Volume 26 Number 5, Part 1 May 1992
4. 5. 6. 7. 8.
menschlischen haut. Arb Physiol-anstalt, Leipzig 1875; 10:69. Heuter C. Die cheilangioscopie, eine neueuntersuchsmethode zu physiologischen und pathologischen zwechen. Zentralb Med Wissensch 1879;13:225. Glickman FS. Capillary microscopy and dermatoscopy: a historicreview. Thesiswritten forfellowship in theAmerican College of Physicians. 1964. Rapp J, Glickman FS, Frank L. Capillarymicroscopy in induced skin inflammation. Arch Dermatol 1963;88:257-66. Glickman FS, Rapp J, Frank L. Capillarymicroscopy in inflammatory dermatoses. Arch Dermatol 1964;90:500-5. Glickman FS. Capillarymicroscopic evidence for the existenceof a psoriatic angiogenic factor [Letter].Arch DermatoI1976;112:1789.
Reply To the Editor: We are indebted to Dr. Glickman for his elaborateletteronthe history ofcapillaroscopy. Although someof his quotations werefamiliar to us,weadmit that his papers on inflammatory capillary changes were not. We are well aware that the changesdescribed in our articleare neithernewnor specific for thediseases discussed. The new aspectof our contribution, however, is that the morphologic observations are presented in a quantitative manner therebyallowing forstatisticalanalysis and comparison. Generally this was not performed before the introduction of electronic media into the clinical laboratory, perhaps becauseit neededrather tedious graphictechniques such as applied by Rouen et al.1 The introduction of television (TV) microscopy by Bollinger et al.?firstresulted in quantitative measurements of dynamic phenomena such as blood cellvelocity or flow types. TV microscopy allowed the introduction offluorescence microscopy' and the development of dynamic examinations by a local cooling test," Another example of a quantitative dynamic measurementisthe high-fidelity pressure recording outof fingernailfold capillaries withthe use ofelectronic servonullingmicropressure systems insteadof static pressuremanometers.' There are relatively few quantitative studies of capillarymorphology. The specific changes of the nailfold capillaries in scleroderma-like disorders, the so-called scleroderma pattern as described by H. Maricq, were perhaps too obvious to be defined quantitatively. Later, she also introduced a quantitative parameter to specify her results." The aim of our approachis to determinethevalueand the limitations ofquantitativecapillaroscopy, ononehand to avoid overstatements ashavebeenmadeinthepast and onthe other,tofurther establish thismethod asan adjunct to diagnosis in the individual patient as well as an objective parameter for statistically controlled follow-up studies in patient groups. Nonspecific but significant
Correspondence 791 changes are not only found in connective tissue diseases as described inour article, but also in arterialand venous disorders as well as in diabetes. Weare encouraged to pursue this approach because the development of electronics including computer technology promises to further facilitate quantitative sampling of objective data.
Felix Mahler, MD,a and Thomas Hunziker, MD,b Angiology Division, Dept. of Medicine, a andDept. of Dermatology,b University of Bern, Switzerland REFERENCES 1. Rouen LR, Terry EN, Doft BA, et al. Classification and measurement ofsurface microvessels in man. Microvasc Res 1972;4:285-92. 2. Bollinger A,ButtiP, BarrasJP, eta!' Redblood cell velocity in nailfold capillaries of man measured by a television microscopy technique. Microvasc Res 1974;7:61-72. 3. Bollinger A, Frey J, Jager K, et al. Patterns of diffusion throughskin capillaries in patients with long-term diabetes. N EnglJ Med 1982;307:1305-10. 4. Mahler F, Saner H, Boss C, et al, Localcold exposure test for capillaroscopic examination of patients with Raynaud's syndrome. Microvasc Res 1987;33:422-7. 5. MahlerF, Muheim MH, Intaglietta M, eta!.Blood pressure fluctuations in human nallfold capillaries. Am J Physiol 1979;236:888-93. 6. Maricq HR. Comparison ofquantitative andsemiquantitative estimates of nailfold capillary abnormalities in scleroderma spectrum disorders. Microvasc Res 1986;32:271-6.
Nonhealing.leg ulcers: A manifestation of basal
cell carcinoma .. ~
To theEditor: I would like to comment onthe articleby Phillips et a!. (J AM ACAD DERMATOL 1991;25:47-9). Althoughthere have beenfewer than 75case reports of malignantdegeneration ofa stasis ulcerin the world literature,' recognition of this complication, as detailed in the articlebyPhillips et al.,isimportant. I agreewiththe authorsthat a biopsy specimen should beobtained of any leg ulcer that does not begin to respond to treatment within3 months. However, I question the "clinical" diagnosis of venous ulcer given to the majority of the eight patients cited in the aforementioned study. For an ulcer to be diagnosed as a venous or stasis or gravitational ulceration, objective measurements as well as clinical examination need to be performed. The most common site fora cutaneous ulceration in the setting of venostasis disease is the gaiterarea, especially the medial malleolar region. 2• 3 Only oneof the eightpatients in the study by Phillips et a!. had anulceration inthisarea.I question how the diagnosis of "venous" ulcer was made. The authors
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.
