e384
Correspondence
With all due respect towards the corresponding group of authors, we would like to object to the statement that nodular prurigo commonly responds to dapsone. In our hands, dapsone is virtually ineffective in the treatment of prurigo nodularis. Usually, long-term treatment and a combination of different treatment modalities are needed to cure these patients. To summarize, Bonciolini et al.1 base their correspondence on a large body of personal experience and literature, and their arguments are highly valuable and consistent. Nevertheless, our central idea that dermatitis herpetiformis should be excluded in patients with nodular prurigo is still valid. Clarissa Huber, Hautarztpraxis Bern
Switzerland E-mail: [email protected] Lars E. French, MD Juerg Hafner, MD Department of Dermatology University Hospital Z€ urich Zurich Switzerland Conflicts of interest: None. Reference 1 Bonciolini V, Antiga E, Fabbri P, et al. Skin manifestations of celiac disease: not always dermatitis herpetiformis. Int J Dermatol 2014; Mar 6. (Epub ahead of print).
MD
Comparison of modified Korean cupping method and conventional respiratory suction unit for epidermal graft
Various suction devices have been introduced to create a good blister for epidermal graft easily and simply; these include the angiosterometer, conventional respiratory suction pump, and the manually operated suction methods such as the suction syringe.1–6 Herein, we introduced a modified Korean cupping epidermal graft method and compared the result with the conventional central respiratory suction unit method. Six patients with stable vitiligo were enrolled in this prospective study (Table 1). This clinical study was approved by the local institutional review board. Korean cupping is a just one big cup (5.5 cm in diameter), but we made a polygonal plate with three small holes (1.2 cm in diameter) and fixed it to the cupping base. Therefore, the modified Korean cupping could make three small blisters at the same time rather than one big blister. To induce negative pressure, the supplied pistol attached to the nozzle on the top of the cupping was triggered manually. The negative pressure in the cavity of the cup was
measured at 250 mmHg. In conventional respiratory suction unit methods, we used a 9.5 9 5.5 cm rectangular plate with eight 1.2 cm diameter holes, and the vacuum pressure was maintained at 250–300 mmHg. Both methods were used on the upper and lower part of the same donor area, respectively (Fig. 1a). As the blisters started to form within the plate, we investigated their gross features and checked the time required for full blister formation and the severity of pain. The recipient area (vitiligo area) was divided randomly into two parts. We transplanted epidermal grafts gained from each method to each of the separate vitiligo sites and observed the cosmetic outcome of both methods. The conventional respiratory suction device required more uses comprising about 1 hour 50 minutes than the modified Korean cupping method (1 hour 15 minutes) to form blisters. The modified Korean cupping method tended to produce more hemorrhagic blisters (Fig. 1b). The average pain score in 10 numerical scales was about 3.0 in the modified Korean cupping method and 2.5 in a conventional respiratory suction device. Repigmentation of the recipient
Table 1 Demographics and results of repigmentation assessment Result (repigmentation)
Case
Sex/age (years)
Duration (years)
Site
Vitiligo type
Conventional central respiratory suction unit (%)
Modified Korean cupping method (%)
1 2 3 4 5 6
F/15 F/55 F/24 F/48 F/26 F/27
3 5 2 7 6 5
Abdomen Chest Lower lip Forehead Thigh Forehead
Segmental Segmental Localized Localized Segmental Segmental
>90 >90 >80 >90 >85 >90
>95 >90 >80 >90 >80 >85
International Journal of Dermatology 2014, 53, e367–e388
ª 2014 The International Society of Dermatology
Correspondence
(a)
(b)
(c)
(d)
Figure 1 (a and b) Operation of the devices and resulting appearance of blisters. (a) Conventional central respiratory suction
unit and modified Korean cupping was applied respectively on the upper and lower part of the buttock (donor area) at the same time. (b) There was no significant difference in gross appearance of fully generated blisters. However, the modified Korean cupping method tended to produce more hemorrhagic blisters. Figure 1 (c and d) Transplantation of epidermal grafts and resulting repigmentation. (c) Each epidermal graft from both methods was separately transplanted to randomly divided recipient site (upper part of dotted line: grafts from conventional respiratory suction unit, lower part of dotted line: epidermal graft from modified Korean cupping method). (d) Repigmentation of recipient sites was nearly the same in both methods 10 weeks postoperatively
