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Figs. 65.3 and 65.4 Tinea faciale
65 Tinea Faciei: Tinea Faciale
Fig. 65.5 Tinea faciale
Fig. 65.6 Tinea incognito on the face
Fig. 65.7 Tinea faciale spread to the neck
causative fungus, so in adult patients with tinea faciale, a
comprehensive mycological investigation to nd the primary
lesion such as nail fungal infection and thorough treatment
are necessary. K’s mother said, “A fungal infection on my
child’s face? Her father has severe athlete’s foot, I should tell
him to get treatment quickly!” and left the examination
room.
Frostbite DuetoAIR PAS (Pain Relief
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Cold Spray)
66
My child was playing with the AIR PAS (pain relief cold
spray) and this strange side effect appeared on his skin.
The mother of a 13-year-old boy, H, said, “My child was
playing with AIR PAS (pain relief cold spray) I used when I
sprained my ankle, and a side effect like a coin appeared on his
skin!” On closer inspection, indeed, dark brown lesions that
look like the process of blistering into various large and small
coin sizes and transitioning into scabs were observed on both
wrists and the back of the left hand (Figs.66.1, 66.2 and 66.3).
These skin lesions, which appear when an AIR PAS is
sprayed close to the skin for several seconds, are skin damage caused by liqueed petroleum gas (LPG) used as a spray
agent for aerosol preparations, rather than side effects caused
by the main or auxiliary ingredients of the drug. LPG itself is
not a substance that causes damage to the skin, but because
its vaporization temperature is below 0 degrees, spraying it
too close for a few seconds can cause a condition similar to
frostbite on the skin. For this reason, the product’s instructions include a warning in red saying, “Spray from a distance
of more than 20cm and do not spray the same area for more
than 3 seconds.” to remind consumers to be cautious.
According to the Consumer Safety Center’s Food and Drug
Safety Information, it is currently difcult to secure immediate alternatives excluding substances subject to environmental regulations such as Freon, and companies are striving to
secure alternatives. Consumers are warned to be aware of
this when using spray AIR PAS. For H’s skin lesions, it
should be treated similarly to frostbite, and proactive treatment for about 2weeks is necessary to minimize sequelae
such as hyperpigmentation and scars.
Figs. 66.1 and 66.2 Coin-shaped lesions found on the hand, wrist, and arm
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
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Fig. 66.3 Coin-shaped lesion caused by spray AIR PAS
66 Frostbite DuetoAIR PAS (Pain Relief Cold Spray)
Acne: Acne Diagnosis
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67
I keep having skin troubles on my face. Is it acne? Is it
folliculitis? Or is it because I’m using cosmetics wrong?
Ms. L, a woman in her 20s, sat in the consultation room
and said, “But I used to have really good skin. Recently, I
suddenly have skin troubles on my face. Is this acne? Is it
folliculitis? Or is it because I’m using cosmetics wrong? I’m
really suffering.” In such cases, I must look for comedones,
which are immovable evidence of acne on the skin. If there
are comedones, it’s acne; if not, it’s another disease
(Figs.67.1 and 67.2).
Acne vulgaris is a chronic inammatory disease of the
pilosebaceous unit that often occurs during puberty, characterized by distinctive comedones, erythematous papules,
pustules, and sometimes nodules, pseudocysts, and scars. It
most frequently occurs between the ages of 16 and 19 in
males and between 14 and 16 in females, as females hit
puberty earlier. It usually begins to disappear from the mid20s, but recently, adult acne that persists or newly occurs
after the age of 25 is increasing, with a higher frequency in
women and unlike adolescent acne, it often occurs on the
chin, jawline, and neck. Acne vulgaris lesions usually appear
on the face, neck, back, and chest, where sebum secretion is
high. Initially, lesions appear on the face, but over time they
also occur on the trunk, with a large number of lesions distributed along the body’s midline. In some cases, even after
facial lesions disappear, trunk lesions can remain for a long
time, a phenomenon more common in men (Fig.67.3).
Acne lesions can be distinguished into non-inammatory
lesions called comedones and inammatory lesions such as
small papules, pustules, and nodules, but they usually appear
mixed. Non-inammatory lesions, or comedones, are formed
by the accumulation of keratin and sebum due to keratinization of the follicular epithelium, mainly consisting of closed
comedones (whiteheads) and open comedones (blackheads).
