A Case of Generalized Pustular Psoriasis with Organizing Pneumonia During Treatment for Rheumatoid Arthritis.

Generalized pustular psoriasis (GPP) is a disease that presents with fever and multiple sterile pustules on flushed skin all over the body. GPP should be considered as systemic inflammatory response syndrome (SIRS), and is occasionally associated with respiratory failure. We encountered a case of GPP with organizing pneumonia (OP) during treatment for rheumatoid arthritis (RA). A 74-year-old Japanese woman with RA developed fever and erythema with small pustules on the trunk and extremities. She was diagnosed as GPP and admitted to our hospital. During the clinical course, she suffered hypoxia from OP. Although RA and OP are known to coexist, GPP and OP share the involvement of cytokines such as interleukin 8 in the pathogenesis. These cytokines are therefore also involved in the complications of GPP and OP.

Case of Pilomatricoma After Coronavirus Disease 2019 Vaccination.

The coronavirus disease 2019 (COVID-19), which is an infection caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), spread worldwide including Japan. This COVID-19 pandemic has changed the way of life around the world. To prevent the spread of infection, several COVID-19 vaccines were rapidly developed and their vaccination is recommended. While safety and effectiveness of these vaccines have been shown, various adverse reactions occur with a certain frequency. Pilomatricoma is a benign subcutaneous tumor. Cause of pilomatricoma is unclear, however, an external insult could be a cause of part of pilomatricoma. Herein, we report a rare case of pilomatricoma after COVID-19 vaccination. Pilomatricoma should be included in the differential diagnoses of nodular lesions arising after vaccination sites, including the COVID-19 vaccine.

Zinc Deficiency with Cheilitis: A Report of Five Cases.

Zinc deficiency has long been known as acrodermatitis enteric dermatitis (congenital zinc deficiency). On the other hand, acquired zinc deficiency has attracted attention as a familiar disease in recent years. Epidemiological studies in Japan have shown that acquired zinc deficiency is more common than expected. It is also known that serum zinc levels fall markedly with age. In this report, several cases of acquired zinc deficiency that caused cheilitis are described. In all cases, the only symptom was cheilitis, the serum zinc level was low, and all cases were relieved by zinc supplementation. Zinc deficiency is associated with a range of pathological conditions, including mucocutaneous symptoms, delayed wound healing, dysgeusia, anemia, impaired immunity, and retarded growth development disorders. However, zinc deficiency may be overlooked even in cases of cheilitis alone. Especially in intractable cases, it is important to suspect zinc deficiency as one at the differential diagnoses.

Case of Wound Myiasis in a Squamous Cell Carcinoma Lesion of the Scalp.

Myiasis refers to the infestation of living humans and vertebrate animals by dipterous larvae. Many organs can be infested by fly larvae, but cutaneous and wound myiases are the most frequently encountered clinical forms. Persistent ulcer or non-healing wound is one of the symptoms of squamous cell carcinoma which is the second most common skin cancer in the world. Here we report a case of an elderly man with a severe wound myiasis in a squamous cell carcinoma lesion of the scalp. The maggots were confirmed to be Lucilia sericata which are widespread flies in Japan. Human myiasis is rarely reported in Japan, but patients with necrotic, hemorrhaging, or pus-filled wounds are susceptible to infestation. It is necessary for doctors and nurses to ensure that their patients change their dressings daily and keep their wounds clean.

Two Atypical Cases of Tick Bites: A Fully Engorged Tick and Multiple Ticks.

Ticks have a cosmopolitan distribution and, as such, are also found in Japan. Ticks are typically ectoparasites of wild animals, however, humans can also be bitten when visiting environments inhabited by ticks. Herein, we describe two cases with atypical tick bites. Case 1 was an elderly Japanese male patient who presented with a fully engorged tick measuring 20 × 17 × 8 mm; it is rare for ticks to attain a length of 20 mm. Case 2 was an elderly Japanese female with severe dementia who presented with multiple tick bites, which is rare, after going missing for 6 days before being found in a densely wooded area. Ticks are responsible for the transmission of many infectious agents, such as bacteria, viruses and parasites. The National Institute of Infectious Diseases and the Ministry of Health, Labour and Welfare regularly inform citizens of the risks posed by tick bites. However, the tick bites could not be prevented in our patients. Further edification about tick bites, tick-borne diseases, and their prevention are considered necessary in Japan.

Biological Retention Rates, the Reasons of Switching, and Prognostic Factors in Patients with Psoriasis Treated Biologics.

OBJECTIVE: To review patients who were treated at Tokai University Hospital with biologic agents for psoriasis vulgaris and psoriatic arthritis and analyze the biological retention rate, reasons for switching biologics, and investigate possible clinical prognostic factor which may affect whether a patient preferred one biologic to another. METHODS: Clinical courses of 63 patients who received biologic agents between Sep of 2010 to June of 2019 were investigated. Biological retention rate of each biologic agents, reasons of switching to another biologic agent, and prognostic factors, if any, between switched and non-switched patients were examined. RESULTS: The biological retention rate of ustekinumab (UST) was significantly longer than that of infliximab (IFX) or adalimumab (ADA). The major reason of switching was due to secondary loss of efficacy. Patients being treated with UST were more likely to switch to another biologic when they exhibited nail lesions. CONCLUSION: These results suggested that biological retention rate of UST was superior than that of IFX or ADA. Furthermore, with patients administered UST, nail symptom suggested possible clinical prognostic factor for switching to other biologic agents.

