bluuebunny/crossref_metadata_2025 huggingface dataset:
A randomized, controlled and blinded study of papulopustular lesions in Turkish Behçet’s patients
Authors: Alpsoy Erkan , Aktekin Mehmet , Er Hanife , Durusoy Çiçek , Yilmaz Ertan
Published: March 2003

Background Papulopustular lesions (PPL), the commonest presentation of skin lesions in Behçet’s disease (BD) are cutaneous, sterile folliculitis or acne‐like lesions on erythematous base. Our purpose was to determine the true frequency and anatomic location of the PPL and compare this with controls. We also sought to determine whether or not there was any relationship between PPL and either disease activity or other manifestations of BD.

Methods Fifty patients with BD, diagnosed according to the criteria of the International Study Group for Behçet’s Disease, were enrolled in the study. The control group consisted of 100 patients with other dermatologic diseases (21 acne and 79 non‐acne patients), selected randomly. A dermatologist counted the lesions, in a blind protocol, on seven anatomic locations: scalp, face, neck, trunk, upper and lower extremities and genitalia.

Results The frequency of PPL in patients with BD was 96% and the most common location was the trunk, whereas in the control group the frequency was 89% and the most common location was the face. In acne and non‐acne patients, the frequency was 100% and 86.1% respectively. The total mean number, and mean numbers of PPL on the location of trunk, upper and lower extremities, and genitalia were higher in patients with BD than in controls. When the PPL in BD patients with a positive pathergy test was compared with that in patients with a negative pathergy test, the difference was significantly higher.

Conclusions Our results indicate that PPL appear to be non‐specific. In the diagnosis of BD the mean number and anatomic location of the lesions are of more importance than the frequency.
A questionnaire study on the management of onychomycosis: a Canadian perspective
Authors: Gupta Aditya K. , Shear Neil H.
Published: March 2003

Background Onychomycosis of the toenails is a condition that responds poorly to griseofulvin. The introduction of terbinafine in Canada in May 1993 resulted in a marked shift in the choice of treatment for pedal onychomycosis.

Methods A questionnaire survey was carried out in 1996 among Canadian dermatologists regarding the management of onychomycosis.

Results There were 160 respondents from the roughly 350 practicing dermatologists. The dermatologists saw 8 ± 0.6 patients per week (average ± standard error (SE)) with suspected or diagnosed onychomycosis, with 5 ± 0.5 patients per week consulting the dermatologists for the first time. Most dermatologists performed mycological testing prior to starting treatment for onychomycosis. The management options for onychomycosis (mean ± SE) were oral systemic antifungal therapy 51 ± 3%, no therapy 31 ± 3%, and nondrug therapy 9 ± 2%. The majority of dermatologists (83%) used terbinafine as first‐line therapy if, indeed, they used oral antifungal agents. In contrast, griseofulvin and ketoconazole were used as first‐line therapy in 5% and 1% of cases, respectively. In Canada, there are no monitoring requirements when using oral terbinafine for onychomycosis. Therefore, it is not surprising that only 30% of dermatologists performed monitoring with terbinafine. In contrast, the frequency of monitoring with griseofulvin and ketoconazole was 40% and 80%, respectively. The subset of dermatologists who reported monitoring carried it out in only a fraction of their patients: 47%, 53%, and 83% for terbinafine, griseofulvin, and ketoconazole, respectively. Therefore, the overall number of patients in whom regular monitoring was performed was 14.1%, 21.2%, and 71.4% for terbinafine, griseofulvin, and ketoconazole, respectively. The perceived cure rates with terbinafine and griseofulvin (mean ± SE) were 83.7 ± 1% and 41 ± 3.1%, respectively.

Conclusions In May 1996, within three years of the introduction of terbinafine to Canada, this agent has become the drug of choice for the treatment of pedal onychomycosis (at the time of the survey neither itraconazole or fluconazole were approved for onychomycosis). Terbinafine has been found to be very effective and safe, and only a minority of dermatologists perform regular monitoring with this drug.
Fluconazole in the treatment of tinea capitis
Authors: Montero‐Gei Fernando
Published: March 2003

Twenty white children (8 girls; 12 boys), ranging in age from 2 to 12 years (most in the age range 5–9 years), were enrolled in a clinical trial with their parents consent to assess the efficacy, safety, and tolerability of a single oral dose of fluconazole given once weekly for 4–8 weeks for the treatment of outpatients with mycologically proven tinea capitis.

Ten children had previously undergone an unsuccessful course of treatment with griseofulvin liquid suspension or the ultramicronized formulation and desired alternative therapy. Factors possibly contributing to the lack of success of griseofulvin included living in a tropical area, poor hygiene, insufficient dosages, and malnutrition. Adverse reactions to griseofulvin included skin eruption, nausea, photosensitivity, and drug interactions. Furthermore, the patients became exasperated with the long duration of griseofulvin therapy.

The diagnosis of tinea capitis was confirmed on the basis of microscopic examination of arthrospores of the infecting fungus located outside or inside the affected hairs. The primary isolation of the causative pathogens in culture was accomplished using Mycosel (BBL, Baltimore, MD) and Sabouraud dextrose agar. The pathogens recovered were Microsporum canis (13), M. gypseum (5), and Trichophyton tonsurans (2). All cases caused by M. canis were positive under Wood’s light.

Patients underwent a physical examination, laboratory tests were performed, and a medical history was obtained from the mother or father of each patient. Any medications taken by the patients at study entry or during the study were recorded.

