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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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25 Pompholyx, Dyshidrotic Eczema
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Figs. 25.6 and 25.7 Pompholyx on the palm—60× magnied photos
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Figs. 25.8–25.10 “Rings of scale” peeling off where the vesicles were over time—60× magnied photos
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25 Pompholyx, Dyshidrotic Eczema
Figs. 25.11–25.13 Pompholyx observed on the palm and wrist
Fig. 25.14 Pompholyx on the foot
lesions that have become lichenied, occlusive therapy with
topical steroids can be performed. There has been a reported
method of tapering off systemic steroids once the vesicles
disappear after short-term use, but long-term use is not recommended due to unwanted side effects. Other immunosuppressants such as azathioprine, low-dose methotrexate,
mycophenolate mofetil, and cyclosporine have insufcient
data to be recommended over other treatments in terms of
efcacy and safety. Antihistamines have not been proven
effective in pompholyx but are used to control accompanying itching, and oral and topical antibiotics are used in the
event of secondary bacterial infection. The retinoid alitretinoin is known to be effective in chronic recurrent hand
eczema, but only limited effects have been reported for pompholyx. There are research results that botulinum toxin injections are effective, but the pain during injection is a common
25 Pompholyx, Dyshidrotic Eczema
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Figs. 25.15 and 25.16 Wet dressing using Burow’s solution and occlusive therapy using steroid cream for pompholyx
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side effect that limits popular use. There are also research
results that phototherapy and photochemotherapy using
ultraviolet light and radiation therapy were effective, and the
effects of tap water iontophoresis used in hyperhidrosis have
been reported. I explained to Mr. J in detail about the nature
of this disease and told him not to worry too much as it can
last for several years, but it is a disease that can denitely be
cured (Figs.25.15 and 25.16).
Aquagenic Urticaria, Water Urticaria
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26
Whenever I come in contact with water, my body itches
and I get hives. It doesn’t matter whether it’s cold or hot.
A 17-year-old male student, H, says that his skin itches
and develops hives when he comes in contact with water.
“Does it happen after you shower? Does it mainly appear
when you shower with hot water?” “No! Whether it’s cold or
hot water, it happens as soon as water touches my body.”
Aquagenic urticaria, which is not cholinergic urticaria or
cold urticaria, is a really rare disease, but is it real? “Teacher
Kim! Wet the gauze with water and place it on the patient’s
skin!” (Fig.26.1).
Aquagenic urticaria, also known as water urticaria, is a
rare condition that causes small hives accompanied by severe
itching on the upper body within a few minutes to 30min
after contact with water, regardless of its temperature or
type. The hives disappear within 30min to an hour after
breaking contact with water. It was rst described in 1964
and was rst reported in Korea in 1990.
Analysis of past cases shows that it occurs more frequently in women than in men and usually develops during
Fig. 26.1 Aquagenic urticaria caused by contact with water
puberty or a few years after puberty. Although it mostly
occurs sporadically, there have been reports of cases with a
family history and in identical twins. Hives do not occur
when alcohol and other organic solvents are applied to the
skin, and systemic symptoms are very rare. It can also appear
in conjunction with other physical urticarias such as cholinergic urticaria and cold urticaria. The mechanism by which
water contact causes hives and itching is not yet clear, but a
hypothesis has been proposed that water inltrating through
the pilosebaceous unit forms a toxic substance by acting on
sebum or sebaceous glands, causing local mast cell degranulation and forming wheals around the follicles. There have
also been claims that the patient’s symptoms are due to the
release of histamine from mast cells as a result of a reaction
to antigens soluble in the water within the epidermis and
spreading to the dermis. In addition, there have been reports
that the local anticholinergic scopolamine suppresses the
occurrence of wheals caused by water, suggesting that the
local release of acetylcholine is important in the onset mechanism. It has also been suggested that sudden changes in ion
concentration and osmotic pressure play a role in triggering
factors, as skin symptoms worsened when in contact with
hypertonic solutions like seawater rather than hypotonic, low
ion concentration water like tap water or swimming pool
water. The lesions of aquagenic urticaria appear as small
wheals (diameter 1–3 mm) mainly on the neck, torso, and
arms of the upper body, similar to cholinergic urticaria after
contact with water. Therefore, it can be distinguished from
aquagenic pruritus, which causes severe itching after contact
with water but does not cause erythema or wheals on the
skin. It can also be easily distinguished from other forms of
physical urticaria such as dermographism, cholinergic urticaria, cold urticaria, heat urticaria, and solar urticaria
(Figs.26.2, 26.3, 26.4, and 26.5).
