SIR, We report a rare case of inhaler-induced burn in a 13-year-old boy caused by applying the nozzle of the inhaler to his hand and discharging the inhaler.A 13-year-old boy presented with a 4-day history of blisters around the edge of an erythematous patch on the dorsum of his left hand, which had been present for a year. His sister suffered from asthma. On examination, there was a welldemarcated erythematous patch on the dorsum of his left hand with crusts from ruptured blisters around the edge of the patch (Fig. 1). On further questioning, he admitted having developed this red patch 1 year previously after he had applied the nozzle of his sister's salbutamol inhaler onto his hand and discharged it a few times playfully. The repetition of this practice had resulted in the inhaler-induced burns we see in this picture.Inhaler-induced burn is very rare, and to our knowledge there are only three cases reported in the literature. 1-3 All three patients were asthmatic. Chemical burn from the pharmaceutical ⁄preservative ⁄propellant aerosol, cold injury to the skin or mechanical abrasive effect of the aerosol blasts were the suggested mechanisms of injury. Burge et al. suggested that the physical signs of inhaler-induced burn are similar to those seen after a standardized cryotherapy freeze injury to the skin. 4 Children who gain access to inhalers may find them to be interesting toys. They could then sustain chemical burns due to inappropriate discharge onto the skin. We need to be aware of this effect of commonly used inhalers and warn parents, teachers and children in order to avoid these injuries.

Antibiotics have been observed to cause drug-induced reactions. These can include a cutaneous adverse reaction to the drug (CARD) such as photosensitivity. A 51-year-old woman initiated doxycycline monohydrate for rosacea. Within nine days, she developed two different, simultaneous skin rashes: a phototoxic reaction and a morbilliform drug eruption. The medication was stopped; topical and oral corticosteroids were initiated. Within two weeks, her rashes resolved. Common cutaneous adverse reactions to doxycycline include photosensitivity and morbilliform exanthem. Less common skin side effects include bullous eruptions, lupus-like eruptions, pigmentary disorders, and vasculitis. Albeit uncommon, doxycycline-associated dual CARD - such as the photosensitivity and morbilliform exanthem - may occur.

Perforating granuloma annulare (PGA) is a rare inflammatory condition characterized by transepithelial elimination of necrobiotic collagen with granulomas in the dermis. It commonly presents as umbilicated papules or pustules on the extremities and dorsal hands. The distribution of PGA can be described as generalized or localized, with only 9% of patients presenting with a single lesion. Herein, we report an unusual presentation of PGA as a single localized plaque on the forearm that resembled psoriasis.

Pseudomonas aeruginosa folliculitis is an infection of the skin commonly associated with swimming pool and hot tub use. It often presents as outbreaks affecting multiple individuals using the same contaminated public water facility. We present a case report of a 50-year-old woman who developed pseudomonal folliculitis after using a hot tub with multiple family members. No other family member developed folliculitis. Factors contributing to susceptibility to P. aeruginosa infection are reviewed.

Erythema elevatum diutinum (EED) is a cutaneous vasculitis that is characterized by histopathologic findings of neutrophilic infiltration, vessel fibrosis, and leukocytoclasia. It most often presents as papules, plaques, and nodules on the extensor surfaces of the extremities. Herein, we present a case of a 44-year-old woman with Hashimoto's disease with an atypical presentation of EED on the palmar surface of the thumb, in addition to the classic appearance on the elbow. Diseases associated with EED, including autoimmune conditions, are discussed.

There are several etiologies for acquired tremors. Medications have been observed to induce tremors. A 64-year-old man initiated oral doxycycline for scalp folliculitis. By the third dose, he noticed development of hand tremors. He continued the medication and the tremor persisted. Doxycycline was stopped after five days. Within three days of discontinuing the drug, all tremors had resolved. Medication-induced tremors have been associated with several drugs. These include antiarrhythmics, antibiotics, antidepressants, antiepileptics, antimycotics, antivirals, bronchodilators, chemotherapeutics, dopamine depleters, drugs of misuse, gastrointestinal drugs, hormones, immunosuppressants, methylxanthines, mood stabilizers, and neuroleptics. Several antibiotics have also been associated with drug-induced tremors. These include aminoglycosides, carbapenems, cephalosporins, fluoroquinolones, folate synthesis inhibitor, glycopeptides, macrolides, penicillins, and tetracyclines. Doxycycline can be added to the list of drugs associated with medication-induced tremors.

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