- Email: [email protected]
“Nevocentric” dermatoses
Journal
842
of the American
Academy
Correspondence
unanswered, and they may even give false security that this form of therapy plays a small role in HIV-l disease other than as a treatment of cutaneous disease. As with other aspects of HIV-l disease, studies that control for skin disease as well as for different UV radiation wavelength and doses may not only benefit patients with this diseasebut may also increase our knowledge of the effects of UV radiation to which we are all exposed.
COL Kathleen J. Smith, MC, USA”, b CAPT Henry G. Skelton, MC, USNb CDR Josef Yeager, MC, USN’ Medical Research Institute for Chemical Defense Aberdeen, Marylandn Department of Dermatopathology AIDS Registry Armed Forces Institute of Pathology Washington, D.C.’ Department of Dermatology National Naval Medical Center Bethesda, Marylandc REFERENCES 1. Escaich S, Ritter J, Rougier P, et al. Plasma viraemia as a marker of viral replication in HIV-infected individuals. AIDS 1991;5:1189-94. 2. Shearer GM, Clerici M. T helper cell immune dysfunction in asymptomatic HIV-1-seropositive individuals: the role of Thl-Th2 cross-regulation. Chem Immunol 1992;54:2143. 3. Keet IPM, Krijnen P, Koot M, et al. Predictors of rapid progression to AIDS in HIV-l seroconverters. AIDS 1993; 751-7. 4. Sheppard HW, Ascher MS, McRae B, et al. The initial immune response to HIV and immune system activation determine the outcome of HIV disease. J AIDS 1991;4:70412. 5. Ranki A, Pnska P, Mattinen S, et al. Effect of PWA on immunologic and virologic tIndings in HIV-infected patients. J AM ACAD DEIIMA~L 1991;24:404-10. 6. Pardo RJ, Bogaert MA, Penneys NS, et al. UVB phototherapy of prnritic pap&r eruption of the acquired immunodeficiency syndrome. J AM ACAD DERMATOL 199226: 423-8. 7. Zmudzka BZ, Stickland AG, Miller SA, et al. Activation of the HIV promotor by WA radiation in combination with psoralens or angelicins. Photochem Photobiol 1993; 58:226-32. 8. Morrey JD, Bourn SM, Bunch TD, et al. In vivo activation of human immunodeficiency virus type 1 long terminal mpeat by W type A W-A) light plus psoralen and W-B light in the skin of transgenic mice. J Vim1 1992;65:504551. 9. Screech R, Ribber P, Barley PA. Reactive oxygen intermediates as apparently widely used messenger in the activation of the NF-kappa&eta transcription factor and I-w-1. EMBO J 1991;10:2247-58. 10. Gallo RI, Stazewski R, Granstein. Physiology and pathology of skin photoimmunology In: Bos JD, ed. Skin immnne system. Boca Raton, Fla: CRC Press, 19903381402.
of Dermatology November 1995
11. Kmtmann J, Czech W, Diepgen T, et al. High-dose WA1 therapy in the treatment of patients with atopic dermatitis. J AM ACAD DERMATOL 1992;26:225-30. 12. Paganelli R, Fanales-Belasio E, Scala E, et al. Serum eosinophil cationic protein (ECP) in hnman immnnodeficiency virus infection. J Allergy Clin Immnnol 1991;88:416-8. 13. Spire B, Barre-Smoussi F, Dormont D, et al. Inactivation of lymphadenopathy-associated virns by heat, gamma rays, and ultraviolet light. Lancet 1985;1:188-9.
Reply To the Editor: I appreciate the comments of Drs. Smith, Skelton, and Yeager regarding our study of the effects of PUVA in HIV-l-infected persons. It is worth mentioning that clinical investigation in HIV-l-positive persons is difficult when a possible outcome is acceleration of disease. In fact, a multicenter prospective study of the effects of UV light on HIV- l-related disease progression is planned. We hope that there will be full participation by dermatologists who treat HIV-l-positive patients by referral of qualifying persons. At this time, we do not know the effects of UV light on HIV-l-related disease in vivo; as dermatologists, we should be in the lead in solving the problem.
