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Background In 1978, the first case of columnar epidermal necrosis was reported in a 6-year-old boy. There were scaly, partially vesicular or crusty, erythematous lesions mainly involving the extremities that histopathologically showed peculiar features of focal, total epidermal necrosis accompanied by a lichenoid tissue reaction. He developed the skin eruption after receiving a blood transfusion from his mother when he showed debility induced by vaccination with an alternated live measles virus vaccine. The lesions rapidly regressed after sun exposure. To our knowledge, there has been no report of a similar case despite such unique features. Observation We encountered a similar case of columnar epidermal necrosis in a 15-year-old Japanese girl with chronic graft-vs-host disease; the lesions occurred 3 months after the transfusion of peripheral blood stem cells from her HLA antigen–matched brother. However, there was no exacerbation of liver dysfunction, diarrhea, or bone marrow aplasia. The peculiar cutaneous lesions responded well to topical phototherapy. Conclusion These 2 patients shared a similarity in their lesions and circumstances under which the blood transfusion was performed to a debilitated patient from a close family member. We believe that focal epidermal necrosis observed in patients with this condition represents a variant of blood transfusion–associated lichenoid graft-vs-host disease that occurs uniquely in a skin-targeted fashion.

Background and Design: The pathogenesis of scleroderma is still unknown. Recently, it has become possible to identify different subpopulations of dermal spindle-shaped cells using anti-CD34 and anti-factor XIIIa antibodies. To elucidate whether entire populations of dermal fibroblasts or only a subpopulation of cells are involved in the fibrosis of scleroderma, we compared the staining pattern of these antibodies and antiprocollagen antibody in paraffin-embedded skin sections from the lesions of 27 patients with scleroderma and 15 patients with other collagen diseases and from normal skin of 17 subjects. Cryostat sections from both involved and uninvolved skin of four patients with scleroderma were also stained with antiCD34, anti-factor XIIIa, and anti—proline-4-hydroxylase antibodies. Results: CD34+cells were few or absent in the lesions of scleroderma, while a number of CD34+cells were found in the lesions of other collagen diseases and in normal skin. In contrast, large numbers of factor XIIIa— and procollagen-positive cells were noted in the lesions of scleroderma. Even in the study in which cryostat sections were used, CD34+cells were totally absent from the lesions of scleroderma, while there were numerous proline-4-hydroxylase—positive cells. Furthermore, although detectable in the clinically uninvolved skin of these patients, CD34+cells were less frequent and more slender than those in normal skin. Conclusion: Immunohistologic staining with anti-CD34 and other antibodies to dermal spindle-shaped cells demonstrated a selective disappearance of CD34+spindle-shaped cells from the lesions of scleroderma. It suggests that CD34+cells might be important target cells in the autoreactive phenomenon in scleroderma. (Arch Dermatol. 1994;130:593-597)

When you see a patient with dermatitis of the feet, how much can you charge for his initial visit? If you are a physician in Japan, it is predetermined nationwide and you cannot expect to receive more than $20, whether you are a board-certified dermatologist with more than 20 years' experience or a total novice. This amount is likely far less than the average American dermatologist charges for a physical examination. How about reimbursement for a KOH examination? No matter how much time you spend meticulously examining the preparations, you receive only $2. Again, this is five to 10 times less than American doctors receive. You cannot charge your patients more than $20 when you conduct patch testing against various substances when you suspect contact dermatitis. This is also the case for many other procedures such as surgery and phototherapy. The upper limits of all medical payment levels are set

Objective: To characterize the functional properties of the stratum corneum (SC) of various scars. Design: A prospective cohort study. Setting: University hospital medical center. Patients: Thirty-two consecutive patients surgically treated for various skin diseases and 26 consecutive patients with hypertrophic scars or keloids. Main Outcome Measures: Noninvasive bioengineering measurements of functional properties of the SC, such as transepidermal water loss (TEWL), high-frequency conductance, and SC turnover time. Results: The SC barrier function assessed by TEWL was found to be a better parameter for the functional evaluation of scars than the hydration state of the skin surface measured by high-frequency conductometry. In general, the SC on the scars of deeper wounds in the dermis took longer to normalize functionally than the SC on the scars of superficial wounds, especially on the thigh compared with the abdomen. Thus, elevated levels of TEWL observed on scars at the donor sites of split-thickness grafts normalized between 200 and 400 days in contrast to fewer than 50 days for those of subepidermal erosions. Both TEWL and high-frequency conductance remained high in hypertrophic scars and keloids, and the SC involved showed a faster turnover time than that of adjacent normal skin. Conclusions: Scars, a proliferative change of the dermis, can be objectively evaluated according to functional abnormalities of the SC, because the dermis has a close relationship with the epidermis and with the SC. The functional characteristics of the SC of fresh scars and those of hypertrophic scars and keloids resemble those of retinoid-treated skin, rather than those found in epidermal hyperproliferative conditions such as psoriasis and dermatitis. Arch Dermatol. 1996;132:1453-1458

