Johannes Weigl
With the following report I would like to give a short overview of my last fiveteen days at the Department of Dermatology. I just write about my experiences I could gather during that time and make no claims of completeness of content regarding specialist knowledge.
My first day at the Department of Dermatology started with meeting other four Japanese medical students in the conference room of the Ward Building in the morning of Monday, 11th March. Following, the physicians and students made the round to the ten patients who were treated at hospital because of severe diseases like subcutaneous cell carcinoma or malign melanoma, for example. At nine o’clock we entered the surgery room; Monday is reserved for surgeries at that department. We could watch laser treatment used at a one-year old child with dermal melanocytosis, exactly a Mongolian spot, as well as excision procedures which were necessary at a baby with nevuscellnevus. The most interesting and also moving surgery of the day was a female 71-years old patient who suffered from malignant melanoma located in her left eyelid and eye. First, the physicians examined the lymph nodes because of possible metastases and removed the sentinel lymph node for pathology and biopsy. Then, they excised the whole left eyeball which was quite shocking, but had to be done because of parts of the tumor inside. To close the open wound, the physicians removed superficial skin from the upper leg and transplanted it inside the orbita. At the end of the four hours lasting surgery, they filled the hole with sterile absorbent cotton and stitched this place as well as the two other sections they made for lymph node examination.
Tuesday began with the same as the day before, you can say every day at the Department of Dermatology, so the visit of the patients at the Ward. After that we students could join the consultings in the outpatient area and I got to know many diseases like seborrheic keratosis, the most common benign skin tumor of which almost every elderly individual has several. Actually, there is no therapy needed, but patients usually desire removal for cosmetic reasons. The next patient complained of a red spot on his nose since last year. The physician, Dr. Ishii, diagnosed rosacea-like dermatosis and recommended laser therapy as well as he asked the patient to avoid sunlight and irritating substances. Rosacea is a disease of middle-aged adults with a peak age of 40-50 years. It is equally common in both sexes, but more severe in men. Another male patient with liver cancer in past medical history and gastric cancer at the moment appeared in the consulting room and told us about itcheness and also painful rash on shoulders and back. Edema could also be seen on his legs which might point to a kidney damage. At the end, the skin problem was harmless and the physician presribed steroids to treat the eczema. The next case was quite interesting. A young 35-years old woman suffering from the Raynaud-syndrome entered the room and reported about rash on her cold fingers. She showed us her hands and we could see blue-red papules. Because of the diagnosis “cold-related pernio” Dr. Ishii said that maybe the problem would disappear in summer when it’s warmer and ordered oil for better blood circulation. He refrained from prescribing steroids because the woman was afraid of the effects to her milk-drinking baby. The following patient was a three-months old baby with a strawberry mark on his back. To remove the infantile hemangioma, Dr. Ishii recommended tunable dye laser destruction. The other diseases I got to know that day were tinea, erythroderma posteczematosa, Becker nevus and Herpes zoster. Especially the last case was interesting because we could watch the steps of the compliance test of varicella zoster virus and see typical virus-infected cells which appear with large nuclei through the microscope. After lunch, the physicians and students met in the outpatient area and the most interesting and doubtful cases were discussed. At the end of the day, the conference of Wednesday was prepared by talking about the different patients at the Ward.
In the morning of 13th March, all physicians including Professor Otsuka and students met in the conference room and the professor was get up to speed. Before making the round, we also heard something about tranexamic acid whose beneficial effect on all cause mortality or deaths from bleeding was not affected by baseline risk of death and fewer thrombotic events were proven according to a recent study. Then, all patients of Dermatology department were introduced to Professor Otsuka and all physicians spoke about the further steps in treatment. For the rest of the day, we students were free and so could study about the diseases we got to know the last time. The cases we students and physicians had to do with on Thursday were widely different to those of Tuesday. Only seborrheic keratosis appeared for the second time. But pemphigus vulgaris, linear IgA dermatosis, an autoimmune disease, or psoriasis I could watch for the first time during my clerkship. All these skin problems are regularly treated with corticosteroids; because of the fact that the male patient suffering from linear IgA dermatosis was old, here the second choice treatment diaphenylsulfone could be applied, too. Possible side effects include anemia as well as loss of liver function. On that day, we got to know many diseases of adnexal structures like alopecia areata or ingrown nail. Dr. Furuta used a wire to flat the nail which will be renewed after two months. But there was also one male patient who appeared with self-injured facial skin denying any psychiatric problems. Furthermore, we students could watch some tumors, for example lipoma, the most common human tumor with no malignant potential, or basal cell carcinoma which is often pigmented in Asian population in contrast to European people. It’s the most common malignant skin cancer which grows slowly, may eventually become locally destructive but almost never metastasizes. At the meeting after lunch, we were introduced to a female patient with SLE who was already taking steroids, but they showed no effect. So, the physicians discussed about the possibility that there might be an infection, additionally. In the afternoon, we students had exercises in recognizing and matching pictures and histological preparats to some diseases. We could choose between Paget cell disease, cutaneous sarcoidosis, squamous cell carcinoma, Bowen disease which is SCC in situ, psoriasis, basal cell carcinoma, melanoma, T-cell-lymphoma and pemphigus foliacaeus as well as pemphigus vulgaris. The last two differ in their IgG antibodies. In pemphigus foliacaeus antibodies are produced against desmoglein 1 whereas pemphigus vulgaris impones by desmoglein 3 antibodies. In the following pathology conference recent results were discussed like nevus sebaceus, radioactive ????? keratosis, lichen myxedematosus, prurigo nodularis and anaphylacted purpura.
