Introduction: Autoimmune bullous skin diseases (ABDs) represent a group of disorders of the skin and mucosa commonly associated with deposits of immunoglobulins, complement and fibrinogen, and usually directed against distinct adhesion molecules. After studing these diseases for many years, we noted alterations not only between the cells junctions of the epidermis and/or the dermal/epidermal junction, but also in dermal skin appendageal structures and in mesenchymal tissue around the blisters. Based on our findings, we wanted to determine if the observed patterns of autoimmunity correlated with cutaneous vimentin expression. Materials and Methods: Archival biopsies previously diagnosed with ABDs by clinical, hematoxylin and eosin (H&E) and direct and/or immunofluorescence data were stained with antibodies directed against vimentin via immunohistochemistry (IHC). We tested 30 patients affected by endemic pemphigus, 30 controls from the endemic area, and 15 normal controls. We also tested 30 biopsies from patients with bullous pemphigoid (BP), 20 with pemphigus vulgaris (PV), 8 with pemphigus foliaceus, 14 with dermatitis herpetiformis (DH) and 3 with Senear-Usher syndrome. Results: The H&E, DIF and vimentin patterns of positivity in the different ABDs confirmed that vimentin was compartmentalized around areas of dermal inflammation, around skin appendages and in epidermal, dermal and mesenchymal cell junction areas. Conclusion: Vimentin may be a useful tool for highlighting patterns of microenvironmental tissue alteration in multiple ABDs. The vimentin staining pattern observed was analogous to that we have previously described for proteases and protease inhibitors in patients affected by ABDs, expanding the concept that the autoimmune process extends beyond cell junctions.

Introduction: Abrupt changes of environmental temperatures and assault of chemical and physical assaults belong to the series of biological stresses recorded by the austro-canadian endocrinologist Seyle onto skin, phenomena that are progressively overset all natural events and anthropological lifestyles, are too often depreciated and underestimated by dermatologists and cosmetologists at all. Aims of our study is to evaluate by electrical admittance magnitude measurements the influence these two irrefutable afflictions, designed as stressors, influence negatively human skin and to do this we have selected, to conduct the study, peculiar individuals that, owing to their choice of living, may or not be injured by extreme changes of temperatures and aggressions by chemical and physical pollutants. Materials and Methods: We have recruited 20 nuns in a cloistered convent in Mid Italy: ten of these have been always accustomed to live inside the cloister and their life-style permits the good conservation of the intact skin physiology (that is living at air temperature and medium-low relative humidity) and the other ten are accustomed to live and work outdoor and to be assaulted by abrupt and extreme changes of environmental temperature and pollutants. Cloistered nuns have the chance to choose where to live, indoor or aoutdoor. We measured the electrical admittance magnitude (in μmho) at the beginning and at the end of the experiment that lasts 29 weeks, using an appropriate instrument based on the system developed by Feldman, working at a single frequency of 30kHz. Results and Conclusion: It is self evident that after the simulation of phyto-induced cortisol release onto the skins of all the 20 volunteers, the subjects that which live outdoor show an exaggerated value of dehydration with regard to the subjects that live indoor. Changes of environmental temperatures and chemical pollutants, is self evident, jeopardize human skin integrity and safety, but we have disclosed the eventuality that these phenomena may reveal devastative effects onto skin to drive even to a praecox skin senescence and degradation.

Introduction: Psoriasis is a common chronic, non-contagious, immune mediated disease. Plaque psoriasis is characterized by thick, white, silvery or red patches on the skin. Plaque psoriasis mainly affects scalp, and palms of hands and soles of feet. T-cells are a type of immune system cells which protect the body from foreign substances. But during psoriasis T-cells activated at a great rate than normal, in turn release of cytokines increases as a result skin cells growing too quickly, moving to the surface to the skin and appear on the skin as dead cells. Materials and Methods: Plaque psoriasis is common form of psoriasis, which mainly affects palms of hands and soles of feet and scalp. Out of 76 patients with plaque psoriasis we selected 50 patients based on PASI scores. Within the 50 patients, 32 patients with Palmoplantar psoriasis and 18 patients with scalp psoriasis. All 50 patients were subjected to randomized control trail, so each type of psoriasis is divided into two groups i.e. A and B. All A group patients were treated with MTX, whereas all B group patients were treated with combination of MTX and Calcipotriol. All necessary investigations like complete blood count, liver enzyme,creatinine, urea, alkaline phosphate, PASI were measured at 0, 2,4 6,8 weeks interval. Results: We observed that, a significant reduction in PASI is observed with combination of MTX and Calcipotriol as compared to Methotrexate alone. Conclusion: From the above study we concluded that, combination of MTX and Calcipotriolis more effective than MTX alone in plaque psoriasis.

