The smell of burnt toast: a case report

A 71-year-old woman awoke one morning to find that she perceived all aromas, odors, and fragrances as smelling like burnt toast. Over the next three years, numerous studies and therapeutic trials failed to elicit the cause of her dysosmia or to provide relief. Finally, the demonstration of small infarcts as seen on a brain MRI suggested that an infarct near the olfactory pathway was responsible for the sudden onset and the 11 year persistence of her unique paromia.

Chronic factitial ulcer of chin cured by endodontic (root-canal) surgery for underlying periapical abscess

In a determined search for the cause of a "factitial" ulcer of the jaw, consultation with 3 dentists was required before an underlying periapical abscess was discovered. Within 3 months of endodontic surgery, this ulcer of 12 years duration had completely healed and remains healed. Too often dental infection is neither suspected nor detected as a cause of skin disease.

The drug line: the clinical expression of the pigmentary Voigt-Futcher line in turn derived from the embryonic ventral axial line

BACKGROUND

Observation of patients with morbilliform eruptions reveals a distinctive demarcation line on the upper arms.

OBJECTIVE

We studied the origin of this sharp "drug line."

METHODS

We performed a literature search of all known variables.

RESULTS

The drug line represents clinical expression of the pigmentary Voigt-Futcher line.

CONCLUSION

The drug line reveals the otherwise inapparent embryologic ventral axial line, which marks the precise border between the sensory innervation of the lateral and medial upper arm. The significance of the cutaneous sensory nerves is thus apparent. The drug line is further evidence of the segmental nature of human skin, as evidenced in evolutionary and embryologic studies.

Long-term antibiotic therapy for balanitis xerotica obliterans

In an open uncontrolled study of 3 patients with balanitis xerotica obliterans we have observed significant improvement after long-term systemic antibiotic therapy. Two of the patients noticed softening of the skin as well as disappearance of pruritus, tenderness, and inflammatory changes within 3 weeks of receiving oral and intramuscular penicillin. The third patient experienced the same degree of improvement after a regimen of dirithromycin, 500 mg/day. Stopping the antiobiotic for 1 month resulted in relapse, with improvement again on resumption.

Chronic staphylococcal scalded skin syndrome

Staphylococcal scalded skin syndrome (SSSS), not previously recorded as a chronic disease, persisted for 2 years in a 50-year-old woman with epilepsy and cerebellar ataxia. Lesions initially suggestive of erythema multiforme and toxic epidermal necrolysis evolved over 2 years into those typical for SSSS, with extensive erosions and subcorneal blisters, showing an epidermal split at the granular cell layer. Exfoliatin A-producing phage I-III Staphylococcus aureus, previously linked only to acute mild adult cases of SSSS, was cultured from purulent discharge in the patient's eyes, ears and open skin lesions. The roles of epilepsy and antiepileptic medications are discussed as possible predisposing factors.

Botulinum toxin therapy for palmar hyperhidrosis

BACKGROUND

Severe palmar hyperhidrosis is a chronic disease, resistant to conventional therapy. Botulinum toxin inhibits sweat production by blocking release of acetylcholine from presynaptic membranes.

OBJECTIVE

Our purpose was to evaluate the short- and long-term effectiveness of botulinum toxin therapy in treatment of palmar hyperhidrosis.

METHODS

Four patients with severe palmar hyperhidrosis were treated with subepidermal injections of botulinum toxin. Fifty injections, 2 mouse units each, were used in each palm. Regional nerve blocks of the median and ulnar nerves were performed before the procedure. Patients were observed for 12 months after treatment.

RESULTS

Botulinum toxin injections significantly reduced sweat production in the treated areas of the palms. Anhidrosis lasted for 12 months in one patient, 7 months in two patients, and 4 months in one patient. Mild weakness of the thumb lasting 3 weeks occurred in one patient. No other side effects were observed.

CONCLUSION

Botulinum toxin provides an effective, safe, and long-lasting alternative therapeutic modality for treatment of severe palmar hyperhidrosis. Additional studies are needed for optimization of the technique.

Aquadynia: noradrenergic pain induced by bathing and responsive to clonidine

We describe two women in whom bathing was regularly followed by intense, widespread burning pain that lasted 15 to 45 minutes, which we term aquadynia. This water-induced pain was not caused by any skin or systemic diseases. We view it as a type of noradrenergic pain induced by contact with water, because it can be blocked with clonidine or propranolol. It appears to be an extension of the phenomenon of aquagenic pruritus, which we have also found to respond to clonidine or propranolol.