4. 5. 6. 7. 8.
menschlischen haut. Arb Physiol-anstalt, Leipzig 1875; 10:69. Heuter C. Die cheilangioscopie, eine neueuntersuchsmethode zu physiologischen und pathologischen zwechen. Zentralb Med Wissensch 1879;13:225. Glickman FS. Capillary microscopy and dermatoscopy: a historicreview. Thesiswritten forfellowship in theAmerican College of Physicians. 1964. Rapp J, Glickman FS, Frank L. Capillarymicroscopy in induced skin inflammation. Arch Dermatol 1963;88:257-66. Glickman FS, Rapp J, Frank L. Capillarymicroscopy in inflammatory dermatoses. Arch Dermatol 1964;90:500-5. Glickman FS. Capillarymicroscopic evidence for the existenceof a psoriatic angiogenic factor [Letter].Arch DermatoI1976;112:1789.
Reply To the Editor: We are indebted to Dr. Glickman for his elaborateletteronthe history ofcapillaroscopy. Although someof his quotations werefamiliar to us,weadmit that his papers on inflammatory capillary changes were not. We are well aware that the changesdescribed in our articleare neithernewnor specific for thediseases discussed. The new aspectof our contribution, however, is that the morphologic observations are presented in a quantitative manner therebyallowing forstatisticalanalysis and comparison. Generally this was not performed before the introduction of electronic media into the clinical laboratory, perhaps becauseit neededrather tedious graphictechniques such as applied by Rouen et al.1 The introduction of television (TV) microscopy by Bollinger et al.?firstresulted in quantitative measurements of dynamic phenomena such as blood cellvelocity or flow types. TV microscopy allowed the introduction offluorescence microscopy' and the development of dynamic examinations by a local cooling test," Another example of a quantitative dynamic measurementisthe high-fidelity pressure recording outof fingernailfold capillaries withthe use ofelectronic servonullingmicropressure systems insteadof static pressuremanometers.' There are relatively few quantitative studies of capillarymorphology. The specific changes of the nailfold capillaries in scleroderma-like disorders, the so-called scleroderma pattern as described by H. Maricq, were perhaps too obvious to be defined quantitatively. Later, she also introduced a quantitative parameter to specify her results." The aim of our approachis to determinethevalueand the limitations ofquantitativecapillaroscopy, ononehand to avoid overstatements ashavebeenmadeinthepast and onthe other,tofurther establish thismethod asan adjunct to diagnosis in the individual patient as well as an objective parameter for statistically controlled follow-up studies in patient groups. Nonspecific but significant
Correspondence 791 changes are not only found in connective tissue diseases as described inour article, but also in arterialand venous disorders as well as in diabetes. Weare encouraged to pursue this approach because the development of electronics including computer technology promises to further facilitate quantitative sampling of objective data.
Felix Mahler, MD,a and Thomas Hunziker, MD,b Angiology Division, Dept. of Medicine, a andDept. of Dermatology,b University of Bern, Switzerland REFERENCES 1. Rouen LR, Terry EN, Doft BA, et al. Classification and measurement ofsurface microvessels in man. Microvasc Res 1972;4:285-92. 2. Bollinger A,ButtiP, BarrasJP, eta!' Redblood cell velocity in nailfold capillaries of man measured by a television microscopy technique. Microvasc Res 1974;7:61-72. 3. Bollinger A, Frey J, Jager K, et al. Patterns of diffusion throughskin capillaries in patients with long-term diabetes. N EnglJ Med 1982;307:1305-10. 4. Mahler F, Saner H, Boss C, et al, Localcold exposure test for capillaroscopic examination of patients with Raynaud's syndrome. Microvasc Res 1987;33:422-7. 5. MahlerF, Muheim MH, Intaglietta M, eta!.Blood pressure fluctuations in human nallfold capillaries. Am J Physiol 1979;236:888-93. 6. Maricq HR. Comparison ofquantitative andsemiquantitative estimates of nailfold capillary abnormalities in scleroderma spectrum disorders. Microvasc Res 1986;32:271-6.
Nonhealing.leg ulcers: A manifestation of basal
cell carcinoma .. ~
To theEditor: I would like to comment onthe articleby Phillips et a!. (J AM ACAD DERMATOL 1991;25:47-9). Althoughthere have beenfewer than 75case reports of malignantdegeneration ofa stasis ulcerin the world literature,' recognition of this complication, as detailed in the articlebyPhillips et al.,isimportant. I agreewiththe authorsthat a biopsy specimen should beobtained of any leg ulcer that does not begin to respond to treatment within3 months. However, I question the "clinical" diagnosis of venous ulcer given to the majority of the eight patients cited in the aforementioned study. For an ulcer to be diagnosed as a venous or stasis or gravitational ulceration, objective measurements as well as clinical examination need to be performed. The most common site fora cutaneous ulceration in the setting of venostasis disease is the gaiterarea, especially the medial malleolar region. 2• 3 Only oneof the eightpatients in the study by Phillips et a!. had anulceration inthisarea.I question how the diagnosis of "venous" ulcer was made. The authors
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.
