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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_141_библиотеки_им_акад_М_И_Перельмана
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Pediculosis Capitis, Head Lice
https://t.me/med1917
Infestation
23
My child said his head was itchy, and when I looked
closely, oh my! There were lice, so I caught some.
There is a head louse here that is hard to nd these days.
No, I didn’t catch it, patient’s mother brought it. The
mother of a 9-year-old girl, L, said, “My child has been
complaining of severe scalp itching for some time, and
when I looked closely today, oh my! There are lice, so I
caught one!” and she took out a louse trapped in Scotch
tape (Figs.23.1 and 23.2).
Recently, head lice infestation (Pediculosis capitis) is on
the rise again in kindergartens and elementary schools, so
caution is needed. Human lice infestations (Pediculosis) are
classied into head lice infestation, body lice infestation
(Pediculosis corporis), and pubic lice infestation (Pthiriasis,
Pediculosis pubis), each caused by the infection of head lice
(Pediculus capitis), body lice (Pediculus corporis), and pubic
lice (Pthirus pubis). The main symptom of head lice infestation is itching, and sometimes you can nd discharges and
scabs from scratching too much. Secondary bacterial infections can occur, but hair loss is usually not common. It is
difcult to nd adult lice of 1–2.7 mm size, but the
0.3–0.8mm size head lice eggs (nit) are attached close to the
scalp on the hair and move to the end as the hair grows.
Unlike dandruff, they do not fall off easily, making them
easy to nd and helpful in diagnosis.
Drugs for the treatment of lice infestation are hardly produced or distributed in Korea, so drugs containing pyrethrin/
piperonyl butoxide are usually used. Apply to dry hair, massage thoroughly into the scalp and hair until wet, leave for
10min (do not use longer), then lather well with warm water
and rinse thoroughly. Afterwards, it is effective to comb the
hair with a lice comb (ne-toothed comb) to remove the dead
lice and nits. The whole family should be treated at the same
time and clothes and bedding should be disinfected. If it is
not cured after one use, use it again after 10 days. These
days, there are treatments that are less risky and more convenient compared to the past, which is a relief. I checked L’s
mother for nits in her child’s hair using a magnifying glass
and prescribed a pediculicide shampoo. It’s hard to see lice
directly these days, so I thanked her for bringing them in
directly (Figs.23.3, 23.4, 23.5, 23.6, 23.7, 23.8, 23.9, 23.10,
and 23.11).
Fig. 23.1 Head louse (Pediculus capitis)—10× magnication
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
J. Y. Jeong, Dermatology Diaries, https://doi.org/10.1007/978-981-97-1578-7_23
Fig. 23.2 Head louse (Pediculus capitis)—60× magnication
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Fig. 23.3 Head louse (Pediculus capitis)—60× magnication
23 Pediculosis Capitis, Head Lice Infestation
Figs. 23.4 and 23.5 Head louse (Pediculus capitis)—60× magnication
Figs. 23.6 and 23.7 Head louse (Pediculus capitis)—200× magnication
23 Pediculosis Capitis, Head Lice Infestation
https://t.me/med1917
Figs. 23.8 and 23.9 Head lice eggs (nit)—200× magnication
95
Figs. 23.10 and 23.11 Head lice eggs (nit)—200× magnication
Molluscum Contagiosum, Molluscum
https://t.me/med1917
Dermatitis, Eczema Molluscatum
24
Can I just leave my child’s molluscum contagiosum
alone? What if it doesn’t get better on its own?
Mrs. K, who is receiving laser treatment for freckles,
brought her son and asked, “My child who goes to kindergarten has severe molluscum contagiosum. A doctor said it
would heal over time, so I’m waiting, but it’s not disappearing and it’s increasing. One or two of them seem to be
inamed and painful. What should I do?” I replied, “I remove
molluscum contagiosum as soon as I nd it” (Figs.24.1 and
24.2).
Molluscum contagiosum is an epidermal infection caused
by the DNA virus MCV-1, 2, which belongs to the poxvirus,
characterized by a semi-spherical nodule with a diameter of
1–5mm and a central part that is sunken and skin-colored.
These lesions consist of molluscum bodies (Henderson–
Paterson bodies) lled with the DNA of the molluscum contagiosum virus. It can occur anywhere on the skin and
mucous membranes, mainly in multiple forms, and occurs
more widely in children than in adults. It mainly occurs
around the face, trunk, inner thighs, anus, and genitals and
can rarely occur on the lips, tongue, palms, soles, and scalp.
