Volume 11 Number 2, Part 1 August, 1984

Correspondence 305

gins can be seen in the same section. Dyes are used to mark the different surfaces and detailed excision maps are drawn. Most practitioners of this technic examine the tissues by frozen section. This is the fastest method but it requires an expensive cryostat or a freezing mi- crotome. Either the surgeon must have the skill to do frozen sections or a technician must be available. Brooks ' method avoids these problems. Paraffin sec- tions, not frozen sections, are obtained.

I have practical suggestions for handling the tissues. After marking the surfaces of the specimens with ap- propriate dyes, the surgeon himself places them in the plastic embedding cassettes. The tissues are squeezed between two small sponges. This flattens the specimens and avoids possible orientation errors. The cassettes, with the specimens securely enclosed, are delivered to the laboratory for processing. The histotechnologist is instructed to embed the material flat (not on edge) in the paraffin. After processing, serial paraffin sections, known as ribbons, are cut, mounted, and stained in the routine fashion. It is important that the consecutive slides be labeled correctly. In this fashion, the sur- geon-dermatopathologist can follow suspicious areas through consecutive levels and reach a more accurate interpretation.

Salasche in his editorial (J AM ACAD DERMATOL 10:285-287, 1984) discusses Brooks' modification of Mohs ' procedure and alludes to the difficulty in in- terpretation of horizontal section: "Presently, the only individuals both competent and qualified to interpret these horizontal sections are Mohs surgeons certified by the American College of Chemosurgery." Problems in interpretation are often due to the fact that frozen sec- tions are generally of poor quality. By going directly to paraffin sections, better material is available for in- terpretation. Of course, the patient must return the fol- lowing day since paraffin sections require at least 8 hours for processing. This is inconvenient and requires additional anesthesia and cleansing of the wound site. But it also spares the patient the expense of a frozen section. In addition, it enables the dermatologist with- out access to frozen sections to employ the basic Mohs' procedure.

D. Friday King, M.D. 515 S. Beach Blvd., Suite 1, Anaheim, CA 92804

Reply

To the Editor: Dr. King's comments aptly illuminate the practical

reasons for using permanent sections in treating pri- mary carcinoma with the procedure I referred to as curettage and shave excision.

I should like to remind readers that the purpose of my paper was to urge that this technic be included in graduate training programs. It offers the histologic control that is missing from the curettage and elec- trodesiccation method. Thus, it has the potential to maximize cure rates while at the same time sacrificing a minimum of normal tissue.

But formal training is essential, The proper technic of shaving, mapping, and orienting the excised tissue and preparation and interpretation of horizontally cut specimens require detailed instruction and close-up ob- servation in actual practice.

Having taught this procedure to residents in training, I have become aware of the potential for serious error. Inadequate training invites complications and perhaps even legal difficulties. In my opinion, curettage and shave excision should become a part of the curriculum of dermatology.

As regards Dr. King's handling of excised tissue, my own preference has been to flatten the tissue against thin pieces of cardboard prior to placing it in formalde- hyde. His method also appears to be effective.

Norman A. Brooks, M.D, 16311 Ventttra Blvd., Suite 690

Encino, CA 91436

Practical management of widespread, atypical keratosis pilaris

To the Editor: Keratosis pilaris is an extremely common, self-

limited, benign disorder of keratinization, having no racial predominance and estimated to affect between 50% and 80% of all adolescents. I In widespread atypi- cal cases, where large areas of the trunk and extremities may be affected for prolonged periods, keratosis pilaris may be quite cosmetically disfiguring and psycholog- ically distressing for the patient.'-'

Since keratosis pilaris is such a common condition and since a wide variety of topical therapies have proved unsatisfactory, '~-n I would like to share with you an effective, well-accepted, well-tolerated, and eco- nomicaI, protocol for managing atypical, widespread, or psychologically troubling keratosJs pilaris. This pro- tocol has been followed in my practice for over 5 years by nine male and twenty-one female patients with widespread atypical or psychologically troubling kera- tosis pilaris. Clearing of most lesions was achieved within 2 to 3 weeks of daily treatments. Maintenance therapy, thereafter, was required only once or twice weekly. All my patients expressed satisfaction with the overall cosmetic result, which ranged from 75% to 100% clearing of their lesions.

