Bifonazole (Mycospor cream) in the treatment of moccasin-type tinea pedis. Comparison between combination therapy of bifonazole cream + 10% urea ointment (Urepearl) and occlusive dressing therapy with the same agents

Moccasin-type tinea pedis(MTTP) is a hardly curable superficial dermatomycosis primarily characterized by hyperkeratosis of the sole. In this study, we compared the usefulness of combination therapy of bifonazole (Mycospor cream) + 10% urea ointment (Urepearl) (overlapping application group = group I) with occlusive dressing therapy with the same agents (group II) in the treatment of MTTP, and obtained the following results. (1) The clinical improvement rate (percentage of "marked improvement" and "moderate improvement") was 60.4% in group I and 83.3% in group II. (2) The mycological eradication rate was 48.7% in group I and 82.1% in group II after 4 weeks of treatment and 90.9 and 96.9%, after 12 weeks of treatment, respectively. (3) The clinical utility rate (percentage of "very beneficial" and "beneficial") was 83.3% in group I and 93.8% in group II. These results indicate the superiority of both combination therapy of bifonazole + 10% urea ointment (overlapping application group) and occlusive dressing therapy with the same agents in terms of efficacy and safety for the treatment of MTTP, and suggest that they can be recommended for treatment of patients for whom it is difficult to use oral antimycotic agents or for patients who fail to respond to oral medications alone.

Dermatitis herpetiformis in a Japanese patient with anaplastic large cell lymphoma

We report a 73-year-old Japanese man with dermatitis herpetiformis which developed after diagnosis of anaplastic large cell lymphoma. The patient suffered fever, sweating, shivering, and multiple enlarged cervical lymph nodes. The diagnosis of anaplastic large cell lymphoma was confirmed by the histologic features of a biopsied cervical lymph node. The patient underwent combination chemotherapy. However, one month after the initial therapy, pruritic erythematous skin lesions with peripheral vesicles appeared on his buttocks. A skin biopsy showed subepidermal blister formation associated with polymorphonuclear and mononuclear cell infiltrates. Direct immunofluorescence examination of the area adjacent to the lesion showed granular deposits of IgA at the dermoepidermal junction. While it is well-known that dermatitis herpetiformis can develop into lymphoma, there have been only a few reports of its appearance after a diagnosis of lymphoma. This case suggests that dermatitis herpetiformis may be induced by anaplastic large cell lymphoma.

Expression of CD40 and CD40 ligand in Bowen's disease and squamous cell carcinoma

CD40 is a member of the tumor necrosis factor receptor super-family expressed by B cells, monocytes, dendritic cells, epithelial cells and hematopoietic progenitor cells. CD40 has recently been reported to be expressed on several epidermal tumors as well. CD40 on epidermal tumor cells interacts with lymphocytes expressing ligand for CD40 (CD40L) or monoclonal antibodies against CD40 with a significant decrease in proliferation. In this study, we examined the expression of CD40 and CD40L in Bowen's disease and squamous cell carcinoma (SCC). CD40 immunoreactivity was observed in a significantly lower proportion of tumor cells from SCC than from Bowen's disease. CD40L mRNA expression was detected in Bowen's disease and SCC by reverse transcriptase polymerase chain reaction (RT-PCR). CD40-CD40L interactions in epidermal tumors may play a role in the proliferation, and the lack of CD40 in tumor cells from SCC might be involved in the mechanisms of escape from the growth inhibitory effect.

Case report. A case of chromoblastomycosis effectively treated with terbinafine. Characteristics of chromoblastomycosis in the Kitasato region, Japan

A 38-year-old male with history of trauma in the left gluteal region 20 years ago presented with a dark red skin eruption at the traumatized area. It gradually grew to form an erythematous plaque with a well-defined border. Clinical findings and mycological cultures resulted in the diagnosis of chromoblastomycosis due to Fonsecaea pedrosoi. After initial administration of 5-fluorocytosine and local heat an almost complete cure was achieved with terbinafine combined with local heat therapy. A review is given on the chromoblastomycosis cases observed in the Kitasato region in Japan.

