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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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39 Prurigo Pigmentosa
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Fig. 39.8 Prurigo pigmentosa on the torso
161
For treatment, dapsone and minocycline, which are
known to be most effective in improving lesions and eliminating itching, are mainly used, but minocycline is known to
have fewer side effects and a longer remission period than
dapsone. Dapsone inhibits the release of lysosomal enzymes
in neutrophils and inhibits oxygen intermediates to protect
tissues from oxidative free radicals, and antibiotics of the tetracycline series like minocycline also exhibit antiinammatory effects by inhibiting the production of reactive
oxygen species and the chemotaxis of neutrophils. In addition, doxycycline, sulfamethoxazole, macrolide antibiotics
(clarithromycin, roxithromycin), isotretinoin, potassium
iodide, etc. can be used. Antihistamines and oral or topical
steroids can also be used additionally, but the effects are not
as clear. However, there is a Korean report that the lesions
Figs. 39.9–39.11 Prurigo pigmentosa observed on the ank and back
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Figs. 39.12 and 39.13 Prurigo pigmentosa lesions where erythematous papules or plaques have disappeared and only pigmentation remains
39 Prurigo Pigmentosa
Figs. 39.14 and 39.15 The effect of clarithromycin on prurigo pigmentosa (before treatment, 4weeks after medication)
improved after 1–2 weeks of application in two pregnant
women who could not use oral preparations and used topical
but he left the clinic with a gloomy expression, perhaps worried about the word “recurrent” (Figs.39.14 and 39.15).
steroids. I explained the nature of this disease well to Ms. E,
Lichen Striatus
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40
What is this strange skin disease that causes bumpy,
scaly, long lines on my child’s limbs? (Fig.40.1)
The mother of 16-month-old girl, W, came into the clinic
with a worried face to treat the strange skin disease that had
grown long and bumpy and scaly on the child’s arms, legs,
and body. “Why does this happen? Can it be treated?” she
asked, so I rst reassured her by saying, “Yes! You don’t
have to worry so much!”
Lichen striatus is an inammatory skin disease of unknown
cause that often occurs in children and is characterized by
linearly arranged lesions. It is common in girls between
5months and 15years old but can also occur rarely in adults.
The cause is not yet clear, but local skin reaction theory,
genetic theory, viral infection theory, and immune theory
have been proposed, especially the cellular immune theory is
strong. The linear lesions are composed of small papules of
1–3 mm in size with a at surface, covered with delicate
scales, and typically show skin color or red but can show
various clinical forms such as hypopigmented patches or
plaques. It occurs suddenly and arranges linearly along
Blaschko’s lines, sometimes appearing broken but continuously connected, ranging from a few centimeters to invading
an entire arm or leg. It mainly occurs on the arms and legs,
but it is also known to occur rarely on the trunk or face.
Itching may be accompanied, but most are asymptomatic. It
usually appears unilaterally but can rarely be bilateral or
multiple, and nail lesions can also occur. In adults, it typically appears on the trunk and is characterized by itching,
vesicles, multiple linear lesions, and frequent recurrence
(Fig.40.2).
Diagnosis is easy with detailed medical history and characteristic clinical ndings. Histological ndings vary, but
initially, spongiform dermatitis and lichenoid inltrates
appear, and vacuolated degeneration and necrotic keratinocytes appear in the basal layer. In the later stage, granulomatous inltration appears within the dermis, and there is
Fig. 40.1 Lichen striatus observed on the leg Fig. 40.2 Lichen striatus observed on the leg and chest
© 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_40
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40 Lichen Striatus
inltration of inammatory cells around hair follicles and
sweat glands. It is necessary to differentiate from linear epidermal nevus, linear discoid lupus erythematosus, linear
lichen planus, and linear psoriasis (Figs. 40.3, 40.4, 40.5,
40.6, 40.7, 40.8, 40.9, 40.10 and 40.11).
Lichen striatus usually disappears naturally within
6months to 2years, so aggressive treatment is not necessary,
but if there is no improvement or recurrence, or in extensive
cases, local application of steroids can be performed. Also,
recently, local tacrolimus preparations can shorten the period
of lesion disappearance without major side effects, and it is
reported that it can be used relatively safely and effectively.
The effects of cyclosporine administration and photodynamic therapy have also been reported. W’s mother leaves
the clinic with a relieved expression after being told that it
usually disappears naturally.
