Journal of the
682 Correspondence
years prior to our seeing him, spontaneous and trauma-
induced blisters appeared on the dorsal surfaces of the
hands, the elbows, the knees, and the legs, with milia
formation, mild scarring, nail dystrophy, and skin fra-
gility. Other bullous diseases were excluded. Electran
microscopy showed dermoepidermal separation in the
papillary dermis, below the lamina densa. This was
confirmed by indirect immunofluorescence of a blister
biopsy: the bullous pemphigoid antigen, laminin, and
collagen IV were found in the roof of the blister. How-
ever, direct immunofluorescence test results of perile-
sionalskin for IgG, IgA, IgM, and C3 showed negative
reactions (7 different biopsies over a 4-year period).
No circulating autoantibodies against basement memo
brane zone were detected. We concluded that absence
of basement membrane zone immunoreactants is pos-
sible in epidermolysis bullosa. This could suggest that
they do not necessarily take part in the pathogenesis of
this disease and that their presence is only secondary.
Another explanation could be that our patient had a new
unknown disease, as suggested by Unis et a1.
J. P. Lacour, M.D., and J. P. Ortonne, M.D.
University of Nice, H6pital Pasteur
Department of Dermatology-IBP No. 69
06002 Nice Cedex-France
REFERENCE
1. Lacour JP, Juhlin L, EI Baze P, Ortonne JP: Epidermolysis
bullosa acquisita with negative direct' immunofluores-
cence. Arch Dermatol 121: II 83-1 ] 85, 1985.
Epidermodysplasia verruciformis
To the Editor:
I am a regular reader of the Self-Assessment ex-
aminations in the JOURNAL. I find them very useful for
refreshment of knowledge. However, I think that the
discussion of questions 1-4 about epidermodysplasia
verruciformis (J AM ACAD DERMATOL 10(No. 3):51A,
1984) is not quite up-to-date.
The human papillomaviruses currently thought to
cause epidermodysplasia verruciformis are types 3, 5,
8, 9, 10, 12, 14, and 15. 1 Of these viruses, types 3,
5, and 8 are believed to be oncogenic in epidermodys~
plasia verruciformis patients. 2 Regarding therapy, etret-
inate seems to be a promising drug. It was reported to
give mild to great improvement in epidermodysplasia
verruciformis patients, particularly those infected with
oncogenic strains types 3 and 5. 3-5 The effective dose
is around 1 mg/kg/day.'
K. El-Hoshy, M.D., 10 Emam-Ali Str.
Heliopolis, Cairo, Egypt
American Academy of
Dermatology
REFERENCES
1. lablonska S, Orth G: Human papoviruses, in Rook A,
Maibach HI, editors: Recent advances in dermatology 6.
New York, 1983, Churchill Livingstone, pp. 1-36.
2. Lutzner MA: The human papillomaviruses. Arch Derma-
tol119:631-635, 1983.
3. Lutzner MA, Blanchet BC, Puissant A: Oral aromatic
retinoid (Ro 10-9359) treatment of two patients suffering
with a severe form of epidermoclysplasia verruciformis, in
Orfanos CE, Braun-Falco 0, Farber E, et aI, editors: Ret-
inoids: Advances in basic research and therapy. Berlin
1981, Springer-Verlag, pp. 407-410.
4. Jablonska S, Obalek S, Wolska H, et al: Ro 10-9359 in
epidermodysplasia verruciformis. Preliminary report, ill
Orfanos CE, Braun-Falco 0, Farber E, et al editors: Ret-
inoids: Advances in basic research and therapy. Berlin,
1981 , Springer-Verlag, pp. 401-405.
5. Marks R: Synthetic retinoids, in Rook A, Maibach HI,
editors: Recent advances in dermatology 6. New York,
1983, Churchill Livingstone, pp. 237-263.
Porokeratosis and immunosuppression
To the Editor:
We have read with interest the paper by Lederman,
Sober, and Lederman entitled, ~ 'Immunosuppression:
A Cause of Porokeratosis?'; (J AM ACAD DERMATOL
13:75-79, 1985). We agree with the authors about the
possibility that immunosuppression may be either the
cause or an exacerbating factor in porakeratosis.
Indeed, in a paper published in 1983' we reported
the occurrence of disseminated actinic superficial po-
rakeratosis in one woman in a population of 105 kid-
ney transplant recipients who were being given con-
ventional immunosuppressive treatment consisting of
daily oral methylprednisolone at a maintenance dose
of 0.2 to 0.3 mg/kg and azathiopri ne at a dose of 1 to
1.3 mg/kg.
The same population has been evaluated for der-
matologic lesions at 3- to 6-month intervals, and so far
two more cases of disseminated actinic superficial po-
rakeratosis have emerged in two patients 3 years after
transplantation. In all three patients, actinic keratoses
and warts also developed. We therefore agree with the
assumption that immunosuppression might be a trig-
gering or an aggravating factor for the development of
disseminated actinic superficial parakeratosis, perh'lps
through the same mechanisms already proposed for
actinic keratoses. I
P. L. Bencini, M.D., * C. Crosti, M.D.,*
G. MontagnillO, M.D., ** and F. Sala, M.D., *
Istituto di Clinica Dermatologica I,
Universita di Milano, * and
Divisione di Nej'rologia e Dialisi, **
Ospedale Maggiore Policlinico.
Milan, Italy