J AM ACAD DERMATOL Letters 1231

VOLUME 65, NUMBER 6

Table I. Susceptibility of C minutissimum to anti- In the literature, it is stated that bacteriologic

microbial agents culture of erythrasma is difficult and usually unnec-
Antimicrobial Susceptibility Resistance P
essary for the diagnosis. Therefore, in daily practice
agents % (No. of cases) % (No. of cases) value* culture and antibiogram are not routinely studied and
Penicillin 5 (2) 95 (38) 0 systemic or topical erythromycin is usually pre-
Ampicillin 30 (12) 70 (28) .011 scribed empirically for the treatment.1-3 We suggest
Cefaclor 67.5 (27) 32.5 (13) .027 testing the antibiotic susceptibility of C minutissi-
Ampicillin 50 (20) 50 (20) 1.000 mum before treatment. However, if a culture-
sulbactam antibiogram is unavailable, fusidic acid should be
Amoxicillin 95 (38) 5 (2) 0 started topically as the first treatment of choice.
clavulanate Topical tetracycline may be an alternate choice if
Tetracycline 57.5 (23) 42.5 (17) .343 fusidic acid is not available. Finally, if there is a
Erythromycin 5 (2) 95 (38) 0
treatment failure, amoxicillin-clavulanate should be
Ofloxacin 55 (22) 45 (18) .527
chosen for the systemic treatment.
Fusidic acid 75 (30) 25 (10) .002
Levofloxacin 65 (26) 35 (14) .058 Bengu Gerceker Turk, MD, Meltem Turkmen, MD,
Azithromycin 5 (2) 95 (38) 0 and Derya Aytimur, MD
*P values for the differences between the susceptible and resistant Department of Dermatology, Ege University Medi-
groups, based on the chi-square test (P \ 0.05). cal Faculty, Izmir, Turkey
Funding sources: None.
absence of hyphae on microscopy from the skin
scrapings of lesions. Skin swab samples were inoc- Conflicts of interest: None declared.
ulated into blood agar and Colombia agar.
Correspondence to: Bengu Gerceker Turk, MD, Ege
Corynebacteria generate non-hemolytic cream colo-
University Medical Faculty, Department of Der-
nies in blood agar after 24 hours of incubation at
matology, TR-35100 Bornova, Izmir, Turkey
378C. A diagnosis was made by urease test, properties
of aesculin hydrolysis, acid production from glucose, E-mail: bengugerceker@yahoo.com
maltose, and saccharose, as well as fermentation of
the growing bacteria. Susceptibility tests for penicillin REFERENCES
G, ampicillin, cefaclor, amoxicillin-clavulanate, am- 1. Morales-Trujillo ML, Arenas R, Arroyo S. Interdigital erythrasma:
picillin-sulbactam, tetracycline, erythromycin, oflox- clinical, epidemiologic, and microbiologic findings. Actas Der-
mosifiliogr 2008;99:469-73.
acin, fusidic acid, levofloxacin, and azithromycin
2. Holdiness MR. Management of cutaneous erythrasma. Drugs
were performed with dry disk-diffusion method. 2002;62:1131-41.
The ethics committee approved the study. Data 3. Schaller M. Other bacterial infections. In: Burgdorf WHC, Plewig
were evaluated by means of the Statistical Package G, Wolff HH, Landthaler M, editors. Dermatology. Italy: Springer
Program for Social Sciences 15.0. Frequency analysis Medizin Verlag Heidelberg; 2009. pp. 140-75.
4. Soriano F, Zapardiel J, Nieto E. Antimicrobial susceptibilities of
was done statistically and chi-square test was also
Corynebacterium species and other non-spore-forming gram-
performed for intergroup comparisons. positive bacilli to 18 antimicrobial agents. Antimicrob Agents
The mean age of 40 patients (20 males, 20 females) Chemother 1995;39:208-14.
included in the study was 47.5 6 8.2 years (range, 5. Lagrou K, Verhaegen J, Janssens M, Wauters G, Verbist L.
28-67 years). Antibiotic susceptibility tests revealed Prospective study of catalase-positive coryneform organisms in
clinical specimens: identification, clinical relevance, and antibi-
statistically significant resistance to erythromycin,
otic susceptibility. Diagn Microbiol Infect Dis 1998;30:7-15.
azithromycin, penicillin, and ampicillin. Significant
susceptibility was statistically found to amoxicillin- doi:10.1016/j.jaad.2011.03.024
clavulanate, cefaclor, and fusidic acid (Table I).
A limited number of susceptibility studies for
C minutissimum are available in the literature. A randomized controlled crossover trial:
However, these studies are old and lack recent data Lidocaine injected at a 90-degree angle causes
about the antibiogram of C minutissimum.4,5 None less pain than lidocaine injected at a 45-degree
of the studies investigates susceptibility to beta lac- angle
tam and beta lactamase inhibitor combination, such To the Editor: Local anesthetic injection results in
as amoxicillin-clavulanate and ampicillin-sulbactam. discomfort to patients.1,2 Anecdotal reports suggest
In our study, we found resistance to ampicillin- that injecting at a 90-degree angle reduces pain.2
sulbactam in half of the patients and susceptibility Controlled studies examining this approach are
to amoxicillin-clavulanate in 95% of patients. lacking. This study examines the effect of angle of
1232 Letters
needle insertion (90 vs 45 degrees) during local
administration of anesthetic on subjects’ pain.
An institutional review boardeapproved random-
ized controlled crossover trial was conducted in
volunteers aged 18 to 70 years without history of
neuropathy, severe skin disease in injection areas,
allergy to lidocaine, or anxiety to needle sticks.
The study used room-temperature lidocaine HCl
1%, containing 1:100,000 epinephrine, which is the
standard anesthetic in our clinics for biopsies. A 0.5-