Leukocytoclastic vasculitis (LCV) is a small-vessel vasculitis with a reported incidence rate of 30 cases per million persons per year. It usually presents as a palpable purpuric skin rash on legs, though any part of the body can be affected. LCV rash may have an associated burning sensation or pain and in some cases may involve internal organs. In some cases, LCV rash may present as nodules, recurrent ulcerations or asymptomatic lesions. The diagnosis of LCV is usually made on skin biopsy. Etiological triggers may not be identified in as many as half of the cases. Treatment is usually conservative and includes identification and removal or treatment of the etiological trigger except in cases with internal organ involvement where systemic steroids and immunosuppressant may be necessary. In this article we present a case of Amoxicillin and Clavulanate potassium associated LCV that improved with discontinuation of the offending agent and treatment with systemic corticosteroids.

Introduction: Psoriasis is a common chronic inflammatory, recurrent, immune mediated disease of the skin and joints. Toll-like receptors are pattern recognition receptors for conserved molecular patterns of pathogenic microorganisms.Under certain circumstances, self nucleic acids can trigger TLR 7 and TLR 9, which can lead to autoimmune diseases such as psoriasis. Materials and Methods: The study included 15 psoriatic patients (plaque type) and 15 controls, patients received 36 sessions of phototherapy (NB-UVB). Skin biopsies were taken from all the patients (before & after NB-UVB) and controls and were assessed for TLR 7 and TLR 9 by PCR. Results: Showed significant difference between patients and controls as regards TLR 7 and TLR 9. In addition a significant decrease in thier levels in patients after phototherapy with NB-UVB. Conclusion: TLR 7 and TLR 9 may play a role in the pathogenesis of poriasis. Decrease in their levels after NB-UVB may be one of the therapeutic mechanisms of NB-UVB in psoriasis.

Introduction: Peroxisome proliferators- activated receptors (PPARs) represent a major research target for the understanding and treatment of many skin diseases, such as benign epidermal tumors, psoriasis and atopic dermatitis. Aim: Estimate and analyze the PPAR gamma expression and its pathological role in psoriasis and atopic dermatitis. Materials and Methods: Fifteen patients with atopic dermatitis, fifteen patients with psoriasis and twenty apparently healthy subjects as controls,were included in the current study. We estimate the PPARgamma gene expression in the lesional skin of atopic and psoriatic patients and control, by quantitative real-time RT-PCR. Results: Our data showed a significant decreased PPARgamma expression in lesional skin of atopic dermatitis patients and psoriatic patients (P value<0.001) compared to the control group, and the decrease was more marked in the psoriatic patients (P value<0.001). Conclusion: Abberent PPAR γ expression has an important role in the pathogenesis of psoriasis and atopic dermatitis through the affection of cell proliferation, differentiation and inflammation.

Melkersson-Rosenthal syndrome (MRS) is a disease of unknown etiology, usually restricted to the orofacial region, characterized by reccurent orofacial swelling, relapsing facial palsy and plicated tongue. We report case of MRS associated with psoriasis in a 25-year-old woman. The patient has been treated with satisfying results with a combination of Cetirizine, Cefuroxime axetil and Mupirocin ointment; psoriatic eruptions were successfully treated with 10 % salicylic-sulphuric ointment twice a day. MRS syndrome is a rare disease and should be considered in the differential diagnosis of labial swelling and facial palsy.

Thalidomide was originally used as a Wonder Drug to treat morning sickness and insomnia in pregnant women in late 1950s. It became apparent in early 1960s that thalidomide treatment resulted in severe birth defects in thousands of children. Then it was banned in most of countries. Later on discovered anti-inflammatory and anti-angiogenic properties of Thalidomide proved to be useful for treatment of leprosy and multiple myeloma. A series of immunomodulatory drugs created by chemical modification of thalidomide have been developed to overcome the original devastating side effects. It’s being investigated extensively as a treatment for many other severe cutaneous disorders and advanced cancers. We briefly review pharmacological and the therapeutic profile of thalidomide.