Fluconazole therapy was administered once a week in the presence of the investigator. The dosage was based on body weight. Initially, the fluconazole dose was 6 mg/kg. The dose subsequently was increased to 8 mg/kg based on safety information, including laboratory test results. All patients, except for four, were treated at the higher dose. Shampoos were not used as adjunctive therapy.

Patients were assessed weekly for clinical and mycologic response and for the occurrence of adverse events. Adverse event information included the date of onset, duration, severity, and relationship to drug therapy.
Epidemiology of onychomycosis in southern Greece
Authors: Rigopoulos Dimitrios , Katsiboulas Vassilios , Koumantaki Elma , Emmanouil Penny , Papanicolaou Assimina , Katsambas Andreas
Published: March 2003

Background Onychomycosis appears to be a variable entity: it presents in different forms in different parts of the world. It is probable that every country has its own particularities of presentation and it is also probable that different regions of the same country, with either different or equivalent environmental conditions, present with different levels of incidence. Large‐scale epidemiological studies performed worldwide have demonstrated different epidemiological results.

Objective This study was undertaken to determine the epidemiology of onychomycosis in the population of southern Greece.

Methods Direct microscopic examination and culture were performed on samples from patients with clinical suspected onychomycosis.

Results The most frequently isolated fungus was Candida (52.44%), followed by dermatophytes (41.04%) and saprophytic molds (6.51%). Finger nails were infected more than toe nails in both sexes. The most frequently isolated fungus in finger nails was Candida (76%), followed by dermatophytes (23%), and molds (1%); toe nails were most often infected by dermatophytes (71%), Candida (13%) and molds (16%). Among the infected women patients, the most frequently isolated fungus was Candida (64%), followed by dermatophytes (30.58%); 5.33% were infected by saprophytic molds. Of the 101 men infected, dermatophytes were most frequently isolated (62.37%), followed by Candida (28.71%) and saprophytic molds (8.91%).

Conclusions Comparison of the results of epidemiological studies of onychomycosis worldwide show great differences, not only between different countries and different climate zones, but also between studies performed in the same country. In our opinion such epidemiological studies should be performed in every country in order to determine the major fungal species responsible; such information is extremely useful in the treatment of nail onychomycosis.
Lupus vulgaris complicated by metastatic squamous cell carcinoma
Authors: Yerushalmi Joseph , Grunwald Marcelo H. , Halevy Dafna Hallel , Avinoach Ilana , Halevy Sima
Published: March 2003

A 47‐year‐old Bedouin man presented with an ulcerated nodule of several months’ duration on the nape of the neck. The nodule developed on an asymptomatic, slowly growing plaque which appeared during childhood. Physical examination revealed two erythematous plaques covering the posterior and right lateral aspects of the neck. The border of the plaques was soft, circinate, with a reddish‐brown color, while the center was slightly erythematous and atrophic. An ulcerated nodule measuring 2 cm was seen on one of the plaques (Fig. 1). Physical examination was unremarkable with no lymphadenopathy. Laboratory tests, including complete blood cell count, erythrocyte sedimentation rate (ESR), and routine chemistry tests, were all within normal limits. Chest X‐ray showed a small calcified perihilar lymph node. The Mantoux test was positive with erythema and induration of 15 mm after 48 h. Biopsy from a plaque showed extensive diffuse granulomatous infiltration throughout the dermis with epithelioid and Langhans giant cells surrounded by mononuclear inflammatory cells. No caseation necrosis was present. Ziehl–Neelsen, periodic acid–Schiff (PAS), and Giemsa stains were negative. Polymerase chain reaction (PCR) for the detection of Mycobacterium tuberculosis and atypical mycobacteria from a skin sample was also negative. Fresh tissue cultures yielded M. tuberculosis after 6 weeks.

Ulcerated nodule on the atrophic plaque

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A biopsy specimen from the ulcerated nodule demonstrated islands of atypical malignant squamous cells invading the dermis, which were compatible with moderately differentiated squamous cell carcinoma (SCC) (Fig. 2). The ulcerated nodule was completely excised, and treatment for tuberculosis was initiated with a combination of isoniazid, rifampicin, and pyrazinamide. Within 3 months of therapy, the patient's lesions resolved, leaving only slightly atrophic hypopigmented scars. A month after the treatment's initiation, an enlarged cervical lymph node was noted showing metastatic SCC on histologic examination. The patient underwent neck dissection and radiation therapy without evidence of any further metastases.

Moderately differentiated squamous cell carcinoma appearing in the ulcerated cutaneous granulomatous lesion (hematoxylin and eosin stain; original magnification, ×400)

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Discussion
Characteristics of bacterial skin infections in children compared to adults at a tertiary dermatologic center
Authors: Sugeng Maria W. , Ang Por , Tan Hiok Hee , Goh Chee Leok , Centre From the National Skin , Singapore .
Published: March 2003

Background Bacterial skin infections in children and adults are caused by different organisms with different antimicrobial susceptibility.

Methods A comparative retrospective study was carried out on 233 adults and 53 children with bacterial skin infections. Skin swab cultures and sensitivity tests were performed using standard methods. Statistical analysis was performed using the Pearson chi‐squared and Fisher tests. A P value of <0.05 was considered to be significant.

Results Primary and secondary skin infections occurred in equal proportions in children, whereas secondary skin infections were more common in adults (70.8%). Staphylococcus aureus was the main cause of skin infections, particularly in children (72.6%). S. aureus in children and adults was highly susceptible to cloxacillin, cephalexin, chloramphenicol, neomycin, cotrimoxazole, and clindamycin, moderately susceptible to erythromycin, and insensitive to tetracycline, ampicillin, and penicillin.

