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Gianotti-Crosti syndrome: A retrospective analysis of 308 cases
Gianotti-Crosti syndrome: A retrospective analysis of 308 cases Ruggero Caputo, MD, Carlo Gelmetti, MD, Elisa Ermacora, MD, Enrica Gianni, MD, and Anna Silvestri, M D Milan, Italy Background: There is no agreement as to whether papular acrodermatitis of childhood caused by hepatitis B virus can be differentiated from other papulovesieular acrolocated syndromes. Objective: We attempted to establish whether such differentiation is possible comparing histories, signs, and symptoms of all patients who have been previously diagnosed as having papular acrodermatitis of childhood or papulovesicular acrolocated syndromes. Methods: Files of 308 patients hospitalized in the past three decades were studied. Photographs were examined by a panel of experts to determine whether it was possible to distinguish between papular acrodermatitis of childhood and papulovesicuIar acrolocated syndromes solely on the basis of cutaneous signs. Results: The retrospective analysis confirmed a significant overlapping of the two types of the disease. The blind survey of photographs of the patients revealed that a distinction between the forms was not clinically possible. Conclusion: Acrodermatitis is a self-limiting cutaneous response to different viruses; clinical differences are probably due to individual characteristics of each patient rather than the causative virus. (J AM ACAD DERMATOL 1992;26:207-10.) In 1955, Gianotti 1 described a disease characterized by an erythematous papular eruption symmetrically distributed on the face, buttocks, and extremities of children that was unlike any other known disease. The disease was called papular acrodermatitis of childhood by various authors 2-5 and Gianotti-Crosti syndrome by others. 4-1~ Although a viral cause was immediately suspected it was not until 1970 that the role of Australia antigen (i.e., hepatitis B surface antigen [HBsAg]) was simultaneously confirmed by Gianotti ll and by an independent group of pediatricians in Milan. 12 In those first cases, acute anicteric hepatitis was always present. 13 In subsequent years, other patients with similar clinical features were reported from different countries but the causative role of hepatitis B virus (HBV) could not be demonstrated in all cases. Those
From the I Dermatoiogic Clinic and Pediatric Dermatology of the University of Milan, I.R.C.C.S. "Ospedale Maggiore". Partially presented as a poster at the Forty-ninth Annual Meeting of the American Academy of Dermatology, Atlanta, Ga, Dec. 1-6, 1990. Accepted for publication Sept. 19, 1991. Reprint requests: Carlo Gelmetti, MD, Cllnica Dermatologica I, Via Pace 9-20122, Milano, Italy. 16/1/33888
cases were classified by Gianotti as papulovesicular acrolocated syndrome, t4 At that time, he believed that a distinction between papular acrodermatitis of childhood and papulovesicular acrolocated syndrome was clinically possible ~5 (Table I). Further studies demonstrated the etiologic role of HBV 162~ and other viruses 2~-26 but failed to differentiate the two forms clinically.27"z9In an attempt to establish whether or not Gianotti's belief was correct, we have critically reviewed these patients. SUBJECTS AND METHODS All files of patients diagnosed as having papular acrodermatitis of childhood or papulovesicular acrolocated syndrome who were admitted to the 1st Department of Dermatology and Pediatric Dermatology of the University of Milan during the last 35 years (1955-t989) were analyzed retrospectively. There were 308 patients (171 boys and 137 girls; male/female ratio: 1:25). Age at first diagnosis was between 6 months and 14 years (mean 2 years). All cases were diagnosed by history and clinical appearance as well as hematologic and biochemical findings. Routine laboratory studies were performed in all patients. Since 1970 the HBV markers were detected by standard techniques (radioimmunoassay, enzyme-linked immunosorbent assay); since 1980 more extensive virologic investigations were performed including the detec-
207
208
Journal of the American Academy of Dermatology
Caputo et al.
120. 100. i
80. i
1
J
60, I 40./ 20. i 0
0
i
1
J 2
I BIB t-IBsAg+
[]
HBsAg- []
Total I
Fig. 1. Cases ofHBsAg + and HBsAg- Gianotti-Crosti syndrome by age groups. Horizontal axis, Age in years; vertical axis, number of cases.
48 40 32
| 24
16
I:
J
[i, H o o+ []
,o!., [
Fig. 2. Cases of HBsAg + and HBsAg- Gianotti-Crosti syndrome by month of onset.
