Letters to the Editor
recommended quantity makes the sunscreen less
effective. Excessive quantity makes the sunscreen
more expensive, and also more uncomfortable. We
calculated that the mean cost of 1 ml of sunscreen of
10 brands is approximately Rs. 3 to 4. It is more
expensive if the patient uses the sunscreen repeatedly,
or in excessive quantity. We recommend 1 ml of
sunscreen for the female, and 1.5 ml for the male
during each application. It is possible to calculate the
sunscreen to be applied over any given area e.g., arm,
back, etc. Figure 2 shows how a string is placed over
the forearm. The same length of thread can be
arranged in form of a circle. Once the area is
determined, the amount of sunscreen can be easily
calculated. This method actually measures the
perimeter of the skin, and assumes it to be a circle. In
general, an oval surface would encompass a lesser
area than a circular surface of the same perimeter.
This method would thus result in a larger calculated
area than the actual, and in the case of the forearms,
we would use more sunscreen than is necessary.
However, this may not make a significant difference.
We do not feel justified to recommend specific
amount of sunscreen for the exposed area of arms,
and upper and lower back, as there would be a
considerable individual variation in the area exposed
to sunlight. The string method can also be helpful in
keeping track of increase or decrease in various
irregular shaped skin lesions including ulcers.
ACKNOWLEDGMENTS
Dr. Sasidharan Nair, Professor, Department of Physics, PSG
Technology, Peelamedu, Coimbatore.
REFERENCES
1. Azurdia RM, Pagliaro JA, Diffey BL, Rhodes LE. Sunscreen
application by photosensitive patient is inadequate for
protection. Br J Dermatol. 1991;140:255-8.
2. Bech-Thomsen N, Wulf HC. Sunbather’s application of sunscreen
is probably inadequate to obtain the sun protection factor
assigned to the preparation. Photodermatol Photoimmunol
Photomed 1993;9:242-4.
3. Diffey BL, Gride J. The influence of sunscreen type of
photoprotection. Br J Dermatol 1997;137:103-5.
4. Gottlieb A, Bourget TD, Lowe NJ. Sunscreen: effects of amounts
Indian J Dermatol Venereol Leprol|July-August 2006|Vol 72|Issue 4
of application of Sun Protection Factors. In: Lowe NJ, Shaath
NA, Pathak MA, editors. Sunscreens: development, evaluation
and regularly aspects. New York: Marcel Dekker; 1997. p. 583-
8.
5. Stenberg C, Larko O. Sunscreen application and is importance
for the Sun Protection Factor. Arch Dermatol 1985;121:1400-2.
C. R. Srinivas, Surendranath Lal,
M. Thirumoorthy,
Shanmuga V. Sundaram,
Prabhu S. Karthick
Department of Dermatology, PSG Hospitals, Coimbatore,
Tamil Nadu, India
Address for correspondence: Dr. CR Srinivas, Department
of Dermatology, PSG Hospitals, Coimbatore - 641 004,
Tamil Nadu, India. E-mail: srini_cr_1955@yahoo.com
Fixed drug eruption and
generalised erythema following
etoricoxib
Sir,
Non steroidal anti-inflammatory drugs (NSAIDs) are
among the most widely used medications – both by
prescription and over the counter. The newer NSAIDs,
inhibitors of the cyclo-oxygenase enzyme-2 (COX-2
inhibitors), are fast becoming the drugs of first choice
in the treatment of acute pain, chronic pain and most
rheumatic conditions. These compounds blunt
prostaglandin production through inhibition of
cyclooxygenase-2 (COX-2) while sparing
cyclooxygenase-1 (COX-1), and have been shown to
cause significantly fewer serious gastrointestinal
adverse events such as ulceration and bleeding, than
the nonselective NSAIDs. [1] Etoricoxib, one of the
newer COX-2 inhibitors, has enhanced biochemical
COX-2 selectivity over that of the other drugs in this
category: rofecoxib and celecoxib.[2] Though, adverse
cutaneous effects to celecoxib and rofecoxib have been
reported, there has been no report of cutaneous side
effects to etoricoxib so far. We report a case of fixed
drug eruption and generalized erythema occurring
simultaneously following etoricoxib.
