Correspondence
References 1. Barker DJP, Clancey JK, Morrow RH, Rao S, Transmission of Buruli disease (Letter), BMJ 1970; iv:558. 2. Water MFR. Mycobacterium ulcerans infection. In: Weatherall DJ, Ledingham JGG, Warrell DA, eds. Oxford textbook of medicine, 2nd Ed, 5:314-315. 3.
Revision of the C,D,C, surveillance case definition for acquired immunodeficiency syndrome. MMWR 1987: 36 (Suppl):3-16S.
Granuloma Annulare Arising after Herpes Zoster To the Editor: Granuloma annulare after herpes zoster has been previously described.'"'' These cases seem to be a rare clinical variant of granuloma annulare. We would like to report an additional case; it is the first case in an oriental person to our knowledge. Case Report A 59-year-old woman presented to the department of dermatology in June 1991 with a 4-year history of reddish eruption on the right anterior chest, upper back, inner side of the right upper arm, and elbow joint. In February 1987, she had developed numerous small vesicles, arranged in the Th2-4 dermatomes. A diagnosis of herpes zoster was made, and mephenamic acid, 500 mg three times a day, was given for her pain. Corticosteroids or antiviral agents were not used. She did not develop post-herpetic neuralgia. About 2 months after vesicular lesions resolved, she noticed reddish eruptions in exactly the sites previously affected by herpes zoster, Pbysical examination in June 1991 revealed reddish papules and circinate plaques, arranged in the right Th2-4 dermatomes (Fig, 1), On the inner side of the elbow joint, whitish herpes zoster scars in which reddish shiny papules arose were clearly visible. A biopsy specimen of a reddish plaque on the upper back showed mild collagen degeneration in the upper to mid dermis. It was surrounded by cell infiltrates that consisted of lymphocytes, epithelial cells with occasional giant cells, Alcian blue staining at pH 2,5 revealed a small amount of mucinous material deposition in the areas corresponding to tbe collagen degeneration. There was no prior surgical history, nor a history of STD, hepatitis, or diabetes mellitus. Her fasting blood sugar was 93 mg/100 mL. Oral glucose tolerance test (75 g) was within normal limits. Erythrocyte sedimentation rate, CBC, liver function, urinalysis, chest X-P were normal. In addition, her serum did not show antibodies against l Iiv virus. The skin lesions almost resolved during a 4month period without any specific therapy.
Pityriasis Rotunda and G6PD Deficiency To the Editor: A glucose-6-pbosphate (cfiPD) deficiency has recently been demonstrated in several Sardinian patients affected by familial pityriasis rotunda,' They postulated a probable linkage between pityriasis rotunda and tbe enzymatic defect. We evaluated G6I'D activity in 13 patients (3 men and 10 women), originating from five Sardinian families, all affected by pityriasis rotunda. In men, G6PD was determined on red cells, using the spectrophotometric method,^ while in women, it was evaluated on lympho-mononuclear cells, using the 2-deoxyglucose-6-phosphate (2d/G6PD) utilization test,'This last method allows accurate determination of the degree of mosaicism in different cell populations. Of our 13 patients, only one woman was heterozygous for G6PD deficiency. Our data do ,tot confirm the supposed correlation between G6PD deficiency and pityriasis rotunda. This observation might be a casual finding. In fact, in the area of Oristano (place of origin of the patients reported by Lodi et al,) tbe prevalence of the enzymatic defect is about 35%;*' it may, therefore, be observable without any correlation with the dermatologic disease. Although pityriasis rotunda is common among black Jamaicans and south African Bantus, who have a high prevalence of G6l'D deficiency, it is also frequent in Japan, where the enzymatic defect is very rare; this observation supports our hypothesis of a casual association of pityriasis rotunda and G6PD deficiency. Sergio Piga, M,D, Francesca Cottoni, M,D, Gian Franco Meloni, M,D, Sassari, Italy
Discussion We present a Japanese woman who developed granuloma annulare arising at exactly same sites previously affected by berpes zoster in the thoracic dermatomes. Granulomatous lesions arising after herpes zoster have been described in pa-
References 1, Lodi A, Betti R, Chiarelli G, et al. Familial pityriasis rotunda, IntJ Dermatol 1990; 29:483-485, 2, Battistuzzi G, Esan GJF, Fasuan FA, et al. Comparison of GdA and GdB activities in Nigerians. A study of the variation of the G6PD activity. Am J Hum Genet 197729:31-36. 3, Ferraris AM, Giuntini P, Galiano S, Gaetani GF. 2-Deoxyglucose-6-phosphate dehydrogenase utilization in the study of glucose-6-phosphate dehydrogenase mosaicism. Am J Hum Genet 1981; 33:307-313. 4. Carcassi U, Marcolongo R. Rapporti tra deficit della glucosio-6-fosfato deidrogenasi e talassemia a livello popolazionistico ed individual. Atti Accademia Fisiocritici 1963; 12:606-622.
