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Three cases of an unusual Pseudomonas skin infection acquired from a health spa whirlpool were reported, and an epidemiologic survey showed 17 additional cases. This dermatosis is characterized by the abrupt onset of urticarial papules and superficial and deep papulopustules that spare only the head and neck and occur eight to 48 hours after using the whirlpool. Cultures from one patient's pustules and from the spa whirlpool environment were positive for P aeruginosa, serotype 0-11. The condition cleared in all but one patient, without treatment, within seven to ten days. This patient continues to have recurrent follicular pustules three months after exposure. Samples from whirlpools at six other selected establishments were also positive for P aeruginosa.(JAMA 239:2362-2365, 1978)

• The four male patients with multiple hamartoma syndrome (Cowden's disease) in this report, have most of the previously reported findings associated with this syndrome and several important unreported findings that include multiple cutaneous trichilemmomas, cafe-au-lait spots, cutaneous squamous cell carcinoma, pathologic fracture, craniomegaly, probable malignant lung tumor, retinal glioma, drusens of the optic disk and retina, pseudotumor cerebri, mediastinal mass, and multiple small papillomatous lesions of the esophagus, stomach, and duodenum.(Arch Dermatol 114:743-746, 1978)

• Herpes gestationis (HG) is a rare, blistering disease of pregnancy and the puerperium that has immunologic findings of C3 with or without IgG deposited in a linear, band-like distribution along the dermoepidermal basement membrane zone (BMZ). A circulating IgG factor has been demonstrated that will fix complement by the classic pathway in vitro. This study involves a patient who had classic HG with C3 at the BMZ, and who had a circulating factor with activity via the alternative complement pathway similar to the previously described C3 nephritic factor found in patients with partial lipodystrophy, systemic lupus erythematosus, and membranoproliferative glomerulonephritis. Like the C3 nephritic factor, the activity was detected in IgG fractions of serum samples.(Arch Dermatol 116:1045-1047, 1980)

• Pyrimethamine, a folate antagonist similar to methotrexate without known hepatotoxicity in man, was administered orally, once a week, to seven patients with severe, long-standing psoriasis. Four patients obtained a good to excellent response; a fifth withdrew from the study early after a partial response; a sixth had minimal response to high doses, and the seventh was withdrawn due to a probable drug-induced hepatotoxic reaction. Hepatotoxic reaction was suspected in another patient with abnormal liver biopsy and liver function test results. Two patients experienced severe gastrointestinal toxic reactions and two developed significant thrombocytopenia, which resolved after oral treatment with folic acid or discontinuation of the drug. These did not recur at lower doses. Pyrimethamine appears to be effective in severe psoriasis, but offers no advantage, and several disadvantages over methotrexate. Pyrimethamine is probably hepatotoxic. It should be used with caution in patients with liver disease or impaired renal function; pretreatment liver biopsy is recommended.(Arch Dermatol 113:172-174, 1977)

Angiolymphoid hyperplasia with eosinophilia (AHE) is a distinct clinical and pathologic entity that demonstrates proliferation of endothelial cells associated with varying degrees of lymphocytic, histiocytic, and eosinophilic infiltration. Lymphoid hyperplasia with germinal centers often is present in older lesions and the patients may have an associated blood eosinophilia. Multiple deep nodules developed in a young man on the palmar aspect of the left hand, and subsequently the forehead, histologically diagnostic of AHE. Direct immunofluorescence of the tumor removed from the forehead demonstrated granular deposits of IgA, IgM, and C3 associated with small vessels. Cryoglobulins (IgA, IgM, and IgG) were found in the patient's serum. This new information lends support to the hypothesis that AHE is an inflammatory reactive lesion, possibly secondary to an immunologic injury, rather than a true vascular neoplasm with an associated inflammatory reaction.(Arch Dermatol 115:205-207, 1979)

Histiocytic medullary reticulosis (HMR) is a rare, uniformly fatal, acute disease of the reticuloendothelial system. The disease is associated with fever, purpura, jaundice, hepatosplenomegaly, lymphadenopathy, and pancytopenia. A patient with HMR is described who had multiple, brown-to-violaceous tumors and plaques in the skin. A biopsy taken from a skin lesion showed the unique histologic finding of HMR, ie, phagocytosis of erythrocytes, platelets, and nuclear debris, by large, atypical histiocytes.

