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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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Prurigo Nodularis
https://t.me/med1917
The backs of my hands and legs are so itchy that when I
scratch them, it gets even more itchy and hard wart-like
things keep forming (Fig.4.1).
Mr. L, a 47-year-old man, came to get treatment saying
that the business he had recently started was not going well
and that he was very stressed due to xed expenses. When he
scratched the backs of his hands and legs due to itching, it
became more itchy and many things like warts appeared on
the areas he scratched. “I really tried to endure it, but it’s too
itchy!” (Figs.4.2 and 4.3).
Prurigo nodularis is a relatively rare disease characterized
by multiple nodules of hyperkeratosis accompanied by
severe itching. Patients suffer severe damage to their quality
of life due to the chronic and recurrent course. According to
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Fig. 4.1 Prurigo nodularis observed on both hands
Figs. 4.2 and 4.3 Prurigo nodularis on the hand
© 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_4
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4 Prurigo Nodularis
a study on patients with prurigo nodularis in Korea, it was
more common in men than women, and the age of onset
ranged from 2 to 64years, but it was relatively common in
teenagers and people in their 40s. The cause is not exactly
known, but it can be associated with atopic dermatitis, mental stress, anemia, liver disease, immunodeciency, pregnancy, renal failure, insect bites, etc. It is particularly
common on the front of the thighs and lower legs and arms
and often appears in a symmetrical distribution, often linearly. Hard, erythematous, lichenied nodules of 0.5–3cm
occur, which become wart-like over time, and new nodules
continue to appear, but the existing nodules do not disappear
well. In most patients, a very difcult “itch-scratch cycle”
occurs, and the intensity of itching in prurigo nodularis is
thought to be the highest among various other types of
chronic pruritus, resulting in very severe damage to the quality of life. The characteristic is intermittent and paroxysmal
severe itching that is conned to the lesion, and the itching
can worsen when going to bed, when not getting enough
sleep, and when under stress. The itching is paroxysmally
induced and disappears and may not be felt at all until it is
induced again. There are many cases where there are behavioral changes such as biting nails or sucking ngers, and the
patient’s emotional problems can also induce itching.
Conversely, even though there are objectively signs of severe
itching and the distal part of the nail is worn away, there are
cases where the patient does not feel any subjective itching
because it occurred in an unconscious state during sleep.
Diagnosis can usually be made based on clinical ndings,
and a biopsy is needed in ambiguous cases (Figs.4.4, 4.5,
4.6, 4.7, 4.8, 4.9, 4.10, 4.11, 4.12 and 4.13).
Prurigo nodularis generally does not respond well to
treatment and causes a lot of suffering due to severe itching.
It usually shows a chronic course and does not naturally
subside, and even if some subside, they leave scars.
Typically, topical treatments that can relieve itching are
used while taking antihistamines, antidepressants, tranquilizers, etc. Strong topical steroids are used primarily, and
occlusive therapy can be performed for better effects.
Steroid injections into the lesion are effective in eliminating
individual lesions, but there are limitations because many
patients have too widespread lesions to inject each one.
Nonsteroidal topical immunomodulators can be used as an
alternative to reduce steroid usage. The effects of various
Fig. 4.4 Prurigo nodularis observed on the back
Figs. 4.5 and 4.6 Prurigo nodularis on the torso
4 Prurigo Nodularis
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Figs. 4.7 and 4.8 Prurigo nodularis on the back of the hand and wrist
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Figs. 4.9 and 4.10 Prurigo nodularis observed on the chest and groin area
Figs. 4.11 and 4.12 Prurigo nodularis on the abdomen and buttocks
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4 Prurigo Nodularis
oral medications have been reported, and phototherapy can
be helpful in some patients, and in some cases, cryotherapy
or CO2 laser can be performed as an adjunct. However, the
problem is that recurrence is common even in cases that
show improvement in treatment. I sincerely hope that Mr. L
will properly understand this disease and show good treatment results by escaping from the vicious cycle of itching
and scratching.
