Correspondence 301

patients is unusual. We report a child with chronic urticariato cockroach.

A 12-year-old boy was referred to our hospital becauseof chronic urticaria that had begun when he was 7 yearsold. It had improved with the use of antihistaminetherapy but he had stopped taking the antihistamines.He did not develop allergic rhinitis, asthma, or atopicdermatitis. His weight and height percentiles were25%. He had urticarial plaques but his breathing soundswere clear, and his heartbeat was regular, without murmur.Abdominal examination was normal without any organenlargement.

The white blood cell count was 7440/mm

3

, eosinophilpercent was 9%, eosinophil count was 670/mm

3

, totalimmunoglobulin E level was 2066, sedimentation ratewas 19 mm/hour, urine examination was normal, para-site examination was negative. He underwent a completeallergy evaluation. Antihistamines were withheld for 10 daysbefore the tests. Skin prick test was performed. Onlycockroach hypersensitivity was found.

Chronic urticaria is a very common skin disease witha considerable impact on quality of life. Whereas atopicsare at increased risk for acute urticaria /angioedema aswell as some forms of physical urticaria, most patientswith chronic urticaria/angioedema are, surprisingly, notatopic. The underlying cause of mast cell degranulationin the majority of patients with chronic urticaria /angio-edema cannot be determined. Although there is a wide-spread belief that cockroach allergy is a common problemin patients with respiratory allergies (4), little is known aboutits possible role in chronic urticaria.

Our patient’s chronic urticaria dramatically improvedfollowing the avoidance of cockroach. We have reportedhim because there are no data about chronic urticariawith isolated cockroach hypersensitivity. We propose thatcockroach hypersensitivity be considered and investi-gated in chronic urticaria patients.

REFERENCES

1. Kaplan AP. Urticaria and angioedema. In: Adkinson NF Jr,Yunginger JW, Busse WW et al eds. Allergy: principles andpractice. Philadelphia: Mosby, 2003:1537–1558.

2. DiCampli C, Gasbarrini A, Nucera E et al. Beneficialeffects of

Helicobacter pylori

eradication on chronicidiopathic urticaria. Dig Dis Sci 1998;43:1226–1229.

3 . Wedi B, Wagner S, Werfel T et al. Prevalence of

Helico-bacter pylori

associated gastritis in chronic urticaria. IntArch Allergy Immunol 1998;116:288–294.

4 . Yilmaz A, Tuncer A, Sekerel BE et al. Cockroach allergy ina group of Turkish children with respiratory allergies. TurkJ Pediatr 2004;46:344–349.

FULYA TAHAN, M.D.Kayseri, Turkey

233CorrespondenceCorrespondencePediatric Dermatology Vol. 23 No. 3 April 2006

AN UNUSUAL PRESENTATION OF ERYTHEMA TOXICUM NEONATORUM:

DELAYED ONSET IN A PRETERM INFANT

To the Editor:

A 14-day-old boy was seen for an acute pustular eruptionthat had begun as small erythematous macules over thetrunk 2 days prior. He was otherwise well and had nofever. It was also noted that a few days before the erup-tion, the infant was fed with cow’s milk. His mother hadno prenatal or natal history of vesicular or pustular erup-tions. His medical history revealed premature deliverysecondary to maternal prenatal hypertension. He wasborn by Cesarean section at 35 weeks of gestation with a2300-g birthweight. Following 5 days of hospitalizationfor prematurity and indirect hyperbilirubinemia, he wasdischarged without any other complications.

Physical examination disclosed an asymptomatic, healthy-appearing, but icteric infant with widespread confluenterythematous macules and 1 to 2 mm discrete pustulesscattered especially over the anterior part of the trunk(Fig. 1). The microscopic examination of a Wright stainof pustular contents revealed large masses of eosino-phils. Gram stain and potassium hydroxide examinationsof the pustules did not show any microorganisms orfungal elements. The bacterial and fungal cultures of thepustules yielded no growth. His blood chemistries werewithin normal limits except for a decreased unconju-gated bilirubin level of 9.62 mg/dL (normal range: 14–19 mg/dL). The jaundice was considered to be secondaryto prematurity, and it was decided to follow him up withfrequent periodic examinations. The eruption and icterusresolved completely by the age of 19 days. Based on thetypical clinical course and laboratory findings, a diagno-sis of erythema toxicum neonatorum (ETN) was made.

The etiology of ETN is still unknown. An inflamma-tory reaction to obstruction of the pilosebaceous orifice

Figure 1. Widespread pustules over the trunk of the pre-term infant.

