Prurigo nodularis. Histological and electron microscopical study.

We describe a typical case of prurigo nodularis, of 15 years' duration, in a middle-aged woman. Histological and electron microscopical examination of the skin lesions revealed distinct changes in the nerve tissue. There were groups of thickened nerve fibers that formed nodules with numerous Schwann cells. Some of the nerve bundles extended to the dermoepidermal junction. Electron microscopy showed very obvious lesions in the Schwann cells and axons. In the Schwann cells there was a lucent cytoplasm with few mitochondria, an absence of endoplasmic reticulum and a few irregular, membrane-bound vacuoles. While the mesaxons all appeared normal, the axons varied greatly in diameter; the small ones appeared normal and contained neurofibrils and neurotubules, whereas the large onew were empty. Every Schwann cell encircled a large number of axons. It may be assumed that the axon swelling is a nonspecific reaction to injury.

Mycosis fungoides-like lesions associated with phenytoin therapy.

An 83-year-old woman developed generalized lymph node hyperplasia together with mycosis fungoides-like skin lesions 11 months after institution of anticonvulsant therapy with phenytoin. The clinicopathological changes disappeared completely three weeks after cessation of therapy. This circumstantial evidence together with the known data on the association of phenytoin with lymphoproliferative disorders suggest that it was the phenytoin that was responsible for the patient's condition. This case had features similar to those associated with the pseudo-mycosis fungoides syndrome except that the cutaneous lesions consisted of two localized erythematous plaques, with no generalized exfoliative erythrodermic dermatitis. Nonetheless, we believe that the use of the term pseudo-mycosis fungoides for this and similar cases would be appropriate.

Determination of IgG subclasses in patients with pemphigus with active disease and in remission.

IgG subclasses were determined in perilesional skin of 13 patients with pemphigus with active disease and of 14 patients in a state of clinical remission. Using indirect immunofluorescence technique, frozen sections were incubated with mouse monoclonal antihuman IgG1, IgG2, IgG3, and IgG4 followed by a second incubation with fluorescein isothiocyanate-conjugated goat antimouse IgG. The results showed that among patients with active disease, IgG1 was found in all of them and IgG4 in 85%, while IgG2 and IgG3 were found in 54% and 77%, respectively. For patients in remission the most common subclass was IgG4 in 79% of patients, and in a decreased order IgG1, 50%; IgG3, 29%; and IgG2, 14%. It appears that IgG1 and IgG4 are predominant among patients with active lesions. IgG1 seems to be the most sensitive indicator for activity of the disease. IgG4, normally found in the lowest concentration in human serum, is the most common subclass in patients who are in remission. IgG3 and C3 may have a predictive value for remission.

Immunologic abnormalities associated with primary anetoderma.

BACKGROUND AND DESIGN: Primary anetoderma is a rare cutaneous elastolytic disorder, the etiopathogenesis of which has not yet been established. Six patients with primary anetoderma were studied in an attempt to assess the role of the immunologic system in the elastolytic process. The investigation included the medical history, physical examination, routine blood tests, specific tests for collagen diseases, prothrombin time, activated partial thromboplastin time, thyroxine, indirect immunofluorescence test, and skin biopsies for histopathologic study and direct immunofluorescence. RESULTS: Two of the patients presented with autoimmune disorders: the first had Graves' disease, lupus anticoagulant, and autoimmune hemolysis, and the second had systemic scleroderma. There were positive direct immunofluorescence findings in most of the patients. Furthermore, all of them were found to have serologic immunologic abnormalities, of which the most common was a positive antinuclear factor. CONCLUSIONS: These findings indicate that there is an immunologic involvement in primary anetoderma.

Macrophage migration inhibition factor (MIF) in drug eruption.

A controlled study was conducted to evaluate the macrophage migration inhibition factor test as a diagnostic aid in 50 patients with drug eruption. Two groups of patients served as controls: group A, 110 patients being treated with drugs without known cutaneous adverse reactions, and group B, 15 patients suffering from dermatologic disorders unrelated to drugs being taken. Positive macrophage migration inhibition factor responses were found toward a variety of drugs in 35 (70%) of the patients with drug eruptions, with no relation to the type of eruption or the duration of drug intake. The percentage of positive macrophage migration inhibition factor responses toward drugs in the patients with drug eruptions was higher than that in the two control groups (4.5% and 6.7%, respectively). The percentage of positive macrophage migration inhibition factor responses recorded for clinically "suspected" drugs was significantly higher than that recorded for the "nonsuspected" drugs.

