scar on the right side of his chin.

According matory, eroded dermatitis between the isolated from society and mutually
to the patient the scar had developed after toes, probably resulting from the applica¬
he had had chickenpox as a small boy. Over tion of caustic chemicals.
the past several months the area began to Psychiatric consultation was recom¬
sting and burn and had not healed after he mended but was immediately rejected by
had nicked it with a razor. the dominant sister. In both patients,
The patient had had a smallpox vaccina- chlorpromazine (Thorazine) therapy was
tion as a child, but had noticed no changes started on a trial basis and seemed to help,
in the vaccination scar. He had had no but the problem did not resolve entirely.
exposure to radiation and no previous skin
After two years of outpatient therapy the
cancers despite a history of frequent sun patients were unavailable for follow-up
exposure over the years. There was no examinations.
family history of skin cancer. In 1979, a final history was obtained. The
On physical examination, there was an evolving ulcers had continued until the
dominant sister had died in 1976. The
ulcers then spontaneously and rapidly
healed in the surviving sibling. Her mental
status seemed to return to a normal state
for her age.
Comment
The cases reported here demon¬
strate the interrelationships of psy¬
chotic disorders and cutaneous dis¬
Fig 2.—Ulcerated lesions on distal extrem¬ ease. The dominant twin had a classic
ity of submissive sister. delusional psychosis and came to med¬
ical attention through the develop¬
ment of factitious ulcérations of the
distal extremities. The secondary,
Antibiotics given for systemic effect submissive person assimilated the
were initiated to treat secondary infection aggressive psychotic disorder of her
present in the ulcers, and chlorothiazide sister, as reflected in the development
diuretics were prescribed to treat the pedal of factitious ulcérations on her own
edema. An occlusive dressing was applied extremities.
to one extremity of each sister. The ulcers
The suggestion of psychiatric con¬
began to resolve spontaneously under the
sultation was totally rejected by the
protective dressing except for one area in dominant sister, and local treatment,
the dominant sister. However, it was
obvious that she was disturbing the dress¬ support, and understanding became
ing over the active lesion. The dominant the primary treatment objectives. The
sister also began to have a severe inflam- two affected individuals had become
self-supporting, with an intensified
need for intimacy. A unitary delusion
was ensured by one partner assuming
the dominant role and the submissive
partner accepting the delusional sys¬
tem, rather than threatening their
interdependent relationship.
More than two persons may share a
unitary delusion (folie à trois; folie à
quatre); even large groups in isolated
conditions such as mental institutions
or communes may accept the delusions
of a single individual. Folie à deux is
clearly a psychotic phenomenon. How¬
ever, shared pruritus or pain is a com¬
mon condition in intimate individuals
and this empathie symptomatology
may be a sign of a similar but less
intense interpersonal disorder.
Folie à deux usually resolves with
the physical separation of the two
individuals. In our patients, the ulcer-
ative dermatitis cleared totally in the
submissive individual after the death
of the primary dominant person of the
pair.
References
1. Laseque C, Falret J: Folie \l=a`\deux ou Folie
commnique. Ann Med Psychol 18:321, 1877
(translated by Michaud R: Am J Psychiatry
121[suppl 4]:2-23, 1964).
2. McNiel JN, Verwoerdt A, Peak D: Folie \l=a`\
deux in the aged: Review and case report of role
reversal. J Am Geriatr Soc 20:316-323, 1972.
3. Gralnick A: Folie \l=a`\deux: The psychosis of
association. Psychiatr Q 16:230-263, 1942.

Basal Cell Carcinoma Arising in a Chickenpox Scar

William M. Hendricks, MD

A basal cell carcinoma developed in a
chickenpox scar on the chin of a
71-year-old man. A review of the per-
tinent literature is presented.
Report of a Case
A 71-year-old man was seen for a recent-
ly developed nonhealing lesion in an old
From the Asheboro (NC) Dermatology
Reprints not available.
scar on the right side of his chin. According
to the patient the scar had developed after
he had had chickenpox as a small boy. Over
the past several months the area began to
sting and burn and had not healed after he
had nicked it with a razor.
The patient had had a smallpox vaccina-
tion as a child, but had noticed no changes
in the vaccination scar. He had had no
exposure to radiation and no previous skin
cancers despite a history of frequent sun
exposure over the years. There was no
Clinic. family history of skin cancer.
On physical examination, there was an
indurated nodule measuring 8 x 10 mm on
the right side of the lower part of the chin
(Figure). The lesion had a central crust and
peripheral telangiectasia. The surrounding
skin was slightly erythematous and atroph¬
ie.
The clinical diagnosis was a basal cell
carcinoma arising in a chickenpox scar.
Under local anesthesia a shave biopsy was
performed. Curettage of the base of the
lesion left a small round depression about
the size of a pea. The biopsy revealed a
basal cell carcinoma, and the lesion was
subsequently excised.

