Letters to the Editor
(a)
(b)
Figure 1. (a) Skin-colored subcutaneous nodule covered with normal mucosa on the mucosal aspect of the upper lip. (b) Histopathological findings showed a basophilic central mass surrounded by peripheral eosinophilic rosette and dense inflammatory infiltration (hematoxylin–eosin, original magnification 940). (c) Gram staining showed numerous filamentous bacteria and peripheral clubs at its edge (9400).
We present a case of actinomycosis of the lip mimicking mucocele, treated with surgical excision. In simple swelling or subcutaneous nodule without pus or tenderness covered with normal mucosa on the lip, biopsy should be performed because of the possibility of actinomycosis.
CONFLICT OF INTEREST:
None declared.
Hyojin KIM,1 In Ho PARK,1 Won Kyung LEE,1 Jung Eun SEOL,1 So Young JUNG,2 Han Young WANG2 1
Busan Paik Hospital, and 2Haeundae Paik Hospital, Inje University, Busan, Korea doi: 10.1111/1346-8138.12887
REFERENCES
(c)
1 Kalioras V, Thanos L, Mylona S, Pomoni M, Batakis N. Scalp actinomycosis mimicking soft tissue mass. Dentomaxillofac Radiol 2006; 35: 117–118. ne chal A, Dupieux C et al. Actinomycosis: etiology, clini2 Valour F, Se cal features, diagnosis, treatment, and management. Infect Drug Resist 2014; 7: 183–197. 3 Lee YS, Sim HS, Lee SK. Actinomycosis of the upper lip. Ann Dermatol 2011; 23 (Suppl 1): S131–S134. 4 Appiah-Anane S, Tickle M. Actinomycosis-an unusual presentation. Br J Oral Maxillofac Surg 1995; 33: 248–249. 5 Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffel DJ, Wolff KF. Actinomycosis, nocardiosis, and actinomycetoma, In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffel DJ, Wolff K, eds. Fitzpatricks Dermatology in General Medicine, 8th edn. New York: McGraw-Hill, 2011:2241–2244.
Questionnaire surveillance of hidradenitis suppurativa in Japan Dear Editor, Hidradenitis suppurativa (HS) is a chronic inflammatory follicular disease that is usually characterized by recurrent inflamed subcutaneous nodules, abscess, draining sinus, and scars in the buttocks, genital, perianal, axilla and inguinal areas.1,2
Several surveillances of HS have been conducted in Europe and the USA.1 Because no epidemiological report has been published in Japan, we conducted a questionnaire surveillance study of HS in Japan.
Correspondence: Ichiro Kurokawa, M.D., Department of Dermatology, Meiwa Hospital, 4-31 Agenaruo-cho, Hyogo 663-8186, Japan. Email: [email protected]
© 2015 Japanese Dermatological Association
747
Letters to the Editor
Questionnaires were sent out to 44 hospitals of training institutions approved by the Japan Dermatology Association. The questionnaire was used to collect information including sex, age, affected locations, disease duration, Hurley’s severity stage, associated diseases, family history, associated factors and therapy. The results are summarized in Table 1. One hundred patients (69 men and 31 women) in 2014 were included. The most prevalent decade of age was the 30s, and the mean age was 40.1 years. The mean disease duration was 7.0 years.
