conversion can be inhibited by other fats, and also in diabetics and the elderly. Therefore, there is a consider¬ able advantage in giving the y-linolen¬ ic acid directly. In patients with both acne and psoriasis,1 the combination of zinc and evening primrose oil seems very successful, and controlled studies are now in progress. It is unlikely that zinc and essential fatty acid deficien¬ cies are causes of either disease, but if these are important nutrients for the skin, then it is possible that patients whose dietary intake of these nu¬ trients is marginal may be more susceptible to all skin problems. The parallel in general medicine would be protein-calorie malnutrition, which can lead to overt expression of a wide variety of diseases depending on indi¬ vidual susceptibility. D. F. Horrobin S. C. Cunnane Montreal 1. Horrobin DF, Manku MS, Cunnane SC, et al: Zinc, penicillamine and prostaglandin E1. Arthritis Rheum 21:492, 1978. 2. Manku MS, Horrobin DF, Karmazyn M, et
al: Prolactin and zinc effects on rat vascular reactivity: Possible relationship to dihomo-\g=g\\x=req-\ linolenic acid and to prostaglandin biosynthesis. Endocrinology, to be published. 3. Horrobin DF: Psoriasis: A defect in the regulation of prostaglandin biosynthesis produced by an endorphin-like agent? IRCS J Med Sci 6:302-306, 1978.
Alopecia Universalis To the
Editor.\p=m-\Manypatients have
symptoms within the clinical
spec-
nonscarring alopecia. Most of these patients display alopecia areata, trum of
fewer display alopecia totalis, and the least number will be classed as alopecia universalis. Causal factors are varied, but there are a number of associations that range from idiopathic to autoimmune reactions and psy-
chological trauma.
A review of the literature, which included over 750 cases of the three varieties, showed that the most commonly associated processes were vitiligo, nail dystrophy, cataracts, and suspected autoimmune processes.1-4 One patient who was mentioned had alopecia areata and a concomitant brain tumor, that were considered to be unrelated.1 There was no mention of tumors related to alopecia totalis or
universalis.
alopecia related to tumors is usually secondary to local infiltration The
of
hair-bearing
areas
by metastatic
tumor,5 mucin,6 systemic chemothera-
py, or ionizing radiation. While making rounds in Detroit General Hospital, I observed two
patients
with
alopecia universalis. being evaluated for suspected neoplasms. Neither was taking any medication before admis¬ sion and both had been previously healthy. One patient gave a 3V2-year history of total body hair loss; the other had an eight-year history of hair loss. Both patients were found to have inoperable squamous carcinomas, pulmonary in one man and oropharyngeal in the other. These two patients piqued my inter¬ est in that they were originally seen within 30 minutes of one another, and both were subsequently found to have malignancies. In addition, these two patients brought the total number of cases of alopecia universalis that I have seen to five. Thus, in my limited experience, there is at least a 40% correlation with malignancy. After reviewing the literature, I find that Both
men were
this appears to be a coincidental observation. On the other hand, could this be another marker of defective immune surveillance? I would be interested in hearing other views. Warren J. Redmond, MD Detroit 1. Muller
SA, Winklemann RK: Alopecia areapatients. Arch Dermatol
ta: An evaluation of 736
88:290-297, 1963. 2. Demis DJ, Weiner MA: Alopecia universalis,
onychodystrophy, and total vitiligo. Arch Derma-
tol 88:195-201, 1963. 3. Kern F, Hoffman WH, Hambrick GW Jr, et al: Alopecia areata: Immunologic studies and treatment with prednisone. Arch Dermatol 107:407-412, 1973. 4. Cunliffe WJ, Hall R, Stevenson CJ, et al: Alopecia areata, thyroid disease, and autoimmunity. Br J Dermatol 81:877-881, 1969. 5. Cohen I, Levy E, Schreiber H: Alopecia neoplastica due to breast carcinoma. Arch Dermatol 84:490-492, 1961. 6. Pinkus H: Alopecia mucinosa: Inflammatory plaques with alopecia characterized by rootsheath mucinosis. Arch Dermatol 76:419-426, 1957.
Lupus Erythematosus Possibly due to Photochemotherapy Discoid
To the Editor.\p=m-\Theoccurrence of light-induced diseases might be anticipated with the increasing use of psoralens plus long-wave ultraviolet radiation (PUVA) therapy. We would like to report a case of discoid lupus erythematosus (DLE) occurring during PUVA therapy.
