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Lessening the pressure on scalp dermabrasions
Volume 15 Number 3 September, 1986
histoplasmosis, and intracellular yeasts were likewise found in a bone marrow biopsy specimen. This technic offers a relatively simple and rapid means of early bedside diagnosis (pending biopsy and culture confirmation) not only of herpes infections but also of significant systemic fungal infections as well. Although modifications of staining may be tried, such as short-method methenamine silver, in order to improve ease of identification of organisms, the technic as described appears to be a helpful aid in the early workup particularly of seriously ill patients such as those with AIDS. Jack L. Lesher, Jr., M.D., and Fred J. Kight, M.D. Medical College of Georgia, Augusta, GA 30912
REFERENCE 1. Borton LK, Wintroub BU: Disseminated cryptococcosis presenting as herpetiform lesions in a homosexual man with acquired immunodeficiency syndrome. J AM ACAD DERMATaL 10:387-390, 1984.
Correspondence 535
Comment. Our patients confirm the assumption of Butterworth3 that leukonychia partialis may be a phase of leukonychia totalis; in fact, all the affected members of the family experienced the simultaneous occurrence of leukonychia partialis and leukonychia totalis during the course of their lives. We want to point out the peculiar course of the disease in all our patients who were affected by total leukonychia at birth but experienced a gradual improvement of the nail discoloration during the course of life. At the present time this family is the third one in the literature presenting leukonychia totalis and leukonychia partialis simultaneously; in the previous reports, however, the course of the disease was different. 4 ,5 The follow-up of our patients will clarify if leukonychia will clear in these patients during the course of life.
Vincenzo Bettoli, M.D., and Antonella Tosti, M.D. University of Bologna, Bologna, Italy
REFERENCES Leukonychia totalis and partialis: A single family presenting a peculiar course of the disease To the Editor: The recent publication of some letters about leukonychia in your journal'·2 has prompted us to report a case of familial leukonychia totalis associated with leukonychia partialis. Case report. A 17-year-old boy was referred to us for consultation because of nail discoloration involving the fingernails. The clinical examination showed that the second and third fingers of both hands presented total leukonychia, while the first and fourth fingers presented partial leukonychia characterized by longitudinal or transverse bands of normal pink color. On the other hand, the fifth fingernails on both hands were completely normal in color. The patient was in good health and potassium hydroxide (KOH) preparations and cultures of nail scrapings were negative. The medical history revealed that leukonychia totaIis was present at birth, but during the course of life several bands of normal pink color appeared. Furthermore, both the paternal grandmother and the paternal aunt were affected with the same kind of nail discoloration; no other family members were affected. The patient said that his grandmother had had leukonychia totalis at birth but that she had complctely recovered by the time she died. During the course of her life she presented both leukonychia totalis and leukonychia partiaIis at the same time. The 24-year-old aunt presented the same clinical picture as our patient and showed a similar progression of the disease.
1. Stewart L, Young E, Lim HW: Idiopathic leukonychia totalis and partialis. J AM ACAD DERMATOL 13:157-158, 1985. (Letter to Editor.) 2. Daniel CR: Reply. JAM ACAD DERMATOL 13:158, 1985. (Letter to Editor.) 3. Butterworth T: Leukonychia partialis. A phase of leukonychia totalis. Cutis 29:363-364, 367, 1982. 4. Albright SD, Wheeler CE: Leukonychia: Total and partial leukonychia in a single family with a review of the literature. Arch DermatoI90:392-399, 1964. 5. Harrington IF: White fingernails. Arch Intern Med 114: 301-306, 1964.
Lessening the pressure on scalp dermabrasions To the Editor: I much enjoyed Winton and Salasche's review (J AM ACAD DERMATOL 14:661-668, 1986) of the status of dermabrasion as treatment for premalignant disease. As they noted, I have long trumpeted that stance'-3 and continue to do so. I have for many years routinely included dermabrasion of the balded scalp when significant numbers of keratoses existed there and I was "dermabrading" the face anyway. As have Winton and Salasche, I have used dermabrasion of the scalp alone down to the forehead level of the preexisting hairline, designing my dermabrasion field much as if I were designing the limits of intervention in a hair transplant candidate. As they have done, I have also used dermabrasion of the dorsal aspect of the scalp and extended it down to cover
536
Correspondence
the forehead, stopping past the brow at the level of the lateral canthus and extending toward the sideburn area under which the temples of the glasses pass. Over the years these have been done with a variety of open and closed dressings, and I have no paired comparisons to offer. However, unlike Winton and Sa~ lasche's five cases, I have had patients experience significantly eventful postoperative courses. I believe this has been a direct result of my heavy-handedness some years ago over the atrophic scalp, resulting in markedly delayed reepithelialization and continued crusting and healing that in one patient extended for a period of almost 3 months. Experiences with that patient, and with some others, have not stayed my dermabrader from the dorsal aspect of the scalp, but those experiences have caused me to lessen the degree of pressure on the diamond fraises that I use for dermabrasion of thinned, atrophic scalps that offer only nonfunctional residue of hair follicles and glands for reepithelialization. Some scalps are so thin that one gets the feeling the calvarium lies within a millimeter of the palpating finger. I would be extremely hesitant to intervene on such scalps unless both the patient and the physician were desperate and unless the patient were preinformed that the only healing he might get after an extended period of time could be a thin scar that would not function well. The article is beautiful, scientific, and additionally compares patients who have had dermabrasion with others being treated with topical 5-fluorouracil. No attempt was made to compare cryosurgical intervention, but we are all well acquainted with the latter's pro and cons. Winton and Salasche's precautions "to control the depth of abrasion" are singularly appropriate, and I strongly urge the scalp abrader to heed their advice.