Table 1. Questionnaire surveillance of hidradenitis suppurativa No. of institutions No. of HS patients Sex Male Female Age, decade 10s 20s 30s 40s 50s 60s 70s Location Axilla Buttock Genital area Inframammary area Leg
44 100 69 31 Total
Male
Female
8 20 24 20 16 9 3
6 12 16 14 11 7 3
2 8 8 6 5 2 0
Total
Male
Female
38 59 26 1 1
21 51 14 0 0
17 8 12 1 1
Affected period (years) Severity (Hurley stage) I II III Family history Associated diseases Diabetes mellitus Acne conglobata Hirsutism Pilonidal sinus Polycystic ovary syndrome Menstrual irregularity Dermatitis papillaris capillitii Perifolliculitis capitis abscedens et suffodiens Crohn’s disease Folliculitis decalvans Associated factors Smoking Obesity Therapy Oral antimicrobials Total excision Incision Topical antimicrobials
748
7 41 40 19 2 11 6 6 2 2 2 1 1 0 0 29 15 85 50 49 48
The most frequently affected location was the buttocks, followed by the axilla and genital areas. The buttocks and axilla were the most commonly affected area in men and women, respectively. Hurley’s severity stage was I in 41% of the patients, II in 40% and III in 19%. The major associated diseases were diabetes mellitus, acne conglobata and hirsutism. Crohn’s disease was not observed. Only 2% of the patients had a family history of HS. Regarding associated factors, 29% of the patients were smokers and 15% were obese. The most frequent therapeutic approach was systemic antimicrobials, followed by total excision, incision and topical antimicrobials. Hidradenitis suppurativa was more prevalent in men, although the male : female ratio was 1:3 in Europe.1,2 Japanese patients with HS were older than the European patients.3 The buttocks were most frequently affected, whereas in Europe, the groin, followed by the axilla, perianal, perineal and intermammary areas were most frequently affected.3 In Europe,4 the prevalence of patients with a family history of the disease was 30–40%, whereas the prevalence was 2%. The associated factors5 are similar. Crohn’s disease was not observed in our study in spite of an established comorbidity in Europe.1 A higher number of severe cases existed in our results than in those from European studies of Hurley severity stages I:II:III (68.2%:27.6%:3.9%).3 Therefore, we speculated that the patients in our study might have been selected as severe cases in the hospitals with a high frequency of male sex and involvement of the buttocks because of sociological reasons. A severe case of HS is showed in Figure S1. We included pyoderma chronica glutealis in HS in this study. But it has been discriminated from HS for a long time in Japan due to the discussion of follicular involvement. Japanese dermatologists are not familiar with the diagnosis of HS on the buttocks, and only severe cases might have been included by some dermatologists. The estimating prevalence of HS ranged 0.33–4 patients/ 1000 inhabitants.1 This study is a preliminary study conducted in Japan. Further epidemiological study should be performed in a larger population to clarify the incidence of HS in Japan.
CONFLICT OF INTEREST: None. Ichiro KUROKAWA,1 Nobukazu HAYASHI,2 Japan Acne Research Society 1
Department of Dermatology, Meiwa Hospital, Nishinomiya, and Department of Dermatology, Toranomon Hospital, Tokyo, Japan
2
doi: 10.1111/1346-8138.12881
REFERENCES 1 Jemec GBE, Revuz J, Leyden JJ eds. Hidradenitis Suppurativa. Springer, Berlin, 2006. 2 Kurzen H, Kurokawa I, Jemec GB et al. What causes hidradenitis suppurativa? Exp Dermatol 2008; 17: 455–472. 3 Revuz J. Hidradenitis suppurativa. J Eur Acad Dermatol Venereol 2009; 23: 985–998. 4 Von Der Werth JM, Williams HC, Raeburn JA. The clinical genetics of hidradenitis suppurativa revisited. Br J Dermatol 2000; 142: 947–953.
© 2015 Japanese Dermatological Association
Letters to the Editor
5 Revuz J, Canoui-Poitrine F, Wolkenstein P et al. Prevalence and factors associated with hidradenitis suppurativa: results from two casecontrol studies. J Am Acad Dermatol 2008; 59: 596–601.
Figure S1. Severe case of hidradenitis suppurativa (Hurley stage III): recurrent inflamed subcutaneous nodules, abscess, undermined draining sinus and scar in the buttocks.
