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Functional familial sebaceous hyperplasia of the face and premature sebaceous gland hyperplasia: A new and unique entity?
768
Journal of the American Academy of Dermatology
Correspondence
i
Fig. 3. Biopsy specimen of waist lesion demonstrating spongiosis and subepidermal vesicle associated with neutrophilic papillitis. (Hematoxylin-eosin stain; original magnification, • 100.) All laboratory studies demonstrated that she was not glucose-6-phosphate dehydrogenase-deficient or anemic, and the patient was started on 200 mg daily of dapsone, with prompt control of her symptoms and eruption. Discussion. The Koebner phenomenon, as defined by Heinrich Koebner in 1877, is the development of isomorphic lesions in the traumatized uninvolved skin of patients who have certain cutaneous diseases.'~ While Koebner's initial study was based on psoriasis patients, with time other skin diseases have been associated with the Koebner reaction, such as lichen planus, lichen nitidus, vitiligo, and pityriasis rubra pilaris. No consistent mechanism of action can be incriminated in the pathogenesis of the Koebner reaction. It is well known that oral potassium iodide will aggravate dermatitis herpetifonnis. 4 Tetrahydrofurfuryl ester of nicotinic acid '~and iodide applied to uninvolved skin and, to a lesser extent, chaotropic ions (such as bromide, fluoride, chloride, and potassium thiocyanate) will produce clinical lesions similar to those of dermatitis herpetiformis.~; Prior to the advent of immunofluorescence, the iodide patch test was used as a diagnostic tool for dermatitis herpetiforrnis. According to Fisher, 7 iodide is not found in, nor used in, the processing of spandex type undergarments, such as those worn by our patient. Allergic contact or irritant dermatitis due to spandex or chemicals in her undergarments, or their chemical alteration by laundrying practice, would have produced different histologic changes and should not be abolished by dapsone therapy. W e have observed typical DH lesions occurring in
areas of trauma. There is no clear-cut explanation. Even though IgA can be detected in both perilesional and normal-appearing skin, the question remains why lesions erupt in one area rather than another. This suggests that additional factors are needed for clinically apparent skin inflammation to occur. Perhaps the linear eruption developed in our patient as a result of irritation, friction, or heat, which may have somehow acted to lower her blistering threshold. It may also be inferred that our patient reacted so profoundly due to her lack of dapsone therapy. In conclusion, we have presented a patient with biopsy-proved dermatitis herpetiformis who developed characteristic DH lesions at sites of trauma due to tight-fitting undergarments. Perhaps a low-grade Koebnet phenomenon does occur in dermatitis herpetiformis and may explain the unique predilection for certain areas of the body to this cutaneous eruption.
Gloria CampbelI-D'Hue, M.D. Stephen A. Estes, M.D. University of Cincinnati Medical Center Department of Dermatology Cincinnati, OH 45267
REFERENCES 1. Duhring LA: Dermatitis herpetiformis. JAMA 3:225-229, 1884. 2. Katz SI, Strober W: The pathogenesis of dermatitis herpctiformis, J Invest Dermatol 70:63-71, 1978. 3. Koebner H: Zur actiologic der psoriasis. Vjschr Dermatol 3:559, 1876. 4. Marks JM: Dogma and dermatitis herpetiformis. Clin Exp Dermatol 2: 189-207, 1978. 5. Juhlin L, Micha~lsson G: Abnormal cutaneous reactions to a nicotinic acid ester. Acta Derm Venereol (Stockh) $1:448-452, 1971. 6. Felscher E: The nature of halogen sensitivity in dermatitis herpetiformis and pemphigus. J Invest Dermatol 8:55-58, 1947. 7. Fisher A: Contact dermatitis, ed. 2. Philadelphia, 1975, Lea & Febiger, p. 169.
Functional familial sebaceous hyperplasia of the face and premature sebaceous gland hyperplasia: A new and unique entity? To the Editor': We read with interest the article by De Villez and Roberts: "Premature Sebaceous Gland Hyperplasia" (J AM ACAO DERMATOL 6:933-935, 1982). We totally agree that this uncommon case is a new entity. However, in an article written by us, ~ we reported two similar cases. We think that the two publications concern the same disease.