Conclusions It is important to monitor the trends of bacterial infections and their antibiotic susceptibility as this can assist medical practitioners in their choice of antimicrobial therapy. Such monitoring will also help to detect the emergence of resistant bacterial strains and caution us to take care in the use of certain drugs.
Quantitative analysis of nailfold capillary abnormalities in patients with connective tissue diseases
Authors: Ohtsuka Tsutomu
Published: March 2003

BackgroundNailfold capillary microscopy has been shown to reflect microvascular disturbances mainly in connective tissue diseases including systemic sclerosis (SSc).

MethodsNailfold capillary abnormalities were analyzed with a light microscope under immersion oil at magnifications of ×60 and ×400.

ResultsAbnormal nailfold capillary pattern in SSc was different from that of systemic lupus erythematosus (SLE) and normal controls, but not from dermatomyositis (DM). Seventy‐two per cent of patients with Raynaud’s phenomenon showed an abnormal nailfold capillary pattern. In primary Raynaud’s phenomenon, 12% of subjects developed undifferentiated connective tissue disease. In undifferentiated connective tissue disease, 23% developed SSc. The apical limb width, capillary width and capillary length of subjects who developed SSc were significantly larger than in those who did not. With regard to the clinicolaboratory findings, the occurrence rate of an abnormal apical limb width, abnormal capillary width, abnormal capillary length, and antinuclear antibody in patients who developed SSc was significantly higher than in those who did not. An abnormal capillary pattern correlated with an elevated pulmonary artery resistance. All the patients with pulmonary arterial hypertension showed an abnormal capillary pattern, decreased diffusion capacity for carbon monoxide, and elevated pulmonary vascular resistance. Nailfold capillary abnormalities show a close relation to pulmonary arterial hypertension.

ConclusionsNailfold capillary abnormalities are useful for detecting vascular abnormality in clinical practice. These facts stress the importance of nailfold capillary abnormalities in SSc.
Ocular toxicity of chloroquine among Thai patients
Authors: Puavilai Siripen , Kunavisarut Skowrat , Vatanasuk Mongkol , Timpatanapong Penwadee , Sriwong Suwitcha T. , Janwitayanujit Suchela , Nantiruj Kanokrat , Totemchokchyakarn Kitti , Ruangkanchanasetr Suwanna
Published: March 2003

Background Chloroquine has been prescribed for the treatment of various diseases. The most serious side‐effect of chloroquine is retinopathy. The frequency of occurrence of retinopathy varies from 0.001 to 40% depending on the criteria used. The purpose of this study was to evaluate the incidence of ocular toxicity from chloroquine treatment among Thai patients.

Methods A retrospective study was carried out in patients treated with chloroquine at Ramathibodi Hospital over the past 10 years (1987–1997). Patients eligible for review were followed by ophthalmic examination by an ophthalmologist for at least 6 months after starting treatment.

Results One hundred and fifty‐five patients were studied. Nineteen were men and 136 were women. They ranged in age from 10 to 70 years. Most patients received 250 mg of chloroquine per day. The duration of treatment varied from 6 months to 14 years, and the cumulative dose of chloroquine ranged from 26 to 1771 g. Fourteen patients (9%) had only corneal deposition, while 22 (14.2%) developed retinopathy. There were no correlations between corneal deposits or retinopathy and age, sex, duration of treatment, or cumulative dose of chloroquine.

Conclusions The present study confirms the finding reported by Mackenzie (Am J Med 1983; 75 (Suppl 1A): 40–45) that retinopathy is not related to the duration of treatment and cumulative dose of chloroquine. Based on our finding that retinopathy can be detected as early as 9 months after starting chloroquine therapy, we recommend routine ophthalmic examination before treatment and every 6 months thereafter.
Fatal cutaneous necrosis in a hemodialyzed patient with oxalosis
Authors: Galimberti Ricardo Luis , Parra Isabel Hidalgo , Imperiali Nora , Diez Guillermo Rosa , Kowalczuk Alicia , Algranati Luis , Galimberti Gaston
Published: March 2003

A 49‐year‐old woman had a history of recurrent nephrolithiasis and urinary infections since childhood that resulted in end‐stage renal disease. She had been receiving hemodialysis for 4 years. Four months before her admission to hospital, she was to have undergone a bilateral nephrectomy but, during anesthesia induction, she suffered a cardiac arrest and the operation was interrupted. Shortly thereafter she developed skin lesions.

Clinical features included bilateral livedo reticularis and painful violaceous plaques with necrotic changes in both legs, with some blisters on the left leg ( Fig. 1). Skin biopsy showed arterial occlusion with calcium salt deposits with von Kossa reaction, necrosis of the small vessels, and epithelial necrosis
(
Fig. 2). A crystallographic study of the skin was performed showing 100% calcium oxalate crystals (wedellita).

Necrotic and ulcerated plaque with blisters on the skin on the left leg

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von Kossa‐stained tissue revealed calcium deposits in blood vessels ( × 40)

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Laboratory tests revealed a hematocrit of 27%, increased calcium/phosphate (Ca 9.8 meq/L; phosphate 14.9 meq/L), blood urea 159 mg/dL, creatinine 9.1 mg/dL, albumin 1.92 mg/dL, serum uric acid 11 mg/dL, diabetes (serum glucose 148 mg/dL), and hyperparathyroidism (serum parathormone 150 pg/mL).

