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HIV-associated eosinophilic pustular folliculitis
670
Journal of the American Academy of Dermatology October 1997
Correspondence
ical dermatologic conditions, either a life-threatening dermatologic illness or a chronic, disabling dermatologic disorder who will receive better health care with less health care expense and with more satisfaction when there is unlimited access to dermatologists (and similar groups of patients with such critical illnesses will be identified for other specialists). However, I believe this group of patients, out of the entire spectrum of those who come for treatment of cutaneous problems, will be tiny. In contrast, I believe the approach of unlimited specialty access will result in less desired outcomes for the great majority of patients. In the example of patients with acne, data quoted from the National Ambulatory Medical Care Survey of 19892 shows that approximately 20% of visits to dermatologists are for care of patients with acne. Most of these patients are teenagers, a group that most primary care physicians would agree are difficult to get into the office for health care. How many of these patients have sufficiently severe acne to truly warrant the specialized skills of the dermatologist? How many dermatologists are prepared to provide counseling to these young adults regarding appropriate immunizations, contraceptive guidance, sexually transmitted infections, substance abuse, advise them to pursue healthy habits with regard to driving and seat belt use, bicycling and helmet use, regular exercise, and weight control? These are the services that a true primary care physician must provide patients in this age group, regardless of presenting complaint. Thus the health care outcomes that need to be studied to answer the questions posed regarding costs, satisfaction, and health indicators must be broad and comprehensive when we talk about first contact care. 3,4 Measuring outcomes for ache alone is only a small part of the picture when you designate yourself as a primary care provider. It is important that we see the forest and not just the trees. Specialty physicians will often come out looking rosier when compared with primary care physicians in narrowly focused discussions of disease management in the specialist's field of expertise. However, when discussing first contact care you are on generalist turf. The outcomes measured to assess the advantage of a given health care delivery system in terms of cost, patient satisfaction, or health measures must be broadly based and not limited to the patient's stated reason for visiting the physician. Do dermatologists feel prepared to be measured against the same standards for providing primary care as my generalist colleagues are held to?
Barry L. Hainer, MD Medical University of South Carolina 171 Ashley Ave. Charleston, SC 29425-5820
REFERENCES 1. Clark R, Rietschel R. The cost of initiating appropriate therapy for skin diseases: a comparison of dermatologists and family physicians. J Am Acad Dermatol 1983;9:787-96. 2. Stern R, Nelson C. The diminishing role of the dermatologist in the office-based care of cutaneous diseases. J Am Acad Dermatol 1993;29:773-7. 3. Forrest C, Starfield B. The effect of first-contact care with primary care clinicians on ambulatory health care expenditures. J Fam Pract 1996;43:40-8. 4. Mark D, Gottlieb M, Zellner M, Chetty V, Midtling J. Medicare costs in urban areas and the supply of primary care physicians. J Fam Pract 1996;43:33-9.
HIV-associated eosinophilic pustular folliculitis To the Editor." We read with interest the case reported by Stell and Leen of a 39-year-old woman with HIVassociated eosinophilic pustular folliculitis (EPF) (J Am Acad Dermatol 1996;35:106-8). We have reported a similar case1; therefore this is not the first case in the literature of EPF occurring in a female patient. The mode of transmission of HIV in the patient of Stell and Leen is not discussed, but in our patient we believe it to be by heterosexual contact, an observation again not previously reported. HIV presenting with EPF has been reported rarely 2 but occurred in both our case and that reported by Stell and Leen. These cases illustrate that HIV-associated EPF differs from classic Ofuji's disease in its clinical presentation and histologic features. Eosinophilic pustules, for example, are relatively infrequently seen in HIVassociated EPF, and none were seen in the two aforementioned patients. Tamara Basarab, MRCP Robin Russell Jones, FRCP St. John's Institute of Dermatology St. Thomas' Hospital London, UK
REFERENCES 1. Basarab T, Russell Jones R. HIV-associated eosinophilic folliculitis: case report and review of the literature. Br J Dermatol 1996;134:499-503. 2. Magro CMJ, Crowson AN. Eosinophilic pustular follicular reaction: a paradigm of immune dysregulation. Int J Dermatol 1994;33:172-8.
