444
CORRESPONDKNCE
British Journal of Dermatology (1992) 1 2 7 .
with adenocarcinoma of the uterus on two previous occasions."'This is the first report of a patient with uterine adenocarcinoma heralded by a combination of these two paraneoplastic cutaneous conditions. This emphasizes the need to screen patients presenting with these signs for the presence of internal malignancy. Department of Dermatology and *Pathology, BdUful Citi) Hospital. Belfast BT9 7Ali, Northern Ireiand.
K.E.MCKENNA D.HAYES* I.C.McMlM,AN
The first, a 2 5-year-old woman, developed a painful linear erythema of her chin and neck (Fig. 1) 48 h after IIVA irradiation. Subsequent enquiry revealed that this line corresponded to the bath water level. The second patient, a 21 -yearold woman, developed phototoxic burning at sites in contact with the bath; on the back of her shoulders and arms (Fig. 2) and buttock.s. The third patient, a 47-yeiir-old male, developed a linear phototoxic burn affecting the backs of his shoulders and backs of his arms, again corresponding to the bath water level. It transpired that, contrary to our advice, he was a bathtime reader!
References 1 Schewach-Millet M, Shpiro D, /iv R. 'I'rau H. Siibacute cutaneous lupus erythcinatasus iissocialt'd with breast carcinoma. / Am Aaid Dermato! 1988: 19: 406-S. 2 Kuhn A, Kaufmann I. Subakuter kataner Lupus erythematodes als paraneoplastischcs Syndrom. Z Hautkr 19S6: 61: 5R1-3 (Cer.l (Eng, Abstr.). 3 Laugier P. Lupus crylhcniatcux gyratus rcpens. Ann Dermalol Venercol 1977: ]04:464-f.. 4 Blanc D. Kienzler J-L. Lupus erythcmatosus gyratiis repens. Report of a case associated with a lung carcinoma. Clin Exp Dcniuttol 1982: 7: I 2 9 - i 4 . 5 Neumann R, Schmidt JB. Niebauert"!. Subacute lupus erythematosus-like gyrate erythema./>micJ(»%ir(j ]98(i: 173: 14f»-9. 6 Sonthcimer RD, Thomas JR, tlilliam |N. Subacute cutaneous lupus erythematosus. Arch Lkrmatol 1979; 115: 1409-1 S. 7 Sonthelmer RD, Maddison P]. Rcichlin M el at. Serologic and HLA associations iu subacutc cutaneous lupus erythematosus, a clinical subset of lupus erythematosus. Ann Intern Med 1982:97: f)f)471. 8 Herrero C, Bielsa I, Font J et al. Subacute cutaneous lupus erythematosus: clinicopathologic findings in thirteen cases. / Am Avad Ihrmatol 1988: 19: 1057-62. 9 )emec CBIL llypertrichosis lanuginosa acquisita. Report of a case and review ol'the literature. Arch Dcrmatol 19Sf); 122: 8l)S-8. 10 Hovenden AL. Acquired iiypertrichosis lanuginosa associated with malignancy. Ardi Ifilmi Mfrf 1987; 147: 2013-18. 11 Kaiser IH, Perry G, Yoonessi M. Acquired hypertrichosis lanuginosa associated with endometrial malignancy. Obstet Gfinecat 1976:47:479-82. 12 Kassis V. Kassis E. Keiding L. Thornsen HK. Hypertrichosis lanuginosa acquisita associated with multiple malignancies. / Am Acadt^malol ISSS: 12: 1106-7.
Unusual pattern of phototoxic burning following trimethylpsoralen (TMP) bath photochemotherapy (PUVA) SIR, Trimethylpsoralen ITMP) bath PUVA is an established psoriasis treatment used particularly in Scandinavia but also in mainland Europe. It has been attracting increasing attention for its advantages in selected patients. We would like to draw attention to an adverse-effect of this treatment which, to our knowledge, has not been reported previously. Shortly after we introduced TMP bath PUVA, three patients in the early stages of their treatment developed unusual patterns of phototoxic burning which necessitated modification of the treatment.
Figure i.
Figure 2.