Background and Design: Atopic dermatitis (AD) is a chronic eczematous skin disease that develops in a patient with atopic diathesis, which is characterized by an increased liability to produce IgE antibodies for environmental allergens mostly derived from other living organisms. Experimentally, eczematous skin lesions cannot be induced by immediate IgE-mediated reactions alone. They are produced by cell-mediated allergic contact reactions, and recently contact sensitivity to various environmental allergens has been demonstrated in patients with AD. However, the pathologic role of IgE-mediated skin hypersensitivity or that of delayed-type hypersensitivity to various environmental allergens in AD is not fully evaluated. They have been studied separately and against only specific allergens. Thus, we performed a combined testing procedure consisting of radioallergosorbent test, prick, and scarification patch tests for eight environmental allergens in 97 Japanese adult patients with AD; 48 of them had a history of atopic respiratory diseases (ARD), whereas the remaining 49 had no history of ARD (pure AD). Results: Patients with AD, particularly those with ARD (AD+ARD), showed a higher incidence of positive radioallergosorbent test and prick test results as well as patch test results against multiple environmental allergens than healthy age—matched control subjects. Among them, we found a significantly high positive correlation between radioallergosorbent test scores and patch test reactions to two allergens, Japanese cedar, and Dermatophagoides farinae allergens in patients with AD. However, the patients with AD displayed a significantly lower incidence of positive patch test reactions to Candida albicans allergen than the healthy control subjects. Patients with AD with negative C albicans patch tests tended to have higher levels of total serum IgE including anti— C albicans IgE antibody. We found negative correlations between total serum IgE levels including specific antibodies and patch test reactions to C albicans allergen. Conclusions: Except for the dissociated reactivities to C albicans allergen consisting of decreased contact sensitivity and heightened IgE response, generally both IgE-mediated skin hypersensitivity and delayed-type hypersensitivity to various environmental allergens are pronounced in patients with AD. The combined use of these in vivo and in vitro tests is useful to estimate the immunological state of patients with AD. (Arch Dermatol. 1994;130:1393-1401)

• Background and Design.— Psoriatic scale extracts contain a unique chemotactic peptide fraction that is likely to be involved in the induction of rhythmic transepidermal leukocyte chemotaxis. Recent studies have identified the presence of two unrelated chemotactic peptides in this fraction, ie, C5a/ C5a des Arg and interleukin 8 (IL-8), and its related cytokines. To investigate their relative contribution to the transepidermal leukocyte migration as well as their interrelationship in psoriatic lesions, we have quantified concentrations of immunoreactive C5a/C5a des Arg and IL-8 in psoriatic lesional scale extracts and those from related sterile pustular dermatoses such as subcorneal pustular dermatosis and pustulosis palmaris et plantaris. Results.— The concentrations of C5a/C5a des Arg and IL-8 were more significantly increased in the horny-tissue extracts from lesional skin than in those from noninflammatory orthokeratotic skin ( P P Conclusion.— Based on these results, we speculate that, although IL-8 may exert a synergistic effect with C5a/C5a des Arg in the induction of transepidermal leukocyte chemotaxis, it constitutes a proinflammatory cytokine that is involved in the production of the persistent inflammatory changes characterized by a T-lymphocyte infiltration. In contrast, C5a/C5a des Arg seems to be generated only in the inflammatory lesional skin under specific circumstances that preferentially favor complement activation and also seems to play a major role in the induction of cyclic transepidermal leukocyte chemotaxis from "squirting papillae." ( Arch Dermatol. 1993;129:74-80)