After the daily round, another day in the consulting area was on schedule. We learned that alopecia could be a result of drug intake, especially steroids, or Morbus Basedow itself, so sometimes it is not easy to find out. Then, with the next patient things shaked up. A Brazilian family entered the room because the two-years old girl suffered from molluscum contagiosum, a common pox virus spread by direct skin contact. The physician ordered drugs and pointed out the importance of taking care of prevent infection in kindergarten or to the little sister. The next young girl appeared with a red spot on her left foot which turned out to be an atheroma, an epidermal cyst, removing by surgery is the best treatment for. We students were also present at the most moving part of the day when squamous cell carcinoma was diagnosed to an older woman. In tears, she explained that she has known of this lesion for nearly three years, but was too ashamed to see a physician because of the awkward location of the tumor. But now, the pain was too strong so that she couldn’t sit anymore and her relatives also complained of the very intensive smell coming from her. The physician then told us that this unique smell was characteristic of malignant skin cancer and we should remember it when we were confronted with the next time.
On Monday, 18th March, the morning round started at 08:30 am and lasted just a few minutes. At the patient who had undergone surgery of her malign melanoma last Monday, the wound was completely treated like removing the stitches and exchanging sterile absorbent cotton. The rest of the day was not very busy because there were only two laser treatments because of port-wine stain diseases.
Tuesday hold new diseases for studying. Beneath the already well-known diseases like infantile hemangioma, mongolian spot, eczema or atopic dermatitis, we also could see patients suffering from corona phlebectatica CVI Grade I or neurofibromatosis Type I which is also known as von Recklinghausen disease and inherited in autosomal dominant fashion. After one more case of Bowen’s disease, the day ended with the presentation of the most important patients like the woman with SCC. We could go home earlier this day because Wednesday was holiday in Japan.
Nevus sebaceous on the head of a one-year old baby was one of the new cases on Thursday. Dr. Furuta explained to us that it normally elevated during adolescence and could develop to a tumor in middle-age. Most of these tumors then were benign, but rarely they could get malignant which is why he recommended removing to the mother. Excision was also suggested to a 26-years old man who complained of a hard lump on his right buttock. The pigmentation above the intradermal tumor pointed to fibroma or also fibrosarcoma, Dr. Furuta told us. On this day, we could see again some examples of psoriasis, atopic dermatitis, veruccae and eczema, as many days before which is, taken by itself, sign for the commonness of those diseases not only in Germany, but also in Japan. The pathology conference at 04:00 pm discussed some cases of NCN, Bowen’s disease, malignant melanoma, SCC, chronic eczema, Graft versus Host disease, verucca vulgaris, dermatitis papillaris ?????? capillitis, porokeratosis, chronic pyoderma and eczema.
On Friday, one of the highlights at the Department of Dermatology took place. Dr. Furuta picked me up at 08:00 am and both we went to the Ibaraki Prefectural Central Hospital in Kasama. And even if some diseases were the same like tinea, rosacea-like dermatitis or psoriasis vulgaris, I could recognize some differences between that hospital and the University of Tsukuba Hospital. Especially, more patients with less severe diseases like acne usually see the physicians in Kasama, quite a rural area north of Tsukuba, nearly one hour by car. The case of a 55-years old woman was interesting because the scalded skin on her right foot could be result of a fungus infection and an eczema, as well. She was farmer and usually wears boots for a long time a day which create a wet milieu around her feet and predispose her for skin problems there. The following test was negative concerning fungus and Dr. Furuta decided just to treat her disease with an ointment, namely salicylate vaseline, to soften the skin. Then, sporotrichosis was diagnosed to a 62-years old man who also suffered from angioedema and was under medical treatment with ACE-blocker which might be the cause for his deep mycosis. Because the cardiologist doesn’t want to change medication, Dr. Furuta prescribed antihistaminic drugs to make the angioedema disappear and potassium iodide to cure sporotrichosis with a scar remaining. Furthermore, he explained to me that hypersensitivity was a very important sign to ensure the diagnosis Herpes zoster in early state because the skin changes could point to another disease, as well. To the patient suffering from varizella zoster reactivation he gave painkiller like acetaminophen and antiviral drugs. After many other cases from prurigo to chronic urticaria, we went back to Tsukuba where I was allowed to enjoy weekend.
