Clinical features of herpes simplex virus reactivation after microvascular decompression for trigeminal neuralgia: Experience of 200 patients and a literature review.

Background: Herpes simplex virus (HSV) reactivation occasionally develops in the early postoperative period after microvascular decompression (MVD) for trigeminal neuralgia (TN). Therefore, the present study investigated the clinical features of this phenomenon. Methods: The study cohort comprised 200 patients with 125 women aged between 17 and 90 years (median age, 66 years) who underwent MVD for TN between January 2010 and December 2020. Characteristics were compared between patients with and without HSV reactivation and clinical features were analyzed. Results: Twenty patients had HSV reactivation: herpes labialis in 18 and herpes zoster (final diagnosis) in 2. A multivariate analysis revealed independent correlations between postoperative HV reactivation and a previous history of herpes labialis (odds ratios [OR]: 6.32, P = 0.0003) and reoperation for recurrent or persistent pain (OR: 5.06, P = 0.0211). No significant differences were observed in pain relief, postoperative facial numbness, or Barrow Neurological Institute Pain Intensity/Facial Numbness Scores in the past follow-up between patients with and without HSV reactivation. HSV reactivation manifested at a median of the 4th postoperative day (1-10 days) and its location was not related to the preoperative distribution of facial pain. All patients were treated with local acyclovir and were completely cured within 1-2 weeks. Conclusion: HSV reactivation occurred in 10% of patients after MVD including 1% of herpes zoster. A previous history of herpes labialis and reoperation was identified as risk factors for reactivation. Symptoms were completely cured by antiviral drugs within 1-2 weeks. It is important to note that cases of herpes zoster may be confused with cases of HSV after MVD.

Guidelines for the management of dermatomycosis (2019).

The "Guidelines for the management of dermatomycosis" of the Japanese Dermatological Association were first published in Japanese in 2009 and the Guidelines Committee of the Japanese Dermatological Association revised it in 2019. The first guidelines was prepared according to the opinions of the Guidelines Committee members and it was of educational value. The revised version is composed of introductory descriptions of the disease concepts, diagnosis, medical mycology and recent advances in treatment, along with clinical questions (CQ), which is intended to help in general practice for dermatologists. The CQ are limited to those involved in therapy but include some of the recently launched antifungal agents. The level of evidence and the degree of recommendation for each item were reviewed by the committee based on clinical studies published by 2018. For rare dermatomycoses, recommendations by the committee are described in the guidelines. In this field, there are still few good quality studies on treatment. Periodic revision in line with new evidence is necessary.

A Case of Tinea Pedis in a Child Caused by Trichophyton interdigitale with Two Different Colony Phenotypes on Primary Culture.

An otherwise healthy 3-year-old girl presented with a several-month history of scaly lesions on her palms and soles. The lesions on the palms and right sole had been successfully treated with a steroid for pompholyx by a nearby dermatology clinic, but the lesion on the left sole persisted and spread to the back of the foot. On the initial visit, the patient exhibited an itchy and scaly erythematous left foot lesion. Direct microscopic examination of the scales revealed a considerable amount of fungal elements. A diagnosis of tinea pedis was made, and antifungal treatment with a neticonazole ointment was initiated. Complete cure was achieved after 4 weeks of treatment. The primary mycological cultures from the scales simultaneously revealed two types of colonies: a white powdery flat colony and a white downy elevated colony with a reddish-yellow bottom. Although the powdery colony was identified as Trichophyton mentagrophytes complex on slide culture, the downy colonies could not be identified based on cultural and morphological characteristics. The nucleotide sequences of the internal transcribed spacer region from both colonies showed an exact match, which eventually led to their identification as Trichophyton interdigitale. Further genotyping at three points in the non-transcribed spacer region in both colonies also showed the same NTS type of D2II. It is very rare for two morphologically different colonies to be isolated from the primary culture under the same conditions in tinea cases. Genetic tests are of extreme value to identify the strain in such cases.

[A Case of Liver Dysfunction Requiring Hospital Admission after Taking Oral Itraconazole for the Treatment of Kerion Celsi].