TMP powder appears to be virtually insoluble in water. HPLC studies indicate variable concentration in the bath. Furthermore, filtered TMP bath water contains virtually none of the drug (unpublished data generated from our ongoing studies into TMP solubility). It appears that despite attempts to dissolve the powder in boiling water, it remains a microcrystalline suspension within the bath. It is therefore likely that the varying distribution within the bath water results in a variation in the pattern of cutaneous phototoxicity. We are at present investigating different ways of dissolving/suspending the TMP powder in bath water. In the meantime, we have overcome our patients' problems by advising them to agitate the water continually with their hands during immersion in the bath. In addition, they are also
British Journal of Dermatology (1992) 127.
CORRESPONDENCE
asked to vary intermittently their position in the bath. This appears to produce a more uniform drug distribution and prevent the unusual patterns of phototoxicity experienced by our Hrst few patients. We continue to use TMP bath PlIVA for selected patients. It has particular advantages over systemic PUVA in the treatment of patients who have renal or hepatic failure or. (in view of its higher photosensitizing capacity and lower UVA irradiation times), those who are unable to tolerate long treatment times. Pliotobiology Unit. NineweHs liospital. Dundee DDl 9SY. U.K.
S.A.GEORGE ].FERGUSON
r,esional biislering following narrow-band (TI--01) UVB phototherapy for psoriasis: a report of four cases STR. Narrow-band (312±2 nm) UVB phototherapy, using l'hilips TI,-OI fluorescent lamps, is being increasingly used in the management of psoriasis, primarily because of its reported increased efficacy and safety when compared with older broadband UVB (270-350 nm) sources.' Over the past 6 years our experience of treating SOO patients has revealed an uncommon blistering problem, which develops towards the middle of a treatment course, and occurs at the site of psoriatic lesions. We wish to outline our experience of four cases who have developed this problem. Our routine TL-OI phototherapy programme involves commencing treatment at 70% of the patient s minimal erythema dose (MED) value and thereafter thrice weekly irradiation, with increments of 40%. to a maximum dose of 2000 mj/cm' (increments being reduced when adverse effects occur). Therapy is conducted in a stand-up cubicle with 50 tubes and a mean irradiance of 3-8 mW/cm^.
445
Case 1. An 18-year-old woman, skin type I. with a 2-year history of psoriasis refractory to topical therapy, developed asymptomatic blisters at the sites of virtually resolved psoriatic plaques on her abdomen and breasts during narrow-band UVB (T1,-()I) phototherapy. The blisters varied in size from 0-5 to I-5 cm in diameter. Blistering arose 12-24 h after her fifteenth treatment at 1074 m|/cm-. representing 3 8 times her initial MED. No systemic or topical photosensitizers had been used: psoriasis, had previously received four courses of oral 8-MOP PUVA and two courses of TL-Ol phototherapy with good results, and no adverse effects. During her third course of her only medication was the oral contraceptive pill. Apart from the mild erythema seen routinely in such patients, her course prior to the eruption of bullae had been unremarkable. The blisters resolved spontaneously despite continuation of treatment without further dose increments. Routine investigations, including plasma porphyrin screen and ANA. were negative. Histology of a skin biopsy demonstrated a blister containing tibrin and neutrophils. with a roof of necrotic keratinocytes. The underlying epithelium lacked a granular layer and was mitotically active. A mild perivascular inflammatory intiltrate was present in the dermis. The appearances suggested a reepithelializing subepidermal blister. Direct immunofluoresence was negative. Case2. A 15-year-old girl, skin type 3. developed asymptomatic blistering (Fig. 1) at the sites of re.solving psoriasis after 11 irradiation sessions at a dose of 1289 mj/cm-. representing J 3 times her initial MED. Uninvolved skin did not show abnormal photosensitivity. Her irradiation dose was reduced, and subsequent increments were restricted to 10% of her previous dose. Her subsequent treatment was uneventful despite receiving doses higher than that which presumably induced the blisters. She was not receiving either topical or systemic photoactive therapy.
Figure 1. Case 2. Blisters occurring on resolving plaques i)f psoriasis.
