Pressure ulcers commonly occur on the sacrum, ischium, lateral trochanter, and heel where pressure or shearing forces continuously affect bony prominences. The following describes three cases of unusual pressure ulcers of the cheek and upper extremity. Patients developed the wounds as a result of lying face downward on the hand for a prolonged period. All facial wounds were treated conservatively and eventually healed, but the damage to the hands was irreversible due to severe complications related to muscle contraction. The authors suggest that the risk factors for these unusual ulcers are living alone, and the combination of sleep aid medication and alcohol consumption..
Many investigators have reported that microsurgical transplanted muscle shows a reduction in volume; however, changes in the size of transplanted fatty tissue have not been studied. The purpose of this study was to describe the degree of fatty tissue atrophy of microsurgical flaps.Nineteen patients who underwent head and neck reconstruction using free flaps between 2003 and 2008 were available for this study. They were divided into an irradiated (8 patients) and nonirradiated (11 patients) group. The free flaps used for reconstruction were rectus abdominal musculocutaneous, anterolateral thigh fasciocutaneous, and forearm flaps. This retrospective study utilized radiographs of magnetic resonance imaging or computed tomography, which were taken two to three and after six months postoperatively. The fatty tissue thickness of free flaps in each magnetic resonance imaging or computed tomography slice was measured. The transplanted fatty tissue thickness of the flap after more than six months was compared with the change in the normal fat thickness of the same slice, to avoid any bias caused by a change in diet due to the general postoperative condition.The thickness of transplanted fatty tissue tends to decrease over period of 6-10 months after surgery. In the nonirradiated group, the mean postoperative fatty tissue thickness change in the free flaps was decreased by 15.9% (range, 0.3-31.4%). In the irradiated group, this change in the free flaps was decreased by 20.9% (range, 2.3-39.4%).Fatty tissue in free flaps shows atrophy over a period of six to nine months after surgery, and irradiation is more likely to result in severer fatty tissue atrophy.
Abstract IL‐22 induces STAT3 phosphorylation and mediates psoriasis‐related gene expression. However, the signaling mechanism leading from pSTAT3 to the expression of these genes remains unclear. We focused on Bcl‐3, which is induced by STAT3 activation and mediates gene expression. In cultured human epidermal keratinocytes, IL‐22 increased Bcl‐3, which was translocated to the nucleus with p50 via STAT3 activation. The increases in CXCL8, S100As and human β‐defensin 2 mRNA expression caused by IL‐22 were abolished by siRNA against Bcl‐3. Although CCL20 expression was also augmented by IL‐22, the knockdown of Bcl‐3 increased its level. Moreover, the combination of IL‐22 and IL‐17A enhanced Bcl‐3 production, IL‐22‐induced gene expression, and the expression of other psoriasis‐related genes, including those encoding IL‐17C, IL‐19, and IL‐36γ. The expression of these genes (except for CCL20) was also suppressed by the knockdown of Bcl‐3. Bcl‐3 overexpression induced CXCL8 and HBD2 expression but not S100As expression. We also compared Bcl‐3 expression between psoriatic skin lesions and normal skin. Immunostaining revealed strong signals for Bcl‐3 and p50 in the nucleus of epidermal keratinocytes from psoriatic skin. The IL‐22‐STAT3‐Bcl‐3 pathway may be important in the pathogenesis of psoriasis.
Pustulosis palmaris et plantaris or palmoplantar pustulosis (PPP) is a refractory pustular eruption of the palms and soles with unknown etiology. In addition to skin lesions, PPP patients may present with severe joint pain and pustulotic arthro-osteitis (PAO), especially of the sternoclavicular joint. PAO is sometimes regarded as a variant of synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome. Hence, macrolide and tetracycline antibiotics are used for the treatment of PPP with PAO. We report 3 cases of PPP with PAO that did not improve upon administration of macrolide antibiotics with NSAIDs. After administration of cefcapene pivoxil hydrochloride (CFPN-PI), a third-generation cephalosporin, the swelling and sternoclavicular joint pain were promptly reduced and dramatically improved in all 3 cases. We review the conventional antibiotic treatments used currently and propose CFPN-PI as a potentially new therapy for PPP or PPP + PAO.
A 45-year-old man presented with erythema on the cheek. He was treated with topical steroids, cyclosporine, etretinate and oral corticosteroids. However, since his symptoms did not improve, his medication was discontinued. A physical examination revealed erythroderma and scaly erythema on his palms. Histology of a biopsy specimen from an erythema on his shoulder demonstrated a compact orthokeratosis alternating with parakeratosis in vertical and horizontal arrays and superficial acantholysis with dyskeratosis reminiscent of pemphigus. The clinical and histopathological findings were consistent with pityriasis rubra pilaris. His symptoms did not improve after administration of three infusions of infliximab at 5 mg/kg/dose, which was then discontinued. Pityriasis rubra pilaris is an uncommon papulosquamous disorder with clinical and histological parallels to psoriasis. Treatment with tumor necrosis factor antagonists is currently being investigated and some results have been reported. Here we present a case of idiopathic classic adult pityriasis rubra pilaris unresponsive to infliximab.
