Online Letters to the Editor
Skin Conditions That Exhibit the Koebner Phenomenon
to the editor: The “Photo Quiz”1 in the January 1, 2005, issue of American Family Physician was a nice quiz about an uncommonly diagnosed condition: lichen nitidus. I would like to add to the discussion of the differential diagnosis. Lichen nitidus is one of only a few skin conditions that exhibit the Koebner phenomenon. Other skin conditions that exhibit the Koebner phenomenon are: juvenile rheumatoid arthritis (systemic form),2 lichen planus, molluscum contagiosum, pityriasis lichenoides et varioliformis acuta,3 psoriasis, vitiligo,4 and warts.
Asking the patient about areas of trauma, and then looking for clustered or linear distribution of isomorphic lesions may be a major clue in the diagnosis of these disorders.
Thank you for an interesting discussion.
REFERENCES
1. Pielop JA, Hsu S. Tiny, skin-colored papules on the arms and hands [Photo Quiz]. Am Fam Physician 2005;71:343-4.
2. Williams G, Katcher M. Primary care dermatology module: nomenclature of skin lesions. Tutorial C: patterns and distribution. University of Wisconsin-Madison. Accessed online May 24, 2005, at: http://www.pediatrics.wisc.edu/education/derm/tutc/koebner.html.
3. Inamdar AC, Palit A. Koebner phenomenon in PLEVA. Indian J Dermatol Venereol Leprol 2003;69:226.
4. Lahiri K, Malakar S. Vitiligo and lichen planus in striae: is it Koebner phenomenon? Indian J Dermatol Venereol Leprol 2004;70:375.
editor’s note: This letter was sent to the authors of “Tiny, skin-colored papules on the arms and hands” [Photo Quiz], who declined to reply.
Intrauterine Device: Acceptable Contraceptive Option
to the editor: We read with great interest the article1 in American Family Physician on intrauterine devices by Dr. Johnson. The author states that the contraceptive effects of the intrauterine device (IUD) are reversible after removal, but adds that long-term use of IUD (i.e., more than 78 months [6.5 years]) may be associated with increased risk for fertility impairment.1 However, researchers in one study observed that pregnancy rates in women who have the IUD removed because of a desire to become pregnant are similar to those in women who discontinued use of other methods of contraception.2 In women involved in monogamous relationships, there is no evidence of an increased risk of infertility after use of an IUD. Further, the World Health Organization (WHO) practice recommendations state: “The use of contraceptive methods, with the exception of male and female sterilization, does not result in an irreversible change in fertility. Return to fertility is immediate with all methods, with the exception of DMPA [depot medroxyprogesterone acetate (Depo-Provera)] and NET-EN [norethisterone enanthate].”3
Although no cases of bacteremia have been reported following insertion of an intrauterine device,4 prophylaxis for endocarditis may be warranted when an infection is presented in the genital tract of patients who have susceptibility to endocarditis.5 Prophylaxis could be especially considered in developing countries where cardiac conditions might be more frequent or where genital tract infections could not be ruled out easily.
Recent systematic reviews4 do not recomend prophylactic antibiotics before insertion of an IUD. However, WHO recommends that “…in settings of both high prevalence of cervical gonococcal and chlamydial infections and limited sexually transmitted infection (STI) screening, such prophylaxis may be considered.”3 Studies addressing the question, “Are prophylactic antibiotics for IUD insertion of any benefit in preventing pelvic inflammatory disease in settings with a high prevalence of sexually transmitted infections?” are needed.
In developing countries like Turkey, where the use of modern contraceptive methods is lower than in western countries, the use of IUDs might be an excellent contraceptive option for women in long-term monogamous relationships.6 Despite misperceptions about IUDs, a major task should be to provide correct information to women and to increase the availability and use of this effective method of contraception.
The authors indicate that this letter was funded by the Akdeniz University Research Foundation.
REFERENCES
1. Johnson BA. Insertion and removal of intrauterine devices. Am Fam Physician 2005;71:95-102.
2. Lippes J, Malik T, Tatum HJ. The postcoital copper-T. Adv Plan Parent 1976;11:24-9.
3. Selected practice recommendations for contraceptive use: technical meeting to develop consensus on evidence-based guidelines for family planning and to review the decision-making tool of the essential care practice guide. London, October 3-6, 2001. World Health Organization, Geneva, 2002. Accessed online May 24, 2005, at: http://www.who.int/reproductive-health/publications/rhr_02_7/spr.pdf.
4. Grimes DA, Schulz KF. Antibiotic prophylaxis for intrauterine contraceptive device insertion. Cochrane Database Syst Rev 2001;(2):CD001327.
5. Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. Circulation 1997;96:358-66.
6. Weir E; Society of Obstetricians and Gynaecologists of Canada. Preventing pregnancy: a fresh look at the IUD. CMAJ 2003;169:585.
in reply: I appreciate the response from Drs. Yaman and Akdeniz. An important aspect of incorporating any guideline into practice is determining the demographics of the specific population. Many authors who are writing for American Family Physician (myself included) fail to remember that the journal is distributed worldwide. It is a benefit to the reader when our international colleagues share their experiences from a global perspective.
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