• Dermatologists universally recognize that the unaffected skin of patients with atopic dermatitis tends to be dry and slightly scaly. To characterize the functional properties of the superficial stratum corneum in atopic xerosis, we studied the forearms of 28 patients with atopic dermatitis, aged 14 to 30 years, and 18 age-matched controls, with the use of mainly noninvasive methods. Patients with atopic xerosis showed markedly higher transepidermal water loss and markedly lower skin surface hydration levels than did the controls. The corneocytes in atopic xerosis tended to desquamate in clumps of cell aggregates instead of as individual cells. They contained a substantially lower amount of water-soluble amino acids, which play a role in the water-retaining capacity of stratum corneum, than did those of controls. Although the number of stratum corneum cell layers in atopic xerosis (21 ± 4) was substantially larger than that in controls (15 1), its turnover time (7 ± 2 days) was appreciably shorter than that for controls (14 ± 2 days). Like those noted in the skin with increased epidermal proliferation, the size of superficial corneocytes in patients with atopic xerosis was substantially smaller than in controls. Histopathologic examination revealed acanthotic epidermis, mild perivascular mononuclear cell infiltrate, and pigment incontinence. Atopic xerosis, the dry skin of patients with atopic dermatitis, shows various stratum corneum functional impairments, probably reflecting increased epidermal proliferation due to a low-level ongoing dermatitis. ( Arch Dermatol. 1991;127:1689-1692)

To the Editor.— In recent years, reactipve oxygen species and lipid peroxides that are produced from reactive oxygen species in the presence of polyunsaturated fatty acids have been implicated in the pathogenesis of many inflammatory disorders, including dermatologic diseases. On the other hand, superoxide dismutase (SOD), catalase, and glutathione peroxidase, all of which effectively remove reactive oxygen species or inhibit lipid peroxidation, serve to protect the host from oxidative tissue injury. We have demonstrated elevated lipid peroxide levels in ulcerated burns, wounds, and other erosive skin lesions, and have found that individual variation in the capacity for SOD induction to scavenge reactive oxygen species or inhibit lipid peroxidation correlates well with the capacity for healing in inflammatory skin diseases.1,2More recently, we have also suggested that the SOD induction capacity assessed by human leukocytes and the toxic herbicide, paraquat, can predict longevity and carcinogenesis in humans.3 In order

We used patch testing to compare the ability to elicit contact sensitivity to dinitrochlorobenzene (DNCB) of uninvolved with vitiliginous skin of 31 patients with vitiligo. The induction of DNCB contact sensitivity was possible in the vitiliginous skin in the same way as in normal skin. The DNCB contact sensitivity reactions, however, were generally diminished in vitiliginous skin, although the number of cases showing similar DNCB contact reactivity between normal and vitiliginous skin increased when the sensitization procedure was performed in vitiliginous skin instead of normal skin. On the other hand, delayed skin reactions to intradermally injected Candida albicans antigen were not suppressed in vitiliginous skin. The number of Langerhans' cells was not decreased in vitiliginous skin as compared with that of normal skin. The epidermal cells derived from vitiliginous skin, however, tended to show a lower stimulatory effect in the allogeneic mixed skin cell lymphocyte culture reaction than those from normal skin. These results suggest a possibility of functional impairment of Langerhans' cells in vitiliginous skin.

• Biopsy specimens of the skin lesions of pityriasis rosea obtained from 15 patients were studied. Characteristic histologic changes were composed of focal intercellular edema, epidermotropism of mononuclear cells often associated with the formation of focal intraepidermal collections of mononuclear cells, and of a perivascular lymphohistiocytic cell infiltration in the superficial dermis. Immunologic analysis using monoclonal antibodies showed that large numbers of lymphoid cells in the perivascular infiltrate reacted with anti—pan-T-cell, anti— helper-inducer subset, and anti-HLA-DR monoclonal antibodies, while the epidermotropic mononuclear cells consisted of helper-inducer cells or supressor-cytotoxic cells without any predominance pattern. In addition to epidermal Langerhans' cells, some of the dermal infiltrating cells were reactive with monoclonal antibody OKT6. Moreover, there was localized expression of HLA-DR antigen on the keratinocytes. We think that cellular immune reactions are taking place in the lesional epidermis of pityriasis rosea. (Arch Dermatol1985;121:761-765)

• Two Japanese patients, a 29-year-old woman and a 21-year-old man, had typical eosinophilic pustular folliculitis characterized by pruritic, tiny, red, follicular papulopustules on the face and trunk and eosinophilia in the peripheral blood. The second patient also had palmoplantar pustular lesions. A review of the literature revealed that this folliculitis primarily affects the seborrheic areas and that in one fifth of the patients palmoplantar lesions are a concomitant finding. (Arch Dermatol1985;121:917-920)