Diffuse large B-cell lymphoma associated with skin, muscle and cranial nerve involvement

The present case, a 75-year-old man with extranodal B-cell lymphoma showed facial hemiplegia, paresthesia and cutaneous manifestations. He was initially diagnosed as having a facial paralysis of unknown etiology. One month after the original diagnosis, erythematous indurated plaques developed on his left cheek and nose. A skin biopsy from the plaque on his cheek showed dense infiltrates of large lymphocytes with irregularly shaped nuclei and prominent nucleoli in the dermis and subcutaneous tissue. The lymphocytes were positive for L26 and CD79a. A diagnosis of diffuse large B-cell lymphoma was made. A muscle biopsy from facial muscle in the area of the erythematous plaque showed massive destruction of the muscle tissues by the lymphomatous infiltrates. Furthermore, electrodiagnostic study showed peripheral cranial nerve palsies, involving the left facial and trigeminal nerves. We conclude that diffuse large B-cell lymphoma may develop symptoms such as facial hemiplegia and paresthesia prior to cutaneous manifestations. Diffuse large B-cell lymphoma must be considered as one of the important causes of palsies of cranial nerves at the peripheral level.

CD40 ligation inhibits trichilemmoma cell proliferation and induces IL-6 production

CD40 is a member of the tumor necrosis factor receptor superfamily expressed by B cells, monocytes, dendritic cells, epithelial cells, and hematopoietic progenitor cells. Recently, CD40 has been reported to also be expressed on human epidermal cells. We have elucidated the function of CD40 on epidermal tumor cells and have found that trichilemmoma (KTL-1) cells constitutively express CD40 and respond to CD40 ligation by anti-CD40 mAb (EA-5) with a significant decrease in proliferation. We were also able to demonstrate that KTL-1 cells respond to CD40 ligation by EA-5 with the up-regulation of interleukin-6 (IL-6) mRNA expression. Together, the results suggest that CD40 on KTL-1 cells may function to regulate their proliferation associated with the induction of IL-6 production.

Case report. Kerion Celsi effectively treated with terbinafine. Characteristics of kerion Celsi in the elderly in Japan

A 75-year-old non-working male living in Sagamihara, Kanagawa Prefecture, had erythematous plaques with scales associated with follicular pustules in the head area extending from the occipital to right temporal regions about 1 month prior to his initial visit, when hair loss increased. The diagnosis was kerion Celsi. Trichophyton rubrum was isolated from scales and tissues taken from lesions in the head. Histopathological examinations showed irregular epidermal thickening with dense cell infiltration from the dermis to subcutaneous adipose tissues. Granulomatous reactions involving neutrophils, histiocytes and giant cells were seen mainly in the hair follicles. Periodic acid-Schiff (PAS) and Grocott-positive microbial elements were detected in the horny layer, and inside and outside the hair follicles. Pustules disappeared 1 week after starting the oral treatment with terbinafine (125 mg day-1). A cure was achieved 2 weeks after starting the treatment, with only slight scales remaining. No recurrence has been observed to date. Terbinafine was thought to be very effective and safe for kerion Celsi. We reviewed 27 cases of kerion Celsi reported in patients, aged at least 70 years, in Japan and found that the major characteristics of this disease in Japan include the following: (1) female cases outnumber male cases; (2) the causative organism was T. rubrum in 14 of 27 patients (51.9%); and (3) topical application of steroids often induces this disease in patients with superficial tinea capitis.