Two Cases of Subcutaneous Tuberculous Granuloma Associated with BCG Vaccination.

In recent years, BCG vaccination is routinely performed worldwide. The Ministry of Health, Labor and Welfare of Japan reported that the vaccination rate was as high as 92.9% in 2011. Majority of the reported local adverse reactions to BCG vaccination included lymph node swelling, keloid formation, and abscesses. Subcutaneous tuberculous granuloma is a rare local adverse reaction to BCG vaccination. Herein, we report two cases of developing subcutaneous tuberculous granuloma associated with BCG vaccination. Both of them were treated with isoniazid. There is no standard management for BCG-induced subcutaneous tuberculous granuloma, however, treatment with anti-tuberculosis drugs should be considered for cases of BCGinduced subcutaneous tuberculous granuloma with abscesses or ulcerations.

Seborrheic keratosis that follows Blaschko's lines.

A 66-year-old Japanese man had skin lesions on the left side of his trunk and the left upper extremity for approximately 10 years. The skin lesions were asymptomatic but increased gradually, which brought the patient to our hospital. On the initial examination, we noticed 5 mm x 5 mm to 15 mm x 5 mm, round or oval, light to dark brown keratotic papules on the left side of chest and abdomen and the left upper extremity. The papules were aligned in an S-shaped line on the trunk and in a straight line on the upper extremity. Clinical and histopathological findings led to a diagnosis of seborrheic keratosis that followed Blaschko's lines. To our knowledge, no such a case has been reported previously. Our case supports the hypothesis that seborrheic keratosis can be associated with genetic mosaicism.

The incidence of internal malignancies in autoimmune bullous diseases.

Autoimmune bullous diseases are classified into pemphigus and pemphigoid. Pemphigus is designated as incurable disease by the Ministry of Health, Labor and Welfare, and it is said that pemphigus is difficult to care and can be fatal. The clinical course of bullous pemphigoid (BP) is better than that of pemphigus. However, as to the incidence of internal malignancies, it is well known that there is a significant difference between the two diseases. As the incidence of internal malignancies is high in BP, it is described in textbooks that patients with BP should be followed by a detailed screening for internal malignancies. We investigated the incidence of internal malignancies in 204 Japanese patients with autoimmune bullous disease who visited Tokai University Hospital in Kanagawa, Japan. We found that the incidence of internal malignancies was 11.2% in patients with pemphigus and 10.4% in patients with BP. Among pemphigus variants, the incidence was as high as 20% for pemphigus erythematosus. No relationship was found between malignancies and the severity of the autoimmune bullous diseases. Therefore it is clinically important to carry out a detailed screening for internal malignancies in patients with pemphigus as well as in patients with BP.

A case of implantation dermatosis that formed a tumor.

A 51-year-old man visited our hospital complaining of a tumor located above his lip. He had been hit on his upper left lip by a chopstick holder 2 months previously. The lesion turned into a tumor and gradually enlarged. The tumor was well circumscribed, smooth and covered with reddish, partially milk-white skin. During surgery to remove the tumor, a piece of a chopstick was found in the subcutaneous tissue, and a diagnosis of implantation dermatosis (ID) was made. On histology, the tumor appeared as an abscess that had increased fibroblasts, small vessels and a large number of neutrophils. In the Japanese published work, we found 86 cases of ID; three were similar to our case and had been clinically diagnosed as adnexal tumors. There were also six cases that showed abscess formation similar to our case on histology. In a survey of the published work from other countries, there were 44 ID cases. There were no common features found among the cases reported in the published work.

Feasibility of modified DLQI-based questionnaires for evaluation of clinical efficacy of herbal medicine in chronic skin diseases.

BACKGROUND: The efficacy of herbal medicines is thought to be ambiguous. The quality of life (QOL) of patients has been well-recognized as an useful measurement and we thought it to be a measurement of the efficacy of herbal medicine. OBJECTIVE: The aim of this study was to examine the feasibility of modified DLQI-based questionnaires in evaluating the efficacy of herbal drugs in chronic skin diseases. METHODS: 19 in-patients with chronic skin diseases were selected and treated by the herbal medicines just added on the previous drugs. By using the QOL-sheet, the patients' QOL before and after herbal treatments were converted to scores and we examined the scores to be a useful measurement. The QOL-sheet was made referring to the dermatology life quality index (DLQI) with our original questions and visual analogue scale (VAS) in Japanese. RESULTS: The herbal drugs were effective as the treatment with significant difference (P < 0.05) at clinical impression, DLQI and VAS. No significant differences of correlation between clinical impression, DLQI/DLQI with AQ and VAS/VAS with AQ was proved (P > 0.05). CONCLUSIONS: The QOL-sheet scored both by DLQI and by VAS may be useful to evaluate the efficacy of herbal medicines. However it may be necessary to reconsider the contents of our original questions.