Milk of
Magnesia Treatment for Acne
To the Editor.\p=m-\Ihave found a nightly topical application of milk of magnesia, when combined with 250mg of tetracycline orally administered four times daily and two daily washes with a fat-free soap, to be highly effective in the reduction of redness from postinflammatory lesions and in the number and severity of acne pustules. Realizing that a laxative as topical medication is not ordinarily prescribed in acne treatment, I write this letter with the two\x=req-\ fold hope that my success in this area may also be shared by those physicians treating this condition, and that this method may become a viable alternative to the abrasion and irrita-
tion inflicted with alcohol- and sulfur\x=req-\ based compounds. Randy Sigal Atlanta Toxic Epidermal Necrolysis To the Editor.\p=m-\RecentlyDrs. Callaway and Tate reported a case of "toxic epidermal necrolysis" caused by gin and tonic.1 We have seen a similar case. A 25-year-old man consulted us about his third episode in 18 months of generalized erythema followed by desquamation after the consumption of gin and tonic. On all three occasions, within six to eight hours after drinking gin and tonic the
patient developed generalized erythema that lasted for two or three days. Eight to ten days later, his skin peeled in sheets from his trunk and extremities and in a glove-like fashion from his palms and soles. Otherwise, he felt well. Flushing and pruritus from quinine have been reported,2 but we could find no mention in the literature of the delayed scarletiniform exfoliation. In addition to this
recently
saw a
patient, we 4-year-old girl who
swallowed an undetermined number of Midol tablets (a mixture of aspirin, caffeine, and cinnamedrine hydrochloride) and subsequently developed generalized erythema and delayed ex¬ foliation identical to that in the first
patient.
In 1956, Lyell coined the term "toxic epidermal necrolysis" to de¬ scribe what now appears to be severe
drug-induced bullous erythema mul¬ tiforme.3 Pediatricians soon picked up the term and applied it to the "scalded skin syndrome," which later was shown to be a specific disease due to an epidermolytic toxin produced by staphylococci.1 Toxic epidermal ne¬ crolysis, of the Lyell type, is a severe and generalized sub-epidermal bul¬ lous process with a 40% to 50% mortal¬ ity rate. Toxic epidermal necrolysis, the staphylococcal type, is a super¬ ficial intra-epidermal process with bulla formation at the level of the
granular layer.
Now that the term "toxic epidermal necrolysis" is widely applied to these two conditions, we must accept this
nomenclature of common usage with the realization that the same name is applied to two etiologically distinct diseases. We would like to discourage the broader use of "toxic epidermal necrolysis" and suggest that the term "toxic exfoliation" might be more ap¬ propriate for these recently reported cases of drug-induced erythema with delayed scarletiniform superficial
desquamation.
1.
Michael Jarratt, MD Andrew Rudolph, MD Houston Tate WE: Toxic epidermal JL, Callaway
necrolysis caused by "gin
and tonic." Arch Dermatol 109:909, 1974. 2. Rollo IM: Drugs used in the chemotherapy of malaria, in Goodman LS, Gilman A (eds): The Pharmacological Basis of Therapeutics. London, MacMillan Co, 1970, p 1120. 3. Lyell H: An eruption resembling scalding of the skin. Br J Dermatol 68:355-361, 1956. 4. Melish ME, Glasgow LA: The staphylococcal scalded skin syndrome. N Engl J Med 282:1114\x=req-\
1119,
1970.