The transverse nasal line: an embryonic fault line

The transverse nasal line has long been neglected and frequently overlooked. This narrow pink or hyperpigmented line or groove extends transversely between the upper two-thirds and the lower third of the nose. It is often hereditary and may be the locus of comedones and milia. Eighteen examples are reported by us, along with a possible embryological interpretation.

The mysterious case of the premenstrual purple chin

Recurrent episodes of a "purple chin" in an adolescent girl eluded definitive diagnosis for three years. The condition occurred premenstrually, but results of extensive tests failed to reveal any abnormal hormonal sensitivity. A diagnosis of factitial purpura was eventually established.

The "K" test for dosage of topical medication

Firmly pressing a sheet of Kleenex to the skin after applying a cream of ointment aids the patient in dosing properly. A positive "K" test results when the Kleenex is soiled, indicating that a wasteful amount of salve has been used.

Aggressive giant keratoacanthoma of the face treated with intramuscular methotrexate and triamcinolone acetonide

Keratoacanthoma is a common skin tumor characterized by rapid growth of a smooth dome-shaped nodule with a central plug of keratin, usually followed by spontaneous involution. We report the case of a giant keratoacanthoma on the face that continued to spread peripherally for several months despite vigorous therapeutic intervention. Treatment with methotrexate (25 mg intramuscularly) and Kenalog (triamcinolone acetonide, 40 mg intramuscularly) weekly finally slowed and stopped the expanding, deforming tumor growth and induced involution.

Detection of streptococcal class I M protein in psoriasis by confocal immunofluorescent microscopy

Epidemiological evidence implicates Streptococcus pyogenes (group A) infection as a common triggering stimulus for psoriasis. Unequivocal demonstration of streptococcal antigens in psoriatic skin has been difficult due to cross-reactive antigens in both normal human tissue and group A streptococci, which complicate immunohistological analysis. In this study cryostat sections of involved psoriatic skin were stained with monoclonal antibody 111-15504 to group A streptococci. The epitope recognized by this antibody was found to be specific for group A streptococci and is associated with class I M protein. Streptococcal antigens were found in the dermal papillae and epidermis of psoriatic skin lesions of 20 out 38 patients. These findings indicate that specific S. pyogenes antigen, associated with class I M protein, is often present in psoriatic lesions. Such an antigen, originating from focal infection elsewhere could be responsible for T-lymphocyte inflammatory responses triggering the development of psoriatic lesions.

Acyclovir therapy for angioedema and chronic urticaria

Angioedema and chronic urticaria result from a variety of causes. Our purpose was to study the therapeutic effect of oral acyclovir on selected patients, by observing the effect of acyclovir in a dosage of from 100 mg every six hours to 800 mg every four hours in fourteen patients with angioedema or chronic urticaria. Five of twelve patients with chronic urticaria and one patient each with hereditary angioedema and idiopathic angioedema noted complete remission with acyclovir therapy. Discontinuation of the acyclovir resulted in reappearance of the hives. Since these patients had high antibody titers to either herpes simplex virus or Epstein-Barr virus, we conclude that acyclovir produced its therapeutic effect by suppressing a circulating viral antigen.

IgE bullous disease

We report two patients with the typical picture of bullous pemphigoid who lacked two critical diagnostic immunopathological features of the disease, namely IgG or C3 bound to the epidermal basement membrane and circulating IgG antibodies directed against the basement membrane zone (BMZ). Both patients had dense infiltrates of eosinophils within their skin lesions, as well as markedly elevated serum IgE levels, while immunofluorescent studies with anti-IgE antibody revealed heavy IgE deposition on inflammatory cells within the dermis surrounding the bullae. These cells were confirmed to be eosinophils by means of specific staining with antibody to major basic protein (MBP). We speculate that this 'IgE bullous disease' resulted from IgE-mediated hypersensitivity induced by focal infection, both patients initially being helped by antibiotics. However, dramatic clearing of bullae was seen following surgical removal of a battery implant (Patient 1), and bilateral above-the-knee amputations of gangrenous legs (Patient 2).

