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Antiandrogens for penile surgery
CORRESPONDENCE State and territorial regulation of tattooing in the United States To the Editor: While reading the informative article on state and territorial regulation of tattooing in the United States (J AM ACAD DERMATOL 1995;32:791-9), I was struck by the stated low incidence of reported complications from tattooing. During this time of sensitivity over the amount of government regulation, it is truly amazing that few reactions or complications are seen from tattooing, especially since it is reported that members in 3% of American households and 5% of male respondents have a tattoo. No federal law is in existence regarding the manufacture of tattoo pigments and there is little legal regulation of tattoo artists, especially in mandating universal precautions. It appears to me that this is an industry cognizant of the problems inherent in their trade and have taken steps without government regulation. They are to be congratulated. Perhaps carrying this trend to other areas of medicine would lead to a decrease in regulation with a subsequent decrease in administrative cost. Do we really need nlore regulation? No. I do not have a tattoo, nor do I perform tattooing. I do, however. remove many tattoos the old-fashioned way. V. A. Muscarella, MD El Camino Medical Center, Suite 300 8100 Constitution Plaza, NE Albuquerque, NM 871 IO
Reply To the Editor: I appreciate Dr. Muscarella’s comments regarding my recent review of statutory tattooing regulations.’ Several points, I believe, illustrate the need for appropriate tattooing regulations. First, while the reported incidence of tattooing complications is low, the actual incidence is unknown. Second, pigment manufacturers may soon come under federal scrutiny as a result of the recent submission to the Food and Drug Administration of a proposal for testing of iron oxide as a tattoo pigment safe for intradermal use. If such testing were performed and received approval from the Food and Drug Administration. presumably all other tattoo pigments would require testing as well. Third, artists are exposed on a daily basis to potentially contaminated body fluids; however, few have been vaccinated against hepatitis B virus. Finally, despite the efforts of those within the tattooing industry who have laudably taken on the responsibility of practicing universal precautions, I have met less altruistic persons who perform tattooing out of a van as a means to fund their existence on the road. In addition, I have met those who received from poorly educated artists unac-
1058 December 19%
ceptable cosmetic tattoos, some of which had been further complicated by incomplete pigment removal and scars after the use of glycolic acid overtattooing to remove these tattoos. Legislation may provide a compromise between the ineffective extremes of simply banning or ignoring tattooing altogether. I do not necessarily demand legislation of tattooing: instead I favor legislation that is accurate and appropriate to its task. I do believe that thoughtful tattooing regulations would not be unduly restrictive but would provide a basis for thorough training of artists, provide for protection of tattoo artists through hepatitis B vaccination, protect the public from those artists who do not follow safe practices, give the public some recourse in the event of complications, allow complications to be handled by physicians and tattoo removal to be performed by the safest and least disfiguring methods (not “the oldfashioned way”), and lend legitimacy to tattooing as both an ancient art form and a profession. Dr. Muscarella, perhaps inadvertently, compares tattooing to the practice of medicine, an art form taught by apprenticeship, “practiced” under license, and governed by state legislation. Do we need nlore though@1 tattooing regulations? Yes. And for the record, I do not tattoo, nor do I have a tattoo. I haven’t decided what to get or where to put it. Whitney D. Tope, MD Dermatology Associates of San Diego County, Inc. 477 N. El Camino Real, #B-303 Encinitas, CA 92024
REFERENCE 1. Tope WD. Stateand territorial regulation of tattooing in the United States.JAM ACAD DERMATOL 1995:32:791-9.
