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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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Excoriated Acne: Acne Excoriée
∗∗∗
https://t.me/med1917
I only have a few pimples, but my facial skin keeps ipping over as if it’s been injured.
A 20-year-old female, L, came with the concern that
although she doesn’t have many pimples, her facial skin
often severely ips over. Upon closer examination, there are
only a few acne lesions, but severe excoriations (scratched
wounds) are noticeable. When asked, “Why do you hurt your
skin like this?” she replied, “What are you talking about? I
didn’t do that!” (Fig.83.1).
Of course, many people try to squeeze out comedones or
pustules with their ngers or tools when they have acne on
their face. However, excoriated acne (acne excoriée) refers to
cases where young women with little or almost no acne show
inammatory lesions with supercial scabs due to multiple
excoriations (scratched wounds), often accompanied by personality disorders, obsessive-compulsive disorders, or
depression. It was rst reported in 1898 as “acne excoriée
des jeunes lles (girls’ excoriated acne).” Excoriations are
mainly caused by scratching or tearing with ngernails,
resulting in round, irregular, linear lesions with red erosions
and crusts, eventually leading to scars and post- inammatory
hyperpigmentation. This is considered a defense mechanism
to hide emotional disorders, and severe excoriated lesions
appearing in patients with one or two minor acne lesions signify emotional instability. Broad, red erosions with adherent
crusts are distinctly different from the natural course of papular or pustular acne lesions. Like neurotic excoriation, most
female patients with excoriated acne deny or forget that they
caused the excoriations. Therefore, it should be explained to
the patient that such lesions can only occur when they damage their skin, and sometimes they may occur unconsciously
83
Fig. 83.1 Excoriated acne
while asleep. However, even if they acknowledge that their
actions caused the excoriations, they cannot suppress such
behavior. Patients have severely distorted thoughts about
their bodies, so a detailed history taking is necessary.
Dermatitis artefacta can be accompanied, and treatment is
not easy. Patients cannot break the obsessive-compulsive
habit of scratching their faces. Therefore, psychiatric advice
and treatment may be necessary, and habit reversal techniques are known to be effective. For erythema and scars,
pulsed dye lasers or long-pulsed KTP lasers are effective,
and for post-inammatory hyperpigmentation, Q-switched
lasers are effective. Ms. L said, “Yes... I understand!” and it
seems that she has a good understanding of the cause of this
disease, and I sincerely hope that there will be an improvement in her symptoms in the future (Figs.83.2, 83.3, 83.4,
83.5, 83.6, 83.7 and 83.8).
© 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_83
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Fig. 83.2 Acne excoriée
83 Excoriated Acne: Acne Excoriée
Figs. 83.3 and 83.4 Acne excoriée
Fig. 83.5 Early lesion of acne excoriée
Fig. 83.6 A case of acne excoriée with hyperpigmentation
83 Excoriated Acne: Acne Excoriée
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Figs. 83.7 and 83.8 Acne excoriée and neurotic excoriation, dermatitis artefacta
349
Carotenosis, Carotenemia,
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Carotenoderma
I suddenly started liking tangerines so much that I
bought a box and ate them, and now I think I have
jaundice (Fig.84.1).
One day, the face of Ms. S, who is receiving skin care,
looked quite yellow, so I was worried and said, “Your face
looks a bit yellow!” She replied, “My hands are even yellower!” When I compared her hand with mine and Teacher
Kim’s hand, her hand was incomparably yellow. I was surprised and quickly checked for jaundice in her eyes, but fortunately, it was not jaundice (jaundice is when the whites of
the eyes, i.e., the sclera, turn yellow). Relieved, I asked,
“Have you been eating a lot of tangerines?” She replied,
“Yes! I’ve recently become addicted to tangerines, and I’ve
been buying them by the box and eating them!”.