Characterization of infiltrating T cells in human scalp explants from alopecia areata to SCID nude mice: possible role of the disappearance of CD8+ T lymphocytes in the process of hair regrowth

T cells may play a role in the pathogenesis of alopecia areata (AA). We attempted to elucidate the linkage between infiltrating T cells and hair regrowth processes by grafting scalp skin from the affected region of patients with AA onto severe combined immune deficiency (SCID) nude mice. When the AA scalp was grafted into the mice, the grafts were accepted, and normal hair regrowth was observed. Before grafting, CD4+ and CD8+ T cells had infiltrated into the peribulb area. After grafting, the telogen hair shifted to anagen hair, and the CD4+ and CD8+ T cell infiltrates in the bulb area decreased in all cases. CD8+ T cells had almost disappeared from all portions of the follicles. It has been suggested that CD8+ T cells play a crucial role in the pathogenesis of AA. The absence of CD8+ T lymphocytes that responded to follicular autoantigens may induce hair regrowth in the grafted skin. In addition, the CD4+ human T cells that had infiltrated or still remained in the upper-middle portions including the bulge area accompanied the HLA-DR expression after grafting. Infiltrating or surviving T cell phenotypes and locations changed during the hair cycle in the grafts. These results indicate that the location of infiltrated T cells and their phenotypes may participate not only in hair loss but also in regrowth of hair in AA.

[Cutaneous manifestations with ulcerative colitis]

Here, we reviewed the skin diseases with ulcerative colitis. The cutaneous manifestations were divided 7 groups; 1) pyoderma gangrenosum (PG), 2) erythema nodosum (EN), 3) acneiform eruption, 4) aphtha, 5) bullous diseases (Bullous pemphigoid, Linear IgA bullous dermatosis), 6) urticarial vasculitis, 7) pyostomatitis vegetans. Most of these skin manifestations were occurred after the onset of UC. These were commonly parallel with the clinical course of UC. The pathomechanisms of the cutaneous alterations have not been fully understood. However, these signs seen in the UC patients were important for the evaluations of disease activity of UC.

Transfusion-associated graft-versus-host disease: an in situ hybridization analysis of the infiltrating donor-derived cells in the cutaneous lesion

BACKGROUND

Acute graft-versus-host disease (GVHD) can occur after a blood transfusion.

OBJECTIVE

In order to elucidate the pathomechanisms responsible for transfusion-associated GVHD, infiltrating donor-derived cells in a cutaneous lesion were analyzed.

METHODS

A skin sample obtained from a 69-year-old woman who developed fatal GVHD after blood transfusions from male donors was studied by performing in situ hybridization (ISH) with a Y-chromosome-specific probe.

RESULTS

The cell infiltrates comprised mainly CD3+ T lymphocytes. Immunohistochemistry and ISH in combination demonstrated that 99% (182/184) of the Y-body-positive cells were CD3+. Y bodies were observed in 80% of the CD8+ cells in the epidermis and dermoepidermal junction and in 77 and 45% of the CD8+ and CD4+ cells, respectively, in the dermis.

CONCLUSION

These findings suggest that both CD4+ and CD8+ cells of donor origin were involved in the development of cutaneous GVHD.

Establishment of a human hemangiosarcoma cell line (ISO-HAS)

A cell line (ISO-HAS) has been established from tumor tissue of a human hemangiosarcoma arising on the scalp by the use of conditioned medium from a murine-phenotypic angiosarcoma cell line (ISOS-1). Cells have been cultured for more than 2 years with up to 100 passages. The cells retained endothelial-cell properties, such as a characteristic cobblestone appearance at confluency, contact-inhibited growth, active uptake of acetylated low-density lipoprotein labeled with 1,1-dioctadecyl 1,3,3,3,3-tetramethyl-indocarbocyanine perchlorate (DiI-Ac-LDL) and CD31 expression. However, they were weakly positive for von-Willebrand-factor (vWf) antigen and for binding of Ulex europaeus agglutinin-I (UEA-I) lectin, and lacked tube-formation activity. These findings indicate that ISO-HAS is a poorly differentiated endothelial cell line. ISO-HAS cells showed accumulation of p53 protein in the nuclei, and a new-typed p53-gene point mutation was found in exon 7 at codon 240. When inoculated s.c. into severe-combined-immunodeficiency (SCID) mice, the cells showed solid-tumor growth that caused death. These properties suggest that ISO-HAS is a malignant endothelial cell line with high tumorigenicity.

