Journal of the American Academy of Dermatology

792 Correspondence stated that many patients had varicose veins or changes of venous insufficiency, but they did not define the word many. Objectively, one could measure light reflection rheography or photoplethysmography to characterize the extent of venous hypertension. Certainly other noninvasive diagnostic techniques, including continuous-wave venous Doppler and duplex scanning, can also be performed to search for an underlying incompetent perforating vein as the primary etiologic event for the venous ulceration. Careful clinical and noninvasive diagnosis of leg ulceration is important because the incidence of malignant ulceration from nonvenous causes is far greater than malignant degeneration of venous ulcers. Therefore one would have a greater clinical suspicion of carcinoma in ulcerations without obvious venous disease. Finally, to reinforce the primary message of Phillips et al., we too have recently reported the development of a basal cell carcinoma arising in an ulcer in the setting of chronic venous insufficiency in a 77-year-old woman. The ulceration had been present for a t least 6 years, and an incompetent communicating vein was found at the base of the ulceration. I This article once again reinforces the need for phlebology training within dermatology residency.

Mitchel P. Goldman, MD 850 Prospect St., Suite 2 La Jolla, CA 92037

REFERENCES I. Goldman MP. Sclerotherapy treatment of varicose and telangiectaticleg veins. St Louis:Mosby-Year Book,1991 :49. 2. Falanga Y, Moosa HH, Nemeth AJ, et a1. Dermal pericapillary fibrin in venous disease and venous ulceration. Arch DermatoI1987;123:620-3. 3. Ruckley CV, Dale JJ, Callum MJ, et al. Causes of chronic leg ulcer. Lancet 1982;2:615-6.

Nonhealing leg ulcers To the Editor: I was interested to read the brief report of basal cell carcinomas (BCCs) presenting as nqphealing ulcers, published by Phillips et al. (J AM ACAD DERMATOL 1991;25:47-9). I agree with the authors that one should consider BCC in any leg ulcer that fails to heal, in particular, an ulcer that is situated at an atypical site for a venous or stasis ulcer. However, in their article the authors fail to mention a much larger series of cases (21 patients), which was published in 1983. 1 Although BCes appear to be much more common on the legs than has previously been recognized, it is interesting to note that in some of our cases we found histologic evidence of multifocal BeC development in skin adjacent to the ulcers. This suggested to us that chronic venous stasis can induce epidermal hyperplasia and that this is somewhat similar to the epidermal hyperplasia that can occur overlying

dermatofibromas.I Perhaps, in both situations the epidermal hyperplasia can lead to frank basal cell carcinomatous change and thus account for the development of BCCs at sites of venous stasis.'

Martin M. Black, MD, FRCP, FRCPath 21 Deansway, Hampstead Garden Suburb

London, N2 ONF,

u.s:

REFERENCES 1. BlackMM, WalkdenVM. Basalcellcarcinomatous changes on the lower leg: a possible association with venous stasis. Histopathology 1983;7:219-27. 2. Halpryn HJ, Allen AC. Epidermal changesassociated with sclerosing hemangiomas. Arch Dermatol 1964;90:271-3. 3. Caron GA, Clink HM. Clinicalassociation of basalcell epitheliomawithhistiocytoma. Arch Dermatol1964;90:271-3.

Reply To the Editor: We thank Dr. Black for his comments and apologize for the inadvertent omission of his excellent article from our references. We agree with Dr. Goldman that objective findings as well as clinical examination are helpful in the diagnosis of venous insufficiency. Seven of the eight patients in our report had previously been under the care of vascular surgeons who had made the clinical diagnosis of venous insufficiency confirmed by vascular studies. Light reflection rheography and photoplethysmography have several disadvantages because the transducer signal is susceptible to fluctuations reflecting the vasoactivity of the microcirculation.' Baseline variations are frequently seen that make accurate assessment ofthe venous refilling time as well as the interpretation of pressure changes difficult. We prefer to perform duplex ultrasound imaging, which is a straightforward practical method allowing the assessment of anatomic structures as well as defining function.' We are not aware of any literature documenting the incidence ofmalignant ulceration from nonvenous causes as being far higher than malignant degeneration of venous ulcers. The dermatology residents in our program, and certainly in many other training centers, are provided extensive exposure to the cutaneous manifestations of venous disease as well as diagnostic and therapeutic modalities. Tania J. Phillips, MD, and Gary S. Rogers, MD Department ofDermatology Boston University School of Medicine 71 E. Concord St. Boston, MA 02118

REFERENCE 1. Coleridge-Smith P. Non-invasive venous investigation. Vase Med Rev 1990;1:139-66.

Nonhealing leg ulcers.

Journal of the American Academy of Dermatology 792 Correspondence stated that many patients had varicose veins or changes of venous insufficiency, bu...
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