J AM ACAD DERMATOL
VOLUME 55, NUMBER 1
profile. However, we have not proven that patients
with cutaneous type PV actually have pathogenic
weak anti-Dsg3 IgG, and further studies are neces-
sary to fully understand the pathophysiological
mechanism of blister formation in pemphigus. To
this end we believe that Dsg compensation theory
will continue to provide a solid framework, although
we maintain an open mind for other possibilities.
Masayuki Amagai, MD
Kazue Yoshida, MD
Yujiro Takae, MD
Hitoshi Saito, MD
Akiko Tanikawa, MD
Takeji Nishikawa, MD
Department of Dermatology
Keio University School of Medicine
Tokyo, Japan
REFERENCES
1. Yoshida K, Takae Y, Saito H, Oka H, Tanikawa A, Amagai M, et al.
Cutaneous-type pemphigus vulgaris: a rare clinical phenotype
of pemphigus. J Am Acad Dermatol 2005;52:839-45.
2. Harman KE, Seed PT, Gratian MJ, Bhogal BS, Challacombe SJ,
Black MM. The severity of cutaneous and oral pemphigus is
related to desmoglein 1 and 3 antibody levels. Br J Dermatol
2001;144:775-80.
3. Tsunoda K, Ota T, Aoki M, Yamada T, Nagai T, Nakagawa T, et al.
Induction of pemphigus phenotype by a mouse monoclonal
antibody against the amino-terminal adhesive interface of
desmoglein 3. J Immunol 2003;170:2170-8.
4. Ishii K, Harada R, Matsuo I, Shirakata Y, Hashimoto K, Amagai M.
In vitro keratinocyte dissociation assay for evaluation of the
pathogenicity of anti-desmoglein 3 IgG autoantibodies in
pemphigus vulgaris. J Invest Dermatol 2005;124:939-46.
5. Payne AS, Ishii K, Kacir S, Lin C, Li H, Hanakawa Y, et al. Genetic
and functional characterization of human pemphigus vulgaris
monoclonal autoantibodies isolated by phage display. J Clin
Invest 2005;115:888-99.
6. Mahoney MG, Wang Z, Rothenberger KL, Koch PJ, Amagai M,
Stanley JR. Explanation for the clinical and microscopic local-
ization of lesions in pemphigus foliaceus and vulgaris. J Clin
Invest 1999;103:461-8.
7. Cheng SW, Kobayashi M, Tanikawa A, Kinoshita-Kuroda K,
Amagai M, Nishikawa T. Monitoring disease activity in pemphi-
gus with enzyme-linked immunosorbent assay using recombi-
nant desmoglein 1 and 3. Br J Dermatol 2002;147:261-5.
8. Jamora MJ, Jiao D, Bystryn JC. Antibodies to desmoglein 1 and
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doi:10.1016/j.jaad.2005.11.1094
The use of a cotton-tipped applicator for
temporary hemostasis during punch biopsy
To the Editor: We read with interest the article by
Wimpee et al1 about the use of cotton-tipped appli-
cator as a temporary tamponade device during
punch biopsy. We would like to point out that the
cotton-tipped applicator has been extensively used
Letters 177
in various fields of ophthalmic operations including
ptosis/entropion correction, eyelid reconstruction,
and vitreoretinal and glaucoma procedures.
Extended use of cotton-tipped applicator in cuta-
neous punch biopsy is innovative. However, in Fig 1
of the article, the cotton-tipped applicator belongs to
the large-size one with long wooden shaft used in
routine wound care. We wonder, if such a long shaft
applicator was used as the temporary hemostasis
measure during unassisted punch biopsy as sug-
gested by the authors, how could such an instrument
become self-retaining and maintain its tamponade
effect without the undue influence of the torque/
rotational force from the long wooden shaft?
To overcome this potential technical difficulty,
we propose an alternative modified cotton-tipped
applicator, with a much shorter shaft that was com-
monly used in ophthalmic surgery.
Alice Y. K. Chan, MRCP a
David T. L. Liu, MRCS b
Social Hygiene Service (Dermatology)
Department of Health, Hong Kong Special
Administrative Regiona
Department of Ophthalmology and Visual Sciences
Prince of Wales Hospital b
Reprint requests: David T. L. Liu, MRCS
Department of Ophthalmology and Visual Sciences
The Chinese University of Hong Kong
Prince of Wales Hospital
Shatin, Hong Kong
E-mail: david_tlliu@yahoo.com
REFERENCE
1. Wimpee HJ, Griess AJ, Hull CM. Surgical pearl: the use of a
cotton-tipped applicator for temporary hemostasis during
punch biopsy. J Am Acad Dermatol 2005;52:1075.
doi:10.1016/j.jaad.2005.07.005
Papular mycosis fungoides: A variant of
mycosis fungoides or lymphomatoid
papulosis?
To the Editor: We would like to comment on the
article by Kodama et al1 in the April 2005 issue of the
Journal. Kodama and coworkers describe 6 patients
with a papular variant of mycosis fungoides (MF).
The evidence they provide that this is a clinical
variant of MF are as follows: (1) histopathologic
features compatible with MF were found in skin
biopsy specimens from all patients; (2) typical patch
lesions of MF subsequently developed in 2 of the
patients; and (3) none of the patients had findings
that characterize conditions that might be confused
with papular MF (ie, there was an absence