X‐Ray of the hands showed soft tissue calcium deposits. X‐Ray of the legs showed signs of bone resorption: subperiosteal erosions in phalangeal bones, vascular calcifications. Bone biopsy showed massive oxalate crystal deposits.

She underwent a parathyroidectomy. Unfortunately, she suffered a terminal cardiac arrest in the immediate postoperative period.
Pattern of skin diseases among pilgrims during Hajj season in Makkah, Saudi Arabia
Authors: Fatani Mohamad Ibrahim , Al‐Afif Khalid Abdullah , Hussain Hameed
Published: March 2003

Background Skin diseases among pilgrims are considered to be one of the possible health problems in our area. Data supporting this observation are scanty and sparse. The aim of this study was to report the most common skin diseases seen in a 15‐day period.

Methods We retrospectively collected all new cases of skin diseases diagnosed during a 15‐day period at King Faisal Hospital, the nearest general medical center to Mina. Pilgrims gather at Mina (which harbors more than two million pilgrims every year) to perform their Hajj.

Results During the Hajj season in 1998, 731 new patients were seen; 63.3% were men and 36.7% were women. Of these cases, Saudi citizens represented 42.5% of the total patients. The peak age group ranged from 20 to 39 years. The incidence in Saudi patients was more than that in other nationalities. Dermatitis of various etiologies (23.6%) was found to be the most common skin disease. Pyoderma was found to be more common in Saudis and Asians than in Arabs, whereas Arabs suffered from intertrigo much more than Asians and Saudis.

Conclusions A high incidence of skin diseases such as pyoderma and intertrigo among pilgrims of such a large congregation is understandable. Investigating these skin infections is worthwhile because they are preventable, easily diagnosed, and are curable in the majority of patients.
Clinical evaluation of a more rapid and sensitive Psoriasis Assessment Severity Score (PASS), and its comparison with the classic method of Psoriasis Area and Severity Index (PASI), before and after climatotherapy at the Dead‐Sea
Authors: Harari Marco , Shani Jashovam , Hristakieva Eugenia , Stanimirovic Andrija , Seidl Wladimir , Burdo Asia
Published: March 2003

Abstract

Background  The Psoriasis Area and Severity Index (PASI) is used to quantify the extent of the disease, and to evaluate its improvement with treatment. It is considered to be a slow, rough, nonsensitive, and complex tool, with high interobserver variability and low reproducibility.

Objectives and methods  To develop a simpler, more sensitive, and more rapid end‐point determination for evaluating the psoriatic condition, and to compare its sensitivity with that of the classic PASI score in psoriatic patients undergoing 4‐week climatotherapy at the Dead‐Sea (Israel).

Results  This study describes a new, rapid, and simple Psoriasis Assessment Severity Score (PASS), whose readings are spread over a longer scale, making the test more sensitive than PASI, and allow better differentiation.

Conclusions  The comparison between the classic PASI and our new PASS emphasizes the weight of the ‘‘sensitivity to change’' (responsivity) in selecting a better evaluation method for psoriatic patients.
Topical gentian violet for cutaneous infection and nasal carriage with MRSA
Authors: Okano Masaki , Noguchi Sanai , Tabata Koshi , Matsumoto Yasutaka
Published: March 2003

This study describes a potential effect of topical gentian violet on cutaneous infection and nasal carriage with methicillin‐resistant Staphylococcus aureus (MRSA). 0.5% gentian violet was used in 28 cases of skin lesions once a day, while a 0.3% solution was applied on the nasal vestibules of nine cases twice a day. The period for eradication in the 28 skin cases was 9.1 ± 6.0 days. It was 15.3 ± 9.0 days for the nine nasal lesions. The minimal inhibitory concentration (MIC) of gentian violet against MRSA from the four isolated strains was 0.0225 ± 0.0096 μg/mL. No adverse reactions occurred throughout the study. It is suggested that gentian violet may be potentially effective against MRSA.
Delayed cutaneous reaction to jellyfish
Authors: Veraldi Stefano , Carrera Carlo
Published: March 2003

A 57‐year‐old woman presented with a widespread papulonodular eruption. The dermatitis had appeared about 1 week after her return from a trip to the Red Sea, where she had come into contact with a shoal of unidentified jellyfish; however, that contact had not been followed by cutaneous lesions and/or symptoms. The patient also stated that she had had previous contacts with jellyfish during other trips to exotic seaside resorts.

The dermatitis was characterized by papulonodular lesions, round or oval in shape, of a few millimeters in diameter, with a color ranging from pink to red to brown, and with a smooth and regular surface. The lesions were grouped in an apparently random fashion ( Fig. 1) or arranged linearly (
Fig. 2). The patient complained of pruritus and burning.

Grouped papulonodular lesions

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Papulonodular lesions linearly arranged

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Histopathologic examination showed the presence of some necrotic keratinocytes; in the upper and mid dermis, edema and a predominantly perivascular and periadnexal lymphohistiocytic infiltrate, with numerous neutrophils and eosinophils, were observed ( Fig. 3).