Figs. 40.3 and 40.4 Lichen striatus observed on the trunk and upper arms
Figs. 40.5 and 40.6 Lichen striatus observed on the trunk
40 Lichen Striatus
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Figs. 40.7 and 40.8 Lichen striatus on the legs
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Fig. 40.9 Lichen striatus in the armpit
Figs. 40.10 and 40.11 Lichen striatus on the hands and feet
Adult Acne, Postadolescent Acne,
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Premenstrual Acne
41
I heard that I have great skin because I didn’t have any
acne when I was in school. Is it true that I have acne at
this age?
A 35-year-old woman, A, is so upset these days that she
feels like she’s going to die. She never had acne when she
was in school and was told she had good skin, but she never
thought she would suffer from skin trouble at this age. “Is
this really acne? Isn’t acne something that only happens to
students?” She asks (Fig.41.1).
Acne has a prevalence rate of almost 98% and is known to
occur mainly in teenagers and naturally improve after the
mid-20s, but clinically, there are many cases where mild
acne continues to recur in women over 25, and the incidence
is increasing. Traditionally, acne that exists at the age of 25
or older is dened as adult acne (postadolescent acne). Adult
acne can be divided into late-onset adult acne, which rst
occurs after the age of 25, and persistent adult acne, which
does not disappear and continues until the age of 25 or older
after occurring in adolescence. Acne, which was observed at
the highest frequency in teenagers, gradually decreases and
mostly disappears between the ages of 20 and 25in men, but
women continue to have acne even as adults. Acne can occur
up to the age of 40, and in some cases, even after 40.
According to reports, 8% of adults aged 25–34 and 3% of
adults aged 35–44 experience adult acne, and the recent
trend is that the incidence is increasing further.
The reasons for the increasing prevalence of adult acne in
women are thought to include an increased recognition of
acne as a disease, increased stress due to more women working, higher childbearing age, a surge in food additives, overuse of hormones and antibiotics, and an increase in metabolic
syndrome related to insulin resistance due to the inux of
Western diets and improved living standards (Figs. 41.2,
41.3, 41.4, 41.5, 41.6, 41.7, 41.8 and 41.9).
Such adult acne is clinically different from adolescent
acne, with fewer comedones and more inammatory lesions.
Fig. 41.1 Adult acne mainly observed on the chin line
© 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_41
Fig. 41.2 Female adult acne
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Fig. 41.3 Female adult acne
41 Adult Acne, Postadolescent Acne, Premenstrual Acne
Fig. 41.4 Female adult acne
Fig. 41.5 Female adult acne on the chin line
Figs. 41.7 and 41.8 60× magnied photo of inammatory acne lesions
Fig. 41.6 Male adult acne on the chin line
41 Adult Acne, Postadolescent Acne, Premenstrual Acne
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169
In women, it often occurs on the face, especially around the
mouth and along the jawline (men tend to be conned to the
torso), overall fewer lesions than adolescent acne, and mainly
exists in the form of inammatory papules and pustules. The
pattern of lesions is similar to perioral dermatitis or rosacea
and often appears concentrated in certain areas. According to
Korean research, the sebum secretion of adult acne patients
was highest in the chin area, but the total sebum secretion
combined from each area and all areas showed no statistically signicant difference from adolescent acne. It was suggested that further research is needed to determine whether
the reason for occurrence on the jawline is related to the
increase in sebum in each area of the face.
Although the prevalence varies by report, it is estimated
that mild acne persists in one-third of adult women. However,
most women do not feel the need for treatment for acne
because the lesions are not severe and show periodic
improvement, so they do not interfere with their social life.
The occurrence of scars from adult acne is thought to be
more common than in adolescent acne, as adult acne is
mainly inammatory lesions, does not respond well to treatment, and treatment is often delayed. Adult acne in women
tends to recur or disappear periodically depending on uc-
Fig. 41.9 Adult acne on the rise
tuations in blood hormone levels, but in some women, it
appears irregularly. Generally, it recurs during ovulation or
before menstruation, and the lesions persist for several days,
but in some cases, they appear for more than a month. The
worsening of acne before menstruation is a common phenomenon in actual patients, and premenstrual acne is characterized by an increase in papules and pustules about a week
before menstruation. This is thought to be due to an increase
in sebum secretion by progesterone, and at the same time, the
size of the opening of the pilosebaceous gland narrows the
most between 15 and 20days of menstruation, causing acne
to worsen. For example, the fact that lesions that occurred
periodically did not occur when progestin was removed from
oral contraceptives is presented as evidence that progesterone mediates premenstrual acne in a unique pattern. The
lesions of premenstrual acne occur quickly and progress
from non-inammatory lesions, microcomedones. The worsening of premenstrual acne usually starts with mild papulopustular acne, and it is not clear in severe acne with deep
nodules or cysts. If about 5–10 pustules appear periodically
every month, premenstrual acne can be suspected. In a survey on worsening factors in adult acne, 64% of patients
responded that acne worsens according to the menstrual
cycle, and menstruation was the most common worsening
factor, which is thought to be more involved in endocrine
changes related to menstruation in adult acne than in adolescent acne where worsening by menstruation is reported as
44% (Table41.1).