Report of a Case.\p=m-\A53-year-old man psoriasis, which he had had since the
with
age of 15 years, was treated with PUVA according to the regimen developed by Parrish et al.1 After 2 1/2 years of treatment with 117 exposures, corresponding to approximately 500 joules of ultraviolet A
(UVA), several bright-red, infiltrated lesions with horny plugs and thin scaling appeared on the cheeks and chin.
Downloaded From: http://archderm.jamanetwork.com/ by a University of Edinburgh Library User on 06/01/2015
Clinically, DLE was suspected, and the face of the patient was shielded during PUVA treatments. After local treatment with betamethasone valerate cream (0.1%), the lesions faded over a period of 14 days.
Histologic Findings.\p=m-\Onconven-
tional light microscopy of biopsy specimens from lesions on the cheek, findings consistent with DLE were seen, such as hyperkeratosis with follicular plugging, atrophy of the Malpighian layer, and hydropic degeneration of the basal cell layer. In the upper dermis, edema and a slight but mainly perivascular lymphocytic infiltration were
present.
Direct immunofluorescent exami¬ nation showed granular deposits of IgG and C3 on the dermoepidermal junction, findings that are typical for DLE. Comment.—The patient described herein has a long history of psoriasis. After 2% years of continuous treat¬ ment with PUVA, clinical and histo¬ logie findings consistent with DLE
developed. Experimental investigations2 have shown provocation of DLE by ultra¬ violet light (300 nm). The light used in PUVA has peak emission between 350 and 360 nm. A causal relationship
between PUVA and DLE in our patient cannot be proved. However, we feel it is important to report this case, as the increasing use of PUVA necessitates the collection of possible side effects. Henry F. Domke Erik Ludwigsen, MD Jens Thormann, MD Aarhus, Denmark JA, Fitzpatrick TB, Tanenbaum L, Photochemotherapy of psoriasis with oral methoxsalen and longwave ultraviolet light. N Engl J Med 291:1207-1211, 1974. 2. Freeman RG, Knox JM, Owens DW: Cutaneous lesions of lupus erythematosus induced by monochromatic light. Arch Dermatol 100:677-682, 1. Parrish
et al:
1969.
Ichthyosiform To the Editor.\p=m-\A.Paul Kelly, MD,
whose letter about ichthyosiform sarcoid appeared in a recent issue of the Archives (114:1551, 1978), deserved better than not having his spelling corrected before his letter was published. The fact that the heading also misspelled the disease as "icthyosiform" suggests a possible explanation of this omission. The reference article by Kauh et al (Archives 114:100-101, 1978) had it spelled correctly: ichthyosiform. Harry L. Arnold, Jr, MD Honolulu
al: Prolactin and zinc effects on rat vascular reactivity: Possible relationship to dihomo-\g=g\\x=req-\ linolenic acid and to prostaglandin biosynthesis. Endocrinology, to be published. 3. Horrobin DF: Psoriasis: A defect in the regulation of prostaglandin biosynthesis produced by an endorphin-like agent? IRCS J Med Sci 6:302-306, 1978.
Alopecia Universalis To the
Editor.\p=m-\Manypatients have
symptoms within the clinical
spec-
nonscarring alopecia. Most of these patients display alopecia areata, trum of
fewer display alopecia totalis, and the least number will be classed as alopecia universalis. Causal factors are varied, but there are a number of associations that range from idiopathic to autoimmune reactions and psy-
chological trauma.
A review of the literature, which included over 750 cases of the three varieties, showed that the most commonly associated processes were vitiligo, nail dystrophy, cataracts, and suspected autoimmune processes.1-4 One patient who was mentioned had alopecia areata and a concomitant brain tumor, that were considered to be unrelated.1 There was no mention of tumors related to alopecia totalis or
universalis.