Figure 1. Reddish papules and circinate plaques. 745
International Journal of Dermatoiogy Vol, 31, No, 10, October 1992
phonuclear leukocytes. Blood lipids were abnormally high. After a short diet, the blood lipids returned to normal range and oral isotretinoin, 0,8 mg/kg/day, was initiated. At a follow-up visit 2 months later, no active disease was observed. Minor scarring and regrowth of hair was noted (Fig. 2).
tients who had chronic lymphocytic leukemia'''^or human immunodeficiency virus infection," In this case, however, hematologic malignancies or immunosuppressive disorders were not found, Granuloma annulare developed 2 months after vesicular lesions or herpes zoster had resolved in the present case. Previous reports'"' and ours demonstrated that intervals between two diseases are relatively short duration, that is within 2 months, except for Packers' case (8 months).^ This may suggest that herpes zoster/varicella virus itself, or tissue antigen altered by virus, directly causes immunologic reaction that leads to granuloma formation. In this case lesions of granuloma annulare almost resolved without any specific therapy in 4 months,
Com,nent
Kazuhito Hayakawa, M,D. Yoshiko Mizukawa, M.D, Tetsuo Shiohara, M,D, Masaji Nagashima, M,D, Tokyo, Japan, References 1, Guill MA, Goette DK. Granuloma annulare at sites of healing herpes zoster. Arch Dermato! 1978; 114:1383, 2, Packer RH, Fields JP, King LE, Granuloma annulare in herpes zoster scars, Cutis 1984; 34:177-179, 3, Friedman SJ, Fox BJ, Albert HL, Granuloma annulare arising in herpes zoster scars: report of two cases and review of the literature. J Am Acad Dermatol 1986; 14: 764-770, 4, Schideler SJ, Richards M, Granuloma annulare arising after herpes zoster. J Am Acad Dermatol 1986; 15: 1049-1050, 5, Kleber R, Landthaler M, Burg G. Postzosterisches granuloma annulare, Hautarzt 1989; 40:110-111, 6, Fischer G, Jaworski R, Granuloma formation in herpes zoster scars [Letter], J Am Acad Dermatol 1987; 16: 1261-1263. 7, Wright AL, Cotton DWK, Winfield DA, et al, Granuloma formation in herpes zoster scars, Dermatologica 1989; 179:45-46, 8,
•,
In view of the relatively scarce number of reports about good response to isotretinoin in PCAS,' we consider this report as another step in making isotretinoin the drug of choice in PCAS. Adrian Herman, M.D, Michael David, M.D. Silvio Pitlik, M.D. Petah Tiqva, Israel Reference 1. Bjellerup M, Wallenger J, Familial perifolliculitis capitis abscedens et suffudiens in two brothers successfully treated with isottetinoin. J Am Acad Dermatol 1990; 23: 752-753. Editorial Note: I have also treated a case of perifolliculitis capitis abscedens et suffodiens with isotretinoin with excellent results. Regretfully, after a few months, the lesions returned. Oral metronidazol was effective for a while, but not local metronidazol. Mauricio Goihman-Yahr, M.D. Section Editor
Langenberg A, Yen TSB, Leboit PE. Granulomatous vasculitis occurring after cutaneous herpes zoster despite absence of viral genome, J Am Acad Dermatol 1991; 24: 429-433, Figure 1. Patient before treatment.
Perifolliculitis Capitis Abscedens et Suffodiens To the Editor: Recently we treated a young man with perifolliculitis capitis abscedens et suffodiens (PCAS) with isotretinoin with excellent response. Case Report A 24-year-old man who had been suffering from acne conglobata at adolescence had a 12-month history of tender suppurating nodules on the scalp. Large areas of alopecia had developed in the affected area (Fig. 1), Two bacterial cultures and two fungal cultures obtained from the affected area were sterile, and therefore, no antibiotics were given, B- and T-lymphocyte function was found regular, Histologic examination of a biopsy specimen showed abscesses filled with polymor-
Figure 2. Patient after treatment.
