J AM ACAD DERMATOL

1230 Letters

DECEMBER 2011

Table I. Risk of developing psoriasis for current statin users, by individual statins
Exposure

Nonuse of any lipid-lowering agents

Individual statins
Current 1-4 rx
Atorvastatin
Cerivastatin
Rosuvastatin
Simvastatin
Pravastatin
Fluvastatin
Current 5-19 rx
Atorvastatin
Cerivastatin
Rosuvastatin
Simvastatin
Pravastatin
Fluvastatin
Current $20 rx
Atorvastatin
Cerivastatin
Rosuvastatin
Simvastatin
Pravastatin
Fluvastatin

No. of cases (%)

n = 36,702

No. of controls (%)

n = 36,702

OR unadjusted
(95% CI)

OR adjusted
(95% CI)

34,681 (94.5)

34,922 (95.2)

Reference

Reference

27
4
1
40
11
0

(0.07)
(0.01)
(0.00)
(0.11)
(0.03)
(0.00)

39
2
2
68
11
2

(0.1)
(0.01)
(0.01)
(0.19)
(0.03)
(0.01)

0.71
2.17
0.54
0.60
1.02

(0.43-1.16)
(0.40-11.98)
(0.05-5.92)
(0.40-0.88)
(0.44-2.35)
NA

0.65
1.58
0.65
0.50
0.92

(0.39-1.08)
(0.28-8.97)
(0.06-7.35)
(0.33-0.75)
(0.39-2.16)
NA

100
7
10
140
38
13

(0.27)
(0.02)
(0.03)
(0.38)
(0.10)
(0.04)

92
10
9
152
25
10

(0.25)
(0.03)
(0.02)
(0.41)
(0.07)
(0.03)

1.11
0.73
1.12
0.95
1.61
1.38

(0.83-1.47)
(0.28-1.93)
(0.45-2.76)
(0.76-1.20)
(0.97-2.67)
(0.58-3.27)

1.02
0.61
1.03
0.91
1.50
1.37

(0.76-1.37)
(0.23-1.66)
(0.40-2.65)
(0.71-1.15)
(0.89-2.52)
(0.56-3.32)

136
1
4
185
49
10

(0.37)
(0.00)
(0.01)
(0.50)
(0.13)
(0.03)

124
0
6
145
47
9

(0.34)
(0.00)
(0.02)
(0.40)
(0.13)
(0.02)

1.13 (0.89-1.45)
NA
0.69 (0.19-2.45)
1.33 (1.07-1.67)
1.07 (0.72-1.61)
1.22 (0.49-3.02)

1.00 (0.77-1.30)
NA
0.53 (0.14-1.96)
1.18 (0.94-1.50)
1.03 (0.68-1.57)
1.14 (0.45-2.90)

CI, Confidence interval; NA, not applicable; OR, odds ratio; rx, prescriptions.

However, we display the findings in more detail,

stratified by individual statin and by exposure
duration (Table I).

Correspondence to: Christoph R. Meier, PhD, MSc,

University Hospital Basel, Hospital Pharmacy,
Spitalstrasse 26, Basel 4031, Switzerland

Yolanda B. Brauchli, PhD, MSc, Susan S. Jick, DSc,

and Christoph R. Meier, PhD, MSc

E-mail: meierch@uhbs.ch

University Hospital Basel, Basel, Switzerland

Funding sources: None.

REFERENCE
1. Brauchli YB, Jick SS, Meier CR. Statin use and risk of first-time
psoriasis diagnosis. J Am Acad Dermatol 2011;65:77-83.

Conflicts of interest: None declared.

doi:10.1016/j.jaad.2011.08.028

RESEARCH
Antibiotic susceptibility of Corynebacterium
minutissimum isolated from lesions of Turkish
patients with erythrasma
To the Editor: Erythrasma is a common, chronic,
cutaneous infection caused by a lipophilic and filamentous gram-positive bacillus, Corynebacterium
minutissimum. In the treatment of the disease, systemic or topical erythromycin is recommended as the
first choice of treatment.1-3 However, in our daily
practice, we observed some cases that did not
respond to erythromycin. Review of the literature

LETTERS
showed no recent data about the antibiotic susceptibility of C minutissimum. Therefore we aimed to
study the antibiotic susceptibility of C minutissimum
isolated from patients with erythrasma.
Forty patients with erythrasma enrolled in the
study. The diagnoses were also confirmed by Woods
lamp examination, which causes erythrasma to fluoresce coral red. None of the patients had been using
systemic or topical antibiotic therapy for the previous
2 weeks. Potassium hydroxide examinations for
dermatophytes were performed to confirm the

J AM ACAD DERMATOL

Letters 1231

VOLUME 65, NUMBER 6

Table I. Susceptibility of C minutissimum to antimicrobial agents

Antimicrobial
agents

Penicillin
Ampicillin
Cefaclor
Ampicillin
sulbactam
Amoxicillin
clavulanate
Tetracycline
Erythromycin
Ofloxacin
Fusidic acid
Levofloxacin
Azithromycin

