scar on the right side of his chin.

According matory, eroded dermatitis between the isolated from society and mutually
to the patient the scar had developed after toes, probably resulting from the applica¬ self-supporting, with an intensified
he had had chickenpox as a small boy. Over tion of caustic chemicals. need for intimacy. A unitary delusion
the past several months the area began to Psychiatric consultation was recom¬ was ensured by one partner assuming
sting and burn and had not healed after he mended but was immediately rejected by the dominant role and the submissive
had nicked it with a razor. the dominant sister. In both patients,
The patient had had a smallpox vaccina- chlorpromazine (Thorazine) therapy was partner accepting the delusional sys¬
tion as a child, but had noticed no changes started on a trial basis and seemed to help, tem, rather than threatening their
in the vaccination scar. He had had no but the problem did not resolve entirely. interdependent relationship.
exposure to radiation and no previous skin
After two years of outpatient therapy the More than two persons may share a
cancers despite a history of frequent sun patients were unavailable for follow-up unitary delusion (folie à trois; folie à
exposure over the years. There was no examinations. quatre); even large groups in isolated
family history of skin cancer. In 1979, a final history was obtained. The conditions such as mental institutions
On physical examination, there was an evolving ulcers had continued until the or communes may accept the delusions
dominant sister had died in 1976. The
ulcers then spontaneously and rapidly of a single individual. Folie à deux is
healed in the surviving sibling. Her mental clearly a psychotic phenomenon. How¬
status seemed to return to a normal state ever, shared pruritus or pain is a com¬
for her age. mon condition in intimate individuals
and this empathie symptomatology
Comment
may be a sign of a similar but less
The cases reported here demon¬ intense interpersonal disorder.
strate the interrelationships of psy¬ Folie à deux usually resolves with
chotic disorders and cutaneous dis¬ the physical separation of the two
Fig 2.—Ulcerated lesions on distal extrem¬ ease. The dominant twin had a classic individuals. In our patients, the ulcer-
ity of submissive sister. delusional psychosis and came to med¬ ative dermatitis cleared totally in the
ical attention through the develop¬ submissive individual after the death
ment of factitious ulcérations of the of the primary dominant person of the
distal extremities. The secondary, pair.
Antibiotics given for systemic effect submissive person assimilated the
were initiated to treat secondary infection aggressive psychotic disorder of her
present in the ulcers, and chlorothiazide sister, as reflected in the development References
diuretics were prescribed to treat the pedal of factitious ulcérations on her own
edema. An occlusive dressing was applied extremities. 1. Laseque C, Falret J: Folie \l=a`\deux ou Folie
to one extremity of each sister. The ulcers
The suggestion of psychiatric con¬ commnique. Ann Med Psychol 18:321, 1877
began to resolve spontaneously under the (translated by Michaud R: Am J Psychiatry
sultation was totally rejected by the 121[suppl 4]:2-23, 1964).
protective dressing except for one area in dominant sister, and local treatment, 2. McNiel JN, Verwoerdt A, Peak D: Folie \l=a`\
the dominant sister. However, it was deux in the aged: Review and case report of role
obvious that she was disturbing the dress¬ support, and understanding became reversal. J Am Geriatr Soc 20:316-323, 1972.
ing over the active lesion. The dominant the primary treatment objectives. The 3. Gralnick A: Folie \l=a`\deux: The psychosis of
sister also began to have a severe inflam- two affected individuals had become association. Psychiatr Q 16:230-263, 1942.

Basal Cell Carcinoma Arising in a Chickenpox Scar

William M. Hendricks, MD

A basal cell carcinoma developed in a scar on the right side of his chin. According indurated nodule measuring 8 x 10 mm on
chickenpox scar on the chin of a to the patient the scar had developed after the right side of the lower part of the chin
71-year-old man. A review of the per- he had had chickenpox as a small boy. Over (Figure). The lesion had a central crust and
tinent literature is presented. the past several months the area began to peripheral telangiectasia. The surrounding
sting and burn and had not healed after he skin was slightly erythematous and atroph¬
Report of a Case had nicked it with a razor. ie.
The patient had had a smallpox vaccina- The clinical diagnosis was a basal cell
A 71-year-old man was seen for a recent- tion as a child, but had noticed no changes carcinoma arising in a chickenpox scar.
ly developed nonhealing lesion in an old in the vaccination scar. He had had no Under local anesthesia a shave biopsy was
exposure to radiation and no previous skin performed. Curettage of the base of the
cancers despite a history of frequent sun lesion left a small round depression about
exposure over the years. There was no the size of a pea. The biopsy revealed a
From the Asheboro (NC) Dermatology Clinic. family history of skin cancer. basal cell carcinoma, and the lesion was
Reprints not available. On physical examination, there was an subsequently excised.