CORRESPONDKNCE
British Journal of Dermatology (1992) 1 2 7 .
with adenocarcinoma of the uterus on two previous occasions."'This is the first report of a patient with uterine adenocarcinoma heralded by a combination of these two paraneoplastic cutaneous conditions. This emphasizes the need to screen patients presenting with these signs for the presence of internal malignancy. Department of Dermatology and *Pathology, BdUful Citi) Hospital. Belfast BT9 7Ali, Northern Ireiand.
K.E.MCKENNA D.HAYES* I.C.McMlM,AN
The first, a 2 5-year-old woman, developed a painful linear erythema of her chin and neck (Fig. 1) 48 h after IIVA irradiation. Subsequent enquiry revealed that this line corresponded to the bath water level. The second patient, a 21 -yearold woman, developed phototoxic burning at sites in contact with the bath; on the back of her shoulders and arms (Fig. 2) and buttock.s. The third patient, a 47-yeiir-old male, developed a linear phototoxic burn affecting the backs of his shoulders and backs of his arms, again corresponding to the bath water level. It transpired that, contrary to our advice, he was a bathtime reader!
References 1 Schewach-Millet M, Shpiro D, /iv R. 'I'rau H. Siibacute cutaneous lupus erythcinatasus iissocialt'd with breast carcinoma. / Am Aaid Dermato! 1988: 19: 406-S. 2 Kuhn A, Kaufmann I. Subakuter kataner Lupus erythematodes als paraneoplastischcs Syndrom. Z Hautkr 19S6: 61: 5R1-3 (Cer.l (Eng, Abstr.). 3 Laugier P. Lupus crylhcniatcux gyratus rcpens. Ann Dermalol Venercol 1977: ]04:464-f.. 4 Blanc D. Kienzler J-L. Lupus erythcmatosus gyratiis repens. Report of a case associated with a lung carcinoma. Clin Exp Dcniuttol 1982: 7: I 2 9 - i 4 . 5 Neumann R, Schmidt JB. Niebauert"!. Subacute lupus erythematosus-like gyrate erythema./>micJ(»%ir(j ]98(i: 173: 14f»-9. 6 Sonthcimer RD, Thomas JR, tlilliam |N. Subacute cutaneous lupus erythematosus. Arch Lkrmatol 1979; 115: 1409-1 S. 7 Sonthelmer RD, Maddison P]. Rcichlin M el at. Serologic and HLA associations iu subacutc cutaneous lupus erythematosus, a clinical subset of lupus erythematosus. Ann Intern Med 1982:97: f)f)471. 8 Herrero C, Bielsa I, Font J et al. Subacute cutaneous lupus erythematosus: clinicopathologic findings in thirteen cases. / Am Avad Ihrmatol 1988: 19: 1057-62. 9 )emec CBIL llypertrichosis lanuginosa acquisita. Report of a case and review ol'the literature. Arch Dcrmatol 19Sf); 122: 8l)S-8. 10 Hovenden AL. Acquired iiypertrichosis lanuginosa associated with malignancy. Ardi Ifilmi Mfrf 1987; 147: 2013-18. 11 Kaiser IH, Perry G, Yoonessi M. Acquired hypertrichosis lanuginosa associated with endometrial malignancy. Obstet Gfinecat 1976:47:479-82. 12 Kassis V. Kassis E. Keiding L. Thornsen HK. Hypertrichosis lanuginosa acquisita associated with multiple malignancies. / Am Acadt^malol ISSS: 12: 1106-7.
Unusual pattern of phototoxic burning following trimethylpsoralen (TMP) bath photochemotherapy (PUVA) SIR, Trimethylpsoralen ITMP) bath PUVA is an established psoriasis treatment used particularly in Scandinavia but also in mainland Europe. It has been attracting increasing attention for its advantages in selected patients. We would like to draw attention to an adverse-effect of this treatment which, to our knowledge, has not been reported previously. Shortly after we introduced TMP bath PUVA, three patients in the early stages of their treatment developed unusual patterns of phototoxic burning which necessitated modification of the treatment.
Figure i.
Figure 2.