inch, 30-gauge needle was inserted bevel-up into the
skin to a depth of 0.25 inch. Each subject received a
1.0-cc injection in each forearm utilizing a 90-degree
angle in one, and a 45-degree angle in the other.
Injections were made at a rate of 0.1 mL per second
by the same investigator with a 1-minute wash-out
period between injections. Subjects were blinded as
to the initial angle of insertion.
After each lidocaine infusion, subjects reported
whether the 45-degree or the 90-degree angle injec-
tion hurt more, or if the pain was the same. Subjects
reported maximum pain felt during the procedure by
using a validated 10-point scale,3 with 0 indicating
‘‘no pain’’ and 10 indicating ‘‘worst possible pain’’.
Data were compared by means of Kruskal-Wallis,
Fisher’s exact, and Wilcoxon-rank sum tests.
Regression was used to control for age, gender,
and body mass index (BMI).
Sixty-five subjects enrolled in this study. The
mean age was 36.3 years (standard deviation [SD],
13.8). Thirty-five percent were male. Twenty-nine
subjects (45%) perceived the 45-degree angle to be
more painful, 22 (34%) reported the 90-degree angle
as more painful, and 14 (22%) reported the same
pain score for both (P \ .0001). The median pain
score for the 45-degree angle was 3 (interquartile
range [IQR] ¼ 2.0-4.0), and the mean pain score
was 2.9 (SD ¼ 1.6). For the 90-degree angle, the
median was 2 (IQR ¼ 2.0-3.0), and the mean was
2.5 (SD ¼ 1.3). The differences were significant
(P ¼ .0002, P ¼ .0295, respectively) (Fig 1). Age
(P ¼ .589), BMI (P ¼ .526), and sex (P ¼ .0985) did
not influence pain.
Our results suggest that a 90-degree angle reduces
pain during lidocaine injection. While the difference
we found was clinically small, we excluded patients
with anxiety associated with needle sticks, and a larger
difference may be appreciated in this population.
Local lidocaine administration results in pain from
the needle stick and the infusion. Egekvist et al4 found
no difference in pain between 45- and 90-degree
angles of injection, but that the energy required to
inject was lower with insertion at 90 degrees. Lower
injection energy may lead to less tissue distension and
thus less pain. In addition, 90-degree angle insertion
J AM ACAD DERMATOL
DECEMBER 2011
Fig 1. Pain assessment using 10-point Wong-Baker Faces
scale. Median pain scores, along with interquartile ranges,
are shown. Difference in medians between the 2 groups
was statistically significant (P ¼ .0002).
may result in less direct transection of nerve endings
than 45-degree angle insertion.2
Up to 21% of adults express anxiety from nee-
dles,5 which may lead to syncope or avoidance of
necessary procedures. To reduce the pain of lido-
caine injections, clinicians use warm, buffered solu-
tions, small needles, and inject slowly.1,2,5 This study
supports use of a 90-degree needle angle as an
additional method of pain reduction.
Kathryn J. Martires, BA,a Christi L. Malbasa, MD,a,b
and Jeremy S. Bordeaux, MD, MPHa,b
Case Western Reserve University School of Medici-
nea and the Department of Dermatology,
University Hospitals Case Medical Center,b Cleve-
land, Ohio
Results of this study were presented at the Research
in Cutaneous Surgery minisymposium at the
Society of Investigative Dermatology Annual
Meeting, May 7, 2010.
Funding sources: Dr. Bordeaux is supported by the
Dermatology Foundation Clinical Career Devel-
opment Award in Dermatologic Surgery.
Conflicts of interest: None declared.
Correspondence to: Jeremy S. Bordeaux, MD, MPH,
University Hospitals Case Medical Center, De-
partment of Dermatology, Lakeside 3500, 11100
Euclid Ave, Cleveland, OH 44106-5028
E-mail: Jeremy.Bordeaux@UHhospitals.org
REFERENCES
1. Long CC, Motley RJ, Holt PJ. How to reduce the discomfort
caused by local anaesthetics. Clin Exp Dermatol 1993;18:291.
2. Zilinsky I, Bar-Meir E, Zaslansky R, Mendes D, Winkler E,
Orenstein A. Ten commandments for minimal pain during
administration of local anesthetics. J Drugs Dermatol
2005;4:212-6.
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3. Wong DL, Baker CM. Pain in children: comparison of assessment
scales. Pediatr Nurs 1988;14:9-17.
4. Egekvist H, Bjerring P, Arendt-Nielsen L. Pain and mechanical
injury of human skin following needle insertions. Eur J Pain
1999;3:41-9.
5. Nir Y, Paz A, Sabo E, Potasman I. Fear of injections in young
adults: prevalence and associations. Am J Trop Med Hyg
2003;68:341-4.
doi:10.1016/j.jaad.2011.04.011
The AC Rule for melanoma: A simpler tool for
the wider community
To the Editor: The AC Rule for melanoma (asymme-
try, color variation) was conceived as a simpler tool
that laypersons might use to successfully identify a
Fig 1. The AC Rule for melanoma educational brochure.
Letters 1233
melanoma. It could potentially be used for both
clinical (naked eye) and dermatoscopic assessment.
We conducted an image-based study using laptop
computers in the community. Two groups of volun-
teers were invited to participate; laypersons and
expert dermoscopists. Laypersons (n ¼ 17) were
between 18 and 65 years of age and had no profes-
sional health care experience. Experts (n ¼ 3) had
more than 15 years of professional dermatoscopy
experience.
Participants were given a one-page information
sheet on the AC Rule for melanoma (Fig 1). Clinical
images of melanocytic lesions (N ¼ 312) were
obtained from the Department of Dermatology at
the Medical University of Graz in Austria. The 100