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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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86 Idiopathic Guttate Hypomelanosis
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Figs. 86.9 and 86.10 Idiopathic guttate hypomelanosis
359
Fig. 86.11 Idiopathic guttate hypomelanosis
Paederus Dermatitis: Dermatitis
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Linearis
87
I recently visited Vietnam. Do you know what the burn
bug is? It’s a famous bug there (Fig.87.1).
Mr. M, a man in his 50s who often visits Vietnam for business, said, “Doctor, have you heard of the burn bug? It’s a
famous bug there. When the bug crawls on the skin, the area
becomes like a burn, so when they are abundant, we can’t
open the windows to sleep.” I told him, “It’s an insect called
Paederus fuscipes, which can also be found in our country.”
But there was a time when I didn’t know how these strange
skin symptoms, which looked like the skin had been corroded, had occurred in several patients.
Paederus dermatitis, also known as “burn bug dermatitis,”
refers to dermatitis caused by contact with pederin, a toxic
substance contained in the body uid of insects belonging to
the order Coleoptera, family Staphylinidae, and genus
Paederus. It is also called “dermatitis linearis” because it
mainly appears linearly. It became well-known mainly
through Vietnamese tourists, but in Korea, there have been
Fig. 87.1 Paederus dermatitis developed after a business trip to
Vietnam
reports of outbreaks of Paederus dermatitis caused by
Paederus fuscipes in Jeollanam-do in 1968 and
Gyeongsangbuk-do in 1994. There are about 600 known species in the genus Paederus, and several species other than
Paederus fuscipes cause dermatitis. Paederus fuscipes is a
small, slender beetle about 7 mm long that lives in elds,
ponds, and riverbanks, and can be seen mainly between June
and September, and is active in temperature zones of
20–35°C.According to a report in Korea in 1999, there are
no symptoms for a few hours after contact with the body uid
of Paederus fuscipes, but gradually erythema appears, vesi-
cles form after 24hours, severe erosion with a burning sensation occurs after 3days, and crusts form after 7days. These
crusts fall off on the 11th day, and slight scaling with pigmentation is observed. In a study in Korea in 1989, dermatitis was
induced by rubbing the anus of Paederus fuscipes directly on
the skin, suggesting that dermatitis can also occur through
body uids secreted during ovulation or excretion. Fortunately,
it does not cause systemic symptoms, but if the body uid
gets into the eyes, it can cause conjunctivitis or keratitis.
Histologically, Paederus dermatitis best shows the ndings of
irritant contact dermatitis, including intraepidermal vesicles,
subepidermal vesicles, epidermal necrosis, and separation of
prickle cells, among dermatitis caused by insects.
If a suspected insect lands, do not touch it, but blow it
away. If you come into contact with insect uid, wash it off
immediately with soapy water. Wet dressings are applied to
the acute inammatory area, and antibiotic ointment is
applied to prevent secondary bacterial infection.
Antihistamines and steroids are administered according to
symptoms. Iodine tincture can be used as a disinfectant as it
destroys pederin. Adult insects that have invaded indoors
should be caught by spraying aerosols containing lowtoxicity organics or pyrethroids or by wrapping them in a wet
towel. Mr. M is almost recovered now, and since this disease
does not cause systemic symptoms, I explained that he will
soon get better with medication, which reassured him
(Figs.87.2, 87.3, 87.4, 87.5 and 87.6).
© 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_87
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Fig. 87.2 Paederus dermatitis occurred during a trip to Vietnam
87 Paederus Dermatitis: Dermatitis Linearis
Fig. 87.3 Paederus dermatitis
Fig. 87.5 Paederus dermatitis
Fig. 87.6 Paederus dermatitis
Fig. 87.4 Paederus dermatitis
Fordyce Spots: Fordyce’s Granules
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88
I’ve been getting countless tiny white spots on my upper
lip that I don’t even like to look at, and I’m worried it
might be cancer.
Mr. P, a 35-year-old man, is greatly worried about countless tiny white spots, less than 1 mm in size, that have
appeared on his upper lip. Sitting in the clinic, he says, “I
have so many of these that my lips don’t look red but pale,
and I don’t like to look at them, but I’m worried it might be
cancer.” (Fig.88.1).
Fordyce’s spot refers to very small white or yellow macular
or papular lesions that occur ectopically, i.e., in areas where
sebaceous glands do not normally exist, such as the lips, oral
mucosa, and rarely, the gums. It was rst named by Fordyce
in 1896 and is generally not considered a disease but a cosmetic issue, hence it is also referred to as “Fordyce’s condition” or “Fordyce’s granules.” (Figs.88.2 and 88.3).
There are two types of very small holes in human skin,
one is the opening of hair follicle (pore), and the other one
is the sweat pore. Most sebaceous glands are connected to
hair follicles, discharging sebum through the pores.
However, sebaceous glands are occasionally observed in
areas where hair follicles are not distributed, such as the
Meibomian glands of the eyelids, the Montgomery’s glands
of the nipples or areola, the Tyson’s glands of the genital
area, and the Fordyce spots of the lips or oral mucosa.
