844 Correspondence

Journal of the American Academy of

Dermatology

]Fig. 1. Acne vulgaris associated with solid facial edema in a pair of twins.

t_ion. Direct immunofluorescence was negative for antihuman IgG, IgA, IgM, and C3, C4 complement. The general medi- cal, the ophthalmologic, and the otolaryngologic examinations showed no further abnormalities except from hypertelorism.

A course of systemic corticosteroid (betamethasone, 1.5 mga day) was started, but this therapy was stopped after 2 weeks because it did not improve the facial edema. At the time of writing the patients were being treated with topical and oral antibiotics and showed a moderate resolution of the acne but had persistence of the facial edema.

Comment . Solid facial edema is a rare complication of acne vulgaris; in fact, until now only 14 cases have been reported in the literature, by Friedman et al, Con- nelly and Winkelmann, I and Strauss. 2 Although it has been hypothesized that chronic cutaneous inflammation from acne can cause a limited cellulitis and a subsequent progressive edema (Friedman et al and Connelly and Winkelmann~), it must be noted that the edema is not strictly associated with severe inflammatory or long- standing acne. Our cases are particularly interesting because both the twins developed the solid facial edema at the same time, 1 year after the onset of acne vulgaris, and the edema persisted unchanged even when the acne improved with the topical and systemic therapies. This fact contrasts with the hypothesis that progressive edema of the face is merely a consequence of the chronic cutaneous inflammation caused by acne, and it suggests that other unknown and possibly inherited fac- tors are involved in the pathogenesis of this unusual complication of acne vulgaris.

Antonella Tosti, M.D., Liliana Guerra, M.D., Vincenzo Bettoli, M.D., and Ugo Bonelli, M.D.

Department of Dermatology University of Bologna, Italy

REFERENCES 1. Connelly MG, Winkelmann RK. Solid facial edema as a

complication of acne vulgaris. Arch Dermatol 1985;121: 87-90.

2. Strauss JS. Sebaceous glands. In: Fitzpatrick TB, Eisen AZ, Wolff K, et al, eds. Dermatology in general medicine. 3rd ed. New York: McGraw-Hill, 1987:678.

Generalized g r a n u l o m a a n n u l a r e in a p a t i e n t wi th a c q u i r e d immunodeficiency syndrome (AIDS)

To the Editor." Drs. Penneys and Hicks, in their excel- lent paper, "Unusual Cutaneous Lesions Associated With Acquired Immunodeficiency Syndrome" (J AM ACAD DERMATOL 1985;13:845-52) reported " . . . two homosexual men with disseminated papular eruptions that resembled granuloma annulare . . . . " stating fur- ther " . . . It is possible that these eruptions have no causal relationship with acquired immunodeficiency syndrome." Recently we saw a patient with AIDS who presented with generalized granuloma annulare, fol- lowed by Kaposi 's sarcoma and death.

The patient was a 34-year-old white homosexual man, first seen in January 1986 with a 4-month history of progressive weight loss, fever, malaise, weakness, joint pain, diarrhea, lymph node enlargement, and an asymptomatic skin eruption. The human immunodefi- ciency virus (HIV; HTLV-III) antibody was positive and the OKT4/OKT8 ratio of 0.3 skin tests for delayed hypersensitivity showed negative findings.

Examination of the skin revealed a widespread erup- tion of small yellowish and skin-colored waxy papules, some of which were umbilicated or annular. Lesions were most extensive over the trunk, thighs, and flexor aspects of the upper limbs (Fig. 1).

Photomicrograph of a skin biopsy specimen showed a palisading granuloma around altered collagen (Fig. 2). Special stains did not demonstrate fungal or bacterial organisms.

Fig. 1. Widespread eruption of umbilicated papules and small annular lesions on the antecubital fossa and flexor aspect of the right forearm.

Volume 17 Number 5, Part 1 November 1987 Correspondence 845

Fig. 2. Foci of altered collagen surrounded by histio- cytes showing palisade arrangement, or scattered be- tween fibers, and occasional giant cells. (Hematoxylin- eosin stain; • 100.)

