762 LETTERS TO THE EDITOR
4 JAGS
The etiology remains unknown, although local trauma,
such as topical treatment of solar keratoses with 5% flu-
orouracil, tretinoin, surgery, cryotherapy, or radiotherapy
has been suggested as a trigger in actinically damaged
scalps.3–7 In addition, associations with other autoimmune
disorders, including rheumatoid arthritis, autoimmune hep-
atitis, Hashimoto’s thyroiditis, and Takayasu’s aortitis,
have been reported.6–7
The list of differential diagnosis is wide, including
chronic bacterial or fungal infection, irritated actinic
keratoses, squamous cell carcinoma, pyoderma gangreno-
sum, pemphigus foliaceus, and factitial damage. Other,
less likely, possibilities include pustular psoriasis of the
scalp, cicatricial pemphigoid, lupus erythematosus, pem-
phigus, Darier’s disease, eczema, dissecting cellulitis of the
scalp, and the neutrophilic scarring alopecias. However,
the appearance in elderly people on previously altered scalp,
the clinical association between erosions, pustules, and
crusts with no specific histopathology and with no infec-
tious agent found, the evolution leading to scarring alopecia
and the resistance to antibiotics and response to topical
steroids allow the diagnosis.
Potent topical corticosteroids have been widely used
in EPDS with variable response. However, in view of
steroid-related cutaneous atrophy, topical tacrolimus
ointment8 and calcipotriol (calcipotriene) cream9 have
been proposed as alternative therapies, to avoid develop-
ment of further atrophy. Anecdotal reports have described
partial responses with nimesulide, oral isotretinoin, or oral
dapsone.5–7 Topical and systemic antibiotics are usually
ineffective.
Our patient was treated with oral methylprednisolone
(16 mg/d with progressive reduction), oral zinc sulphate
(200 mg/d), and a 0.05% clobetasol propionate foam. After
2 months, complete resolution of the lesions with residual
scarring alopecia was observed, and the patient is healthy
after 10 months follow-up.
Mario Vaccaro, MD, PhD
Claudio Guarneri, MD
Institute of Dermatology
University of Messina
Policlinico Universitario
Messina, Italy
Olga Barbuzza, MD, PhD
Institute of Occupational Health
Policlinico Universitario
Messina, Italy
Biagio Guarneri, MD
University of Messina
Institute of Dermatology
Policlinico Universitario
Messina, Italy
ACKNOWLEDGMENTS
Conflict of Interest: The editor in chief has reviewed the
conflict of interest checklist provided by the author and has
determined that none of the authors have any financial or
any other kind of personal conflicts with this letter.
APRIL 2008–VOL. 56, NO.
Author Contributions: All authors contributed to
study concept and design, acquisition of subjects and
data, analysis and interpretation of data, and preparation
of manuscript.
Sponsor’s Role: N/A (no sponsor).
REFERENCES
1. Burton JL. Case for diagnosis. Pustular dermatosis of scalp. Br J Dermatol 1977;
97(Suppl 15):67–69.
2. Pye RJ, Peachey RD, Burton JL. Erosive pustular dermatosis of the scalp. Br J
Dermatol 1979;100:559–566.
3. Grattan CE, Peachey RD, Boon A. Evidence for a role of local trauma in the
pathogenesis of erosive pustular dermatosis of the scalp. Clin Exp Dermatol
1988;13:7–10.
4. Mastroianni A, Cota C, Ardigo M et al. Erosive pustular dermatosis of the scalp:
A case report and review of the literature. Dermatology 2005;211:273–276.
5. Martin FJ, Herrera A, Rios JJ et al. Erosive pustular dermatosis of the scalp after
skin grafting. Dermatol Surg 2001;27:766–767.
6. Van Exel CE, English JC. Erosive pustular dermatosis of the scalp and nonscalp.
J Am Acad Dermatol 2007;57(2 Suppl):S11–S14.
7. Patton D, Lynch PJ, Fung MA et al. Chronic atrophic erosive dermatosis of the
scalp and extremities: A recharacterization of erosive pustular dermatosis. J
Am Acad Dermatol 2007;57:421–427.
8. Laffitte E, Kaya G, Piguet V et al. Erosive pustular dermatosis of the scalp:
Treatment with topical tacrolimus. Arch Dermatol 2003;139:712–714.
