Letters to the Editor
systemic antihistamines, photochemotherapy, UVB phototherapy, liquid nitrogen cryotherapy, electrical nerve stimulation, and allopurinol, have all been tried with varying degrees of success.[3] Our patient was treated with oral antihistamines and topical tretinoin (0.05%) twice daily. Within six weeks, the lesions started to resolve but the patient was subsequently lost to follow-up.
Sudip Kumar Ghosh, Debabrata Bandyopadhyay, Gobinda Chatterjee Departments of Dermatology, Venereology, and Leprosy, R.G. Kar Medical College, Kolkata, India Address for correspondence: correspondence: Dr. Sudip Kumar Ghosh, Vill+ P.O- Rajballavpur (Via –Maslandpur), Dist-24 Parganas (N), West Bengal - 743 289, India. E-mail:
[email protected]
Figure 1: Close-up view showing a papule with a central keratotic plug and a shallow scar adjacent to the papule
DOI: 10.4103/0378-6323.51269 - PMID: 19439891
REFERENCES 1. 2. 3. 4.
Figure 2: Transepidermal elimination of dermal basophilic material into a cup-shaped epidermal depression (H and E, ×40)
Faver IR, Daoud MS, Su WP. Acquired reactive perforating collagenosis: Report of six cases and review of the literature. J Am Acad Dermatol 1994;30:575-80. Kawakami T, Saito R. Acquired reactive perforating collagenosis associated with diabetes mellitus: Eight cases that meet Faver’s criteria. Br J Dermatol 1999;140:521-4 3. Schmults CA. Acquired reactive perforating collagenosis. Dermatol Online J 2002;8:8. Kim EJ, Kim MY, Kim HO, Park YM. Acquired reactive perforating collagenosis triggered by insect bite. J Dermatol 2007;34:677-9.
Isomorphic and isotopic phenomenon occurring simultaneously in a case of granuloma annulare
The condition is often resistant to treatment. Control of pruritus is the cornerstone of management. Topical glucocorticoids, retinoids, keratolytics,
Sir, A 65-year-old male patient presented to us with generalized annular skin lesions over his body. The patient had no other significant comorbidities except for peripheral neuropathy over the legs for which he was being managed in the Neurology department. Dermatological examination showed well-defined discrete, skin-colored papules and annular plaques in a generalized manner, more so over the extremities. There was no evidence of any sensory loss or thickened nerves. Systemic examination was within normal limits. Clinical diagnoses of granuloma annulare and cutaneous sarcoidosis were considered. The initial skin biopsy showed a non-specific granulomatous inflammation—a possibility of intestitial granuloma
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Figure 3: Transepidermal elimination of dermal basophilic material with sparse lymphocytic infiltrate with scattered neutrophils into a cup-shaped epidermal depression (H and E, ×100)
Letters to the Editor
annulare was considered. The patient was extensively investigated to rule out any systemic association, especially diabetes mellitus, sarcoidosis, Hansen’s disease, connective tissue diseases and any underlying malignancy. Results of all investigations were within normal limits. The patient was empirically started on a low dose of systemic steroids, following which the skin lesions subsided dramatically. The patient had to be maintained on a dose of 10 mg prednisolone for more than 6 months, with intermittent relapses of the skin lesions on withdrawal of the steroid. Approximately a year later, the patient presented with an episode of herpes zoster over the left lower thoracic dermatomes. The patient was treated appropriately with systemic antiviral medication. A month later, the patient presented with an exacerbation of the skin lesions (similar to his previous lesions a year ago), with significant grouping of the lesions over the healed herpes zoster scars [Figure 1]. The possibility of granuloma annulare presenting as a Wolf’s isotopic
response was considered. Interestingly, many areas of the body showed lesions in a linear configuration, suggesting an isomorphic response (Koebner’s phenomenon) [Figure 2]. A skin biopsy was repeated from the new lesions. Histopathology was consistent with granuloma annulare [Figures 3 and 4]. The patient was otherwise well with no other significant systemic complaints. He was restarted on a short course of low-dose prednisolone (10 mg), following which the skin lesions showed a good response. The patient is continuing on regular follow-up. Various cutaneous lesions including granulomatous reactions are known to occur at the site of resolved herpes zoster infection. The term isotopic response refers to the occurrence of a new skin disorder at the site of another, unrelated, and already healed skin disease. It was first described by Wolf et al., in 1985 and is hence referred to as the Wolf’s isotopic response.[1]
Figure 1: Grouped annular lesions on the left side of abdomen (over healed herpes zoster lesions)
Figure 2: Lesions in a linear pattern-isomorphic response
Figure 3: Granulomatous dermal inflammation (H & E, ×10)
Figure 4: Degenerated collagen with surrounding histiocytes (H & E, ×40)