Local cytokine expression in steroid-modified tinea faciei

In tinea faciei, a dermatophyte infection of the face, early stage lesions show erythema with crust and/or vesicles, a condition often misdiagnosed as dermatitis. Steroid application retards the healing in some cases and may induce penetration of the dermatophyte hyphae into hair and hair follicles. In the present study, we examined local immunity mediated by cytokines derived from lesional T lymphocytes in late stage of this disease. Interferon-gamma (IFN-gamma) and macrophage migration inhibitory factor (MIF) were highly expressed, but neither interleukin-4 (IL-4) nor interleukin-5 (IL-5) could be detected by RT-PCR using cryosections. These data suggested that IFN-gamma and MIF may be important in the delayed-type hypersensitivity (DTH) response against the fungus in the hair follicle in late stages.

Efficacy of oral fluconazole in tinea pedis of the hyperkeratotic type. Stratum corneum levels

In this study, in addition to studying the efficacy and safety of the once-daily administration of 100-mg capsules of fluconazole over an 8-week administration period with six patients with hyperkeratotic-type tinea pedis, we also measured the serum and horny layer concentrations of fluconazole to study the mobility into the horny layer in diseased areas of the sole skin. The final overall efficacy and overall safety were both 100% (six out of six), and no side-effects, including abnormal laboratory changes, were observed in any of the patients. The drug mobility study revealed that in the horny layer of the skin a steady state was reached after 4 weeks of administration, with the mean concentration being 12.8 micrograms g-1. This concentration was a high concentration that was no less than 13 times the geometric mean MIC (0.972 microgram ml-1) for fresh clinical isolates of Trichophyton rubrum. Based on the above results, fluconazole is considered to be highly useful for treating various kinds of dermatomycosis, including hyperkeratotic-type tinea pedis.

The analysis of mRNA expression of cytokines from skin lesions in Churg-Strauss syndrome

We report our recent clinical experience with a patient suffering from Churg-Strauss syndrome and the results of our investigation into the mRNA expression of cytokines in the patient's lesions as well as in the frozen sections from a previous patient. In both cases, blood IgG was at a high level. Cytokine mRNA expression differed according to the degree of cellular infiltration. In the presence of marked infiltration, counteracting Th1 and Th2 cytokines were simultaneously detected; the former included IL-12 and IFN-gamma, and the latter, IL-6 and IL-10. The concurrence of both types of cytokine could be attributed to several factors. For example, IL-6 is involved through some mechanism in the formation of immune complexes by IgG, and IL-12 and IFN-gamma appeared to participate in the development of granuloma. These suppositions support the suggested immunological etiology of the disease. It is also inferred that the dominance of one of the two types of cytokines depends on the clinical phase of the disease.

Establishment of a new murine-phenotypic angiosarcoma cell line (ISOS-1)

A cell line, designated ISOS-1, was established from a tumor formed by transplantation of a human angiosarcoma into mice with severe combined immunodeficiency (SCID). The cells showed endothelial properties, based on the uptake of Dil-Ac-LDL and binding of UEA-I/GSA-I lectins, but were negative for CD11b and Pan Cytokeratin. However, the cells lost differentiated characteristics such as expression of von Willebrand factor, contact inhibition growth and tube formation activity. These findings indicate that ISOS-1 is a poorly-differentiated endothelial cell line. At the 81st passage, all of the cells were positive for H-2Dd in various intensity, but not HLA-ABC. The metaphase chromosomes consistently showed a characteristic mouse, but not human, telocentric form. Furthermore, this cell line produced fatal tumor growth in SCID mice and also in BALB/c mice. These results suggest that ISOS-1 is a murine-phenotypic angiosarcoma cell line.