Unbelievably, Mr. H showed a positive result in the water
contact provocation test (a test where a wet gauze is placed
on the abdomen or back for 30 min), which many challengers (?) have failed in the past, causing great concern.
© 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_26
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Figs. 26.2 and 26.3 Provocation test by placing a water-soaked gauze on the skin for 30min
26 Aquagenic Urticaria, Water Urticaria
Figs. 26.4 and 26.5 Determining the occurrence of wheals after 30min of contact with a water-soaked gauze
Fiddler’s Neck, Violin andViola Player’s
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Neck
27
I’m learning to play the violin, but at some point, the area
under my left jaw and neck became swollen and turned a
dark color.
Mr. M, a 17-year-old male who was passionately practicing the violin to major in it at university, came for a consultation because he was worried that the area under his left jaw
where the violin chin rest touches had become rough, swollen, and seemed to have turned a darker color. He said, “I
think my skin has become rough and thick because of the
violin chin rest, and recently it seems to be staining a bit
darker!” (Fig.27.1).
Fiddler’s neck (the neck of violin and viola players) is a
type of occupational skin disease in which lichenication,
erythema, pigmentation, papules, and pustules appear on the
skin under the left chin and neck area of violin or viola players. Fiddler’s neck is well known among professional violinists and violists in orchestras, and it is said that skin lesions
occur in more than half. The cause is said to be pressure on
the neck area by the violin or viola, friction between the skin
and the chin rest, and poor hygiene due to excessive sweating. However, it has also been reported that it can occur due
to a delayed hypersensitivity reaction caused by the material
of the instrument’s chin rest. Histological ndings include
hyperkeratosis, acanthosis, and follicular keratin plugs of the
epidermis, and in the dermis, cysts and foreign body reactions can be seen. Common skin lesions are localized lichenied patches or plaques with mild pigmentation or erythema
of about 2–4cm in diameter, and papules and pustules can be
seen, and rarely, cysts and scars can also occur. Diagnosis is
possible by visual examination in violin or viola players, and
if necessary, patch testing for allergies can be performed.
Skin diseases that need to be differentiated include mechanical acne and traumatic anserine folliculosis, but mechanical
acne can be differentiated from Fiddler’s neck by the formation of comedones or pustules due to mechanical stimulation
such as pressure and friction in a short period of time in those
with acne tendencies, without showing pigmentation, and
traumatic anserine folliculosis can show similar lesions but
can be differentiated by the fact that the cause is continuous
pressure and friction on the patient’s own skin (Figs.27.2,
27.3, 27.4, 27.5, 27.6, 27.7, 27.8, 27.9, 27.10, and 27.11).
Fig. 27.1 Fiddler’s neck of a violin player Fig. 27.2 Fiddler’s neck under the left jaw of a violin player
© 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_27
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27 Fiddler’s Neck, Violin andViola Player’s Neck
Figs. 27.3–27.6 Fiddler’s neck of a violin player
Figs. 27.7 and 27.8 Fiddler’s neck of a violin player
27 Fiddler’s Neck, Violin andViola Player’s Neck
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Fig. 27.9 Fiddler’s neck of a violin player
Fig. 27.10 Fiddler’s neck of a viola player
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Fig. 27.11 Fiddler’s neck showing inammatory reaction
In addition to these, it is known that musicians who play
instruments professionally can also develop conditions such
as autist’s chin, clarinetist’s cheilitis, cellist’s chest, cellist’s
knee, and even cello scrotum, guitar nipple. Violin and viola
players’ necks do not require treatment other than for cosmetic purposes as long as there is no pain or inammation.
Depending on the case, topical steroid cream, skin softeners,
proper instrument care, neck padding, replacement of instrument chin rest, and reduction of playing time may be necessary, but surgical excision is not recommended. For Mr. M, it
was decided to repeatedly perform skin care including supercial peeling, explaining the nature of this disease in detail
and treating acne and pigmentation on the face including the
lesion.
