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28 Pityriasis Alba

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Fig. 28.7 Pityriasis alba on the neck

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Figs. 28.8 and 28.9 Pityriasis alba on the face and neck

Figs. 28.10 and 28.11 Pityriasis alba observed on the body of a patient with atopic dermatitis

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28 Pityriasis Alba

Figs. 28.12 and 28.13 Pityriasis alba on the back, arms, and legs

White Dermographism

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When other people scratch their skin with something, the area turns red, but my child’s skin turns white, so I’m worried.

The mother of E, a 16-year-old male suffering from atopic dermatitis, said, “Usually, when other people scratch their skin, their skin turns red for a moment, but my child’s skin turns white instead. Is that okay? (Fig.29.1).

White dermographism refers to the phenomenon where the skin of patients with atopic dermatitis turns pale instead of reddening when stimulated from the outside, unlike in normal people. That is, when the skin is gently scratched with a wooden tongue depressor or the like, a pale white line appears instead of turning red. White dermographism is known to be due to changes in blood ow in the skin vessels and local vasoconstriction and is one of the abnormal vascular reactions that can be seen in patients with atopic dermatitis, along with facial pallor and delayed blanch response. In studies measuring skin blood ow before and immediately after skin stimulation, it has been reported that a decrease in

skin blood ow was observed in patients with atopic dermatitis at the time when white dermographism appeared. In a Korean study comparing 82 clinically typical adolescent and adult patients with atopic dermatitis aged 13–42 with a normal control group of the same age, white dermographism was not found at all in the normal control group but was observed in 39.0% (32 people) of the patient group with atopic dermatitis. In addition, in a study comparing 48 clinically typical pediatric patients with atopic dermatitis aged 2–12 with a normal control group of the same age, it was reported that it was observed in 35.4% (17 people) of the patient group with atopic dermatitis. According to the results of these two studies, among a total of 38 (or 39) minor clinical features of atopic dermatitis, white dermographism was one of the most statistically signicant symptoms observed in the atopic dermatitis patient group compared to the normal control group. Thus, white dermographism is one of the minor features among diagnostic criteria for atopic dermatitis and is signicant for diagnosis, it is a symptom that does not really need to be worried about (Fig.29.2).

Fig. 29.1 White dermographism

Fig. 29.2 Diagnosis of white dermographism

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29 White Dermographism

After hearing the explanation, E’s mother said, “Ah! So, I don’t need to worry too much about it” and left the examina-

tion room with a relieved expression (Figs.29.3, 29.4, 29.5,

29.6, 29.7, and 29.8).

Figs. 29.3–29.6 White dermographism

Figs. 29.7 and 29.8 White dermographism observed in atopic dermatitis

Cherry Angioma, Senile Angioma

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One day, I noticed red spots on my body that keep increasing in number. Is it okay to just leave them?

A 40-year-old male, B, came for a consultation because he was very worried about whether it was okay to just leave the red spots that started appearing on his body and arms and kept increasing. When he asked, “Why are these appearing?” I replied, “The exact cause is not known yet, but skin aging is considered one of the causes.” He responded, “Are you saying I’m that old?” (Fig.30.1).

Cherry angioma (senile angioma) is a benign tumor, a type of capillary angioma that occurs with age, mainly appearing after the age of 30, with no difference in incidence between men and women. As one ages, the number and size of these angiomas gradually increase, and they are observed in 75% of 70-year-old seniors. However, they are also reported to appear in about 5% of adolescents. In a study of 172 elderly men and women aged 51–90 in Korea, it was

Fig. 30.1 Cherry angioma (senile angioma) found on the body

reported that cherry angiomas were observed in 47.7%, and in a survey of 525 elderly men and women over 65, a prevalence rate of 26.9% was reported. The most common skin conditions in the elderly were reported to be senile lentigo, seborrheic keratosis, dry skin, whole body pruritus, onychomycosis, and cherry angioma. The cause of occurrence is not yet clear, but since the number increases with age, it is thought that the aging process plays a role in the occurrence of cherry angiomas and also pregnancy, diabetes, tropical climate, and exposure to certain chemicals. In addition, there are reports of case related to liver transplantation, graftversus- host disease, and cyclosporine treatment. Cherry angiomas are 1–5 mm in size, light pink or ruby-colored (also known as ruby spots), semi-spherical nodules, mainly occurring on the trunk and arms, but occasionally on the face, hands, and feet. Also, lesions occurring on the scalp often go unnoticed by the individual as they are asymptomatic and hidden by hair. Cherry angiomas usually occur in multiple clusters, often with 20 or more found on the trunk. There are no symptoms, but bleeding can occur due to trauma. In the early stages of histological examination, proliferated capillaries in the form of lobules are observed in the upper dermis, with narrow vascular lumens and large, distinct endothelial cells. As they grow, the vascular lumen expands, the endothelial cells atten, and the thinned epidermis forms a collarette, enveloping the angioma. The dermal matrix shows edema and homogenization of collagen bers (Figs.30.2, 30.3, 30.4, 30.5, 30.6, and 30.7).

