Carlson et al object that this hypothesis does not explain why macrophages accumulate in the papillary dermis. We think that the superficial location of the xanthomatous cells can be explained by the fact that the papillary dermis is the part of the dermis, which is the closest of the damaged epidermis. The poor lymphatic drainage reported by Carlson et al in 14 genital and 4 trunk LS cases could account for the accumulation of macrophages in the papillary dermis. However, to confirm this hypothesis one should demonstrate the following: (1) that all the other conditions associated with mucosal or cutaneous VX are associated with lymphostasis (eg, Paget disease, lichen planus, graft-vs-host disease, discoid lupus erythematosus, pemphigus vulgaris, recessive dystrophic epidermolysis bullosa, lichen planus, epidermal nevus); (2) that lymphostasis is not just an incidental finding related to inflammation, whatever its cause. In addition, if an increased number and dilation of lymphatic vessels is present in most LS cases, these abnormalities cannot alone explain alone the occurrence of VX with LS. Indeed, VX only exceptionally occurs concomitantly with LS.