Soon after biopsy the eruption started to fade, and the skin had almost cleared in late February. At this time the patient developed anemia, jaundice, and a few dull-red nodules on the shins. The biopsy showed a typical picture of Kaposi 's sarcoma. The patient died 1 week later, after massive intestinal bleeding. At au- topsy the lungs and adrenal glarids showed evidence of cytomegalovirus and there was extensive visceral in- volvement with Kaposi 's sarcoma.

The pathogenesis of generalized granuloma annulare is not resolved. There is some evidence suggesting a delayed hypersensitivity reaction to an unknown anti- gen. J Primary vascular mechanisms may be involved. 1.2

Immune complex vasculitis has been described in AIDS, directly related to HIV (HTLV-III) antigen. 3

There is, as yet~ no recognized clinical association between generalized granuloma annulare and AIDS, However, the finding of one more case of this associ- ation, added to the two previously reported by Penneys and Hicks, suggests that this association may be more than simply coincidental, perhaps having vasculitis as a common link.

Lucio Bakos, M.D., Suzana Hampe, M.D., Jodo L. da Rocha, M.D., Ane S. Pires, M.D.,

Marlene Weissbluth, M.D., and Marcia Zampese, M.D.

Hospital de Clinicas de Porto Alegre Federal University of Rio Grande do Sul

Porto Alegre, Brazil

REFERENCES

1. Umbert P, Winkelmann RK. Histologic, ultrastructural and histochemical studies of granuloma annulare. Arch Der- matol 1977;113:1681-6.

2. Dahl M, Ullman S, Goltz R. Vasculitis in granuloma an- nulare: histopathology and direct immunofluorescence. Arch Dermatol 1977;113:463-7.

3. Farthing CF, Staughton RCD, Rowland Payne CMF. Skin disease in homosexual patients with acquired immune de- ficiency syndrome (AIDS) and lesser forms of human T cell leukaemia virus (HTLV III) disease. Clin Exp Der- matol 1985;10:3-12.

Tar: An ultraviolet B screen

The the Editor: The controversy over the role o f tar in the Goeckehnan regimen for psoriasis continues. Stem et al. (J AM ACAD DEP, MATOL 1986;14:742-7) found insufficient evidence of substantial clinical benefit of tar oil as compared to oil vehicle in combination with suberythemogenic doses o f ultraviolet B radiation (UVB). In a letter to the editor, Nicholas J. Lowe (J AM ACAD DERMATOL 1986; 15:1053-4) believed that differences in study design could explain the contra- diction between Stem's observations and his own study ~ in which tar oil was more effective than oil vehicle when combined with suberythemogenic UVB. In our opinion there is another drawback to S tem ' s otherwise well-conducted bilateral comparison study. The tar oil and oil vehicle were reapplied immediately before UVB treatment. The tar may have interfered with proper pen- etration of UVB rays. In order to test this possibility we performed UVB minimal erythema dose (MED) testing simultaneously on normal skin without topicals and after application of tar oil and mineral oil.

Materials and methods. MED testing was performed on 10 healthy volunteers with skin types II, III, and IV (Ta- ble I). A grid containing three horizonal rows with six squares (15 x 15 mm) per row was firmly attached to the upper part of the back. The remainder of the skin was entirely covered with drapes. No topicals were applied to the first row. Im- mediately before t.IVB irradiation, T/Derm oil was applied to the second row and mineral oil to the third row. The oils were applied by gently rolling a cotton-tipped applicator over the test squares with the backs in vertical position. This pro- duced a thin film of oil, similar to that obtained after clinical application of oil. In two cases the application of topicals to the second and third rows was reversed to make certain that the site of application did not influence the test results. MED testing was performed simultaneously in all three rows. The starting dose was dependent on the patient's skin type. The dose was increased by increments of 10 mjouleslcm 2 per square, Thus, the exposure doses varied among the test sub- jects from 40 mjoules/cm ~ as the lowest starting dose in square 1 to 140 mjoules/cm ~ as the highest dose in square 6. UVB irradiation was administered in a UVB walk-in unit manu- factured by National Biological Corporation, Cleveland, OH, equipped with Westinghouse FS72T12 UVB bulbs. The UVB dose delivered at the skin test site was 1 mW/cm" as measured by a National Biological Corporation UVB LMH06 C light meter.