squares of ivory-white skin produced in deeply pigmented blacks by topical
Topical Colchicine Therapy To the Editor.\p=m-\Thearticle by Kaidbey et al titled "Topical Colchicine Therapy for Recalcitrant Psoriasis" in the Archives (111:33-36,1975) suggests use of another chemotherapeutic agent for the topical treatment of psoriasis. The authors, unfortunately, have neglected to provide adequate controls, an essential feature for the validity of a clinical study. Colchicine incorporated in hydrophilic petrolatum was allegedly responsible for the resolution of the psoriatic plaques,
with distant, untreated psoriatic lesions serving as controls. In addition, the article was vague about whether control lesions were also "scrubbed vigorously in a daily bath to remove excess scales." It cannot be concluded from this study that colchicine in petrolatum is superior to either hydrophilic petrolatum alone or hydrophilic petrolatum combined with some other drug, such as erythromycin or vitamin E. In conclusion, adequate controls in clinical investigations should include untreated areas as well as areas treated with the drug vehicle. James V. O'Connell, MD Steven L. Karassik, MD Long Beach, Calif
Reply to Drs. O'Connell and Karassik To the Editor.\p=m-\Asnap judgment deserves a snappy answer. O'Connell and Karassik are science fanatics and cannot imagine studies in which controls are superfluous. The orthodox always hold that the rules permit no exceptions\p=m-\out,Heretic! It comes down to knowing the model with which one is working. Re-
calcitrant, steroid-resistant, longstable, unchanging psoriatic plaques do not undergo complete clearing by placebo ointments, weather changes, a boom in the stock market, a new mistress, exposure to faith healers, or even delirious dermatologists. They don't go away spontaneously within a few weeks, except when driven away by potent medications. I conclude
that O'Connell and Karassik believe in magic, Philadelphia magic at that (the worst kind). We recently published photos of
application of a new depigmentation formula. One of the reviewers offered the criticism that there were no controls and hence recommended rejection. I advised the editors to take it or leave it. Intelligence prevailed and I didn't have to export the article abroad. The word science means to know, not to bring forth the official dogma for all possible events. One needs to know when controls are necessary and when they are not. Albert M. Kligman, MD, PhD
When a lightly pigmented, scaling, mildly pruritic eruption is seen in the groin, axillae, or perineal regions, conditions such as dermatophyte in¬ fections, erythrasma, and seborrheic dermatitis must be considered. To these diagnoses must be added tinea versicolor, which may be typical in configuration but highly atypical in location. We think inverse tinea ver¬ sicolor is an appropriate term for this clinical condition. Robert I. Rudolph, MD Jay M. Holzwanger, MD
Philadelphia
Philadelphia
in
Inverse Tinea Versicolor
To the Editor.\p=m-\Tinea versicolor is a very common superficial fungal infection caused by the filamentous form of Pityrosporon orbiculare. The characteristic, slightly scaling, fawn to light pink, flat patches occurring discreetly and confluently present an easily recognized picture, and the diagnosis is quickly confirmed by both Wood light and potassium hydroxide preparation examinations. The typical locations are the upper parts of the chest and back, the neck, and the arms. Very extensive cases have been frequently seen and reported. In a few rare instances, however, the eruption has been confined to highly atypical areas, such as one palm, the soles, the face, and the scalp (Diseases of the Skin, St. Louis, CV Mosby Co,
1939, pp 1102-1106).
We have recently seen two patients who have had highly unusual cases of tinea versicolor in that the eruption was limited solely to the groin and axillae or the perineum alone. The first patient was a 32-year-old man who had a mildly pruritic, red, scaling eruption for over one year limited to his axillae and inguinal regions. The second patient was a 23-year-old pregnant woman who had a mildly pruritic, scaling rash for several months localized solely over her perineal region and upper inner parts of the thighs. In both cases the clinical impression (from the typical appear¬ ance of the lesions) was tinea versi¬ color. The potassium hydroxide prepa¬ rations gave strongly positive results in both cases, while the Wood light examination was positive only in the second case. Both patients were treated successfully with a selenium sulfide shampoo.