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Indian J Dermatol Venereol Leprol | May-June 2009 | Vol 75 | Issue 3
Letters to the Editor
Feroze Kaliyadan, Siby Gopinath1, M. G . Jayasree2, Chirag Parmar 2
Granuloma annulare has been a commonly reported “second disease” as part of an isotopic response. Other diseases reported include lichen planus, granulomatous folliculitis, tinea, multiple epidermoid cysts, morphea, rosacea, erythema annulare cetrifugum and sarcoidosis (scar sarcoidosis).[2-4] Our case was interesting because it represented a segmental presentation of a preexisting generalized disease. The segmental presentation usually precedes the development of generalized lesions. The other salient feature was the presence of prominent Koebnerization or isomorphic phenomenon, concurrently presenting with an isotopic response. The need for distinguishing isomorphic response as a totally different entity from the isotopic response has been dealt before by Thappa. [4] The term isotopic response as mentioned earlier refers to the occurrence of a new skin disorder at the site of another, unrelated, and already healed skin disease. The isomorphic response, or Koebner phenomenon, indicates the appearance of typical skin lesions of an existing dermatosis at sites of injury.[4] However, considering that granuloma annulare has been described commonly in the contexts of both isomorphic and isotopic response, we wonder if there could be an underlying common pathology? Happle[5] has, in a recent article, suggested that in polygenic disorders, such as granuloma annulare, which sometimes shows segmental or linear patterns, a genetically oriented concept of an isolated or superimposed segmental manifestation may be more meaningful. Happle suggests that this genetic basis possibly involves loss of heterozygosity of one of the genes that predispose to the disorder.[6] Local neuroimmune dysregulation set off by herpes virus-induced lesions of dermal sensory nerve fibers has been suggested as a possible explanation for the Wolf’s response by Ruocco et al.[3] Psoriasis is another condition, which has been described in the context of both isotopic and isomorphic responses. The role of substance P has been considered in the pathogenesis of psoriasis occurring in herpes zoster scars, as substance P is implicated in the pathogenesis of psoriasis as well as in the pathogenesis of pain associated with herpes zoster.[5] Through this article we would like to highlight the possibility of both isotopic and isomorphic response occurring simultaneously, thus suggesting the possibility of some common link in the etiopathogenesis. It is possible that neuropeptides are significantly involved in both conditions. Indian J Dermatol Venereol Leprol | May-June 2009 | Vol 75 | Issue 3
Departments of Dermatology, 1Neuro-Medicine, 2Pathology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India Address for correspondence: correspondence: Dr. Feroze Kaliyadan, Department of Dermatology, Amrita Institute of Medical Sciences and Research Centre, Elamakkara PO, Kochi - 26,Kerala,India. E-mail:
[email protected] DOI: 10.4103/0378-6323.51270 - PMID: 19439892
REFERENCES 1. 2.
3. 4. 5. 6.
Wolf R, Brenner S, Ruocco V, Filioli FG. Isotopic response. Int J Dermatol 1995;34:341-8. Sanli HE, Koçyiğit P, Arica E, Kurtyüksel M, Heper AO, Ozcan M. Granuloma annulare on herpes zoster scars in a Hodgkin’s disease patient following autologous peripheral stem cell transplantation. J Eur Acad Dermatol Venereol 2006;20:314-7. Ruocco E, Baroni A, Cutrì FT, Filioli FG. Granuloma annulare in a site of healed herpes zoster: Wolf’s isotopic response. J Eur Acad Dermatol Venereol 2003;17:686-8. Thappa DM. Isotopic response versus isomorphic response. Indian J Dermatol Venereol Leprol 2004;70:376. Happle R. Superimposed segmental manifestation of polygenic skin disorders. J Am Acad Dermatol 2007;57:690-9. Gupta S. Many faces of Koebner phenomenon in psoriasis. Indian J Dermatol Venereol Leprol 2002;68:222-4.
Finasteride-induced gynecomastia Sir, Finasteride has successfully been used for treatment of male androgenetic alopecia.[1] Gynecomastia is a rare adverse effect of this drug, which has been reported by some authors, especially at the dose of 5 mg/d;[2] few authors have also reported of this complication with 1 mg/d finasteride.[1] We also observed the same adverse effect in two patients receiving orally 1 mg/d finasteride. Case 1: A 19- year-old man affected by male pattern hair loss (MPHL) received finasteride, 1 mg/d for 8 months. Seven months later, he presented with a painful enlargement of his left breast, with no evident nodules at palpation. On sonography, there was diffuse increase in breast tissue, without any abnormal mass or parenchymal distortion [Figure 1]. Axillary lymph nodes were normal. Laboratory evaluations including testosterone, free testosterone, luteinizing hormone, dehydroepiandrosterone, and prolactin were within normal range. Dihydrotestosterone level was 135 µg/ 309
