. Although DM is usually accompanied by BCC later in life, no case of coexisting polypoid BCC has been reported to the best of our knowledge. As the mechanism of onset is not clear, accumulationof further cases is necessary. Skin Research, 20 : 92-96, 2021

A 69-year-old woman presented with itchy blisters and erythema on her trunk and upper limbs that developed 6 months ago. Skin biopsy revealed an intraepidermal blister with acantholytic cells in the cavity. Direct immunofluorescence demonstrated intercellular deposits of IgG and C3 in the epidermis, and anti-Desmoglein1 antibodies were detected by enzyme-linked immunosorbent assay (ELISA), resulting in the diagnosis of pemphigus foliaceus. Although her skin condition improved by tetracycline, niacinamide, diaminodiphenylsulfone and topical steroid treatment, her rash temporarily recurred 7 years later in association with an increase in anti-Desmoglein1 antibody. Four months later, itchy tense bullas developed on her limbs. Skin biopsy revealed subepidermal bulla containing eosinophils. Direct immunofluorescence detected depositions of IgG and C3 along the basement membrane zone and in the intercellular space of the epidermis, and anti-BP180 antibody was positive on ELISA, resulting in the diagnosis of pemphigus foliaceus accompanied by bullous pemphigoid. She was treated using oral prednisolone. The onset of bullous pemphigoid in our case may have been related to pemphigus foliaceus. When skin lesions different from the original diagnosis develop during the clinical course of autoimmune blistering disease, further investigation for a new blistering disease is required. Skin Research, 20 : 97-103, 2021

A 69-year-old female with known eosinophilic fasciitis treated using 7.5 mg/day of prednisolone (PSL) was referred to our hospital for painful skin lesions following cosmetic treatment. One month before the first clinical visit, she received injections of hyaluronic acid fillers in the corners of her mouth at a cosmetic surgery clinic. Painful erythema and indurative lesions developed at the injection sites one week later, and she received hyaluronidase injections at the cosmetic surgery clinic. Subsequently, infiltrative erythema developed at non-injected sites on her face, left upper arm, and right thigh, and she was referred to our hospital. Histopathological examination of a biopsy specimen from indurated erythema on her right thigh revealed a foreign body granuloma in the subcutaneous tissue and the lower dermis. We administered 15 mg of PSL (total PSL dose :22.5 mg/day) and her symptoms gradually improved. She is currently being followed up with a tapered dose of PSL (12 mg/day). Most reported cases of foreign body granuloma after hyaluronic acid filler injections occurred at the injection sites. However, in this case, multiple cutaneous lesions of foreign body granuloma appeared at both the injected and non-injected sites. This is a rare case and suggested an association with the underlying eosinophilic fasciitis. Skin Research, 20 : 104-109, 2021

A 49-year-old woman developed fever after exposure to a child diagnosed with erythema infectiosum. The fever resolved in 1 week ; however, she developed lower leg edema and arthralgia. As the symptoms continued for approximately 6 months, she was referred to our department. We prescribed oral prednisolone (8.5 mg/day) and celecoxib (400 mg/day), but her symptoms did not improve. After she was admitted to our department, the lower leg edema improved by rest only, but arthralgia was prolonged even though we increased the amount of prednisolone to 20 mg/day. We added methotrexate (8 mg/week), and arthralgia decreased 1 week later. The standard treatment for joint symptoms after viral infection has not been established. We consider methotrexate to be effective in the case of persistent arthralgia after human parvovirus B19 infection. Skin Research, 20 : 110-114, 2021

We report three cases of nodular fasciitis. Case 1 was a 53-year-old Japanese female. A subcutaneous nodule developed on the flexor site of the left forearm 7days earlier, and spontaneously disappeared after biopsy. Case 2 was a 29-year-old Japanese female. A subcutaneous nodule developed on the flexor site of the right forearm 10 days earlier, and spontaneously disappeared after biopsy. Case 3 was a 64-year-old Japanese female. A subcutaneous nodule developed on the flexor site of the left forearm without recurrence after enucleation. The onset time was unknown. All patients exhibited irregularly-shaped nodules with a fingerlike projection in which pleomorphic spindle cells proliferated from the septa to the lobules in the subcutaneous tissue. A vague storiform pattern was noted in myxoid stroma in case 1. An intertwining arrangement was observed in collagenous stroma in case 3. Osteoclast-like giant cells were scattered. Immunohistochemically, all patients were positive for α-smooth muscle actin, but negative for desmin and CD34. The proliferation indexes of Ki-67were 20%, 20%, and 2% in case 1,case 2, and case 3 respectively. Although the index in case 3 was lower than those in previous reports, it may have been because of the late lesion at the time of enucleation. The accumulation of further cases is required to assess the Ki-67proliferation index in nodular fasciitis. Skin Research, 20: 115-121, 2021

