In october 2005, we opened the Atopic Dermatitis Clinic at Obama Public Hospital in the Department of Dermatology. Before its establishment, our medical care proved to be a total failure because of our outpatients inadequate knowledge of atopic dermatitis, their inappropriate use of medicine, and their insufficient knowledge of skin care. It was common to see patients with a resistance to steroids and treatment was difficult to explain to patients in the time of a typical doctor-patient visit. It was thought that we would get more satisfactory results in paitient outcomes with the opening of the Atopic Dermatitis Clinic. In order to determine the general outcomes of our outpatients we issued them a questionnaire.

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A 33-year-old woman with atopic dermatitis had been treated with some kinds of topical ointments. She applied Hirudoid®soft, which was prescribed by a dermatologist, but 2 weeks after, itchy erythematous macules developed on the applied parts. When she applied again Hirudoid®soft prescribed by another clinician, itchy erythema developed at the next day and were getting worse. Topical steroids were effective for the eruption. At her first visit, brownish erythematous macules were seen on the neck, upper extremities and anterior chest. The result of patch testing showed positive reactions to Hirudoid® soft and a mixture of glycerol ester of fatty acids, one of constituents of Hirudoid®soft. From these results, contact dermatitis due to glycerol esters of fatty acids contained in Hirudoid®soft was diagnosed in this case.

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We report a case of atopic dermatitis with licorice-induced pseudoaldosteronism. For the treatment of atopic dermatitis, a 19 year-old woman received Chinese herbal medicines, Kamishouyousan and Epikajyututou, which contain 1.0g and 1.3g licorice extracts, respectively. After 6 weeks of use, patient presented with edema on her lower legs. Her plasma renin activities and plasma aldosterone levels were undetectable. She was diagnosed with licorice-induced pseudoaldosteronism. The symptom and clinical data normalized within 2 weeks after terminating use of these Chinese herbal medicines.

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We used carbon dioxide laser to treat refractory cutaneous ulcers of 2 cases resistant to various topical treatments. Biopsies of the ulcers revealed that regenerative epithelium entered into the bottoms of the ulcers and rolled the wound surface up. We thought that regenerating epithelium rolling up a wound surface might disturb wound healing in such chronic ulcers. The carbon dioxide laser was very effective to remove the regenerating epithelium and to activate wound healing process. We discuss here the merits of carbon dioxide laser treatment for refractory cutaneous ulcers.

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A 53-year old woman presenting with bullae and ulcerations on her lower limbs was diagnosed with coma blisters. In October 25, 2000, she was found by her daughter in an unconscious state, possible due to administration of excessive amount of major tranquilizers and sedatives in an attempted suicide. Upon being transported to our emergency room, apparent tense bullae under comatose condition led to a diagnosis of “coma blister”. The mechanism of coma blisters is not fully understood. Various complications have been reported.
The diagnosis of coma blister is the first line diagnosis in a patient with “blistering in or after coma”. Such patients should be intensively evaluated and treated under consideration of serious complications.

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A 63-year-old male showed several erythematous macules on his trunk, extremities, and scrotum after he took a PL® granule and a Flomox® tablet for a common cold. An erythematous macule on his left lower leg persisted as a pigmented macule, whereas the others disappeared within 7 days. He had experienced the same reaction twice in a recent year, when he had taken the same two drugs. An oral challenge test with acetaminophen (200mg), one of the constituents of PL®, induced erythematous reactions on the pigmented macule of his left lower leg at 5 hours and the reappearance of erythematous macules on the previously responded sites on his trunk, extremities and scrotal skin at 24 hours. Thus, mixed pigmented and non-pigmented type of multiple fixed drug eruptions due to acetaminophen was diagnosed in this patient.

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We report a case of scleroderma-like reaction induced by TS-1^®, a compound drug of tegafur. An 81-year-old man with recurrent oral cavity cancer was treated by TS-1^®. Ten days after administration of TS-1^®, he felt stiffness in his fingers. After 14 days, edematous erythema developped on the face. Skin stiffness on his forearms and fingers and around his mouth was recognized. Anti-nuclear antibody was 80-fold. Histopathology of skin biopsy specimen revealed fibrotic change in the deep dermis. After discontinuation of TS-1^® and administration of prednisolone 20mg per day, progression of sclerotic change was arrested.