Fig. 4.13 Prurigo nodularis on the leg
Insect Bites
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The patient came to me because it was itching to death,
but after the examination, I was told that the itchy area
was caused by an insect bite, and she got very angry
(Fig.5.1).
A 66-year-old female, H, came in saying she was itching
to death since last night, but upon closer examination, lesions
appeared in a straight line and there were signs of insect bites
in the central area. When I said, “It looks like you’ve been
bitten by a bug!” she got angry and said, “What? Bitten by a
bug? Do I look like someone who would come to the hospital
for such a trivial thing?”.
Insect bites refer to the damage caused by being bitten by
insects such as mosquitoes, ants, bedbugs, eas, etc., and the
corresponding reactions in the human body. The mechanisms
of skin reactions vary depending on the type of insect, but
they are caused by (1) physical wounds, (2) the injection of
toxins or antigenic substances contained in the insect’s
saliva, and (3) foreign body reactions caused by parts of the
biting area remaining on the skin. Clinical symptoms can
vary depending on the type of insect causing the bite and the
individual’s reaction, but the most common symptoms are
temporary erythema or edema, often characterized by a bitten mark in the center. Vesicular lesions often appear on the
leg, but in young children, they can be seen anywhere. In
addition, wheal, hemorrhagic lesions, nodules, ulcers, etc.,
can occur. Depending on the type of insect, the distribution
of lesions can vary. For ying insects like mosquitoes, lesions
are scattered mainly on exposed areas, but for crawling
insects like bedbugs, lesions can occur anywhere and are
usually clustered in a limited area, showing the characteristic
of lesions along their movement path. The diagnosis is made
by combining a detailed medical history, including the
patient’s living environment, occupation, travel, pets, etc.,
and clinical ndings. In general, it is often difcult to accurately identify the causative insect (Figs.5.2, 5.3–5.5, 5.6,
5.7, 5.8, 5.9, 5.10, 5.11 and 5.12).
Fig. 5.1 Insect bite lesions observed linearly on the skin of 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_5
Fig. 5.2 In cases caused by insects that crawl and bite the skin, a characteristic distribution of lesions showing the insect’s movement path is
observed
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5 Insect Bites
Figs. 5.3–5.5 Various forms of skin lesions caused by insect bites
Figs. 5.6 and 5.7 Characteristic insect bite lesions on the leg
5 Insect Bites
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Figs. 5.8 and 5.9 Insect bites on the arm and neck
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Figs. 5.10 and 5.11 Bedbug bites on the body and arm
The purpose of treating insect bites is to relieve itching
and prevent secondary bacterial infections. To eliminate itching, cold wet dressings are applied, topical antipruritics or
steroid ointments are applied, and oral antihistamines are
administered. In severe cases or those that do not respond
well to treatment, steroids can be administered systemically
over a short period, and if a secondary bacterial infection
occurs, antibiotics are used both topically and systemically.
After the examination, many people, like Mrs. H, get angry
or are incredulous when told they have insect bites. Therefore,
like Hong Gil-dong (the main character of a classic Korean
novel who was born as an illegitimate child) who can’t call
his father “father,” there are times when it’s difcult to say
the term “insect bite,” even if diagnosed as an insect bite
after the examination.
Fig. 5.12 Extremely large insect bite lesions
Lichen Nitidus
∗∗∗
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My child has a lot of small things like tiny, shiny millet on
his body. Is it okay to leave it alone without treatment?
(Fig.6.1).
The mother of 8-year-old boy, K, came to the clinic with
a worried expression, saying that many small, shiny things
like millet had grown on her child’s body and were gradually
increasing. “It’s been a few months since they appeared, but
they haven’t disappeared. He says it’s not itchy, but is it okay
to just leave it alone?” she asked.
Lichen nitidus is a chronic skin disease characterized by the
appearance of multiple, very small (1–2mm), shiny, skincolored papules. The lesions are very distinctive in shape.
