of repository penicillin G benzathine was 6.
Lochner JC, Pomeranz JR: Lichenoid sec-
ticular, the posterior occipital, the axillary,
and inguinal lymph nodes. The physical ex¬
amination findings were otherwise normal.
Blood pressure was 120/70 mm Hg, and the
temperature, 37.3 C (99.1 F). A biopsy
specimen of a lesion of the right forearm
showed a characteristic picture of second¬
ary syphilis (Fig 2 and 3). The VDRL test
for syphilis was reactive with a titer of
1:16, and the FTA-ABS was also reactive
on June 15,1974. A total of 7.2 million units
shows massive granulo-
Fig 2.—Section
matous infiltrate involving upper dermis
(hematoxylin-eosin, original magnification
X105).
Fig 3.—Higher magnification shows infil¬
trate mainly composed of plasma cells and
histocytes with marked perivascular local¬
ization (hematoxylin-eosin, original magni¬
fication x 1,235).
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administered intramuscularly in doses of
2.4 million units/week. The patient related
that she experienced "fever and chills"
within a few hours of the first injection.
When the patient was seen a month later,
the skin lesions had completely resolved,
the VDRL was reactive at eight dilutions,
and the FTA-ABS was reactive. The pa¬
tient failed to complete further pulmonary
studies. One year later, she returned; at
this time, the chest x-ray films continued
to show the nodular densities, which were
again interpreted as compatible with sar¬
coidosis in both lungs. On June 20, 1974,
the VDRL test for syphilis, undiluted, and
the FTA-ABS were reactive. Further stud¬
ies were not done.
Comment—Secondary syphilis has
a wide variety of clinical signs and
symptoms.12 The wide spectrum of
histological features of this disease is
well-recorded.38 The sarcoidal reac¬
tion of secondary syphilis is well-
recognized,910 and the implication
was once made that syphilis could be
a cause of sarcoidosis.1113 To our
knowledge, our case is unusual in that
it was labeled sarcoidosis, while the
patient also had secondary syphilis, as
proven by a positive sérologie test for
syphilis, a skin biopsy, a Herxheimer
reaction, and complete resolution of
the patient's skin lesions with anti-
syphilitic therapy. The pulmonary
sarcoidal infiltrate remains un¬
changed. This case shows that syphi¬
lis, the ubiquitous fellow traveler, can
be found in association with any dis¬
ease and that it might well have been
missed if this papular eruption had
been assumed to be caused by the pri¬
mary disease process, in this case,
sarcoidosis.
Gary L. McMillan, MD
Robert E. Burns, MD
Detroit
George R. Mikhail, MD, interpreted the sec¬
tions removed for histopathologic study.
1. Lomholt G: Syphilis, in Rook A, Wilkinson
DS, Ebling FG (eds): Textbook of Dermatology.
Oxford, England, Blackwell Scientific Publica-
tions, 1972, pp 634-638.
2. O'Lansky S, Norins LC: Syphilis and other
treponematoses, in Fitzpatrick TB, Arndt KA,
Clark WH Jr, et al (eds): Dermatology in General
Medicine. New York, McGraw-Hill Book Co Inc,
1971, pp 1955-1978.
3. Lever WH: Histopathology of the Skin.
Philadelphia, JB Lippincott Co, 1967.
4. Pinkus H, Mehregan AH: A Guide to Der-
matopathology. New York, Appleton-Century\x=req-\
Crofts, 1969.
5. Jeerapaet P, Ackerman AB: Histological
patterns of secondary syphilis. Arch Dermatol
104:373-377, 1973.
ondary syphilis. Arch Dermatol 109:81-83, 1974.
7. Miller RL: Pustular secondary syphilis. Bull
Assoc Milit Dermatol 21:24-27, 1973.
8. Mikhail GR, Chapel TA: Follicular papulo-
pustular syphilid. Arch Dermatol 100:471-473,
1969.
9. Van Dersarb JV: Granulomatous secondary
syphilis. Bull Assoc Milit Dermatol 19:25-27,
1971.
