lnteniiitional Journal of Dermatology Vol. 31, No. y, September 1992
revealed that there was a definite correlation between tbe onset of beadacbe, loss of bair, and cutis verticis gyrata. Tbe patient bad tbe nature of ber problem explained, and sbe was advised to keep the bair loose. A mild topical corticosteroid preparation was prescribed for tbe inflammatory lesions over tbe scalp, which cleared within a week. There was complete resolution of headache, and no furtber bair loss was observed. Comment The present case is interesting because of its unusual presentation and a diagnostic dilemma. Tbe patient underwent a series of investigations to elucidate the cause of her headache, which was ultimately attributed to traction. Prolonged traction, as well as causing bair loss, may at times result in bypertropby and folding of tbe skin of tbe scalp (i.e., cutis verticis gyrata).''^ Intractable beadacbe due to traction bas not been reported previously to tbe best of our knowledge.
Figure 1.
diffuse tissue eosinophilia and marked edema, fibrinoid "flame-figures," and pallisading microgranulomata. The pathogenesis and etiology are unknown. Wells' syndrome must be considered a part of tbe differential diagnosis in a patient witb the occurrence of iritis and tbe above-described dermatologic manifestations.
Amrinder J. Kanwar, M.D. Srabani Gbosb, M.D. Gurvinder P. Tbami, M.D. Surrinder Kaur, M.D., F.A.M.S. Cbandigarb, India.
Bruce Alan Miller, M.D. Craig E. Geist, M.D. Arlington, Virginia
References 1. Khare AK, Singh G. Acquired cutis verticis gyrata due to rotational traction. Br J Dermatol 1984; 110:125. 2.
Cranuloma Annulare Following Herpes Zoster
Kanwar AJ, Kaur S. Some dermatoses peculiar to Sikh men. Int J Dermatol 1990; 29:739-740.
To the Editor: 1 was interested to read tbe article by Zanoli et al.' as tbeir case report bore striking similarities to one of our patients.In our patient, bistologic examination revealed loose unstructured granulomas witb occasional giant cells and no pallisading. On review of tbe literature we discovered a total of seven case reports of granulomatous cbanges at tbe site of berpes zoster scars. Interestingly three, now four,' cases bave occurred in patients witb cbronic lympbocytic leukaemia (CLL). We concluded the change might be due to an atypical delayed bypersensitivity reaction to tbe berpes zoster virus in patients immunocompromised by CLL. The more striking histologic changes in tbe case reported by Zanoli suggest tbat tbis change may be true granuloma annulare. Tberefore granuloma annulare should possibly be added to tbe list of conditions tbat can exhibit the Koebner phenomenon, which was so well presented in this journal.'
Iritis and Wells' Syndrome To the Editor: According to our search. Wells' syndrome, a rare dermatosis, has not been associated with iritis. We are currently treating a 50-year-old white woman for recurrent nongranulomatous anterior uveitis, which has affected each eye at different times since 1987. She has undergone the appropriate uveitic work-up for underlying autoimmune disease, sarcoidosis, tuberculosis, and sypbilis. Tbe only finding of interest was an RA screen witb a slightly increased titer of 1:160. Past medical history is only significant for asthma. Recently, tbe patient acutely developed raised, urticarial plaques on ber abdomen. A puncb biopsy was performed and revealed a normal epidermis witb a diffuse infiltrate tbroughout the dermis consisting of numerous eosinophils in a rather edematous stroma. Focal granuloma formation was noted consisting of histiocytes in a pallisaded array around areas of collagen disruption and associated with eosinophils some of which have degranulated forming so-called flame-figures. Multinucleated giant cells and chronic inflammation were also present (Fig. 1). The histologic description of eosinophilic cellulitis together with the clinical presentation is consistent with Wells' syndrome. Wells' syndrome is a distinctive dermatosis clinically resembling acute cellulitis with solid edema. Recurrence over many years is a common finding. Light microscopy reveals
A.L. Wright Bradford, UK References 1. Zanoli MD, Powell BL, McCalmont T, et al. Granuloma annulare and disseminated herpes zoster. Int J Dermatol 1992; 31:55-57.
672
2.
Wright AL, Cotton DWK, Winfield DA, Messenger AG. Granuloma formation in herpes zoster scars. Dermatologica 1989; 179:45-46.
3.
