Volume 15 Number 6 December, 1986

Correspondence 1303

Gentian violet and wound repair

To the Editor: Recently Drs. Barbara R. Reed and Rich- ard A. F. Clark wrote an informative review on the practical implications of current knowledge about cu- taneous tissue repair (J AM ACAD DERMATOL 13;919- 941, 1985). In the section on gentian violet they con- clude that " . . . its effect on wound healing is not known." Their resource material, however, overlooked several relevant studies.

Necrotic ulcerations may occur on injured skin painted with 1% gentian violet in aqueous solution. 1 Similar lesions can be reproduced by painting "stripped," but not "unstripped," normal skin in man and guinea pig. Crystal violet is usually supplied when gentian violet is requested. The tissue-damag- ing potency of the triphenylmethane group of dyes has also been demonstrated in different experimental models.

Crystal violet in low concentrations markedly inhib- ited the formation of granulation tissue in cellulose sponges implanted subcutaneously for 10 days in rats. 2 Likewise, one application of crystal violet to incisional skin wounds before suturing retarded the development of strength in the wounds for at least 3 weeks.3 Crystal violet caused marked vascular proliferation, indicating tissue damage as visualized by microangiography after deposition of crystal violet into rabbit's ear. 4 In vitro, crystal violet was cytotoxic at very low concentrations to HeLa cells and fibroblasts. ~ Granulation tissue slices exposed to crystal violet had a decreased capacity to consume oxygen, to incorporate 14C-proline into col- lagen and noncollagenous proteins, and to synthesize ribonucleic acid (RNA). 6

The results obtained with crystal violet were in con- centrations well below those used clinically. The tissue- irritating effect of crystal violet ("gentian violet"), added to the other disadvantages such as discoloration and masking, must be noted when its use in ulcers is contemplated. Gentian violet should be used with cau- tion in open wounds.

H&kan Mobacken, M.D. Sahlgren's Hospital

Giiteborg, Sweden

REFERENCES I. Bjrrnberg A, Mobacken H: Necrotic skin reactions caused

by 1% gentian violet and brilliant green. Acta Derm Ve- nereol (Stoekh) 52:55-60, 1972.

2. Mobacken H, Zederfeldt B: Influence of a cationic tri- phenylmethane dye on granulation tissue growth in vivo. An experimental study in rats. Aeta Derm Venereol (Stockh) 53:161-172, 1973.

3, Mobacken H, Zederfeldt B, /~hrrn Chr: Effects of two cationic triphenylmethane dyes on the healing of skin in- cisions. A tensiometric and histologic study in the rat. Aeta Derm Venereol (Stockh) 53:161-166, 1973.

4. Mobacken H, Eriksson E: Mierovascular effects of a top- ically applied cationic triphenylmethane dye (crystal vi- Net). Acta Derm Venereol (Stockh) 57,45-49, 1977.

5. Norrby K. Mobacken H: Effect of triphenylmethane dyes (brilliant green, crystal violet, methyl violet) on prolif- eration in human normal fibroblast-like and established epithelial-like cell lines. Acta Derm Venereol (Stockh) 52:476-483, 1972.

6. Mobacken H, Ahonen J, Zederfeldt B: The effect of a cationic triphenylmethane dye (crystal violet) on rabbit granulation tissue: Oxygen consumption and RNA and protein synthesis in tissue slices. Acta Derm Venereol (Stockh) 54:343-347, 1974.

Pimozide for delusions of bromosis

To the Editor: Monosymptomatic hypochondriac syn- dromes are a group of disorders in which the patient is convinced that he is diseased despite a conspicuous lack of objective evidence. Three major varieties include delusions of dysmorphosis, parasitosis, and bromosis.' The dermatologist may be confronted by any one of these, each presenting a therapeutic dilemma. Pimozide (Orap) has been suggested as an alternative in the man- agement of these disorders. The drug was recently used at our institution with good short-term results in a pa- tient complaining of bromosis.

Case report. A 26-year-old woman presented with a 5-year history of an offensive body odor, allegedly first no- ticed by her boyfriend. She had been told that she had the smell of vitamins, which improved briefly for 2 to 3 hours after showering. In addition to many over-the-counter prep- arations, Xerac AC and Hibiclens had been ineffective. The symptom, coupled with these treatment failures, was distress- ing to the patient.

On physical examination the patient was a I young, well- groomed woman who appeared in good health. Close in- spection of both axillae disclosed no moiphologic change or foul odor. The patient explained the lack of odor by noting that she had bathed shortly before her appointment. At none of her visits was she found to be malodorous by any of three of four observers.

The patient first applied topical erythromycin twice daily to the axillae for several months. This therapy was totally ineffective. Because of the discordance of subjective and ob- jective evidence, a trial of pimozide was initiated. The patient was started on 4 mg every morning, which was well tolerated. She experienced persistent improvement of her symptoms for 2 months on pimozide.