Pityriasis Alba
∗∗∗
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28
Why do rough, white patches spread all over my child’s
face and neck? Is it malnutrition? What if it’s vitiligo?
The mother of a 15-year-old male student, G, came into
the clinic with her son and worriedly asked, “Why does my
child have dry patches all over his face and neck? It’s not
some kind of malnutrition, is it? What if it’s vitiligo?” I
quickly told him to put his face under a Wood’s lamp to differentiate this lesion from vitiligo (Fig.28.1).
Pityriasis alba refers to asymptomatic round or oval
hypopigmented lesions with slight scaling commonly seen
on the faces of children aged 3–16. The incidence in children
is about 1.9–5.2%, with no difference between boys and
girls, and it is more common in people with darker skin.
Especially, the incidence is higher in those with a history of
atopic dermatitis, and pityriasis alba is a minor diagnostic
feature of atopic dermatitis. The cause is not clear, but since
the lesions commonly occur in areas exposed to sunlight, it
is thought to be a type of eczematous dermatitis showing
hyperkeratosis and parakeratosis with the UV blocking effect
of the epidermis and pigment reduction after inammation.
It often occurs when the skin is dry after exposure to strong
sunlight, and it is thought that frequent long-term bathing
and physical exfoliation may deteriorate the skin barrier
function and cause lesions. There have also been reports on
the relevance of serum copper concentration, Malassezia,
bacteria, and parasites (Fig.28.2).
Pityriasis alba gradually brings about changes in skin
ndings over a long period of time in multiple stages. In the
initial stage, erythematous changes with slightly raised edges
appear and persist for several weeks. In the next stage, the
erythema disappears, leaving a soft scale, and then a hypopigmented lesion with clear boundaries of about 0.5–5 cm,
showing a slight scale at the edge, appears. At this stage,
patients nally seek medical attention. Lesions often occur
on the face, but can also occur on the neck, upper arms, and
shoulder blade areas. The lesions are white (not true depigmentation) or light pink, with clear boundaries from the surrounding skin. The scales are thin and rmly attached,
Fig. 28.1 Pityriasis alba observed on the face and neck
© 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_28
Fig. 28.2 Pityriasis alba
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28 Pityriasis Alba
usually without any subjective symptoms, but occasionally
there may be slight itching or a burning sensation. The course
is generally good, and the lesions usually disappear naturally
within a few months to years, but they often recur. Atypical
forms include pigmenting pityriasis alba and extensive pityriasis alba (Figs.28.3, 28.4, 28.5, and 28.6).
Histological ndings are nonspecic, so biopsy is not recommended. The lesion can be differentiated from pityriasis
versicolor by the lack of scales when scratched and from vitiligo by the fact that the color and boundaries of the lesion
are not clearly emphasized in Wood’s lamp examination.
Nevus depigmentosus appears as a single lesion, is unilateral, and persists for life, so it can be differentiated. Nevus
anemicus disappears when pressed with a slide glass.
Hypomelanosis of Ito usually presents with unilateral or
bilateral hypopigmented skin lesions on the trunk and limbs
from birth, along with neurological and musculoskeletal
abnormalities (Fig.28.7).
The most primary treatment is to protect the skin from
sunlight. Since it usually disappears naturally within a few
months to years, emollients and moisturizers are regularly
applied. A low concentration of topical steroids can be
applied to reduce psychological stress, but there is a concern
about side effects from long-term application. The effect of
topical tretinoin has been reported, and in cases of extensive
pityriasis alba, it may respond to short-term PUVA therapy.
Recently, the effects of calcineurin inhibitors (tacrolimus,
pimecrolimus), calcitriol, and 308 nm excimer laser have
been reported. It was decided to apply sunscreen evenly and
frequently to student G, prescribe therapeutic moisturizer
and tacrolimus ointment, and observe him regularly
(Figs.28.8, 28.9, 28.10, 28.11, 28.12, and 28.13).
Figs. 28.3 and 28.4 Wood’s lamp ndings of pityriasis alba
Figs. 28.5 and 28.6 Pityriasis alba on the face
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