We investigated the efcacy, safety, and treatment satisfaction of oxybutynin hydrochloride lotion in clinical practice. We recruited 48 patients with primary palmar hyperhidrosis and a Hyperhidrosis Disease Severity Scale (HDSS) score of 2 or higher. Four weeks after starting treatment, HDSS scores had improved to 1or 2 in 76.1% of the patients, and there were signicant improvements in the quantity of perspiration, visual analog scale for sweating, and Dermatology Life Quality Index total score compared with before treatment. Overall, 93.8% (45/48 patients) were able to continue topical application of the lotion. More than half of all the patients (58.4%) were“very satised”or “moderately satised”with the treatment. Furthermore, 75.6% of the patients responded that they liked that“the treatment can be done easily by simply applying the lotion.” Most patients (68.9%) felt the onset of effectiveness was within 1week of starting the treatment. These aspects may have contributed to patient satisfaction. Skin Research, 23 : 165-171, 2024

A 68-year-old Japanese man was referred to our department with a reddish mass on his head for the past year. Hismedical history included left nephrectomy, which wasperformed 14 yearspreviously due to clear cell renal cell carcinoma, type 2 diabetes mellitus, and end-stage renal dysfunction requiring dialysis. Physical examination revealed a red rough-surfaced tumor with black crusts on the right temporal area and dermoscopy exhibited reddish homogeneous areas, whitish veils, white rail lines, and irregular telangiectasias. Hematoxylin-eosin staining revealed tumor cells with pale cytoplasm proliferating within a dense network of vasculature in the dermis. Immunohistochemically, PAX-8 and CD10 were positive, leading to the diagnosis of cutaneous metastasis of clear cell renal cell carcinoma. Clear cell renal cell carcinoma isoften poorly recognized, with skin metastases frequently being the rst detected manifestation. Patients with cutaneous metastases generally have a poor prognosis and require prompt diagnosis and treatment. However, cutaneous metastases can often resemble pyogenic granulomas. This case presents a rare instance of late cutaneous metastasis, occurring 13 years after nephrectomy. Notably, there was a one-year delay between the onset of the skin metastasis and the patient’sreferral to our department. It iscrucial to consider metastasis as a possible diagnosis when examining skin tumors in patients with a history of clear cell renal cell carcinoma, even if 10 years or more have passed since the initial surgery. Skin Research, 23 : 172-176, 2024

A 65-year-oldwoman was treatedwith a combination of encorafenib＋binimetinib (BRAF/MEK inhibitor) andcetuximab for stage IV BRAF mutation-positive rectal cancer 1 month prior to her rst visit. She was referred to our department because multiple small nodules developed on her limbs andtrunk 2 weeks later. At the rst visit, 1-5 mm bright redsmall nodules with a shiny surface resembling cherry hemangioma were observedon her limbs andtrunk. Histopathological examination demonstrated lobular proliferation of dilated capillaries in the supercial dermis. A diagnosis of pyogenic granuloma (PG) was made. After discontinuation of BRAF/MEK inhibitor, the number and size of the small nodules decreased, without development of new lesions, which led to the conclusion that the PG was causedby the BRAF inhibitor. PG can be causedby inammatory reactions, such as infection or trauma, andit can also be triggeredby drugs such as BRAF inhibitor and ramucirumab, a vascular endothelial growth factor receptor-2 monoclonal antibody. In the present case, ramucirumab was administered prior to BRAF/MEK inhibitors ; thus, BRAF inhibitor as well as ramucirumab may have been involvedin the development of PG. In recent years, genetic mutations in the MAPK pathway, including BRAF, have been reported in PG, suggesting that PG is a vascular tumor causedby activation of the MAPK pathway. In the present case, we examined, but could not detect genetic mutations. Further studies are needed to clarify the mechanism of druginduced PG. Skin Research, 23 : 177-182, 2024

A 52-year-old man visited a local doctor after noting a subcutaneous abscess in the posterior neck area. The patient underwent incision and drainage ; however, there was no improvement, and he was referred to our clinic 7 days later. Blood tests showed an increased level of C-reactive protein and CT revealed subcutaneous inammation in the posterior neck area. An emergency debridement was performed under general anesthesia on the same day. Methicillin-resistant Staphylococcus aureus (MRSA) was detected in the tissue culture of the abscess, which was later identied as Panton-Valentine leukocidin (PVL)-positive community-acquired MRSA (CA-MRSA) by genetic testing. After treatment with anti-MRSA drugs, including vancomycin, the patient received local negative pressure closure therapy. As the patient’s condition had improved, he was discharged after 25 days from the hospital. In recent years, infections caused by PVL-positive CAMRSA have been emerging in Japan ; thus, dermatologists should consider that such infections may be the cause of serious skin and soft tissue infections and select antimicrobials targeting MRSA in severe cases with subsequent surgical debridement. Skin Research, 23 : 183-189, 2024