Open comedones are formed by the expansion of the follicular opening due to the accumulation of keratin and sebum,
and when observed with the naked eye, they appear as at or
slightly raised lesions with black material composed of keratin and sebum in the center of the follicle. That is, when the
follicle is blocked by keratin and sebum, forming a kerati-
Fig. 67.1 Acne lesions on the face
© 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_67
Fig. 67.2 Comedones (blackheads and whiteheads)—60×
magnication
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67 Acne: Acne Diagnosis
nous plug, it forms a closed comedone, and when the opening of the sebaceous follicle widens, it becomes an open
comedone. The plug is not caused by dust or contaminants
from the outside but is a mixture of the products of the keratinization process of the follicular epithelium and sebum
derived from the sebaceous glands, and the exposed part
appears black due to oxidation, hence it is called a blackhead. Closed comedones are formed when sebum and keratin
increase in the follicle and it becomes difcult to discharge
them outside, blocking the follicular canal, and keratin and
sebum accumulate in the lower part of the follicular opening.
Of course, closed and open comedones often occur mixed,
but clinically, closed comedones are reported to be more
common than open comedones. Whiteheads, also known as
closed comedones, are mostly lesions of macules or papules
with a diameter of less than 1mm, and since the follicular
opening is blocked, there is a possibility of progressing to
inammatory lesions, which is clinically very important.
Closed comedones are slightly raised or in the form of small
papules, and clinically, the opening is not easily visible, so it
is easy to miss if not carefully observed. Therefore, thorough
inspection and palpation should be performed to conrm the
presence of closed comedones. Stretching the skin on both
sides to observe is a very important examination method for
diagnosing these non-inammatory acne lesions. That is, if
there are ambiguous macules or papular lesions, lightly
stretching the skin on both sides can easily observe hidden
closed comedones in the case of acne (Figs.67.4, 67.5, 67.6,
67.7, 67.8 and 67.9).
Fig. 67.3 Coexistence of non-inammatory and inammatory lesions
observed in acne vulgaris
Figs. 67.6 and 67.7 Acne diagnosis method to nd hidden comedones
Figs. 67.4 and 67.5 Hidden comedones are discovered when the skin
is stretched
67 Acne: Acne Diagnosis
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Figs. 67.8 and 67.9 Numerous comedones appearing when the skin is stretched
275
If acne is not treated in time and appropriately, various
sequelae may occur. These include erythema, hyperpigmentation, enlarged pores, and scars, and whether these sequelae
occur depends entirely on how acne was treated and managed, which applies equally to everyone. Therefore, it is
important to accurately diagnose and explain well so that
timely treatment can be received. After a careful examination, I told Ms. L, “You denitely have acne, as evidenced by
blackheads and whiteheads. Don’t miss the timing to get
proper treatment so that sequelae like scars or enlarged pores
don’t damage your quality of life!”
Macrocomedones
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68
The pimples on my face seem to be bigger than other
people’s pimples. Is there something else wrong?
(Fig.68.1)
Mr. S, a 19-year-old man, came for treatment because he
had severe acne on his face and the whiteheads seemed to be
much larger than those of other people. After taking a closer
look, I said, “That’s right. These comedones, which are
larger than other people’s comedones, are called macrocomedones, and these are the most unsightly lesions that cause
cosmetic problems among comedones, so it is best to actively
seek treatment!” (Fig.68.2).
Macrocomedones are closed or open comedones larger
than 1mm, usually showing a size of 3–4mm or more and
occur more frequently in closed comedones than in open
comedones. However, the mechanism that triggers the formation of comedones progressing to macrocomedones is not
yet clearly understood. They cause cosmetic problems and
especially, in the case of taking isotretinoin, a sebum suppressant, they can resist treatment or cause temporary inam-
matory worsening, which is why treatment is needed.
Macrocomedones are large, so they can usually be diagnosed
visually, but if they are deep in the skin, they may not be
diagnosed well without a careful examination. Under appropriate lighting, stretching the skin up and down or left and
right can accurately diagnose macrocomedones (Fig.68.3).
Although sebaceous follicles and comedones appear similar to each other, the expression of circulating cells and proliferation markers is observed to be different, suggesting that
pilosebaceous ducts have the same cycle as hair follicles.