Downloaded From: http://archderm.jamanetwork.com/ by a New York University User on 06/01/2015
Kaposi Sarcoma
To the Editor.\p=m-\Inthe article "Kaposi Sarcoma and Polymyositis," Archives (110:605-607, 1974), Dr. Dantzig states that, to his knowledge, Kaposi sarcoma has not "been reported with any of the cutaneous or muscular signs of malignant tumor."3 We would like to point out that acquired ichthyosis has been described by us
(Dermatologica 147:348-351,1973) as a skin marker of Kaposi sarcoma. We
have since noted the association of ichthyosis and Kaposi sarcoma in two additional patients. In one patient, an 85-year-old man,
pronounced ichthyosiform changes
had begun to appear three years prior to development of the widespread plaques, nodules and tumors of Kaposi sarcoma (Figure). In the other patient, a 77-year-old man, plaques of Kaposi sarcoma on the palms, legs and feet, and ichthyosis of the legs and feet have developed simultaneously over the last two years. The diagnoses of Kaposi sarcoma and ichthyosis (the latter indistinguishable from dominant ichthyosis vulLesions of Kaposi of ichthyosis on
changes
sarcoma
patient.
and
garis) have been confirmed histologi¬ cally in both patients. This brings the total of such three.
cases on our
record to
Kaposi sarcoma should probably be added to those conditions, such as
Hodgkin disease, multiple myeloma, cancer of the lung, cancer of the breast, sarcoidosis etc, in which sec¬ ondary ichthyosis is bound to occur. Anatol Krakowski, MD Sarah Brenner, MD Joseph Covo, MD Tel Aviv, Israel
Spiny Palmar Keratosis To the Editor.\p=m-\Dobsonet al1 wrote of increased incidence of palmar keratoses in patients with various internal malignant diseases. This finding was disputed by Bean et al,2 who suggest that exposure to the carcinogenic effects of arsenicals could possibly explain the coincidence. The hyperkeratosis these authors describe is in the form of flat or rounded papules on the palms, especially involving the thenar and hypothenar eminences.3 We have recently seen a patient with unusual keratotic lesions who also had malignant carcinoma. Report of a Case.\p=m-\A65-year-old woman
shelled out. No erythema or tenderness was noted. Similar but less densely placed papules were also found on the palms, sparing the creases, and the toes. Unfortu¬ nately, the patient died before a biopsy
performed.
was
Comment.-Our patient's papules differ from those previously described by being spiny rather than flat or round, and by being present on the pulps of the distal phalanges rather than on the palms only. These lesions were also present on the toes. We are interested to know if others have seen similar spiny papules of the fingertips and toes, either associated with internal malignant disease or not.
Sidney Barsky, MD Sammy A. Hutman, MD
an
receiving therapy
for an advanced bronchogenic carcinoma that had been diagnosed seven months earlier. Six weeks before examination, she noted the development of small "spines" on her hands that were annoying but were otherwise asymptomatic. She had no history of psoriasis, Darier disease, or other skin disease, and denied exposure to arsenicals. The patient had had a mastectomy 26 years previously for breast carcinoma. Examination showed skin-colored to translucent spiny protrusions, about 1 to 2 mm high, on the ventral surfaces of all dis¬ tal phalanges of the hands (Figure). These protrusions were hard and could not be was
Spiny protrusions, 1 to 2 mm high, on ventral surfaces of distal phalanges of hands.
Chicago
1. Dobson RL, Young MR, Pinto JS: Palmar keratoses and cancer. Arch Dermatol 92:553-558, 1965. 2. Bean SF, Foxley EG, Fusaro RM: Palmar keratoses and internal malignancy: A negative study. Arch Dermatol 97:528-532, 1968. 3. Braverman IM: Skin Signs of Systemic Disease. Philadelphia, WB Saunders Co, 1970.
Malignant Melanoma
From
Thermal Burn Scar
To the Editor.\p=m-\We wish to report a of malignant melanoma that arose in an occupationally related thermal burn scar. To our knowledge, there have been no prior reports of the development of a malignant melanoma in a thermal burn scar in the literature, based on our own review and that of the American Medical Association's staff (personal communication, George X. Trimble, MD, case
May 17, 1974).
Report of a Case.\p=m-\A47-year-old, blue\x=req-\ eyed, light-complexioned fireman sustained burns over 40% of his body surface on May 5, 1964, when gasoline exploded in a fire he was fighting, igniting his clothes and skin. First and second degree burns were especially severe on the lower limbs. All burns healed without the need for skin
grafting. In 1966, he first noted a pigmented growth on the upper outer part of the right leg in the center of one of the healed burn scars. No prior pigmented spot at that site was recalled.
In mid 1973, there ment of the
ule
was
excised
logically, it
obvious enlarge¬ 1- to 2-cm nod¬ Nov 13, 1973. Histo¬ was
growth, and on
was a
a
malignant melanoma,
nodular type, with invasion to level IV of the reticular dermis. A week later, exten¬ sive local excision and grafting was done. No tumor was found in the tissue removed
Downloaded From: http://archderm.jamanetwork.com/ by a New York University User on 06/01/2015
at the second excision.