TMP powder appears to be virtually insoluble in water. HPLC studies indicate variable concentration in the bath. Furthermore, filtered TMP bath water contains virtually none of the drug (unpublished data generated from our ongoing studies into TMP solubility). It appears that despite attempts to dissolve the powder in boiling water, it remains a microcrystalline suspension within the bath. It is therefore likely that the varying distribution within the bath water results in a variation in the pattern of cutaneous phototoxicity. We are at present investigating different ways of dissolving/suspending the TMP powder in bath water. In the meantime, we have overcome our patients' problems by advising them to agitate the water continually with their hands during immersion in the bath. In addition, they are also
British Journal of Dermatology (1992) 127.
CORRESPONDENCE
asked to vary intermittently their position in the bath. This appears to produce a more uniform drug distribution and prevent the unusual patterns of phototoxicity experienced by our Hrst few patients. We continue to use TMP bath PlIVA for selected patients. It has particular advantages over systemic PUVA in the treatment of patients who have renal or hepatic failure or. (in view of its higher photosensitizing capacity and lower UVA irradiation times), those who are unable to tolerate long treatment times. Pliotobiology Unit. NineweHs liospital. Dundee DDl 9SY. U.K.
S.A.GEORGE ].FERGUSON
r,esional biislering following narrow-band (TI--01) UVB phototherapy for psoriasis: a report of four cases STR. Narrow-band (312±2 nm) UVB phototherapy, using l'hilips TI,-OI fluorescent lamps, is being increasingly used in the management of psoriasis, primarily because of its reported increased efficacy and safety when compared with older broadband UVB (270-350 nm) sources.' Over the past 6 years our experience of treating SOO patients has revealed an uncommon blistering problem, which develops towards the middle of a treatment course, and occurs at the site of psoriatic lesions. We wish to outline our experience of four cases who have developed this problem. Our routine TL-OI phototherapy programme involves commencing treatment at 70% of the patient s minimal erythema dose (MED) value and thereafter thrice weekly irradiation, with increments of 40%. to a maximum dose of 2000 mj/cm' (increments being reduced when adverse effects occur). Therapy is conducted in a stand-up cubicle with 50 tubes and a mean irradiance of 3-8 mW/cm^.
445
Case 1. An 18-year-old woman, skin type I. with a 2-year history of psoriasis refractory to topical therapy, developed asymptomatic blisters at the sites of virtually resolved psoriatic plaques on her abdomen and breasts during narrow-band UVB (T1,-()I) phototherapy. The blisters varied in size from 0-5 to I-5 cm in diameter. Blistering arose 12-24 h after her fifteenth treatment at 1074 m|/cm-. representing 3 8 times her initial MED. No systemic or topical photosensitizers had been used: psoriasis, had previously received four courses of oral 8-MOP PUVA and two courses of TL-Ol phototherapy with good results, and no adverse effects. During her third course of her only medication was the oral contraceptive pill. Apart from the mild erythema seen routinely in such patients, her course prior to the eruption of bullae had been unremarkable. The blisters resolved spontaneously despite continuation of treatment without further dose increments. Routine investigations, including plasma porphyrin screen and ANA. were negative. Histology of a skin biopsy demonstrated a blister containing tibrin and neutrophils. with a roof of necrotic keratinocytes. The underlying epithelium lacked a granular layer and was mitotically active. A mild perivascular inflammatory intiltrate was present in the dermis. The appearances suggested a reepithelializing subepidermal blister. Direct immunofluoresence was negative. Case2. A 15-year-old girl, skin type 3. developed asymptomatic blistering (Fig. 1) at the sites of re.solving psoriasis after 11 irradiation sessions at a dose of 1289 mj/cm-. representing J 3 times her initial MED. Uninvolved skin did not show abnormal photosensitivity. Her irradiation dose was reduced, and subsequent increments were restricted to 10% of her previous dose. Her subsequent treatment was uneventful despite receiving doses higher than that which presumably induced the blisters. She was not receiving either topical or systemic photoactive therapy.
Figure 1. Case 2. Blisters occurring on resolving plaques i)f psoriasis.
