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Combination phototherapy of psoriasis with calcipotriene and narrow-band (311 nm) UVB
Journal of the American Academy of Dermatology Volume 36, Number 3, Part 1
Psoriasis flare caused by recombinant interferon beta injections To the Editor: We read with interest the case report by Webster et al. (J Am Acad Dermatol 1996;34:365-7). They reported cutaneous side effects of subcutaneous injections of recombinant, serine-substituted interferon beta (Betaseron) including a case of a pustular psoriasis flare. This fits our observation that recombinant, Chinese hamster ovary cell (CHO)-derived, not serine-substituted interferon beta (CHO beta, Dr. Rentschler, Laupheim, Germany) induced a psoriasis plaque at the injection side during intralesional treatment of a superficial basal cell carcinoma.2 The single injection dose in our case was 0.5 x 106 U compared with 32 × 106 U in the observation of Webster et al. This might explain the more disseminated and more severe disease in the latter case. That an unspecific Koebner phenomenon might not be the most important mechanism for the provocation of disease by interferons was demonstrated by Fierlbeck et al.3 who observed punctiform psoriasis at the injection site of recombinant interferon gamma but not at the injection site of insulin at the same time in the same patient.
Lutz Kowalzick, MD Department of Dermatology Vogtland-Hospital Box 39 D-08505 Plauen, Germany
REFERENCES 1. Kowalzick L, Wever U. Psoriasis induced at the injection site of recombinant intefferons. Arch Dermatol 1990;126: 1515-6. 2. Kowalzick L, Rogozinski T, Schober C, et al. Treatment of basal cell carcinoma with inWalesional recombinant interferon beta: a dose finding study. Eur J Dermatol 1994; 4:430-3. 3. Fierlbeck G, Rassner G, Mtiller C. Psoriasis at the injection site of recombinant interferon gamma. Arch Dermato11990; 126:351-5.
Reply To the Editor." Because the psoriasis triggered in our patient by serine-substituted interferon beta was not at all localized to the injection site, it is difficult to invoke a traditional Koebner phenomenon to explain the worsening of psoriasis. It may, however, be justified to consider this a sort of generalized Koebner phenomenon. Because koebnerization represents the provocation of disease after wounding of the skin, it has been assumed for many years that the healing process elaborates factors that exacerbate the underlying inflammatory disease. It is thus conceivable that one of the wound healing factors that trigger psoriasis is interferon beta; systemic administra-
Correspondence
501
tion of the drug can therefore provoke a systemic flare of disease.
Guy Webster, MD, PhD Jefferson Medical College 211 S. 9th St. Walnut Towers, Suite 500 Philadelphia, PA 19107-5102
Combination phototherapy of psoriasis with calcipotriene and narrow-band (311 nm) UVB To the Editor: We read with interest the comments of Marisco and Dijkstra regarding the UVB-blocking effect of calcipotriene ointment (J Am Acad Dermatol 1996;34:539-40). Unfortunately, a decisive misunderstanding occurred when they referred to and discussed our previously published study on the combination therapy of calcipotriene and narrow-band UVB (311 nm) for psoriasis.i, 2 This misunderstanding led them to state that the results of their study "raise more questions than answers" and we hope to be able to clarify this subject. Contrary to their statement, we applied calcipouiene in our study afterthe narrow-band UVB irradiation and then for a second time in the evening. Unfortunately, when we first described the preliminary results of our study as a letter in The Lancet, we could not write the mode of application and irradiation in detail because of the required brevity of these contributions. However, we did publish in detail the correct method in a subsequent article, which appeared in the German literature 2 and was obviously not available to Marisco and Dijkstra. Similarly, Kragballe 3 also applied the ointment after the UVB irradiation. His results showed a beneficial effect of the combination therapy compared with calcipotriene ointment alone, although the difference did not reach statistical significance. In contrast to our study, which demonstrated a significant superiority of the combination therapy, Kragballe used a conventional broadband UVB lamp. Our findings support the concept that narrow-band UVB at 311 nm is of higher efficacy in patients with psoriasis than traditional broad-band LrVB, whether used alone or in combination with other treatment modalities. 4 We fully agree with the concluding remarks in the letter reply by Lebwohl (J Am Acad Dermatol 1996;34:540) and the recommendations made by Marisco and Dijkstra to use calcipotriene after UV irradiation as a combination therapy. In our and other departments it has become a standard regimen and one of the most rewarding treatment modalities, when applied correctly, for patients with widespread psoriasis.
