岩田 洋平

患者は47歳女性,多発性硬化症による第4胸椎以下の神経障害があり,数年前より車椅子生活であった。2011年3月より左坐骨結節部に褥瘡が生じたが放置していた。3月下旬より38度台の発熱が生じ,解熱しないため,当科を受診した。初診時,左坐骨結節部の褥瘡部に壊死組織を認め,CTでは左臀部から左下腿にかけて皮下深部組織内にガス像を認めガス壊疸と診断した。創部からの細菌培養ではEnterococccus avium,Lactbacillus spが検出された。抗生剤の全身投与を開始したが,第3病日に意識障害を来したため,第4病日に広範囲にデブリードマンを行い,感染の沈静化を得ることができ救命することができた。デブリードマン部の欠損は,複数回の植皮術を行い上皮化した。坐骨部褥瘡は,各種外用剤による保存的治療,局所陰圧閉鎖療法(VAC療法)を約5ヵ月間にわたり試みるも治癒しなかった。そのため左坐骨突出部の削除を含めたデブリードマンと大臀筋皮弁形成術を行うことで退院が可能となった。(著者抄録)

膠原病・血管炎にともなう皮膚潰瘍診療ガイドラインでの基本的治療アプローチ方法は、外用薬を中心とした局所治療ではなく、内服や点滴を中心とした全身治療である。そのガイドラインに慣れてもらうため、まず、関節リウマチの治療アルゴリズムに基づいて治療した症例を提示した。そして、全身性強皮症、全身性エリテマトーデス、皮膚筋炎、関節リウマチ、血管炎、抗リン脂質抗体症候群 各疾患 現行の診療ガイドラインと改良点を提案した。膠原病・血管炎になじみの少ない医師でも治療方針が決定できるように、将来的には、病態(皮疹)に基づくアルゴリズム作成やClinical Question作成を検討していきたい。(著者抄録)

2012年に持参香粧品と関連アレルゲンのパッチテストを施行した77例中、持参品に陽性反応を呈したのは14例、持参化粧品は持参しなかったか陰性であったが化粧品関連アレルゲンに陽性反応を呈した(染毛剤を持参しなかった染毛剤皮膚炎を含む)のは13例、パッチテストで持参化粧品も化粧品関連アレルゲンも陰性であったのは50例であった。ロドデノール含有製品陽性は1例であった。成分パッチテストは6例に施行し、そのうち5例で原因アレルゲンを確定できた。その内訳はラウリン酸ジエタノールアミドおよびラウリン酸ミリスチン酸ジエタノールアミド、フェニルエチルレゾルシノール、シリコーン15、3-0-エチルアスコルビン酸、アルガニアスビノサ核エキス+ココイルグルタミン酸Na+カルボマーであった。化粧品関連アレルゲンのみに陽性反応を呈した症例のアレルゲンは、ヘアダイ関連アレルゲン4例、香料6例、防腐剤2例であった。(著者抄録)

It has been reported that the abnormal regulation of melanocyte stem cells (McSCs) causes hair greying; however, little is known about the role of McSCs in skin hyperpigmentation such as solar lentigines (SLs). To investigate the involvement of McSCs in SLs, the canonical Wnt signalling pathway that triggers the differentiation of McSCs was analysed in UVB-induced delayed hyperpigmented maculae in mice and human SL lesions. After inducing hyperpigmented maculae on dorsal skin of F1 mice of HR-1x HR/De, which was formed long after repeated UVB irradiation, the epidermal Wnt1 expression and the number of nuclear -catenin-positive McSCs were increased as compared to non-irradiated control mice. Furthermore, the expression of dopachrome tautomerase (Dct), a downstream target of -catenin, was significantly upregulated in McSCs of UVB-irradiated mice. The Wnt1 expression and the number of nuclear -catenin-positive McSCs were also higher in human SL lesions than in normal skin. Recombinant Wnt1 protein induced melanocyte-related genes including Dct in early-passage normal human melanocytes (NHEMs), an in vitro McSC model. These results demonstrate that the canonical Wnt signalling pathway is activated in SL lesions and strongly suggest that the accelerated differentiation of McSCs is involved in SL pathogenesis.

61歳男性、歯科医。2010年12月より右頬部に浸潤性紅斑を自覚し、2011年3月当科を紹介受診。右頬部に小児手掌大の紅褐色局面と、右耳珠上方の小病変を認めた。いったん自然軽快を示したが、次第に拡大したため、全摘、極薄分層植皮術を施行。病理組織所見では表皮と連続して重層扁平上皮が不規則に増生し、真皮全層にわたり異型リンパ球が浸潤していた。免疫組織化学染色ではCD3(+)、CD4(+)、CD30(+)、TIA-1(+)、CD8(-)、CD10(-)、CD79a(-)、ALK-1(-)、EMA(-)。骨髄穿刺、PET-CT等の全身検索を行ったが異常所見なく、偽癌性増殖を伴う原発性皮膚未分化大細胞リンパ腫と診断。残存病変に電子線治療(48Gy)を行い、軽快・安定している。(著者抄録)

