Volume 24 Number 2, Part 1 February 1991
ment sound incentives for development, but also realize that industry may push for widespread use in advance of unequivocal, peer-reviewed evidence of effectiveness. It seems that health care reimbursements for newly "approved" therapies may be directly and indirectly providing the corporate incentive to support their further refinement. Such a strategy may prove unsound in the future as the health care financing crisis deepens. The introduction of new therapies must be responsibly monitored by the dermatologic partners in academic-corporate relationships if the specialty hopes to maintain independence and integrity.
Steven D. Resnick, MD, Departments ofDermatology and Pediatrl'cs, University ofNorth Carolina at Chapel Hill, Chapel Hill, NC 27514 REFERENCES
1. Edelson R, Berger C, Gasparro F, et al. Treatment of cuta-
neous T-cell lymphoma by extracorporeal photochemotherapy. N Engl J Med 1987;316:297-303. 2. Chren M, Landefeld CS, Murray TH. Doctors, drug companies, and gifts. lAMA 1989;262:3448-51. 3. Storrs Fl. Drug samples. A conflict of interest? Arch DermatoI1988;124:1283-5.
Ichthyosis and dermatophyte fungal infection To the Editor: The presence of multiple cutaneous diseases in one patient can easily be a source of confusion. Identification of one condition can easily delay the diagnosis of the other when the diseases exhibit similar symptoms. A recent article by Shelley et al. (J AM ACAD DERMATOL 1989;20:1133-4) suggested that dermatophyte infection is rarely recognized in patients who also have congenital ichthyosis. In fact, the authors identified only four previous reported cases. We have had experience with a similar patient. The fungal infection had gone unrecognized for many years and all aspects of her scaling were assumed to be caused by ichthyosis. A 31-year-old woman had had extensive scaling since birth, Nail changes had appeared when she was 5 years of age and a scalp infection was noted then as well. Recurring scalp infections eventually resulted in extensive scarring and total hair loss. A clinical diagnosis of congenital ichthyosiform erythroderma had been made, but the patient reported that no biopsies had ever been done. Examination revealed onychodystrophy on some fingernails and all toenails. The trunk and extremities showed large dark scales and poorly marginated hyperkeratotic plaques. An examination with KOH of truncal skin scale revealed hyphae that were subsequently proved by culture to be Trichophyton rubrum. A biopsy specimen supported the clinical diagnosis oflamellar ichthyosis. Treat-
Correspondence 321 ment with griseofulvin (500 mg twice a day) and topical lubrication led to a significant degree of improvement. The fingernails cleared completely and the toenails improved. Moderate scaling on the trunk and extremities continued. 13-cis-Retinoic acid was subsequently prescribed and nearly all remaining scale cleared. Maintenance treatment with isotretinoin (Accutane) (Roche Dermatologies, Nutley, N.J.) has resulted in continued relief for the patient.
Kydee Sheetz and Peter J. Lynch, MD Department of Dermatology University ofMinnesota Minneapolis, MN 55455
Dermatologic problems of musicians To the Editor: I read the clinical review by Rimmer and Spielvogel (J AM ACAD DERMATOL 1990;22:657-63) with great interest. As a percussionist and dermatology resident, I can attest to still another dermatologic malady ofthe musician. Drummers who use the "traditional" grip hold the butt ofthe left drum stick between the thumb and index finger and rest the midshaft of the left stick between the middle and ring fingers. This results in repeated pressure and trauma to the lateral aspect of the middle phalanx of the left ring finger and often results in a single frictional vesicle. This condition usually occurs in beginning percussionists and may temporarily interrupt further study. It eventually resolves with regular practice. I wish to add "drummer's digit" to the list of unique dermatologic problems of musicians. Robert J. Signore, DO, Pontiac Osteopathic Hospital, 50 N. Perry St., Pontiac, MI48058
More dermatologic problems of musicians To the Editor: We read with interest the clinical review "Dermatologic Problems of Musicians" by Rimmer and Spielvogel (J AM ACAD DERMATOL 1990;22:657-63). Although most musical instruments were covered, three notable exceptions were the sitar, the sarod, and the tabla. The sitar is a stringed instrument that is played with a metallic conical cover, called a "mujraf," on the index finger of right hand while the fingers of the other hand stretch the strings. This repeated stretching ofstrings with pressure produces transverse depressions and scars on the pulp spaces of the fingers. In addition, the cover, usually made of nickel, has been known to produce contact dermatitis of the fingertips. The sarod, a stringed instrument, is ptayed with a small
ment sound incentives for development, but also realize that industry may push for widespread use in advance of unequivocal, peer-reviewed evidence of effectiveness. It seems that health care reimbursements for newly "approved" therapies may be directly and indirectly providing the corporate incentive to support their further refinement. Such a strategy may prove unsound in the future as the health care financing crisis deepens. The introduction of new therapies must be responsibly monitored by the dermatologic partners in academic-corporate relationships if the specialty hopes to maintain independence and integrity.