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A 23-year-old man was seen with a 5-year history of multiple asymptomatic keratotic lesions which were distributed throughout the body except for head, palms and soles. Histopathologic examination of the biopsy specimen revealed the cornoid lamella. As patients with disseminated superficial porokeratosis(DSP) are predisposed to skin cancer, they should be fully evaluated periodically. At this time, there is no cure for DSP to inhibit malignant alteration. Further study of causative gene will explain the pathogenesis of this disorder which will lead to development of new treatments.

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A 42-year-old woman presented with a diffuse, erythematous and indurated facial edema on April 2005. Histopathological examination of a skin biopsy revealed cavities of different sizes and granuloma formation in the subcutaneous fat tissue, which led to the diagnosis of foreign body granuloma. The likely cause was injections of some substance in her face for cosmetic augmentation about 15 years ago in a non-medical institution in the foreign country. We surmised that the injected foreign material was most probably a silicone. We started treating the foreign body granuloma with minocycline at 100mg per day and obtained significant improvement in the swelling and induration. Minocycline was stopped approximately after 3 months of the therapy, and there has been no recurrence of the symptoms for 4 months since then. The beneficial effects of minocycline are thought to be related to anti-inflammatory and/or immunomodulating effects and to antigranulomatous properties which has been demonstrated in vitro.

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A 52-year-old woman had been noticing a subcutaneous mass on her right inguinal resion and a skin lesion on her right thigh since June 2005. Lymph node biopsy from right inguinal area was performed in department of surgery, Aijinkai Takatsuki Hospital in October, 2005, and it was diagnosed as lymph node metastasis of squamous cell carcinoma. Skin cancer with inguinal lymph node metastasis was suspected and skin lesion of the right thigh was excised in department of dermatology, Aijinkai Takatsuki Hospital. Histopathological observation of the skin lesion also suggested the evidence of squamous cell carcinoma, the patient was referred to Osaka Medical College for the evaluation and therapy of the disease. Reexamination of the specimen showed that the skin tumor can be diagnosed as malignant trichilemmoma, and the lymph node can be diagnosed as malignant proliferating trichilemmal tumor histopathologically. By the additional and detailed histological examination, we finally confirmed that the patient have malignant trichilemmoma of the skin with inguinal lymph node metastasis.

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An 88-year-old male developed an eczematoid lesion in the genital area about 3 years earlier but did not seek treatment because of no symptoms. In March 2006, he was referred to our department. At the initial examination, an infiltrative erythematous macule (57×42 mm) accompanied by erosion and a nodule was observed in the genital area. Differentiation from extramammary Paget’s disease was necessary. However, since well-differentiated adenocarcinoma accompanied by decapitation secretion was observed immediately below the nodule, a diagnosis of apocrine adenocarcinoma and its Paget’s phenomenon was made. Initially extensive resection was planned. However, his family did not desire active treatment because of his advanced age and dementia. Therefore, simple resection of the primary lesion with the least margin was performed. This patient made us realize again the difficulty in the treatment of malignant tumors with a poor prognosis in the elderly.

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A 43-year old woman found a rice-sized tumor on her forehead, and the tumor gradually enlarged with some pain. Six months after that, she came to our hospital. She had a firm, 12×10 mm sized, erythematous tumor on the right forehead in the examination. Histologic examination revealed large cell masses with cribriform and tubular pattern through the dermis. Perineural invasion was also seen. Other obvious primary lesion were not detected in the systemic examination. From these findings we diagnosed this tumor as primary cutaneous adenoid cystic carcinoma. Wide local excision was performed 7 mm apart from the tumor margin. No recurrence or metastasis of the tumor has been observed in the course of three years’ follow up.

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We report a case of desmoplastic malignant melanoma. A 66-year-old man had a pigmented spot on his right cheek.
He had noticed a black nodule which grew gradually on the surface of the spot since April in 2004, the nodule was excised, and its histopathological examination showed proliferation of amelanotic spindle-shaped cells with desmoplasia. On immunohistological examination S-100 and Vimentin stains were positive, while HMB-45 stain was negative. Based on these findings, we diagnosed this tumor as desmoplastic malignant melanoma.

