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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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Allergic Contact Dermatitis, Contact
https://t.me/med1917
Dermatitis
61
My wrist hurts, and I put a PAS (pain relief patch) on it,
but the spot turned red and small blisters appeared, and
it’s very itchy. Is there a problem with the patch?
Ms. L, a 34-year-old woman, suddenly felt pain in her
wrist, so she briey applied a patch at home. Afterwards, the
area where the patch was applied became itchy, red, and
many small blisters appeared, so she came for treatment.
“Isn’t there a problem with this patch? What if they sell
something like this?” she asked, and asked for a medical certicate, saying that the pharmaceutical company that produces the patch should compensate for the treatment cost
(Fig.61.1).
Contact dermatitis is a type of eczematous dermatitis that
occurs due to contact with external substances and can be
classied into allergic contact dermatitis and irritant contact
dermatitis. Irritant contact dermatitis occurs in anyone when
irritation exceeds a certain concentration, but allergic contact
dermatitis does not occur in anyone even if the skin comes
into contact with a causative substance called an allergen or
Fig. 61.1 Allergic contact dermatitis that occurred after applying a
PAS (pain relief patch) to the wrist
antigen. In particular, it can be dened as a case where
eczematous dermatitis occurs only in people who are specically sensitized to the substance. Since the lesion is manifested by a delayed-type hypersensitivity (type IV), it should
be distinguished from contact urticaria, which is presumed to
be due to non-immunological mechanisms or immediate
hypersensitivity (type I), where hives immediately appear at
the contact site when in contact with a specic substance.
The pathogenesis of allergic contact dermatitis can be
divided into sensitization and elicitation phases, and it generally occurs within 12–48h after exposure to the antigen in a
sensitized state and lasts for 3–4weeks. The primary symptom is itching, which induces a desire to scratch or rub the
skin, ranging from a simple tingling or prickling sensation to
unbearable severe itching. This itching appears suddenly or
persistently and varies depending on the body part or individual. There are some differences in the shape, distribution,
and contour of the lesions between various other forms of
eczema and allergic contact dermatitis. That is, the rash
occurs at the exposure or contact site, shows an articial pattern, and is characterized by clear boundaries, small angles,
and straight lines. Therefore, if the rash appears in a peculiar
shape, allergic contact dermatitis can be suspected rst
(Figs.61.2, 61.3, 61.4, 61.5, 61.6 and 61.7).
The typical acute stage skin lesions of allergic contact
dermatitis consist of erythema and linear or grouped vesicles
and bullae, and exudate may come out when the bullae burst
due to stimulation (Figs.61.8–61.11).
In the subacute stage, the exudate gradually decreases
over several days, and erythema and scales with unclear
boundaries appear. In the chronic stage, the lesions become
dry, scaly, thickened, and in some cases, lichenied
(Figs.61.12–61.15 and 61.16–61.19).
I explained to Ms. L that there are two types of contact
dermatitis caused by contact. And then I said “Irritant contact dermatitis is a case in which everyone develops contact
dermatitis when exposed to that level of stimulation, but
© 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_61
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Figs. 61.2 and 61.3 Allergic contact dermatitis caused by PAS (pain relief patch)
61 Allergic Contact Dermatitis, Contact Dermatitis
Figs. 61.4 and 61.5 Allergic contact dermatitis caused by a patch containing ketoprofen applied to a painful area
Figs. 61.6 and 61.7 Allergic contact dermatitis that occurred after applying a nicotine patch as a smoking cessation aid
61 Allergic Contact Dermatitis, Contact Dermatitis
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249
Figs. 61.8–61.11 Acute stage skin lesions of allergic contact dermatitis
allergic contact dermatitis is a case in which only those who
are sensitive develop contact dermatitis. You didn’t attach it
for that long, and the dermatitis occurred exactly at the contact area, so I think this is allergic contact dermatitis.” Then
she said, “But please at least write a conrmation. I should at
least receive compensation for treatment costs from the pharmaceutical company!”