Fig. 88.2 Fordyce spots observed on the upper and lower lip
Fig. 88.1 Fordyce spots on the upper lip
© 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_88
Fig. 88.3 Fordyce spots (Fordyce’s granules) observed on the oral
mucosa
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Figs. 88.4 and 88.5 Fordyce spots
Fordyce spots are rare in childhood, but their incidence
increases with age after puberty, appearing in 25% of people
over 35 and in 70–80% of the elderly. They are commonly
found in men, older people, and those with oily skin. The
exact cause is not yet clear, but it is hypothesized that they
may occur due to endocrine effects on the sebaceous glands,
as the incidence tends to increase with age. Recently, there
have also been reports of a correlation with hyperlipidemia
(Figs.88.4 and 88.5).
The clinical appearance is characterized by very small
white to yellow papules less than 1mm in size, clustered and
distributed mainly on the lips. Lesions appear scattered but
occasionally merge. Most patients with Fordyce spots have
them on the upper lip (75%). In addition to the lips, they can
also occur on the oral mucosa, especially on the inner side of
the labial commissure where the upper and lower lips meet
and rarely on the gums, glans or prepuce, penis, areola, and
labia minora. There are no symptoms such as pain or itching,
but occasionally neurotic patients may complain of a burning
sensation. Diagnosis is usually possible by visual inspection
based on characteristic clinical ndings and typical locations. Histologically, small but mature sebaceous lobules
proliferate around small sebaceous ducts, and the sebaceous
ducts can be observed to be directly connected to the epithelial surface without attaching to the hair follicle. Clinically, it
needs to be differentiated from lichen planus, and histologically, it needs to be differentiated from sebaceous hyperplasia (Fig.88.6).
Fordyce spots do not cause any symptoms, so most people do not feel discomfort in their daily lives and do not necessarily need treatment. It is good to reassure the patient that
it is not cancer to prevent anxiety, and treatment may be necessary if the patient is under psychological stress due to cosmetic problems. It can be removed using a CO
laser, but the
2
traditional CO2 laser procedure has the problem of common
recurrences and scarring, and the results can vary greatly
depending on the doctor performing the procedure. There
have been reports of therapeutic effects by orally administer-
88 Fordyce Spots: Fordyce’s Granules
Fig. 88.6 Fordyce spots causing serious cosmetic problems
ing isotretinoin as a drug therapy, but there is a drawback that
it soon recurs after discontinuation, so it is not widely used.
Recently, there have been reports that the number of Fordyce
spots decreased, and cosmetic improvement and patient satisfaction were obtained by treating with 100% BCA (bichloracetic acid) applied to the lesion site. There have also been
reports of satisfactory effects without special side effects by
removing relatively supercial lesions using a CO2 laser and
then applying 50% TCA to deep tissue to remove remaining
sebaceous glands. In addition, there have been reports of
Fordyce spots effectively treated by electrocautery and highpower diode lasers, but photodynamic therapy (ALA-PDT)
performed on Fordyce spots does not show satisfactory
effects compared to side effects such as pain, heat sensation,
erythema, swelling, and blister formation. Therefore, it is
known that photodynamic therapy for Fordyce spots is not an
appropriate treatment. For Mr. P, it was decided to repeat the
procedure at intervals of 1–3 months using the pinhole
method, which creates a deep and narrow hole in the lesion
by focusing with a CO
laser (Figs. 88.7–88.10).
2
88 Fordyce Spots: Fordyce’s Granules
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Figs. 88.7–88.10 Treatment of Fordyce spots with CO2 laser
Eczema Herpeticum
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A child with atopic dermatitis suddenly has small vesicles
on his lips, and after that, shallow vesicles with a sunken
center are spreading all over his face.
A 13-year-old boy P has atopic dermatitis, and recently,
small vesicles appeared on his lips and small vesicles with
sunken centers spread all over his face in no time, so he came
to see a doctor with his mother. The mother worriedly says,
“In other hospitals, they say it’s impetigo and give antibiotics, is it okay to treat it like that?” (Fig.89.1).
Eczema herpeticum is a skin infection that mainly occurs
due to herpes simplex virus infection in patients with preceding skin diseases such as atopic dermatitis, and it appears as
a cluster of many shallow vesicles with sunken centers on
eczematous lesions. In the past, it was recognized as a disease that occurs in infants, but according to recent reports, it
occurs a lot in age groups over 20. It mainly occurs due to
herpes simplex virus type 1 (HSV-1), but rarely, it can also
occur due to herpes simplex virus type 2 (HSV-2), and it can
occur in both primary and recurrent infections. In addition to
skin lesions, systemic symptoms such as fever, lymphadenopathy, and malaise can occur. It has been reported that
accompanying skin diseases include eczematous diseases
such as atopic dermatitis and seborrheic dermatitis, as well
as various chronic diseases such as burns, pemphigus,
mycosis fungoides, Sézary syndrome, ichthyosis, and
Darier’s disease (Figs. 89.2, 89.3, 89.4 and 89.5).
