To the Editor, Chronic inducible urticaria (CIndU) is characterized by wheals, angioedema or both in response to specific and definite triggers. 1 Half

To the Editor, Omalizumab (Xolair ® ) is a recombinant humanized monoclonal anti-IgE antibody, which binds to free IgE, lowers free IgE levels, and causes FcεRI receptors on basophils and mast cells to be downregulated. 1 Omalizumab is the first drug approved as an add-on therapy for patients (≥12 years old) with antihistamine-resistant chronic spontaneous urticaria (CSU). It is not approved for CSU patients younger than 12 years or patients with other forms of chronic urticaria (CU). 2 The information on the efficacy and safety of omali-

nation revealed multiple, flat-topped, skin-colored papules over the dorsal left hand (Figure 1A). Routine histology results from lesional skin confirmed the diagnosis of VP. The patient was instructed to mix fluorouracil, 5%, cream in a 1:1 weight ratio with calcipotriol, 0.005%, ointment applied in a thin layer on the affected area twice daily for 10 consecutive days. Complete clearance was seen after 3 weeks, and only mild erythema was noted (Figure 1B).Case 2. A 20-year-old man without relevant medical history except for mild atopic dermatitis during childhood presented with multiple flat, skin-colored papules on his forehead for several months (Figure 2A). Treatment with fluorouracil, 5%, cream and calcipotriol, 0.005%, ointment applied twice a day for 4 consecutive days was indicated. Complete response was seen after 3 weeks without any adverse effects (Figure 2B).Discussion | There are several treatment options available for multiple VPs, but clinical resolution usually takes several months, and most of these may cause pain, erythema, ulceration, and crusting. There are few studies on the effectiveness of topical vitamin D derivates in treating VP. Biologic effects of vitamin D3 derivates may include regulation of epidermal proliferation and modulation of cytokine production. 1 The combination of calcipotriol with fluorouracil has shown to have a synergistic specific induction of CD4+ T-cell immune response against actinic keratoses after a 4-day treatment. 2 It is well established that cell-mediated immune response plays a major role in treating HPV infections by enhancing recognition of the virus by the immune system. We hypothesized that a similarly effective immune response may be seen for treating VP. This combination has been recently reported also as a palliative treatment for recurrent, refractory extramammary Paget disease, 3 and it has shown to achieve complete clearance in a patient with porokeratosis of Mibelli. 4 The 2 patients described in this article presented with multiple VPs, and the combination therapy of topical fluorouracil and calcipotriol was followed by complete clearance with a very short-course treatment. The different duration of treatment among patients was chosen because of the acral location of the VP for patient 1. This treatment was well tolerated by both patients. Based on this observation, further studies are needed to assess the effectiveness, safety, and optimal duration of this treatment for VP.