Table I. Papular acrodermatitis of childhood (PAC) versus papulovesicular acrolocated syndrome (PVAS) PAC
Age Lesions Eruption Pruritus Capillary fragility Koebner phenomenon Liver HBsAg Course Relapse Frequency
6 too-12 yr Erythematous papules do not coalesce Not recurrent Absent Common Present Acute hepatitis Present 15-25 days Never Rare
.,
PVAS
2-6 yr Pink pinhead-sized vesicle-like papules may coalesce Sometimes recurrent Common Rare Absent Normal Absent 20-50 days Rare Frequent
Volume 26 Number 1, Part 1 February 1992
tion of herpesvirus, cytomegalovirus, Epstein-Barr virus, and coxsackie virus. Three of us (R. C., C. G., and E. E.) reviewed all clinical slides of patients in an attempt to differentiate HBsAg+ from HBsAg- forms on the basis of the morphology and distribution of the lesions. RESULTS O f 308 patients with Gianotti-Crosti syndrome, 69 cases (22.4%) were caused by H B V and 239 cases (77.6%) were caused by another virus (e.g., cytomegalovirus and Epstein-Barr virus in our cases). We called these cases HBsAg + and H B s A g - forms, respectively. A review of the photographs reveated that a distinction between the two forms was not possible morphologically. In addition, a retrospective analysis did not confirm a significant difference in symptoms or in the course of the two types of the disease. T h e HBsAg + and H B s A g - forms of acrodermatitis also did not show differences in the age of patients at onset of the disease (Fig. 1) and in the time of the year of its onset (Fig. 2). The frequency of both HBsAg + and H B s A g - forms of acrodermatitis showed fluctuation in the seasonal incidence of both f o r m s ) ~ This could be related to the natural fluctuation of viral infections. Finally the frequencies of HBsAg + form of acrodermatitis and HBVinduced hepatitis have both shown a sharp decrease since 1983. 31"34 DISCUSSION On the basis of these findings we believe that papular acrodermatitis of childhood is a self-limiting cutaneous response to different viruses, only some of which have been identified. The differences in the clinical manifestations are probably due to individual characteristics of the patient (e.g., age, general health, immune status) rather than the responsible virus. To avoid confusion, the terms papular acrodermatitis of childhood35 and papulovesicular acrolocated syndrome 36 should be eliminated and replaced by the term Gianotti-Crosti syndrome.37 In our opinion, Gianotti-Crosti syndrome can be used to describe all those eruptive acrolocated dermatoses clinically characterized by papular or papulovesicufar lesions that are caused by different viruses and almost always run a benign and self-healing course in a few weeks. Only patients affected by the HBsAg form need to be treated and followed up for a longer period. REFERENCES
1. Gianotti F. RiUevidiuna particolare casisisticatossinfettiva caratterizzata da eruzione eritemato-infiltrativa desqua-
Gianotti-Crosti syndrome
209
mativa a foeolailenticolari, a sede elettiva acroesposta. G Ital Derrn Sif 1955;96:678-97. 2. Crosti A, Gianotti F. Dermatose 6ruptive aero-situ~e d'origine probablement virosique. Acta Derm Venereol (Stockh) 1957;2:146-9. 3. Crosti A, Gianotti F. Weitere beobachtungen uber die eruptive papulose infantile akrodermatose. Arc Klin Exp Dermatol 1961;213:858-63. 4. BessoneL. Sopra una particolare dermatite eruttiva acroesposta dei bambini (tipo Crosti-Gianotti). Minerva Dermatol 1957;32(suppl 12):109. 5. Dogliotti M. Considerazionisu una particolare dermatosi eruttiva acroesposta dei bambini (reticolo-endotelite)subacuta infattiva con eruzione cutanea a sede elettiva a~roesposta (Crosti-Gianotti). Minerva Dermatol 1957;32: 81-6. 6. Chapuis H. Acro-~ryth~mepapuleux infantile (syndrome de Gianotti-Crosti). Rev M~d Suisse Romande 1958; 74:136-42. 