site was induced very well (>85%) after operation, and there was no cosmetic difference in both methods (Fig. 1c,d). It is important to make a time-saving device for suction blisters because the longer operation time of suction blister epidermal grafting is a major disadvantage. Presently, the time required for making adequate blisters in the modified Korean cupping method was shorter than with the conventional respiratory suction pump. A previous study using the Chinese cupping method with 2.5–5 cm diameter cupping reported a time of 2–3 hours to make a single large blister.3 A variety of factors affect the time required for making blisters, including the diameter of the suction device, negative pressure, skin laxity, and blister site.2 Incidentally, the time for blister formation tends to be less; as the size of the suction cup or syringe is smaller, it might be time-efficient to make blisters using a plate with small holes in it.3 Those blisters formed by the modified Korean cupping device were more hemorrhagic compared with the conventional respiratory suction unit. The presence of blood in blisters does not affect the nature of ª 2014 The International Society of Dermatology
the harvested epithelial roof or the outcome.3 In our study, the results were almost the same in both methods. The main advantage of our method is a shorter operation time, and the blister could be induced in about one hour. In addition, the apparatus is relatively cheap and easy to use, and any complicated devices, connections, or electrical instruments were not needed in the present method. However, the amount of graft obtained by this method is not much because the round shape of the cupping structurally limits the creation of multiple small holes in each cup. Various modifications of the suction blister device have been invented to simplify the apparatus and procedure. Our modified Korean cupping could be used as a simple method without an electricity supply, which can be easily applied for epidermal grafts. Acknowledgments The present research was conducted by the research fund of Dankook University in 2012.
International Journal of Dermatology 2014, 53, e367–e388
e385
e386
Correspondence
Kyung E. Jung, MD Department of Dermatology Eul Ji Medical College Dae-jeon Cheonan Korea Myung H. Kim, MD Jee Y. Kim, MD Byung C. Park, MD Department of Dermatology Dankook Medical College Cheonan Korea Byung Cheol Park, MD Department of Dermatology Dankook Medical college san 16-5, Anseo-dong, Dongnam-gu Cheonan-si, Chungcheongnam-do Korea E-mail: [email protected]
Multiple clear cell acanthoma associated with multiple Bowen’s disease
Clear cell acanthoma (CCA) is a relatively uncommon benign epidermal tumor characterized by clear glycogen containing epidermal cells, and two main clinical forms are recognized: solitary and multiple CCA.1 Bowen’s disease is a form of intraepidermal squamous cell carcinoma, and multiple Bowen’s disease is uncommon in individuals with pigmented skin, and in these individuals, etiological factors such as arsenic intake may be important.2 Herein we present the first case of multiple CCA associated with multiple Bowen’s disease. A 76-year-old Japanese woman with a medical history of multiple Bowen’s disease from 1993 to March 2011 was introduced to our department in October 2012. She had drank water from a well in her childhood. A red-brown macule on the back of her left hand had been resected and diagnosed as Bowen’s disease in 1993. Thereafter, redbrown macules on her left thigh (Fig. 1a) and the left dorsum of her foot in 2008, on the back of her hand (Fig. 1c) in 2009, on the right dorsum of her foot and the left leg in 2011, and on the left dorsum of her foot in March 2011 had all been resected and diagnosed histologically as multiple Bowen’s disease (Fig. 1b, d). She was referred to our department for multiple small red papules on her thighs (Fig. 2a, b), which had appeared six months previously and were suspected to be early stages of multiple Bowen’s disease. There were four International Journal of Dermatology 2014, 53, e367–e388
Conflicts of interest: None. References 1 Kim HU, Yun SK. Suction device for epidermal grafting in vitiligo: employing a syringe and a manometer to provide an adequate negative pressure. Dermatol Surg 2000; 26: 702–704. 2 Somesh G, Ajith C, Kanwar AJ, et al. Surgical pearl: standardized suction syringe for epidermal grafting. J Am Acad Dermotol 2005; 52: 348–350. 3 Awad SS. Chinese cupping: a simple method to obtain epithelial grafts for the management of resistant localized vitiligo. Dermatol Surg 2008; 34: 1186–1192. 4 Gupta S, Chandrashenkar BS, Reddy R, et al. Rapid induction of suction blisters by intra-cavity positive pressure enhancement. Dermatol Surg 2011; 37: 843–845. 5 Li J, Fu WW, Zheng ZZ, et al. Suction blister epidermal grafting using a modified suction method in the treatment of stable vitiligo: a retrospective study. Dermatol Surg 2011; 37: 999–1006. 6 Rusfianti M, Wirohadidjodjo YW. Dermatosurgical techniques for repigmentation of vitiligo. Int J Dermatol 2006; 45: 411–417.