9. Boffa MJ. Erosive pustular dermatosis of the scalp successfully treated with
calcipotriol cream. Br J Dermatol 2003;148:593–595.
MEDICAL COMPLAINTS AND PSYCHOSOCIAL AND
CULTURAL CHARACTERISTICS OF A NATIONWIDE
SAMPLE OF 2,136 COMMUNITY-DWELLING
BRAZILIAN ELDERLY PEOPLE: THE FUNDAÇÃO
PERSEU ABRAMO PROJECT
To the Editor: The Brazilian Foundation ‘‘Fundação Perseu
Abramo’’ has recently (May 2007) published on-line
(in Portuguese) the results of a nationwide survey involving
a probabilistic population-based sample of 2,136 Brazilians
aged 60 and older living in 204 municipalities distributed
throughout the country.1 As a comparative group, 1,608
people aged 16 to 59 were also evaluated using the same
methodology. Interviews were conduced at home in April
2006. Three hundred fifty variables were evaluated. Here,
the main findings of this national survey, which is one of
the largest-ever gerontological surveys in Latin America,
are reported, including some internationally relevant cul-
tural and psychosocial perspectives.
Fifty-seven percent of those surveyed were female. Ap-
proximately 33% of the sample was aged 60 to 64; 25%, 65
to 69; 17%, 70 to 74; and 25%, 75 and older. Fifty-one
percent were white; 43%, Mestizo or Black; and 3%, other.
Thirty-eight percent lived in rural areas and 62% in urban
areas. Fifty-two percent were married, 34% were widows,
8% were divorced; 6% had never been married, and 6%
had never had children.
Each subject lived with an average of four other per-
sons; only 15% lived alone, as opposed to 30% in the
United States and 46% in Germany.2 Nearly 50% of the
elderly couples lived with at least one family member, usu-
ally an adult child or a grandchild. In Latin America it is not
uncommon for three or even four generations to live in the
same home.3
Table 1 shows the most common self-reported com-
plaints. Asymptomatic conditions such as hypertension, di-
JAGS APRIL 2008–VOL. 56, NO. 4 LETTERS TO THE EDITOR 763

Table 1. Medical Complaints and Psychosocial and Cul- Table 2. Values, Feelings, and Attitudes Associated with
tural Characteristics of a Nationwide Sample of Commu- Aging and Death, According to Age Group
nity-Dwelling Brazilian Elderly People (N 5 2,136)
Age
Medical Complaints and
Psychosocial and Cultural Characteristics Frequency (%) 16–59  60
(n 5 1,608) (n 5 2,136)
Prevalence of main self-reported
complains in elderly people Values, Feelings, and Attitudes %
High blood pressure 43
Feelings related to death
Vision problems 26
I am not afraid of death but to suffer/endure pain 75 87
Back pain 23
I am not afraid of death but I would not like to be 59 72
Diabetes mellitus 13 alone when it arrives
Heart diseases 13 Death is all I am waiting for 10 33
High cholesterol 13 Most often daily feelings
Joint pain or arthrosis 11 Irritability or impatience 24 13
Osteoporosis 9 Anxiety 30 10
Shortness of breath 8 Sadness 11 20
Stomach problems 7 Happiness 43 42*
Anxiety or depression 6 Most important values and attitudes
Dizziness or falls 6 Wisdom 37 44
Memory complains 6 Religiosity 27 34
Chronic headache 5 Does not matter to make many plans or dreams 37 59
No problems at all 17 because what happens in life depends more on
Nursing homes (only binary answers were considered) chance than on will or effort
The elderly person no longer has contact with family 78 Being aged means
and friends, and people forget the person More bad things 42 35
Treat the elderly person like children 77 More good things 36 33
Health care Depends on the point 18 23
Uses the public national health system (free) 68 There is no difference on being aged 1 5
Private health plan 26 I do not know* 3 4
Pays doctors and hospitals privately 11
*No statistically significant difference between the groups. Po.05 for all
Took influenza vaccine in the local health unit 71
other differences (chi-square).