Antiandrogens for penile surgery To the Editor: The review of verrucous carcinoma of the skin (JAM ACAD DERMATOL 1995;32:1-21) recommends surgical therapy for carcinoma of the penis. Dermatologists involved in the care of a patient with such a tumor should be aware of a possible postoperative complication that we recently encountered. A 53-year-old heterosexually active black man had a well-circumscribed, 6 cm verrucous lesion that extended from the base of the penis onto the scrotum and along the ventral surface of the penis. After a biopsy specimen confined the diagnosis of Buschke-Lowenstein verrucous carcinoma, a wide local excision and primary closure with about 2 dozen interrupted 3-O chromic catgut sutures was performed. A week later, when he returned to the clinic, the wound had dehisced. He stated that “the stitches popped” when he had an erection. The wound healed by second intention. Journal of the American
Academy
of Dermatology
Journal of the American Academy of Dermatology Volume 33, Number 6
‘Ihe urologist who had done the surgery suggested that perhaps extensive surgery on the penis should be followed by postoperative administration of an antiandrogen until the wound is well healed to prevent this complication. J. Elliott Paulson, MD Simion Zelicof, MD Yelvu Lynfield, MD Depat-tmenr of Veteran Afsairs Dermutology Service 800 Poly Place Brooklyn, NY 11209
Reply To the Editor: I thank Drs. Paulson, Zelicof, and Lynfield for their comments concerning my article on verrucous carcinoma. They have described an interesting patient with a Buschke-Loewenstein tumor, a vermcous carcinoma of the penis, in whom the tumor excision was complicated by posterection wound dehiscence. Their suggestion for the use of a postoperative antiandrogen appears to be an excellent one. I appreciate their contribution.
Correspondence
been cast on the immunogenetic background.2 There is clearly an association with autoimmune disease, but we know of no evidence that such disease is a stimulus to the development of lichen sclerosus, as seems to be suggested in the conclusions of the article. We would like to have seen a fuller discussion of the association with squamous cell carcinoma, again of great importance when the dermatologist is trying to cormnunicate with the gynecologist. There is some good evidence linking so-called VIN3, differentiated type, with malignancy in lichen sclerosus3 and little to incriminate HPV.4-6 From clinical experience it is difficult not to see a significant connection between lichen sclerosus and malignancy: in our opinion, to seek to view it as of less than prime importance would be unwise. Finally, the authors use the word “dystrophy” at some points in the text. This term has been responsible for much misunderstanding in the past and was discontinued with the classification introduced in 1987. It has unfortunately been slow to die, and we think that every opportunity should be taken to stressthat it must no longer be used as a current term. C. M. Ridley, FRCP Sallie Neill, MRCP St Thomas’ Hospital Lambeth Palace Road London, SE1 7EH, United Kingdom
Robert A. Schwartz, MD, MPH Dermatology New Jersey Medical School I85 S. Orange Ave. Newark, NJ 07103-2714
Lichen
sclerosus
To the Editor: We appreciate the review on lichen sclerosus by Meffert, Davis, and Grimwood (J AM ACAD D~TOL 1995;32:393-416), especially the invaluable collation of references and the masterly marshalling of the work on historical aspects of the disease. However, we think that it would be helpful to give more emphasis to several positive features of current clinical practice and research. Because lichen sclerosus is an important and common clinical problem, it behooves dermatologists to guide our gynecologic colleagues, who are still inclined to carry out unnecessary, dangerous, and mutilating operations. This can be done, we believe, by explaining that we have a generally accepted, safe, and effective management, consisting of clobetasol propionate 0.05% applied topically in carefully monitored amounts, coupled with the liberal use of bland emollients. This may be, and usually is, continued for long periods; it also appears to be safe in children. The use of testosterone ointment is outmoded. Oral retinoids may occasionally be a useful adjuvant in adults. With regard to the pathogenesis of lichen sclerosus, there have been two recent contributions of interest: ~53 expression is different in vulval lesions than in normal vulva1 skin and extragenital lesions,’ and some light has
1059
REFERENCES 1. Tan S-H. Derrick E, McKee P, et al. Altered p53 epidermal cell proliferation is seen in vulval lichen sclerosus.J Cutan Path011994;21:316-23. 2. Matren P, Yell J. Chamock FM, et al. The association between lichen sclerosus and antigens of the HLA system. Br J Dermatol 1995;132:197-203. 3. Leibowitch M, Neill SM, PelisseM, et al. The epithelial changes associated with squamous cell carcinoma of the vulva: a review of the clinical, histological and viral findings in 78 women. Br J Obstet Gynaecol 1990;97:113.5-9. 4. Crum CP. Carcinoma of the vulva: epidemiology and pathogenesis. Obstet Gynecol 1992;79:448-54. 5. Toki T, Kurman RJ, Park JS, et al. Probable nonpapilloma-
virus etiology of squamouscell carcinomain older women: a pathologic study using in situ hybridisation and polymerase chain reaction. J Gynecol Path01 199 1: 10: 107-25. 6. Rdley CM. The aetiology of vulval neoplasia. Br J Obstet Gynaecol 1994;101:655-7.
