Tobia Caccavale

Inverse notalgia paresthetica: a strange case of professional disease.

intermarriage. Fitzpatrick’s classification of skin types holds true today and can be used to broadly distinguish between skin types according to their ability or lack of it to burn and tan, and to distinguish among the degrees of lighter and darker skin, and thus seems more relevant than a geographically based descriptor such as Asian. The more accurate term South Asian skin as a descriptor for skin of Fitzpatrick phototypes IV–VI in people living in India has already been suggested and is factually correct not just for the 1.3 billion people of India but for populations of the entire Indian subcontinent, including those of Bangladesh, Pakistan, Sri Lanka, the Maldives, Afghanistan, Tibet, and Nepal. Interestingly, the Indian subcontinent is also referred to as the South Asian subcontinent by many workers for political considerations. Therefore, this letter may also serve as a reminder to use the term South Asian skin for skin of Fitzpatrick types IV, V, and VI in native people living in these locations.

Varicella within a Prior Immunization Reaction Site: Another Example of "Isovaccinetopic Response".

To the Editor: We read with great interest the report by Wu et al (1) in which they describe an interesting case of varicella appearing within a prior immunization reaction site after pentavalent vaccination in the left anterior thigh of an 18-month-old boy. They refer to Wolf’s isotopic response as a possible pathogenic explanation for the specific distribution of varicella lesions in this child. We agree with Piccolo and Russo (2), that this is not an example of Wolf’s isotopic response. Wolf’s postherpetic isotopic response (PHIR) refers to the occurrence of a new skin disorder at the site of a previous and already healed herpetic eruption (herpes zoster in most cases) (2), not any prior healed unrelated dermatologic condition. In this case, the clinical event that preceded the appearance of varicella lesions was a vaccine-induced immunization reaction, not a herpetic infection, which is the essential element of PHIR. As Piccolo et al suggest, this case is an example of immunocompromised cutaneous district (ICD) (3), which refers to a locoregional cutaneous immune dysregulation deriving from a prior damaging event that has made a skin area prone to the local onset of immunity-related eruptions or skin disorders (3). The factors responsible for localized immune dysregulation are multifarious (4–20) and include chronic lymphatic stasis, herpetic infections, ionizing or ultraviolet radiation, burns, trauma (especially amputation), tattooing, intradermal vaccinations (as happened in this case), and others of disparate nature. A recent classification of isomorphic and isotopic skin reactions (19,20) proposed a new terminology to indicate each specific cause responsible for the occurrence of an ICD and has encompassed additional conditions (isotattootopic, isomosaictopic, isovaccinetopic, isoneuraltopic, isolymphostatic response and nonresponse) that had not been defined previously (20). According to this new categorization (20), the case of Wu et al (1) can be seen as a typical example of isovaccinetopic response. We thank the authors for giving us the opportunity to discuss such a complex and interesting topic. REFERENCES

Facial flat warts in a young patient with a previous trauma: an example of isotraumatopic response.

Dyschromatosis symmetrica hereditaria by ADAR1 mutations and viral encephalitis: a hidden link? Int J Dermatol 2013; 52: 1582–1584. 8 Liu Q, Wang Z, Wu Y, et al. Five novel mutations in the ADAR1 gene associated with dyschromatosis symmetrica hereditaria. BMC Med Genet 2014; 15: 69. 9 Okamura K, Abe Y, Fukai K, et al. Mutation analyses of patients with dyschromatosis symmetrica hereditaria: ten novel mutations of the ADAR1 gene. J Dermatol Sci 2015; 79: 88–90. 10 Xu XG, Lv Y, Zhai JL, et al. Two novel mutations of the ADAR1 gene in Chinese patients with dyschromatosis symmetrica hereditaria successfully treated with fractional CO2 laser. J Eur Acad Dermatol Venereol 2015. doi: 10.1111/jdv.13090. [Epub ahead of print].

