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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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Trichostasis Spinulosa
https://t.me/med1917
1
I have a lot of black dots on my nose. These are acne
blackheads, right? No, they are clumps of ne hairs
(Fig.1.1).
Mr. C, a 42-year-old man, recently became interested in
his facial skin and came for a consultation because he had
what he thought were blackheads, which are common during
puberty, all over his cheeks and nose. Upon closer examination with a magnifying glass, it was not blackheads (open
comedones) that had oxidized and turned black due to excessive sebum secretion, but rather multiple ne hairs (vellus
hairs) clumped together in the hair follicles. I explained,
“The numerous black dots on your nose and cheeks are not
blackheads. They are many ne hairs that have not fallen out
in time and are wrapped in keratinized material.” He
responded, “Really? I always thought they were blackheads
lled with sebum” (Fig.1.2).
Trichostasis spinulosa is a condition where vellus hairs do
not fall out, resulting in multiple bundles of vellus hairs in one
follicle. It is commonly observed on the face or back (especially between the shoulder blades) and clinically appears as
small, black, thorn-like keratin plugs, similar to blackheads or
keratosis pilaris. It is a relatively common disease rst named
in 1913. There is no difference in incidence between men and
women, and it can occur at any age, but it is more common in
middle-aged and elderly people and occasionally occurs in
children. The cause is not yet clear, but hair shedding being
inhibited or delayed by hair follicle hyperkeratosis, abnormal
hair follicle angulation, excessive normal cyclic activity of
hair papillae, damage to hair follicles due to external factors
(irritants, oil, or dust), yeast, or acne bacteria are suggested as
the causative agents. The group of protruding hairs buried in
the keratin lump in the follicle appears as dots like blackheads
on the nose, cheeks, forehead, shoulders, back, chest, etc.,
causing cosmetic problems. Most people have no particular
symptoms, but occasionally it can be accompanied by redness, scales, and itching. The duration of the disease varies
from several months to decades, but it is difcult to calculate
the exact duration of the disease because it is often not recognized properly because there are few subjective symptoms.
Histologically, the follicular opening is enlarged, and within
Fig. 1.1 Trichostasis spinulosa observed on the nose Fig. 1.2 Trichostasis spinulosa observed on the cheek
© 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_1
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1 Trichostasis Spinulosa
the enlarged hair follicle, a large number of vellus hairs are
bundled and wrapped in keratinous material, and the epidermis around the hair follicle shows hyperkeratosis and acanthosis. For diagnosis, if the lesion area is enlarged and
observed using a magnifying glass, dermoscope, or digital
scope, several vellus hairs can be observed at the entrance of
one hair follicle. Alternatively, if you extrude the keratin plug
with tweezers or a comedo extractor and then examine it
under a microscope, you can see that many vellus hairs are
surrounded by keratinized material. Recently, there have been
reports that standardized skin surface biopsy using cyanoacrylate, an instant adhesive commonly used to diagnose demodicidosis, is a cheap and easy diagnostic method for
trichostasis spinulosa. It is necessary to differentiate it from
keratosis pilaris, open comedones, eruptive vellus hair cysts,
and pili multigemini. Especially when there are lesions similar to open comedones that resist conventional acne treatment, it is important to denitely check for the presence of
trichostasis spinulosa (Figs. 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9,
1.10, 1.11, 1.12 and 1.13).
Fig. 1.3 Early lesion of trichostasis spinulosa on the nose—10×
magnication
Figs. 1.5 and 1.6 Early lesion of trichostasis spinulosa—200× magnication
Fig. 1.4 Early lesion of trichostasis spinulosa—60× magnication
1 Trichostasis Spinulosa
https://t.me/med1917
Figs. 1.7 and 1.8 Trichostasis spinulosa
3
Figs. 1.9 and 1.10 Very commonly observed trichostasis spinulosa
Fig. 1.11 When extruded with a comedo extractor, many vellus hairs
are observed to be clumped together
Fig. 1.12 150× magnication after extrusion
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Fig. 1.13 Treatment of trichostasis spinulosa using long-pulsed alexandrite laser
1 Trichostasis Spinulosa
For treatment, topical keratolytics or hair removal
agents, topical and systemic retinoids are used, but they
are not satisfactory and only show temporary improvement. For cosmetic effects, it can be removed using a
comedo extractor or cilia forceps, but regular procedures
are required, and there is a problem that it takes a lot of
time to remove each one when it occurs in a wide area.