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 skin tumors arising in them. Basal cell
carcinomas have been reported in
scars left by thermal burns,1 blunt-f
trauma and lacerations,4 tattoos,5 co-
lostomy surgery,6 epidermolysis hullo¬
sa lesions,7 and hair transplantation.8
Whether or not these associations are
conincidental is not clear.
Malignant tumors have been re¬
ported at the site of smallpox vaccina¬
tions912 but not within the smallpox
scars themselves. Basal cell carcino¬
mas are the most common tumors
found in vaccination scars, although
squamous cell carcinomas, malignant
melanomas, and dermatofibrosarco-
ma protuberans have also been
reported.12 The interval between vac¬
Depressed scar with crusted, indurated cination and the clinical appearance of
area on right side of chin. the tumor varies considerably. Zelick-
son9 reported a basal cell carcinoma
that developed immediately after vac¬
cination, while others have reported
Comment intervals of greater than 50 years.11
Sunlight has been implicated in the
Despite the fact that chickenpox pathogenesis of basal cell carcinomas
scars are not uncommon, to my knowl¬ arising in smallpox vaccination
edge, there are no previous reports of scars.11
What role the scarring process itself
plays in the pathogenesis of these skin
cancers is not well understood. Con¬
nolly1 proposed that scar tissue may
be more sensitive to the effects of
sunlight because of its decreased vas-
cularity and atrophie adnexal and epi¬
dermal structures. However, scarring
alone, in light-protected areas, has
been associated with the development
of squamous cell carcinomas in ther¬
mal burns and in chronic skin ulcers.13
This association has not been con¬
firmed for basal cell carcinomas.
Although basal cell carcinomas have
been reported after conditions that
have resulted in scarring, their ap¬
pearance may have been coincidental.
If one considers the scarring that
results from the dissemination of the
variola and varicella-zoster viruses in
the skin, it is surprising that there
have been no previous reports of ma¬
lignant tumors arising in smallpox or
chickenpox scars. This would suggest
that scarring alone may not be suffi¬
cient for the induction of basal cell
carcinomas.

References

1. Connolly JG: Basal cell carcinoma occurring
in burn scars. Can Med Assoc J 83:1433-1434,
1960.
2. Kantor I, Berger BW, Wilentz JM: Basal cell
epithelioma in a thermal burn scar. J Occup Med
12:170-172, 1970.
3. Treves N, Pack GT: The development of
cancer in burn scars. Surg Gynecol Obstet 51:749\x=req-\
782, 1930.
4. Ewing MR: The significance of a single
injury in the causation of basal-cell carcinoma of
the skin. Aust NZJ Surg 41:140-147, 1971.
5. Bashir AH: Basal cell carcinoma in tattoos:
Report of two cases. Br J Plast Surg 29:288-290,
1976.
6. Didolkar MS, Douglass HO, Holyoke ED, et
al: Basal-cell carcinoma originating at the colos-
tomy site: Report of a case. Dis Colon Rectum
18:399-402, 1975.
7. Wechsler HL, Krugh FJ, Domonkos AN, et
al: Polydysplastic epidermolysis bullosa and
development of epidermal neoplasms. Arch Der-
matol 102:374-380, 1970.
8. White JW Jr: Basal cell carcinoma in a hair
transplant recipient site. Cutis 23:322-325, 1979.
9. Zelickson AS: Basal cell epithelioma at site
and following smallpox vaccination: Report of a
case. Arch Dermatol 98:35-36, 1968.
10. Castrow FF II, Williams TE: Basal-cell
epithelioma occurring in a smallpox vaccination
scar. J Dermatol Surg Oncol 2:151-152, 1976.
11. Reed WB, Wilson-Jones E: Malignant
tumors as a late complication of vaccination.
Arch Dermatol 98:132-135, 1968.
12. Hazelrigg DE: Basal cell epithelioma in a
vaccination scar. Int J Dermatol 17:723-725,
1978.
13. Cruickshank AH, McConnell EM, Miller
DG: Malignancy in scars, chronic ulcers, and
sinuses. J Clin Pathol 16:573-580,1963.

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