502
Journal of the American Academy of Dermatology March 1997
Correspondence
Prof. Dr. Percy Lehmann Department of Dermatology Heinrich-Heine-Universitgit Diisseldorf Moorenstr. 5 40001 Diisseldorf, Germany Dr. Martina Kerscher Department of Dermatology University of Bochum Gudrunstr. 56 44791 Bochum, Germany REFERENCES 1. Kerscher M, Volkenandt M, Plewig G, et al. Combination phototherapy of psoriasis with calcipotriol and narrow-band UVB [letter]. Lancet 1993;342:923. 2. Kerscher M, Plewig G, Lehmann P. Kombinationstherapie der Psoriasis vulgaris mit einem Schmalspektmm UV-BStrahler (Philips TL 01,311 nm) und CalcipotrioL Aktuel Dermatol 1993;19:151-4. 3. Kragballe K. Combination of topical calcipotriol (MC 903) and UVB radiation for psoriasis ~mlgaris. Dermatologica 1990;181:211-4. 4. Storbeck K, H6lzle E, Lehmann P, et al. Narrow-band UVB (311 nm) versus conventional broad-band UVB with and without dithranol in phototherapy for psoriasis. J Am Acad Dermatol 1993;28:227-31.
Folliculosebaceous cystic h a m a r t o m a
To the Editor." We read with interest the article by Templeton entitled "Folliculosebaceous Cystic Hamartoma: A Clinical Pathologic Study" (J A m Acad Dermatol 1996;34:77-81), but in our opinion further observations would be helpful. Our case showed a neural component in the stroma, to our knowledge never before described, that emphas~xl the hamartomatous origin of the lesion. 1 W e agree with the author that the incidence of the lesion " . . . although reported only rarely . . . . is much higher." In fact, after a brief review of our histopathologic findings from the past 5 years, we observed eight cases; one of these showed two nodular lesions of the nose, which represented folliculosebaceous cystic hamartoma. We believe that this finding has not been previously reported. We do not completely agree on the differential diagnoses proposed by Templeton. In our experience, the "sebaceous trichofolliculoma" described by Plewig 2 is only a histologic variant of folliculosebaceous cystic hamaxtoma, with a minimal stromal component. Pietro Donati, MD Laurian Balus, MD Pierpaolo Bellomo, MD Istituto S. Maria e S. Gallicano Rome 00153, Italy REFERENCES 1. Donati P, Balus L. Folliculosebaceous cystic hamartoma: reported case with a neural component. Am J Dermatopathol 1993; 15:277-9.
2. Plewig G. Sebaceous trichofolliculoma. J Cutan Pathol 1980;7:394-403.
Reply
To the Editor: I appreciate the comments by Donati and his colleagues and agree with their first two statements. The neural element they observed in their case is part of the mesenchymal component in folliculosebaceous cystic hamartoma (FCH). This mesenchymal element is the most polymorphous component of FCH and contains variable amounts of collagen, fat, blood vessels, and neural tissue, as described by Donati and Balus.11 am pleased that they have also observed several FCHs in their pracrice; this sUpports the notion that these lesions are not rare. Although sebaceous trichofolficuloma (ST) has some similar features, in m y opinion it is a distinct lesion and not simply a variant of FCH. ST has a different clinical appearance and is generally a depressed rather than an exophytic lesion with a central punctum containing a cluster of short pigmented hairs. 2 In contrast, F C H is an exophytic papule or nodule with a sessile or pedunculated profile and no short pigmented hairs. Microscopically, ST is a true trichofolliculoma consisting of numerous rudimentary follicles radiating around a dilated cystic space. 2 Sebaceous lobules are present because of the anatomic location of these lesions (i.e., the central par-t of the face), where they are normally abundant. F C H is more exophyric with a sessile or pedunculated profile, whereas ST usually has a more endophytic component. Finally, ST lacks significant stroma, which is one of the diagnostic criteria in FCH. Stephen F. Templeton, MD Departments of Dermatology and Pathology Emory University School of Medicine Atlanta, GA 30322 REFERENCES 1. Donati P, Balus L. Folliculosebaceous cystic hamartoma: reported case with a neural component. Am J Dermatopathol 1993;15:277-9. 2. Plewig G. Sebaceous trichofolliculoma. J Cutan Pathol 1980;7:394-403.