Thomas D. Horn, MD Department of Dermatology The Johns Hopkins Medical Institutions 600 N. Wolfe St. Baltimore, MD 21287-4915
“Nevocentric”
dermatoses
To the Editor: A patient whose lesions of erythema multiforme had a tendency to surround some of his pigmented neviwasdescribed(JAMAc,4DDERMATo~ 1994;31:4912). Dr. Pariser also discussed the diseases producing a “ring around the nevus,” namely, halo nevus (Sutton’s nevus), “halo eczema” (Meyerson’s nevus), and “targetoid halo nevus. ’ ’ A previous report mentioned that erythema multiforme-like changes were histologically observed in 1 of 10 patients with halo dermatitis around acquired nevus cell nevi.l Pityriasis rosea may be another cause for appearance of a “ring” around melanocytic nevi.2 In some case reports the halo dermatitis around nevi appeared to be part of a widespread nummular dermatitis or was associated with atopic dermatitis.‘, 3 Although psoriasis is common, I was able to find only one report incriminating it as a cause of “halo dermatitiS.“3 During the past 3 years I have seen two patients with “nevocentric” psoriatic lesions. The first of them was a 36-year-old woman with stable plaque-type psoriasis, and recent eruptive guttate psoriasis; three oval psoriatic lesions on the waist surrounded melanocytic nevi.
Journal of the American Academy of Dermatology Volume 33, Number 5, Part 1
The second patient was a 9-year-old girl with guttate psoriasis. The only melanocytic nevus on the abdomen was in the center of a psoriatic plaque. It is evident that a broad spectrum of skin diseases can show a tendency to surround melanocytic nevi. A circular eczematous reaction has also been described around seborrheic keratoses, stucco keratoses, lentigines, keloids, insect bites, basal ceil and squamous cell carcinomas, and dermatofibromas.‘, 4,5 Ivan N. Botev, MD Department of Dermatology Medical Faculty Alexander’s University Hospital Sofia 1431, Bulgaria
Correspondence
843
Pacheco de Melo 1848, (1126) Buenos Aires, Argentina
REFERENCES 1. Grinspan D, Abulafia J. Oral florid papillomatosis (verrucous carcinoma).Int Dermatol 1979;1X:806-22. 2. Yoel J. Oral florid papillomatosis(verrucouscarcinoma).In: Oral Oncology. Varma AK, ed. Proceedingsof the 3rd Intemational Congress on Oral Cancer, Madras, India; vol LIIB. Therapy. New Delhi, India: MacMillan, 1994:433-6. Under the auspicesof UICC and World Health Organization. 3. Yoel J, Galmarini EC. Surgeryand regional infusion of cystostatic agents in the treatment of head and neck. Gazzetta Sanitaria 1972;21:61-8.
REFERENCES
Reply
1. Tegner E, Bjijmberg A, JonssonN. Halo dermatitis around tumours. Acta Derm Venereol (Stockh) 1990;70:31-4. 2. Crovato F, Nazzari G, Gambini C, et al. Meyerson’s naevi in pityriasisrosea [Letter]. Br J Dermatol 1989;120:318-9. 3. Shifer 0, Tchetchik R, Glazer 0, et al. Halo dermatitis in children. Pediatr Dermatol 1992;9:275-7. 4. Rosen R, PaverK, KossardS. Halo eczemasurroundingseborrhoeic keratoses:an example of perilesionalnummnlar dermatitis. AustralasJ Dermatol 1990;31:73-6. 5. Gallais V, Lacour JP,Perrin C, et al. Halo eczkmatifonne autour d’nn histiocytofibrome: ph&nom&nede Meyerson. Ann Dermatol Venereol 1993;120:617-20.