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We report two cases of relative rare fibrolipoma of which pre-operative diagnosis suggested malignant tumor as a potential diagnosis.
Case1 : 59-year-old male presented with palpable 4×4cm tumor on the nuchal region. There was low and fat signal isointensity in the tumor area on MRI findings. The tumor was resected and histopathologic examination revealed fibrolipoma. Post-operative course was uneventful and no recurrence was found at 13-months follow-up point. Case 2 : 59-year-old male presented with slowly progressive mass on the nuchal region. Preoperative MRI showed 53×26mm tumor with combined low and fat signal isointensity. Postoperative histopathologic findings of the specimen revealed fibrolipoma. At 14-months follow-up point, no signs of recurrence were seen. The diagnosis of fibrolipoma should be considered in patients who have slow progressive mass on the nuchal region with combined low and fat signal isointensity on MRI imaging.

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Ninety four years-old male noticed a cutaneous painful tumor(about 1cm in diameter) on his right knee 3 years ago. Although spontaneous pain was unremarkable, severe pain was induced by daily minimal mechanical stimuli, thus this was problematic in daily care of the patient. At the initial examination, dark-purplish and elastic tumor with smooth surface was observed. Surgical resection was done, and a diagnosis of glomus tumor was made pathologically. After the excision, pain disappeared completely. We reviewed reported cases of glomus tumor developed on extremities (other than fingers and toes) from 1994 to 2004 in Japan. As a result, only 10 cases of the tumor developed on knee, and there was no case with over 90 years of onset age.

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A 45-year-old man noticed subcutaneous nodules on the forehead and the neck 5 months before the first visit. He had also a stomach tumor, which had been diagnosed as a leiomyosarcoma 2 months before the visit.
Biopsy specimens revealed that the tumors were composed of spindle shaped cells with pleomorphic nuclei. The tumor cells demonstrated positive staining for α-smooth muscle actin and negative for CD34 and KIT. Extensive clinical investigations revealed multiple metastatic tumors in the stomach, kidney and intestines. Then, skin tumors were diagnosed as skin metastasis of leiomyosarcoma.
Skin tumors increased in the number, and finally resulted in more than 40 mass lesions. The autopsy findings strongly suggested that a leiomyosarcoma originated from the left kidney and multiple metastases occurred to the skin.

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It is rare that the leiomyosarcoma occurs in the skin and subcutaneous tissues. We experienced 2 cases of cutaneous leiomyosarcoma.
Case 1 : An 85-year-old woman came to our hospital complaining of a 3-month history of red mass on her left cheek.
Case 2 : A 63- year-old woman consulted our hospital for the examination of orange-colored mass on her left shoulder which was noticed one month before. Histopathological and immunohistochemical analyses revealed that both patients had leiomyosarcoma. Surgical resection including 3cm margin of the normal skin and reconstruction was performed.

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A 66-years-old Japanese male presented to our clinic with the papillomatous skin lesion on the left ear. Histopathology of the lesion showed dermal dense infiltration of atypical large lymphoid cells composed of CD20 and Bcl-2 positive-centroblast and -centrocyte like cells. From these observations, we diagnosed the patient as being with follicular lymphoma. Involvement of lymph nodes in coeliac was identified by CT scan. These tumors have been regressed by radiation therapy. We also summarized the clinical features and treatments for follicular lymphoma reported in our country.

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We report a case of staphylococcal scalded skin syndrome (SSSS) in an adult. A 57-year-old woman with stupor and severe malnutrition developed diffuse erythema and edema on her face. Scaling and crusting then appeared in the perioral region. Erythroderma with exfoliation and erosion rapidly spread to her trunk and extremities. Nikolsky’s sign was positive. We used frozen-sections of a skin biopsy for rapid histological diagnosis of SSSS, which disclosed a cleavage in the upper layer of the epidermis. Methicillin-resistant Staphylococcus aureus was cultured from the skin, arterial blood, pharynx and everywhere else tested. She was successfully treated with intravenous arbekacin sulfate. The most important disease that should be diagnostically separated from SSSS in adults is drug-induced toxic epidermal necrolysis (TEN). Since standard treatments for SSSS and for drug-induced TEN are entirely different, dermatologists should acquire rapid and reliable procedures for histologically differentiating between these two diseases.

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The patient was a 47-year-old female whom painful flare appeared on the medial side of the left lower leg in April 2003. The patient visited a physician, and was diagnosed as phlebitis. Anti-inflammatory and antiplatelet agents were administered, but the symptoms aggravated, and the patient was referred to our hospital in August 2003. On the first examination, induration accompanied by pain and flare was noted at a site consistent with the great saphenous vein on the medial side of the left lower leg. Administration of anti-inflammatory agent and antibiotics was initiated, but the symptoms did not improve, and the patient was admitted for treatment at the end of August 2003. Resting and drip infusion of antibiotics improved the symptoms, and the patient was discharged after 10 days. However, the induration recurred after discharge, and spread. Based on these findings, mobile phlebitis was diagnosed. Anticoagulant treatment was initiated around the middle of October 2003, but remission and aggravation repeatedly occurred. The patient was again observed from around the middle of April 2004, and the induration spontaneously remitted in early December 2004.

