lournal of the American Academy of Dermatology

276 C,orrespondence REFERENCES

REFERENCES 1. Cho KH, Shin KS, Sohn Sl, et al. Behget's disease with Sweet's syndrome-like presentation: a report of six cases. Clin Exp DerrnatoI1989;14:20-4. . 2. Hazen PG, Kark EC, Davis BR, et al. Acute febnle neutrophilic dermatosis in children. Arch DermatoI1983;119:9981002. 3. Powell FC, Perry RO. Pyoderma gangrenosum in childhood. Arch DermatoI1984;120:757-61. 4. Hidano A, Watanabe K. Pyoderma gangrenosum et cardiovasculopathies, et particulier arterite de Takayasu: revue de la litterature japonaise. Ann Dermatol VenereoI1981;108: 13-21.

Annular erythema associated with Sjogren's syndrome To the Editor: We read with interest the case report by Ruzickaeta1. (J AM ACADDERMATOL 1991;25:557-60). The authors reported an Oriental man in whom annular erythema developed and who fulfilled the diagnostic criteria for both Sjogren's syndrome and systemic lupus erythematosus (SLE). They stated that these cutaneous manifestations might be helpful clues to detect underlying Sjogren's syndrome and SLE in accordance with our previous reports. l , 2 However, we emphasize that annular erythema may predict a favorable prognosis in antiRo(SS-A)-positive patients, as suggested by Provost et a1. 3 In our experience, only 3 of 22 patients developed proteinuria and one had pericarditis. All showed a good response to corticosteroid therapy (unpublished observation). Therefore, although there is some controversy about the cutaneous manifestations in these cases as suggested by Nishikawa and Provost,4 we believe that antiRo-positive patients with annular erythema may comprise one subset in Sjogren's syndrome. In this subset other systemic manifestations include interstitial nephritis, neuropsychiatric disease, malignant lymphoma, or a higher frequency of drug sensitivity as reported by Katz et a1. 5 The latter authors were able to reproduce annular erythematous lesions with UV radiation, which contrasts with our finding in Japanese cases, l although a different radiation schedule was used in their study. This may be attributable to racial differences in cutaneous reaction patterns, as suggested by Nishikawa and Provost. 4 Our studies also suggested that persistant lymphocyte hyperreactivity to exogenous antigens may be another important factor in the development of the erythematous response in Sjogren's syndrome.6 I. Katayama,a N. Teramoto,b H. Arai,b S. Nishiyama,b and K. Nishioka,a

Departments ofDermatology, Tokyo Medical and Dental University, 1-5-45, Yushima Bunkyo-ku Tokyo,a and Kitasato University School ofMedicine, 1-15-1, Kitasato Sagamihara,b Japan

1. Katayama I, Terarnoto N, Arai H, et a!. Annular erythema: a comparative study of Sjogren's syndrome with subacute cutaneous lupus erythematosus. Int J Dermatol 1991; 30:635-9. 2. Teramoto N, Katayama I, Arai H, et a!. Annular erythema: a possible association with primary Sjogren's syndrome. 1 AM ACAD DERMATOL 1989;20:596-601. 3. Provost TT, Talal N, Harley lB, et al. The relationship between anti-Ro(SS-A) antibody positive Sjogren's syndrome and anti-Ro(SS-A) positive lupus erythematosus. Arch DermatoI1988;124:63-71. 4. Nishikawa T, Provost IT. Differences in clinical, serologic, and immunogenetic features of white versus Oriental antiSS-A/Ro-positive patients [Editorial]. 1 AM ACAD DERMATOL 1991;25:563-4. 5. Katz 1, LivnehA, Danon Y. Drug allergy in Sjogren's syndrome [Letter]. Lancet 1991;337:239. 6. Katayama I, Asai T, Nishiyama S, et aI. Lymp~ocyte response to staphylococcal enterotoxin Bin patients With annular erythema associated with Sjogren's syndrome. 1 Dermatol (Tokyo) 1991;18:63-8.

Follicular thyroid carcinoma metastatic to the skin To the Editor: We read with interest the article by Elgart et a1. (J AM ACAD DERMATOL 1991;25:404-8). They reported a case of cutaneous metastasis from papillary carcinoma of the thyroid. At the Second Congress of the European Academy of Dermatology and Venereology (Athens, Greece, October 1991), we presented another case of cutaneous metastasis from a follicular thyroid carcinoma. In 1990 we examined a 71-year-old woman who had an asymptomatic cutaneous red-violet nodule on the interparietal scalp that had appeared 2 years earlier. No regional lymphadenopathy or an enlarged thyroid gland was noted. She had a previous subtotal thyroidectomy for a follicular carcinoma from the left lobe of the thyroid gland in 1981. A skin biopsy specimen confirmed the diagnosis of metastatic follicular thyroid carcinoma. Findings of chest roentgenography and bone scintigraphy were normal. The following laboratory values were obtained: thyroid-stimulating hormone, 7.8 mill/ml (normal 0.2 to 3.5 mID/ml); thyroglobulin, 1545 ng/ml (normal up to 60 ng/mI). A thyroid scan revealed uptake in both lobes. The patient was treated with radioactive iodine and thyroxine because she refused surgical resection of the thyroid. In October 1991 she was asymptomatic and her serum thyroglobulin level had decreased substantially (147 ng/mi). . Cutaneous metastases from thyroid carcinoma are Infrequent. The review by Elgart et al. contained most ofthe reported cases. We have uncovered several more: Ibaiiez et al., 1 Barr and Dann, 2 Ordonez and Samaan, 3 and Pavlidis et al. 4 There have been a total of 21 cases of cutaneous metastases from thyroid carcinoma; they were six

Volume 27 Number 2, Part 1 August 1992 follicular carcinomas (including ours), five papillary carcinomas, four giant-cell carcinomas, I four medullary carcinomas, I ,:I one anaplastic carcinoma? and one follicular-papillary carcinoma.

