Correspondence 327

Figure 1. Child with complete loss of scalp hair and per- sistent hair at the margins.

negative for fungal hyphae and spores. His alopecia did not respond to diphencyprone (DPC) sensitization for 6 months or to monthly oral corticosteroid pulse therapy (prednisolone 5 mgkg) for 4 months. Subsequently we have seen two adult patients with a similar presentation of hair loss over the center of the scalp, with persistence of hair only at the hair margin. One of these patients was also atopic, and both of them were resistant to conven- tional therapy.

Based on the pattern of hair loss, alopecia areata has been classified into focalllocal, reticular, ophiasis, tota- lis, and universalis (3). The clinical pattern of alopecia areata is important because it has prognostic and etio- logic implications. The reticular pattern has been de- scribed as a marker of an endocrine/autoimmune type of alopecia areata by Ikeda (6) and it progresses to the totalis form in a significant number of patients. Ophiasic alopecia areata frequently affects the posterior and lateral hair line and is associated with atopy and poor prognosis. Recently we have observed a few patients who had the reverse of the ophiasic pattern, that is, loss of hair in the center of the scalp and persistence of hair at the periph- ery. We use the term “ophiasis inversus” to describe it. Galen used the term ophiasis first to describe a type of baldness which literally means snaky (oph-) condition (-iasis) and is applied to that form of alopecia areata in which loss of hair snakes along the temples, parietal scalp, and occiput (7). Ophiasis inversus is rare, and cases have been reported in adults under the term si- saihpo, an anagram of ophiasis. We prefer the term

ophiasis inversus as it is simple and easily understood. An ophiasis inversus pattern was observed in only 3 out of 1300 cases of alopecia areata seen by us and was associated with atopy. It may be found to be more fre- quent if prospective studies are undertaken. Ophiasis in- versus seems to be resistant to conventional therapy in our limited experience and further studies are needed to validate this finding. A possible association of ophiasis inversus and atopy also needs to be studied.

REFERENCES

1. Hippolito MS, Brasilina BS, Cerqueira CS, et al. Clinical- epidemiologic study of alopecia areata. Int J Dermatol

2. Tobin DJ, Hann SK, Song SM, and Bystryn JC. Hair fol- licle structures targeted by antibodies in patients with alo- pecia areata. Arch Dermatol 1997;133:57-61.

3. Dawber RPR, Ebling FJG, and Wojnarowska FT. Disor- ders of hair. In: Champion RA, Burton JL, Ebling FJG, eds. Textbook of dermatology, 5th ed. London: Blackwell Scientific Publications, 1992:2586-2694.

4. Brown CA. Alopecia areata: a neuroendocrine disorder. Semin Dermatol 1985;4: 16-28.

5. Munoz MA, Camacho MF. Sisaihpo: a new form of pre- sentation of alopecia areata. Arch Dermatol 1996; 132:

6. Ikeda T. A new classification of alopecia areata. Derma- tologica 1965;113:421445.

7. Leider M, Rosenblum M. A dictionary of dermatological words, terms, and phrases. New York: McGraw Hill, 1968: 309.

1996;35: 181-184.

1255-1 256.

S. MUEULIDHAR, M.D. VINOD KUMAR SHAFWA, M.D. SUKHJOT KAUR, M.D. Chandigarh, India

HYPERTRICHOSIS WITH PSEUDOACANTHOSIS NIGRICANS OVER THE NAPE: A NEW “MINOR CLINICAL FEATURE”

OF ATOPIC DERMATITIS?

To the Editors: The diagnosis of atopic dermatitis (AD) is mostly

made on the basis of the presence of various basic and minor features established by Hanifin and Rajka (1). Of late, the specificity of some of the minor clinical features in various races and religious and ethnic groups has been questioned (2-5). Moreover, the specificity of many of the minor clinical features vary considerably with the age group of the patients studied (5). Therefore an agewise categorization of various minor features has been sug- gested (6). Some new minor features such as infraauricu- lar fissuring (2,6) and diffuse scaling of the scalp (2,6) have been added to the existing list of minor features. We herein describe one more feature frequently found in patients with AD in the 5- to 12-year-old age group.