The outcomes m o v e m e n t and n e w measures of psoriasis
To the Editor: In a timely review McKenna and Stem have stressed the importance of creating further measures for psoriasis (J A m Acad Dermatol 1996;34:534-8). They have called for the development of health status measures that originate from patients' experiences, are able to quantify changes in health care status with treamaent, and are easy to administer and interpret. The Dermatology
Psoriasis flare caused by recombinant interferon beta injections To the Editor: We read with interest the case report by Webster et al. (J Am Acad Dermatol 1996;34:365-7). They reported cutaneous side effects of subcutaneous injections of recombinant, serine-substituted interferon beta (Betaseron) including a case of a pustular psoriasis flare. This fits our observation that recombinant, Chinese hamster ovary cell (CHO)-derived, not serine-substituted interferon beta (CHO beta, Dr. Rentschler, Laupheim, Germany) induced a psoriasis plaque at the injection side during intralesional treatment of a superficial basal cell carcinoma.2 The single injection dose in our case was 0.5 x 106 U compared with 32 × 106 U in the observation of Webster et al. This might explain the more disseminated and more severe disease in the latter case. That an unspecific Koebner phenomenon might not be the most important mechanism for the provocation of disease by interferons was demonstrated by Fierlbeck et al.3 who observed punctiform psoriasis at the injection site of recombinant interferon gamma but not at the injection site of insulin at the same time in the same patient.
Lutz Kowalzick, MD Department of Dermatology Vogtland-Hospital Box 39 D-08505 Plauen, Germany
REFERENCES 1. Kowalzick L, Wever U. Psoriasis induced at the injection site of recombinant intefferons. Arch Dermatol 1990;126: 1515-6. 2. Kowalzick L, Rogozinski T, Schober C, et al. Treatment of basal cell carcinoma with inWalesional recombinant interferon beta: a dose finding study. Eur J Dermatol 1994; 4:430-3. 3. Fierlbeck G, Rassner G, Mtiller C. Psoriasis at the injection site of recombinant interferon gamma. Arch Dermato11990; 126:351-5.
Reply To the Editor." Because the psoriasis triggered in our patient by serine-substituted interferon beta was not at all localized to the injection site, it is difficult to invoke a traditional Koebner phenomenon to explain the worsening of psoriasis. It may, however, be justified to consider this a sort of generalized Koebner phenomenon. Because koebnerization represents the provocation of disease after wounding of the skin, it has been assumed for many years that the healing process elaborates factors that exacerbate the underlying inflammatory disease. It is thus conceivable that one of the wound healing factors that trigger psoriasis is interferon beta; systemic administra-
Correspondence
501
tion of the drug can therefore provoke a systemic flare of disease.
Guy Webster, MD, PhD Jefferson Medical College 211 S. 9th St. Walnut Towers, Suite 500 Philadelphia, PA 19107-5102
Combination phototherapy of psoriasis with calcipotriene and narrow-band (311 nm) UVB To the Editor: We read with interest the comments of Marisco and Dijkstra regarding the UVB-blocking effect of calcipotriene ointment (J Am Acad Dermatol 1996;34:539-40). Unfortunately, a decisive misunderstanding occurred when they referred to and discussed our previously published study on the combination therapy of calcipotriene and narrow-band UVB (311 nm) for psoriasis.i, 2 This misunderstanding led them to state that the results of their study "raise more questions than answers" and we hope to be able to clarify this subject. Contrary to their statement, we applied calcipouiene in our study afterthe narrow-band UVB irradiation and then for a second time in the evening. Unfortunately, when we first described the preliminary results of our study as a letter in The Lancet, we could not write the mode of application and irradiation in detail because of the required brevity of these contributions. However, we did publish in detail the correct method in a subsequent article, which appeared in the German literature 2 and was obviously not available to Marisco and Dijkstra. Similarly, Kragballe 3 also applied the ointment after the UVB irradiation. His results showed a beneficial effect of the combination therapy compared with calcipotriene ointment alone, although the difference did not reach statistical significance. In contrast to our study, which demonstrated a significant superiority of the combination therapy, Kragballe used a conventional broadband UVB lamp. Our findings support the concept that narrow-band UVB at 311 nm is of higher efficacy in patients with psoriasis than traditional broad-band LrVB, whether used alone or in combination with other treatment modalities. 4 We fully agree with the concluding remarks in the letter reply by Lebwohl (J Am Acad Dermatol 1996;34:540) and the recommendations made by Marisco and Dijkstra to use calcipotriene after UV irradiation as a combination therapy. In our and other departments it has become a standard regimen and one of the most rewarding treatment modalities, when applied correctly, for patients with widespread psoriasis.