A Behçet-like disease presenting as ulcerative stomatitis and scarring pustular lesions of the face

Behçet's disease is a complex multisystem disease of unknown origin. It presents clinically as oral, pharyngeal, and genital ulcerations, uveitis, and inflammatory papulopustules. Diagnosis is made clinically since laboratory and histologic observations are not specific. We present a patient who, despite the absence of eye and genital lesions, seems best viewed as having Behçet's disease.

"Stat." single dose of acyclovir for prevention of herpes simplex

A single "stat." 800-mg dose of acyclovir taken at the first sensory signs for either oral or genital herpes simplex regularly prevented lesions from appearing in twenty-six of thirty-two persons known to have recurrent attacks. This dosage schedule is a cost-effective alternative to the long-term daily prophylactic dosing currently recommended.

Acyclovir in the treatment of hand-foot-and-mouth disease

Twelve children ages 1 to 5 years and one adult with hand-foot-and-mouth disease were treated with oral acyclovir within one to two days of onset of the rash. Symptomatic relief, defervescence, and significant involution of lesions were seen within twenty-four hours of initiating therapy. Acyclovir was continued for five days, by which time palmar, plantar, and oral lesions were virtually gone. Acyclovir is a molecule tailored to inactivate the thymidine kinase of the herpesvirus. Since the Coxsackie A16 virus causing hand-foot-and-mouth disease lacks this enzyme, the beneficial therapeutic effect must be explained on other grounds, possibly due to enhancement of the antiviral effect of the patient's own interferon.

Painful fingers, heat intolerance, and telangiectases of the ear: easily ignored childhood signs of Fabry disease

Generalized anhidrosis with heat collapse, painful fingers, and angiokeratomas were the presenting signs in a 23-year-old man who was shown by enzyme studies and electron microscopy to have Fabry disease. His 6-year-old brother had the early diagnostic findings of episodic painful fingers, heat intolerance, and retroauricular telangiectasia. Both had an absence of alpha-galactosidase. Over 6 years of observation, the older brother developed progressive renal failure and the younger one developed acrodynia and anhidrosis. Their mother had diminished alpha-galactosidase activity and several angiomatous papules on one breast. A review of Fabry disease emphasizes the need for skin inspection for angiomas and telangiectasia, and enzyme assay in patients with inexplicable complaints or findings. Carrier females are most easily recognized by the presence of unique corneal opacities.

Hypersensitivity to retinol palmitate injection

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Occult Streptococcus pyogenes in cellulitis: demonstration by immunofluorescence

A 23-year-old man developed cellulitis and ascending lymphangitis of the right leg. Blood cultures and skin saline aspirates were sterile. Gram stain of the aspirate did not show any bacteria. Direct and indirect immunofluorescent staining with polyclonal and monoclonal antibodies to Streptococcus pyogenes revealed streptococci in the reticular dermis. The cellulitis resolved following treatment with intravenous cefazoline.

Estrogen dermatitis

BACKGROUND

Autoimmune progesterone dermatitis includes pruritus, urticaria, papulovesicular eruptions, and bullous erythema multiforme. Sensitivity to estrogen has not been described, although it was probably first recognized almost 50 years ago.

OBJECTIVE

Our purpose was to assess sensitization to selected hormones in women with a significant premenstrual flare of skin lesions.

METHODS

Intradermal skin tests to 18 hormones and control substances were performed in seven patients and four control subjects and read for immediate urticarial and delayed type reactions. Six other control subjects had only estrone and progesterone skin tests. The effect of the antiestrogen tamoxifen on the course of the dermatosis was studied.

RESULTS

Seven women exhibiting severe premenstrual exacerbations of papulovesicular eruptions, urticaria, eczema, or generalized pruritus proved to have an unrecognized sensitivity to estrogen. Five patients had a positive delayed tuberculin-type skin test to estrogen. Two patients with generalized chronic urticaria had only an urticarial reaction to intradermal estrogens. Antiestrogen therapy with tamoxifen proved effective in all five patients, whereas elimination of oral estrogen therapy cured the other two patients.

CONCLUSION

Women can become sensitized to their own estrogens; the major clue is worsening of the skin problem premenstrually. Positive intradermal skin tests to estrogens are diagnostic. Tamoxifen is a specific therapy. We have named this disorder estrogen dermatitis.