We report a 76-year-old man who had four depigmented macules in the genital area as the sole manifestation of extramammary Paget's disease (EMP). Histologically, many scattered, dissociated, plump Paget cells, and small intraepidermal nests of these cells were seen in all four lesions. The distribution of Paget cells extended beyond the margin of the depigmented areas into adjacent normally pigmented skin. Fontana-Masson staining revealed a reduction in, or absence of, melanin deposition along the basal layer of the depigmented lesions, in contrast with an abundance of melanin along the basal layer of the adjacent normal skin. Pigment-blockade melanocytes and melanophages were seen within or below the affected epidermis. The depigmentation in this case could have been caused by a symbiotic disorder between melanocytes and keratinocytes (including melanocyte destruction), and by a disorder in melanosome transmission to the keratinocytes. This case illustrates that a depigmented macule may be a diagnostic feature of EMP. Moreover, depigmentation is probably one of the earliest clinical features of EMP, and not a neighbouring secondary change such as occurs in the Sutton's halo naevus phenomenon.

background. It is difficult to reconstruct an entire alar defect. We report a case of an entire alar reconstruction carried out in two stages with a composite nasolabial flap lined with retroauricular skin and supported with the attached conchal cartilage. objective. A composite nasolabial flap was applied for reconstruction of entire alar defect in this patient. methods. The lining skin for the flap was obtained from retroauricular region acceptable to the patient, and the conchal cartilage was used simultaneously for support and as the attachment for the lining skin. The flap was then replaced and se-cured. Half a year later, the flap was flipped and transferred to the alar defect as a second step. results. The final shape and texture were satisfactory. All procedures were performed under local anesthesia. conclusion. Our design of composite flap has been successfully utilized to repair an entire alar defect with cosmetically and functionally good results, minimizing the donor area and the resulting operation scars. This composite nasolabial flap is thought to be the best choice of a flap for an entire alar defect reconstruction.H. Kakinuma, MD, U. Iwasawa, MD, M. Honjoh, MD, and T. Koura, MD have indicated no significant interest with commercial supporters.

We describe a case of Mycobacterium avium infection of the skin in a 51-year-old woman with systemic lupus erythematosus. Two lesions were treated with a combination of oral tetracycline or minocycline and hyperthermia using a portable warmer. One subsequently healed, leaving an atrophic scar, but the other lesion persisted, and was eventually excised.

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We present two patients with refractory papular eruptions and severe candidiasis. Both of them are positive for treponema pallidum and have suffered from pruritic papular eruptions (PPE) that had resisted therapy for years. Also, candidiasis appeared in the mouth, at intertriginous sites, and on the feet. The clinical features suggested immunodeficiency, and HIV tests were positive. Histologically, the specimen from the PPE lesion showed perivascular and perifollicular mixed cell infiltration. The fungus was identified by both Parker-KOH-mount examination and mycologic culture as Candida albicans. The pruritic papules were healed almost completely with oral antihistamine and topical corticosteroid treatment, and the candidiasis mostly disappeared after treatment with topical antifungal agents alone. We learned from these two cases that refractory PPE and severe candidiasis indicate a need for HIV testing.