TO THE EDITOR.— We would like to bring your attention to a potentially dangerous situation involving two widely different but commonly prescribed topical medications.A 40-year-old woman had been seen by several physicians during a threeyear period for treatment of a mild perioral dermatitis. When she arrived in this area, she was seen by a dermatologist who prescribed several modes of therapy, with minimal success, before finally prescribing 0.05% fluocinonide ointment. During the next four weeks, her rash became progressively worse. She was seen in consultation with other dermatologists, and their differential diagnosis included polymorphous light eruption, systemic lupus erythematosus, pemphigus erythematosus, and airborne contact dermatitis. She was referred to our service for further examination. She had a severe, eczematous, painful, facial dermatitis with a papular telangiectatic component sparing the upper eyelids.When her topical medications were analyzed, it was discovered that the pharmacy had inadvertently given her 5%

TO THE EDITOR.— Since its description in 1957 by Frumess and Lewis as a "light-sensitive seborrheid," perioral dermatitis (PD) has continued to be a perplexing entity.1 Many causes have been postulated, including sunlight sensitivity, birth control pills, emotional stress, fluorinated steroid creams, Candida albicans, and rosacea. We have gathered clinical and historical data implicating fluoride dentifrices as an important etiologic factor in this dermatosis. The following two cases support this observation. REPORT OF CASES.—CASE 1.— A 63-year-old woman developed PD in mid-1971 that persisted for 24 months. There were exacerbations and remissions even though she was initially treated for one month with 0.025% fluocinolone acetonide cream and then intermittently with a mixture of 1% hydrocortisone, coal tar, and diiodohydroxyquin (Cor-Tar-Quin) and 250 mg of tetracycline hydrochloride four times a day. In August 1973, it was ascertained that she had been using a fluoride dentifrice for as long

TO THE EDITOR.— We have recently seen three patients with allergic contact dermatitis to vitamin E aerosol deodorant. REPORT OF CASES CASE 1.— An 18-year-old white man first used vitamin E deodorant on Dec 24, 1972. The following day he noted pruritus and erythema of the axillae extending onto the proximal medial aspects of the upper extremities and onto the thorax. His eruption had almost subsided by the 28th of December 1972, when he used the deodorant again. Within 24 hours, he noted severe pruritus and erythema. By 48 hours, he had developed vesiculobullous lesions that progressed and extended over the following week. The patient was essentially incapacitated for two weeks, and his eruption took a total of three weeks to clear. The patient denied any known contact with vitamin E prior to his acute dermatitis. CASE 2.— A 22-year-old white man was seen in the Dermatology Clinic

TO THE EDITOR.— We would like to thank Dr. Fisher for his comments regarding the patient we reported with probable systemic eczematous "contact-type" dermatitis associated with parabens. We certainly agree that this must be quite rare, and probably small doses of parenterally administered parabens given intradermally or subcutaneously will not cause a flare of eczematous dermatitis in a previously sensitized patient. However, in our patient a parenterally administered dose was given for mandibular block anesthesia. Our dental colleagues state that 2 to 8 ml of anesthetic solution for dental procedures is commonly used. Also intraoral submucosal tissues are extremely vascular, and certainly a large percentage of the administered dose finds its way directly into the circulation. Nichols and Cutright reported that aramine, aminophylline, epinephrine, and wyamine have almost an identical pharmacologic action when intraoral submucosal administration is compared with intravenous administration (Oral Surg 32:677-684, 1971).We think that only