Carotenosis is a condition where an increase in blood carotene levels leads to carotene deposition in the skin, causing
yellow discoloration. One molecule of beta-carotene is
converted into two molecules of retinol in the body. If carotene is not converted into retinol at a normal rate, it can
exist in excess in the blood, and if carotene accumulates in
tissues, especially the skin, due to an increase in blood carotene levels, the palms of the hands and the soles of the
Feet can turn orange-yellow color. Although it can be found
in liver disease, diabetes, hypothyroidism, nephritis, and
hyperlipidemia, it is most commonly seen in cases where
fruits or vegetables high in carotene, such as carrots,
oranges, tangerines, pumpkins, and spinach, are consumed
in large quantities. It usually appears most commonly on
the palms and soles, where the stratum corneum is thick,
and also on the forehead, nose, upper eyelids, and behind
84
Fig. 84.1 Carotenosis with yellow hands
the ears. It is important to distinguish it from jaundice, as it
shows a more yellowish color than jaundice, does not
invade the mucous membranes including the sclera, and
does not have the itching or changes in the color of urine
and feces that can occur in jaundice. If differential diagnosis is needed, liver function tests, blood tests, and urine
tests are performed, and unless there are special circumstances, limiting foods rich in carotene such as tangerines
and oranges will naturally disappear. Tangerines are high in
nutritional value and rich in vitamins, which are good for
health and skin beauty, but as Confucius said, “Too much is
as bad as too little.” (Figs.84.2, 84.3, 84.4, 84.5, 84.6 and
84.7).
© 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_84
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Figs. 84.2 and 84.3 Carotenosis
84 Carotenosis, Carotenemia, Carotenoderma
Figs. 84.4 and 84.5 Carotenosis
Figs. 84.6 and 84.7 Carotenosis
Cholinergic Urticaria
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85
When I take a hot bath or exercise a bit too much, my
skin stings and small hives like millet appear (Fig.85.1).
21-year-old Mr. B says, “I don’t know when it started, but
when I take a hot bath or exercise a bit too much, my skin
stings and small hives like millet appear, which is really
painful! Is it cholinergic urticaria?” These days, thanks to the
internet, many people come in already knowing a lot, so
there are many cases where no explanation is needed
(Fig.85.2).
Cholinergic urticaria is a type of physical urticaria that
occurs when the core body temperature rises by about 1°C
due to hot baths, spicy food intake, excessive exercise, and
mental stress. It accounts for 5–7% of all urticaria, typically
starting in the 10s to 20s and is more common in men. As a
mechanism of occurrence, excessive production of acetylcholine has been reported in patients with cholinergic urticaria, but it does not respond to oral anticholinergics and
responds well to H1 antihistamines, suggesting the relevance
of histamine. The possibility of a serum factor was also
reported as symptoms appeared when the patient’s serum
was injected into a monkey. It is characterized by the appearance of many very small wheals of 1–2mm and erythematous ares of 1–2cm around it. It mainly appears on the torso
and does not appear on the face and hands and feet. Generally,
the rash disappears after 30–60min, but individual lesions
can last longer depending on the case. Sometimes the lesions
can merge or develop into angioedema. Many patients complain of stinging skin rather than itching, and systemic symptoms such as sweating, abdominal pain, dizziness, headache,
nausea, and vomiting can accompany. In Korea, there are
reports of cholinergic urticaria accompanying cold urticaria,
idiopathic generalized anhidrosis, and exercise-induced
asthma. Sweating exercises or bathing in hot water around
43°C for 20–30min can induce typical cholinergic urticaria.
The prognosis is relatively good, but it persists for more than
10years in 31% of patients, and the average duration of the
disease is known to be 7.5years (3–16years). If cholinergic
urticaria is suspected, the patient is exercised to sweat for
10–15 min (running, cycling, etc.) and the occurrence of
characteristic small hives is observed for about an hour.
However, precautions should be taken against exerciseinduced anaphylaxis (Figs.85.3, 85.4, 85.5, 85.6, 85.7, 85.8
and 85.9).
