J AM ACAD DERMATOL
VOLUME 55, NUMBER 5
Fig 2. Improvement in tazarotene-treated areas on back
(A) and right shoulder (B) after 3 months.
acetylenic retinoid with selective binding to RAR-
gamma and RAR-beta receptors, and 90% of retinoid
receptors in the skin are of the RAR-gamma subtype.
RAR-gamma receptor specificity may be one reason
tazarotene can be more effective than systemic
retinoids that do not demonstrate receptor specific-
ity. Variability in expression of retinoid receptors and
in metabolism of prodrug to the active form may
account for individual differences in therapeutic
response. Although our patient experienced rapid
and significant improvement, larger controlled stud-
ies are needed to evaluate the efficacy of topical
tazarotene in the treatment of lamellar ichthyosis and
other ichthyotic disorders.
Roopal V. Kundu, MD,a Amit Garg, MD,b and
Sophie M. Worobec, MDc
Department of Dermatology, Northwestern Univer-
sity Medical School, Chicago, Illinois,a Division
of Dermatology, University of Massachusetts
Medical School, Worcester, Massachusetts,b De-
partment of Dermatology, University of Illinois
College of Medicine, Chicago, Illinoisc
Reprint requests: Sophie M. Worobec, MD, Depart-
ment of Dermatology, University of Illinois Col-
lege of Medicine, 808 S Wood, 376CME, Chicago,
IL 60612
E-mail: sworobec@uic.edu
Letters S95
REFERENCES
1. Hofmann B, Stege H, Ruzicka T, Lehmann P. Effect of topical
tazarotene in the treatment of congenital ichthyoses. Br J
Dermatol 1999;141:642-6.
2. Stege H, Hofmann B, Ruzicka T, Lehmann P. Topical application
of tazarotene in the treatment of nonerythrodermic lamellar
ichthyosis. Arch Dermatol 1998;134:640.
3. Marulli GC, Campione E, Chimenti MS, Terrinoni A, Melino G,
Bianchi L. Type I lamellar ichthyosis improved by tazarotene
0.1% gel. Clin Exp Dermatol 2003;28:391-3.
doi:10.1016/j.jaad.2005.09.018
Subcutaneous emphysema resulting from
liquid nitrogen spray
To the Editor: The presence of gas within subcuta-
neous tissue, known as subcutaneous emphysema
(SE), can be a worrisome finding. It may indicate the
presence of serious infection or may result from
antecedent trauma or rupture of a visceral organ. SE
has been described in conjunction with a variety of
causes, including dental procedures, endotracheal
procedures, respiratory and gastrointestinal tract
disease, loosely sutured wounds, and even hydrogen
peroxide irrigation.1-3 We report a case of SE of the
forearm caused by liquid nitrogen spray to a curetted
hypertrophic actinic keratosis (HAK).
A 79-year-old Caucasian woman presented to our
clinic for a routine skin check. Multiple actinic
keratoses, including an HAK on the left forearm,
were noted. The skin over the dorsum of the hands
and forearms was also noted to be significantly
atrophic. To achieve maximum therapeutic effect
from the liquid nitrogen spray, the HAK was curetted
to remove much of the dense hyperkeratosis. On
administration of the spray, SE instantly appeared
throughout the left forearm, involving an area of
approximately 10 cm. Soft tissue swelling was readily
visible, and crepitus was palpated diffusely (Fig 1).
This effect improved modestly over the next 30
minutes, and the patient was sent home with the
reassurance that the air infiltration would continue to
dissipate. At the time of follow-up, we learned that
the SE had resolved by the following day.
As already mentioned, several pathological events
can give rise to SE. Perhaps the most serious causes
are related to soft tissue infection and respiratory
tract disease. Notably, the presence of gas in the
subcutaneous tissue does not always indicate a
serious underlying disorder, such as in the case of
our patient. The association between compressed
nitrogen gas causing tissue insufflation has been
reported as a complication of cutaneous cryother-
apy, but it is rare.1,4-6 Specifically, SE has been
described with the use of sprayed liquid nitrogen
in the periorbital area in two cases. In one case, the
S96 Letters
Fig 1. Soft-tissue swelling after open-spray cryotherapy
preceded by curettage of hypertrophic actinic keratosis
on an elderly patient’s atrophic extremity. Crepitus was
palpated diffusely.