250
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61 Allergic Contact Dermatitis, Contact Dermatitis
Figs. 61.12–61.15 Subacute stage skin lesions of allergic contact dermatitis
61 Allergic Contact Dermatitis, Contact Dermatitis
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251
Figs. 61.16–61.19 Chronic stage skin lesions of allergic contact dermatitis
Drug Eruption
https://t.me/med1917
62
I went to the mountain and sprained my ankle, took an
anti-inammatory analgesic, and red rashes spread all
over my body (Fig.62.1).
A woman in her 20s, P, went to the mountain, sprained her
ankle, was prescribed an anti-inammatory analgesic, she
suddenly got a red rash all over her body and came to get
treatment. “No matter I think there’s no cause other than taking the medicine, why is this happening?” she asks. In this
case, since a symmetric erythematous rash suddenly occurred
all over the body, the possibility of a drug rash is the greatest
(Fig.62.2).
Drug eruption refers to a rash on the skin caused by an
abnormal reaction to a drug. It is the most common among
drug abnormal reactions, and the lesion suddenly occurs and
is widely distributed symmetrically. Other systemic organ
involvement is mild, and since it is related to drug administration, it improves when the drug is discontinued. Knowing
that a specic drug often causes a specic lesion can help in
identifying the cause and diagnosing. However, it is important to keep in mind that new drugs are continuously being
developed and frequently used drugs change depending on
time and place, so the causative drug also changes. Depending
on the form of lesion, eruptive drug rashes similar to lesions
caused by viral or bacterial infections, drug eruptions that
appear in the form of urticaria, and xed drug eruptions in
which similar lesions continuously occur in the same area
are relatively common. In addition, it also shows a variety of
clinical manifestations, including drug eruptions similar to
acne or folliculitis, drug eruptions with blisters, drug eruptions similar to erythema multiforme and pemphigus, drug
eruptions with peeling of the skin all over the body, drug
eruptions with nodules forming in the subcutaneous fat layer,
lichenoid drug eruptions, drug eruptions that look similar to
lupus erythematosus, drug eruptions with purpura where
blood vessels in the skin burst, photosensitive drug eruptions
that occur mainly in areas exposed to sunlight, and drug
eruptions similar to pityriasis rosea. It usually heals well, but
Fig. 62.1 Drug eruption that occurred after taking anti-inammatory
analgesics Fig. 62.2 Drug eruption observed on the back
© 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_62
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Fig. 62.3 Drug eruption appearing as hives after taking antibiotics
62 Drug Eruption
conditions such as exfoliative erythroderma, leukocytoclastic vasculitis, drug-induced hypersensitivity syndrome,
Stevens-Johnson syndrome, toxic epidermal necrolysis, and
anaphylaxis can lead to serious consequences (Fig.62.3).
The diagnosis of drug eruption involves patient history,
discontinuation of suspected drugs, skin tests, genetic mutation tests, provocation tests, and laboratory tests, but it is not
easy. Also, while a specic drug can often cause a specic
type of lesion, it is not accurate to infer the cause of a specic
drug eruption from the name of the drug alone, as it does not
only cause one type of lesion (Figs.62.4–62.11).
The treatment of drug eruption involves discontinuing all
suspected drugs if possible, replacing them with drugs that
do not cross-react, and administering steroids or antihistamines depending on the symptoms. However, if there is no
alternative drug essential for the patient’s treatment, desensitization therapy can be performed to maintain mast cells that
specically react to antigens in a state where they can no
longer respond. I explained to Ms. P that she needs to stop
taking his current medication and needs about 5–7days of
treatment. Also, I asked him to make a note of the name of
the drug that caused the reaction and to always inform the
doctor in advance at each visit.
62 Drug Eruption
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255
Figs. 62.4–62.11 Drug eruption showing various forms
Prurigo, Prurigo Simplex
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63
My skin is breaking out as if I’ve been bitten by something, but it’s not an insect bite and the itching is driving
me crazy (Fig.63.1).