My last week in Tsukuba started with three surgeries on Monday, 25th March. First, we could watch the excision of pilomatricoma, a cystic childhood tumor, at a nine-years old boy. Before lunch, we students also were present at the surgery of subungual exostosis, the most common osteoma seen in skin, but not cutaneous in origin. It arises from the bone of the distal digit of a toe and erodes through the skin, causing a friable subungual mass. The third disease which was operated on that day, still has to be diagnosed because it was not possible to prove the suspicion of malignant cylindroma before taking a specimen. Cylindroma is often described as “turban tumor” and was located in the axilla area at the 65-years old patient. Fortunately, the tumor was not grown too deep, so it was easier to remove it than thought and the surgery ended more than one hour earlier as planned.
The new cases on Tuesday were a harmless nevus spilus as well as lichen planus, an inflammatory T-cell-mediated disease of the skin and mucosa, which involves the dermal-epidermal junction. Another patient entered the consulting room and you could see that he felt pruritus all over the body. That matched to the diagnosis of reactive proliferating collagenosis which sometimes occurs as a corollary of Diabetes mellitus, kidney insufficiency, malignant lymphoma or AIDS, for example. Dr. Ishii ordered UV-B treatment to reduce the symptoms. The last patient of the day, a 18-year old male model complained of his primary hyperhidrosis at his hands and was very well-informed about the opportunities of treatment. So, he was adamant that he will be operated by endoscopic thoracic sympathectomy, a quite unusual surgery, feared because of its side effects. Dr. Ishii discouraged him from doing that and recommended lotions and ointments for first- and iontophoresis for second-choice treatment instead. Some of the patients were introduced to all the physicians at 01:00 pm and at the 05:00 pm meeting the conference of Wednesday morning was prepared.
Wednesday was marked by the morning conference where the physicians talked about a study which examined carbamazepine-induced toxic effects and HLA-B 1502 screening in Taiwan drawing the conclusion that the identification of subjects carrying the HLA-B 1502 allele and the avoidance of carbamazepine therapy in these subjects was strongly associated with a decrease in the incidence of carbamazepine-induced SJS-TEN, the Stevens-Johnson syndrom and its related disease, toxic epidermal necrolysis. In the afternoon, I had the opportunity to go to the Red Cross Hospital in Mito with Dr. Fujisawa who is specialist for skin tumors. So, I saw many tumors like SCC, B-cell-carcinoma, melanoma or keratoacanthoma. Most moving was the past medical history of a 66-years old woman who suffered from a melanoma on her pelvis which was resected two years ago. At that time, the lymph node biopsy was negative and she hoped having defeated the cancer, but now, skin metastases could be seen all over the body and Dr. Fujisawa told me that also bones and other organs were affected. The woman just came for talking to the physician because she knew that there is no way to be treated anymore. After the consultings, three ambulatory surgeries took place, namely the nevus on the sole of a 27-years old woman was operated as well as a non-defining subcutaneous tumor and an atypical fibroxanthoma at a 94-years old woman which is a malignant tumor, rarely metastasizing and affecting especially older people.
Thursday started with my last morning round and continued with one more forenoon at the consulting area of the hospital. Again, I came in contact with seborrheic keratosis, psoriasis palmaris et plantaris, neurofibromatosis, ingrown nail or lichen planus which was very good to identify because of the characertistic lacy white lines on the surface of the papules on the oral mucosa, reflecting hypergranulosis and called Wickham striae. At the demonstration at 01:00 pm, a 14-years old boy suffering from purpura on legs, arms and even face since October 2012 was introduced to all and the physicians discussed about possible causes. Blood and urine check had already been ordered. The pathology conference in the afternoon was a very good summary of all dermatologic diseases I got to know the last three weeks. SCC, Lipoma, BCC, Bowen’s disease, rheumatoid vasculitis, seborrheic keratosis, epidermal and mucous cyst, NCN, eczema, sebaceous nevus, chronic pyoderma, pyogenic granuloma, soft fibroma – all these diseases appeared once again. With lentigo senile, a flat seborrheic keratosis, SSc which stands for systemic sclerosis and DFSP or dermato-fibrosarcoma protuberans also new cases were shown and completed my last day at the Department of Dermatology at the University of Tsukuba Hospital.
On Friday, 29th March, Dr. Furuta and I went to Kasama again and after that, he showed me wonderful cherry blossom trees near the agricultural research center in Tsukuba, a beautiful view I will never forget.
All in all, I’m very grateful for the last three weeks!!! I could get so many unforgettable impressions I never dreamed of. And even though I could do my medical clerkship in a country whose health care system seems to be quite similar to the German one, there still are many differences which to know is very enriching! I would like to give many thanks to all the physicians and students who helped me so much by translating many times and who brought me wonderful days because of joint lunch or dinner and even a Welcome Party!!! Special thanks I would like to give to Dr. Furuta, my first person to turn to who made so many efforts to me!!!!!