Reply To the Editor: I read with interest the case report "HIVassociated Eosinophilic Folliculitis: Case Report and Review of the Literature," which was published in the British Journal of Dermatology (1996:134:499-503). The authors are correct in saying that theirs is the first
Journal of the American Academy of Dermatology October 1997
Correspondence
ical dermatologic conditions, either a life-threatening dermatologic illness or a chronic, disabling dermatologic disorder who will receive better health care with less health care expense and with more satisfaction when there is unlimited access to dermatologists (and similar groups of patients with such critical illnesses will be identified for other specialists). However, I believe this group of patients, out of the entire spectrum of those who come for treatment of cutaneous problems, will be tiny. In contrast, I believe the approach of unlimited specialty access will result in less desired outcomes for the great majority of patients. In the example of patients with acne, data quoted from the National Ambulatory Medical Care Survey of 19892 shows that approximately 20% of visits to dermatologists are for care of patients with acne. Most of these patients are teenagers, a group that most primary care physicians would agree are difficult to get into the office for health care. How many of these patients have sufficiently severe acne to truly warrant the specialized skills of the dermatologist? How many dermatologists are prepared to provide counseling to these young adults regarding appropriate immunizations, contraceptive guidance, sexually transmitted infections, substance abuse, advise them to pursue healthy habits with regard to driving and seat belt use, bicycling and helmet use, regular exercise, and weight control? These are the services that a true primary care physician must provide patients in this age group, regardless of presenting complaint. Thus the health care outcomes that need to be studied to answer the questions posed regarding costs, satisfaction, and health indicators must be broad and comprehensive when we talk about first contact care. 3,4 Measuring outcomes for ache alone is only a small part of the picture when you designate yourself as a primary care provider. It is important that we see the forest and not just the trees. Specialty physicians will often come out looking rosier when compared with primary care physicians in narrowly focused discussions of disease management in the specialist's field of expertise. However, when discussing first contact care you are on generalist turf. The outcomes measured to assess the advantage of a given health care delivery system in terms of cost, patient satisfaction, or health measures must be broadly based and not limited to the patient's stated reason for visiting the physician. Do dermatologists feel prepared to be measured against the same standards for providing primary care as my generalist colleagues are held to?
Barry L. Hainer, MD Medical University of South Carolina 171 Ashley Ave. Charleston, SC 29425-5820
REFERENCES 1. Clark R, Rietschel R. The cost of initiating appropriate therapy for skin diseases: a comparison of dermatologists and family physicians. J Am Acad Dermatol 1983;9:787-96. 2. Stern R, Nelson C. The diminishing role of the dermatologist in the office-based care of cutaneous diseases. J Am Acad Dermatol 1993;29:773-7. 3. Forrest C, Starfield B. The effect of first-contact care with primary care clinicians on ambulatory health care expenditures. J Fam Pract 1996;43:40-8. 4. Mark D, Gottlieb M, Zellner M, Chetty V, Midtling J. Medicare costs in urban areas and the supply of primary care physicians. J Fam Pract 1996;43:33-9.
HIV-associated eosinophilic pustular folliculitis To the Editor." We read with interest the case reported by Stell and Leen of a 39-year-old woman with HIVassociated eosinophilic pustular folliculitis (EPF) (J Am Acad Dermatol 1996;35:106-8). We have reported a similar case1; therefore this is not the first case in the literature of EPF occurring in a female patient. The mode of transmission of HIV in the patient of Stell and Leen is not discussed, but in our patient we believe it to be by heterosexual contact, an observation again not previously reported. HIV presenting with EPF has been reported rarely 2 but occurred in both our case and that reported by Stell and Leen. These cases illustrate that HIV-associated EPF differs from classic Ofuji's disease in its clinical presentation and histologic features. Eosinophilic pustules, for example, are relatively infrequently seen in HIVassociated EPF, and none were seen in the two aforementioned patients. Tamara Basarab, MRCP Robin Russell Jones, FRCP St. John's Institute of Dermatology St. Thomas' Hospital London, UK
REFERENCES 1. Basarab T, Russell Jones R. HIV-associated eosinophilic folliculitis: case report and review of the literature. Br J Dermatol 1996;134:499-503. 2. Magro CMJ, Crowson AN. Eosinophilic pustular follicular reaction: a paradigm of immune dysregulation. Int J Dermatol 1994;33:172-8.
Reply To the Editor: I read with interest the case report "HIVassociated Eosinophilic Folliculitis: Case Report and Review of the Literature," which was published in the British Journal of Dermatology (1996:134:499-503). The authors are correct in saying that theirs is the first