A 38-year-old female, doctor by profession, developed
a 1.5 cm size, well circumscribed, round, erythematous
307
Letters to the Editor
patch on the right forearm, 3 days following ingestion
of etoricoxib that was prescribed for bursitis of right
knee. In the next few days, the center of the patch
developed a blister and necrosis which later healed
with residual hyperpigmentation. She had taken
various NSAIDs many times in the past and rofecoxib
on more than two occasions. Celecoxib had been
taken at least for one week, once, about two years
back. Etoricoxib was taken once, for one week, 5
months back. There were no adverse effects to any of
the drugs previously. Therefore the possibility of a
drug eruption was not thought of and a diagnosis of
‘insect bite reaction’ was considered. Two months
after the lesion healed, the patient took a single tablet
of etoricoxib again. She noticed erythema, itching
and burning over the old lesion within two hours
[Figure 1]. In addition, over the next three to four
hours she developed generalized itching and burning
sensation followed by intense erythema all over the
body. Nikolsky’s sign was negative. There was no
mucosal involvement. The patient had neither fever
nor other constitutional symptoms. No systemic
abnormalities were found on physical and routine
laborator y examination. A histopathological
examination was not performed as the patient did
not consent for skin biopsy.
A drug reaction was diagnosed and systemic steroids
were administered. Though most of the symptoms
and signs gradually subsided in ten days, mild acral
dusky erythema persisted for 4 weeks. The lesion over
the right forearm developed a small blister and healed
Figure 1: FDE with diffuse erythema
308 Indian J Dermatol Venereol Leprol|July-August 2006|Vol 72|Issue 4
with a larger area of residual pigmentation. The
erythema over the rest of the body subsided leaving
behind no residual pigmentation.
Since a reliable positive oral re-challenge had already
taken place, although inadvertently; further
confirmatory tests were not carried out immediately.
However, a patch test with etoricoxib 10% in
petrolatum was done six months later. Erythema and
edema which was double the size of the old patch
was seen within eight hours, over the healed FDE
lesion, whereas the non-lesional control area did not
react.
Fixed drug eruption (FDE) characteristically presents
as a round, sharply circumscribed, pruritic or burning,
edematous patch with violaceous or dusky
erythema.[3] Vesicles or bullae may develop. It heals
leaving a hyper-pigmented patch and recurs at the
same site on drug rechallenge. The residual
pigmentation and recurrence of lesion at the same
site are the typical features of FDE. Additional lesions
may develop with drug rechallenge. Although a
histopathological examination was not performed in
our patient, the typical round patch with bulla, the
residual pigmentation on healing and the recurrence
of the rash at the same site, support a diagnosis of
fixed drug eruption. The severity of the patch test
reaction confirms etoricoxib as the causative drug.
An unusual feature of this case, however, was the
occurrence of two different types of cutaneous adverse
reactions simultaneously to the same drug. Clinically
the patient had a FDE and a generalized erythematous
rash. Although very rare, occurrence of more than
one type of cutaneous reactions to the same drug
has been reported. [4] Most of the known adverse
cutaneous reactions to coxibs have been attributed
to either celecoxib or rofecoxib. They include:
urticaria/angioedema (by far the most common),
Sweet’s syndrome, vasculitis, erythema multiforme,
Stevens Johnson syndrome, toxic epidermal necrolysis
(TEN) and maculopapular rash.[5-7] To the best of our
knowledge cutaneous reactions to etoricoxib have not
been reported so far.