We present 4 cases just to express the importance of the differential diagnosis of these two entities with great impact on clinical practice (Fig. 1 – 4). In French literature there is the terminology of “angiomes cutanés”(cutaneous angiomas) that includes both hemangiomas and vascular malformations. The persistence of using this medical term creates confusions among physicians of different specialties and within member of the families.

Introduction: Peroxisome proliferators- activated receptors (PPARs) represent a major research target for the understanding and treatment of many skin diseases, such as benign epidermal tumors, psoriasis and atopic dermatitis. Aim: Estimate and analyze the PPAR gamma expression and its pathological role in psoriasis and atopic dermatitis. Materials and Methods: Fifteen patients with atopic dermatitis, fifteen patients with psoriasis and twenty apparently healthy subjects as controls,were included in the current study. We estimate the PPARgamma gene expression in the lesional skin of atopic and psoriatic patients and control, by quantitative real-time RT-PCR. Results: Our data showed a significant decreased PPARgamma expression in lesional skin of atopic dermatitis patients and psoriatic patients (P value<0.001) compared to the control group, and the decrease was more marked in the psoriatic patients (P value<0.001). Conclusion: Abberent PPAR γ expression has an important role in the pathogenesis of psoriasis and atopic dermatitis through the affection of cell proliferation, differentiation and inflammation.

Plasmoacanthoma and plasma cell cheilitis are rare disorders of obscure etiology characterized by a plasma cell infiltrate an 80-year-old woman presented with a verrucous, fleshy, skin colored plaque over lips, gingiva, and the palate and painful swallowing for over a period of 6 months. Histopathology of the lesion showed dense infiltrate of plasma cells. The lesions resolved completely after intralesional triamcinolone acetonide. Another 52-year-old male had progressively enlarging, erosive lesion over vermilion border of lower lip for 6months resembling actinic cheilitis. Histology was diagnostic of plasma cell cheilitis. Treatment with topical clobetasol propionate was effective. Plasma cell cheilitis and plasmoacanthoma perhaps represent a spectrum of oral ”plasma cell mucositis” with plasmoacanthoma being an advanced version of the former.

A 29 years old woman was come to our dermatology clinic with a 1 month history of lesions on her face and extremity. She was diagnosed with HIV from 6 months ago and since then she was on treatment for HIV. Clinical examination was notable for painless indurated erythematous plauqe on her face and erythematous papule on her extremities.

Introduction: Human genes responsible for human antigen presentation and transplant rejection functions are located on the short arm of Chromosome 6 and are called the Major Histocompatibility Complex (MHC). Moreover, the primary physiologic function of MHC molecules is to present peptides to T lymphocytes. MHC molecules are integral components of the ligands that most T cells recognize, since the T cell receptor (TCR) has specificity for complexes of foreign antigenic peptides, as well as self-MHC molecules. Aim: Our investigation attempts to investigate the presence of HLA-DPDQDR within lesional skin biopsies from patients affected by autoimmune skin blistering diseases (ABDs). Materials and Methods: We utilized immunohistochemistry (IHC) to evaluate the presence of HLA-DPDQDR in lesional skin biopsies of patients affected by ABDs. We tested 30 patients with endemic pemphigus foliaceus (EPF), 15 controls from the EPF endemic area, and 15 biopsies from healthy controls from the USA. We also tested archival biopsies from patients with selected ABDs, including 30 patients with bullous pemphigoid (BP), 20 with pemphigus vulgaris (PV), 8 with pemphigus foliaceus (PF), 14 with dermatitis herpetiformis (DH) and 2 with epidermolysis bullosa acquisita (EBA). Results: Most ABD biopsies stained positive for HLA-DPDQDR in the lesional blisters and/or inflamed neurovascular plexus in the superficial dermis, and also at mesenchymal-endothelial like-cell junctions in the dermis. In BP, EBA and EPF, the HLA-DPDQDR staining was also seen in the dermal eccrine sweat gland coils and and ducts. Conclusion: Here, we document that HLA-DPDQDR is expressed in several anatomic areas of lesional skin in patients with ABDs. Notably, HLA-DPDQDR positivity was also consistently present in areas of the classic immune response in pemphigus epidermal keratinocytic intercellular junctions, and at basement membrane sites in bullous pemphigoid and other subepidermal blistering diseases.