nozzle aperture was placed in direct contact with an
actinic keratosis on fragile elderly skin. The swelling
resolved without complication after 12 hours.1,5 The
other case involved treatment of an ulcerated basal
cell carcinoma. The author makes no reference to the
time course to resolution or if other complications
were noted.6 The same principle has been described
with other types of compressed air injuries. The
literature states a benign course is expected, but
there is the potential for infection if microbes are
carried along with the forced injection of com-
pressed air into the subcutaneous tissue.1 Other
complications associated with liquid nitrogen are
numerous and have been previously described in
detail.1,4,6-8 They may be acute, delayed, protracted,
or permanent and include changes such as excessive
blistering, bleeding, infection, dyspigmentation, hair
loss, altered sensation, nerve damage, atrophy, and
scarring.
Our case further illustrates a rare and seldom
reported complication associated with the use of
liquid nitrogen spray. Any type of compressed gas
has the potential to insufflate tissue. The risk of this
complication is significantly enhanced with cutane-
ous defects from ulcerations, curettage procedures,
and freshly closed wounds. We believe that patients
with frail, atrophic skin are at particular risk for this
cryotherapy complication. Therefore, in these pa-
tients, the use of a cotton-tipped applicator or a
cryoprobe may be a better choice. Another option
would be to utilize pressure rings or cones when
spraying open lesions.6 Overall this complication is
benign and self-resolving, but it can be startling to
the physician and patient.
Thomas J. Lambert, BA, Michael J. Wells, MD, and
Keith W. Wisniewski, MD
Department of Dermatology, Texas Tech University
Health Sciences Center, Lubbock, Texas
J AM ACAD DERMATOL
NOVEMBER 2006
Funding sources: None.
Conflicts of interest: None identified.
Correspondence to: Michael J. Wells, MD, Depart-
ment of Dermatology, Texas Tech University
Health Sciences Center, 3601 Fourth St, Stop
9400, Lubbock, TX 79430
E-mail: mjwells@pol.net
REFERENCES
1. Samlaska CP, Maggio KL. Subcutaneous emphysema. Adv
Dermatol 1996;11:117-51; discussion 152.
2. Doweiko JP, Alter C. Subcutaneous emphysema: report of a
case and review of the literature. Dermatology 1992;184:62-4.
3. Willy PJ, McArdle P, Peters WJ. Surgical emphysema and Collet-
Sicard syndrome after cryoblockade of the inferior alveolar
nerve. Br J Oral Maxillofac Surg 2003;41:190-2.
4. Dawber RP. Cryosurgery: complications and contraindications.
Clin Dermatol 1990;8:108-14.
5. Collins AG. Complication of cryotherapy. Med J Aust 1992;
157:843.
6. Elton RF. Complications of cutaneous cryosurgery. J Am Acad
Dermatol 1983;8:513-9.
7. Andrews MD. Cryosurgery for common skin conditions. Am
Fam Physician 2004;69:2365-72.
8. Heidenheim M, Jemec GB. Side effects of cryotherapy. J Am
Acad Dermatol 1991;24:653.
doi:10.1016/j.jaad.2005.09.023
Toxic epidermal necrolysis in a mother
and fetus
To the Editor: Toxic epidermal necrolysis (TEN) is
a rare, life-threatening hypersensitivity reaction to
certain medications.1,2 Only 4 cases of TEN in the
newborn have been reported in the literature.3-6 We
report a case of TEN simultaneously developing in
a mother and her fetus.7,8
A 17-year-old, 22-week primigravida female with
a history of seizure disorder presented to the emer-
gency department with generalized rash, fever,
conjunctivitis, and sore throat or 4 days’ duration.
Three weeks before appearance of the rash, her
long-standing seizure medication was changed from
divalproex, a derivative of valproic acid, to phenyt-
oin. She was not taking any other prescription or
over-the-counter medications. Physical examination
revealed orolabial and genital erosions as well as
irregular, poorly defined purpuric macules on her
face, trunk, and extremities, some of which con-
tained flaccid central bullae, and areas of desqua-
mation covering 60% of her body surface area (Fig 1,
A). She was given a diagnosis of TEN on the basis of
clinical findings.
A 3-mm punch biopsy specimen of skin for
microscopic evaluation was obtained. Phenytoin
was immediately stopped, and divalproex was