都市部の医療機関で凍傷を診療することはきわめてまれである。今回著者らは2例の凍傷の治療と長期間の経過観察を行い、良好な機能的予後を得られたので報告する。症例1は67歳男性。雪山遭難でIII度凍傷を受傷し、プロスタグランディンE1投与のあと、デブリードマン、極薄分層植皮術を施行し手指・爪を温存できた。術後7年半経過し手指の機能に問題はない。症例2は21歳男性。アラスカで自転車旅行中に右小指の凍傷を受傷した。保存的治療を行い、受傷5ヵ月後には上皮化完了した。2年間の経過観察を行ったが、機能的にも問題はない。凍傷の初期では保存的に加療・経過観察し、壊死の範囲、深度の明瞭化を待つことが重要であり、手術療法の選択は慎重に検討する必要がある。(著者抄録)

Background: Solar lentigines (SLs) are characterized by hyperpigmented macules, commonly seen on sun-exposed areas of the skin. Although it has been reported that an increase in the number of melanocytes and epidermal melanin content was observed in the lesions, the following questions remain to be answered: (1) Is acceleration of melanogenesis in the epidermis caused by an increased number of melanocytes or the high melanogenic potential of each melanocyte? (2) Why does the number of melanocytes increase? Objective: To elucidate the pathogenic mechanism of SLs by investigating the number, melanogenic potential and proliferation status of the melanocyte lineage in healthy skin and SL lesions. Methods: Immunostaining for melanocyte lineage markers (tyrosinase, MART-1, MITF, and Frizzled-4) and a proliferation marker, Ki67, was performed on skin sections, and the obtained images were analyzed by image analysis software. Results: The expression level of tyrosinase to MART-1 of each melanocyte was significantly higher in SL lesions than healthy skin. The numbers of melanocytes in the epidermis, melanoblasts in the hair follicular infundibulum and melanocyte stem cells in the bulge region were increased in SL; however, no significant difference was observed in the Ki67-positive rate of these cells. Conclusion: The melanogenic potential of each melanocyte was elevated in SL lesions. It was suggested that the increased number of melanocytes in the SL epidermis might be attributed to the abnormal increase of melanocyte stem cells in the bulge. (C) 2013 Japanese Society for Investigative Dermatology. Published by Elsevier Ireland Ltd. All rights reserved.

A 77-year-old man with a history of surgical resection of malignant melanoma involving the fifth toe of his left foot 14 years ago presented at the Kariya Toyota General Hospital with a 3-month history of skin ulcer at the same site and red nodules on the lower left leg. Malignant melanoma was suspected, and the patient was referred to our department. On examination, a skin ulcer measuring 25 × 20 mm was observed at the amputation site on the left foot. In addition, multiple red nodules were observed on the lower left leg. Skin biopsies of the ulcer and nodules revealed recurrent malignant melanoma with in-transit metastasis. Two weeks later, he developed acute myocardial infarction and was hospitalized at the Kariya Toyota General Hospital. One month later, the myocardial infarction ameliorated, and he was transferred to our department. As the myocardial infarction had decreased the patient's tolerance to surgery, interferon-β was administered by intravenous infusion. The skin ulcer and red nodules on the lower left leg disappeared 26 weeks after infusion had been initiated. The patient's progress has been satisfactory, with no evidence of recurrence or metastasis at 1 year and 9 months after the initiation of intravenous infusion. © 2014 S. Karger AG, Basel.

Immunoglobulin G4-related disease (IgG4-RD) is a newly recognized disease characterized by elevated serum IgG4 levels, tissue infiltration rich in IgG4(+) plasma cells. We report on a case which was first considered as pseudolymphoma from the histopathological analysis, but finally diagnosed as IgG4-related skin lesions. As the morphological features of cutaneous involvement of IgG4-RD are consistent with those of cutaneous pseudolymphoma, we tried immunostaining past potential cases of IgG4-RD. Thirty-two skin specimens (15 men and 17 women; mean age, 53years) diagnosed as having pseudolymphoma were retrieved from the archives to conduct hematoxylin-eosin, IgG and IgG4 staining. Out of the 32 cases of cutaneous pseudolymphoma, germinal center formation was seen in 22 cases, and moderate-severe fibrosis was seen in seven cases. Eleven cases showed more than 10 IgG4(+) plasma cell infiltration/high-power field, and among these 11 cases, seven cases (22%) showed A ratio of IgG4(+)/IgG(+) cells of more than 40%. Thus, out of the 32 cases of cutaneous pseudolymphomas, two cases (6.3%) satisfied IgG4-RD histopathological diagnostic criteria. As clinical presentations and histopathological features of skin involvement of IgG4-RD are analogous to cutaneous B-cell pseudolymphoma, careful identification is required through systemic examination, serum IgG4 measurement and other means.