Correspondence Letters to the Editor are welcomect for publication (subject to editing). Letters must be ;^gned by all authors, tjiKwritten double spaced, and must not exceed two pages of text induding references. Two copies of all letters should be submitted. Letters should not duplicate materiai sahmitted or published in other journals. Prepublication proofs will not be provided.
LICHEN SCLEROSUS IN GIRLS To the Editor: I was interested in the paper by Helm and colleagues {1991;8(2):97-101) on a large group of patients with lichen sclerosus. They refer to my comment (for "he," read "she"!) that I have not seen childhood lichen sclerosus in girls remit; I was speaking of anogenital lesions, not of extragenital lesions. I am at present engaged in reporting my follow-up of a group of girls and, although some have defaulted and may indeed be completely free of signs as well as symptoms, those I have observed personally still have some evidence of the disease, albeit sometimes with minimal physical signs. Follow-up by questionnaire, although useful, has certain drawbacks, and it may be that some of the patients mentioned by Helm et al thought they were free of the condition whereas an observer would have detected its persistence. I should also like to comment on the authors' view that lichen sclerosus "usually occurs in elderly females." It is quite common at all ages, and the duration in such elderly women often dates back to their youth. C M . RIDLEY, FRCP London, England
SCALP AND FACIAL EDEMA PRECEDING SCHONLEIN-HENOCH SYNDROME BY 28 DAYS To the Editor: A 9-year-old boy had a two-day history of painful scalp and facial swelling. He had no complaint of rash, arthralgia, or abdominal pain. The only positive clinical finding was tender edema involving the entire scalp, periorbital and zygomatic areas, and forehead. Routine blood and serum tests were normal. The painful scalp and facial edema improved over the next three days. Twenty-eight days later the patient was readmitted to the hospital with a two-day history of rash, vomiting, abdominal pain, swelling in the left knee, and scalp edema. He had a hemorrhagic urticarial rash over his lower limbs, tender edema of the scalp and periorbital tissue, and an inflamed and tender swelling in the left knee with full range of motion.
One day later purpuric lesions spread to the buttocks. Urinalysis showed microscopic hematuria. Results of a complete blood count and coagulation studies were normal. The erythrocyte sedimentation rate was 62 mm/hour. The results of the following investigations were nonnal or negative: rheumatoid factor, antinuclear antibodies, tests for LE cells, antistreptolysin O titer, C-reactive protein, and throat culture. All of these factors led to the diagnosis of Schonlein-Henoch purpura, and prednisolone was started to treat the abdominal pain. The scalp and facial edema and abdominal pain gradually improved in two days, and the signs of arthritis disappeared in a week. Painful scalp edema in Schonlein-Henoch syndrome is an uncommon symptom (1). Since it is present during, or a maximum of three to four days before rash (2,3), the diagnosis of SchonleinHenoch syndrome is usually not difficult. In this patient, the first episode of scalp edema 28 days prior to the onset of the rash was a diagnostic handicap, because such a long latent period has not been described before. I think that, in the light of the features in this patient, Schonlein-Henoch syndrome should be considered in the differential diagnosis of children with scalp and facial edema, even if no other manifestation of the disease occurs in the next few days. REFERENCES 1. Sahn DJ, Schwartz AD. Schonlein-Henoch syndrome: observations on some atypical clinical presentations. Pediatrics 1972;49:614-618. 2. Cream JJ, Gumpel JM, Peachey RD. SchonieinHenoch purpura in the adult. A study of 77 adults with anaphylactoid or Schonlein-Henoch purpura. Q J Med 1970;39:461-466. 3. Caglar MK, Arisoy ES. Scalp and face edema in Schonletn-Henoch syndrome. Turk J Pediatr 1983; 25:135-138. MEHMET CEYHAN, M.D. Ankara, Turkey HARLEQUIN FETUS TREATED WITH ETRETINATE To the Editor: A harlequin giri was born at 37 weeks' gestation to a 24-year-old Chinese woman. She was the first child of nonconsanguineous parents and required a cesarean section because of breech presentation.
