Streptococcal infection may make psoriasis worse but do antibiotics help?

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4 Uitto J, Pulkkinen L, Ringpfeil F. Molecular genetics of pseudo-
xanthoma elasticum: a metabolic disorder at the environment–
genome interface? Trends Mol Med 2001; 7: 13–17.
The syringe skin hook: the history and evolution of the
improvised skin hook
DOI: 10.1111/j.1365-2133.2004.06052.x
S
IR
, The cosmetic results from skin surgery depend upon a
number of variables, particularly those relating to surgical
techniques and the handling of tissue. Skin hooks provide the
least traumatic way of manipulating skin borders and are an
important tool for the provision of an intact specimen for
histopathological assessment. We therefore feel that skin
hooks should be available in the surgical packs for all routine
skin surgery. However, when standard skin hooks are not
available, one can improvise.
The manufacture of improvised, disposable skin hooks at
the operating table is well reported. Fischl described an early
improvised skin hook.
1
He manipulated the point of a safety
pin to create a hooked end (Fig. 1A). The use of safety pins is
cumbersome and has been superseded by the development of
readily available disposable sterile needles. Thus more recent
reports have focused on the use of a syringe with a disposable
needle attached.
2,3
The needle is bent to create the desired
hooked effect (Fig. 1B). This has the advantage of sterility and
is quick and easy to manufacture. A disadvantage of this
technique is that there is the possibility of the syringe skin
hook separating into its constitutive elements, the syringe
and the needle, when the skin is under tension. This may lead
to inconvenience in surgery and may increase the risk of
injury to the surgeon. The risk of injury may be further
increased if larger needles are used to create the hook, as
larger hooks can easily penetrate through the skin. This risk
of separation can be reduced by the use of a syringe with a
locking mechanism for the needle (Fig. 1C); however, syrin-
ges with the Luer locking system may not be readily
available.
We report further evolution of this technique by using the
insulin syringe with a fixed, integrated needle, which we
commonly use for the administration of local anaesthetic. The
skin hook is formed by grasping the distal needle with either
the suture holder or by using artery forceps and bending the
tip through 180(Fig. 2A). A skin hook is formed (Fig. 2B).
The fixed needle reduces the chance of separation of the
needle from the syringe when the skin is under tension
(Fig. 2C). Thus, the theoretical risk of needlestick injury
caused by separation of the needle from the syringe is
reduced.
We have found the insulin syringe fixed hook to be an
invaluable tool, superior to previously described improvised
hooks and very cheap to make (approximately 7 p). The
improvised hook is often necessary in situations where one is
limited by the number of hooks available. It also offers the
surgeon more control over the hook angle. In our experience
the insulin syringe fixed hook is an effective, safe device and
we would like to bring it to the attention of others.
J.C.R.Bowling
J.Botting
E.V.J.Edmonds
N.Heaton
K.L.Agnew
Department of Dermatology, Chelsea &
Westminster Hospital, 369 Fulham
Road, London SW10 9NH, U.K.
E-mail:
jonathan.bowling@chelwest.nhs.uk
References
1 Fischl RA. An improvised skin hook. Br J Plast Surg 1966; 19: 391.
2 Azab AS, Kamal MS. The syringe skin hook. J Dermatol Surg Oncol
1985; 11: 368–9.
3 Verma AK. Devising an instant skin hook at the operation table by
using a syringe and needle. J Am Coll Surg 1994; 179: 225.
Streptococcal infection may make psoriasis worse but
do antibiotics help?
DOI: 10.1111/j.1365-2133.2004.06059.x
S
IR
, we read with great interest the paper by Gudjonsson and
colleagues about the role of streptococcal throat infections in
the exacerbation of chronic plaque psoriasis.
1
A prospective
study of this quality and size is very valuable in confirming
both anecdotal and retrospective reports of this association.
Figure 1. (A) Fischl’s early improvised skin hook. (B) Standard syr-
inge with disposable hooked needle. (C) Luer lock syringe with dis-
posable hooked needle.
Figure 2. (A) Formation of insulin syringe skin hook. (B) Insulin
syringe skin hook. (C) Insulin syringe skin hook in use, under tension.
244 CORRESPONDENCE
2004 British Association of Dermatologists, British Journal of Dermatology,151, 232–257

We do feel, however, that their conclusion that early
treatment of streptococcal sore throat may be beneficial for
patients with chronic psoriasis is somewhat premature
without a randomized controlled prospective study to support
this assertion. We feel that a conclusion calling for further
study in this area (as the authors have done for the effects of
tonsillectomy) would be more appropriate.
The streptococcal M protein hypothesis is well-established
and supports the link between streptococcal infection and a
psoriatic flare. However, it has not been established that
antibiotic intervention at an early stage of infection can abort
the cross-reaction between M protein and human epidermal
keratin and the ensuing T-cell activation which is strongly
implicated in the pathogenesis of psoriasis.