Delayed Blanch in Alopecia Mucinosa To the Editor.\p=m-\Inhis report of
alopecia mucinosa with neurofollicular changes, Burket1 cites an explanation for the delayed blanch phenomenon (of acetylcholine injected into atopic skin), which was postulated by Lobitz and Campbell2 in their report. This explanation, postulating a paradoxic vasoconstriction in the atopic individual, has been supplanted by the the-
ory that the delayed blanch represents edema fluid in the skin that appears after extreme vasodilatation, thus obscuring the erythema. Ram-
use of a photoelectric pulsimeter, and Copeman and Winkelmann,4 with the use of Evans Blue dye intravenously injected, have demonstrated such an outpouring of edema fluid. Ramsey also found evidence of vasodilatation, not vasoconstriction, at the site of methacholine injec-
sey,3 with the
tion. The delayed blanch in alopecia mucinosa may be explained, however, by the phenomenon of denervation supersensitivity.5 This phenomenon is defined as a reduction in the threshold of responsiveness of skeletal muscle and some postganglionic parasympathetic end organs after denervation. In the case under consid¬ eration, the denervated parasympa¬ thetic end organs are hyperreactive to the vasodilator effect of acetylcholine, while denervated sweat glands fail to respond to such direct chemical stimulation, as Burket points out. It is, thus, not necessary to postulate a reversal of the normal vasodilator ef¬ fect of acetylcholine. Stephen P. Stone, MD Springfield, Ill
1. Burket JM: Alopecia mucinosa with neurofollicular changes. Arch Dermatol 110:243-244, 1974. 2. Lobitz WC Jr, Campbell CJ: Physiologic studies in atopic dermatitis (disseminated neurodermatitis). Arch Dermatol 67:575-589, 1953. 3. Ramsey C: Vascular changes accompanying white dermographism and delayed blanch in atopic dermatitis. Br J Dermatol 81:37-43, 1969. 4. Copeman PW, Winkelmann RK: Vascular changes accompanying white dermographism and delayed blanch in atopic dermatitis. Br J Dermatol 81:944-945, 1969. 5. Cannon WB, Rosenblath A, cited in Goodman LS, Gilman A: The Pharmacological Basis of Therapeutics, ed 4. New York, Macmillan Co Publishers, 1970, p 418.
Reply
to Dr. Stone
To the Editor.\p=m-\Iwas pleased to learn of Ramsey, Copeman and Winkelmann's work regarding the delayed blanch as detailed by Dr. Stone. This explanation certainly makes more sense when one considers the clinical situation. Dr. Stone's letter is very appropriate and I appreciate his comments, which I feel help clarify the findings in this patient with alopecia mucinosa.
Downloaded From: http://archderm.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/01/2015
John M.
Burket, MD Medford, Ore
Magnesia Treatment for Acne
To the Editor.\p=m-\Ihave found a nightly topical application of milk of magnesia, when combined with 250mg of tetracycline orally administered four times daily and two daily washes with a fat-free soap, to be highly effective in the reduction of redness from postinflammatory lesions and in the number and severity of acne pustules. Realizing that a laxative as topical medication is not ordinarily prescribed in acne treatment, I write this letter with the two\x=req-\ fold hope that my success in this area may also be shared by those physicians treating this condition, and that this method may become a viable alternative to the abrasion and irrita-
tion inflicted with alcohol- and sulfur\x=req-\ based compounds. Randy Sigal Atlanta Toxic Epidermal Necrolysis To the Editor.\p=m-\RecentlyDrs. Callaway and Tate reported a case of "toxic epidermal necrolysis" caused by gin and tonic.1 We have seen a similar case. A 25-year-old man consulted us about his third episode in 18 months of generalized erythema followed by desquamation after the consumption of gin and tonic. On all three occasions, within six to eight hours after drinking gin and tonic the
patient developed generalized erythema that lasted for two or three days. Eight to ten days later, his skin peeled in sheets from his trunk and extremities and in a glove-like fashion from his palms and soles. Otherwise, he felt well. Flushing and pruritus from quinine have been reported,2 but we could find no mention in the literature of the delayed scarletiniform exfoliation. In addition to this
recently
saw a
patient, we 4-year-old girl who
swallowed an undetermined number of Midol tablets (a mixture of aspirin, caffeine, and cinnamedrine hydrochloride) and subsequently developed generalized erythema and delayed ex¬ foliation identical to that in the first
patient.
In 1956, Lyell coined the term "toxic epidermal necrolysis" to de¬ scribe what now appears to be severe
drug-induced bullous erythema mul¬ tiforme.3 Pediatricians soon picked up the term and applied it to the "scalded skin syndrome," which later was shown to be a specific disease due to an epidermolytic toxin produced by staphylococci.1 Toxic epidermal ne¬ crolysis, of the Lyell type, is a severe and generalized sub-epidermal bul¬ lous process with a 40% to 50% mortal¬ ity rate. Toxic epidermal necrolysis, the staphylococcal type, is a super¬ ficial intra-epidermal process with bulla formation at the level of the
granular layer.