Boyd AS, Neldner KH. Tbe isomorphic response of Koebner. IntJ Dermatol 1990; 29:401-410.
revealed that there was a definite correlation between tbe onset of beadacbe, loss of bair, and cutis verticis gyrata. Tbe patient bad tbe nature of ber problem explained, and sbe was advised to keep the bair loose. A mild topical corticosteroid preparation was prescribed for tbe inflammatory lesions over tbe scalp, which cleared within a week. There was complete resolution of headache, and no furtber bair loss was observed. Comment The present case is interesting because of its unusual presentation and a diagnostic dilemma. Tbe patient underwent a series of investigations to elucidate the cause of her headache, which was ultimately attributed to traction. Prolonged traction, as well as causing bair loss, may at times result in bypertropby and folding of tbe skin of tbe scalp (i.e., cutis verticis gyrata).''^ Intractable beadacbe due to traction bas not been reported previously to tbe best of our knowledge.
Figure 1.
diffuse tissue eosinophilia and marked edema, fibrinoid "flame-figures," and pallisading microgranulomata. The pathogenesis and etiology are unknown. Wells' syndrome must be considered a part of tbe differential diagnosis in a patient witb the occurrence of iritis and tbe above-described dermatologic manifestations.
Amrinder J. Kanwar, M.D. Srabani Gbosb, M.D. Gurvinder P. Tbami, M.D. Surrinder Kaur, M.D., F.A.M.S. Cbandigarb, India.
Bruce Alan Miller, M.D. Craig E. Geist, M.D. Arlington, Virginia
References 1. Khare AK, Singh G. Acquired cutis verticis gyrata due to rotational traction. Br J Dermatol 1984; 110:125. 2.
Cranuloma Annulare Following Herpes Zoster
Kanwar AJ, Kaur S. Some dermatoses peculiar to Sikh men. Int J Dermatol 1990; 29:739-740.
To the Editor: 1 was interested to read tbe article by Zanoli et al.' as tbeir case report bore striking similarities to one of our patients.In our patient, bistologic examination revealed loose unstructured granulomas witb occasional giant cells and no pallisading. On review of tbe literature we discovered a total of seven case reports of granulomatous cbanges at tbe site of berpes zoster scars. Interestingly three, now four,' cases bave occurred in patients witb cbronic lympbocytic leukaemia (CLL). We concluded the change might be due to an atypical delayed bypersensitivity reaction to tbe berpes zoster virus in patients immunocompromised by CLL. The more striking histologic changes in tbe case reported by Zanoli suggest tbat tbis change may be true granuloma annulare. Tberefore granuloma annulare should possibly be added to tbe list of conditions tbat can exhibit the Koebner phenomenon, which was so well presented in this journal.'
Iritis and Wells' Syndrome To the Editor: According to our search. Wells' syndrome, a rare dermatosis, has not been associated with iritis. We are currently treating a 50-year-old white woman for recurrent nongranulomatous anterior uveitis, which has affected each eye at different times since 1987. She has undergone the appropriate uveitic work-up for underlying autoimmune disease, sarcoidosis, tuberculosis, and sypbilis. Tbe only finding of interest was an RA screen witb a slightly increased titer of 1:160. Past medical history is only significant for asthma. Recently, tbe patient acutely developed raised, urticarial plaques on ber abdomen. A puncb biopsy was performed and revealed a normal epidermis witb a diffuse infiltrate tbroughout the dermis consisting of numerous eosinophils in a rather edematous stroma. Focal granuloma formation was noted consisting of histiocytes in a pallisaded array around areas of collagen disruption and associated with eosinophils some of which have degranulated forming so-called flame-figures. Multinucleated giant cells and chronic inflammation were also present (Fig. 1). The histologic description of eosinophilic cellulitis together with the clinical presentation is consistent with Wells' syndrome. Wells' syndrome is a distinctive dermatosis clinically resembling acute cellulitis with solid edema. Recurrence over many years is a common finding. Light microscopy reveals
A.L. Wright Bradford, UK References 1. Zanoli MD, Powell BL, McCalmont T, et al. Granuloma annulare and disseminated herpes zoster. Int J Dermatol 1992; 31:55-57.
672
2.
Wright AL, Cotton DWK, Winfield DA, Messenger AG. Granuloma formation in herpes zoster scars. Dermatologica 1989; 179:45-46.
3.
Boyd AS, Neldner KH. Tbe isomorphic response of Koebner. IntJ Dermatol 1990; 29:401-410.