When it occurs around the eyelids, it can cause conjunctivitis, keratitis, etc. The molluscum contagiosum virus characteristically invades only the upper epidermis without invading
the basal layer. Usually, there are no symptoms, but sometimes there may be itching or pain, and if inammation
occurs in large lesions, it may look like a furuncle. It is more
common in children than adults and more frequently occurs
in boys than girls. In children, it is mainly caused by MCV-1,
while in adults, MCV-2 is the predominant subtype. It is
often transmitted through sexual intercourse in sexually
active adults and occurs in the genital area or its surroundings. In children, lesions can occur widely, including in the
genital area. However, it is rare for lesions to occur in other
areas when they occur in the genital area in adults. Recently,
the incidence has been increasing in patients with decreased
systemic immune function, such as patients with acquired
immunodeciency syndrome, organ transplant recipients
receiving immunosuppressants, and patients with malignant
tumors receiving anticancer treatment. Infections occur
Fig. 24.1 A case of molluscum contagiosum that has grown large and
shows an inammatory reaction
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
J. Y. Jeong, Dermatology Diaries, https://doi.org/10.1007/978-981-97-1578-7_24
Fig. 24.2 60× magnied image of molluscum contagiosum
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24 Molluscum Contagiosum, Molluscum Dermatitis, Eczema Molluscatum
through direct contact (skin-to-skin) and transmission
through fomites and can sometimes be caused by sexual
intercourse. If it occurs in patients with atopic dermatitis or
decreased immunity, it can invade widely and not heal well,
and secondary bacterial infections can also frequently occur.
It is rarely known to occur in conjunction with other skin
diseases, but there have been reports of cases in conjunction
with epidermal cysts, melanocytic nevi, halo nevi, soft bromas, sebaceous hyperplasia, epidermal nevi, and Kaposi’s
sarcoma. The incubation period is 2 weeks to 2 months, and
each lesion lasts for about 2–4 months. Natural healing
occurs about 6–9 months later, but it can also last for several
years. Therefore, it is recommended to treat immediately
rather than wait (Figs.24.3, 24.4, 24.5, 24.6, 24.7, 24.8, 24.9,
24.10, 24.11, 24.12, 24.13, 24.14, and 24.15).
Molluscum contagiosum is known to heal naturally over
time, although there are exceptions, and a rash resembling
eczema due to delayed hypersensitivity may be a precursor
to the immunological clearance of the lesion in people with
immunity. Molluscum dermatitis or eczema molluscatum, a
rash-like lesion surrounding the lesion due to hypersensitivity to the molluscum contagiosum virus, can occur, and
sometimes a rash-like lesion appears far from the molluscum
contagiosum lesion due to an id reaction. This phenomenon
may be a precursor symptom of remission in which the molluscum contagiosum lesion disappears, and in Japan it is
Fig. 24.6 Molluscum contagiosum observed on the eyelid
Fig. 24.3 Typical form of molluscum contagiosum
Figs. 24.4 and 24.5 Molluscum contagiosum on the face
Fig. 24.7 Molluscum contagiosum on the thigh
24 Molluscum Contagiosum, Molluscum Dermatitis, Eczema Molluscatum
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99
commonly called the “molluscum reaction.” These eczemalike lesions that occur around molluscum contagiosum can
be mistaken for “eczema” because they cover the molluscum
contagiosum lesions, or if they occur far away, they can be
misdiagnosed as “atopic dermatitis are-ups.” In such cases,
Fig. 24.8 Single molluscum contagiosum
the use of steroids or immunomodulators for asymptomatic
lesions is unnecessary and can sometimes delay the extinction of molluscum contagiosum, so caution is needed. If
symptoms are present, local skin softeners or antibiotics are
Fig. 24.9 Molluscum contagiosum lesion with inammation
Figs. 24.10 and 24.11 Molluscum contagiosum showing linear distribution due to self-inoculation by scratching with ngernail
Figs. 24.12 and 24.13 Molluscum contagiosum in a patient with atopic dermatitis
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Figs. 24.14 and 24.15 Molluscum reaction
24 Molluscum Contagiosum, Molluscum Dermatitis, Eczema Molluscatum
sufcient, and if severe itching is present, the use of local
steroids should be limited to a short period.