Volume 9 Number 5 November 1983
Correspondence
In our paper, we reviewed the mare characterlsttcs of this new syndrome (1) Two brothers were presented with the same lesions (2) The patients suffered of a devastating sebaceous hyperplasm of the face w~th confluence of the lesions resulting m the formation of large patches that were shghtly tumid and erythematous (3) This glandular hyperplasla was highly func uonal and resulted m severe seborrhea oleosa making the patients faces very unaesthetlc (4) Paradoxmally no symptoms of conventtonal acne such as mfl,'unmatory papules pustules cysts or scars were found (5) The sebaceous hyperplasla was not strictly located on the face but was spreading on the neck and the upper part of the thorax with a hnear pattern m~m~ckmg a cuUs punctata hnearls coh (6) The use of all conventmnal acne treatments was totally mefficactous (7) Bxopsy showed a hyperplasm o f the sebaceous glands similar to that found m sende sebaceous adenomas (8) The other characteristics of the d~sease were its ap pearance dunng puberty or just afterwards, the lack of involvement of penonficml areas and the slow pro gresslve nature o f the disorder The hypeffuncnonal nature of the lestons excluded a nosolog~c inclusion m the so-called semle sebaceous hyperplas~a We concluded that thts famlhal dmorder was a new autonomous chmcal syndrome that ~t could be in eluded m the spectrum of receptor dtseases named receptor n e v u s " or ' pharmacologic nevus and that it would reflect a congemtal and abnormal hypersensl bd~ty of the receptors to c~rculatmg androgens So th~s new disease could be mterpreted as the reverse of the acne free-nevus" described b y Cunhffe et al 2 Recently, rn a Letter to the Editor ' a new case of premature sebaceous gland hyperplasla was cited by Bhawan and Calhoun :~ We thrnk that lsotretmom therapy would dramatically ~mprove th~s functmnal extensive sebaceous hy perplasm of the face and the resulting esthetic and so cml embarrassment
Andre Dupre M D Jean Louts Bonafe M D Pierre Lamon M D Department of Dermatology C H U Purpan 31059 Toulouse Cedex France
REFERENCES I Dupre A Bonafe J Lamon P Functional famthal seba ceous hyperplasm of the face Reverse of the Cunhffe acne free naevus'~ Its mclusmn among naevold seba ceous receptor diseases Chn Exp Dermatol 5 203 207 1980
769
2 Cunhffe WJ Ead RD Perera W H e t al An acne free naevus Br J Dermatol 96 287 290 1977 3 Bhawan J Calhoun J Premature sebaceous gland hyper plasta J AM ACAD DERMATOL 8 136 1983 (Letter to Editor )
Reply To the Edttor W e thank Drs Dupre Bonafe and Lamon for their comments Our case did differ slgmficantly from thetrs m that chmcally the penortfictal regions were p n m a n l y revolved and acnefform lesions were present N o les~ons were present on the chest or back W e , hkewlse d~d not measure sex hormone receptors m the normal or damaged skin We feel ~t would be unfair at th~s time to suggest that th~s syndrome be a part of the spectrum of receptor diseases W e concur that ~sotretmom therapy should be appropnate
Richard L De Vdlez, M D Larry C Roberts, M D Dlvlston of Dermatology Untverstty of Texas Health Sctence Center 7703 Floyd Curl Dr San Antonzo, TX 78234
An ancient method and a modern scourge The condom as a barrier against herpes To the Editor Gemtal herpes as appeared m Tzme has become the "scarlet letter" of the 1980s Casual sexual habits have contributed to the n s m g incidence o f the mfectton, and medm attention has promulgated a certain hysteria among the sexually actwe populatlon Fear of gemtal herpes has slowed the sexual revolution heralded by the " p a l l " and has increased the attractweness of vLrgmity and o f condoms for those who do partake Several weeks ago a recently dtvorced attorney mqmred how he might prevent catching herpes on a Club Med vacauon He was antlclpaung a sexual p o t p o u m but was deathly afraid of catching the herpes curse " A dlscussmn ensued among the physlcmns present regarding this situation and the question arose " A r e condoms an effectwe b a m e r against the transmlsston of herpesvlms~" Conmdenng the various techmcs of tbreplay and sexual intercourse the effectweness of the condom m d~sease preventmn will vary, however simply put Can the herpesvlrus an mosahedral part~cle 100 to 150 nanometers m dtameter pass d~rectly across the condom m e m b r a n e 9 ' With thts m mind, a Trojan latex condom was subnutted for electron mmroscop~c studies For transmts-