Hidradenitis suppurativa associated with squamous cell carcinoma: an example of an isoscartopic response

activated partial thromboplastin time within the normal ranges. We did not perform debridement, considering the prolonged effects of antiplatelet therapy despite its discontinuation. Skin overlying the hematoma became completely necrotic at 13 days after onset (Fig. 2b) and was removed naturally. The wound was covered by granulation tissue at 21 days (Fig. 2c) and reconstituted by split-thickness skin grafting at 31 days. In a review of 34 cases of DDH, Kaya et al. reported that deep incision or surgical debridement was performed in all cases. However, the present case showed irreversible necrotic changes twice during hospitalization. Considering the low possibility of rescue for skin tissue overlying the hematoma and the high risk of bleeding due to the prolonged effects of antiplatelet agents, early debridement does not appear to always be the best policy. On the other hand, we performed debridement in the late phase of the first episode but not for the second episode. The fact that both outcomes were similar suggests that debridement at least in the late phase of first case may be skipped, particularly when the patient shows a tendency to bleed and no signs of infection.

Hidradenitis suppurativa complicated by squamous cell carcinoma: isoscartopic response

Dear Editors, We read with great interest the report recently published in the International Wound Journal by Jourabchi et al., (1) which describes a patient with a 53-year history of hidradenitis suppurativa (HS) involving the perineum and buttocks complicated by squamous cell carcinoma (SCC), requiring multiple surgical resections and radiotherapy (1). HS is a chronic, inflammatory, debilitating skin disease characterised by painful, inflamed lesions in apocrine gland-bearing areas of the body, most commonly the axillary, inguinal and anogenital regions (2). The authors review 80 cases of SCC complicating HS found in the English literature (1). They state that case reports and studies suggest that the human papilloma virus (HPV) and smoking may be risk factors associated with SCC in HS (1). Furthermore, according to Jourabchi et al.’s opinion, consideration should be given to the increasing use of biological immunosuppressants in HS and the association between chronic immunosuppression and SCC as beta-HPV is activated under conditions of immune suppression (1). Jourabchi et al. observe the highly aggressive nature of SCC in HS and its likelihood of rapid progression, recurrence, metastasis and mortality, recommending an aggressive approach to management at the time of SCC diagnosis in HS (1). However, Jourabchi et al. do not fully clarify all the pathomechanisms involved in the occurrence of SCC in skin areas affected by HS (1). The authors do not mention the possible occurrence of SCC on HS because of the disruption of lymph microcirculation (that hinders the normal trafficking of immunocompetent cells) and damage to peripheral nerve endings (that release immunity-related peptides) that can occur in scarred skin areas affected by HS (2). In fact, the immunological behaviour of a scarred site is different from that of the rest of the body (2). Many times, HS can provoke the presence of scars (2), thus altering the local interplay between immune cells conveyed by lymph vessels and neuromediators running along peripheral nerve fibres. Depending on which of the neurotransmitters and immune cells are involved, the destabilisation could be either defective, thus predisposing to infections and tumours (such as SCC), or excessive, thus favouring the occurrence of some immune disorders or dysimmune reactions at the sites ‘marked’ by scarring (2). In our opinion, this concept could represent another reading key of this case and could be an additional mechanism for the SCC development. The injuring events capable of rendering a skin region potentially immunodestabilised are various, numerous and, most of the times, identifiable by means of a careful clinical history (2–22). According to a new categorisation of isomorphic and isotopic skin reactions (21,22), the report of Jourabchi et al. could be seen as a typical example of ‘isoscartopic response’ (2,14). We thank the authors for giving us the opportunity to discuss such a complex and interesting topic.

Evaluation of skin disorders of lower limb amputation sites: is there a common denominator?

tional work at school. Questions on the total number of sexual partners and age of first sexual intercourse should be added to the survey. The 5% prevalence of HPV vaccination in our students is similar to data from other European countries lacking national HPV vaccination programs. Our findings showed poor understanding of HPV-related cervical cancer prevention in medical students – what chance has the general population of young women? An HPV-related cancer preventive campaign is needed. Broader studies on HPV-related cancer awareness and vaccination in young women are needed so that when vaccination is proposed, there will be a better understanding.

