I read with interest the article by Manders et al1 on recurrent toxin-mediated perineal erythema. However, I have some reservations about the authors1 conclusion that this represents a toxin-mediated disease. There is no logical reason a material acting as a systemic toxin should focally and recurrently affect only 1 small area of integumentf.
I have observed patients who have developed multiply recurrent episodes of cellulitis restricted to a stereotypical site, usually a lower limb. Within several hours, these patients developed constitutional symptoms—erythema, swelling, and tenderness—delimited, as best I could discern, to the exact distribution previously involved. In 1 patient the process involved an entire lower limb that seemed to react more or less as a unit; there was no sequential progression of inflammation proximally. Peculiar localization of hypersensitivity reactions to systemic antigen challenge is a phenomenon well recognized by dermatologists in the form of fixed drug reactions. This phenomenon of stereotypical recurrences suggested a hypersensitivity reaction whereby a small number of bacteria release antigens that cause an abrupt and widespread reaction
Leicht S. Multiply Recurrent Cellulitis. Arch Dermatol. 1996;132(9):1131. doi:10.1001/archderm.1996.03890330147032