Laser hair removal treatment using a long-pulsed alexandrite laser, etc., is being attempted for permanent treatment effects. Mr. C decided to undergo follow- up
observation while receiving treatment ve times at
1-month intervals. After receiving the treatment, he left
the laser treatment room again saying, “I thought it was
just a blackhead, but it’s really surprising that it’s just a
bunch of downy hairs!”
Erythema Infectiosum
https://t.me/med1917
Suddenly, our granddaughter’s face turned red as if she
had been slapped, and after a while, a red rash in the
shape of a net appeared on her arms and legs (Fig.2.1).
A 60-year-old woman, D, who is receiving whitening
rejuvenation treatment, brought her 6-year-old granddaughter who had developed a net-like red rash on her arms and
legs a few days ago. When I asked, “Did her cheeks turn red
before the rash appeared on her arms and legs?” she immediately showed me a photo she had taken on her phone
(Figs.2.2 and 2.3).
Erythema infectiosum, also known as fth disease, is an
infection caused by parvovirus B19. It is characterized by an
asymptomatic erythema on the cheeks, followed by a netlike erythematous rash or papules on the body, neck, or
limbs. It was rst proven to be a distinct disease in 1896 and
was named “erythema infectiosum” in 1899. It is primarily
transmitted through respiratory secretions, but transmission
through blood is also possible. The virus spreads before the
2
Fig. 2.1 Erythema infectiosum rash observed on the arms and legs
Figs. 2.2 and 2.3 Erythema infectiosum on the face and limbs
© 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_2
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2 Erythema Infectiosum
skin rash appears, and after the rash appears, it is not contagious. Parvovirus B19 can infect people of all ages, but erythema infectiosum mainly occurs in school-age children
(5–14 years old) in spring and winter. After an incubation
period of 4–14days (average 7days), prodromal symptoms
such as low fever, fatigue, runny nose, headache, abdominal
pain, and loss of appetite appear 1–2days before the rash.
The rash initially appears on the cheeks as a clear, slightly
raised, asymptomatic erythema, as if the cheeks have been
slapped (“slapped cheek”), with the area around the mouth
being pale. This phenomenon is not common in adults, but
arthritis symptoms are more common (Fig.2.4).
The cheek rash disappears after 1–4days, and then erythematous spots or papules about 3–5mm in size appear on
the body, neck, and limbs. The initial rash is small and scattered but gradually spreads and becomes a net-like rash as
the center of the rash clears. The skin lesions do not leave
scales and improve after 5–9days, but the rash can recur and
persist due to sunlight, heat, exercise, stress, etc. Arthritis,
the most common complication of erythema infectiosum, is
rare in children (less than 10%), but more than 80% of adult
women experience arthritis, which can range from mild joint
pain to clear arthritis. In conditions such as sickle cell anemia, hereditary spherocytosis, and chronic hemolytic anemia, a temporary aplastic crisis can occur, and in
immunodecient patients, it can cause aplastic anemia. Also,
it has been reported that clinical manifestations such as fetal
hydrops or intrauterine death appear in about 5–10% of pregnant women conrmed with parvovirus infection. In addition, cytopenia, vascular purpura, kidney lesions, and
infections in immunocompromised patients can occur. The
diagnosis of erythema infectiosum is usually easily possible
with characteristic clinical ndings. The most sensitive test
is the polymerase chain reaction (PCR), which can detect
viral DNA most sensitively, and while IgM antibodies are
positive in 80% even 4–6 months after the onset of symptoms, PCR becomes negative quickly, so it has been reported
that PCR testing is more useful for the diagnosis of acute
lesions (Figs.2.5, 2.6, 2.7, 2.8, 2.9, 2.10, 2.11, 2.12, 2.13,
2.14, 2.15 and 2.16).
