The staphylococcal scalded skin syndrome in historical perspective: Emergence of dermopathic strains of Staphylococcus aureus and discovery of the epidermolytic toxin: A review of events up to 1970

The gradual recognition of dermopathic strains of Staphyloccus aureus, which cause staphylococcal impetigo, pemphigus neonatorum, Ritter's disease, and what was originally called staphylococcal toxic epidermal necrolysis, is described, Obstacles delaying their recognition included an entrenched belief that staphylococci should produce pus, the striking dissimilarity of their main clinical effects (impetigo and scalding), the strongly held opinions of von Rittershain, and controversy over the cause of impetigo, Phage typing and histopathology confirmed the common etiology of these diseases and established the existence of dermopathic strains securely. The important contributions made by Melish and Glasgow were to provide an experimental model for these strains and to discover the epidermolytic toxin, whose action of splitting the epidermis underlies the pathogenesis of all these diseases (which have become known collectively as the staphylococcal scalded skin syndrome). Clinically, however, the impetigo effects and the scalding effects differ markedly, so it is proposed that staphylococcal impetigo should be retained as a separate clinical entity, and that staphylococcal impetigo and the modified staphylococcal scalded skin syndrome should be known collectively as the staphylococcal epidermolytic toxin syndrome.     

Cutaneous plasmacytomas. A review and presentation of an unusual case.

Recent reviews separate four types of plasma cell tumor: multiple myeloma, extramedullary plasmacytoma (without multiple myeloma), solitary myeloma of bone, and plasma cell leukemia. Cutaneous plasma cell tumors may arise from lymphatic or vascular spread of tumor (metastatic cutaneous plasmacytoma) or by direct extension from bone lesions. The former, metastatic cutaneous plasmacytomas, are quite rare. Specific malignant plasmacyte cutaneous tumors can also be seen in extramedullary plasmacytoma, solitary myeloma of bone, and plasma cell leukemia. We present a patient with multiple myeloma and lymphedema of the right arm, who developed a pathologic fracture of the right humerus and subsequently developed numerous metastatic cutaneous plasmacytomas localized to the lymphedematous arm. Direct immunofluorescence of frozen sections and enzymatically released cells from tumor nodule failed to reveal cell-associated immunoglobulins.     

Cutaneous nocardiosis. Case reports and review

Two cases of cutaneous nocardial infection are reported. The Nocardia species are gram-positive, partially acid-fast bacteria. Cutaneous involvement may develop as one of four types: (1) mycetoma, (2) lymphocutaneous (sporotrichoid) infection, (3) superficial skin infection, or (4) systemic disease with cutaneous involvement. A review of each of these types of infection is included, as well as potential clues that may suggest the diagnosis of nocardiosis.     

Suppression of histamine-induced pruritus by hydroxyzine and various neuroleptics.

This study evaluates the ability of hydroxyzine and various neuroleptics to suppress histamine-induced pruritus in ten volunteer subjects with the use of a double-blind crossover protocol. The itch threshold was determined in each volunteer by intradermal injection of gradually increasing concentrations of histamine. Volunteers were then given the study drugs and placebo at the same interval of time, under near identical conditions, and the itch threshold was determined. Thiothixene, hydroxyzine hydrochloride, chlorpromazine, thioridazine, and a lactose placebo were evaluated. Compared to other drugs, hydroxyzine alone was more effective in the suppression of histamine-induced itch. Consequently, hydrozyzine may be more effective in histamine-induced pruritus. The neuroleptic drugs used in this study do not significantly suppress histamine-induced pruritus, but they may be beneficial in nonhistamine-induced pruritus or psychogenic pruritus.     

Cutaneous and pulmonary cancers associated with Bowen''s disease

Thirty-one patients with Bowen's disease were studied in a restricted district of Namikata and its neighborhood of Ehime, Japan. Nineteen were alive and 12 were dead; the youngest living patient was 52 years of age. Invasive skin cancers were found in 10 patients and internal malignancies in 10, including 7 patients with pulmonary cancers. Palmoplantar keratosis was present in 25 patients and raindrop-type pigment anomalies in 15. Neutron activation analysis of hair showed only slightly higher arsenic values in patients with Bowen's disease than those in normal controls, though the differences were statistically significant at p less than 0.05. A possible arsenic exposure 43 years previously was considered responsible for the occurrence of neoplasms, though the arsenic route and amount were not determined. Bowen's disease started within 10 years, invasive skin cancers after 20 years, and pulmonary cancers after 30 years following the suspected arsenic exposure.     

Boric acid poisoning

The skin manifestations associated with boric acid intoxication are particularly striking. We present a case report of a 44-year-old black woman who, following a suicide attempt, demonstrated the classic features of acute boric acid poisoning. She developed generalized erythema creating a "boiled lobster" appearance with massive areas of desquamation. A discussion of the history of the use of boric acid by the medical profession follows the patient presentation.     

Cutaneous tissue repair: practical implications of current knowledge. II

This article reviews the scientific basis for the certain factors that delay wound repair in the clinical setting. A brief history of wound healing is given, followed by a discussion of endogenous local factors (bacterial infection, hypoxia, foreign body, and desiccation) and endogenous systemic factors (nutritional deficiencies, aging, coagulation disorders, and the Ehlers-Danlos syndromes) associated with poor wound repair. Also reviewed are the mechanisms by which exogenously administered agents (glucocorticoids, antineoplastic agents, and anticoagulants) may delay healing. Commonly used topical antimicrobials, their spectrum of activity, and evidence of effects on wound healing are examined. Finally, properties of commercially available wound coverings and wound care in the future are discussed.     