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 skin tumors arising in them. Basal cell What role the scarring process itself
carcinomas have been reported in plays in the pathogenesis of these skin
scars left by thermal burns,1 blunt-f
cancers is not well understood. Con¬
trauma and lacerations,4 tattoos,5 co- nolly1 proposed that scar tissue may
lostomy surgery,6 epidermolysis hullo¬ be more sensitive to the effects of
sa lesions,7 and hair transplantation.8 sunlight because of its decreased vas-
Whether or not these associations are cularity and atrophie adnexal and epi¬
conincidental is not clear. dermal structures. However, scarring
Malignant tumors have been re¬ alone, in light-protected areas, has
ported at the site of smallpox vaccina¬ been associated with the development
tions912 but not within the smallpox of squamous cell carcinomas in ther¬
scars themselves. Basal cell carcino¬ mal burns and in chronic skin ulcers.13
mas are the most common tumors This association has not been con¬
found in vaccination scars, although firmed for basal cell carcinomas.
squamous cell carcinomas, malignant Although basal cell carcinomas have
melanomas, and dermatofibrosarco- been reported after conditions that
ma protuberans have also been have resulted in scarring, their ap¬
reported.12 The interval between vac¬ pearance may have been coincidental.
Depressed scar with crusted, indurated cination and the clinical appearance of If one considers the scarring that
area on right side of chin. the tumor varies considerably. Zelick- results from the dissemination of the
son9 reported a basal cell carcinoma variola and varicella-zoster viruses in
that developed immediately after vac¬ the skin, it is surprising that there
cination, while others have reported have been no previous reports of ma¬
Comment intervals of greater than 50 years.11 lignant tumors arising in smallpox or
Sunlight has been implicated in the chickenpox scars. This would suggest
Despite the fact that chickenpox pathogenesis of basal cell carcinomas that scarring alone may not be suffi¬
scars are not uncommon, to my knowl¬ arising in smallpox vaccination cient for the induction of basal cell
edge, there are no previous reports of scars.11 carcinomas.

References

1. Connolly JG: Basal cell carcinoma occurring 1976. 10. Castrow FF II, Williams TE: Basal-cell
in burn scars. Can Med Assoc J 83:1433-1434, 6. Didolkar MS, Douglass HO, Holyoke ED, et epithelioma occurring in a smallpox vaccination
1960. al: Basal-cell carcinoma originating at the colos- scar. J Dermatol Surg Oncol 2:151-152, 1976.
2. Kantor I, Berger BW, Wilentz JM: Basal cell tomy site: Report of a case. Dis Colon Rectum 11. Reed WB, Wilson-Jones E: Malignant
epithelioma in a thermal burn scar. J Occup Med 18:399-402, 1975. tumors as a late complication of vaccination.
12:170-172, 1970. 7. Wechsler HL, Krugh FJ, Domonkos AN, et Arch Dermatol 98:132-135, 1968.
3. Treves N, Pack GT: The development of al: Polydysplastic epidermolysis bullosa and 12. Hazelrigg DE: Basal cell epithelioma in a
cancer in burn scars. Surg Gynecol Obstet 51:749\x=req-\ development of epidermal neoplasms. Arch Der- vaccination scar. Int J Dermatol 17:723-725,
782, 1930. matol 102:374-380, 1970. 1978.
4. Ewing MR: The significance of a single 8. White JW Jr: Basal cell carcinoma in a hair 13. Cruickshank AH, McConnell EM, Miller
injury in the causation of basal-cell carcinoma of transplant recipient site. Cutis 23:322-325, 1979. DG: Malignancy in scars, chronic ulcers, and
the skin. Aust NZJ Surg 41:140-147, 1971. 9. Zelickson AS: Basal cell epithelioma at site sinuses. J Clin Pathol 16:573-580,1963.
5. Bashir AH: Basal cell carcinoma in tattoos: and following smallpox vaccination: Report of a
Report of two cases. Br J Plast Surg 29:288-290, case. Arch Dermatol 98:35-36, 1968.

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