Blue in the Skin, Griseofulvin for the Treatment of Onychomycosis, and the Psychological Burden of Skin Disease


Christine Ahn, MD

Blue in the skin

Color provides a great deal of information when looking at cutaneous pathology. Certain colors are readily related to certain disease processes, such as the yellow hues of xanthomas, or the blue or purple colors seen in Kaposi’s sarcoma and blue nevi. Several theories have sought to explain the occurrence of blue colors in the skin. Some have posited that blue hue in the skin was due to the ability of collagen to selectively reflect blue light while transmitting red and green or due to the predominance of bluish scatter in the skin. This article aims to determine the effect of background colors on the perception of blue color in a superficial vein.

Fifteen subjects were asked to observe the color of a small area of skin overlying a vein on the dorsum of the hand. Quantitative measurement of color was obtained by the use of Munsell color matching, which categorizes colors according to perceptual increments in hue, value, and chroma, which also correlate with psychologic attributes of color, hue, lightness, and saturation. When viewed surrounded by normal skin, the vein was reported to be bluish-green. However, when the vein color was actually measured, it was found to have a yellowish-gray color. Furthermore, once placed on a neutral background, the bluish-green hue was not observed in the majority of viewers.

This study suggests that the surround color on which skin lesions are viewed can have a profound influence on color perception due to color contrast. In this phenomenon, there is a shift in the perceived hue of a color towards the color complementary to the background color. In the case of veins in the skin, the vein appears bluish in color when on a background of an orange-peach hue (or “skin color”), but then appears gray when the background is replaced with neutral white or gray color. It is thought that the predominance of color in a visual field produces an adaptation of the color receptors stimulated by its hue, and reducing the influence of this hue leads to increased perception of the complement color, a phenomenon known as chromatic induction. Color contrast may play a role in the appearance of purplish lesions in the skin, and may explain why certain dermatologic conditions may appear different hues when observed in the context of different background colors, e.g. psoriatic plaques in lighter versus darker pigmented individuals.

Reisfeld PL. Blue in the skin. J Am Acad Dermatol. 2000;42(4):597-605.

Short-term treatment of onychomycosis with griseofulvin

Griseofulvin for the treatment of onychomycosis is typically 4 to 6 months or longer, which is both costly and time-consuming. In this short report, Maibach and Kligman compared outcomes in patients with varying durations of treatment with griseofulvin for finger onychomycosis with Trichophyton rubrum. A total of 58 patients were distributed into 6 treatment groups: (1) 3 grams of griseofulvin daily for 15 days, (2) 1 gram of griseofulvin daily for 30 days, (3) 1 gram of griseofulvin daily for 60 days, (4) 2 grams of griseofulvin daily for 30 days, (5) 1 gram of griseofulvin daily for 7 days then 1 gram every third day thereafter for 90 days, (6) 1 gram of griseofulvin daily for 7 days then 1 gram every second day thereafter for 90 days.

Over an average post-treatment follow-up of 5 months, 2 grams of griseofulvin for 30 days had higher cure rates than 1 gram for the same amount of time, and was equivalent in efficacy to 1 gram of griseofulvin for 60 days. All patients who were noted to have coexistent tinea corporis infections were treatment failures, regardless of the treatment schedule with griseofulvin.

In this series of 58 patients, the authors concluded that short term therapy did not lead to sufficiently higher cure rates to justify changing treatment schedules to shorter durations. The authors supported the continued use of the conventional schedule of 1 gram of griseofulvin until the nails grow out normally, and also note that there was a low rate of adverse effects of the drug and no patients required cessation of the mediation over longer-duration treatment courses.

Maiback HI, Kligman AM. Short-term treatment of onychomycosis with griseofulvin. Arch Dermatol. 1960;81:733-4.

The Psychological Burden of Skin Diseases

This cross-sectional study was conducted across 13 European countries to determine the association between depression, anxiety, and suicidal ideation with various dermatologic diseases. Over 5,000 individuals were enrolled in this study, with a response rate of 80%. A total of 3,641 patients with dermatologic conditions were enrolled, and 1,416 control patients were enrolled. Overall, patients reported higher levels of stress and had more physical comorbidities when compared to the control group. Suicidal ideation was reported in 13% of all patients, and only patients with psoriasis had a significant association with suicidal ideation. The association with depression and anxiety was seen among patients with common diseases such as psoriasis, atopic dermatitis, hand eczema, and leg ulcers. The highest rates of depression were observed in patients with leg ulcers, and depression was also prevalent among patients with atopic dermatitis, and particularly among those with hand eczema. The highest rates of anxiety were observed in patients with psoriasis and hand eczema.

This study was a prospective study with a control group, which sets it apart from prior studies. The presence of a control group allowed for the comparison of outcome variables with a reference population. In addition, this study evaluates anxiety separately from depression and suicidal ideation, which has shed light on some differences between dermatologic disorders.  For example, patients with acne reported significantly higher levels of anxiety compared with controls, but were not depressed.

Dalgard FJ, Gieler U, Tomas-Aragones L et al. The Psychological Burden of Skin Diseases: A Cross-Sectional Multicenter Study among Dermatological Out-Patients in 13 European Countries. J Invest Derm. 2015;135(984-991).