In our systematic review of antistreptococcal interventions
for guttate and chronic plaque psoriasis
2
we also postulated
that antistreptococcal treatment may be beneficial in the
treatment of both chronic plaque psoriasis and guttate
psoriasis but stated that there is no good evidence to support
this hypothesis. Equally there is no good evidence of lack of
benefit and we would like to take this opportunity to call
again for further study in this important area.
C.M.Owen
R.J.G.Chalmers*
C.E.M.Griffiths*
Department of Dermatology, Burnley
General Hospital, Burnley, and
*Dermatology Centre, University of
Manchester, Hope Hospital, Salford,
Manchester, U.K.
E-mail: carolineo@doctors.org.uk
References
1 Gudjonsson JE, Thorarinsson AM, Sigurgeirsson B et al. Strepto-
coccal throat infections and exacerbation of chronic plaque psori-
asis: a prospective study. Br J Dermatol 2003; 149: 530–4.
2 Owen CM, Chalmers RJ, O’Sullivan T, Griffiths CE. A systematic
review of antistreptococcal interventions for guttate and chronic
plaque psoriasis. Br J Dermatol 2001; 145: 886–90.
Streptococcal infection may make psoriasis worse but
do antibiotics help?: reply from authors
DOI: 10.1111/j.1365-2133.2004.06064.x
S
IR
, We thank Owen and colleagues for their constructive
comments on our paper reporting exacerbation of chronic
plaque psoriasis after streptococcal throat infections.
1
We
certainly agree with them that a controlled prospective study
is required for evaluating the effect of an early antistrepto-
coccal treatment on patients with psoriasis. This is in fact
what we intended to state in the last paragraph of our paper
where we conclude that an early treatment of streptococcal
sore throat may be beneficial for patients with chronic
psoriasisand a controlled trial for assessing the effects of
tonsillectomy on patients with severe psoriasis should also be
considered. We are grateful to Owen and colleagues to give
us the opportunity to reiterate more lucidly our view on this
important issue.
J.E.Gudjonsson
H.Valdimarsson*
Department of Internal Medicine,
University of Michigan Health
System, Ann Arbor, MI 48109,
U.S.A. and *Department of
Immunology, Landspitali University
Hospital, Reykjavik, Iceland
E-mail: johanng@med.umich.edu;
helgiv@landspitali.is
Reference
1 Gudjonsson JE, Thorarinsson AM, Sigurgeirsson B et al. Strepto-
coccal throat infections and exacerbation of chronic plaque psori-
asis: a prospective study. Br J Dermatol 2003; 149: 530–4.
Granuloma annulare restricted to Becker’s naevus
DOI: 10.1111/j.1365-2133.2004.06049.x
SIR, Granuloma annulare is a benign inflammatory skin
disease usually localized to the distal extremities, although
generalized, perforating and subcutaneous variants have also
been identified. Becker’s naevus is a common benign epider-
mal naevus, present in about 0Æ5% of young men. There have
been rare reports of inflammatory dermatoses occurring
solely within a Becker’s naevus, including lichen planus
1
and
acneiform lesions.
2–5
We report the first case of granuloma
annulare occurring solely within a Becker’s naevus, with no
involvement of the remainder of the skin.
A 25-year-old man presented with a papular eruption on
his left upper extremity. The eruption had started 3 weeks
previously, with an increase in the number of lesions over
that time. He had no symptoms of pain or pruritus. The
patient also noted that this eruption occurred exclusively in
an area of the left upper extremity which had developed
darker pigmentation and excessive hair growth during
adolescence.
On physical examination, there were multiple flesh-col-
oured 2–3 mm papules on the medial aspect of the left upper
extremity. In addition, there was a large area of macular
brown pigmentation with hypertrichosis, consistent with a
Becker’s naevus. The Becker’s naevus extended from the left
axilla to below the elbow, mostly on the medial aspect of the
arm. The flesh-coloured papules were located exclusively
within the Becker’s naevus (Fig. 1). The remaining skin,
nails, and mucous membranes were normal. A punch biopsy
was obtained from a papular lesion. Histological examination
of this specimen displayed a palisaded granulomatous der-
matitis, with zones of mucinous necrobiosis of collagen,
surrounded by mononuclear cells. The findings were diag-
nostic for granuloma annulare.
Reports of inflammatory dermatoses restricted to Becker’s
naevus are rare.
1–5
Terheyden et al.
1
reported the occurrence
of lichen planus restricted to a large Becker’s naevus, in a
50-year-old man with a Becker’s naevus involving the right
lower abdomen, thigh, leg and genitalia. The authors
concluded that the occurrence of lichen planus entirely
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2004 British Association of Dermatologists, British Journal of Dermatology,151, 232–257