Vibrio vulnificus infection. Case report and update since 1970

Vibrio vulnificus infections is being reported with increasing frequency in coastal regions of the United States. Raw seafood consumption, particularly raw oysters, and wounds acquired in a marine environment predispose to infection. Patients with advanced liver disease are at increased risk of developing septicemia. V. vulnificus is a virulent pathogen producing significant morbidity and mortality; its virulence relates in part to the production of exotoxin. Skin lesions occur early in the clinical course of infection and provide means of specific diagnosis. The patient and the consulting physician are well served by the dermatologist capable of recognizing this infectious disease.     

A stain for plucked anagen hairs.

Anagen and telogen plucked hairs may be difficult to distinguish based on their microscopic appearance. The root ends of plucked anagen hairs develop a red color when stained with 4-dimethylaminocinnamaldehyde, while those of plucked telogen hairs do not. This is the result of a reaction with citrulline-containing proteins in the internal root sheath. This histochemical stain provides a simple and accurate means of determining the telogen/anagen ratio in plucked hairs.     

Chlorpromazine-induced lupuslike disease. Case report and review of the literature

A lupuslike disease with cutaneous manifestations secondary to the use of chlorpromazine (Thorazine) is presented. Skin biopsy specimens demonstrated classic findings consistent with lupus erythematosus and abundant mucin deposition in the cutaneous lesions--a finding not previously reported to occur in drug-induced lupuslike disease. Laboratory and serologic examinations included a positive antinuclear antibody titer, presence of single-stranded deoxyribonucleic acid (DNA), absence of double-stranded DNA, presence of antihistone antibodies, normal complement level, increased IgM level, and prolongation of partial thromboplastin time. These data confirmed our clinical and histologic diagnosis. Cessation of the medication (chlorpromazine) led to resolution of the skin abnormalities. Electron microscopy revealed electron-dense drug metabolites in vascular endothelial cells, as well as tubuloreticular inclusion bodies. This is only the second reported case of chlorpromazine-induced lupuslike disease with cutaneous manifestations.     

Perianal orf

The parapox viral infection orf is usually diagnosed without difficulty when the lesions have the characteristic morphology and there is an appropriate history of contact with sheep. Two cases of orf in a perineal location in young children are presented to illustrate modification of the physical signs by flexural occluded sites. Electron microscopy of scrapings from the lesions established the diagnosis.     

Piroxicam-induced photosensitivity. In vivo and in vitro studies of its photosensitizing potential

A 36-year-old woman developed a photolocalized erythematous papulovesicular eruption while taking piroxicam. Histologic study revealed a superficial and deep spongiotic dermatitis. Phototesting with ultraviolet B (UVB) and ultraviolet A (UVA) was abnormal at the time the patient was seen and after oral challenge with the drug for 5 days. A modified lymphocyte transformation test was positive. The photosensitizing potential of the drug was evaluated in vivo and in vitro. In vivo studies consisted of phototesting twelve medical students before and after intake of piroxicam during 5 consecutive days. No lowering of the minimal erythema dose (MED) values or abnormal reactions to UV and visible light were observed in these students. In vitro studies by the Candida plate method and by photohemolysis showed negative results. Our studies suggest a systemic photoallergy mechanism requiring wavelengths in the UVA range for the reaction. This drug should be avoided in patients receiving photochemotherapy.     

Annular elastolytic giant cell granuloma. A clinicopathologic study of five cases and a review of similar entities

Five patients with annular lesions of the face, scalp, and other exposed surfaces were studied using the radial triple zone biopsy technic. Interestingly, one of the patients had necrobiosis lipoidica diabeticorum (NLD) and another had systemic sarcoidosis. Clinically, the lesions were annular patches with erythematous borders and hypopigmented centers. The histopathology of the lesions showed many multinucleated giant cells, (often with prominent asteroid bodies), histiocytes, lymphocytes, scattered epithelioid cells, total lysis of elastic tissue, no necrobiosis, and absence of both mucin and lipid. This entity can be differentiated from granuloma annulare (GA), NLD, and cutaneous sarcoidosis. It is identical with several previously described entities; we propose a more appropriate term: "annular elastolytic giant cell granuloma (AEGCG)."     

Implantation technics for injectable collagen. Two and one-half years of personal clinical experience

The successful use of injectable collagen, a xenogeneic material indicated as a tissue replacement for correcting certain soft tissue anomalies, depends primarily on appropriate lesion selection and proper technic. Treatment with injectable collagen yields best results in soft, distensible lesions with relatively smooth margins. Lesions most amenable to correction include acne scars, steroid- or disease-induced areas of atrophy, glabellar furrows, nasolabial lines, postrhinoplasty irregularities, and depressed skin grafts. Optimal correction with the fewest number of injections is chiefly dependent upon deliberate overcorrection and superficial intradermal placement of the material. Outlined here are my experiences with over 1,000 patients treated with injectable collagen for a variety of soft tissue deficiencies.