7. Duperrat B, Puissant A. La dermatite 6ruptive des extrtmitts chez les enfants (Syndrome de Gianotti-Crosti). Presse Med 1958;66:1862-3. 8. Braun-FalcoO, Rupec M. Lleber das Gianotti-Crosti Syndrom. Med Klin 1964;59:210-4. 9, Schirren CG, Mutter M. Die akrodermatitis paulosa infantum (Gianotti-Crosti Syndrom) in differential diagnostischen Grenzgebietyon Dermatologie una Paediatrie. Monatsschr Kinderheilkunde 1964;112:65-7. 10. Eiloart M, The Gianotti-Crosti syndrome, Report of fortyfour cases. Br J Dermatol 1966;78:488-92. 11. Gianotti F. L'acrodermatite papulosa infantile"malattia." Gazz Sanitaria 1970;41:271-4. 12. De Gasperi G, Bardare M, Costantino D. Au antigen in Crosti-Gianotti acrodermatitis [Letter]. Lancet 1970;1: 1116. 13. ColomboM, Rumi MG, Sagnelli E, et al. Acute hepatitis B in children with papular acrodermatitis. Pediatr Pathol 1986;6:249-57. 14. Gianotti F, Gianni E. Das infantile Akrodermatiis syndrome und Epstein-Barr virus infektion. Hautarzt 1985; 60:1789-90. 15. Gianotti F. Papular acrodermatitis of childhood and other papulovesicular aerolocated syndromes. Br J Dermatol 1979;100:49-59. 16. Ishimaru Y, lshimanl H, Toda G, et al. An epidemicof infantile papular acrodermatitks in Japan. Lancet 1976; 1:707-9. 17. Toda G, Ishimaru Y, Mayumi M, et al. Infantile papular acrodermatitis. J Infect Dis 1978;138:211-6. 18. Fergin P. Gianotti-Crostisyndrome. Non-parenterally acquired hepatitis B with a distinctiveexanthem, Med J Aust 1983;1:i75-6. 19. McElgunn PS. Dermatologicmanifestations of hepatitis B infection. J AM ACADDERMATOL1983;8:539-48. 20. Lee S, Kim KY, Hahn CS, et al. Gianotti-Crosti syndrome associated with hepatitis B surface antigen (subtype adr). J AM ACADDERMATOL1985;12:629-33. 21. Sagi EF, Linder N, Shouval D. Papular acrodermatitis of childhoodassociatedwith hepatitis A virus infection. Pediatr Dermatol 1985;3:31-3. 22. Timar L, Budai J, Gero A, et al. Rare complications and unusual syndromesassociatedwith Epstein-Barr virus. Pediatr Infect Dis 1985;4:212-3. 23. KonnoM, Kikuta S, Ishikawa N, et al. A possiblerelationship between hepatitis B antigen negative infantile papular acrodermatitis and Epstein-Burr virus. J Pediatr 1982; 101:222-4.
210
Journal of the American Academy of Dermatology
Caputo et al.
24. Lowe L, Hebert AA, Duvie M. Gianotti-Crosti syndrome associated with Epstein-Barr virus infection. J AM ACAD DERMATOL1989;20:336-8. 25. Berant M, Naveh Y, Weismann I. Papular aerodermatitis with eytomegalovirus hepatitis. Arch Dis Child 1983; 58:1024-5, 26. James WD, Odom RB, Hatch MH. Gianotti-Crosti-like eruption associated with coxsackievirusA-16 infection. J AM ACADDERMA'COL1982;6:862-6. 27. Spear KL, Winkelmann RK. Gianotti-Crosti syndrome. A review of ten cases not associated with hepatitis B. Arch Dermatol 1984;120:891-6. 28. Draelos ZK, Hansen RC, James WD. Gianotti-Crosti syndrome associated with infections other than hepatitis B. JAMA 1986;256:2386-8. 29. Taieb A, Plantin P, DuPasquier P, et al. Gianotti-Crosti syndrome: a studyof 26 cases. BrJ Dermatol 1986;115;4959.
30. FiocchiA, Codara L, Colombini A, et al. Epidemiological significance of infantile papular acrodermatitis [Letter], J Pediatr 1984;104:163. 31. Dati epidemiologicidelia Regione Lombarda, 1990, 32. Yeoh EK. Hepatitis B virus infection in children. Vaccine 1990;8:29-30. 33. Maynard JE. Hepatitis B: global importance and need for control. Vaccine 1990;8:18-20. 34. Plot P, Goilav C, Kegels E. Hepatitis B: transmission by sexual contact and needle sharing. Vaccine 1990;8:37-40. 35. Tunnessen WW Jr. A striking papular rash. Papular acredermatitis of childhood,Arch Dermatol 1988;124:1706-7. 36. Paltzick RL, Aiello AM. Papulovesicular acroloealized syndrome. Cutis 1985;35:362-3. 37. Ramon MD, Verdeguer JM, Moragon M, et al. Sindrome de Gianotti-Crosti en un adulto. Med Cutan Ibero Lat Am 1989;17:357-9.
