A 79-year-old male suffered from intense pruritus for about 10 months. Topical corticosteroid applications provided little relief. Physical examination showed faint red papules located symmetrically on the neck, trunk, and limbs without erythroderma or desquamation. On skin biopsy specimen, atypical lymphocytes infiltrated densely into the upper dermis with epidermotropism, and Pautrier microabscesses were present. Peripheral blood tests showed Sézary cell count ＞1,000/μL. Flow cytometry revealed infiltration of tumor cells into lymph nodes and bone marrow. The patient was diagnosed as Sézary syndrome (SS). Sézary syndrome is a cutaneous T-cell lymphoma defined by erythroderma, lymphadenopathy, and circulating atypical T cells with poor prognosis. In our case, the symptoms were intense pruritus and inconspicuous eruption, without erythroderma at the first visit. Only 25.5% of SS patients present with erythroderma from the first visit, and 5.7% do not eventually develop erythroderma. It is reported that 86% of SS cases without erythroderma have strong pruritus. Although the mechanism of erythroderma has not been clarified, immune abnormalities and partial deletion of skin-homing molecules in Sézary cells may contribute to the absence of erythroderma. Dermatologists should be aware of non-erythrodermic variants of SS. Skin Research, 21 : 267-271, 2022

A 48-year-oldJapanese male complainedof a postoperative tumor that expandedgradually. A slightly soft, comparatively well-defined, subcutaneous tumor, 90×45 mm in size, was foundin the middle to the right side of the posterior neck. The patient received surgical resection. Histopathological findings showed haphazardly arranged thick collagen bundles from the dermis to subcutaneous tissue. Adipose tissue and nerve fiber bundles were observed surrounding the tumor. Immunohistological findings showed that the spindle-shaped cells between the collagen bundles were positive for CD34, CD99, andvimentin. This case was diagnosedas nuchal-type fibroma. Although it is a rare disease with only a few cases reported in Japan so far, regular postoperative observation is necessary because of the possibility of recurrence. Skin Research, 21 : 272-275, 2022

A 75-year-old male developed anaphylactic shock after administration of the CT contrast agent iopamidol (Oypalomin ^○R ) and was hospitalized to our hospital. Immediate-type reactions after intravascular injection of iodinated radiocontrast media were considered to be non-allergic mechanisms such as the direct histamine-releasing effects of iodinated radiocontrast media and nonspecific complement activation. However, increasing evidence suggests that there is a drugspecific true IgE-mediated allergy among the immediate reactions, and it can be differentiated from non-allergic reactions using skin tests. We have developed an iodinated radiocontrast media allergy test protocol based on previous publications that reported how to identify the allergic reactions. According to the protocol, we performed an intradermal test of a 10-fold diluted solution of iopamidol in a patient. The immediate reaction of the intradermal test of iopamidol was positive, whereas the intradermal test for all other iodine contrast media was negative. The patient was diagnosed with immediate allergy to iopamidol. As iohexol had a negative intradermal test and showed no symptoms in the intravenous test, it could be used as an alternative drug. Although the mechanism of the iodine contrast medium allergy is unclear, devising such a protocol is useful for differentiating allergic reactions with iodine contrast media. It will be very useful for patients to find alternative contrast media that can be used in the future. We will continue to use this protocol and improve it. Skin Research, 21 : 276-282, 2022

A 36-year-old man underwent coil embolization for a cerebral arteriovenous malformation. Three days later, the patient developed painful dendritic purpura on his right sole and toes, which was suspected of cholesterol crystal embolism (CCE). Skin biopsy showed intravascular mucous-like lamellated basophilic structures in the middle layer of the dermis, and he was diagnosed with hydrophilic polymer embolism (HPE). The skin lesions improved spontaneously within 10 days. Hydrophilic polymers are used as coating agents for endovascular treatment devices such as catheters. HPE is caused by the polymer coating peeling off ; thus, contact between the devices and the calcified vessel walls with devices increases the risk of HPE. All reported HPE cases were elderly people with the arteriosclerotic disease ; however, the present patient had a congenital arteriovenous malformation and was young. It may be difficult to distinguish between HPE and CCE clinically, so a biopsy is necessary for patients who develop livedo reticularis or purpura in the lower extremities after endovascular treatment. is necessary for patients who develop livedo reticularis or purpura in the lower extremities after endovascular treatment. Skin Research, 21 : 283-287, 2022