• Acupuncture needles implanted in the skin for more than ten years caused peculiar bluish macules, each of which clinically resembled a blue nevus in the extremities of a 63-year-old Japanese woman. Histologically, the involved skin showed deposition of fine brownish granules in the basement membrane of the eccrine sweat glands, on the inner surface of the blood vessel walls, and along elastic fibers of the superficial dermis in addition to sparse deposits noted throughout the dermis. Electron microscopy revealed deposits of electron-dense particles on the basal lamina of the secretory coils of the eccrine sweat glands, below the basal lamina of the dermoepidermal junction, and on elastic fibers. Roentgenographic microanalysis of the involved skin demonstrated that most of the granules consisted of silver and chloride; silver was a major component in the removed needles. ( Arch Dermatol 1985;121:1550-1552)

• An erythematous patch was noted on the abdominal wall of an 8-year-old boy. The lesion showed a prolonged initial clinical course, followed by rapid later growth, finally reaching 3.7 × 7.0 cm in size over four years. Despite the harmless clinical appearance, the lesion was histologically characterized by tortuous vascular channels with some cellular atypia. Immunoperoxidase staining disclosed no factor VIII-related antigen or reaction to Ulex europaeus I lectin on tumor cells. There has been no recurrence three years after local excision. Although many features in our case resemble those reported in the literature under the term low-grade angiosarcoma , our preferred designation for such cases is acquired progressive lymphangioma , rather than angiosarcoma , because of their benign behavior. ( Arch Dermatol 1988;124:699-701)

• An unusual case of ashy dermatosis of Ramirez occurred in a 5-year-old-girl who had ash-colored hyperpigmented macules and plaques on the left leg and the left side of the trunk. These unilateral lesions showed histopathologic changes of a lichenoid tissue reaction. Although the exact cause of ashy dermatosis remains unknown, the positive test result for serum rheumatoid factor and the granular deposition of IgM at the dermoepidermal junction found in our case has immunologic implications. ( Arch Dermatol 1984;120:1491-1493)

• Scaly skin lesions are caused by decreased water content of the stratum corneum, despite the well-known fact that they usually show increased water passage. By performing simultaneous measurements of transepidermal water loss (TEWL) to check the water-barrier function of the stratum corneum and cutaneous conductance to the high-frequency electric current of 3.5 MHz, which is an indicator of skin-surface hydration state, in patients with psoriasis who had lesions of various grades of severity, we obtained data indicating that there is an inverse relationship between these functions of the stratum corneum. Furthermore, a time course study of TEWL and functional analysis of stratum corneum by an in vivo water sorption-desorption test performed on the experimentally induced scaly lesions after adhesive-tape stripping demonstrated that such pathologic stratum corneum is characterized by a water-holding defect that is associated with increased TEWL. ( Arch Dermatol 1985;121:642-645)

• Trichophytin contact sensitivity was investigated in patients with dermatophytosis by patch testing with highly concentrated purified trichophytin on partially stripped skin. The lack of primary irritant reactions was confirmed on the skin of children. Positive patch tests were noted in 113 of 178 patients (63.5%). However, there was a great difference in the incidence of trichophytin contact sensitivity between cases with different clinical types. The highest frequency of positive patch tests was obtained in patients with the vesiculobullous type of tinea pedis (83.3%). In contrast, a very low incidence was noted in patients with tinea corporis (37%) and the squamous hyperkeratotic type of tinea pedis (36%). Causative organisms and the age and sex of the patients did not show a relationship with the reactivity. A diminished incidence of positive reactions was noted in atopic individuals and in patients seen in winter. Patients who had persistent or recurrent infections for a long period of time, especially those having inflammatory lesions, had a higher frequency of positive patch tests. ( Arch Dermatol 113:1409-1414, 1977)

• The occurrence of multinucleated epidermal giant cells (MEGCs) with more than three clumping nuclei has been considered an episodic and exceptional phenomenon in inflammatory skin diseases. However, we have found them in 97 histologic specimens obtained from inflammatory lesions. They appeared in 88 of 196 biopsy specimens from a group of patients with chronic eczema or prurigo. In pruriginous lesions alone, they were found in 67 (74%) of 90 specimens. On the other hand, MEGCs were found rarely in lichen amyloidosus (2/11), dermatitis herpetiformis (1/6), erythema multiforme (1/11), pustular psoriasis (1/17), lichen planus (1/29), lupus erythematosus (1/30), and pustulosis palmaris et plantaris (1/41), probably representing just a chance occurrence in these dermatoses. ( Arch Dermatol 117:23-25, 1981)