67-year-old female patient developed drug-induced liver dysfunction after taking oral itraconazole (ITCZ) for the treatment of kerion celsi. Red papules appeared on the temporal area of the patient one month prior to her visit to our clinic. The patient presented with a nodule with yellow crust, erosion, infiltration, and hair loss on the area. Diagnosis of kerion celsi caused by Trichophyton rubrum was made from clinical, pathological, and mycological findings. Laboratory data showed normal liver function, and the patient was not taking any other medication, thus, daily oral ITCZ 100 mg was started. The skin lesion improved, but severe liver dysfunction was found 1 month after starting ITCZ. Oral ITCZ was therefore terminated, and the patient was admitted to a medical ward for the treatment of liver dysfunction. Hepatobiliary enzymes increased after admission: AST 232 IU/L, ALT 465 IU/L, T-bil 6.1 mg/dL, and D-bil 3.9 mg/dL. The patient was kept at rest and was given oral ursodeoxycholic acid. Hepatobiliary enzymes returned to normal level 2 1/2 months after starting ITCZ. The skin lesion healed without further treatment. No recurrence was observed. It is noteworthy that liver function has to be carefully monitored during treatment with oral ITCZ.

Chronology of lichen planus-like keratosis features by dermoscopy: a summary of 17 cases.

Dermoscopic findings for 17 cases of lichen planus-like keratosis (LPLK) were chronologically evaluated. Three males and 14 females were included in the study and the ages ranged from 43 to 85 years (median 65 years). Three cases were diagnosed based on stereotypical dermoscopic findings, while the other 14 cases were histopathologically diagnosed as LPLK. Dermoscopy photographs were divided into four groups depending on the number of days (D) from the initial visit: 1) D = 0 (initial visit or biopsy day); 2) D = 61 to 180; 3) D = 181 to 270; 4) D = 271 to 360. Dermoscopic findings, described as light brown pseudonetwork, pinkish area, gray pseudonetwork, annular granular structures, and blue-gray fine dots, were evaluated at every visit to the hospital. Initial dermoscopy features included light brown pseudonetworks due to residual solar lentigo and overlapping pinkish areas attributed to lichenoid inflammation. Annular granular structures and gray pseudonetwork appeared to be the main features of the regressing stage; these features seemed to progress to "blue-gray fine dots" in the late regressing stage. Blue-gray dots or globules reflecting melanophages, the hallmark dermoscopic features of LPLK, were believed to resolve in approximately one to two years. Based on the clinical and dermoscopic observations, we have specified five stages of evolution of LPLK, namely 1) pre-existing solar lentigo, 2) early inflammatory stage, 3) early regressing stage, 4) regressing stage, and 5) late regressing stage. The limitations of the study are that this is a small-sized, retrospective, observational study and that ethnicity of participants is limited to Japanese patients with skin phototype III.

Condylomata lata on the ankle: an unusual location.

A 43-year-old Japanese man presented with reddish nodules on the ankle. The nodules had a yellowish crust and eroded surface. Dermoscopy revealed red to milky-red globules at the periphery and some glomerular vessels in the center and a whitish-pink network, which corresponded to capillary dilatation in the papillary dermis and prominent acanthosis, respectively. These structures were surrounded by a yellowish peripheral structureless area and multiple white, small, round structures in the center, corresponding to the macerated horny layer and keratin plugs. Blood samples were positive for rapid plasma reagin (1:64), Treponema pallidum hemagglutination assay (1:20480), and fluorescent treponemal antibody-absorption (1:1280). A lesional skin biopsy specimen showed irregular acanthosis and papillomatosis. The Warthin-Starry and anti-Treponema pallidum antibody stains on the biopsy specimen revealed many spirochetes in the lower epidermis and the papillary dermis. A diagnosis of secondary syphilis with condylomata lata was made. After one week of treatment with oral benzylpenicillin benzathine hydrate (Bicillin(®) G granules 400,000 units; Banyu Pharmaceutical Co., Ltd, Tokyo, Japan), 1.6 million units (U) daily, the ankle lesions had resolved with a small ulcer and pigmentation. Although syphilis is a relatively common disease, this case study reports an unusual presentation as well as dermoscopy findings.

Histological Classification and Differential Diagnosis of Nonepisodic Angioedema With Eosinophilia: A Clinicopathologic Study of 12 Cases With Literature Review.

