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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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57 Cement Dermatitis
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233
Figs. 57.7–57.10 Cement dermatitis that occurred after direct contact with cement
Phytophotodermatitis, Lime-Induced
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Phytophotodermatitis
58
I’m worried because I have a lot of dark spots like freckles on my hands and arms after traveling to Southeast
Asia (Fig.58.1).
Mr. S, a man in his 30s, came for treatment worried about
the numerous spots that appeared on his right hand and arm
after a recent trip to Southeast Asia. When I said, “You
squeezed the lime with your bare hands and sprinkled it on
your food, didn’t you?” he asked, “How did you know that?”
Phytophotodermatitis is a phototoxic skin disease that
occurs when exposed to ultraviolet light (especially UVA)
after contact with plants containing photosensitive substances such as psoralen, 8-methoxypsoralen,
5- methoxypsoralen, and other furocoumarins. Erythema in a
patchy or linear pattern, swelling, and blisters occur within a
few hours after contact with citrus fruits such as lime, lemon,
and grapefruit, or celery, gs, wild parsnip, etc. and leave
pigmentation as the acute lesions disappear. This disease can
often be mistaken for cellulitis, tinea, allergic contact dermatitis, etc., so caution is needed. Especially, berloque dermatitis, which occurs after using eau de cologne or perfume
containing bergamot oil extracted from the fruit peel of bergamot (Citrus bergamia), causes pigmentation with or without preceding erythema on the area where the perfume was
sprayed after exposure to sunlight (UVA) due to the photosensitive ingredient bergapten (5-methoxypsoralen).
However, this ingredient is found in various plants and fruits
besides bergamot, and the dermatitis caused by it is classied
as phytophotodermatitis, not berloque dermatitis (Fig.58.2).
The g tree (Ficus carica), which belongs to the Moraceae
family, is known in Korea as a plant that commonly causes
phytophotodermatitis, with the furocoumarins in g leaves
playing a major role. If g leaf juice is applied and exposed
to sunlight, erythema occurs in the exposed area, gradually
turning into vesicular rash, and after healing, the skin lesions
show pigmentation that lasts for several months. There have
been reports of cases in Korea where g leaf juice was
applied for the treatment of psoriasis, causing phytophotodermatitis (Fig.58.3).
Fig. 58.1 Phytophotodermatitis caused by lime
© 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_58
Fig. 58.2 Phytophotodermatitis that occurred after exposure to sunlight after contact with lime
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58 Phytophotodermatitis, Lime-Induced Phytophotodermatitis
Lime is an evergreen shrub of the Rutaceae family, native
to India and cultivated in Sri Lanka, the Mediterranean coast,
Mexico, etc. The fruit is about 4cm in diameter and is harvested when it is green, turning yellow when ripe. The peel
is thin, and the fruit is white with a bluish tint, with plenty of
Fig. 58.3 Phytophotodermatitis that occurred after contact with gs at
a g farm
juice and a strong sour taste and aroma, so it is eaten raw or
used as a source of juice and citric acid. Phytophotodermatitis
typically develops erythematous patches with clear boundaries, may be accompanied by blisters, and may cause itching
and pain. However, sometimes, as in the case of phytophotodermatitis caused by lime, pigmentation may suddenly occur
without any other symptoms. Recently, there have been
many cases of people coming in with many freckles or
lentigines- like hyperpigmentation on their hands or arms
after squeezing limes with their bare hands and sprinkling it
on food while traveling in countries with strong sunlight. In
this case, a thorough history taking of contact with citrus
plants and overseas travel (exposure to sunlight) within
1–2weeks before pigmentation appears should be conducted
to avoid misdiagnosis. This pigmentation caused by lime is
known to disappear naturally without any special treatment
in 2–3months, and in cases where it persists for a long time,
application of hydroquinone preparations or azelaic acid
ointment and low-uence Q-switched Nd:YAG laser treatment have been shown to be effective. Mr. S decided to apply
sunscreen well and observe regularly for a while, and if the
pigmentation lasts for a long time, he decided to receive laser
treatment (Figs.58.4, 58.5, 58.6 and 58.7).
Figs. 58.4 and 58.5 Phytophotodermatitis caused by lime
58 Phytophotodermatitis, Lime-Induced Phytophotodermatitis
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Figs. 58.6 and 58.7 Lime phytophotodermatitis—photos at rst visit and 5weeks later
237
Contact Dermatitis DuetoPlants,
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Urushiol-Induced Contact Dermatitis
59
After going to the mountains on the weekend and coming
in contact with lacquer tree, my arm got red and swollen,
small blisters appeared, and it’s incredibly itchy
(Fig.59.1).
Mr. K, a man in his 30s, came for treatment after developing small blisters and severe itching on his arm, which had
turned red as if a line had been drawn, after visiting the
mountains a few days ago. “I went to the mountains over the
weekend, and I think I’ve been exposed to lacquer. I’m very
sensitive to lacquer, so I don’t even go near lacquer trees, but
I must have brushed against one without realizing it! It’s
incredibly itchy!” he said.