Lawrence M. Field, M.D. University of California, San Francisco, CA 94143 REFERENCES 1. Field LM: On the prophylactic value of dermabrasion. Cutis 8:186, 1971. 2. Field LM: Dermabrasion vs 5-FU for actinic damage. J AM ACAD DERMATOL 6:269-270, 1982. (Letter to Editor.) 3. Field LM: On the value of dermabrasion in the management of actinic keratoses, in Epstein E, editor: Controversies in dermatology. Philadelphia, 1984, W. B. Sauneleers Co., pp. 96-102.
Leukonychia striata associated with systemic lupus erythematosus To the Editor: Discoid and systemic lupus erythematosus may produce many nail changes. Subungual hyperkeratosis has been associated with discoid lupus
Journal of the American Academy of Dermatology
Fig. 1. Leukonychia striata of fingernails associated with systemic lupus erythematosus. erythematosus, I and nail changes, including pitting, ridging, leukonychia, onychomadesis, splinter hemorrhages, clubbing, and onycholysis were observed in approximately 25% of patients with systemic lupus erythematosus. 1.2 I present a patient who developed leukonychia striata associated with active systemic lupus erythematosus and discuss the relationship of leukonychia striata and systemic lupus erythematosus. Case report. A 38-year-old Latin American woman presented to the dermatology service in February 1986 with a whitish bandlike discoloration of her fingernails and toenails that had been present for 2 months. She had had intermittent flares of systemic lupus erythematosus since 1978. Past clinical manifestations included discoid lesions, photosensitivity, digital ulcerations, intermittent fever, nephritis, arthritis, pericarditis, and severe Raynaud's phenomenon. There was no family history of connective tissue disease. In October through December 1985, she had numerous episodes of fever, chills, arthralgias, and myalgias lasting for approximately 5 days. In late December she developed a solitary 1.0 cm ulceration of the upper orolabial mucosa and numerous annular erythematous lesions on the dorsal aspects of her arms. She had more frequent episodes of Raynaud's phenomenon with moderate discomfort. Therapy at that time
histoplasmosis, and intracellular yeasts were likewise found in a bone marrow biopsy specimen. This technic offers a relatively simple and rapid means of early bedside diagnosis (pending biopsy and culture confirmation) not only of herpes infections but also of significant systemic fungal infections as well. Although modifications of staining may be tried, such as short-method methenamine silver, in order to improve ease of identification of organisms, the technic as described appears to be a helpful aid in the early workup particularly of seriously ill patients such as those with AIDS. Jack L. Lesher, Jr., M.D., and Fred J. Kight, M.D. Medical College of Georgia, Augusta, GA 30912
REFERENCE 1. Borton LK, Wintroub BU: Disseminated cryptococcosis presenting as herpetiform lesions in a homosexual man with acquired immunodeficiency syndrome. J AM ACAD DERMATaL 10:387-390, 1984.
Correspondence 535
Comment. Our patients confirm the assumption of Butterworth3 that leukonychia partialis may be a phase of leukonychia totalis; in fact, all the affected members of the family experienced the simultaneous occurrence of leukonychia partialis and leukonychia totalis during the course of their lives. We want to point out the peculiar course of the disease in all our patients who were affected by total leukonychia at birth but experienced a gradual improvement of the nail discoloration during the course of life. At the present time this family is the third one in the literature presenting leukonychia totalis and leukonychia partialis simultaneously; in the previous reports, however, the course of the disease was different. 4 ,5 The follow-up of our patients will clarify if leukonychia will clear in these patients during the course of life.
Vincenzo Bettoli, M.D., and Antonella Tosti, M.D. University of Bologna, Bologna, Italy
REFERENCES Leukonychia totalis and partialis: A single family presenting a peculiar course of the disease To the Editor: The recent publication of some letters about leukonychia in your journal'·2 has prompted us to report a case of familial leukonychia totalis associated with leukonychia partialis. Case report. A 17-year-old boy was referred to us for consultation because of nail discoloration involving the fingernails. The clinical examination showed that the second and third fingers of both hands presented total leukonychia, while the first and fourth fingers presented partial leukonychia characterized by longitudinal or transverse bands of normal pink color. On the other hand, the fifth fingernails on both hands were completely normal in color. The patient was in good health and potassium hydroxide (KOH) preparations and cultures of nail scrapings were negative. The medical history revealed that leukonychia totaIis was present at birth, but during the course of life several bands of normal pink color appeared. Furthermore, both the paternal grandmother and the paternal aunt were affected with the same kind of nail discoloration; no other family members were affected. The patient said that his grandmother had had leukonychia totalis at birth but that she had complctely recovered by the time she died. During the course of her life she presented both leukonychia totalis and leukonychia partiaIis at the same time. The 24-year-old aunt presented the same clinical picture as our patient and showed a similar progression of the disease.