Epidermal erosion, covered by a crust, at the center of the lesion. Dermoepidermal detachment, edema, and lymphohistiocytic infiltrate, with numerous neutrophils and eosinophils in the upper and mid dermis (hematoxylin and eosin, ×12.5)

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The patient was treated with hydroxyzine (37.5 mg/day) and hydrocortisone butyrate, which resulted in the rapid disappearance of the symptoms; however, the cutaneous lesions persisted for about 3 weeks.
Cytodiagnosis of cutaneous basal and squamous cell carcinoma
Authors: Vega‐Memije Elisa , De Larios Nassira Martinez‐. , Waxtein Leon M. , Dominguez‐Soto Luciano
Published: March 2003

Objective We performed a prospective study to evaluate the diagnostic accuracy of cytologic examination in basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs), in order to assess its clinical value.

Study design Samples were taken by the “scraping” technique which involves scraping with a scalpel blade directly over the skin tumor surface, smearing the cells onto several glass slides, and fixing them with “citospray.” The specimens were stained with the Papanicolaou stain. Punch biopsies were taken to confirm the clinical and cytologic impression.

Results We collected 45 skin tumors in total, clinically presumed to be either BCC (n = 15) or SCC (n = 30). Imprint cytology demonstrated to be of help in the rapid diagnosis of skin tumors.

Conclusions Cytologic examination is easy to perform, saves time, provides a rapid diagnosis, and can be considered, under experienced hands, reliable in the confirmation of malignant skin tumors.

Cytology does not give much information about tumor patterns or subtypes which can be related to aggressive behavior and can be very important in further therapeutic decisions. Therefore, histopathologic confirmation is mandatory before any therapeutic maneuver.
Recurrent aphthous stomatitis and smoking
Authors: Tüzün Binnur , Wolf Ronni , Tüzün Yalçin , Serdaroğlu Server
Published: March 2003

Background Several studies have reported cigarette smoking to have a beneficial protective effect on recurrent aphthous stomatitis (RAS). In this study, we evaluated once again the incidence of smoking in RAS patients compared with controls. This study differs from most previous ones in that the patients were diagnosed by direct observation of active lesions by a dermatologist.

Methods Thirty‐four patients with RAS who were seen at the dermatology clinic during a period of 2 years were compared with 115 outpatients with other skin diseases and 20 healthy hospital personnel who had no history of aphthae, with regard to their smoking habits.

Results Among the 34 patients with RAS, 8.8% were active smokers compared with a significantly higher percentage (25.2%) among the control subjects.

Conclusions In agreement with others, we found a negative epidemiologic association between smoking and RAS. This finding can be used to clarify the cause and pathogenesis of the disease, and possibly to identify better treatment or preventive options than those currently available.
Indolent Acremonium strictum infection in an immunocompetent patient
Authors: Anadolu Rana , Hilmioğlu Süleyha , Oskay Tuğba , E Boyvat Ayş , Peksari Yavuz , Gürgey Erbak
Published: March 2003

A 35‐year‐old housewife presented with an 11‐year history of a painless lesion on the right cheek, which had enlarged over the last 2 years. She had no history of travel or trauma. Various topical and systemic antimicrobial and antifungal agents, such as fluconazole, ketoconazole, sulbactam/ampicillin, and mupirocin, had been prescribed, with a probable diagnosis of pyoderma and blastomycosis, without significant benefit. Her medical history was otherwise unremarkable. Dermatologic examination revealed a well‐circumscribed, erythematous, infiltrative, 8 × 10 cm plaque covering the right cheek and a 2 × 3.5 cm vegetative, ulcerated lesion on the chin (Fig. 1). There were no sinus tracts or grains.

Erythematous, infiltrative plaque covering the right cheek, and vegetative, ulcerated lesion on the chin

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The following laboratory test results were within the normal limits: complete blood count, blood biochemistry, urinalysis, immunoglobulins and complement levels, T lymphocyte, CD4 and CD8 cell counts, and response to mitogens. X‐Rays of the chest and maxillar and mandibular bones were normal. Routine bacterial cultures were negative. Skin biopsies and fungal and mycobacterial cultures were taken with a preliminary diagnosis of deep fungal or mycobacterial infection.

Dermatopathologic examination revealed irregular epidermal hyperplasia with follicular plugging. A dense nodular lymphohistiocytic infiltrate was observed within the reticular dermis, with many multinucleated giant cells and plasma cells. In higher magnification, even in hematoxylin and eosin sections, large septate hyphae and spores were noticeable. Periodic acid–Schiff stain revealed abundant fungal structures within the giant cells and extracellularly throughout the inflammatory infiltrate (Fig. 2). Lymphocytes were rather sparse in comparison to the large amount of microorganisms within the tissue.

Periodic acid–Schiff‐positive hyphae with phialides and yeast‐like phialoconidia (arrow) within the tissue (× 400)

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Fungal cultures were performed on Sabouraud's dextrose agar and, within 1 week of incubation, white fungal colonies were observed. On multiple passages at 26 °C, white tufted colonies with a salmon‐colored base had formed (Fig. 3). Native preparations from the cultured colonies revealed septate hyphae, and 90° angled branches, together with phialides decorated with ellipsoidal conidia with rounded edges (Fig. 4). These findings were consistent with Acremonium strictum, a saprophytic fungus.

Fungal culture: salmon‐colored base of the colonies

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Lactophenol cotton blue (× 40): 90° branching septate hyphae with ellipsoidal, round‐ended conidia

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Further laboratory examinations revealed no systemic involvement. Following the diagnosis of Acremonium infection, amphotericin B therapy and surgical excision of the tumoral lesion were planned, but the patient refused further treatment and failed to respond to our follow‐up attempts.
Smoking effect on skin wrinkling in the aged population
Authors: Aizen Efraim , Gilhar Amos
Published: March 2003

Abstract

Objectives  Smoking causes premature wrinkling and is one of the more potent risk factors for atherosclerosis. The aims of the present study were to verify: (i) whether there is a difference between the wrinkling appearance in aged smokers and the nonsmoking population; and (ii) whether the systemic effects of smoking, such as atherothrombotic disease and cerebrovascular disease, are associated with a more striking appearance of wrinkling.