alopecia related to tumors is usually secondary to local infiltration The
of
hair-bearing
areas
by metastatic
tumor,5 mucin,6 systemic chemothera-
py, or ionizing radiation. While making rounds in Detroit General Hospital, I observed two
patients
with
alopecia universalis. being evaluated for suspected neoplasms. Neither was taking any medication before admis¬ sion and both had been previously healthy. One patient gave a 3V2-year history of total body hair loss; the other had an eight-year history of hair loss. Both patients were found to have inoperable squamous carcinomas, pulmonary in one man and oropharyngeal in the other. These two patients piqued my inter¬ est in that they were originally seen within 30 minutes of one another, and both were subsequently found to have malignancies. In addition, these two patients brought the total number of cases of alopecia universalis that I have seen to five. Thus, in my limited experience, there is at least a 40% correlation with malignancy. After reviewing the literature, I find that Both
men were
this appears to be a coincidental observation. On the other hand, could this be another marker of defective immune surveillance? I would be interested in hearing other views. Warren J. Redmond, MD Detroit 1. Muller
SA, Winklemann RK: Alopecia areapatients. Arch Dermatol
ta: An evaluation of 736
88:290-297, 1963. 2. Demis DJ, Weiner MA: Alopecia universalis,
onychodystrophy, and total vitiligo. Arch Derma-
tol 88:195-201, 1963. 3. Kern F, Hoffman WH, Hambrick GW Jr, et al: Alopecia areata: Immunologic studies and treatment with prednisone. Arch Dermatol 107:407-412, 1973. 4. Cunliffe WJ, Hall R, Stevenson CJ, et al: Alopecia areata, thyroid disease, and autoimmunity. Br J Dermatol 81:877-881, 1969. 5. Cohen I, Levy E, Schreiber H: Alopecia neoplastica due to breast carcinoma. Arch Dermatol 84:490-492, 1961. 6. Pinkus H: Alopecia mucinosa: Inflammatory plaques with alopecia characterized by rootsheath mucinosis. Arch Dermatol 76:419-426, 1957.
Lupus Erythematosus Possibly due to Photochemotherapy Discoid
To the Editor.\p=m-\Theoccurrence of light-induced diseases might be anticipated with the increasing use of psoralens plus long-wave ultraviolet radiation (PUVA) therapy. We would like to report a case of discoid lupus erythematosus (DLE) occurring during PUVA therapy.
Report of a Case.\p=m-\A53-year-old man psoriasis, which he had had since the
with
age of 15 years, was treated with PUVA according to the regimen developed by Parrish et al.1 After 2 1/2 years of treatment with 117 exposures, corresponding to approximately 500 joules of ultraviolet A
(UVA), several bright-red, infiltrated lesions with horny plugs and thin scaling appeared on the cheeks and chin.
Downloaded From: http://archderm.jamanetwork.com/ by a University of Edinburgh Library User on 06/01/2015
Clinically, DLE was suspected, and the face of the patient was shielded during PUVA treatments. After local treatment with betamethasone valerate cream (0.1%), the lesions faded over a period of 14 days.
Histologic Findings.\p=m-\Onconven-
tional light microscopy of biopsy specimens from lesions on the cheek, findings consistent with DLE were seen, such as hyperkeratosis with follicular plugging, atrophy of the Malpighian layer, and hydropic degeneration of the basal cell layer. In the upper dermis, edema and a slight but mainly perivascular lymphocytic infiltration were
present.
Direct immunofluorescent exami¬ nation showed granular deposits of IgG and C3 on the dermoepidermal junction, findings that are typical for DLE. Comment.—The patient described herein has a long history of psoriasis. After 2% years of continuous treat¬ ment with PUVA, clinical and histo¬ logie findings consistent with DLE
developed. Experimental investigations2 have shown provocation of DLE by ultra¬ violet light (300 nm). The light used in PUVA has peak emission between 350 and 360 nm. A causal relationship
between PUVA and DLE in our patient cannot be proved. However, we feel it is important to report this case, as the increasing use of PUVA necessitates the collection of possible side effects. Henry F. Domke Erik Ludwigsen, MD Jens Thormann, MD Aarhus, Denmark JA, Fitzpatrick TB, Tanenbaum L, Photochemotherapy of psoriasis with oral methoxsalen and longwave ultraviolet light. N Engl J Med 291:1207-1211, 1974. 2. Freeman RG, Knox JM, Owens DW: Cutaneous lesions of lupus erythematosus induced by monochromatic light. Arch Dermatol 100:677-682, 1. Parrish
et al:
1969.
Ichthyosiform To the Editor.\p=m-\A.Paul Kelly, MD,
whose letter about ichthyosiform sarcoid appeared in a recent issue of the Archives (114:1551, 1978), deserved better than not having his spelling corrected before his letter was published. The fact that the heading also misspelled the disease as "icthyosiform" suggests a possible explanation of this omission. The reference article by Kauh et al (Archives 114:100-101, 1978) had it spelled correctly: ichthyosiform. Harry L. Arnold, Jr, MD Honolulu
