In the present study, therapeutic drug monitoring (TDM), as well as changes in skin lesions and pruritus, was employed to monitor the efficacy of short-term therapy of Cyclosporine A (CyA) on atopic dermatitis. A daily divided dose of 3mg/kg CyA (Neoral®) was administered orally for a week.
One week after CyA treatment, both skin lesions and pruritus had improved significantly. Trough levels were no lower than 110ng/ml, and the area under the concentration-time curve (AUC_0-4) was greater than 2000ng,hr/ml and Cmax was 700-1500 ng/ml. Short-term cyclosporine therapy could be a useful treatment for severe atopic dermatitis in terms of skin lesions and pruritus improvement.

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An 87-year-old woman presented with purpura of the lower leg that had been present since June 2006. Skin biopsy was performed at the first medical examination in September and the histopathology of the skin showed necrotizing vasculitis. From urinary findings and rapidly progressive renal dysfunction, she was diagnosed with rapidly progressive glomerulonephritis. MPO-ANCA was positive. These findings fulfilled the diagnostic criteria for microscopic polyangiitis (MPA). When she visited again in October, purpura of the lower legs had disappeared without treatment. Despite the deterioration of renal function resulting in dialysis, no relapse of eruption occurred. MPA eruptions occasionally disappear spontaneously and the occurrence rate of eruptions as the initial symptom is not high, so it is important for the diagnosis not to omit a skin biopsy.

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A 45-year-old man, who suffered from herpes zoster in the right breast with a Th2-3 lesion, was treated with valaciclovir and Carbamazepine. After 10 days, he developed exanthemic drug eruption erythema exsudativum multiforme diffusely resolving herpes zoster lesion and its periphery. We obtained a biopsy specimen from the erythema exsudativum multiforme exanthemic drug eruption and from the herpes zoster lesion. Compared with the specimen from the erythema exsudativum multiforme exanthemic drug eruption, the specimen from the herpes zoster lesion showed mild infiltration of lymphocytes and no remarkable decrease of Langerhans cells. We report this case with a review of the literature.

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A 24-year-old woman started combination drug therapy of lansoprazol, clarithromycin and amoxicillin (Lansap®) for Helicobacter pylori eradication therapy. Erythematous macules developed on her lower extremities4 hours after administration and spread gradually. At her first visit, diffuse erythema was found over her whole body, except her face. We successfully treated her with oral prednisolone for 10 days. Patch testing gave a positive reaction for amoxicillin and negative reactions for lansoprazol and clarithromycin at 24 and 48 hours. The results of drug lymphocyte stimulation tests for each drug were negative. From these results, we diagnosed this case as erythroderma-type drug eruption due to amoxicillin

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A 75-year-old man was administered imipenem and cilastatin (IPM/CS) intravenously for gall bladder infection and liver abscess. He also developed cardiopulmonary arrest due to coronary artery dysfunction and was treated in a coronary care unit. He developed erythema covering his entire body 20 days after starting IPM/CS, which was discontinued immediately, and treatment with meropenem (MEPM) was started ; however, the skin lesions exacerbated and MEPM was discontinued. Four days after discontinuation of MEPM, wide spread bullae and Nicolsky sign were observed, and a skin biopsy specimen from a macular lesion showed epidermal necrosis with extensive apoptosis and subepidermal bullae. Therefore, he was diagnosed with toxic epidermal necrolysis (TEN) and steroid pulse therapy (methyl prednisolone 1000mg/day for 3 days) was performed. Despite the therapy, his skin lesions did not heal and so plasma exchange therapy (PE) was performed for 2 days. After the second PE, exudation from the erosion stopped and he recovered. A lymphocyte stimulation test with MEPM gave a positive result, suggesting that not only IPM/CS but also MEPM were the causative drugs of TEN. In conclusion, PE should be considered as a useful treatment for patients with TEN induced by drugs, even if the patient is in a serious condition and shows little response to corticosteroid therapy.

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An 81-year-old man with brain infarction was administrated vancomycin chloride due to aspiration pneumonia. Twelve days after treatment initiation, the patient developed multiple edematous and erythematous eruptions over the whole surface of the body, including the oral cavity. The eruptions tended to coalesce, making larger plaques where large and small blisters were distributed. The blisters were histologically subepidermal and immunohistochemically associated with linear deposits of IgA along the basement membrane zone of the epidermis. Indirect immunohistochemistry using 1M salt-split skin as the substrate demonstrated IgA class auto-antibody in the patient’s serum reacting to the epidermal side of the split. Immunoblot analysis disclosed an IgA class antibody recognizing a protein with molecular weight of 230kD. Based on the diagnosis of linear IgA bullous dermatosis induced by vancomycin, the patient underwent treatment with corticosteroids and discontinuation of the drug, and recovered from the skin condition quickly. A summary of 6 similar cases reported in the Japanese literature was also discussed.