As such, adult female acne is highly related to the menstrual cycle and is treated by the pathophysiology similar to
premenstrual acne, and treatment is performed with topical
retinoid application and oral isotretinoin therapy. In women
who do not respond well to such general treatment, hormonal
therapy can be an effective treatment method. I explained to
Ms. A that it seems that adult acne has increased a lot these
days, and that she should reduce stress, and that adult acne is
not easy to treat, and scars can easily form, so she should
receive good treatment so that no sequelae remain.
Table 41.1 Comparison of adult acne and adolescent acne
Age at occurrence 25years or older Puberty and adolescence
Gender differences Predominantly affected in females Similarly affected
Types of lesions Mild inammatory papulopustular lesions Ranging from mild comedones to severe nodules and
Facial lesions U-zone of face T-zone of face
Truncal lesions Rare Common
Presence of comedones Less common, but more common in smokers Must exist
Number of lesions Few Many
Menstrual effects More affected Affected
Occurrence of scars Common May occur
Treatment response Difcult due to frequent recurrences Expected results
Adult acne Adolescent acne
cysts
Childhood Flexural Comedones
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42
I was bathing my child and found something strange in
his armpit, so I brought him in worried (Fig.42.1).
One day, the mother of a 6-year-old boy, J, was surprised
to see two strange things that looked like acne blackheads in
her child’s armpit while bathing him and came to get an
examination. She asked, “What on earth are these two black
dots?” (Fig.42.2)
Childhood exural comedones refer to lesions that resemble
comedones with two openings, found in areas such as the
armpits, groin, inner elbows, and neck, without any particular subjective symptoms like pain or itching. Comedones,
immovable evidence of acne, are typically found in areas
with high sebum secretion, such as the face, back, and chest.
However, scattered comedones are also found in a few rare
skin diseases, and secondary comedones can occur due to
sun damage, radiation therapy, trauma, or hidradenitis sup-
purativa. This lesion, located on the exural side and occurring at a young age, was rst named “childhood exural
comedones” in 2007. The two openings are connected by a
thin layer of the epidermis, and the comedone content is
underneath. It has a similar incidence rate in girls and boys,
mainly found in children aged 2–15years (average 6.2years).
Seventy-two percent have a single lesion, 80% appear unilaterally, and 88% of patients are reported to have lesions in the
armpits.
The cause is unclear, and a relationship with hidradenitis
suppurativa or molluscum contagiosum has been suggested,
and it is thought that it could be due to local trauma such as
friction, but it is not yet clear. Recently, there have been
reports that these lesions can persist into adulthood and that
comedones with two openings can occur in other parts of the
body. Due to the characteristic clinical appearance, a visual
diagnosis is possible, and histologically, expansion of the
infundibulum of the hair follicle and keratin deposits inside
Fig. 42.1 Childhood exural comedones observed in the armpit—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_42
Fig. 42.2 Childhood exural comedones—60× magnication
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42 Childhood Flexural Comedones
the follicle were conrmed (Figs.42.3, 42.4, 42.5, 42.6 and
42.7).
Although the contents can be easily extruded by applying
force with a comedo extractor or cotton swab, denitive
treatment, if necessary, is to remove the thin layer of the epi-
Fig. 42.3 Childhood exural comedones observed in the armpit
dermis with a laser or excise the lesion area. J’s childhood
exural comedones were carefully extruded, and when
explained to the mother that there was no need to worry, she
showed a relieved expression (Figs.42.8 and 42.9).
Fig. 42.4 Childhood exural comedones in the armpit—10×
magnication
Figs. 42.5 and 42.6 60× magnied images of childhood exural comedones
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