10. Sing R, Kaur D, Parameswaran M: Sarcoi-
dal reaction of the skin in syphilis. Br J Vener
Dis 47:209-211, 1971.
11. Stillians AW: Sarcoid and syphilis. JAMA
77:1615-1618, 1921.
12. Frazier CN, Ch'uan-k'uei H: Isolation of
treponema pallidum from a subcutaneous sar-
coid. Proc Soc Exp Biol Med 30:898-901, 1933.
13. Berstein ET, Leider M: Cutaneous sarcoi-
dosis as an expression of syphilis. J Invest Der-
matol 15:75-79, 1950.
Neurotic Excoriations
To the Editor.\p=m-\Ireceived a letter
from a patient with neurotic excoria-
tions, asking for a prescription refill.
She is 75 years old, retired, and was
one of the first members of her sex to
become an architect in this country.
The insight and clarity with which
she described her problem was most
striking, and I now quote her:
I believe the habit comes from the state
of worry, apprehension and tension, in
which circumstances have placed me. The
sincere wish that I were not here encum-
bering the earth, now that my years of
usefulness are over, also colors an impulse
toward self destruction which perhaps un-
consciously expresses itself in this way.
Our texts do not express it better,
if as well.
Henry R. Corwin, MD
Norwalk, Conn
Methylene Blue and Light Therapy
for Herpes Simplex
To the Editor.\p=m-\Photodynamicinac-
tivation of herpesvirus by methylene
blue was demonstrated in our labora-
tory. About 70% of freshly isolated
strains of herpesvirus was found to be
highly photosensitive after appli-
cation of methylene blue at concen-
tration of 10 5M. Strains resistant to
methylene blue were also resistant to
neutral red, but were sensitive to
proflavine, and vice versa.
Our initial clinical trial on patients
with recurrent genital herpes indi-
cated that about 70% of 36 individuals
treated with methylene blue and light
improved: symptoms subsided in 48
hours, and the duration of the illness
shortened appreciably. However, the
relapse rate was not substantially re-
duced.
 Treatment consisted of application
of 0.1% methylene blue and, 20 min-
utes later, exposure to either fluores-
cent light at a close distance or to
sunlight whenever possible. The lat-
ter gave a better result. Treatment
was carried out at home by the pa-
tient. This made treatment possible
at the earliest stage of the disease
when response was the best. Early
treatment could abort the develop¬
ment of vesiculation and stop the dis¬
ease at the erythematous stage.
Te-Wen Chang, MD
Nicholas Fiumara, MD
Louis Weinstein, MD
Boston
Krinkle Finger Syndrome
To the Editor.\p=m-\Ihave recently en-
countered an unusual reaction to
treatment with betamethasone ben-
zoate gel (Benisone Gel) that may be
worth noting.
A 29-year-old package dealer had a
dermatitis of the right hand that ap-
peared as small, discrete vesicles on
the sides of the fingers and the dorsal
surfaces, but spared the palmar as-
pect (Figure). The eruption occurred
two days after the patient had
worked in the garden pulling up
weeds with the affected hand.
Past history disclosed that 15 years
ago, after working on his mother's
lawn, the patient had developed a ve-
sicular eruption over the hands and
face. He notes itching and conjuncti-
vitis when cutting grass at present,
but no dermatitis. Until five years
ago, he took pills during August for
hay fever.
Believing that this was a probable
contact dermatitis, I prescribed a
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.025% betamethasone benzoate gel
preparation to be used six times daily,
with 4 mg of chlorpheniramine
(Chlortrimeton) to be applied every
six hours.
After two days of this program, the
patient felt symptomatically much
improved. Appearance of new vesicles
ceased, but his hand felt dry. He con¬
tinued to use the gel six times a day.