To the Editor: I appreciate the comments of Dr. Grinspan with regard to my article about verrucous carcinoma.’ This is especially true because he has so much experience with this tumor.” He recommends methotrexate to reduce tumor size before surgical excision, electrocoagulation, or other options. Yoe13 uses intraarterial methotrexate if the carcinoma is large. I agree with them and others4-6that reducing hunor bulk by chemotherapy before excision is advantageous for patients with verrucous carcinoma. Although it does not always work,7 chemotherapy, or the use of other agents for this purpose, such as recombinant interferon aIfa* or retinoids,g* lo is worthy of consideration in an individual patient. In addition, these medications may be used to reduce the risk of postoperative recurrence after excision or other destructive techniques.“l, I2
Verrucous mucosa
carcinoma
of the skin and
To the Editor: In the CME article by Dr. Schwartz publishedinJanuary1995(JAMA~mDmT0~1995;32:121) entitled “Verrucous Carcinoma of the Skin and Mucosa,” we read the following: “the basic approach to this tumor is surgical.” (p. 12, column 2) On the basis of my experience with 106 cases,I believe that the best treatment of this disease is methotrexate in the following dosage: one 50 mg intramuscular injection, followed by an oral or intramuscular dose of 25 mg administered once a week for 6 weeks.’ The size of the tumor will be noticeably reduced. Surgery can then be done, although there are other options (except for radiotherapy). This small methotrexate dosage does not produce undesirable effects. Sometimes with methotrexate the tumor disappears completely. When the tumor is la.rge, Dr. JosC Yoel recommends methotrexate by intraarterial infusion, which he has used in the treatment of 85 cases of verrucous ca.rcinoma.2,3 I only prescribe this treatment in exceptional cases. David Grinspan, MD Consulting Professor of Dermatology School of Medicine Buenos Aires University San Martin General School Hospital
Robert A. Schwartz, MD, MPH Dermatology New Jersey Medical School I85 S. Orange Ave. Newark, NJ 07103-2 714
REFERENCES 1. Schwartz. R4. Verrucous carcinoma of the skin and mucosa. J AM ACADDWMATOL199.5;32:1-21. 2. Grinspan D, Abulafia J. Oral florid papillomatosis(verrucous carcinoma). Int J Dermatol 1979;18:608-22. 3. Yoel J. Oral florid papillomatosis (vermcouscarcinoma). In: Oral Oncology. Varma AK, ed. Proceedingsof the 3rd Congresson Oral Cancer,Madras, India; vol IIJB. Therapy. New Delhi, India: MacMillan, 1994:433-6. 4. Kanee B. oral florid papillomatosiscomplicatedby verrucous squamous carcinoma: treatment with methotrexate. Arch Dermatol 1969;99:196-202. 5. Pomatto E, Bocca M, Carbone V, et al. Carcinoma verrucoso de1cave orale: experienzepersonali snl trattamento chemio-chirurgicointegrate. Minerva Chir 1993;48:213-9. 6. Hagedom M, Weigel K, PetresJ. Treatment of oral florid papillomatosiswith bleomycin: use of Holter catheter for intra-arterial administration. Arch Dermatol 1978;114: 1083-4.
842
of the American
Academy
Correspondence
unanswered, and they may even give false security that this form of therapy plays a small role in HIV-l disease other than as a treatment of cutaneous disease. As with other aspects of HIV-l disease, studies that control for skin disease as well as for different UV radiation wavelength and doses may not only benefit patients with this diseasebut may also increase our knowledge of the effects of UV radiation to which we are all exposed.
COL Kathleen J. Smith, MC, USA”, b CAPT Henry G. Skelton, MC, USNb CDR Josef Yeager, MC, USN’ Medical Research Institute for Chemical Defense Aberdeen, Marylandn Department of Dermatopathology AIDS Registry Armed Forces Institute of Pathology Washington, D.C.’ Department of Dermatology National Naval Medical Center Bethesda, Marylandc REFERENCES 1. Escaich S, Ritter J, Rougier P, et al. Plasma viraemia as a marker of viral replication in HIV-infected individuals. AIDS 1991;5:1189-94. 2. Shearer GM, Clerici M. T helper cell immune dysfunction in asymptomatic HIV-1-seropositive individuals: the role of Thl-Th2 cross-regulation. Chem Immunol 1992;54:2143. 3. Keet IPM, Krijnen P, Koot M, et al. Predictors of rapid progression to AIDS in HIV-l seroconverters. AIDS 1993; 751-7. 4. Sheppard HW, Ascher MS, McRae B, et al. The initial immune response to HIV and immune system activation determine the outcome of HIV disease. J AIDS 1991;4:70412. 5. Ranki A, Pnska P, Mattinen S, et al. Effect of PWA on immunologic and virologic tIndings in HIV-infected patients. J AM ACAD DEIIMA~L 1991;24:404-10. 6. Pardo RJ, Bogaert MA, Penneys NS, et al. UVB phototherapy of prnritic pap&r eruption of the acquired immunodeficiency syndrome. J AM ACAD DERMATOL 199226: 423-8. 7. Zmudzka BZ, Stickland AG, Miller SA, et al. Activation of the HIV promotor by WA radiation in combination with psoralens or angelicins. Photochem Photobiol 1993; 58:226-32. 8. Morrey JD, Bourn SM, Bunch TD, et al. In vivo activation of human immunodeficiency virus type 1 long terminal mpeat by W type A W-A) light plus psoralen and W-B light in the skin of transgenic mice. J Vim1 1992;65:504551. 9. Screech R, Ribber P, Barley PA. Reactive oxygen intermediates as apparently widely used messenger in the activation of the NF-kappa&eta transcription factor and I-w-1. EMBO J 1991;10:2247-58. 10. Gallo RI, Stazewski R, Granstein. Physiology and pathology of skin photoimmunology In: Bos JD, ed. Skin immnne system. Boca Raton, Fla: CRC Press, 19903381402.