A case of tinea barbae successfully treated with terbinafine

Terbinafine was remarkably effective in tinea barbae due to Trichophyton rubrum on the cheek in front of the right ear in a 75-year-old man. This patient also showed tinea pedis and unguium, but these were due to Trichophyton mentagrophytes and were unrelated to the tinea in the cheek. This patient showed an atypical clinical picture slightly different from that during the initial visit, requiring histological differentiation from trichophytic granuloma.

Conversion of the CD4+ T cell profile from T(H2)-dominant type to T(H1)-dominant type after varicella-zoster virus infection in atopic dermatitis

Skin lesions of atopic dermatitis were examined for cytokine expression by reverse transcription-polymerase chain reaction. The profile of mRNA for various cytokines revealed that both T(H1) and T(H2) types of CD4+ T cells, probably including T(H0) type, infiltrate into the skin lesion. We observed that atopic skin lesions improved after varicella infection. In such lesions, expression of T(H1) type cytokines predominated. The peripheral blood T cells from atopic patients exhibited a differentiation into T(H2) type cells upon in vitro stimulation with mite antigen. In contrast they differentiated into T(H1) type cells upon stimulation by varicella antigen. Since IL-12 has been reported to switch the in vitro recall response of allergen-specific T cells of atopic donors from a T(H2)- to a T(H1)-like phenotype, we examined its local production in varicella lesions. IL-12 p35 and p40 mRNA were expressed in fresh lesions. Peripheral blood mononuclear cells from atopic patients expressed p40 mRNA upon in vitro stimulation with live varicella zoster virus, but they did not show p40 mRNA without stimulation. This finding suggested that in atopic skin lesions containing the virus, IL-12 was produced and the cell type was changed to T(H1) type-predominance. These results suggested that patients with atopic dermatitis always have highly reactive CD4+ T cells infiltrating into their skin, and that the switch to T(H1) or T(H2) dominance is related to whether the lesion is improved or exacerbated.

A case report of twenty-nail dystrophy

A case report of twenty-nail dystrophy in a 21-year-old woman is presented. All her finger nails were affected with numerous small superficial pits. The histological findings showed the focal spongiotic change in the nail matrix reflecting the clinical appearance of the nail plate surface.

Lichen planus and Sjögren-type sicca syndrome in a patient with chronic hepatitis C

We report a 54-year-old Japanese male with lichen planus and Sjögren-type sicca syndrome, accompanied by the latent complication of chronic hepatitis C. The patient first showed erythematous and erosive lesions with white irregular striae in the buccal mucous membrane, and blepharitis and hyperemia of conjunctiva in his eyes. He later had two small erosions on the glans penis, and flat-topped violaceous papules on the dorsa manus and nape. A biopsy specimen of the lower lip lesion demonstrated a lichenoid tissue reaction at the basement membrane zone, and lymphocytic focal accumulations in the salivary glands. Immunohistochemical study of this specimen revealed CD45RO- (T) cells associated with the expression of HLA-DR antigens predominantly in both the lichenoid tissue reaction and the lymphocytic sialadenitis. Objective keratoconjunctivitis sicca was confirmed by the Schirmer and Rose-Bengal tests. Anti-DNA antibody was positive; however anti-SS-A, and anti-SS-B antibodies were negative. Increased levels of transaminase enzymes, TTT, ZTT, and IgG were observed in first laboratory examinations; thereafter, antihepatitis C virus (HCV) antibodies and HCV-RNA were detected. The high serum amylase level, in which salivary amylase predominated, was normalized by etretinate therapy in parallel with the clinical improvement of the oral LP lesions. Our case is considered to support the hypothesis that an etiologic association may be present among lichen planus, Sjögren's syndrome, and chronic hepatitis C.