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We report a case of linear scleroderma. A 60-year-old woman presented with a nodule on her left shoulder which had appeared 47 years ago and had begun to enlarge downward to her elbow three years previously. The first medical examination showed a 35mm×25mm, dark-red nodule on her left shoulder with a belt-shaped indurated lesion on her left upper arm which was located along Blaschko’s lines. Histopathological examination showed the proliferation of collagen fibers as well as perivascular infiltration of inflammatory cells, mainly in the lower dermis. We diagnosed this patient with linear scleroderma appearing along Blaschko’s lines.

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A 57-year old female patient had found two nodules on her left elbow three months previously. On examination, two skin-colored or pink nodules, 4mm and 6mm in diameter, were seen on the left elbow. She had no history of trauma to the elbow. Laboratory findings showed no evidence of dyslipidemia.
Histopathological findings revealed a granuloma lesion in the dermis with many spindle clefts, some of which were in the cytoplasm of multinucleated giant cells. Lightning materials were observed in part of the cleft by polarization microscope and we diagnosed granuloma cholesterinicum (GC). There have been 11 reported cases of GC. As in our case, most cases developed at easily injured sites, such as the elbow or arm. It is therefore postulated that GC is a type of foreign body granuloma of cholesterol crystals caused by trauma.
More cases should be accumulated to elucidate the pathogenesis of GC.

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A 56-year-old man had swelling of the left inguinal lymph nodes and the lesion was diagnosed as metastasis of genital Paget carcinoma. We diagnosed his condition as T3N1M1 stage IV by histological examination and whole body PET-CT screening. The primary lesion was removed surgically with a 2cm free margin, and we performed a chemosensitivity test by CD-DST (collagen gel droplet embedded culture drug sensitivity test) with a biopsy specimen. After the operation, he was treated with combination therapy consisting of chemotherapy determined in reference to the chemosensitivity test and radiation therapy, and showed a good response to the therapy. In previous studies, it has been demonstrated that not all chemosensitivity test positive agents are clinically effective and that most chemosensitivity test negative agents are clinically ineffective. We think that the chemosensitivity test is useful for selecting anti-cancer agents and that we should make use of this method in treating advanced skin cancer.

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Sentinel lymph node biopsy (SLNB) is the most common and accurate method to detect the first lymphatic basin of metastasis in malignant melanoma. In this study, we applied the SLNB technique with color fluorescence, using Indocyanine Green (ICG), to an advanced melanoma patient with an ulcerated black-to-brownish cutaneous nodule on the back. Sentinel lymph node navigation with ICG could be used to detect micro-metastasis of melanoma cells to the bilateral axillar lymph node regions without adverse events, whereas it was not sufficient with blue dye. ICG dye emits 845 nm color fluorescence with 760 nm excitation and can be visualized dynamically by an infrared camera. This technique seems to be superior to SLNB with a radioisotope for the following reasons : relatively easy approach, available for tracing lymphatic flow around the tumor, and avoiding exposure to radioactive elements. While we used this novel technique for malignant melanoma, further investigation of SLNB with ICG is required for evaluation and precise handling.

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A 48-year-old woman was referred to Kobe-University Hospital with a 3-month history of a slowly increasing number of papules appeared on the labia majora of the vulva. A cervical carcinoma had been treated at the age of 28 by radical hysterectomy followed by radiotherapy and chemotherapy. Histological examination of the papule revealed a dilated lumen lined by a single layer of endothelial cells, which were positively stained with D2-40, a monoclonal antibody specific to lymphatic vessels, in the upper dermis, with overlying epidermal acanthosis and hyperkeratosis. From these findings we diagnosed this case as acquired lymphangiectasia.

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A newborn girl had papular eruptions on the trunk and extremities at birth. The cutaneous lesions changed to blisters and crusts the next day. At her initial visit, scattered pale brownish crusts and papules were present on the trunk and extremities.
Histopathological analysis revealed infiltrative proliferation of histiocyte-like mononuclear cells whose nucleus appears kidney-shaped in the upper dermal layer.
The tumor cells were positively stained with S100 protein, CD1a, and langerin. We initially suspected congenital self-healing reticulohistiocytosis because of the characteristic rash, but we diagnosed Langerhans cell histiocytosis (multi-system multi-site type) on the grounds of an enlarged thymus and lung involvement on a chest computed tomography scan. The rash and lung involvement disappeared after administration of prednisolone. We administered multidrug chemotherapy four months after birth. Her thymus tended to shrink over time but we started re-induction chemotherapy because it began to increase in size again.

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