Diagnosis can easily be made based on the clinical ndings of a characteristic lesion, a hemispherical papule with a
sunken center. If the diagnosis is unclear with the naked eye,
smear the contents of the papule on a glass slide and conduct
a KOH test, or observe molluscum bodies under a microscope after staining. Multiple small molluscum contagiosum
need to be differentiated from verruca plana, condyloma
accuminatum, bowenoid papulosis, syringoma, milium,
sebaceous hyperplasia, prurigo, trichoepithelioma, folliculitis, etc., and solitary lesions need to be differentiated from
wart, keratoacanthoma, epidermal cyst, basal cell carcinoma,
apocrine hidrocystoma, etc. In patients with acquired immunodeciency syndrome, a skin biopsy is performed to differentiate from deep mycosis caused by cryptococcosis
(Figs.24.16, 24.17, 24.18, and 24.19).
Most people with normal immunity show a course of
spontaneous disappearance over several months to a year and
generally heal without scars if there is no secondary bacterial
infection, so the treatment of molluscum contagiosum may
initially wait for the lesions to disappear on their own.
However, it can persist for several years, spread seriously
throughout the body, or cause unexpected scars if the lesions
are large and inamed, so it is not comfortable to leave it
alone. The basis for active treatment of molluscum contagiosum includes the spread of lesions through autoinoculation,
the possibility of transmission to others, concerns about secondary bacterial infections, cosmetic issues, and subjective
symptoms such as itching. Therefore, it is better to remove it
as early as possible. Curettage in the treatment of molluscum
contagiosum is a relatively safe and simple method, and
when continuous treatment is performed at 4-week intervals,
it is reported to show a relatively good cure rate. For removal
of molluscum contagiosum, tweezers, forceps, curettes, or
comedo extractors are used for this purpose. Although curettage is reported as an effective treatment with high satisfaction and few side effects, there are problems such as pain and
bleeding during the procedure, and inammation of the skin
or changes due to it after the procedure. A method of making
a hole with a needle and then removing it with a curette has
been suggested as an alternative, but molluscum contagiosum lesions only invade the upper epidermis without invading the basal layer and are hemispherical papules with a
depressed center, so unlike milia, they can be easily removed
without opening the central area of the lesion. It is good to
apply a surface anesthetic cream and then perform occlusion
for a sufcient time before the procedure. Treatment effects
are also seen with liquid nitrogen, podophyllin, cantharidin,
KOH, retinoids, 25–50% TCA, silver nitrate, 1–5% imiquimod cream, etc. In cases where it continues to recur despite
cryotherapy, especially in HIV-infected individuals, electrocautery or laser treatment is necessary. CO2 lasers were used
in the past but are not commonly used recently due to side
effects such as scarring and aerosolization of virus particles,
and there are reports that 585nm pulsed dye laser treatment
is an effective laser treatment. Also, the high-dose administration method of taking cimetidine at 40 mg/kg of body
weight twice a day for 8–12 weeks is reported to be a safe
treatment method with no pain, no scarring, no carcinogenicity or serious side effects compared to conventional molluscum contagiosum treatment and can be used in cases where
it recurs multiple times, or the lesion is on the face (especially the eyelid), or is widely spread and difcult to apply
conventional treatment, or there is a history of atopy. In
patients with decreased immune function, new skin lesions
and recurrence are common, so when lesions occur extensively, it is recommended to reduce the number or size of
24 Molluscum Contagiosum, Molluscum Dermatitis, Eczema Molluscatum
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Figs. 24.16–24.18 Molluscum dermatitis
Fig. 24.19 Scar caused by scratching molluscum contagiosum
lesions that are cosmetic problems rather than removing all
lesions. For Mrs. K, I told her to apply anesthetic cream and
remove it immediately according to our clinic’s “remove as
soon as found” principle and gently removed all lesions
while soothing the child. Afterwards, there are four follow up observations at one-week intervals, and any new noticeable lesions are immediately removed. Unless there are
special cases, a complete cure is usually achieved.
Pompholyx, Dyshidrotic Eczema
https://t.me/med1917
25
I’ve been getting a lot of small blisters on my palms and
the sides of my ngers, and it’s really annoying because
they keep recurring.
Mr. J, a 40-year-old man, has been suffering from a skin
disease for some time now that causes numerous small blisters to form on the palms and sides of his ngers. The blisters
keep appearing and disappearing repeatedly, making him so
irritated that he almost dies. “Do you know how disgusting it
is when I look at my palm in the light? I can’t even reach out
my hand to shake hands with others,” he complains
(Figs.25.1 and 25.2).
