Letters to the Editor


8 Riva MA, Riva E, Spicci M, Strazzabosco M, Giovannini M, Cesana G. “The city of Hepar”: rituals, gastronomy and politics at the origins of the modern names for the liver. J Hepatol 2011; 55: 1132–1136. DOI: 10.1111/jdv.12663

Topical corticosteroid phobia among parents of children with atopic dermatitis in a semirural area of Norway Editor Topical corticosteroids (TCS) are important in the treatment of atopic dermatitis (AD), but many parents of children with AD are sceptical to their use having heard or read about possible side-effects.1 Such negative attitudes towards TCS are often termed TCS phobia and may lead to low treatment adherence, poor effect of treatment and reduced quality of life. Most studies on TCS phobia have been performed in large urban populations,2–5 and to the best of our knowledge none in Scandinavia. We wanted to study attitudes towards the use of TCS among parents of children with AD in a semirural area in Norway. We prepared and pilot-tested a questionnaire on attitudes towards and knowledge about TCS based on other similar questionnaires.2,3 Questions on disease severity and age were not included. The questionnaire was sent to parents of children aged 0–10 years (n = 127) treated for AD in a specialist practice with two part-time dermatologists in the small town of Hønefoss, Norway (population in 2012: 14 000). Seventy-seven completed questionnaires (60%) were returned. Forty-nine respondents (64%) reported that they worry ‘much’ or ‘a lot’ using TCS on their child. Of these, 45 reported that they did not use physician-prescribed TCS due to these worries ‘very often’ or ‘often’ (n = 10) or sometimes (n = 35). The most frequent reasons for concern were side-effects, especially thinning of the skin. Common sources of information on TCS were dermatologists (70%), general practitioners (55%), package leaflets (46%) and pharmacies (38%). Only 12 respondents (9%) were able to identify the potency of the four most commonly used TCS in Norway. Twelve respondents (9%) gave systematically incorrect answers on corticosteroid potency, possibly on the basis of the percentage declared on the package. There was no correlation between worries regarding TCS and level of knowledge on corticosteroid potency. Our study indicates that TCS phobia among parents of children with AD is as frequent in a small town with surrounding rural districts in Norway as in major cities in other countries.2–5 The study is small and undertaken without extensive validation

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of the questionnaire. The TOPICOP scale for evaluating TCS phobia in AD patients and their parents6 was published after the completion of our study. In our opinion, the term TCS phobia is a misnomer, as negative attitudes against TCS is not without some rationale; misuse of TCS may indeed lead to adverse side-effects. In their encounters with parents of children with AD, clinicians should explore parents’ attitudes towards TCS to personalize patient management and avoid poor treatment adherence. H.E. Gustavsen,1,2 P. Gjersvik1,2,* 1

Institute of Clinical Medicine, University of Oslo, Oslo, Norway 2 Department of Dermatology, Oslo University Hospital, Oslo, Norway *Correspondence: P. Gjersvik. E-mail: [email protected]

References 1 Charman C, Williams H. The use of corticosteroids and corticosteroid phobia in atopic dermatitis. Clinics Dermatol 2003; 21: 193–200. 2 Charman CR, Morris AD, Williams HC. Topical corticosteroid phobia in patients with atopic eczema. Br J Dermatol 2000; 142: 931–936. 3 Hon K-LE, Kam W-YC, Leung T-F et al. Steroid fears in children with eczema. Acta Paediatr 2006; 95: 1451–1455. 4 Aubert-Wastiaux H, Moret L, Le Rhun A et al. Topical corticosteroid phobia in atopic dermatitis: a study of its nature, origins and frequency. Br J Dermatol 2011; 165: 808–814. 5 Kojima R, Fujiwara T, Matsuda A et al. Factors associated with steroid phobia in caregivers of children with atopic dermatitis. Ped Dermatol 2013; 30: 29–35. 6 Moret L, Anthoine E, Aubert-Wastiaux H et al. TOPICOP©: a new scale evaluating topical corticosteroid phobia among atopic dermatitis outpatients and their parents. PLoS ONE 2013; 8: e76493. DOI: 10.1111/jdv.12670

Nocardia beijingensis outside of Asia Editor A 47-year-old male, renal transplant patient presented to our dermatology clinic. He was under three medications: cyclosporine, methylprednisolone and mycophenolate mofetil. Four months ago while walking in the woods, near the Mediterranean sea, his right thigh was scratched by a bush. After 2 weeks, a red slightly painful lesion appeared on the site of the wound. No other important findings on his skin or mucosa and no locoregional lymphadenopathy were found. Upon physical exam, a nodular lesion that emitted purulent material was observed (Fig. 1). Differential diagnoses considered were sporotrichosis and atypical mycobacteria. CBC with differential and pulmonary and abdominal CT were within normal limits. Ecography demonstrated oedema with thickening of the adipose tissue in the overlying fascia.

