Volume 25 Number S, Part 1 November 1991
Correspondence 867
did notjustify to us separating the twoconditions. However, PPE bydefinition isanHIV-associated eruption and we now learn that those patients reportedby Rosen and Algra have remained Hlv-negative. This would indeed justifyseparating these twoconditions. Regarding our attempt to include Demodex "into the same broad category of nonspecific pruritus into which PPE falls, " there was simply nointent to do this. Demodex was referenced as a cause of pruritus in AIDS patients.'
to find onethat gives a significant result is generally not considered appropriate.
Oscar Hevia, MD Department ofDermatology and Cutaneous Surgery, University of Miami Schoolof Medicine P.O. Box 016940 tu-tt; Miami, FL 33101
tanceofbeta. the type II error and samplesizein thedesign and interpretation ofthe randomized control trial. N EnglJ Med 1978;299:690-4.
William F. Keenan. MD Department ofFamily Practice Williamsport Hospital 699 Rural Ave. Williamsport, PA 17701
REFERENCE 1. Freiman JA, Chalmers TC, Smith H Jr, et al. The impor-
REFERENCES
Grafting of venous leg ulcers
1. Rosen T, Algra RJ. Papular eruption in blackmen. Arch
To the Editor: I would liketo comment on the articleby Mol et aL (J AM ACAD DERMATOL 1991;24:77-82). The treatment ofvenous leg ulcers,as reported in many medicaljournals, ischaracteristically onlyconcerned withthe rate ofreepithelialization. Often, ashas occurredwiththis manuscript, there is no mention made of the underlying etiologic events that causethe ulceration. It is well established that venous hypertension is a primary etiologic eventleading to the development ofcutaneousbreakdown and ulceration. Venous hypertension may besecondary to deepvenous thrombosis with the resultingincrease in superficial venous pressure, transexudation of fluid, white bloodcelltrapping, and perivascular fibrin cuffing, with or without underlying incompetence of perforatorveins. It should beemphasized that beforesuccessful treatment of the ulceration, the physician must treat the venous insufficiency. Thiscantake the formof sclerotherapy injection into incompetent perforatingveins,surgical ligation of said veins, or moreconservative treatment with graduated compression hosiery. The patients treated by Mol et al. weretreated with bed rest alone. No mentionwas madeofadditional treatmentwithsclerotherapy, surgery, or graduatedcompression stockings/bandages. Inthe age of diagnosis-related groups, it is highly unlikely that one wouldbe able to keep a patient at completebed restwith leg elevation for the time required to producehealing of the ulceration. Obviously, if the ulceration is to heal, either through pinch grafting or cultured skin equivalent grafting without treatment of the underlying cause Of venous hypertension, the ulcers are likely to recur. Although the follow-up in this study was relatively short (8 to 10months), ulcerationrecurred in oneof the seven patients.It would be interesting to knowwhat postoperative treatmentwas given to the patient (weregraduated compression stockings worn?). I applaudthe authorsfor their development of an out-
DermatoI1980;116:416-8. 2. Hevia 0, Jimenez-Acosta F, Ceballos PI, et al.Pruritic pap" ular eruption of the acquired immunodeficiency syndrome: a clinicopathologic study. J AM ACAD DERMATOL 1991; 24:231-5. 3. Ashack RJ, FrostML, Norins AL.Papularpruritic eruption ofDemodex folliculitis inpatients withacquired immunodeficiency syndrome. JAM ACAD DERMATOL 1989;21:306-7.
Efficacy of terbinafine To theEditor: In hisstudyon the treatment oftinea cruris (J AM ACAD DERMAToL 1990;23:795-9), Dr. Millikan found a large difference in the efficacy ofterbinafine between the treated and control groups (78% vs 33%); however, this difference did not reach statistical significance. The author postulates that this failure to reach statistical significance wasin part due to the higherincidenceof chronic diseases in the treatment group. Given the magnitude of the observed difference, a muchmorelikely explanation isthat thestudysimply did not have the power to exclude a falsely negative result. Thiscanleadto thefalseassumption that a realdifference in treatment efficacy does not exist when statistical significance isnot found. Thishas beencalled a type II or beta error. Asdiscussed elsewhere,' both samplesizeand the real magnitude ofpopulation differences determine a sample's power. It is possible that had this study included more than 18subjects, it might havereachedstatistical significance. Incidentally, the use of 2 X 2 tablesand Fisher's exact test onthisstudy'sdata gives apvalue between 0.025 and 0.05,which is oftenconsidered statistically significant. It should be pointed out that trying various statistical tests
Journal of the American Academy of Dermatology
868 Correspondence standing treatment modality for accelerating reepithelialization',However, forthistechnique to bepractical, the postoperative treatment must be detailed as well.