The NSAIDs and coxibs with a sulfonamide structure

(celecoxib and valdecoxib) could possibly cross react
with sulfonamides.[8] The sulfonamide-type reactions
(erythema multiforme, Stevens Johnson syndrome,
toxic epidermal necrolysis (TEN) and maculopapular
rash) were found to be twice as common with
celecoxib as with rofecoxib.[5] The pathogenesis of
these reactions is likely to be the same as for
sulfonamide induced reactions – T cell mediated type
IV hypersensitivity reaction. However, Shapiro et al in
their study on the safety of celecoxib in 28 patients
with a history of sulfonamide allergy found cross
reactivity between celecoxib and sulfonamides to be
low.[5]
The coxibs have generally been found to be safe even
in patients allergic to the classic NSAIDs. Sanchez-
Borges et al, in their review of cutaneous reactions to
selective COX-2 inhibitors, reported that, among
patients previously exhibiting urticaria or angioedema
triggered by classic NSAIDs, only 1.6% developed
urticaria or angioedema to rofecoxib and 11.2% to
celecoxib.[5] However, in the present case, the patient
had been tolerating various NSAIDs in the past but
reacted to a coxib.
As the patient had taken rofecoxib on more than two
occasions, with no side effects, it appears that there
may not necessarily be cross reactivity between
different coxibs.
To conclude, cutaneous adverse reactions to coxibs
continue to be reported. Although these drugs are
considered safer in individuals sensitive to other
NSAIDs, this case suggests that the reverse could also
be true.
REFERENCES
1. Fitzgerald GA, Patrono C. The coxibs, selective inhibitors of
cyclooxygenase-2. N Engl J Med 2001;345:433-42.
2. Cochrane DJ, Jarvis B, Keating GM. Etoricoxib. Drugs
2002;62:2637-51;discussion 2652-3.
3. Korkij W, Soltani K. Fixed drug eruption: A brief review. Arch
Dermatol 1984;120:520-4.
4. Gupta PK, Luniya AK, Gupta NK, Tiwari ML. Coexistence of
fixed drug eruptions and Stevens Johnson syndrome due to
thiacetazone in a patient of pulmonary tuberculosis. Indian J
Chest Dis Allied Sci 1983;25:152-4.
5. Sánchez BM, Capriles HA, Caballero FF. Adverse Reactions to
Indian J Dermatol Venereol Leprol|July-August 2006|Vol 72|Issue 4
Letters to the Editor
Selective Cyclooxygenase-2 Inhibitors (Coxibs). Am J Ther
2004;11:494-500.
6. Fye KH, Crowley E, Berger TG, Le Boit PE, Connolly MK.
Celecoxib-induced Sweet’s syndrome. J Am Acad Dermatol
2001;45:300-2.
7. Schneider F, Meziani F, Chartier C, Alt M, Jaeger A. Fatal allergic
vasculitis associated with celecoxib. Lancet 2002;359:852-3
8. Sarkar R, Kaur C, Kanwar AJ. Extensive fixed drug eruption to
nimesulide with cross-sensitivity to sulfonamides in a child.
Pediatr Dermatol 2002;19:553-4.
Mary Augustine, Pooja Sharma,
John Stephen, Elizabeth Jayaseelan
Department of Dermatology, St. John’s Medical College
Hospital, Bangalore, India.
Address for correspondence: Mary Augustine,
Department of Dermatology, St. John’s Medical College
Hospital, Sarjapur Road, Bangalore - 560 034, Karnataka,
India. E-mail: maryjoseph1@rediffmail.com
Isolated scalp collagenoma
mimicking cutis verticis gyrata
Sir,
Cutis verticis gyrata (CVG) is a descriptive term for a
condition of the scalp, in which deep furrows and
convolutions are seen, that resembles the outer
surface of the cerebrum. The etiology is diverse, since
different collections of cell types may be responsible
for outward convoluted appearance, and range from
inflammatory or hamartomatous infiltrations to
neoplastic proliferations.[1] Collagenoma or connective
tissue nevi of the collagen type are hamartomatous
lesions, consisting of proliferation of normal collagen
tissue. They can be hereditary or sporadic. The lesions
consist of slightly elevated nodules that may be
grouped or disseminated. Collagenomas located in
the plantar or palmar surface with a cerebriform
appearance are rare, and have been reported in Proteus
syndrome.[2,3] Herewith, isolated scalp collagenoma
mimicking cutis verticis gyrata is being reported for
its rarity and unique localization.
A 35-year-old female presented with asymptomatic,
asymmetrically located, solitary, cerebriform skin
colored plaque of 18×12 cm over the left temporal
scalp since birth [Figure 1]. The plaque had been
309