© 2014 European Academy of Dermatology and Venereology

Letters to the Editor


East China. Pulmonary human infections were subsequently observed in Thailand and Japan. However, N. beijingensis outside of these geographic areas is exceptional. This is perhaps the third documented case of this species outside of Asia.1–3 It likely that this species is underreported due to the lack of gene sequencing and amplification performed upon confirming the presence of Nocardia. Although, a previous case report attributed the presence of cutaneous N. beijingensis in Europe due to leg trauma during professional contact with imported wood products,2 this explanation does not hold for the present clinical case. Meena Arunachalam,1,* Massimiliano Galeone,1 Andrea Bassi,1 Federica Scarfi,1 Alessandro Mariottini,2 Maria Tullia Simonetti,3 Elisa Difonzo1 1

Department of Translational Medicine and Surgery, Division of Dermatology, 2Department of Cytogenetics and Genetics, and 3 Department of Microbiology and Virology, University of Florence, Florence, Italy *Correspondence: M. Arunachalam. E-mail: [email protected]


Figure 1 Nocardia beijingensis. Nodular lesion with emission of purulent material.

Mycological investigation was negative. However, culture on L€ owenstein Jensen medium demonstrated growth of numerous colonies of a Gram-positive, filamentous, ramifying bacteria, supporting our final diagnosis of primary cutaneous nocardiosis. Using amplification and gene 16s rRNA sequencing, we were able to identify the species as Norcardia beijingensis. Treatment with ciprofloxacin for 3 weeks led to complete resolution of the lesion. Primary cutaneous nocardiosis is a bacterial infection of the genus Nocardia, a saprophyte that is present in the ground. The infection is always due to a traumatic inoculation of the bacteria. The two species more commonly involved are N. brasiliensis and N. otitidiscaviarum. There are three possible presentations: lymphocutaneous infection, mycetoma and a superficial infection with abscess and cellulitis as seen in the present clinical case. N. beijingensis responds well to antibiotic therapy.1 Other than ciprofloxacin, garenoxacin (400 mg⁄day) for 2 weeks has shown complete healing,1 while the use of Sulfamethoxazole (800 mg)-Trimethoprim (160 mg) six times a day showed an improvement of the cutaneous lesions.2 In the case of partial regression and a limited area of infection, surgery can be considered in addition to antibiotic therapy. In current literature, N. beijingensis has been shown to be extremely diffuse in Asia, where it was identified for the first time in 2001 in the soil of the Xishan mountain, in

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1 Ohmori S, Kobayashi M, Yaguchi T, Nakamura M. Primary cutaneous nocardiosis caused by Nocardia beijingensis in an immunocompromised patient with chemotherapy for advanced prostate cancer. J Dermatol 2012; 39: 740–741. 2 Derancourt C, Theodose R, Deschamps L et al. Primary cutaneous nocardiosis caused by Nocardia beijingensis. Br J Dermatol 2012; 167: 216– 218. 3 Crozier JA, Andhavarapu S, Brumble LM, Sher T. First report of Nocardia beijingensis infection in an immunocompetent host in the United States. J Clin Microbiol 2014; 52: 2730–2732. DOI: 10.1111/jdv.12671

Successful treatment of mutilating palmoplantar keratoderma with acitretin capsule and adapalene gel: a case report with review of the literature Editor A 26-year-old man, who was born of a non-consanguineous marriage and worked as a mason, was referred to our hospital with multiple skin lesions on his palms and soles. Hyperkeratosis had developed on his feet 7 years ago, and a few months later, he experienced pain owing to verrucous hyperplasia in the keratinized lesions. Gradually, similar lesions were noted on his hands. During the course of these 7 years, he received several

© 2014 European Academy of Dermatology and Venereology