An 80-year-old Japanese man presented to our department for the first time with exacerbated psoriasis vulgaris. Psoriasis area and severity index (PASI) score upon initial visit was 47.3. Oral antihypertensive drugs were discontinued and changed to differentiate drug-induced psoriasis ; however, the skin rash did not improve. The patient was treated with combined topical steroids and vitamin D3 ; however, hypercalcemia appeared. The treatment was changed to topical steroid monotherapy. Thereafter, the patient was unable to continue the topical therapy due to advanced age and decreased activities of daily living. Consequently, the skin rash worsened and developed into erythroderma. Pneumonia developed, and the patient was admitted to our department. His PASI score upon admission was 59.4. Biologic agents could not be administered due to concomitant pneumonia. Therefore, combination therapy with apremilast and phototherapy was started. Six months after initiation, PASI score was 3.2. In psoriasis vulgaris treatment, biologics are often selected for cases that are treatment-resistant, have severe joint symptoms, and those with psoriatic erythroderma. Here, a patient with psoriatic erythroderma who had severe infection was unable to receive biologics ; however, he was successfully treated with combined apremilast and phototherapy and maintained long-term remission. Skin Research, 23: 1-8, 2024

In this report, we describe three cases of alopecia areata accompanied by atopic dermatitis that were treated with dupilumab. Case 1 was a 40-year-old male. Following the initiation of dupilumab treatment for atopic dermatitis, both the rash and alopecia areata showed improvement. Case 2 was an 11-year-old male who had suffered from atopic dermatitis since childhood and experienced hair loss over the entire scalp, eyebrows, and eyelashes. The rash and alopecia areata were resistant to standard treatment. Dupilumab treatment was initiated 9 years after the initial diagnosis, resulting in improvement of the rash and noticeable hair growth over the eyebrows and eyelashes. However, hair loss over the entire scalp persisted. Case 3 was a 41-year-old male who, despite treatment with dupilumab for atopic dermatitis, experienced a worsening of alopecia areata. Subsequently, a change in treatment to baricitinib and cyclosporine led to noticeable hair regrowth. In cases 1 and 2, elevated non-specific IgE levels were observed, and the use of dupilumab markedly ameliorated the symptoms of alopecia areata. However, in case 3, the non-specific IgE levels were within the normal range, and dupilumab administration resulted in a deterioration of alopecia areata symptoms. Studies have reported that individuals with alopecia areata complicated by extrinsic atopic dermatitis tend to exhibit a more pronounced Th2-oriented peripheral blood cytokine balance compared to those with alopecia areata complicated by intrinsic atopic dermatitis. Extrinsic and intrinsic atopy are classified according to non-specific IgE level. We hypothesize that IgE level could serve as a valuable indicator of symptom amelioration with dupilumab. Skin Research, 23 : 9-15, 2024

A 62-year-old woman scheduled for breast cancer surgery presented with a 10×5 mm blackish-brown, slightly flattened nodule on her right neck that had been present for several years. Dermoscopy revealed leaf-like areas and vasodilation. Skin biopsy led to the diagnosis of superficial basal cell carcinoma. The patient had recently received breast cancer surgery and subsequent adjuvant therapy with paclitaxel, cyclophosphamide, pertuzumab, and trastuzumab ; therefore, we surgically removed the basal cell carcinoma six months after her initial presentation. Histopathological examination of the resected specimen showed no residual tumor cells. The dermis exhibited dense infiltration of inflammatory cells, vascular proliferation, and increased collagen. Melanin granules and melanophages were also observed in the dermis. This case demonstrates the complete regression of basal cell carcinoma, and we hypothesize that tumor immunity was activated by the skin biopsy as well as the chemotherapy for breast cancer. As basal cell carcinoma is considered to have high immunogenicity, further studies are required to elucidate the mechanisms underlying the regression of basal cell carcinoma. Skin Research, 23 : 16-20, 2024

We report a patient with Sweet’s syndrome who required a tracheotomy for subglottic stenosis. The patient was a 67-year-old woman who presented with a high fever, erythema of the face and both upper limbs, and hoarseness one week prior to her initial visit to our hospital. She was referred to our department by her previous physician. At her first visit, we suspected Sweet’s syndrome based on the presence of painful, edematous erythema on her face and both forearms, accompanied by fever. Otorhinolaryngological endoscopy was performed to investigate the cause of her hoarseness, revealing the presence of subglottic stenosis. Due to the rapid deterioration of her subglottic stenosis, a tracheotomy was performed on the same day. She was treated with betamethasone (4 mg/day) to reduce airway edema. By the third day of treatment, her hoarseness had improved, and the erythema on her face and upper limbs had resolved. A skin biopsy revealed an infiltrate of inflammatory cells, predominantly neutrophils, in the dermis ; thus, a definite diagnosis of Sweet’s syndrome was made. Two years following treatment, there has been no recurrence of the skin rash or hoarseness. The present case highlights that airway obstruction due to progressive edema from dermal neutrophil infiltration may necessitate emergent intubation in Sweet’s syndrome patients. Therefore, in cases of Sweet’s syndrome, systemic corticosteroid therapy should be considered, and careful follow-up is necessary. Skin Research, 23 : 21-26, 2024

A 90-year-old woman was admitted to the Department of Cardiology complaining of right lower leg pain and difficulty walking. Lower extremity angiography revealed no arterial stenosis. Upon referral to our department, she exhibited circumferential redness, swelling with purpura, and hemorrhagic blisters on her right lower leg. Her level of consciousness was decreased to JCSII-20, and she was in shock. A test incision of the swollen area revealed necrosis of the subcutaneous adipose tissue. Although extensive surgical debridement was considered necessary, we selected conservative treatment due to her poor general condition. Group G streptococci were identified in the bacterial culture of the wound exudate. Despite ongoing treatment with antimicrobial agents and wound cleansing, her hypoalbuminemia worsened due to persistent inflammation and advanced poor nutritional status. She died of respiratory failure on the 11th day of admission. Pathological autopsy revealed extensive soft tissue necrosis extending to the cnemis in the right lower leg, leading to a diagnosis of necrotizing fasciitis caused by group G streptococcal infection. Reports of streptococcal toxic shock syndrome have been increasing in recent years and are anticipated to rise further in the aging society. Prompt diagnosis, evaluation, and therapeutic intervention are necessary for managing cases of streptococcal toxic shock syndrome. Skin Research, 23 : 27-31, 2024

A 44-year-old woman underwent a robot-assisted total hysterectomy and bilateral oophorectomy under general anesthesia in the Department of Gynecology. At the conclusion of the surgery, erythema of the extremities and trunk and hypotension were observed. After administration of adrenaline, her blood pressure stabilized, and the erythema resolved. As we suspected anaphylactic shock due to intraoperative drugs, including intravenous acetaminophen (AAP), we performed skin tests three months postoperatively. The intradermal test yielded a positive result for 0.1% AAP, leading to a diagnosis of anaphylaxis due to intravenous AAP. AAP is considered a safe drug with few side effects and is widely used for perioperative analgesia ; however, it can induce anaphylaxis. Anaphylaxis caused by AAP is often diagnosed through a provocation test ; however, this case is noteworthy as it was diagnosed using a skin test. As a potential route of sensitization, we considered the possibility that the patient had been exposed to AAP during previous surgeries or through over-the-counter cold remedies. Although skin testing is complicated due to the use of multiple drugs in general anesthesia, it is important to perform skin tests for accurate perioperative management and medical guidance. Skin Research, 23 : 32-36, 2024