In reply

We appreciate the letter from Dr Cox and his colleagues regarding our published manuscript. We also stress that we would like to promote recognition of the unusual cutaneous manifestation, striaelike epidermal distension, that we have described in 2 reports^1,2 and that their group has also described.³ Although we do not regularly see these unique clinical features among our many clinical practice patients with acute leg edema, the condition is not rare. We have experienced 4 cases since 1999. (We noted the fourth case recently.⁴)

The progression of the condition from acute severe edema for a short period followed by entire epidermal distension is surely necessary for these remarkable appearances. However, we believe that another factor is also necessary, namely, malnutrition. In our 4 cases, this malnutrition arose from severe anorexia nervosa in 2 cases and the end stages of cancer in the other 2. We realized from the histopathologic findings of epidermal necrosis in our 2 cancer cases that these manifestations were entirely different from the "crazy-paving" pattern seen in eczéma craquelé. We think that the name striaelike epidermal distension is more suitable than eczéma craquelé for this manifestation, although we agree with Cox et al that the term acute edema/cutaneous distension syndrome is descriptive of this manifestation and acute edema blister.⁵