On May 30, 1974, because of an enlarge¬ right groin, he had a right in¬ guinal and groin dissection and explora¬ tion of retroperitoneal nodes. Two inguinal nodes were positive for malignant mela¬ noma; 19 others were normal. Since August 1974, he has been included in a protocol immunotherapy study at the Melanoma Clinical Cooperative Group Clinic in the Department of Dermatology of the Uni¬ versity of California, San Francisco. The patient remains well and grossly tu¬ mor-free as of Feb 1975. He has been working full time as a fireman since Sept 1974. He has had no other skin cancers, and no family members have had any malig¬ nant neoplasms of the skin. ment of the
Comment.—It is recognized that burn scars may lead to skin cancer, al¬ though such a transformation is un¬ common. Trêves and Pack found that 2% of 1,091 squamous cell carcinomas developed from bum scars, and 0.5% of 1,374 basal cell epitheliomas arose in burn scars.1 They had no cases of malignant melanomas arising in a burn scar. In the modern scientific lit¬ erature, the first report of skin cancer arising in a bum scar was by an En¬ glish surgeon, Hawkins, in 1825.1 The cancers that have arisen in burn scars have been predominantly squamous cell carcinomas.2-3 A much smaller percentage have been adenocarcinomas, basal cell epitheliomas, and fibrosarcomas.1 Trauma is recognized as a factor in the formation of a malignant neo¬ plasm on the skin or soft tissues, or subjacent bone.45 Trauma may be single, blunt, physical, chemical, ther¬ mal, or chronic and repetitive.5 Skep¬ ticism has been reflected in several articles on the causal relationship of trauma to oncogenesis. Two recent reports discounted the speculation that trauma could induce formation of a malignant melanoma.6'7 How¬ ever, a statistical study in England concluded that "the relationship of trauma to the production of malig¬ nant melanoma of the skin is re¬ garded as established beyond reason¬ able doubt."8 (Burns were not mentioned, however). Reports have been published of malignant mela¬ nomas arising in such injuries as within a tattoo," a puncture wound by an indelible pencil,10 and within vacci¬ nation scars.11 The causal role of heat and wood smoke to induce malignant melanomas on the feet in black Afri¬ cans in Uganda has recently been suggested.12 Sunlight has also been
Topical Colchicine Therapy To the Editor.\p=m-\Thearticle by Kaidbey et al titled "Topical Colchicine Therapy for Recalcitrant Psoriasis" in the Archives (111:33-36,1975) suggests use of another chemotherapeutic agent for the topical treatment of psoriasis. The authors, unfortunately, have neglected to provide adequate controls, an essential feature for the validity of a clinical study. Colchicine incorporated in hydrophilic petrolatum was allegedly responsible for the resolution of the psoriatic plaques,
with distant, untreated psoriatic lesions serving as controls. In addition, the article was vague about whether control lesions were also "scrubbed vigorously in a daily bath to remove excess scales." It cannot be concluded from this study that colchicine in petrolatum is superior to either hydrophilic petrolatum alone or hydrophilic petrolatum combined with some other drug, such as erythromycin or vitamin E. In conclusion, adequate controls in clinical investigations should include untreated areas as well as areas treated with the drug vehicle. James V. O'Connell, MD Steven L. Karassik, MD Long Beach, Calif
Reply to Drs. O'Connell and Karassik To the Editor.\p=m-\Asnap judgment deserves a snappy answer. O'Connell and Karassik are science fanatics and cannot imagine studies in which controls are superfluous. The orthodox always hold that the rules permit no exceptions\p=m-\out,Heretic! It comes down to knowing the model with which one is working. Re-
calcitrant, steroid-resistant, longstable, unchanging psoriatic plaques do not undergo complete clearing by placebo ointments, weather changes, a boom in the stock market, a new mistress, exposure to faith healers, or even delirious dermatologists. They don't go away spontaneously within a few weeks, except when driven away by potent medications. I conclude
that O'Connell and Karassik believe in magic, Philadelphia magic at that (the worst kind). We recently published photos of
application of a new depigmentation formula. One of the reviewers offered the criticism that there were no controls and hence recommended rejection. I advised the editors to take it or leave it. Intelligence prevailed and I didn't have to export the article abroad. The word science means to know, not to bring forth the official dogma for all possible events. One needs to know when controls are necessary and when they are not. Albert M. Kligman, MD, PhD
When a lightly pigmented, scaling, mildly pruritic eruption is seen in the groin, axillae, or perineal regions, conditions such as dermatophyte in¬ fections, erythrasma, and seborrheic dermatitis must be considered. To these diagnoses must be added tinea versicolor, which may be typical in configuration but highly atypical in location. We think inverse tinea ver¬ sicolor is an appropriate term for this clinical condition. Robert I. Rudolph, MD Jay M. Holzwanger, MD
Philadelphia
Philadelphia
in
Inverse Tinea Versicolor
To the Editor.\p=m-\Tinea versicolor is a very common superficial fungal infection caused by the filamentous form of Pityrosporon orbiculare. The characteristic, slightly scaling, fawn to light pink, flat patches occurring discreetly and confluently present an easily recognized picture, and the diagnosis is quickly confirmed by both Wood light and potassium hydroxide preparation examinations. The typical locations are the upper parts of the chest and back, the neck, and the arms. Very extensive cases have been frequently seen and reported. In a few rare instances, however, the eruption has been confined to highly atypical areas, such as one palm, the soles, the face, and the scalp (Diseases of the Skin, St. Louis, CV Mosby Co,
1939, pp 1102-1106).