Mitchel P. Goldman, MD Dermatology Associates ofSan Diego County, Inc. 850Prospect St., Suite 2 La Jolla, CA 92037
Sometimes the elderly patient is not able to put on the rigid elasticstockings. Sometimes the patient forgets the treatment.Wemustrememberthepatientis buta human being.
Wiete Westerhof, MD, Bart Naninga, MD, and Marijke Mol, PhD Rijswijk, the Netherlands
Reply To theEditor: In general I agreewithDr. Goldmanthat toomuchemphasis is put on the reepithelialization technique and toolittleon the preventive measures in many articles dealing with the treatment of chronic leg ulcers. However, this is notthe casein our article. It was stated in the "Patients and Methods" section that we selected only patients withvenous legulcers. Furthermore weindicated that treatment after grafting and the complete healing consisted of compression therapy (p. 79, line9). We have approximately 10 years of experience in grafting legulcers. The underlying causeis of primeimportance. This can be determined by thorough history taking, physical examination, laboratory investigations, andvascular laboratory investigation. Mainlyvenous insufficiency ulcers are admitted forgrafting, if the ambulatory technique with compression therapy fails. If the phlebologic diagnostics with continuous-wave Doppler andlightreflection rheography incriminate a perforating vein as thecausative factor, ligation forsclerosing ofsuch an insufficient perforating vein is performed. Furthermore, not muchbenefit from suchan operation is to be expected: the .recurrence rate is high because many neighboring vems canbecome insufficient from the often totally insufficient deep venous system. The solution isto implant artificial valves into these deep veins. However, this technique isstill in an experimental phase. Therefore our approach towards prevention, after the grafting of ulcers, is compression therapy. Initial nonelastic compression is followed by wearing made-to-measure elastic stockings after6 weeks. Although wehaveperformed the punch biopsy grafting underambulatory conditions (unpublished results) weget betterresults if we givethe patient bed rest for 2 to 3 weeks. The explanation is that during mobilization minimal edema develops, despite accurate application of the compression therapy. This edema causes blister formation and extravasation of blood, especially inthefragile newly formed tissueofthe outgrowing punch grafts. We are presently doing a follow-up study of our ~tients whounderwent grafting (approximately 350patients). The recurrence rate of ulceration is about 50%.
Round ftngerpad sign as an early sign of scleroderma To the Editor: In the article by Mizutani et al, (J AM 1991;24:67-9) on the round fingerpad (RFP) sign as an earlysignof scleroderma, the authors state:"Wewereableto show a highlevelofsensitivityand specificity of the RFP sign when affected patients were compared with normal control subjects. If the sign is found on the fourthfinger, the probability of scleroderma is high and further evaluation is indicated." (p.69) Byfinding the RFP signon 72 of 72 ring fingers in 36 patients with progressive systemic sclerosis, the authors make a valid argument for sensitivity of the sign. Their claimthat thissignisalso highlyspecific, however, is refuted by their own findings of the sign in 69 of 72 ring fingers in patients with mixed connective tissue disease and in 24 of 24 ring fingers in patients with Raynaud's phenomenon andsclerodactyly. Granted,the signwas not ~een in any "normal"patients, but to claim true specifictty, theauthors must showthat thissign isnot present in otherdiseasestates.If patientswithcontact dermatitis of the hands, Reiter's disease, and psoriasis involving the fingers, as well as withotherassorted skinconditions were examined, the RFP sign might well be found. Although the RFP sign, asdescribed byMizutani et al., is an interesting finding, we think that their conclusion that "the probability of scleroderma is high" is not substantiatedby the limited data presented. To substantiate their claim, the authors must show that this sign is not seen in other skin conditions involving the hands. ACAD DERMATOL
Matthew H. Kanzler, MD,a and David C. Gorsulowsky, MD,b Division ofDermatology, Santa Clara Valley Medical Center 751 S. Bascom Ave.• San Jose, CA 95128°; and 39210 State St., #218, Fremont, CA 94538b
Correspondence 867
did notjustify to us separating the twoconditions. However, PPE bydefinition isanHIV-associated eruption and we now learn that those patients reportedby Rosen and Algra have remained Hlv-negative. This would indeed justifyseparating these twoconditions. Regarding our attempt to include Demodex "into the same broad category of nonspecific pruritus into which PPE falls, " there was simply nointent to do this. Demodex was referenced as a cause of pruritus in AIDS patients.'
to find onethat gives a significant result is generally not considered appropriate.