Already received a visit from the 11
family doctor of the local health unit
Already received a visit from the health 48 Whereas nearly the same proportion of younger adults
agent of the local health unit who reported that they were ‘‘simply waiting for death’’
(10%) reported ‘‘sadness’’ (11%), many more older people
reported that they were ‘‘simply waiting for death’’ (33%)
than reported sadness (20%). This phenomenon suggests
abetes mellitus, hyperlipidemia, and osteoporosis were that at least one-third of depressed elderly people deny or
among the most common self-reported conditions, possi- do not present ‘‘sadness.’’ Geriatricians know this phenom-
bly indicating a high level of knowledge about health. This, enon well, because late-onset depression often presents only
in turn, might be a consequence of the recent (1988) uni- as unexplained somatic complaints or apathy.5
versality of free access to health care in Brazil. In addition, whereas ‘‘sadness’’ was found to be almost
As expected, in family-oriented Latin America, nursing two times as common in elderly people as in younger ones,
homes are viewed with distrust. anxiety was three times as prevalent in younger adults.
Nearly 70% of all elderly people use the Public Na- Possibly as a net effect, the proportion of people reporting
tional Health System, which is free of any extra charge. daily ‘‘happiness’’ was not significantly different between
Brazil was one of the first countries (1999) to provide young and older adults (43% vs 42%). This is in accord
free access to yearly mass influenza vaccination for people with studies that suggest that older people are less suscep-
aged 60 and older,4 and approximately 70% of them usu- tible to anxiety6 but more so to depression (because of
ally take the vaccine yearly. greater risks for comorbidities, cerebrovascular disease, and
Table 2 shows some characteristics associated with ag- social isolation).7
ing and death according to age group. Death itself did not Finally, whereas younger adults think that being aged
seem to be as feared as its circumstances (e.g., pain, lone- means ‘‘more bad than good things,’’ there is no such
liness), and this is more evident in the older group. One- difference in older adults. This is possibly one of the most
third of the Brazilian elderly population consider that they important findings of this researchFthat the image young-
are ‘‘simply waiting for death,’’ as opposed to one-tenth of the er adults have of old age is more negative (and thus subject
younger adult population. This suggests a high prevalence of to prejudice) than the evaluation elderly people make of
depression in both age groups but especially in the elderly. their own condition.
764 LETTERS TO THE EDITOR
Even though past nationwide data are not available for
comparison, it seems that the growth of the Brazilian Uni-
fied Health System (since 1988) is improving recognition of
several aging-associated chronic diseases, because its self-
reported prevalences are not far from the medically diag-
nosed ones in Brazil.8
Just as children are not small adults, elderly people are
not merely chronologically older adults. Their peculiarities
should be seriously considered not just in biological and
psychosociological but also in cultural terms.
Matheus Roriz-Cruz, MD, PhD
Instituto de Geriatria e Gerontologia
Pontifı́cia Universidade Católica do Rio Grande do Sul/
World Health Organization Collaborating Research Center
for the Prevention of Chronic-Degenerative Diseases
Associated with Aging
Porto Alegre, Rio Grande do Sul, Brazil
Idiane Rosset, GNP, MPH
Departamento de Enfermagem Geral e Especializada
Universidade de São Paulo-RP
São Paulo, São Paulo, Brazil
Jarbas Roriz-Filho, MD
Divisão de Clı́nica Médica Geral e Geriatria
Universidade de São Paulo-RP
São Paulo, São Paulo, Brazil
Thadeu R. S. Cruz, MSc
Faculdade de Odontologia
Centro de Estudos Superiores de Maceió
Maceio, Alegras, Brazil
Eliane P. Morais, GNP, MSc
Rosalina P. Rodrigues, GNP, PhD
Departamento de Enfermagem Geral e Especializada
Universidade de São Paulo
São Paulo, São Paulo, Brazil
Flávio Dias-Silva, MD
Serviço de Medicina de Famı́lia e Comunidade, Grupo
Hospitalar Conceição, Ministério da Saúde,
Porto Alegre, Rio Grande do Sul, Brazil
Ivana B. M. Cruz, PhD
Divisão de Biogenômica do Envelhecimento
Universidade Federal de Santa Maria
Santa Maria, Rio Grande do Sul, Brazil
Francisco Arsego de Oliveira, MD, MSc
Serviço de Medicina de Famı́lia e Comunidade, Grupo
Hospitalar Conceição, Ministério da Saúde,
Porto Alegre, Rio Grande do Sul, Brazil
Antonio C. A. Souza, MD, PhD
Instituto de Geriatria e Gerontologia
Pontifı́cia Universidade Católica do Rio Grande do Sul/
World Health Organization Collaborating Research Center
for the Prevention of Chronic-Degenerative Diseases
Associated with Aging
Porto Alegre, Rio Grande do Sul, Brazil
APRIL 2008–VOL. 56, NO. 4 JAGS
ACKNOWLEDGMENTS
We would like to thank the ‘‘Fundação Perseu Abramo’’ for
having published the full report for this research online
(Portuguese only) so that it can be accessed and evaluated
by the Portuguese-speaking scientific community free
of charge.1
Conflict of Interest: The editor in chief has reviewed the
conflict of interest checklist provided by the author and has
determined that none of the authors have any financial or
any other kind of personal conflicts with this letter.
