J AM ACAD DERMATOL
VOLUME 60, NUMBER 2
recognized type of finger nail onychodystrophy is
not listed.
I refer to the claw-like ‘‘parrot beak’’ malforma-
tion and curvature of the nails often seen in
patients who use crack cocaine.2 Such changes
have most often been recognized in young fe-
males, and are commonly found in association
with perniosis, hyperkeratosis over the knuckles,
and some atrophy of the distal portions of the
pulps of some of the digits (especially the thumbs
and index fingers). The skin findings may be
caused by ischemia from peripheral vasoconstric-
tion induced by crack cocaine, and it is thought
that persons with vasomotor instability are more
susceptible to this type of reaction. These skin
findings do not occur in all crack cocaine users,
and early cutaneous changes may resolve with
drug avoidance.
Robert I. Rudolph, MD, FACP
Department of Dermatology, University of Pennsyl-
vania School of Medicine, Philadelphia,
Pennsylvania
Funding sources: None.
Conflicts of interest: None declared.
Correspondence to: Robert I. Rudolph, MD, FACP,
1134 Penn Ave, Wyomissing, PA 19610
E-mail: robrudolph@comcast.net
REFERENCES
1. Brewer JD, Meves A, Bostwick JM, Hamacher KL, Pittelkow MR.
Cocaine abuse: dermatologic manifestations and therapeutic
approaches. J Am Acad Dermatol 2008;59:483-7.
2. Payne-James JJ, Munro MH, Rowland Payne CM. Pseudoscler-
odermatous triad of perniosis, pulp atrophy and ‘parrot-
beaked’ clawing of the nails—a newly recognized syndrome
of chronic crack cocaine use. J Forensic Leg Med 2007;14:65-71.
doi:10.1016/j.jaad.2008.09.064
Topical gentian violet in dermatology
To the Editor: I was delighted to see topical gentian
violet (GV; also known as crystal violet and methyl-
rosanilinium chloride) given column space in the
April 2008 issue of the Journal, and congratulate
Bhandarkar et al1 on their ingenuity. I was fascinated
to learn (but not surprised) that it inhibits reactive
oxygen.
I have not personally used GV for oral hairy
leucoplakia, but I use it frequently for leg ulcers,
especially in the presence of methicillin-resistant
Staphylococcus aureus (MRSA),2 and occasionally
for paronychia and other eclectic indications, such as
herpes simplex virus immune reconstitution disease
Letters 347
in HIV/AIDS (with indifferent results, as it happens).3
It is available in the United Kingdom as an unli-
censed (category B) product for topical application
as a 0.5% aqueous solution.4 I recommend GV to
colleagues for its simplicity, efficacy, and inexpen-
siveness. Given the increasing concern about the
role of MRSA in skin infections, perhaps it deserves
to be more widely exhibited.
However, its safety is controversial. Bhandarkar
et al1 write that 2% GV is approved by the US Food
and Drug Administration as an over the counter
medication and that to their knowledge, it is safe.1 In
the United Kingdom, GV has enjoyed some notoriety
as a potential carcinogen and is held to be potentially
injurious to mucous membranes and open wounds,
such that its application to such sites is not recom-
mended by Martindale.5
In vitro GV has been shown to interact with DNA
and is carcinogenetic in mice; necrotic skin reactions
of the submammary and gluteal folds, genitalia, and
toe webs have been reported after the use of the
topical 1% aqueous solution. Oral ulceration has
been reported in neonates treated for oral candidosis
with 0.5% or 1% aqueous solutions. My patients have
not experienced adverse effects to my knowledge,
but although I have used GV (0.5% aqueous solu-
tion) on open wounds and on the genitalia, I have
not used it in the oral cavity. I remember my father (a
physician in the Royal Air Force) treating me as a
school boy for onychomycosis of the right index
finger nail with topical GV more than 40 years ago
when we lived in Ghana. I am alive and well.
Christopher B. Bunker, MA, MD, FRCP
Department of Dermatology, Chelsea & Westmin-
ster Hospital and Imperial College School of
Medicine, London, United Kingdom
Funding sources: None.
Conflicts of interest: None identified.
Correspondence to: Christopher B. Bunker, MA,
MD, FRCP, Consultant Dermatologist and Pro-
fessor of Dermatology, Chelsea & Westminster
Hospital and Imperial College School of Medi-
cine, Fulham Road, London SW10 9HH, United
Kingdom
E-mail: cbb@hamderm.demon.co.uk
REFERENCES
1. Bhandarkar SS, MacKelfresh J, Fried L, Arbiser JL. Targeted
therapy of oral hairy leukoplakia with gentian violet. J Am Acad
Dermatol 2008;58:711-2.