A 35-year-old male presented with an erythematous rash on the trunk and small nodules in the perianal region as the chief complaint. He identied as men who have sex with men (MSM) and had sexual contact with several male partners during the past six months. At the rst clinical examination, tiny erythema was disseminated on the trunk and limbs, in addition to at-topped, red,small nodules in the perianal region. Syphilis serology showed high values. A skin biopsy was performed from a perianal nodule. Histopathological examination showed positive reactivity for Treponema pallidum by immunohistochemistry, conrming the diagnosis of condyloma lata. The erythematous rash was diagnosed as syphilitic roseola. He was administered oral amoxicillin 1,500 mg/day for six weeks, which initially achieved cure ; however, perianal condyloma acuminatum occurred two months later. Herein, we discuss the signicance of perianal condyloma in MSM with recurrent sexually transmitted infections based on current literature. Skin Research, 23 : 190-195, 2024

A 61-year-old woman with a history of recurrent oral aphthous ulcers and vulvar erosions since her 30s. She had been diagnosed with Behçet’s disease and was undergoing treatment with colchicine 1 mg/day, apremilast 60mg/day, and prednisolone 10mg/day. Two weeks before admission, her oral ulcers worsened without an apparent cause. She had experienced difculty swallowing apremilast due to the large pill size and had discontinued it without consulting her doctor. The patient had been instructed to increase her prednisolone dose in response to her symptoms, so she had increased her prednisolone dose from 10mg to 25 mg/day ; however, the oral ulcers persisted. She visited our clinic due to poor oral intake and was admitted urgently. Upon admission, she exhibited multiple painful white erosions across a large area of the oral cavity, with an increased amount of tongue plaque. A KOH test of the tongue plaque was positive, leading to a diagnosis of oral candidiasis and initiation of oral amphotericin B syrup. Although the tongue plaque decreased,the oral ulcers continued. Biopsy of the oral ulcers revealed lymphocytic inltration and immature neutrophils in the mucous epithelium and intermuscular space, conrming an exacerbation of Behçet’s disease. Apremilast was reintroduced, and within ten days, the oral ulcers had almost completely resolved. Apremilast is an oral phosphodiesterase 4 inhibitor that increases intracellular cyclic AMP levels and inhibits the production of inammatory cytokines. It is known to be effective for treating oral ulcers associated with Behçet’s disease. It has a reported response time of about two weeks, which is consistent with this case’s clinical course. This case underscores the importance of maintaining oral hygiene and adhering to prescribed medications in the management of Behçet’s disease, as oral candidiasis and self-discontinuation of apremilast may have triggered the exacerbation. Skin Research, 23 : 196-200, 2024

Herein, we describe two cases of dermatobrosarcoma protuberans with brosarcomatous change : Case 1 : A 36-year-old man presented with a subcutaneous mass in the right rib area, which had gradually increased in size. He recalled a history of trauma to the same area from being struck by disposable chopsticks several years prior. Upon examination and after skin biopsy, the mass was diagnosed as dermatobrosarcoma protuberans (DFSP). An extended excision with a 3 cm margin was performed to remove the tumor. Case 2 : A 40-year-old man noticed a subcutaneous mass on his lower abdomen two months prior. He underwent a total excisional biopsy at the rstvisit. In both cases, the tumors consisted of spindle-shaped tumor cells with storiform pattern. In some areas, there was a dense proliferation of atypical spindle cells arranged in fascicular and herringbone patterns with mitotic gures. Immunohistochemical staining revealed decreased expression of CD34 in the brosarcomatous area. We diagnosed both patients as DFSP with brosarcomatous change (DFSP-FS). DFSP is a relatively rare soft tissue tumor that is considered to be intermediate malignancy. It frequently recurs locally ; however, systemic metastases are rare. DFSP-FS is more likely to metastasize than normal DFSP. In both the present cases, no local recurrence and metastases were observed over 3 years post-operation. It is necessary to perform careful long-term follow-up for the management of DFSP-FS Skin Research, 23 : 201-205, 2024

We present the case of a 52-year-old male with neutropenia induced by adalimumab. He had been diagnosed with psoriasis vulgaris approximately 20 years earlier and was administered adalimumab at our hospital. The improvement rate according to the Psoriasis Area and Severity Index was 75%. Adalimumab was administered at doses of 40 mg or 80 mg per injection. Six and a half years after the start of the treatment, blood tests revealed a decreased neutrophil count. The patient had exacerbation of neutropenia eight and a half years after the start of adalimumab ; however, treatment with adalimumab was continued cautiously. As the exacerbation of neutropenia became more severe and no improvement was observed within the interval of administration, adalimumab was discontinued and ixekizumab was initiated. Ixekizumab proved to be as effective as adalimumab, and absolute blood neutrophil counts signicantly improved one month after the last administration of adalimumab. It is important to recognize that not only IL-17 inhibitors but also TNF-α inhibitors may cause neutropenia. Skin Research, 23 : 206-210, 2024