Fig. 85.1 Cholinergic urticaria observed on the torso
© 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_85
Fig. 85.2 Cholinergic urticaria characterized by small wheals like
millet
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85 Cholinergic Urticaria
Fig. 85.3 If cholinergic urticaria is suspected, try exercising to see if it
triggers urticaria
Figs. 85.5 and 85.6 Cholinergic urticaria, unlike other urticaria, appears as very small wheal
Fig. 85.4 Cholinergic urticaria induced by 10minutes of exercise
Fig. 85.7 and 85.8 Cholinergic urticaria observed on the neck and torso
To alleviate symptoms, rst avoid factors that can trigger
or worsen them, and implement step-by-step drug treatment
for symptom control. In fact, I also get severe hives when I
eat pupae or shrimp, so I feel more familiar with urticaria
patients as if we share the same disease, and I explained the
treatment method for urticaria to Mr. B with all my heart.
85 Cholinergic Urticaria
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Fig. 85.9 Cholinergic urticaria
Idiopathic Guttate Hypomelanosis
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86
I have a lot of white spots the size of beans on my arms,
legs, and back. Could it be vitiligo? How should I treat it?
(Fig.86.1).
Mr. H, a 55-year-old man, came for treatment because he
was curious about whether the white spots on his arms, legs,
and torso, which had been noticeable one or two at a time
and were gradually increasing in number, were vitiligo, and
how to treat it, as he was reminded of the photos of vitiligo
he had seen on the Internet. “Is this vitiligo? I’m worried
because the number keeps increasing,” he said (Fig.86.2).
Idiopathic guttate hypomelanosis is an acquired leukodermic dermatosis that appears as round, white macules and
patches with clear boundaries, mainly on the arms and legs.
The size of the lesions is about 5mm in diameter on average,
and more than 20 lesions are commonly found. They start to
appear after the age of 10, with 50% observed in people over
40 and 70% in people over 60. As age increases, the number
of lesions tends to increase, or their size tends to grow. The
color of the hair in the lesion area does not change, and the
lesions do not improve over time. There are no scales on the
lesions, and there are no subjective symptoms such as itching.
The cause is unknown, but it is presumed to be an aging phe-
nomenon caused by chronic sun exposure, it can occur due to
skin friction, and it also shows a familial tendency. According
to a report on 793 people in Korea, the average prevalence
was 88% in people over 40, with 52% in men and 46% in
women, showing no signicant gender difference. The occurrence sites were lower legs (97%), forearms (94%), thighs
(79%), upper arms (71%), back (46%), abdomen (27%), neck
(18%), and face (5%) in order. 53% reported a family history,
and as age increases, the prevalence increases, skin problems
related to photoaging appear, and the occurrence rate was
56% in the group who responded that they scrub their skin,
and 21% in the group who responded that they do not scrub
their skin. It is reported that it is presumed to occur due to the
combined action of intrinsic skin aging, photoaging, local
trauma, etc., in addition to genetic factors. It is characterized
by clear white macules about 5mm in size that occur mainly
on the arms, legs, and back of the elderly, so it can be diagnosed with the naked eye. Histologically, a decrease in the
number of melanocytes and a quantitative decrease in melanin pigment can be conrmed in the lesions (Figs.86.3, 86.4,
86.5, 86.6, 86.7, 86.8, 86.9, 86.10 and 86.11).
Fig. 86.1 Idiopathic guttate hypomelanosis observed on the leg Fig. 86.2 Idiopathic guttate hypomelanosis found 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_86
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86 Idiopathic Guttate Hypomelanosis
Fig. 86.3 Idiopathic guttate hypomelanosis—60× magnication
Figs. 86.5 and 86.6 Idiopathic guttate hypomelanosis
Fig. 86.4 Idiopathic guttate hypomelanosis
Figs. 86.7 and 86.8 Idiopathic guttate hypomelanosis
This disease is a cosmetic issue and poses no risk. There
is no effective treatment, but intralesional steroid injections
or cryotherapy can be used, tretinoin is sometimes used for
partial recovery of pigment and recovery of skin elasticity,
and the effects of topical tacrolimus application and frac-
tional laser have been reported. I advised Mr. H to apply sunscreen well to prevent further deterioration and explained
that there are no treatments with proven effectiveness yet,
subtly expressing concern. Fortunately, he smiled brightly,
saying, “As long as it’s not vitiligo, it’s okay!”
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