A 37-year-old man was admitted with fever in the 38°C range, erythema with skin flushing and scaling all over the body, and numerous needle-head-sized pustules, some of which had fused to form a sea of pus. He had a paternal history of psoriasis vulgaris and had himself suffered from the condition for 10 years. He had earlier complained of chest pain, and his creatine kinase level was high ; thus, he underwent contrast (iohexol) -enhanced computed tomography 6 days before admission. On admission, his Psoriasis Area Severity Index (PASI) score was 54.1, neutrophil count was 21,000/μL, and C-reactive protein level was 29.79 mg/dL. Bacterial culture of the pustules was negative. Histopathological examination revealed a thickened club-shaped epidermis,hyperkeratosis, and loss of the granular layer. Some neutrophil aggregations were observed under the stratum corneum, and there were many spongiform pustules. We diagnosed pustular psoriasis preceded by psoriasis vulgaris. We administered topical systemic steroids and oral etretinate capsules (30 mg/day). The rash rapidly improved, and 13 days after admission, the patient was discharged with a PASI score of 22.4. The rapid improvement of the rash suggested that iohexol may have triggered acute generalized exanthematous pustulosis (AGEP) ; thus, additional tests were performed. Iohexol drug-induced lymphocyte stimulation test was negative, the patch test was positive, and we detected no mutation in the IL36RN gene or CARD14 gene exon 2-4. The AGEP score was 10 (using the criteria of the Euro SCAR study group). He met the diagnostic criteria for both pustular psoriasis and AGEP. We diagnosed AGEP based on the rapid disease improvement and the positive patch test. We report a case for whom it was difficult to distinguish AGEP from pustular psoriasis because of the many similarities between the two conditions. Skin Research,21: 288-294,2022

A 61-year-old man presented with severe edematous, urticarial erythema on his face, neck, and trunk after two courses of combination therapy for multiple myeloma with bortezomib, lenalidomide,and dexamethasone (VRD). After the first course of the therapy, he had presented with pruritic erythema and eosinophilia, which improved on topical corticosteroid therapy. The clinical symptoms resolved by administration of anti-allergy drug ; however, they got worse after the beginning of the third course of VRD therapy. Biopsy specimen revealed slight dermal edema and perivascular infiltration of eosinophils without vasculitis ; therefore, we diagnosed as angioedema induced by lenalidomide. After the withdrawal of lenalidomide and administration of oral prednisolone (15 mg/day), clinical symptoms and eosinophilia improved quickly. To our knowledge,cases of angioedema induced by lenalidomide are extremely rare and only six cases have been reported so far. The pathogenesis of angioedema has not been clarified yet, but it has been suggested that the cytokines from eosinophils and IgE-mediated reaction may be involved in the process of induction of angioedema. Further clinical studies based on the accumulation of cases should explore the pathogenesis of this disease. Skin Research, 21 : 295-299, 2022

A 91-year-old man presented with variously-sized, oval, red masses on bilateral lower legs. Histopathologically, atypical large lymphocytes were diffusely and densely infiltrated from just below the epidermis to the middle dermis. Immunohistochemically, tumor cells were positive for CD20,BCL2, MUM1, and C-MYC, and negative for CD10 and BCL6. Ki-67 proliferation index was85%. We diagnosed diffuse large B-cell lymphoma, non-GCB type. Detailed medical interview revealed a history of primary nasal diffuse large B-cell lymphoma 7 years ago. A recurred lesion was detected in the nasal cavity. We concluded that the present case was consistent with a recurrence to the nasal cavity and an infiltration to the lower legs by nasal diffuse large B-cell lymphoma. We administered a combination regimen with rituximab ＋ THP-COP in consideration of past treatment and his age. After two courses of THP-COP, the masses had shrunk. However, additional courses could not be continued because of diarrhea. Treatment with prednisolone and etoposide in addition to local irradiation therapy brought a further therapeutic effect. Although the patient waselderly and had a poor prognosis factor in immunohistochemistry, chemoradiotherapy was efficacious. Skin Research, 21 : 300-306, 2022