Nonepisodic angioedema with eosinophilia (NEAE) is a rare condition characterized with monoepisodic angioedema, a nonfebrile state, eosinophilia, normal serum IgM levels, and lack of internal organ involvement. The histology of this disease is not yet well known. The purpose of this study was to characterize the histopathologic features of NEAE. Twelve cases of clinically confirmed NEAE were retrieved from 6 institutions, and these cases were reviewed regarding the clinical data and histopathology, particularly regarding granulomatous lesions. The authors demonstrated that the histology of NEAE can be classified into 3 patterns that of eosinophilic granulomatous panniculitis (7/12 cases), eosinophilic dermatitis without granuloma formation (3/12 cases), and invisible dermatosis (2/12 cases). Six of the 7 granulomatous cases showed the characteristic eosinophilic granulomatous lesions containing individual necrotic adipocytes with membranous fat changes, which could be a differential clue to the diagnosis of NEAE. Review of the previously reported cases (n = 37) revealed that the histological classification could be adaptable to these reported cases. The authors should recognize the histological variation of NEAE and distinguish it from the histological mimickers, including eosinophilic granulomatosis with polyangiitis, erythema nodosum, hypereosinophilic syndrome, and episodic angioedema with eosinophilia.

Abrupt Intralesional Color Change on Dermoscopy as a New Indicator of Early Superficial Spreading Melanoma in a Japanese Woman.

Diagnosis of superficial spreading melanoma in the early stage is often difficult, even with dermoscopy. We report the case of a 37-year-old Japanese woman with superficial spreading melanoma in her left buttock. The lesion developed 20 years before becoming visible and gradually enlarged over the past few years without any symptoms. Physical examination showed a well-demarcated dark-brown macule 10 mm in diameter. Dermoscopy demonstrated a central dark area with a blue-grey structureless area, a milky-red area with irregular blue-grey dots or globules suggestive of regression structures, and multifocal black pigmentation with whitish scaly areas. An abrupt intralesional change in color from a central dark area to a peripheral light-brown area was also seen. The peripheral area showed an atypical pigment network with an obscure mesh and holes. Histopathologic examination of the lesion showed acanthosis with melanocytic proliferation and nuclear atypia, a band-like lymphocytic infiltrate, melanophages and a few nests of melanocytes just beneath the epidermis. The epidermal melanocytes were positive for S-100, Melan-A and HMB-45, but the dermal nests of melanocytes were negative for HMB-45 and positive for S-100 and Melan-A. A diagnosis of superficial spreading melanoma with a tumor thickness of 0.4 mm (pT1aN0M0, stage 1A) was established based on the clinical, dermoscopic and histopathologic findings. This case suggests that dermoscopy is useful in the diagnosis of this condition. An abrupt intralesional change of color might be a new indicator of early superficial spreading melanoma.

Comparison of dermatoscopic images of acral lentiginous melanoma and acral melanocytic nevus occurring on body weight-bearing areas.

BACKGROUND: Because body weight-bearing produces a shift in the horny layer, acral melanocytic nevus on the body weight-bearing area of the sole showed a regular fibrillar pattern (FP) due to slanting of the melanin columns in the horny layer. On the other hand, acral lentiginous melanoma (ALM) on the body weight-bearing area of the sole tended to show irregular fibrillar pattern showing rather structureless pigmentation instead of a parallel ridge pattern, which is due to the shift of the horny layer. OBJECTIVE: To elucidate the subtle difference between the regular FP of nevus and irregular FP in ALM. METHODS: In this study, the dermatoscopic features of five cases of ALM and five cases of acral melanocytic nevus on the weight-bearing area of the sole were compared. RESULTS: All the cases with nevi showed regular FP showing regular distribution of fibrils, whereas all the melanomas showed irregular distribution of fibrils and colors. Fibrils in nevi tended to be clear at the furrows and dim at the ridges. White fibrils corresponding to the eccrine ducts in the horny layer were more often present on the ridges in ALM, which showed negative FP. CONCLUSION: Differentiating between the regular and irregular FP, including negative FP, might be helpful for the discrimination of melanoma from nevus.

Calcinosis cutis confined to the dermis after intravenous administration of a calcium preparation: a case report and review of the Japanese literature.

A 61-year-old female received intravenous injection of calcium chloride after common iliac artery bypass surgery. A red flare appeared at the site of the intravenous infusion on the left forearm and gradually progressed to induration. Seven weeks later, she was referred to the Department of Dermatology for management. Physical examination showed an indurated plaque measuring 13 × 65 mm in size, with linearly distributed ulcers covered by yellowish-white substance, surrounded by reddish skin. Laboratory tests showed no significant abnormalities including serum calcium, phosphate and thyroid hormones. Cultures were negative for microorganisms. Histopathological examination showed calcium deposition confined to the dermis. The lesion healed spontaneously within 2 months with scar formation. A review of the Japanese literature showed confinement of calcium deposits to the dermis in most of the reported cases. We speculate that the pathomechanism of dermal calcinosis includes needle-induced tissue injury with capillary destruction, leading to release of excess calcium between collagen fibers, and its binding to phosphate in the dermis and deposition as calcium phosphate crystals.