746
References 1. Barker DJP, Clancey JK, Morrow RH, Rao S, Transmission of Buruli disease (Letter), BMJ 1970; iv:558. 2. Water MFR. Mycobacterium ulcerans infection. In: Weatherall DJ, Ledingham JGG, Warrell DA, eds. Oxford textbook of medicine, 2nd Ed, 5:314-315. 3.
Revision of the C,D,C, surveillance case definition for acquired immunodeficiency syndrome. MMWR 1987: 36 (Suppl):3-16S.
Granuloma Annulare Arising after Herpes Zoster To the Editor: Granuloma annulare after herpes zoster has been previously described.'"'' These cases seem to be a rare clinical variant of granuloma annulare. We would like to report an additional case; it is the first case in an oriental person to our knowledge. Case Report A 59-year-old woman presented to the department of dermatology in June 1991 with a 4-year history of reddish eruption on the right anterior chest, upper back, inner side of the right upper arm, and elbow joint. In February 1987, she had developed numerous small vesicles, arranged in the Th2-4 dermatomes. A diagnosis of herpes zoster was made, and mephenamic acid, 500 mg three times a day, was given for her pain. Corticosteroids or antiviral agents were not used. She did not develop post-herpetic neuralgia. About 2 months after vesicular lesions resolved, she noticed reddish eruptions in exactly the sites previously affected by herpes zoster, Pbysical examination in June 1991 revealed reddish papules and circinate plaques, arranged in the right Th2-4 dermatomes (Fig, 1), On the inner side of the elbow joint, whitish herpes zoster scars in which reddish shiny papules arose were clearly visible. A biopsy specimen of a reddish plaque on the upper back showed mild collagen degeneration in the upper to mid dermis. It was surrounded by cell infiltrates that consisted of lymphocytes, epithelial cells with occasional giant cells, Alcian blue staining at pH 2,5 revealed a small amount of mucinous material deposition in the areas corresponding to tbe collagen degeneration. There was no prior surgical history, nor a history of STD, hepatitis, or diabetes mellitus. Her fasting blood sugar was 93 mg/100 mL. Oral glucose tolerance test (75 g) was within normal limits. Erythrocyte sedimentation rate, CBC, liver function, urinalysis, chest X-P were normal. In addition, her serum did not show antibodies against l Iiv virus. The skin lesions almost resolved during a 4month period without any specific therapy.
Pityriasis Rotunda and G6PD Deficiency To the Editor: A glucose-6-pbosphate (cfiPD) deficiency has recently been demonstrated in several Sardinian patients affected by familial pityriasis rotunda,' They postulated a probable linkage between pityriasis rotunda and tbe enzymatic defect. We evaluated G6I'D activity in 13 patients (3 men and 10 women), originating from five Sardinian families, all affected by pityriasis rotunda. In men, G6PD was determined on red cells, using the spectrophotometric method,^ while in women, it was evaluated on lympho-mononuclear cells, using the 2-deoxyglucose-6-phosphate (2d/G6PD) utilization test,'This last method allows accurate determination of the degree of mosaicism in different cell populations. Of our 13 patients, only one woman was heterozygous for G6PD deficiency. Our data do ,tot confirm the supposed correlation between G6PD deficiency and pityriasis rotunda. This observation might be a casual finding. In fact, in the area of Oristano (place of origin of the patients reported by Lodi et al,) tbe prevalence of the enzymatic defect is about 35%;*' it may, therefore, be observable without any correlation with the dermatologic disease. Although pityriasis rotunda is common among black Jamaicans and south African Bantus, who have a high prevalence of G6l'D deficiency, it is also frequent in Japan, where the enzymatic defect is very rare; this observation supports our hypothesis of a casual association of pityriasis rotunda and G6PD deficiency. Sergio Piga, M,D, Francesca Cottoni, M,D, Gian Franco Meloni, M,D, Sassari, Italy
Discussion We present a Japanese woman who developed granuloma annulare arising at exactly same sites previously affected by berpes zoster in the thoracic dermatomes. Granulomatous lesions arising after herpes zoster have been described in pa-
References 1, Lodi A, Betti R, Chiarelli G, et al. Familial pityriasis rotunda, IntJ Dermatol 1990; 29:483-485, 2, Battistuzzi G, Esan GJF, Fasuan FA, et al. Comparison of GdA and GdB activities in Nigerians. A study of the variation of the G6PD activity. Am J Hum Genet 197729:31-36. 3, Ferraris AM, Giuntini P, Galiano S, Gaetani GF. 2-Deoxyglucose-6-phosphate dehydrogenase utilization in the study of glucose-6-phosphate dehydrogenase mosaicism. Am J Hum Genet 1981; 33:307-313. 4. Carcassi U, Marcolongo R. Rapporti tra deficit della glucosio-6-fosfato deidrogenasi e talassemia a livello popolazionistico ed individual. Atti Accademia Fisiocritici 1963; 12:606-622.