A 54-year-old man presented to our hospital with a one-month history of erythema on his face and trunk. During the initial visit, he did not complain of muscle weakness, and blood tests showed a high creatine kinase (CK) level (2,436 U/l). He tested positive for the anti-TIF1-γ antibody and was diagnosed with dermatomyositis. Computed tomography showed liver and multiple lymph node metastases. He was diagnosed with stage IV advanced gastric cancer based on the results of an upper endoscopy. Two weeks after the initial visit, he developed rapid muscle weakness with an increased CK level of 9,083 U/l. Moreover, despite receiving steroid treatment for dysphagia that had developed, his symptoms persisted. Despite chemotherapy, he died four months after the initial visit. In patients with dermatomyositis concurrent with malignant tumor who test positive for antiTIF1-γ antibody, there are relatively less myositis symptoms. However, three patients, including our patient, who had remarkably high CK levels at the initial examination experienced rapid deterioration of myositis-related symptoms, resulting in cancer-stage progression. A literature review suggested that rapid, detailed examination is required to confirm the presence or absence of malignant tumors in patients with dermatomyositis who test positive for anti-TIF1-γ antibody as this condition has a poor prognosis. Skin Research, 21 : 307-313, 2022

We report three cases of cutaneous vascular lesions during anticancer therapy with combinations of ramucirumab and taxane chemotherapy. Case 1 was a 60-year-old man who developed a red nodule on the face. Case 2 was a 46-year-old woman who presented with a red nodule on the neck. Case 3 was a 58-year-old woman who had a fresh-red nodule on the right thumb. Histopathologically, all cases were diagnosed as pyogenic granuloma, and there was no withdrawal or dose-limitation of anticancer drug therapy. Ramucirumab is approved for diverse types of malignancy including nonsmall cell lung cancer, hepatocellular carcinoma, gastric cancer, and colorectal cancer. Dermatologists should be aware that even though there is an association between the cutaneous vascular lesions and ramucirumab, skin lesions can be managed by local procedures and the oncologist can maintain ramucirumab therapy. Skin Research, 21 : 314-320, 2022

A 67-year-old woman with a mass in the back of her head since 40 years ago was referred to our department because the mass had gradually increased in size. An elastic, soft, subcutaneous mass of tennis ball size with slightly poor mobility was found in the occipital region. Ultrasonography revealed a spindle-shaped hypoechoic mass with some linear hyperechoic areas inside, and lipoma was suspected with some depression of the skull. Increased blood flow was also noted at the same site. CT and MRI revealed that although the skull outer plate in contact with the mass was partially lost, the inner plate remained and no intracranial extension was observed. Tissue biopsy diagnosed the mass as a lipoma, and total excision was performed. After five years follow-up, there has been no local recurrence. Intraosseous lipoma is a rare bone tumor. We considered that the intraosseous lipoma had developed within the crown of the skull, destroyed the outer plate, and expanded subcutaneously. To the best of our knowledge, 14 cases of intraosseous lipomas have been reported within the cranial cap, and only one of themwas accompanied by bone destruction ;thus, the present case is an extremely rare occurrence. Skin Research, 21 : 321-327, 2022

A 60-year-old woman had suffered from neck, chest and ankle joint pain for the past 10 years. Five years ago, she developed skin lesions on her palms and soles and was diagnosed with palmoplantar pustulosis. She continued to have recurrent episodes of skin inflammation and abscesses of the chest area, which were treated with incisional drainage and antibiotics following remissions and exacerbations. In our hospital, we also observed erythema, sensations of burning,swelling, fistula, and abscesses in the anterior thoracic region, indicating an increased inflammatory response. In addition, CT, MRI images, and bone scintigraphy revealed subcutaneous abscess, and accumulation on the bone, which led to the diagnosis of SAPHO syndrome. Administration of adalimumab for four months achieved marked improvement of skin and bone lesions. We experienced a case in which the patient did not improve with antimicrobial therapy and incisional drainage but improved markedly with adalimumab. Skin Research, 21 : 328-332, 2022

Three middle-aged and elderly patients with skin infections without underlying disease presented to our hospital during a 3-month period in 2021. Panton-Valentine leukocidin (PVL)-positive methicillin-resistant Staphylococcus aureus (MRSA) strains were detected in all three patients, two of which were highly pathogenic USA300 clones. The mean age of patients with skin infections caused by PVL-positive organisms was lower than that of those with infections caused by PVL-negative organisms (20. 8 years vs. 48. 0 years). The prevalence of PVL-positive MRSA is low in the Kansai area. Our study suggests that PVLpositive MRSA is spreading not only among young patients but also middle-aged and elderly patients. We consider that skin infections caused by PVL-positive MRSA should be paid attention in the Kansai area. Skin Research, 21 : 333-337, 2022