AMERICAN BOARD OF DERMATOLOGY EXAMINATIONS In 1992 the Certifying Examination of the American Board of Dermatology will be held at the Holiday Inn O'Hare Airport in Rosemont, Illinois on Nov. 1 and 2. The
deadline for receipt of applications is May 1, 1992. EffectiVe in 1992, the Dermatopathology Special Qualification Examination will be given biennially. Thus no examination will be given in 1992; an examination wiU be given in 1993 and every other year thereafter. The deadline for receipt of applications is July l, 1993. The next Examination for Special Qualification in Dermatological Immunology/ Diagnostic and Laboratory immunology will be held in Rosemont, Illinois on Nov. 5, 1993. The deadline for receipt of applications is April 1, 1993. For further information about these examinations, please contact: Clarence S. Livingood, MD Executive Director American Board of Dermatology Henry Ford Hospital Detroit, MI 48202
From the I Dermatoiogic Clinic and Pediatric Dermatology of the University of Milan, I.R.C.C.S. "Ospedale Maggiore". Partially presented as a poster at the Forty-ninth Annual Meeting of the American Academy of Dermatology, Atlanta, Ga, Dec. 1-6, 1990. Accepted for publication Sept. 19, 1991. Reprint requests: Carlo Gelmetti, MD, Cllnica Dermatologica I, Via Pace 9-20122, Milano, Italy. 16/1/33888
cases were classified by Gianotti as papulovesicular acrolocated syndrome, t4 At that time, he believed that a distinction between papular acrodermatitis of childhood and papulovesicular acrolocated syndrome was clinically possible ~5 (Table I). Further studies demonstrated the etiologic role of HBV 162~ and other viruses 2~-26 but failed to differentiate the two forms clinically.27"z9In an attempt to establish whether or not Gianotti's belief was correct, we have critically reviewed these patients. SUBJECTS AND METHODS All files of patients diagnosed as having papular acrodermatitis of childhood or papulovesicular acrolocated syndrome who were admitted to the 1st Department of Dermatology and Pediatric Dermatology of the University of Milan during the last 35 years (1955-t989) were analyzed retrospectively. There were 308 patients (171 boys and 137 girls; male/female ratio: 1:25). Age at first diagnosis was between 6 months and 14 years (mean 2 years). All cases were diagnosed by history and clinical appearance as well as hematologic and biochemical findings. Routine laboratory studies were performed in all patients. Since 1970 the HBV markers were detected by standard techniques (radioimmunoassay, enzyme-linked immunosorbent assay); since 1980 more extensive virologic investigations were performed including the detec-
207
208
Journal of the American Academy of Dermatology
Caputo et al.
120. 100. i
80. i
1
J
60, I 40./ 20. i 0
0
i
1
J 2
I BIB t-IBsAg+
[]
HBsAg- []
Total I
Fig. 1. Cases ofHBsAg + and HBsAg- Gianotti-Crosti syndrome by age groups. Horizontal axis, Age in years; vertical axis, number of cases.
48 40 32
| 24
16
I:
J
[i, H o o+ []
,o!., [
Fig. 2. Cases of HBsAg + and HBsAg- Gianotti-Crosti syndrome by month of onset.