Reply To the Editor: We appreciate Drs. Ridley and Neill’s attention to our review, particularly in light of Dr. Ridley’s contributions to the study and treatment of vulvar diseases.We tried to make it clear that there are many alternatives to topical testosterone in the treatment of lichen sclerosus (LS) and that there is no current role for mutilating surgery, especially for “prophylactic” purposes.
Reply To the Editor: I appreciate Dr. Muscarella’s comments regarding my recent review of statutory tattooing regulations.’ Several points, I believe, illustrate the need for appropriate tattooing regulations. First, while the reported incidence of tattooing complications is low, the actual incidence is unknown. Second, pigment manufacturers may soon come under federal scrutiny as a result of the recent submission to the Food and Drug Administration of a proposal for testing of iron oxide as a tattoo pigment safe for intradermal use. If such testing were performed and received approval from the Food and Drug Administration. presumably all other tattoo pigments would require testing as well. Third, artists are exposed on a daily basis to potentially contaminated body fluids; however, few have been vaccinated against hepatitis B virus. Finally, despite the efforts of those within the tattooing industry who have laudably taken on the responsibility of practicing universal precautions, I have met less altruistic persons who perform tattooing out of a van as a means to fund their existence on the road. In addition, I have met those who received from poorly educated artists unac-
1058 December 19%
ceptable cosmetic tattoos, some of which had been further complicated by incomplete pigment removal and scars after the use of glycolic acid overtattooing to remove these tattoos. Legislation may provide a compromise between the ineffective extremes of simply banning or ignoring tattooing altogether. I do not necessarily demand legislation of tattooing: instead I favor legislation that is accurate and appropriate to its task. I do believe that thoughtful tattooing regulations would not be unduly restrictive but would provide a basis for thorough training of artists, provide for protection of tattoo artists through hepatitis B vaccination, protect the public from those artists who do not follow safe practices, give the public some recourse in the event of complications, allow complications to be handled by physicians and tattoo removal to be performed by the safest and least disfiguring methods (not “the oldfashioned way”), and lend legitimacy to tattooing as both an ancient art form and a profession. Dr. Muscarella, perhaps inadvertently, compares tattooing to the practice of medicine, an art form taught by apprenticeship, “practiced” under license, and governed by state legislation. Do we need nlore though@1 tattooing regulations? Yes. And for the record, I do not tattoo, nor do I have a tattoo. I haven’t decided what to get or where to put it. Whitney D. Tope, MD Dermatology Associates of San Diego County, Inc. 477 N. El Camino Real, #B-303 Encinitas, CA 92024
REFERENCE 1. Tope WD. Stateand territorial regulation of tattooing in the United States.JAM ACAD DERMATOL 1995:32:791-9.
Antiandrogens for penile surgery To the Editor: The review of verrucous carcinoma of the skin (JAM ACAD DERMATOL 1995;32:1-21) recommends surgical therapy for carcinoma of the penis. Dermatologists involved in the care of a patient with such a tumor should be aware of a possible postoperative complication that we recently encountered. A 53-year-old heterosexually active black man had a well-circumscribed, 6 cm verrucous lesion that extended from the base of the penis onto the scrotum and along the ventral surface of the penis. After a biopsy specimen confined the diagnosis of Buschke-Lowenstein verrucous carcinoma, a wide local excision and primary closure with about 2 dozen interrupted 3-O chromic catgut sutures was performed. A week later, when he returned to the clinic, the wound had dehisced. He stated that “the stitches popped” when he had an erection. The wound healed by second intention. Journal of the American
Academy
of Dermatology
Journal of the American Academy of Dermatology Volume 33, Number 6
‘Ihe urologist who had done the surgery suggested that perhaps extensive surgery on the penis should be followed by postoperative administration of an antiandrogen until the wound is well healed to prevent this complication. J. Elliott Paulson, MD Simion Zelicof, MD Yelvu Lynfield, MD Depat-tmenr of Veteran Afsairs Dermutology Service 800 Poly Place Brooklyn, NY 11209
Reply To the Editor: I thank Drs. Paulson, Zelicof, and Lynfield for their comments concerning my article on verrucous carcinoma. They have described an interesting patient with a Buschke-Loewenstein tumor, a vermcous carcinoma of the penis, in whom the tumor excision was complicated by posterection wound dehiscence. Their suggestion for the use of a postoperative antiandrogen appears to be an excellent one. I appreciate their contribution.
