Tatsuhiko Mori

Occurrence of Psoriasiform Eruption During Nivolumab Therapy for Primary Oral Mucosal Melanoma

described in the Japanese population, several PP cases have also been reported in Western countries and, recently, in the Middle East.2,3 The pathogenesis of PP is not completely clear. In addition to being associated with several factors including exogenous (physical trauma, friction) and hormonal (pregnancy, menstruation), PP has classically been reported in association with metabolic derangements, especially ketotic states (dieting, fasting, diabetes mellitus).2,3 Actually, several studies have detected elevated urine and/or blood ketone levels in patients with PP.2,3 In such circumstances, it is believed that ketone bodies may distribute around blood vessels leading to perivascular inflammation or enter into cells modifying their intracytoplasmic processes. The inflammation is believed to be mainly mediated by neutrophils: PP usually responds well to medications with antineutrophil effect, such as dapsone and tetracyclines, which would support this neutrophil-mediated theory. A role for decreased insulin levels, which is reported to occur after bariatric surgery,4 has also been hypothesized as cause of PP.2 In addition to its effect in changing the course of many skin diseases such as psoriasis, bariatric surgery has been associated with several dermatoses including bowel-associated dermatosis–arthritis syndrome, nutritional deficiency dermatoses, and alopecia.5 However, PP has never been reported after bariatric surgery. Given that such surgery may easily replicate the metabolic disturbance associated with other ketotic states such as dieting or fasting,5,6 we believe that the association between PP and bariatric surgery may be underdiagnosed or underreported. In conclusion, to our knowledge, this report is the first to describe PP developing after bariatric surgery, adding PP to the cutaneous complications of such procedures. Increased awareness of this rare entity and this association is important because bariatric surgery is a common procedure nowadays, and the metabolic abnormalities accompanying it mimic those that occur with other ketotic states.

Cellulitis-like skin necrosis induced by postoperative local interferon-β injection for malignant melanoma on the buttock.

arthritis. IGD can be associated with autoimmune or rheumatologic diseases in 20–30% of patients. Etiology of IGD remains enigmatic, however; because of the frequent association with autoimmune diseases, some postulate that circulating autoantibodies may contribute to the pathogenesis. As circulating autoantibodies are not ubiquitous in patients with IGD, further studies are necessary. Interstitial granulomatous dermatitis is associated with internal malignancies. Cornejo et al. reported an IGD-like eruption in a myelodysplasia patient that ultimately progressed to leukemia, suggesting that IGD-like eruption may represent a paraneoplastic phenomenon in pre-leukemic patients. Moreover, Schreckenberg et al. reported a case of IGD with paraneoplastic rheumatoid arthritis, suggesting that IGD should be considered a paraneoplastic phenomenon in patients with malignancies. In conclusion, we report a first case of IGD with arthritis associated with anaplastic large cell lymphoma. IGD should remain a differential diagnosis for patients with rheumatologic condition that have concomitant skin lesions with histological features of interstitial infiltration with collagen degeneration. The association between IGD and malignancies indicates that further study is needed to determine whether IGD represents a paraneoplastic syndrome.

Eosinophilic fasciitis with severe joint contracture in a patient with bladder cancer and B-cell lymphoma

has been reported. Our patient further developed hematological malignancy during the course. Dichloromethane and 1,2dichloropropane were carcinogenic, ink-removal agents used in the printing industry, that can cause cholangiocarcinoma, and we suspect that they were contained in the organic solvents used by our patient. This might have played a role in the occurrence of hematological malignancy. Eosinophilic fasciitis is sometimes associated with several autoimmune conditions, among which morphea is the most frequent but association with generalized morphea is rare. Furthermore, association with vitiligo and eosinophilic fasciitis is also rare, and only a few cases have been reported including vitiligo-like hypopigmentation. Whether hematological malignancy is associated with eosinophilic fasciitis or environmental factors is uncertain, however, our rare case demonstrates that diverse hematological as well as immunological manifestations can occur in association with eosinophilic fasciitis.

Epidermal mast cells in the nail matrix of a patient with psoriasis confined to the nails

Mast cells are occasionally increased in number in several nonallergic inflammatory skin diseases; however, only a few reports of intraepidermal infiltration exist in psoriasis. We describe a patient with psoriasis restricted to the nails, with mast cells detected within the nail epithelium in the biopsy specimen. A 72-year-old man presented with a 3-year history of nail changes in the bilateral fingers and toes. He was not on any medication. He had been treated previously with a topical corticosteroid lotion for the nail lesions, which had not had any effect. Physical examination revealed nail-plate dystrophy and periungual erythema involving all fingernails and toenails (Fig. 1a), but no psoriatic lesions were observed at areas other than the nails. Histological examination of a biopsy specimen taken from the middle finger nail matrix revealed slight epidermal proliferation with neutrophil infiltration (Fig. 1b,c). Immunohistological examination showed CD4-positive T cells in the upper dermis and CD8-positive T cells in the epidermis. Toluidine blue (pH 4.1) staining revealed an increased number of mast cells below and within the nail epithelium (Fig. 1d). By contrast, no mast cells were detected within the overlying epidermis, although mast cells were located below the epidermis.