SUPPORTING INFORMATION Additional Supporting Information may be found in the online version of this article:
Lupus erythematosus profundus in a patient with myasthenia gravis Dear Editor, A 33-year-old woman complained of subcutaneous indurations of the extremities. Seven years prior, she had developed myasthenia gravis (MG), which was confirmed by the detection of the acetylcholine receptor antibodies in the serum (25 nmol/L; normal,
(a)
(b)
Figure 1. (a) Skin-colored subcutaneous nodule covered with normal mucosa on the mucosal aspect of the upper lip. (b) Histopathological findings showed a basophilic central mass surrounded by peripheral eosinophilic rosette and dense inflammatory infiltration (hematoxylin–eosin, original magnification 940). (c) Gram staining showed numerous filamentous bacteria and peripheral clubs at its edge (9400).
We present a case of actinomycosis of the lip mimicking mucocele, treated with surgical excision. In simple swelling or subcutaneous nodule without pus or tenderness covered with normal mucosa on the lip, biopsy should be performed because of the possibility of actinomycosis.
CONFLICT OF INTEREST:
None declared.
Hyojin KIM,1 In Ho PARK,1 Won Kyung LEE,1 Jung Eun SEOL,1 So Young JUNG,2 Han Young WANG2 1
Busan Paik Hospital, and 2Haeundae Paik Hospital, Inje University, Busan, Korea doi: 10.1111/1346-8138.12887
REFERENCES
(c)
1 Kalioras V, Thanos L, Mylona S, Pomoni M, Batakis N. Scalp actinomycosis mimicking soft tissue mass. Dentomaxillofac Radiol 2006; 35: 117–118. ne chal A, Dupieux C et al. Actinomycosis: etiology, clini2 Valour F, Se cal features, diagnosis, treatment, and management. Infect Drug Resist 2014; 7: 183–197. 3 Lee YS, Sim HS, Lee SK. Actinomycosis of the upper lip. Ann Dermatol 2011; 23 (Suppl 1): S131–S134. 4 Appiah-Anane S, Tickle M. Actinomycosis-an unusual presentation. Br J Oral Maxillofac Surg 1995; 33: 248–249. 5 Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffel DJ, Wolff KF. Actinomycosis, nocardiosis, and actinomycetoma, In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffel DJ, Wolff K, eds. Fitzpatricks Dermatology in General Medicine, 8th edn. New York: McGraw-Hill, 2011:2241–2244.
Questionnaire surveillance of hidradenitis suppurativa in Japan Dear Editor, Hidradenitis suppurativa (HS) is a chronic inflammatory follicular disease that is usually characterized by recurrent inflamed subcutaneous nodules, abscess, draining sinus, and scars in the buttocks, genital, perianal, axilla and inguinal areas.1,2
Several surveillances of HS have been conducted in Europe and the USA.1 Because no epidemiological report has been published in Japan, we conducted a questionnaire surveillance study of HS in Japan.
Correspondence: Ichiro Kurokawa, M.D., Department of Dermatology, Meiwa Hospital, 4-31 Agenaruo-cho, Hyogo 663-8186, Japan. Email: [email protected]
© 2015 Japanese Dermatological Association
747
Letters to the Editor
Questionnaires were sent out to 44 hospitals of training institutions approved by the Japan Dermatology Association. The questionnaire was used to collect information including sex, age, affected locations, disease duration, Hurley’s severity stage, associated diseases, family history, associated factors and therapy. The results are summarized in Table 1. One hundred patients (69 men and 31 women) in 2014 were included. The most prevalent decade of age was the 30s, and the mean age was 40.1 years. The mean disease duration was 7.0 years.