Correspondence
been cast on the immunogenetic background.2 There is clearly an association with autoimmune disease, but we know of no evidence that such disease is a stimulus to the development of lichen sclerosus, as seems to be suggested in the conclusions of the article. We would like to have seen a fuller discussion of the association with squamous cell carcinoma, again of great importance when the dermatologist is trying to cormnunicate with the gynecologist. There is some good evidence linking so-called VIN3, differentiated type, with malignancy in lichen sclerosus3 and little to incriminate HPV.4-6 From clinical experience it is difficult not to see a significant connection between lichen sclerosus and malignancy: in our opinion, to seek to view it as of less than prime importance would be unwise. Finally, the authors use the word “dystrophy” at some points in the text. This term has been responsible for much misunderstanding in the past and was discontinued with the classification introduced in 1987. It has unfortunately been slow to die, and we think that every opportunity should be taken to stressthat it must no longer be used as a current term. C. M. Ridley, FRCP Sallie Neill, MRCP St Thomas’ Hospital Lambeth Palace Road London, SE1 7EH, United Kingdom
Robert A. Schwartz, MD, MPH Dermatology New Jersey Medical School I85 S. Orange Ave. Newark, NJ 07103-2714
Lichen
sclerosus
To the Editor: We appreciate the review on lichen sclerosus by Meffert, Davis, and Grimwood (J AM ACAD D~TOL 1995;32:393-416), especially the invaluable collation of references and the masterly marshalling of the work on historical aspects of the disease. However, we think that it would be helpful to give more emphasis to several positive features of current clinical practice and research. Because lichen sclerosus is an important and common clinical problem, it behooves dermatologists to guide our gynecologic colleagues, who are still inclined to carry out unnecessary, dangerous, and mutilating operations. This can be done, we believe, by explaining that we have a generally accepted, safe, and effective management, consisting of clobetasol propionate 0.05% applied topically in carefully monitored amounts, coupled with the liberal use of bland emollients. This may be, and usually is, continued for long periods; it also appears to be safe in children. The use of testosterone ointment is outmoded. Oral retinoids may occasionally be a useful adjuvant in adults. With regard to the pathogenesis of lichen sclerosus, there have been two recent contributions of interest: ~53 expression is different in vulval lesions than in normal vulva1 skin and extragenital lesions,’ and some light has
1059
REFERENCES 1. Tan S-H. Derrick E, McKee P, et al. Altered p53 epidermal cell proliferation is seen in vulval lichen sclerosus.J Cutan Path011994;21:316-23. 2. Matren P, Yell J. Chamock FM, et al. The association between lichen sclerosus and antigens of the HLA system. Br J Dermatol 1995;132:197-203. 3. Leibowitch M, Neill SM, PelisseM, et al. The epithelial changes associated with squamous cell carcinoma of the vulva: a review of the clinical, histological and viral findings in 78 women. Br J Obstet Gynaecol 1990;97:113.5-9. 4. Crum CP. Carcinoma of the vulva: epidemiology and pathogenesis. Obstet Gynecol 1992;79:448-54. 5. Toki T, Kurman RJ, Park JS, et al. Probable nonpapilloma-
virus etiology of squamouscell carcinomain older women: a pathologic study using in situ hybridisation and polymerase chain reaction. J Gynecol Path01 199 1: 10: 107-25. 6. Rdley CM. The aetiology of vulval neoplasia. Br J Obstet Gynaecol 1994;101:655-7.
Reply To the Editor: We appreciate Drs. Ridley and Neill’s attention to our review, particularly in light of Dr. Ridley’s contributions to the study and treatment of vulvar diseases.We tried to make it clear that there are many alternatives to topical testosterone in the treatment of lichen sclerosus (LS) and that there is no current role for mutilating surgery, especially for “prophylactic” purposes.