Pompholyx is a recurrent eczematous skin disease that
forms small blisters symmetrically in the epidermis of the
palms and soles without a specic cause. Since the skin of
the palms and soles has a lot of eccrine sweat glands, the
relationship between these small blisters and sweat glands
was suspected, and the lesions usually worsen in the summer
and coincide with the areas where sweat occurs related to
psychological stress, so it was named “dyshidrotic eczema
(pompholyx)” long ago. However, it has been revealed that
the blisters are not directly related to the sweat ducts, and it
is considered a special type of eczema in which marked
spongiosis and edema uid accumulate in the epidermal area
where the stratum corneum is thick. It is known to account
for 5–20% of all hand eczema. In the past, pompholyx and
dyshidrotic eczema were dened as the same disease, but
recently, vesicular palmoplantar dermatitis is used to describe
endogenous dermatitis where various sized blisters are found
on the hands and feet and vesicles with spongiosis are
observed histologically. Among them, acute cases are classied as pompholyx, and chronic cases as dyshidrotic eczema,
but the distinction is still unclear. The term “dyshidrotic
eczema” continues to be used even though there are no
changes in the sweat ducts in the epidermis and no abnormalities in the function of the sweat glands, and it has nothing to do with the cause of the disease. The cause is not yet
clear, but it is thought to be related to stress, and in addition,
primary irritants, contact antigens contained in dyes or cosmetics, and rarely, aspirin or oral contraceptives, intravenous
immunoglobulin injections, and other drugs are associated
with its occurrence. It mainly occurs between the ages of 12
and 40, and there is no difference in gender. Cases appearing
Fig. 25.1 Pompholyx
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
J. Y. Jeong, Dermatology Diaries, https://doi.org/10.1007/978-981-97-1578-7_25
Fig. 25.2 Pompholyx observed on the palm
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25 Pompholyx, Dyshidrotic Eczema
on the hands are called cheiropompholyx, and those appearing on the feet are called podopompholyx. Also, clinically, it
is divided into bullous type and vesicular type (Fig.25.3).
Initially, transparent small blisters shaped like sago or
tapioca appear in clusters on the edges of the ngers or on
the palms and soles. Erythema is barely visible, and sometimes small blisters (vesicles) fuse together to form large
blisters (bullae). They occur symmetrically on both sides and
often come with itching. They may also feel hot, and for sensitive people, the sight of numerous tiny blisters on the palm
when exposed to light can be quite disgusting. Pompholyx
occurs only on the hands in about 80% of cases. Over time,
erythema and rings of scale, as well as chronic eczematous
changes like lichenication, appear where the vesicles were.
Usually, the vesicles heal naturally with desquamation after
2–3 weeks, but most cases recur, impairing quality of life.
The period until recurrence varies from several weeks to several months, and the course may change if there is a second-
Fig. 25.3 Pompholyx
ary infection. When it occurs on the upper part of the ngers,
onychodystrophy can occur (Figs. 25.4, 25.5, 25.6, 25.7,
25.8, 25.9, 25.10).
When eczematous lesions with characteristic intraepider-
mal vesicles that look like tapioca or bubble wrap appear
symmetrically on the relatively thick stratum corneum of the
edges of the ngers, palms, or soles and frequently recur
over several weeks to several months, it can be diagnosed as
pompholyx. Histologically, spongiotic vesicles mainly
appear, which is thought to occur because the thick stratum
corneum of the hands and feet prevents the vesicles from
bursting out to the skin surface. It should be differentiated
from other conditions that can occur on the palms and soles,
such as trichophytid, palmoplantar pustulosis, atopic dermatitis, allergic contact dermatitis, drug eruption, pustular bacterid, and friction blisters (Figs. 25.11, 25.12, 25.13, and
25.14).
Pompholyx mostly occurs as idiopathic and impairs qual-
ity of life due to frequent recurrences, but its treatment is
never simple. The goals of pompholyx treatment can be
divided into (1) suppression of vesicle formation and inammation, (2) alleviation of itching, and (3) prevention or treatment of infection. The Dyshidrotic Eczema Area and Severity
Index (DASI) is mainly used as a standardized evaluation
method for the severity of pompholyx. DASI determines
based on the number of vesicles per square centimeter (V),
erythema (E), desquamation (S), itch (I), and the extension of
the affected area (A), it can be used to evaluate not only
severity but also the effectiveness of treatment. In the treatment of pompholyx, it is necessary to avoid aggravating factors such as smoking, and if a patient has contact allergies,
they should avoid conrmed allergens. Wet dressings using
Burow’s solution, etc. can help alleviate symptoms in the
acute phase of the disease. Initially, topical steroids and topical calcineurin inhibitors (tacrolimus, pimecrolimus) can be
used, and there have been reports on the effects of bexarotene (bexarotene gel). In the case of chronic eczematous
Figs. 25.4 and 25.5 Pompholyx—60× magnied photos
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