red papules on her right thigh (A–D in Fig. 2a) and two on her left thigh (E and F in Fig. 2b). The papules were round, flattened, and brownish red, with a diameter of 3–4 mm and a peripheral scaling collarette except for one papule on her left thigh (F). Excisional skin biopsy specimens obtained from all the papules revealed that histologically five of them (A–E) showed abrupt welldemarcated areas of clear cell acanthosis surrounded by an epidermal collarette, organized in a psoriasiform pattern with papillomatosis (Fig. 2c). Epidermal cells, except basal cell keratinocytes, had clear cytoplasm (Fig. 2d) and abundant glycogen, as demonstrated by positive PAS staining (data not shown). The nuclei of the clear epidermal cells appeared normal. Histology of one papule (F) disclosed dermatofibroma. Taken together, a diagnosis of multiple localized CCA associated with multiple Bowen’s disease was made. To the best of our knowledge, there have been no associated reports of multiple CCA and multiple Bowen’s disease. Multiple Bowen’s disease is sometimes associated with chronic arsenism. Although the patient did not show typical features of chronic arsenism, such as a corn-like, punctate keratosis characteristically affecting the palms and soles, the possibility remains that the water from the well that she had drunk in her childhood might have contained some amounts of arsenic. The patient described the initial clinical features of multiple Bowen’s disease as being similar to those of ª 2014 The International Society of Dermatology
Correspondence
With all due respect towards the corresponding group of authors, we would like to object to the statement that nodular prurigo commonly responds to dapsone. In our hands, dapsone is virtually ineffective in the treatment of prurigo nodularis. Usually, long-term treatment and a combination of different treatment modalities are needed to cure these patients. To summarize, Bonciolini et al.1 base their correspondence on a large body of personal experience and literature, and their arguments are highly valuable and consistent. Nevertheless, our central idea that dermatitis herpetiformis should be excluded in patients with nodular prurigo is still valid. Clarissa Huber, Hautarztpraxis Bern
Switzerland E-mail: [email protected] Lars E. French, MD Juerg Hafner, MD Department of Dermatology University Hospital Z€ urich Zurich Switzerland Conflicts of interest: None. Reference 1 Bonciolini V, Antiga E, Fabbri P, et al. Skin manifestations of celiac disease: not always dermatitis herpetiformis. Int J Dermatol 2014; Mar 6. (Epub ahead of print).