Fig. 2.4 Cheek rash in erythema infectiosum (“slapped cheek”)
Figs. 2.6 and 2.7 Facial lesions of erythema infectiosum
Fig. 2.5 Red erythema as if slapped on the cheek and pale around the
mouth observed in erythema infectiosum
2 Erythema Infectiosum
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Figs. 2.8 and 2.9 Arm lesions of erythema infectiosum
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Figs. 2.10 and 2.11 Arm lesions of erythema infectiosum
Figs. 2.12 and 2.13 Leg lesions of erythema infectiosum
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Figs. 2.14 and 2.15 Leg lesions of erythema infectiosum
Fig. 2.16 Trunk lesions of erythema infectiosum
There is no specic antiviral treatment for parvovirus
B19 infection. The treatment of erythema infectiosum is by
symptomatic therapy, and joint pain is relieved by aspirin
or ibuprofen. Let the child rest, avoid bathing in hot water
2 Erythema Infectiosum
if possible, and avoid exposure to ultraviolet rays. In the
case of aplastic crisis, red blood cells are transfused until
the hemoglobin level increases. Intravenous immunoglobulin is effective for chronic infection in immunodecient
patients. There is no vaccine for parvovirus B19 yet, and
although this virus is mainly transmitted through the respiratory tract, patients with clinical symptoms already have
low or no infectivity, so there is no need to isolate even if
there are erythema infectiosum patients in kindergartens or
schools. However, patients with aplastic crisis are infectious, so immunocompromised patients or hemolytic anemia patients who can develop severe anemia if infected
with this virus need to be isolated from these patients. The
problem is that it is very difcult to prevent parvovirus
B19in advance of group outbreaks or in people who can
have serious complications like pregnant women because
most parvovirus B19 infected patients have no symptoms
when the virus is most excreted. After hearing a detailed
explanation about erythema infectiosum, D said, “Until
now, I only knew about measles, chickenpox, and hand,
foot, and mouth disease, but now there are all kinds of
strange diseases!”
Giant Comedo
∗∗∗
https://t.me/med1917
3
There’s something strange that looks like a big eyeball on
my grandfather’s back (Fig.3.1).
The grandson of Mr. P, a man in his 70s, spoke with a
rather worried expression. “Our grandfather asked us to look
at something that had grown on his back, and oh my gosh!
There was something strange bulging out of his skin, looking
like a big eyeball!” I was really curious about what it was, so
I even put on a loupe to take a closer look.
Giant comedo primarily appears on the back of middle- aged
or elderly people over a long period of time, gradually growing into a dome-shaped or semi-spherical nodule. The nodule has an opening at the top, exposing hard contents that are
brown, gray, or black. Comedones are formed by the accumulation of keratin and sebum due to keratinization of the
follicular epithelium. The main factors contributing to the
formation of comedones are excessive sebum secretion from
the sebaceous glands, excessive keratinization at the pore
entrance, and abnormal bacterial strains, similar to the case
of acne (acne vulgaris). However, another reason for the formation of comedones is the degeneration and regression of
connective tissue, especially elastic bers, as seen in senile
comedones. The formation of giant comedones is usually
due to senile degeneration of connective tissue. After initial
formation, the keratin plug inside the opening gradually
grows without inammation over a long period of time, and
its shape changes. It can occur anywhere on the body, but it
mainly occurs on the back, chest, and face, where there is a
lot of sebaceous gland distribution. However, sometimes it is
found in the apocrine sweat gland areas such as the armpits,
the scrotum, around the anus, and the groin. The lesions are
usually several mm to cm in size, and the larger ones are usually found on the back, presumably because this area is not
visible and not easily reached by hand. The surface of the
nodule is pale or translucent, and there are no subjective
symptoms such as itching or pain. Histologically, the contents are composed of layered keratin, similar to what is
observed in epidermal cysts (Figs.3.2, 3.3, 3.4 and 3.5).
Fig. 3.1 Giant comedo observed on the back Fig. 3.2 Giant comedo
© 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_3
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Figs. 3.3 and 3.4 Extrusion of the contents of the giant comedo
3 Giant Comedo
Due to the greatly expanded opening, the contents can be
easily removed simply by placing gauze on both sides of the
lesion and gently squeezing it with pressure with two ngers.
Since the follicular duct usually lls up again after 2–3months,
it is thought necessary to perform cauterization or surgical
excision after removing the contents, but it is still difcult to
nd literature reporting on effective treatment methods.
Fortunately, in Mr. P’s case, the contents of the giant comedo
were easily extruded without serious damage, and it was
decided to observe it for a few days while dressing it.
Fig. 3.5 Giant comedo observed on the back of a middle-aged woman
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