Now that the term "toxic epidermal necrolysis" is widely applied to these two conditions, we must accept this
nomenclature of common usage with the realization that the same name is applied to two etiologically distinct diseases. We would like to discourage the broader use of "toxic epidermal necrolysis" and suggest that the term "toxic exfoliation" might be more ap¬ propriate for these recently reported cases of drug-induced erythema with delayed scarletiniform superficial
desquamation.
1.
Michael Jarratt, MD Andrew Rudolph, MD Houston Tate WE: Toxic epidermal JL, Callaway
necrolysis caused by "gin
and tonic." Arch Dermatol 109:909, 1974. 2. Rollo IM: Drugs used in the chemotherapy of malaria, in Goodman LS, Gilman A (eds): The Pharmacological Basis of Therapeutics. London, MacMillan Co, 1970, p 1120. 3. Lyell H: An eruption resembling scalding of the skin. Br J Dermatol 68:355-361, 1956. 4. Melish ME, Glasgow LA: The staphylococcal scalded skin syndrome. N Engl J Med 282:1114\x=req-\
1119,
1970.
Delayed Blanch in Alopecia Mucinosa To the Editor.\p=m-\Inhis report of
alopecia mucinosa with neurofollicular changes, Burket1 cites an explanation for the delayed blanch phenomenon (of acetylcholine injected into atopic skin), which was postulated by Lobitz and Campbell2 in their report. This explanation, postulating a paradoxic vasoconstriction in the atopic individual, has been supplanted by the the-
ory that the delayed blanch represents edema fluid in the skin that appears after extreme vasodilatation, thus obscuring the erythema. Ram-
use of a photoelectric pulsimeter, and Copeman and Winkelmann,4 with the use of Evans Blue dye intravenously injected, have demonstrated such an outpouring of edema fluid. Ramsey also found evidence of vasodilatation, not vasoconstriction, at the site of methacholine injec-
sey,3 with the
tion. The delayed blanch in alopecia mucinosa may be explained, however, by the phenomenon of denervation supersensitivity.5 This phenomenon is defined as a reduction in the threshold of responsiveness of skeletal muscle and some postganglionic parasympathetic end organs after denervation. In the case under consid¬ eration, the denervated parasympa¬ thetic end organs are hyperreactive to the vasodilator effect of acetylcholine, while denervated sweat glands fail to respond to such direct chemical stimulation, as Burket points out. It is, thus, not necessary to postulate a reversal of the normal vasodilator ef¬ fect of acetylcholine. Stephen P. Stone, MD Springfield, Ill
1. Burket JM: Alopecia mucinosa with neurofollicular changes. Arch Dermatol 110:243-244, 1974. 2. Lobitz WC Jr, Campbell CJ: Physiologic studies in atopic dermatitis (disseminated neurodermatitis). Arch Dermatol 67:575-589, 1953. 3. Ramsey C: Vascular changes accompanying white dermographism and delayed blanch in atopic dermatitis. Br J Dermatol 81:37-43, 1969. 4. Copeman PW, Winkelmann RK: Vascular changes accompanying white dermographism and delayed blanch in atopic dermatitis. Br J Dermatol 81:944-945, 1969. 5. Cannon WB, Rosenblath A, cited in Goodman LS, Gilman A: The Pharmacological Basis of Therapeutics, ed 4. New York, Macmillan Co Publishers, 1970, p 418.
Reply
to Dr. Stone
To the Editor.\p=m-\Iwas pleased to learn of Ramsey, Copeman and Winkelmann's work regarding the delayed blanch as detailed by Dr. Stone. This explanation certainly makes more sense when one considers the clinical situation. Dr. Stone's letter is very appropriate and I appreciate his comments, which I feel help clarify the findings in this patient with alopecia mucinosa.
Downloaded From: http://archderm.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/01/2015
John M.
Burket, MD Medford, Ore