of Dermatology November 1995
11. Kmtmann J, Czech W, Diepgen T, et al. High-dose WA1 therapy in the treatment of patients with atopic dermatitis. J AM ACAD DERMATOL 1992;26:225-30. 12. Paganelli R, Fanales-Belasio E, Scala E, et al. Serum eosinophil cationic protein (ECP) in hnman immnnodeficiency virus infection. J Allergy Clin Immnnol 1991;88:416-8. 13. Spire B, Barre-Smoussi F, Dormont D, et al. Inactivation of lymphadenopathy-associated virns by heat, gamma rays, and ultraviolet light. Lancet 1985;1:188-9.
Reply To the Editor: I appreciate the comments of Drs. Smith, Skelton, and Yeager regarding our study of the effects of PUVA in HIV-l-infected persons. It is worth mentioning that clinical investigation in HIV-l-positive persons is difficult when a possible outcome is acceleration of disease. In fact, a multicenter prospective study of the effects of UV light on HIV- l-related disease progression is planned. We hope that there will be full participation by dermatologists who treat HIV-l-positive patients by referral of qualifying persons. At this time, we do not know the effects of UV light on HIV-l-related disease in vivo; as dermatologists, we should be in the lead in solving the problem.
Thomas D. Horn, MD Department of Dermatology The Johns Hopkins Medical Institutions 600 N. Wolfe St. Baltimore, MD 21287-4915
“Nevocentric”
dermatoses
To the Editor: A patient whose lesions of erythema multiforme had a tendency to surround some of his pigmented neviwasdescribed(JAMAc,4DDERMATo~ 1994;31:4912). Dr. Pariser also discussed the diseases producing a “ring around the nevus,” namely, halo nevus (Sutton’s nevus), “halo eczema” (Meyerson’s nevus), and “targetoid halo nevus. ’ ’ A previous report mentioned that erythema multiforme-like changes were histologically observed in 1 of 10 patients with halo dermatitis around acquired nevus cell nevi.l Pityriasis rosea may be another cause for appearance of a “ring” around melanocytic nevi.2 In some case reports the halo dermatitis around nevi appeared to be part of a widespread nummular dermatitis or was associated with atopic dermatitis.‘, 3 Although psoriasis is common, I was able to find only one report incriminating it as a cause of “halo dermatitiS.“3 During the past 3 years I have seen two patients with “nevocentric” psoriatic lesions. The first of them was a 36-year-old woman with stable plaque-type psoriasis, and recent eruptive guttate psoriasis; three oval psoriatic lesions on the waist surrounded melanocytic nevi.
Journal of the American Academy of Dermatology Volume 33, Number 5, Part 1
The second patient was a 9-year-old girl with guttate psoriasis. The only melanocytic nevus on the abdomen was in the center of a psoriatic plaque. It is evident that a broad spectrum of skin diseases can show a tendency to surround melanocytic nevi. A circular eczematous reaction has also been described around seborrheic keratoses, stucco keratoses, lentigines, keloids, insect bites, basal ceil and squamous cell carcinomas, and dermatofibromas.‘, 4,5 Ivan N. Botev, MD Department of Dermatology Medical Faculty Alexander’s University Hospital Sofia 1431, Bulgaria
Correspondence
843
Pacheco de Melo 1848, (1126) Buenos Aires, Argentina
REFERENCES 1. Grinspan D, Abulafia J. Oral florid papillomatosis (verrucous carcinoma).Int Dermatol 1979;1X:806-22. 2. Yoel J. Oral florid papillomatosis(verrucouscarcinoma).In: Oral Oncology. Varma AK, ed. Proceedingsof the 3rd Intemational Congress on Oral Cancer, Madras, India; vol LIIB. Therapy. New Delhi, India: MacMillan, 1994:433-6. Under the auspicesof UICC and World Health Organization. 3. Yoel J, Galmarini EC. Surgeryand regional infusion of cystostatic agents in the treatment of head and neck. Gazzetta Sanitaria 1972;21:61-8.