Comment. Pimozide is a neuroleptic that acts through a blockade of central dopaminergic receptors,2.3

1304 Correspondence

Journal of the American Academy of

Dermatology

It is currently indicated for use in Tourette's syndrome but has been advocated for a number of disorders, a'2 including delusions of parasitosis, delusions of dys- morphosis, neurotic excoriations, postherpetic neural- gia, and delusions of bromosis. After oral administra- tion plasma concentration peaks in 3 to 8 hours, with a half-life of 29 plus or minus 10 hours. Excretion is mostly in the urine but is partially through feces. Pre- cautions include monitoring the patient for hypertension and sedation, plus avoiding concomitant use of alcohol and opiates. Pimozide may also lower the convulsive threshold and should therefore be used with discretion in epileptics. Adverse effects include extrapyramidal symptoms, prolongation of the Q-T interval, and men- strual irregularities. Safety for use in pregnancy has not been established. Because of its long half-life, pimozide may be administered once daily, usually beginning with 2 to 4 mg/day and gradually increasing as necessary to a maximum of 20 rag/day? "~

"Delusions of bromosis" is a diagnosis of exclusion and a difficult therapeutic problem once diagnosed. When a patient comes to the dermatologist with these symptoms, there is often the feeling of inability to be of help. The use of pimozide in these disorders is, therefore, a welcome addition to the arsenal of medi- cations for use in these therapeutically frustrating problems.

Curt M. Littler, M.D. University of New Mexico School of Medicine

Albuquerque, NM

REFERENCES 1. Bishop ER Jr: Monosymptomatic hypochondriacal syn-

dromes in dermatology. J AM ACAD DERMATOL 91152- 158, 1983.

2. Duke EE: Clinicat experience with pimozide: Emphasis on its use in postherpetic neuralgia. J AM ACAD DERMATOL 8:845-850, 1983.

3. Colvin CL, Tankanow RM: Pimozide: Use in Tourette's syndrome. Drug Intell Clin Pharrn 19:421-424, 1985.

Reply To the Editor: Dr. Littler writes in regard to the use of pimozide in a case of delusions of bromosis. In a dis- order that affects every facet of a patient's existence and in which no other suitable remedy has proved use- ful, pimozide is more than warranted.

I suggest to the readers that in regard to this drug the following reservations be kept in mind:

1. Pimozide is an extremely potent neuroleptic.

2. Early signs of toxicity are increased salivation, hyper- activity, and insomnia. Late signs are extrapyramidal, in- eluding parkinsonism. Some of these, such as the tardive dyskinesias, a group of disorders characterized by rhythmic involuntary movements of the tongue, face, mouth, and jaw, may be irreversible.

3. The use of pimozide in neurotic excoriations should be on/y in the rare severe disabling disease in which the risks of the medication are justified.

4. Although benefit is noted within 1 to 2 weeks, the drug requires prolonged administration, stoppage being associated with a recurrence of symptoms. A 26-year-old woman re- quires advice regarding pregnancy. As well, close supervision over her lifetime may be necessary and indeed may be man- datory.

5. In the management of the monosymptomatic hypo- chondriasis, doses of 4 to 6 mg/day are usually adequate; up to 10 mg may be needed. Higher doses of 20 mg have been advocated for the use of pimozide in chronic schizophrenia. I would encourage any who become this adventurous to secure consultation for the patient with a psychiatrist and, perhaps, at the same time for themselves.

Elgin E. Duke, M.D. 770 Broadview Ave.

Ottawa, Ontario K2A 3Z3 Canada

Notalgia paresthetica To the Editor: I wish to call attention to a striking

1 2 experience with a case of notalgia paresthetica., I have followed this patient for 34 years, since he was 35. Over the course of these years, he complained of an itch, persistent but sporadic, localized on the skin along the inferomedial border of his right scapula. No treat- ment of notalgia paresthetica being known, I simply sympathized with him.

During the recent wave of interest in the possible medical effects of environmental pollution, I reviewed the man's medical history and found what I had not noticed before--that he had from time to time exhibited some chemical sensitivities. Notably, there had been an episode of tobacco ambly0pia to cigarettes, after which he had given up smoking.

Intrigued by the possibilities, I suggested that he try to identify and avoid chemical agents that might be causing the neuropathy. Among the suspected culprits I listed were saccharin and hexachlorophene-containing deodorant soap. He admitted using both of these to excess. Saccharin is a sulfa compound. Many such compounds are allergens.

He stopped using these products and, to the delight of both of us, the symptoms cleared. He remained asymptomatic for 10 years.

There is a postscript. Recently the man's itch re-