306 Correspondence

Journal of the American Academy of

Dermatology

Treatment protocol. The patient with widespread keratosis pilaris should first be advised about general measures to prevent excessive skin dryness. Such mea- sures include decreasing the frequency of skin cleans- ing; taking tepid brief water showers, rather than long hot baths; using neutral or superfatted soaps; and humidifying his home environment.

Patients wi~ a prominent inflammatory component tll~l~ lesit~ns should :apply; 'at the outset Only, a

medlum.potency, emollient-based, topical steroid prep- aration once or twice daily until overall inflammation is markedly reduced. This is usually achidved in 7 days. Many patients are gratified by both the rapid decrease in the perilesional erythema and the general softening of the papules. At this point, the topical steroid should be discontinued.

Following a daily showe r, the patient should gently pat-dry his skin, leaving it moist to wet, rather than dry. A. compound preparation consisting of salicylic acid 2% t93.% in20% ureacream (Carmol 20) should then be gently massaged into the moist skin. with a polyester or combination polyester/sponge cleansing sponge (e.g., Buf-Puf). At first each affected area should be lightly massaged for about 5 seconds, This duration of massage should be maintained for at least the first week of therapy. After the sponge massage, the

residual cream should be gently massaged into the skin with the fingertips. Assuming no irritation has resulted, after the first week, the patient may increase the dura- tion of massage by 5 seconds every 2 to 3 days and/or the pressure of the massage; skin tolerance to theabra- sion must be built tip gradually. Patients will seldom require more than 20 seconds on each area daily to establish satisfactory control.

If this procedure is not done gradually, in the hope of effecting a more rapid clearing, excessive irritation and dryness may result. If for any reason the patient's skin does become dry or irritated, therapy can be withheld for several days and then reinstituted at a fewer number of seconds, a lighter pressure, or on an alternate or every-third-day schedule.

Once satisfactory control is obtained, patients can then be switched to a maintenance routine. The dura- tion of massage and the degree of pressure that were needed to effect cleating should be maintained, but the frequency now may be reduced to once or twice weekly, rather than daily. Should the patient sub- sequenfly note an increased number of new lesions, he may resume a daily regimen until clearing is once again achieved, If after several weeks maintenance control remains satisfactory, straight 20% urea cream (Carmol

20), an over the counter item, can be substituted for the compound preparation, to the delight of the patient who no longer requires an expensive prescription item. Maintenance may be continued indefinitely.

When followed as outlined, this therapy for distress- ing or extensive keratosis pilaris has proved in my pa- tients to be an effective, convenient, well-accepted, well-tolerated regimen; lack of need for frequent or protracted use of topical steroid preparations is an ad- ditional advantage.

Nelson Lee Novick, M.D. Department of Dermatology

The Mount Sinai Medical Center One Gustave Levy Place, New York, NY 10029

REFERENCES

1. Rook A, Wilkinson DS, Ebling, FJG: Textbook of der- matology, ed. 3. Oxford, 1979, Blackwell Scientific Pub- lications, pp. 1288-1289.

2. Coombs FP, Butterworth T: Atypical keratosis pilaris. Arch Dermatol Syph 62:305-313, 1950.

3. Villanova X, Canadell VJM: Dermatopatias, hypotiroid- ismo avitaminosis A. Actas Dermosifiliogr 40:689-695, 1949.

4. Lowenthal LJA: New cutaneous manifestations in the syndrome of vitamin A deficiency. Arch Dermatol Syph 28:700-708, 1933.

5. Forrnan L: Keratosis pilaris. Br J Dermatol 66:279-282, 1954.

R a b b i t ea r a n d comedogenicity

To the Editor: Fulton et al, in their article, "Comedogenicity of

Current Therapeutic Products, Cosmetics, and Ingre- dients in the Rabbit Ear" (J AM AcA• DERMAToL 10:96-105, 1984) have perpetuated the great American dream of the b o x score and the list. The rabbit ear model for comedogenicity is a test used both properly and improperly. It is a very sensitive model for irrita- tion and we assume comedone formation in man. We are not sure whether the "lesions" manufactured in the rabbit's ear are the same as acneiform lesions in the human and we are not sure whether irritation alone makes for positivity in the rabbit ear. Many anti-acne preparations used in the human are irritants and cause some erythema and desquamation of the outer layer of skin and help in the treatment of acne. The rabbit ear tends to make small follicular keratoses when it is irri- tated. I am not sure that the two are equal phenomena.

Also, many of the preparations that Fulton lists are widely used as anti-acne preparations and have had a