Human skin has many opportunities to come into contact
with various plants, and as a result, contact dermatitis due to
plants can commonly occur. Contact dermatitis caused by
plants can be broadly divided into irritant contact dermatitis,
Fig. 59.1 Allergic contact dermatitis caused by contact with a lacquer
tree
allergic contact dermatitis, phytophotodermatitis, and
pseudo-phytophotodermatitis, among which allergic contact
dermatitis has the highest frequency. Many types of plants,
such as trees, grass, owers, vegetables, fruits, and herbs,
can be potential causes of allergic contact dermatitis. The
rash caused by plants can vary greatly in form, but usually
small vesicles appear with signicant swelling. After becoming sensitized to the active substances present in plants, a
characteristic dermatitis occurs when contact is made again.
It usually takes several hours to a few days for symptoms to
appear after contact. The characteristic lesions that appear in
groups along a line are probably caused by the edges of
leaves or broken branches brushing against the skin or by
antigens stuck under the patient’s ngernails. However, contrary to popular belief, it is known that the liquid substance
in the vesicles does not create new lesions. Widespread or
strange patterns of inammation can occur when plant antigens are obtained from contaminated animal fur or clothing
or from smoke produced when plants burn. People have
many opportunities to be exposed to plants, knowingly or
unknowingly. In other words, there are always opportunities
to be exposed to plants, whether at work, at home, or when
visiting public or special places. Therefore, suspecting plants
as a cause in all cases of contact dermatitis results in a faster
diagnosis of allergic contact dermatitis caused by plants
(Figs.59.2 and 59.3–59.8).
For Mr. K, who has severe lacquer allergy, I provided wet
dressing using Burow’s solution for quick symptom improvement and prescribed oral antihistamines and topical steroid
cream. However, at least 5–7days of treatment is required,
and the rst treatment for allergic diseases is “avoidance of
the cause,” so I asked him not to eat lacquer chicken, lacquer
shoots, etc., and also not to eat mangoes, cashew nuts, and
pistachios, which belong to the same lacquer tree family.
© 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_59
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Fig. 59.2 A branch of lacquer tree brought by another patient
59 Contact Dermatitis DuetoPlants, Urushiol-Induced Contact Dermatitis
59 Contact Dermatitis DuetoPlants, Urushiol-Induced Contact Dermatitis
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241
Figs. 59.3–59.8 Vesicular lesions on a line, typically observed in allergic contact dermatitis caused by plants
Psychogenic Urticaria
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60
I get hives all over my body if I just get nervous. But can
hives really occur due to nervousness? (Fig.60.1).
A 26-year-old woman, Ms. A, came for treatment saying
that she suddenly got hives on her body after getting severe
stress at work a while ago, and since then, she gets hives if
she just worries. “Is there such a thing as hives caused by
mental stress? If I just worry, not only all over my body but
also my palms are so itchy.” She was struggling (Fig.60.2).
There is a medical term called psychogenic urticaria, and
it has long been widely believed that psychological stress
triggers acute urticaria and is involved in the pathogenetic
mechanism of chronic urticaria. Also, severe stress exacerbates the urticarial reaction regardless of the primary cause
that triggered the urticaria. Sometimes, stress appears to trigger angioedema, known as angioneurotic edema, over a long
period of time. According to one study, 81% of patients with
chronic idiopathic urticaria believe that their disease is due to
stress. However, the evidence base for this belief that stress
triggers urticaria is surprisingly limited (Fig.60.3).
Psychogenic urticaria is classied into an acute emotional
form that occurs after a specic event with a clear cause-andeffect relationship, and a chronic recurrent form that seems
to be deeply rooted in psychodynamics as a psychosomatic
disorder. In 30–81% of patients with psychogenic urticaria,
severe stress from life’s some events precede the rst occurrence of hives. These range from major life events such as
earthquakes, bereavement or accidents, and severe traumas,
to chronic and persistent stress such as family, marriage, or
work problems. There are various discussions about how
stress causes and exacerbates hives through certain psychological and physiological processes, but it is known that
stress increases plasmin activity, which induces the release
of kinins and increases the permeability of capillaries, leading to hives. Also, emotional tension itself is explained to
lower the threshold for the occurrence of skin rashes, making
rashes appear more easily. Recently, dehydroepiandrosterone
sulfate (DHEAS) has been reported to play an important role
as a possible mediator in the relationship between stress and
Fig. 60.1 Psychogenic urticaria Fig. 60.2 Psychogenic urticaria
© 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_60
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Fig. 60.3 Angioedema caused by stress
60 Psychogenic Urticaria
hives. In some patients with chronic urticaria, blood DHEAS
levels are low during the active phase of the disease, and low
DHEAS is associated with greater mental distress, such as
high anxiety and depression scores. And patients with
chronic idiopathic urticaria have been reported to have a
higher rate of anxiety, depression, and mental disorders compared to healthy controls. However, I told Mr. A that although
there are such reports on psychogenic urticaria, it is not easy
to diagnose psychogenic urticaria, and I decided to do some
allergy tests using blood and some provocation tests to see if
there are other causes of hives (Figs.60.4, 60.5, 60.6, 60.7,
and 60.8–60.10).
Figs. 60.4 and 60.5 Can hives occur due to psychological reasons?
Figs. 60.6 and 60.7 Patient who claims hives occur due to nervousness
60 Psychogenic Urticaria
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Figs. 60.8–60.10 Patients who claim hives occur when they are nervous
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