We have recently seen two patients who have had highly unusual cases of tinea versicolor in that the eruption was limited solely to the groin and axillae or the perineum alone. The first patient was a 32-year-old man who had a mildly pruritic, red, scaling eruption for over one year limited to his axillae and inguinal regions. The second patient was a 23-year-old pregnant woman who had a mildly pruritic, scaling rash for several months localized solely over her perineal region and upper inner parts of the thighs. In both cases the clinical impression (from the typical appear¬ ance of the lesions) was tinea versi¬ color. The potassium hydroxide prepa¬ rations gave strongly positive results in both cases, while the Wood light examination was positive only in the second case. Both patients were treated successfully with a selenium sulfide shampoo.
Downloaded From: http://archderm.jamanetwork.com/ by a New York University User on 06/01/2015
Kaposi Sarcoma
To the Editor.\p=m-\Inthe article "Kaposi Sarcoma and Polymyositis," Archives (110:605-607, 1974), Dr. Dantzig states that, to his knowledge, Kaposi sarcoma has not "been reported with any of the cutaneous or muscular signs of malignant tumor."3 We would like to point out that acquired ichthyosis has been described by us
(Dermatologica 147:348-351,1973) as a skin marker of Kaposi sarcoma. We
have since noted the association of ichthyosis and Kaposi sarcoma in two additional patients. In one patient, an 85-year-old man,
pronounced ichthyosiform changes
had begun to appear three years prior to development of the widespread plaques, nodules and tumors of Kaposi sarcoma (Figure). In the other patient, a 77-year-old man, plaques of Kaposi sarcoma on the palms, legs and feet, and ichthyosis of the legs and feet have developed simultaneously over the last two years. The diagnoses of Kaposi sarcoma and ichthyosis (the latter indistinguishable from dominant ichthyosis vulLesions of Kaposi of ichthyosis on
changes
sarcoma
patient.
and
garis) have been confirmed histologi¬ cally in both patients. This brings the total of such three.
cases on our
record to
Kaposi sarcoma should probably be added to those conditions, such as
Hodgkin disease, multiple myeloma, cancer of the lung, cancer of the breast, sarcoidosis etc, in which sec¬ ondary ichthyosis is bound to occur. Anatol Krakowski, MD Sarah Brenner, MD Joseph Covo, MD Tel Aviv, Israel
Spiny Palmar Keratosis To the Editor.\p=m-\Dobsonet al1 wrote of increased incidence of palmar keratoses in patients with various internal malignant diseases. This finding was disputed by Bean et al,2 who suggest that exposure to the carcinogenic effects of arsenicals could possibly explain the coincidence. The hyperkeratosis these authors describe is in the form of flat or rounded papules on the palms, especially involving the thenar and hypothenar eminences.3 We have recently seen a patient with unusual keratotic lesions who also had malignant carcinoma. Report of a Case.\p=m-\A65-year-old woman
shelled out. No erythema or tenderness was noted. Similar but less densely placed papules were also found on the palms, sparing the creases, and the toes. Unfortu¬ nately, the patient died before a biopsy
performed.
was
Comment.-Our patient's papules differ from those previously described by being spiny rather than flat or round, and by being present on the pulps of the distal phalanges rather than on the palms only. These lesions were also present on the toes. We are interested to know if others have seen similar spiny papules of the fingertips and toes, either associated with internal malignant disease or not.