1. Stewart L, Young E, Lim HW: Idiopathic leukonychia totalis and partialis. J AM ACAD DERMATOL 13:157-158, 1985. (Letter to Editor.) 2. Daniel CR: Reply. JAM ACAD DERMATOL 13:158, 1985. (Letter to Editor.) 3. Butterworth T: Leukonychia partialis. A phase of leukonychia totalis. Cutis 29:363-364, 367, 1982. 4. Albright SD, Wheeler CE: Leukonychia: Total and partial leukonychia in a single family with a review of the literature. Arch DermatoI90:392-399, 1964. 5. Harrington IF: White fingernails. Arch Intern Med 114: 301-306, 1964.
Lessening the pressure on scalp dermabrasions To the Editor: I much enjoyed Winton and Salasche's review (J AM ACAD DERMATOL 14:661-668, 1986) of the status of dermabrasion as treatment for premalignant disease. As they noted, I have long trumpeted that stance'-3 and continue to do so. I have for many years routinely included dermabrasion of the balded scalp when significant numbers of keratoses existed there and I was "dermabrading" the face anyway. As have Winton and Salasche, I have used dermabrasion of the scalp alone down to the forehead level of the preexisting hairline, designing my dermabrasion field much as if I were designing the limits of intervention in a hair transplant candidate. As they have done, I have also used dermabrasion of the dorsal aspect of the scalp and extended it down to cover
536
Correspondence
the forehead, stopping past the brow at the level of the lateral canthus and extending toward the sideburn area under which the temples of the glasses pass. Over the years these have been done with a variety of open and closed dressings, and I have no paired comparisons to offer. However, unlike Winton and Sa~ lasche's five cases, I have had patients experience significantly eventful postoperative courses. I believe this has been a direct result of my heavy-handedness some years ago over the atrophic scalp, resulting in markedly delayed reepithelialization and continued crusting and healing that in one patient extended for a period of almost 3 months. Experiences with that patient, and with some others, have not stayed my dermabrader from the dorsal aspect of the scalp, but those experiences have caused me to lessen the degree of pressure on the diamond fraises that I use for dermabrasion of thinned, atrophic scalps that offer only nonfunctional residue of hair follicles and glands for reepithelialization. Some scalps are so thin that one gets the feeling the calvarium lies within a millimeter of the palpating finger. I would be extremely hesitant to intervene on such scalps unless both the patient and the physician were desperate and unless the patient were preinformed that the only healing he might get after an extended period of time could be a thin scar that would not function well. The article is beautiful, scientific, and additionally compares patients who have had dermabrasion with others being treated with topical 5-fluorouracil. No attempt was made to compare cryosurgical intervention, but we are all well acquainted with the latter's pro and cons. Winton and Salasche's precautions "to control the depth of abrasion" are singularly appropriate, and I strongly urge the scalp abrader to heed their advice.
Lawrence M. Field, M.D. University of California, San Francisco, CA 94143 REFERENCES 1. Field LM: On the prophylactic value of dermabrasion. Cutis 8:186, 1971. 2. Field LM: Dermabrasion vs 5-FU for actinic damage. J AM ACAD DERMATOL 6:269-270, 1982. (Letter to Editor.) 3. Field LM: On the value of dermabrasion in the management of actinic keratoses, in Epstein E, editor: Controversies in dermatology. Philadelphia, 1984, W. B. Sauneleers Co., pp. 96-102.
Leukonychia striata associated with systemic lupus erythematosus To the Editor: Discoid and systemic lupus erythematosus may produce many nail changes. Subungual hyperkeratosis has been associated with discoid lupus
Journal of the American Academy of Dermatology
Fig. 1. Leukonychia striata of fingernails associated with systemic lupus erythematosus. erythematosus, I and nail changes, including pitting, ridging, leukonychia, onychomadesis, splinter hemorrhages, clubbing, and onycholysis were observed in approximately 25% of patients with systemic lupus erythematosus. 1.2 I present a patient who developed leukonychia striata associated with active systemic lupus erythematosus and discuss the relationship of leukonychia striata and systemic lupus erythematosus. Case report. A 38-year-old Latin American woman presented to the dermatology service in February 1986 with a whitish bandlike discoloration of her fingernails and toenails that had been present for 2 months. She had had intermittent flares of systemic lupus erythematosus since 1978. Past clinical manifestations included discoid lesions, photosensitivity, digital ulcerations, intermittent fever, nephritis, arthritis, pericarditis, and severe Raynaud's phenomenon. There was no family history of connective tissue disease. In October through December 1985, she had numerous episodes of fever, chills, arthralgias, and myalgias lasting for approximately 5 days. In late December she developed a solitary 1.0 cm ulceration of the upper orolabial mucosa and numerous annular erythematous lesions on the dorsal aspects of her arms. She had more frequent episodes of Raynaud's phenomenon with moderate discomfort. Therapy at that time