Eleven days later, examination of the
hand disclosed a remarkable finding,
namely, a krinkled type of macerated
skin such as is seen in immersion syn¬
dromes. The underlying skin was
pink. There was no vesiculation. The
patient was pleased, but noted that
the hand felt "tight" and slightly ten¬
der. It was as if the gel had sealed
moisture in the hand, as is seen with
the current-day fad of occlusive ther¬
apy with plastic wrapping.
We stopped the use of the gel and
started treatment with .05% fluoran-
drenolide cream applied four times a
day, which abated the dry, tight sen¬
sation. The maceration "krinkling"
reaction decreased. The patient com¬
plained of dryness especially in the
webs, which showed a fine branny
scaling. Petrolatum was added to his
regimen. He made a rapid recovery to
an "eczema craquelé" type of skin
and finally to mild scaling erythema.
I thought that the probable mecha¬
nism of the eruption was the drying
of the gel that sealed a hyperhidrotic
palm in a patient with mild xerosis
type. The clinical picture was dra¬
matic but did not bother the patient
who was amused by my consternation
and the notoriety his dermatitis pro¬
duced.
Howard S. Yaffee, MD
Cambridge, Mass
Presumed Generalized Exfoliative
Dermatitis to Lidocaine
To the Editor.\p=m-\Sinceits introduc-
tion in 1948, lidocaine hydrochloride,
an acetanilide derivative, has become
a widely used local anesthetic because
of the rarity of toxic effects. Only 11
cases of presumed hypersensitivity
reactions, such as urticaria, anaphy-
lactoid reactions, and convulsions
have been published. We report a pa-
tient with generalized papulovesicu-
lar lesions leading to exfoliative der-
matitis.
Report of a Case.\p=m-\A21-year-old man
was referred because of generalized papu-
lovesicular eruption. He had no history of
previous skin disease or allergy. A pheno-
barbital-belladonna mixture and thiamine
hydrochloride capsules were the drugs he
received orally recently. He had for the
first time 2% lidocaine hydrochloride with
epinephrine, 1:50,000, injections as a dental
anesthetic the previous month.
Three days after the second injection, he
developed a papular pruritic eruption on
his arms. A flare-up occurred one day after
the third injection. This eruption became
generalized the following week, but spared
the palms and soles. He had a blood eosino-
philia of 21%. Because of malaise and this
dermatitis he was hospitalized and treated
with topically applied and systemically
administered corticosteroids and anti-
histamines. His skin cleared. Despite the
order not to give any drugs, he received
another lidocaine hydrochloride injection
for dental anesthesia. Eight hours later, he
developed periorbital edema and a papu-
lovesicular rash on his arms similar to the
rash he developed in the first episode. At
that time, he was still under systemic cor¬
ticosteroid treatment. The dermatitis
spread to his legs the following day, but
did not lead to generalized exfoliation.
Skin tests were performed as follows: (1)
Patch test with 20% lidocaine hydrochloride
in petrolatum; the results were negative at
72 and 96 hours after the test. (2) Intrader¬
mal test with 2% lidocaine was negative to
45 minutes. (3) Epinephrine showed normal
blanching only. (4) Sterile physiologic sa¬
line was negative. (5) Paraben mixture
(15% in petrolatum) was negative at 72 and
96 hours. However, eight hours after intra¬
dermal and patch testing, a papular prurit¬
ic rash appeared on his upper extremities
and shoulders.
One week later, the phenobarbital-bella-
donna mixture was given orally; no reac¬
tion was observed.
Comment—The inadvertent drug
challenge test when lidocaine was in¬
jected a fourth time and the flare-up
noted after intradermal testing (even
without a visible local reaction) make
it likely that the exfoliative derma¬
titis was caused by hypersensitivity
response to lidocaine hydrochloride.
In this instance, a careful medical
history, an alert patient historian, in¬
advertent dental drug challenge, and
the flare-up after skin testing led to
the presumptive diagnosis. Is it pos¬
sible that other patients exist without
the cause being suspected because the
patient and physician did not specifi¬
cally make this relationship?
Heidelore Hofmann, MD
Howard I. Maibach, MD
Eugene Prout, MD
Davis and San Francisco, Calif