2. Bunker CB. Malodorous wounds. Lancet 1996;348:1737.
3. Fox PA, Barton SE, Francis N, Youle M, Henderson DC, Pillay D,
et al. Chronic erosive herpes simplex virus infection of the
348 Letters
penis, a possible immune reconstitution disease. HIV Med
1999;1:10-8.
4. Berth-Jones J. Topical therapy. In: Burns T, Breathnach S, Cox N,
Griffiths C, editors. Rook’s dermatology, 7th ed. Oxford: Black-
well Publishing; 2004. p. 7550.
RESEARCH
Goeckerman treatment for remission of
psoriasis refractory to biologic therapy
To the Editor: We are increasingly seeing patients
with recalcitrant psoriasis for whom the option of
Goeckerman treatment has not been previously rec-
ognized, and the patients have been placed on one
biologic treatment after another without response. We
undertook a 5-year retrospective study to assess the
efficacy of Goeckerman treatment for psoriasis recal-
citrant to one or more biologic agents that, generally,
had been prescribed by the referring physician; the
patients received Goeckerman treatment for psoriasis
at Mayo Clinic, Rochester, Minnesota, between
September 2002 and September 2007.
Goeckerman treatment is a 3-week program
administered on an outpatient basis that includes
the application of 2% crude coal tar to all affected skin
areas; the coal tar is removed daily to permit irradi-
ation with broadband ultraviolet B phototherapy
administered with a quartz lamp.1,2 Goeckerman
treatment historically has had the highest and most
enduring remission rates in moderate to severe pso-
riasis.3,4 In our study, the response to Goeckerman
treatment was globally assessed with documentation
from daily clinical notes compiled by treating physi-
cians during the patient’s hospitalization and from the
clinical summary. The results were categorized as
follows: [80% clearance, 50% to 80% clearance, 30%
to 50% clearance, \30% clearance, no response, or
worsening.
Twenty-three consecutive patients with psoria-
sis recalcitrant to biologic treatment received
Goeckerman treatment during the 5-year period
(Table I). Thirteen patients were female, and 21
were white; the mean age was 51 years (range, 11-
82 yrs). Patients had no success with various numbers
of biologic therapies: one agent (16 patients), two
agents (5 patients), three agents (1 patient), and five
agents (1 patient). The biologic agents included
etanercept (18 patients), infliximab (3 patients),
efalizumab (9 patients), adalimumab (3 patients),
and alefacept (1 patient). The duration of each bio-
logic treatment ranged from 2 weeks to 36 months.
The average duration of Goeckerman treatment was
J AM ACAD DERMATOL
FEBRUARY 2009
5. Martindale website. Martindale: the complete drug reference.
Gentian violet. Available from: www.medicinescomplete.
com/mc/ [subscription required]. Accessed November 7, 2008.
doi:10.1016/j.jaad.2008.07.063
LETTERS
23 days (range, 15-31 days). In response to treatment,
20 patients had [80% clearance of psoriasis; 3 pa-
tients had 50% to 80% clearance. During Goeckerman
treatment, no patient had a worsening of psoriasis or
any adverse effects.
In this age of biologics, Goeckerman treatment
has been almost abandoned in most US medical
centers, but it remains extremely effective for psori-
asis by inducing remission in most patients, including
those unresponsive to biologic agents. Nonetheless,
there are caveats to our conclusion. The study is small
and retrospective, and the global assessment mea-
surements we used are not easily comparable to
Psoriasis Area and Severity Index scores used in
recent psoriasis trials. However, this study confirms
our observation5 that patients whose psoriasis had
previously resisted treatment with biologic agents
may respond well to Goeckerman treatment.
Rocco Serrao,a and Mark D. P. Davis, MDb
Visiting medical student, College of Medicine,a and
the Department of Dermatology,b Mayo Clinic,
Rochester, Minnesota
Funding sources: None.
Conflicts of interest: None declared.
Reprint requests to: Mark D. P. Davis, MD, Depart-
ment of Dermatology, Mayo Clinic, 200 First St
SW, Rochester, MN 55905
E-mail: davis.mark2@mayo.edu
REFERENCES
1. Goeckerman WH. The treatment of psoriasis. Northwest Med
1925;24:229-31.
2. Muller SA, Perry HO. The Goeckerman treatment in psoriasis: six
decades of experience at the Mayo Clinic. Cutis 1984;34:265-8, 270.
3. Menter A, Cram DL. The Goeckerman regimen in two psoriasis
day care centers. J Am Acad Dermatol 1983;9:59-65.
4. Koo J, Lebwohl M. Duration of remission of psoriasis therapies.
J Am Acad Dermatol 1999;41:51-9.
5. Soares TF, Davis MD. Success of Goeckerman treatment in 2
patients with psoriasis not responding to biological drugs. Arch
Dermatol 2007;143:950-1.
doi:10.1016/j.jaad.2008.10.016