A bizzare erythematosquamous, partially verrucose, crustly or eroded eruption developed in a 6-year-old boy one week after his first measles vaccination. The eruption regressed completely after a two-year clinical course. Histologically, the epidermis showed unique columnar eosinophilic degeneration. There was a dense, mononuclear cell infiltration in the upper part of the dermis. To our knowledge these clinical and histologic features have not been reported in the literature, although they resemble, in some aspects, Kyrle's disease, Mucha-Haberman's disease, or lichen planus verrucosus. Regarding the pathomechanisms underlying the development of this unique epidermal change, a postulate was made that it represented a special form of toxic epidermal reaction, probably resulting from autoagressive lymphoid cell response to epidermal cells. Furthermore, relationship of measles vaccination to this special response is suggested.

• Based on clinical and histological studies in 25 patients, we have confirmed that plane warts show a characteristic phenomenon of spontaneous regression totally distinct from that described in common warts. This regression developed during various treatments in nine cases, and in 16 cases, it occurred spontaneously. In all the patients, there was a sudden and systemic onset of inflammation in every flat wart. Within two to six weeks, all the warts completely involuted. Histologically, there were variable degrees of epidermal changes depending on the stage of inflammation. However, a mononuclear cell infiltration with epidermal invasion was demonstrated in every biopsy specimen. This evidence further supports the earlier concept that this regressive phenomenon of plane warts is mediated by cellular immunity. It represents a natural experimental model of rejection of tumors induced by papovavirus in humans. (Arch Dermatol113:1209-1213, 1977)

• The regressing process of plane warts can be divided into two phases: initial changes of wart virus-infected cells that later result in degeneration of warts, and recovery phase in which degenerating warts are rejected from the level of the basal layer followed by regeneration of normal epidermal cells from the surrounding epidermis. Electron microscopic observations of recovery phase of wart regression showed (1) the epidermal lesion was clearly divided into degenerating wart possessing altered viruses and regenerating epidermis; (2) melanocytes were demonstrated in degenerating warts; and (3) a new granular layer was evident beneath regressing wart in late recovery. Throughout the recovery process, infiltration of lymphocytes and macrophages was observed only in regenerating epidermis. ( Arch Dermatol 113:1214-1218, 1977)

Numerous multiple hairs scattered over a chronic, pyodermatous plaque of 18 years' duration on the parietal region of the scalp occurred in a healthy 19-year-old Japanese boy. The outlook of the hair distribution on the lesion resembled a hairbrush. Although the histologic feature was similar to that of folliculitis keloidalis, the lesion responded well to topically applied antibacterial therapy.

To the Editor.— Involving the Central Nervous System Mycosis fungoides (MF) lymphoma affects the skin primarily, but ultimately can involve almost every organ and tissue of the body.1Immunohistochemical studies with monoclonal antibodies specific for T-cell subsets disclose helper T-cell predominance in most cases,2,3but, in some cases, the malignant clone of the cells belongs to a suppressor-cytotoxic subclass.2-4We herein describe a case of MF that had a fulminant clinical course followed by widespread central nervous system involvement. Unique features in this case are the single proliferation of monoclonal OKT8-reactive T cells and peculiar palmar lesions resembling pustules. Report of a Case.— A 48-year-old man was hospitalized on Oct 25, 1982, because of numerous infiltrative erythematous plaques, pigmented patches, and ulcerated or crusted tumors all over his body (Fig 1). Pruritic, scaly erythema first appeared on the extremities and buttocks in 1977. On admission, lymph node enlargement was palpable in the axillae and groin. Laboratory studies revealed elevated levels of aspartate aminotransferase