Cycling of normal follicles and of comedones is important
for the occurrence and disappearance of comedones, and it is
speculated that this cycle may cause comedones to disappear
on their own. However, macrocomedones are made up of a
lot of lipids and corneocytes and do not heal on their own
with the comedones cycle and can persist for years unless
they are extracted. Also, it can progress into a larger inammatory lesion if ruptured, and severe ares matching the
macrocomedones can occur when using isotretinoin, so it is
Fig. 68.1 Macrocomedones observed on the right cheek Fig. 68.2 Macrocomedones
© 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_68
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68 Macrocomedones
known to be important to treat macrocomedones before taking isotretinoin. Follicular hyperkeratosis is a key factor in
acne occurrence, causing microcomedones and various acne
lesions caused by it. Therefore, opening the pores and remov-
Fig. 68.3 Macrocomedones—60× magnication
ing their contents is the most important approach to comedones treatment. Small closed comedones less than 1mm can
be effective with topical retinoids, but macrocomedones do
not respond to such drug treatments due to the large amount
of content in the lesion. The contents of the macrocomedones must be physically extruded, and this lesion is not a cyst,
so extraction can be an effective treatment. Closed macrocomedones do not respond to topical and oral treatments and
are the longest-lasting lesions, and macrocomedones that
occur in adolescence create an unhealthy skin condition with
macrocomedones and scars in the acne area for a long time.
Macrocomedones are one of the most unsightly acne lesions,
leaving signicant physical and psychological scars, so
active treatment of macrocomedones is recommended as it
can improve quality of life and self-esteem and reduce psychological pain. Mr. S was given a sufcient explanation and
was advised to receive appropriate treatment immediately
from today so as not to miss the treatment time and create
many unwanted scars (Figs. 68.4, 68.5, 68.6 68.7 and
68.8–68.10).
Figs. 68.4 and 68.5 Macrocomedones observed under the chin of an adult
Figs. 68.6 and 68.7 Many macrocomedones are observed when stretching the skin for diagnosis
68 Macrocomedones
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279
Figs. 68.8–68.10 CO2 laser treatment for macrocomedones with a large amount of discharge
Erythema Ab Igne
∗∗∗
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69
I’m not sure when it started, but I’m worried because
many red stains in the shape of a net are appearing on my
legs and the color is getting darker.
Ms. K, a woman in her 20s, came to see a doctor with a
worried expression, saying that red stains in the shape of a
net have been appearing here and there on her legs and the
color is getting darker. When I asked, “Do you work with a
heater close by?” she replied, “Yes? How did you know
that?” (Fig.69.1).
Erythema ab igne is a distinct net-shaped erythema or
hyperpigmentation that occurs on the skin when exposed to
heat that is not enough to cause a burn for a long time or
repeatedly. The term “erythema ab igne,” which comes from
Latin, means “redness from re,” and it is also known as
“toasted skin syndrome,” “hot water bottle rash,” and “re
stains.” In the past, it was known to occur mainly on the inner
side of women’s shins exposed to re pits or stoves in winter,
but the frequency of occurrence has signicantly decreased
as most buildings now use central heating. However, it still
Fig. 69.1 Erythema ab igne lesions observed on the leg
occasionally occurs in rural areas and among the elderly who
are close to heating devices and is seen in occupations that
are constantly exposed to heat, such as foundry workers,
bakers, and coal transporters. In addition, it has been reported
to occur due to heated chairs, electric mats, electric blankets,
car heaters, local heat devices for abdominal and pelvic pain
treatment, portable computers, diet heat pads, foot baths, hot
popcorn, etc. Initially, a net-like erythema appears on the
skin exposed to heat, and if the exposure to heat continues,
hyperpigmentation gradually occurs, and the lesion becomes
xed. The deposited color varies from brown, dark brown, to
black and disappears when exposure to heat is stopped, but
permanent pigmentation may remain. In cases of chronic
exposure, thermal keratosis may occur within the erythema
ab igne lesion. Also, dysplasia of keratinocytes can occur in
long-lasting erythema ab igne, which can ultimately progress
to squamous cell carcinoma. In the meantime, actinic keratosis, Bowen’s disease, Merkel cell carcinoma, and squamous
cell carcinoma arising from erythema ab igne have been
reported. Usually, it is diagnosed by detailed history taking
and characteristic clinical features, and it is rare to need a
biopsy for conrmation. Histologically, the elastic bers in
the dermis increase and the collagen bers become thin and
broken, but they do not show the basophilic degeneration
seen in solar elastosis. Melanin granules are usually seen in
the upper dermis, but hemosiderin is often observed. It
should be differentiated from other diseases that form a netlike erythema on the skin in relation to external temperature
changes, such as livedo reticularis and cutis marmorata
(Figs. 69.2, 69.3, 69.4, 69.5, 69.6, 69.7, 69.8, 69.9 and
69.10).
As it is a disease that occurs due to long-term or repeated
exposure to heat, it is important not to be exposed to heat
anymore for treatment. When skin lesions rst occur due to
exposure to heat below 45°C for less than 3weeks, they may
be cured by discontinuing exposure. However, if the patient
continues to be exposed to heat even after the lesion occurs,
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