502
Journal of the American Academy of Dermatology March 1997
Correspondence
Prof. Dr. Percy Lehmann Department of Dermatology Heinrich-Heine-Universitgit Diisseldorf Moorenstr. 5 40001 Diisseldorf, Germany Dr. Martina Kerscher Department of Dermatology University of Bochum Gudrunstr. 56 44791 Bochum, Germany REFERENCES 1. Kerscher M, Volkenandt M, Plewig G, et al. Combination phototherapy of psoriasis with calcipotriol and narrow-band UVB [letter]. Lancet 1993;342:923. 2. Kerscher M, Plewig G, Lehmann P. Kombinationstherapie der Psoriasis vulgaris mit einem Schmalspektmm UV-BStrahler (Philips TL 01,311 nm) und CalcipotrioL Aktuel Dermatol 1993;19:151-4. 3. Kragballe K. Combination of topical calcipotriol (MC 903) and UVB radiation for psoriasis ~mlgaris. Dermatologica 1990;181:211-4. 4. Storbeck K, H6lzle E, Lehmann P, et al. Narrow-band UVB (311 nm) versus conventional broad-band UVB with and without dithranol in phototherapy for psoriasis. J Am Acad Dermatol 1993;28:227-31.
Folliculosebaceous cystic h a m a r t o m a
To the Editor." We read with interest the article by Templeton entitled "Folliculosebaceous Cystic Hamartoma: A Clinical Pathologic Study" (J A m Acad Dermatol 1996;34:77-81), but in our opinion further observations would be helpful. Our case showed a neural component in the stroma, to our knowledge never before described, that emphas~xl the hamartomatous origin of the lesion. 1 W e agree with the author that the incidence of the lesion " . . . although reported only rarely . . . . is much higher." In fact, after a brief review of our histopathologic findings from the past 5 years, we observed eight cases; one of these showed two nodular lesions of the nose, which represented folliculosebaceous cystic hamartoma. We believe that this finding has not been previously reported. We do not completely agree on the differential diagnoses proposed by Templeton. In our experience, the "sebaceous trichofolliculoma" described by Plewig 2 is only a histologic variant of folliculosebaceous cystic hamaxtoma, with a minimal stromal component. Pietro Donati, MD Laurian Balus, MD Pierpaolo Bellomo, MD Istituto S. Maria e S. Gallicano Rome 00153, Italy REFERENCES 1. Donati P, Balus L. Folliculosebaceous cystic hamartoma: reported case with a neural component. Am J Dermatopathol 1993; 15:277-9.
2. Plewig G. Sebaceous trichofolliculoma. J Cutan Pathol 1980;7:394-403.
Reply
To the Editor: I appreciate the comments by Donati and his colleagues and agree with their first two statements. The neural element they observed in their case is part of the mesenchymal component in folliculosebaceous cystic hamartoma (FCH). This mesenchymal element is the most polymorphous component of FCH and contains variable amounts of collagen, fat, blood vessels, and neural tissue, as described by Donati and Balus.11 am pleased that they have also observed several FCHs in their pracrice; this sUpports the notion that these lesions are not rare. Although sebaceous trichofolficuloma (ST) has some similar features, in m y opinion it is a distinct lesion and not simply a variant of FCH. ST has a different clinical appearance and is generally a depressed rather than an exophytic lesion with a central punctum containing a cluster of short pigmented hairs. 2 In contrast, F C H is an exophytic papule or nodule with a sessile or pedunculated profile and no short pigmented hairs. Microscopically, ST is a true trichofolliculoma consisting of numerous rudimentary follicles radiating around a dilated cystic space. 2 Sebaceous lobules are present because of the anatomic location of these lesions (i.e., the central par-t of the face), where they are normally abundant. F C H is more exophyric with a sessile or pedunculated profile, whereas ST usually has a more endophytic component. Finally, ST lacks significant stroma, which is one of the diagnostic criteria in FCH. Stephen F. Templeton, MD Departments of Dermatology and Pathology Emory University School of Medicine Atlanta, GA 30322 REFERENCES 1. Donati P, Balus L. Folliculosebaceous cystic hamartoma: reported case with a neural component. Am J Dermatopathol 1993;15:277-9. 2. Plewig G. Sebaceous trichofolliculoma. J Cutan Pathol 1980;7:394-403.
The outcomes m o v e m e n t and n e w measures of psoriasis
To the Editor: In a timely review McKenna and Stem have stressed the importance of creating further measures for psoriasis (J A m Acad Dermatol 1996;34:534-8). They have called for the development of health status measures that originate from patients' experiences, are able to quantify changes in health care status with treamaent, and are easy to administer and interpret. The Dermatology