A 42-year-old male had been aware of asymptomatic swelling of the PIP joints on the dorsal aspect of both hands since childhood. As it did not interfere with his daily life, he did not seek treatment. A few years before his initial visit to our department, he began to experience morning stiffness. On examination, swelling and scaling of the lateral skin of the PIP joints of the second to fourth ngers on both hands were observed. However, there was no pain or limitation of joint range of motion. Radiographic examination revealed soft tissue swelling without any bony lesions. Blood tests were negative for antinuclear antibodies, rheumatoid factor, and other autoantibodies. Histopathological examination of the skin biopsy from the swollen area showed epidermal thickening and hyperkeratosis. Based on these ndings, the patient was diagnosed with pachydermodactyly. Pachydermodactyly can be diagnosed clinically without the need for skin biopsy or MRI. Previous reports have suggested an association with mechanical stimulation, but no specic habits were identied in our case. Although the absence of morning stiffness is considered a characteristic feature of pachydermodactyly, our patient reported experiencing morning stiffness. We hypothesize that the limited number of reported cases of morning stiffness may be due to misdiagnosis,particularly in cases where differentiation from inammatory joint diseases is challenging. Pachydermodactyly is a benign condition that can be easily misdiagnosed. Increased awareness of this condition may help avoid unnecessary investigations and treatments. Skin Research, 23 : 211-216, 2024

A 61-year-old female had painful erythema on the left corner of her mouth and left external canthus a few days before her rst visit to her practicing doctor. She was diagnosed with herpes zoster on the left face and prescribed famciclovir and suprofen ointment. She visited our department the next day due to the appearance of similar erythema on the left side of the abdomen after returning home. Edematous erythema with small vesicles was observed on the left side of the abdomen and left face in the period from the initial visit to the diagnosis of unilateral double herpes zoster. We administered intravenous acyclovir (750 mg/day), which was effective. Herpes zoster usually presents unilaterally on one or several adjacent innervated areas. The frequency of double or multiple herpes zoster, in which the eruption occurs on multiple nonadjacent innervated areas, is low. A review of Japanese reports of double or multiple herpes zoster over the past 40 years revealed that the frequency of patients with underlying conditions was higher (45.5%) among patients with double or multiple herpes zoster than with ordinary herpes zoster. Examination for underlying conditions, such as malignant tumor, should be considered when treating patients with double or multiple herpes zoster. Skin Research, 23 : 217-221, 2024

A 35-year-old man presented with a skin eruption that developed two days after taking medication for a cold. Over the past three years, cold treatments had caused erythema on his buttocks and thighs, which resolved without hyperpigmentation. However, he now experienced erythema accompanied by heat and mild pain in his groin, buttocks, thighs, popliteal fossae, and both sides of his hands. Histopathological analysis revealed minimal changes in the epidermis and lymphocytic inltration around blood vessels in the supercial dermis. Patch testing on the affected skin area using the three drugs he had taken yielded a positive result for the combination tablet of fexofenadine hydrochloride and pseudoephedrine hydrochloride, and a negative result for fexofenadine alone. Oral provocation testing with fexofenadine alone was also negative. We diagnosed the patient with a nonpigmenting xed drug eruption caused by pseudoephedrine hydrochloride in the combination tablet. In nonpigmenting xed drug eruption, large erythematous lesions appear in intertriginous areas, recur in the same location, and resolve within 2 to 3 weeks without hyperpigmentation. Due to its presentation in intertriginous areas, it may initially be diagnosed as an intertriginous drug eruption. There is some overlap between nonpigmenting xed drug eruption and intertriginous drug eruption, necessitating further investigation. The present case represents the fth report of nonpigmenting xed drug eruption caused by pseudoephedrine in Japan. Patch tests were performed in three of these cases, including ours, and all showed positive results, suggesting that patch testing is a useful diagnostic tool. For eruptions in intertriginous areas, we recommend performing patch tests on both affected and unaffected skin areas to examine the possibility of nonpigmenting xed drug eruption. Skin Research, 23 : 222-228, 2024

A 29-year-old woman had clubfoot and repeated joint dislocations since birth. She had been clinically diagnosed with classical Ehlers-Danlos syndrome (EDS). She had multiple histories of giant hematoma formation in her lower legs and head due to trauma. The patient presented to our clinic with a self-destructed giant subcutaneous hematoma in her head. As the scalp became necrotic with infection, the patient underwent debridement and split-thickness skin grafting. Afterwards, she consulted a dentist for gingival damage with food residue. We suspected types of EDS other than the classic type due to a history of recurrent giant hematomas, abnormal teeth alignment (crowded teeth), and a distinctive facial appearance. Genetic testing, followed by genetic counseling, revealed a homozygous missense variant in CHST14,leadingtoadenitivediagnosis of musculocontractural EDS. Musculocontractural EDS is a subtype newly registered in the New International Classication in 2017, with the causative genes identiedasCHST14 and DSE. Giant hematomas and the specic facial appearance observed in our case are characteristic ndings. As many patients with CHST14 variant havea specic facial appearance and crowded teeth, fetal development may be affected by the pathogenic variant. As musculocontractural EDS is a relatively newly classied subtype, accumulation of cases with adequate evaluation and diagnosis, including crowded teeth, specic facial appearance, and giant hematoma formation, is necessary. Skin Research, 23: 229-234, 2024