Lichen planus after rabies vaccination: an example of isovaccinetopic response.

isovaccinetopic response Editor, We read with great interest the report recently published in this journal by Ozbagcivan et al., which describes a young patient affected by lichen planus developing after administration of the rabies vaccine. We speculate that Ozbagcivan et al.’s report is a striking example of the “immunocompromised cutaneous district” (ICD). The injuring events capable of rendering a skin region a potential ICD are various, numerous, and most of the times identifiable by means of a careful clinical history. Ample documentation of multifarious disorders (infectious, neoplastic, immune) appearing in ICDs was delineated by Ruocco et al. in 2009. In the following 8 years, what was a “novel” pathogenic concept has been extended to an enlarging variety of clinical conditions. A recent classification of isomorphic and isotopic skin reactions has proposed a newly coined terminology to indicate each specific cause responsible for the occurrence of an ICD and has encompassed additional conditions that had not been defined previously. According to this new categorization, the report by Ozbagcivan et al. can be seen as an example of “isovaccinetopic response,” which can be defined as a new skin disease that appears at the site of previously diseased or injured (due to previous vaccination) skin. In this peculiar case, the lichenoid eruption spread and generalized later on the trunk, extremities, face, and palmoplantar surfaces. Disruption of lymph microcirculation and damage to peripheral nerve endings could have occurred in the young patient’s vaccinated skin, thus altering the local interplay between immune cells conveyed by lymph vessels and neuromediators running along peripheral nerve fibers. This destabilization could have been excessive in the patient reported by Ozbagcivan et al., thus predisposing him to a cutaneous dysimmune disease (such as lichen planus). We thank the authors for giving us the opportunity to discuss such a complex and interesting topic.

Herpes compuctorum: a cutaneous infection related to permanent tattoo

References 1 Chuh A, Lee A, Zawar V, et al. Pityriasis rosea–an update. Indian J Dermatol Venereol Leprol 2005; 71: 311–315. 2 Mandal SB, Dutta AK. A clinical study of pityriasis rosea. Indian J Dermatol 1972; 17: 100–105. 3 Dhar S, Kanwar AJ, Handa S. ‘Hanging curtain’ sign in pityriasis rosea. Dermatology 1995; 190: 252. 4 Chuh A, Zawar V, Lee A. Atypical presentations of pityriasis rosea: case presentations. J Eur Acad Dermatol Venereol 2005; 19: 120–126. 5 Prasad D, Mittal RR, Walia R, et al. Pityriasis rosea: a histopathologic study. Indian J Dermatol Venereol Leprol 2000; 66: 244–246. 6 Chuh AA. Diagnostic criteria for pityriasis rosea: a prospective case control study for assessment of validity. J Eur Acad Dermatol Venereol 2003; 17: 101–103. 7 Lallas A, Kyrgidis A, Tzellos TG, et al. Accuracy of dermoscopic criteria for the diagnosis of psoriasis, dermatitis, lichen planus and pityriasis rosea. Br J Dermatol 2012; 166: 1198–1205.

A case of morphea following radiotherapy for an intracranial tumor: An example of isoradiotopic response

Sir, We read with great interest the report recently published in the Indian Journal of Dermatology by Balegar et al.,[1] which describes a case of a 27-year-old male who developed radiation-induced progressive generalized morphea after getting radiotherapy (RT) for an intracranial tumor. In this patient, morphea, initially strictly localized on the irradiated zone, appeared some months after the last cycle of RT, suggesting induction by ionizing radiation.[1]

Pustular psoriasis occurring on the striae distensae: An umpteenth example of immunocompromised cutaneous district

Sir, We read with great interest the report recently published in the Indian Journal of Dermatology by Balasubramanian and Srinivas[1] which describes a patient with pustular psoriasis occurring on the striae distensae.[1] The patient complained recurrent episodes of generalized pustular eruptions since the age of 15 years. Since the disease was recalcitrant, the patient had assumed systemic steroids during an acute exacerbation, developing steroid-induced striae distensae over the anterior abdomen, arms, and thighs. The authors reported that the current episode of pustular psoriasis was characterized by the striking occurrence of pustular eruptions on the striae.[1]