Oriental hornet venom enhances wound healing and repair in rat skin, possibly through its collagenolytic activity.

Oriental hornet (Vespa orientalis) venom sac extract (VSE) was topically applied to experimental wounds produced on the back skin of rats in order to observe histologically its effect on the healing process. In other studies the collagenolytic effect of VSE was investigated. The results clearly indicated that application of VSE enhanced the process of wound healing. Two weeks after wound induction a thick epidermis and maturation of the dermal connective tissue were seen in the experimental animals, whereas in the controls the dermis was thin and still showed granulation tissue, and the epidermis was thin. Incubation of VSE with purified neutral salt-soluble collagen (NSSC) labeled by reduction with [3H]NaBH4 brought about degradation of the substrate. It is assumed that VSE enhances the process of wound healing in the skin, probably due to its collagenolytic effect.

Bromoderma caused by carbromalhydroxyzine hydrochloride.

A patient is described who developed a pyoderma-gangrenosum-like ulcer of the leg and acneiform eruption on the face following intake of carbromalhydroxyzine hydrochloride (Dormax). Serum levels of bromide were found to have risen to 105 mg%. There was a return to normal levels of serum bromide and regression of the skin lesions after one week of treatment with natrium chloride and erythromycin. The importance of increasing awareness of the potential hazards of bromide administration is stressed.

Pseudolymphoma of skin induced by oriental hornet (Vespa orientalis) venom ultrastructural study.

A single subcutaneous injection of Oriental hornet venom into black mice led to the development of a subcutaneous nodule which showed no change during the period of 1 year. Study of the ultrastructure revealed an accumulation of lymphocytes and lymphoblasts and a few plasma cells with formation of Russel bodies. In addition, a few melanin-containing macrophages and macrophages filled with cellular debris were found. This reaction is compared to other pseudolymphomatous reactions in the dermis.

Simple methods for estimation of prednisone intake and metabolism.

For patients treated with high doses of prednisone (over 40 mg/day) laboratory follow-up is important, particularly when the therapeutic response does not correlate with the dose of prednisone prescribed. Taking advantage of the similarity in structure of prednisone to cortisone and of prednisolone to cortisol we evaluated simple, inexpensive methods for the assessment of prednisone and prednisolone intake and bio-availability. Free urinary prednisolone was estimated by radioimmunoassay for cortisol and found to be linearly correlated with the dose of prednisone administered (r = 0.9310). Levels of free prednisolone were 6.5-11% of the dose of prednisone per day. Free and metabolized prednisone and prednisolone were estimated as 17-OHCS in the 24-hr urine collection. Total, conjugated and free 17-OHCS were linearly correlated with the dose of prednisone, the best correlation being with total 17-OHCS (r = 0.9060). About 40% of the prednisone administered was secreted as total 17-OHCS.

State of leukocyte adhesiveness/aggregation in the peripheral blood of pemphigus and psoriatic patients.

The purpose of this study was to assess the role of leukocyte adherence in the pathogenesis of the psoriatic lesion. Use was made of the fact that psoriasis and pemphigus differ considerably as to the presence of leukocytes in the respective lesions: abundance in psoriasis, and absence in pemphigus. The state of leukocyte adhesiveness/aggregation (LAA) was determined in the peripheral blood of 56 patients with psoriasis and 31 patients with pemphigus. Both classes of patients were subdivided into two categories according to the severity of the disease. It was found that in both diseases elevated values of LAA were obtained in the severe cases, whereas the mild cases did not differ significantly from normal controls. Thus, in psoriasis mean LAA values of 9.5% +/- 8% were recorded in the severe patients and 5.5% +/- 4.2% in the mild cases (p = 0.01), while in pemphigus the values were 15% +/- 9.6% and 6.6% +/- 3.7% respectively (p = 0.03). It is concluded that LAA per se does not play a primary role in causing the psoriatic lesion.

Multiple dermal fibroblasts in patients with pruritic urticarial papules and plaques of pregnancy. A clue to the etiology?

We have recently demonstrated that in pruritic urticarial papules and plaques of pregnancy (PUPPP) there are multiple dermal fibroblasts with no deposition of mucin. We suggest that in the dermis of patients with PUPPP there is a deposition of a substance that induces fibroblasts proliferation. We assume that this substance (marked as F-substance) is a product of the placenta, which is released to the maternal circulation during pregnancy.

Disseminated superficial porokeratosis in patients with pemphigus vulgaris treated with steroids.