Steven D. Resnick, MD, Departments ofDermatology and Pediatrl'cs, University ofNorth Carolina at Chapel Hill, Chapel Hill, NC 27514 REFERENCES
1. Edelson R, Berger C, Gasparro F, et al. Treatment of cuta-
neous T-cell lymphoma by extracorporeal photochemotherapy. N Engl J Med 1987;316:297-303. 2. Chren M, Landefeld CS, Murray TH. Doctors, drug companies, and gifts. lAMA 1989;262:3448-51. 3. Storrs Fl. Drug samples. A conflict of interest? Arch DermatoI1988;124:1283-5.
Ichthyosis and dermatophyte fungal infection To the Editor: The presence of multiple cutaneous diseases in one patient can easily be a source of confusion. Identification of one condition can easily delay the diagnosis of the other when the diseases exhibit similar symptoms. A recent article by Shelley et al. (J AM ACAD DERMATOL 1989;20:1133-4) suggested that dermatophyte infection is rarely recognized in patients who also have congenital ichthyosis. In fact, the authors identified only four previous reported cases. We have had experience with a similar patient. The fungal infection had gone unrecognized for many years and all aspects of her scaling were assumed to be caused by ichthyosis. A 31-year-old woman had had extensive scaling since birth, Nail changes had appeared when she was 5 years of age and a scalp infection was noted then as well. Recurring scalp infections eventually resulted in extensive scarring and total hair loss. A clinical diagnosis of congenital ichthyosiform erythroderma had been made, but the patient reported that no biopsies had ever been done. Examination revealed onychodystrophy on some fingernails and all toenails. The trunk and extremities showed large dark scales and poorly marginated hyperkeratotic plaques. An examination with KOH of truncal skin scale revealed hyphae that were subsequently proved by culture to be Trichophyton rubrum. A biopsy specimen supported the clinical diagnosis oflamellar ichthyosis. Treat-
Correspondence 321 ment with griseofulvin (500 mg twice a day) and topical lubrication led to a significant degree of improvement. The fingernails cleared completely and the toenails improved. Moderate scaling on the trunk and extremities continued. 13-cis-Retinoic acid was subsequently prescribed and nearly all remaining scale cleared. Maintenance treatment with isotretinoin (Accutane) (Roche Dermatologies, Nutley, N.J.) has resulted in continued relief for the patient.
Kydee Sheetz and Peter J. Lynch, MD Department of Dermatology University ofMinnesota Minneapolis, MN 55455
Dermatologic problems of musicians To the Editor: I read the clinical review by Rimmer and Spielvogel (J AM ACAD DERMATOL 1990;22:657-63) with great interest. As a percussionist and dermatology resident, I can attest to still another dermatologic malady ofthe musician. Drummers who use the "traditional" grip hold the butt ofthe left drum stick between the thumb and index finger and rest the midshaft of the left stick between the middle and ring fingers. This results in repeated pressure and trauma to the lateral aspect of the middle phalanx of the left ring finger and often results in a single frictional vesicle. This condition usually occurs in beginning percussionists and may temporarily interrupt further study. It eventually resolves with regular practice. I wish to add "drummer's digit" to the list of unique dermatologic problems of musicians. Robert J. Signore, DO, Pontiac Osteopathic Hospital, 50 N. Perry St., Pontiac, MI48058
More dermatologic problems of musicians To the Editor: We read with interest the clinical review "Dermatologic Problems of Musicians" by Rimmer and Spielvogel (J AM ACAD DERMATOL 1990;22:657-63). Although most musical instruments were covered, three notable exceptions were the sitar, the sarod, and the tabla. The sitar is a stringed instrument that is played with a metallic conical cover, called a "mujraf," on the index finger of right hand while the fingers of the other hand stretch the strings. This repeated stretching ofstrings with pressure produces transverse depressions and scars on the pulp spaces of the fingers. In addition, the cover, usually made of nickel, has been known to produce contact dermatitis of the fingertips. The sarod, a stringed instrument, is ptayed with a small