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A 62-year-old husband and 57-year-old wife presented to our clinic with papular pruritic eruptions on their trunks and extremities. Scabies was suspected, but, no mites or eggs were detected by microscopy from their skin. Their domestic dog was found to have erythematous maculopapular eruptions with crusting and alopecia accompanied by secondary self-traumatic excoriations. Many mites, eggs and feces were found from the crust. The dog was treated by ivermectin. The couple’s symptoms cured by topical corticosteroid and oral anti-allergic drugs. Though we could not find mites or eggs from the couple’s eruptions, we diagnosed them as canine scabies by circumstantial evidences.

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A 66-year-old woman who had erythematous papules on the face with joint pain in her legs visited our clinic. Although laboratory data showed no abnormalities and serological tests for syphilis were negative, she believed and insisted that she was infected with syphilis that caused those symptoms. She also consulted an orthopedist and a physician, but her symptoms were not resolved. She then saw us again and complained that some insects appeared from her skin. However, those were only dusts and scales. From these findings, the patient was given a diagnosis of delusions of cutaneous parasitosis associated with delusions of infection with syphilis. Oral pimozide was effective and her symptoms gradually improved. Delusions of cutaneous parasitosis may be a psychiatric disease, but most of the patients need help of dermatologist. We have to deal with them by appropriate counseling and medications.

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A man in his thirties presented with multiple scaly oval reddish macules, papules, and nodules on his face, limbs, and trunk. He had suffered from pharyngitis for two months. Serologic tests showed that he was infected with HIV and Treponema pallidum. Histopathological examinations revealed psoriasiform epidermal hyperplasia, and superficial and deep dermal perivascular infiltration of lymphocytes, histiocytes, and plasma cells. He was diagnosed with secondary syphilis coinfected with HIV. After treatment with oral amoxicillin 1.0g/day for 8 weeks, the macules, papules, and nodules disappeared.

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In recent years, the number of cases of scabies has been increasing due to the growing number of senior citizens living in communal nursing facilities. Various drugs exist for the treatment of scabies. Oral medicine for scabies has been authorized recently. However, some of these drugs are often hard to obtain. In cases of pregnant women and children their use are limited.
Sulfur and Camphor Lotion is inexpensive and almost always available for institutional use. We tried Sulfur and Camphor Lotion in conjunction with Eurax^® or Salicylic Acid Petrolatum for the treatment of 7 patients of scabies in 2 week and 4 week periods. In all cases patients healed without side effects.

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A clinical experiment was conducted in order to evaluate the safety and effects of a treatment aid in patients with atopic dermatitis or asteatosis. The test products were the “FDR series” cosmetic skin care products comprising cleansers and moisturizers. Evaluation was performed by clinical examination and the observation of tape-stripped corneocytes on the arms and face of 241 patients who used the test products for 4 weeks along with therapeutic drugs. On clinical examination, more than 70% of the patients exhibited moderate or considerable improvement, and more than 60% of the patients who did not require the therapeutic drugs also exhibited moderate or considerable improvement. The incidence of adverse effects due to the test products was low ; adverse effects were observed in 6 patients. These results suggested that the FDR series can be used as skin care products to support the therapeutics used to treat atopic dermatitis and asteatosis. For comparison of product efficacy in seasonal usage, the patients were categorized into 3 groups according to the season in which they used the products. The clinical features of the skin improved significantly and identically in all 3 groups, i.e., in patients who used the products in summer, autumn, and winter. Desquamation of the tape-stripped corneocytes improved significantly in patients belonging to the summer group. These results indicate the benefits of moisturizing the skin not only in winter but also in summer.

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Twenty cases with hypercalcemia, who were treated with calcipotriol (Dovonex^®) ointment, were surveyed and risk factor of hypercalcemia was analyzed. Suspected risk factors are as follows : complication and history of renal disturbance, hypertension, hyperuricemia and diabetes ; combined administration of calcium, cyclosporin, etretinate, topical and systemic corticosteroid, other topical active vitamin D₃ and emollient. Algorithm for prevention is presented.

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