Correction to Iotaderma #43

CORRESPONDENCE The classification of psoriatic arthritis To the Editor: I read with great interest the article "The classification of psoriatic arthritis: What will happen in the future?" (J Am Acad Dermatol 1997;36:78-83). One particular clinical form was not mentioned by the authors. This was first described by Marguery et al. 1 under the title of "Psoriatic Acropachydermodactyly." In this study we described ungual dystrophy suggestive of psoriasis with the distal part of the fingers enlarged as a result of thickening of the soft part of the distal phalanges; these lesions are painful. These cutaneous lesions are associated with inflammatory arthralgia of the distal phalanges with limited movement in flexion. Radiographs of the hands showed osteitis and periostitis of the distal phalanges and sometimes arthritis of the distal interphalangeal joint. We have proposed a physiopathologic hypothesis indicating a direct link between ungual lesions and lesions of the distal phalanx by its soft parts: the pathologic process concerns the enthesis connecting nail and bone, along with inflammatory processes involving the soft parts (fibrous sheets traversing the cellular fatty tissue). Often at the beginning, the distal interphalangeal joint is normal. This typical aspect sometimes involves only the big toes but can also involve the fingers as well as the other toes. Sometimes one toe, a few toes, and/or finger(s) are spared. The diagnosis of psoriatic acropachydermodactyly is easy if there are o.Jher psoriatic lesions, but this form may be the first sign of psoriasis. J. Bazex, MD Dermatology Service Hopital Purpan 31059 Toulouse Cedex France

REFERENCE 1. Marguery MC, Baran RJ Pages M, Bazex J. Acropachydermie psoriasique. Ann Dermatol Venereol 1991;118: 373-6.

al. rejected this term. They outlined its association with psoriatic onychopathy and the absence of an evident articular involvement. He also suggested a direct pathogenetic link between ungual and bone lesions with the involvement of the enthesis connecting nail and phalanx and proposed the term of psoriatic onychopachydermoperiostitis. Marguery et al. 4 has recently described the localization of this condition to other digits and suggest that it may represent the first step of the articular involvement in psoriasis. In their experience this enthesopathy may be helpful in the diagnosis of arthritic cases, particularly if skin involvement is not evident. I have not found similar features in our patients, and consequently I have not included this among psoriatic arthritis subsets. However, I think it can be easily included among peripheral enthesopathies. I agree that peripheral enthesopathies may represent in some cases an early finding of a spondyloarthropathy.5 However, because oftheir low classification specificity, when present as isolated features, I think they have no diagnostic value.

R. Scarpa, MD Department of Internal Medicine Rheumatology Research Unit University of Naples "Federico II" 80131 Naples, Italy

REFERENCES 1. Scarpa R, Biondi Oriente C, Oriente P. The classification of psoriatic arthritis: What will happen in the future? J Am Acad Dermatol 1997;36:78-83. 2. Foumie B, Viraben R, Durroux R, Lassoued S, Gay R, Foumie A. L' onycho-pachydermo-periostite psoriasique du gros orteil. Rev Rhumatisme 1989;56:579-82. 3. Resnik D, Broderick RW. Bony proliferation of terminal phalanges in psoriasis: the ivory phalanx. J Can Assoc RadioI1977;28:187-92. 4. Marguery MC, Baron R, Pages M, Bazex J. Acropachydermie psoriasique. Ann Dermatol Venereol 1991;118:373-6. 5. Scarpa R, Ames PRJ, della Valle G, Lubrano E, Oriente P. A rare enthesopathy in psoriatic oligoarthritis. Acta Derm Venereol Suppl (Stockh) 1994;186:74-6.

Reply To the Editor: I read with interest the comment of Bazex about my article) He mentions psoriatic onychopachydermoperiostitis described by Foumie et al. 2 in 1991, which we have not included among the clinical subsets of psoriatic arthritis. This condition, classically confined to the terminal phalanx of the big toe, was first described by Resnick and Broderick3 as "ivory phalanx." In 1991 Fournie et

1012 June, Part I, 1998

Correction to Iotaderma #43 To the Editor: A note from lotaderma enthusiasts: Regarding the answer to the August 1997 lotaderma (#43, "How can the 'itch to write' be diagnosed in a glance?"),1 one must look for the writer's callus on the distal lateral aspect of the middle finger, not the medial aspect, at or near the level of the distal interphalangeal Journal of the American Academy of Dermatology

Journal of the American Academy of Dermatology Volume 38, Number 6, Part 1

joint. In the cited article,2 the figure shows a hand in the pronated position; however, in the anatomic position the callus is on the lateral aspect of the finger. Jeffrey J. Berti, MD Donald S. Schuster, MD 4414 Regent St. Grayson Bldg. Madison, WI 53705

REFERENCES 1. Bernhard J. Iotaderma #43. J Am Acad Dermatol 1997;37:474. 2. Ronchese F. Calluses: cicatrices and other stigmas as an aid to personal identification. JAMA 1945;128:925-31.