Table I. Papular acrodermatitis of childhood (PAC) versus papulovesicular acrolocated syndrome (PVAS) PAC
Age Lesions Eruption Pruritus Capillary fragility Koebner phenomenon Liver HBsAg Course Relapse Frequency
6 too-12 yr Erythematous papules do not coalesce Not recurrent Absent Common Present Acute hepatitis Present 15-25 days Never Rare
.,
PVAS
2-6 yr Pink pinhead-sized vesicle-like papules may coalesce Sometimes recurrent Common Rare Absent Normal Absent 20-50 days Rare Frequent
Volume 26 Number 1, Part 1 February 1992
tion of herpesvirus, cytomegalovirus, Epstein-Barr virus, and coxsackie virus. Three of us (R. C., C. G., and E. E.) reviewed all clinical slides of patients in an attempt to differentiate HBsAg+ from HBsAg- forms on the basis of the morphology and distribution of the lesions. RESULTS O f 308 patients with Gianotti-Crosti syndrome, 69 cases (22.4%) were caused by H B V and 239 cases (77.6%) were caused by another virus (e.g., cytomegalovirus and Epstein-Barr virus in our cases). We called these cases HBsAg + and H B s A g - forms, respectively. A review of the photographs reveated that a distinction between the two forms was not possible morphologically. In addition, a retrospective analysis did not confirm a significant difference in symptoms or in the course of the two types of the disease. T h e HBsAg + and H B s A g - forms of acrodermatitis also did not show differences in the age of patients at onset of the disease (Fig. 1) and in the time of the year of its onset (Fig. 2). The frequency of both HBsAg + and H B s A g - forms of acrodermatitis showed fluctuation in the seasonal incidence of both f o r m s ) ~ This could be related to the natural fluctuation of viral infections. Finally the frequencies of HBsAg + form of acrodermatitis and HBVinduced hepatitis have both shown a sharp decrease since 1983. 31"34 DISCUSSION On the basis of these findings we believe that papular acrodermatitis of childhood is a self-limiting cutaneous response to different viruses, only some of which have been identified. The differences in the clinical manifestations are probably due to individual characteristics of the patient (e.g., age, general health, immune status) rather than the responsible virus. To avoid confusion, the terms papular acrodermatitis of childhood35 and papulovesicular acrolocated syndrome 36 should be eliminated and replaced by the term Gianotti-Crosti syndrome.37 In our opinion, Gianotti-Crosti syndrome can be used to describe all those eruptive acrolocated dermatoses clinically characterized by papular or papulovesicufar lesions that are caused by different viruses and almost always run a benign and self-healing course in a few weeks. Only patients affected by the HBsAg form need to be treated and followed up for a longer period. REFERENCES
1. Gianotti F. RiUevidiuna particolare casisisticatossinfettiva caratterizzata da eruzione eritemato-infiltrativa desqua-
Gianotti-Crosti syndrome
209
mativa a foeolailenticolari, a sede elettiva acroesposta. G Ital Derrn Sif 1955;96:678-97. 2. Crosti A, Gianotti F. Dermatose 6ruptive aero-situ~e d'origine probablement virosique. Acta Derm Venereol (Stockh) 1957;2:146-9. 3. Crosti A, Gianotti F. Weitere beobachtungen uber die eruptive papulose infantile akrodermatose. Arc Klin Exp Dermatol 1961;213:858-63. 4. BessoneL. Sopra una particolare dermatite eruttiva acroesposta dei bambini (tipo Crosti-Gianotti). Minerva Dermatol 1957;32(suppl 12):109. 5. Dogliotti M. Considerazionisu una particolare dermatosi eruttiva acroesposta dei bambini (reticolo-endotelite)subacuta infattiva con eruzione cutanea a sede elettiva a~roesposta (Crosti-Gianotti). Minerva Dermatol 1957;32: 81-6. 6. Chapuis H. Acro-~ryth~mepapuleux infantile (syndrome de Gianotti-Crosti). Rev M~d Suisse Romande 1958; 74:136-42. 7. Duperrat B, Puissant A. La dermatite 6ruptive des extrtmitts chez les enfants (Syndrome de Gianotti-Crosti). Presse Med 1958;66:1862-3. 8. Braun-FalcoO, Rupec M. Lleber das Gianotti-Crosti Syndrom. Med Klin 1964;59:210-4. 9, Schirren CG, Mutter M. Die akrodermatitis paulosa infantum (Gianotti-Crosti Syndrom) in differential diagnostischen Grenzgebietyon Dermatologie una Paediatrie. Monatsschr Kinderheilkunde 1964;112:65-7. 10. Eiloart M, The Gianotti-Crosti syndrome, Report of fortyfour cases. Br J Dermatol 1966;78:488-92. 