2. Ronchese F: Keratoses, cancer and the sign of Leser-Tr\l=e'\lat.Cancer 18:1003-1006, 1965. 3. Dantzig PI: Sign of Leser-Tr\l=e'\lat.Arch Dermatol 108:700-701, 1973. 4. Zetkin M, Schaldach H: Worterbuch der Medizin. Berlin, Veb Verlag Volk und Gesundheit, 1956.
Toothpastes: A Cause Eruptions
To the Editor.\p=m-\Ifeel that I should share with my colleagues in dermatology an observation relative to the treatment of problem acne. All of us have seen the adult female acne patient who has closed comedonal or papular acne extending from the corner of the mouth to the chin area, sometimes in a slightly fan-like distribution from the corner of the mouth to the chin area and the proximal area of the cheek. This type of acne has often been recalcitrant to standard methods of therapy, and many of us have been under the impression that it is caused either by chemicals from cosmetics, such as lipsticks (as per Dr. Kligman), or hand-to-face activity in this area. Having accumulated a number of such patients ranging in age from the early 20s to the 40s, all of whom were adamant in their denial of hand-to\x=req-\ face activity, and many of whom willingly abstained from the use of lipsticks and cosmetics on a relatively long basis without effect, I have had to reevaluate my thinking and inter¬ view the patients thoroughly, with an eye to determine a common denomi¬ nator. My hypothesis was that either the saliva of these particular individu¬ als, or some chemical carried in the saliva, could, during sleep, drain on the areas involved, enter the follicles, and cause a process resembling acne. The only common denominator I was able to elicit from all of these patients
(approximately 65 in number) was that they all used toothpastes contain¬ ing fluoride. This brought to mind a fact that has recently been elucidated: fluoridated steroids applied to the faces of women resulted in a perioral erythema-type eruption resembling acne. Industrial halogen fumes may also cause an acne-like eruption gen¬ erally referred to as chloracne. Recognizing the fact that fluoride toothpastes are the prevalent type of dentrifrice and that my findings could be a mere coincidence, I requested, nevertheless, that these patients switch, on a trial basis, from their fluoride toothpastes to a nonfluoridecontaining toothpaste. Within a peri-
varying from two to four weeks, approximately one half of the patients
Adenoid of Scalp
To the Editor.\p=m-\A tumor with typical morphologic features of adenoid cystic carcinoma (ACC) was seen as a primary skin lesion in one patient. I believe this case could represent an
thus observed cleared of their pre¬ acne-like eruption. The condition of the other 50% tended to persist without change. No other variation in the therapy of these patients was undertaken during the test period. On the basis that at this time I had at least circumstantial evidence that the hypothesis might be true, I asked the remaining patients who had not responded to switch from their present dentifrice, which con¬ tained brightening and flavoring agents and other unknown chemicals, to baking soda and a commercially available mouthwash (Scope) as a mouth freshener after brushing. The results of this maneuver were remark¬ ably successful in that nearly all of the patients thus treated had considerable improvement and an almost complete clearing of their acne-like eruptions. Several of the patients, who were concerned about the dental health factors relative to fluoride and its exclusion, requested to resume use of a fluoride toothpaste despite assur¬ ances that fluoride in water and dental treatments should be sufficient for good dental health and protection. These patients were then allowed to resume use of a fluoride toothpaste. Without exception, each developed the same distribution of acne-like erup¬ tion that had previously occurred. I note again that all of these patients had been treated for some time with standard acne therapy consisting of special washing agents, dietary control, tetracycline in vary¬ ing dosages, and lotions of various types and strengths. But no patient during the treatment period had any variations of his therapy other than the dentifrice. It was also interesting to note that the patients who were able to recall uniformly stated that the side on which they had the greatest involve¬ ment was the side on which they generally slept, thus giving further credence to the hypothesis of noctur¬ nal salivary drainage of chemicals onto the involved areas of skin. I am hopeful that this observation will be of help to my colleagues in dermatology and that perhaps it might be worthy of a more scientifi¬ cally controlled and statistically evalu¬ ated study. Milton A.
Saunders, Jr., MD Virginia Beach, Va
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different from the mucinous (adenocystic) carcinoma described by Mendoza and Helwig.1 Furthermore, the tumor reported here had an unusually long duration of 14 years without metastasis, and was located in the
to my knowledge, primary instance of such a tumor has not
been previously mentioned in the literature.
Report of a Case.\p=m-\The patient was a 66\x=req-\ year-old woman who for 14 years had a mass in the left parietal region of the scalp.