Participants  Eighty volunteers (mean age, 76 years) were included in the study, 40 of whom were smokers and 20 of whom had suffered a stroke.

Results  The mean value of the wrinkling score measured for the smokers' group (stroke and nonstroke) was significantly higher than that for the nonsmokers' group (analysis of variance, ANOVA; P < 0.01). There was no significant difference between the smokers who had suffered from stroke and smokers who had not.

Conclusion  The study indicated that prominent facial wrinkling was significantly more common among smokers than nonsmokers, not only in the relatively young but also among the aged population.
Topical formic acid puncture technique for the treatment of common warts
Authors: Bhat Ramesh M. , Vidya Krishna , Kamath Ganesh
Published: March 2003

Abstract

Background  Warts are a common chronic skin disorder that can be cosmetically disfiguring and, depending on the location, cause inhibition of function. The presence of dozens of topical and systemic treatments for warts is a testament to the lack of a rapid, simple, uniformly effective, inexpensive, nonscarring, and painless treatment.

Aim  The purpose of this study was to determine the efficacy and safety of 85% formic acid application, an inexpensive therapy, for the treatment of warts.

Methods  A placebo‐controlled, nonrandomized, open trial was performed in 100 patients with common warts attending Father Muller's Medical College Hospital, Mangalore. Fifty patients received 85% formic acid application and 50 patients received placebo (water) using a topical application/needle puncture technique every other day.

Results  Ninety‐two per cent of patients who received formic acid application showed complete disappearance of warts after a 3–4‐week treatment period, compared to 6% in the placebo group.

Conclusions  The results show that 85% formic acid application is a safe, economical, and effective alternative in the treatment of common warts with few side‐effects and good compliance. A multicenter trial is needed to examine the efficacy and safety of this treatment.
Expression of bcl‐2 protein in active skin lesions of Behçet's disease
Authors: Senturk Nilgün , Yildiz Levent , Sullu Yuksel , Kandemir Bedri , Turanli Ahmet Yasar
Published: March 2003

Abstract

Background  Expression of bcl‐2 protein has been shown to play an important role in the pathogenesis of some inflammatory as well as neoplastic disorders. In this study we have investigated the presence of bcl‐2 protein in active skin lesions of Behçet's disease and compared these results with normal skin samples of Behçet's disease (BD) patients and BD unrelated leukocytoclastic vasculitis.

Methods  Active skin lesions of 23 Behçet's disease patients, normal skin samples of seven Behçet's disease patients, and archival biopsy specimens of 23 cutaneous leukocytoclastic vasculitis were investigated for the presence of bcl‐2 protein by immunohistochemical methods. Results of staining were assessed semiquantitatively. Chi‐square tests were used for statistical analysis.

Results  Expression of bcl‐2 protein were demonstrated in 16 of 23 (69.5%) and 8 of 23 (34.7%) patients with Behçet's disease and leukocytoclastic vasculitis, respectively. There were statistically significant difference between two groups (x2 = 4.27, P < 0.05). None of the normal skin samples of Behçet's disease patients showed bcl‐2 expression.

Conclusion  Expression of bcl‐2 protein may play a particular role in the development of skin lesions in Behçet's disease by causing prolonged survival of infiltrating lymphocytes.
Cutaneous HSV‐2 infection with serial recurrences at multiple sites
Authors: Dacko Anne , Don Philip C. , Weinberg Jeffrey M.
Published: March 2003

A 60‐year‐old white male presented to the dermatology clinic in early 1997 complaining of painful, recurrent lesions on his arms, legs, and hands for several months. At presentation, he was noted to have a cluster of erythematous pustules on his right thigh and left palm (Fig. 1). He had no systemic complaints, fever, chills or adenopathy. His past medical history included a seizure disorder, type 2 diabetes, coronary artery disease, benign prostatic hypertrophy, diverticulosis, and a history of bowel surgery. He reported he was in a monogamous relationship with a partner after the death of his wife of many years. He reported no history of similar lesions in the past. Biopsy of a lesion was performed, which was consistent with herpes virus infection. Basic screening labs at the time were all within normal limits. The lesions resolved within 10 days.

Vesicular lesions on left palm

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The following month, new lesions appeared on his right ankle and right medial calf. Within the second and third month after presentation, new lesions appeared on his left neck and right thigh, respectively. Biopsy of lesions from both time points again demonstrated pathology consistent with herpes virus infection.

Within the next several weeks, the patient subsequently developed pustulovesicular lesions on his lower back with dermatomal pain. Serologies using ELISA for HSV‐1 and HSV‐2 were both positive for IgG; but both were IgM negative. He was started on famciclovir 500 mg po three times daily for 2 weeks, but continued to develop lesions on his right buttock and right hand (May 1998) (Fig. 2). Four viral cultures of lesions returned positive for HSV‐2.

HSV infection of right palm

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Valacyclovir 1 gram po three times daily was prescribed to suppress outbreaks and for 2 months, the patient had no new lesions. Serum protein electrophoresis was normal; and CD4 count done at this time was 1081. T‐helper to suppressor ratio and absolute numbers were within normal limits. The patient was seen in infectious disease clinic in the interim, and twice tested negative for HIV. Valacyclovir was decreased to 500 mg twice daily then to 500 mg daily over the next 5 months. On the lower dosage however, new lesions developed on his left leg and both hands, and the dose was increased to valacyclovir 1 gram po three times daily.