Sidney Barsky, MD Sammy A. Hutman, MD
an
receiving therapy
for an advanced bronchogenic carcinoma that had been diagnosed seven months earlier. Six weeks before examination, she noted the development of small "spines" on her hands that were annoying but were otherwise asymptomatic. She had no history of psoriasis, Darier disease, or other skin disease, and denied exposure to arsenicals. The patient had had a mastectomy 26 years previously for breast carcinoma. Examination showed skin-colored to translucent spiny protrusions, about 1 to 2 mm high, on the ventral surfaces of all dis¬ tal phalanges of the hands (Figure). These protrusions were hard and could not be was
Spiny protrusions, 1 to 2 mm high, on ventral surfaces of distal phalanges of hands.
Chicago
1. Dobson RL, Young MR, Pinto JS: Palmar keratoses and cancer. Arch Dermatol 92:553-558, 1965. 2. Bean SF, Foxley EG, Fusaro RM: Palmar keratoses and internal malignancy: A negative study. Arch Dermatol 97:528-532, 1968. 3. Braverman IM: Skin Signs of Systemic Disease. Philadelphia, WB Saunders Co, 1970.
Malignant Melanoma
From
Thermal Burn Scar
To the Editor.\p=m-\We wish to report a of malignant melanoma that arose in an occupationally related thermal burn scar. To our knowledge, there have been no prior reports of the development of a malignant melanoma in a thermal burn scar in the literature, based on our own review and that of the American Medical Association's staff (personal communication, George X. Trimble, MD, case
May 17, 1974).
Report of a Case.\p=m-\A47-year-old, blue\x=req-\ eyed, light-complexioned fireman sustained burns over 40% of his body surface on May 5, 1964, when gasoline exploded in a fire he was fighting, igniting his clothes and skin. First and second degree burns were especially severe on the lower limbs. All burns healed without the need for skin
grafting. In 1966, he first noted a pigmented growth on the upper outer part of the right leg in the center of one of the healed burn scars. No prior pigmented spot at that site was recalled.
In mid 1973, there ment of the
ule
was
excised
logically, it
obvious enlarge¬ 1- to 2-cm nod¬ Nov 13, 1973. Histo¬ was
growth, and on
was a
a
malignant melanoma,
nodular type, with invasion to level IV of the reticular dermis. A week later, exten¬ sive local excision and grafting was done. No tumor was found in the tissue removed
Downloaded From: http://archderm.jamanetwork.com/ by a New York University User on 06/01/2015
at the second excision.
On May 30, 1974, because of an enlarge¬ right groin, he had a right in¬ guinal and groin dissection and explora¬ tion of retroperitoneal nodes. Two inguinal nodes were positive for malignant mela¬ noma; 19 others were normal. Since August 1974, he has been included in a protocol immunotherapy study at the Melanoma Clinical Cooperative Group Clinic in the Department of Dermatology of the Uni¬ versity of California, San Francisco. The patient remains well and grossly tu¬ mor-free as of Feb 1975. He has been working full time as a fireman since Sept 1974. He has had no other skin cancers, and no family members have had any malig¬ nant neoplasms of the skin. ment of the
Comment.—It is recognized that burn scars may lead to skin cancer, al¬ though such a transformation is un¬ common. Trêves and Pack found that 2% of 1,091 squamous cell carcinomas developed from bum scars, and 0.5% of 1,374 basal cell epitheliomas arose in burn scars.1 They had no cases of malignant melanomas arising in a burn scar. In the modern scientific lit¬ erature, the first report of skin cancer arising in a bum scar was by an En¬ glish surgeon, Hawkins, in 1825.1 The cancers that have arisen in burn scars have been predominantly squamous cell carcinomas.2-3 A much smaller percentage have been adenocarcinomas, basal cell epitheliomas, and fibrosarcomas.1 Trauma is recognized as a factor in the formation of a malignant neo¬ plasm on the skin or soft tissues, or subjacent bone.45 Trauma may be single, blunt, physical, chemical, ther¬ mal, or chronic and repetitive.5 Skep¬ ticism has been reflected in several articles on the causal relationship of trauma to oncogenesis. Two recent reports discounted the speculation that trauma could induce formation of a malignant melanoma.6'7 How¬ ever, a statistical study in England concluded that "the relationship of trauma to the production of malig¬ nant melanoma of the skin is re¬ garded as established beyond reason¬ able doubt."8 (Burns were not mentioned, however). Reports have been published of malignant mela¬ nomas arising in such injuries as within a tattoo," a puncture wound by an indelible pencil,10 and within vacci¬ nation scars.11 The causal role of heat and wood smoke to induce malignant melanomas on the feet in black Afri¬ cans in Uganda has recently been suggested.12 Sunlight has also been