In a Korean study on 62 hospitalized patients with eczema
herpeticum, atopic dermatitis showed the highest distribution at 67.7%, nummular and infantile eczema 6.5%, seborrheic dermatitis 3.2%, Darier’s disease 1.6%, while 21.0%
had no history of other skin diseases. The average age of
onset was 25.3years, and the proportion of patients in their
20s was the highest at 32.2%. Also, the male to female ratio
was 2:1, with more cases in men, especially a relatively high
proportion in men in their 20s. Eczema herpeticum is said to
be complicated in less than 3% of patients with atopic dermatitis, but in a Korean study of 1637 patients under 18 diag-
89
Fig. 89.1 Eczema herpeticum
nosed with atopic dermatitis, it was surveyed at 2.7%, and in
cases of severe atopic dermatitis, frequent bacterial skin
infections, IgE-mediated atopic dermatitis and food allergies, immediate examination and treatment are necessary
when multiple clustered vesicles occur on eczematous
lesions throughout the body, including the face, considering
the possibility of eczema herpeticum.
The main route of transmission of eczema herpeticum is
direct contact, and airborne transmission is known not to
© 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_89
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89 Eczema Herpeticum
occur. The herpes simplex virus can be directly or indirectly
inoculated, and direct inoculation refers to the route in which
the herpes simplex virus is released when the infected vesicle ruptures and infects normal skin, not the lesion site of the
same person. It has also been reported that infection is possible through indirect inoculation, and the herpes simplex
virus was detected in the hands without eczematous lesions
in most patients with eczema herpeticum, and it was said that
the virus is inoculated when patients scratch eczematous
lesions with their hands due to itching. The characteristic
clinical features of eczema herpeticum are uniform vesicular
lesions with a sunken center that are common on the neck
Fig. 89.2 Typical lesions of eczema herpeticum with spreading vesicles with a sunken center
Figs. 89.3 and 89.4 Eczema herpeticum
Fig. 89.5 Eczema herpeticum in infants
89 Eczema Herpeticum
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369
and chest, mainly occur in areas where eczematous lesions
previously existed, and rarely occur on the legs. However, it
should be recognized that damage to the skin barrier can be
a precursor to eczema herpeticum, and when uniform vesicular lesions occur in the diaper area in children, eczema herpeticum should be suspected.
Eczema herpeticum is often recurrent (26.7% in Korean
studies), and attention is needed for systemic symptoms and
complications that accompany it. Skin lesions often come
with fever, headache, fatigue, and lymph node swelling,
which are more common in primary infections. Primary
infections often show severe skin rashes, edema, lymph node
swelling, toxemia, and high mortality rates, while recurrent
infections show milder progress with less spread to internal
organs and viremia than primary infections and lower mortality rates. Deaths are mainly due to bacterial superinfections and bacteremia, and the mortality rate was 10% before
the use of antiviral drugs. Complications of eczema
herpeticum can include herpes keratitis, meningitis, enceph-
Fig. 89.6 Eczema herpeticum
alitis, and organ invasion by viremia, such as the liver, lungs,
and gastrointestinal tract.
Clinically, the diagnosis is easy as uniform vesicular
lesions with a sunken center mainly appear on the head and
neck, but according to Korean research, 81.8% of cases were
misdiagnosed as bacterial infections and only received antibiotic treatment after the onset of eczema herpeticum, indicating the need for more attention and education on eczema
herpeticum. Tzanck smear, virus culture, skin biopsy, and
serological tests help in diagnosis. Blood tests show that the
white blood cell count, eosinophil fraction, ESR, and total
IgE antibodies are signicantly high, and the risk of eczema
herpeticum is higher in IgE-mediated atopic dermatitis
(Figs.89.6, 89.7, 89.8, 89.9 and 89.10).
The main treatment for eczema herpeticum is antiviral
drugs, with acyclovir recommended at 750 mg/m2 three
times a day for under 12years old, and 5–10 mg/kg three
times a day for over 12years old, administered intravenously
for 7days. Oral administration of acyclovir is known to have
only 15–30% of the bioavailability of intravenous injection,
and while valacyclovir and famciclovir have higher bioavailability than acyclovir, they are not used in children.
Combination therapy with antibiotics may be needed due to
secondary bacterial infection caused by skin barrier damage,
and controlling pain and itching can be helpful. There are
various opinions on the use of steroids, but generally, immunosuppressants such as steroids, cyclosporine, and calcineurin inhibitors are reported to be better not used in the early
stages of eczema herpeticum treatment as they can increase
virus spread. However, in patients without evidence of secondary infection, the anti-inammatory effects of steroids
can improve eczematous lesions of the underlying disease
such as atopic dermatitis. Therefore, steroids can be administered in combination for this purpose. In severe atopic dermatitis patients with concurrent or past history of eczema
herpeticum, it has been reported that it is preferable to use
Figs. 89.7 and 89.8 Eczema herpeticum
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Figs. 89.9 and 89.10 Eczema herpeticum
89 Eczema Herpeticum
IFN-γ or IVIG, which do not increase susceptibility to viral
infections, rather than immunosuppressants, in cases where
symptoms are severe and resistant to treatment. P’s mother
was reassured by the fact that although there were reports
about the dangers of this disease, most cases show rapid
improvement if antiviral drugs are used immediately.
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