Journal of the American Academy of Dermatology
Correspondence
i
Fig. 3. Biopsy specimen of waist lesion demonstrating spongiosis and subepidermal vesicle associated with neutrophilic papillitis. (Hematoxylin-eosin stain; original magnification, • 100.) All laboratory studies demonstrated that she was not glucose-6-phosphate dehydrogenase-deficient or anemic, and the patient was started on 200 mg daily of dapsone, with prompt control of her symptoms and eruption. Discussion. The Koebner phenomenon, as defined by Heinrich Koebner in 1877, is the development of isomorphic lesions in the traumatized uninvolved skin of patients who have certain cutaneous diseases.'~ While Koebner's initial study was based on psoriasis patients, with time other skin diseases have been associated with the Koebner reaction, such as lichen planus, lichen nitidus, vitiligo, and pityriasis rubra pilaris. No consistent mechanism of action can be incriminated in the pathogenesis of the Koebner reaction. It is well known that oral potassium iodide will aggravate dermatitis herpetifonnis. 4 Tetrahydrofurfuryl ester of nicotinic acid '~and iodide applied to uninvolved skin and, to a lesser extent, chaotropic ions (such as bromide, fluoride, chloride, and potassium thiocyanate) will produce clinical lesions similar to those of dermatitis herpetiformis.~; Prior to the advent of immunofluorescence, the iodide patch test was used as a diagnostic tool for dermatitis herpetiforrnis. According to Fisher, 7 iodide is not found in, nor used in, the processing of spandex type undergarments, such as those worn by our patient. Allergic contact or irritant dermatitis due to spandex or chemicals in her undergarments, or their chemical alteration by laundrying practice, would have produced different histologic changes and should not be abolished by dapsone therapy. W e have observed typical DH lesions occurring in
areas of trauma. There is no clear-cut explanation. Even though IgA can be detected in both perilesional and normal-appearing skin, the question remains why lesions erupt in one area rather than another. This suggests that additional factors are needed for clinically apparent skin inflammation to occur. Perhaps the linear eruption developed in our patient as a result of irritation, friction, or heat, which may have somehow acted to lower her blistering threshold. It may also be inferred that our patient reacted so profoundly due to her lack of dapsone therapy. In conclusion, we have presented a patient with biopsy-proved dermatitis herpetiformis who developed characteristic DH lesions at sites of trauma due to tight-fitting undergarments. Perhaps a low-grade Koebnet phenomenon does occur in dermatitis herpetiformis and may explain the unique predilection for certain areas of the body to this cutaneous eruption.
Gloria CampbelI-D'Hue, M.D. Stephen A. Estes, M.D. University of Cincinnati Medical Center Department of Dermatology Cincinnati, OH 45267
REFERENCES 1. Duhring LA: Dermatitis herpetiformis. JAMA 3:225-229, 1884. 2. Katz SI, Strober W: The pathogenesis of dermatitis herpctiformis, J Invest Dermatol 70:63-71, 1978. 3. Koebner H: Zur actiologic der psoriasis. Vjschr Dermatol 3:559, 1876. 4. Marks JM: Dogma and dermatitis herpetiformis. Clin Exp Dermatol 2: 189-207, 1978. 5. Juhlin L, Micha~lsson G: Abnormal cutaneous reactions to a nicotinic acid ester. Acta Derm Venereol (Stockh) $1:448-452, 1971. 6. Felscher E: The nature of halogen sensitivity in dermatitis herpetiformis and pemphigus. J Invest Dermatol 8:55-58, 1947. 7. Fisher A: Contact dermatitis, ed. 2. Philadelphia, 1975, Lea & Febiger, p. 169.
Functional familial sebaceous hyperplasia of the face and premature sebaceous gland hyperplasia: A new and unique entity? To the Editor': We read with interest the article by De Villez and Roberts: "Premature Sebaceous Gland Hyperplasia" (J AM ACAO DERMATOL 6:933-935, 1982). We totally agree that this uncommon case is a new entity. However, in an article written by us, ~ we reported two similar cases. We think that the two publications concern the same disease.