11. Gianotti F. L'acrodermatite papulosa infantile"malattia." Gazz Sanitaria 1970;41:271-4. 12. De Gasperi G, Bardare M, Costantino D. Au antigen in Crosti-Gianotti acrodermatitis [Letter]. Lancet 1970;1: 1116. 13. ColomboM, Rumi MG, Sagnelli E, et al. Acute hepatitis B in children with papular acrodermatitis. Pediatr Pathol 1986;6:249-57. 14. Gianotti F, Gianni E. Das infantile Akrodermatiis syndrome und Epstein-Barr virus infektion. Hautarzt 1985; 60:1789-90. 15. Gianotti F. Papular acrodermatitis of childhood and other papulovesicular aerolocated syndromes. Br J Dermatol 1979;100:49-59. 16. Ishimaru Y, lshimanl H, Toda G, et al. An epidemicof infantile papular acrodermatitks in Japan. Lancet 1976; 1:707-9. 17. Toda G, Ishimaru Y, Mayumi M, et al. Infantile papular acrodermatitis. J Infect Dis 1978;138:211-6. 18. Fergin P. Gianotti-Crostisyndrome. Non-parenterally acquired hepatitis B with a distinctiveexanthem, Med J Aust 1983;1:i75-6. 19. McElgunn PS. Dermatologicmanifestations of hepatitis B infection. J AM ACADDERMATOL1983;8:539-48. 20. Lee S, Kim KY, Hahn CS, et al. Gianotti-Crosti syndrome associated with hepatitis B surface antigen (subtype adr). J AM ACADDERMATOL1985;12:629-33. 21. Sagi EF, Linder N, Shouval D. Papular acrodermatitis of childhoodassociatedwith hepatitis A virus infection. Pediatr Dermatol 1985;3:31-3. 22. Timar L, Budai J, Gero A, et al. Rare complications and unusual syndromesassociatedwith Epstein-Barr virus. Pediatr Infect Dis 1985;4:212-3. 23. KonnoM, Kikuta S, Ishikawa N, et al. A possiblerelationship between hepatitis B antigen negative infantile papular acrodermatitis and Epstein-Burr virus. J Pediatr 1982; 101:222-4.
210
Journal of the American Academy of Dermatology
Caputo et al.
24. Lowe L, Hebert AA, Duvie M. Gianotti-Crosti syndrome associated with Epstein-Barr virus infection. J AM ACAD DERMATOL1989;20:336-8. 25. Berant M, Naveh Y, Weismann I. Papular aerodermatitis with eytomegalovirus hepatitis. Arch Dis Child 1983; 58:1024-5, 26. James WD, Odom RB, Hatch MH. Gianotti-Crosti-like eruption associated with coxsackievirusA-16 infection. J AM ACADDERMA'COL1982;6:862-6. 27. Spear KL, Winkelmann RK. Gianotti-Crosti syndrome. A review of ten cases not associated with hepatitis B. Arch Dermatol 1984;120:891-6. 28. Draelos ZK, Hansen RC, James WD. Gianotti-Crosti syndrome associated with infections other than hepatitis B. JAMA 1986;256:2386-8. 29. Taieb A, Plantin P, DuPasquier P, et al. Gianotti-Crosti syndrome: a studyof 26 cases. BrJ Dermatol 1986;115;4959.
30. FiocchiA, Codara L, Colombini A, et al. Epidemiological significance of infantile papular acrodermatitis [Letter], J Pediatr 1984;104:163. 31. Dati epidemiologicidelia Regione Lombarda, 1990, 32. Yeoh EK. Hepatitis B virus infection in children. Vaccine 1990;8:29-30. 33. Maynard JE. Hepatitis B: global importance and need for control. Vaccine 1990;8:18-20. 34. Plot P, Goilav C, Kegels E. Hepatitis B: transmission by sexual contact and needle sharing. Vaccine 1990;8:37-40. 35. Tunnessen WW Jr. A striking papular rash. Papular acredermatitis of childhood,Arch Dermatol 1988;124:1706-7. 36. Paltzick RL, Aiello AM. Papulovesicular acroloealized syndrome. Cutis 1985;35:362-3. 37. Ramon MD, Verdeguer JM, Moragon M, et al. Sindrome de Gianotti-Crosti en un adulto. Med Cutan Ibero Lat Am 1989;17:357-9.
AMERICAN BOARD OF DERMATOLOGY EXAMINATIONS In 1992 the Certifying Examination of the American Board of Dermatology will be held at the Holiday Inn O'Hare Airport in Rosemont, Illinois on Nov. 1 and 2. The
deadline for receipt of applications is May 1, 1992. EffectiVe in 1992, the Dermatopathology Special Qualification Examination will be given biennially. Thus no examination will be given in 1992; an examination wiU be given in 1993 and every other year thereafter. The deadline for receipt of applications is July l, 1993. The next Examination for Special Qualification in Dermatological Immunology/ Diagnostic and Laboratory immunology will be held in Rosemont, Illinois on Nov. 5, 1993. The deadline for receipt of applications is April 1, 1993. For further information about these examinations, please contact: Clarence S. Livingood, MD Executive Director American Board of Dermatology Henry Ford Hospital Detroit, MI 48202