Cherry angiomas are asymptomatic, but they can become a concern as red spots increase on the skin. People usually visit a hospital to nd out the reason, but after learning that it is a benign capillary angioma, they mainly want to remove it for cosmetic reasons or to prevent future bleeding due to trauma. To remove cherry angiomas, curettage, electrocoagulation, cryotherapy, and laser treatment can be performed. However, recently, laser treatment has become the most popular method, as it is fast, effective, and provides excellent cosmetic results. The lasers and phototherapy

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Fig. 30.2 Cherry angioma (senile angioma)

30 Cherry Angioma, Senile Angioma

Fig. 30.3 Cherry angioma—60× magnied gure

Figs. 30.6 and 30.7 Cherry angioma

Figs. 30.4 and 30.5 Cherry angioma

30 Cherry Angioma, Senile Angioma

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Figs. 30.8–30.11 Treatment of cherry angioma using CO2 laser

devices commonly used for cherry angioma treatment include pulsed dye lasers (PDL), long-pulsed Nd:YAG lasers, long-pulsed KTP lasers, argon lasers, CO₂ lasers, and IPL.For Mr. B, after removing the lesion with a laser, posttreatment care must be thoroughly performed to reduce the possibility of scars and pigmentation. Cherry angiomas usu-

ally appear in early adulthood and gradually increase in number with age. Although current lesions can be removed with various lasers if desired, new ones cannot be prevented from forming, so they must be removed repeatedly as they appear (Figs.30.8–30.11).

Exfoliative Cheilitis

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I really suffer from my lips. My lips are peeling off all the time, causing pain and burning, and no matter what treatment I get, it doesn’t help.

Ms. F, a 21-year-old woman, is always worried about her lips. Her lips are covered with scales and crusts, and they peel off, causing her lips to become red, cracked, sore, and burning over and over again. This cycle continues, damaging her quality of life and causing immense stress. “No treatment seems to help!” she said as she sat in the examination room (Fig.31.1).

Exfoliative cheilitis is a chronic supercial inammatory disease of the lips that occurs for unknown reasons or secondary to other diseases, characterized by continuous lip peeling. It is known to worsen due to external factors such as harsh wind, cold and dry seasons, or sunlight. However, in

Fig. 31.1 Exfoliative cheilitis

many cases, it can occur secondary to atopic dermatitis, seborrheic dermatitis, psoriasis, or after retinoid treatment and has been reported to be related to anxiety neurosis such as lip biting or licking habits and can appear as a symptom of factitial cheilitis. Especially, in atopic dermatitis occurring in Korea, cheilitis tends to increase relatively in adults compared to children. Sometimes it disappears on its own, and it can improve when oral hygiene is improved. Clinically, the lips are covered with scales and crusts that easily fall off, so the peeled lips turn red. Persistent peeling of the lips is accompanied by cracking, burning sensation, pain, or tenderness. In cases where the cause is unknown, it continues to recur, mainly on the upper lip, but in cases where it occurs secondary to other diseases, it shows chronic inammation, mainly on the lower lip.

The lesions of exfoliative cheilitis are conned to the lips and differential diagnosis is required with various cheilitis including allergic contact cheilitis, actinic cheilitis (Figs. 31.2, 31.3, 31.4, 31.5, 31.6, 31.7, 31.8, 31.9, 31.10, and 31.11).

For treatment, it is prioritized to remove the cause if it is found. Topical application of steroid ointment is effective, and in severe cases, systemic steroid treatment or intralesional injection can be done. Also, tacrolimus and pimecrolimus topical treatments can be helpful, and if the lips are cracked, Vaseline or zinc oxide ointment is used. Recently, the effects of excimer laser treatment and ultraviolet treatment for refractory exfoliative cheilitis have been reported. If there are mental health issues, psychiatric treatment may be needed. I told Ms. F that there may be very difcult cases to treat, but let’s overcome it together without being too discouraged, as it is not a malignant disease (Figs.31.12, 31.13,

31.14, 31.15, 31.16, and 31.17).

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