Susceptibility
% (No. of cases)

5
30
67.5
50

(2)
(12)
(27)
(20)

95 (38)
57.5
5
55
75
65
5

(23)
(2)
(22)
(30)
(26)
(2)

Resistance
% (No. of cases)

95
70
32.5
50

(38)
(28)
(13)
(20)

5 (2)
42.5
95
45
25
35
95

(17)
(38)
(18)
(10)
(14)
(38)

P
value*

0
.011
.027
1.000
0
.343
0
.527
.002
.058
0

*P values for the differences between the susceptible and resistant

groups, based on the chi-square test (P \ 0.05).

absence of hyphae on microscopy from the skin

scrapings of lesions. Skin swab samples were inoculated into blood agar and Colombia agar.
Corynebacteria generate non-hemolytic cream colonies in blood agar after 24 hours of incubation at
378C. A diagnosis was made by urease test, properties
of aesculin hydrolysis, acid production from glucose,
maltose, and saccharose, as well as fermentation of
the growing bacteria. Susceptibility tests for penicillin
G, ampicillin, cefaclor, amoxicillin-clavulanate, ampicillin-sulbactam, tetracycline, erythromycin, ofloxacin, fusidic acid, levofloxacin, and azithromycin
were performed with dry disk-diffusion method.
The ethics committee approved the study. Data
were evaluated by means of the Statistical Package
Program for Social Sciences 15.0. Frequency analysis
was done statistically and chi-square test was also
performed for intergroup comparisons.
The mean age of 40 patients (20 males, 20 females)
included in the study was 47.5 6 8.2 years (range,
28-67 years). Antibiotic susceptibility tests revealed
statistically significant resistance to erythromycin,
azithromycin, penicillin, and ampicillin. Significant
susceptibility was statistically found to amoxicillinclavulanate, cefaclor, and fusidic acid (Table I).
A limited number of susceptibility studies for
C minutissimum are available in the literature.
However, these studies are old and lack recent data
about the antibiogram of C minutissimum.4,5 None
of the studies investigates susceptibility to beta lactam and beta lactamase inhibitor combination, such
as amoxicillin-clavulanate and ampicillin-sulbactam.
In our study, we found resistance to ampicillinsulbactam in half of the patients and susceptibility
to amoxicillin-clavulanate in 95% of patients.

In the literature, it is stated that bacteriologic

culture of erythrasma is difficult and usually unnecessary for the diagnosis. Therefore, in daily practice
culture and antibiogram are not routinely studied and
systemic or topical erythromycin is usually prescribed empirically for the treatment.1-3 We suggest
testing the antibiotic susceptibility of C minutissimum before treatment. However, if a cultureantibiogram is unavailable, fusidic acid should be
started topically as the first treatment of choice.
Topical tetracycline may be an alternate choice if
fusidic acid is not available. Finally, if there is a
treatment failure, amoxicillin-clavulanate should be
chosen for the systemic treatment.
Bengu Gerceker Turk, MD, Meltem Turkmen, MD,
and Derya Aytimur, MD
Department of Dermatology, Ege University Medical Faculty, Izmir, Turkey
Funding sources: None.
Conflicts of interest: None declared.
Correspondence to: Bengu Gerceker Turk, MD, Ege
University Medical Faculty, Department of Dermatology, TR-35100 Bornova, Izmir, Turkey
E-mail: bengugerceker@yahoo.com
REFERENCES
1. Morales-Trujillo ML, Arenas R, Arroyo S. Interdigital erythrasma:
clinical, epidemiologic, and microbiologic findings. Actas Dermosifiliogr 2008;99:469-73.
2. Holdiness MR. Management of cutaneous erythrasma. Drugs
2002;62:1131-41.
3. Schaller M. Other bacterial infections. In: Burgdorf WHC, Plewig
G, Wolff HH, Landthaler M, editors. Dermatology. Italy: Springer
Medizin Verlag Heidelberg; 2009. pp. 140-75.
4. Soriano F, Zapardiel J, Nieto E. Antimicrobial susceptibilities of
Corynebacterium species and other non-spore-forming grampositive bacilli to 18 antimicrobial agents. Antimicrob Agents
Chemother 1995;39:208-14.
5. Lagrou K, Verhaegen J, Janssens M, Wauters G, Verbist L.
Prospective study of catalase-positive coryneform organisms in
clinical specimens: identification, clinical relevance, and antibiotic susceptibility. Diagn Microbiol Infect Dis 1998;30:7-15.
doi:10.1016/j.jaad.2011.03.024

A randomized controlled crossover trial:

Lidocaine injected at a 90-degree angle causes
less pain than lidocaine injected at a 45-degree
angle
To the Editor: Local anesthetic injection results in
discomfort to patients.1,2 Anecdotal reports suggest
that injecting at a 90-degree angle reduces pain.2
Controlled studies examining this approach are
lacking. This study examines the effect of angle of