MD
Comparison of modified Korean cupping method and conventional respiratory suction unit for epidermal graft
Various suction devices have been introduced to create a good blister for epidermal graft easily and simply; these include the angiosterometer, conventional respiratory suction pump, and the manually operated suction methods such as the suction syringe.1–6 Herein, we introduced a modified Korean cupping epidermal graft method and compared the result with the conventional central respiratory suction unit method. Six patients with stable vitiligo were enrolled in this prospective study (Table 1). This clinical study was approved by the local institutional review board. Korean cupping is a just one big cup (5.5 cm in diameter), but we made a polygonal plate with three small holes (1.2 cm in diameter) and fixed it to the cupping base. Therefore, the modified Korean cupping could make three small blisters at the same time rather than one big blister. To induce negative pressure, the supplied pistol attached to the nozzle on the top of the cupping was triggered manually. The negative pressure in the cavity of the cup was
measured at 250 mmHg. In conventional respiratory suction unit methods, we used a 9.5 9 5.5 cm rectangular plate with eight 1.2 cm diameter holes, and the vacuum pressure was maintained at 250–300 mmHg. Both methods were used on the upper and lower part of the same donor area, respectively (Fig. 1a). As the blisters started to form within the plate, we investigated their gross features and checked the time required for full blister formation and the severity of pain. The recipient area (vitiligo area) was divided randomly into two parts. We transplanted epidermal grafts gained from each method to each of the separate vitiligo sites and observed the cosmetic outcome of both methods. The conventional respiratory suction device required more uses comprising about 1 hour 50 minutes than the modified Korean cupping method (1 hour 15 minutes) to form blisters. The modified Korean cupping method tended to produce more hemorrhagic blisters (Fig. 1b). The average pain score in 10 numerical scales was about 3.0 in the modified Korean cupping method and 2.5 in a conventional respiratory suction device. Repigmentation of the recipient
Table 1 Demographics and results of repigmentation assessment Result (repigmentation)
Case
Sex/age (years)
Duration (years)
Site
Vitiligo type
Conventional central respiratory suction unit (%)
Modified Korean cupping method (%)
1 2 3 4 5 6
F/15 F/55 F/24 F/48 F/26 F/27
3 5 2 7 6 5
Abdomen Chest Lower lip Forehead Thigh Forehead
Segmental Segmental Localized Localized Segmental Segmental
>90 >90 >80 >90 >85 >90
>95 >90 >80 >90 >80 >85
International Journal of Dermatology 2014, 53, e367–e388
ª 2014 The International Society of Dermatology
Correspondence
(a)
(b)
(c)
(d)
Figure 1 (a and b) Operation of the devices and resulting appearance of blisters. (a) Conventional central respiratory suction
unit and modified Korean cupping was applied respectively on the upper and lower part of the buttock (donor area) at the same time. (b) There was no significant difference in gross appearance of fully generated blisters. However, the modified Korean cupping method tended to produce more hemorrhagic blisters. Figure 1 (c and d) Transplantation of epidermal grafts and resulting repigmentation. (c) Each epidermal graft from both methods was separately transplanted to randomly divided recipient site (upper part of dotted line: grafts from conventional respiratory suction unit, lower part of dotted line: epidermal graft from modified Korean cupping method). (d) Repigmentation of recipient sites was nearly the same in both methods 10 weeks postoperatively
site was induced very well (>85%) after operation, and there was no cosmetic difference in both methods (Fig. 1c,d). It is important to make a time-saving device for suction blisters because the longer operation time of suction blister epidermal grafting is a major disadvantage. Presently, the time required for making adequate blisters in the modified Korean cupping method was shorter than with the conventional respiratory suction pump. A previous study using the Chinese cupping method with 2.5–5 cm diameter cupping reported a time of 2–3 hours to make a single large blister.3 A variety of factors affect the time required for making blisters, including the diameter of the suction device, negative pressure, skin laxity, and blister site.2 Incidentally, the time for blister formation tends to be less; as the size of the suction cup or syringe is smaller, it might be time-efficient to make blisters using a plate with small holes in it.3 Those blisters formed by the modified Korean cupping device were more hemorrhagic compared with the conventional respiratory suction unit. The presence of blood in blisters does not affect the nature of ª 2014 The International Society of Dermatology
the harvested epithelial roof or the outcome.3 In our study, the results were almost the same in both methods. The main advantage of our method is a shorter operation time, and the blister could be induced in about one hour. In addition, the apparatus is relatively cheap and easy to use, and any complicated devices, connections, or electrical instruments were not needed in the present method. However, the amount of graft obtained by this method is not much because the round shape of the cupping structurally limits the creation of multiple small holes in each cup. Various modifications of the suction blister device have been invented to simplify the apparatus and procedure. Our modified Korean cupping could be used as a simple method without an electricity supply, which can be easily applied for epidermal grafts. Acknowledgments The present research was conducted by the research fund of Dankook University in 2012.
