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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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42 Childhood Flexural Comedones
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Fig. 42.7 Comedo with two openings observed in an adult’s neck
173
Figs. 42.8 and 42.9 The process of extruding the contents using a comedo extractor
Pitted Keratolysis
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It has a unique terrible foot odor, but it’s not athlete’s
foot (Fig.43.1).
Mr. L, who is in his 30s, often works in a humid environ-
ment where his shoes are poorly ventilated. His feet sweat a
lot and are often damp. One day, he noticed many crater-like
formations on the soles of his feet and suffered from severe
foot odor. He had received treatment for athlete’s foot several
times, but there was no improvement. “I’ve been taking medication for athlete’s foot for over 6 months, but it’s not getting better. Please help me get rid of this foot odor!” he
pleads.
This disease, which can be easily diagnosed by its characteristic lesions and unique foot odor, is called pitted keratolysis.
Unlike athlete’s foot caused by fungi, this condition is caused
by bacteria such as Micrococcus or Corynebacterium. These
bacteria invade the softened stratum corneum due to excessive sweating or frequent contact with water and secrete
keratin-degrading enzymes or protein-degrading enzymes.
This results in the formation of round, shallow holes of
0.5mm or larger and 1–2mm deep on the weight-bearing
skin of the soles, which fuse to form deep craters. Sometimes
these holes merge to form grooves. The bacteria produce thiols and thioesters, which give off a unique, strong odor that
is hard to forget once smelled (Figs.43.2, 43.3, 43.4, 43.5,
43.6, 43.7, 43.8, 43.9, 43.10, 43.11, 43.12 and 43.13).
Although it can be treated well with topical creams and
oral antibiotics, recurrence is common, so it is advisable to
43
Fig. 43.1 Pitted keratolysis observed on the sole of the foot
avoid wearing shoes that are poorly ventilated or enclosed, to
wear cotton socks that absorb sweat well, and to keep the
feet dry. Also, if you have excessive sweating on the soles of
your feet, you should receive treatment for it. Mr. L is
relieved to know that his condition is caused by bacteria, not
fungi, and to nd a treatment method, but he is worried about
how to deal with his work shoes and the humid environment
due to his job.
© 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_43
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Figs. 43.2 and 43.3 Pitted keratolysis
43 Pitted Keratolysis
Figs. 43.4 and 43.5 Pitted keratolysis
Figs. 43.6 and 43.7 Pitted keratolysis
43 Pitted Keratolysis
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Figs. 43.8 and 43.9 Pitted keratolysis
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Figs. 43.10 and 43.11 Pitted keratolysis
Figs. 43.12 and 43.13 Pitted keratolysis of the toes—10× magnied photo
Digital Mucous Cyst
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44
At some point, the area near the joint at the tip of my toe
has started to bulge and a hemispherical lump lled with
clear uid has formed and won’t go away. Is it okay if I
just leave it alone?
Ms. E, a woman in her 50s, came for a consultation
because a dome-shaped lump lled with a transparent liquid had formed near the toenail of her right second toe.
Despite waiting for it to disappear on its own, the lump
persisted. “Can I just leave it like this? I’m worried,” she
said (Figs. 44.1 and 44.2).
Digital mucous cyst is a dome-shaped non-inammatory
cyst that occurs on the dorsal digits between the distal interphalangeal joint and the proximal nail fold. This lesion is
common in middle-aged to elderly women between the ages
of 50 and 70 and is often accompanied by osteoarthritis. It is
also called mucoid cyst, mucinous cyst, myxoid cyst, synovial cyst, ganglion cyst, etc. Depending on the mechanism of
occurrence, they can be classied into two types. The rst
type is a case in which hyaluronic acid in mucus originates
from the distal interphalangeal joint due to degenerative
changes, as evidenced by the discovery of a stem connecting
the cyst and the distal interphalangeal joint during surgery.
The second type is caused by excessive production of hyaluronic acid due to metabolic derangement of broblasts,
regardless of joints, and mainly occurs in the proximal nail
folds. They typically appear as hard or soft, round, semitransparent, dome-shaped papulonodular lesion with diameters ranging from 1 to 10mm. The skin covering the cyst can
be slightly thick or very thin. The contents are a transparent
or yellowish viscous jelly-like liquid. Although they are usually asymptomatic, pain can occur if the cyst is large.
Sometimes, compression of the nail matrix may cause the
nail plate to depress or cause longitudinal groove and may be
accompanied by limitations in the range of joint movement.
According to recent Korean research, 82.1% occurred on the
ngers and 17.9% on the toes. When they occurred on the
ngers, 38.5% were on the middle nger and 25.6% on the
index nger (Figs. 44.3, 44.4, 44.5, 44.6, 44.7, 44.8, 44.9 and
44.10).
Digital mucous cysts rarely disappear naturally, so in
most cases treatment is necessary, and there is a high possibility of recurrence. Various treatments such as repeated
puncture, sclerotherapy, intralesional steroid injections,
cryotherapy, and CO2 laser treatment are being performed,
but the problem is the high recurrence rate. There are reports
that radical excision, including the removal of the mucous
cyst, the part connecting the mucous cyst and the distal interphalangeal joint, and the bone spur of the joint boundary,
shows a high cure rate of about 95%. But the results depend
on the skill level of the surgical operation and aftereffects
may result in limitation of joint movement and permanent
damage to the nail matrix. I told Ms. E that she needs to
receive CO2 laser treatment and dressing for about 2 weeks,
and if there is a recurrence, surgery may be necessary.