In two patients with pemphigus vulgaris a rash identical with that seen in disseminated superficial porokeratosis developed on the trunk and extremities during periods in which they were receiving relatively high doses of steroids. Some time after reduction of the daily dose or discontinuance of treatment this rash disappeared. In one patient, however, this rash subsequently recurred twice, both times after reinstitution of treatment because of the reappearance of pemphigus lesions. It is suggested that disseminated superficial porokeratosis should be added to the list of possible skin eruptions developing as the result of the systemic use of corticosteroids at a high dose for a prolonged period of time, although the mechanism of its appearance in these cases is not yet clear.

Pruritic urticarial papules and plaques of pregnancy. A review of 21 cases.

Twenty-one patients with pruritic urticarial papules and plaques of pregnancy (PUPPP) were reviewed. Direct immunofluorescence (DIF) examination was negative in all patients. DIF in patients with PUPPP is a useful and reliable laboratory aid in distinguishing this peculiar dermatosis from herpes gestationis.

Studies of Kaposi's sarcoma with infrared photography.

Infrared photography, known to be useful in the study of cutaneous vascular structures but not yet extensively explored in the investigation of skin diseases, was used to study lesions of Kaposi's sarcoma in three patients. In all photographs, the tumors appeared as a stain which was lighter in color than the normal skin. In two patients, the infrared photographs showed a tumor identical with that seen clinically. In the third patient, the tumor showed a larger extension than it seemed to have on physical examination. We believe that this technique can be of value in establishing the presence of such tumors and evaluating their actual size.

Seborrheic keratoses of the areola.

A patient noted the appearance of a few asymptomatic lesions on both areolae eighteen months after delivery of her last son. Histologic examination showed typical seborrheic keratosis. A brief review of the differential diagnosis of skin problems of the nipple and the areola is provided.

Mask phenomenon: postemesis facial purpura.

A bizarre form of purpura seen on the face and neck after vigorous vomiting is described. Physicians should be familiar with this form of purpura since patients are very concerned about the mask that appears suddenly. Recovery is spontaneous, and no treatment is needed.

Skin infection provoked by coagulase-negative Staphylococcus resembling gram-negative folliculitis.

A superficial pustular eruption with acute onset has been reported in patients with acne vulgaris receiving systemic antibiotic treatment. In all past cases the causative micro-organism was found to be a gram-negative bacterium. This case report describes a similar clinical picture under the same circumstances, in which the bacterium incriminated was a coagulase-negative Staphylococcus.

Secondary milia following bullous erysipelas.

Secondary milia associated with bullous erysipelas developed in the right leg of a 64-year-old woman. The milia, measuring up to 6 mm, appeared one month after healing of the erysipelas. Findings of histopathologic and immunohistochemical studies showed that the milia were related to dilated eccrine ducts and not to the hair follicle. Topical treatment with 0.05 percent tretinoin cream resulted in almost full resolution of the lesions.

Norwegian-type scabies mimicking contact dermatitis in an immunosuppressed patient.

Patients taking immunosuppressive drugs are susceptible to various forms of infection, including dermatologic disease. Recently, atypical manifestations of scabies have been reported in such patients. In the case reported here, a 26-year-old woman who had had a renal transplant and was taking immunosuppressive drugs had a pruritic rash on the back that closely resembled contact dermatitis. However, skin scrapings from the involved areas and punch biopsy specimen of the back showed live scabies mites. The pruritus was relieved and the skin lesions disappeared within ten days of treatment with scabicides. We believe that current widespread use of immunosuppressive agents may result in more cases of atypical forms of scabies. Therefore, physicians who deal with immunosuppressed patients should be aware of this possibility.

[Macrophage migration inhibition factor as a diagnostic aid in drug eruptions].

The diagnostic value of the macrophage migration inhibition factor (MIF) test was evaluated in 90 patients with the clinical diagnosis of drug eruption. There were 40 males and 50 females who ranged in age from 15-84 years (mean 61.0). Controls were 120 patients being treated with drugs without adverse reactions and 21 patients with dermatologic disorders unrelated to drugs. Positive MIF responses for 1 or more drugs were observed in 71.1% of the patients with drug eruptions as compared to 4.2% and 9.5% of the control groups, respectively (p less than 0.001 for both). The proportion of positive MIF responses in those in whom drugs were implicated (45.2%) was significantly greater (p less than 0.0001) than in those with eruptions in whom drugs were not implicated (18%). The MIF test may be of aid in the diagnosis of drug eruptions and in the identification of the offending drugs.