Mr. K, a man in his 40s, has been suffering from unbearable itching on his lower abdomen and both sides of his waist
for some time. The itchy rash, which looks like he’s been
bitten by something, is symmetrically popping up on both
sides, but it’s denitely not an insect bite. He asks, “I’ve been
everywhere, and they all say it’s an allergy, but what kind of
disease is this?” (Figs.63.2 and 63.3).
Prurigo is a dermatological term that has been used for a
long time without a precise denition, and its position in disease classication is still unclear. Although it is a difcult
and burdensome disease to treat, the epidemiology, causes,
clinical features, natural progress, and treatment methods
have not yet been thoroughly reviewed. Only recently, discussions on denitions, classications, and terminology
have begun. Prurigo simplex is characterized by severe pru-
Fig. 63.1 Prurigo observed on the lower abdomen
ritus, presenting as papular or nodular rashes, and is classied into acute, subacute, and chronic forms. According to
recent classications, chronic prurigo refers to cases with
chronic pruritus lasting more than 6weeks, a history and/or
signs of repetitive scratching, and multiple pruritic skin
lesions localized or generalized. Clinically, it is classied
into (1) papular, (2) nodular, (3) plaque, and (4) umbilicated
forms. It has also been further divided into polymorphic
chronic prurigo and nodular prurigo. Although further discussions are needed for acute and subacute prurigo, acute
prurigo is often described synonymously with papular urticaria, which mainly occurs in infants and children, and subacute prurigo is known by synonyms such as papular
dermatitis and subacute prurigo simplex. Acute prurigo simplex primarily presents with papular urticaria lesions, while
subacute and chronic prurigo show papules, excoriations
(scratches, erosions, crusts), hyperpigmentation, and
hypopigmentation. The cause of subacute prurigo is still
unclear, but it mainly occurs in women after middle age. It is
known to be associated with psychosocial stress and can be
associated with diabetes, atopy, hypertension, renal and liver
dysfunction, lymphoma, Hodgkin’s disease, leukemia, internal malignancies, polycythemia, gout, pregnancy, etc. Very
severe pruritus is induced, and the typical lesion is a prurigo
papule, which is mainly hemispherical with a vesicle at the
end. The vesicle on the papule often disappears when
scratched, so it is often observed as a crusted papule.
Sometimes, initial vesicular papular lesions and late scratchinduced scar lesions are observed simultaneously. It mainly
occurs symmetrically on the trunk and limbs and also on the
face, neck, lower abdomen, and buttocks. Polymorphic
chronic prurigo occurs mainly in middle-aged and older
men, where exudative or hard papules combine to form an
invasive plaque on the trunk and legs. Continuous scratching
due to pruritus results in a mixture of prurigo papules with
exudate and crusts and lichenied lesions. Other types
include prurigo nodularis, prurigo pigmentosa, and prurigo
gestationis.
© 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_63
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Figs. 63.2 and 63.3 Prurigo
63 Prurigo, Prurigo Simplex
Fig. 63.4 Subacute prurigo
The diagnosis of prurigo can be made through detailed
history taking and visual examination and must be differentiated from scabies, insect bites, atopic dermatitis, contact dermatitis, dermatitis herpetiformis, pityriasis lichenoides et
varioliformis acuta, papuloerythroderma of Ofuji, and physical urticaria. The histological ndings of prurigo simplex are
not characteristic, often observed in insect bites, with spongiosis of the epidermis and inltration of monocytes and
eosinophils around the dermal vessels (Figs.63.4, 63.5, 63.6
and 63.7).
Fig. 63.5 Prurigo
Topical steroids and oral antihistamines are used for the
primary treatment of prurigo. Initially, medium-strength topical steroids are used, but if there is no response, highpotency topical steroids should be applied. There are reports
on the efcacy of the topical calcineurin inhibitor tacrolimus. Each lesion can disappear with intralesional triamcinolone injection, but if this treatment method is not effective,
phototherapy can be attempted. I explained to Mr. K that he
should never scratch and that he needed maintenance treatment to prevent recurrence after completely eliminating the
symptoms with consistent treatment.
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