Tocilizumab-induced pustular drug eruption

Dear Editor, Tocilizumab is a humanized anti-interleukin-6 (IL-6) receptor antibody, which has recently been approved for the treatment of moderate to severe rheumatoid arthritis (RA). However, since then several types of tocilizumab-related rash have been reported. A 69-year-old woman who had been suffering from RA for over 15 years was referred to our department, complaining of symptomless skin eruptions on the extremities and trunk. She had been treated with tocilizumab (400 mg) infusion once a month for 7 months, and 2 days after the seventh infusion, erythema appeared on her upper extremities, which spread to the shoulders and lower extremities. On physical examination, multiple erythema with many tense vesicles and small pustules were widely recognized on the dorsal aspects of the upper and lower extremities (Fig. 1a). Laboratory examination showed normal ranges of white blood cell counts (3200/lL) and C-reactive protein (0.03 mg/dL), whereas increased levels of eosinophil ratio (12%), positive rheumatoid factor (93 IU/mL, normal < 20), and matrix metalloproteinase-3 (MMP-3; 715 ng/mL, normal 17.3–59.7). Serological examination revealed positive anti-nuclear antibody (1 : 160, homogeneous and speckled), antiDNA antibody (8.3 IU/mL, normal < 6.0), and anti-double-stranded DNA immunoglobulin G (IgG) antibody was weakly positive (13 IU/mL). Serum titers of IgG

Genital porokeratosis with amyloid deposition mimicking extramammary Paget disease

projections, comparable to the proliferative activity of intradermal nodular fasciitis. Mehregan reported that nodular fasciitis is histopathologically composed of a central solid mass with many irregular projections extending outward into the surrounding fatty tissue, thus indicating a highly invasive growth. Therefore the US findings of an irregular margin with string-like projections seem to correspond well to these histological features. The localized clear blood-flow signals detected by colour Doppler US represent the pronounced dilatation of blood vessels and hypervascularity seen by histological examination. In addition to skin cancers and inflammatory/infectious diseases, benign skin tumours (haemangioma, etc.) are known to show increased blood flow signals on colour Doppler US. Intradermal nodular fasciitis therefore should be considered as one of the skin tumours with malignant features that can be seen with colour Doppler US.

Clinicopathological analysis of mechanic's hand associated with dermatomyositis.

Mechanics hand is often seen in the fingers of patients with dermatomyositis and is frequently associated with anti‐aminoacyl‐transfer RNA synthetase autoantibodies and interstitial lung disease. We analysed the clinical symptoms of 50 patients with dermatomyositis who had visited our department, 26 of whom also had mechanics hand. A histological examination was carried out in 16 of the 26 cases, which revealed hyperkeratosis in all cases and colloid bodies in the epidermis in 15 cases. The number of cases of interstitial lung disease in patients with mechanics hand (22/26, 85%) was significantly higher than that in those without mechanics hand (12/24, 50%) (P < 0.05). Mechanics hand is an important skin lesion of dermatomyositis, and increases the likelihood of interstitial lung disease

Secondary calcification associated with subcutaneous sarcoidosis

Tomonori OKA, Tomomitsu MIYAGAKI, Sayako ISOMURA, Yohei ICHIMURA, Masahiro KAMATA, Hiroshi MITSUI, Norito ISHII, Takashi HASHIMOTO, Shinichi SATO Department of Dermatology, Graduate School of Medicine, The University of Tokyo, Department of Dermatology, Teikyo University School of Medicine, Tokyo, and Department of Dermatology, Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology, Fukuoka, Japan

Dactylitis in sarcoidosis

Dear Editor, A 56-year-old woman was diagnosed with pulmonary sarcoidosis, based on the presence of bilateral hilar lymphadenopathy and bronchoscopic lung biopsy showing non-caseating epithelioid granulomas. Almost concurrently, she developed finger swelling on both hands, which thereafter showed spontaneous improvement and worsening. Since 2 months previous to presentation, her finger swelling relapsed, and she was therefore referred to the dermatology clinic of Fukushima Rosai Hospital. Physical examination showed prominent swelling on the bilateral fingers with superficial erythema (Fig. 1a). In addition, infiltrative erythematous plaques were observed on the scalp (Fig. 1b), which histologically revealed non-caseating granulomas with epithelioid cells throughout the dermis (Fig. 1c). In contrast, another biopsy taken from the left index finger did not reveal sarcoidal granulomas, even in serial cut sections (Fig. 1d). Laboratory examination showed increased serum levels of angiotensin-converting enzyme (32.5 IU/L; normal, 7–25). Ophthalmological and cardiac examinations denied sarcoidosis; however, X-ray findings revealed osteolytic bone

Late-onset pyoderma gangrenosum following surgical operation in a patient with malignant melanoma

1 Banba K, Fujioka A, Takasu H, Ishibashi A, Ohta M. Spitz nevus on the palmar surface. J Dermatol 2000; 27: 333–336. 2 Yasuma A, Hara H, Hukuda N, Terui T. Usefulness of dermoscopy for diagnosing pigmented Spitz nevus occurring on the glabrous skin. J Eur Acad Dermatol Venereol 2006; 20: 1362–1363. 3 Vaccaro M, Borgia F, Cannavo SP. Dermoscopy of pigmented variant of acral Spitz nevus. J Am Acad Dermatol 2015; 72: s11–s12. 4 Mackie RM, Champion RH, Burton JL, Burns DA, Breathnach SM, eds. Textbook of Dermatology, 6th edn. London: Blackwell Science, 1998; 1717–1752. 5 Kerner M, Jaimes N, Scope A, Marghoob AA. Spitz nevi: a bridge between dermoscopic morphology and histopathology. Dermatol Clin 2013; 31: 327–335.