Financial Disclosure: The authors’ report is indepen-
dent, but the original study was funded by the ‘‘Fundação
Perseu Abramo’’ in collaboration with the ‘‘SESC Nacio-
nal’’ and ‘‘SESC São Paulo.’’
Author Contributions: Matheus Roriz-Cruz had the
idea and wrote the letter together with Idiane Rosset, Jarbas
Roriz-Filho, and Thadeu Cruz. Eliane Morais, Rosalina
Rodrigues, Flávio Dias-Silva, Ivana Cruz, Francisco Arsego
de Oliveira, and Antonio Souza revised the letter and con-
tributed substantially to its final version.
Sponsor’s Role: None.
REFERENCES
1. Fundação Perseu Abramo. Idosos no Brasil. Vivências, desafios e expectativas
na 3a idade [on-line]. Available at www2.fpa.org.br/portal/modules/news/
index.php?storytopic=1642 Accessed May 16, 2007.
2. Rowland D. A five-nation perspective on the elderly. Health Aff (Millwood)
1992;11:205–215.
3. Beltrão KI, Camarano AA, Mello JL. Mudanças nas condições de vida dos
idosos rurais brasileiros: resultados não-esperados dos avanços da Seguridade
Rural [on-line]. Available at www.abep.nepo.unicamp.br/site_eventos_alap/
PDF/ALAP2004_288.PDF Accessed May 20, 2007.
4. Henry M, for the WHO Department of Immunization. Pandemic influenza
vaccine: WHO and international community make progress towards
ensuring access of developing countries [on-line]. Available at www.who.
int/mediacentre/news/notes/2007/np13/en/print.html Accessed May 20, 2007.
5. Gallo JJ, Rabins PV. Depression without sadness: Alternative presentations of
depression in late life. Am Fam Physician 1999;60:820–826.
6. Flint AJ. Epidemiology and comorbidity of anxiety disorders in the elderly. Am
J Psychiatry 1994;151:640–649.
7. Van den Berg MD, Oldehinkel AJ, Bouhuys AL et al. Depression in
later life: Three etiologically different subgroups. J Affect Disord 2001;65:
19–26.
8. Roriz-Cruz M, Rosset I, Wada T et al. Stroke-independent association between
metabolic syndrome and functional dependence, depression, and low quality
of life in elderly community-dwelling Brazilian people. J Am Geriatr Soc
2007;55:374–382.
ATYPICAL PRESENTATION OF ACUTE GOUT IN AN
ELDERLY PATIENT
To the Editor: A 73-year-old woman presented with a 2-day
history of acute bilateral ankle pain and swelling. She de-
scribed sweats, rigors, and fevers but no other symptoms.
Previously functionally independent, she had become bed
bound. She reported a history of ischemic heart disease,
heart failure, hypertension, type 2 diabetes mellitus, obesity,
and cerebellar infarct. She was treated with furosemide,
spironolactone, carvedilol, perindopril, insulin, and aspirin.
She had osteoarthritis and a history of nine miscarriages.
She was febrile (39.31C). Both ankle joints were tender
and swollen, with overlying skin erythema. The hands had
features of osteoarthritis. Her white blood cell count was
6.5  109/L (lymphocytes 0.5  109/L); urea, electrolytes,
liver function tests, calcium, and bone chemistry were nor-