Age-related prevalence of dermatoscopic patterns of acral melanocytic nevi.

The objective of this study was to evaluate the relation between age and dermatoscopic features of acral nevi. We evaluated 159 dermatoscopic images of melanocytic nevi from 146 individuals filed at the Dermatoscopy Outpatient Clinic of Tokyo Women's Medical University Medical Center East between April 2006 and March 2009. All images of melanocytic lesions on acral volar skin that showed a clear-cut dermatoscopic pattern of an acral nevus at the time of initial observation were included. The dermatoscopic patterns of all images were retrospectively examined in a blinded fashion according to the standard dermatoscopic classification criteria for acral melanocytic nevi. Images were classified using 15 structural variants of the parallel furrow pattern. These variants were then re-classified into two groups; the "single" line group and "double" line group. Patients of the double line group (age, 25.5 years) were significantly younger than those of the single line group (32.4 years). There was no significant difference in the age-related predominance between the solid line patterns and dotted line patterns. There was a significant age difference between patients with nevi showing the crista dotted pattern (mean age 24.9 years) and patients with nevi without the crista dotted pattern (mean age 34.6 years). We conclude that the double line variant of the parallel furrow pattern and crista dotted pattern, which probably correspond to the congenital type acral nevus, tend to be more common in young patients.

Remission of generalized erythematous granuloma annulare after improvement of hyperlipidemia and review of the Japanese literature.

Granuloma annulare has been associated with systemic disease including diabetes mellitus. We report a case of a 62-year-old Japanese woman with generalized erythematous granuloma annulare who showed remission after substantial improvement in hyperlipidemia following a strict lipid-lowering diet. The lesion appeared in the lower abdomen one year before current presentation and subsequently spread to other areas of the trunk despite treatment with topical steroid and oral epinastine hydrochloride. Physical examination showed a well-demarcated erythematous plaque measuring 10 cm in diameter with fine scales on the left abdomen, and slightly indurated pinkish plaques of up to 5 cm in diameter on the right side of the abdomen and axillae. Clinical laboratory tests showed mild glucose intolerance (HbA1c 6.2%), mild liver dysfunction (AST: 86 IU/L, ALT: 76 IU/l), slight hypercholesterolemia (total cholesterol: 235 mg/dl), and severe hyperlipidemia (triglyceride: 962 mg/ml). Histopathological examination of the lesions showed homogenization of collagen fibers and granulomatous infiltrates between fibers in the upper and middle dermis. A diagnosis of generalized erythematous granuloma annulare was established based on the clinical and histopathological findings, especially with the distribution on more than one anatomic site. A lipid-lowering diet for three months resulted in major improvement of hyperlipidemia and remission of the skin lesions. A review of generalized erythematous granuloma annulare in the Japanese literature indicated a well-known association of granuloma annulare with diabetes mellitus, however, the relation with hyperlipidemia was described only recently. This case suggests a possible relationship between granuloma annulare and hyperlipidemia, with possible improvement of granuloma annulare with a lipid-lowering diet.

Inguinal porokeratosis in a Japanese man.

Inguinal and genital porokeratosis are rare but seem to be more common in Asians. We report a case of a 69-year-old Japanese man with multiple lesions of porokeratosis in both inguinal regions. The lesions first appeared in the inguinal region and subsequently spread to the trunk. The patient reported that his father had had similar lesions. Dermoscopy demonstrated central brown pigmentation and blue-gray dots surrounded by a single "white track" at the periphery. The exterior border of the white track also showed light brown pigmentation. Genital or inguinal porokeratosis is uncommon and may be misdiagnosed as Bowen's disease, lichen planus or extramammary Paget's disease. However, awareness of this entity and the use of dermoscopy are helpful to establish a correct diagnosis.

Peristomal pagetoid spread of urothelial carcinoma of the ureter.

Patients with ostomy including urinary stoma often develop peristomal complications, especially skin damage. The patient in this case was a 69-year old female with a history of urothelial carcinoma of the bladder and left ureter who underwent transurethral resection of a bladder tumor, nephroureterectomy and cystectomy combined with ureterocutaneostomy. Later, she had recurrence of urothelial carcinoma in the remaining ureter that spread to the peristomal epidermis, with a skin appearance resembling Paget's disease. We report this case based on its clinical significance since we believe it is the first description of this condition in the literature.