For 3 months, the patient also complained of left facial swelling and pain. CT scan of the parotid glands showed enlargement bilaterally of the superficial lobes which was consistent with viral infection or synulosis. When the patient has stopped taking valacyclovir, new lesions developed on his posterior scalp, left shoulder, right posterior auricular scalp and right buttock (July 1999).

As of the fall of 1999, the patient continued to have intermittent outbreaks clinically consistent with his previous HSV outbreaks.
Comparison of two surgical approaches for treating vitiligo: a preliminary study
Authors: Özdemir Mustafa , Çetinkale Oğuz , Wolf Ronni , Kotoğyan Agop , Mat Cem , Tüzün Binnur , Tüzün Yalçın
Published: March 2003

Background Surgical techniques have recently been introduced for patients with vitiligo. Randomized controlled trials have not been performed.

Aim To compare the efficacy and side‐effects of two surgical methods (suction blister vs. thin split‐thickness graft technique) for the treatment of vitiligo.

Methods Three suction blisters, approximately 0.8 cm in diameter, made with a special tool attached to a vacuum extractor, which were converted to erosions by removal of the roofs of the bullae, and one round erosion of approximately the same diameter, made using a silver knife, were created. One roof of a blister and two cutaneous thin split‐thickness grafts taken from the gluteal region were transferred onto recipient vitiliginous areas; one was left alone. The results were evaluated by one non‐blind and two blind observers bimonthly during the 3‐month follow‐up period.

Results Repigmentation rates were 25–65% in the suction blister technique and 90% in the thin split‐thickness graft technique (P < 0.001).

Conclusions The thin split‐thickness graft technique is superior to the suction blister technique in treating vitiligo.
Unusual location of cutaneous leishmaniasis on the hallux in a Brazilian patient
Authors: Ogawa Marília M. , Macedo Fernando S. , Alchorne Maurício M. A. , Tomimori‐Yamashita Jane
Published: March 2003

A 70‐year‐old white Brazilian woman from a rural area had a 2‐year history of a painful lesion on her left toe. The lesion increased progressively in size followed by toenail destruction. She was treated with systemic antibiotics for secondary bacterial infection several times without any clinical response.

Physical examination showed an erythematous swelling on the first toe with an irregular 2.5 cm ulcer with a raised edge that was infiltrating and destroying the toenail. The bottom of the ulcer was granular and partially covered with a crust (Fig. 1).

Erythematous swelling on the first toe showing an ulcer and toenail destruction

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Laboratory studies showed a strong positive Montenegro intradermal reaction (2.5 mm). Other intradermal reactions were also performed, such as purified protein derivative (PPD) and sporotrichin, which were negative. On X‐ray examination of the left foot, bone destruction of the distal phalanx of the first toe and a soft tissue swelling were observed (Fig. 2).

X‐ray examination: bone destruction of the distal phalanx and a soft tissue swelling

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A biopsy was taken and the histologic picture showed a chronic inflammatory change with tuberculoid‐type granuloma and necrosis suggesting leishmaniasis, although parasites were not observed.

Based on the clinical, histologic, and immunologic aspects, we concluded that this was a case of leishmaniasis. Methylglucamine (Glucantime®) was introduced at a total dose of 17 g of the salt (10 mg/kg daily for 40 days). Immediately after the start of treatment, the lesion began to improve, and 4 months later the lesion had healed completely and the dystrophic nail had started to grow (Fig. 3).

Complete healing of the wound and dystrophic nail growth

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An atypical, painful foot ulcer
Authors: Gill Jona K. , El‐Azhary Rokea A. , Davis Mark D. P.
Published: March 2003

A 27‐year‐old woman presented with a 2‐year history of a progressively enlarging, painful ulcer on her right foot. Two years earlier, she had noticed an apparent wart on her right foot. The lesion had been treated with liquid nitrogen. An ulcer developed at the site of treatment and enlarged progressively, becoming so painful that she had difficulty walking. Extensive surgical debridement and closure were unsuccessful in healing the ulcer; the ulcer grew larger and more painful. After an amputation was recommended by her local doctors, the patient sought another opinion.

At physical examination, the patient had a painful, 9.5 cm × 5 cm ulcer on the plantar aspect of the right foot (Fig. 1). Exuberant, rolled borders were present, and a yellow exudate covered the base of the lesion. The right inguinal lymph nodes were enlarged and firm. A punch biopsy specimen from the ulcer border was examined.

A 27‐year‐old woman presented with a 2‐year history of a progressively enlarging, painful ulcer on the right foot. At physical examination, she had a painful, 9.5 cm × 5 cm ulcer on the plantar aspect of the right foot

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Microscopic examination of a hematoxylin and eosin preparation of the punch biopsy specimen showed a reasonably well‐demarcated neoplasm within the deep reticular dermis down to the dermal‐pannicular junction (Fig. 2). This proliferation was composed of a population of round cells and spindle cells. The round cells were arranged in nests separated by delicate, fibrous septa, and the spindle cell proliferation was intercalated between collagen bundles. The nuclei of both cell types were uniform and vesicular with prominent nucleoli. No typical or atypical mitotic figures were identified within this proliferation. Staining with S‐100 protein was strongly positive. These findings were consistent with a clear cell sarcoma.