International Journal of Dermatology 2014, 53, e367–e388
e385
e386
Correspondence
Kyung E. Jung, MD Department of Dermatology Eul Ji Medical College Dae-jeon Cheonan Korea Myung H. Kim, MD Jee Y. Kim, MD Byung C. Park, MD Department of Dermatology Dankook Medical College Cheonan Korea Byung Cheol Park, MD Department of Dermatology Dankook Medical college san 16-5, Anseo-dong, Dongnam-gu Cheonan-si, Chungcheongnam-do Korea E-mail: [email protected]
Multiple clear cell acanthoma associated with multiple Bowen’s disease
Clear cell acanthoma (CCA) is a relatively uncommon benign epidermal tumor characterized by clear glycogen containing epidermal cells, and two main clinical forms are recognized: solitary and multiple CCA.1 Bowen’s disease is a form of intraepidermal squamous cell carcinoma, and multiple Bowen’s disease is uncommon in individuals with pigmented skin, and in these individuals, etiological factors such as arsenic intake may be important.2 Herein we present the first case of multiple CCA associated with multiple Bowen’s disease. A 76-year-old Japanese woman with a medical history of multiple Bowen’s disease from 1993 to March 2011 was introduced to our department in October 2012. She had drank water from a well in her childhood. A red-brown macule on the back of her left hand had been resected and diagnosed as Bowen’s disease in 1993. Thereafter, redbrown macules on her left thigh (Fig. 1a) and the left dorsum of her foot in 2008, on the back of her hand (Fig. 1c) in 2009, on the right dorsum of her foot and the left leg in 2011, and on the left dorsum of her foot in March 2011 had all been resected and diagnosed histologically as multiple Bowen’s disease (Fig. 1b, d). She was referred to our department for multiple small red papules on her thighs (Fig. 2a, b), which had appeared six months previously and were suspected to be early stages of multiple Bowen’s disease. There were four International Journal of Dermatology 2014, 53, e367–e388
Conflicts of interest: None. References 1 Kim HU, Yun SK. Suction device for epidermal grafting in vitiligo: employing a syringe and a manometer to provide an adequate negative pressure. Dermatol Surg 2000; 26: 702–704. 2 Somesh G, Ajith C, Kanwar AJ, et al. Surgical pearl: standardized suction syringe for epidermal grafting. J Am Acad Dermotol 2005; 52: 348–350. 3 Awad SS. Chinese cupping: a simple method to obtain epithelial grafts for the management of resistant localized vitiligo. Dermatol Surg 2008; 34: 1186–1192. 4 Gupta S, Chandrashenkar BS, Reddy R, et al. Rapid induction of suction blisters by intra-cavity positive pressure enhancement. Dermatol Surg 2011; 37: 843–845. 5 Li J, Fu WW, Zheng ZZ, et al. Suction blister epidermal grafting using a modified suction method in the treatment of stable vitiligo: a retrospective study. Dermatol Surg 2011; 37: 999–1006. 6 Rusfianti M, Wirohadidjodjo YW. Dermatosurgical techniques for repigmentation of vitiligo. Int J Dermatol 2006; 45: 411–417.
red papules on her right thigh (A–D in Fig. 2a) and two on her left thigh (E and F in Fig. 2b). The papules were round, flattened, and brownish red, with a diameter of 3–4 mm and a peripheral scaling collarette except for one papule on her left thigh (F). Excisional skin biopsy specimens obtained from all the papules revealed that histologically five of them (A–E) showed abrupt welldemarcated areas of clear cell acanthosis surrounded by an epidermal collarette, organized in a psoriasiform pattern with papillomatosis (Fig. 2c). Epidermal cells, except basal cell keratinocytes, had clear cytoplasm (Fig. 2d) and abundant glycogen, as demonstrated by positive PAS staining (data not shown). The nuclei of the clear epidermal cells appeared normal. Histology of one papule (F) disclosed dermatofibroma. Taken together, a diagnosis of multiple localized CCA associated with multiple Bowen’s disease was made. To the best of our knowledge, there have been no associated reports of multiple CCA and multiple Bowen’s disease. Multiple Bowen’s disease is sometimes associated with chronic arsenism. Although the patient did not show typical features of chronic arsenism, such as a corn-like, punctate keratosis characteristically affecting the palms and soles, the possibility remains that the water from the well that she had drunk in her childhood might have contained some amounts of arsenic. The patient described the initial clinical features of multiple Bowen’s disease as being similar to those of ª 2014 The International Society of Dermatology