REFERENCES
Reply
1. Tegner E, Bjijmberg A, JonssonN. Halo dermatitis around tumours. Acta Derm Venereol (Stockh) 1990;70:31-4. 2. Crovato F, Nazzari G, Gambini C, et al. Meyerson’s naevi in pityriasisrosea [Letter]. Br J Dermatol 1989;120:318-9. 3. Shifer 0, Tchetchik R, Glazer 0, et al. Halo dermatitis in children. Pediatr Dermatol 1992;9:275-7. 4. Rosen R, PaverK, KossardS. Halo eczemasurroundingseborrhoeic keratoses:an example of perilesionalnummnlar dermatitis. AustralasJ Dermatol 1990;31:73-6. 5. Gallais V, Lacour JP,Perrin C, et al. Halo eczkmatifonne autour d’nn histiocytofibrome: ph&nom&nede Meyerson. Ann Dermatol Venereol 1993;120:617-20.
To the Editor: I appreciate the comments of Dr. Grinspan with regard to my article about verrucous carcinoma.’ This is especially true because he has so much experience with this tumor.” He recommends methotrexate to reduce tumor size before surgical excision, electrocoagulation, or other options. Yoe13 uses intraarterial methotrexate if the carcinoma is large. I agree with them and others4-6that reducing hunor bulk by chemotherapy before excision is advantageous for patients with verrucous carcinoma. Although it does not always work,7 chemotherapy, or the use of other agents for this purpose, such as recombinant interferon aIfa* or retinoids,g* lo is worthy of consideration in an individual patient. In addition, these medications may be used to reduce the risk of postoperative recurrence after excision or other destructive techniques.“l, I2
Verrucous mucosa
carcinoma
of the skin and
To the Editor: In the CME article by Dr. Schwartz publishedinJanuary1995(JAMA~mDmT0~1995;32:121) entitled “Verrucous Carcinoma of the Skin and Mucosa,” we read the following: “the basic approach to this tumor is surgical.” (p. 12, column 2) On the basis of my experience with 106 cases,I believe that the best treatment of this disease is methotrexate in the following dosage: one 50 mg intramuscular injection, followed by an oral or intramuscular dose of 25 mg administered once a week for 6 weeks.’ The size of the tumor will be noticeably reduced. Surgery can then be done, although there are other options (except for radiotherapy). This small methotrexate dosage does not produce undesirable effects. Sometimes with methotrexate the tumor disappears completely. When the tumor is la.rge, Dr. JosC Yoel recommends methotrexate by intraarterial infusion, which he has used in the treatment of 85 cases of verrucous ca.rcinoma.2,3 I only prescribe this treatment in exceptional cases. David Grinspan, MD Consulting Professor of Dermatology School of Medicine Buenos Aires University San Martin General School Hospital
Robert A. Schwartz, MD, MPH Dermatology New Jersey Medical School I85 S. Orange Ave. Newark, NJ 07103-2 714
REFERENCES 1. Schwartz. R4. Verrucous carcinoma of the skin and mucosa. J AM ACADDWMATOL199.5;32:1-21. 2. Grinspan D, Abulafia J. Oral florid papillomatosis(verrucous carcinoma). Int J Dermatol 1979;18:608-22. 3. Yoel J. Oral florid papillomatosis (vermcouscarcinoma). In: Oral Oncology. Varma AK, ed. Proceedingsof the 3rd Congresson Oral Cancer,Madras, India; vol IIJB. Therapy. New Delhi, India: MacMillan, 1994:433-6. 4. Kanee B. oral florid papillomatosiscomplicatedby verrucous squamous carcinoma: treatment with methotrexate. Arch Dermatol 1969;99:196-202. 5. Pomatto E, Bocca M, Carbone V, et al. Carcinoma verrucoso de1cave orale: experienzepersonali snl trattamento chemio-chirurgicointegrate. Minerva Chir 1993;48:213-9. 6. Hagedom M, Weigel K, PetresJ. Treatment of oral florid papillomatosiswith bleomycin: use of Holter catheter for intra-arterial administration. Arch Dermatol 1978;114: 1083-4.