Table 1. Questionnaire surveillance of hidradenitis suppurativa No. of institutions No. of HS patients Sex Male Female Age, decade 10s 20s 30s 40s 50s 60s 70s Location Axilla Buttock Genital area Inframammary area Leg
44 100 69 31 Total
Male
Female
8 20 24 20 16 9 3
6 12 16 14 11 7 3
2 8 8 6 5 2 0
Total
Male
Female
38 59 26 1 1
21 51 14 0 0
17 8 12 1 1
Affected period (years) Severity (Hurley stage) I II III Family history Associated diseases Diabetes mellitus Acne conglobata Hirsutism Pilonidal sinus Polycystic ovary syndrome Menstrual irregularity Dermatitis papillaris capillitii Perifolliculitis capitis abscedens et suffodiens Crohn’s disease Folliculitis decalvans Associated factors Smoking Obesity Therapy Oral antimicrobials Total excision Incision Topical antimicrobials
748
7 41 40 19 2 11 6 6 2 2 2 1 1 0 0 29 15 85 50 49 48
The most frequently affected location was the buttocks, followed by the axilla and genital areas. The buttocks and axilla were the most commonly affected area in men and women, respectively. Hurley’s severity stage was I in 41% of the patients, II in 40% and III in 19%. The major associated diseases were diabetes mellitus, acne conglobata and hirsutism. Crohn’s disease was not observed. Only 2% of the patients had a family history of HS. Regarding associated factors, 29% of the patients were smokers and 15% were obese. The most frequent therapeutic approach was systemic antimicrobials, followed by total excision, incision and topical antimicrobials. Hidradenitis suppurativa was more prevalent in men, although the male : female ratio was 1:3 in Europe.1,2 Japanese patients with HS were older than the European patients.3 The buttocks were most frequently affected, whereas in Europe, the groin, followed by the axilla, perianal, perineal and intermammary areas were most frequently affected.3 In Europe,4 the prevalence of patients with a family history of the disease was 30–40%, whereas the prevalence was 2%. The associated factors5 are similar. Crohn’s disease was not observed in our study in spite of an established comorbidity in Europe.1 A higher number of severe cases existed in our results than in those from European studies of Hurley severity stages I:II:III (68.2%:27.6%:3.9%).3 Therefore, we speculated that the patients in our study might have been selected as severe cases in the hospitals with a high frequency of male sex and involvement of the buttocks because of sociological reasons. A severe case of HS is showed in Figure S1. We included pyoderma chronica glutealis in HS in this study. But it has been discriminated from HS for a long time in Japan due to the discussion of follicular involvement. Japanese dermatologists are not familiar with the diagnosis of HS on the buttocks, and only severe cases might have been included by some dermatologists. The estimating prevalence of HS ranged 0.33–4 patients/ 1000 inhabitants.1 This study is a preliminary study conducted in Japan. Further epidemiological study should be performed in a larger population to clarify the incidence of HS in Japan.
CONFLICT OF INTEREST: None. Ichiro KUROKAWA,1 Nobukazu HAYASHI,2 Japan Acne Research Society 1
Department of Dermatology, Meiwa Hospital, Nishinomiya, and Department of Dermatology, Toranomon Hospital, Tokyo, Japan
2
doi: 10.1111/1346-8138.12881
REFERENCES 1 Jemec GBE, Revuz J, Leyden JJ eds. Hidradenitis Suppurativa. Springer, Berlin, 2006. 2 Kurzen H, Kurokawa I, Jemec GB et al. What causes hidradenitis suppurativa? Exp Dermatol 2008; 17: 455–472. 3 Revuz J. Hidradenitis suppurativa. J Eur Acad Dermatol Venereol 2009; 23: 985–998. 4 Von Der Werth JM, Williams HC, Raeburn JA. The clinical genetics of hidradenitis suppurativa revisited. Br J Dermatol 2000; 142: 947–953.
© 2015 Japanese Dermatological Association
Letters to the Editor
5 Revuz J, Canoui-Poitrine F, Wolkenstein P et al. Prevalence and factors associated with hidradenitis suppurativa: results from two casecontrol studies. J Am Acad Dermatol 2008; 59: 596–601.
Figure S1. Severe case of hidradenitis suppurativa (Hurley stage III): recurrent inflamed subcutaneous nodules, abscess, undermined draining sinus and scar in the buttocks.
SUPPORTING INFORMATION Additional Supporting Information may be found in the online version of this article:
Lupus erythematosus profundus in a patient with myasthenia gravis Dear Editor, A 33-year-old woman complained of subcutaneous indurations of the extremities. Seven years prior, she had developed myasthenia gravis (MG), which was confirmed by the detection of the acetylcholine receptor antibodies in the serum (25 nmol/L; normal,