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Vol. 23 No. 3 May/June 2006

(1) and mechanical or thermal stimulation (2) has beenproposed, as well as a mild, self-limited, acute cutaneousgraft-versus-host reaction in the transiently immunosup-pressed newborn (3). Another explanation given is acti-vation of the cutaneous immune system secondary to rapidcolonization of the skin and mucosal surfaces at birth(4). This disorder is rarely seen in premature infants andits incidence decreases parallel to decreased maturityand birthweight (5). The eruption is most common interm infants in the first 1 to 2 days of life. However a 10-day-old-term infant with delayed onset of ETN has beenreported by Chang et al (6). Our patient was born at35 weeks of gestation with a low birthweight. He had adelayed presentation of ETN at 12 days of age, whichmay be the result of a late inflammatory response tomicrobial colonization because of the delayed maturationof his immune system. It is also important to note that hewas given cow’s milk just before the rash appeared. Thismay suggest that not only cutaneous microbial coloniza-tion but also gastrointestinal colonization or an allergicreaction to a foreign substance may have induced the acti-vation of the immune system, leading to recruitment of thosecells to the skin.

REFERENCES

1. Hurwitz S. Clinical pediatric dermatology, 2nd ed. Phila-delphia: W.B. Saunders, 1993:13–14.

2. Keitel H, Yadav V. Etiology of toxic erythema. Am J DisChild 1963;106:306–309.

3. Bassukas ID. Is erythema toxicum neonatorum a mildself-limited acute cutaneous graft-versus-host reaction frommaternal-to-fetal lymphocyte transfer? Med Hypotheses1992;38:334–338.

4 . Marchini G, Ulfgren AK, Loré K et al. Erythema toxicumneonatorum: an immunohistological analysis. PediatrDermatol 2001;18:177–187.

5. Carr J, Hodgman J, Freeman R et al. Relationship betweentoxic erythema and infant maturity. Am J Dis Child1966;112:129–134.

6 . Chang MW, Jiang SB, Orlow SJ. Atypical erythema toxi-cum neonatorum of delayed onset in a term infant. PediatrDermatol 1999;16:137–141.

GULSEN AKOGLU, M.D.SIBEL ERSOY EVANS, M.D.TULAY AKCA, M.D.SEDEF SAHIN, M.D.Ankara, Turkey

233CorrespondenceCorrespondencePediatric Dermatology Vol. 23 No. 3 April 2006

NARROW BAND UVB TREATMENT FOR A CHILD WITH MYCOSIS FUNGOIDES

To the Editor:

A 12-year-old boy presented with multiple erythema-tous patches, plaques and hypopigmented patches onhis trunk, buttocks and legs. The lesions began six years

earlier as erythematous scaly patches on his trunk thatslowly increased in size and numbers and developedinto hypopigmented patches and plaques on his entirebody. He had Fitzpatrick skin phototype II. The lesionswere treated with mid-potency topical corticosteroidsunsuccessfully.

Histologic examination revealed atypical lymphocyticinfiltrations within the superficial dermis and epider-motropism of the lymphocytic infiltrate throughout thebasal layer and upper epidermis.

Various other investigations, including complete bloodcounts, serum biochemistry, human immunodeficiencyvirus (HIV) serology, hepatitis screening, findings onchest X-ray film, and abdominal and lymph node ultra-sonographic examination, were all normal or negative.

A diagnosis of mycosis fungoides (MF) was indicatedby the clinical appearance of the lesions and confirmedhistologically. Disease stage was classified IA based onthe TNM classification of the National Cancer Instituteworkshop on MF (1).

In addition to emollients, narrowband UVB therapywas given in a UV phototherapy unit containing twenty-onenarrow-band fluorescent tubes (TL-100W/01, Philips,Rosendal, Netherlands) with a spectrum of 310 to 315nm and maximum wavelength of 311 nm installed in aCosmedico GP-42® Cabinet (Medizintecknik, Germany).During the treatment the boy’s eyes were protected byUV-blocking goggles and the genital area was shielded.This monotherapy was given three times weekly. The initialdose was 0.005 J/cm

2

, increased after every 3 sessionsof treatment by 0.010 J/cm

2

. The lesions became pro-gressively less indurated and cleared completely in sixmonths. On histologic examination, basketweave hyper-keratosis and basal cell hyperpigmentation in the epidermisand dermis was seen as normal. The follow-up period isnow 6 months, and he is disease-free.

A variety of therapies have been used to treat childrenand adolescents with MF, but no established treatmentprotocols have been especially designed for children. Vari-ous skin directed therapies including topical corticosteroids(2,3), topical nitrogen mustard (3), and topical carmustine(4,5) are the most commonly used modalities for childrenwith stage IA MF. Broadband UVB (4,6), psoralen plusUVA (PUVA) (6), topical PUVA (7), and local radiother-apy to isolated resistant lesions (6) are also used.

Early stage MF has long been treated with topicalagents and phototherapy. Four publications have demon-strated the usefulness of NB-UVB for MF (8–11). Patientswho respond best are those with less photosensitive skintypes, those who seek treatment early in their diseasecourse, and those with earlier stage MF.

Narrow band UVB phototherapy appears to producesimilar results in children and adults. This therapy is also