Tuberous sclerosis is an autosomal dominant neurocutaenous disorder or neuroectodermatosis affecting multiple organ systems with variable clinical manifestations. We are reporting a case of a 26 years old female with history of epilepsy with mental retardation presented with fever and convulsions following an episode of stillbirth on first time with normal fetal outcome on second time. She had facial angiofibromas, shagreen patch, ash-leaf macules, periungual and subungual fibromas. She also had bilateral renal angiomyolipomas with haemorrhages and sub ependymal cortical tubers in brain. We report such a unique case having all clinically diagnostic physical sings of tuberous sclerosis with complicated obstetric history.

Female patient, 35 years old who came to the private office due to discoloration of her left thumbnail and little pain since 1 month ago. Clinical examination shows nail disease on her left thumbnail with onycholysis and dyschromia, dermatoscopy showed white-yellowish discoloration (Fig. 1A, B). The rest of the clinical examination was normal. Patient use to using acrylic nails since 2 years ago and denied some trauma at the nail.

We write to express our concerns on the adoption of only physician-rated outcome measurement, namely the Psoriasis Area and Severity Index, in this otherwise exceptionally well conducted randomised controlled trial, without the adoption of any patient-rated outcome variable, such as quality of life (QOL) indexes. Skin diseases might cast very significant impacts on the quality of life of patients. However, symptoms and impacts on the QOL are known to be not necessarily correlate directly with disease severity as rated by physicians for skin diseases [1, 2], including psoriasis vulgaris [3]. QOL indexes, such as the Dermatology Life Quality Index [4] and the Children Dermatology Life Quality Index [5], have been constructed, validated, and validly translated into a large number of languages [1, 6, 7].

Several researchers have called for reforms in drug naming, labeling, and packaging standards. Giving the patients the medications remains the most important stage in patients care. There are medical errors associated with this stage. In the following disquisition, we shall highlights on some points on the prescriptions and the dispensing of the medications. We wish that these points encourage further discussions by the readers.

Hair can grow in areas which are not usually hairy in human skin. The Online Mendelian Inheritance in Man (OMIM) (http:// www.ncbi.nlm.nih.gov/omimhave) some entries in this regards. These include ( %139600 – HAIRY ELBOWS, #605130 – HAIRY ELBOWS, SHORT STATURE, FACIAL DYSMORPHISM, AND DEVELOPMENTAL DELAY, 139630 – HAIRY NOSE TIP, 139500 – HAIRY EARS, and 425500 – HAIRY EARS, Y-LINKED). Hairy ears, (Fig. 1), are uncommon trait and it is rare to see a person with very long hair on the ears.

Introduction: Previous research on autoimmune skin blistering diseases (ABD) has primarily focused on the humoral immune response; moreover, little attention has been given to the potential role of the antigen presenting cells (APCs) in lesional skin. Aim: The purpose of our study was to immunophenotype selected APC in the lesional skin of ABDs, utilizing immunohistochemistry (IHC) stains. Materials and Methods: We utilized IHC to stain for dendritic cells (DC), staining with CD1a, CD68, HAM56, and S-100 in lesional skin from 30 patients with endemic pemphigus foliaceus (EPF), 15 controls from the EPF endemic area, and 15 healthy controls from the USA. We also tested archival biopsies from patients with selected ABD, including 30 patients with bullous pemphigoid (BP), 20 with pemphigus vulgaris (PV), 8 with pemphigus foliaceus (PF) and 14 with dermatitis herpetiformis (DH) and 2 with epidermolysis bullosa acquisita (EBA). Results: Cells stained by CD68, HAM56 and S-100 were present in the majority of the ABD skin biopsies; these cells were located primarily in perivascular infiltrates surrounding dermal vessels subjacent to the blisters. However, these cells were also noted within the blisters, in vessels supplying dermal eccrine glands and ducts, and in areas of dermal endothelial-mesenchymal cell junction-like structures, especially in BP cases. In our CD1a staining, the number and location of positive staining cells varied with each disease, being abundant in most ABD in the epidermis suprajacent to the blisters, or in the epidermis surrounding the blister site if the blister site epidermis was missing. In the control biopsies, most did not display positive IHC staining, with the exception of a few CD1a positive cells in the epidermis Conclusion: Our findings confirm positive IHC staining for APCs in areas of the skin besides the disease blisters. Our findings suggest that the antigen presentation in ABD proceeds in areas distant from the blister site. Further studies are needed to confirm our findings, and to explore their full significance.