Rosario Vives, MD,a Ana Valcayo, MD,a Edelmiro Menendez, MD,b and Rosa Guarch,c Department of Dermatology,a Section of Endocrinology,b and the Department of Pathology,c Hospital de Navarra, 31008, Pamp!ona, Spain

REFERENCES 1. Ibanez M, Russell WO, Albores-Saavedra J, et ai. Thyroid carcinoma: biologic behaviour and mortality. Cancer 1966; 19: 1039-46. 2. Barr R, Dann F. Anaplastic carcinoma metastatic to skin. J Cutan PathoI1974;1:201-3. 3. Ordonez NG, Samaan NA. Medullary carcinoma of the thyroid metastatic to the skin: report of two cases. J Cutan PathoI1987;14:251-4. 4. Pavlidis NA, Sourla AD, Nikolaou NG, et aL Neglected cases of papillary and follicular thyroid carcinoma: occurrence of subcutaneous scalp metastases. Eur J Surg Oncol 1990;16:175-9.

Essential thrombocythemia and idiopathic cold agglutinin disease: Two additional disorders associated with intravascular coagulation necrosis of the skin To the Editor: We recently reported a case of intravascular coagulation necrosis (lCN) of the skin associated with cryofibrinogenemia, diabetes mellitus, and cardiolipin autoantibodies (J AM ACAD DERMATOL 1991; 25:882-8), a rare condition characterized by hemorrhagic infiltrates that may develop into circumscribed ulcerating necrosis, mostly in acral areas, and histologically by vascular occlusion without evidence of leukocytoclastic or lymphocytic vasculitis. We also reviewed ICN and we found similar clinical and histologic pictures described in association with cryofibrinogenemia, monoclonal cryoglobulinemia, antiphospholipid antibody syndrome, thrombotic thrombocytopenic purpura, purpura fulminans, coumarin necrosis, and cholesterol crystal embolization. ICN was also observed in patients with essential thrombocythemia 1,2 and idiopathic cold agglutinin disease. 3 We would like to add these two disorders to the list of diseases that are possibly associated with ICN. Christos C. Zouboulis, MD, Harald Gollnick, MD, and Constantin E. Orfanos, MD Department of Dermatology University Medical Center Steglitz The Free University of Berlin Berlin, Germany

Correspondence 277

REFERENCES 1. !tin PH, Winkelmann RK. Cutaneous manifestations in patients with essential thrombocythemia. J AM ACAD DERMA.TOL 1991;24:59-63. 2. Velasco JA, Santos JC, Bravo J, Santana 1. Ulceronecrotic lesions in a patient with essential thrombocythaemia. Clio Exp Dermatol1991;16:53-4. 3. Seabury-Stone M, Piette WW, Davey WP. Cutaneous necrosis at sites of transfusion: cold agglutinin disease. J AM ACAD DERMATOL 1988;19:356-7.

Melanocytic nevus density in Asian, Indo-Pakistani, and white children To the Editor: I would like to call attention to a word that is misused in the article "Melanocytic Nevus Density in Asian, Indo-Pakistani, and white children: The Vancouver Mole Study" by Gallagher et al., in the September 1991 issue of the JOURNAL (1991;25:507-12). In that article, the word ethnic is used to denote populations characterized by physical attributes. The term ethnic is becoming popular in the medical literature, and I do not mean to take these particular authors to task, but this incorrect usage is a matter of some significance. The concept of ethnicity is essentially cultural; physical characteristics, such as skin pigmentation, are properly regarded as racial. The term race has had a particularly checkered career and is rapidly joining the list of other unsavory four-letter words that must be eschewed in polite society. The words racism and racist are epithets. Ifa euphemism for "racial" is required, so be it, but the substitution of the word "ethnic" simply won't do. The distinction between "racial" and "ethnic" is one of the most important in all the social sciences. The concept of race is founded in genetics. The concept ofethnicity, on the other hand, is completely nongenetic and is concerned with learned behavior, independent both of mere physical appearance, and the arbitrary nature of national citizenship. A few dermatologic examples may help clarify the issue. A dermatosis such as cao gio among Vietnamese is fundamentally ethnic and not racial. The photodermatosis of American Indians is racial and not ethnic. A dermatosis such as leishmaniasis is geographic and is neither racial nor ethnic. In the social sciences, the term ethnic is frequently used in pointed opposition to the concept of race, and it is thus particularly ironic to find the two words frequently used in medical literature as if they were interchangeable. I believe it is important to always keep before the public the distinction between racial and cultural characteristics and to use each term where it is specifically applicable. A blending of these two concepts obscures distinctions which are in fact crucial, not only from a scientific point of view, but from an everyday social point of view. Con-

Follicular thyroid carcinoma metastatic to the skin.

lournal of the American Academy of Dermatology 276 C,orrespondence REFERENCES REFERENCES 1. Cho KH, Shin KS, Sohn Sl, et al. Behget's disease with S...
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