Microscopic examination of the punch biopsy specimen from the edge of the ulcer in Fig. 1 showed a neoplasm composed of round cells and spindle cells in the deep reticular dermis (hematoxylin and eosin; A, × 100; B, × 400)

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A biopsy specimen from the right inguinal lymph node was positive for metastatic clear cell sarcoma. Chest radiography and computed tomography showed multiple nodules throughout both lungs. The patient received five cycles of therapy with cisplatin, vinblastine, dacarbazine, and interferon‐α, and is alive 2 years later.
Shortness of breath: an uncommon side‐effect of cyproterone acetate in the treatment of androgenetic alopecia
Authors: Mallari Rica , Sinclair Rodney D.
Published: March 2003

Cyproterone acetate is indicated for treatment of acne, hirsutism, seborrhea, and androgenetic alopecia in females. In general this medication is well tolerated in standard doses. Shortness of breath has been previously reported in men with prostatic carcinoma, receiving high‐dose (200 mg/day) treatment with cyproterone acetate. We report a 66‐year‐old lady taking 50 mg/day of cyproterone acetate for biopsy proven androgenetic alopecia, who developed this unusual complication of shortness of breath. To our knowledge it has not been previously reported in women undergoing treatment for androgenization.
Intramuscular lipoma within the temporal muscle
Authors: Ban Masanori , Kitajima Yasuo
Published: March 2003

A 61‐year‐old male presented with a 6‐month history of a subcutaneous nodule on the left forehead, which had gradually enlarged. He had suffered from headaches from 20 days before the first visit. His medical history included hepatitis C virus infection. He had had no history of trauma in this area.

Clinical examination showed a subcutaneous soft nodule, 15 × 15 mm in size, which was adjacent to the left superficial temporal artery (Fig. 1). Though this artery revealed strong pulsation, the nodule had neither pulsation nor tenderness. His headache was localized in the left temporal area. He had no complaints of fever or weakness. Clinically, these features suggested a pseudoaneurysm of the superficial temporal artery.

A subcutaneous soft nodule adjacent to the superficial temporal artery

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We operated on him under local anesthesia. An incision through the skin and subcutaneous fat exposed a nodule located within the temporal muscle. The fine branches of the superficial temporal artery reached out to the nodule through the muscle. After ligation of the branches, we resected the nodule surrounded by muscular tissue. Histopathology showed the proliferation of mature adipose cells embedded in muscular fibers. These cells had no nuclear pleomorphism or mitoses (Fig. 2). The tumor tissue contained partial fibrosis and some muscular fiber bundles scattered between the adipose cells (Fig. 3). Intramuscular lipoma within the temporal muscle was diagnosed.

Proliferation of the mature adipose tissue within the muscle (hematoxylin‐eosin stain; magnification ×5.5)

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Some muscle bundles scattered between adipose cells (hematoxylin‐eosin stain; magnification ×22)

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His headache was reduced after the operation, and he has had no recurrence of the tumor for 16 months. The relationship between the tumor and his headache was unknown.
Leg ulcers and hydroxyurea: report of three cases with essential thrombocythemia
Authors: Demirçay Zeynep , Cömert Asuman , Adıgüzel Cafer
Published: March 2003

A 65‐year‐old woman with essential thrombocythemia (ET) had been taking oral hydroxyurea (HU), 1000 mg daily, for 7 years. Six months ago, she developed an ulcer on the outer part of her left ankle, which healed spontaneously within 2 months. She presented with a new, tender, shallow ulcer, 2 cm × 2 cm in size, at the same site. Doppler examination revealed thrombosis of the left common femoral vein and a calcified atheroma plaque of the left common femoral artery. The dosage of HU was decreased to 500 mg daily when the platelet counts were found to be within normal levels. The ulcer completely healed within 2 months with occlusive wound dressings, and has not recurred within the follow‐up period of 1 year.

A 56‐year‐old women presented with multiple, painful, leg ulcers of 1 year duration. She had been diagnosed as having ET and had been on HU therapy, 1500 mg/day, for the past 5 years. Interferon‐α‐2b was started 3 months ago, in addition to HU, which was tapered to 1000 mg daily. She had suffered from hypertension for 20 years treated with nifedipine and enalapril, and had recently been diagnosed with diabetes mellitus which was controlled by diet. Examination revealed three ulcers located on the lateral aspects of both ankles and right distal toe. Arterial and venous Doppler examinations were within normal limits. Histopathology of the ulcer revealed nonspecific changes with a mixed inflammatory cell infiltrate around dermal vessels. The ulcers completely healed within 10 weeks with topical hydrocolloid dressings. After healing, she was lost to follow‐up. A year later, it was learned that she had developed a new ulcer at her right heel, 3 months after her last visit (by phone call). This ulcer persisted for 8 months until HU was withdrawn.

A 64‐year‐old woman with ET presented with a painful leg ulcer of 6 months’ duration. She had been taking oral HU for 5 years. She had a 20‐year history of hypertension treated with lisinopril. Examination revealed a punched‐out ulcer of 2 cm × 2 cm over the right lateral malleolus (Fig. 1). Doppler examination of the veins revealed insufficiency of the right greater saphenous and femoral veins. Angiography showed multiple stenoses of the right popliteal and femoral arteries. As her platelet count remained high, HU was continued. During the follow‐up period of 13 months, the ulcer showed only partial improvement with local wound care.

Punched‐out ulcer surrounded by an erythematous border over the right malleolus (Case 3)

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