They often occur on the genitalia, abdomen, and limbs but
can occasionally occur all over the body. Subjective symptoms such as pain or itching are rare, but when it occurs systemically, itching is common, it progresses chronically, and
Koebner phenomenon can be observed. It mainly occurs in
Fig. 6.1 Lichen nitidus lesions observed on the body
children and young adults, but systemic cases mainly occur
in adults and are extremely rare in children. Variants of lichen
nitidus are purpuric, keratodermic, vesicular, hemorrhagic,
petechial, spinous follicular, linear, palmoplantar, actinic,
and perforating types. In the case of the perforating type, it
affects the trunk and limbs at the same time and shows systemic distribution, or if it occurs locally, it is common on the
hands and is characterized by an umbilication in the center of
the papule. The cause of lichen nitidus is not yet clear, but it
is thought to occur due to lymphocytic and histiocytic granulomatous inltration caused by a cellular immune mechanism involving allergens or infectious factors. Histologically,
there is typically granulomatous inltration composed of
lymphocytes and histiocytes in the expanded papillary dermis, and adjacent rete ridges are extended and surrounded,
which is a characteristic nding (“ball and claw” conguration). Generally, it is known to have no association with systemic diseases, but there have been reports of lichen nitidus
associated with Crohn’s disease, hepatitis C, juvenile chronic
arthritis, amenorrhea, growth hormone deciency, etc.
Lichen nitidus is said to be associated with 25–35% of lichen
planus, but there is still controversy over the association with
lichen planus. The association with atopic dermatitis has also
been suggested, but more research is needed. Lichen nitidus
usually shows a chronic course of several months or years,
and in a few cases, it can heal naturally within a few weeks,
and the lesions can persist for a long time. In a follow-up
study of 29 patients, 20 (69%) observed the disappearance of
lesions within a year, and 9 (31%) reported that skin lesions
persisted for several years. In Korea, there was a report of
generalized lichen nitidus that persisted for 15years. When
the existing lesion disappears, new lesions can occur in other
areas, and no atrophy or abnormal pigmentation is left after
the disappearance of the lesion. There have been cases where
it also occurs on the palms and soles, and it can be accompanied by mucosal lesions and onychodystrophy. Most of the
individual lesions are isolated, but sometimes they cluster
© 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_6
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6 Lichen Nitidus
and merge. The Koebner phenomenon rarely appears in isolated forms, but it can appear in conuent forms. Although it
is easy to diagnose with characteristic clinical ndings, skin
biopsy may be needed for differential diagnosis with lichen
planus, verruca plana, keratosis pilaris, and lichen spinulosus
(Figs.6.2, 6.3, 6.4, 6.5, 6.6, 6.7, 6.8, 6.9 and 6.10).
Fig. 6.2 Lichen nitidus around the navel
Lichen nitidus usually has no subjective symptoms and
most lesions naturally disappear within a year, so treatment
is generally not necessary. However, treatment is needed
when it occurs systemically, when symptoms such as itching
are accompanied, when the lesion does not naturally disappear and persists, or when there is a demand from a cosmetic
perspective. Oral antihistamines, topical and systemic steroids, and acitretin are used for the treatment of lichen nitidus, and their treatment effects are reported to vary. Recently,
it has been known that DPCP topical application, cyclosporine, or narrowband UVB are effective. There have also been
reports of complete disappearance of the lesion in 4months
by applying the vitamin D derivative tacalcitol, a treatment
for perforated lichen nitidus. In addition, there have been
reports that the 3-month topical application of tacrolimus
0.03% ointment, which has the advantage of no side effects
such as skin atrophy or telangiectasia unlike topical steroids,
was effective, and it is expected to be an alternative for those
who care about their face or beauty. Since most of them naturally disappear within a few months to a few years, it was
decided to prescribe tacrolimus ointment, which is clinically
effective, to boy K and observe him periodically and
explained to his mother to put her mind at ease.
Figs. 6.3 and 6.4 Lichen nitidus observed on the abdomen
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Fig. 6.5 Lichen nitidus lesion where the Koebner phenomenon is
observed
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Fig. 6.7 Lichen nitidus found on the back of the hand
Fig. 6.6 Lichen nitidus observed on the forehead
Fig. 6.8 Lichen nitidus on the torso
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