Oscar Hevia, MD Department ofDermatology and Cutaneous Surgery, University of Miami Schoolof Medicine P.O. Box 016940 tu-tt; Miami, FL 33101
tanceofbeta. the type II error and samplesizein thedesign and interpretation ofthe randomized control trial. N EnglJ Med 1978;299:690-4.
William F. Keenan. MD Department ofFamily Practice Williamsport Hospital 699 Rural Ave. Williamsport, PA 17701
REFERENCE 1. Freiman JA, Chalmers TC, Smith H Jr, et al. The impor-
REFERENCES
Grafting of venous leg ulcers
1. Rosen T, Algra RJ. Papular eruption in blackmen. Arch
To the Editor: I would liketo comment on the articleby Mol et aL (J AM ACAD DERMATOL 1991;24:77-82). The treatment ofvenous leg ulcers,as reported in many medicaljournals, ischaracteristically onlyconcerned withthe rate ofreepithelialization. Often, ashas occurredwiththis manuscript, there is no mention made of the underlying etiologic events that causethe ulceration. It is well established that venous hypertension is a primary etiologic eventleading to the development ofcutaneousbreakdown and ulceration. Venous hypertension may besecondary to deepvenous thrombosis with the resultingincrease in superficial venous pressure, transexudation of fluid, white bloodcelltrapping, and perivascular fibrin cuffing, with or without underlying incompetence of perforatorveins. It should beemphasized that beforesuccessful treatment of the ulceration, the physician must treat the venous insufficiency. Thiscantake the formof sclerotherapy injection into incompetent perforatingveins,surgical ligation of said veins, or moreconservative treatment with graduated compression hosiery. The patients treated by Mol et al. weretreated with bed rest alone. No mentionwas madeofadditional treatmentwithsclerotherapy, surgery, or graduatedcompression stockings/bandages. Inthe age of diagnosis-related groups, it is highly unlikely that one wouldbe able to keep a patient at completebed restwith leg elevation for the time required to producehealing of the ulceration. Obviously, if the ulceration is to heal, either through pinch grafting or cultured skin equivalent grafting without treatment of the underlying cause Of venous hypertension, the ulcers are likely to recur. Although the follow-up in this study was relatively short (8 to 10months), ulcerationrecurred in oneof the seven patients.It would be interesting to knowwhat postoperative treatmentwas given to the patient (weregraduated compression stockings worn?). I applaudthe authorsfor their development of an out-
DermatoI1980;116:416-8. 2. Hevia 0, Jimenez-Acosta F, Ceballos PI, et al.Pruritic pap" ular eruption of the acquired immunodeficiency syndrome: a clinicopathologic study. J AM ACAD DERMATOL 1991; 24:231-5. 3. Ashack RJ, FrostML, Norins AL.Papularpruritic eruption ofDemodex folliculitis inpatients withacquired immunodeficiency syndrome. JAM ACAD DERMATOL 1989;21:306-7.
Efficacy of terbinafine To theEditor: In hisstudyon the treatment oftinea cruris (J AM ACAD DERMAToL 1990;23:795-9), Dr. Millikan found a large difference in the efficacy ofterbinafine between the treated and control groups (78% vs 33%); however, this difference did not reach statistical significance. The author postulates that this failure to reach statistical significance wasin part due to the higherincidenceof chronic diseases in the treatment group. Given the magnitude of the observed difference, a muchmorelikely explanation isthat thestudysimply did not have the power to exclude a falsely negative result. Thiscanleadto thefalseassumption that a realdifference in treatment efficacy does not exist when statistical significance isnot found. Thishas beencalled a type II or beta error. Asdiscussed elsewhere,' both samplesizeand the real magnitude ofpopulation differences determine a sample's power. It is possible that had this study included more than 18subjects, it might havereachedstatistical significance. Incidentally, the use of 2 X 2 tablesand Fisher's exact test onthisstudy'sdata gives apvalue between 0.025 and 0.05,which is oftenconsidered statistically significant. It should be pointed out that trying various statistical tests
Journal of the American Academy of Dermatology
868 Correspondence standing treatment modality for accelerating reepithelialization',However, forthistechnique to bepractical, the postoperative treatment must be detailed as well.