Birth weight was 2250 g. The infant's entire body was covered with a rigid, horay membrane of skin 311
LICHEN SCLEROSUS IN GIRLS To the Editor: I was interested in the paper by Helm and colleagues {1991;8(2):97-101) on a large group of patients with lichen sclerosus. They refer to my comment (for "he," read "she"!) that I have not seen childhood lichen sclerosus in girls remit; I was speaking of anogenital lesions, not of extragenital lesions. I am at present engaged in reporting my follow-up of a group of girls and, although some have defaulted and may indeed be completely free of signs as well as symptoms, those I have observed personally still have some evidence of the disease, albeit sometimes with minimal physical signs. Follow-up by questionnaire, although useful, has certain drawbacks, and it may be that some of the patients mentioned by Helm et al thought they were free of the condition whereas an observer would have detected its persistence. I should also like to comment on the authors' view that lichen sclerosus "usually occurs in elderly females." It is quite common at all ages, and the duration in such elderly women often dates back to their youth. C M . RIDLEY, FRCP London, England
SCALP AND FACIAL EDEMA PRECEDING SCHONLEIN-HENOCH SYNDROME BY 28 DAYS To the Editor: A 9-year-old boy had a two-day history of painful scalp and facial swelling. He had no complaint of rash, arthralgia, or abdominal pain. The only positive clinical finding was tender edema involving the entire scalp, periorbital and zygomatic areas, and forehead. Routine blood and serum tests were normal. The painful scalp and facial edema improved over the next three days. Twenty-eight days later the patient was readmitted to the hospital with a two-day history of rash, vomiting, abdominal pain, swelling in the left knee, and scalp edema. He had a hemorrhagic urticarial rash over his lower limbs, tender edema of the scalp and periorbital tissue, and an inflamed and tender swelling in the left knee with full range of motion.
One day later purpuric lesions spread to the buttocks. Urinalysis showed microscopic hematuria. Results of a complete blood count and coagulation studies were normal. The erythrocyte sedimentation rate was 62 mm/hour. The results of the following investigations were nonnal or negative: rheumatoid factor, antinuclear antibodies, tests for LE cells, antistreptolysin O titer, C-reactive protein, and throat culture. All of these factors led to the diagnosis of Schonlein-Henoch purpura, and prednisolone was started to treat the abdominal pain. The scalp and facial edema and abdominal pain gradually improved in two days, and the signs of arthritis disappeared in a week. Painful scalp edema in Schonlein-Henoch syndrome is an uncommon symptom (1). Since it is present during, or a maximum of three to four days before rash (2,3), the diagnosis of SchonleinHenoch syndrome is usually not difficult. In this patient, the first episode of scalp edema 28 days prior to the onset of the rash was a diagnostic handicap, because such a long latent period has not been described before. I think that, in the light of the features in this patient, Schonlein-Henoch syndrome should be considered in the differential diagnosis of children with scalp and facial edema, even if no other manifestation of the disease occurs in the next few days. REFERENCES 1. Sahn DJ, Schwartz AD. Schonlein-Henoch syndrome: observations on some atypical clinical presentations. Pediatrics 1972;49:614-618. 2. Cream JJ, Gumpel JM, Peachey RD. SchonieinHenoch purpura in the adult. A study of 77 adults with anaphylactoid or Schonlein-Henoch purpura. Q J Med 1970;39:461-466. 3. Caglar MK, Arisoy ES. Scalp and face edema in Schonletn-Henoch syndrome. Turk J Pediatr 1983; 25:135-138. MEHMET CEYHAN, M.D. Ankara, Turkey HARLEQUIN FETUS TREATED WITH ETRETINATE To the Editor: A harlequin giri was born at 37 weeks' gestation to a 24-year-old Chinese woman. She was the first child of nonconsanguineous parents and required a cesarean section because of breech presentation.
Birth weight was 2250 g. The infant's entire body was covered with a rigid, horay membrane of skin 311