Fig. 44.1 Digital mucous cyst observed on the second toe
© 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_44
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Fig. 44.2 Mucus observed by puncture
44 Digital Mucous Cyst
Figs. 44.3 and 44.4 Digital mucous cysts observed on the nger
Figs. 44.5 and 44.6 Digital mucous cyst
44 Digital Mucous Cyst
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Figs. 44.7 and 44.8 Digital mucous cyst
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Figs. 44.9 and 44.10 Digital mucous cyst
Onychogryphosis: Ram’s Horn Nails
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45
My mother who had a stroke has toenails that have
deformed like Ram’s horns and can’t be cut with a nail
clipper (Fig.45.1).
A 70-year-old woman, Mrs. B, who had difculty moving
after a stroke, was brought in by her son. Some of her toenails have grown large and hard like Ram’s horns, and he
asked for help because they couldn’t be cut with a nail clipper. In this case, if there are no special surgical tools, the
deformed toenails cannot be trimmed or removed, so it is
essential to always be prepared with good sterilization.
Onychogryphosis, also known as Ram’s horn nails, is a
nail disease where the thickness and length of the nail plate
increase abnormally due to congenital abnormalities or
acquired causes, and clinically, the nails look like a “‘Ram’s
horn.” Although there had been a report of case of 20-nail
onychogryphosis in Korea, it is a rare disease that usually
occurs on one or both big toenails, and it is extremely rare for
it to occur on other toenails, especially on ngernails.
Fig. 45.1 Extremely rare onychogryphosis of the third toenail
Initially, as the thickness of the nail plate increases and
hypertrophies and the length increases, it gradually worsens,
and due to the difference in growth speed on both sides, it
bends to one side, and the surface becomes uneven with horizontal grooves, showing a characteristic Ram’s horn shape.
The pathogenetic mechanism is not clear, but two hypotheses have been proposed. The rst is that it occurs when
there is a problem with the nail matrix under the proximal
nail fold, which attens the nail, and the second is when
there is excessive keratin proliferation from the nail bed. The
causes can be broadly divided into those due to embryological abnormalities and those that are acquired. Among them,
the most common is due to repeated trauma, which was often
seen in people who enjoyed horse riding in the past and was
also called Ostler’s nail. Congenital onychogryphosis affects
all nails and is most pronounced within 1 year after birth,
often appearing in the form of syndromes due to genetic
causes, and both autosomal dominant and recessive cases
have been reported. In the case of acquired, the most common are due to trauma or improper care of the nails, so it
often occurs in people who cannot manage their nails due to
diseases such as dementia, intellectual disability, chronic
alcoholism, schizophrenia, and stroke. In addition, it can be
caused by peripheral vascular disorders such as varicose
veins, thrombophlebitis, and aneurysms, or central and
peripheral nervous system diseases. Also, it can occur in
conjunction with onychomycosis, psoriasis, ichthyosis,
syphilis, elephantiasis, and pemphigus. The early lesion is
difcult to diagnose because only the hypertrophy of the nail
plate appears, but the hypertrophy of the nail plate and the
nail bed that occur later, and severe deformities of the nails
are important for diagnosis. Diseases that need to be differentiated clinically include pachyonychia congenita, epidermolysis bullosa, ectodermal dysplasia, and congenital
malalignment of the big toenail (Figs.45.2, 45.3, 45.4, 45.5
and 45.6).
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
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Fig. 45.2 Onychogryphosis (Ram’s horn nails)
45 Onychogryphosis: Ram’s Horn Nails
The treatment of onychogryphosis can use conservative
treatment methods or surgical resection and CO2 lasers
depending on the patient’s condition. Conservative treatment is applied to patients with peripheral vascular disease
or diabetes, and the thickened nail plate can be shaved off
with a drill, subungual hyperkeratosis can be removed, or
the pathological nail can be destroyed chemically using a
urea ointment or potassium iodide ointment. It is absolutely impossible to shape the nail a little with a general
nail clipper, so you must use a bone rongeur or a suitable
medical nail clipper. This disease often occurs in people
who cannot manage their nails due to diseases such as
dementia, intellectual disability, chronic alcoholism,
schizophrenia, and stroke, so it can be treated simply by
removing the nail plate, but regular follow- up observation
Fig. 45.3 Onychogryphosis
Figs. 45.4 and 45.5 Onychogryphosis
Fig. 45.6 Onychogryphosis
45 Onychogryphosis: Ram’s Horn Nails
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Fig. 45.7 Partial toenail removal using a CO2 laser
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is necessary to prevent recurrence along with education on
nail care. Surgical resection removes the nail plate and
resects the nail matrix and nail bed to permanently, and it
is reported that using a CO2 laser has the advantage that the
surgical method is simple, and the patient feels little discomfort after surgery. Although it’s not a wide-ranging
resection, I felt a great sense of accomplishment just by
neatly removing or trimming Mrs. B’s deformed toenails
(Figs.45.7, 45.8, 45.9 and 45.10).
Fig. 45.8 Method of removing part of the toenail using a bone
rongeur
Figs. 45.9 and 45.10 After partial removal of the nail plate for onychogryphosis
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