ecthyma. Ecthyma is a pyogenic infection of the skin characterized by the formation of adherent crusts, beneath which ulceration occurs. Poor hygiene and malnutrition are known predisposing factors [1]. Similarly to impetigo contagiosa, infection by streptococci or staphylococci may be causative. However, unlike impetigo contagiosa, the lesion spreads to the superficial dermis. In Japan, ecthyma is very rare, whereas it is commonly reported in tropical developing countries [2, 3]. In many solid tumours, the epidermal growth factor receptor (EGFR) is overexpressed, making it an ideal target for anti-tumour therapy. However, EGFR is normally expressed in the basal and suprabasal layers of the epidermis, sebaceous glands and hair follicular epithelium and, thus, the use of EGFR inhibitors is commonly accompanied by cutaneous adverse effects such as acneiform reaction, xerosis, pruritus and paronychia. The patient presented herein represents a rare case of extensive erosion or ulcer during the treatment of unresectable colon cancer by an EGFR inhibitor. To our knowledge, there are only 4 previous reports in the literature of ulcer formation during treatment with an EGFR inhibitor [4-7]. In these reports, the authors concluded that, in addition to the effects of the EGFR inhibitor on the normal epidermis, concomitant radiotherapy [4], bacterial infection [5], immunosuppressive effects of the anti-cancer drug [5] and sustained physical stimulation [6, 7], may all have contributed to the development of skin ulcers. Lastly, as a pathological change caused by an EGFR inhibitor, Kobayashi et al [8], reported enlargement of the intercellular spaces in the basal and suprabasal layers of the epidermis, similar to what was observed in our case. Since there are currently very few reports of skin ulcers or erosions caused by EGFR inhibitors in the literature, we believe that accumulation of data regarding this phenomenon is crucial and that the case presented herein provides important information regarding the potential cutaneous adverse events associated with this treatment regimen.
Disclosure. Financial support: none. Conflict of interest: none. 1

Department of Dermatology, Department of Surgery, Odawara Municipal Hospital, Kuno 46, Odawara-shi, Kanagawa-ken, Japan 2

Takashi MIZUNO1 Tomohiko TANEGASHIMA1 Aki SUZUKI1 Sayaka KUZE1 Takashi KOYAMA2

1. Adriaans BM, Hay RJ. Bacterial Infections. In: Burns T, Breathnach S, Cox N, Griffiths C, eds. Rook’s Textbook of Dermatology. 8th edn. Oxford: Wiley-Blackwell Scientific Publications, 2010: 30-17. 2. Yamamoto T, Morita H, Umeda J, Shirabe H. A case of ecthyma vulgare progressing rapidly with phlegmone. Rinsho Hifuka 2003; 57: 778-80. 3. Iwagaki M, Kono Y, Hirata Y, Kubouchi H. Ecthyma vulgare on the face with delirious condition. Rinsho Hifuka 2003; 57: 125-7. 4. Pryor DI, Porceddu SV, Burmeister BH, et al. Enhanced toxicity with concurrent cetuximab and radiotherapy in head and neck cancer. Radiother Oncol 2009; 90: 172-6. 5. Navarini AA, Kamacharova I, Kerl K, Donghi D, Cozzio A. Ecthymatous skin eruption during therapy with cetuximab. Eur J Dermatol 2011; 21: 282-3.

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6. Tsuboi K, Kawase Y, Okochi O, et al. Cetuximab-associated skin ulceration in patient with metastatic colorectal cancer-a case report. Gan To Kagaku Ryoho 2011; 38: 1549-52. 7. Inoshita K, Katayama T, Matsumoto C, Miyake Y. A case of multiple ulceration of acneiform skin lesions induced by panitumumab. Rinsho Hifuka 2013; 67: 21-5. 8. Kobayashi I, Katsumi S, Asada H, Miyagawa S, Fukuoka K, Kimura H. Cutaneous side-effects induced by gefitinib (Iressa). Jpn J Dermatol 2004; 114: 1107-13. doi:10.1684/ejd.2014.2390

IgG/IgA pemphigus recognizing desmogleins 1 and 3 in a patient with Sjögren’s syndrome A 66-year-old Japanese female presented with a one-month history of pustular lesions on the trunk and perineal regions. Physical examination revealed a number of varying-sized pustules rimmed by erythema (Fig. 1A). Some lesions showed flaccid pustules and/or blisters at the periphery and yellow crusts in the center of the erythematous plaque (figure 1B). Oral mucosa showed extensive erosions, which appeared approximately two weeks before the admission

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Figure 1. Clinical and histopathological features of the present case. A) Pustules on the perineal region. B) Erythematous plaques with flaccid pustules and vesicles at the periphery. C) Histopathological features of many neutrophils with few eosinophils within and underneath the epidermis (original magnification, ×100). D) An acantholytic bulla formation in the lower epidermis (original magnification, ×100). E,F) Direct immunofluorescence for IgG (E) and IgA (F). EJD, vol. 24, n◦ 4, July-August 2014

to our hospital. Her past history was unremarkable, but laboratory findings showed positive results for anti-nuclear antibody (titer; 1:640, speckled pattern), anti-SSA antibody (131 U/mL; normal,