Reply To the Editor: Drs. Berti and Schuster are correct. In the spirit of iotaderrnism, I can hardly complain that they have made much ado about little. I must instead thank them for their enthusiasm and admit to a modicum of pleasure in knowing that someone reads those things. Jeffrey D. Bernhard, MD Division of Dermatology University of Massachusetts Medical Center Worcester, MA 01655-0307

Ivermectin usage for cheyletiellosis To the Editor: I compliment Drs. Cvancara and Elston on their recent cheyletiellosis article (J Am Acad Dermatol 1997;37:265-7). However, they state "To our knowledge, this is the first case of ivermectin (Ivomec) usage for Cheyletiella mite eradication." This is not the case. Veterninarians have been successfully treating cheyletiellosis in cats, dogs, foxes, and rabbits with the subcutaneous or oral administration of ivermectin since the 1980s.1-4 Danny W. Scott, DVM, DACVD Department of Clinical Sciences College of Veterinary Medicine Cornell University Ithaca, NY 14853-6401

REFERENCES 1. Malczewski A, Kopczewski A, Malczewska M, Zieli J. Mange due to Cheyletiella blakei in polar foxes in Poland. Zentralb Bakterio [A] 1984;258:412-3. 2. Paradis M, Villeneuve A. Efficacy of ivermectin against Cheyletiella yasguri infestation in dogs. Can Vet J 1988;29:633-5. 3. Paradis M, Scott DW, Villeneuve A. Efficacy of ivermectin against Cheyletiella blakei infestation in cats. J Am Anim Hosp Assoc 1990;26:125-8. 4. Scott DW, Miller WH Jr, Griffin CEo Muller and Kirk's

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Small animal dermatology. 5th ed. Philadelphia: WB Saunders; 1996. p. 412-7, 1158.

Bullous eruption in a patient with systemic lupus erythematosus To the Editor: We enjoyed reading the brief communication in the August 1997 issue of the Journal on the bullous eruption in a patient with systemic lupus erythematosus subtitled "Mite Dermatitis Caused by Cheyletiella blake i." However, we find it necessary to ask for clarification of a few points not mentioned in the article. Did the authors consult with a veterinarian or a recent veterinary dermatology textbook before treating the animals? Did the authors choose to treat the cats and dog themselves or was the patient advised to seek veterinary care for her pets (this would be in keeping with the medical and veterinary practice acts). We would also like to point out that, in contradiction to the authors' statement, theirs was not the first use of ivermectin for Cheyletiella mite eradication in cats or dogs. In current veterinary literature l ,2 it is well recognized that ivermectin, although unapproved for this use, is effective in the treatment of cheyletiellosis in veterinary patients. In fact, veterinarians have been using ivermectin to treat numerous parasitic dermatoses in their patients for more than a decade. Unfortunately, few of the references cited by the authors were current. Although ivermectin is known to be toxic to collies at the dosages used to eradicate external parasites, it is also considered toxic to Old English sheepdogs, Shetland sheepdogs, and Australian shepherds. Although ivermectin is used frequently in the veterinary field, a toxicity may develop in any animal at any time. Animals should be free of Dirofilaria immitis microfilaria (heartworms) before receiving high doses of ivermectin. Could the authors cite the dosage and frequency of administration of ivermectirt used in the patients' animals? Moriello has found that in some cases Cheyletiella mites may be difficult to eradicate and currently recommends a high dose of ivermectin given on three occasions during a 6-week period. In addition, the environment should be treated with insecticidal agents. Although we enjoy reading the Journal, we hope that the editors are not encouraging the treatment of veterinary patients by physicians. Veterinarians receive significant education in zoonotic diseases (dermatophytosis, Sarcoptes infestation. cat-scratch fever, cheyletiellosis) and encourage our physician colleagues to consult veterinarians when confronted with such issues. Diane Lewis, DVM Dawn B. Logas, DVM Janet Wojciechowski, DVM