Volume 9 Number 5 November 1983
Correspondence
In our paper, we reviewed the mare characterlsttcs of this new syndrome (1) Two brothers were presented with the same lesions (2) The patients suffered of a devastating sebaceous hyperplasm of the face w~th confluence of the lesions resulting m the formation of large patches that were shghtly tumid and erythematous (3) This glandular hyperplasla was highly func uonal and resulted m severe seborrhea oleosa making the patients faces very unaesthetlc (4) Paradoxmally no symptoms of conventtonal acne such as mfl,'unmatory papules pustules cysts or scars were found (5) The sebaceous hyperplasla was not strictly located on the face but was spreading on the neck and the upper part of the thorax with a hnear pattern m~m~ckmg a cuUs punctata hnearls coh (6) The use of all conventmnal acne treatments was totally mefficactous (7) Bxopsy showed a hyperplasm o f the sebaceous glands similar to that found m sende sebaceous adenomas (8) The other characteristics of the d~sease were its ap pearance dunng puberty or just afterwards, the lack of involvement of penonficml areas and the slow pro gresslve nature o f the disorder The hypeffuncnonal nature of the lestons excluded a nosolog~c inclusion m the so-called semle sebaceous hyperplas~a We concluded that thts famlhal dmorder was a new autonomous chmcal syndrome that ~t could be in eluded m the spectrum of receptor dtseases named receptor n e v u s " or ' pharmacologic nevus and that it would reflect a congemtal and abnormal hypersensl bd~ty of the receptors to c~rculatmg androgens So th~s new disease could be mterpreted as the reverse of the acne free-nevus" described b y Cunhffe et al 2 Recently, rn a Letter to the Editor ' a new case of premature sebaceous gland hyperplasla was cited by Bhawan and Calhoun :~ We thrnk that lsotretmom therapy would dramatically ~mprove th~s functmnal extensive sebaceous hy perplasm of the face and the resulting esthetic and so cml embarrassment
Andre Dupre M D Jean Louts Bonafe M D Pierre Lamon M D Department of Dermatology C H U Purpan 31059 Toulouse Cedex France
REFERENCES I Dupre A Bonafe J Lamon P Functional famthal seba ceous hyperplasm of the face Reverse of the Cunhffe acne free naevus'~ Its mclusmn among naevold seba ceous receptor diseases Chn Exp Dermatol 5 203 207 1980
769
2 Cunhffe WJ Ead RD Perera W H e t al An acne free naevus Br J Dermatol 96 287 290 1977 3 Bhawan J Calhoun J Premature sebaceous gland hyper plasta J AM ACAD DERMATOL 8 136 1983 (Letter to Editor )
Reply To the Edttor W e thank Drs Dupre Bonafe and Lamon for their comments Our case did differ slgmficantly from thetrs m that chmcally the penortfictal regions were p n m a n l y revolved and acnefform lesions were present N o les~ons were present on the chest or back W e , hkewlse d~d not measure sex hormone receptors m the normal or damaged skin We feel ~t would be unfair at th~s time to suggest that th~s syndrome be a part of the spectrum of receptor diseases W e concur that ~sotretmom therapy should be appropnate
Richard L De Vdlez, M D Larry C Roberts, M D Dlvlston of Dermatology Untverstty of Texas Health Sctence Center 7703 Floyd Curl Dr San Antonzo, TX 78234
An ancient method and a modern scourge The condom as a barrier against herpes To the Editor Gemtal herpes as appeared m Tzme has become the "scarlet letter" of the 1980s Casual sexual habits have contributed to the n s m g incidence o f the mfectton, and medm attention has promulgated a certain hysteria among the sexually actwe populatlon Fear of gemtal herpes has slowed the sexual revolution heralded by the " p a l l " and has increased the attractweness of vLrgmity and o f condoms for those who do partake Several weeks ago a recently dtvorced attorney mqmred how he might prevent catching herpes on a Club Med vacauon He was antlclpaung a sexual p o t p o u m but was deathly afraid of catching the herpes curse " A dlscussmn ensued among the physlcmns present regarding this situation and the question arose " A r e condoms an effectwe b a m e r against the transmlsston of herpesvlms~" Conmdenng the various techmcs of tbreplay and sexual intercourse the effectweness of the condom m d~sease preventmn will vary, however simply put Can the herpesvlrus an mosahedral part~cle 100 to 150 nanometers m dtameter pass d~rectly across the condom m e m b r a n e 9 ' With thts m mind, a Trojan latex condom was subnutted for electron mmroscop~c studies For transmts-