Methotrexate (MTX), a common anti-rheumatic drug, became available for psoriasis treatment in November 2018 in Japan, and use by dermatologists is expected to increase. However, MTX is associated with a high frequency of adverse effects and requires careful administration. We report a case of agranulocytosis induced by methotrexate, which was diagnosed based on concurrent herpetic mucositis and herpes zoster. The patient, an 82-year-old female, received MTX for polymyalgia rheumatica and was hospitalized for herpes zoster on the left lower limb and an aphthous oral ulcer. After admission, MTX was discontinued due to agranulocytosis, and she was treated using folic acid,acyclovir, and granulocyte colony-stimulating factor. All symptoms improved as a result of these treatments. Biopsy of the oral mucosa and viral antibody tests demonstrated that the aphthous ulcer was due to HSV-2 infection. MTX use is associated with many side effects ; therefore,dermatologists should be familiar with them and their treatment methods. If stomatitis occurs during MTX administration, the possibility of HSV infection should be considered. Skin Research, 20 : 122-127, 2021

A 70-year-old man visited a clinic for skin rashes on his left thigh and buttock, and was diagnosed with herpes zoster. Four days after starting famciclovir treatment, he developed headache, nausea, and low fever, and came to our hospital. At the first visit, there was a generalized rash of painful and pruritic vesicles on the neck and trunk, in addition to the left sacral region, buttocks, and lower extremities. We diagnosed him with generalized herpes zoster and he was immediately admitted to the hospital. On the same day, we consulted a neurologist for the possibility of meningitis associated with herpes zoster. Based on spinal fluid examination, meningitis caused by varicellazoster virus was diagnosed. After treatment using double-dosing with acyclovir, his symptoms of headache, fever, nausea, and rash improved markedly, and he was discharged 17days after the admission. The complication of meningitis due to herpes zoster is relatively rare. If any of the three symptoms of headache, nausea, and fever over 37°C are present after the start of treatment for herpes zoster, meningitis should be considered and a neurologist should be contacted as soon as possible. As there have been no reports on herpes zoster-related meningitis and the exact frequency is still unknown, similar cases should be accumulated. Skin Research, 20 : 128-133, 2021

An 80-year-old woman was referred to our hospital with four black tumors on both axilla and upper right arm that developed over the past 10 years. She visited her previous doctor because bleeding from the tumors was noted 9 months before our first visit. After the diagnosis of BCC by the previous doctor, all of the tumors were removed by wide surgical excision with a 3 mm normal margin. A new tumor in the left axilla was found during the follow-up period of 9 months. There have been 358 cases of BCC between 1991 and 2020 at our hospital, but BCC in the axilla is rare. In our 21-year experience, only 9 cases of axillary BCC have been confirmed. We present a rare case of multiple BCC at both axilla. Skin Research, 20 : 134-140, 2021

Biopsy examination of a 61-year-old male with digitate dermatosis demonstrated small-scale Pautrier’s microabscesses just above papillary dermis, atypical nuclei of infiltrating mononuclear cells, and aberrant loss of CD7 antigen of infiltrating T cells. Narrow band UVB irradiation therapy was successful, but this case may possess the capacity to progress to mycosis fungoides and requires further careful follow-up. Skin Research, 20: 141-144, 2021

In this study, a patch test of skincare products (sunscreen and makeup cosmetics) containing metal materials and patch test reagents was performed to assess the causes of metal allergy for 30 patients examined at the Department of Dermatology in Shiga University of Medical Science between September 2018 and December 2019. We included patients in whom metal allergy was suspected from the manifestation of past symptoms. After 48 h of occlusive application, they were removed and judged according to the ICDRG (International Contact Dermatitis Research Group) criteria and the Japanese standard criteria for determining the patch test at 2h, 24 h, and 1 week after patch removal. Allergy was diagnosed when reactions were rated as“＋”(at over 24 h after patch removal) according to the ICDRG criteria. Moreover, the metallic species responsible for allergy was identified in approximately 16 out of 30 cases ; however, there were no allergic reactions to skincare products in any of the patients, including these 16 patients. There was no significant difference in the irritant response (irritation index) between 16 patients with metal allergy and 14 without metal allergy according to the Japanese standard criteria. In dermatology practice, it is necessary to confirm the existence of allergy and the causative metal for patients with metal allergy. Moreover, cosmetics contain metallic components for UV protection, skin protection, and coloring. Therefore, it is important to confirm the characteristics of the formulation, such as inhibition of metal ion release and surface coating, and then prescribe it according to the patient’s preference. Skin Research, 20 : 145-151, 2021