Sulfasalazine, or salicylazosulfapyridine, is capable of producing allergic types of drug reactions. 1 Furthermore, in recent years, a severe adverse reaction to sulfasalazine that is clinically similar to infectious mononucleosis has been reported. 2-6 We report herein an additional case associated with atypical lymphocytes observed in the peripheral blood of the patient. Report of a Case A 36-year-old man had had a three-month history of watery diarrhea, suggestive of the presence of inflammatory bowel disease, which had been treated with oral sulfasalazine, 500 mg three times daily. He had otherwise been in good health and received no other medications. Two months later, temperature to 39 °C, malaise, nausea, arthralgia, and a dermatitis developed while he was still taking sulfasalazine. The sulfasalazine therapy was stopped and the patient was admitted to the hospital a week later. On physical examination at admission, he had a temperature of 37.5 °C. Several enlarged, nontender

† An allergic sensitivity to gold earrings produced a lymphadenoid reaction with germinal centers in the dermis of the pierced earlobes of a 21-year-old woman. However, a patch test for 1% gold sodium thiomalate gave a long-lasting, clinically and histologically eczematous response. Electron microscopic and cytochemical observations showed that non-T lymphocytes and plasma cells were dominant in the dermal infiltrate of the lesions, whereas lymphocytes with convoluted nuclei (which were probably T cells) and monocytes invaded the epidermis in the patch test site. These findings suggest that continuous exposure of the dermis to gold in a sensitized person may induce a lymphadenoid cellular reaction different from the histologic findings seen after contact with the epidermis. ( Arch Dermatol 1982;118:608-611)

• Peculiar erythematosquamous lesions were observed in two adult patients in Japan with hereditary lactate dehydrogenase M-subunit deficiency. Although these patients showed excessive fatigue and myoglobulinuria after extended exercise, they were usually asymptomatic. However, nonpruritic follicular papules or erythematous patches with scaly edges were present on the extensor surfaces of the extremities of these patients since childhood, showing some improvement after puberty. There were also erythematous patches on the weight-bearing areas of their soles. These patches showed exacerbation and a tendency toward peripheral spreading in summer. These skin lesions provide an important clue in the detection of this genetic enzyme deficiency. ( Arch Dermatol 1986;122:1420-1424)

• Immunohistologically, cellular infiltrates in regressing plane warts were mainly composed of lymphocytes and mononuclear phagocytes. There were many infiltrating T lymphocytes. Immunoelectron microscopic observation demonstrated that both helper/inducer and suppressor/cytotoxic phenotypes of T lymphocytes infiltrated in the lesions. OKT6-positive cells were observed in the dermis as well as in the epidermis. Moreover, as noted in allergic contact dermatitis, the apposition of T lymphocytes to Langerhans' cell—like cells could be seen. Lymphocytes and a small number of mononuclear phagocytes were found adjacent to damaged keratinocytes in the epidermis, the picture of which has been described as satellite cell necrosis, a hallmark of cytotoxic reaction by aggressors. These findings suggest that specific cell-mediated immunity against virus-infected keratinocytes takes place in the process of regressing plane warts. (Arch Dermatol1986;122:655-659)

In Reply.— We appreciate the interest in our article and the opinions expressed by Roujeau et al. We admit that the incidence of delayed hypersensitivity to penicillin in the hospital population is much higher than that of actual allergic reactions to penicillin. Thus, it is unfortunate for us that instead of being induced by other much rarer drugs, our case of TEN was induced by ampicillin and our patient had delayed skin responses to it. This, however, does not exclude the possibility that the remarkable delayed hypersensitivity to ampicillin disclosed in our patient played a crucial role in the pathogenesis in her case of TEN. Most of all we wanted to emphasize the histologic finding of the positive patch test site to ampicillin that showed a prominent degenerative change in the epidermis

To the Editor.— We describe a case of congenital Horner's syndrome affecting a 4-year-old boy with a complaint of one-sided flushing of the face. Although this very rare disease has not been reported before in the dermatologic literature, we should remember that the patient with one-sided flushing might have congenital Horner's syndrome. Report of a Case.— A 4-year-old boy was brought to us by his mother because she noticed that the right side of his face became flushed after exercise. His mother was also aware that sweat was not coming from the left side of his face. His delivery had been spontaneous by the vertex, with a birthweight of 2565 g at 40 weeks' gestation. There was no evidence of brachial plexus lesion or any untoward event in the newborn period. At the first consultation, he had a normal skin color on both sides of his face. After 10 minutes