There were no similar lesions elsewhere. The mass was removed with the covering skin and a segment of periosteum adherent to the undersurface. Grossly, it consisted of multiple, elevated, confluent nodules. The overlying skin showed areas of alopecia. The tumor measured 8.0 cm at its largest dimension. It involved almost the full thickness of the scalp, reaching 1.5 cm in the thickest area. On sectioning, it ap¬ peared soft, white-opaque, and somewhat friable. Alcian blue and PAS stains, both before and after diastase digestion, were used in addition to the routine stains. The micro¬ scopical findings were typical of true ACC, similar to those tumors originating in sali¬ vary glands. The various patterns long recognized in this type of tumor,2 such as cribriform or adenoid cystic formation of cylinders, development of cords and duct¬ like structures, and invasion of perineural spaces,, were all noted in this case (Fig 1 to
4). or cystic pattern was the prominent (Fig 1). The cystic spaces contained a substance that was weakly PAS-positive, but reacted strongly with
Alcian blue. This reaction is characteristic of ACC.3 The ducts resembled eccrine sweat struc¬ tures. Sweat glands seen enmeshed with tumor showed a subtle neoplastic transfor¬ mation (Fig 2). The cytoplasm of the neoplastic cells contained granules that reacted with PAS before, but not after, diastase digestion. A similar reaction was noted in the adjacent normal-looking sweat glands, suggesting derivation of the tumor from these structures.
suggest that this gland tumor represents true adenoid cystic carcinoma similar to sweat
illustrates that true ACC can also in sweat glands. Perhaps this fact has not been recognized before because these tumors have been classified under other terms. For instance, Stout and Cooley4, in study¬ ing a series of carcinomas of the sweat glands, found at least one case (case 8) with the histological characteristics of ACC, but they did not separate it from the other tumors that had a different histological appearance. Because of its distinct histological appearance, adenoid cystic carcinoma should be separated from the mucinous group, since the clinical behav¬ 1 .—Adenoid cystic carcinoma of scalp showing character¬ Fig may iour also be different. istic cribriform pattern (hematoxylin-eosin, original magnifica¬ case
Fig 3.—Formation of cylinders (arrow) (hematoxylin-eosin, original magnification, x 100). the salivary counterpart. The presence in the scalp for 14 years without evidence of metastasis or of similar lesions in other areas is the unusual feature of this tumor. This neoplasm is different from the mucinous carci¬ noma of the skin reported by Mendoza and Helwig.1 In contrast to the true ACC, the mucinous variety of tumors
usually small, showed large pools of strongly PAS-positive material résistent to diastase digestion, and were not reported to invade the peri¬
neural spaces. The authors, therefore, suggested to drop the term "adenocystic" and to simply use the term "muci¬ nous carcinoma" when referring to these skin tumors. The term "adenocystic" in connection with mucinous carcinoma of the skin is confusing, since it may be interpreted as being synonymous with the adenoid cystic carcinoma of the salivary type. This
Fig 2.—Eccrine structures within tumor, showing subtle neoplastic changes (arrows) (hematoxylin-eosin, original magnifi¬ cation x 200).
Fig 4.—Invasion of perineural original magnification x 100).
illustrates that true ACC can also in sweat glands. Perhaps this fact has not been recognized before because these tumors have been classified under other terms. For instance, Stout and Cooley4, in study¬ ing a series of carcinomas of the sweat glands, found at least one case (case 8) with the histological characteristics of ACC, but they did not separate it from the other tumors that had a different histological appearance. Because of its distinct histological appearance, adenoid cystic carcinoma should be separated from the mucinous group, since the clinical behav¬ iour may also be different. Raul Boggio, MD Boston case
1. Mendoza S, Helwig EB: Mucinous (adenocarcinoma of the skin. Arch Dermatol 103:68-78, 1971.
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2. Foote F, Frazell E: Tumors of the major salivary glands, in Atlas of Tumor Pathology. Washington, DC, Armed Forces Institute of Pathology, 1954, section 4, pt 2, pp 103-115. 3. Evans RW, Cruickshank AH: Epithelial Tumors of the Salivary Glands. Philadelphia, WB Saunders Co, 1970, pp 142-166. 4. Stout AP, Cooley SGE: Carcinoma of sweat glands. Cancer 4:521-536, 1951.
Pemphigus vs Acantholytic Herpetiform Dermatitis To the Editor.\p=m-\Ifound the report of Drs. Demento and Grover in the Archives (107:883, 1973) very interesting. Isolated reports in which features of pemhigus and dermatitis herpetiformis have overlapped have appeared from time to time. The confusion engendered by these reports gave rise to the myth that dermatitis herpetiformis could sometimes transform into pemphigus. Rook and Whimster1 stated that until