“Wolf’s isotopic response” describes the occurrence of a new skin disorder at the site of another, unrelated and already healed skin disease. In most cases of isotopic response, the initial dermatosis is herpes zoster, herpes simplex, varicella, thrombophlebitis, scrofuloderma and striae distense. The most frequent second dermatoses are granulomatous reactions, particularly granuloma annulare, and lichenoid diseases. Various etiological reasons including viral, immunologic, neural and vascular have been put forth. We report here a case in which the second disease was herpes zoster that appeared over the same dermatomes of pre-existing segmental vitiligo. The occurrence of vitiligo as first and herpes zoster as second disease in the “Wolf’s isotopic response” has not, to the best of our knowledge, been reported previously.

Keratosis follicularis spinulosa decalvans (KFSD) is a keratinization disorder characterized by diffuse follicular hyperkeratosis, progressive cicatricial alopecia, corneal dystrophy, and photophobia. Acne keloidalis nuchae (AKN) is a syndrome of chronic folliculitis that manifests as follicular-based pustules and papules on the occipital region of the scalp, which may eventually lead to cicatricial alopecia. Various diseases such as cutis laksa, deafness, aminoaciduria, mental retardation, and atopy have been reported to be associated with KFSD, but AKN is a rare cutaneous manifestation. Herein, we report the case of a patient with KFSD associated with AKN. He was presented to our clinic with follicular-based pustules and papules that had been progressively advancing for five years that were now manifesting as cicatricial alopecia.

Pyogenic granulomas are common, acquired, benign vascular lesions of the skin and mucousmembranes that can develop both spontaneously and traumatically. Pyogenic Granuloma more commonly involves Gingiva (75% of all the cases). An extragingival occurrence of pyogenic granuloma is rare. We present an unique case of a male patient aged 24 years affected by Pyogenic Granuloma of urethral meatus. Although penile pyogenic granulomas have previously been observed over glans penis,prepuce and shaft of penis,there are no reports affecting meatus.

Morphea is a fibrosing disorder of the skin and subcutaneous tissues, wherein the overabundant collagen deposition destroys adnexal structures and hair follicles. In linear morphea erythematous or violaceous patches or plaques are seen with central sclerosis and active red border distributed in linear configuration which over time become sclerotic, white or hypopigmented. We report a series of cases encompassing all the three clinical variants of linear morphea. Case one had en coup de sabre deformity, case two had progressive facial hemiatrophy and case three had linear limb morphea with involvement of the face. This series is being reported for its rarity.

Eponyms are used almost daily in the clinical practice of dermatology. And yet, information about the person behind the eponyms is difficult to find. Indeed, who is? What is this person’s nationality? Is this person alive or dead? How can one find the paper in which this person first described the disease? Eponyms are used to describe not only disease, but also clinical signs, surgical procedures, staining techniques, pharmacological formulations, and even pieces of equipment. In this article we present the symptoms starting with (L) and other. The symptoms and their synonyms, and those who have described this symptom or phenomenon.

Female patient, 47 years old who was hospitalized due to urinary tract infection, during her hospitalization bullous lesions appeared on her left limb and interconsultation to the Dermatology Department was made. The patient has been treated by breast cancer with docetaxel, doxorubicin and cyclophosphamide; she had received 5 cycles of chemotherapy Clinical examination showed vesicles on an erythematous base of the left arm following a linear pattern and the diagnosis of herpes zoster was done. The rest of the clinical examination of the patient showed black color and transverse lines was observed on finger and toenails predominantly on both big toenails seeing four Beau lines on each one.

Lichen Planus actinicus (LP actinicus) is a variant of lichen planus often confined to individuals in tropical and subtropical regions. The lesions involve sun-exposed areas and are characterized by well-defined nummular patches which have a deeply hyperpigmented centre surrounded by a hypopigmented zone. It mainly involves teenagers with an Asian racial profile. We report a rare case of a 10 year old male child who reported to the department of dermatology with multiple annular pigmented patches on the face, forearms and shins which developed slowly over a period of one year.