Mitchel P. Goldman, MD Dermatology Associates ofSan Diego County, Inc. 850Prospect St., Suite 2 La Jolla, CA 92037
Sometimes the elderly patient is not able to put on the rigid elasticstockings. Sometimes the patient forgets the treatment.Wemustrememberthepatientis buta human being.
Wiete Westerhof, MD, Bart Naninga, MD, and Marijke Mol, PhD Rijswijk, the Netherlands
Reply To theEditor: In general I agreewithDr. Goldmanthat toomuchemphasis is put on the reepithelialization technique and toolittleon the preventive measures in many articles dealing with the treatment of chronic leg ulcers. However, this is notthe casein our article. It was stated in the "Patients and Methods" section that we selected only patients withvenous legulcers. Furthermore weindicated that treatment after grafting and the complete healing consisted of compression therapy (p. 79, line9). We have approximately 10 years of experience in grafting legulcers. The underlying causeis of primeimportance. This can be determined by thorough history taking, physical examination, laboratory investigations, andvascular laboratory investigation. Mainlyvenous insufficiency ulcers are admitted forgrafting, if the ambulatory technique with compression therapy fails. If the phlebologic diagnostics with continuous-wave Doppler andlightreflection rheography incriminate a perforating vein as thecausative factor, ligation forsclerosing ofsuch an insufficient perforating vein is performed. Furthermore, not muchbenefit from suchan operation is to be expected: the .recurrence rate is high because many neighboring vems canbecome insufficient from the often totally insufficient deep venous system. The solution isto implant artificial valves into these deep veins. However, this technique isstill in an experimental phase. Therefore our approach towards prevention, after the grafting of ulcers, is compression therapy. Initial nonelastic compression is followed by wearing made-to-measure elastic stockings after6 weeks. Although wehaveperformed the punch biopsy grafting underambulatory conditions (unpublished results) weget betterresults if we givethe patient bed rest for 2 to 3 weeks. The explanation is that during mobilization minimal edema develops, despite accurate application of the compression therapy. This edema causes blister formation and extravasation of blood, especially inthefragile newly formed tissueofthe outgrowing punch grafts. We are presently doing a follow-up study of our ~tients whounderwent grafting (approximately 350patients). The recurrence rate of ulceration is about 50%.
Round ftngerpad sign as an early sign of scleroderma To the Editor: In the article by Mizutani et al, (J AM 1991;24:67-9) on the round fingerpad (RFP) sign as an earlysignof scleroderma, the authors state:"Wewereableto show a highlevelofsensitivityand specificity of the RFP sign when affected patients were compared with normal control subjects. If the sign is found on the fourthfinger, the probability of scleroderma is high and further evaluation is indicated." (p.69) Byfinding the RFP signon 72 of 72 ring fingers in 36 patients with progressive systemic sclerosis, the authors make a valid argument for sensitivity of the sign. Their claimthat thissignisalso highlyspecific, however, is refuted by their own findings of the sign in 69 of 72 ring fingers in patients with mixed connective tissue disease and in 24 of 24 ring fingers in patients with Raynaud's phenomenon andsclerodactyly. Granted,the signwas not ~een in any "normal"patients, but to claim true specifictty, theauthors must showthat thissign isnot present in otherdiseasestates.If patientswithcontact dermatitis of the hands, Reiter's disease, and psoriasis involving the fingers, as well as withotherassorted skinconditions were examined, the RFP sign might well be found. Although the RFP sign, asdescribed byMizutani et al., is an interesting finding, we think that their conclusion that "the probability of scleroderma is high" is not substantiatedby the limited data presented. To substantiate their claim, the authors must show that this sign is not seen in other skin conditions involving the hands. ACAD DERMATOL
Matthew H. Kanzler, MD,a and David C. Gorsulowsky, MD,b Division ofDermatology, Santa Clara Valley Medical Center 751 S. Bascom Ave.• San Jose, CA 95128°; and 39210 State St., #218, Fremont, CA 94538b