328 Pediatric Dermatology Vol. 1.5 No. 4 July/August 1998

Fifty children, 29 (48%) boys and 21 (42%) girls, with AD in the 5- to 12-year-old age group constituted the study population. The diagnosis of AD was made fol- lowing the criteria laid down by Hanifin and Rajka (1). Of the 50 children, 28 (56%) had mild hypertrichosis over the nape with pseudoacanthosis nigricans. The mile- stones of development and growth were normal in all of them. There was no evidence of precocious puberty or abnormality in secondary sexual characteristics in any of these patients. None of them had been treated with sys- temic corticosteroids in the past. There was no family history of similar skin lesions over the nape in any of the patients. When compared with the age- and sex-matched controls, only 4 (8%) children had pseudoacanthosis ni- gricans with hypertrichosis over the nape. However, such a feature was not found in children with AD less than 5 years or more than 12 years of age. The exact etiopatho- genesis and significance of such a finding in AD remains to be elucidated. However, as of now, it appears to be more than a chance association.

REFERENCES

1 .

2.

3.

4.

5.

6.

Hanifin JM, Rajka G. Diagnostic features of atopic derma- titis. Acta Dermatol Venereol Suppl 1980;92:44-47. Kanwar AJ, Dhar S, Kaur S. Evaluation of minor clinical features of atopic dermatitis. Pediatr Dermatol 1991 $3:

Mevorah B, Manazzi A, Frenk E. The prevalence of ac- centuated palmoplantar markings and keratosis pilaris in atopic dermatitis, autosomal dominant ichthyosis and con- trols of dermatological patients. Br J Dermatol 1985;112:

Kang K, Tian R. Atopic dermatitis-an evaluation of clini- cal and laboratory findings. Int J Dermatol 1987;26:27-32. Rudzki E, Samochocki Z , Rebandel P, et al. Frequency and significance of major and minor clinical features of Hani- fin and Rajaka among patients with atopic dermatitis. Der- matology 1994;189:41-46. Nagaraja, Kanwar AJ, Dhar S, et al. Frequency and sig- nificance of minor clinical features in various age related subgroups of atopic dermatitis in children. Pediatr Derma- to1 1996: 13: 10-13.

114-1 16.

6 19-685.

SANDIPAN DHAR, M.D. SUBRATA MALAKAR, M.D Calcutta. India

CLEAR CELL PAPULOSIS: A UNIQUE DISORDER IN EARLY CHILDHOOD

CHARACTERIZED BY WHITE MACULES IN MILK-LINE DISTRIBUTION

To the Editors: I found the article “Clear cell papulosis: case report

and literature review” by Kim et al. (1) very interesting. The lesions were innumerable and diffusely distributed over the entire lower back and buttocks. These findings

differ drastically from those of the six original cases reported by Kuo et al. (2,3) and our five cases in which the lesions were basically located along the milk lines. In fact, it is the milk-line distribution of the white lesions that has supported its possible histogenetic rela- tionship with Toker’s clear cell of the nipple. The lesions tend to increase in number gradually over the first 2 to 3 years after birth. The clear cells in clear cell papulosis are situated not only along the basal layer but also at the suprabasal location. The nuclei of the clear cells are typi- cally pale, basophilic, and centrally located. With immu- nostaining for AEI, some of the clear cells displayed an interesting tadpole shape with a single cytoplasmic pro- cess often pointing upward. M u c h granules have been observed in the cytoplasm of the clear cells in the cases where ultrastructural studies were done. Although the pathologic findings of the clear cells described by Kim et al. resemble the clear cells of clear cell papulosis, I would like to point out some differences that might be worth noting. Judging from the published photos, the nuclei of the clear cells appear to be eccentric and were about the same size and had the same degree of baso- philia as the neighboring keratinocytes, features quite suggestive of basal melanocytes. No mucin granules were detected in the clear cells. Thus the clear cells re- ported by Kim et al. might not be the same type of clear cell as those in clear cell papulosis. If this is the case then the condition probably deserves a different, perhaps new, designation. Could the clear cells in question represent a new type of clear cell with aberrant differention, possibly a hybrid of melanocytes and epithelial cells? It would be interesting to know whether the authors had observed normal melanocytes ultrastructurally in their case.

REFERENCES

1 . Kim YC, Bang D, Cinn YW. Clear cell papulosis: case report and literature. Pediatr Dermatol 1997;14:380-382.

2. Kuo T, Chan HL, Hseuh S. Clear cell papulosis of the skin: a new entity with histogenetic implications for cutaneous Page’s disease. Am J Surg Pathol 1987;11:827-834.

3. Kuo T, Huang C, Chan HL, Yang L, Chen M. Clear cell papulosis: report of three cases of a newly recognized dis- ease. J Am Acad Dermatol 199.5;33:230-233.

J. YU-YUN LEE, M.D. Tainan. Taiwan

REPLY

To the Editors: Thank you, Dr. Lee, for your attention and advice

with regard to our case of clear cell papulosis. Even though you pointed out some differences between the original cases reported by Kuo et al. (1,2) and our case