Both pemphigus vulgaris and subcorneal pustular dermatoses are intraepidermal blistering disorders though the treatment for the two varies. We present a 26 years old male patient with multiple vesicles and bullae filled with clear fluid as well as pus, hypopyon sign present, predominantly over the trunk and crusted lesions over the scalp. The patient did not have mucosal involvement at presentation and Nikolsky’s and bulla spread sign were negative. A clinical diagnosis of subcornealpustulardermatosis and IgA pempgigus was made; however, direct immunofluorescence was suggestive of pemphigus vulgaris as was histopathology examination. The patient responded to treatment with oral corticosteroids. A previous case report of pemphigus foliaceous presenting as IgA pemphigus and responding to dapsone has been reported and so has a report of pemphigus vulgaris presenting with multiple pustules.

Las poroqueratosis (PQ) son un grupo de trastornos de la queratinización cutánea, de carácter adquirido o hereditario. Su expresión clínica consiste en una mácula o placa anular de centro atrófico y bordes bien definidos e hiperqueratósicos, cuya imagen histológica es una columna paraqueratósica compacta, denominada laminilla cornoide. El número y la distribución de las lesiones definen las diferentes formas clínicas: poroqueratosis de Mibelli, poroqueratosis actínica superficial diseminada (PASD), poroqueratosis lineal, poroqueratosis palmo-plantar y poroqueratosis punctata. Presentamos 3 casos clínicos y hacemos una breve revisión de la literatura.

Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) has recently been separated from baboon syndrome and proposed as a unique type of drug eruption [1], which appears only on intertriginous or flexural folds and in gluteal areas in the absence of systemic involvement. Antibiotics including amoxicillin and cephalosporins are the most common drugs causing SDRIFE [2]. We report herein a case of SDRIFE showing symmetrical erythema predominantly on major flexural areas, rapidly developed after taking valacyclovir, which was suggested as a causative drug by skin patch test.

Acitretin is a systemic retinoid drug used in the treatment of severe psoriasis and various other skin disorders, such as lichen planus, ichthyosis, lupus erythematosus. The mechanism of action of acitretin is still incompletely understood although, like retinoic acid, it is thought to interfere with the terminal differentiation of keratinocytes. The most frequent adverse reactions associated with this drug are the mucocutaneous effects on the lips, eyes, mouth, and other epidermal surfaces [1]. Herein, we present a case of a 54-year old man who developed rectal bleeding and detection of early stage colon carcinoma during the treatment with systemic acitretin for psoriasis vulgaris.

Tuberculosis of the oral cavity accounts for less than one percent of all cases of tuberculosis, seen in both the primary and secondary stages of the disease. It presents usually as a single, painful, ulcer however, multiple painless ulcers may also be seen. The most common location in the oral cavity is tongue. The palate, buccal mucosa, floor of the mouth, gingiva, and lip are other possible sites of involvement. In secondary tuberculosis, oral lesions are accompanied by lesions in the lungs, lymph nodes, or in any other part of the body. We hereby report a case of tuberculosis of lip in a 24 year old female, secondary to pulmonary tuberculosis.

Seborrheic keratosis (SK) is common benign epithelial tumor of the skin that can be associated with other cutaneous tumors such as basal cell carcinoma, squamous cell carcinoma and melanoma. On the other hand, melanocytic nevus (MN) is another very common disease, showing anecdotal association with other cutaneous tumors such as trichoepithelioma, syringoma, basal cell carcinoma, trichilemmal cyst and epidermoid cyst. Although it has recently been reported that somatic mutation of BRAF gene is implicated in MN quite frequently, their pathogenic mechanisms, especially the association with other cutaneous tumors, are still elusive. Despite the high frequency of both tumors, however, collision tumors of SK and MN are extremely rare that only a few case reports have been documented so far. Hereby, we report five cases of simultaneous occurrence of SK and MN in 14-year-old female, 36-year-old female, 39-year-old female, 58-year-old male, and 62-year-old male patients. Additional molecular tests for BRAF mutation (V600E) on micro-dissected tissue of the 58-year-old man revealed positivity on the MN and negativity on the SK. Although these results cannot give direct evidence that both tumors have different pathogenic mechanisms, it seems to be more relevant that these collision tumors may occur by chance.

A 71-year-old female visited the Department of Dermatology at Tokyo Metropolitan Bokuto Hospital, complaining of a nodule in the face. She was diagnosed as Merkel cell carcinoma by a skin biopsy in another clinic, and referred to our hospital for operation. A physical examination revealed a dome-shaped reddish nodule, sized 1-cm in diameter, in the center of the left cheek. Cervical lymph nodes were not palpable. The nodule was totally removed with a margin.