Figure 1. Reddish papules and circinate plaques. 745
International Journal of Dermatoiogy Vol, 31, No, 10, October 1992
phonuclear leukocytes. Blood lipids were abnormally high. After a short diet, the blood lipids returned to normal range and oral isotretinoin, 0,8 mg/kg/day, was initiated. At a follow-up visit 2 months later, no active disease was observed. Minor scarring and regrowth of hair was noted (Fig. 2).
tients who had chronic lymphocytic leukemia'''^or human immunodeficiency virus infection," In this case, however, hematologic malignancies or immunosuppressive disorders were not found, Granuloma annulare developed 2 months after vesicular lesions or herpes zoster had resolved in the present case. Previous reports'"' and ours demonstrated that intervals between two diseases are relatively short duration, that is within 2 months, except for Packers' case (8 months).^ This may suggest that herpes zoster/varicella virus itself, or tissue antigen altered by virus, directly causes immunologic reaction that leads to granuloma formation. In this case lesions of granuloma annulare almost resolved without any specific therapy in 4 months,
Com,nent
Kazuhito Hayakawa, M,D. Yoshiko Mizukawa, M.D, Tetsuo Shiohara, M,D, Masaji Nagashima, M,D, Tokyo, Japan, References 1, Guill MA, Goette DK. Granuloma annulare at sites of healing herpes zoster. Arch Dermato! 1978; 114:1383, 2, Packer RH, Fields JP, King LE, Granuloma annulare in herpes zoster scars, Cutis 1984; 34:177-179, 3, Friedman SJ, Fox BJ, Albert HL, Granuloma annulare arising in herpes zoster scars: report of two cases and review of the literature. J Am Acad Dermatol 1986; 14: 764-770, 4, Schideler SJ, Richards M, Granuloma annulare arising after herpes zoster. J Am Acad Dermatol 1986; 15: 1049-1050, 5, Kleber R, Landthaler M, Burg G. Postzosterisches granuloma annulare, Hautarzt 1989; 40:110-111, 6, Fischer G, Jaworski R, Granuloma formation in herpes zoster scars [Letter], J Am Acad Dermatol 1987; 16: 1261-1263. 7, Wright AL, Cotton DWK, Winfield DA, et al, Granuloma formation in herpes zoster scars, Dermatologica 1989; 179:45-46, 8,
•,
In view of the relatively scarce number of reports about good response to isotretinoin in PCAS,' we consider this report as another step in making isotretinoin the drug of choice in PCAS. Adrian Herman, M.D, Michael David, M.D. Silvio Pitlik, M.D. Petah Tiqva, Israel Reference 1. Bjellerup M, Wallenger J, Familial perifolliculitis capitis abscedens et suffudiens in two brothers successfully treated with isottetinoin. J Am Acad Dermatol 1990; 23: 752-753. Editorial Note: I have also treated a case of perifolliculitis capitis abscedens et suffodiens with isotretinoin with excellent results. Regretfully, after a few months, the lesions returned. Oral metronidazol was effective for a while, but not local metronidazol. Mauricio Goihman-Yahr, M.D. Section Editor
Langenberg A, Yen TSB, Leboit PE. Granulomatous vasculitis occurring after cutaneous herpes zoster despite absence of viral genome, J Am Acad Dermatol 1991; 24: 429-433, Figure 1. Patient before treatment.
Perifolliculitis Capitis Abscedens et Suffodiens To the Editor: Recently we treated a young man with perifolliculitis capitis abscedens et suffodiens (PCAS) with isotretinoin with excellent response. Case Report A 24-year-old man who had been suffering from acne conglobata at adolescence had a 12-month history of tender suppurating nodules on the scalp. Large areas of alopecia had developed in the affected area (Fig. 1), Two bacterial cultures and two fungal cultures obtained from the affected area were sterile, and therefore, no antibiotics were given, B- and T-lymphocyte function was found regular, Histologic examination of a biopsy specimen showed abscesses filled with polymor-
Figure 2. Patient after treatment.
746