• A patient with ampicillin-induced toxic epidermal necrolysis (TEN) showed pronounced delayed hypersensitivity to ampicillin sodium by both intradermal and patch tests. In addition, a positive lymphocyte transformation test to ampicillin was demonstrated by an in vitro study. On the basis of these findings and the data found in the literature, we believe that delayed hypersensitivity plays a crucial role in the development of drug-induced TEN. We recommend patch testing with suspected medications in such cases. ( Arch Dermatol 1983;119:910-913)

• We studied eight cases of Schamberg's disease immunohistologically by using monoclonal antibodies. The dermal infiltrate was composed of Leu-1-reactive T cells, 0KT6-reactive Langerhans' cells, and Leu-M5-reactive (Leu-M5+) macrophages. Among them, the major population consisted of T cells with the predominance of Leu-3a-reactive (Leu-3a+) T cells over Leu-2a-reactive (Leu-2a+) T cells. On the other hand, the epidermotropic mononuclear cells consisted of Leu-2a+and Leu-3a+T cells without any predominant pattern, and Leu-M5+ macrophages. Furthermore, note that a pemphiguslike intercellular staining pattern was observed in the epidermis in most of the cases, when the sections were stained either with anti-HLA-DR antibody or with OKT6, suggesting the HLA-DR antigen expression on the keratinocyte surface and possibly an enlargement of Langerhans' cells. Based on these immunohistologic findings, we think that Langerhans' cells play an important role in the pathomechanism of Schamberg's disease, and that cellular immune reactions are taking place in the lesional skin. (Arch Dermatol1988;124:1058-1062)

• A 34-year-old man with epidermodysplasia verruciformis showed increased natural killer (NK) cell activity in his peripheral blood cells, which was found to be due to abnormal expansion of large granular lymphocytes (LGL). Surface marker analysis of LGL in a two-color immunofluorescence test demonstrated that all LGL subsets, Leu7+11-, Leu-7+11+, and Leu-7-11+, were increased. In contrast, his peripheral blood mononuclear cells showed a remarkable decrease in response to T cell mitogens, which could not be restored by depletion of the LGL subpopulation from the mononuclear cells. Immunohistologic studies for dermal distribution of LGL showed numerous Leu-7+ cells but no Leu-11+ cells at the sites of delayed hypersensitivity reaction or interferon β- or interferon γ-injected sites. These findings suggest that the elevated NK cell activity in this patient with epidermodysplasia verruciformis was caused by overall expansion of normal LGL subpopulations, but that the decreased T-cell mitogenic response represented a primary T-cell defect rather than a direct suppression by increased NK cells. It is noteworthy that despite this extraordinary increase of all LGL subpopulations in the blood, Leu-11+ NK cells never appeared in the skin. ( Arch Dermatol 1989;125:660-665)

To the Editor.— When bizarre skin conditions are encountered, the possibility of factitial lesions should be considered. In children, such changes may be induced inadvertently, since they play with various kinds of unexpected objects. Some lesions are also characteristic that the correct diagnosis can be made if the peculiar stigma (eg, ulceration of oral mucous membrane by electrical burn

An aged man with a large scaly plaque over the left buttock was successfully treated by local heat therapy using an electric bed-warmer with a surface temperature of 46 °C. Clinically, the lesion involuted completely after two months of treatment. This was concomitantly confirmed by histopathological and mycological studies of biopsy specimens obtained from the lesion at an interval of several weeks. The isolated fungus strain of Fonsecaea pedrosoi could grow at 37 °C on Sabouraud's dextrose agar, but was totally eradicated 24 hours after the culture was incubated at 46 °C. We consider that local heat therapy carried out under strict supervision is a quite effective treatment for chromomycosis. Moreover, it can be performed safely and without much discomfort to patients, and can yield satisfactory results in a relatively short time. ( Arch Dermatol 115:740-741, 1979)

• The effect of oral doses of colchicine on pustule formation was studied in 32 patients with pustulosis palmaris et plantaris without associated psoriasis. Oral administration of colchicine, 1 to 2 mg daily, was started during periods of disease exacerbation, and the dosage was gradually decreased to 0.5 to 1 mg daily in responsive patients. Thirteen patients showed complete clearing of pustulation, and 14 patients showed a remarkable reduction in pustule formation after two to eight weeks of treatment. One patient did not respond and four discontinued treatment because of nausea or diarrhea. During a three-month follow-up evaluation after treatment was stopped, relapse occurred in eight cases. Colchicine appears to be effective in the suppression of acute exacerbations of pustulosis palmaris et plantaris. (Arch Dermatol1982;118:458-460)